1
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Young SL. Nonsurgical approaches to the diagnosis and evaluation of endometriosis. Fertil Steril 2024; 121:140-144. [PMID: 38103884 PMCID: PMC11149605 DOI: 10.1016/j.fertnstert.2023.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
An inability to make the diagnosis of endometriosis or evaluate lesion response to treatment without surgery is a clear impediment to understanding the disease and to developing new therapies. The need is particularly strong for rASRM Stage 1 or 2 disease, since higher stage (rASRM Stage 3 or 4) endometriosis can often be diagnosed by ultrasound or other imaging techniques. Despite promising findings in association studies, no biomarkers or nonsurgical diagnostic or evaluation methods for Stage 1 or Stage 2 endometriosis has yet been clinically validated. Admittedly, validation is difficult, since surgery is required as a gold standard diagnostic method for comparison. This manuscript is aimed as a succinct review of what is known about nonsurgical approaches to detect and assess endometriosis, with an emphasis on Stage 1 and 2.
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Affiliation(s)
- Steven L Young
- Reproductive Endocrinology and Infertility, Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina.
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2
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Fierro JJ, Prins JR, Henning S, Bootsma H, Westra J, de Leeuw K. Endometrial immune profiling as a new tool for preconceptional assessment in patients with systemic autoimmune diseases. Front Immunol 2024; 14:1334231. [PMID: 38250081 PMCID: PMC10797870 DOI: 10.3389/fimmu.2023.1334231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/15/2023] [Indexed: 01/23/2024] Open
Affiliation(s)
- Juan J Fierro
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Grupo Reproducción, Departamento de Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Svenja Henning
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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3
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Frankfurter D, Kliman H. Progress on the Endometrium. Obstet Gynecol Clin North Am 2023; 50:677-694. [PMID: 37914487 DOI: 10.1016/j.ogc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
The endometrium is a dynamic tissue that facilitates mammalian internal reproduction and thus, the ability to deliver live born progeny that are more easily protected from predators. This tissue is unique in its ability to undergo cyclic regeneration and destruction in the absence of pregnancy. Ovarian steroids guide endometrial proliferation and maturation promoting its receptivity and selectivity with regards to blastocyst implantation. It is decidualization, terminal stromal maturation, that prevents the trophoblast from breeching containment of the uterus and allows for endometrial sloughing should pregnancy not occur. Endometrial pathology is highly variable and therefore a wide array of diagnostic measures are required for its interrogation. There remains no single test that can distinguish between all potential issues and it is critical that appropriate and evidence-based endometrial assessment is carried out. Emerging data on developmental markers, inflammatory mediators, and bacterial profiling offer hope that conditions including endometriosis, cancer, infertility, and implantation failure will be more easily and less invasively diagnosed. This will allow for a more timely and targeted approach to intervention. Accordingly, assessing novel measures requires an evidence-based approach prior to their mass utilization.
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Affiliation(s)
- David Frankfurter
- Yale Meidcal School, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale Fertility Center, 200 West Campus Drive, 2nd Floor, Orange, CT 06477, USA.
| | - Harvey Kliman
- Yale University School of Medicine, Kliman Laboratories, Reproductive and Placental Research Unit, Department of Obstetrics, Gynecology and Reproductive Sciences, 310 Cedar Street, FMB 225, New Haven, CT 06510, USA. https://twitter.com/placentatalk
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4
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Pirtea P, de Ziegler D, Ayoubi JM. Endometrial receptivity in adenomyosis and/or endometriosis. Fertil Steril 2023; 119:741-745. [PMID: 36914148 DOI: 10.1016/j.fertnstert.2023.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023]
Abstract
A narrative review of endometrial receptivity in adenomyosis and/or endometriosis revealed that this parameter is difficult to assess in natural conception because both disorders alter natural fertility. Recent data emanating from assisted reproductive technology have allowed the study of endometrial receptivity in women affected by adenomyosis and endometriosis. This has upended our views on the effects of these 2 disorders on embryo implantation. Today, the very existence of altered receptivity in assisted reproductive technology is questioned. In this context, we now know that frozen euploid blastocyst transfers in estradiol and progesterone cycles have unaltered outcomes in both adenomyosis and endometriosis.
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Affiliation(s)
- Paul Pirtea
- Department of Obstetrics, Gynecology and ART, Hospital Foch, Paris, France.
| | | | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and ART, Hospital Foch, Paris, France
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5
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Ekemen S, Comunoglu C, Kayhan CK, Bilir E, Cavusoglu I, Etiler N, Bilgi S, Ince U, Coban C, Erden HF. Endometrial Staining of CD56 (Uterine Natural Killer), BCL-6, and CD138 (Plasma Cells) Improve Diagnosis and Clinical Pregnancy Outcomes in Unexplained Infertility and Recurrent IVF Failures: Standardization of Diagnosis with Digital Pathology. Diagnostics (Basel) 2023; 13:diagnostics13091557. [PMID: 37174948 PMCID: PMC10177933 DOI: 10.3390/diagnostics13091557] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
In women with unexplained infertility (UI) and recurrent in vitro fertilization (IVF) failures, the etiology is often unclear. Endometrial immune perturbations and the use of immune markers associated with these dysregulations are of great interest in the diagnosis and treatment of UI. However, reliable biomarkers and standardized quantification methods are lacking. Here, to address endometrial immune dysregulation in UI patients with recurrent IVF failures, we performed endometrial tissue sampling and immunostaining of CD56 (uNK), CD138, and BCL-6. Of these cases, 57.9% had positive CD56 in the endometrial stroma, while 46.1% had positive BCL-6 in the glandular epithelium, and 14.5% of the cases were found to be positive for CD138. Combined staining rates were 60.5%, 68.4%, and 71.05% for (CD56 or BCL-6), (CD56 or CD138), and (CD56, BCL-6, or CD138), respectively. There was a significant correlation between CD56 and BCL-6 positivity, while CD138 positivity was an independent parameter. After the recommended targeted therapy, pregnancy rates were found to increase from 58.5% to 61.6% and 73.8% in CD56-positive, (CD56- or BCL-6-positive), and (CD56-, BCL-6-, or CD138-positive) cases, respectively. Notably, a retrospective evaluation of digital pathology and light microscopy results showed a significant correlation. This study suggests that the examination of CD56, BCL-6, and CD138 in the same endometrial sample may be an effective method in determining the etiology of UI and reaching an early diagnosis and treatment options. Moreover, digital pathology can be used in the evaluation of CD56 and BCL-6 to provide objective, rapid, and reliable results.
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Affiliation(s)
- Suheyla Ekemen
- Vocational School of Health Services, Kerem Aydınlar Campus, Acıbadem University, Istanbul 34752, Turkey
- Acibadem Central Pathology Laboratory, Kerem Aydinlar Campus, Istanbul 34752, Turkey
| | - Cem Comunoglu
- Department of Pathology, Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul 34668, Turkey
| | - Cavit Kerem Kayhan
- Acibadem Central Pathology Laboratory, Kerem Aydinlar Campus, Istanbul 34752, Turkey
| | - Ebru Bilir
- School of Medicine, Bahcesehir University, Istanbul 34349, Turkey
| | - Ilkay Cavusoglu
- Women's Health and Gynecological Nursing, Institute of Health Sciences, Biruni University, Istanbul 34010, Turkey
| | - Nilay Etiler
- Department of Public Health, School of Medicine, Istanbul Okan University, Istanbul 34947, Turkey
- Public Health Department, University of Nevada, Reno, NV 89509, USA
| | - Selcuk Bilgi
- Acibadem Central Pathology Laboratory, Kerem Aydinlar Campus, Istanbul 34752, Turkey
| | - Umit Ince
- Acibadem Central Pathology Laboratory, Kerem Aydinlar Campus, Istanbul 34752, Turkey
- Department of Digital Pathology, School of Medicine, Acıbadem University, Istanbul 34752, Turkey
| | - Cevayir Coban
- Division of Malaria Immunology, Department of Microbiology and Immunology, Institute of Medical Science (IMSUT), University of Tokyo, Tokyo 108-8639, Japan
| | - Halit Firat Erden
- Obstetrics and Gynecology Infertility Clinic, Zorlu Center, Istanbul 34340, Turkey
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6
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Awonuga AO, Camp OG, Abu-Soud HM, Rappolee DA, Puscheck EE, Diamond MP. Determinants of Embryo Implantation: Roles of the Endometrium and Embryo in Implantation Success. Reprod Sci 2023:10.1007/s43032-023-01224-w. [PMID: 36988904 DOI: 10.1007/s43032-023-01224-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023]
Abstract
Both uterine endometrium and embryo contribute to implantation success. However, their relative role in the implantation success is still a matter for debate, as are the roles of endometrial receptivity analysis (ERA), endometrial scratch (ES), endometrial microbiome, and intrauterine or intravenous measures that are currently advocated to improve the implantation success. There is insufficient evidence to suggest that the endometrium is more important than the embryo in determining the implantation success and the utility of these measures, especially when euploid embryos are transferred is limited. Although embryo implantation on epithelium other than the endometrium is a very rare event, evidence suggests that embryo implantation and growth is not limited to the endometrium alone. Embryos can implant and develop to result in livebirths on epithelium that lacks the typical endometrial development present at implantation. Currently, the role of embryo euploidy in implantation success is underappreciated. At a minimum, it is the author's opinion that until robust, definitive studies are conducted that demonstrate benefit, reproductive endocrinologists and infertility specialist should be prudent in the way they counsel patients about the utility of ERA, ES, and other measures in improving implantation success.
