Effect of ejaculatory abstinence period on fertilization and clinical outcomes in ICSI cycles: a retrospective analysis

RESEARCH QUESTION

Does ejaculatory abstinence impact fertilization outcomes in intracytoplasmic sperm injection (ICSI) cycles in infertile couples?

DESIGN

This single-centre retrospective observational study included 6919 ICSI cycles from 2013 to 2022. The primary outcome was the assessment of oocyte fertilization, measured in terms of the rate of formation of two-pronuclear (2PN), 3PN and 1PN zygotes. Secondary outcomes were blastulation, cumulative positive β-human chorionic gonadotrophin test and clinical pregnancy rates. Relationships between ejaculatory abstinence and fertilization outcomes, and ejaculatory abstinence and clinical outcomes were evaluated with multivariable analysis, including possible confounders.

RESULTS

A positive association was observed between ejaculatory abstinence and semen sample volume (P < 0.001), sperm concentration (P < 0.001) and total motile sperm count (P < 0.001). No association was found between the 1PN zygote rate and ejaculatory abstinence (P = 0.97). Conversely, for each additional day of ejaculatory abstinence, the likelihood of obtaining 2PN zygotes from all inseminated oocytes decreased by 3% [adjusted odds ratio (aOR) 0.97, 95% CI 0.94-0.99], whilst the likelihood of obtaining 3PN zygotes from all inseminated oocytes increased significantly by 14% (aOR 1.14, 95% CI 1.07-1.22). No significant associations were found between ejaculatory abstinence and blastulation, cumulative pregnancy or miscarriage rates.

CONCLUSIONS

A longer ejaculatory abstinence period significantly decreases the rate of 2PN zygotes, and increases the rate of 3PN zygotes without directly affect blastulation and pregnancy rates.

P-300 Evaluation of CYP19A1 gene expression in luteinized granulosa cells of women affected by endometriosis undergoing assisted reproductive technology (ART) treatments

Study question

Does endometriosis affect the expression of the aromatase gene CYP19A1 in the cumulus oophorous (COCs) and mural lutein-granulosa cells (GCs) influencing ART procedures?

Summary answer

Endometriosis does not impair CYP19A1 gene expression. However, the correlation between the aromatase expression and the number of oocytes retrieved is lost in endometriosis patients.

What is known already

Endometriosis-related infertility could be associated with a dysregulation of oocytes development. Indeed, endometriosis seems to have a negative effect on the intrafollicular environment, hindering oocyte maturation. A dysregulated synthesis of steroid hormones by GCs in the ovaries of affected women may be at the basis of an inadequate folliculogenesis. In line, some studies have investigated the expression levels of aromatase p450 ( CYP19A1 ) -the key enzyme involved in 17β-estradiol (E2) synthesis - in GCs and COCs collected from endometriosis women, reporting controversial results.

Study design, size, duration

In order to identify novel prognostic factors of ART outcomes in affected women, we set the evaluation of CYP19A1 expression in GCs samples isolated from endometriosis patients undergoing ART in comparison to control women. In a subgroup of patients, COCs were also collected. CYP19A1, StAR and 3βHSD gene expression was evaluated in both cell types. Finally, we evaluated the association between the expression of the analyzed genes and E2 levels with the clinical ART outcomes

Participants/materials, setting, methods

GCs were isolated from follicular fluids(FF) of n = 68 women with stage III-IV endometriosis and of n = 69 control patients. CYP19A1 gene expression was quantified by qPCR. 17β-estradiol levels in FF were assessed using an ELISA kit. In addition to CYP19A1 gene expression, mRNA levels of StAR and 3βHSD both in GCs and COCs (n = 20 endometriosis;n=21 controls) were evaluated in both cell types using qPCR. Differences between the two patients’ groups were estimated using linear regression models.

Main results and the role of chance

qPCR results showed no differences in mRNA expression of CYP19A1, StAR and 3βHSD in both GCs and COCs between the two groups of ART patients. These results were supported by the presence of the same concentration of E2 in the FF of controls (median: 877.7 ng/mL) and endometriosis patients (median: 878.3 ng/mL) (p-value=0.87). Linear regression model including as input variables gene expression values and ART outcomes showed that the blastulation rate was the only ART outcome associated with the expression levels of CYP19A1  (p-value=0.043, 95% CI: 0.001-0.061). In particular, a decrease of aromatase levels was associated with an increase in blastulation rate. After stratification of the population based on the presence of the disease, it emerged that, in the control group, the CYP19A1 expression correlated with the number of oocytes retrieved [β:-1.214;95%CI: -2.085 - (-0.343); p-value=0.007], while in the group of patients with endometriosis this association was no more present [β:-0.003;95%CI:-0.468 - 0.461; p-value=0.988)]. These results do not support data from the literature indicating that aromatase expression is reduced in GCs of affected women, but they highlight a potential disease-related mechanism affecting the ovulation process in these women

Limitations, reasons for caution

These findings need to be validated in a different cohort of samples. An RNA-seq approach is needed in order to validate our results and to obtain the overall transcriptome profiles of GCs and COCs in endometriosis patients.

