Reproductive Outcome After GnRH Agonist Triggering With Co-Administration of 1500 IU hCG on the Day of Oocyte Retrieval in High Responders: A Long-Term Retrospective Cohort Study.

While triggering oocyte maturation with GnRH agonist (GnRHa) seems to be safe and effective in terms of the risk of developing OHSS and the number of metaphase II oocytes, it nevertheless results in luteal phase deficiency. To date, strategies have been developed in order to rescue defective luteal phase of GnRHa triggered cycles. Our study aimed to assess the reproductive outcome of GnRHa triggered cycles combined with modified luteal support (1500 IU hCG at the day of oocyte retrieval) in women with high ovarian response and to compare the outcome with hCG triggered cycles in GnRH antagonist IVF-ICSI procedures. A retrospective cohort database review of the results of GnRH antagonist IVF-ICSI cycles was conducted at a tertiary-care IVF center in Ljubljana, Slovenia. A total of 6126 cycles, performed from January 1, 2014, to December 31, 2020, were included in the final analysis. Final oocyte maturation was performed with either 5000, 6500, or 10,000 IU hCG (women with normal ovarian response) or 0.6 mg GnRHa (buserelin), supplemented with 1500 IU hCG on the day of oocyte retrieval (in women with high ovarian response). In cases of excessive ovarian response and/or high risk of OHSS luteal support was not introduced and all good quality blastocysts were frozen. According to significant differences in patients' age and the number of oocytes in the two groups, matching by age and number of oocytes was performed. No significant differences were observed regarding pregnancy rate per embryo transfer, rate of early pregnancy loss, and livebirth rate per pregnancy between the GnRHa and hCG trigger groups, respectively. A significant difference in the number of developed embryos and blastocysts, as well as the number of frozen blastocysts, was seen in favor of the GnRHa trigger. However, the birth weight in the GnRHa trigger group was significantly lower. Conclusion: The results of our study support the use of GnRHa for final oocyte maturation in GnRH antagonist IVF cycles in women with high ovarian response. Luteal phase rescue was performed by co-administration of 1500 IU hCG on the day of oocyte retrieval and estradiol and progesterone supplementation. In our experience, such an approach results in a comparable reproductive outcome with hCG trigger group.

Poor Ovarian Response to Gonadotrophins in PCOS Women after Laparoscopic Ovarian Drilling.

Background and Objectives: Polycystic ovary syndrome (PCOS) is a major cause of anovulatory infertility, and ovulation induction is the first-line treatment. If this fails, laparoscopic ovarian drilling (LOD) is used to induce mono-ovulations. There have been implications, that LOD can cause destruction of ovarian tissue and therefore premature ovarian failure. Furthermore, unexpected poor ovarian response (POR) to gonadotrophins can occur in PCOS women after LOD. There have been reports about FSH receptor polymorphisms found in women with PCOS that are related to higher serum FSH levels and POR to gonadotrophins. Materials and Methods: In the present study, we retrospectively analyzed data of 144 infertile PCOS women that had LOD performed before IVF. Results: Thirty of included patients (20.8%) had POR (≤3 oocytes) to ovarian stimulation with gonadotrophins. Women with POR had significantly higher median levels of basal serum FSH (7.2 (interquartile range (IQR), 6.0-9.2) compared to women with normal ovarian response (6.0 (IQR, 5.0-7.4); p = 0.006). Furthermore, women with POR used a significantly higher median cumulative dose of gonadotrophins (1875 IU (IQR, 1312.5-2400) for ovarian stimulation compared to women with normal ovarian response (1600 IU (IQR, 1200-1800); p = 0.018). Conclusion: Infertile PCOS women who experience POR after LOD have significantly higher serum FSH levels compared to women with normal ovarian response after LOD. As these levels are still within the normal range, we speculate that LOD is not the cause of POR. We presume that women with PCOS and POR after LOD could have FSH-R genotypes associated with POR and higher serum FSH levels.

Transcriptome study of receptive endometrium in overweight and obese women shows important expression differences in immune response and inflammatory pathways in women who do not conceive.

Obesity and being overweight are growing worldwide health problems that also affect women of reproductive age. They impair women's fertility and are associated with lower IVF success rates. The mechanism by which increased body weight disrupts fertility has not yet been established. One possibility is that it affects the process of embryo implantation on the endometrial level. The purpose of our study was to determine the differences in enriched biological pathways in the endometrium of overweight and obese women undergoing IVF procedures. For this purpose, 14 patients (5 pregnant, 9 non-pregnant) were included in the study. Endometrial samples were obtained during the window of implantation and RNA sequencing was performed. There were no differences in general patient's and IVF cycle characteristics between pregnant and non-pregnant women. In the endometrial samples of women who did not conceive, pathways related to the immune response, inflammation, and reactive oxygen species production were over-expressed. Our findings show that the reason for implantation failure in overweight and obese women could lie in the excessive immune and inflammatory response at the endometrial level.