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Affiliation(s)
- Awoniyi O Awonuga
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA.
- Kindbody Fertility, 26400 W 12 Mile Road, Ste. 140D, Southfield, MI, 48034, USA.
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, 26400 West 12 Mile Road, Suite 140, Southfield, MI, 48034, USA.
| | - Olivia G Camp
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
| | - Husam M Abu-Soud
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Daniel A Rappolee
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
- Reproductive Stress, Inc., 135 Lake Shore Rd, Grosse Pointe Farms, MI, USA
| | - Elizabeth E Puscheck
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
- Reproductive Stress, Inc., 135 Lake Shore Rd, Grosse Pointe Farms, MI, USA
- InVia Fertility, 2718 W Roscoe St Suite 500, Chicago, IL, 60618, USA
- InVia Fertility, 1585 N. Barrington Road, Suite 406, Doctor's Building Two, Hoffman Estates, IL, 60169, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, 1120 15Th Street, CJ‑1036, Augusta, GA, 30912, USA
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7
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Gordts S, Puttemans P, Segaert I, Valkenburg M, Schutyser V, Campo R, Gordts S. Diagnosis and treatment of early-stage endometriosis by
Transvaginal Hydro laparoscopy. Facts Views Vis Obgyn 2023; 15:45-52. [PMID: 37010334 PMCID: PMC10392117 DOI: 10.52054/fvvo.15.1.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background: Transvaginal Hydro Laparoscopy (THL) is known as a minimal invasive procedure allowing endoscopic exploration of the female pelvis.
Objective: To evaluate the possibilities of the THL as a tool for early diagnosis and treatment of minimal endometriosis.
Materials and methods: A retrospective study of a consecutive series of 2288 patients referred for fertility problems to a tertiary centre for reproductive medicine was undertaken. Mean duration of infertility was 23.6 months (SD ±11-48), mean age of patients was 31.25 (SD± 3.8y). With normal findings at clinical and ultrasound examination patients underwent, as part of their fertility exploration, a THL.
Main outcome measures: Evaluation of feasibility, identified pathology and pregnancy rate.
Results: Endometriosis was diagnosed in 365 patients (16%); the localisation was higher on the left side (n=237) than on the right side (n=169). Small endometriomas, with diameters between 0.5 and 2 cm, were present in 24.3% (right side in 31, left side 48 and bilateral 10). These early lesions were characterised by the presence of active endometrial like cells and a pronounced neo-angiogenesis. Destruction of the endometriotic lesions with bipolar energy resulted in an in vivo pregnancy rate (spontaneous/IUI) of 43.8% (CPR after 8 months: spontaneous 57.7%; IUI/AID 29.7%).
Conclusion: THL allowed in a minimally invasive way an accurate diagnosis of the early stages of peritoneal and ovarian endometriosis with the possibility of offering treatment with minimal damage.
What is new? This is the largest series reporting the usefulness of THL for the diagnosis and treatment of peritoneal and ovarian endometriosis in patients without obviously visible preoperative pelvic pathology.
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8
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Xu Y, Cai S, Wang Q, Cheng M, Hui X, Dzakah EE, Zhao B, Chen X. Multi-Lineage Human Endometrial Organoids on Acellular Amniotic Membrane for Endometrium Regeneration. Cell Transplant 2023; 32:9636897231218408. [PMID: 38097275 PMCID: PMC10725651 DOI: 10.1177/09636897231218408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/18/2023] [Accepted: 11/18/2023] [Indexed: 12/18/2023] Open
Abstract
Asherman's syndrome is an endometrial regeneration disorder resulting from injury to the endometrial basal layer, causing the formation of scar tissue in the uterus and cervix. This usually leads to uterine infertility, menstrual disorders, and placental abnormalities. While stem cell therapy has shown extensive progress in repairing the damaged endometrium and preventing intrauterine adhesion, issues of low engraftment rates, rapid senescence, and the risk of tumorigenesis remain to be resolved for efficient and effective application of this technology in endometrial repair. This study addressed these challenges by developing a co-culture system to generate multi-lineage endometrial organoids (MLEOs) comprising endometrial epithelium organoids (EEOs) and endometrial mesenchymal stem cells (eMSCs). The efficacy of these MLEOs was investigated by seeding them on a biocompatible scaffold, the human acellular amniotic membrane (HAAM), to create a biological graft patch, which was subsequently transplanted into an injury model of the endometrium in rats. The results indicated that the MLEOs on the HAAM patch facilitated endometrial angiogenesis, regeneration, and improved pregnancy outcomes. The MLEOs on the HAAM patch could serve as a promising strategy for treating endometrial injury and preventing Asherman's syndrome.
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Affiliation(s)
- Yuhui Xu
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Shuyan Cai
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Qian Wang
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Minzhang Cheng
- School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, China
- Institute of Respiratory Disease, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xianrui Hui
- Institute of Organoid Technology, bioGenous Biotechnology, Inc., Suzhou, China
| | | | - Bing Zhao
- School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Nanchang, China
- Institute of Respiratory Disease, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Institute of Organoid Technology, bioGenous Biotechnology, Inc., Suzhou, China
- Institute of Organoid Technology, Kunming Medical University, Kunming, China
| | - Xiaojun Chen
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
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9
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Leyendecker G, Wildt L, Laschke MW, Mall G. Archimetrosis: the evolution of a disease and its extant presentation : Pathogenesis and pathophysiology of archimetrosis (uterine adenomyosis and endometriosis). Arch Gynecol Obstet 2023; 307:93-112. [PMID: 35596746 PMCID: PMC9836992 DOI: 10.1007/s00404-022-06597-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE This article presents a novel concept of the evolution and, thus, the pathogenesis of uterine adenomyosis as well as peritoneal and peripheral endometriosis. Presently, no unifying denomination of this nosological entity exists. METHODS An extensive search of the literature on primate evolution was performed. This included comparative functional morphology with special focus on the evolution of the birthing process that fundamentally differs between the haplorrhine primates and most of the other eutherian mammals. The data were correlated with the results of own research on the pathophysiology of human archimetrosis and with the extant presentation of the disease. RESULTS The term Archimetrosis is suggested as a denomination of the nosological entity. Archimetrosis occurs in human females and also in subhuman primates. There are common features in the reproductive process of haplorrhine primates such as spontaneous ovulation and corpus luteum formation, spontaneous decidualization and menstruation. These have fused Müllerian ducts resulting in a uterus simplex. Following a usually singleton pregnancy, the fetus is delivered in the skull position. Some of these features are shared by other mammals, but not in that simultaneous fashion. In haplorrhine primates, with the stratum vasculare, a new myometrial layer has evolved during the time of the Cretaceous-Terrestrial Revolution (KTR) that subserves expulsion of the conceptus and externalization of menstrual debris in non-conceptive cycles. Hypercontractility of this layer has evolved as an advantage with respect to the survival of the mother and the birth of a living child during delivery and may be experienced as primary dysmenorrhea during menstruation. It may result in tissue injury by the sheer power of the contractions and possibly by the associated uterine ischemia. Moreover, the lesions at extra-uterine sites appear to be maintained by biomechanical stress. CONCLUSIONS Since the pathogenesis of archimetrosis is connected with the evolution of the stratum vasculare, tissue injury and repair (TIAR) turns out to be the most parsimonious explanation for the development of the disease based on clinical, experimental and evolutionary evidence. Furthermore, a careful analysis of the published clinical data suggests that, in the risk population with uterine hypercontractility, the disease develops with a yet to be defined latency phase after the onset of the biomechanical injury. This opens a new avenue of prevention of the disease in potentially affected women that we consider to be primarily highly fertile.
