Sex steroids regulate epithelial-stromal cell cross talk and trophoblast attachment invasion in a three-dimensional human endometrial culture system

Human embryo implantation involves a complex network of molecular signaling that is modulated by endocrine and paracrine pathways. Here, we performed studies using a unique and recently developed three-dimensional (3D) implantation model, characterized by an endometrium-like 3D culture system and Jar cell-derived spheroids mimicking the embryo/trophoblast. The aims were to investigate the effects of 17β estradiol (E2) and medroxyprogesterone acetate (MPA) on (1) the interaction between epithelial and stromal cells, and (2) the attachment and invasion of trophoblast cells. We observed that epithelial and stromal cells in the 3D culture were ERα⁺, ERβ⁺, and PR⁺. Decidualization was confirmed by enhanced prolactin gene expression on day 7 of E2 plus MPA treatment. An effect of epithelial cells on the decidualization of stromal cells was indicated by significantly higher levels of prolactin mRNA expression in the 3D culture compared to stromal cells grown within the fibrin-agarose gel matrix. On the other hand, the relative gene expressions of E-cadherin and IL-1β in epithelial cells of the 3D culture under decidualization conditions significantly differed from those in epithelial cells grown over the fibrin-agarose gel matrix without stromal cells, pointing to regulation of epithelial cells by the stroma. The attachment rate of Jar spheroids to the 3D was significantly increased by E2 plus MPA treatment. Analyses of Z-stack confocal and stained optic microscopic images demonstrated that Jar spheroids breached the epithelial cell monolayer, invaded, and were embedded into the 3D matrix in response to decidualization signals. In summary, the newly bioengineered system provides a unique model for studying interactions between the different endometrial cell compartments, via soluble-paracrine signals as well as cell-to-cell interactions, and is a useful tool to study early embryonic implantation events.

Modulation of the expression of the transcription factors T-bet and GATA-3 in immortalized human endometrial stromal cells (HESCs) by sex steroid hormones and cAMP

T-bet and GATA-3 are known to regulate cytokine expression in T lymphocytes, and cytokines have been implicated in endometrial regulation and implantation. Previous work showed that female steroid hormones modulate the expression of T-bet in endometrial epithelial cells, suggesting a mechanism for local immune regulation in the human endometrium. We hypothesized that stromal cells are involved in immune regulation, as they have been shown to exert paracrine effects on other endometrial cells and compartments and also secrete cytokines. The objective of this study was to examine the modulation of the gene expression of T-bet and GATA-3, and of the cytokines interferon γ (IFN-γ) and interleukin 4 (IL-4), by female steroid hormones, in human endometrial stromal cells (HESC) in long-term cultures (30 days) mimicking the normal menstrual cycle. T-bet and GATA-3 messenger RNA (mRNA) expression was detected by real-time polymerase chain reaction, and intracellular protein production was demonstrated by immunoblotting. In addition, secretion of IL-4 and IL-15 was measured by enzyme-linked immunosorbent assay. T-bet and IL-4 mRNA expression increased and GATA-3 decreased under decidualization conditions; IFN-γ was not detected. Secretion of IL-15 increased during decidualization, and IL-15 upregulated T-bet gene expression. In conclusion, gene expression of T-bet and GATA-3 by endometrial stromal cells is under hormonal conditions mimicking decidualization, and the results are consistent with an autocrine regulatory mechanism of IL-15 secretion and T-bet expression.

Does the degree of hypothalamic-pituitary-ovarian recovery after oral contraceptive pills affect outcomes of IVF/ICSI cycles receiving GnRH-antagonist adjuvant therapy in women over 35 years of age?

PURPOSE

To evaluate if the degree of recovery of serum gonadotropins after oral contraceptive pills (OCP) pretreatment has an impact on ovarian response in GnRH-antagonist IVF cycles in women of advanced maternal age.

METHODS

In this retrospective cohort study, we included 98 women 35-42 years undergoing their first IVF cycle receiving gonadotropins and a fixed GnRH-antagonist adjuvant protocol. Data analysis was carried out according to changes in serum FSH, LH and estradiol (E(2)) levels (basal and post-OCP) divided in quartiles, and also according to absolute levels. The main outcomes were peak serum E(2), number of mature oocytes retrieved, length of stimulation, and amount of gonadotropins used.

RESULTS

By quartile analysis, patients with the highest levels of serum gonadotropins suppression and also patients with gonadotropin rebound needed larger amounts of LH during the treatment. On the other hand, women with absolute suppression of FSH/LH had increased length of stimulation.

CONCLUSIONS

The results of this study provide data that assist in clinical management. Gonadotropin serum levels after OCP treatment provide information for optimization of supplementation with LH in GnRH-antagonist cycles in women over age 35.

