How does endometriosis affect infertility?

Retinoic Acid Action in Cumulus Cells: Implications for Oocyte Development and In Vitro Fertilization

In the field of human in vitro fertilization (IVF), selecting the best oocyte for freezing or embryo for transfer remains an important focus of clinical practice. Although several techniques are and have been used for this goal, results have generally not been favorable and/or are invasive such that damage to some embryos occurs, resulting in a reduced number of healthy births. Therefore, the search continues for non-invasive oocyte and embryo quality markers that signal the development of high-quality embryos. Multiple studies indicate the important positive effects of retinoic acid (RA) on oocyte maturation and function. We previously showed that a high follicular fluid (FF) RA concentration at the time of oocyte retrieval in IVF protocols was associated with oocytes, giving rise to the highest quality embryos, and that cumulus granulosa cells (CGCs) are the primary source of follicle RA synthesis. Data also demonstrated that connexin-43 (Cx43), the main connexin that forms gap junctions in CGCs, is regulated by RA and that RA induces a rapid increase in gap junction communication. Here, we hypothesize that CGC RA plays a causal role in oocyte competency through its action on Cx43 and, as such, may serve as a biomarker of oocyte competence. Multiple studies have demonstrated the requirement for Cx43 in CGCs for the normal progression of folliculogenesis, and that the increased expression of this connexin is linked to the improved developmental competence of the oocyte. The data have shown that RA can up-regulate gap junction intercellular communication (GJIC) in the cumulus-oocyte complex via a non-genomic mechanism that results in the dephosphorylation of Cx43 and enhanced GJIC. Recognizing the positive role played by gap junctions in CGCs in oocyte development and the regulation of Cx43 by RA, the findings have highlighted the possibility that CGC RA levels may serve as a non-invasive indicator for selecting high-quality oocytes for IVF procedures. In addition, the data suggest that the manipulation of Cx43 with retinoid compounds could provide new pharmacological approaches to improve IVF outcomes in cases of failed implantation, recurrent miscarriage, or in certain diseases that are characterized by reduced fecundity, such as endometriosis.

Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

The rate of oocytes with granular cytoplasm is higher in women with endometrioma in ICSI cycles

The purpose of this study was to investigate the impact of endometrioma on oocyte morphology and fertility outcome in intracytoplasmic sperm injection (ICSI)cycles. The study material was obtained from 114 ICSI cycles of infertile women aged between 20 and 38 years with ovarian endometriomas and unexplained infertility. In total, 644 mature oocytes were included in the analysis. The rates of specific oocyte morphological abnormalities were similar between the two groups however the central granulation rate was significantly higher in the group with endometrioma (p < .05). Fertilisation rate were not significantly different between the groups (p ≥ .05) however the numbers of metaphase 2 (MII) oocytes and embryos were lower in the endometrioma group (p ≤ .05). Endometrioma was associated with a higher rate of oocytes with granular cytoplasm, despite the fertilisation rate the numbers of the MII oocytes and embryo were affected.IMPACT STATEMENTWhat is already known on this subject? The association between endometrioma and infertility is a well-known condition, but the possible mechanisms of the effects of endometrioma on women's fertility is still debated and controversial. There is limited data on the effect of endometrioma on oocyte morphology. Low oocyte quality and lower fertilisation rates might be the main cause of adverse pregnancy outcomes during in vitro fertilisation/intracytoplasmic sperm injection cycles.What do the results of this study add? Endometrioma was associated with a higher rate of oocytes with granular cytoplasm, and lower metaphase 2 oocytes and embryos.What are the implications of these findings for clinical practice and/or further research? Future studies using further oocyte quality assessment methods and prospective observational studies including live-birth rate should be designed to better understand how endometrioma affects fertility outcomes.

The search for assisted reproduction: profile of patients seen in the fertility outpatient clinic of a public hospital

OBJECTIVE

To analyze the epidemiological profile of patients treated at the Fertility Outpatient Clinic of a tertiary public hospital in Juiz de Fora.