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Affiliation(s)
| | | | - Matthias W. Laschke
- Institut für Klinisch-Experimentelle Chirurgie, Universität des Saarlandes, 66421 Homburg, Germany
| | - Gerhard Mall
- Wiesenbacher Str. 10, 69151 Neckargemünd, Germany
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10
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Haas J, Casper RF. Observations on clinical assessment of endometrial receptivity. Fertil Steril 2022; 118:828-831. [PMID: 36198510 DOI: 10.1016/j.fertnstert.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 01/13/2023]
Abstract
This brief review will examine the investigation of the endometrial cavity before embryo transfer using various techniques, including hysteroscopy, endometrial biopsy using immunohistochemistry and molecular microarray, and ultrasound imaging. All these investigative tools are presently subject to controversy and require large prospective controlled trials for validation. During embryo transfer, the occurrence of a retained embryo does not appear to have a negative impact on pregnancy outcome, and finally, consistent data indicate that physical activity immediately after embryo transfer has no impact on pregnancy outcome.
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Affiliation(s)
- Jigal Haas
- IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Robert F Casper
- TRIO Fertility, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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11
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Bonavina G, Taylor HS. Endometriosis-associated infertility: From pathophysiology to tailored treatment. Front Endocrinol (Lausanne) 2022; 13:1020827. [PMID: 36387918 PMCID: PMC9643365 DOI: 10.3389/fendo.2022.1020827] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.
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Affiliation(s)
- Giulia Bonavina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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12
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Squatrito M, Blacher S, Henry L, Labied S, Noel A, Nisolle M, Munaut C. Comparison of Morphological and Digital-Assisted Analysis for BCL6 Endometrial Expression in Women with Endometriosis. J Clin Med 2022; 11:6164. [PMID: 36294483 PMCID: PMC9604760 DOI: 10.3390/jcm11206164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2024] Open
Abstract
BCL6 (B-cell lymphoma 6) is a proto-oncogene and transcriptional repressor initially described as being involved in B-cell lymphoma. Recently, this factor has been identified as a promising tissue biomarker which could be used to diagnose women affected by endometriosis. Previous studies used HSCORE for BCL6 staining quantification in the endometrium. However, this semi-quantitative technique of analysis has some limitations, including a lack of objectivity, robustness, and reproducibility that may lead to intra- and inter-observer variability. Our main goal was to develop an original computer-assisted method to quantify BCL6 staining from whole-slide images reliably. In order to test the efficiency of our new digital method of quantification, we compared endometrial BCL6 expression between fertile and infertile women without or with different stages of endometriosis by using the widely used HSCORE analysis and our new automatic digital image analysis. We find a higher expression of BCL6 in the endometrium of infertile women with endometriosis and women with stage IV endometriosis. Furthermore, we demonstrate a significant correlation between the two types of independent measurements, indicating the robustness of results and also the reliability of our computer-assisted method for BCL6 quantification. In conclusion, our work, by using this original computer-assisted method, enables BCL6 quantification more objectively, reliably, robustly, and promptly compared to HSCORE analysis.
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Affiliation(s)
- Marlyne Squatrito
- Laboratory of Tumor and Development Biology, GIGA-Cancer, University of Liège, 4000 Liège, Belgium
| | - Silvia Blacher
- Laboratory of Tumor and Development Biology, GIGA-Cancer, University of Liège, 4000 Liège, Belgium
| | - Laurie Henry
- Obstetrics and Gynecology Department, University of Liege, 4000 Liège, Belgium
| | - Soraya Labied
- Obstetrics and Gynecology Department, University of Liege, 4000 Liège, Belgium
| | - Agnès Noel
- Laboratory of Tumor and Development Biology, GIGA-Cancer, University of Liège, 4000 Liège, Belgium
| | - Michelle Nisolle
- Laboratory of Tumor and Development Biology, GIGA-Cancer, University of Liège, 4000 Liège, Belgium
- Obstetrics and Gynecology Department, University of Liege, 4000 Liège, Belgium
| | - Carine Munaut
- Laboratory of Tumor and Development Biology, GIGA-Cancer, University of Liège, 4000 Liège, Belgium
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13
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Klimczak A, Scott RT. Reply of the Authors: B-cell lymphoma 6 (BCL6) testing before in vitro fertilization as a predictor of failure. Fertil Steril 2022; 118:420. [PMID: 35697533 DOI: 10.1016/j.fertnstert.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Amber Klimczak
- Reproductive Medicine Associates of New Jersey Basking Ridge, New Jersey
| | - Richard T Scott
- Reproductive Medicine Associates of New Jersey Basking Ridge, New Jersey
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Savaris RF, Lessey BA. B-cell lymphoma 6 (BCL6) testing before in vitro fertilization as a predictor of failure. Fertil Steril 2022; 118:419. [PMID: 35717285 DOI: 10.1016/j.fertnstert.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/17/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Ricardo F Savaris
- Wake Forest University School of Medicine, Winston-Salem, North Carolina; Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bruce A Lessey
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Abstract
PURPOSE OF REVIEW To succinctly review the basic mechanisms of implantation and luteal phase endometrial differentiation, the etiologies of impaired endometrial function and receptivity, and the current methods that exist to evaluate and treat impaired endometrial receptivity. RECENT FINDINGS Human embryo implantation requires bidirectional communication between blastocyst and a receptive endometrium. Etiologies of impaired endometrial receptivity are varied. Some of these include delayed endometrial maturation, structural abnormalities, inflammation, and progesterone resistance. Current methods to evaluate endometrial receptivity include ultrasonography, hysteroscopy, and endometrial biopsy. Treatments are limited, but include operative hysteroscopy, treatment of endometriosis, and personalized timing of embryo transfer. SUMMARY Although some mechanisms of impaired endometrial receptivity are well understood, treatment options remain limited. Future efforts should be directed towards developing interventions targeted towards the known mediators of impaired endometrial receptivity.
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Nezhat C, Agarwal S, Lee DA, Tavallaee M. Can we accurately diagnose endometriosis without a diagnostic laparoscopy? J Turk Ger Gynecol Assoc 2022; 23:117-119. [PMID: 35642436 PMCID: PMC9161000 DOI: 10.4274/jtgga.galenos.2022.2022-2-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Louwen F, Kreis NN, Ritter A, Friemel A, Solbach C, Yuan J. BCL6, a key oncogene, in the placenta, pre-eclampsia and endometriosis. Hum Reprod Update 2022; 28:890-909. [PMID: 35640966 PMCID: PMC9629482 DOI: 10.1093/humupd/dmac027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/02/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The key oncogene B-cell lymphoma 6 (BCL6) drives malignant progression by promoting proliferation, overriding DNA damage checkpoints and blocking cell terminal differentiation. However, its functions in the placenta and the endometrium remain to be defined. OBJECTIVE AND RATIONALE Recent studies provide evidence that BCL6 may play various roles in the human placenta and the endometrium. Deregulated BCL6 might be related to the pathogenesis of pre-eclampsia (PE) as well as endometriosis. In this narrative review, we aimed to summarize the current knowledge regarding the pathophysiological role of BCL6 in these two reproductive organs, discuss related molecular mechanisms, and underline associated research perspectives. SEARCH METHODS We conducted a comprehensive literature search using PubMed for human, animal and cellular studies published until October 2021 in the following areas: BCL6 in the placenta, in PE and in endometriosis, in combination with its functions in proliferation, fusion, migration, invasion, differentiation, stem/progenitor cell maintenance and lineage commitment. OUTCOMES The data demonstrate that BCL6 is important in cell proliferation, survival, differentiation, migration and invasion of trophoblastic cells. BCL6 may have critical roles in stem/progenitor cell survival and differentiation in the placenta and the endometrium. BCL6 is aberrantly upregulated in pre-eclamptic placentas and endometriotic lesions through various mechanisms, including changes in gene transcription and mRNA translation as well as post-transcriptional/translational modifications. Importantly, increased endometrial BCL6 is considered to be a non-invasive diagnostic marker for endometriosis and a predictor for poor outcomes of IVF. These data highlight that BCL6 is crucial for placental development and endometrium homeostasis, and its upregulation is associated with the pathogenesis of PE, endometriosis and infertility. WIDER IMPLICATIONS The lesson learned from studies of the key oncogene BCL6 reinforces the notion that numerous signaling pathways and regulators are shared by tumors and reproductive organs. Their alteration may promote the progression of malignancies as well as the development of gestational and reproductive disorders.
