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Garçon V, Dietrich J, Strowitzki T, Freis A. P-167 Male infertility and polycystic ovary syndrome (PCOS) affect absolute and relative embryo morphokinetics observed by time-lapse imaging. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
This study aimed to test if morphokinetics are altered in embryos from patients with male infertility, polycystic ovary syndrome (PCOS) or recurrent pregnancy loss (RPL).
Summary answer
Morphokinetics differed significantly between embryos from patients with male infertility or PCOS compared to the control groups, possibly suggesting a negative impact on development potential.
What is known already
Time-lapse imaging technology allows continuous observation of embryonic morphology and developmental kinetics during the preimplantation period. The ESHRE Working group on Time-lapse technology recently summarised common absolute morphokinetic time points and intervals [DOI: 10.1093/hropen/hoaa008]. Additionally, four relative morphokinetic expressions were introduced by Cetinkaya et al.: Cleavage Synchronicity 2-8-, 4-8-, 2-4-cell stage (CS2-8, CS4-8, CS2-4) and DNA Replication time ratio (DR) [DOI: 10.1007/s10815-014-0341-x]. A study by Freis et al. observed worse CS2-8 and CS4-8 ratios in embryos from patients with endometriosis [DOI: 10.1177/1933719117741373]. Other studies have found that male infertility and PCOS may affect morphokinetic time points.
Study design, size, duration
In this retrospective observational study n = 1433 two-pronuclei oocytes from n = 433 patients between 18 and 45 years undergoing IVF/ICSI-treatment between 09/2016 and 12/2019 were examined. The use of a time-lapse incubator was obligatory. Exclusion criteria were the presence of endometriosis, history of chemotherapy, preimplantation genetic testing (PGT) cycles and genetic abnormalities. Every patient was included only once. Control groups were uterine, tubal factor and idiopathic infertility.
Participants/materials, setting, methods
Male infertility (n = 928 oocytes; 288 patients) versus control (n = 400; 115), PCOS (n = 48; 14) versus control (n = 400; 115) and RPL (n = 79; 21) versus control (n = 321; 94) were compared. Patient and treatment characteristics were compared using Mann-Whitney-U and Fisher’s exact test. Times normalised to fading of pronuclei (tPNf), intervals and ratios were analysed using a Generalised Linear Mixed Model (GLMM).
Main results and the role of chance
The male infertility group was significantly different (p < 0.05) from the control group regarding male age (p = 0.009), fertilisation rate (p = 0.008), number of embryos per patient (p = 0.033), treatment method (p < 0.001) and use of Calcium-Ionophore (p = 0.049) or SpermMobile (p = 0.003). DR was significantly higher in the male infertility group compared to the control group (p = 0.031). The start of blastulation (tSB-tPNf; p = 0.008) and start of expansion of the blastocyst (tEB-tPNf; p = 0.002) were significantly delayed.
The PCOS group was significantly different concerning female age (p = 0.023) and AMH blood level (p < 0.001). CS2-8 was significantly lower (p = 0.003) and CS2-4 significantly higher (p = 0.001) in the PCOS group compared to the control group. The time intervals from three- to four-cell (s2; p = 0.013), from five- to eight-cell (s3; p = 0.032) and from four- to eight-cell stage (ECC3; p = 0.043) were significantly longer in the PCOS group.
There was no significant difference in patient or treatment related characteristics between the RPL group and the control group. Also, none of the morphokinetic parameters analysed in this study was significantly different between the groups.
Limitations, reasons for caution
Small group sizes decreased further at later developmental time points. In general, time-lapse data show a high intra- and inter-observer variability. A GLMM was performed to take statistical dependencies between embryos of one patient into account. Its Gaussian assumption was partially violated by the true distribution of the data.
Wider implications of the findings
These data support the hypothesis that patients’ co-morbidities may affect embryo morphokinetics. The impact on clinical outcome should be examined further. Accordingly, our working group conducted another study about the predictive value of morphokinetics on blastocyst quality and implantation (DRKS-ID: DRKS00022983). The long-term goal is to improve embryo assessment.
Trial registration number
not applicable
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Affiliation(s)
- V Garçon
- Heidelberg University Women's Hospital, Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
| | - J.E Dietrich
- Heidelberg University Women's Hospital, Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
| | - T Strowitzki
- Heidelberg University Women's Hospital, Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
| | - A Freis
- Heidelberg University Women's Hospital, Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
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Dietrich J, Garçon V, Strowitzki T, Freis A. P-176 Morphokinetic Expressions Predict Day Five Embryo Quality and Implantation - A Prospective Observational Study. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
The aim of this prospective study was to investigate the value of human embryo morphokinetics as predictors of day 5 embryo quality and implantation.
Summary answer
Day 5 embryo quality was predicted best by Cleavage Synchronicity 2-8-cell stage (CS2-8). Implantation was predicted best by the time to the expanded blastocyst (tEB-tPNf).
What is known already
Time-lapse imaging technology enables embryologists to observe and assess not only embryo morphology but also kinetics and cleavage synchronicity. It was found that time intervals like time from 5- to 8-cell stage (s3 = t8 - t5) can predict blastocyst formation. Cetinkaya et al. defined four relative morphokinetic expressions describing cleavage synchronicity: Cleavage Synchronicity 2-8-, 4-8-, 2-4-cell stage (CS2-8, CS4-8, CS2-4) and DNA Replication time ratio (DR). In a retrospective study they found that CS2-8 followed by s3, and CS4-8 were better predictors of blastocyst quality than absolute cleavage time points (https://doi.org/10.1007/s10815-014-0341-x).
Study design, size, duration
This prospective observational study was conducted between December 2020 and October 2021 at a single university hospital. Patients between 18 and 45 years who underwent stimulated IVF or ICSI treatment with embryo culture in a time-lapse incubator were included. Exclusion criteria were endometriosis, PCOS, history of chemotherapy, PGT cycles and end of culture before day 5. Every patient was included only once (n = 100). Implantation was assessed for all patients with embryo transfer.
Participants/materials, setting, methods
Embryos (n = 298) reaching at least 8-cell stage were annotated for morphokinetics and divided into four groups based on day 5 morphology: top (TQ; n = 60), good (GQ; n = 69), poor quality (PQ; n = 105) or not reaching blastocyst stage (AE; n = 64). Absolute times were normalized to fading of pronuclei (tPNf). ROC-analysis was performed to test how morphokinetics predict quality and implantation (only known-implantation-data; n = 110).