METHODS

This cross-sectional study analyzed the medical records of 448 patients who sought fertility treatment at a tertiary public hospital. The data collected from the medical records were used to assess the main causes of infertility, find the most frequently performed procedures, and the cases eligible to therapeutic or prophylactic intervention.

RESULTS

Of the 448 patients included in the study, 385 (86%) sought fertility consultation, 49 (10%) came in for repeated miscarriages, and 14 (3%) for other reasons. Of the 438 infertile patients, 280 (63.9%) had primary and 158 (36.1%) had secondary infertility. The top-three conditions of the 295 patients with established diagnoses were chronic anovulation (n=98; 33%); tubal factor infertility (n=86; 29%); and male factor infertility (n=59; 20%).

CONCLUSIONS

Improving care in reproductive health requires a more profound comprehension of the epidemiological profile of patients seeking treatment. There are alternative cost-effective means to contain the development of infertility. Additional expenditure in public healthcare is needed to accommodate the growing number of individuals seeking fertility treatment in Brazil.

Effect of Maternal Advanced Endometriosis on Risk of Congenital Malformations for Infants Born After in vitro Fertilization and Frozen-Thawed Embryo Transfer: Analysis of 28,600 Newborns

Background: Endometriosis is one of the most challenging diseases for doctors helping infertile women conceive, which has become a common method to help maternal endometriosis-associated infertility. Women with advanced endometriosis possess a higher risk of several adverse outcomes both during pregnancy and at the time of delivery. Whether endometriosis gives rise to a higher occurrence of congenital abnormalities in infants via in vitro fertilization and frozen-thawed embryo transfer (IVF-ET) remains unknown. Methods: Data collected on 22,865 women undergoing IVF using a freeze-all strategy from 2007 to 2017 were analyzed to estimate the rate of congenital malformations. We used an adjusted OR to compare the fertility outcomes of women with advanced endometriosis to the control group. Results: We studied 1,495 infants born from women with advanced endometriosis and 27,105 infants born from endometriosis-free women. There was a 1.557-fold risk that the infants with advanced maternal endometriosis would develop a congenital malformation (adjusted OR: 1.557, 95% CI: 1.03-2.35). Compared with singletons, twins were 1.957 times more likely to experience an adverse outcome (OR: 1.957, 95% CI: 1.561-2.455). When analyzing specific categories of birth defects, the proportion of circulatory system defects was higher than the other categories of birth defects in total (0.56%), followed by musculoskeletal system defects (0.15%). Conclusions: Maternal advanced endometriosis might increase the risk of congenital malformations for infants born after IVF-ET. The organ system most frequently affected by congenital malformations was the cardiovascular system, followed by the musculoskeletal system.

Uterine Cavity Abnormalities in Patients with Endometriosis in Alexandria: A Diagnostic Test Accuracy Study

Endometriosis is strongly associated with infertility. Endometrial polyps are prevalent in infertile women and they have similar pathological characteristics to endometriosis, suggesting a possible association. Uterine malformations as uterine septum and hypoplastic uterus are also linked to endometriosis. Hysterosalpingogram and transvaginal ultrasonography are used to diagnose endometrial lesions. Hysteroscopy can detect small lesions that might be missed. Recently, 4D ultrasonography is being used, but which is superior has not been established yet. We aim to compare 4D ultrasonography to office hysteroscopy in evaluating uterine cavity in cases with endometriosis; also we aim at correlating these findings with the stage of endometriosis. 50 cases of endometriosis diagnosed by laparoscopy were randomly selected from El Shatby fertility clinic, Alexandria University, Egypt, with exclusion of cases with any previous intrauterine surgery or any hormonal treatment. Transvaginal 4D ultrasonography and office hysteroscopy were done. 4D ultrasonography agreed with office hysteroscopy in diagnosing abnormal uterine findings in 14 cases and four additional cases were diagnosed by hysteroscopy alone. Conclusion. Endometrial polyps, septate uterus, and hypoplastic uterus are more prevalent among infertile women who happen to have endometriosis. 4D ultrasonography and office hysteroscopy are equally successful in assessing the uterine cavity.

