Molecular Mechanisms of Laparoscopic Ovarian Drilling and Its Therapeutic Effects in Polycystic Ovary Syndrome

Outcomes of subsequent IVF cycles among women with PCOS after the first unstimulated IVM treatment: a single-center matched retrospective case-control study

OBJECTIVE

In-vitro maturation (IVM) is an advanced technique and an alternative to conventional in-vitro fertilization (IVF). It is safe, effective, and cost-effective in patients with polycystic ovary syndrome (PCOS). However, no clinical guidelines state that IVM could work without compromised pregnancy outcomes in patients with PCOS. The purpose of this study was to identify whether previous unstimulated IVM improved the clinical outcomes of women with PCOS in the subsequent IVF cycle.

METHODS

In this matched retrospective case-control study, we compared the results of IVF treatment in two groups of women with PCOS between January 2008 and December 2017. The study group comprised 79 women who underwent a subsequent IVF treatment after IVM failure (IVM-IVF group). Considering the year, age, and BMI, a 1:3 matched control group of 237 women with PCOS who received their first IVF cycle was established (IVF group).

RESULTS

Compared with the IVF group, the IVM-IVF group had a significantly lower initial gonadotropin dose [112.5 IU (112.5-150 IU) vs. 150 IU (150-200 IU), p < 0.001] and total gonadotropin dose [1350 IU (1125-2162.5 IU) vs. 1875 IU (1425.00-2643.75 IU), p < 0.001]. The live birth rate, clinical pregnancy, and miscarriage rates were comparable between the IVM-IVF and IVF groups at 12 months [55.6% vs. 48.6%, (adjusted p = 0.923), 68.1% vs. 59% (adjusted p = 0.677), and 18.8% vs. 17.7% (adjusted p = 0.645), respectively] and the first transfer cycle [36.1% vs. 34.2% (adjusted p = 0.560), 55.6% vs. 41.9% (adjusted p = 0.177), and 35% vs. 18.3% (adjusted p = 0.396), respectively]. The occurrence of moderate/severe OHSS did not significantly differ between the groups [5.1% vs. 7.6% (adjusted p = 0.698)]. Notably, LH levels, the LH/FSH ratio, and androstenedione levels were significantly reduced in the IVM-IVF group after the IVM treatment.

CONCLUSION

Alternatives to IVF are underappreciated in clinical practice and research because of the lack of evidence on the efficacy of IVM in certain populations. IVF treatment given during a follow-up visit after an unstimulated IVM can achieve pregnancy outcomes comparable to those of a first IVF cycle without adversely affecting the subsequent pregnancy outcome.

New insights on mitochondrial heteroplasmy observed in ovarian diseases

BACKGROUND

The reportedly high mutation rate of mitochondrial DNA (mtDNA) may be attributed to the absence of histone protection and complete repair mechanisms. Mitochondrial heteroplasmy refers to the coexistence of wild-type and mutant mtDNA. Most healthy individuals carry a low point mutation load (<1 %) in their mtDNA, typically without any discernible phenotypic effects. However, as it exceeds a certain threshold, it may cause the onset of various diseases. Since the ovary is a highly energy-intensive organ, it relies heavily on mitochondrial function. Mitochondrial heteroplasmy can potentially contribute to a variety of significant ovarian disorders.

AIM OF REVIEW

In this review, we have elucidated the close relationship between mtDNA heteroplasmy and ovarian diseases, and summarized novel avenues and strategies for the potential treatment of these ovarian diseases.

KEY SCIENTIFIC CONCEPTS OF REVIEW

Mitochondrial heteroplasmy can potentially contribute to a variety of significant ovarian disorders, including polycystic ovary syndrome, premature ovarian insufficiency, and endometriosis. Current strategies related to mitochondrial heteroplasmy are untargeted and have low bioavailability. Nanoparticle delivery systems loaded with mitochondrial modulators, mitochondrial replacement/transplantation therapy, and mitochondria-targeted gene editing therapy may offer promising paths towards potentially more effective treatments for these diseases, despite ongoing challenges.