A study of the cost, accuracy, and benefits of 3-dimensional sonography compared with hysterosalpingography in women with uterine abnormalities

OBJECTIVES

We conducted a prospective blinded study to evaluate the costs, accuracy, risks, and benefits of 3-dimensional (3D) transvaginal sonography compared to hysterosalpingography.

METHODS

A total of 101 women aged 26 to 44 years with evidence of uterine anomalies were enrolled. All participants had routine hysterosalpingography as part of their infertility evaluation as well as 3D transvaginal sonography as part of the study. Surgical findings were used as the standard for final diagnosis.

RESULTS

A total of 6 normal uteri and 119 uterine anomalies were classified: 30 congenital uterine anomalies (3 arcuate, 1 unicornuate, 4 bicornuate, 2 didelphys, and 20 septate uteri) and 89 acquired anomalies (38 polyps, 30 fibroids, 17 synechiae, and 4 adenomyosis). Congenital anomalies were correctly identified in 30 of 30 cases by 3D sonography but from 10 to 30 of 30 cases by hysterosalpingography. The detection rates for acquired uterine anomalies were lower for both techniques: 44 to 89 of 89 cases for 3D sonography and 22 to 74 of 89 cases for hysterosalpingography. Only 7 of the 20 septi would have been surgically corrected if patients only had hysterosalpingography. On the contrary, 30 of 30 patients with congenital uterine anomalies, 2 of 4 patients with adenomyosis, and all 6 patients with normal uteri were spared from surgery with diagnoses by 3D sonography. No adverse effects were reported after sonography, and only 6 minor ones were reported after hysterosalpingography.

CONCLUSIONS

Three-dimensional transvaginal sonography provides visualization and evaluation of the uterine cavity with similar or better accuracy than standard hysterosalpingography in the office setting, with lower cost and morbidity.

Semen analysis and sperm function testing

Despite controversy regarding the clinical value of semen analysis, male fertility investigation still relies on a standardized analysis of the semen parameters. This is especially true for infertility clinics in both developing and developed countries. Other optional tests or sophisticated technologies have not been widely applied. The current review addresses important changes in the analysis of semen as described in the new World Health Organization (WHO) manual for semen analysis. The most important change in the manual is the use of evidence-based publications as references to determine cutoff values for normality. Apart from the above mentioned changes, the initial evaluation and handling methods remain, in most instances, the same as in previous editions. Furthermore, the review evaluates the importance of quality control in andrology with emphasis on the evaluation of sperm morphology. WHO sperm morphology training programmes for Sub-Saharan countries were initiated at Tygerberg Hospital in 1995. The external quality control programme has ensured that the majority of participants have maintained their morphological reading skills acquired during initial training. This review reports on current sperm functional tests, such as the induced acrosome reaction, and sperm-zona pellucida binding assays, as well as the impact of sperm quality in terms of DNA integrity, and the relationship of sperm function tests to sperm morphology.

A novel model of human implantation: 3D endometrium-like culture system to study attachment of human trophoblast (Jar) cell spheroids

There is an urgent need to develop optimized experimental models to examine human implantation. These studies aimed to (i) establish a human endometrium-like three-dimensional (3D) culture system, and (ii) examine the attachment of trophoblast-like Jar spheroids to the culture. In the present work, 3D endometrial cultures were constructed with fibrin-agarose as matrix scaffold, and using epithelial and stromal cells from both human primary cultures and established cell lines. An attachment assay between trophoblast cells and the 3D culture was developed. Epithelial cells (cytokeratin(+)) concentrated on top of the matrix forming a monolayer, and stromal cells (vimentin(+)) resided within the matrix, resembling the normal endometrial structure. The capability of primary epithelial cells to form glands spontaneously was observed. Human trophoblast cells (Jar cells) were hCG(+) by immunostaining, allowed to form spheroids, and confirmed to secrete hCG into the medium. Time-dependent experiments demonstrated a high rate of attachment of Jar spheroids to the epithelium, and adhesion was strongly related to the various cell types present in the 3D culture. An architecturally and functionally competent 3D endometrial culture system was established, that coupled with Jar spheroids mimicking trophoblast cells, provides a unique in vitro model for the study of certain aspects of human implantation.

Timing of oocyte retrieval and embryo transfer with pregnancy duration

BACKGROUND

Recent studies have suggested that assisted reproductive technology (ART) may be associated with a shorter pregnancy duration, possibly due to various aspects of the ART procedure. The purpose of this study was to examine whether pregnancy duration is affected by timing of oocyte retrieval and embryo transfer with respect to the first day of the last menstrual period (LMP) among pregnancies achieved through in vitro fertilization with or without intracytoplasmic sperm injection.

