Fertility Preservation Knowledge, Attitudes, and Self-Reported Behaviors of Resident Physicians

Purpose: Fertility preservation (FP) and family building are important considerations for quality survivorship for young cancer patients. Resident physicians across all specialties encounter reproductive-aged cancer patients. The purpose of this study was to assess resident physicians' attitudes and awareness about FP with the goal to identify specific educational gaps to direct future training. Methods: The Institutional Review Board (IRB)-approved anonymous online survey was sent to resident physicians across specialties at three separate academic-affiliated campuses in one state. The survey consisted of three sections: awareness about FP options and knowledge about referral placement, attitudes and comfort levels discussing FP, and practices regarding FP. Data were collected in Qualtrics and analyzed by resident specialty, age, level of training, and gender. Statistical analyses were conducted with Prism. Results: Obstetrics and gynecology residents and fellows were significantly more aware of FP options in cancer patients than their counterparts in other specialties. Postgraduate year (PGY 3) residents and beyond were more aware of at least one male and one female FP option compared with PGY 1 and 2 residents. Of importance, we found that the majority of resident physicians are aware of FP options and the referral process, but they are uncomfortable discussing these techniques with their patients. Conclusion: To provide better education for patients, focus should be on outpatient educational activities for both the health care provider and the patient to facilitate conversation about FP.

Relationships between reproductive hormones and maternal pregnancy physiology in women conceiving with or without in vitro fertilization

We evaluated maternal pregnancy adaptations and their relationships with circulating hormones in women who conceived with or without in vitro fertilization (IVF). Pregnancies were grouped by corpus luteum (CL) number: 1 CL with physiological plasma relaxin concentration (P_RLN; spontaneous pregnancies); 0 CL without circulating RLN (programmed cycles); >1 CL with elevated P_RLN (ovarian stimulation). Major findings were that declines in plasma osmolality (P_osm) and plasma sodium concentration ([Formula: see text]) were comparable in the 1 CL and 0 CL cohorts, correlated with plasma estradiol and progesterone concentrations but not P_RLN; gestational declines in plasma uric acid (UA) concentration (P_UA) were attenuated after IVF, especially programmed cycles, partly because of subdued increases of renal UA clearance; and P_RLN and cardiac output (CO) were inversely correlated when plasma estradiol concentration was below ∼2.5 ng/mL but positively correlated above ∼2.5 ng/mL. Unexpectedly, P_RLN and plasma sFLT1 (P_sFLT1) were directly correlated. Although P_sFLT1 and CO were not significantly associated, CO was positively correlated with plasma placental growth factor (PLGF) concentration after the first trimester, particularly in women who conceived with 0 CL. Major conclusions are that 1) circulating RLN was unnecessary for gestational falls in P_osm and [Formula: see text]; 2) P_RLN and CO were inversely correlated during early gestation, suggesting that P_RLN in the lower range may have contributed to systemic vasodilation, whereas at higher P_RLN RLN influence became self-limiting; 3) evidence for cooperativity between RLN and estradiol on gestational changes in CO was observed; and 4) after the first trimester in women who conceived without a CL, plasma PLGF concentration was associated with recovery of CO, which was impaired during the first trimester in this cohort.

COVID-19: changing the care process for women's health-the patient's perspective

OBJECTIVE

Assess women's perceptions of the impact of COVID-19 on their health care and well-being, access to and satisfaction with medical care due to the changes in delivery of care triggered by the pandemic.

METHODS

An online survey of women having health care appointments in the outpatient facilities across all divisions of a Department of Obstetrics and Gynecology at a tertiary care referral center in North Central Florida. Patients had outpatient appointments that were scheduled, canceled or rescheduled, in person or by telemedicine, between 11 March 2020 and 11 May 2020, a time during which a COVID-19 stay-at-home order was enacted across our state. A total of 6,697 visits were planned. Patients with multiple visits were unified, leaving 6,044 unique patients to whom the survey was emailed between 20 July 2020 and 31 July 2020. The survey was closed on 21 August 2020. Analyses were focused on simple descriptive statistics to assess frequency of responses. Analyses of variance and chi-square analyses were conducted to compare outcomes when all cells were ≥ 10, based on sub-specialty and insurance status; otherwise, frequencies were examined for the entire sample only. Missing data were excluded listwise.

RESULTS

A total of 6044 patients were contacted. Completed surveys numbered 1,083 yielding a response rate of 17.9%. The most common sub-specialty visit was gynecology (56.7%) followed by obstetrics (31.5%,), pelvic floor disorders (4.8%), gynecological oncology (2.9%,), and reproductive endocrinology (0.5%). A substantial percentage of women had visits canceled (19.2%), rescheduled (32.8%) or changed (42.1%) to telemedicine. In our patient population, 32.6% were worried about visiting the clinic and 48.1% were worried about visiting the hospital. COVID-19 triggered changes were perceived to have a negative impact by 26.1% of respondents. Refusal of future telemedicine visits was by 17.2%, however, 75.2% would prefer to use both in-person and telemedicine visits.