Cardiac Arrest and Inverted Takotsubo Cardiomyopathy Following Intramyometrial Vasopressin Injection During Myomectomy.

Vasopressin is involved in cardiovascular homeostasis that can influence coronary perfusion. It is commonly used as a local vasoconstricting agent during gynaecological procedures. We present a case of cardiac arrest and inverse Takotsubo features following intramyometrial vasopressin administration during myomectomy. The patient was successfully resuscitated and recovered completely. Cardiac presentation was compatible with inverse Takotsubo cardiomyopathy that could have been triggered by high-dose vasopressin-induced coronary vasoconstriction. The patient's cardiac function resolved with no long-term sequelae. Takotsubo cardiomyopathy usually results from an excessive catecholaminergic surge. High-dose vasopressin-induced coronary vasospasm could have been the mechanism underlying the clinical presentation in our patient. LEARNING POINTS: Local vasopressin administration during gynaecological procedures can result in rare but severe cardiovascular compromise.Takotsubo cardiomyopathy can result from multiple rare causes.High-dose vasopressin may cause Takotsubo cardiomyopathy features via coronary vasoconstriction.

Perinatal outcome of in vitro fertilization pregnancies in women with polycystic ovary syndrome by pregravid BMI.

OBJECTIVES: Given the adverse effects of either polycystic ovary syndrome (PCOS) or overweight/obesity, one could speculate that patients with both would fare worse than others. We sought to evaluate the relationship between pregravid BMI and pregnancy complications in PCOS patients conceived by assisted reproductive techniques (ART). METHODS: Maternal and fetal/neonatal outcomes of singleton pregnancies after assisted reproduction in women with and without PCOS were compared by pregravid body mass index (BMI, <24.9 vs. ≥25 kg/cm2). RESULTS: The study population comprised 185 with a BMI <24.9 kg/cm2 including 39 (21%) with PCOS and 146 (79%) without. We also included 84 patients with BMI ≥25 kg/cm2, involving 34 (40.5%) with PCOS and 50 (59.5%) without. PCOS (total 73 patients) was significantly more common among overweight/obese patients, OR 2.5 (95% CI 1.4, 4.4). Neonates >4,000 g were born only to the overweight/obese mothers in the PCOS group. A higher incidence of gestational diabetes, chronic hypertension, and gestational hypertension was related to pregravid overweight/obesity rather than PCOS. CONCLUSIONS: In this specific subgroup of patients conceived after assisted reproduction, pregravid BMI>25 kg/cm2 rather than PCOS itself appears to be associated with GDM and hypertensive disorders.

Effect of the oral intake of astaxanthin on semen parameters in patients with oligo-astheno-teratozoospermia: a randomized double-blind placebo-controlled trial.

BACKGROUND: Higher concentrations of seminal reactive oxygen species may be related to male infertility. Astaxanthin with high antioxidant activity can have an impact on the prevention and treatment of various health conditions, including cancer. However, efficacy studies on astaxanthin in patients with oligospermia with/without astheno- or teratozoospermia (O±A±T) have not yet been reported. Our aim was to evaluate the effect of the oral intake of astaxanthin on semen parameters. PATIENTS AND METHODS: In a randomized double-blind trial, 80 men with O±A±T were allocated to intervention with 16 mg astaxanthin orally daily or placebo. At baseline and after three months basic semen parameters, sperm deoxyribonucleic acid (DNA) fragmentation and mitochondrial membrane potential (MMP) of spermatozoa and serum follicle-stimulating hormone (FSH) value were measured. RESULTS: Analysis of the results of 72 patients completing the study (37 in the study group, 35 in the placebo group) did not show any statistically significant change, in the astaxanthin group no improvements in the total number of spermatozoa, concentration of spermatozoa, total motility of spermatozoa, morphology of spermatozoa, DNA fragmentation and mitochondrial membrane potential of spermatozoa or serum FSH were determined. In the placebo group, statistically significant changes in the total number and concentration of spermatozoa were determined. CONCLUSIONS: The oral intake of astaxanthin did not affect any semen parameters in patients with O±A±T.

Counselling before first trimester abortion and acceptability of the procedure: results from a Slovenian cross-sectional study.