Wider implications of the findings

Our data do not confirm previous evidence supporting a reduced expression/activity of aromatase in GCs in endometriosis. However, they suggest that aromatase may have a complex and sophisticated regulation of its expression in this cell type, which is not maintained in presence of endometriosis.

Trial registration number

not applicable

P-275 Delayed blastocyst development is associated with a higher level of progesterone: the missing link in the chain

Study question

Is there an association between progesterone (P) level on the day of trigger and blastulation rate on day 5 versus day 6?

Summary answer

Higher level of progesterone on the day of trigger is associated with lower blastulation rate on day 5 versus day 6.

What is known already

Premature progesterone elevation is known to determine a premature advanced endometrium by worsening endometrial-embryo asynchrony and affecting live birth rate during fresh cycles. To overcome the detrimental effect on the implantation window shift, freeze-all-strategy was introduced. Questions have been raised about the possible impact of progesterone also on oocyte’s quality and embryo’s euploidy rate. Studies on preimplantation genetic testing (PGT) cycles have demonstrated no differences in terms of fertilization, blastulation, euploidy and pregnancy rates. However, no studies have evaluated whether progesterone may impact blastocyst development in terms of blastulation rate.

Study design, size, duration

This was a retrospective cohort study with autologous IVF cycles performed at our institution from January 2019 to December 2021. 2819 IVF cycles were screened for inclusion. A total of 888 IVF cycles were included. The primary outcome was to compare blastulation rate on day5 versus day6 in terms of percentage of formed blastocysts on day5 versus day6 according to progesterone level at trigger.

Participants/materials, setting, methods

Patients between 18 and 42 years of age who underwent blastocyst culture of the whole cohort of embryos formed were included. Blastocyst evaluation was performed by a team of expert embryologists according to the Istanbul Consensus. We performed the Kruskal-Wallis test to assess differences between groups (blastulation rate according to progesterone level at trigger) and a multiple logistic regression analysis to evaluate association between the presence/absence of full blastocyst on day5 and progesterone levels.

Main results and the role of chance

A total of 3249 blastocysts were analyzed. The blastulation rate per total number of cycles was 39.4% for day-5 blastocyst, 54.0% for day-6 blastocyst, and 6.6% for day-7 blastocyst. After dividing progesterone level in quartiles (Q1, P &lt; 0.51 ng/ml; Q2, 0.51 ng/ml ≤ P &lt; 0.82 ng/ml; Q3, 0.82 ng/ml ≤ P &lt; 1.21 ng/ml; Q4, P ≥ 1.21 ng/ml), we observed a progressive delay in blastocyst development according to the increasing level of progesterone at trigger (with a median blastulation rate on day5 of 50.00% for Q1 versus 40.00% for Q2, 30.00% for Q3 and 30.00% for Q4, p &lt; 0.001). After adjusting for confounding factors, the the probability to observe at least one full blastocysts on day5 was significantly reduced for Q3 (OR = 0.44, CI 0.28-0.70, p &lt; 0.001) and Q4 (OR = 0.31, CI 0.19-0.48, p &lt; 0.001) compared to Q1 (reference).

Limitations, reasons for caution

The retrospective nature of the study and potential variability between our study center’s laboratory protocol(s) and blastocyst culture medium used compared to those of other reproductive centers may limit the external validity of our findings. A well-designed multicenter study is needed to further extend and validate our results.

Wider implications of the findings

This study suggests that progesterone level on the day of induction may affect blastocyst development. Thus, embryologists should not be worried by a slow growing embryo and should expect different blastulation rate on day 5/6 according to progesterone level.

Trial registration number

Not applicable

P-786 Perinatal outcomes of assisted reproduction technology (ART) pregnancies after transfer of mosaic blastocysts: a single centre matched cohort study

Study question

Do viable pregnancies after transfer of mosaic blastocysts present different perinatal outcomes as compared to those deriving from transfer of euploid blastocysts?

Summary answer

Pregnancies from transfer of mosaic vs. euploid blastocysts showed an increased rate of fetal structural malformations and postpartum haemorrhages (PPH).

What is known already

The incidence of mosaicisms in the trophoectoderm is a relatively frequent event and most true embryo mosaicisms result in spontaneous intrauterine demise. The confirmation of the mosaic aneuploidy in the fetus is related to the type and grade of the aneuploidy with higher risk for chromosomes 13, 14, 15, 16, 18 and 21 and X monosomy. On the other hand, selected mosaic blastocysts have been transferred with subsequent birth of healthy neonates. However, the risk of abnormal obstetric outcomes after transfer of mosaic embryos remains to be completely elucidated.

Study design, size, duration

Explorative cohort study between 2016 and 2021 including consecutive viable ART pregnancies developing from transfer of mosaic blastocysts (n = 39 cases). Transfer of available mosaic embryos was considered for patients with a poor response to ovarian stimulation or recurrent implantation failures and no available euploid blastocysts, after genetic counselling. Cases were matched for maternal age, parity and body mass index to women with viable pregnancies after transfer of euploid blastocysts (n = 39, controls) and followed-up until delivery.