Main results and the role of chance
To predict day 5 embryo quality, four morphokinetic expressions had an Area Under the Curve (AUC) of more than 0.7, including CS2-8 (AUC = 0.732), CS4-8 (AUC = 0.717), s3 (AUC = 0.724) and the start of blastulation (tSB-tPNf) (AUC = 0.725). All morphokinetic expressions mentioned were significantly different between TQ plus GQ versus PQ plus AE embryos (p < 0.001). Additionally, the data of each morphokinetic parameter were divided into four quarters using the 25th, 50th and 75th percentile. CS2-8 had a rate of 67.6% TQ plus GQ blastocysts in the fourth quarter (CS2-8 > 0.86). CS4-8, s3 and tSB-tPNf had the highest rate of TQ plus GQ blastocysts (64.3 %, 64.3 %, 72.9 %) in the first quarter (CS4-8≤0.20, s3≤3.01 h, tSB-tPNf ≤ 67.06 h).
Implantation was predicted best by the time to reach the morula stage (tM-tPNf; AUC = 0.636, p = 0.049), start blastulation (tSB-tPNf; AUC = 0.660, p = 0.022) and expanded blastocyst (tEB-tPNf; AUC = 0.688, p = 0.009). The relative expressions CS2-8 and CS4-8 and the interval s3 were not significantly different between implanted and non-implanted embryos.
Limitations, reasons for caution
Morphokinetic annotation is open to inter- and intraobserver variability, although partially controlled by prospectivity. The ROC-analysis does not adjust for statistical dependence between embryos of one patient. The used morphological groups do not necessarily measure developmental potential. Embryos with KID showed less morphokinetic variation because of pre-selection for transfer.
Wider implications of the findings
The findings could contribute to an early decision model on transfer hierarchy that would help avoiding costs and a potential negative influence of prolonged blastocyst culture. Observing the kinetics of blastocyst formation (tM, tSB, tEB) might allow an improved prediction of implantation potential.
Trial registration number
DRKS00022983
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Affiliation(s)
- J.E Dietrich
- Heidelberg University Women's Hospital, Department of Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
| | - V Garçon
- Heidelberg University Women's Hospital, Department of Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
| | - T Strowitzki
- Heidelberg University Women's Hospital, Department of Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
| | - A Freis
- Heidelberg University Women's Hospital, Department of Gynecologic Endocrinology and Fertility Disorders , Heidelberg, Germany
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Rehnitz J, Capp E, Messmer B, Nguyen XP, Germeyer A, Freis A, Dietrich JE, Hinderhofer K, Strowitzki T, Vogt PH. FMR1 and AKT/mTOR Signaling in Human Granulosa Cells: Functional Interaction and Impact on Ovarian Response. J Clin Med 2021; 10:jcm10173892. [PMID: 34501340 PMCID: PMC8432207 DOI: 10.3390/jcm10173892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 01/12/2023] Open
Abstract
We aimed to determine whether a functional link with impact on female ovarian reserve exists between FMR1 expression and expression ratios of AKT/mTOR signaling genes in human granulosa cells in vivo, as suggested from prior in vitro data. Three hundred and nine women, who were classified as normal (NOR; n = 225) and poor (POR; n = 84) responders based on their ovarian reserve, were recruited during stimulation for assisted reproductive techniques. Expressions of FMR1 and of key genes of the AKT/mTOR and AKT/FOXO1/3 signaling pathways were comparatively analyzed in their granulosa cells. FMR1 expression in granulosa cells of NOR and POR correlated significantly with AKT1, TSC2, mTOR, and S6K expression. No correlation was found between FMR1 and FOXO1 in all, and FOXO3 expression in POR, patients. AKT1 expression was significantly higher and FOXO1 expression lower in POR samples, whereas AKT1 expression was lower and FOXO1 expression was higher in NOR samples. In human native granulosa cells, FMR1 expression significantly correlated with the expression of key genes of the AKT/mTOR signaling pathway, but not with the FOXO1/3 signaling pathway. Our data point to a functional link between FMR1 expression and expression of the AKT/mTOR signaling pathway genes controlling human follicular maturation.
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Affiliation(s)
- Julia Rehnitz
- Division of Reproductive Genetics, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (B.M.); (X.P.N.); (P.H.V.)
- Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (E.C.); (A.G.); (A.F.); (J.E.D.); (T.S.)
- Correspondence: ; Tel.: +49-6221-56-7910
| | - Edison Capp
- Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (E.C.); (A.G.); (A.F.); (J.E.D.); (T.S.)
- Department of Obstetrics and Gynecology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-003, Brazil
| | - Birgitta Messmer
- Division of Reproductive Genetics, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (B.M.); (X.P.N.); (P.H.V.)
| | - Xuan Phuoc Nguyen
- Division of Reproductive Genetics, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (B.M.); (X.P.N.); (P.H.V.)
| | - Ariane Germeyer
- Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (E.C.); (A.G.); (A.F.); (J.E.D.); (T.S.)
| | - Alexander Freis
- Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (E.C.); (A.G.); (A.F.); (J.E.D.); (T.S.)
| | - Jens Erik Dietrich
- Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (E.C.); (A.G.); (A.F.); (J.E.D.); (T.S.)
| | - Karin Hinderhofer
- Laboratory of Molecular Genetics, Institute of Human Genetics, University Heidelberg, 69120 Heidelberg, Germany;
| | - Thomas Strowitzki
- Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (E.C.); (A.G.); (A.F.); (J.E.D.); (T.S.)
| | - Peter H. Vogt
- Division of Reproductive Genetics, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital Heidelberg, 69120 Heidelberg, Germany; (B.M.); (X.P.N.); (P.H.V.)