CONCLUSION

During the initial COVID-19 surge with lockdown, the majority of survey respondents were following public health precautions. However, there were significant concerns amongst women related to obstetric and gynecologic medical appointments scheduled during that period. During pandemics, natural disasters and similar extreme circumstances, digital communication and telemedicine have the potential to play a critical role in providing reassurance and care. Nevertheless, given the concerns expressed by survey respondents, communication and messaging tools are needed to increase comfort and ensure equity with the rapidly changing methods of care delivery.

Implications of the vaginal microbiome and potential restorative strategies on maternal health: a narrative review

The vaginal microbiome undergoes dramatic shifts before and throughout pregnancy. Although the genetic and environmental factors that regulate the vaginal microbiome have yet to be fully elucidated, high-throughput sequencing has provided an unprecedented opportunity to interrogate the vaginal microbiome as a potential source of next-generation therapeutics. Accumulating data demonstrates that vaginal health during pregnancy includes commensal bacteria such as Lactobacillus that serve to reduce pH and prevent pathogenic invasion. Vaginal microbes have been studied as contributors to several conditions occurring before and during pregnancy, and an emerging topic in women's health is finding ways to alter and restore the vaginal microbiome. Among these restorations, perhaps the most significant effect could be preterm labor (PTL) prevention. Since bacterial vaginosis (BV) is known to increase risk of PTL, and vaginal and oral probiotics are effective as supplemental treatments for BV prevention, a potential therapeutic benefit exists for pregnant women at risk of PTL. A new method of restoration, vaginal microbiome transplants (VMTs) involves transfer of one women's cervicovaginal secretions to another. New studies investigating recurrent BV will determine if VMTs can safely establish a healthy Lactobacillus-dominant vaginal microbiome. In most cases, caution must be taken in attributing a disease state and vaginal dysbiosis with a causal relationship, since the underlying reason for dysbiosis is usually unknown. This review focuses on the impact of vaginal microflora on maternal outcomes before and during pregnancy, including PTL, gestational diabetes, preeclampsia, and infertility. It then reviews the clinical evidence focused on vaginal restoration strategies, including VMTs.

Maternal endothelial function, circulating endothelial cells, and endothelial progenitor cells in pregnancies conceived with or without in vitro fertilization

In women who conceived with or without assisted reproduction, we evaluated endothelial function by EndoPAT [reactive hyperemia index (RHI)], circulating numbers of endothelial cells (CEC) and endothelial progenitor cells (EPC), and their function before during and after pregnancy. In vitro fertilization (IVF) pregnancies were stratified by method of conception and corpus luteum (CL) number-controlled ovarian stimulation (>1 CL) or programmed (0 CL) cycles and spontaneous singleton pregnancies (1 CL). We observed 1) comparable gestational decline of RHI in the three participant groups secondary to gestational rise of baseline preocclusion pulse-wave amplitude (PWA) incorporated into the RHI calculation by EndoPAT software; 2) progressive rise in "normalized" RHI throughout pregnancy (calculated by substituting prepregnancy baseline preocclusion PWA into the RHI equation), greater in spontaneous conception vs. IVF cohorts; 3) similar gestational increase of maximum PWA and time to maximum PWA after the ischemia stimulus among the three participant groups; 4) modest gestational increase of ischemia response (reactive hyperemia) in the spontaneous conception group and no change or significant decline, respectively, in women who conceived using programmed or controlled ovarian stimulation cycles; 5) enhanced basal nitric oxide production by early (primitive) outgrowth EPC during pregnancy in women who conceived spontaneously, but not through IVF; and 6) gestational increase in CEC in all three participant cohorts, more pronounced in women who conceived by IVF using programmed cycles. On balance, the evidence supported enhanced endothelial function during pregnancy in spontaneous conceptions but less so in IVF pregnancies using either controlled ovarian stimulation or programmed cycles.

Increased Preeclampsia Risk and Reduced Aortic Compliance With In Vitro Fertilization Cycles in the Absence of a Corpus Luteum

In vitro fertilization involving frozen embryo transfer and donor oocytes increases preeclampsia risk. These in vitro fertilization protocols typically yield pregnancies without a corpus luteum (CL), which secretes vasoactive hormones. We investigated whether in vitro fertilization pregnancies without a CL disrupt maternal circulatory adaptations and increase preeclampsia risk. Women with 0 (n=26), 1 (n=23), or >1 (n=22) CL were serially evaluated before, during, and after pregnancy. Because increasing arterial compliance is a major physiological adaptation in pregnancy, we assessed carotid-femoral pulse wave velocity and transit time. In a parallel prospective cohort study, obstetric outcomes for singleton livebirths achieved with autologous oocytes were compared between groups by CL number (n=683). The expected decline in carotid-femoral pulse wave velocity and rise in carotid-femoral transit time during the first trimester were attenuated in the 0-CL compared with combined single/multiple-CL cohorts, which were similar (group-time interaction: P=0.06 and 0.03, respectively). The blunted changes of carotid-femoral pulse wave velocity and carotid-femoral transit time from prepregnancy in the 0-CL cohort were most striking at 10 to 12 weeks of gestation ( P=0.01 and 0.006, respectively, versus 1 and >1 CL). Zero CL was predictive of preeclampsia (adjusted odds ratio, 2.73; 95% CI, 1.14-6.49) and preeclampsia with severe features (6.45; 95% CI, 1.94-25.09) compared with 1 CL. Programmed frozen embryo transfer cycles (0 CL) were associated with higher rates of preeclampsia (12.8% versus 3.9%; P=0.02) and preeclampsia with severe features (9.6% versus 0.8%; P=0.002) compared with modified natural frozen embryo transfer cycles (1 CL). In common in vitro fertilization protocols, absence of the CL perturbed the maternal circulation in early pregnancy and increased the incidence of preeclampsia.

