Effects of gonadotrophin releasing hormone analogues on human endometrial stromal cells and embryo invasion in vitro

A clinical and basic study of optimal endometrial preparation protocols for patients with infertility undergoing frozen-thawed embryo transfer

The optimal protocol for endometrial preparation in patients with infertility remains unclear. Due to this, the current study retrospectively analyzed 1,589 patients with infertility and regular menstrual cycles to assess reproductive outcomes per embryo transferred and per embryo transfer (ET) cycle following the transfer of frozen-thawed embryos (FET) in a modified natural cycle (mNC) or hormone therapy cycle (HT) with or without gonadotropin-releasing hormone agonist (GnRHa)-induced pituitary suppression. The molecular mechanisms involved were also studied using tissues from endometrial biopsies. Patients who underwent FET were assigned to 5 groups as follows: Group A underwent a mNC (n=276); group B (n=338) received estradiol (E2) and progesterone (P4); group C received 1 cycle of GnRHa, E2 and P4 (n=323); group D received 2 cycles of GnRHa, E2 and P4 (n=329); and group E received 3 cycles of GnRHa, E2 and P4 (n=323). Tissues from endometrial biopsies of 91 patients performed on the day of ET were tested for endometrial receptivity marker mRNA expression and microRNA (miR)-223-3p mRNA. Furthermore, endometrial stromal cells (ESCs) were used for an in-depth study of the molecular mechanisms involved. Among the 5 groups of patients, implantation rates, clinical pregnancy rates and live birth rates were not significantly different. However, endometrial receptivity was enhanced in group E when compared with groups A-D, which was associated with endometrial leukemia inhibitory factor (LIF), osteopontin, vascular endothelial growth factor, integrin β3 and homeobox gene 10 and 11 mRNA upregulation, and miR-223-3p miRNA downregulation. Transfection of ESCs with an miR-223-3p mimic significantly reduced levels of LIF mRNA and protein. In addition, pre-treating ESCs with GnRHa upregulated mRNA and protein expression of the decidualization markers prolactin and insulin-like growth factor binding protein-1 in a time-dependent manner. In conclusion, these results indicated that HT with GnRHa may be a potential endometrial preparation protocol for FET.

Conditional loss of ERK1 and ERK2 results in abnormal placentation and delayed parturition in the mouse

Extracellular-signal-regulated kinases (ERK) 1 and 2 regulate many aspects of the hypothalamic-pituitary-gonadal axis. We sought to understand the role of ERK1/2 signaling in cells expressing a Cre allele regulated by the endogenous GnRHR promoter (GRIC-ERKdko). Adult female GRIC-ERKdko mice were hypogonadotropic and anovulatory. Gonadotropin administration and mating led to pregnancy in one-third of the ERKdko females. Litters from ERKdko females and pup weights were reduced coincident with delayed parturition and 100% neonatal mortality. Based on this, we examined Cre expression in implantation sites as a potential mechanism. GnRHR mRNA levels at e10.5 and e12.5 were comparable to pituitary levels from adult female mice at proestrus and GnRHR mRNA in decidua was enriched compared to whole implantation site. In vivo studies confirmed recombination in decidua, and GRIC-ERKdko placentas showed reduced ERK2 expression. Histopathology revealed abnormalities in placental architecture in the GRIC-ERKdko animals. Regions of apoptosis at the decidual/uterine interface at e18.5 were observed in control animals but apoptotic tone in these regions was reduced in ERKdko animals. These studies support a potential model of ERK-dependent signaling within the implantation site leading to loss of placental architecture and mis-regulation of apoptotic events at parturition occurring coincident with prolonged gestation and neonatal mortality.

GnRH antagonist for endometrial priming in an oocyte donation programme: a prospective, randomized controlled trial

RESEARCH QUESTION

Can gonadotrophin releasing hormone (GnRH) antagonist be used in egg donation recipients with ovulatory cycles for the purpose of achieving synchronization between the donor´s and recipient´s cycle?

DESIGN

Prospective randomized controlled trial to compare 7-day dosage of GnRH antagonist for endometrial priming in an oocyte donation programme with a single dose of long-acting GnRH agonist. A total of 563 women were randomized in a private single centre, and 473 women underwent embryo transfer. Ongoing pregnancy rate was the primary end point. Analysis was adjusted for embryonic stage at the time of embryo transfer; data collected included days on the waiting list; number of fresh-vitrified oocytes collected; and oocyte donor´s age at the time of retrieval.