Objectives: In Slovenia, first-trimester abortion is performed at the woman's request, either surgically under general anaesthesia or medically with mifepristone and misoprostol, in a public hospital. Our study aimed to evaluate pre-abortion counselling and to reveal differences in acceptability and satisfaction with the two abortion methods.Methods: A cross-sectional study was carried out at Ljubljana University Medical Centre between January and June 2015. Women requesting termination of a pregnancy up to 10 weeks' gestation voluntarily completed an anonymous questionnaire after the procedure and were divided into a surgical and a medical abortion group.Results: Of the 266 women who were invited to take part, 229 accepted; 16.6% chose a surgical abortion, 83.4% a medical abortion. The most frequent reason cited for requesting an abortion was economic/housing problems. Most women who chose a surgical abortion did so because it was faster, whereas most women who chose a medical abortion did so on the advice of a primary care gynaecologist. Women choosing a surgical abortion had more previous pregnancies and presented with a higher gestational age pregnancy. The choice of method was not related to the woman's age. There were no differences in acceptability of the two procedures. Pain during the procedure was, however, more severe in the medical abortion group (p = .026), along with bleeding, nausea and chills; there were no differences in severity of vomiting, diarrhoea, dizziness or headache between the groups. Women in the surgical abortion group reported higher satisfaction with the method (p < .001). The study revealed a low frequency of pre-abortion contraceptive counselling.Conclusion: The most common reason given for choosing a surgical abortion was the speed of the procedure; for a medical abortion, it was on the advice of a primary care gynaecologist. Satisfaction was higher with the surgical abortion method. There were no differences in general acceptability of the methods.

Independent factors influencing large-for-gestation birth weight in singletons born after in vitro fertilization.

PURPOSE: Higher risk for birth of singletons being large for gestational age (LGA) has been revealed after in vitro fertilization (IVF) frozen-thawed embryo-transfer (FET). This phenomenon is now being investigated, since there is a speculation that these neonates could suffer from underlying epigenetic disturbances. The aim of the study was to expose independent LGA risk factors and to identify those connected to the IVF techniques. METHODS: Altogether, 4508 singleton pregnancies and births were included in the cohort case-matched study. Two hundred eleven singleton pregnancies and births after FET and 916 after fresh embryo transfer (ET) were included into two study groups. The IVF procedures were performed at the University Medical Centre Ljubljana between 2004 and 2011. For each IVF pregnancy, three matched consecutive controls after natural conception were included. Using logistic regression models, we observed LGA connection to maternal parameters (smoking, hypertension, parity, BMI, gestational diabetes, IVF conception, FET, double ET, and ICSI procedure). RESULTS: Singletons born after FET had a significantly higher risk for being LGA (p = 0.032; OR 1.697; 95 % CI 1.047-2.752). BMI 25-30 was a significant independent risk factor for LGA in the IVF groups (FET p = 0.041, OR 2.460, 95 % CI 1.030-5.857 and fresh ET p = 0.003; OR 2.188, 95 % CI 1.297-3.691). ICSI and double ET had no significant effect on LGA occurrence. CONCLUSIONS: Besides maternal BMI, FET is a significant independent LGA risk factor in IVF patients. Other observed factors (smoking, hypertension, multiparity, GDM, ICSI procedure, or number of embryos transferred) do not influence LGA risk significantly.

Differences in cumulus cells gene expression between modified natural and stimulated in vitro fertilization cycles.

PURPOSE: The aim of our study was to determine whether there are any differences in the cumulus cell gene expression profile of mature oocytes derived from modified natural IVF and controlled ovarian hyperstimulation cycles and if these changes could help us understand why modified natural IVF has lower success rates. METHODS: Cumulus cells surrounding mature oocytes that developed to morulae or blastocysts on day 5 after oocyte retrieval were submitted to microarray analysis. The obtained data were then validated using quantitative real-time PCR. RESULTS: There were 66 differentially expressed genes between cumulus cells of modified natural IVF and controlled ovarian hyperstimulation cycles. Gene ontology analysis revealed the oxidation-reduction process, glutathione metabolic process, xenobiotic metabolic process and gene expression were significantly enriched biological processes in MNIVF cycles. Among differentially expressed genes we observed a large group of small nucleolar RNA's whose role in folliculogenesis has not yet been established. CONCLUSION: The increased expression of genes involved in the oxidation-reduction process probably points to hypoxic conditions in modified natural IVF cycles. This finding opens up new perspectives for the establishment of the potential role that oxidation-reduction processes have in determining success rates of modified natural IVF.

Comparison of clinical and analytical performance of the Abbott Realtime High Risk HPV test to the performance of hybrid capture 2 in population-based cervical cancer screening.