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Affiliation(s)
- Frank Louwen
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Frankfurt, Germany
| | - Nina-Naomi Kreis
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Frankfurt, Germany
| | - Andreas Ritter
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Frankfurt, Germany
| | - Alexandra Friemel
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Frankfurt, Germany
| | - Christine Solbach
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Frankfurt, Germany
| | - Juping Yuan
- Division of Obstetrics and Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital Frankfurt, J. W. Goethe-University, Frankfurt, Germany
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Sun B, Yeh J. Non-Invasive and Mechanism-Based Molecular Assessment of Endometrial Receptivity During the Window of Implantation: Current Concepts and Future Prospective Testing Directions. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:863173. [PMID: 36303672 PMCID: PMC9580756 DOI: 10.3389/frph.2022.863173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/07/2022] [Indexed: 12/03/2022] Open
Abstract
Suboptimal endometrial receptivity and altered embryo-endometrial crosstalk account for approximately two-thirds of human implantation failures. Current tests of the window of implantation, such as endometrial thickness measurements and the endometrial receptivity assay, do not consistently improve clinical outcomes as measured by live birth rates. Understanding the mechanisms regulating the endometrial receptivity during the window of implantation is a critical step toward developing clinically meaningful tests. In this narrative review, the available literature is evaluated regarding mechanisms that regulate the endometrial receptivity during the window of implantation and the current tests developed. Overall, both animal and human studies point to five possible and interrelated mechanisms regulating the endometrial window of implantation: suitable synchrony between endometrial cells, adequate synchrony between the endometrium and the embryo, standard progesterone signaling and endometrial responses to progesterone, silent genetic variations, and typical morphological characteristics of the endometrial glands. The biological basis of current clinical markers or tests of window of implantation is poor. Future studies to elucidate the mechanisms shaping the window of implantation and to investigate the potential markers based on these mechanisms are required. In addition, molecular testing of the endometrium at single-cell resolution should be an initial step toward developing clinically meaningful tests for the optimal window of implantation. As understanding of the optimal window of implantation continues to evolve, one can envision the future development of non-invasive, mechanism-based testing of the window of implantation.
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Affiliation(s)
- Bei Sun
- Sackler Faculty of Medicine, Sackler School of Medicine, New York State/American Program of Tel Aviv University, Tel Aviv University, Tel Aviv, Israel
| | - John Yeh
- Reproductive Endocrinology and Infertility, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA, United States
- *Correspondence: John Yeh
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Kwak-Kim J, AlSubki L, Luu T, Ganieva U, Thees A, Dambaeva S, Gilman-Sachs A. The role of immunologic tests for subfertility in the clinical environment. Fertil Steril 2022; 117:1132-1143. [DOI: 10.1016/j.fertnstert.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/17/2022] [Accepted: 04/06/2022] [Indexed: 11/04/2022]
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Kosturakis AK, Ryan GL. Predicting implantation failure: to BCL6 or not to BCL6. Fertil Steril 2022; 117:359. [DOI: 10.1016/j.fertnstert.2021.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022]
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Recurrent Implantation Failure-Is It the Egg or the Chicken? LIFE (BASEL, SWITZERLAND) 2021; 12:life12010039. [PMID: 35054432 PMCID: PMC8777926 DOI: 10.3390/life12010039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022]
Abstract
Recurrent implantation failure (RIF) is an undefined, quite often, clinical phenomenon that can result from the repeated failure of embryo transfers to obtain a viable pregnancy. Careful clinical evaluation prior to assisted reproduction can uncover various treatable causes, including endocrine dysfunction, fibroid(s), polyp(s), adhesions, uterine malformations. Despite the fact that it is often encountered and has a critical role in Assisted Reproductive Technique (ART) and human reproduction, RIF’s do not yet have an agreed-on definition, and its etiologic factors have not been entirely determined. ART is a complex treatment with a variable percentage of success among patients and care providers. ART depends on several factors that are not always known and probably not always the same. When confronted with repeated ART failure, medical care providers should try to determine whether the cause is an embryo or endometrium related. One of the most common causes of pregnancy failure is aneuploidy. Therefore, it is likely that this represents a common cause of RIF. Other RIF potential causes include immune and endometrial factors; however, with a very poorly defined role. Recent data indicate that the possible endometrial causes of RIF are very rare, thereby throwing into doubt all endometrial receptivity assays. All recent reports indicate that the true origin of RIF is probably due to the “egg”.
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Shen M, O’Donnell E, Leon G, Kisovar A, Melo P, Zondervan K, Granne I, Southcombe J. The role of endometrial B cells in normal endometrium and benign female reproductive pathologies: a systematic review. Hum Reprod Open 2021; 2022:hoab043. [PMID: 35146127 PMCID: PMC8825379 DOI: 10.1093/hropen/hoab043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/02/2021] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION What are the similarities and differences in endometrial B cells in the normal human endometrium and benign reproductive pathologies? SUMMARY ANSWER Endometrial B cells typically constitute <5% of total endometrial CD45+ lymphocytes, and no more than 2% of total cells in the normal endometrium, and while their relative abundance and phenotypes vary in benign gynaecological conditions, current evidence is inconsistent. WHAT IS KNOWN ALREADY B cells are vitally important in the mucosal immune environment and have been extensively characterized in secondary lymphoid organs and tertiary lymphoid structures (TLSs), with the associated microenvironment germinal centre. However, in the endometrium, B cells are largely overlooked, despite the crucial link between autoimmunity and reproductive pathologies and the fact that B cells are present in normal endometrium and benign female reproductive pathologies, scattered or in the form of lymphoid aggregates (LAs). A comprehensive summary of current data investigating B cells will facilitate our understanding of endometrial B cells in the endometrial mucosal immune environment. STUDY DESIGN, SIZE, DURATION This systematic review retrieved relevant studies from four databases (MEDLINE, EMBASE, Web of Science Core Collection and CINAHL) from database inception until November 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS The search strategy combined the use of subject headings and relevant text words related to ‘endometrium’, ‘B cells’ and B-cell derivatives, such as ‘antibody’ and ‘immunoglobulin’. Non-benign diseases were excluded using cancer-related free-text terms, and searches were limited to the English language and human subjects. Only peer-reviewed research papers were included. Each paper was graded as ‘Good’, ‘Fair’ or ‘Poor’ quality based on the NEWCASTLE-OTTAWA quality assessment scale. Only ‘Good’ quality papers were included. MAIN RESULTS AND THE ROLE OF CHANCE Twenty-seven studies met the selection criteria and were included in this review: 10 cross-sectional studies investigated B cells in the normal endometrium; and 17 case–control studies compared the characteristics of endometrial B cells in control and benign female reproductive pathologies including endometritis, endometriosis, infertility, abnormal uterine bleeding, endometrial polyps and uterine fibroids. In all studies, B cells were present in the endometrium, scattered or in the form of LAs. CD20+ B cells were more abundant in patients with endometritis, but the data were inconsistent as to whether B-cell numbers were increased in endometriosis and patients with reproductive pathologies. LIMITATIONS, REASONS FOR CAUTION Although only ‘good’ quality papers were included in this systematic review, there were variations in patients’ age, diagnostic criteria for different diseases and sample collection time among included studies. Additionally, a large number of the included studies only used immunohistochemistry as the identification method for endometrial B cells, which may fail to provide an accurate representation of the numbers of endometrial B cells. WIDER IMPLICATIONS OF THE FINDINGS Histological studies found that endometrial B cells are either scattered or surrounded by T cells in LAs: the latter structure seems to be under hormonal control throughout the menstrual cycle and resembles TLSs that have been observed in other tissues. Further characterization of endometrial B cells and LAs could offer insights to endometrial B-cell function, particularly in the context of autoimmune-associated pathologies, such as endometriosis. Additionally, clinicians should be aware of the limited value of diagnosing plasma cell infiltration using only CD138. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by Finox Biotech. The authors have no conflicts of interest to declare. PROSPERO REGISTRATION NUMBER This systematic review was registered in PROSPERO in January 2020 (PROSPERO ID: CRD42020152915).