RESULTS

No statistically significant differences were found between groups in per intention-to-treat analysis: adjusted OR 1.42 (CI 0.97 to 2.09); per treatment received: adjusted OR 1.43 (CI 0.97 to 2.09); per embryo transfer: adjusted OR for ongoing pregnancy rate 1.47 (CI 1.01 to 2.13), P = 0.047.

CONCLUSIONS

For women with ovulatory cycles undergoing oocyte donation, the outcomes are similar between GnRH antagonist and down-regulated hormone replacement protocols.

Treatment options and reproductive outcome for adenomyosis-associated infertility

PURPOSE

Adenomyosis is a benign gynecological disease mostly diagnosed in the forth and fifth decades. The recent improvement of the diagnostic tools and a better understanding of the pathology allowed clinicians to postulate a possible relationship between adenomyosis and infertility and to diagnose it in younger asymptomatic women during infertility work-up. Purpose of this article is to review the different theories regarding the possible correlation between adenomyosis and infertility and to discuss the treatment options and the final reproductive outcome after the treatment.

MATERIALS AND METHODS

We search Pubmed for articles published in the English language with the use of the following MeSH search terms: "adenomyosis" combined with "treatment" and "fertility outcome" with the restriction to the human species. A manual search of review articles and cross-references completed the search. All selected articles were assessed for study design, patients characteristic, diagnosis of adenomyosis, type of treatment, post-treatment rates of conception, full-term pregnancy and completeness of information of the data sets.

RESULTS

Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and the only ones published are retrospective evaluations or small case series.

CONCLUSIONS

Adenomyosis represents a common gynecological disorder with a negative impact on fertility. However, it remains challenging to establish if adenomyosis is the only cause of the infertility or not, because patients, in both case and control groups, may be affected by concomitant endometriosis. Further studies are required to determine the reason of implantation failure in women with adenomyosis and the impact of adenomyosis on infertile women with or without endometriosis.

Mid-luteal phase gonadotropin-releasing hormone agonist support in frozen-thawed embryo transfers during artificial cycles: A prospective interventional pilot study

OBJECTIVE

To assess the effect of an additional single mid-luteal dose of gonadotropin-releasing hormone agonist (GnRHa) on pregnancy and perinatal outcomes in hormonally substituted frozen embryo transfer (FET) cycles.

STUDY DESIGN

A prospective interventional pilot study. Women scheduled for FET were randomly selected to receive standard hormonal replacement therapy (HRT) for endometrial preparation or HRT with a single additional subcutaneous dose of 0.1mg triptorelin at the time of implantation. If FET was not followed by a pregnancy, women with surplus embryos were scheduled for a single second attempt in a crossover setting. Altogether, 144 FET cycles were analyzed. The carryover effect was tested using a logistic regression model. Logistic regression analysis for binary variables was applied with generalized estimation equation extension to account for dependence among repeated treatments.

RESULTS

The live birth rate (LBR) was 9.8 percentage points higher and the miscarriage rate 14.7 percentage points lower in the intervention group (n=72) than in the control group (n=72), but the differences did not reach statistical significance. Implantation and clinical pregnancy rates were comparable between the groups. No congenital malformations or differences in the median birth weight of newborns were detected.

CONCLUSIONS

Observable but statistically insignificant difference in LBR and miscarriage rate favoring luteal phase GnRHa support was detected. Further, no malformations or effect on fetal growth were observed. Larger studies are needed to confirm the results of this pilot study.

The effect of luteal phase gonadotropin-releasing hormone antagonist administration on IVF outcomes in women at risk of OHSS

BACKGROUND

Gonadotropin-releasing hormone (GnRH) plays essential roles in embryo implantation, invasion of trophoblastic tissue, and steroid synthesis in the placenta.

OBJECTIVE

The aim of this study was to evaluate the effect of GnRH antagonist administration on pregnancy outcomes in early implantation period.

MATERIALS AND METHODS

In this retrospective study, 94 infertile women undergoing GnRH antagonist protocol who were at risk of ovarian hyperstimulation syndrome (OHSS) were included. Sixty-seven patients (group I) received Cetrorelix 0.25 mg/daily in the luteal phase for 3 days while in 27 participants (group II), it was not administered. Pregnancy outcomes were assessed based on chemical and clinical pregnancy rates.

RESULTS

The pregnancy outcomes were not significantly different between two groups (p=0.224).

CONCLUSION

The present study proposed that luteal phase GnRH antagonist administration does not influence the chance of successful pregnancy outcomes.

