Can Classifications Adequately Represent Genital Malformations?: EVA Study ( E SHRE/ESGE | V CUAM | A FS) - A Prospective Multicenter Study to Evaluate the Current Female Genital Malformation Classifications.

Introduction Genital malformations are a common clinical occurrence that can be represented using different classifications. Reproducibility is an essential quality characteristic for a classification, and it plays an important role, especially in consultations and the treatment of infertile patients and in obstetric management. The aim of this study is to demonstrate the reproducibility and clinical practicality of three commonly used classifications: the ESHRE/ESGE (European Society of Human Reproduction and Embryology/ European Society for Gynecological Endoscopy), VCUAM (Vagina Cervix Uterus Adnex-associated Malformation), and AFS (American Fertility Society) classifications. Materials and Methods Sixty-five patients with female genital malformations were included in this prospective, multicenter, exploratory, observational study. All participants underwent a clinical examination and a medical interview. The investigators were instructed to classify the presenting malformations according to the ESHRE/ESGE, VCUAM, and AFS classifications using a structured questionnaire. Investigators were asked whether the malformation could be reproducibly classified (yes/no) and about the grade (grade 1-5 from "very good" to "deficient") they would assign to each classification. Classification assessment was queried for vagina, cervix, uterus, adnexa, and associated malformations and was scored from 1 to 5. Results Reproducibility was rated as 80% (n = 52/65), 92.3% (n = 60/65), and 56.9% (n = 37/65) for the ESHRE/ESGE, VCUAM, and AFS classification, respectively. ESHRE/ESGE, VCUAM and AFS were rated as "very good" or "good" for 83.3%, 89.2%, and 10.8% of vaginal malformations; for 75.8%, 87.5%, and 24.2% of cervical malformations; and for 89.7%, 89.5%, and 86.2% of uterine malformations, respectively. VCUAM was rated as "very good" or "good" for 77.8% and 69.6% of adnexal malformations and associated malformations, respectively. ESHRE/ESGE and AFS were rated as "sufficient" or "deficient" for 100% and 75% of adnexal malformations and for 77.3% and 69.6% of associated malformations, respectively. Conclusion The prospective multicenter EVA ( E SHRE/ESGE | V CUAM | A FS) study revealed that the organ-based ESHRE/ESGE and VCUAM classifications of female genital malformations perform better in terms of reproducibility as well as in the assessment of individual compartments than the non-organ-based AFS classification.

Reduced Steroid Synthesis in the Follicular Fluid of MTHFR 677TT Mutation Carriers: Effects of Increased Folic Acid Administration.

Objective To compare steroid profiles in the follicular fluid (FF) from women homozygous for the methylenetetrahydrofolate reductase (MTHFR) 677C>T mutation and wildtype controls and to correlate it with the folic acid administration scheme applied at the time of oocyte retrieval. Design Retrospective single center study. Subjects and Methods Infertile patients treated by using assisted reproductive techniques were genotyped routinely for the MTHFR 677C>T mutation. In 2006 they had received folic acid supplementation doses of 400 µg daily per os. This group was designated Group-400 (n = 10). From 2008 onwards, all of our infertility patients received a daily dose of 800 µg folic acid per os. Women from this group were designated Group-800 (n = 28). FF were collected and a panel of steroid hormones (estradiol, estrone, estriol, cortisol, progesterone, 17-OH progesterone, testosterone, androstenedione, aldosterone, DHEA, and DHEA-S) was measured by isotope dilution liquid chromatography-tandem mass spectrometry employing atmospheric pressure photo ionization (APPI). Results In Group-400, the FF hormone profile confirmed a significant reduction of estradiol in homozygous 677TT carriers (0.52 ± 0.08-fold, exact p = 0.032) and for the first time also revealed significantly reduced estriol concentrations in these individuals (0.54 ± 0.05-fold, p = 0.016), as compared to wildtype controls. In Group-800, no significant differences were found for concentrations of any of the steroid hormones between homozygous 677TT carriers and wildtype controls. Conclusions The current findings support and extend previous reports on reduced concentrations of specific steroid hormones in follicular fluids of homozygous MTHFR 677C>T mutation carriers. The restoration of the FF hormone profile by elevated-dose folic acid supplementation might impact performing ART in infertile women with the MTHFR 677TT-genotype. Further adequately powered studies are necessary to verify our finding and to demonstrate the clinical effect of enhanced folic supplementation on ovarian function.

Induction of G protein-coupled estrogen receptor (GPER) and nuclear steroid hormone receptors by gonadotropins in human granulosa cells.

Estradiol and progesterone mediate their actions by binding to classical nuclear receptors, estrogen receptor α (ERα) and estrogen receptor ß (ERß) and progesterone receptor A and B (PR-A and PR-B) and the non-classical G protein-coupled estrogen receptor (GPER). Several animal knock-out models have shown the importance of the receptors for growth of the oocyte and ovulation. The aim of our study was to identify GPER in human granulosa cells (GC) for the first time. Moreover, the effect of different doses of gonadotropins on estrogen and progesterone receptors in the human ovary should be investigated as follicle stimulating hormone (FSH) and luteinizing hormone (LH) are also responsible for numerous mechanisms in the ovary like induction of the steroid biosynthesis. Human GC were cultured in vitro and stimulated with different doses of recombinant human FSH or LH. Receptor expression was analyzed by immunocytochemistry and quantitative real-time RT-PCR. GPER could be identified for the first time in human GC. It could be shown that high concentrations of LH increase GPER protein expression. Furthermore FSH and LH increased ERß, PR-A and PR-B significantly on protein level. These findings were verified for high doses of FSH and LH on mRNA level. ERα was not affected with FSH or LH. We assume that gonadotropins induce GPER, ERß and PR in luteinized granulosa cells.

