Clinical outcomes of assisted reproductive technology treatment by using a self-injection of recombinant human chorionic gonadotropin as the final maturation trigger.

PURPOSE: To evaluate the efficacy and safety of self-injections of the prefilled recombinant human chorionic gonadotropin (r-hCG) in a syringe in assisted reproductive technology (ART) treatment for the maturation trigger (MT), as compared to self-injections of conventional hCG and intranasal administration of gonadotropin-releasing hormone agonist (GnRH-a). METHODS: Between January and April, 2017, 396 patients who underwent oocyte retrieval were recruited. Of these, 396 patients were classified into three groups, according to the types of MT: (1) the urinary human chorionic gonadotropin (u-hCG) group that consisted of patients who had a self-injection of u-hCG (n = 127); (2) the GnRH-a group that received nasal administration of GnRH-a (n = 159); and (3) the r-hCG group that had a self-injection of r-hCG (n = 110). Several ART outcomes were evaluated. RESULTS: The mature oocyte retrieval rate was not different between the u-hCG, r-hCG, and GnRH-a groups and the fertilization and cleavage rates were similar between the three groups. The clinical pregnancy rates did not significantly differ between the GnRH-a group and the u-hCG group; however, it was significantly lower in the GnRH-a group, compared to the r-hCG group. No difference was observed in the incidence of moderate or more severe ovarian hyperstimulation syndrome among the three groups. CONCLUSION: The self-injection of the prefilled r-hCG is a favorable MT for ART patients.

Increased risk of placenta previa is associated with endometriosis and tubal factor infertility in assisted reproductive technology pregnancy.

Although assisted reproductive technology (ART) is suspected to increase the risk of placenta previa, a life-threatening complication of pregnancy, the reason is poorly understood. We recruited consecutive 318 pregnancies conceived by ART in our clinic and examined relation of ten variables, i.e. maternal age, gravidity, parity, male or female fetus, previous abortion, previous cesarean delivery, endometriosis, ovulatory disorder, tubal disease, and male infertility, to placenta previa, by logistic regression analysis. As a result, we found that endometriosis (odds ratio = 15.1; 95% CI = 7.6-500.0) and tubal disease (odds ratio = 4.4; 95% CI = 1.1-26.3) were significantly associated with placenta previa. It would be preferable to take the increased risk of placenta previa into account in treating ART pregnancy with endometriosis and tubal disease.

Successful pregnancy following low-dose hCG administration in addition to hMG in a patient with hypothalamic amenorrhea due to weight loss.

We describe successful ovulation induction with low-dose hCG administration in addition to hMG in a patient with refractory hypothalamic amenorrhea. A 24-year-old woman with weight loss-related amenorrhea underwent ovulation induction and intracytoplasmic sperm injection (ICSI). Administration of exogenous gonadotropins was ineffective in ovulation induction. Supplementation with low-dose hCG in order to increase luteinizing hormone (LH) activity in the late follicular phase produced late folliculogenesis and steroidogenesis, and ovulation was then successfully induced. This report reacknowledges the critical role that LH plays cooperatively with follicle-stimulating hormone in both folliculogenesis and steroidogenesis.

Singleton pregnancy outcomes after assisted and non-assisted reproductive technology in infertile patients.

PURPOSE: Singleton pregnancy after assisted reproductive technology (ART) has been associated with higher risks of adverse pregnancy outcome than naturally conceived singleton pregnancy. This study was to elucidate whether the ART procedure is responsible for abnormal pregnancy outcome comparing those after ART and non-ART in infertile patients. METHODS: We compare the singleton pregnancy outcome of infertile patients in our university hospital between 2000 and 2008 following ART (351 pregnancies) and non-ART (213 pregnancies) procedures. Pregnancy outcome parameters were incidence of pregnancy induced hypertension, placenta previa, placental abruption, cesarean delivery, preterm birth, very preterm birth, stillbirth, low birth weight and very low birth weight. RESULTS: Most of the pregnancy outcome parameters were not significantly different between the ART group and the non-ART group. Only placenta previa was significantly higher in the ART group than in the non-ART group (odds ratio 4.0; 95 % CI 1.2-13.7). CONCLUSIONS: ART procedure may itself be a risk factor for the development of placenta previa. Some of the abnormal perinatal outcomes that had been previously attributed to ART, however, may be due to the baseline characteristics of infertile patients.

Analysis of the therapeutic effects of hysteroscopic polypectomy with and without doxycycline treatment on chronic endometritis with endometrial polyps.

