Pregnancy in a patient with a displaced levonorgestrel-releasing intrauterine system: a case report

We report the case of a 39-year-old woman who became pregnant despite a levonorgestrel-releasing intrauterine system (LNG-IUS), which was inserted 40 months before the pregnancy was detected. When a Caesarean section was performed, the LNG-IUS was found within the omentum majus. It has been reported, that displaced LNG-IUS can cause amenorrhea and high plasma levels of LNG in affected women, probably due to the higher resorptive capacity of the peritoneum, recommending a removal of the displaced LNG-IUS. Our case report demonstrates that a dislocated LNG-IUS does not necessary has the ability to suppress ovulation and therefore pregnancy. Therefore, every gynaecologist should be aware of a pregnancy despite a dislocated LNG-IUS.

Effects of the common 677C>T mutation of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene on ovarian responsiveness to recombinant follicle-stimulating hormone

PROBLEM

The common 677C>T mutation of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene is less prevalent in mothers of spontaneously conceived dichorionic twins than in those with singleton pregnancies. (Hasbargen U, Lohse P, Thaler CJ: Hum Reprod 2000; 15:2659-2662). As polyovulation is a pre-requisite for dichorionic pregnancies, we investigated whether the T allele is associated with reduced ovarian responsiveness to follicle-stimulating hormone (FSH).

MATERIALS AND METHODS

We studied 105 infertility patients undergoing a total of 269 A.R.T cycles stimulated with recombinant (r)-FSH. The MTHFR 677C>T genotype was analyzed by digestion of polymerase chain reaction-amplified DNA fragments.

RESULTS

Homozygous 677C patients older than 35, required significantly (P <0.02) less r-FSH and produced significantly more oocytes (P < 0.04) and higher maximal serum estradiol concentrations (P < 0.002) than heterozygous or homozygous carriers of the 677T allele.

CONCLUSION

Our results suggest that, in patients of advanced reproductive age, the MTHFR 677C>T mutation affects ovarian responsiveness.

Seminal plasma induces mRNA expression of IL-1beta, IL-6 and LIF in endometrial epithelial cells in vitro

The influence of seminal plasma on the mRNA expression of cytokines in human endometrial epithelial and stromal cells and the cytokine production of spermatozoa were investigated in vitro. Seminal plasma and spermatozoa were collected from healthy volunteers and were screened by enzyme-linked immunosorbent assay for cytokines. Epithelial and stromal cells from fertile women were cultured on matrigel or polystyrol and incubated with pooled seminal plasma or with transforming growth factor beta1 (TGF-beta1), interleukin 8 (IL-8) and vascular endothelial growth factor (VEGF), which were found to be significantly concentrated in seminal plasma. Endometrial cytokine expression was analysed by RNase protection assay and supported by RT-PCR. Supernatants of highly purified spermatozoa did not contain detectable levels of IL-1beta, IL-6 and VEGF. Screening of seminal plasma revealed concentrations >10-fold above the serum level for TGF-beta1, IL-8 and VEGF. Incubation of epithelial cells with 0.1, 1 and 10% seminal plasma resulted in concentration-dependant stimulation of IL-1beta, IL-6 and LIF mRNA expression. Maximum stimulation was found in epithelial cells from tissue samples taken in the mid secretory phase. Epithelial mRNA expression of IL-1beta, IL-6 and LIF increased by stimulation with TGF-beta1 and IL-8, but not with VEGF. In conclusion, seminal plasma stimulates expression of pro-inflammatory cytokines in endometrial epithelial cells in vitro. This effect might at least in part be exerted by TGF-beta1 and IL-8, abundantly present in seminal plasma. The in-vivo physiological relevance of these in-vitro studies remains to be determined.

Vasoconstrictively acting AT1R A1166C and NOS3 4/5 polymorphisms in recurrent spontaneous abortions (RSA)

PROBLEM

Inadequate uteroplacental perfusion is one of the main reasons for recurrent spontaneous abortions (RSA). Coagulation, fibrinolysis, and vasoconstriction affect tissue perfusion. These systems are regulated by different gene products. Polymorphisms can modulate the expression levels of the respective genes and can thereby affect perfusion. Vasoconstriction is influenced by the expression of endothelial nitric oxide synthase (eNOS) and of the angiotensinogen II type 1 receptor (AT1R).

METHOD

The aim of our study was to investigate, whether two polymorphisms in the AT1R and NOS3 genes shown to result in maternal vasoconstriction are associated with an increased risk for RSA.

