P-408 IL-10 and IL-17 pathway enrichment in uterine fluid-derived extracellular vesicles (UF-EVs) is associated with failed implantation in women with recurrent implantation failure undergoing PGT-A

Study question

Can the UF-EVs transcriptome provide markers of implantation in women diagnosed with recurrent implantation failure (RIF)?

Summary answer

Enrichment in IL-10 and IL-17 pathway transcripts in UF-EVs of women with RIF might identify those at risk for negative outcome after euploid blastocyst transfer.

What is known already

Our group has recently found that transcriptomic changes occur in UF-EVs during the window of implantation and closely resemble those occurring in the endometrial tissue. Patients affected by RIF represent a debated and heterogeneous population of patients who currently undergo several investigations, empirical therapies and embryo transfer attempts, with inconclusive results. We investigated whether UF-EVs can provide markers to define subgroups of patients within the RIF population, to predict outcomes and tailor interventions.

Study design, size, duration

We herein present the first sub-analysis of our previous larger observational study on the human UF-EVs transcriptome (Giacomini et al., 2021). RIF was defined by > 3 failed embryo transfers (ETs) with high quality embryos and patients affected by RIF and undergoing their first PGT-A cycle were enrolled (n = 19). Fertile women undergoing PGT-A+PGT-M for monogenic diseases and achieving successful implantation were used as controls (n = 29). PGT-A was performed by Next Generation Sequencing.

Participants/materials, setting, methods

RNA-Seq was performed on UF-EVs collected on day LH + 7 of the cycle preceding that of the blastocyst transfer. Differential Gene Expression (DGE) analysis was performed between RIF patients failing implantation (Group A) versus RIF patients achieving implantation (Group B) and between Group A and fertile controls achieving implantation (Group C). Pre-ranked gene set enrichment (GSEA) with WebGestalt was used for pathway enrichment analysis, with Normalized Enrichment Score (NES) indicating the strength of the enrichment.

Main results and the role of chance

RIF patients had a mean (± SD) age of 36.6 (± 3.4) and 5.1 ± 2.1 (mean ± SD) previous failed ETs. DGE comparisons between UF-EVs of RIF women who failed implantation (n = 10) showed 135 up- and 32 down-regulated genes compared to Group B, and 258 up- and 44 down-regulated genes compared to Group C, with 63 genes showing consistent significantly different ‘expression’ values in both comparisons. UF-EVs of Group A were enriched in transcripts belonging to the IL-17 pathway compared to both groups (Group A vs B, NES=2.2044, FDR <0.0001; Group A vs C, NES=2.3584, FDR <0.0001).Also transcripts belonging to the IL-10 pathway were enriched compared to both groups (Group A vs B NES=2.2741, FDR = 0.002; Group A vs C NES=2.2047, FDR < 0.0001). Among genes enriched in both DGE comparisons, C-X-C motif chemokine ligand (CXCL)1, CXCL2, CXCL8, and prostaglandin-endoperoxide synthase 2 (PTGS2) belonged to both the IL-10 and IL-17 pathway. On multivariate analysis controlling for relevant confounders (i.e. number of previous failed ETs), expression levels of CXCL8 emerged as a significant negative predictor of implantation (OR 0.675, 95%CI 0.493-0.925, p = 0.01).

Limitations, reasons for caution

As the main limitation of our study, we collected UFs in the cycle immediately preceding (and not corresponding to) the euploid ET. This approach was considered the most appropriate in relation to the current paucity of data regarding the safety of UF aspiration in the same cycle of an ET.

Wider implications of the findings

UF-EVs represent a source of transcriptomic markers related to the endometrial immune profile in RIF patients. Enrichment in the IL-17 and IL-10 pathways in this population could define the subgroup who is at risk for implantation failure even after euploid ET and who could potentially benefit from tailored immunotherapies.

Trial registration number

not applicable

Are extremely high progesterone levels still an issue in IVF?

