Histone H3 E50K mutation confers oncogenic activity and supports an EMT phenotype

Sequencing of human patient tumors has identified recurrent missense mutations in genes encoding core histones. We report that mutations that convert histone H3 amino acid 50 from a glutamate to a lysine (H3E50K) support an oncogenic phenotype in human cells. Expression of H3E50K is sufficient to transform human cells as evidenced by a dramatic increase in cell migration and invasion, and a statistically significant increase in proliferation and clonogenicity. H3E50K also increases the invasive phenotype in the context of co-occurring BRAF mutations, which are present in patient tumors characterized by H3E50K. H3E50 lies on the globular domain surface in a region that contacts H4 within the nucleosome. We find that H3E50K perturbs proximal H3 post-translational modifications globally and dysregulates gene expression, activating the epithelial to mesenchymal transition. Functional studies using S. cerevisiae reveal that, while yeast cells that express H3E50K as the sole copy of histone H3 show sensitivity to cellular stressors, including caffeine, H3E50K cells display some genetic interactions that are distinct from the characterized H3K36M oncohistone yeast model. Taken together, these data suggest that additional histone H3 mutations have the potential to be oncogenic drivers and function through distinct mechanisms that dysregulate gene expression.

P–649 Should women receive luteal support following natural cycle frozen embryo transfer? A systematic review and meta-analysis

Study question

Should women receive luteal phase support (LPS) following natural cycle frozen embryo transfer (NC-FET)?

Summary answer

Progesterone LPS following NC-FET increases the live birth rate. There is no evidence to support the administration of hCG for LPS in these cases.

What is known already

Whether or not women should receive LPS following NC-FET is highly controversial. Previous studies have shown conflicting results.

Study design, size, duration

We conducted a systematic search of the literature published in Medline/PubMed, Embase and the Cochrane Library, from January 2000 until December 2020. We included all original English, peer-reviewed articles, irrespective of study-design. The search strategy included keywords related to natural cycle frozen embryo transfer and luteal phase support. Studies reporting the results of artificial or stimulated FET cycles were excluded.

Participants/materials, setting, methods

Our systematic search generated 395 records. After screening, eight studies were included in the review and seven studies were included in the meta-analysis. Two studies (n = 858) used hCG, and 6 studies (n = 1507) used progesterone for luteal support. Four studies were randomized controlled trials (RCTs), whereas the other four were historic cohort studies.

Main results and the role of chance

In a meta-analysis using random effects model, hCG administration for LPS did not increase the clinical pregnancy rate (two studies, OR 0.85, 95% CI 0.64–1.14). On the other hand, progesterone LPS was associated with a higher clinical pregnancy rate (five studies, OR 1.48, 95% CI 1.14–1.94), and a higher live birth rate (three studies, OR 1.67, 95% CI 1.19–2.36).

Limitations, reasons for caution

There was large heterogeneity in progesterone dose and route of administration, as well as the methods used for ovulation detection and triggering. Moreover, only four studies were randomized. Finally, both studies examining the use of hCG for LPS were performed by the same group of researchers in a single center.

Wider implications of the findings: The available evidence indicates that progesterone administration for LPS is beneficial following natural cycle frozen embryo transfer. There is no evidence to support the administration of hCG for LPS in these cases. Additional Large RCTs are necessary in order to improve the quality of evidence and validate our findings.

Trial registration number

PROSPERO ID: CRD42020199045

Diagnosis of ruptured fetal membranes in pregnancy with the use of urograffin

The objective of our study was to assess the value of intraamniotic injection of urograffin in the diagnosis of premature rupture of membranes (PROM). Intra-amniotic injection of urograffin with the concomitant insertion of a vaginal tampon was performed in 30 consecutive patients who were admitted because of suspected PROM and the presence of a heavy bloody vaginal secretion. The vaginal tampons were X-rayed for the presence of radio-opacity. In 23 patients, traces of urograffin were found in the vaginal tampons by X-ray. No fetal or maternal complications were observed during delivery and puerperium. We suggest the use of intraamniotic injection of urograffin for the diagnosis of PROM in cases where heavy bloody vaginal discharge is present.

Timing of testicular sperm retrieval procedures and in vitro fertilization-intracytoplasmic sperm injection outcome

OBJECTIVE

To compare the outcome of IVF-intracytoplasmic sperm injection (ICSI) using testicular spermatozoa obtained on the day of ovum pick-up (OPU) or on the day before OPU.

DESIGN

Retrospective study.

SETTING

An IVF clinic in a university hospital.

PATIENT(S)

Forty-seven IVF-ICSI cycles using testicular spermatozoa in 28 couples with the male partner suffering from nonobstructive azoospermia.

INTERVENTION(S)

Sperm retrieval was performed either on the OPU day (23 cycles in 19 patients; group A) or on the day before OPU (24 cycles in 15 patients; group B). Testicular sperm aspiration (TESA) was performed and followed by testicular sperm extraction (TESE) if no spermatozoa could be found.

MAIN OUTCOME MEASURE(S)

The presence of motile spermatozoa at the time of ICSI and fertilization and clinical pregnancy rates.

RESULT(S)

A similar proportion of motile spermatozoa (60.9% vs. 62.5%), fertilization rate (61.7% vs. 58.9%), and clinical pregnancy rate per transfer (34.8% and 29.2%) were obtained for groups A and B, respectively.

