[Premenstrual syndrome and premenstrual dysphoric disorder-Overview on pathophysiology, diagnostics and treatment]

Premenstrual syndrome and premenstrual dysphoric disorder become episodically manifest during the second half of the female menstrual cycle and are characterized by psychological and physical symptoms causing relevant functional and social impairments. Mood swings, depression and dysphoria are associated depressive symptoms. Therefore, affective disorders should be considered as a differential diagnosis. Of women in reproductive age 3-8% suffer from premenstrual syndrome and 2% of women are affected by premenstrual dysphoric disorder. Genetic and sociobiographical risk factors are discussed. Furthermore, genetic polymorphisms of specific hormone receptors are considered to be genetic risk factors. From a pathophysiological perspective premenstrual syndrome and premenstrual dysphoric disorder are caused by a complex interaction between cyclic changes of ovarian steroids and central neurotransmitters. An imbalance of estrogen and progesterone in the luteal phase is believed to cause the symptoms. Therefore, the first treatment approach consists of regulation of the menstrual cycle or luteal support with progesterone or synthetic progestins even if their effectiveness has not yet been proven in randomized controlled studies and meta-analyses. The administration of combined oral contraceptives is also an option. Especially treatment with selective serotonin reuptake inhibitors (SSRI) represent an evidence-based approach. In severe cases the administration of gonadotropin releasing hormone (GnRH) agonists with add back treatment can also be considered. In the field of affective disorders premenstrual syndromes represent clinically relevant differential diagnoses and comorbidities, which confront the treating physician with particular clinical challenges. Therefore, this literature review gives the readership a clinical orientation for dealing with these disorders.

O-312 Does infertility relate to Human Leucocyte Antigen similarity? – a genetic analysis based on 609 couples

Study question

Do infertile couples differ from the average population in Human Leukocyte Antigen (HLA) similarity?

Summary answer

Infertile couples share a significantly higher number of genes than expected by chance in four out of six HLA loci.

What is known already

HLA genes encode the peptides for the formation of the innate immune system and are highly polymorphic. To allow increased variability of the innate immune system for the offspring, it is necessary that the parental alleles of the HLA complex are dissimilar. In animal studies, such mechanisms have been shown to play a role in mate choice. While some large studies show that humans in Western cultures do not engage in HLA-based mate choice, it has also long been hypothesized that a couple's fertility and pregnancy outcome is influenced by the degree of HLA similarity.

Study design, size, duration

A multicenter study including a total number of 609 couples was performed between May 2020 and November 2021 at a private fertility center and a department of reproductive medicine of a university clinic. All couples were diagnosed with primary infertility prior to assisted reproductive techniques. Buccal swab samples were provided by both partners to determine HLA profiles.

Participants/materials, setting, methods

Primary infertile couples (mean age women: 34.35 years, men: 37.59 years) were recruited before undergoing IVF or ICSI therapy. Couples with former pregnancies, tubal factor, azoospermia or donor therapies were excluded. Six different HLA genes (HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1) were analysed using next-generation sequencing. Subsequently the number of HLA similarities was determined per couple. Comparison against chance level was performed using a random permutation approach with 100,000 repetitions.

Main results and the role of chance

Our analysis revealed a higher degree of HLA similarity in infertile couples, than expected by chance, for the loci HLA-C, -DPB1, -DRB1 and HLA-DQB1, but not for the loci HLA-A and HLA-B. A priori power analysis was performed to statistically ensure a small effect size at a �  = 0.05 ������������ 1 − �  = 0.95 and resulted in a number of 536 couples.

Limitations, reasons for caution

Conclusions are limited due to the inclusion of predominantly Caucasian couples.

Wider implications of the findings

This study adds new evidence to former publications with small study groups. HLA similarities may be a contributing factor to primary infertility. Further on, we will examine whether HLA similarities relate to success rates of infertility treatment and outcome of pregnancies.

Trial registration number

not applicable

Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part I: Indications for fertility preservation

Purpose

Most guidelines about fertility preservation are predominantly focused on scientific evidence, but are less practically orientated. Therefore, practically oriented recommendations are needed to support the clinician in daily practice.

Methods

A selective literature search was performed based on the clinical and scientific experience of the authors, focussing on the most relevant diseases and gynaecological cancers. This article (Part I) provides information on topics that are essential for the fertility preservation indication, such as disease prognosis, disease therapy and its associated risks to fertility, recommending disease-specific fertility preservation measures. Part II specifically focusses on fertility preservation techniques.

Results

In breast cancer patients, fertility preservation such as ovarian tissue and oocyte cryopreservation is especially recommended in low-stage cancer and in women < 35 years of age. In Hodgkin’s lymphoma, the indication is mainly based on the chemotherapy regime as some therapies have very low, others very high gonadotoxicity. In borderline ovarian tumours, preservation of fertility usually is achieved through fertility sparing surgery, ovarian stimulation may also be considered. In cervical cancer, endometrial cancer, rheumatic diseases and other malignancies such as Ewing sarcoma, colorectal carcinoma, non-Hodgkin lymphoma, leukaemia etc., several other factors must be considered to enable an individual, stage-dependent decision.