BACKGROUND

Premature luteinization of one or more developing follicles complicates 1-2 % of controlled ovarian stimulation cycles for assisted reproduction. The management of this complication is controversial, with cycle cancellation likely representing the most commonly used strategy. The aim of this study was to evaluate the efficacy of the "freeze-all" policy-where the entire cohort of blastocysts is cryopreserved for subsequent frozen-thawed embryo transfer-in treating cases of premature luteinization.

METHODS

Patients experiencing premature luteinization during controlled ovarian stimulation-identified by extremely high progesterone levels at induction (P levels ≥3.0 ng/ml and/or P/estradiol ratio ≥1, n = 42)-were included in a "freeze-all" program and compared to controls undergoing a "freeze-all" program with normal progesterone levels at induction (P < 1.5 ng/ml, n = 67).

RESULTS

Blastulation rate was comparable between patients with premature luteinization and controls (48.1 ± 20.5 % in Cases vs. 52.3 ± 24.9 % in Controls, p = 0.36). Ongoing pregnancy rates after the first frozen-thawed embryo transfer (38.1 % in Cases and 41.0 % in Controls, p = 0.83) and cumulative ongoing pregnancy rates after three frozen-thawed embryo transfer cycles (40.5 % in Cases vs. 47.8 % in Controls, p = 0.55) were also similar.

CONCLUSIONS

These results show that extremely marked progesterone elevation throughout controlled ovarian stimulation does not impair blastocyst development and implantation potential in the context of a "freeze-all" strategy. Based on this, adoption of the "freeze-all" strategy represents a valuable tool in treating premature luteinization. In contrast, cycle cancellation-likely the most frequently used method for management of this complication-currently represents a misconduct.

Myo-inositol products in polycystic ovary syndrome (PCOS) treatment: quality, labeling accuracy, and cost comparison

OBJECTIVES

To evaluate the labeling accuracy of four myo-inositol products, designed for polycystic ovary syndrome (PCOS) treatment, available on the italian market and to perform a cost comparison based on myo-inositol content in milligrams for products analyzed.

MATERIALS AND METHODS

Four (4) myo-inositol products (3 sachet and 1 tablet formulations) were dissolved using water, and each sample was analyzed for myo-inositol content using a high-performance liquid chromatography (HPLC) method with index refraction detector. The amount of myo-inositol per purchased product was then divided into its purchase price in order to make cost comparisons between the products based on a 2 and 4 g/day dose.

RESULTS

A significant difference in the myo-inositol content, compared with the labeling was found for the products. Only 1 product contained more than 95% of the myo-inositol content claimed on the label, and there was a product with less than 75% of the labeling amount. Based on a 2-g myo-inositol per day dose, the cost of a 30-day supply ranged from Euro 20,77 and Euro 71,86, after correction by actual amount of myo-inositol.

CONCLUSION

There is a lack of conformity between declared and actual amount of myo-inositol among the products tested and the majority of the products contained less than 95% of labeled amounts. There should be a better control in the manufacturing process in order to ensure more quality and accuracy. Nowadays consumers cannot trust myo-inositol product labels to represent the product's content accurately or that product pricing is a reflection of myo-inositol content.

Intramuscular vs intravaginal natural progesterone in patients undergoing in vitro fertilization-embryo transfer cycles. A retrospective observational, case-control study

OBJECTIVE

To compare the effectiveness of intramuscular (IM) and intravaginal (IV) progesterone for luteal phase support, in patients undergoing in vitro fertilization-embryo transfer cycles (IVF-ET).

DESIGN

retrospective, observational, case-control study

SETTING

Centro Natalità, San Raffaele Hospital, Milan, Italy, from July 2007 to June 2009.

PATIENT(S)

172 A-GnRH down-regulated IVF-ET cycles in patients with age < 40 years.

INTERVENTION(S)

Luteal phase support with IM progesterone (50 mg daily) or IV progesterone (90 mg daily).

MAIN OUTCOME MEASURE(S)

Biochemical pregnancy, clinical pregnancy, miscarriage, ongoing pregnancy rates and patient's acceptability.