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Affiliation(s)
- Mengni Shen
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Elizabeth O’Donnell
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Gabriela Leon
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Ana Kisovar
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Pedro Melo
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Krina Zondervan
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Ingrid Granne
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Jennifer Southcombe
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
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Klimczak AM, Herlihy NS, Scott CS, Hanson BM, Kim JG, Titus S, Seli E, Scott RT. B-cell lymphoma 6 expression is not associated with live birth in a normal responder in vitro fertilization population. Fertil Steril 2021; 117:351-358. [PMID: 34809978 DOI: 10.1016/j.fertnstert.2021.09.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/07/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether increased endometrial B-cell lymphoma 6 (BCL6) expression is associated with live birth in a normal responder in vitro fertilization (IVF) population. DESIGN Case-control study. SETTING University-affiliated infertility center. PATIENT(S) Two groups of women undergoing IVF with preimplantation genetic testing for aneuploidy followed by warmed, single, euploid embryo transfer. Group 1 consisted of women who failed to achieve live birth, and group 2 consisted of women who achieved live birth. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Endometrial BCL6 expression measured by immunohistochemistry in endometrial tissue samples. Overexpression was defined by mean HSCORE with a cutoff of positivity of >1.4, as previously described in the literature. RESULT(S) Twenty-seven patients who achieved live birth and 23 patients who failed to achieve live birth were included. B-cell lymphoma 6 expression/HSCORE and live birth rate were not associated (Odds ratio [OR], 0.78 [0.24-2.55]). Using a cutoff of >1.4 for positivity, 8 of 23 samples were positive for BCL6 in the no live birth group, whereas 7 of 27 were positive in the live birth group. There was no significant association between BCL6 positivity and live birth (OR, 0.66 [0.19-2.21]). CONCLUSION(S) The proportion of patients with BCL6 positivity did not significantly differ between those who achieved live birth and those who did not. In the population of patients at our center, who compromise of women who respond normally to IVF stimulation, BCL6 overexpression was not associated with IVF success. Physicians implementing BCL6 testing as a diagnostic tool for clinical decision making should counsel patients that results may have limited utility in predicting IVF outcomes in this population.
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Affiliation(s)
- Amber M Klimczak
- Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey.
| | - Nola S Herlihy
- Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey
| | - Cynthia S Scott
- Foundation for Embryonic Competence, Basking Ridge, New Jersey
| | - Brent M Hanson
- Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey
| | - Julia G Kim
- Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey
| | - Shiny Titus
- Foundation for Embryonic Competence, Basking Ridge, New Jersey
| | - Emre Seli
- Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey; Foundation for Embryonic Competence, Basking Ridge, New Jersey; Yale School of Medicine, New Haven, Connecticut
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Preoperative Neutrophil-to-Lymphocyte Ratio Level is a Predictor of Postoperative Fertility in Infertile Patients with Ovarian Endometrioma. Reprod Sci 2021; 29:1145-1155. [PMID: 34729718 DOI: 10.1007/s43032-021-00782-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
To investigate the predictive efficacy of the preoperative neutrophil-lymphocyte ratio (NLR) for natural pregnancy outcome after laparoscopic cystectomy in infertile patients with ovarian endometrioma (OMA). Current evidence suggests that endometriosis likely induces local and systemic inflammatory processes. The NLR has been demonstrated to be of great utility in the diagnosis of endometriosis. However, the association between NLR and natural pregnancy outcome after laparoscopic surgery for endometriosis remains unknown. Data on infertile OMA patients undergoing laparoscopic surgery from January 2014 to October 2019 were retrospectively analyzed. Cox regression analysis was used to identify predictors of natural pregnancy outcome. A predictive model was then established using the nomogram. Among 217 patients, 115 patients (53.0%) experienced natural pregnancy after surgery. Compared with patients with pregnancy failure, those with pregnancy success had a significantly higher NLR (P < 0.05). Multivariate analysis revealed that age, least function (LF) score, and NLR were independent predictors of postoperative pregnancy (all P < 0.05). The NLA (NLR, LF score and age) scoring was then established and had a high predictive ability (AUC = 0.725). Patients were divided into three groups (low-, intermediate- and high-risk) based on the scoring, and the 1-year pregnancy rates were 43.5%, 34.4%, and 21.0%, respectively (P < 0.05). The preoperative NLR level was significantly associated with natural pregnancy outcome in infertile OMA patients after surgery. A predictive model combining NLR, LF score, and age could assist in the clinical decision-making process.
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25
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Recent Advances and Current Perspectives on Endometrial Receptivity. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2021. [DOI: 10.1007/s13669-021-00313-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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El estudio de receptividad endometrial ER®map mejora los resultados reproductivos tras fallos previos de implantación en ciclos de fecundación in vitro. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2021.100688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gordts S, Gordts S, Puttemans P, Segaert I, Valkenburg M, Campo R. Systematic use of transvaginal hydrolaparoscopy as a minimally invasive procedure in the exploration of the infertile patient: results and reflections. Facts Views Vis Obgyn 2021; 13:131-140. [PMID: 34184842 PMCID: PMC8291988 DOI: 10.52054/fvvo.13.2.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background The aim of this study was to evaluate the added value of transvaginal hydrolaparoscopy (THL) in the investigation of the infertile patient. Methods A retrospective cohort study, based on records from 01/09/2006 to 30/12/2019 was undertaken in a tertiary care infertility centre. THL was performed in 2288 patients. These were patients who were referred for endoscopic exploration of the female pelvis as part of their infertility investigation. In 374 patients with clomiphene- resistant polycystic ovary syndrome (PCOS), ovarian capsule drilling was also performed. The outcome objectives of this study included the evaluation of the added diagnostic value of THL as well as the feasibility and safety of the visual inspection of the female pelvis using this technique. Results Of the 2288 procedures failed access to the pouch of Douglas occurred in in 23 patients (1%). The complication rate was 0.74%, due to bowel perforations (n= 13) and bleeding (n= 4) requiring laparoscopy. All bowel perforations were treated conservatively, with 6 days of antibiotics, and no further complications occurred. Findings were normal in 49.8% of patients. Endometriosis was diagnosed in 366 patients (15.9%); adhesions were present in 144 patients. Conclusions THL is a minimally invasive procedure, with a low complication and failure rate, providing an accurate visual exploration of the female pelvis in a one-day hospital setting. When indicated, minimally invasive surgery is possible in the early stages of endometriosis and for ovarian capsule drilling in patients with clomiphene- resistant PCOS.
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Pirtea P, Scott RT, de Ziegler D, Ayoubi JM. Recurrent implantation failure: how common is it? Curr Opin Obstet Gynecol 2021; 33:207-212. [PMID: 33896917 DOI: 10.1097/gco.0000000000000698] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To clarify a lingering issue, the true incidence of repeated implantation failures (RIF) in women undergoing successive frozen euploid single embryo transfers (FE-SET). RECENT FINDINGS As not all Assisted reproductive techinique (ART) attempts are crowned by success, it has been questioned since incept of ART whether failures resulted from an embryonic or endometrial cause. RIF has received no precise definition but a trend has existed toward setting a more stringent definition, as reproductive biology has become more effective and ART success rates improved. No scientific society has yet convened on a universally accepted definition. The advent of effective and well tolerated pregestational testing of embryos for aneuploidy (PGT-A) has allowed to not transfer aneuploid embryos, which are bound not to succeed. This, therefore, justify revisiting the concept of RIF when only euploid embryos are transferred. SUMMARY Contrary to lingering beliefs, the results of our study indicate that RIF following three successive euploid embryo transfers in a morphologically normal endometrium is a rare occurrence (<5%). This supports the concept that ART failures mainly result from embryonic causes. Our data also propose a new - functional - definition of RIF being an ART failure following 3 successive FE-SET attempts. Our findings, therefore seriously question the soundness of prescribing the often complex and expensive endometrial testing procedures that largely publicized for treating RIF.
