The classification, functions and clinical use of different isoforms of HCG

HCG is composed of two subunits, HCGalpha and HCGbeta. During early pregnancy, HCG stimulates progesterone production in the corpus luteum, and injection of HCG is widely used to induce ovulation in assisted reproduction treatment (ART). Under experimental conditions, the free subunits have been shown to exert functions other than those of HCG, but the relevance of these remains to be determined. Intact HCG, free subunits and degraded forms of these occur in biological fluids, and determinations of these are important for diagnosis and monitoring of pregnancy, pregnancy-related disorders and several types of cancer. Development of optimal methods for the various forms has been hampered by lack of appropriate standards and expression of the concentrations of the various forms in units that are not comparable. Furthermore, the nomenclature for HCG assays is confusing and in some cases misleading. These problems can now be solved; a uniform nomenclature has been established, and new standards are available for HCG, its subunits HCGalpha and HCGbeta, the partially degraded or nicked forms of HCG and HCGbeta, and the beta-core fragment. This review describes the biochemical and biological background for the clinical use of determinations of various forms of HCG. The clinical use of HCG and studies on HCG vaccines are briefly reviewed.

Fatty acid esterification of lipoprotein-associated estrone in human plasma and follicular fluid

Estrogen fatty acid esters constitute a unique family of extremely hydrophobic hormonal derivatives which are exclusively transported in lipoprotein particles in plasma. In estradiol, the fatty acyl residues are conjugated at the 17beta-hydroxyl of the steroid D-ring, leaving the phenolic 3-hydroxyl group unsubstituted and, therefore, preserving antioxidative efficacy. The 17beta-fatty acid derivative of estradiol is proposedly an even more efficient antioxidant protecting LDL and HDL than the parent steroid. Previous studies have established that the enzyme lecithin:cholesterol acyltransferase which catalyzes the fatty acid esterification of 3beta-hydroxyl group of cholesterol, also catalyzes the formation of estrogen 17beta-esters. Estrone, the principal estrogen in the postmenopausal female, has a keto group at carbon-17 and has been thought unable to form fatty acid esters. However, we detected hydrophobic derivatives of estrone following incubations with human plasma and ovarian follicular fluid. These derivatives accumulated in HDL and LDL during incubation showing chemical characteristics similar to estrone-3-fatty acid esters. Liquid chromatographic-mass spectrometric analyses established the presence of unhydrolyzed estrone esters consisting of different fatty acid species, the major one being estrone-3-linoleate, in human HDL particles following incubation of estrone with plasma. These extremely hydrophobic estrone conjugates could, in theory, represent a storage form of this estrogen.

Fear of Childbirth and Pregnancy-Related Anxiety in Women Conceiving With Assisted Reproduction

OBJECTIVE

To compare the prevalence and predictors of severe fear of childbirth and pregnancy-related anxiety in groups of assisted reproduction treatment (ART) and spontaneously conceiving women with singleton pregnancies.

METHODS

The ART group (n = 367, nulliparous 260) represented a cohort from five Finnish infertility clinics in 1999. The control group (n = 379, nulliparous 135) was enrolled in this study by consecutive sampling the same year. Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire and pregnancy-related anxiety by means of the Pregnancy Anxiety Scale at gestational week 20 +/- 3.2 (mean+/-standard deviation).

RESULTS

The frequency of severe fear of childbirth and anxiety (classified as total scores in the 90th percentile or higher in the revised Fear of Childbirth Questionnaire and Pregnancy Anxiety Scale) did not differ between the groups. Nulliparity was associated with more frequent severe anxiety only in the controls. In nulliparous participants, a partnership of more than 5 years decreased the risk of severe fear of childbirth (odds ratio 0.3, 95% confidence interval 0.2-0.7). In the nulliparous ART group, a long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (odds ratio 4.4, 95% confidence interval 1.2-16.9).

CONCLUSION

Women conceiving after ART do not experience severe fear of childbirth or pregnancy-related axiety more often than spontaneously conceiving controls. However, a long duration of infertility is an independent risk factor regarding severe fear of childbirth.

LEVEL OF EVIDENCE

II-2.

Elective single embryo transfer in women aged 36–39 years

BACKGROUND

The elective single embryo transfer policy is the only effective strategy known to minimize the risk of multiple pregnancy. However, little is known about its applicability to women older than 35 years.