Participants/materials, setting, methods

All patients recruited at San Raffaele, Scientific Institute of Milan, underwent a prenatal genetic testing by trophoectoderm biopsy and next-generation sequencing analysis. Patients with a viable fetus at 12 weeks gestation were included and underwent detailed ultrasound assessment at 12, 20 and 32 weeks including fetal biometry and anatomical survey. Frequency of adverse pregnancy and perinatal outcomes including maternal, fetal and delivery complications were compared between patients who received a mosaic versus a euploid blastocyst.

Main results and the role of chance

No difference in indications to preimplantation diagnosis was found between cases and controls. In the group who transferred mosaic embryos, median rate of mosaicisms was 35% (IQR 30%-40%) and they were characterized by heterogeneous anomalies including complex aneuploidies (n = 12), autosomal monosomies (n = 13), trisomies (n = 8) and duplications/deletions (n = 6). Invasive testing was performed in 62.0% of mosaics (5 chorion villous samplings; 19 amniocenteses; 2 anomalies: confined placental mosaicism trisomy 15 after transfer of mosaic monosomy 6 and fetal microduplication 6p after transfer of mosaic deletion 10p) vs 2.5% of controls (p &lt; 0.001). Structural malformations were observed in 6 neonates in the study group (tanatophoric skeletal dysplasia, complex central nervous system anomaly, congenital diaphragmatic hernia, cerebral arteriovenous fistulae, pyeloureteral junction stenosis, diffuse haemangiomatosis) compared to 1 in controls (pulmonary stenosis) (p = 0.04). One neonate per group was followed-up for future surgery. PPH rate was significantly higher in cases vs controls (15 vs 7; p = 0.04). Neonatal survival at hospital discharge was not different in the two groups (p = 0.30). No significant differences were recorded in rates of preterm birth, small or large for gestational age, fetal growth restriction, miscarriage, preeclampsia and median birthweight centile or gestational age at birth.

Limitations, reasons for caution

Data from our exploratory study should be interpreted cautiously given the limited sample size which makes it challenging to infer a causal relationship between the association found and transfer of mosaic blastocysts.

Wider implications of the findings

The higher rates of structural malformations and PPH in ART pregnancies after transfer of mosaic embryos strongly suggest the need for strict monitoring of these patients. First and second trimester ultrasound screening for structural defects, and preventive measures to minimize bleeding at delivery should be implemented.

Trial registration number

not applicable

P-031 The extent of late paternal effect: does the blastocyst matter? A retrospective analysis of 703 single, frozen-thawed embryo-transfers

Study question

Do the blastocysts derived from severe male infertility show different ongoing pregnancy rates(OPR) compared to blastocysts of couples requiring assisted reproduction techniques(ART) for other indications?

Summary answer

First, single, frozen-thawed embryo transfers of blastocysts derived from severe male infertility did not affect OPR in-vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) cycles.

What is known already

Several studies reported a negative impact of severe male infertility on fertilization rate, embryo morphology and embryo cleavage speed, due to the so-called early paternal effect, caused by sperm cytoplasm deficiencies. Nuclear sperm defects are responsible for the late paternal effect, causing lower blastocyst formation rates and, theoretically, reducing implantation potential of the obtained blastocysts. However, the effects of male infertility on OPR and live birth rates (LBR) are still debated. Additionally, the heterogeneity in the definition and estimation of male infertility makes the existing data difficult to interpret.

Study design, size, duration

Retrospective analysis of first IVF/ICSI cycles performed between January 2019 and December 2021 in the Reproductive Sciences Unit of Gynaecology/Obstetrics Department of San Raffaele Hospital in Milan, Italy.

Participants/materials, setting, methods

First, single, frozen-thawed embryo transfers of infertile couples first IVF/ICSI cycles were included. Embryo transfers obtained by frozen semen were excluded. Couples characteristics, semen parameters and controlled ovarian stimulation (COS) data were collected. Semen quality was assessed using total motile count (TMC) and grouped into quartiles of TMC for the analyses. The effect of severe male factor infertility evaluated through TMC over OPR was the primary outcome of the study.

Main results and the role of chance

N = 703 transfers were analysed. Performing a logistic regression analysis adjusted for confounding factors (maternal age, COS protocols, number of oocytes retrieved and quality of transferred blastocysts), OPR was not influenced by TMC values [odds ratio (OR) = 0.999; confidence interval (CI) = 0.986-1.013; p = 0.932]. After grouping male infertility population into quartiles of TMC, no significant differences in OPR were found between extreme quartiles (TMC ≤2.55 million and TMC ≥20 million respectively), even when adjusted for confounders [OR = 1.007; CI 0.609-1.663; p = 0.98]. Therefore, the implantation potential of the obtained blastocysts, once formed, seems to be independent from sperm quality.

Limitations, reasons for caution

The major limitations of the present study are the retrospective design and sample size. Additionally, the estimation of male infertility as well as the routinary use of TMC in clinical practice are not yet standardized. However, having analysed only the first transfers of the included couples makes our results reliable.

Wider implications of the findings

Further prospective studies with larger sample size are needed to confirm our results and to validate the use TMC as a standard tool to classify male factor and to guide clinical choices. Pregnancy and obstetrical outcomes are also necessary to better understand the role of male infertility in human reproduction.

