New perspectives for unexplained infertility

Discrete choice experiment exploring women's preferences in a novel device designed to monitor the womb environment and improve our understanding of reproductive disorders

OBJECTIVES

The study aims to determine the relative importance of key attributes of a novel intrauterine device. The device monitors uterine oxygen, pH and temperature in real time with the aim of improving our understanding and treatment of reproductive disorders.

DESIGN

A discrete choice experiment was used to elicit preferences in this novel investigative tool. The attributes and levels used in the choice scenarios were length of time using the device (7, 14 or 28 days), information obtained to guide treatment (limited, majority or all cases), risk of complications (1% or 10%) and discreteness (completely discrete, moderately discrete or indiscrete).

SETTING

Secondary care hospital in Hampshire, UK.

PARTICIPANTS

361 women of reproductive age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Conditional logit and latent class logit regression models to determine the preference for each attribute.

RESULTS

Conditional logit coefficients allow comparison between attributes; women placed most importance on obtaining information to guide treatment in all cases (2.771), followed by having a completely discrete device (1.104), reducing risk of complications by 1% (0.184) and decreased length of time by 1 day (0.0150). All coefficients p<0.01. Latent class conditional logit assigns participants to two classes with 27.4% in class 1 who are less likely to have higher education or qualify for National Health Service-funded in vitro fertilisation compared with class 2. Those in class 2 placed 1.7 times more importance on a device whose information guided treatment in all cases and a 1% decrease in complications risk was nearly 15 times more attractive.

CONCLUSIONS

Women placed most importance on having a device that obtains information to guide treatment and are willing to use the device for a longer, have a device with higher risk of complications and an indiscrete device if it is able to provide answers and direction for treatment of their reproductive disorder.

Unexplained infertility categorization based on female laparoscopy and total motile sperm count, and its impact on cumulative live-births after one in-vitro fertilization cycle. A retrospective cohort study involving 721 cycles

PURPOSE

To determine how subcategorizing unexplained infertility based on female laparoscopy and total-motile-sperm-count assessment would impact cumulative live-births after one in-vitro fertilization (IVF) cycle.

METHODS

Seven hundred twenty one IVF cycles from Jan 2014-April 2019 performed at a single-center were retrospectively analyzed. Couples with unexplained infertility having normal uterine and endometrial morphology were subcategorized into three cohorts, UI (1): those with no tuboperitoneal pathology on laparoscopy and total-motile-sperm-count (TMSC) ≧20 million: n = 103; UI (2): tuboperitoneal pathology on laparoscopy or TMSC <20 million, n = 86; and UI(3): tuboperitoneal status not known: n = 114. Controls were severe male factor, bilateral tubal block, and grade 3/4 endometriosis: n = 418. Primary Outcome was cumulative-live-birth-per-initiated-IVF cycle (CLBR). Odds ratio for live-births were adjusted for confounding factors.

RESULTS

The CLBR in UI1 cohort was significantly lower than controls (29.1% vs 39; OR = 0.62; 95%CI = 0.39-0.98; P = .04); but similar in UI2 and UI3 vs. controls. (37.2% vs 39.95%; OR = 0.89, 95%CI = 0.55-1.44; P = .89) and (38.6% vs 39.95%; OR = 0.98, 95%CI = 0.64-1.55; P = .98). After adjusting for age, infertility duration, past live-births, and AMH, the adjusted odds for CLBR in UI1 was 0.48 (95%CI = 0.28-0.82; P = .007).

CONCLUSIONS

Unexplained infertility when defined after a normal laparoscopy and TMSC significantly lowered cumulative-live-births-per-initiated-IVF cycle when compared with traditional diagnosis of tubal, endometriosis, or male factor infertility. In UI subcategory with abnormal laparoscopy or TMSC, CLBR remained unaffected. This information could be useful for counseling couples prior to IVF. Large-scale prospective studies are needed to confirm this observation.

Effects of clomiphene citrate for prevention of premature luteinizing hormone surge in those undergoing intrauterine insemination outcome: A randomized, double-blind, placebo-controlled trial

The objective of the study is to determine the effects of clomiphene citrate (CC) on preventing premature luteinizing hormone (LH) surge in infertile patients with polycystic ovary syndrome (PCOS) undergoing intrauterine insemination (IUI). This was a randomized clinical trial being performed at Shiraz Mother and Child Hospital. We included 162 women with PCOS selected for IUI cycles. Patients were randomly allocated to receive 150 mg/day CC from the 8^th of the cycle though the day of human chorionic gonadotropin (hCG) injection (n = 81) or nothing in the same period (n = 81). Main outcomes included the incidence of premature LH surge, pregnancy rate, abortion and ongoing pregnancy rates, number of maturing follicles, and endometrial thickness. The incidence of premature LH surge was significantly lower in those who received CC (3.0% vs. 14.9%; P = 0.021). The pregnancy rate was 10 (15.1%) and 6 (8.9%) in CC and control groups, respectively (P = 0.342). The ongoing pregnancy rate found to be comparable between two study groups (12.1% vs. 5.9%; P = 0.068). Serum level of estradiol (E₂) level at the time of hCG administration was significantly higher in those who were treated with CC when compared to control (1153.5 ± 326.4 vs. 943.2 ± 215.3; P < 0.001). Patients who received CC also had higher number of mature follicles >18 mm when compared to controls (3.85 ± 1.3 vs. 2.94 ± 1.01; P < 0.001). Administration of CC from the 8^th day of the cycle to the day of hCG injection in combination with Gonal-f in infertile patients with CC-resistant PCOS undergoing IUI cycles is associated with decreased incidence of premature LH surge, higher E₂levels, and higher number of mature ovarian follicles. This protocol is safe and simple and could be considered to be cost-effective.