RESULTS

IM progesterone conferred more benefit compared with IV progesterone in terms of ongoing pregnancy rate (24.4% vs 12.7%; P < 0.05).

CONCLUSIONS

In standard IVF cycles, our data showed that IM progesterone appears to be more effective at providing luteal support, thus rendering with IV progesterone.

Association of alcohol consumption with HDL subpopulations defined by apolipoprotein A-I and apolipoprotein A-II content

OBJECTIVE

To investigate the relationship between alcohol intake and serum level of high-density lipoprotein (HDL) subfractions defined on the basis of their apolipoprotein A-I and A-II content (LpA-I and LpA-I: A-II).

DESIGN

Observational study.

SETTING

Institute of Internal Medicine and Medical Physiopathology, IRCCS Maggiore Hospital, University of Milan.

SUBJECTS

One hundred healthy males with a mean age of 42 +/- 11.1 y, selected among blood donors.

RESULTS

Both LpA-I and LpA-I:A-II were significantly higher in men drinking more than 30 g a day of alcohol than in non-drinkers (LpA-I: difference between means 6.5 mg/dL, 95% C.I. 1.14-11.9; LpA-I:A-II difference between means 11.5 mg/dL, 95% C.I. 0.52-22.5). The association of alcohol consumption with LpA-I and LpA-I:A-II levels was independent from age, body mass index, physical activity, serum triglycerides and diet composition.

CONCLUSIONS

Alcohol consumption is associated with an increase of serum levels of both LpA-I and LpA-I:A-II particles and this may, at least in part, explain the reduced cardiovascular morbidity observed in subjects drinking moderate amounts of alcoholic beverages.

SPONSORSHIP

Supported by grants from Ricerca Corrente Ospedale Maggiore di Milano IRCCS, Milan Italy.

Serum cholesterol levels in patients with cancer. Relationship with nutritional status

Epidemiological surveys indicate an inverse relationship between cancer occurrence and serum cholesterol. Low serum cholesterol might be either a risk factor for cancer or the effect of factors associated with cancer itself, such as biological properties of malignant cells, tumor mass, and poor nutritional status. We have measured serum cholesterol in 975 selected patients admitted to our hospital; 496 (272 males, 224 females) had solid tumors and 479 (253 males, 226 females) had non-neoplastic diseases. Serum cholesterol was positively correlated with body mass index, serum albumin, hemoglobin, and cholinesterase in both cancer and non-cancer subjects. Cholesterol was significantly lower in cancer patients than in age- and sex-matched non-cancer subjects. After adjustment for nutritional variables (analysis of covariance), the difference in cholesterol level between cancer and non-cancer subjects lost statistical significance in all but patients with tumors of the upper gastrointestinal tract. No difference was found in adjusted mean serum cholesterol between cancer patients subdivided according to the extension of the tumor was defined by the TNM system. In patients with solid tumors, serum cholesterol seems to be more related to the nutritional status than the presence and extension of cancer.

Estimation of cardiovascular risk: total cholesterol versus lipoprotein profile

The complete lipoprotein profile is thought to give more information about the individual risk of coronary heart disease than total cholesterol alone. Although total cholesterol has a low sensitivity in the correct assessment of the risk of coronary heart disease, it may be of value in screening programs because of its low cost. In this study of 5,335 subjects, total cholesterol gave a different assessment of coronary heart disease risk (United States National Cholesterol Education Program guidelines) in 25% of subjects than the complete lipoprotein profile. Differences in risk assignment were mainly accounted for by high- and low-density lipoprotein-cholesterol (Friedewald equation). The calculated low-density lipoprotein-cholesterol was highly correlated with the value measured with a mixed ultracentrifugation and precipitation procedure. However, calculated values gave estimates of coronary heart disease risk which were 20% different from those from measure values. In 200 subjects in whom the lipoprotein profile was assessed three times in 1 year, the total cholesterol low-density lipoprotein-cholesterol varied by more than 30 mg/dl (0.78 mmol/l) in 52% and 50%, respectively, triglycerides by more than 30 mg/dl (0.34 mmol/l) in 75%, and high-density lipoprotein-cholesterol by more than 15 mg/dl (0.39 mmol/l) in 34%. Compared with the mean of the measurements, the single measurement of total cholesterol misclassified 48% of subjects, low-density lipoprotein-cholesterol 60%, high-density lipoprotein-cholesterol 12%, and 28%. We conclude that total cholesterol alone may be misleading in the assignment of coronary heart disease risk. Calculation of low-density lipoprotein-cholesterol, although less accurate than desirable, is the only way of evaluating this in clinical practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Acid clearance and oesophageal sensitivity in patients with progressive systemic sclerosis