Potential influence of the corpus luteum on circulating reproductive and volume regulatory hormones, angiogenic and immunoregulatory factors in pregnant women

Cardiovascular function is impaired and preeclampsia risk elevated in women conceiving by in vitro fertilization (IVF) in the absence of a corpus luteum (CL). Here, we report the serial evaluation of hormones and other circulating factors in women who conceived with (or without) IVF. After a prepregnancy baseline, the study participants (n = 19-24/cohort) were evaluated six times during pregnancy and once postpartum (~1.6 yr). IVF pregnancies were stratified by protocol and CL number, i.e., ovarian stimulation (>1 CL) or hypothalamic-pituitary suppression (0 CL) versus spontaneous conceptions (1 CL). Results include the following: 1) relaxin was undetectable throughout pregnancy (including late gestation) in the 0 CL cohort, but markedly elevated in ~50% of women in the >1 CL cohort; 2) progesterone, plasma renin activity, and aldosterone transiently surged at 5-6 gestational weeks in the >1 CL group; 3) soluble vascular endothelial growth factor-1 (sFLT-1) abruptly increased between 5-6 and 7-9 gestational weeks in all three participant cohorts, producing a marked elevation in sFLT-1/PLGF (placental growth factor) ratio exceeding any other time point during pregnancy; 4) sFLT-1 was higher throughout most of gestation in both IVF cohorts with or without abnormal obstetrical outcomes; 5) during pregnancy, C-reactive protein (CRP) increased in 0 and 1 CL, but not >1 CL cohorts; and 6) plasma protein, but not hemoglobin, was lower in the >1 CL group throughout gestation. The findings highlight that, compared with spontaneously conceived pregnancy, the maternal milieu of IVF pregnancy is not physiologic, and the specific perturbations vary according to IVF protocol and CL status.

Wave reflections and global arterial compliance during normal human pregnancy

Profound changes occur in the maternal circulation during pregnancy. Routine measures of arterial function - central systolic pressure (CSP) and augmentation index (AIx) - decline during normal human pregnancy. The objectives of this study were twofold: (1) explore wave reflection indices besides CSP and AIx that are not routinely reported, if at all, during normal human pregnancy; and (2) compare wave reflection indices and global arterial compliance (gAC) obtained from carotid artery pressure waveforms (CAPW) as a surrogate for aortic pressure waveforms (AOPW) versus AOPW synthesized from radial artery pressure waveforms (RAPW) using a generalized transfer function. To our knowledge, a comparison of these two methods has not been previously evaluated in the context of pregnancy. Ten healthy women with normal singleton pregnancies were studied using applanation tonometry (SphygmoCor) at pre-conception, and then during 10-12 and 33-35 gestational weeks. CSP and AIx declined, and gAC increased during pregnancy as previously reported. As a consequence of the rise in gAC, the return of reflected waves of lesser magnitude from peripheral reflection sites to the aorta was delayed that, in turn, reduced systolic duration of reflected waves, augmentation index, central systolic pressure, LV wasted energy due to reflected waves, and increased brachial-central pulse pressure. For several wave reflection indices, those derived from CAPW as a surrogate for AOPW versus RAPW using a generalized transfer function registered greater gestational increases of arterial compliance. This discordance may reflect imprecision of the generalized transfer function for some waveform parameters, though potential divergence of carotid artery and aortic pressure waveforms during pregnancy cannot be excluded.

Maternal Cardiovascular Dysregulation During Early Pregnancy After In Vitro Fertilization Cycles in the Absence of a Corpus Luteum

Commonly used in vitro fertilization protocols produce pregnancies without a corpus luteum (CL), a major source of reproductive hormones. In vitro fertilization pregnancies without a CL showed deficient gestational increases of central (aortic) arterial compliance during the first trimester and were at increased risk for developing preeclampsia. Here, we investigated whether there was generalized impairment of cardiovascular adaptation in in vitro fertilization pregnancies without a CL compared with pregnancies conceived spontaneously or through ovarian stimulation, which lead to 1 and >1 CL, respectively (n=19-26 participants per cohort). Prototypical maternal cardiovascular adaptations of gestation were serially evaluated noninvasively, initially during the follicular phase before conception, 6× in pregnancy, and then, on average, 1.6 years post-partum. The expected increases of cardiac output, left atrial dimension, peak left ventricular filling velocity in early diastole (E wave velocity), peripheral/central arterial pulse pressure ratio, and global AC, as well as decrease in augmentation index were significantly attenuated or absent during the first trimester in women who conceived without a CL, when compared with the 1 and >1 CL cohorts, which were comparable. Thereafter, these cardiovascular measures showed recovery in the 0 CL group except for E wave velocity, which remained depressed. These results provided strong support for a critical role of CL factor(s) in the transformation of the maternal cardiovascular system in early gestation. Regimens that lead to the development of a CL or replacement of missing CL factor(s) may be indicated to improve cardiovascular function and reduce preeclampsia risk in in vitro fertilization pregnancies.