Research Priorities for Endometriosis

The 3rd International Consensus Workshop on Research Priorities in Endometriosis was held in São Paulo on May 4, 2014, following the 12th World Congress on Endometriosis. The workshop was attended by 60 participants from 19 countries and was divided into 5 main sessions covering pathogenesis/pathophysiology, symptoms, diagnosis/classification/prognosis, disease/symptom management, and research policy. This research priorities consensus statement builds on earlier efforts to develop research directions for endometriosis. Of the 56 research recommendations from the 2011 meeting in Montpellier, a total of 41 remained unchanged, 13 were updated, and 2 were deemed to be completed. Fifty-three new research recommendations were made at the 2014 meeting in Sao Paulo, which in addition to the 13 updated recommendations resulted in a total of 66 new recommendations for research. The research recommendations published herein, as well as those from the 2 previous papers from international consensus workshops, are an attempt to promote high-quality research in endometriosis by identifying and agreeing on key issues that require investigation. New areas included in the 2014 recommendations include infertility, patient stratification, and research in emerging nations, in addition to an increased focus on translational research. A revised and updated set of research priorities that builds on this document will be developed at the 13th World Congress on Endometriosis to be held on May 17-20, 2017, in Vancouver, British Columbia, Canada.

A Western Primer of Chinese Herbal Therapy in Endometriosis and Infertility

Endometriosis is a disease that affects approximately 10% of all reproductive-aged women and the prevalence rises to 20–50% in infertile women. There is growing evidence that medicinal Chinese herbs with pain-alleviating and anti-inflammatory properties may be useful in the treatment of endometriosis and infertility, but the mechanisms of action of these herbs have yet to be investigated. In addition, studies of adequate design, sample size and appropriate control are lacking. Therefore, prospective randomized, controlled studies to evaluate the efficacy, mechanism of action and toxicities of Chinese herbs in the treatment endometriosis and infertility are needed.

Dexamethasone attenuates the embryotoxic effect of endometriotic peritoneal fluid in a murine model

PURPOSE

The in vitro fertilization (IVF) pregnancy rate of women with advanced stage endometriosis is nearly half that of the general population, suggesting incomplete targeting of the pathophysiology underlying endometriosis-associated infertility. Compelling evidence highlights inflammation as the etiologic link between endometriosis and infertility and a potential target for adjunctive treatment. The objective of this study was to examine the effect of dexamethasone on murine embryos exposed to human endometriotic peritoneal fluid (PF) using the established murine embryo assay model.

METHODS

PF was obtained from women with and without severe endometriosis. Murine embryos were harvested and randomly allocated to five groups of culture media conditions: (1) human tubal fluid (HTF), (2) HTF and 10 % PF from women without endometriosis, (3) HTF and 10 % PF from women with endometriosis (PF-E), (4) HTF with PF-E and 0.01 mcg/mL dexamethasone, and (5) HTF with PF-E and 0.1 mcg/mL dexamethasone. Embryos were cultured in standard conditions and evaluated for blastocyst development.

RESULTS

A total of 266 mouse embryos were cultured. Baseline blastulation rates were 63.6 %. The addition of peritoneal fluid from women with endometriosis decreased the blastocyst development rate to 38.9 % (P = 0.008). The addition of 0.1 mcg/mL of dexamethasone to the culture media restored the blastulation rate to near baseline levels (61.2 %; P = 0.019).

CONCLUSIONS

The results of our in vitro study demonstrate the capacity of dexamethasone to mitigate the deleterious impact of endometriotic PF on embryo development. If confirmed in vivo, dexamethasone may prove a useful adjunct for the treatment of endometriosis-associated infertility.