Effects of vitamin D supplementation on oxidative stress biomarkers of Iranian women with polycystic ovary syndrome: a meta-analysis study

Objective

To identify the impact of redox imbalance on the clinical evolution of patients with polycystic ovary syndrome and carry out a qualitative and quantitative projection of the benefits of vitamin D supplementation.

Data sources

Combinations of the keywords polycystic ovary syndrome, vitamin D, oxidative stress, reactive oxygen species, antioxidant, and free radicals were used in PubMed, Cochrane Library, LILACS, EMBASE, and Web of Science databases. The last search was conducted on August 22, 2023.Selection of studies: Based on the inclusion and exclusion criteria, studies were selected considering a low risk of bias, published in the last 5 years in English, which investigated the effects of vitamin D supplementation in women with PCOS, focusing on oxidative stress markers. Of the 136 articles retrieved, 6 intervention studies (445 women) were included.

Data collection

The risk of bias in included studies was assessed using the Jadad scale, and analysis and visualization of continuous data were performed using Review Manager 5.4.1, summarized as standardized mean differences (SMD) with confidence intervals (CI) of 95%.

Data synthesis

Vitamin D effectively reduced malondialdehyde (P=0.002) and total testosterone (P=0.0004) levels and increased total antioxidant capacity levels (P=0.01). Although possible improvements in the modified Ferriman-Gallwey hirsutism score, levels of sex hormone-binding globulin, and free androgen index were identified and the results were not statistically significant.

Conclusion

Vitamin D is a promising alternative for the treatment of PCOS with a positive influence on the oxidative, metabolic, and endocrine disorders of this syndrome.

Ovarian Reserve and Hormone Alteration Following Laparoscopic Ovarian Drilling for Polycystic Ovarian Syndrome: A Systematic Review

We aimed to conduct a systematic review of the data in the literature on ovarian reserve and ovarian hormone following laparoscopic ovarian drilling (LOD). The PubMed, ScienceDirect, and ProQuest databases were comprehensively searched using a combination of keywords such as "ovarian reserve", "laparoscopic ovarian drilling", "luteinizing hormone", "follicle-stimulating hormone", "inhibin", "LH/FSH ratio", "ovulation", and "testosterone". All studies involving females of reproductive age who were officially diagnosed with polycystic ovarian syndrome (PCOS) and had undergone LOD with reported data concerning at least one of the following parameters were considered for inclusion: ovarian reserve, anti-Mullerian hormone (AMH), inhibin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH ratio, and testosterone. All the included studies were evaluated by the GRADE scale for bias and their findings were synthesized by four independent coauthors. A total of 38 studies involving 3118 female patients were included. Based on our findings, a significant number of participants experienced spontaneous ovulation along with a significant decrease in ovarian reserve, and a significant decrease in AMH, LH, and testosterone, with no significant changes in FSH and inhibin B. With the end goal of LOD being to improve fertility and pregnancy rates among females with PCOS, it is important to look at the first few steps that enable this. As expected, there was a significant improvement in ovulation while the ovarian reserve decreased. Along with the decrease in ovarian reserve, there was a significant normalization in AMH, LH, and testosterone levels. LOD may exert its main effects through the manipulation of the ovarian reserves.

Isorhamnetin inhibits inflammatory response to alleviate DHEA-induced polycystic ovary syndrome in rats

OBJECTIVE

To explore the role of isorhamnetin on polycystic ovary syndrome (PCOS) in rats.

METHODS

Sprague Dawley (SD) rats were subcutaneously injected with dehydroepiandrosteron (DHEA) to establish PCOS model. Hematoxylin and eosin (H&E) staining and TdT-mediated dUTP Nick-End Labeling (TUNEL) were used to measure histological changes and apoptosis of ovary tissues. The levels of serum hormones and inflammatory factors in ovary tissues were measured by enzyme-linked immuno sorbent assay (ELISA).