Comparison of multiple non-invasive methods of measuring cardiac output during pregnancy reveals marked heterogeneity in the magnitude of cardiac output change between women

Various non-invasive methods are available to measure cardiac output (CO) during pregnancy. We compared serial measures of CO using various methods to determine which provided the least variability. Ten patients with spontaneous pregnancy had estimation of CO at baseline prior to becoming pregnant and at the end of the first and third trimesters. Echocardiographic data were used to estimate CO using the Teichholz method, Simpson's biplane method, and the Doppler determined velocity time integral (VTI) method. In addition, a Bioz Dx device was used to estimate CO by impedance cardiography. CO estimated with the VTI method had the lowest beat-to-beat variability. CO estimated with the VTI method was higher than CO estimated with the 2D-Teichholz method and Simpson's method. The percent change in CO during pregnancy was similar for all echo methods (VTI, Teichholz, and Simpson's biplane). Baseline CO determined with impedance cardiography was higher than CO determined with the VTI method. However, change in CO during pregnancy was significantly lower when measured with impedance cardiography. There was marked heterogeneity in the degree of rise in CO during the first trimester (-3 to 55%). The wide variation in the gestational rise in CO was unexpected, and at least in part secondary to variable increase in heart rate. We recommend the use of the Doppler determined VTI method for the estimation of CO in pregnancy.

Sperm preservation and neutron contamination following proton therapy for prostate cancer study

BACKGROUND

The present study investigates the impact of scatter dose radiation to the testis on ejaculate and sperm counts from treatment of prostate cancer with passive-scatter proton therapy.

MATERIAL AND METHODS

From March 2010 to November 2014, 20 men with low- or intermediate-risk prostate cancer enrolled in an IRB-approved protocol and provided a semen sample prior to passive-scatter proton therapy and 6-12 months following treatment. Men were excluded if they had high-risk prostate cancer, received androgen deprivation therapy, were on alpha blockers (due to retrograde ejaculation) prior to treatment, had baseline sperm count <1 million, or were unable to produce a pre-treatment sample or could not provide a follow-up specimen. Sperm counts of 0 were considered azoospermia and <15 million/ml were classified as oligospermia.

RESULTS

Four patients were unable to provide a sufficient quantity of semen for analysis. Among the 16 remaining patients, only one was found to have oligospermia (7 million/ml). There was a statistically significant reduction in semen volume (median, 0.5 ml) and increase in pH (median 0.5). Although not statistically significant, there appeared to be a decline in sperm concentration (median, 16 million/ml), total sperm count (median, 98.5 million), normal morphology (median, 9%), and rapid progressive motility (median, 9.5%).

DISCUSSION

Men did not have azoospermia 6-12 months following passive-scatter proton therapy indicating minimal scatter radiation to the testis during treatment. Changes in semen quantity and consistency may occur due to prostate irradiation, which could impact future fertility and/or sexual activity.

Age and Fertility: A Study on Patient Awareness

Objective

Fertility declines as women age. Advancing maternal age increases pregnancy risks such as diabetes or hypertension. Studies suggest women are not aware of the risks of aging on fertility and pregnancy. The study objective was to assess women's knowledge of fertility and reproductive outcomes affected by aging.

Methods

Prospective IRB approved survey of women (n=94) attending an obstetrics and gynecology (OB/GYN) clinic. Data collected included demographics, pregnancy history, and knowledge of age-related fertility decline and pregnancy risks. Statistical analysis performed using JMP Pro11.0.

Results

Ages ranged from 18 to 67. One third (30.5%) were aware fertility begins to decline at age 35, however this varied among groups depending on prior history of infertility or requiring fertility treatment. Nulliparous women were more unaware of the health risks of pregnancy over age 35 (1.4% vs 13.6%, P 0.02). African Americans (AA) women were less likely to think obesity (76% Caucasian vs 47.8% AA vs 66.7% other, P < 0.05) and older age (88% Caucasian vs 60.9% AA vs 82.7% other, P 0.02) affected fertility.

Conclusion

Knowledge regarding fertility and reproduction related to aging was variable and differed by age and race. Difficulty conceiving appears to be associated with higher knowledge levels. Public education will increase awareness of age-related fertility declines. Increased contact during pregnancy is an excellent opportunity to educate women in a nondirective way.