Oocyte quality is decreased in women with minimal or mild endometriosis

Endometriosis, a pathological condition in which the endometrium grows outside the uterus, is one of the most common causes of female infertility; it is diagnosed in 25–40% of infertile women. The mechanism by which endometriosis affects the fertility of females remains largely unknown. We examined the ultrastructure of oocytes from patients with minimal or mild endometriosis and control females undergoing in vitro fertilization (IVF) treatment by transmission electron microscopy (TEM) to investigate the physiological significance of oocyte quality for patients with minimal or mild endometriosis. The TEM results revealed that the oocytes from women with minimal or mild endometriosis exhibited abnormal mitochondrial structure and decreased mitochondria mass. Quantitative real time PCR analysis revealed that the mitochondrial DNA copy number was significantly reduced in the oocytes from women with minimal or mild endometriosis compared with those of the control subjects. Our results suggest that decreased oocyte quality because of impaired mitochondrial structure and functions probably an important factor affecting the fertility of endometriosis patients.

Preoperative serum anti-mullerian hormone level in women with ovarian endometrioma and mature cystic teratoma

PURPOSE

To investigate whether preoperative serum anti-mullerian hormone (AMH) levels are lower in women with ovarian endometrioma and in women with mature cystic teratoma of the ovaries.

MATERIALS AND METHODS

In a tertiary university hospital, a retrospective case-control study was performed. Serum AMH levels between an advanced (stage III and IV) endometrioma group (n=102) and an age- and body mass index (BMI)-matched control group were compared. Serum AMH levels between an ovarian mature cystic teratoma group (n=48) and age- and BMI-matched controls were also compared.

RESULTS

Absolute serum AMH and multiples of the median for AMH (AMH-MoM) relevant to Korean standards were lower in the endometrioma group than controls, but this was not statistically significant (mean±SEM, 2.9±0.3 ng/mL vs. 3.3±0.3 ng/mL, p=0.28 and 1.3±0.1 vs. 1.6±0.1, p=0.29, respectively). Specifically, the stage IV endometriosis group (n=51) exhibited significantly lower serum AMH and AMH-MoM (2.1±0.3 vs. 3.1±0.4 ng/mL, p=0.02 and 1.1±0.1 vs. 1.7±0.2, p=0.03, respectively). Serum AMH and AMH-MoM levels were similar between stage III endometriosis and controls (3.7±0.5 vs. 3.4±0.5 ng/mL and 1.6±0.2 vs. 1.5±0.2, respectively), as well as between the mature cystic teratoma group and controls (4.0±0.5 ng/mL vs. 4.0±0.5 ng/mL and 1.6±0.2 vs. 1.6±0.3, respectively). Interestingly, AMH-MoM level was negatively correlated with endometriosis score with statistical significance (r²=0.13, p<0.01).

CONCLUSION

In women with advanced ovarian endometrioma, preoperative serum AMH values tended to be lower than those for age and BMI-matched controls. Notably, stage IV endometrioma appeared to be closely associated with decreased ovarian reserve, even before operation. Clinicians should keep this information in mind before undertaking surgery of ovarian endometrioma.

Cellular and molecular basis for endometriosis-associated infertility

Endometriosis is a gynecological disease characterized by the presence of endometrial glandular epithelial and stromal cells growing in the extra-uterine environment. The disease afflicts 10%–15% of menstruating women causing debilitating pain and infertility. Endometriosis appears to affect every part of a woman’s reproductive system including ovarian function, oocyte quality, embryo development and implantation, uterine function and the endocrine system choreographing the reproductive process and results in infertility or spontaneous pregnancy loss. Current treatments are laden with menopausal-like side effects and many cause cessation or chemical alteration of the reproductive cycle, neither of which is conducive to achieving a pregnancy. However, despite the prevalence, physical and psychological tolls and health care costs, a cure for endometriosis has not yet been found. We hypothesize that endometriosis causes infertility via multifaceted mechanisms that are intricately interwoven thereby contributing to our lack of understanding of this disease process. Identifying and understanding the cellular and molecular mechanisms responsible for endometriosis-associated infertility might help unravel the confounding multiplicities of infertility and provide insights into novel therapeutic approaches and potentially curative treatments for endometriosis.