METHODS

Analysis was carried out on 1224 fresh IVF/ICSI cycles with embryo transfer and 828 frozen embryo transfer (FET) cycles of women aged 36-39 years. In the fresh cycles, 335 elective single top quality embryo (eSET), 110 elective single non top quality embryo (nt-eSET), 194 compulsory single embryo (cSET) and 585 double embryo transfers (DET) were carried out.

RESULTS

Pregnancy rate/embryo transfer (33.1 versus 29.9%) and live birth rate (26.0 versus 21.9%) in fresh cycles did not differ significantly between the eSET and the DET groups. However, women in the eSET group had a higher cumulative pregnancy rate (54.0% versus 35.0%) and a higher cumulative live birth rate (41.8% versus 26.7%, P < 0.0001) compared with those in the DET group. The cumulative multiple birth rate in the eSET group was 1.7%, whereas in the DET group it was 16.6% (P < 0.0001).

CONCLUSIONS

The eSET policy can be applied also to patients aged 36-39 years, reducing the risk of multiple birth and increasing the safety of assisted reproduction technique (ART) in this age group.

Effects of alendronate and hormone replacement therapy, alone and in combination, on saliva, periodontal conditions and gingival crevicular fluid matrix metalloproteinase-8 levels in women with osteoporosis

OBJECTIVE

To compare the effects of hormone replacement therapy (HRT), alendronate and their combination on oral health of elderly postmenopausal women with osteoporosis.

MATERIALS AND METHODS

Sixty patients, aged 65-80 years (mean 71 years), with a T-score of bone mineral density of -2.5 s.d. or less at either the lumbar spine or the femoral neck, were randomized to receive 2 mg of estradiol plus 1 mg norethisterone acetate (HRT) (n = 20), 10 mg of alendronate (n = 18), or their combination (n = 22) for 2 years. Periodontal and oral status and mouth symptoms were recorded, and salivary analyses made at the beginning and at the end of the study. Gingival crevicular fluid (GCF) matrix metalloproteinase (MMP-8) levels were determined to address destructive events in periodontal tissue.

RESULTS

Resting salivary flow rate decreased by 19% (P < 0.05), and GCF MMP-8 tended to increase in the alendronate group. None of the regimens affected subjective feelings of dry or burning mouth. There were no significant changes in dental or periodontal status, stimulated flow rate or composition of saliva during the study.

CONCLUSIONS

Alendronate decreased resting salivary flow rate but otherwise HRT or alendronate separately or in combination had no effect on oral health in elderly women with osteoporosis.

IL-10 polymorphism and cell-mediated immune response to Chlamydia trachomatis

Chlamydia trachomatis infection induces an inflammatory response that is crucial in resolving acute infection but may also play a key role in the pathogenesis of C trachomatis associated infertility. The immune response is linked to cytokine secretion pattern which is influenced by the host genetic background. To study a relationship between interleukin-10 (IL-10) promoter -1082 polymorphism and cell-mediated immune response during C trachomatis infection in vitro, lymphocyte proliferation and cytokine (IL-10, IFN-gamma, TNF-alpha, IL-2, IL-4 and IL-5) secretion were analysed in subjects with different IL-10 genotypes. Enhanced IL-10 secretion and reduced antigen-specific lymphocyte proliferative and IFN-gamma responses were found in subjects with IL-10 -1082 GG genotype when compared to those with -1082 AA genotype. CD14+ monocytes were main source of IL-10 indicating that these cells are important regulators of the antigen-specific cell-mediated responses during active C trachomatis infection. We conclude that impaired cell-mediated response to C trachomatis is associated with IL-10 genotype in subjects with high IL-10 producing capacity. A comparison of immune markers between subjects with a history of noncomplicated and complicated infection is needed to further understand the confounding factors associated with the development of C trachomatis associated sequelae.

Chlamydia trachomatis and chlamydial heat shock protein 60-specific antibody and cell-mediated responses predict tubal factor infertility

BACKGROUND

To evaluate the role of Chlamydia trachomatis-induced humoral and cell-mediated immune (CMI) responses in predicting tubal factor infertility (TFI).