Characterization of a mechanism to inhibit ovarian follicle activation

OBJECTIVE

To demonstrate that a small molecule can induce the transcription factor Foxo3 in the ovary and lead to inhibition of follicle activation.

DESIGN

Cell culture, organ culture, and animal studies.

SETTING

University-based laboratory.

ANIMAL(S)

23 female C57BL/6 mice.

INTERVENTION(S)

Human ovary cells and mouse ovaries in culture treated with 2-deoxyglucose (2-DG) to mimic glucose deprivation, and mice intraperitoneally injected with 100 mg/kg, 300 mg/kg, or 600 mg/kg 2-DG daily for 2 weeks.

MAIN OUTCOME MEASURE(S)

In cell and organ culture, Foxo3 expression analyzed by quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR); in treated animals, expression of genes regulated by nutrient deprivation (Foxo3, ATF4, GRP78, CHOP, ASNS, c-Myc) measured in brain, kidney, and ovary by qRT-PCR; and ovarian follicles histologically classified and counted.

RESULT(S)

Foxo3 expression is induced by 2-DG at both the mRNA and protein level in human ovarian cell culture, possibly through ATF4-dependent gene regulation. Foxo3 expression is also induced by 2-DG in ovarian organ culture. Treatment of mice with 100 mg/kg 2-DG resulted in a 2.6 fold induction of Foxo3 in the ovary and a 58% decrease in type 3a primary follicles.

CONCLUSION(S)

Expression of Foxo3 is induced by nutrient deprivation in cell culture, organ culture, and in vivo. In mice, 2-DG treatment results in an inhibition of primordial follicle activation. These data indicate that Foxo3 induction by 2-DG may be useful for fertility preservation.

Circulating chemokine levels and miscarriage

Evidence suggests that chemokines, proteins involved in regulation of inflammation and immune response, may have a regulatory function in pregnancy. The authors hypothesized that circulating levels of chemokines are associated with increased risk of miscarriage. Serum samples were obtained from women in the Collaborative Perinatal Project cohort who had had a miscarriage (n=439) and controls (n=373) matched by gestational age at sample collection. Concentrations of interleukin 8, epithelial cell-derived neutrophil-activating peptide (ENA)-78, macrophage inhibitory protein (MIP)-1alpha, MIP-1beta, monocyte chemotactic protein 1, and RANTES (regulated upon activation, normal T-cell-expressed, and secreted) were determined by multiplex assays, and values were standardized using the standard deviation among controls. Conditional logistic regression was used to model the relation between chemokine levels and risk of miscarriage. In multivariable analysis using all available data, the authors did not observe significant associations between any of the evaluated chemokines and miscarriage risk. In analyses using subsets of the study population based on the collection-outcome interval, elevated ENA-78 levels were associated with increased risk of miscarriage as the collection-outcome interval increased; the adjusted odds ratio was 1.25 (95% confidence interval: 1.04, 1.49) for samples collected more than 35 days prior to pregnancy outcome. The observation regarding ENA-78, which has roles in regulation of angiogenesis and leukocyte recruitment, suggests a possible role for this chemokine as an early indicator of miscarriage risk.

Endometrial expression of epithelial neutrophil-activating peptide-78 during the menstrual cycle or in progestin-only contraceptive users with breakthrough bleeding and the influence of doxycycline therapy

BACKGROUND

Endometrial breakthrough bleeding is characterized by an inflammatory reaction and increased production of proinflammatory mediators, one of which may be epithelial neutrophil-activating peptide-78 (ENA-78), a chemokine with neutrophil-activating properties.

METHODS AND RESULTS

We therefore investigated the endometrial expression of ENA-78 in Norplant users as progestin-only contraceptive with various bleeding patterns (n=35) as compared with non-users with a normal menstrual cycle (n=55). The endometrial stromal cells (ESCs) were the major site of ENA-78 expression with the highest levels found during the secretory phase. The expression of ENA-78 was increased in Norplant users with irregular bleeding as compared with those with regular cycles and amenorrhoea. The levels of ENA-78 detected in uterine washes and sera after the use of Norplant for 3-6 months (n=25) increased compared with baseline (P < 0.05). These levels did not significantly change in Norplant users who received doxycycline (Dox) therapy (25 mg/twice daily for 6 months) when measured midway through or at the conclusion of study when compared with the baseline (n=25). Treatments with medroxyprogesterone acetate (MPA) and tumour necrosis factor-alpha (TNF-alpha) (25 ng/ml), but not 17beta-estradiol (E2) or E2 + MPA (10(-8) M), representing endometrium exposed to contraceptive and inflammatory conditions, respectively, increased the levels of ENA-78 production by ESCs, and this was reduced by co-treatments with Dox (25 microg/ml) (P < 0.05).

CONCLUSIONS

The endometrial production of ENA-78 is altered in progestin-only contraceptive users experiencing breakthrough bleeding and is regulated by MPA and TNF-alpha in ESCs. Although Dox therapy did not alter uterine ENA-78 secretion, its suppression in ESCs suggests that Dox, acting site-specifically and through an anti-inflammatory mechanism, may influence the outcome of breakthrough bleeding in contraceptive users.