CONCLUSION(S)

Testicular sperm retrieval can be performed on the day before OPU without compromising success. Considerable medical and practical advantages may be offered by further advancement of testicular sperm retrieval procedures to 48 hours before OPU. This approach should thus be further evaluated.

Poor outcome with round spermatid injection in azoospermic patients with maturation arrest

OBJECTIVE

To compare the outcome of intracytoplasmic sperm injection (ICSI) and round spermatid injection (ROSI), both obtained by testicular sperm extraction (TESE), and to compare the results of fresh versus frozen ROSI.

DESIGN

Retrospective study.

SETTING

An IVF unit at a university hospitalPatient(s): Eighteen infertile couples with nonobstructive azoospermia.

INTERVENTION(S)

TESE with ROSI or ICSI of mature spermatozoa into metaphase II oocytes was performed. The resulting embryos were transferred to female partners. The spare round spermatids were frozen.

MAIN OUTCOME MEASURE(S)

Fertilization and cleavage rates, embryo quality, and clinical pregnancy rates.

RESULT(S)

Seventeen ROSI cycles and six ICSI cycles were compared. Fertilization rate following ROSI (44.9%) was significantly lower than with ICSI (69%). A significantly higher rate of cleavage arrest occurred following ROSI (40.8%) as compared to ICSI (8.2%). The morphology of embryos resulting from ROSI was significantly poorer. No pregnancies were achieved following ROSI as compared to a 50% clinical pregnancy rate in the ICSI group. The fertilization and cleavage rates following ROSI with fresh versus frozen-thawed spermatids were comparable.

CONCLUSION(S)

In azoospermic patients with maturation arrest at the stage of round spermatids the efficiency of ROSI appears to be extremely poor. The role of ROSI in the treatment of nonobstructive azoospermia should be reevaluated.

Zygote intrafallopian transfer in patients with tubal factor infertility after repeated failure of implantation with in vitro fertilization-embryo transfer

OBJECTIVE

To evaluate the efficacy of zygote intrafallopian transfer (ZIFT) in terms of implantation and pregnancy rates in patients with tubal factor infertility and repeated implantation failure in IVF-ET cycles.

DESIGN

Retrospective analysis of ZIFT cycles.

SETTING

An IVF unit in a university hospital.

PATIENT(S)

Criteria for patient selection for ZIFT included at least four failures of implantation in IVF-ET cycles in which at least 3 embryos were replaced per transfer and a cause of infertility diagnosed as male, unexplained, or tubal factor with proof of one patient tube.

INTERVENTION(S)

Four to six zygotes were transferred by laparoscopy into the fallopian tube 24-26 hours after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Implantation and pregnancy rates were determined in 112 ZIFT cycles performed in 81 patients with repeated failure of implantation. Results were further stratified for patients with tubal factor (n = 15) and patients without tubal factor (n = 66).

RESULT(S)

The pregnancy and implantation rates for all ZIFT cycles were 35.1% and 11.1%, respectively. Pregnancy and implantation rates per cycle in patients with tubal factor versus patients without tubal factor were 26.6% versus 37.1% and 9.4% versus 11.4%, respectively.

CONCLUSION(S)

ZIFT can be considered as a mode of treatment for patients with repeated failure of implantation in IVF-ET and with tubal factor with proved patency of one tube.

Estradiol supplementation during the luteal phase may improve the pregnancy rate in patients undergoing in vitro fertilization-embryo transfer cycles

OBJECTIVE

To evaluate the effect of adding E(2) to progestin supplementation during the luteal phase on pregnancy and implantation rates in patients undergoing IVF cycles.

DESIGN

Prospective, randomized study.

SETTING

An IVF unit in a university hospital.

PATIENT(S)

Patients who were undergoing IVF with controlled ovarian hyperstimulation using a GnRH analog and who had E(2)2,500 pg/dL at the time of hCG administration.

INTERVENTION(S)

Serum concentrations of E(2) and progesterone were measured in all patients on days 7, 10, and 12 after ET.

MAIN OUTCOME MEASURE(S)

The E(2) and progesterone profiles of the luteal phase and the pregnancy and implantation rates were documented. Data were analyzed for the entire study population and further stratified according to the GnRH analog protocol used (short or long).

RESULT(S)

Significantly higher E(2) levels were found during the luteal phase in the group that received E(2) supplementation. This effect was more pronounced in the patients who were treated with the long GnRH analog protocol. Significantly higher pregnancy and implantation rates were recorded in the patients who received E(2) supplementation and were treated with the long GnRH analog protocol.

CONCLUSION(S)

For patients who are treated with the long GnRH analog protocol for controlled ovarian hyperstimulation and for whom luteal support with hCG is contraindicated, the addition of E(2) to the progestin support regimen may have a beneficial effect on pregnancy and implantation rates.

Follicle-stimulating hormone treatment for men with idiopathic oligoteratoasthenozoospermia before in vitro fertilization: the impact on sperm microstructure and fertilization potential

OBJECTIVE

To assess the effect of FSH on sperm fertilization potential and sperm intracellular structure in men with oligoteratoasthenozoospermia and a proven low fertilization rate in IVF.

DESIGN

Prospective, randomized, partial crossover study.

SETTING

IVF Unit, Golda Campus, Rabin Medical Center, Petah Tikva, Israel.

PATIENT(S)

Forty normogonadotropic, normogonadal men with oligoteratoasthenozoospermia and at least one previous IVF attempt in which fertilization failed or the fertilization rate was <30%.