METHODS

Blood samples were taken from 88 women with TFI and 163 control women. C. trachomatis and chlamydial heat shock protein 60 (CHSP60)-specific immunoglobulin G (IgG) antibodies were analysed using enzyme-linked immunosorbent assay (ELISA) kits. Proliferative reactivity of peripheral blood mononuclear cells was studied in vitro against Chlamydia elementary body (EB) and recombinant CHSP60 antigens.

RESULTS

C. trachomatis-specific IgG antibodies were found more frequently (43.2 versus 13.5%), and the antibody levels were higher in the TFI cases than in the controls (P < 0.001). C. trachomatis EB-induced lymphocyte responses were positive in 81.8% of the TFI cases and 58.9% of the controls (P < 0.001). Similarly, CHSP60-induced lymphocyte responses were found in 45.5% of the TFI cases and 30.7% of the controls (P < 0.001). CHSP60 antibody test was the best single test predicting TFI. Compared to cases with all four markers negative, the estimated risk for TFI was 4.1 (95% CI 1.4-11.9) among those with one positive marker and 19.9 (95% CI 6.9-57.4) among those with three to four positive markers.

CONCLUSION

Our results show that TFI prediction model can be improved by combining tests for humoral and CMI response to chlamydial antigens.

Maternal mental health and medical predictors of infant developmental and health problems from pregnancy to one year: does former infertility matter?

BACKGROUND

Transition to parenthood involves considerable psychological, social and physiological changes. We examined how prenatal and perinatal mental health and medical conditions predict infant's developmental and health status at 12 months, and whether former infertility and assisted reproduction treatment (ART) affect the predictor model.

METHODS

The participants were 520 mothers who filled in questionnaires at the second trimester of pregnancy (T1), and when the child was 2 months (T2) and 12 months old (T3). Depressive and anxiety symptoms indicate reduced levels of mental health, and medical factors involve problems in pregnancy (e.g., high blood pressure and bleeding) and birth complications (pain and loss of blood). Neonatal health refers to, e.g., birth-weight and neurological status. At 12 months mothers reported infants' verbal and motor development and general health status.

RESULTS

First, it was shown that generally maternal prenatal anxiety and medical problems in pregnancy together predicted infant's developmental problems at 12 months through poor neonatal health, and medical problems alone also through increased level of birth complications. Second, the predictor models differed according to the history of infertility. In the ART group prenatal depression and anxiety and medical problems together predicted infant's developmental problems through maternal post-partum depression, and medical problems also through birth complications, whereas in the spontaneous conception group psychological and medical paths were separated and did not carry on developmental and health problems into 12 months.

CONCLUSIONS

Maternal health care should consider both psychological and medical risk paths across the whole transition to parenthood, and be aware of specific mediating paths in the risk groups.

Impact of infertility characteristics and treatment modalities on singleton pregnancies after assisted reproduction

Obstetric and neonatal outcomes of assisted reproduction and control singletons were evaluated after taking into account treatment characteristics and infertility background. The elective single embryo transfer (eSET) group (n = 45) was compared with the compulsory single embryo transfer (cSET; n = 52), double embryo transfer (DET; n = 227) and control (n = 304) groups. Infertility-related prognostic factors for neonatal outcomes were also analysed. Data were collected with structured questionnaires at gestational week 20 and 8 weeks after delivery. Spontaneous onset of delivery was more typical of the eSET group than of cSET and DET groups (68.9 versus 52.0%, P = 0.02). Mean (+/-SD) gestation at birth (39.3 +/- 1.6 weeks) and mean birth weight (3,470 +/- 505 g) of eSET singletons were comparable with other assisted reproduction groups, but gestational duration was lower than in the eSET group than in the control group (39.9 +/- 1.4; P < 0.05). However, numbers of preterm births and low birth weight infants were similar between groups. History of induced abortion increased risk of preterm birth (OR 4.5 and 95% CI 1.2-17.1) in assisted reproduction singletons. A small though clinically unimportant difference in gestational age at birth and birth weight between assisted reproduction and control singletons was found regardless of the number of embryos transferred.