RESULTS

Our data indicate that the vasoconstrictively acting genotypes AT1R C/C and NOS3 4/4 are of similar prevalence in RSA patients and in controls.

CONCLUSION

Results do not show any influence of the polymorphisms studied on early pregnancy development. This is in concordance with the concept of an independent regulation of placental perfusion.

Polymorphisms in the ACE and PAI-1 genes are associated with recurrent spontaneous miscarriages

BACKGROUND

Successful pregnancies require fine tuning of fibrinolytic activities in order to secure fibrin polymerization and stabilization of the placental basal plate as well as to prevent excess fibrin deposition in placental vessels and intervillous spaces. Fibrinolysis is tightly regulated by plasminogen activator inhibitor-1 (PAI-1). Endothelial PAI-1 synthesis is induced by angiotensin II, which is generated by angiotensin I-converting enzyme (ACE).

METHODS

We studied the ACE deletion (D)/insertion (I) polymorphism and the PAI-1 4G/5G polymorphism in women with recurrent spontaneous miscarriages (RM). Both polymorphisms have been shown to be associated with ACE and PAI-1 expression levels respectively. A study group of 184 patients with a history of two or more consecutive unexplained spontaneous miscarriages was compared with a control group of 127 patients with uneventful term deliveries and no history of miscarriages.

RESULTS

Our findings show: (i) homozygosity for the D allele of the ACE gene, which results in elevated PAI-1 concentrations and hypofibrinolysis, is associated with an elevated risk of RM; (ii) the combination of the D/D genotype with two 4G alleles of the PAI-1 promoter, which further increases PAI-1 plasma levels, is significantly more frequent in RM patients compared with controls.

CONCLUSIONS

Based on these results, we recommend the incorporation of these two polymorphisms into the spectrum of thrombophilic mutations which should be analysed in individuals with recurrent spontaneous miscarriages. Patients homozygous for both the ACE D and PAI-1 4G alleles may benefit from the application of low molecular weight heparin as early as possible in the pregnancy in order to prevent uteroplacental microthromboses.

Primary cervical cancer screening by self-sampling of human papillomavirus DNA in internal medicine outpatient clinics

BACKGROUND

We determined whether testing of self-collected vaginal swabs for human papillomavirus (HPV) DNA can be used to screen for cervical disease within internal medicine outpatient clinics.

PATIENTS AND METHODS

In this prospective study, 560 patients visiting two referral outpatient clinics for internal medicine were asked to take an HPV self-sample. Acceptability of self sampling, HPV prevalence and cervical intraepithelial neoplasia (CIN) detection rate were evaluated.

RESULTS

435 women (78%) performed HPV self-sampling; 1.5% considered self-sampling to be difficult. 134 women (31%) tested positive for high-risk type of HPV. There were significant differences between HPV-positive and -negative women with respect to the following: mean age (42 versus 46 years), number of women aged <16 years at first coitus (35% versus 23%) and history of drug abuse (8.3% versus 2.6%). Colposcopy could be performed for 70 HPV positive women: CIN 1-3 was identified in 24%. Two of 52 women with HPV-negative results undergoing colposcopy had biopsy-confirmed CIN 1. Test performance for detection of CIN 2-3 after correction for verification bias: sensitivity, 100%; specificity, 71%; negative predictive value, 100%; positive predictive value, 10%. HPV persistence was associated with a 5.7-fold risk of CIN 2-3 detection at follow-up.

CONCLUSIONS

Self-assessment for HPV DNA is an easy, feasible and well-accepted method for HPV testing and for cervical cancer screening in internal medicine outpatient clinics.

Inherited Thrombophilia: Impact on Human Reproduction

The development of thrombotic disorders is a major threat for young women during pregnancy. It is one of the main causes of pregnancy-related disorders, which may also result in harm for the conceptus. Successful pregnancies require an even balance of coagulation and fibrinolysis, in order to secure stabilization of the basal plate as well as adequate placental perfusion. Thrombophilia is a laboratory definition for pre-disposing factors of thrombosis, which can be inherited or acquired. Many individuals, who carry a thrombotic defect remain asymptomatic, at least until additional boosting factors arise. The documentation of thrombophilic causes of recurrent miscarriage or pregnancy-related disorders is important, because of availability of effective early treatment. There is a rapidly growing awareness on the relationship of genetic factors influencing hemostasis and pregnancy-related disorders. The aim of our review is to summarize this knowledge, focusing on common genetic variations.