Trial registration number

not applicable

O-192 Concomitant autoimmunity in endometriosis-affected women and In Vitro Fertilization (IVF) outcomes: a cohort study

Study question

To evaluate whether the presence of concomitant autoimmunity in endometriosis patients may affect In Vitro Fertilization (IVF)/Intracytoplasmic Injection (ICSI) outcomes.

Summary answer

In ‘normo-responders’ patients autoimmunity did not affected ovarian response to gonadotrophin stimulation yet was the only significant negative predictor of cumulative pregnancy rate (CPR).

What is known already

In the last years, endometriosis has been redefined as a multifactorial disease with a complex pathogenesis. In this setting, a role of both innate and adaptive immune systems have been proposed in endometriosis development. The coexistence of endometriosis and autoimmunity is well-documented. Also, an increased risk of more severe stages of endometriosis in patients with autoimmunity has been recently reported. Even if autoimmunity has been associated with lower pregnancy rates and higher miscarriage rates, whether the presence of autoimmunity in endometriosis patients could act as an additive factor worsening IVF/ICSI response is still not known.

Study design, size, duration

Single-center, retrospective, cohort study. First IVF/ICSI cycles of endometriosis patients with or without autoimmunity carried out from 2007 to 2021 at the Fertility Unit of IRCSS San Raffaele Hospital(Milan) were included. Patients with endometriosis and concomitant autoimmunity were age-matched to endometriosis only controls. Only patients with a complete disease control following endometriosis treatment were admitted to IVF/ICSI. A total of 471 patients were enrolled. The study was conducted according to STROBE guidelines for observational studies.

Participants/materials, setting, methods

Endometriosis diagnosis was surgical/histopathological, yet also ovarian endometriosis at ultrasound assessment by expert operators was included. Autoimmunity was assessed by blood tests for auto-antibodies and/or rheumatological records. Stratified analysis by “expected” ovarian response at baseline according to AFC and/or AMH were performed. Expected ‘poor-responders’ were defined according to Bologna Criteria. The primary outcome was CPR. Secondary outcomes included oocytes retrieved, metaphase II(MII)oocytes and ovarian sensitivity index(OSI), the latter defined as:(number of retrieved oocytes/total gonadotrophin dose)×1000.

Main results and the role of chance

113/471 cases with endometriosis and concomitant autoimmunity and 358/471 age-matched endometriosis only controls were enrolled. The mean age was 35.70±3.75 and 35.95±3.72 (p = 0.543) in cases and controls respectively. No baseline differences in endometriosis disease stage (p = 0.414), surgical treatment for endometriosis prior to IVF (p = 0.617), BMI (p = 0.866) or type of infertility (p = 0.255) were observed when comparing the two groups. In “expected normo-responders”, cases with autoimmunity had significantly higher numbers of oocytes retrieved (p = 0.007), MII oocytes (p = 0.007) and OSI index (p = 0.013) when compared to controls with endometriosis only; the CPR was 12.5% in cases vs. 17.5% in controls, thus comparable between the two groups (p = 0.143). In “expected poor-responders” no significant differences were observed neither in the number of oocytes retrieved and MII oocytes, nor in OSI index; the CPR was 12% in cases with concomitant autoimmunity compared to 7.75% in controls with endometriosis only (p = 0.256). In the generalized linear models (GLMs) of independent predictors associated with CPR, in expected ‘normo-responders’ autoimmunity was the only significant negative predictor of CPR (p = 0.004) whereas in ‘poor-responders’ only age negatively affected CPR (p = 0.001).

Limitations, reasons for caution

This study has a retrospective design. The interpretation of results is based on the validated yet still debated definition of poor-responders according to Bologna Criteria. Results should be interpreted with caution until replicated by future research providing multi-centric and prospective design, larger sample size and more standardized data collection.

Wider implications of the findings

Autoimmunity does not seem to impact neither ovarian reserve nor ovarian response to gonadotropin, as it may act a ‘competitive’ rather than ‘additive’ risk factor for infertility in endometriosis. However, in ‘normo-responders’ autoimmunity seems to reduce the chances of pregnancy following IVF/ICSI perhaps impairing endometrial receptivity and embryo implantation.

Trial registration number

Due to the retrospective design of the study, full IRB approval at the institution was not needed.

P–432 Do stage and grade of malignancy impact fertility preservation in breast cancer patients?

Study question

Do stage and grade of breast cancer impact the number of retrieved mature oocytes during controlled ovarian stimulation for fertility preservation?

Summary answer

Stage and grade of breast cancer do not impact the number of retrieved mature oocytes. Higher grade breast cancer requires higher gonadotropin doses during stimulation.

What is known already

Cancer can impair ovarian response by unknown mechanisms. Some authors suggest that it could be detrimental on fertility because it elicits a catabolic state, increasing stress hormone levels. Some studies have also shown that ovarian response to controlled ovarian stimulation (COS) is, in some way, compromised in oncological patients. Little is known about the impact of different types of cancer on ovarian reserve, and specifically whether higher stage and grade could compromise egg retrieval during fertility preservation (FP) techniques. Study design, size, duration: Retrospective cohort study evaluating data of FP treatment cycles among women with breast cancer at the Oncofertility Unit of San Raffaele Hospital, Milan in the period from 2011 to 2019.