RESULTS

In DHEA-induced PCOS rats, the levels of serum glucose, insulin, testosterone and luteinizing hormone (LH) were enhanced, estradiol (E2), sex hormone-binding globulin (SHBG), follicle stimulating hormone (FSH) levels were decreased, inflammatory levels and apoptosis of ovary tissues were increased. Additionally, DHEA increased the body weight, ovary weight, and ovary volume, cystic follicles, and decreased corpus luteum. Moreover, the tumor necrosis factor (TNF) signaling pathway was activated in PCOS rats. The levels of TNF receptor superfamily member 1 A (TNFR1), TNF-α, and fas cell surface death feceptor (FAS) were enhanced in ovary tissues of DHEA induced PCOS rats. Isorhamnetin (ISO) treatment after DHEA modeling markedly reduced serum levels of glucose, insulin, testosterone and LH, increased E2, SHBG, FSH level, decreased inflammatory levels, and inhibited apoptosis and decreased body weight, ovary weight, and ovary volume. The levels of TNFR1, TNF-α, and FAS were markedly decreased after ISO treatment in PCOS rats. Additionally, ISO alone had no significant effect on rats.

CONCLUSION

Isorhamnetin inhibits inflammatory response to alleviate DHEA-induced PCOS in rats by inactivating the TNF signaling pathway.

Signaling pathways and targeted therapeutic strategies for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. Although promising strides have been made in the field of PCOS over the past decades, the distinct etiologies of this syndrome are not fully elucidated. Prenatal factors, genetic variation, epigenetic mechanisms, unhealthy lifestyles, and environmental toxins all contribute to the development of this intricate and highly heterogeneous metabolic, endocrine, reproductive, and psychological disorder. Moreover, interactions between androgen excess, insulin resistance, disruption to the hypothalamic-pituitary-ovary (HPO) axis, and obesity only make for a more complex picture. In this review, we investigate and summarize the related molecular mechanisms underlying PCOS pathogenesis from the perspective of the level of signaling pathways, including PI3K/Akt, TGF-β/Smads, Wnt/β-catenin, and Hippo/YAP. Additionally, this review provides an overview of prospective therapies, such as exosome therapy, gene therapy, and drugs based on traditional Chinese medicine (TCM) and natural compounds. By targeting these aberrant pathways, these interventions primarily alleviate inflammation, insulin resistance, androgen excess, and ovarian fibrosis, which are typical symptoms of PCOS. Overall, we hope that this paper will pave the way for better understanding and management of PCOS in the future.

No difference in morbidity between perimenopausal women with PCOS with and without previous wedge resection

OBJECTIVE

Polycystic ovary syndrome (PCOS), affecting more than every 10th woman of reproductive age, is associated with increased risk factors for cardiovascular disease (CVD). Most knowledge regarding longtime consequences concerning morbidity is based on women where ovarian wedge resection (WR) was used as a surgical treatment, a method not used today. The aim of this study was to compare women with PCOS who had and had not undergone WR, regarding risk factors for CVD. The hypothesis was that women who had undergone WR had a more severe PCOS phenotype, and that this cohort thus had more associated CVD risk factors compared with women diagnosed through non-invasive methods.

STUDY DESIGN

A cross-sectional study was performed. A PCOS cohort who underwent WR in the 1950-60 s (n = 27) were compared with a PCOS cohort diagnosed by NIH-criterions in the 1990s without WR (n = 32). Both cohorts were examined at perimenopausal age.

RESULTS

No differences were seen in prevalence of hypertension, obesity or type 2 diabetes mellitus (T2DM) between the women with PCOS with or without WR, respectively. The results were persistent irrespective of the lower mean BMI in the WR group, 26.4 vs. 30.7 kg/m2, p = 0.01. In the stratified group of overweight and obese, there was no difference in T2DM 27% vs 25% or hypertension 27% vs 25%, in WR and non-WR women with PCOS, respectively. The cohort diagnosed through WR had higher free androgen index (6.3 vs. 2.1, p < 0.01) and total testosterone (2.20 vs. 0.99 nmol/L, p < 0.01).

CONCLUSION

No differences in CVD risk factors were found in perimenopausal women with PCOS with or without a previous WR, and irrespective of body weight. The results indicate that CVD morbidity and mortality from studies in women with PCOS who have undergone WR are generalizable to women with PCOS who have not undergone WR.

Is There Still a Place for Surgery in Patients with PCOS? A Review

OBJECTIVE

The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates.

METHODS

A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included.

RESULTS

Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described.

CONCLUSIONS

Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.