Endometrial interleukin-6 in vitro is not regulated directly by female steroid hormones, but by pro-inflammatory cytokines and hypoxia

Endometrial interleukin-6 (IL-6) mRNA has been reported to be suppressed in the mid-secretory phase in patients with recurrent early spontaneous abortions. This prompted our study concerning the regulation of endometrial IL-6 in cell culture models of endometrial epithelial and stromal cells. Steroid-dependent secretion of IL-6 was analysed by 17beta-estradiol (10(-8) mol/l) or progesterone (10(-6) mol/l) treatment and withdrawal (n = 8). Regulation by pro-inflammatory cytokines was studied in co-cultures of endometrial cells with human blood peripheral mononuclear cells (PBMC; n = 5) and by stimulation with IL-1beta, IL-6 and tumour necrosis factor alpha (TNFalpha), secreted by PBMCs at high concentrations. Regulation by hypoxia was assessed by culture of endometrial cells in 2% oxygen for 6 and 24 h (n = 5). IL-6 mRNA and protein levels were analysed by RT-PCR and enzyme-linked immunosorbent assays respectively. Endometrial IL-6 was not directly affected by 17beta-estradiol and/or progesterone. Co-culturing endometrial cells with PBMCs led to an increase of stromal but not epithelial IL-6 mRNA levels. In stromal cells, IL-6 secretion increased 2-10-fold if stimulated with 10 ng/ml recombinant IL-1beta or TNFalpha (P < 0.05). Hypoxia stimulated IL-6 secretion in epithelial cells up to 2-fold and in stromal cells up to 48-fold (P < 0.05). In conclusion, IL-6 expression in stromal and epithelial cells in vitro is regulated differently by pro-inflammatory cytokines and hypoxia. These results suggest a tight and specific network of control for this important cytokine within different endometrial compartments.

Endometrial expression and secretion of interleukin-6 throughout the menstrual cycle

Previous findings revealing reduced endometrial interleukin-6 (IL-6) mRNA expression in patients with recurrent early abortions gave rise to the analysis of IL-6 synthesis in the human endometrium, and how it relates to concentrations in uterine secretions. Endometrial tissues and uterine secretions were collected from patients undergoing hysterectomy. Expression of IL-6 receptor and gp130 mRNA (n = 28) in total endometrium, of IL-6 mRNA in endometrial epithelial and stromal cells, and CD45-positive leukocytes were investigated by RNAase protection assay throughout the cycle. IL-6 protein was assessed in endometrial tissue by immunohistochemistry (n = 32) and in uterine secretions by enzyme-linked immunosorbent assay (ELISA) (n = 33). IL-6 mRNA was expressed at low levels in the proliferative phase, and expression increased progressively in the secretory phase. The increase was attributed to epithelial and stromal cells and leukocytes. Concentrations of IL-6 protein in endometrial glands and in uterine secretions were low in the proliferative phase, and increased 5-10-fold in the mid- to late secretory phase. mRNA expression of IL-6 receptor and gp130 remained constant in total endometrium throughout the menstrual cycle. High concentrations of IL-6 in the mid-secretory phase, the putative implantation window, and a further increase in the late secretory phase, the premenstrual period, support a role of IL-6 in the regulation of endometrial functions.

A repertoire of cytokines in human seminal plasma

The pathophysiological significance of seminal cytokines in sperm function is still controversial. We determined the repertoire of cytokines in seminal plasma obtained from men with or without abnormalities in semen and assessed the pathophysiological significance of seminal cytokines. After conventional analysis of semen samples obtained from 86 men, levels of seminal cytokines (interleukin [IL]-1alpha, IL-2, IL-4, IL-6, IL-8, tumor necrosis factor-alpha [TNF-alpha], interferon-gamma, granulocyte colony-stimulating factor [G-CSF], macrophage CFS [M-CSF]) and granulocyte elastase were measured by an enzyme-linked immunosorbent assay. Leukocytospermia was defined as seminal plasma, which has > or =1000 ng/ml granulocyte elastase. Leukocytospermia was found in nine of 62 of the subjects in the normozoospermic group but in none of the 24 subjects showing abnormal sperm parameters (azoospermia, n=5; oligozoospermia, n=4; asthenozoospermia, n=15). The IL-8 level in the leukocytospermic group was significantly higher than those in the normal and oligozoospermic groups. IL-1alpha and TNF-alpha levels in the leukocytospermic group were significantly higher than those in the normal and asthenozoospermic groups. Although the G-CSF level in the leukocytospermic group was significantly higher than that in the normal group, high levels of M-CSF were detected in all groups. The IL-8 level was strongly correlated with IL-1alpha (r=0.935, P<0.0001) and G-CSF (r=0.916, P<0.0001) levels. Cytokines detected in seminal plasma are associated with the pathogenesis of leukocytospermia but not with the pathogenesis of asthenozoospermia and oligozoospermia.