The clinical performance of the Abbott RealTime High Risk HPV (human papillomavirus) test (RealTime) and that of the Hybrid Capture 2 HPV DNA test (hc2) were prospectively compared in the population-based cervical cancer screening setting. In women >30 years old (n = 3,129), the clinical sensitivity of RealTime for detection of cervical intraepithelial neoplasia of grade 2 (CIN2) or worse (38 cases) and its clinical specificity for lesions of less than CIN2 (3,091 controls) were 100% and 93.3%, respectively, and those of hc2 were 97.4% and 91.8%, respectively. A noninferiority score test showed that the clinical specificity (P < 0.0001) and clinical sensitivity (P = 0.011) of RealTime were noninferior to those of hc2 at the recommended thresholds of 98% and 90%. In the total study population (women 20 to 64 years old; n = 4,432; 57 cases, 4,375 controls), the clinical sensitivity and specificity of RealTime were 98.2% and 89.5%, and those of hc2 were 94.7% and 87.7%, respectively. The analytical sensitivity and analytical specificity of RealTime in detecting targeted HPV types evaluated with the largest sample collection to date (4,479 samples) were 94.8% and 99.8%, and those of hc2 were 93.4% and 97.8%, respectively. Excellent analytical agreement between the two assays was obtained (kappa value, 0.84), while the analytical accuracy of RealTime was significantly higher than that of hc2. RealTime demonstrated high intralaboratory reproducibility and interlaboratory agreement with 500 samples retested 61 to 226 days after initial testing in two different laboratories. RealTime can be considered to be a reliable and robust HPV assay clinically comparable to hc2 for the detection of CIN2+ lesions in a population-based cervical cancer screening setting.

Expression of 11ß-hydroxysteroid dehydrogenase type 1 in visceral and subcutaneous adipose tissues of patients with polycystic ovary syndrome is associated with adiposity.

Polycystic ovary syndrome (PCOS) is characterized by insulin resistance (IR) and central obesity. The impact of adipose tissue cortisol reactivation by 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) on markers of obesity and IR was assessed in PCOS patients. Eighty-five PCOS patients and 43 controls were enrolled for subcutaneous adipose tissue biopsy; 25/85 patients and 29/43 controls underwent also visceral adipose tissue biopsy. HSD11B1 gene expression and expression of lipid metabolism genes were measured in subcutaneous and visceral adipose tissues. Anthropometric and biochemical markers of IR and PCOS were also assessed. HSD11B1 expression in visceral and subcutaneous adipose tissue was increased in PCOS patients compared to controls (p<0.05). After BMI adjustment, the difference was no longer significant. In PCOS patients, visceral HSD11B1 expression correlated positively with waist circumference (p=0.001), BMI (p=0.002), plasma insulin (p<0.05), systolic blood pressure (p=0.003), and lipoprotein lipase (LPL), hormone-sensitive lipase (LIPE) and peroxisome-proliferator activated receptor γ gene expression. Subcutaneous HSD11B1 expression correlated positively with BMI, waist circumference (p<0.001 for both) and HOMA-IR (p=0.003), and negatively with LPL, LIPE, adiponectin and glucose transporter GLUT4 gene expression. HSD11B1 expression in both depots showed a negative correlation with plasma HDL-cholesterol (p<0.03) and a positive one with C-reactive protein (p<0.001). In multiple regression analysis, HSD11B1 expression in visceral adipose tissue was most prominently associated with waist circumference, and that in subcutaneous adipose tissue with BMI (p<0.001 for both). Our results show that PCOS is not associated with increased HSD11B1 expression once adiposity is controlled for. Increased expression of this gene correlates with markers of adiposity and predicts IR and an unfavorable metabolic profile, independently of PCOS.

Serum and follicular endocrine profile is different in modified natural cycles than in cycles stimulated with gonadotropin and gonadotropin-releasing hormone antagonist.

This study compared serum and follicular anti-müllerian hormone, LH, FSH, E(2), and P concentrations in modified natural cycles and controlled ovarian hyperstimulation cycles to analyze their effect on oocyte and embryo quality and implantation. Follicular anti-müllerian hormone, FSH, E(2), and P concentrations had no effect on embryo quality, whereas high serum and follicular LH concentrations in natural cycles modified only with hCG did not compromise oocyte and embryo quality but might have a negative effect on implantation.

Distribution of human papillomavirus genotypes in women with cervical cancer in Slovenia.