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Freis A. Therapie der „missed abortion“ – wo stehen wir? Gynäkologische Endokrinologie 2020. [DOI: 10.1007/s10304-020-00354-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Holzer I, Machado WA, Marshall A, Freis A, Strowitzki T, Germeyer A. Expression von Fibronektin und Progranulin in eutopem Endometrium – potenzielle stadienabhängige Biomarker für die Endometriose. Geburtshilfe Frauenheilkd 2020. [DOI: 10.1055/s-0040-1717678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- I Holzer
- Frauenklinik des Universitätsklinikum Heidelberg, Klinik für Gynäkologische Endokrinologie und Fertilitätsstörungen
| | - Weber A. Machado
- Frauenklinik des Universitätsklinikum Heidelberg, Klinik für Gynäkologische Endokrinologie und Fertilitätsstörungen
| | - A Marshall
- Frauenklinik des Universitätsklinikum Heidelberg, Klinik für Gynäkologische Endokrinologie und Fertilitätsstörungen
| | - A Freis
- Frauenklinik des Universitätsklinikum Heidelberg, Klinik für Gynäkologische Endokrinologie und Fertilitätsstörungen
| | - T Strowitzki
- Frauenklinik des Universitätsklinikum Heidelberg, Klinik für Gynäkologische Endokrinologie und Fertilitätsstörungen
| | - A Germeyer
- Frauenklinik des Universitätsklinikum Heidelberg, Klinik für Gynäkologische Endokrinologie und Fertilitätsstörungen
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Goeckenjan M, Freis A, Glaß K, Schaar J, Trinkaus I, Torka S, Wimberger P, Germeyer A. Motherhood after cancer: fertility and utilisation of fertility-preservation methods. Arch Gynecol Obstet 2020; 301:1579-1588. [PMID: 32377787 PMCID: PMC7246243 DOI: 10.1007/s00404-020-05563-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/25/2020] [Indexed: 12/03/2022]
Abstract
Purpose Due to modern and individualised treatments, women at reproductive age have a high survival rate after cancer therapy. What are pregnancy and birth rates of women after cancer and how often do they use cryopreserved ovarian tissue or gametes? Methods From 2007 to 2015, 162 women aged 26.7 ± 6.9 years were counselled for fertility preservation at a single University Fertility Centre. A questionnaire study was performed in average 3 and 6 years after the diagnosis of cancer. The women were asked about their fertility, partnership, family planning, and pregnancy history. 72 women (51%) answered a written questionnaire in 2016. 59 women were reached again by phone in 2019 (82%). Results The preferred method of fertility preservation was ovarian tissue cryopreservation (n = 36, 50%); none of the women had ovarian hyperstimulation in order to cryopreserve oocytes. About 3 years after treatment, 37 women of 72 women (51%) of the women with a mean age of 29.9 years had a strong wish to conceive. 21/72 (29%) had actively tried to conceive after successful cancer treatment; eight women (11%) were already pregnant or had children. Six years after cancer diagnosis 16/59 (27%) women had ongoing anticancer treatment. 12/59 (20%) were pregnant or had children, while 39% (23/59) had no menstrual cycle. Only one woman used her cryopreserved ovarian tissue, but did not become pregnant. Conclusion After cancer and gonadotoxic treatment, women’s desire to have a child is substantial. In this study, the rate of spontaneous pregnancies and births was 20% 6 years after gonadotoxic therapies. Not every woman, however, has the opportunity to conceive: factors impairing fertility include ongoing cancer treatment or persistent disease, no partner, no menstrual cycle, as well as other reasons for infertility.
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Affiliation(s)
- Maren Goeckenjan
- Department for Gynaecology and Obstetrics, Technische Universität Dresden, University Hospital, Dresden, Germany.
| | - A Freis
- Department for Gynaecological Endocrinology and Reproductive Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - K Glaß
- Department for Gynaecology and Obstetrics, Technische Universität Dresden, University Hospital, Dresden, Germany
| | - J Schaar
- Department for Gynaecology and Obstetrics, Technische Universität Dresden, University Hospital, Dresden, Germany
| | - I Trinkaus
- Department for Gynaecology and Obstetrics, Technische Universität Dresden, University Hospital, Dresden, Germany
| | - S Torka
- Department for Gynaecology and Obstetrics, Technische Universität Dresden, University Hospital, Dresden, Germany
| | - P Wimberger
- Department for Gynaecology and Obstetrics, Technische Universität Dresden, University Hospital, Dresden, Germany
| | - A Germeyer
- Department for Gynaecological Endocrinology and Reproductive Medicine, University Hospital of Heidelberg, Heidelberg, Germany
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Dietrich JE, Freis A, Beedgen F, von Horn K, Holschbach V, Liebscher J, Strowitzki T, Germeyer A. Intraindividual Embryo Morphokinetics Are Not Affected by a Switch of the Ovarian Stimulation Protocol Between GnRH Agonist vs. Antagonist Regimens in Consecutive Cycles. Front Endocrinol (Lausanne) 2020; 11:246. [PMID: 32411093 PMCID: PMC7198727 DOI: 10.3389/fendo.2020.00246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/03/2020] [Indexed: 11/26/2022] Open
Abstract
Background: The impact of controlled ovarian stimulation (COS) during medically assisted reproduction (MAR) on human embryogenesis is still unclear. Therefore, we investigated if early embryonic development is affected by the type of gonadotropin-releasing hormone (GnRH) analog used to prevent a premature LH surge. We compared embryo morphology and morphokinetics between GnRH agonist and antagonist cycles, both involving human chorionic gonadotropin (hCG)-trigger. To reduce possible confounding factors, we used intraindividual comparison of embryo morphokinetics in consecutive treatment cycles of the same patients that underwent a switch in the COS protocol. Methods: This retrospective cohort study analyzed morphokinetics of embryos from patients (n = 49) undergoing a switch in COS protocols between GnRH agonists followed by GnRH antagonists, or vice versa, after culture in a time-lapse incubator (EmbryoScope®, Vitrolife) in our clinic between 06/2011 and 11/2016 (n = 49 GnRH agonist cycles with n = 172 embryos; n = 49 GnRH antagonist cycles with n = 163 embryos). Among time-lapse cycles we included all embryos of the two consecutive cycles before and after a switch in the type of COS in the same patient. In-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) was performed and embryos were imaged up to day 5. Data were analyzed using Mann-Whitney U test or Fisher's exact test. The significance level was set to p = 0.05. Patients with preimplantation genetic screening cycles were excluded. Results: The mean age (years ± standard deviation) of patients at the time of treatment was 35.7 ± 4.3 (GnRH agonist) and 35.8 ± 4.0 (GnRH antagonist) (p = 0.94). There was no statistically significant difference in the number of oocytes collected or the fertilization rate. The numbers of top quality embryos (TQE), good-quality embryos (GQE), or poor-quality embryos (PQE) were also not different in GnRH agonist vs. antagonist cycles. We found no statistically significant difference between the analyzed morphokinetic parameters between the study groups. Conclusions: Our finding supports the flexible use of GnRH analogs to optimize patient treatment for COS without affecting embryo morphokinetics.
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Affiliation(s)
- Jens E. Dietrich
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
- *Correspondence: Jens E. Dietrich
| | - Alexander Freis
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
| | - Franziska Beedgen
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
- Faculty of Veterinary Medicine, Justus-Liebig-University Giessen, Giessen, Germany
| | - Kyra von Horn
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
| | - Verena Holschbach
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
| | - Julia Liebscher
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
| | - Thomas Strowitzki
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
| | - Ariane Germeyer
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg, Germany
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Freis A, Germeyer A, Jauckus J, Capp E, Strowitzki T, Zorn M, Machado Weber A. Endometrial expression of receptivity markers subject to ovulation induction agents. Arch Gynecol Obstet 2019; 300:1741-1750. [PMID: 31667611 DOI: 10.1007/s00404-019-05346-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 10/15/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Implantation rates differ according to ovulation induction agents in ART. This study investigates the different local endometrial effects of LH- versus hCG-induced ovulation. METHODS Endometrial stromal cells from healthy patients were cultured with hCG or LH in different concentrations, supplemented with 250 ng/mL hCG and progesterone after 2 and 5 days. In addition after decidualization induction, cells were treated with hCG (50 or 250 ng/mL) or LH (10 or 50 ng/mL) for 3 days. Receptivity markers expression was evaluated by real-time quantitative PCR on day 3 and 6. RESULTS On day 3, non-decidualized cells treated with LH showed an increased expression of IGFBP1, IL-8 and CXCL12 compared to hCG. The expression pattern changed on day 6, where cells treated with hCG showed higher expression of implantation markers compared to LH-treated cells. Furthermore, on day 3, decidualized cells treated with hCG250 showed an increased IL8 and CXCL12 expression compared to LH10. CONCLUSIONS LH seems to modulate the local endometrial expression of receptivity markers earlier compared to hCG; however, the effect is not sustained over time in cells without prior decidualization. Though, in decidualized cells, pattern changed and an earlier positive effect of hCG was shown on IL-8 and CXCL12.