Disruption of the SLC26A3-mediated anion transport is associated with male subfertility

Male subfertility in congenital chloride diarrhea (CLD) was possible after identification of expression of an epithelial Cl-/HCO3- exchanger SLC26A3 in the male reproductive tract and by the observation that adult men with CLD had very few children. A prospective clinical and laboratory study among eight adult Finnish men with CLD revealed constant oligoasthenoteratozoospermia but normal spermatogenesis, high chloride and low pH in seminal plasma, and three spermatoceles, suggesting that male subfertility is a clinical manifestation of CLD and could be caused by an analogous defect in the epithelial Cl-/HCO3- and water transport, as described for the CLD intestine.

Serum cholesterol efflux potential in postmenopausal women treated with isolated isoflavones

OBJECTIVE

Based on the low cardiovascular risk in Asian populations, phytoestrogens are believed to provide vascular benefits. To elucidate the mechanisms behind the possible cardiovascular effects of phytoestrogens, we evaluated reverse cholesterol transport by assessing the capacity of serum to promote cholesterol efflux in postmenopausal women treated with isolated isoflavones.

DESIGN

Thirty postmenopausal women were treated in a randomized, placebo-controlled, crossover trial with isoflavones or placebo for 3 months interrupted by a 2-month washout period. Serum samples were collected before and after each treatment period, and the cholesterol efflux potential was investigated by using H-cholesterol--labeled Fu5AH cells in culture.

RESULTS

Serum promoted 20.2% +/- 3.0% and 19.9% +/- 3.4% (mean +/- SD) cholesterol efflux after isoflavonoid treatment and after placebo treatment, respectively. Thus, the isoflavone treatment did not affect serum cholesterol efflux. We also studied separately women who produced high concentrations of the isoflavone metabolite equol into serum because some studies suggest that equol could exert favorable vascular effects. However, there was no difference in serum cholesterol efflux capacity between the equol producers (n = 15) and non-equol producers (n = 15).

CONCLUSIONS

In conclusion, isoflavone treatment did not affect serum cholesterol efflux potential in postmenopausal women. Based on our findings, isolated isoflavones do not provide vascular benefits by improving cholesterol efflux.

The impact of successful assisted reproduction treatment on female and male mental health during transition to parenthood: a prospective controlled study

BACKGROUND

The dynamics of mental health during the transition to parenthood have not been a focus of research. Our prospective longitudinal study was designed to reveal whether there are differences in mental health during the transition to parenthood between parents undergoing treatment with assisted reproduction techniques (ART) and those who conceive spontaneously.

METHODS

STUDY GROUP

367 couples with a singleton ART pregnancy using their own gametes.

CONTROL GROUP

379 couples with a spontaneous singleton pregnancy. Men and women separately filled in questionnaires including the General Health Questionnaire: at the 18th-20th week of pregnancy, 2 months postpartum and 1 year postpartum (T3). The effect of social and child-related factors on mental health was examined.

RESULTS

ART women had fewer depressive symptoms during pregnancy than controls, but at T3 their depressive symptoms were at the same level as seen in controls. Anxiety symptoms increased among control but not among ART women across the transition. ART men reported generally fewer mental health symptoms than their controls. Social and child-related stressors had negative impacts on mental health changes among control couples, whereas no impact was found among ART couples.

CONCLUSIONS

Successful ART did not predict mental health problems during the transition to parenthood. Moreover, ART couples' mental health was remarkably resistant to social and child-related stress during the transition to parenthood.

Single embryo transfer is an option in frozen embryo transfer

BACKGROUND

A good strategy to decrease multiple pregnancy rate in assisted reproduction technology (ART) is the use of single embryo transfer (SET).

METHODS

This retrospective study analysed 1647 frozen embryo transfers carried out during 1998-2003 in Helsinki University Central Hospital; of these, 872 were double embryo transfers (DETs) and 775 SETs. The SET group included 140 (18.1%) elective SETs (eSETs).

RESULTS

The yearly rate of SETs in frozen cycles increased from 28 to 66%. Overall, the clinical pregnancy rate per frozen embryo transfer was 30.7% and the delivery rate 22.6%. The delivery rate was significantly higher in DET cryocycles than in SET cryocycles (25.7 versus 19.2%, respectively; P < 0.01). In DET cryocycles, the multiple delivery rate was 21.9%, 10 times higher than that observed in cryocycles with SET (2.0%) (P < 0.0001). When eSET was applied, no difference in delivery rate was observed when compared with cryocycles with DET (28.6 and 25.7%, respectively).