The effects of first-line pharmacological treatments for reproductive outcomes in infertile women with PCOS: a systematic review and network meta-analysis

BACKGROUND

Polycystic ovarian syndrome (PCOS) is one of the most common causes of infertility in reproductive-age women. However, the efficacy and optimal therapeutic strategy for reproductive outcomes are still under debate. We conducted a systematic review and network meta-analysis to compare the efficacy of different first-line pharmacological therapies in terms of reproductive outcomes for women with PCOS and infertility.

METHODS

A systematic retrieval of databases was conducted, and randomized clinical trials (RCTs) of pharmacological interventions for infertile PCOS women were included. The primary outcomes were clinical pregnancy and live birth, and the secondary outcomes were miscarriage, ectopic pregnancy and multiple pregnancy. A network meta-analysis based on a Bayesian model was performed to compare the effects of the pharmacological strategies.

RESULTS

A total of 27 RCTs with 12 interventions were included, and all therapies tended to increase clinical pregnancy, especially pioglitazone (PIO) (log OR 3.14, 95% CI 1.56 ~ 4.70, moderate confidence), clomiphene citrate (CC) + exenatide (EXE) (2.96, 1.07 ~ 4.82, moderate confidence) and CC + metformin (MET) + PIO (2.82, 0.99 ~ 4.60, moderate confidence). Moreover, CC + MET + PIO (2.8, -0.25 ~ 6.06, very low confidence) could increase live birth most when compared to placebo, even without a significant difference. For secondary outcomes, PIO showed a tendency to increase miscarriage (1.44, -1.69 ~ 5.28, very low confidence). MET (-11.25, -33.7 ~ 0.57, low confidence) and LZ + MET (-10.44, -59.56 ~ 42.11, very low confidence) were beneficial for decreasing ectopic pregnancy. MET (0.07, -4.26 ~ 4.34, low confidence) showed a neutral effect in multiple pregnancy. Subgroup analysis demonstrated no significant difference between these medications and placebo in obese participants.

CONCLUSIONS

Most first-line pharmacological treatments were effective in improving clinical pregnancy. CC + MET + PIO should be recommended as the optimal therapeutic strategy to improve pregnancy outcomes. However, none of the above treatments had a beneficial effect on clinical pregnancy in obese PCOS.

TRIAL REGISTRATION

CRD42020183541; 05 July 2020.

To do one and to get more: Part II. Diabetes and metabolic dysfunction-associated fatty liver diseases

Type 2 diabetes mellitus (DM) is characterized by inability of faulty pancreatic β-cells to secret a normal amount of insulin to maintain normal body consumption, and/or peripheral tissue has a decreased susceptibility to insulin, resulting in hyperglycemia and insulin resistance. Similar to other chronic systemic inflammatory diseases, DM is a result from dysregulated interactions between ethnic, genetic, epigenetic, immunoregulatory, hormonal, and environmental factors. Therefore, it is rational to suppose the concept as "To do one and to get more", while using antidiabetic agents (ADA), a main pharmacologic agent for the treatment of DM, can provide an extraglycemia effect on comorbidities or concomittent comorbidities to DM. In this review, based on the much strong correlation between DM and metabolic dysfunction-associated fatty liver diseases (MAFLD) shown by similar pathophysiological mechanisms and a high prevalence of DM in MAFLD and its vice versa (a high prevalence of MAFLD in DM), it is possible to use the strategy to target both diseases simultaneously. We focus on a new classification of ADA, such as glucagon-like peptide-1 receptor (GLP1R) agonist and sodium-glucose cotransporter-2 (SGLT-2) inhibitors to show the potential benefits of extraglycemic effect on MAFLD. We conclude that the management of DM patients, especially for those who need ADA as adjuvant therapy should include healthy lifestyle modification to overcome the metabolic syndrome, contributing to the urgent need of an effective weight-reduction strategy. GLP1R agonist is one of effective body weight-lowering medications, which may be a better choice for DM complicated with MAFLD or its-associated severe form as metabolic associated steatohepatitis (MASH), although the role of SGLT-2 inhibitors is also impressive. The prescription of these two classes of ADA may satisfy the concept "To do one and to get more", based on successful sugar-lowering effect for controlling DM and extraglycemia benefits of hepatoprotective activity in DM patients.