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Affiliation(s)
- Paul Pirtea
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch - Faculté de Médecine Paris Ouest (UVSQ), Suresnes, France
- IVI-RMA New Jersey, Basking Ridge, New Jersey, USA
| | | | - Dominique de Ziegler
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch - Faculté de Médecine Paris Ouest (UVSQ), Suresnes, France
| | - Jean Marc Ayoubi
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch - Faculté de Médecine Paris Ouest (UVSQ), Suresnes, France
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Pirtea P, De Ziegler D, Tao X, Sun L, Zhan Y, Ayoubi JM, Seli E, Franasiak JM, Scott RT. Rate of true recurrent implantation failure is low: results of three successive frozen euploid single embryo transfers. Fertil Steril 2021; 115:45-53. [DOI: 10.1016/j.fertnstert.2020.07.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/13/2020] [Accepted: 07/02/2020] [Indexed: 12/30/2022]
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Hernández-Vargas P, Muñoz M, Domínguez F. Identifying biomarkers for predicting successful embryo implantation: applying single to multi-OMICs to improve reproductive outcomes. Hum Reprod Update 2020; 26:264-301. [PMID: 32096829 DOI: 10.1093/humupd/dmz042] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/08/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Successful embryo implantation is a complex process that requires the coordination of a series of events, involving both the embryo and the maternal endometrium. Key to this process is the intricate cascade of molecular mechanisms regulated by endocrine, paracrine and autocrine modulators of embryonic and maternal origin. Despite significant progress in ART, implantation failure still affects numerous infertile couples worldwide and fewer than 10% of embryos successfully implant. Improved selection of both the viable embryos and the optimal endometrial phenotype for transfer remains crucial to enhancing implantation chances. However, both classical morphological embryo selection and new strategies incorporated into clinical practice, such as embryonic genetic analysis, morphokinetics or ultrasound endometrial dating, remain insufficient to predict successful implantation. Additionally, no techniques are widely applied to analyse molecular signals involved in the embryo-uterine interaction. More reliable biological markers to predict embryo and uterine reproductive competence are needed to improve pregnancy outcomes. Recent years have seen a trend towards 'omics' methods, which enable the assessment of complete endometrial and embryonic molecular profiles during implantation. Omics have advanced our knowledge of the implantation process, identifying potential but rarely implemented biomarkers of successful implantation. OBJECTIVE AND RATIONALE Differences between the findings of published omics studies, and perhaps because embryonic and endometrial molecular signatures were often not investigated jointly, have prevented firm conclusions being reached. A timely review summarizing omics studies on the molecular determinants of human implantation in both the embryo and the endometrium will help facilitate integrative and reliable omics approaches to enhance ART outcomes. SEARCH METHODS In order to provide a comprehensive review of the literature published up to September 2019, Medline databases were searched using keywords pertaining to omics, including 'transcriptome', 'proteome', 'secretome', 'metabolome' and 'expression profiles', combined with terms related to implantation, such as 'endometrial receptivity', 'embryo viability' and 'embryo implantation'. No language restrictions were imposed. References from articles were also used for additional literature. OUTCOMES Here we provide a complete summary of the major achievements in human implantation research supplied by omics approaches, highlighting their potential to improve reproductive outcomes while fully elucidating the implantation mechanism. The review highlights the existence of discrepancies among the postulated biomarkers from studies on embryo viability or endometrial receptivity, even using the same omic analysis. WIDER IMPLICATIONS Despite the huge amount of biomarker information provided by omics, we still do not have enough evidence to link data from all omics with an implantation outcome. However, in the foreseeable future, application of minimally or non-invasive omics tools, together with a more integrative interpretation of uniformly collected data, will help to overcome the difficulties for clinical implementation of omics tools. Omics assays of the embryo and endometrium are being proposed or already being used as diagnostic tools for personalised single-embryo transfer in the most favourable endometrial environment, avoiding the risk of multiple pregnancies and ensuring better pregnancy rates.
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Affiliation(s)
- Purificación Hernández-Vargas
- IVI-RMA Alicante, Innovation. Avda. de Denia 111, 03015 Alicante, Spain.,Fundación IVI, Innovation-IIS La Fe, Avda. Fernando Abril Martorell 106, Torre A, 1° 1.23, 46026 Valencia, Spain
| | - Manuel Muñoz
- IVI-RMA Alicante, Innovation. Avda. de Denia 111, 03015 Alicante, Spain.,Fundación IVI, Innovation-IIS La Fe, Avda. Fernando Abril Martorell 106, Torre A, 1° 1.23, 46026 Valencia, Spain
| | - Francisco Domínguez
- Fundación IVI, Innovation-IIS La Fe, Avda. Fernando Abril Martorell 106, Torre A, 1° 1.23, 46026 Valencia, Spain
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Nezhat C, Rambhatla A, Miranda-Silva C, Asiaii A, Nguyen K, Eyvazzadeh A, Tazuke S, Agarwal S, Jun S, Nezhat A, Roman RA. BCL-6 Overexpression as a Predictor for Endometriosis in Patients Undergoing In Vitro Fertilization. JSLS 2020; 24:e2020.00064. [PMID: 33414614 PMCID: PMC7757768 DOI: 10.4293/jsls.2020.00064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the positive predictive value (PPV) of endometrial BCL-6 overexpression as a noninvasive screening test endometriosis in patients undergoing in vitro fertilization (IVF). METHODS Retrospective cohort study at a university-affiliated private practice. Inclusion criteria were reproductive age females currently undergoing IVF with a diagnosis of unexplained infertility or unexplained recurrent pregnancy loss. Those with endometrial BCL-6 overexpression underwent laparoscopic surgery with an indication for treatment of suspected endometriosis. The primary outcome was the PPV of endometrial BCL-6 testing to surgically diagnose endometriosis. Statistical analysis was performed using SPSS v.25.0. RESULTS Seventy-five patients met inclusion criteria for our study. The PPV of BCL-6 testing for endometriosis was 96%. Of those patients without endometriosis, 100% had other inflammatory pelvic pathologies, which were diagnosed and treated at the time of laparoscopy. CONCLUSIONS Endometrial BCL-6 overexpression has a high PPV for diagnosing endometriosis and can help identify a patient population that may require surgical treatment before embryo transfer.
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Affiliation(s)
- Camran Nezhat
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Anupama Rambhatla
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Catarina Miranda-Silva
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Atena Asiaii
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Kimsa Nguyen
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | | | - Salli Tazuke
- The Colorado Center for Reproductive Medicine - San Francisco. Menlo Park, CA
| | - Shruti Agarwal
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Sunny Jun
- The Colorado Center for Reproductive Medicine - San Francisco. Menlo Park, CA
| | - Azadeh Nezhat
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
| | - Robert A Roman
- Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA
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Huber WJ, Sauerbrun-Cutler MT, Krueger PM, Sharma S. Novel predictive and therapeutic options for better pregnancy outcome in frozen embryo transfer cycles. Am J Reprod Immunol 2020; 85:e13300. [PMID: 32654307 DOI: 10.1111/aji.13300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 12/25/2022] Open
Abstract
Since 1978, in the first decades of in vitro fertilization (IVF), the use of ovarian hyperstimulation allowed for the development and transfer of multiple embryos. As IVF technology improved, the number of multiple pregnancies increased, which led to gradual reduction in the number of embryos that were transferred. Embryo freezing (vitrification) was recommended to allow subsequent transfer if the fresh cycle was unsuccessful. However, experimentation has continued to improve pregnancy outcomes. We discuss here the significance of frozen embryo transfer cycle and the impact of uterine and peripheral immunity dominated by NK cells and regulatory T cells and human chorionic gonadotropin on pregnancy outcome in this innovative mode of IVF therapy.
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Affiliation(s)
- Warren J Huber
- Department of Obstetrics and Gynecology, LSUHSC School of Medicine and The Fertility Institute, New Orleans, LA, USA
| | - May-Tal Sauerbrun-Cutler
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI, USA
| | - Paula M Krueger
- Department of Pediatrics, Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI, USA
| | - Surendra Sharma
- Department of Pediatrics, Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI, USA
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Craciunas L, Gallos I, Chu J, Bourne T, Quenby S, Brosens JJ, Coomarasamy A. Conventional and modern markers of endometrial receptivity: a systematic review and meta-analysis. Hum Reprod Update 2020; 25:202-223. [PMID: 30624659 DOI: 10.1093/humupd/dmy044] [Citation(s) in RCA: 217] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/31/2018] [Accepted: 12/04/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Early reproductive failure is the most common complication of pregnancy with only 30% of conceptions reaching live birth. Establishing a successful pregnancy depends upon implantation, a complex process involving interactions between the endometrium and the blastocyst. It is estimated that embryos account for one-third of implantation failures, while suboptimal endometrial receptivity and altered embryo-endometrial dialogue are responsible for the remaining two-thirds. Endometrial receptivity has been the focus of extensive research for over 80 years, leading to an indepth understanding of the processes associated with embryo-endometrial cross-talk and implantation. However, little progress has been achieved to translate this understanding into clinically meaningful prognostic tests and treatments for suboptimal endometrial receptivity. OBJECTIVE AND RATIONALE The objective of this systematic review was to examine the evidence from observational studies supporting the use of endometrial receptivity markers as prognostic factors for pregnancy outcome in women wishing to conceive, in order to aid clinicians in choosing the most useful marker in clinical practice and for informing further research. SEARCH METHODS The review protocol was registered with PROSPERO (CRD42017077891). MEDLINE and Embase were searched for observational studies published from inception until 26 February 2018. We included studies that measured potential markers of endometrial receptivity prior to pregnancy attempts and reported the subsequent pregnancy outcomes. We performed association and accuracy analyses using clinical pregnancy as an outcome to reflect the presence of receptive endometrium. The Newcastle-Ottawa scale for observational studies was employed to assess the quality of the included studies. OUTCOMES We included 163 studies (88 834 women) of moderate overall quality in the narrative synthesis, out of which 96 were included in the meta-analyses. Studies reported on various endometrial receptivity markers evaluated by ultrasound, endometrial biopsy, endometrial fluid aspirate and hysteroscopy in the context of natural conception, IUI and IVF. Associations were identified between clinical pregnancy and various endometrial receptivity markers (endometrial thickness, endometrial pattern, Doppler indices, endometrial wave-like activity and various molecules); however, their poor ability to predict clinical pregnancy prevents them from being used in clinical practice. Results from several modern molecular tests are promising and further data are awaited. WIDER IMPLICATIONS The post-test probabilities from our analyses may be used in clinical practice to manage couples' expectations during fertility treatments (IUI and IVF). Conventionally, endometrial receptivity is seen as a dichotomous outcome (present or absent), but we propose that various levels of endometrial receptivity exist within the window of implantation. For instance, different transcriptomic signatures could represent varying levels of endometrial receptivity, which can be linked to different pregnancy outcomes. Many studies reported the means of a particular biomarker in those who achieved a pregnancy compared with those who did not. However, extreme values of a biomarker (as opposite to the means) may have significant prognostic and diagnostic implications that are not captured in the means. Therefore, we suggest reporting the outcomes by categories of biomarker levels rather than reporting means of biomarker levels within clinical outcome groups.