INTERVENTION(S)

The men were randomly assigned to treatment with daily injections of 75 IU of FSH or 150 IU of FSH for at least 60 days before IVF treatment. A control group of men underwent an IVF cycle without treatment and then were randomly assigned tojoin group 1A or 1B for an additional IVF cycle with treatment.

MAIN OUTCOME MEASURE(S)

LH, FSH, and testosterone levels during FSH treatment, evaluation of ultramorphologic changes in sperm by electron microscopy, and comparison of fertilization rates in the control and study groups.

RESULT(S)

After treatment with 75 IU or 150 IU of FSH, the mean fertilization rates were 19.7% and 20.5%, respectively, compared with a 5.8% fertilization rate in the study control cycles.

CONCLUSION(S)

Prolonged treatment with FSH results in a significant increase in fertilization rates. This effect may be related to improvements in subcellular components of the sperm.

The role of purified follicle stimulating hormone therapy in the male partner before intracytoplasmic sperm injection

OBJECTIVE

To evaluate the impact of long-term purified FSH (pFSH) therapy in male partners before intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective, randomized, controlled study.

SETTING

Large university-based IVF unit.

PATIENT(S)

Seventy-eight patients made up the study and control groups (39 patients each). All patients had severe male factor infertility.

INTERVENTION(S)

Induction of ovulation, oocyte retrieval, ICSI, and ET were carried out in both groups. In the study group, male partners received pFSH (75 IU FSH, <1 IU LH) for > or = 50 days before oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Fertilization rate, embryo quality, implantation and pregnancy rates.

RESULT(S)

Fertilization and pregnancy rates were higher in the study group (68% and 35.9%, respectively) were higher than in the control group (59% and 17.9%, respectively), although the differences did not reach statistical significance. The implantation rate was significantly higher in the study group (15.5% versus 6.5%). The study group showed a trend toward a higher number of better-quality embryos per transfer (mean +/- SD, 2.2 +/- 1.6 versus 1.6 +/- 1.6).

CONCLUSION(S)

Purified FSH therapy in male partners before ICSI improves implantation rate. Improved embryo quality may be a contributory factor.

ART success and in vivo sperm cell selection depend on the ultramorphological status of spermatozoa

Management of male infertility has recently shifted from treatment of the subfertile man towards techniques of assisted reproduction (ART). This study aimed to evaluate the possible role of the ultramorphological status of the spermatozoon with respect to sperm selection in vivo and prediction of ART success. Ultramorphological sperm parameters were assessed retrospectively for 92 males with sufficient sperm density (10(7) spermatozoa ejaculate-1) whose wives conceived following a stepwise discarding of the female genital tract barriers, using intra-uterine insemination (IUI) (n = 26), in vitro fertilization (IVF) (n = 45) or intracytoplasmic sperm injection (ICSI) (n = 21). In parallel, sperm samples of 71 fertile males were examined. Normal ultramorphology of all head and tail subcellular organelles was found to be essential for the ability of spermatozoa to pass the lower female genital tract. The ultramorphological migration threshold for this barrier is apparently higher than that essential for oocyte fertilization. No specific indication associated with passage through the upper genital tract was found. A high prevalence of axonema defects was found to impair the ability of sperm cells to penetrate the oocyte investment. The natural fertility index, based on routine sperm parameters and the ultrastructural status of the spermatozoon's subcellular organelles was confirmed to be beneficial for directing patients to ART. A discriminative score based on axonema integrity was found to contribute additional information for the first choice decision between conventional ART and ICSI (75% prediction ability). Thus it may be helpful in finding the simplest and least expensive procedure with the greatest long-term chance for pregnancy.

Pre-operative ultrasonographic evaluation of nongravid, enlarged uteri--correlation with bimanual examination

OBJECTIVE

To correlate the size of the nongravid uterus measured by ultrasound and bimanual examination before hysterectomy, with the actual size of the specimens.

PATIENTS AND METHODS

Uterine size of 49 consecutive patients, who underwent elective hysterectomy, was assessed by bimanual pelvic examination, preoperative ultrasonographic evaluation and actual postoperative size.

RESULTS

All preoperative ultrasonographic uterine dimensions significantly correlated with the corresponding actual dimensions of the uterine specimens. Furthermore, ultrasonographic uterine length had the best correlation with uterine size estimation by bimanual examination. A formula was established in an attempt to calculate clinical uterine size by gestational week, using preoperative ultrasonographic dimensions.

CONCLUSIONS

By using the aforementioned formula, ultrasonographic uterine dimensions can be extrapolated to uterine size in terms of gestational week, and therefore, be applicable to traditional clinical practice.

Zygote intrafallopian transfer may improve pregnancy rate in patients with repeated failure of implantation

OBJECTIVE

To evaluate the efficacy of zygote intrafallopian transfer (ZIFT) on implantation rates and pregnancy rates (PRs) in patients with repeated failure of implantation in IVF-ET cycles.

DESIGN

A case-control study.

PATIENT(S)

Criteria for patient selection included male factor or unexplained infertility, normal uterine cavity, and at least three failures of implantation in IVF-ET cycles in which at least three embryos were placed per transfer. Data on 70 patients who underwent 92 ZIFT cycles are presented. A control group consisted of patients with the same selection criteria who underwent an additional standard IVF-ET cycle during the same time period.

INTERVENTION(S)

Ovulation induction consisted of down-regulation with GnRH analogue followed by ovarian stimulation with FSH and hMG. Intracytoplasmic sperm injection was performed on the oocytes of all patients with male factor infertility. Zygotes were transferred by laparoscopy into the fallopian tube 24-26 hours after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Implantation rates and PRs in the ZIFT and control groups were compared.