Contribution to More Patient-Friendly ART Treatment: Efficacy of Continuous Low-Dose GnRH Agonist as the Only Luteal Support-Results of a Prospective, Randomized, Comparative Study

Background. The aim of this pilot study was to evaluate intranasal buserelin for luteal phase support and compare its efficacy with standard vaginal progesterone in IVF/ICSI antagonist cycles. Methods. This is a prospective, randomized, open, parallel group study. Forty patients underwent ovarian hyperstimulation with human menopausal gonadotropin under pituitary inhibition with gonadotropin-releasing hormone antagonist, while ovulation trigger and luteal support were achieved using intranasal GnRH agonist (group A). Twenty patients had their cycle downregulated with buserelin and stimulated with hMG, while ovulation trigger was achieved using 10,000 IU human chorionic gonadotropin with luteal support by intravaginal progesterone (group B). Results. No difference was observed in estradiol levels. Progesterone levels on day 5 were significantly lower in group A. However, significantly higher levels of luteinizing hormone were observed in group A during the entire luteal phase. Pregnancy rates (31.4% versus 22.2%), implantation rates (22% versus 15.4%), and clinical pregnancy rates (25.7% versus 16.7%) were not statistically different between groups, although a trend towards higher rates was observed in group A. No luteal phase lasting less than 10 days was recorded in either group. Conclusion. Intranasal administration of buserelin is effective for providing luteal phase support in IVF/ICSI antagonist protocols.

Prolonged GnRH suppression period in controlled ovarian hyperstimulation cycles: Impacts on IVF outcomes?

BACKGROUND

Prolonged GnRH-a administration in IVF cycles may have some advantages related to the treatment outcomes.

OBJECTIVE

In this study, we aimed to analyse the effect of prolonged gonadotropin releasing hormone agonist (GnRH-a) administration on controlled ovarian hyperstimulation outcomes of in vitro fertilization (IVF) patients.

MATERIALS AND METHODS

In this retrospective study, 55 patients with a GnRH-a administration period more than 10 days were compared with 55 patients whose same period was ≤10 days with respect to the demographic characteristics, metaphase II (MII) oocyte ratio, grade I (GI) embryo ratio, blastocyst ratio, fertilization, implantation, and the clinical pregnancy rates.

RESULTS

The mean hospital visit count of the prolonged GnRH-a patients was 2.6±0.4. As we expected, total GnRH-a doses used during hypophyseal down regulation were significantly different between the groups (p<0.0001). MII oocyte, G1 embryo and the blastocyst ratios were also significantly different between the groups (p<0.0001; p<0.01 and p<0.05). All the other parameters were insignificant.

CONCLUSION

Prolonged GnRH-a administration during ovarian suppression in IVF patients may have positive impacts on the oocytes and the embryos, but this affect may not be observed in the overall pregnancy rates.

Adenomyosis and infertility

Today an accurate diagnosis of adenomyosis can be made thanks to progress in imaging techniques: sonography and magnetic resonance imaging (MRI). This has made it possible to clinically correlate the presence of adenomyosis to infertility. At the same time, a series of pathogenetic hypotheses have been presented to explain this correlation. First, the identification of the myometrial junctional zone (JZ) and of its disruption and thickening has been linked to poor reproductive performance mainly through perturbed uterine peristalsis, a phenomenon that originates exclusively from the JZ in the nonpregnant uterus. In addition, a number of biochemical and functional alterations in both eutopic and heterotopic endometrium in women with adenomyosis have now been found to lead to lower receptivity, indicated by the presence of 'implantation marker' defects. In these patients there is also an altered decidualization and abnormal concentrations of intrauterine free radicals. All these abnormalities in the endometrial environment seem to contribute to subfertility. Several attempts have been made to restore fertility in adenomyosis patients, the oldest being gonadotrophin-releasing hormone agonists coupled to conservative surgery. Also, uterine artery embolization and MRI-assisted high-intensity focused ultrasound ablation have been tried with some degree of success.

Follicular dominance on the fifth day of controlled ovarian stimulation reduces implantation in long down-regulated ICSI cycles

OBJECTIVE

To determine if follicular dominance on the fifth day of controlled ovarian stimulation (COS) predicts implantation rates in down-regulated intracytoplasmic sperm injection (ICSI) cycles.

STUDY DESIGN

One hundred and sixty-two consecutive women undergoing ICSI treatment with long down-regulation and recombinant follicle-stimulating hormone injections were included in a prospective cohort analysis. The clinical pregnancy and implantation rates per transfer were compared between two groups, one with and the other without follicular dominance detected by ultrasound on the fifth day of COS.

RESULTS

There was no significant difference between the groups regarding the number of good quality embryos transferred, but clinical pregnancy and implantation rate per transfer were higher in group with follicular synchrony.

CONCLUSIONS

Follicular dominance on COS day 5 results in reduced implantation rates after ICSI.