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Affiliation(s)
- Laurentiu Craciunas
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Ioannis Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Justin Chu
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Tom Bourne
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Siobhan Quenby
- Tommy's National Centre for Miscarriage Research, University of Warwick, Coventry, UK
| | - Jan J Brosens
- Tommy's National Centre for Miscarriage Research, University of Warwick, Coventry, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Abstract
Recurrent implantation failure (RIF) is an uncommon, imprecisely defined clinical disorder characterized by failure to achieve pregnancy after repeated embryo transfers. The diverse etiologies and incomplete understanding of RIF provide significant diagnostic and therapeutic challenges to patients and providers. Careful clinical evaluation prior to assisted reproduction can uncover many treatable causes, including thyroid dysfunction, submucosal myomas, and tobacco use. The more-subtle causes often require a more-targeted assessment. Undetected, small polyps or small areas of intrauterine synechiae are relatively common and easily treated contributors to RIF. Molecular and cellular abnormalities pose a greater therapeutic challenge. Putative causes of RIF, including progesterone resistance, shifted window of receptivity, decreased integrin expression, and immunologic disturbances, should be considered in the evaluation of a patient with otherwise unexplained RIF. It may also be true that a more complex and standardized definition of RIF would be helpful in these cases. In this paper, we review the diagnostic and therapeutic approaches to RIF, with emphasis on disorders of endometrial receptivity.
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Affiliation(s)
- Sarah Moustafa
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Steven L Young
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Casper RF. Frozen embryo transfer: evidence-based markers for successful endometrial preparation. Fertil Steril 2020; 113:248-251. [DOI: 10.1016/j.fertnstert.2019.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 12/24/2022]
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Boynukalin FK, Gultomruk M, Turgut E, Demir B, Findikli N, Serdarogullari M, Coban O, Yarkiner Z, Bahceci M. Measuring the serum progesterone level on the day of transfer can be an additional tool to maximize ongoing pregnancies in single euploid frozen blastocyst transfers. Reprod Biol Endocrinol 2019; 17:102. [PMID: 31783865 PMCID: PMC6884867 DOI: 10.1186/s12958-019-0549-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Endometrial preparation with hormone replacement therapy (HRT) is the preferred regimen for clinicians due to the opportunity to schedule the day of embryo transfer and for patients due to the requirement of fewer visits for frozen-warmed embryo transfers (FET). The increasing number of FETs raises the question of the serum P levels required to optimize the pregnancy outcome on the embryo transfer day. METHODS This prospective cohort study includes patients who underwent single euploid FET. All patients received HRT with oestradiol valerate (EV) and 100 mg of intramuscular (IM) progesterone (P). FET was scheduled 117-120 h after the first IM administration of 100 mg P. The serum P level was analyzed 1 h before the embryo transfer (ET). In all cycles, only embryos that were biopsied on day 5 were utilized for FET. Next generation sequencing (NGS) was used for comprehensive chromosomal analysis. RESULTS Overall, the ongoing pregnancy rate (OPR) was 58.9% (99/168). Data were then categorized according to the presence (Group I; n = 99) or the absence (Group II; n = 69) of an ongoing pregnancy. No significant differences regarding, female age, body mass index (BMI), number of previous miscarriages, number of previous live birth, sperm concentration, number of oocytes retrieved, number of mature oocytes (MII), rate of fertilized oocytes with two pronuclei (2PN), trophectoderm score, inner cell mass (ICM) score, endometrial thickness (mm), oestrodiol (E2) and P levels prior to IM P administration were found between two groups. The P levels on the day of ET (ng/ml) were significantly higher in Group I (28 (5.6-76.4) vs 16.4 (7.4-60) p = 0.039). The P level on the day of ET was a predictor of a higher OPR (p < 0.001 OR: 1.033 95%CI [1.009-1.056]) after multivariate analysis. The ROC curve showed a significant predictive value of serum P levels on the day of ET for OPR, with an AUC (95%CI) = 0.716 (0.637-0.795). The optimal cut-off value for prediction of the OPR was a P level of 20.6 ng/ml (71.7% sensitivity, 56.5% specificity). CONCLUSIONS The present study suggests a minimum threshold of the serum P value on the day of ET that needs to be reached in HRT cycles to optimize the clinical outcome. Individualization of the P dosage should be evaluated in further studies.
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Affiliation(s)
| | - Meral Gultomruk
- Bahceci Health Group, Hakki Yeten Cad. No: 11 Terrace Fulya, Fulya, Istanbul, Turkey
| | - Emre Turgut
- Bahceci Health Group, Hakki Yeten Cad. No: 11 Terrace Fulya, Fulya, Istanbul, Turkey
| | - Berfu Demir
- Bahceci Health Group, Hakki Yeten Cad. No: 11 Terrace Fulya, Fulya, Istanbul, Turkey
| | - Necati Findikli
- Bahceci Health Group, Hakki Yeten Cad. No: 11 Terrace Fulya, Fulya, Istanbul, Turkey
| | | | - Onder Coban
- Bahceci Health Group, Hakki Yeten Cad. No: 11 Terrace Fulya, Fulya, Istanbul, Turkey
| | - Zalihe Yarkiner
- Department of Statistics, Cyprus Science University, 99320 Dr. Fazil Kucuk Cad. Ozankoy, Kyrenia, Cyprus
| | - Mustafa Bahceci
- Bahceci Health Group, Hakki Yeten Cad. No: 11 Terrace Fulya, Fulya, Istanbul, Turkey
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Fox CW, Savaris RF, Jeong JW, Kim TH, Miller PB, Likes CE, Schammel DP, Young SL, Lessey BA. Unexplained recurrent pregnancy loss and unexplained infertility: twins in disguise. Hum Reprod Open 2019; 2020:hoz021. [PMID: 36694811 PMCID: PMC9869655 DOI: 10.1093/hropen/hoz021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/07/2019] [Indexed: 01/27/2023] Open
Abstract
STUDY QUESTION Is B-cell CLL/lymphoma 6 (BCL6) endometrial expression, a surrogate biomarker of endometriosis, elevated in women with unexplained recurrent pregnancy loss (uRPL) and unexplained infertility (UI) compared to fertile subjects? SUMMARY ANSWER Endometrial BCL6 expression is elevated to a similar degree in women with uRPL and UI compared to fertile controls. WHAT IS KNOWN ALREADY Endometriosis has been linked to the genesis of endometrial progesterone resistance and to specific nuclear proteins, including endometrial BCL6. BCL6 overexpression (immune histologic score > 1.4) has been strongly associated with poor reproductive outcomes in IVF cycles in women with UI. Our previous data have demonstrated an accuracy of 94% for diagnosing endometriosis, and BCL6 protein is elevated in the decidua of women with uRPL. STUDY DESIGN SIZE DURATION In this case-control study, at a tertiary university teaching hospital, 110 samples (control n = 28; uRPL n = 29; UI n = 53) from pathological archives were analyzed. Timed endometrial biopsies were obtained between 2 January 2002 and 31 December 2016. PARTICIPANTS/MATERIALS SETTING METHOD LH-timed endometrial biopsies were obtained from women with UI, uRPL (two or more consecutive losses) and normal fertile subjects during the mid-secretory phase of the menstrual cycle. Endometrial BCL6 protein levels were compared in women with UI and uRPL and fertile controls using western blot analysis and immunohistochemistry (HSCORE). MAIN RESULTS AND THE ROLE OF CHANCE The mean age of the uRPL group was significantly higher than the others [mean (SD)] control = 32.7 (2.6); uRPL = 35.8 (3.7); UI = 32.7 (4.4); P = 0.002, ANOVA]. Seventy-nine percent of women in both subfertile groups (uRPL and UI, 65 out of 82) displayed elevated BCL6 protein levels. From these, a subset of cases with abnormal BCL6 went to laparoscopy and endometriosis was found in 9 out of 11 cases of uRPL and in 20 out of 21 cases of UI. Median BCL6 HSCORE for controls versus uRPL and UI was significantly different [median (interquartile); control = 0.3 (0.02 to 0.5); uRPL = 3 (1.9 to 3.6); UI = 2.9 (1.6 to 3.1); P < 0.0001, Kruskal-Wallis]. A significant trend in the association between the degree of infertility (fertile, uRPL and UI) and the HSCORE level (negative, medium and high) was found (P < 0.001; x 2 for trend). Western blot of representative samples from each group demonstrated similar findings based on protein levels in the whole endometrium. After running ANCOVA analysis for age difference, the BCL6 difference among groups was still significant (P-value < 0.0001). LIMITATIONS REASONS FOR CAUTION We studied subjects with two consecutive pregnancy losses rather than the definition adopted in Europe of three losses. The findings may lack external validity in other clinical settings (e.g. low prevalence of endometriosis). WIDER IMPLICATIONS OF THE FINDINGS Based on the data presented here, we postulate that the degree of BCL6 expression may represent a continuum of progesterone resistance and response to inflammation that occurs in women with endometriosis, yielding different degrees of infertility, from uRPL to UI. STUDY FUNDING/COMPETING INTERESTS This study was supported by NICHD/NIH R01 HD067721 (SLY and BAL), by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior: Grant 99999.003035/2015-08 (BAL) and by CAPES/PROAP (RFS). Two authors (BAL, SLY) have licensed intellectual property for the detection of endometriosis. Dr Bruce Lessey is an unpaid scientific Advisor for CiceroDx. The other authors report no conflict of interest.