RESULT(S)

The PRs and implantation rates were significantly higher in the ZIFT group than in the control group: 34.2% (24/70) and 8.7% (29/333) versus 17.1% (12/70) and 4.4% (13/289), respectively (P = 0.002 and P = 0.04). The cumulative conception rate for two ZIFT cycles was 59.3%.

CONCLUSION(S)

Zygote intrafallopian transfer should be considered a beneficial mode of treatment for patients with repeated failure of implantation in IVF and transcervical ET. More prospective randomized studies are needed to support this observation.

A new concept of cotreatment with human growth hormone and menotropins in ovulation induction protocols

Follicular development in the primordial and preantral stages is almost completely independent of gonadotrophins or steroids and is mainly dependent on growth factors and local regulators. Since human growth hormone (hGH) was found to facilitate ovarian response to gonadotrophin stimulation, we hypothesized that the administration of hGH in an hypogonadotrophic state and prior to ovarian stimulation with menotropins, may initiate or facilitate the propagation of the primordial and preantral follicles to the gonadotrophin-dependent stages. We suggest that treatment with hGH prior to menotropin administration may be useful to improve results for poor responders to gonadotrophins.

Incubation with sperm enhances in vitro maturation of the oocyte from the germinal vesicle to the M2 stage

OBJECTIVE

To evaluate the effect of sperm in the culture medium on the rate of oocyte maturation in vitro from the germinal vesicle to the M2 stage.

DESIGN

Prospective randomized controlled study.

SETTING

The IVF Unit, Wolfson Medical Center, Holon, Israel.

PATIENT(S)

All women in whom oocytes were retrieved at the germinal vesicle stage between December 1995 and March 1996.

INTERVENTION(S)

Oocytes retrieved at the germinal vesicle stage were divided prospectively and randomly into four groups of incubation conditions: group 1, intact germinal vesicle with cumulus; group 2, intact germinal vesicle with sperm cells in the culture medium; group 3, stripped germinal vesicle; and group 4, stripped germinal vesicle with sperm cells. Oocytes were observed 24 hours after retrieval, and the stage of maturation was recorded. Oocytes that reached the M2 stage underwent the intracytoplasmic injection procedure, and the fertilization rate in each group was recorded at 48 hours.

MAIN OUTCOME MEASURE(S)

Maturation rate from the germinal vesicle to M2 stage and fertilization rate.

RESULT(S)

Each group contained 20 germinal vesicle oocytes. In groups 1 and 2, 2 (10%) and 9 (45%) oocytes, respectively, reached the M2 stage at 24 hours; at 48 hours, 1 (5%) and 8 (40%) embryos developed, respectively. The results in group 2 were significantly higher than in group 1. In groups 3 and 4, 6 (30%) and 16 (80%) oocytes, respectively, reached the M2 stage at 24 hours; at 48 hours, 5 (25%) and 14 (70%) embryos developed, respectively. Results in group 4 were significantly higher than those in groups 1, 2, and 3.

CONCLUSION(S)

Both methods of oocyte activation (i.e., addition of sperm to the culture medium or removal of the cumulus) enhance oocyte maturation in vitro, but the sperm-incubation method has a more pronounced effect. A combination of both methods leads to an exceptionally high rate of oocyte maturation, followed by a high fertilization rate.

Early prediction of ovarian multifollicular response during ovulation induction in patients with polycystic ovary syndrome

OBJECTIVE

To examine the association between the midfollicular FSH-LH ratio and the number of follicles, and the multifollicular ovarian response to gonadotropin stimulation in patients with polycystic ovary syndrome (PCOS) with normal basal LH and FSH levels.

SUBJECT(S)

Eighteen patients who had an abandoned treatment cycle because of multifollicular ovarian response. For comparison, all other completed treatment cycles in the same group of patients were used.

MAIN OUTCOME MEASURE(S)

The dose of hMG or FSH, daily effective dose, day 8 serum FSH and LH concentration, day 8 number of follicles > or = 8 mm, E2 and number of follicles on hCG day or day of cycle was abandoned.

RESULT(S)

In the abandoned cycles, day 8 serum LH concentrations were significantly lower and day 8 number of follicles and FSH-LH ratios were significantly higher compared with the completed cycles. A high predictive power (> 90%) for multifollicular response was established by using a set of two criteria: a FSH-LH ratio > or = 1.6 and the number follicles > or = 7 as the cutoff point.

CONCLUSION(S)

When aiming for a monofollicular response in women with PCOS and normal basal FSH and LH levels, cycles with high midfollicular FSH-LH ratios (> or = 1.6) and a high number of follicles (> or = 7) are those prone to develop a multifollicular ovarian response.