PROBLEM: We aimed to compare the therapeutic effects of hysteroscopic polypectomy with and without doxycycline treatment on chronic endometritis (CE) with endometrial polyps. METHOD OF STUDY: DESIGN: A cross-sectional study was conducted on 267 infertile patients, of whom 243 were recruited, who underwent hysteroscopic polypectomy between March 2019 and March 2020. During surgery, the endometrial specimens for the immunohistochemistry analysis of the plasma cell marker CD138 and for the intrauterine bacterial culture were obtained to diagnose CE, and the prevalence of CE was analyzed. Of the 222 women who were diagnosed with CE after polypectomy, we treated 62 women with doxycycline (antibiotic group) and did not provide antibiotics in 160 women (non-antibiotic group). RESULTS: Most of the infertile patients with endometrial polyps had CE (92.6%). The recovery rate from CE by hysteroscopic polypectomy was significantly higher in the non-antibiotic group than in the antibiotic group (88.8% and 58.1%, respectively, p < 0.0001). The duration of recovery from CE in the non-antibiotic group was shorter than that in the antibiotic group (42.6 ± 41.0 and 56.5 ± 32.3 days, respectively, p < 0.0001). The clinical pregnancy rate within 6 months in non-antibiotic group was higher than that in the antibiotic group (63.2% and 43.8%, respectively, p = 0.034). CONCLUSION: Endometrial polyps are significantly associated with CE. Most CE patients with endometrial polyps had been cured by polypectomy without doxycycline. Inappropriate antibiotic therapy may delay recovery from CE and decrease the efficacy of polypectomy on CE and pregnancy rates.

Uterine artery pseudoaneurysm after cesarean section: case report and literature review.

Uterine artery pseudoaneurysm (UAP) occurs rarely and can develop after various gynecologic or obstetric procedures. The delayed diagnosis of this disease often results in life-threatening hemorrhage. Herein is described a case of UAP after cesarean section. The patient visited our emergency outpatient department 99 days after cesarean section because of abnormal uterine bleeding, which was diagnosed as UAP using color Doppler ultrasonography and contrast medium-enhanced computed tomography. Selective transcatheter arterial embolization was performed to resolve the lesion without complications. We also conducted a review to identify the demographic etiology of UAP. A PubMed search yielded 57 cases reported in the English literature. The most frequent cause of UAP was cesarean section, which accounted for 47.4% of all cases. The mean interval between the incident and the symptoms was approximately 2 weeks, regardless of cause. At analysis of 17 cases diagnosed within a day, it became evident that the definitive diagnosis was made at angiography (41.2%), computed tomography (29.4%), or color Doppler ultrasonography (29.4%). Almost all cases (94.1%) were conservatively treated with transcatheter uterine artery embolization. Consideration of UAP in the differential diagnosis is crucial for proper treatment before rupture and to preserve fertility.

Inhibitory effects of cholesterol sulfate on progesterone production in human granulosa-like tumor cell line, KGN.

Cholesterol sulfate (CS) is a component of cell membranes that plays a role in stabilizing the cell membrane. We previously reported that CS increased in the endometrium during implantation, suggesting that CS plays an important role in reproduction. It has been reported that CS regulates progesterone and pregnenolone production in the placenta, adrenal glands and ovary. The regulatory mechanisms of steroid hormone production by CS, however, are still unknown. In the present study, we investigated the effect of CS on the expression of progesterone production-related genes in KGN cells, derived from human granulosa-like tumor. KGN cells were cultured with CS (10 muM) or cholesterol (10 muM) in the presence of 8-bromo-cAMP (1 mM). Progesterone levels in the culture media were measured by enzyme linked fluorescent assay at 24 h after treatment of CS and cAMP. Total RNAs were extracted for quantitative real time RT-PCR with specific primer of StAR protein, P450scc, HSD3B2, ferredoxin and ferredoxin reductase. Whole cell lysates were extracted for western blot analysis with antibody for StAR protein. Progesterone concentration in the culture medium increased to 38-fold by treatment of cAMP. CS significantly reduced progesterone concentration by 30% compared with those of cAMP treatment (p<0.05), while cholesterol did not change the progesterone concentration. CS treatment down-regulated the expression of StAR mRNA and P450scc mRNA was to 54% and 60%, respectively (p<0.05). Western blot analysis revealed that the amount of StAR protein was also reduced by CS treatment. The expression of HSD3B2 mRNA was up-regulated to 3.4-fold by treatment of cAMP. The expression of ferredoxin and ferredoxin reductase mRNA was not affected by CS treatment. These data implied that CS has an inhibitory effect on progesterone production by regulating the expression of StAR and P450scc gene expression.