Histological characteristics and altered expression of interleukins (IL) IL-13 and IL-15 in endometria of levonorgestrel users with different uterine bleeding patterns

OBJECTIVE

To determine the relationship between uterine bleeding patterns in levonorgestrel users with endometrial histology and expression of interleukins (IL) IL-13 and IL-15.

DESIGN

Prospective observational study.

SETTING

Academic research center.

PATIENT(S)

Questionnaires were sent to patients (n = 578) who had levonorgestrel implants concerning bleeding patterns; 35 of these patients were identified to have regular cycle (n = 13), amenorrhea (n = 8), or metrorrhagia (n = 14).

INTERVENTION(S)

Endometrial biopsies, serum, histology, and immunostaining.

MAIN OUTCOME MEASURE(S)

Endometrial histological assessment and immunostaining for IL-13 and IL-15 and for blood levonorgestrel, E2, and progesterone levels by ELISA or RIA.

RESULT(S)

No correlation was found between circulating levonorgestrel, E2, or progesterone levels with the bleeding patterns, although a trend toward a lower E2 level was observed in patients with amenorrhea who had inactive endometrium. There was a direct correlation between bleeding patterns and endometrial histology, as well as IL-13 and IL-15 expression in patients with regular cycles and metrorrhagia, demonstrating secretory and proliferative endometrium, respectively. Some patients in each group were also identified as demonstrating endometritis.

CONCLUSION(S)

Endometrial histology may assist directing therapy and subsequently increasing compliance in progestin-only contraceptive users with irregular bleeding who fail to respond to standard therapies. Altered endometrial expression of IL-13 and IL-15, key cytokines in inflammatory and immune cell trafficking, may influence events, leading to irregular bleeding.

A randomized, multicenter study comparing the efficacy of recombinant FSH vs recombinant FSH with Ganirelix during superovulation/IUI therapy

OBJECTIVE

The purpose of this study was to determine if use of a Gonadotropin releasing hormone (GnRH) antagonist, Ganirelix (Antagon), can improve pregnancy rates during superovulation with recombinant follicle-stimulating hormone (rFSH) followed by intrauterine insemination (IUI).

STUDY DESIGN

This was a multicenter, prospective, randomized, open-label, assessor-blind, controlled trial of females (n = 54), ages 18 to 39 undergoing superovulation/IUI with up to 4 cycles of superovulation/IUI without Ganirelix (n = 66), or up to 4 cycles of superovulation/IUI with the addition of Ganirelix (n = 52).

RESULTS

No statistically significant difference in clinical pregnancy rates per cycle initiated was found for patients in the treatment or control group (12% vs 7%, P =.29). Other variables assessed, including endometrial thickness, size of follicles, peak serum estradiol levels, mid-lutea progesterone levels, and total vials of rFSH used also showed no statistically significant difference.

CONCLUSION

Superovulation/IUI cycles using Ganirelix produce similar pregnancy rates when compared with cycles not using a GnRH antagonist, although there is a trend towards better pregnancy rates in cycles with Ganirelix.

Pregnancy rates in varying age groups after in vitro fertilization: a comparison of follitropin alfa (Gonal F) and follitropin beta (Follistim)

OBJECTIVE

Our purpose was to assess the efficacy of two recombinant follicle-stimulating hormones, follitropin beta (Follistim, Organon, West Orange, NJ) and follitropin alfa (Gonal F, Serono, Norwell, Mass) on pregnancy rates in varying age groups of women undergoing in vitro fertilization (IVF).

STUDY DESIGN

Three hundred sixty-five IVF cycles were retrospectively compared, 233 by use of follitropin beta and 132 by use of follitropin alfa, both after gonadotropin-releasing hormone agonist down-regulation. Assignment to each medication was indiscriminate. The primary outcome measured was pregnancy evidenced by fetal heartbeat on ultrasonography. Secondary outcomes included days of stimulation, ampules per patient cycle, estradiol level on the day of human chorionic gonadotropin administration, total follicles present on the day of human chorionic gonadotropin administration, follicles greater than 14 mm, oocytes retrieved, mature eggs, fertilization rate, and embryos transferred. Outcomes were stratified by age, including women less than 36 years old, 36 to 39 years old, and more than 39 years old.

RESULTS

There was no significant difference between follitropin beta and follitropin alfa in either the primary or secondary outcomes, although the pregnancy rate was significantly decreased with advancing age.

CONCLUSION

Success rates are similar, when stratified by age, in women undergoing IVF with either follitropin beta or follitropin alfa.

Expression of matrix metalloproteinase-26 and tissue inhibitor of matrix metalloproteinase-3 and -4 in endometrium throughout the normal menstrual cycle and alteration in users of levonorgestrel implants who experience irregular uterine bleeding

OBJECTIVE

To determine the expression of matrix metalloproteinase (MMP-26) and tissue inhibitor of MMP (TIMP) in the endometrium of women with normal menstrual cycles compared with users of levonorgestrel implants.