Non-response to ovarian stimulation in normogonadotrophic, normogonadal women: a clinical sign of impending onset of ovarian failure pre-empting the rise in basal follicle stimulating hormone levels

The most important aspect of diminished ovarian reserve is the associated decline in reproductive potential. Assessment of ovarian reserve is mainly based on measurement of early follicular phase follicle stimulating hormone (FSH) concentration. The objective of this study was to report the identification of a group of 12 infertile women initially diagnosed as having unexplained or anovulatory infertility, who had a normal baseline hormonal profile and did not respond to repeated ovarian stimulation with gonadotrophins. All developed ovarian failure within a relatively short time span. Non-response to ovarian stimulation was defined by failure to achieve development of follicles >12 mm and failure to raise oestradiol concentration >350 pmol/l in two successive cycles of human menopausal gonadotrophin (HMG) doses of up to five ampoules per day for 5-8 days. Within a mean of 9 months following the failed attempts of ovarian stimulation the mean day 3 FSH concentrations rose from 5.4 +/- 2.7 IU/l to 53.5 +/- 19.7 IU/l. In these patients, day 3 FSH concentration failed to indicate the low ovarian reserve manifested only by lack of clinical response to treatment with gonadotrophins which was the first sign of impending ovarian failure. We conclude that women with normal early follicular phase serum FSH concentrations who do not respond to ovarian stimulation by HMG are at risk of developing ovarian failure within several months.

Induction of ovulation in clomiphene-resistant polycystic ovary syndrome with pulsatile GnRH

OBJECTIVE

To determine the efficacy of pulsatile GnRH alone and in combination with clomiphene citrate or gonadotropins in a stepwise approach for inducing ovulation in women with clomiphene-resistant polycystic ovary syndrome (PCOS).

METHODS

Eighty women with clomiphene-resistant anovulatory infertility and PCOS were given subcutaneous pulsatile GnRH (15 micrograms every 90 minutes) using a portable infusion pump. If no follicular development was seen, clomiphene citrate (100 mg/day for 5 days) was given concurrently with the hormone in the next cycle of treatment. Those who still failed to ovulate regularly were treated with combined pulsatile GnRH with intramuscular gonadotropins (one ampule per day for 5-7 days). RESULTS. Sixty-six of 131 (50%) pulsatile GnRH cycles, 94 of 142 (66%) pulsatile GnRH with clomiphene cycles, and 48 of 69 (70%) pulsatile GnRH with gonadotropin cycles were ovulatory. Monofollicular response (one follicle at least 14 mm on the day of ovulation) occurred in 80.6, 83.9, and 53.6% of cycles, and multifollicular response occurred in 4.8, 3.1, and 21.6% of cycles in the three groups, respectively. Mild ovarian hyperstimulation occurred in one of the 342 cycles. The cumulative conception rate was 30% after three cycles, 60% after six cycles, and 73% after nine cycles. The miscarriage rate was 22% (ten of 45 pregnancies), and 35 women (78%) had live births (33 singletons and two sets of twins).

CONCLUSION

The use of subcutaneous pulsatile GnRH alone and in combination with clomiphene citrate or gonadotropins for induction of ovulation in clomiphene-resistant PCOS in a stepwise approach produces a high cumulative conception rate associated with a low rate of multiple pregnancy and ovarian hyperstimulation syndrome.

The outcome of hypophysectomy for prolactinomas in the era of dopamine agonist therapy

OBJECTIVE

Dopamine agonists are the primary therapeutic modality for the majority of patients with prolactinomas, with pituitary surgery reserved for those patients intolerant of or resistant to these agents. Most published surgical series, however, contain patients treated by surgery as the primary therapeutic modality. Previous exposure to dopamine agonists or the selection of patients with prolactinomas resistant to conventional therapy may potentially compromise the surgical success rate. The purpose of this study was to evaluate the efficacy and safety of pituitary surgery for prolactinomas in a tertiary referral centre where the majority of patients were operated on after treatment with dopamine agonists.

DESIGN

A retrospective review of the outcome of pituitary surgery for prolactinomas performed at a tertiary neurosurgical centre by a single neurosurgeon.

PATIENTS

Twenty-three patients underwent excision of a macro and 11 excision of a micro-prolactinoma.

MEASUREMENTS

Pituitary tumour diameter was determined by CT or MRI imaging. Pre and post-operative measurements were made of serum PRL concentration (off dopamine agonist therapy), free T4, free T3, LH and testosterone (males). Post-operative restoration of a menstrual cycle was taken to indicate resolution of hypogonadism in female patients.

RESULTS

The majority (73.9%) of the patients with macro and all with micro-prolactinomas had received dopamine agonists preoperatively. Of the 23 patients with macroprolactinomas, in whom the median preoperative PRL concentration was 13255 mU/l, 17 (73.9%) had radiological evidence of suprasellar extension and 5 (21.7%) cavernous sinus invasion. Only 4 (17.4%) of the patients with macroprolactinomas had a normal serum PRL post-operatively, although there was an improvement in visual fields in 66% of those with preoperative defects. The median preoperative PRL concentration was 4309 mU/l in the patients with microprolactinomas, significantly lower than in the macroprolactinoma group (P = 0.02). Despite a significant fall in serum PRL postoperatively (median PRL 860 mU/l, P = 0.0001), only 45.5% of patients had a normal serum PRL concentration after surgery.

CONCLUSIONS

The cure rate following pituitary surgery for prolactinomas in a tertiary referral centre was low when compared with previous series in which surgery was used as the primary therapeutic modality. We suggest this may result both from dopamine agonist pretreatment and the referral of prolactinomas resistant to conventional therapy. The outcome is probably a more realistic reflection of the results of pituitary surgery for prolactinomas as currently practised in the majority of neuroendocrine centres.