Endometrial osteopontin, a ligand of beta3-integrin, is maximally expressed around the time of the "implantation window"

OBJECTIVE

To analyze endometrial mRNA and protein expression of osteopontin and its receptor, beta3-integrin, throughout the menstrual cycle.

DESIGN

Study by immunohistochemistry, RNase protection assay, and ELISA.

SETTING

Academic research unit.

PATIENT(S)

Forty-five regularly cycling women without endometrial pathology.

INTERVENTION(S)

Expression of endometrial osteopontin and beta3-integrin mRNA was analyzed by RNase protection assay in endometrium, endometrial epithelial cells, stromal cells, and endometrial leukocytes (CD45) and by immunohistochemistry in frozen sections of endometrium throughout the menstrual cycle. Concentration of osteopontin was studied in uterine secretions by ELISA.

MAIN OUTCOME MEASURE(S)

mRNA and protein expression of osteopontin and beta3-integrin.

RESULT(S)

Osteopontin mRNA and protein was weakly expressed in the proliferative phase and maximally expressed in the mid to late secretory phases in endometrium, endometrial epithelial cells, and endometrial leukocytes and in uterine secretions. Beta3-integrin mRNA and protein were expressed in stromal cells throughout the menstrual cycle and were maximally expressed in epithelial cells in the mid to late secretory phases.

CONCLUSION(S)

Expression of osteopontin and its receptor, beta3-integrin, in human endometrial glands and osteopontin secretion into the uterine cavity around the time of the "implantation window" suggest a role for these proteins in endometrial function and implantation.

Thrombophilic gene mutations and recurrent spontaneous abortion: prothrombin mutation increases the risk in the first trimester

PROBLEM

Thrombophilic predisposition may be one of the underlying causes of recurrent spontaneous abortions (RSA). We studied the prevalence of five thrombophilic gene mutations in patients with RSA.

METHOD OF STUDY

102 patients with two or more consecutive abortions and 128 women without miscarriage were analyzed for factor V Leiden mutation (FVL), prothrombin G20210A mutation (PTM), C677T mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, glycoprotein IIIa (GPIIIa) C1565T polymorphism, and beta-fibrinogen G-455A polymorphism by polymerase chain reaction (PCR) techniques.

RESULTS

No differences in the prevalence of FVL, MTHFR T/T, GPIIIa and 1-fibrinogen polymorphism were detected. Heterozygous PTM occurred more often in patients with RSA. This effect was significant in a subgroup with abortions exclusively in the first trimester (6.7%, vs. 0.8%, P = 0.027, OR 8.5).

CONCLUSIONS

In contrast to the other mutations and polymorphisms, heterozygous PTM is more common in patients with abortions in the first trimester. This might reflect an influence of PTM on pathogenesis of early pregnancy loss.

S680N substitution of the follicle-stimulating hormone receptor is a common polymorphism not associated with spontaneous human twinning

OBJECTIVE

To determine the influence of the A307/S680 and T307/N680 isoforms of the follicle-stimulating hormone receptor (FSHR) gene on the incidence of spontaneous human twinning.

DESIGN

Case-control study.

SETTING

Departments of Obstetrics and Gynecology and of Clinical Chemistry-Grosshadern, University Hospital Munich, Germany.

PATIENT(S)

Fifty-four mothers with dichorionic twin pregnancies and 92 singleton mothers as controls, who had conceived without assisted reproduction.

INTERVENTION(S)

Exon 10 of the FSHR gene was screened for the G2105A/S680N mutation.

MAIN OUTCOME MEASURE(S)

Amplification of genomic DNA by the polymerase chain reaction followed by restriction fragment length polymorphism analysis.