Impact of endometriosis on in vitro fertilization and embryo transfer cycles in young women: a stage-dependent interference

OBJECTIVE

Endometriosis is a frequent indication for in vitro fertilization and embryo transfer (IVF-ET). Its influence on IVF-ET cycles remains controversial. We evaluated the impact of the severity of endometriosis on IVF-ET cycles in young women.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary referral centre.

SAMPLE AND METHODS

In a retrospective cohort analysis, 164 IVF-ET cycles in 148 women with endometriosis-associated infertility were analyzed. Eighty cycles performed during the same period on 72 consecutive women with tubal infertility were considered as controls. All patients were younger than 35 years old.

MAIN OUTCOME MEASURES

Response to controlled ovarian hyperstimulation (COH), number of oocytes retrieved, fertilization, implantation and pregnancy rate (PR).

RESULTS

Clinical PR was lower in the group with endometriosis (all stages) in comparison with the tubal factor group. Higher total gonadotropin requirements, lower response to COH and lower oocyte yield were also found in the endometriosis group. Stage-stratified analysis showed a lower fertilization rate in stage I-II (52.6% stage I-II, 70.5% stage III-IV and 71.9% tubal factor). In stage III-IV endometriosis there was a higher cycle cancellation rate, a reduced response to COH and a lower PR compared with both the stage I-II and the tubal infertility groups (PR 9.7, 25 and 26.1%, respectively).

CONCLUSIONS

Stage III-IV was strongly associated with poor IVF outcome. A decreased fertilization rate in stage I-II might be a cause of subfertility in these women, owing to a hostile environment caused by the disease.

The endometrial response to chorionic gonadotropin is blunted in a baboon model of endometriosis

Endometriosis-associated infertility has a multifactorial etiology. We tested the hypothesis that the endometrial response to the early embryonic signal, human chorionic gonadotropin (hCG), alters over time in a nonhuman primate model of endometriosis. Animals with experimental or spontaneous endometriosis were treated with hCG (30 IU/d), from d 6 after ovulation for 5 d, via an oviductal cannula. Microarray analysis of endometrial transcripts from baboons treated with hCG at 3 and 6 months of disease (n=6) identified 22 and 165 genes, respectively, whose levels differed more than 2-fold compared with disease-free (DF) animals treated with hCG (P<0.01). Quantitative RT-PCR confirmed abnormal responses of known hCG-regulated genes. APOA1, SFRP4, and PAPPA, which are normally down-regulated by hCG were up-regulated by hCG in animals with endometriosis. In contrast, the ability of hCG to induce SERPINA3 was lost. Immunohistochemistry demonstrated dysregulation of C3 and superoxide dismutase 2 proteins. We demonstrate that this abnormal response to hCG persists for up to 15 months after disease induction and that the nature of the abnormal response changes as the disease progresses. Immunohistochemistry showed that this aberrant gene expression was not a consequence of altered LH/choriogonadotropin receptor distribution in the endometrium of animals with endometriosis. We have shown that endometriosis induces complex changes in the response of eutopic endometrium to hCG, which may prevent the acquisition of the full endometrial molecular repertoire necessary for decidualization and tolerance of the fetal allograft. This may in part explain endometriosis-associated implantation failure.

Endometriosis and in vitro fertilisation: a review

This review aims to evaluate whether severe endometriosis has an impact on the outcome of in vitro fertilisation (IVF), whether IVF is associated with specific complications in this context, whether a specific ovarian stimulation protocol is most appropriate, whether the endometrial condition progresses following ovarian stimulation, and whether endometrial cysts pose a specific problem for IVF. In patients with severe endometriosis, IVF represents an effective treatment option for infertility, as a complement to surgery. The prognostic parameters of IVF are identical to those of other patients. However, the risks related to the severity of endometriosis, particularly the risk of ovarian deficiency, need to be considered. Because of this issue, to which endometriosis-related pain often adds, IVF treatment should be initiated as early as possible, using appropriate protocols and after having fully informed the patient about the specific oocytes retrieval-related risks.

Anti muellerian hormone serum levels in women with endometriosis: a case-control study

OBJECTIVE

To compare the anti muellerian hormone (AMH) serum levels in women with and without endometriosis.