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Affiliation(s)
- Alexander Freis
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Ariane Germeyer
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Jauckus
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Edison Capp
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany.,Department of Obstetrics and Gynecology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Thomas Strowitzki
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Zorn
- Central Laboratory, University of Heidelberg, Heidelberg, Germany
| | - Amanda Machado Weber
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany.
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Riedel F, Riedel M, Freis A, Heil J, Golatta M, Schuetz F, Sohn C, Hennigs A. Exam preparatory course for the 2nd part of the German medical examination in obstetrics and gynecology - a potential tool for the recruitment of new residents during the occupational decision process before the practical year? BMC Med Educ 2019; 19:24. [PMID: 30654790 PMCID: PMC6335710 DOI: 10.1186/s12909-019-1457-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 01/08/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The "Second Stage of the Physician Exam" at the end of the 5th year of medical school in Germany is the final step before the "Practical Year." An exam preparatory class can cover the complete content of Obstetrics and Gynecology (OB/GYN) in two days. We raise the question of whether such training might promote students' interest in the given specialty during occupational decision making and whether it could even be used by hospitals as a recruitment tool. This investigation is even more important in the context of fierce competition among young professionals at clinics and in different specialties. METHODS We conducted a multimodal course evaluation for four exam preparatory courses (each of which lasted two days and involved 8.5 h of teaching), including pre- and post-course tests with 20 multiple-choice questions to quantify the level of skill gain. Additionally, a standardized evaluation of course satisfaction was performed, followed by a post-exam questionnaire that dealt with studying activities and individual professional objectives. RESULTS Overall, n = 197 students took part in four identical courses. Among them, n = 121 completed the pre-/post-course tests, n = 170 completed the evaluation, and n = 110 completed the post-exam questionnaire. An average improvement from 13.9 to 17.2 correct answers was observed (max. 20; pre-/post-difference 95%-CI: [2.77; 3.86], t-test: p < 0.0001). By trend, the students noted that course participation positively influenced their later choice of specialty training (m = 3.63; scale 1 = "strongly disagree," 5 = "strongly agree"). CONCLUSIONS In addition to self-studying, condensed classroom training is effective and reasonable and might also increase the attractivity of OB/GYN among students and have a positive effect on recruitment.
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Affiliation(s)
- Fabian Riedel
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Maximilian Riedel
- Department of Gynecology and Obstetrics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alexander Freis
- Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Hospital, Heidelberg, Germany
| | - Joerg Heil
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Schuetz
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof Sohn
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
| | - André Hennigs
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Heidelberg, Germany
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Freis A, Schlegel J, Daniel V, Jauckus J, Strowitzki T, Germeyer A. Chemokin/hCG-ratios – neue Marker zur Bestimmung des Schwangerschaftsverlaufs. Geburtshilfe Frauenheilkd 2018. [DOI: 10.1055/s-0038-1670977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- A Freis
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - J Schlegel
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - V Daniel
- Institut für Immunologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - J Jauckus
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - T Strowitzki
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - A Germeyer
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
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Freis A, Schlegel J, Kuon RJ, Doster A, Jauckus J, Strowitzki T, Germeyer A. Periostin-Profil bei Patientinnen mit konsekutivem Abort in der Frühschwangerschaft. Geburtshilfe Frauenheilkd 2018. [DOI: 10.1055/s-0038-1670978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- A Freis
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - J Schlegel
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - RJ Kuon
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - A Doster
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - J Jauckus
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - T Strowitzki
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
| | - A Germeyer
- Universitätsfrauenklinik Heidelberg, Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Deutschland
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Freis A, Schlegel J, Daniel V, Jauckus J, Strowitzki T, Germeyer A. Cytokines in relation to hCG are significantly altered in asymptomatic women with miscarriage - a pilot study. Reprod Biol Endocrinol 2018; 16:93. [PMID: 30266090 PMCID: PMC6162891 DOI: 10.1186/s12958-018-0411-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/25/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Spontaneous abortion is one of the most common complications in early pregnancy. A preventive test to identify women who will experience a miscarriage, even before first symptoms occur, is not established. Activation of maternal immunological tolerance seems to be essential for early fetal development and various cytokines have been described in different stages of pregnancy. Therefore, we aimed to investigate if chemokine levels at the time of pregnancy testing relative to human Choriogonadotropin (hCG) are altered in patients who will experience a miscarriage in this pregnancy. METHODS We obtained blood samples from 39 women. Dependent on the follow-up, patients with a positive pregnancy test were subsequently divided in two groups: ongoing pregnancy (n = 22) and miscarriage (n = 17) in this pregnancy. Immunological and endocrine profiling of maternal plasma at the time of pregnancy testing (5th week of gestation) was performed for each group at the time of pregnancy test using Multiplex and ELISA analysis. RESULTS hCG was significantly decreased in patients with abortion whereas levels of IL-1ra, MIP-1a and TNF-alpha were significantly increased. GCSF/ IL-1ra-ratio was 1.66-fold increased in patients with ongoing pregnancy. TGF-beta /MIP1a-ratio was significantly 3.45-times higher in patients with miscarriage. Comparing patients with ongoing pregnancy to patients experiencing a miscarriage, we could demonstrate significant alterations of the ratios MIP1a/hCG, IL-1ra/hCG, TNFalpha/hCG, MCP1/hCG, IL-6/hCG, TPO/hCG and TGF-beta1/hCG. The strongest effects were seen for the ratio MIP1a/hCG, IL-1ra/hCG and TNFalpha/hCG. CONCLUSIONS We have shown that cytokines in relation to hCG after 4 weeks of gestation are significantly altered in women with miscarriage, promising potential as a prognostic biomarker.