DESIGN

Prospective observational study.

SETTING

Academic research center.

PATIENT(S)

Fifty patients with normal menstrual cycles who requested permanent surgical sterilization (tubal ligation) and 35 users of levonorgestrel implants.

INTERVENTION(S)

Endometrial biopsy.

MAIN OUTCOME MEASURE(S)

Expression of MMP-26, TIMP-3, and TIMP-4 by immunohistochemistry and semiquantitative analysis of staining intensity by using the H score.

RESULT(S)

Endometrium from women with a normal menstrual cycle and users of levonorgestrel implants expresses MMP-26, TIMP-3, and TIMP-4. These substances are present in various types of endometrial cells; expression is strongest in surface and glandular epithelial cells, followed by vascular endothelial and endometrial stromal cells. Inflammatory and immune-related cells also stained strongly for MMP-26 and TIMPs. Semiquantitative analysis of the staining intensity of endometrial epithelial and stromal cells indicated that expression of MMP-26, TIMP-3, and TIMP-4 peaks during the early to mid-luteal phase. Expression of MMP-26 is elevated in users of levonorgestrel implants who experienced irregular uterine bleeding.

CONCLUSION(S)

Endometrial expression of MMP-26 and TIMP-4 is present throughout the menstrual cycle and is elevated during the early to mid-luteal phase in normally cycling women. Further elevations in MMP-26 are seen in users of levonorgestrel implants who experience irregular uterine bleeding. These substances thus seem to play a role in hormonal regulation and endometrial tissue remodeling.

Localization and cellular distribution of pregnancy-associated plasma protein-a and major basic protein in human ovary and corpora lutea throughout the menstrual cycle

OBJECTIVE

To assess the expression and cellular distribution of pregnancy-associated plasma protein-A (PAPP-A) and major basic protein (MBP) in human ovarian tissue during the menstrual cycle.

DESIGN

Ovarian tissues (n = 50) and corpora lutea (n = 18) were obtained from patients undergoing hysterectomy/oophorectomy for benign conditions and tissue sections were immunostained for MBP and PAPP-A.

SETTING

University medical center.

INTERVENTION(S)

Immunostaining of tissue sections using antibodies to PAPP-A and MBP.

MAIN OUTCOME MEASURE(S)

Microscopic evaluation to assess the presence, distribution, and cellular co-localization of MBP and PAPP-A and to describe any variations in their expression during the menstrual cycle.

RESULT(S)

Major basic protein (MBP) is found in several ovarian cell types throughout the menstrual cycle. The MBP immunostaining of ovarian follicles varied depending on the size, with primordial follicles staining in the ooplasm with a lack of staining in the granulosa and theca cells. In the intermediate/mature follicles, MBP was immunolocalized in theca, but not in granulosa cells except in the mature follicles. Pregnancy-associated plasma protein-A (PAPP-A) was immunolocalized in primordial follicle ooplasm, theca externa of intermediate/mature follicles, and in granulosa cells with increased intensity as luteinization progressed. The luteal tissue is the major site of MBP and PAPP-A with highest intensity found during the midluteal phase associated with both small and large luteal cells.

CONCLUSION(S)

The expression and distinct pattern of MBP and PAPP-A cellular localization in human ovarian tissue during folliculogenesis and in luteal tissue suggest that their individual and combined actions in a cell specific fashion may play a role in growth and differentiation of theca, granulosa, and luteal cells.

Validity of a rapid assay for antisperm antibodies in semen

OBJECTIVE

To determine the validity of a rapid assay for antisperm antibodies in semen.

DESIGN

Prospective comparison of the results of standard and rapid antisperm antibody assays performed simultaneously.

SETTING

Tertiary care infertility center.

PATIENT(S)

Couples who presented for infertility evaluation.

INTERVENTION(S)

Semen analysis and measurement of antisperm antibodies in semen using a standard and a rapid immunobead binding test (IBT).

MAIN OUTCOME MEASURE(S)

[1] Comparison of sperm parameters between semen-containing antisperm antibodies and semen free of antisperm antibodies. [2] Validation of the rapid test by calculation of sensitivity, specificity, positive and negative predictive values of the rapid assay using the standard assay as a gold standard. [3] Cost comparison of the standard and rapid test.

RESULT(S)

[1] Nine semen specimens with antisperm antibodies had a significantly lower sperm concentration, motility, and total motile fraction compared to 44 specimens without antisperm antibodies. Also, specimens with antisperm antibodies had a significantly higher percentage of vibratory sperm and percent of bound antisperm antibodies. The strict morphology, liquefaction time, semen volume, and white blood cell concentration were no different between the two groups. [2] Using a threshold of > or =12% of bound antisperm antibodies in the rapid assay, the sensitivity, specificity, positive and negative predictive values of the test are 100% when correlated with a threshold of > or =20% in the standard assay. Increasing the threshold in the standard assay decreases the specificity and positive predictive value of the rapid assay but not the sensitivity and the negative predictive value. [3] The cost of the rapid assay was 16% that of the standard test and its performance took 20% of the time it took to set and perform the standard test.