DESIGN

A case-control study

SETTING

Women's General Hospital, Linz, Austria.

PATIENT(S)

Our study included a total of 909 patients undergoing in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) treatment or consulting our specific endometriosis unit. After proofing the exclusion criteria, 153 of these patients with endometriosis (study group) were matched with 306 patients undergoing IVF/ICSI treatment because of a male factor (control group).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

AMH serum level.

RESULTS

Mean AMH serum level was significantly lower in the study than in the control group (2.75 + or - 2.0 ng/ml vs. 3.46 + or - 2.30 ng/ml, p < 0.001). In women with mild endometriosis (rAFS I-II), the mean AMH level was almost equal to the control group (3.28 + or - 1.93 ng/ml vs. 3.44 + or - 2.06 ng/ml; p = 0.61). A significant difference in mean AMH serum level was found between women with severe endometriosis (rAFS III-IV) and the control group (2.38 + or - 1.83 ng/ml vs. 3.58 + or - 2.46 ng/ml; p < 0.0001).

CONCLUSION

Lower AMH serum levels and an association with the severity were found in women with endometriosis. Physicians have to be aware of this fact. Because of the expected lower response on a controlled ovarian hyperstimulation (COH), AMH serum level should be measured to optimise the dose of gonadotropin treatment previous to a COH, especially in women with severe endometriosis.

The impact of endometriosis, endometrioma and ovarian cystectomy on assisted reproductive technology

Purpose

To assess outcomes in assisted reproductive technology (ART) in infertile women with endometriosis with respect to their concomitant endometrioma status and surgical history in our department.

Methods

This is a retrospective case control study which analyzes informational data obtained at a university hospital. The study drew from a patient pool of 332 cases (877 cIVF/ICSI cycles) that took place in our department from 2006 to 2008. Sixty-one cases (97 cycles) had major indications for cIVF/ICSI with endometriosis. We classified groups from these 61 cases as follows: an unoperated endometrioma group (A) with 31 cycles, a postoperative endometrioma group (B) with 51 cycles, and a no endometrioma group (C) with 15 cycles. We analyzed and compared these three groups and also included a non-endometriosis tubal infertility group (D) with 27 cycles.

Results

In the control group (D), serum FSH levels and the cancellation rates were significantly lower than those of other groups, and the number of developing follicles was higher. E2 levels before oocyte aspiration in the postoperative endometrioma group (B) was lower. Implantation, pregnancy, delivery and miscarriage rates were not significantly different among the four groups.

Conclusion

The results suggest that endometriosis causes a decrease in endocrinologic ovarian function whether or not an endometrioma is also present. As for E2 level before oocyte aspiration, our results suggest that ovarian reserves might be reduced by endometrioma excision, but this is difficult to evaluate. In the endometriosis groups, cancellation rates were significantly higher, although when embryos were transferred the pregnancy rates were not significantly different when compared with the non-endometriosis group. As for infertile women with endometriomas, our results suggest that preexisting ovarian reserve is reduced by the presence of endometriosis, and ovarian reserve might also be reduced by excision of endometriomas.

Reduced fecundity in female rats with surgically induced endometriosis and in their daughters: a potential role for tissue inhibitors of metalloproteinase 1

The cause of reduced fecundity in women with endometriosis is unknown. Expression of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) by both ectopic and eutopic endometrium reportedly has a role in the pathogenesis of endometriosis. We hypothesize that anomalous endometriotic TIMP protein synthesis, secretion, and localization also cause reproductive pathologies resulting in reduced fecundity. An established rat model for endometriosis (Endo) compared with nonendometriotic controls (Shams) was used to investigate reduced fecundity in endometriosis. Comparing Endo and Sham rats, Endo rats had altered ovarian dynamics, including fewer ovarian follicles and corpora lutea with luteinized unruptured follicles. Furthermore, in vivo anomalies in postovulatory oocyte structure and preimplantation embryo development, including misaligned chromosomes, nuclear and cytoplasmic fragmentation, and delayed or arrested cleavage, as well as spontaneous abortions, were found only in Endo rats. A causative role for TIMP1 in these phenomena is supported by our findings that Endo rats have more TIMP1 in their peritoneal fluid as detected by ELISA and more TIMP1 immunolocalization in the theca of antral follicles as measured by computer-assisted morphometric analysis. These data suggest that in endometriosis the accumulation of TIMP1 disrupts the normal MMP/TIMP enzymatic milieu in the peritoneal cavity and negatively affects ovarian dynamics, oocyte quality, and preimplantation embryo development, thereby decreasing fecundity. Most intriguingly, daughters of Endo rats that had no experimental interventions exhibited these same reproductive abnormalities. We predict that developmental exposure to endometriosis leads to permanent epigenetic changes in subsequent generations.