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Affiliation(s)
- Alexander Freis
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - Janina Schlegel
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - Volker Daniel
- Transplantation-Immunology, Institute of Immunology, University Hospital Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Julia Jauckus
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - Thomas Strowitzki
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - Ariane Germeyer
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
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Rehnitz J, Alcoba DD, Brum IS, Dietrich JE, Youness B, Hinderhofer K, Messmer B, Freis A, Strowitzki T, Germeyer A. FMR1 expression in human granulosa cells increases with exon 1 CGG repeat length depending on ovarian reserve. Reprod Biol Endocrinol 2018; 16:65. [PMID: 29981579 PMCID: PMC6035797 DOI: 10.1186/s12958-018-0383-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/02/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Fragile-X-Mental-Retardation-1- (FMR1)-gene is supposed to be a key gene for ovarian reserve and folliculogenesis. It contains in its 5'-UTR a triplet-base-repeat (CGG), that varies between 26 and 34 in general population. CGG-repeat-lengths with 55-200 repeats (pre-mutation = PM) show instable heredity with a tendency to increase and are associated with premature-ovarian-insufficiency or failure (POI/POF) in about 20%. FMR1-mRNA-expression in leucocytes and granulosa cells (GCs) increases with CGG-repeat-length in PM-carriers, but variable FMR1-expression profiles were also described in women with POI without PM-FMR1 repeat-length. Additionally, associations between low numbers of retrieved oocytes and elevated FMR1-expression levels have been shown in GCs of females with mid-range PM-CGG-repeats without POI. Effects of FMR1-repeat-lengths-deviations (n < 26 or n > 34) below the PM range (n < 55) on ovarian reserve and response to ovarian stimulation remain controversial. METHODS We enrolled 229 women undergoing controlled ovarian hyperstimulation for IVF/ICSI-treatment and devided them in three ovarian-response-subgroups: Poor responder (POR) after Bologna Criteria, polycystic ovary syndrome (PCO) after Rotterdam Criteria, or normal responder (NOR, control group). Subjects were subdivided into six genotypes according to their be-allelic CGG-repeat length. FMR1-CGG-repeat-length was determined using ALF-express-DNA-sequencer or ABI 3100/3130 × 1-sequencer. mRNA was extracted from GCs after follicular aspiration and quantitative FMR1-expression was determined using specific TaqMan-Assay and applying the ΔΔCT method. Kruskall-Wallis-Test or ANOVA were used for simple comparison between ovarian reserve (NOR, POR or PCO) and CGG-subgroups or cohort demographic data. All statistical analysis were performed with SPSS and statistical significance was set at p ≤ 0.05. RESULTS A statistically significant increase in FMR1-mRNA-expression-levels was detected in GCs of PORs with heterozygous normal/low-CGG-repeat-length compared with other genotypes (p = 0.044). CONCLUSION Female ovarian response may be negatively affected by low CGG-alleles during stimulation. In addition, due to a low-allele-effect, folliculogenesis may be impaired already prior to stimulation leading to diminished ovarian reserve and poor ovarian response. A better understanding of FMR1 expression-regulation in GCs may help to elucidate pathomechanisms of folliculogenesis disorders and to develop risk-adjusted treatments for IVF/ICSI-therapy. Herewith FMR1-genotyping potentially provides a better estimatation of treatment outcome and allows the optimal adaptation of stimulation protocols in future.
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Affiliation(s)
- Julia Rehnitz
- 0000 0001 0196 8249grid.411544.1Reproduction Genetics Unit, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
- 0000 0001 0196 8249grid.411544.1Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
| | - Diego D. Alcoba
- 0000 0001 0196 8249grid.411544.1Reproduction Genetics Unit, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
- 0000 0001 2200 7498grid.8532.cDepartment of Physiology, Institute of Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ilma S. Brum
- 0000 0001 2200 7498grid.8532.cDepartment of Physiology, Institute of Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Jens E. Dietrich
- 0000 0001 0196 8249grid.411544.1Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
| | - Berthe Youness
- 0000 0001 0196 8249grid.411544.1Reproduction Genetics Unit, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
| | - Katrin Hinderhofer
- 0000 0001 2190 4373grid.7700.0Laboratory of Molecular Genetics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Birgitta Messmer
- 0000 0001 0196 8249grid.411544.1Reproduction Genetics Unit, Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
| | - Alexander Freis
- 0000 0001 0196 8249grid.411544.1Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
| | - Thomas Strowitzki
- 0000 0001 0196 8249grid.411544.1Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
| | - Ariane Germeyer
- 0000 0001 0196 8249grid.411544.1Department of Gynecological Endocrinology and Fertility Disorders, University Women’s Hospital, Heidelberg, Germany
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Hudalla H, Karmen C, Bruckner T, Wallwiener S, Fluhr H, Michael Z, Freis A, Maul H, Strowitzki T, Pöschl J, Kuon RJ. Tocolysis with the β 2-sympathomimetic fenoterol does not increase the occurrence of infantile hemangioma in preterm and term infants. Arch Gynecol Obstet 2018; 298:521-527. [PMID: 29938346 DOI: 10.1007/s00404-018-4830-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 06/18/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE β2-sympathomimetics are used in obstetrics as tocolytic agents, despite a remarkable profile of side effects. Recently, the β2-sympathomimetic tocolytic drug hexoprenaline was identified as an independent risk factor for the development of infantile hemangioma (IH) in preterm infants. The aim of this study was to evaluate whether this observed effect was applicable to other β2-mimetic tocolytic agents like fenoterol. METHODS Clinical prospectively collected data of all infants born between 2001 and 2012 and admitted to the neonatal intensive care unit (NICU) at Heidelberg University Hospital and respective maternal data were merged. For the current retrospective cohort study, cases (IH) were matched to controls (no IH) at a ratio of 1:4, adjusting for birth weight, gestational age, gender and multiple gestations. Prenatal exposure to fenoterol and perinatal outcome were analyzed in the total cohort and in subgroups. RESULTS N = 5070 infants were admitted to our neonatal department, out of which n = 172 infants with IH were identified and compared to n = 596 matched controls. Exposure to fenoterol was not associated with a higher rate of IH in the total matched population (OR 0.926, 95% CI 0.619-1.384) or in a subgroup of neonates < 32 weeks of gestation or with a birth weight < 1500 g (OR 1.127, 95% CI 0.709-1.791). In the total matched population, prenatal exposure to glucocorticoids was associated with a reduced occurrence of IH (OR 0.566, 95% CI 0.332-0.964) and neonates with IH showed a prolonged total hospital stay compared to controls (69 vs. 57 days, p = 0.0033). Known risk factors for IH were confirmed by our large study cohort and included female gender, low birth weight, preterm birth and multiple gestations (all p < 0.005). CONCLUSIONS Exposure to fenoterol during pregnancy does not increase the occurrence of IH. Further studies are needed to explore differences in the risk profiles of different β2-sympathomimetic tocolytic drugs.