This study examined the hypothesis that impaired oesophageal peristalsis was associated with delayed oesophageal clearance of acid in patients with progressive systemic sclerosis (PSS), some of whom are thought to have impaired oesophageal sensitivity to acid. Sixteen patients with PSS had: (a) oesophageal manometry and endoscopy; (b) acid perfusion of the oesophagus with simultaneous measurement of intraoesophageal pH during perfusion and for the next 10 minutes; (c) 22 hour monitoring of intraoesophageal pH; and (d) an evaluation of reflux symptoms during and after perfusion and during overnight pH monitoring. By oesophageal manometry, eight patients had normal peristalsis and eight patients had impaired peristalsis. Oesophageal endoscopy was unremarkable in patients with normal peristalsis, whereas all patients with impaired peristalsis had oesophagitis. The time needed to clear the oesophagus of perfused acid was shorter (p < 0.01) in patients with normal peristalsis and acid clearance time was significantly correlated (p < 0.01) with acid exposure time during overnight pH monitoring. During and after oesophageal perfusion, the nature, duration, and severity of symptoms did not differ between the groups, but overnight symptoms lasted longer (p < 0.05) in patients with impaired peristalsis. It is concluded that in PSS: (1) Impaired oesophageal motility delayed the clearance of acid and increased the exposure time to acid. (2) Acid clearance time is a useful parameter of impaired oesophageal motor function. The assessment of acid clearance time can be used as an alternative to overnight pH monitoring, to assess the impairment of oesophageal acid clearance. (3) Oesophageal sensitivity to acid was preserved in patients with impaired peristalsis and oesophagitis. (4) Reflux symptoms lasted longer in patients with prolonged oesophageal acid exposure but were still reported for a small fraction of the total acid exposure time. Thus, reflux symptoms reflect poorly prolonged exposure of the oesophagus to acid and are not a reliable guide to acid injury of the oesophagus in PSS.

Single doses of ritodrine delay orocaecal transit in patients with irritable bowel syndrome

The lactulose hydrogen breath test was used to assess the effect of a single dose of the beta 2-adrenoceptor agonist ritodrine on orocaecal transit time in 11 patients (three men) with irritable bowel syndrome. Transit time (median values, range) was significantly longer (P less than 0.01) after ritodrine than after placebo (120, 50-200 vs 75, 40-100 min). Median heart rate was similar before treatments whereas the maximal increase in heart rate was significantly greater (P less than 0.01) after ritodrine than after placebo.

Intragastric and intraoesophageal pH monitoring in duodenal ulcerpatients: effect of the new histamine H2-receptor antagonist ramixotidine

The effect of the new histamine H2-receptor antagonist ramixotidine 750 mg p.o., administered at 22.00 h, on intragastric and intraoesophageal pH monitored from 22.00 h to 08.00 h, was studied in a double-blind cross-over trial in 11 duodenal ulcer patients. Placebo and ramixotidine were given to each patient on 2 consecutive days in a randomized sequence. Three patients were excluded from the intragastric pH analysis as the records on the second study day were technically inadequate. No significant carry-over or sequence effect was noted. Intragastric hydrogen ion activity was significantly lower (p = 0.01) after ramixotidine than after placebo: median (range) 24 (9-100) vs 97 (27-188) mmol/l. The percentage of time with intraoesophageal pH less than 4 was less than 5% in all but three recordings, with a maximum value of 12%, and it was not significantly different after the two treatments.