METHODS

A retrospective study was conducted at an academic center in Norfolk, Virginia, with analyses based on 294 ART cycles.

RESULTS

Median and interquartile range for pregnancy duration was estimated at 38.2 ± 3.4 weeks. Similarly, median and interquartile ranges for days between LMP and day of oocyte retrieval (27.0 ± 2.0) and between LMP and embryo transfer (29.8 ± 2.2) differed significantly from the standard of 14 days. Timing of oocyte retrieval and embryo transfer with respect to LMP were accelerated among multiple compared with single gestations. For single gestations, pregnancy duration was positively associated with time duration between LMP and embryo transfer (β=0.14, p=0.036). The number of days between oocyte retrieval and embryo transfer was marginally associated with a shorter pregnancy duration in women with multiple gestations (β=3.70, p=0.083). Controlling for patient characteristics, timing of oocyte retrieval and embryo transfer were not significantly associated with pregnancy duration.

CONCLUSIONS

With few exceptions, timing of oocyte retrieval or embryo transfer did not affect pregnancy duration among ART-conceived live births.

Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles

Ovulation induction (OI) or ovulation enhancement (OE) with gonadotrophins can be a reasonable treatment option for patients with a variety of infertility diagnoses. It must be used with extensive monitoring and management given the risk of multiple pregnancy,especially high-order multiples. This retrospective study evaluated per cycle outcomes of a large cohort of 1452 gonadotrophin OI/OE cycles at an academic infertility centre, and the efficacy of specific guidelines in limiting multiple pregnancy. The lowest possible gonadotrophin doses were used and cycle cancellation was recommended if more than three dominant follicles were present, and/or ifserum oestradiol was above 1500 pg/ml. Overall, pregnancy rate (PR) was 12% and live birth rate was 7.7%, with an increasing trend in younger patients (P = 0.0002 and <0.0001, respectively). Multiple clinical PR was 2.6% with 1.9% twins and 0.7% triplets and above.The birthweight of a singleton from a vanishing twin pregnancy (n = 8)was significantly lower than other singletons (2882 g versus 3250 g,P = 0.013). Reducing multiple pregnancies from OI/OE cycles remains an important and challenging goal. In this large cohort, high-order multiple clinical PR was limited to 0.7% per cycle by using specific management strategies while maintaining a reasonable PR.

Clinical management of male infertility in assisted reproduction: ICSI and beyond

The advent of in vitro fertilization and its augmentation with intracytoplasmic sperm injection (ICSI) has allowed a large number of couples suffering from moderate to severe male infertility, and also presenting with female pathologies, to achieve their reproductive dreams. Notwithstanding the existence of fundamental questions about the pathophysiological mechanisms leading to sperm dysfunction, and still unanswered concerns about health risks following ICSI, it appears that overall ICSI is safe and here to stay. Although on one hand ICSI possibly hampered advances of the knowledge in some areas of gamete biology and interaction, on the other it definitely gave impulse to studies designed to unveil the sperm contributions during and beyond fertilization, including the normalcy of the DNA/chromatin as well as molecular mechanisms of genetic/epigenetic control and nuclear organization status. In all, almost entering the fourth decade of assisted reproductive technologies, we should continue monitoring the safety of the technique and long-term development of offspring, whereas at the same time prioritizing areas of research addressing these fundamental questions.

Ovulation induction in IVF

This review examined current controlled ovarian hyperstimulation (COH) protocols used in ART. Controversies still exist regarding selection of gonadotropin preparation (i.e., recombinant versus urinary forms, pure FSH versus FSH-LH containing preparations), choice of adjuvant therapy with GnRH analogues (agonists versus antagonists), and pretreatment with oral contraceptive pills. Patients prospectively identified as intermediate responders have excellent outcomes with adjuvant therapy with either a GnRH agonist (long protocol) or a GnRH antagonist, but tailoring of gonadotropin dose and type must be performed to achieve optimized results. High responders perform satisfactorily with gentler gonadotropin stimulation regimens that minimize the occurrence of ovarian hyperstimulation syndrome. On the other hand, results in low/poor responders remain sub optimal both in terms of ovarian response and oocyte/embryo quality in spite of a variety of stimulation approaches and adjuvant therapies implemented. It is concluded that ovarian stimulation is a critical step in IVF therapy. There are a variety of available and efficacious novel COH regimens but individualization of management is essential and dependent upon proper and prospective assessment of the ovarian reserve. The identification of the pathogeneses underlying poor ovarian response constitutes a formidable challenge facing reproductive endocrinologists.