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Affiliation(s)
- Hannes Hudalla
- Department of Neonatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Karmen
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Stephanie Wallwiener
- Department of Obstetrics and Gynecology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Fluhr
- Department of Obstetrics and Gynecology, Heidelberg University Hospital, Heidelberg, Germany
| | - Zoe Michael
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Freis
- Department of Gynecological Endocrinology and Fertility Disorders, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Holger Maul
- Department of Obstetrics and Gynecology, Asklepios Klinik, Hamburg, Germany
| | - Thomas Strowitzki
- Department of Gynecological Endocrinology and Fertility Disorders, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Johannes Pöschl
- Department of Neonatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ruben-J Kuon
- Department of Gynecological Endocrinology and Fertility Disorders, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
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Freis A, Von Horn K, Göggl T, Hecht S, Roesner S, Strowitzki T, Germeyer A. Serum levels of Pentraxin 3 differ significantly at the time of blastocyst transfer depending on implantation success: a pilot study. Arch Gynecol Obstet 2018; 297:1565-1570. [PMID: 29616311 DOI: 10.1007/s00404-018-4769-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Many approaches try to identify the underlying molecular mechanisms to detect new potential biomarkers for successful artificial reproductive therapies. One factor has been described as a possible regulator of inflammation during implantation: Pentraxin 3 (PTX3), which seems to be essential for female fertility on one hand, but whose overexpression has been described in many obstetric complications based on abnormal placentation on the other hand. Therefore, we investigated if serum levels of PTX3 at the time of embryo transfer differ between women with an ongoing pregnancy compared to those without implantation. METHODS/DESIGN During in vitro fertilization cycles of 51 patients, PTX3 levels at the time of embryo transfer were compared between patients without implantation (n = 26) and those with ongoing pregnancy (n = 25) using an enzyme-linked immunosorbent assay. Statistical analysis was performed using the Kolmogorov-Smirnov test, Fisher's exact test and Student's t test RESULTS: No significant differences were found concerning possible confounders (patients age, smoking pattern, embryo quality, number of embryos transferred and prior IVF attempts). Patients without implantation presented with significantly higher serum levels of PTX3 at the time of embryo transfer compared to women who became pregnant (0.781 ± 0.074 ng/ml vs. 0.578 ± 0.055 ng/ml, p < 0.05). CONCLUSIONS PTX3 could present as a possible biomarker for ART success. The main limitation of this pilot study is its small sample size that needs validation with a larger study population.
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Affiliation(s)
- Alexander Freis
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany.
| | - Kyra Von Horn
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany
| | - Tamara Göggl
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany
| | - Stephanie Hecht
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany
| | - Sabine Roesner
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany
| | - Thomas Strowitzki
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany
| | - Ariane Germeyer
- Department of Gynecologic Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120, Heidelberg, Germany
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Freis A, Freundl-Schütt T, Wallwiener LM, Baur S, Strowitzki T, Freundl G, Frank-Herrmann P. Plausibility of Menstrual Cycle Apps Claiming to Support Conception. Front Public Health 2018; 6:98. [PMID: 29666788 PMCID: PMC5891577 DOI: 10.3389/fpubh.2018.00098] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/16/2018] [Indexed: 11/23/2022] Open
Abstract
The interval of peak fertility during the menstrual cycle is of limited duration, and the day of ovulation varies, even in women with fairly regular cycles. Therefore, menstrual cycle apps identifying the "fertile window" for women trying to conceive must be quite precise. A deviation of a few days may lead the couple to focus on less- or non-fertile days for sexual intercourse and thus may be worse than random intercourse. The aim of the present investigation was to develop a scoring system for rating available apps for determining the fertile window and secondarily pilot test 12 apps currently available in both German and English (consisting of 6 calendar-based apps: Clue Menstruations- und Zykluskalender, Flo Menstruationskalender, Maya-Mein Periodentracker, Menstruationskalender Pro, Period Tracker Deluxe, and WomanLog-Pro-Kalender; 2 calculothermal apps: Ovy and Natural Cycles; and 4 symptothermal apps: myNFP, Lady Cycle, Lily, and OvuView). The calendar-based apps were investigated by entering several series of cycles with varying lengths, whereas the symptom-based apps were examined by entering data of cycles with known temperature rise, cervical mucus pattern, and clinical ovulation. The main criteria for evaluating the cycle apps were as follows: (1) What methods/parameters were used to determine the fertile window? (2) What study results exist concerning that underlying method/parameters? (3) What study results exist concerning the app itself? (4) Was there a qualified counseling service? The calendar-based apps predicted the fertile days based on data of previous cycles. They obtained zero points in our scoring system, as they did not comply with any of the evaluated criteria. Calculothermal apps had similar deficits for predicting the most fertile days and produced suboptimal results (Ovy 3/30 points and Natural Cycles 2/30 points). The symptothermal apps determined the fertile days based on parameters of the current cycle: Lady Cycle scored 20/30 points, myNFP 20/30 points, Lily 19/30 points, and OvuView 11/30 points. We concluded that the available cycle apps vary according to their underlying scientific quality and clear rating criteria have been suggested. Three of the tested apps were judged to be eligible for further study. The scientific evaluation of cycle apps depends on good prospective studies undertaken by independent investigators who are free of commercial bias.
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Affiliation(s)
- Alexander Freis
- Department of Gynecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany
| | | | - Lisa-Maria Wallwiener
- Department of Obstetrics and Gynecology, University Clinic of Munich, Munich, Germany
| | - Sigfried Baur
- Section Natural Fertility, German Society of Gynecological Endocrinology and Fertility Medicine (DGGEF e.V.), Heidelberg, Germany
| | - Thomas Strowitzki
- Department of Gynecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany
| | - Günter Freundl
- Section Natural Fertility, German Society of Gynecological Endocrinology and Fertility Medicine (DGGEF e.V.), Heidelberg, Germany
| | - Petra Frank-Herrmann
- Department of Gynecological Endocrinology and Fertility Disorders, University of Heidelberg, Heidelberg, Germany
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Freis A, Keller A, Ludwig N, Meese E, Jauckus J, Rehnitz J, Capp E, Strowitzki T, Germeyer A. Altered miRNA-profile dependent on ART outcome in early pregnancy targets Wnt-pathway. Reproduction 2017; 154:799-805. [DOI: 10.1530/rep-17-0396] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/11/2017] [Accepted: 09/28/2017] [Indexed: 12/20/2022]
Abstract
Main goal of this study is to detect the possible alterations in microRNA (miRNA) expression and the pathway targeted in plasma at the time of embryo transfer and pregnancy testing dependent on the assisted reproductive treatment (ART) outcome after ovarian hyperstimulation for in vitro fertilization. Changes in miRNA expression in plasma of women, who became pregnant (n = 6) vs women who failed implantation (n = 6) following day 5 embryo transfer (ET), were investigated at the day of ET and pregnancy testing (PT). Protein expression to validate the finding was performed with a sample size of n = 20 (10 per group) using enzyme-linked immunosorbent assay. Enriched Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed using DIANA-miRPath, v3.0 software based on predicted targets by DIANA-microT-CDS. 4 miRNAs could be identified as possible biomarkers for implantation success. The 11 miRNAs showing the highest significant alterations were all associated with the regulation of WNT3 and WNT7a. While WNT7a presented with a significant decrease between ET and PT in case of ongoing pregnancy, women with implantation failure showed unaltered concentrations. WNT3 presented with a significant decrease in both groups. However, the loss of WNT3 between ET and PT was significantly higher in patients who became pregnant. Main limitation of this prospective study is its small sample size, defining it as a pilot analysis. To conclude, we could demonstrate a significant change in miRNA profile dependent on the ART outcome affecting Wnt pathway. Our findings indicate a possible prospective use of miRNA as biomarkers for implantation success.