Conclusion

The decision for or against fertility preservation depends on the prognosis, the risks to fertility and individual factors such as prospective family planning.

Natural conception rates in subfertile couples following fertility awareness training

PURPOSE

To analyze cumulative pregnancy rates of subfertile couples after fertility awareness training.

METHODS

A prospective observational cohort study followed 187 subfertile women, who had received training in self-observation of the fertile phase of the menstrual cycle with the Sensiplan method, for 8 months. The women, aged 21-47 years, had attempted to become pregnant for 3.5 years on average (range 1-8 years) before study entry. Amenorrhea, known tubal occlusion and severe male factor had been excluded. An additional seven women, who had initially been recruited, became pregnant during the cycle immediately prior to Sensiplan training: this is taken to be the spontaneous pregnancy rate per cycle in the cohort in the absence of fertility awareness training.

RESULTS

The cumulative pregnancy rate of subfertile couples after fertility awareness training was 38% (95% CI 27-49%; 58 pregnancies) after eight observation months, which is significantly higher than the estimated basic pregnancy rate of 21.6% in untrained couples in the same cohort. For couples who had been seeking to become pregnant for 1-2 years, the pregnancy rate increased to 56% after 8 months. A female age above 35 (cumulative pregnancy rate 25%, p = 0.06), couples who had attempted to become pregnant for more than 2 years (cumulative pregnancy rate 17%, p < 0.01), all significantly reduce the chances of conceiving naturally at some point.

CONCLUSIONS

Training women to identify their fertile window in the menstrual cycle seems to be a reasonable first-line therapy in the management of subfertility.

Avoiding OHSS: Controlled Ovarian Low-Dose Stimulation in Women with PCOS

The polycystic ovary syndrome is a common endocrine disorder which influences outcome and potential risks involved with controlled ovarian stimulation for artificial reproductive techniques (ART). Concrete practical recommendations for the dosage of gonadotropins, the preferred protocol and preventive methods to avoid ovarian hyperstimulation syndrome (OHSS) are lacking. We present retrospective data of 235 individually calculated gonadotropin low-dose stimulations for ART in a single center from 2012 to 2014. Clinical data and outcome parameter of patients diagnosed with PCOS according to Rotterdam criteria (n = 39) were compared with patients without PCOS (n = 196). The starting dose of gonadotropins was individually calculated depending on patients' age, BMI, ovarian reserve, ovarian response in previous cycles, and diagnostic criteria of PCOS. Mean age and duration of infertility did not differ between the groups, whereas mean BMI (p = 0.007) and AMH (p < 0.001) were higher in the PCOS-group. A lower mean FSH-starting and maximum dose was administered to women with PCOS (p < 0.001). The biochemical pregnancy rate of 42.4 % and the clinical pregnancy rate of 32.2 % for PCOS-patients did not differ from those of the control group (42.2 % and 34.4 % respectively). Neither mild, nor moderate or severe manifestation of OHSS occurred significantly more often in patients with PCOS. Our study supports the use of a calculated low-dose FSH-stimulation strategy in ART for patients with PCOS. Further randomized clinical trials should confirm this strategy and lead to define individual risk factors for OHSS, which can be used for recommendation of safer ART-techniques like in vitro maturation.

[Prenatal care in Germany]

Prenatal care in Germany is based on a nationwide standardized program of care for pregnant women. Besides support and health counseling, it comprises prevention or early detection of diseases or unfavorable circumstances with risks for mother and child. Prenatal care is regulated by law and structured by directives and standard procedures in maternity guidelines (Mutterschafts-Richtlinien). This includes information and counseling of future mothers on offers of psychosocial and medical assistance in normal pregnancies as well as in unplanned or unwanted pregnancies. Further aspects are clinical examinations and risk determinations for genetic variations or direct genetic analysis. During pregnancy, medical history, clinical examination, and blood testing are part of the sophisticated program, which includes at least three standardized sonographic examinations at 10, 20, and 30 weeks of gestation. The maternity passport allows a pregnant woman to carry the most relevant information on her pregnancy and her personal risks with her. For 45 years now, women in Germany are used to carrying their Mutterpass. Societal changes have influenced the central goals of maternity care: In the beginning, the mortality of mother and child had to be reduced. Today, maternal morbidity and impaired development of the child are the center of interest, with expansion to familial satisfaction. The reduction in the mortality and morbidity of both the mother and the child during pregnancy, delivery, and postpartum can be attributed to prenatal care. Thus, investment in a program of nationwide structured prenatal care seems to be worthwhile-despite the lack of evidence concerning its effectiveness.