An update of polycystic ovary syndrome: causes and therapeutics options

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by menstrual irregularities, chronic anovulation, hirsutism, androgenic alopecia, and acne. At diagnosis, patients can with different manifestations according to the disease phenotype, patient's age, and lifestyle. However, most patients pursue medical care because of the clinical symptoms of PCOS, such as hyperandrogenism, menstrual irregularities and infertility. Recent studies have shown that PCOS is associated with 80% of anovulatory infertility; however, the precise mechanism of PCOS-induced anovulation is still undetermined. The treatment strategies of PCOS are symptomatic depending mainly on the desired goals and clinical benefits. Life style intervention is still the first line treatment option for overweight females seeking pregnancy. In addition, there are many pharmacological agents that could be added to induce ovulation such as metformin, and clomiphene citrate. Nowadays, many patients preferred to use some herbal medicine that was proved to have potential therapeutic benefits in many studies in the management of PCOS. The purpose of this review was to discuss PCOS-induced infertility and the available therapeutic options as well as the impact of COVID-19 infection on the success of fertility attempts. To address this purpose, Pubmed, Scopus, EMBASE and Google databases were searched for studies discussing PCOS-induced infertility. The literature search revealed the proper therapeutic plans to treat PCOS-induced infertility, and that treatment should be modified according to patient's complaints, reproductive desires, and disease phenotypes. In conclusion, the use of specific therapeutic agents and patients' adherence to lifestyle interventions could help patients recover their reproductive and metabolic health.

To do one and to get more: Part I. Diabetes and bone

Type 2 diabetes mellitus (T2DM), is a chronic metabolic disease, characterized by the presence of hyperglycemia and insulin resistance. The key treatment strategies for T2DM include modification of lifestyle, medications, and continuous glucose monitoring. DM patients often have DM-associated morbidities and comorbidities; however, disorders of musculoskeletal system are often neglected, compared to other major systems in DM patients. Based on sharing similar pathophysiology of DM and osteoporosis, it is supposed that the use of antidiabetic agents (ADAs) may not only provide the lowering glucose level effect and the maintenance of the sugar homeostasis to directly delay the tissue damage secondary to hyperglycemia but also offer the benefits, such as the prevention of developing osteoporosis and fractures. Based on the current review, evidence shows the positive correlation between DM and osteoporosis or fracture, but the effectiveness of using ADA in the prevention of osteoporosis and subsequent reduction of fracture seems to be inconclusive. Although the benefits of ADA on bone health are uncertain, the potential value of "To do one and to get more" therapeutic strategy should be always persuaded. At least, one of the key treatment strategies as an establishment of healthy lifestyle may work, because it improves the status of insulin resistance and subsequently helps DM control, prevents the DM-related micro- and macrovascular injury, and possibly strengthens the general performance of musculoskeletal system. With stronger musculoskeletal system support, the risk of "fall" may be decreased, because it is associated with fracture. Although the ADA available in the market does not satisfy the policy of "To do one and to get more" yet, we are looking forward to seeing the continuously advanced technology of drug development on diabetic control, and hope to see their extra-sugar-lowering effects.

The Relationship between Ovarian Ultrasound Parameters and Endocrine and Metabolic Indicators in Patients with Ovarian Syndrome

Objective. The aim of this study is to investigate the relationship between the levels of endocrine and metabolic indicators and ovarian ultrasonography indicators in patients with ovarian syndrome (PCOS). Methods. Three hundred and forty patients with PCOS from January 2017 to February 2022 were selected as the observation group, and 340 healthy women of the same age were selected as the control group. A retrospective analysis was performed to observe the levels of endocrine and metabolic indicators and ovarian ultrasound examination indicators in the two groups. Results. The levels of testosterone, dehydroepiandrosterone (DHEA-S), luteinizing hormone (LH), LH/FSH, blood glucose, and insulin were higher in the observation group than those in the control group. The levels of low-density lipoprotein (LDL) and free insulin-like growth factor (IGF-I) were higher in the observation group than those in the control group. However, the level of high-density lipoprotein (HDL) was lower in the observation group than that in the control group. The ovarian interstitial area, total ovarian area, ovarian volume, number of follicles, uterine artery pulsatility index (PI), and resistance index (RI) were higher in the observation group than those in the control group. Pearson correlation analysis concluded that estrone (E1) levels in PCOS patients were correlated with ovarian interstitial area, total ovarian area, and ovarian volume. In addition, E1 levels correlated with LH levels, LH/FSH, testosterone, DHEA-S, and progesterone at $P<0.05$ . Compared with different treatment methods, the total testosterone, LH, and LH/FSH levels in the two groups were decreased compared with those before treatment, and the degree of decrease in the combined treatment group was more significant than that in the treatment alone group. Conclusion. The levels of endocrine metabolism and ovarian ultrasound in PCOS patients are abnormal and there is a close relationship between the levels of endocrine metabolism and ovarian ultrasound. Attention should be paid to the monitoring and regulation of endocrine metabolism and ovarian ultrasound. Integrated traditional Chinese and western medicine can greatly improve the hormone levels in PCOS patients.