Participants/materials, setting, methods

Inclusion criteria were: breast cancer diagnosis; age 22–41; oocyte cryopreservation after stimulation with a random start GnRH-antagonist protocol. Patients receiving chemotherapy before FP were excluded. We compared outcomes between low-stage (stage I) and high-stage (stage II-III) patients and low-grade (G1-G2) and high-grade (G3) patients. Main study outcome was the total number of retrieved mature oocytes. Univariate analysis was performed by Mann-Whitney test, Kruskal-Wallis test and Fisher’s exact test. Multivariate analysis was performed by logistic regression.

Main results and the role of chance

101 stimulation cycles were included. High-stage disease patients were significantly younger than low-stage. Median antral follicle count (AFC) was 12 in low-stage and 10 in high-stage (age-adjusted p = 0.92) and median anti-mullerian hormone (AMH) levels were 1.9 ug/L in low-stage and 1.8 ug/L in high-stage (age-adjusted p = 0.22). No significant difference in stimulation protocols and follicle-stimulating hormone (FSH) start and total dose could be detected between the 2 groups. Median number of vitrified oocytes was 7 in both groups (p = 0.75). No significant difference could be observed in median AFC (13 vs 10, p = 0.14) and AMH levels (2.1 vs 1.5, p = 0.88) between low-grade and high-grade disease patients. When adjusting for age, AFC was found to be significantly lower in high-grade disease patients (p = 0.03). Patients with high-grade tumors were stimulated with higher doses of FSH (age-adjusted p-value=0.03). Median number of vitrified oocytes was 6 in low-grade patients and 7 in high-grade (p = 0.35). In a multivariate model including age, cancer stage, cancer grade and molecular classification, the only significant factor found to be inversely associated with AFC was cancer grade (OR 3.6; 95% CI 0.7 – 6.5, p = 0.01), while only age was significantly associated with oocyte retrieval (OR 0.4; 95% CI 0.01 – 0.9, p = 0.04).

Limitations, reasons for caution

The main limitations of our study are its retrospective design and the small sample size.

Wider implications of the findings: Fertility preservation counselling and ovarian stimulation protocols of breast cancer patients could be implemented with cancer grade.

Trial registration number

Not applicable

P–031 The effect of ejaculatory abstinence period on embryological and clinical outcomes in ICSI cycles: A retrospective analysis of 3,353 cycles

Study question

Does ejaculatory abstinence period in male affect embryological and pregnancy outcomes following fresh embryo transfers in ICSI cycles?

Summary answer

Shorter ejaculatory abstinence period is associated with lower triploid zygotes rate per ICSI cycle but it does not affect clinical outcomes after fresh embryo transfers.

What is known already

Lower sperm quality may negatively impact on fertilisation rate and embryo morphokinetic parameters after ICSI and the effect of the ejaculatory abstinence period before semen collection on seminal parameters and sperm quality has been widely reported. However, the impact of ejaculatory abstinence on clinical outcomes is still controversial. WHO (World Health Organization) guideline recommended that abstinence period should be 2–7 days. Even so, there are no larger prospective trials determining the optimal timing for ejaculatory abstinence period for infertile couples.

Study design, size, duration

This is a single center retrospective observational study of 3,353 fresh cycles from January 2017 to December 2020. Semen analysis was done according to the WHO criteria. Exclusion criteria for this study were frozen gametes and cycles with no retrieved oocytes. Primary outcomes were fertilization rate and triploid zygotes rate. Secondary outcomes were blastulation rate, ongoing pregnancy rate and live birth rate per fresh embryo transfer.

Participants/materials, setting, methods

The correlation between ejaculatory abstinence and continuous outcomes was evaluated by Spearman’s correlation analysis in order to detect potential non-linear associations. Generalized linear model and logistic regression were used, respectively for continuous and binary outcomes, in order to adjust for confounders such as female age, male age, number of retrieved oocytes, percentage of mature oocytes, infertility causes, seminal volume, sperm concentration and total progressive sperm motility. A p value &lt;0.05 was considered significant.

Main results and the role of chance

The male mean age was 40.3±5.5 and mean duration of abstinence was 2.9±1.7 days. The mean age of female patients was 38.2±4.0. Higher ejaculatory abstinence period was associated with a higher sperm concentration (Spearman p = 3.1x10–6) but not with a higher total sperm progressive motility. Even so, no significant correlation with EA were observed when considering fertilization rate, blastulation rate, ongoing pregnancy and live birth rate per transfer in analyzed cycles. Triploid zygote rate was positively associated with a higher ejaculatory abstinence period. For the ejaculatory abstinence period of 1 day (n = 64), 2 days (n = 1523), 3 days (n = 1032), 4 days (n = 408), 5 days (n = 174), 6 days (n = 47) and ≥7 days (n = 105) the mean triploid rate was 2.4%, 2.4%, 2.5%, 4.1%, 3.6%, 5.4% and 4.3%, respectively (Spearman p = 9x10–3). Triploid zygote rate was independent of semen volume, concentration and total progressive motility.