OBJECTIVE: The purpose of the present study was to establish the distribution of human papillomavirus (HPV) genotypes in a representative population of women with cervical cancer in Slovenia in order to contribute to the lacking data on HPV in cervical cancer and to assess the potential local benefit of future prophylactic HPV vaccination. STUDY DESIGN: A total of 284 samples of cervical cancer were analyzed including archival samples, cervical scrapes and fresh tissue samples. Polymerase chain reaction with GP5+/GP6+ primers was performed in all samples for HPV deoxyribonucleic acid (DNA) detection. All GP5+/GP6+ negative samples were additionally tested using CPI/CPIIg primers and INNO-LiPA HPV genotyping assay. RESULTS: After exclusion of 6 samples with unsuccessful amplification of beta-globin gene, 262 of 278 cervical cancer samples (94.2%) were HPV DNA positive. HPV genotypes found in the decreasing order of frequency were: HPV 16 (64.9%), HPV 18 (12.2%), HPV 33 (4.7%), HPV 45 (4.1%), followed by HPV 31, 51, 58, 59, 35, 52, 73 and 82 (3.5-0.2%). HPV positive samples were more frequent among squamous cell carcinomas than among adenocarcinomas/adenosquamous carcinomas (95.8% versus 85.5%; P=0.003). HPV 16 was more frequently found in squamous cell carcinomas than in adenocarcinomas/adenosquamous carcinomas (69.9% versus 37.5%; P<0.001), while the opposite was true for HPV 18 (6% versus 41.7%; P<0.001). CONCLUSION: Prophylactic HPV vaccination with currently available vaccines could prevent up to 77.1% of cervical cancer in Slovenia, which is caused by HPV 16 or HPV 18.

Effect of apoptosis and reactive oxygen species production in human granulosa cells on oocyte fertilization and blastocyst development.

PURPOSE: The aim was to establish the impact of human granulosa cell apoptosis and reactive oxygen species (ROS) production on fertilization competence of the oocyte, embryo developmental stage and implantation rate. METHODS: Thirty women undergoing IVF-ET for tubal factor infertility were included; GnRH antagonists and gonadotrophins were used for ovarian stimulation. Granulosa cells were isolated from each aspirated follicle using gradient centrifugation. Apoptosis was studied by flow cytometry using annexin V and propidium iodide. ROS production was studied with hydroethidine staining and analyzed by flow cytometry. RESULTS: There were no differences in characteristics of granulosa cells between the follicles with fertilized and non-fertilized oocytes. The analyzed characteristics of granulosa cells in corresponding follicles had no effect on embryo developmental stage on day 5. The percentage of ROS producing granulosa cells was lower in the follicles giving rise to blastocysts that resulted in implantation compared to those that did not (39.9% versus 69.9%, P = 0.031). CONCLUSIONS: Apoptosis and ROS production in granulosa cells have no significant impact on fertilization and do not correlate with the development of blastocysts. An increased percentage of ROS producing granulosa cells results in fewer oocytes retrieved and diminishes implantation rate.

[Prevalence of human papillomavirus infection in Slovenian women with repeated Pap II smears]. / Prevalencija infekcije humanim papilomavirusima kod slovenackih zena sa ponavljajucim Pap II rezultatom.

In the detection of precancerous lesions the cervical Papanicolaou smear screening is used in Slovenia and worldwide. Management of patients with repeat abnormal smears (Pap II) represents a great and complex clinical and public health problem. Repeated cytologic examinations are routine procedure in many countries, also in Slovenia, although the sensitivity of Pap smear testing in the detection of cervical intraepithelial neoplasia (CIN) II and III is relatively low. In cases of abnormal squamous cells and mildly dyskaryotic cells the presence of infections with high-risk HPV genotypes is being increasingly used as a complementary method to Pap smear testing. In the study we enrolled 148 cervical samples of women who within two years had three subsequent Pap II smears (abnormal squamous cells or mildly dyskaryotic cells). The prevalence of HPV infections was determined using three molecular tests: Hybrid Capture 2 (hc2) test and two variants of polymerase chain reaction (PCR-PGMY11/PGMY09 and PCR-CPI/CPIIG). HPV infection was detected in 25.7% of women. In women aged < or = 30 years a statistically significant higher prevalence of HPV infections was found (37.8%) than in women aged > 30 years (20.4%). Our findings show that repeat Pap smear as the method of follow-up and detection of precancerous lesions of the observed population do not provide relevant results due to low prevalence of HPV infections in Slovenia, which indirectly indicates low sensitivity and specificity of Pap smear testing. In the detection of HPV infections, molecular methods are thus sensitive screening tests to be used complementary to cytologic tests in women with abnormal squamous cells and mildly dyskaryotic cells.