Association between Pre-Pregnancy Overweightness/Obesity and Pregnancy Outcomes in Women with Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis

Polycystic ovary syndrome (PCOS) is a common metabolic problem in women of reproductive age. Evidence suggests pregnant women with PCOS may have a higher risk of the development of adverse pregnancy outcomes; however, the relationship between pre-pregnancy overweight/obesity and pregnancy outcomes in women with PCOS remains uncertain. We try to clarify the relationship between pre-pregnancy overweight/obesity and subsequent pregnancy outcomes. Therefore, we conducted this systematic review and meta-analysis. We used the databases obtained from the PubMed, Embase, Web of Science, and Cochrane databases, plus hand-searching, to examine the association between pre-pregnancy overweightness/obesity and pregnancy outcomes in women with PCOS from inception to 4 February 2022. A total of 16 cohort studies, including 14 retrospective cohort studies (n = 10,496) and another two prospective cohort studies (n = 818), contributed to a total of 11,314 women for analysis. The meta-analysis showed significantly increased odds of miscarriage rate in PCOS women whose pre-pregnancy body mass index (BMI) is above overweight (OR 1.71 [95% CI 1.38–2.11]) or obese (OR 2.00 [95% CI 1.38–2.90]) under a random effect model. The tests for subgroup difference indicated the increased risk was consistent, regardless which body mass index cut-off for overweight (24 or 25 kg/m²) or obesity (28 and 30 kg/m²) was used. With the same strategies, we found that pregnant women in the control group significantly increased live birth rate compared with those pregnant women with PCOS as well as pre-pregnancy overweight/obesity (OR 0.79 [95% CI 0.71–0.89], OR 0.78 [95% CI 0.67–0.91]). By contrast, we did not find any association between PCOS women with pre-pregnancy overweight/obesity and preterm birth. Based on the aforementioned findings, the main critical factor contributing to a worse pregnancy outcome may be an early fetal loss in these PCOS women with pre-pregnancy overweight/obesity. Since PCOS women with pre-pregnancy overweightness/obesity were associated with worse pregnancy outcomes, we supposed that weight reduction before attempting pregnancy in the PCOS women with pre-pregnancy overweightness/obesity may improve the subsequent pregnancy outcomes.

A modified GnRH antagonist method in combination with letrozole, cabergoline, and GnRH antagonist for PCOS: Safe and effective ovarian stimulation to treat PCOS and prevent OHSS

PURPOSE

To analyze the therapeutic efficacy of a modified controlled ovarian stimulation (COS) protocol for polycystic ovary syndrome (PCOS) that does not cause ovarian hyperstimulation syndrome (OHSS) while maintaining oocyte quality.

METHOD

This study is a retrospective cohort study of reproductive medicine at St. Mother Clinic. We analyzed ART clinical outcomes, embryonic development, and hormone levels in 175 PCOS patients treated with four COS (GnRH agonist based long protocol, Group A; GnRH antagonist protocol with HCG trigger, Group B; GnRH antagonist protocol with GnRH agonist trigger, Group C, and the modified COS group) between 2010 and 2021.