Limitations, reasons for caution

This is a large observational study with a retrospective data collection. Despite our methodological approach, the presence of biases related to retrospective design can not be excluded and it may be a reason for caution.

Wider implications of the findings: Our results demonstrate that ejaculatory abstinence period do not affect blastulation, ongoing pregnancy and live birth rates. The current findings discourage an abstinence time longer than 3 days due to its association with a higher abnormal fertilization rate.

Trial registration number

Not applicable

Assessment of ovarian reserve after cystectomy versus 'one-step' laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial

STUDY QUESTION

Does CO2 laser vaporization offer better results in treating endometrioma in terms of ovarian reserve preservation compared to traditional cystectomy?

SUMMARY ANSWER

Assessing both antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels as measures of ovarian reserve, the results suggest that CO2 technology may be an alternative treatment for endometrioma, causing minimal damage to adjacent healthy ovarian tissue.

WHAT IS KNOWN ALREADY

Excisional surgery has been questioned as an ideal surgical approach for endometriomas because it is associated with potential reduction of ovarian reserve. Recently, vaporization with CO2 laser in-line-of-sight, according to the 'three-step procedure', has been proposed as the best method to preserve ovarian function. However, no randomized controlled trials have been conducted to compare cystectomy and 'one-step' CO2 fiber laser vaporization (without GnRH agonist therapy) with respect to the ovarian reserve.

STUDY DESIGN, SIZE, DURATION

A multicentre randomized clinical trial including 60 patients was performed between July 2017 and February 2018. Computerized randomization was conducted to allocate them in a proportion of 1:1 either to Group 1 (laparoscopic stripping: cystectomy) or Group 2 (CO2 laser vaporization). Patients in Group 1 underwent a standardized laparoscopic stripping technique; patients in Group 2 underwent drainage of the cyst content, biopsy and vaporization of the internal wall with a CO2 fiber laser. Patients underwent pelvic ultrasound examination to determine the AFC and blood sampling to determine AMH levels before surgery and at 1- and 3-month follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients undergoing surgery for symptomatic endometriomas (infertility and/or pelvic pain) larger than 3 cm were randomized in two groups according to the surgical technique. Patients aged ≥40 years, or with deep infiltrating endometriosis/adenomyosis, or previously submitted to surgical procedures on the ovaries or to hysterectomy were excluded from the study. The primary endpoint was the comparison of intra-group AFC changes before and after surgery (ΔAFC) between the two groups (ΔAFC Group 1 versus ΔAFC Group 2). The secondary endpoint was the modification of serum AMH before and after surgery (ΔAMH) between the two groups (ΔAMH Group 1 versus ΔAMH Group 2).

MAIN RESULTS AND THE ROLE OF CHANCE

The AFC of the operated ovary was significantly increased in Group 2 (laser vaporization) compared with Group 1 (cystectomy) after surgery (Group 1: from 4.1 ± 2.2 [mean ± SD] at baseline to 6.3 ± 3.5 at 3-month follow-up; 95% CI: 0.9-4; Group 2: from 3.6 ± 1.9 at baseline to 8.6 ± 4.2 at 3-month follow-up; 95% CI: 2.8-7.1; P = 0.016); serum AMH levels were significantly reduced at 3 months in Group 1 (from 2.6 ± 1.4 ng/mL at baseline to 1.8 ± 0.8 ng/mL at 3-month follow-up; 95% CI: -1.3 to -0.2; P = 0.012) compared with no reduction in Group 2 (from 2.3 ± 1.1 ng/mL at baseline to 1.9 ± 0.9 ng/mL at 3-month follow-up; 95% CI: -1 to -0.2; P = 0.09).

LIMITATIONS, REASON FOR CAUTION

The key limitations of the trial were the low accuracy of AFC in estimating the ovarian reserve in ovaries with endometriomas, the limited study size and the relatively short follow-up, which do not allow us to draw definitive conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

The present study suggests that CO2 technology may treat endometrioma with minimal damage to the adjacent healthy ovarian tissue; however, this study should be considered as a preliminary clinical trial, intended to stimulate future larger trials to address this clinically relevant issue.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03227640.

TRIAL REGISTRATION DATE

9 July 2017.

DATE OF FIRST PATIENT’S ENROLLMENT

24 July 2017.

Endometriosis: seeking optimal management in women approaching menopause

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

Multifactorial analysis of the stochastic epigenetic variability in cord blood confirmed an impact of common behavioral and environmental factors but not of in vitro conception

Background

An increased incidence of imprint-associated disorders has been reported in babies born from assisted reproductive technology (ART). However, previous studies supporting an association between ART and an altered DNA methylation status of the conceived babies have been often conducted on a limited number of methylation sites and without correction for critical potential confounders. Moreover, all the previous studies focused on the identification of methylation changes shared among subjects while an evaluation of stochastic differences has never been conducted. This study aims to evaluate the effect of ART and other common behavioral or environmental factors associated with pregnancy on stochastic epigenetic variability using a multivariate approach.