Endometriosis - A Chameleon: Patients' Perception of Clinical Symptoms, Treatment Strategies and Their Impact on Symptoms

Introduction: Endometriosis is a chronic disease with differing clinical presentations. Treatment strategies depend mainly on clinical presentation and patient lifestyle. In women newly diagnosed with endometriosis, it is often difficult to understand the pathophysiologic origin, the potential individual impairment due to disease and the different treatment options. Compliance with the selected treatment is therefore often not optimal. Material and Methods: In a descriptive study, data of 51 women with endometriosis (mean age 36.2 years ± 11.3) were analyzed according to the predominant clinical presentation: asymptomatic disease, disease with typical symptoms, ovarian cysts or infertility. Results: More than 50 % of patients ascribed a therapeutic benefit to surgical intervention or endocrine treatment, especially women in the subgroup with dysmenorrhea who received combined treatment. It should be noted that in the group of women facing infertility, more than half stated that they could not decide on the value of diagnostic and therapeutic reproductive medicine. Nevertheless, more than half of the women in this group became pregnant within two years after the initial diagnosis. Discussion: When deciding on the best treatment strategy for endometriosis, it is important to take account of potential pain and infertility. Women's perception of endometriosis will vary depending on their symptoms, the time of diagnosis and their lifestyle. Offering continuous information on clinical aspects and manifestations of the disease may improve treatment outcomes. Personalized counseling is an essential part of the clinical management of the disease.

Successful controlled ovarian stimulation despite elevated hCG levels after first-trimester abortion in the context of fertility preservation

Fertility preservation prior to gonadotoxic chemotherapy by cryopreservation of the ovarian tissue and controlled ovarian stimulation can be effective immediately after induced abortion in the first trimenon. In a reproductive endocrinology and infertility unit of a tertiary care university-based medical centre (University Hospital of Heidelberg) a 37-year-old women with breast cancer was counseled for fertility preservation. Cryopreservation of ovarian tissue, followed by ovarian stimulation for planned intracytoplasmatic sperm injection (ICSI), transvaginal oocyte aspiration and cryopreservation of fertilized eggs was performed in spite of persistently elevated human chorionic gonadotropin (hCG)-levels after induced abortion. Twenty-four fertilized oocytes with a fertilization rate of 92% were cryopreserved. Ovarian stimulation and oocyte cryopreservation can be successfully performed with good results immediately after miscarriage, despite persistent high hCG-levels.

Differential regulation of phospholipase A2 in human leukemia cells by the etherphospholipid analogue hexadecylphosphocholine

Hexadecylphosphocholine (HePC) is the main representative of a new group of antineoplastic agents, the alkylphosphocholines, which were originally derived from cytotoxic etherlysophospholipids. HePC shows antiproliferative action against a whole variety of tumor cells and tumors in vitro and in vivo. Furthermore, it also induces differentiation in some hematologic cell lines and prevents invasive growth of neoplastic cells in vitro. To date, the precise molecular mechanisms mediating the biological effects of HePC have not been identified yet. As etherlysophospholipids seem to inhibit some pathways of lipid-dependent intracellular signalling, similar effects may be relevant for HePC. We therefore investigated the influence of HePC on phospholipase A2 (PLA2-EC 3.1.1) in the human leukemia cell line U 937. HePC seems to inhibit enzyme activity independently of protein kinase C (PKC) in differentiated U 937 cells stimulated by tumor necrosis factor alpha (TNFalpha). Inhibition of purified secretory PLA2 from snake venom (EC 3.1.1.4) in vitro shows characteristics of a non-competitive mode. In contrast, HePC leads to an enhancement of PLA2 activity in immature cells which cannot be explained by changes in membrane composition. Our data suggest that PLA, inhibition is most probably not the mechanism by which HePC mediates its antiproliferative effects.

Hexadecylphosphocholine inhibits phosphatidylinositol and phosphatidylcholine phospholipase C in human leukemia cells

Hexadecylphosphocholine (HePC) is the main representative of a new group of antineoplastic agents, the alkylphosphocholines. Besides remarkable antiproliferative properties on tumor cells in vitro and in vivo, HePC also induces differentiation and inhibits invasive growth of neoplastic cells. Knowledge of the molecular mechanisms by which HePC mediates its biological effects is poor. The observation that analogous substances, the alkyllysophospholipids, may interfere with lipid dependent intracellular signaling suggested similar mechanisms for HePC. We therefore investigated the effects of HePC on phospholipase C (PLC) activation in intact human leukemia cell lines. HePC inhibited fMLP induced phosphatidylinositol-specific PLC activation in HL60 cells and TNF-alpha induced activation of phosphatidylcholine-specific PLC in U937 cells. HePC reduced the number of TNF-alpha receptors on the surface of U937 cells by about 60%. Receptors for fMLP were not affected. Inhibition of TNF-alpha induced PC-PLC activation, however, seemed to be regulated at a post-receptor level as PLC inhibition and receptor occupancy did not correlate.