RESULTS

Of 175 patients with PCOS, 45 and 130 patients underwent 47 and 136 oocyte retrieval cycles, 75 and 250 embryo transfer cycles with the modified COS, and with conventional methods, respectively. The cumulative pregnancy rate at one trial was a significantly higher result than in Group A and higher than in Groups B and C (cumulative pregnancy rate at one trial of Group A, B, C, and modified COS: 40.0%, 54.5%, 56.3%, and 72.3%, respectively). With this method, not clinically problematic OHSS and higher clinical outcomes than in conventional methods were observed.

CONCLUSION

This modified COS can significantly improve clinical outcomes and eliminate OHSS.

Androgen Excess Induced Mitochondrial Abnormality in Ovarian Granulosa Cells in a Rat Model of Polycystic Ovary Syndrome

BACKGROUND

Androgen excess could profoundly lead to follicular dysplasia or atresia, and finally result in polycystic ovary syndrome (PCOS); however, the exact mechanism remains to be fully elucidated.

METHODS

PCOS model rats were induced by dehydroepiandrosterone, and their fertility was assessed. The ovarian granulosa cells (GCs) from matured follicles of PCOS model rats were collected and identified by immunofluorescence. The mitochondrial ultrastructure was observed by transmission electron microscope and the mitochondrial function was determined by detecting the adenosine triphosphate (ATP) content and mtDNA copy number. Besides, the expressions of respiratory chain complexes and ATP synthases in relation to mitochondrial function were analyzed.

RESULTS

The PCOS model rats were successfully induced, and their reproductive outcomes were obviously adverse. The GCs layer of the ovarian was apparently cut down and the mitochondrial ultrastructure of ovarian GCs was distinctly destroyed. The ATP content and mtDNA copy number of ovarian GCs in PCOS model rats were greatly reduced, and the expressions of NDUFB8 and ATP5j were significantly down-regulated without obvious deletion of mtDNA 4834-bp.

CONCLUSIONS

Androgen excess could damage mitochondrial ultrastructure and function of GCs in rat ovary by down-regulating expression of NDUFB8 and ATP5j in PCOS.

Aberrant activation of the Hedgehog signaling pathway in granulosa cells from patients with polycystic ovary syndrome

The molecular mechanism that triggers polycystic ovary syndrome (PCOS) is mysterious. Abnormal development of ovarian granulosa cells (GCs) is one of the causes of PCOS. Herein, our study was carried out using RNA-seq to detect the different gene expression levels in ovarian GCs between three patients with PCOS and four normal controls. To verify the RNA-seq data, GCs from 22 patients with PCOS and 21 controls with normal ovulation were collected to perform the RT-PCR analysis. Hedgehog signaling pathway (Hh) members, Ihh and Ptch2 were abnormally highly expressed in the PCOS tissue (PT). The qPCR also indicated that the expression levels of Hh signaling pathway downstream members, Ptch1, Gli1, and Gli2 in the PT were significantly higher than those in the normal tissue (NT). Besides, the expression of TNF-α mRNA in PCOS patients was higher than that in the control group. Through the chromatin immunoprecipitation assay (ChIP), we found that the Gli1-IP-DNA enriched from the granular cells of PCOS patients was higher than that of the control group. Finally, the Hh signaling pathway inhibitor, cyclopamine, can decrease the apoptosis of PCOS ovarian granulosa cells. These results suggest that abnormal activation of Hh signaling pathway, especially Ihh signal, may have a profound influence on PCOS.

High-frequency electroacupuncture improves endometrial receptivity via regulating cell adhesion molecules and leukemia inhibitory factor / signal transducer and activator of transcription signaling pathway