Treatment of anovulatory infertility: the problem of multiple pregnancy

The aim of the study was to assess patient, treatment and cycle characteristics in relation to the risk of multiple conception following ovulation induction in order to reduce the prevalence of this complication of treatment. We performed a retrospective analysis of 208 pregnancy cycles achieved in the Middlesex Hospital outpatient fertility unit. These pregnancies were achieved in 175 anovulatory women who conceived after gonadotrophin or pulsatile GnRH therapy. The multiple conception rate was 13.4%. After spontaneous reductions and abortions the multiple delivery rate was 9.6%. Clinical features associated with an increased risk of multiple pregnancies were the presence of polycystic ovary syndrome and secondary infertility. Comparison between different protocols of ovulation induction revealed no relationship with the risk of multiple conceptions. Although total number of follicles was increased in the multiple conception cycles, the distribution of follicles according to their diameter on the day of human chorionic gonadotrophin (HCG) administration was similar in multiple and singleton conception cycles. Thus, the risk of multiple conception could not be attributed to an increased number of follicles of any particular size but directly related to the total number of the cohort follicles ( > or = 14 mm) and leading follicles > or = 17 mm), rising from 7% with one follicle to 33% with six or more follicles. As we could not find a specific pattern of follicular development that could be associated with multiple conception, we conclude that the difference in the ovarian response leading to multiple conception is quantitative rather than qualitative. The data presented enable the assessment of the risk of multiple conception in any given cycle.

Effect of laparoscopic ovarian electrocautery on ovarian response and outcome of treatment with gonadotropins in clomiphene citrate-resistant patients with polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of ovarian electrocautery on the ovarian response to gonadotropic stimulation and pregnancy rate (PR) in clomiphene citrate (CC)-resistant women with polycystic ovary syndrome (PCOS) and high basal serum LH levels.

DESIGN

Retrospective study.

SETTING

Outpatient infertility clinic in a tertiary referral center.

SUBJECTS

Twenty-two women with PCOS, high basal serum LH concentrations, and CC resistance who underwent laparoscopic ovarian electrocautery. Treatment with gonadotropin was scheduled after failure to ovulate spontaneously or conceive after electrocautery. Data from gonadotropin-stimulated cycles were compared with data from treatment cycles in the same patients before ovarian electrocautery.

MAIN OUTCOME MEASURES

Number of ampules, duration of induction phase, daily effective dose, PR, and pregnancy outcome.

RESULTS

Markedly reduced basal serum LH concentrations and normal menstrual cyclicity in 41% of patients were recorded after laparoscopic ovarian electrocautery. Comparison of gonadotropin-stimulated cycles before and after electrocautery revealed significantly higher rates of ovulation and pregnancy after electrocautery as well as significant reduction in the number of ampules, daily effective dose, and duration of the induction phase with hMG and in daily effective dose with FSH.

CONCLUSIONS

Our results indicate an increased ovarian sensitivity to gonadotropins after laparoscopic ovarian electrocautery. A preference for laparoscopic ovarian electrocautery over medical treatment in all or selected groups of CC-resistant PCOS patients is suggested.

The use of fibrin sealant in in vitro fertilization and embryo transfer

OBJECTIVE

To evaluate the role of fibrin sealant for embryo transfer (ET) and the effect of patient mobilization after ET on pregnancy rates.

DESIGN

A prospective, randomized, controlled study.

METHODS

Two hundred eleven patients who were admitted to the IVF Unit over a period of 6 months participated in the study. Patients who had three or more embryos were randomly divided into two groups: group 1 (study group), in which ET was performed using fibrin sealant, and group 2, who served as the controls. Ovulation induction was carried out using the long GnRH-a suppression protocol.

RESULTS

Comparison of the results regarding the implantation and pregnancy rates and ectopic pregnancy rate revealed a nonsignificant difference between the two groups. However, analysis of the results according to the patients' age revealed a significant increase in pregnancy (P < .05) and implantation (P < .01) rate in elderly patients (aged 39-42) using fibrin sealant for ET as compared with controls. Furthermore, we found that bed rest has no advantage over patient mobilization after ET.

CONCLUSION

The use of fibrin sealant for ET is advantageous in elderly women, but has no apparent effect on the success rate or ectopic pregnancy rate in younger patients. Immediate mobilization does not jeopardize the results of IVF-ET.

Effect of uterine leiomyomata on the results of in-vitro fertilization treatment

The effect of uterine leiomyoma on infertility is subject to controversy. Two main mechanisms associating leiomyomata and infertility have been suggested: the obstruction of gamete transport and impaired implantation. In-vitro fertilization (IVF) is a unique setting for examining the effect of leiomyomata on the implantation rate. This study was designed to determine the impact of uterine leiomyomata on the results of IVF. In a retrospective analysis of IVF cycles, 46 women with documented uterine leiomyoma were compared with a control group with mechanical infertility. The implantation rate and pregnancy outcome in relation to the leiomyoma were observed. Implantation (22.1%/transfer, 6.8%/embryo) and abortion rates (36%) in the study group were similar to the results in the control group with pure mechanical factor. An analysis of IVF results according to the hysteroscopic pretreatment findings revealed that impaired implantation is associated with leiomyoma only where uterine intracavitary abnormalities co-exist. We conclude that implantation rate and pregnancy outcome are impaired in women with uterine leiomyomata only when they cause deformation of the uterine cavity. In patients with leiomyomata associated with an abnormal uterine cavity, surgical treatment should be considered prior to IVF because of the reduced implantation rate.

Polycystic ovary syndrome patients as oocyte donors: the effect of ovarian stimulation protocol on the implantation rate of the recipient

OBJECTIVE

To evaluate the outcome of oocytes donated by women with polycystic ovarian syndrome (PCOS) compared with oocytes donated by women with mechanical infertility.