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Freis A, Dietrich JE, Binder M, Holschbach V, Strowitzki T, Germeyer A. Relative Morphokinetics Assessed by Time-Lapse Imaging Are Altered in Embryos From Patients With Endometriosis. Reprod Sci 2017; 25:1279-1285. [PMID: 29141509 DOI: 10.1177/1933719117741373] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Time-lapse technology allows almost continuous noninvasive assessment of embryonic development. It was shown previously that relative kinetics defining cleavage synchronicity are better predictors of blastocyst quality than absolute time points. This study aims to compare relative kinetics in embryos from patients with and without endometriosis. METHODS Time-lapse data were collected retrospectively from 596 patients undergoing infertility treatment for in vitro fertilization from January 2011 to July 2016. Four hundred twenty-eight patients with confounding comorbidities (ie, polycystic ovary syndrome, pathological spermiogram in the included cycle, numerical/structural genetic abnormalities, preimplantation genetic screening performed) or incomplete data sets were excluded. Of the 168 included patients, 72 (42.9%) had endometriosis. Indications for in vitro fertilization of controls were tubal factor, unexplained infertility, or prolonged infertility. Relative kinetics were calculated as defined previously: cleavage synchronicity (CS)2-8=((t3-t2) + (t5-t4))/(t8-t2), CS4-8=(t8-t5)/(t8-t4), CS2-4=(t4-t3)/(t4-t2), DNA replication time ratio (DR)=(t3-t2)/(t5-t3). In women with more than one embryo, the median time was analyzed. RESULTS Median age, body mass index, smoking status, and AMH levels were similar in both groups. Embryos from patients with endometriosis showed poorer relative kinetics. The relative time CS2-8 was decreased in embryos from patients with endometriosis (0.7 [0.0-0.93] vs 0.8 [0.0-0.94], P < .05) and CS4-8 was increased (0.4 [0.0-1.0] vs 0.3 [0.0-1.0], P < .05). The less powerful diagnostic relative kinetic parameters (CS2-4 and DR) were not significantly different. CONCLUSIONS Embryos from patients with endometriosis presented with altered relative kinetics suggesting poorer embryo quality. These findings support recently published data demonstrating reduced oocyte quality in patients with endometriosis which is one possible explanation for their poor response to fertility treatment.
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Affiliation(s)
- Alexander Freis
- 1 Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Jens Erik Dietrich
- 1 Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Binder
- 2 Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Verena Holschbach
- 1 Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Strowitzki
- 1 Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Ariane Germeyer
- 1 Department of Gynecologic Endocrinology and Fertility Disorders, Heidelberg University Women's Hospital, Heidelberg University Hospital, Heidelberg, Germany
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Freis A, Schlegel J, Kuon RJ, Doster A, Jauckus J, Strowitzki T, Germeyer A. Serum periostin levels in early in pregnancy are significantly altered in women with miscarriage. Reprod Biol Endocrinol 2017; 15:87. [PMID: 29096644 PMCID: PMC5667517 DOI: 10.1186/s12958-017-0307-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/23/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Miscarriage is a common complication in pregnancy and there is still a lack of biomarkers usable in asymptomatic patients before the event occurs. Periostin (PER), whose levels rise particularly during injury or inflammation, has been shown to play an important local role in implantation and early embryonic development. As PER has been described as a biomarker in various medical conditions we intended to evaluate if changes in PER serum levels may help to identify women at risk for spontaneous abortion in the first trimester. METHODS Women between 18 and 42 years without confounding comorbidities who conceived by IVF/ICSI and ovarian hyperstimulation were analysed in the study after informed consent. Maternal serum samples from 41 patients were assessed at the time of pregnancy testing (PT) and the following first ultrasound checkup (US). Patients were subsequently divided in two groups: (1) patients with subsequent miscarriage in the first trimester (n = 18) and (2) patients with ongoing pregnancy (n = 23), allowing for statistical analysis and investigating the change of PER levels per individual. PER levels were measured using enzyme-linked immunosorbent assay. Statistical analysis was performed using the Fisher exact and Student's t test. p ≤ 0.05 was considered to be significant. RESULTS There was no significant difference concerning possible confounders between the two groups. We did not find any significant difference in PER levels at the time point of PT or US. By investigating the interindividual changes of PER between the two time points however, we observed that patients with a following miscarriage showed increasing levels of PER at the time point of PT compared to US in contrast to patients with an ongoing pregnancy who demonstrated a decrease in PER levels. These alterations were significant in the absolute as well as in the relative comparison. CONCLUSION The relative expression of PER between PT and US is significantly altered in asymptomatic women with subsequent miscarriage compared to women with ongoing pregnancy. Therefore systemic PER levels might represent a potential promising biomarker for the assessment of pregnancy outcome. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- A. Freis
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - J. Schlegel
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - R. J. Kuon
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - A. Doster
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - J. Jauckus
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - T. Strowitzki
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
| | - A. Germeyer
- 0000 0001 0328 4908grid.5253.1Department of Gynecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, INF 440, 69120 Heidelberg, Germany
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Heublein S, Au A, Michel L, Freis A, Rom J, Wallwiener M, Marmé F, Schütz F, Sohn C. Einführung eines individuellen Curriculums in der studentischen Lehre im Fach Gynäkologie und Geburtshilfe – ein Vorher-Nachher Vergleich an der Universitäts-Frauenklinik Heidelberg. Geburtshilfe Frauenheilkd 2017. [DOI: 10.1055/s-0037-1606167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- S Heublein
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - A Au
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - L Michel
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - A Freis
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - J Rom
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - M Wallwiener
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - F Marmé
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - F Schütz
- Universitäts-Frauenklinik Heidelberg, Heidelberg
| | - C Sohn
- Universitäts-Frauenklinik Heidelberg, Heidelberg