Expression and regulation of periostin/OSF-2 gene in rat uterus and human endometrium.

Periostin/OSF2 is a ligand for alphavbeta3 and alphavbeta5 integrins and activates the Akt/PKB pathway. Recent reports of periostin/OSF2 gene disrupted mice indicate that periostin/OSF-2 plays an important role in implantation. Quantitative RT-PCR revealed that the expression of periostin/OSF-2 mRNA in rat uteri was reduced to approximately 10% at 12 h after 17beta-estradiol (E2) injection, but was not changed after progesterone (P) injection. RT-PCR revealed the expression of periostin/OSF-2 in human endometrium, cultured human endometrial stromal cells (ESCs), and cultured human endometrial epithelial cells. In ESCs, the expression of periostin/OSF-2 mRNA was reduced to approximately 50% at 6 h after E2 treatment. The amount of periostin/OSF2 mRNA in human endometrium significantly increased during mid-proliferative and early secretory phases of menstrual cycle, and decreased during late-proliferative, mid-secretory and late secretory phases. The expression of periostin/OSF2 mRNA significantly decreased in ESCs decidualized by treatment with E2 and P for 7 and 11 days. By immunohistochemistry, the expression of periostin/OSF-2 was strongly detected in endometrial stromal cells during early proliferative, mid-proliferative and early secretory phases, and was strongly detected in endometrial epithelial cells during late secretory phase. This study demonstrated that the expression of periostin/OSF-2 is regulated by ovarian steroid hormones in rat uterus and human endometrium.

Evidence for the expression of alcohol dehydrogenase class I gene in rat uterus and its up-regulation by progesterone.

The endometrium is one of the target tissues of the ovarian steroid hormones, estrogen and progesterone. In order to elucidate the mechanism of gene regulation in the endometrium, suppressive subtraction hybridization was performed to isolate the candidate genes controlled by progesterone in rat uterus. Alcohol dehydrogenase (ADH) class I gene was one of the candidate genes. Here we investigated the expression and regulation of ADH class I gene in rat uterus. The mRNA of ADH class I was detected in uterus by RT-PCR using specific primers. Using specific probe for ADH class I, in situ hybridization was performed to investigate localization in rat uterus. Positive signals were detected in the endometrial stromal cells of rat uterus by in situ hybridization and were not detected in endometrial epithelial cells and myometrium in rat uterus. Ovariectomized rats were treated with 17-beta estradiol and progesterone and the uteri of these rats were used for Northern blot analysis and assay of the ADH activity. Northern blot analysis revealed that the expression of ADH class I mRNA in rat uteri was up-regulated approximately two-fold after progesterone treatment, but not estrogen. Likewise, ADH activity was approximately two-fold higher in progesterone-treated rat uteri compared with controls. This study demonstrated that ADH class I gene is progesterone-responsive in the uterus. This implies that progesterone might be involved with retinoic acid synthesis in the uterus, since ADH is the key enzyme for retinoic acid synthesis.

Expression and regulation of transient receptor potential cation channel, subfamily M, member 2 (TRPM2) in human endometrium.

To identify estrogen-responsive genes, we previously isolated estrogen receptor (ER)-binding DNA fragments from human genomic DNA using a recombinant ER protein. Six DNA fragments, each including a perfect palindromic estrogen response element (ERE), were obtained. The nucleotide sequence of one of the six fragments (E1 fragment) showed that the ERE of the E1 fragment is located in the 3'-untranslated region (UTR) of transient receptor potential cation channel, subfamily M, member 2 (TRPM2). Here, we confirmed the estrogen-dependent enhancer activity of the ERE of the E1 fragment by chloramphenicol acetyltransferase assay. TRPM2 mRNA expression was investigated in human endometrium, cultured human endometrial stromal cells (ESCs), and cultured human endometrial epithelial cells (EECs) using RT-PCR. Quantitative RT-PCR revealed that TRPM2 mRNA expression in ESCs increased after 17ß-estradiol (E2) treatment. This study demonstrated for the first time that TRPM2 is an estrogen-responsive gene expressed in human endometrial cells.

Expression of retinoic acid-related orphan receptor alpha and its responsive genes in human endometrium regulated by cholesterol sulfate.