p27 and its ubiquitin ligase Skp2 expression in endometrium of IVF patients with repeated hormonal stimulation

This preliminary study examined a possible effect of long duration repeated hormonal stimulation on the endometrium using a molecular tool. The expression of the hormone stimulated, cell cycle regulators, p27 and its ligase S-phase kinase-interacting protein2 (Skp2), were assessed in 46 endometrial samples of patients who underwent repeated IVF cycles (3-21). Skp2 protein is usually undetectable in normal tissue and can be demonstrated only in rapidly dividing cells. Samples from non-stimulated, normal cycling women served as control group A. Samples of endometrial carcinoma served as control group B. In secretory endometrium, the expression of p27 was found to be lower and Skp2 higher in the study group compared with control group A. Moreover, in 25% of patients of the study group, Skp2 expression was significantly higher (P < 0.05) compared with control group A, reaching concentrations demonstrated in endometrial carcinoma. The findings of this study suggest that repeated hormone stimulation cycles may disrupt endometrial physiology, potentially towards abnormal proliferation. These changes in protein expression are described for the first time in IVF patients and should be further investigated.

Clinical Effectiveness of Modified Laparoscopic Fimbrioplasty for the Treatment of Minimal Endometriosis and Unexplained Infertility

Objective. To study the reproductive outcomes of modified laparoscopic fimbrioplasty (MLF), a surgical technique designed to increase the working surface area of the fimbriated end of the fallopian tube. We postulated that an improvement in fimbrial function through MLF will improve reproductive outcomes. Design. Retrospective cohort study. Setting. Academic tertiary-care medical center. Patients. Women with minimal endometriosis or unexplained infertility, who underwent MLF during diagnostic laparoscopy (n = 50) or diagnostic laparoscopy alone (n = 87). Intervention. MLF involved gentle, circumferential dilatation of the fimbria and lysis of fimbrial adhesions bridging the fimbrial folds. Main Outcome Measures. The primary outcome was pregnancy rate and the secondary outcome was time to pregnancy. Results. The pregnancy rate for the MLF group was 40.0%, compared to 28.7% for the control group. The average time to pregnancy for the MLF group was 13 weeks, compared to 18 weeks for the control group. The pregnancy rate in the MLF group was significantly higher for patients ≤35 ys (51.5% versus 28.8%), but not for those >35 ys (17.6% versus 28.6%). Conclusion. MLF was associated with a significant increase in pregnancy rate for patients ≤35 ys.

An integrated view on the luteal phase: diagnosis and treatment in subfertility

The term 'luteal phase deficiency' was first coined more than 60 years ago, and, since then, it has been suggested as a clinical entity per se and an aetiological factor for subfertility, implantation failure and recurrent miscarriage. Despite the existing recommendations for rational work-up in subfertility, luteal phase evaluation and progesterone therapy alone is still common in daily practice. This review comprises results from a Pubmed literature search with the terms 'luteal phase' and 'subfertility', focussing on clinical situations not primarily related to assisted reproduction techniques. Additional data from the experimental studies published in the past 10 years on follicular maturation, oocyte developmental competence and the ovulatory cascade are integrated into the clinical continuum of dysfunctional ovulation, menstrual cycle irregularity and impaired corpus luteum function. As reliable diagnostic tools for adequate luteal function are missing, the presence of clinical symptoms such as cycle irregularity or premenstrual spotting is indicative and should initiate early follicular phase diagnostic work-up. New evidence on the interdependence of oocyte and follicular maturation and resulting developmental competence of the embryo further support the use of ovarian stimulation as the first-line therapeutic option in different subsets of patients with subfertility including luteal phase deficiency.

Altered endometrial expression of endothelial nitric oxide synthase in women with unexplained recurrent miscarriage and infertility

Endothelial nitric oxide synthase (eNOS) has diverse roles in the female reproductive system including a role in blastocyst implantation. Aberrant expression of eNOS could therefore be significant in the pathogenesis of disorders of implantation. In this study, eNOS protein and mRNA levels in the endometrium of women with recurrent miscarriages, unexplained infertility and a control group were determined by compartmental quantitative immunohistochemistry and real-time reverse-transcription PCR. eNOS was found to be immunolocalized to all layers of the endometrium and vascular endothelium. eNOS protein was higher in glandular epithelium (P = 0.004) and luminal epithelium (P = 0.002), but not vascular endothelium and stroma, in women with recurrent miscarriage. Similarly, in women with unexplained infertility, eNOS was significantly higher (P < 0.03) in luminal epithelium but not in any other compartments compared with the control group. The levels of mRNA confirmed the protein data, demonstrating higher eNOS mRNA in the endometrium of women with recurrent miscarriage and unexplained infertility compared with controls. In conclusion, increased expression of eNOS in glandular and luminal epithelium of the endometrium in women with recurrent miscarriages and unexplained infertility suggests a detrimental effect of excess nitric oxide in endometrial receptivity and implantation.