Ontogeny of the estrogen receptor in the human fetal uterus.

The role of estrogen and its receptor in the development of the human fetal reproductive tract is unknown, but it may be involved in uterine maturation. In mouse and guinea pig uteri, studies have identified estrogen receptor (ER) protein during the fetal period. In the human, there are no published data regarding the ER during fetal uterine development. The purpose of this study was to investigate the pattern of ER gene and protein expression in the human fetal uterus. Uteri were obtained from abortuses (n = 43; range, 10-24 weeks gestation) of women undergoing elective termination of pregnancy. Reverse transcription-polymerase chain reaction was performed with whole uteri as well as cultured fetal uterine stroma-like cells (n = 15). Immunolocalization studies were performed on frozen uterine sections using the H222 monoclonal antibody (Abbott Laboratories) directed against the ER (n = 20). Western blotting was used to confirm the identity of the ER protein (n = 3). Ligand binding studies were performed using radiolabeled [3H]estradiol (n = 5). Using reverse transcription-polymerase chain reaction, a 263-basepair DNA fragment corresponding to the ER was consistently present in uteri after 15 weeks gestation. By immunohistochemistry, the ER is expressed within the uterine mesenchyme in a discrete cylindrical pattern at the interface of the differentiating endometrial stroma and myometrium. Western blotting confirmed the presence of a protein of an apparent mol wt of 66 kilodaltons, the predicted size of the ER. Ligand binding studies for the ER gave a value less than 8 fmol/mg protein. In summary, the ER gene is expressed in the uterus beginning in the early second trimester during fetal development. ER protein is localized in a discrete cylindrical pattern within the developing uterus. The highly specific location of the ER protein together with the messenger ribonucleic acid data suggest a role for the ER in differentiation of the primitive uterine mesenchyme into stromal and myometrial compartments.

Human fetal uterine cells: culture, characterization, and analysis of growth factor receptor gene expression.

Peptide growth factors are postulated to have a role in uterine maturation during organogenesis. The purpose of this investigation was to establish a model to study human fetal uterine development. To that end, we describe an in vitro culture system and have characterized the cell types present during the period of uterine maturation. In addition, we evaluated the pattern of growth factor receptor gene expression in these cultured cells. Uteri were dissected from human first and second trimester fetuses (n = 20). Characterization studies were performed against three intermediate filament proteins, cytokeratin, vimentin, and desmin, and against a fibroblast-associated cell surface antigen. Ribonucleic acid was extracted from pure stroma-like cultures, and reverse transcription-polymerase chain reaction (RT-PCR) was used to amplify sequences specific for the epidermal growth factor receptor (EGF-R), fibroblast growth factor receptor (FGF-R), and the insulin receptor (I-R). Two predominant cell types were identified in the cultured fetal tissue: stroma-like cells and clusters of uterine epithelium. Immunofluorescent studies demonstrated positive expression of cytokeratin, vimentin, and a fibroblast-associated antigen in the fetal stroma-like cells, in contrast to adult stromal cells, which consistently expressed only vimentin. Using RT-PCR, the uterine cells were positive for the EGF-R, two forms of the FGF-R, and two forms of the I-R. In conclusion, we provide the first report of a human fetal cell culture system. Characterization studies of fetal stroma-like cells demonstrate immunoreactivity to vimentin, cytokeratin, and a fibroblast antigen, in contrast to the adult stromal cell, which consistently expressed only vimentin. Using RT-PCR, we found that messenger ribonucleic acids for the EGF-R and two forms of both the FGF-R and I-R are expressed. This model may be useful for studying the dynamics of human uterine development in vitro.

The reproducibility of the postcoital test: a prospective study.