Results

DNA methylation levels of cord blood from 23 in vitro and 41 naturally conceived children were analyzed using the Infinium HumanMethylation450 BeadChips. After multiple testing correction, no statistically significant difference emerged in the number of cord blood stochastic epigenetic variations or in the methylation levels between in vitro- and in vivo-conceived babies. Conversely, four multiple factor analysis dimensions summarizing common phenotypic, behavioral, or environmental factors (cord blood cell composition, pre or post conception supplementation of folates, birth percentiles, gestational age, cesarean section, pre-gestational mother’s weight, parents’ BMI and obesity status, presence of adverse pregnancy outcomes, mother’s smoking status, and season of birth) were significantly associated with stochastic epigenetic variability. The stochastic epigenetic variation analysis allowed the identification of a rare imprinting defect in the locus GNAS in one of the babies belonging to the control population, which would not have emerged using a classical case-control association analysis.

Conclusions

We confirmed the effect of several common behavioral or environmental factors on the epigenome of newborns and described for the first time an epigenetic effect related to season of birth. Children born after ART did not appear to have an increased risk of genome-wide changes in DNA methylation either at specific loci or randomly scattered throughout the genome. The inability to identify differences between cases and controls suggests that the number of stochastic epigenetic variations potentially induced by ART was not greater than that naturally produced in response to maternal behavior or other common environmental factors.

Electronic supplementary material

The online version of this article (10.1186/s13148-018-0510-3) contains supplementary material, which is available to authorized users.

Top quality blastocyst formation rates in relation to progesterone levels on the day of oocyte maturation in GnRH antagonist IVF/ICSI cycles

Cycles with progesterone elevation during controlled ovarian stimulation (COS) for IVF/ICSI are commonly managed with a "freeze-all" strategy, due to a well-recognized detrimental effect of high progesterone levels on endometrial receptivity. However, also a detrimental effect of elevated progesterone on day-3 embryo quality has recently been found with regards to top quality embryo formation rate. Because blastocyst culture and cryopreservation are largely adopted, we deemed relevant to determine whether this detrimental effect is also seen on blastocyst quality on day 5-6. This issue was investigated through a large two-center retrospective study including 986 GnRH antagonist IVF/ICSI cycles and using top quality blastocyst formation rate as the main outcome. Results showed that on multivariate analysis sperm motility (p<0.01) and progesterone levels at ovulation triggering (p = 0.01) were the only two variables that significantly predicted top quality blastocyst formation rate after adjusting for relevant factors including female age, BMI, basal AMH and total dose of FSH used for COS. More specifically, progesterone levels at induction showed an inverse relation with top quality blastocyst formation (correlation coefficient B = -1.08, 95% CI -1.9 to -0.02) and ROC curve analysis identified P level >1.49 ng/ml as the best cut-off for identification of patients at risk for the absence of top quality blastocysts (AUC 0.55, p<0.01). Our study is the first to investigate the top quality blastocyst formation rate in relation to progesterone levels in IVF/ICSI cycles, showing that increasing progesterone is associated with lower rates of top quality blastocyst. Hence, the advantages of prolonging COS to maximize the number of collected oocytes might eventually be hindered by a decrease in top quality blastocysts available for transfer, if increasing progesterone levels are observed. This observation extends the results of two recent studies focused on day-3 embryos and deserves further research.

Are extremely high progesterone levels still an issue in IVF?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stimulatory effect of SOM230 on human and rat adrenal corticosteroid secretion in vitro

SOM230 (pasireotide, Signifor), a recently developed somatostatin analog, has been tested in ACTH-secreting pituitary tumors with promising results. No study has yet evaluated whether this analog also directly affects adrenal steroid production. The aim of the current study was to evaluate whether SOM230 modulates corticosteroid secretion by normal adrenals in vitro. Primary cultures from normal human and rat adrenals were incubated with 10-100 nM SOM230 with and without 10nM ACTH. Dose-response studies with 1 nM-1 μM SOM230 were performed on rat adrenals. Cortisol/corticosterone levels in medium were measured after 4 and 24h. SOM230 (10nM) significantly increased corticosteroid levels after 24h incubation in both human (36.4 ± 0.43 ng/well vs 27.7 ± 3.17 ng/well, p<0.05) and rat (16.2 ± 1.16 ng/well vs 11.6 ± 0.92 ng/well p<0.05) adrenals; lesser effects were observed with 100 nM SOM (33.4 ± 2.59 ng/well vs 27.7 ± 3.17 ng/well p<0.05; 13.4 ± 0.82 ng/well vs 11.6 ± 0.92 ng/well, N.S. vs baseline secretion for human and rat adrenals, respectively). Dose-response curves confirmed maximal effect at 10nM SOM230. The corticosteroid secretory response to ACTH was unaffected by SOM230 co-incubation. In conclusion, SOM230 exerts a moderate stimulatory effect on adrenal corticosteroid secretion in vitro. This argues against a direct adrenal involvement in the clinical efficacy of SOM230 in patients with ACTH-secreting pituitary tumors and widens the known range of action of SOM230.