Embryo selection or uterine environment: which plays the greater role in blastocyst transfer cycles?

AIM

Blastocyst stage embryo transfer (BET) leads to higher pregnancy rates when compared to cleavage stage transfer. Better embryo selection and a more physiologic stage of transfer are possible explanations. We assessed the significance of embryo selection in achieving an improved outcome.

METHODS

Retrospective analysis of all BETs from our 2007 IVF database was performed. The BET cycles were grouped based on the number of top-quality cleavage stage embryos (≤3 or >3). A cut-off of ≤3 embryos was chosen, because with ≤3 embryos those that will likely make it to the blastocyst stage have already been identified, therefore embryo selection becomes less important. Baseline characteristics, stimulation and embryology parameters, as well as treatment outcome, were compared. The T-test and χ(2)-test were used where appropriate. P < 0.05 was considered significant.

RESULTS

A total of 251 cycles where at least one blastocyst was transferred on day 5 were identified and included in the analysis (≤3 top-quality cleavage embryos, n = 32; >3 top-quality cleavage embryos, n = 219). The number of follicles >14 mm and the number of eggs/mature eggs were higher in the group with >3 good quality day 3 embryos. Slightly more embryos were transferred in the ≤3 embryo group. Pregnancy rates (14/32 [43.8%] vs 96/219 [43.8%]; P = NS) and ongoing pregnancy rates (10/32 [31.2%] vs 80/219 [36.5%]; P = NS) were comparable.

CONCLUSION

Based on the analysis of our data, the number of top-quality cleavage stage embryos did not significantly influence BET outcome. Besides embryo selection, other factors such as improved embryo-endometrium synchrony probably play an important role in the higher implantation and pregnancy rates.

Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles: a meta-analysis

BACKGROUND

The effects of gonadotrophin-releasing hormone agonist (GnRH-a) administered in the luteal phase remains controversial. This meta-analysis aimed to evaluate the effect of the administration of a single-dose of GnRH-a in the luteal phase on ICSI clinical outcomes.

METHODS

The research strategy included the online search of databases. Only randomized studies were included. The outcomes analyzed were implantation rate, clinical pregnancy rate (CPR) per transfer and ongoing pregnancy rate. The fixed effects model was used for odds ratio. In all trials, a single dose of GnRH-a was administered at day 5/6 after ICSI procedures.

RESULTS

All cycles presented statistically significantly higher rates of implantation (P<0.0001), CPR per transfer (P=0.006) and ongoing pregnancy (P=0.02) in the group that received luteal-phase GnRH-a administration than in the control group (without luteal-phase-GnRH-a administration). When meta-analysis was carried out only in trials that had used long GnRH-a ovarian stimulation protocol, CPR per transfer (P=0.06) and ongoing pregnancy (P=0.23) rates were not significantly different between the groups, but implantation rate was significant higher (P=0.02) in the group that received luteal-phase-GnRH-a administration. On the other hand, the results from trials that had used GnRH antagonist multi-dose ovarian stimulation protocol showed statistically significantly higher implantation (P=0.0002), CPR per transfer (P=0.04) and ongoing pregnancy rate (P=0.04) in the luteal-phase-GnRH-a administration group. The majority of the results presented heterogeneity.

CONCLUSIONS

These findings demonstrate that the luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol. Nevertheless, by considering the heterogeneity between the trials, it seems premature to recommend the use of GnRH-a in the luteal phase. Additional randomized controlled trials are necessary before evidence-based recommendations can be provided.

Oocyte peptides as paracrine tools for ovarian stimulation and oocyte maturation

Recent studies report the production and isolation of a stable bioactive recombinant human bone morphogenetic protein 15 (rhBMP15) that is appropriately processed in HEK-293 cells and activates the SMAD 1/5/8 pathway in mouse granulosa cell cultures. Further, the purified rhBMP15 induces the expression of genes associated with cumulus expansion. Thanks to recent research, we have a greater understanding of the importance of the dialogue that occurs between the oocyte and the granulosa cell layer with regard to regulating folliculogenesis and the acquisition of oocyte developmental competence and maturation. BMP15 is one of the critical components of these intra-follicular communication pathways. The production of recombinant human BMP15 is important for understanding the biochemistry of this specific pathway and for also fully understanding its functional contributions to mediating oocyte development. The production of a stable recombinant human BMP15 is also important for use in experiments aimed at optimizing ovarian stimulation protocols and in vitro oocyte maturation methods. This is required to improve oocyte and embryonic developmental competence and increase our ability to effectively use in vitro methods for animal production and the treatment of human infertility.