Cholesterol sulfate (CS) is a major sterol sulfate in human plasma that is detected in the uterine endometrium. CS plays a role in steroidogenesis, cellular membrane stabilization, and regulation of the skin barrier. We previously reported that CS increased in rabbit endometrium during the implantation period. Recently, CS has been reported to be a ligand of retinoic acid receptor-related orphan receptor alpha (RORA). NR1D1 is one of the genes regulated by RORA. In the present study, we investigated the regulation of RORA and NR1D1 by CS in human endometrium. We determined the association-dissociation curves for the interaction of CS with RORA and the kinetic rates by surface plasmon resonance. Immunohistochemical staining and in situ hybridization revealed that RORA and NR1D1 were expressed in human endometrial stromal and epithelial cells. CS treatment significantly induced the mRNA expression of RORA and NR1D1 mRNA in ESCs. The results of a luciferase assay showed that RORA significantly activated the human NR1D1 promoter regardless of CS. Our results suggest that CS regulates the expression of RORA responsive genes in human endometrial cells but not as a ligand for RORA.

The progesterone-responsive gene 14-3-3τ enhances the transcriptional activity of progesterone receptor in uterine cells.

Members of the 14-3-3 family are intracellular dimeric phosphoserine-binding proteins that can associate with and modulate the activities of many proteins. In our efforts to isolate the genes regulated by progesterone (P(4)) using suppressive subtractive hybridization, we previously found that 14-3-3τ is one of the genes upregulated by P(4). In this study, we demonstrated by quantitative RT-PCR (qRT-PCR), western blot analyses, and immunohistochemistry that 14-3-3τ mRNA and protein levels were increased in the rat uterus after P(4) treatment. Furthermore, qRT-PCR indicated that P(4) increased 14-3-3τ mRNA levels in human endometrial epithelial cells and endometrial stromal cells (ESCs). Western blot and qRT-PCR analyses revealed that in vitro decidualization using cAMP and medroxyprogesterone 17-acetate increased levels of 14-3-3τ mRNA and protein in ESCs. We have shown by qRT-PCR and western blot analyses that P(4) increased the mRNA and protein levels of 14-3-3τ in Ishikawa cells that stably express P(4) receptor-B (PR-B). Immunocytochemistry revealed that 14-3-3τ colocalizes with PR and translocates from the cytoplasm to the nucleus in response to P(4). Moreover, by luciferase reporter assay, we demonstrated that 14-3-3τ enhances the transcriptional activity of PR-B. Taken together, we propose that 14-3-3τ is a P(4)-responsive gene in uterine cells that modulates P(4) signaling.

Expression and regulation of cholesterol sulfotransferase (SULT2B1b) in human endometrium.

OBJECTIVE: To investigate the hormonal regulation of SULT2B1b in human endometrium. DESIGN: In vitro study with human endometrial tissues and cultured human endometrial cells. SETTING: University hospital. PATIENT(S): Thirty-seven women undergoing hysterectomy for benign disease. INTERVENTION(S): Human endometrial tissues were collected for in situ hybridization. Culture medium of human endometrial epithelial cells (EECs) was collected for determination of secretion of cholesterol sulfate (CS). Total RNAs were extracted from human endometrial tissues and cultured cells for real-time reverse transcriptase-polymerase chain reaction (RT-PCR). MAIN OUTCOME MEASURE(S): The expression of SULT2B1b mRNA in human endometrial tissues and cultured cells. RESULT(S): In situ hybridization studies and real-time RT-PCR showed that the amount of SULT2B1b mRNA in human endometrial tissues was significantly higher during the midluteal phase than during other phases of the menstrual cycle. The secretion of CS from EECs was confirmed using [(35)S]-phosphoadenosine phosphosulfate. The expression of SULT2B1b mRNA was induced by cAMP or P in human endometrial stromal cells (ESCs), whereas it was induced by cAMP or relaxin in EECs. The induction of SULT2B1b mRNA by P or relaxin was abolished by the specific protein kinase A (PKA) inhibitor, Rp-adenosine 3',5' cyclic monophosphothioate (Rp-cAMPS). CONCLUSION(S): The expression of SULT2B1b mRNA in ESCs is induced by P and that in EECs is induced by relaxin via the cAMP pathway.

Induction of early decidualization by cadmium, a major contaminant of cigarette smoke.

To investigate the effect of cadmium (Cd) contamination on endometrial function, human endometrial stromal cells were isolated and cultured with E(2) plus P in the presence of Cd, a major contaminant in cigarette smoke, and assayed for PRL concentrations and its messenger RNA expression. Cd significantly increased PRL concentrations in the culture media and significantly up-regulated PRL messenger RNA expression of the endometrial stromal cells, suggesting that Cd stimulates decidualization of the endometrium and may disrupt endometrial environment, causing early decidualization.