Responses to corticotrophin-releasing hormone and dexamethasone in a large series of human adrenocorticotrophic hormone-secreting pituitary adenomas in vitro reveal manifold corticotroph tumoural phenotypes

Patients with Cushing's disease are known to present a variable secretory response to stimulatory and inhibitory challenges. Evaluation of the secretory behaviour of pituitary adrenocorticotrophic hormone (ACTH)-secreting adenomas in vitro aids in the comprehension of its behaviour in vivo; however, given the small size of these tumours and the consequent paucity of material available to in vitro studies, a comprehensive study on the secretory behaviour of human corticotroph tumours has not yet been performed. The present study aimed to assess the spectrum of responses to the two main corticotroph modulators, corticotrophin-releasing hormone (CRH) and dexamethasone, in a large series of human ACTH-secreting pituitary tumours. Seventy-two ACTH-secreting pituitary tumours were collected during surgery and established in culture. Specimens were incubated with 10 nm CRH and/or 10 nm dexamethasone for 4 h and 24 h. Secretion in unstimulated, control wells was set at 100% and changes in ACTH concentrations by at least 20% were considered as responses. Parallel experiments in 12 rat anterior pituitary primary cultures were evaluated. A marked ACTH increase was observed during incubation with CRH in 70% of tumoural specimens at 4 h (range 124-3500% of control wells) and in 57% at 24 h (range 122-3323%). Dexamethasone reduced ACTH secretion in almost 50% of tumours (range 78-2% of control at 4 h; 76-3% at 24 h), whereas it did not affect ACTH medium levels in 30% of specimens and induced a paradoxical ACTH increase in 20% of tumours (range 130-327% of control at 4 h; 156-348% at 24 h). By comparison, CRH uniformly increased ACTH levels in rat anterior pituitary primary cultures (mean 745 ± 84% at 4 h; 347 ± 25% at 24 h), whereas dexamethasone decreased ACTH levels by 40-50% in all experiments. In conclusion, the present study of a large series of human ACTH-secreting pituitary tumours in vitro revealed a considerable variability in the responses to CRH and dexamethasone. This finding indicates the existence of multiple corticotroph tumoural phenotypes and may account for the different responses to physiological and pharmacological modulators in vivo.

The human POMC gene promoter: where do we stand?

Proopiomelanocortin (POMC) is crucial for several life-essential functions and its regulation has been studied extensively in the past decades. The first studies provided the framework for POMC promoter activity, namely the identification for the major response elements contained in the promoter, e.g., the glucocorticoid response element, the Nur response element, while subsequent studies showed the importance of cooperation and interplay between transcription factors to achieve optimal promoter activity. The involvement of constitutive repressors of POMC transcription, such as Bmp4, provided the latest clues to our understanding of POMC promoter activity. This increased knowledge benefits the clinician as it allows genetic testing and early recognition of patients with congenital ACTH deficiency due to mutations in TPIT and paves the way to new medical treatments in Cushing's disease. The present review will illustrate the current standing on regulation of the human POMC promoter, focusing on its activity in corticotropes.

Inhibitory effect of prepro-thyrotrophin-releasing hormone (178-199) on adrenocorticotrophic hormone secretion by human corticotroph tumours

Prepro-thyrotrophin-releasing hormone (TRH) (178-199), a 22-amino acid cleavage product of the TRH prohormone, has been postulated to act as an adrenocorticotrophin hormone (ACTH)-release inhibitor. Indeed, although in vitro evidence indicates that this peptide may inhibit basal and stimulated ACTH secretion in rodent anterior pituitary primary cultures and cell lines, not all studies concur and no study has as yet evaluated the effect of this peptide in Cushing's disease. The present study aimed to test the effect of preproTRH(178-199) in human tumoural corticotrophs. Twenty-four human ACTH-secreting pituitary tumours (13 macroadenomas, 11 microadenomas) were collected during surgery and incubated with 10 or 100 nm preproTRH(178-199). ACTH secretion was assessed after 4 and 24 h of incubation by immunometric assay and expressed relative to levels observed in control, unchallenged wells (= 100%). Parallel experiments were performed in rat anterior pituitary primary cultures. A clear inhibition of ACTH secretion at 4 and 24 h was observed in 12 specimens (for 10 nm ppTRH: 70 +/- 4% control at 4 h and 83 +/- 5% control at 24 h; for 100 nm ppTRH: 70 +/- 4% control at 4 h and 85 +/- 5% control at 24 h), whereas a mild and short-lasting stimulatory effect was observed in three tumours and no changes in ACTH secretion in the remaining nine tumoural specimens. The inhibitory effect of preproTRH(178-199) was more evident in macroadenomas and significantly correlated with sensitivity to dexamethasone inhibition. Significant inhibition of ACTH secretion by preproTRH(178-199) in rat pituitary cultures was observed after 24 h of incubation. The present study conducted in a large series of human corticotroph tumours shows that preproTRH(178-199) inhibits tumoural ACTH secretion in a sizable proportion of specimens, in close relation to the size of the tumour and its sensitivity to glucocorticoid negative feedback. This appears a promising avenue of research and further studies are warranted to explore the full scope of preproTRH(178-199) as a regulator of ACTH secretion.