RESULT(S)

Allele frequencies for the G2105A/ S680N substitution of the FSHR in twin mothers were not different from those of controls (genotype (isoform) [twins vs. controls]: G/G (S/S) [24.1% vs. 22.3%]; A/G (N/S) [57.4% vs. 55.4%]; A/A (N/N) [18.5% vs. 22.3%]). Subgroup analysis of women with three or more successful pregnancies gave a similar result (G/G (S/S) [17.7% vs. 13.7%]; A/G (N/S) [64.7% vs. 63.6%]; A/A (N/N) [17.6% vs. 22.7%]). There was no correlation between FSHR isoform and twinning.

CONCLUSION(S)

The S680N substitution of the follicle-stimulating hormone receptor is a common polymorphism not associated with spontaneous human twinning.

Concentration of granulocyte elastase in seminal plasma is not associated with sperm motility

Although elastase could affect sperm motility in vitro, secretory leukocytes protease inhibitor (SLPI) prevents sperm from being attacked by elastase. The authors investigated the correlations of elastase level with sperm motility and SLPI level in vivo. Semen samples (n = 116) were collected and centrifuged after semen analysis. Elastase and SLPI levels were determined by an enzyme immunosorbent assay. Samples were classified by elastase levels into low (<250 ng/mL), moderate (250-1,000 ng/mL), and high elastase groups (> or =1,000 ng/mL). Elastase levels (range, 2.8-23,974.4 ng/mL) were not associated with sperm motility. The median SLPI level in the high elastase group was 15,900 ng/mL (range, 2.860-46,900 ng/mL). However, there was no significant correlation between elastase and SLPI levels in seminal plasma. Since SLPI forms a 1:1 complex with elastase, these results suggest that seminal plasma has a sufficient amount of SLPI to protect spermatozoa from elastase.

Decreased suppression of antibody-dependent cellular cytotoxicity by seminal plasma in unexplained infertility

OBJECTIVE

To determine whether seminal plasma (SP) from unexplained infertile males has different suppressive activity on antibody-dependent cellular cytotoxicity (ADCC) than SP from fertile males or SP from males of couples with known infertility factor.

DESIGN

Comparative clinical/experimental study.

SETTING

In vitro fertilization program in a university hospital and a hospital research laboratory.

PATIENT(S)

A total of 245 SP samples from 174 infertile and 16 fertile couples were compared.

INTERVENTION(S)

SP suppression of ADCC was measured by using human 51chromium-labeled red blood cells (RBC), sensitized with IgG-rabbit-anti-human-RBC as targets and peripheral blood lymphocytes as effector cells.

MAIN OUTCOME MEASURE(S)

Suppressive activity of each sample was determined by calculating 51Cr-release in the presence and absence of SP.

RESULT(S)

When analyzed with respect to sperm number, motility, and morphology, suppressive activities of samples with normal semen analyses (n = 142) were significantly higher (x = 37% +/- 14%) than suppressive activities of abnormal samples (n = 103; x = 32% +/- 13%). There was no strong correlation of suppressive activity to other semen parameters. Within the andrologically normal males, SP from the unexplained infertile couples (n = 15) showed significantly lower suppressive activity (x = 24% +/- 11%) compared with the SP from fertile males (n = 16; x = 35% +/- 13%) and from couples with female infertility factor (n = 65; x = 39% +/- 14%).

CONCLUSION(S)

Loss of suppressive activity is associated with unexplained infertility, even in male patients who previously were considered normal by traditional methods of semen analysis.

The number of dichorionic twin pregnancies is reduced by the common MTHFR 677C-->T mutation

In multiple pregnancies, demands for folic acid are considerably increased. The most common inborn error of folate metabolism is mild methylenetetrahydrofolate reductase (MTHFR) deficiency due to the synthesis of a thermolabile variant of the enzyme with impaired catalytic activity which leads to reduced 5-methyltetrahydrofolate (5-methyl-THF) and mildly elevated homocysteine plasma concentrations when folate status is inadequate. To investigate whether the number of offspring is influenced by this mutation, we determined the frequency of the 677C-->T substitution in 156 singleton and 40 twin mothers with dichorionic placentation. The T allele frequency in singleton (0.30) and twin mothers (0.16) was significantly different (P = 0.011). Mothers with the 677C-->T mutation had a 2.28 times lower risk of having a twin pregnancy than those without (95% confidence interval = 1.18-4.66; P = 0.008). Our observation would explain, at least in part, the hereditary trait of multiple gestations and is in agreement with the ethnic distribution pattern of the T allele which has been found to be inversely correlated with the incidence of dichorionic twins. Our findings suggest that the MTHFR 677C-->T mutation interferes with human brood size, probably by influencing the proliferation of rapidly dividing embryonic and maternal cells.