GnRH agonist and antagonist protocols for stage I–II endometriosis and endometrioma in in vitro fertilization/intracytoplasmic sperm injection cycles

OBJECTIVE

To investigate the outcomes of intracytoplasmic sperm injection (ICSI) cycles after controlled ovarian hyperstimulation (COH) with GnRH antagonist or GnRH agonist (GnRH-a) in mild-to-moderate endometriosis and endometrioma.

DESIGN

Prospective randomize trial.

SETTING

A private IVF center.

PATIENT(S)

A total of 246 ICSI cycles in 246 patients were divided into three groups: women with mild-to-moderate endometriosis (n = 98); women who had ovarian surgery for endometrioma (n = 81); women with endometrioma and no history of previous surgery (n = 67).

INTERVENTION(S)

Patients in each group were randomized to COH with either triptrolein or cetrorelix.

MAIN OUTCOME MEASURE(S)

Clinical parameters, characteristics of COH, and ICSI results were analyzed.

RESULT(S)

Outcomes of COH with both GnRH antagonist and GnRH-a were similar in patients with mild-to-moderate endometriosis. Implantation rates were 15.9% vs. 22.6% and clinical pregnancy rates were 27.5% vs. 39% with GnRH antagonist and GnRH-a protocols, respectively, in patients who had ovarian surgery for endometrioma. Implantation rates were 12.5% vs. 14.8% and clinical pregnancy rates were 20.5% vs. 24.2% with GnRH antagonist and GnRH-a protocols, respectively, in patients with endometrioma and no history of ovarian surgery.

CONCLUSION(S)

Considering the implantation and clinical pregnancy rates, COH with both GnRH antagonist and GnRH-a protocols may be equally effective in patients with mild-to-moderate endometriosis and endometrioma who did and did not undergo ovarian surgery.

Identification of molecular markers for endometriosis in blood lymphocytes by using deoxyribonucleic acid microarrays

OBJECTIVE

To identify molecular biomarkers for endometriosis in peripheral blood lymphocytes by using DNA microarrays.

DESIGN

Case-control.

SETTING

Multicenter academic research programs.

PATIENT(S)

Premenopausal women with or without endometriosis, determined by obstetrics and gynecology specialists during surgery. Microarray analysis included six endometriosis patients and five controls; 15 endometriosis patients and 15 controls were analyzed by using real-time reverse-transcription polymerase chain reaction (RT-PCR). Patients with all disease stages were included.

INTERVENTION(S)

Peripheral blood samples were collected by venipuncture.

MAIN OUTCOME MEASURE(S)

The expression levels of mRNAs in blood lymphocytes from endometriosis patients and controls were compared with those of a standard total RNA. Gene expression data were validated by real-time RT-PCR analysis.

RESULT(S)

A gene selection program identified genes that were differentially expressed in samples from endometriosis patients. To validate the gene expression data, the nine most discriminatory genes were analyzed by real-time RT-PCR. Two of the nine genes identified, IL2RG and LOXL1, were shown to be significantly differentially expressed.

CONCLUSION(S)

This is the first report of genes that are differentially expressed in peripheral blood lymphocytes of patients with endometriosis, which may provide important clues regarding the pathogenesis of this disease. Moreover, they could be considered potential targets for noninvasive diagnostic assays for endometriosis and need to be validated in a larger population.