DESIGN

A retrospective study.

PATIENTS

The outcome of 159 oocyte donation cycles with oocyte donated by PCOS patients were compared with 69 oocyte donation cycles with oocytes donated by patients with mechanical infertility. We compared the stimulation protocols in the donors to assess if the combination of GnRH analogue (GnRH-a), FSH, and hMG has an advantage over FSH and hMG alone with respect to their effect on fertilization and implantation rates in oocyte donation cycles.

RESULTS

When treated with GnRH-a, pregnancy rates in PCOS and mechanical infertility donors were higher than those treated with FSH and hMG alone. The comparison between PCOS and mechanical factor oocyte recipients revealed no significant difference in the pregnancy and abortion rates, but the oocytes of patients with PCOS that were exposed to GnRH-a had a significantly higher implantation rate than those not exposed to GnRH-a.

CONCLUSIONS

Oocytes obtained from PCOS patients had a fertilization potential equal to oocytes obtained from mechanical infertility donors. Furthermore, because the oocytes of patients with PCOS exposed to GnRH-a had a significantly higher implantation rate, a detrimental role of high LH on oocyte quality seems probable. However, because PCOS has a high familial prevalence, some reservations may arise due to a possible propagation of the problem in the next generation of oocyte donation programs.

Growth hormone and reproduction

It has become apparent that the reproductive and somatotrophic axes may often be interlinked, and that the ovary may be a target for growth hormone action. Within the ovary, there exists a complex regulating system involving growth factors, which promote gonadotrophin action, and their binding proteins, which modulate these actions. The realization of the existence of this fine-tuning system has prompted clinical trials of cotreatment with growth hormone and gonadotrophins, mainly directed at the poor responder to gonadotrophin stimulation. The effect of this treatment is dependent on the hormonal status and 'ovarian age' of the patient. Studies have delineated a possible role for additional growth hormone in those with a lack of growth hormone but it has little place in a normal system. Although an improvement in pregnancy rate has not yet emerged, more research should be forthcoming on the effect of growth hormone and growth factors on the follicle, oocyte and endometrium and their possible role in polycystic ovary syndrome.

Laparoscopic unwinding of hyperstimulated ischaemic ovaries during the second trimester of pregnancy

Successful unwinding of large, hyperstimulated, ischaemic-haemorrhagic adnexa by laparoscopy during the second trimester of pregnancy is described. Three women in their second trimester of pregnancy were treated by laparoscopy. In all cases, the ovaries were unwound and replaced in their anatomical position. Shortly after the procedure they became pink. Serial ultrasound examinations showed viable, intrauterine fetuses and ovaries with normal blood flow. Laparoscopic ovarian detorsion is a safe and easy procedure, and can be carried out in advanced gestation until approximately 20th week if special safety measures are adhered to.

In-vitro cervical mucus-sperm penetration tests and outcome of infertility treatments in couples with repeatedly negative post-coital tests

The results of in-vitro cervical mucus-sperm penetration tests and cross-hostility tests in 178 couples with repeatedly negative post-coital tests were recorded. Using a protocol of three cycles with intra-uterine inseminations (IUI) followed by three cycles with ovulation induction + IUI, the association between the cause of infertility, results of the in-vitro tests and the outcome of infertility treatment was investigated. We found that repeatedly negative post-coital tests are a good indicator of a cervical mucus-sperm penetration problem. The cross-hostility test clearly differentiates the abnormal factor in this interaction, and a good performance of the donors' spermatozoa in the cervical mucus correlates with increased pregnancy rate. In male factor infertility, failure of the husbands' spermatozoa to penetrate cervical mucus was not indicative of a deficient fertilization potential in vivo. In these patients a serious attempt should therefore be made to reverse the infertility by treatment with IUI or ovulation induction + IUI before attempting assisted reproduction. Women with polycystic ovaries and repeatedly negative post-coital tests should be investigated for sperm receptivity of the cervical mucus. Low receptivity of the cervical mucus may imply that endometrial receptivity and oocyte quality are also low. Ovulation induction and not IUI alone should therefore be used as the preferred mode of treatment to improve pregnancy rate.

Minidose gonadotropin-releasing hormone agonist is the treatment of choice in poor responders with high follicle-stimulating hormone levels

OBJECTIVE

To investigate the effectiveness of minidose GnRH agonist (GnRH-a) + hMG in poor responders with elevated basal level FSH.

DESIGN

Retrospective analysis of IVF cycles.

SETTING

IVF Unit, Golda Medical Center, Petah Tikva, Israel.

PATIENTS

One hundred six patients who were defined as poor responders on two previous IVF attempts. Three treatment protocols of midluteal Decapeptyl (D-Trp6) were compared: [1] a single-dose of 3.75 mg; [2] 0.5 mg daily until menstruation, followed by 0.1 mg daily; and [3] 0.1 mg daily until menstruation, followed by 0.05 mg daily.

MAIN OUTCOME MEASURES

Comparisons were made among the three protocols regarding basal FSH levels, number of oocytes retrieved and fertilized, number of days of stimulation, follicular phase, P levels, and pregnancy and miscarriage rates.

RESULTS

Treatment with minidose GnRH-a resulted in higher E2 levels and lower P levels on the day of hCG and lower cancellation rates. Furthermore, a higher number of oocytes recovered and fertilized and embryos transferred were recorded. The trend indicated improved pregnancy and implantation rates with a lower miscarriage rate.

CONCLUSION

Minidose GnRH-a is a better choice than regular GnRH-a strategies in poor-responder patients undergoing IVF treatment.