CONCLUSIONS

SET can be used in frozen cycles to reduce multiple delivery rates.

Changes in bone mineral density during and after 3 years' use of tamoxifen or toremifene

OBJECTIVES

To study the effects of tamoxifen and toremifene on bone mineral density (BMD) in postmenopausal women with breast cancer.

METHODS

Seventy patients with stage II-III breast cancer were randomized to start either tamoxifen (n = 36; 20 mg per day) or toremifene (n = 34; 40 mg per day) for 3 years. BMD in the lumbar spine and in the proximal femur was measured by dual-energy X-ray absorptiometry both before and during the treatment and 1 year after the discontinuation of the anti-estrogens.

RESULTS

The baseline BMD measurements were comparable between the groups. In 3 years, lumbar BMD decreased by 1.7% in tamoxifen (P = 0.048) and 3.0% in toremifene (P = 0.001) users (ns between the groups), and femoral neck BMD by 0.9% (P = 0.040) and 1.3% (P = ns), respectively. The use of hormone replacement therapy (HRT) until the diagnosis of breast cancer was associated with decreases in lumbar BMD during anti-estrogen regimen (4% at 3 years) in contrast to unchanged lumbar BMD in women with no previous use of HRT. During the 1st year after the cessation of anti-estrogen, lumbar BMD did not change at all in either group whereas femoral BMD decreased in both the groups at the rate of 1.5-3.2%, as expected.

CONCLUSIONS

We conclude that tamoxifen (20 mg) and toremifene (40 mg) have similar bone-sparing efficacy that in lumbar spine extends up to 1 year after the cessation of these regimens. This effect is not seen in lumbar spine BMD in those postmenopausal women who discontinue HRT at the time of breast cancer diagnosis.

Lack of effect of isoflavonoids on the vagina and endometrium in postmenopausal women

OBJECTIVE

To determine the effects of soy-derived isoflavones on vaginal epithelium and the endometrium.

DESIGN

Double-blind, randomized, placebo-controlled crossover trial.

SETTING

Outpatient clinic of a university hospital.

PATIENT(S)

Sixty-four postmenopausal women with a history of breast cancer.

INTERVENTION(S)

The women took (in a randomized order) 114 mg of isolated isoflavonoids or placebo in tablets daily for 3 months; the treatment regimens were crossed over after a 2-month washout period. The subjects were studied before and on the last day of each treatment period.

MAIN OUTCOME MEASURE(S)

Vaginal dryness, maturation index (MI) of vaginal epithelium, endometrial thickness, histology, and expression of estrogen (E) and progesterone (P) receptors and the proliferation marker Ki-67 in the endometrium.

RESULT(S)

Isolated isoflavones did not relieve vaginal dryness. Maturation index values remained unchanged during the isoflavone regimen, but decreased during the placebo regimen. No changes were found in any of the variables measured in the endometrium.

CONCLUSION(S)

Daily administration of 114 mg of isolated isoflavones for 3 months had no effect on the subjective perception of vaginal dryness or on objective findings in the vagina or endometrium. This implies safety with regard to the endometrium.

Effect of in vitro fertilization practices on multiple pregnancy rates in Finland

The high occurrence of multiple pregnancies associated with IVF and embryo transfer is the main complication of assisted reproduction. The Finnish experience shows that the practice of reducing the number of transferred embryos can be implemented while maintaining good pregnancy rates.

What is the most relevant standard of success in assisted reproduction?

The most relevant standard of success in IVF has been discussed widely. An optimal standard should reflect both the risk aspects and the effectiveness of the treatment. The most important parameter for the couple is the ultimate cumulative delivery rate per started cycle. Even if the long-term follow-up of the treatment cycles is difficult in practice, we would stress that more emphasis should be given to embryo freezing, in order to maximize the efficiency of the IVF/ICSI cycles. The contribution of embryo cryopreservation in elective single embryo transfer cycle programmes may result in a cumulative delivery rate of >50%. In Finland, the implementation of single embryo transfer has been possible with good cryopreservation programmes. The effect of this strategy has been seen in a decrease in the proportion of twin deliveries after assisted reproduction, being 13.9% for 2002, as well as a reduction of the proportion of multiple births in the nationwide Medical Birth Registry.