Endométriose et infertilité

Relationship between infertility and endometriosis is still controversial. Many mechanisms have been reported such as anatomical disorders, biologic and cytological modifications of peritoneal liquid, functional ovarian and endometrial disorders, reduced embryo quality. Management of infertility related to endometriosis is difficult and no consensus has been published yet. Following recent clinical data, therapeutic strategies are discussed.

Effects of peritoneal fluid on preimplantation mouse embryo development and apoptosis in vitro

To evaluate the effect of peritoneal fluid (PF) on preimplantation mouse embryo development and apoptosis, PF was obtained from women presenting with (n = 7) and without endometriosis (n = 7). Mouse embryos were cultured to the blastocyst stage in human tubal fluid medium alone (control) or 10% PF. Embryo development was assessed and the total cell number per embryo was determined by Hoechst 33258 staining. Allocation of inner cell mass and trophectoderm in blastocysts, and incidence of apoptosis were determined using confocal microscopy. The blastocyst development rate was significantly lower in the presence of 10% PF (P < 0.01). Total cell number and trophectoderm in blastocysts cultured in culture media alone was significantly higher than in the presence of PF (P = 0.034 and P = 0.01 respectively). A higher incidence of apoptosis was seen in blastocysts cultured in culture media alone, compared with those cultured in the presence of PF (P = 0.04). PF decreases the development of early mouse embryos to the blastocyst stage, as well as the incidence of apoptosis in the resulting mouse blastocysts. No difference was seen in the effect of PF from women with and without endometriosis on mouse embryo development and apoptosis.

Effect of endometriosis on IVF/ICSI outcome: stage III/IV endometriosis worsens cumulative pregnancy and live-born rates

BACKGROUND

Women with endometriosis often need IVF to conceive-most women need several cycles of treatment.

METHODS

To evaluate the impact of moderate to severe endometriosis on cumulative IVF outcome, we carried out an observational study on 98 consecutive women who underwent IVF or ICSI treatment and had endometriosis diagnosed by laparoscopy or laparotomy and classified as minimal to mild endometriosis (American Society for Reproductive Medicine I/II) (n = 31) or moderate to severe endometriosis (American Society for Reproductive Medicine III/IV) (n = 67). The reference group consisted of 87 consecutive women with tubal infertility. The main outcome measures were cumulative pregnancy and live birth rates.

RESULTS

There was a significantly lower pregnancy rate per fresh embryo transfer after pooled cycles (1-4) among women with stage III/IV endometriosis (22.6%) compared to stage I/II group (40.0%) or tubal infertility (36.6%). After 1-4 IVF/ICSI treatments, including frozen embryo transfer, 56.7% of the women with stage III/IV endometriosis were pregnant and 40.3% gave birth. The corresponding values were 67.7/55.8% when endometriosis was stage I/II and 81.6/43.7% in the controls respectively.

CONCLUSION

Stage III/IV endometriosis means a worse prognosis for IVF/ICSI treatments compared to milder stages or tubal factors. Lower implantation and multiple pregnancy rates offer some support to our practice to continue two embryo transfers in this group.

Cytoplasmic transfer in the mouse in conjunction with intracytoplasmic sperm injection

Cytoplasmic transfer (CT) from a donor to a recipient oocyte has been used clinically to facilitate human pregnancies. Data reported here describe the first characterization of CT coincident with intracytoplasmic sperm injection in the mouse system. Sibling oocytes were used to transfer 2, 4, or 6 pl of ooplasm to a recipient egg along with a sperm head using piezo-actuated injection. Survival and fertilization after CT were comparable to controls at 2 pl and 4 pl, but survival was significantly reduced with 6 pl volumes. Development to the blastocyst stage was also inversely related to CT volume, with some decline beginning with the 4 pl CT group. However, some blastocysts did develop in all of the groups. The results are in contrast with human eggs, which tolerate larger CT volumes. Results indicate that the mouse system can be used to characterize the transfer of exogenous materials concomitant with sperm injection, provided that the CT volume is not excessive.