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Freis A, Renke T, Kämmerer U, Jauckus J, Strowitzki T, Germeyer A. Effects of a hyperandrogenaemic state on the proliferation and decidualization potential in human endometrial stromal cells. Arch Gynecol Obstet 2017; 295:1005-1013. [PMID: 28168653 DOI: 10.1007/s00404-017-4295-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/10/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, involving hyperandrogenaemia and insulin resistance. Treatment options include dexamethasone, as well as the off-label use of metformin. To evaluate the impact of those drugs on cyclic changes in endometrial development, we tested possible effects of metformin and dexamethasone on endometrial stromal cells decidualisation, proliferation, and gene regulation in a hyperandrogenaemic microenvironment in vitro. METHODS/DESIGN Ten endometrial biopsies (of which five were decidualized in vitro) were used from regularly cycling women. Cells were treated with testosterone, dexamethasone, and metformin in different concentrations. Thereafter, cells were assessed for proliferation and decidualization capacity, as well as mTor and MMP-2 gene regulation. RESULTS Metformin showed a dose-dependent negative effect on prolactin secretion, a known decidualization marker. This effect was stronger in a hyperandrogenaemic condition and could not be compensated by dexamethasone. Testosterone had a dose dependent negative effect on proliferation in decidualized endometrial stromal cells. Dexamethasone slightly compensated the negative proliferative effect only in low-dose testosterone. High-dose metformin also showed a dose-dependent reduction in endometrial stromal cell proliferation without a major impact by testosterone or dexamethasone in decidualized and non-decidualized cells. High-dose metformin significantly reduced the expression of matrix metalloproteinase-2 (MMP-2) and mechanistic Target of Rapamycin (mTor), regardless of the concentration of dexamethasone and testosterone. The strongest effect could be observed for the combination with high-dose dexamethasone. CONCLUSION When therapies, such as metformin and dexamethasone, are used to normalize peripheral androgen levels in patients with PCOS, their effect on the endometrial microenvironment should be taken into consideration as well, especially metformin has to be used with caution because of its dose dependent, possibly inhibiting effect at the endometrial proliferation.
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Affiliation(s)
- Alexander Freis
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany.
| | - Tobias Renke
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrike Kämmerer
- Department of Gynecology and Obstetrics, University Hospital Würzburg, Würzburg, Germany
| | - Julia Jauckus
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Strowitzki
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Ariane Germeyer
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
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Freis A, Diesend C, Hartmann J, Capp E, Strowitzki T, Germeyer A, Goeckenjan M. Fertility characteristics of female oncological patients after fertility preservation counseling. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1592769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Abstract
Twin pregnancy consisting of one fetus and one complete mole (CMCF, complete hydatidiform mole and a coexistent fetus) is an obstetric rarity with an incidence of 1/22 000 to 1/100 000 pregnancies. Associated risks include prematurity, intrauterine death, vaginal bleeding, preeclampsia, hyperthyroidism, theca lutein cysts, uterine rupture and the development of malignant neoplasia in the form of a trophoblastic tumour (GTD, persistent gestational trophoblastic disease), which is thought to be the most common complication. We report the case of a 33-year-old patient diagnosed with CMCF in the 15th week of pregnancy. After comprehensive counselling the patient chose to proceed with her pregnancy under close observation and prophylactic fetal lung maturation. We were able to extend the pregnancy to 32 weeks gestation when heavy vaginal bleeding forced a decision to deliver by caesarean section.
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Affiliation(s)
- A Freis
- Gynecological endocrinology and fertility disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - M Elsässer
- Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
| | - C Sohn
- Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
| | - H Fluhr
- Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
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Freis A, Dietrich J, Holschbach V, Strowitzki T, Germeyer A. Auffällige Oozyten-Spermien-Interaktion in einer schwer stimulierbaren PCOS-Patientin. Gynäkologische Endokrinologie 2014. [DOI: 10.1007/s10304-014-0653-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Freis A, Rau S, Friedrich RW, Geyer R. Glycosylation pattern and processing of envelope gene products encoded by glycosylation mutants of Friend spleen focus-forming virus. Glycobiology 1993; 3:465-73. [PMID: 8286859 DOI: 10.1093/glycob/3.5.465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The protein encoded by the envelope gene of Friend spleen focus-forming virus is responsible for the acute leukaemogenicity of this virus. In order to correlate glycosylation and intracellular processing of this protein with viral pathogenicity, envelope gene products of pathogenic and apathogenic glycosylation mutants were expressed in Rat-1 cells and metabolically labelled with [6-3H]glucosamine. Following immunoprecipitation, primary and secondary gene products (gp55, gp65) were separated by preparative polyacrylamide gel electrophoresis. Oligosaccharides were released from tryptic glycopeptides by treatment with endo-beta-N-acetylglucosaminidase H (gp55), peptide-N4-(N-acetyl-beta-glucosaminyl)asparagine amidase F (gp65) or by reductive beta-elimination. Resulting glycans were characterized by co-chromatography with authentic oligosaccharide standards using different HPLC systems and digestion with exoglycosidases. The results revealed that the primary envelope gene products of pathogenic glycosylation mutants were, in part, further processed in Rat-1 cells similar to wild-type glycoprotein, resulting in polypeptides carrying complex-type N-glycans as well as partially sialylated O-linked oligosaccharides. In contrast, corresponding glycoproteins encoded by apathogenic mutants were found to remain at the level of the primary translation product exclusively comprising high-mannose-type N-glycans. Hence, intracellular maturation of the envelope gene products in this model cell line seems to correlate with the in vivo pathogenicity of the glycosylation mutants studied.
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MESH Headings
- Animals
- Carbohydrate Sequence
- Friend murine leukemia virus/genetics
- Friend murine leukemia virus/metabolism
- Friend murine leukemia virus/pathogenicity
- Gene Products, env/chemistry
- Gene Products, env/genetics
- Gene Products, env/metabolism
- Genes, env
- Glycosylation
- Leukemia, Erythroblastic, Acute/etiology
- Leukemia, Erythroblastic, Acute/metabolism
- Mice
- Molecular Sequence Data
- Mutation
- Polysaccharides/chemistry
- Polysaccharides/metabolism
- Protein Processing, Post-Translational
- Rats
- Tumor Cells, Cultured/metabolism
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Affiliation(s)
- A Freis
- Institute of Biochemistry, Justus Liebig University, Giessen, FRG
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Freis A. [Tolerance of clotrimazole applied locally]. Arzneimittelforschung 1972; 22:1289-91. [PMID: 4678390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Freis A. [The occurrence of systemic candida mycoses in relation to primary disease and pretreatment]. Arzneimittelforschung 1971; 21:320-2. [PMID: 4927568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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