Acute pelvic inflammatory disease after oocyte retrieval: adverse effects on the results of implantation

OBJECTIVE

To determine the impact of pelvic inflammation on the results of IVF after oocyte retrieval.

DESIGN

Retrospective analysis of IVF cycles.

SETTING

IVF Unit, Golda Medical Center, Petah Tikva, Israel.

PATIENTS

Twenty-eight women with a diagnosis of pelvic inflammatory disease (PID) during IVF therapy.

MAIN OUTCOME MEASURE

The pregnancy rate (PR) of IVF cycles complicated by PID after oocyte retrieval was compared with our ongoing IVF results.

RESULTS

All 28 women with PID during IVF treatment did not conceive, despite the high number of oocytes retrieved, fertilized, and transferred. The PR over the same period was 23% to 31%.

CONCLUSIONS

Pelvic infection after IVF treatment might have a detrimental effect on the results of treatment. In an effort to maximize the chances for normal implantation, postponement of ET should be considered when pelvic infection or inflammation is diagnosed.

[Pregnancy in Marfan's syndrome]

Marfan's syndrome is a hereditary disorder of connective tissue affecting mainly the bones, cardiovascular system and eyes. Women affected by this syndrome who are considering pregnancy are confronted with several problems: a 50% risk of inheritance of the syndrome by their offspring, shortened life expectancy as a parent, and the potential for cardiovascular complications, such as aortic aneurysm and dissection during pregnancy.

The choice of treatment for anovulation associated with polycystic ovary syndrome following failure to conceive with clomiphene

The choice of treatment for clomiphene-resistant anovulation associated with polycystic ovary syndrome (PCOS) is presently arbitrary and selection criteria are not available. A total of 144 women with anovulatory infertility associated with PCOS who failed to conceive on clomiphene were treated with either pure follicle stimulating hormone (FSH) (n = 29), or human menopausal gonadotrophin (HMG) (n = 60), or gonadotrophin-releasing hormone analogue (GnRHa) and HMG (n = 55). Analysis of 306 treatment cycles and 53 pregnancies revealed a cumulative conception rate at 4 months of 23% with FSH, 47% with HMG and 69% with GnRHa + HMG. The miscarriage rate was highest in the HMG group (44%) and consequently the cumulative live birth rate was superior when GnRHa was used in combination with HMG. There were no significant differences in the basal clinical and endocrinological features of those who conceived compared with those who did not, either in the whole group, or in the individual treatment groups. Thus, the choice of treatment for clomiphene-resistant women with PCOS cannot be guided by the basal clinical or endocrinological features of this heterogeneous syndrome with the present state or knowledge.

Induced regeneration of endometrium following curettage for abortion: a comparative study

A significant increase in endometrial thickness and volume was observed in 30 patients given oestrogen and progestin supplementation following curettage for first trimester abortions, compared with 30 women who received no treatment. This indicates an enhanced regeneration of the endometrium following treatment. The ability to induce this response, creating a space between the intra-cavity surface area a short time after abortion, may theoretically be suggested as preventative treatment to reduce the risk of intrauterine adhesions.

[Laparoscopic hysterectomy]

Abdominal hysterectomy is one of the most common major operations in gynecology. However, it is associated with considerable morbidity and relatively slow recovery. We describe a laparoscopic procedure for removal of the uterus, with or without the adnexa, in women in whom abdominal hysterectomy would otherwise be indicated. Laparoscopy is performed with the 3-puncture technic and an additional incision for the electrocoagulation instrument. The infundibulopelvic and round ligaments are dissected and divided if oophorectomy is to be done. If not, the broad ligament lateral to the uterine body is similarly treated and finally the dissections are extended to the uterine vessels and the uterosacral and upper parts of the transverse cervical ligaments. Surgery is completed vaginally after deflation of the abdomen, as in vaginal hysterectomy. Laparoscopy is repeated when the vagina has been closed, to ensure hemostasis. We have successfully performed laparoscopic hysterectomy, with or without salpingo-oophorectomy, in 7 women, aged 39-57. The procedure lasted 90-160 minutes and postoperative discomfort was minimal. All patients returned to normal activity within 4 weeks and were delighted with the outcome as well as with the cosmetic results. This technique offers an attractive alternative to conventional approaches and has significant advantages. Nevertheless, further studies are necessary to evaluate the true efficacy of the procedure.

The value of repeat hysteroscopic evaluation in patients with failed in vitro fertilization transfer cycles

One hundred ten women with normal initial hysteroscopy who failed to conceive during three or more IVF-ET cycles underwent repeat hysteroscopic evaluation. In 20 patients (18.2%), visualization revealed uterine abnormalities, mainly newly added endometrial lesions, i.e., hyperplasia, polyps, endometritis, and synechiae. Our results indicate that repeat hysteroscopic evaluation, in cases of recurrent IVF-ET failure, is an important adjunctive method for further evaluating and possibly optimizing the IVF-ET procedure.

Giant diverticulum of the bladder simulating ovarian cyst

A patient was admitted for investigation of a giant ovarian cyst, confirmed by physical examination. At laparotomy the genital organs appeared normal. Ultrasonic reexamination affirmed the preliminary findings of a pelvic cystic mass. A urinary bladder diverticulum was suspected and confirmed by cystography and found to be nonobstructive in nature. Although extremely rare, bladder diverticulum should be considered in the differential diagnosis of a cystic pelvic mass.