Controlled ovarian hyperstimulation (COH) impairs the endometrium receptivity during the implantation window, resulting in a lower clinical pregnancy rate and a higher abortion rate. Our study explored the effect of electroacupuncture on the endometrial receptivity of COH rats. Female rats were randomly divided into normal treatment (Normal), model treatment (Model), low-frequency electroacupuncture treatment (LF-EA) and high-frequency electroacupuncture treatment (HF-EA). Rats in the Model, LF-EA, and HF-EA treatment groups were injected with pregnant mare serum gonadotropin (PMSG) and human chorionic gonadotropin (HCG) to establish a model of COH rats. Compared with the Normal, the endometrial thickness, the number of pinopodes and amount of blastocyst implantation in the Model group were significantly reduced. Among them, the endometrial thickness and the amount of blastocyst implantation in the Model group were substantially decreased than those in the HF-EA group. High-frequency electroacupuncture treatment could markedly reduce the protein expression levels of E-cadherin, β-catenin and claudin-1 (CLDN1). During HF-EA treatment, the LIF/STAT3 signaling pathway of COH rats was enhanced. In conclusion, electroacupuncture could improve the endometrium receptivity and promote the blastocyst implantation in COH rats by reducing cell adhesion molecules and enhancing the LIF/STAT3 signaling pathway.Highlights High-frequency electroacupuncture could effectively improve endometrial receptivity and blastocyst implantation amount in COH rats.Electroacupuncture, especially high-frequency electroacupuncture, could significantly increase endometrial thickness and the number of pinopodes.High-frequency electroacupuncture significantly reduced the protein expression levels of E-cadherin, β-catenin and CLDN1 adhesion molecules in COH rats.High-frequency electroacupuncture could markedly enhance the LIF/STAT3 signaling pathway in COH rats.

Special Issue "Reproductive Health Concerns for Women"

There are specific health issues concerning the reproductive age of women, including inflammatory disease, fertility, and childbearing [...].

Two cases of polycystic ovary syndrome with onset of severe ovarian hyperstimulation syndrome following controlled ovarian stimulation with aromatase inhibitors for fertility preservation before breast cancer treatment

OBJECTIVE

The risks of ovarian hyperstimulation syndrome (OHSS) involve high estrogen (E₂) levels. We report two breast cancer patients with polycystic ovarian syndrome who underwent fertility preservation and had severe OHSS; their E₂ levels were lowered using aromatase inhibitors (AI).

CASE REPORTS

A 36-year-old woman underwent controlled ovarian stimulation (COS) with AI and cryopreserved 10 blastocysts. She was hospitalized with OHSS (E₂ = 139.1 pg/mL). She improved with infusion alone. A 31-year-old woman underwent COS with AI and cryopreserved 8 blastocysts. She was hospitalized for OHSS (E₂: 429 pg/mL). Her vascular endothelial growth factor (VEGF) levels were high (62 pg/mL) at 8 days after the procedure. She needed hospitalization for 9 days. The planned adjuvant therapy was delayed for a week in both cases.

CONCLUSION

Elevated VEGF levels should be considered as a risk factor of OHSS even if E₂ levels are low with AI treatment.

The impact of COVID-19 in pregnancy: Part I. Clinical presentations and untoward outcomes of pregnant women with COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019, COVID-19) is a pandemic disease with rapidly and widely disseminating to the world. Based on experiences about the H1N1, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) coronavirus pandemics, pregnant women who are infected are disproportionately more likely to develop severe illness and need more hospitalizations, intensive care, and finally die of diseases compared with those nonpregnant counterparts or those pregnant women without infection. Although more than one half of pregnant women with COVID-19 are asymptomatic, and as well as their symptoms are frequently mild, this observation presents a further challenge regarding service provision, prevention, and management, in which this may result in overlooking the risk of COVID-19 during pregnancy. As predictable, despite much advance in critical care in recent decades, during the 2020 COVID-19 pandemic, pregnant women with COVID-19 are really at higher risk to progress to severe illness; require hospitalization; need intensive care, such as the use of mechanical ventilation as well as extracorporeal membrane oxygenation (ECMO), and of most important, die than their nonpregnant counterparts and pregnant women without COVID-19. The magnitude of the risk to pregnant women further extend to their newborn from COVID-19 with resultant significantly increasing perinatal and neonatal morbidity and mortality rates. The heightened risk of untoward outcomes in pregnant women emphasizes an urgent need of national or international recommendations and guidelines to optimize prevention and management strategies for COVID-19 in pregnancy. Active and passive prevention of COVID-19 is approved as effective strategies for women who attempt to be pregnant or during pregnancy. Understanding that pregnant women who are a vulnerable population is essential to improve the care in the novel and urgent COVID-19 pandemic. The current review is a part I to summarize the up-to-date information about the impact of laboratory-confirmed SARS-CoV-2 infection on pregnant women and focus on clinical presentations and untoward pregnancy outcomes of these pregnant women infected with SARS-CoV-2.