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Affiliation(s)
- Chelsea W Fox
- University of San Diego, Department of Obstetrics and Gynecology, San Diego, CA, USA
| | - Ricardo F Savaris
- Departamento de Ginecologia e Obstetrícia, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-903, Brazil
| | - Jae-Wook Jeong
- Obstetrics, Gynecology and Reproductive Biology of Michigan State University, Grand Rapids, MI 49503, USA
| | - Tae Hoon Kim
- Obstetrics, Gynecology and Reproductive Biology of Michigan State University, Grand Rapids, MI 49503, USA
| | - Paul B Miller
- Obstetrics and Gynecology, Greenville Health System, Greenville, SC 29605, USA
| | - Creighton E Likes
- Obstetrics and Gynecology, Greenville Health System, Greenville, SC 29605, USA
| | - David P Schammel
- Pathology Associates, Greenville Health System, Greenville, SC, USA
| | - Steven L Young
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Bruce A Lessey
- Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Wake Forest Health, Winston-Salem, NC 27157, USA
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Should we stop offering endometrial scratching prior to in vitro fertilization? Fertil Steril 2019; 111:1094-1101. [PMID: 31155116 DOI: 10.1016/j.fertnstert.2019.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 12/12/2022]
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Lessey BA, Young SL. What exactly is endometrial receptivity? Fertil Steril 2019; 111:611-617. [PMID: 30929718 DOI: 10.1016/j.fertnstert.2019.02.009] [Citation(s) in RCA: 166] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 01/10/2023]
Abstract
Endometrial receptivity is a complex process that provides the embryo with the opportunity to attach, invade, and develop, culminating in a new individual and continuation of the species. The window of implantation extends 3-6 days within the secretory phase in most normal women. In certain inflammatory or anatomic conditions, this window is narrowed or shifted to preclude normal implantation, leading to infertility or pregnancy loss. Of the factors that prevent normal implantation and pregnancy, embryo and endometrial quality share responsibility. In this review, we highlight the advances in the study of implantation from the perspective of the endometrium, normally a barrier to implantation. New advances will allow the early identification of defects in endometrial receptivity and provide new avenues for treatment that promote successful establishment of pregnancy.
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Affiliation(s)
- Bruce A Lessey
- Department of Obstetrics and Gynecology, Wake Forest Baptist Health, Winston-Salem, North Carolina.
| | - Steven L Young
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Kliman HJ, Frankfurter D. Clinical approach to recurrent implantation failure: evidence-based evaluation of the endometrium. Fertil Steril 2019; 111:618-628. [PMID: 30929719 DOI: 10.1016/j.fertnstert.2019.02.011] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/12/2019] [Indexed: 01/08/2023]
Abstract
The endometrium is a dynamic, repetitively cycling tissue that mediates the implantation of the blastocyst. Evaluation of this complex tissue necessitates sophisticated methods that can assess its functional potential. Beginning in the 1950s with simple histological endometrial "dating," these methods have crossed into the molecular era with the use of arrays aimed at dating, functional tests that assess for proliferation and differentiation, and tests that screen for inflammatory markers. In addition to these specialized tests, histologic evaluation for pathologic conditions-such as growth disorders (i.e. polyps and hyperplasia), inflammatory lesions, and retained products of conception-are critical for a complete assessment of the patient with recurrent implantation failure. Whatever the means of testing, the goal is to reveal actionable findings that can assist in offering the best options to patients who have failed multiple transfers with high quality embryos.
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Affiliation(s)
- Harvey J Kliman
- Reproductive and Placental Research Unit, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
| | - David Frankfurter
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Fertility and IVF, George Washington University School of Medicine and Health Sciences, Washington, D.C
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Likes CE, Cooper LJ, Efird J, Forstein DA, Miller PB, Savaris R, Lessey BA. Medical or surgical treatment before embryo transfer improves outcomes in women with abnormal endometrial BCL6 expression. J Assist Reprod Genet 2019; 36:483-490. [PMID: 30610661 PMCID: PMC6439015 DOI: 10.1007/s10815-018-1388-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/14/2018] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the effect of medical or surgical treatment prior to embryo transfer in women with elevated endometrial BCL6 expression and suspected endometriosis in a prospective, cohort study design at a university-associated infertility clinic. METHODS All subjects had at least 1 year of unexplained infertility (UI) and each prospectively underwent endometrial biopsy and immunostaining for the oncogene BCL6, prior to embryo transfer during an assisted reproductive technology (ART) cycle. To be included, subjects had to have an abnormal BCL6 result, defined by elevated HSCORE ≥ 1.4. Women that were pre-treated with laparoscopy or medical suppression with GnRH agonist (depot leuprolide acetate; Lupron®, Abbvie, Inc., Chicago, IL) for 2 months were compared to a group that went untreated (controls). Endpoints included implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR), and as well as cycle characteristics. Miscarriage rate were also compared between treatment and control group. RESULTS Women in each group had similar characteristics. Those treated by medical suppression and those undergoing laparoscopy for endometriosis had a significantly higher LBR, (5/10; 50%; 95%CI 23.7 to 76.3%) and (11/21; 52.4%; 95%CI 32.4 to 71.7), respectively, compared to controls (4/54; 7.4%; 95%CI 2.9 to 17.6). An absolute benefit of 44.2% (16/31; 95%CI 24.6 to 61.2) and a number need to treat of 3 for those that received treatment (medical suppression and laparoscopy), compared to no treatment. Miscarriages were significantly more common in the control group. CONCLUSIONS Women with suspected endometriosis and aberrant endometrial BCL6 expression have worse reproductive outcomes following embryo transfer, including a high miscarriage rate, poor IR, and low LBR and CPR compared to cycles pre-treated with medical and surgical management.
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Affiliation(s)
- Creighton E Likes
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA
| | - Leah J Cooper
- Obstetrics and Gynecology, University of South Carolina SOM-Greenville, 900 Grove Rd, Greenville, SC, USA
| | - Jessica Efird
- Obstetrics and Gynecology, University of South Carolina SOM-Greenville, 900 Grove Rd, Greenville, SC, USA
| | - David A Forstein
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA
| | - Paul B Miller
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA
| | - Ricardo Savaris
- Departamento de Ginecologia e Obstetrícia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-903, Brazil
| | - Bruce A Lessey
- Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Rd, Ste 470, Greenville, SC, 29605, USA.
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Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach? Fertil Steril 2018; 110:1218-1226. [DOI: 10.1016/j.fertnstert.2018.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/01/2023]
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Mol BW, Bossuyt PM, Sunkara SK, Garcia Velasco JA, Venetis C, Sakkas D, Lundin K, Simón C, Taylor HS, Wan R, Longobardi S, Cottell E, D'Hooghe T. Personalized ovarian stimulation for assisted reproductive technology: study design considerations to move from hype to added value for patients. Fertil Steril 2018; 109:968-979. [DOI: 10.1016/j.fertnstert.2018.04.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 12/20/2022]
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