OBJECTIVE: To determine the reproducibility of the postcoital test among trained observers. METHODS: Twenty-eight infertile patients presenting to the Brigham and Women's Hospital over a 1-year period were recruited for the study. After a standardized collection of specimens for the postcoital test, four fellowship-trained reproductive endocrinologists evaluated six postcoital test characteristics and gave their overall impression of the test. Each observer was blinded to the patients' identities and clinical histories as well as to the ratings of the other observers. The six characteristics included an assessment of the cervical mucus by ferning, cellularity, spinnbarkeit, and consistency, and of sperm by total count per high power field and percent motility. Scoring was adapted from World Health Organization (WHO) criteria for semen-cervical mucus interaction. Statistical analysis included the kappa statistic to determine agreement among observers for postcoital test characteristics and the Mantel-Haenszel test to determine the association between overall impression and the other test characteristics. RESULTS: Agreement among the four observers was best for sperm number and motility (39% of cases) and worst for cellularity, spinnbarkeit, and overall test impression (11, 14, and 14% of cases, respectively). The kappa statistic ranged from a low of 0.13 for cellularity, demonstrating poor reliability (95% confidence interval [CI] 0.03-0.23), to a high of 0.51 for sperm number, demonstrating fair reliability (95% CI 0.41-0.60). Only sperm number and percent motility were significantly associated with the overall impression (P < .001). CONCLUSIONS: In a blinded study, the characteristics of the postcoital test were found to have poor to fair reproducibility among trained observers using a standardized WHO scoring system. The observers' overall impressions of test quality correlated with sperm number and motility only. We question the validity of the postcoital test as a diagnostic tool in the evaluation of infertility.

Practice patterns among reproductive endocrinologists: further aspects of the infertility evaluation.

OBJECTIVE: To characterize infertility testing in clinical practice. DESIGN: A cross-sectional study assessing differences in clinical practice based on identifiable practitioner variables, such as gender, age, and type of practice. SETTING: A population-based national survey. PARTICIPANT(S): U.S. board-certified reproductive endocrinologists. MAIN OUTCOME MEASURE(S): Physicians' preferences in the interpretation and performance of the semen analysis, postcoital test (PCT), hysterosalpingography (HSG), laparoscopy, immunologic testing, hamster egg penetration assay, and screening for the luteinized unruptured follicle syndrome. RESULT(S): Younger physicians more often favor the use of Kruger strict morphology for the semen analysis, rely on urine or blood LH measurements for the timing of the PCT, and use a less strict cutoff for the definition of a normal PCT. About half of all physicians use antibiotic prophylaxis before HSG and 90% rely on water-soluble dye for imaging. Eighty percent of physicians in western U.S. practices schedule diagnostic laparoscopy during the follicular phase compared with 50% of their East Coast colleagues. Two thirds of physicians would conduct immunologic testing for infertility, but most would not use the hamster egg penetration test or screen for the luteinizing unruptured follicule syndrome. CONCLUSION(S): Although most board-certified reproductive endocrinologists agree on the major areas of the performance of infertility testing, there was significant variability in the details of the performance of most testing, especially with respect to physician age and geographic location.

Practice patterns among reproductive endocrinologists: the infertility evaluation.

OBJECTIVE: To determine how board-certified reproductive endocrinologists vary in their approach to the clinical tests performed on the infertile couple. DESIGN: A cross-sectional study to assess differences in the approach to evaluating the infertile couple. SETTING: A population-based national survey. PARTICIPANT(S): United States board-certified reproductive endocrinologists. MAIN OUTCOME MEASURE(S): The frequency of clinical tests and evaluation procedures by physician age, sex, size and setting of practice, institutional affiliation, and geographic location. RESULT(S): The overall response rate was 84%. Although the majority of practitioners routinely order a semen analysis (99.9%), an assessment of ovulation (98%), a hysterosalpingogram, (HSG; 96%), laparoscopy (89%), and a postcoital test (PCT, 79%), there was less agreement regarding hormonal testing (range, 22% [LH] to 66% [PRL]), use of pelvic ultrasounds (55%), hysteroscopy (53%), cervical cultures (range, 24% to 54%), and antisperm antibody testing (24%). Compared with male colleagues, female physicians order two to three times more cervical cultures and endometrial biopsies. Serum hormonal testing was two to three times more commonly ordered by younger (< 40 years) compared with older physicians, and physicians in private practice twice as frequently ordered hormonal testing, cervical cultures, PCTs, and antisperm antibody studies compared with their academic-affiliated colleagues. Western U.S. physicians order hormonal tests and cervical cultures 50% less often than their midwest and eastern counterparts. CONCLUSION(S): Trained specialists rely heavily on five "traditional" infertility tests: semen analysis, an assessment of ovulation, HSG, laparoscopy, and PCT. With regard to additional modes of testing, there is marked variability by physician sex, age, type of practice, and geographic location.

Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis.

OBJECTIVE: To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET. DESIGN: Case reports describing two patients. SETTING: Tertiary care, assisted reproduction practice. PATIENT(S): Two patients with cervical stenosis and a history of multiple failed cycles of IVF. INTERVENTION(S): Laminaria tents were placed intracervically before ET. MAIN OUTCOME MEASURE(S): Presence of a gestational sac and fetal heartbeat on ultrasound. RESULT(S): Successful clinical pregnancies occurred in both patients after laminaria placement and ET. CONCLUSION(S): Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis.

The predictive value of discriminatory human chorionic gonadotropin levels in the diagnosis of implantation outcome in in vitro fertilization cycles.

OBJECTIVE: To determine if early serum hCG levels are predictive of implantation outcome in patients undergoing IVF-ET. DESIGN: Retrospective study of IVF cycles using receiver operator characteristic curve (ROC) analysis. SETTING: Tertiary-care, university hospital-affiliated IVF program. PATIENTS: Three hundred fifty-one conception cycles were studied. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Implantation failure, defined as chemical pregnancies, ectopic gestations, and first trimester abortions, or implantation success, defined as delivered singleton and multiple pregnancies, and second trimester abortions. RESULTS: For each post-ET day 14 to 20, mean hCG levels of the implantation success group were significantly greater than implantation failure outcomes (P < 0.0001). Using ROC curve analysis, hCG cutoff values for each post-ET day were calculated for optimal discrimination of implantation failure from implantation success cycles. A patient with an hCG measurement greater than the calculated cutoff value had a > or = 90% chance of having an implantation success after IVF-ET. CONCLUSION: Discriminatory hCG cutoff values may be useful in predicting implantation outcome in IVF-ET cycles and may guide clinicians in identifying those pregnancies at risk for adverse outcomes and instituting more intensive surveillance in this population. This information also may be useful in providing counseling to IVF patients regarding pregnancy prognosis and result in cost savings.

Observer variability in the diagnosis and management of the hysterosalpingogram.

OBJECTIVE: To determine the reproducibility of hysterosalpingogram (HSG) interpretation and clinical management recommendations among trained observers. DESIGN: Fifty HSG films were distributed to five fertility practitioners with a mean of 20 years clinical experience. Each observer evaluated components of uterine and tubal status and provided clinical recommendations for hysteroscopy and laparoscopy. SETTING: University hospital-affiliated reproductive endocrine practice. INTERVENTION(S): None MAIN OUTCOME MEASURE(s): The level of agreement among observers for each uterine and tubal category as determined by the kappa(kappa) statistic. Determinants of clinical recommendation for further diagnostic studies were assessed. RESULT(S): The level of agreement between observers as determined by kappa ranged from 0.645 in the hydrosalpinx category, indicating fair reliability, to 0.111 for pelvic adhesions, indicating poor reliability. The composite kappa for uterine status was 0.345 whereas the composite kappa for tubal status was 0.430. Agreement among observers concerning management showed marginal reproducibility with a kappa of 0.261. Overall, more than one abnormality of either the cavity or the fallopian tubes led to a diagnostic recommendation for further workup in > or = 90% of cases. CONCLUSION(S): In a group of five experienced clinicians, there was considerable variability in the interpretation as well as the clinical management of the HSG. Physicians caring for infertile couples should be aware of this discrepancy and should, if possible, review carefully both the original films as well as the report of the attending radiologist in formulating their diagnostic evaluation and management plan.