CONCLUSION(S)

A rapid test for antisperm antibodies is valid, reliable, and more cost and labor effective than a standard IBT.

Placental site trophoblastic tumor: human placental lactogen and pregnancy-associated major basic protein as immunohistologic markers

Placental site trophoblastic tumor (PSTT) consists of a neoplastic proliferation of intermediate or extravillous trophoblast (also known as X cells). Pregnancy-associated major basic protein (pMBP) is a marker for placental intermediate trophoblast. We compared the distribution of pMBP and human placental lactogen (hPL) in 24 PSTT and 3 exaggerated placental site (EPS) specimens using two distinct immunohistologic methods. Statistical analyses were used to compare staining intensities in metastatic and nonmetastatic lesions. By immunofluorescence, 77% of the PSTT specimens and 100% of the EPS specimens stained with antibodies to pMBP, and the pMBP was localized in intermediate trophoblast and surrounding extracellular areas. By immunohistochemistry, 78% of the PSTT specimens and 100% of the EPS specimens stained for pMBP with a pattern comparable with that of immunofluorescence. Likewise, by immunohistochemistry, hPL stained 96% of the PSTT specimens and 100% of the EPS specimens. Immunohistochemical staining intensities for pMBP and hPL correlated (r2 = +.24; P = .013), but hPL staining was mainly confined to intermediate trophoblast and was more intense. Anti-pMBP tended to stain metastatic PSTT weakly. Thus, pMBP is a useful marker for intermediate trophoblast tumors and could help distinguish these from other forms of trophoblastic disease.

Efficacy of calcium ionophore A23187 oocyte activation for generating parthenotes for human embryo research

PURPOSE

Our purpose was to examine the efficacy of Ca-A23187 to activate human oocytes and produce parthenotes for research purposes. We examined the feasibility of using fluorescence in situ hybridization (FISH) to study the sex chromosome constitution of activated oocytes.

METHODS

One hundred eight nonfertilized oocytes from our IVF program were exposed to Ca-A23187. Oocyte activation was determined by the presence of pronuclear (PN) development. FISH was done on chromosome preparations using X and Y dual-colored probes. Polyploidic and parthenogenetically activated oocytes from our IVF program served as controls.

RESULTS

Of the 108 oocytes, 59 (55%) had no PN, 38 (35%) one PN, 10 (9%) two PN, and 1 (0.9%) three PN. Fiftyseven oocytes (53%) were not recovered following spreading and no chromatin was observed on 14 slides (13%) after FISH. This contrasted with 50 of 227 (22%) and 3 of 227 (1.7%) loss rates, respectively, for controls (P < 0.0001). Eight of 49 activated oocytes underwent cleavage. FISH was performed on 37 oocytes. Of 21 zero-PN oocytes, I had no FISH signals, 15 had a single X, 4 had two X's, and I had four X's. For one-PN oocytes, two had no FISH signals, seven had one X, and three had two X's. For two-PN oocytes, two had no FISH signals and two had two X's. FISH results were consistent with a maternal origin of genetic material.

CONCLUSIONS

Ca-A23187 resulted in a 45% activation rate, with 16% of oocytes progressing to cleavage before degeneration. Oocyte activation with Ca-A23187 allowed the generation of parthenotes for human embryo research. FISH was useful for evaluation of oocytes and parthenotes.

Glove perforations and blood contact associated with manipulation of the fetal scalp electrode

OBJECTIVE

To assess prospectively the frequency of glove injury associated with insertion of the fetal scalp electrode and subsequent examination of the cervix with the electrode in place.

METHODS

Over a 7-month period, sterile gloves were collected after use for insertion of the fetal scalp electrode or cervical examination with the electrode in place. Attendants indicated their level of training, time, date and purpose of glove use, and cervical examination. They also noted whether they were aware of a glove perforation or observed blood, amniotic fluid, or genital tract secretions on their hand. Glove patency was assessed by filling the glove with water to 1.5-2.0 times its normal volume and observing for leaks. One hundred unused gloves were tested for patency and served as controls.

RESULTS

Five hundred one gloves were evaluated, of which 13 (2.6%, 95% confidence interval [Cl] 1-4%) had perforations. Seven of 277 gloves (2.5%) used only for examinations had perforations, compared with six of 244 (2.5%) used only for insertion of the electrode. Two percent (95% CI 0-5%) of the unused control gloves had perforations. These observed differences were not statistically significant. Nineteen attendants (3.8%, 95% CI 2.1-5.5%) noted blood or genital tract secretions on their hand after insertion of the electrode (N = 4) or subsequent cervical examination (N = 15). Only one point of contract resulted from a glove perforation; the other 18 were on the wrist and apparently resulted from leakage of fluid around the open cuff of the glove.

CONCLUSIONS

The risk of glove perforation during insertion of the fetal scalp electrode or subsequent cervical examination is low if proper technique is observed. Blood or fluid contact is more likely to result from leakage of fluid around the open cuff of the glove during a vaginal examination.