The effect of nasal oxytocin on pregnancy rates following intrauterine insemination: double-blind, randomized, clinical pilot study.

PURPOSE: We tested the hypothesis that the application of intranasal oxytocin (8 IU) following intrauterine insemination (IUI) would increase pregnancy rates, without causing major side effects. METHODS: Randomized, double-blind, placebo-controlled pilot study: eighty-six couples with idiopathic infertility, polycystic ovary syndrome and/or male sub-fertility treated with 132 homologous IUI cycles with nasal application of placebo or 8 IU oxytocin following IUI. RESULTS: In 132 IUI cycles of 86 women, 17 pregnancies were achieved, accounting for a pregnancy rate of 12.9% (17/132) per IUI cycle. The pregnancy rates were 13.4% (9/67) per IUI cycle in the placebo group, and 12.3% (8/65) per IUI cycle in the oxytocin group, the difference not being statistically significant. No relevant side effects were observed in both groups. CONCLUSIONS: Intranasal application of 8 IU oxytocin has no major side effects but at the same time did not affect pregnancy rates after IUI in our population. This study does not exclude that a larger patient group, a different time interval between oxytocin application and IUI, higher or multiple oxytocin applications or a different mode of application would have achieved different effects on pregnancy rates.

Effective ovarian stimulation in a patient with resistant ovary syndrome and antigonadotrophin antibodies.

PROBLEM: We report on a successful ovarian stimulation and pregnancy in a patient with 'resistant ovary syndrome' (ROS) and antigonadotrophin antibodies. ROS is characterized by high endogenous gonadotrophins, low estradiol, normal ovarian antral follicle counts and normal antimuellerian hormone values. METHOD OF STUDY: After cyclical hormone treatment, downregulation with GnRH analogue and ICSI procedure followed. Granulosa cells were treated with LH, FSH or hMG and expression of receptors for FSH, LH, oestrogen receptor beta (ERb) and progesterone receptor A (PR-A) was determined. Serum of the patient was analysed for antibodies directed against hMG. RESULTS: After fertilization of ten metaphase II oocytes and transfer of two blastocysts, a singleton pregnancy was established. Stimulation of granulosa cells with FSH, LH and hMG upregulated ERb and PR-A. Dot blot analysis showed strong reactivity with hMG but not with recFSH. CONCLUSION: This patient with normal expression of gonadotrophin receptors showed antibodies directed to hMG but not to recFSH.

Divergent effects of the 677C>T mutation of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene on ovarian responsiveness and anti-Müllerian hormone concentrations.

OBJECTIVE: To investigate the influence of the 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C>T mutation on serum anti-Müllerian hormone (AMH) concentrations and on the numbers of oocytes retrieved (NOR) following controlled ovarian hyperstimulation (COH). DESIGN: Prospective cohort study. SETTING: University-based infertility clinic. PATIENT(S): Two hundred and seventy women undergoing COH for IVF with or without intracytoplasmic sperm injection. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): AMH levels were determined from blood samples collected after 10 days of GnRH superagonist treatment and before COH. The MTHFR 677C>T genotype was characterized by a TaqMan 5' nuclease assay. RESULT(S): AMH serum concentrations correlated significantly with the NOR in all individuals studied. Average (±SD) AMH levels of TT carriers (2.85±2.23 ng/mL) were significantly higher than those of homozygous CC (1.91±1.59 ng/mL) or heterozygous CT individuals (2.23±1.74 ng/mL). When evaluated by multiple regression analysis, AMH had a significant positive effect on NOR, whereas age and MTHFR 677TT genotype had significant negative effects. CONCLUSION(S): The MTHFR 677TT genotype is associated with higher serum AMH concentrations and has a negative effect on NOR. This apparent paradox might be resolved in light of recent findings describing a negative feedback function of AMH in the coordination of follicle development.

Expression of mucin-1, galectin-1 and galectin-3 in human leiomyosarcoma in comparison to leiomyoma and myometrium.

BACKGROUND: The potential mechanism of malignant transformation from leiomyoma to leiomyosarcoma is still debated. The aim was the evaluation of expression patterns of mucin-1 (MUC1) (MUC1 VU-4-H5), galectin-1 (Gal-1) and galectin-3 (Gal-3) in human myometrium and leiomyoma and in comparison to leiomyosarcoma. MATERIALS AND METHODS: Myometrium, leiomyoma and leiomyosarcoma tissues were obtained from 79 patients. Samples were analyzed regarding the expression of MUC1, Gal-1 and Gal-3 by immunohistochemical staining of paraffin-embedded material. RESULTS: The expression of MUC1 (VU4-H5) was up-regulated in leiomyoma (p = 0.065) and leiomyosarcoma (p = 0.039) as compared to the myometrium. In contrast, there were no significant differences in expression of Gal-3 in the tissues from the myometrium, myoma and leiomyosarcoma. Concerning Gal-1 expression, the differences were not significant comparing myometrium and leiomyosarcoma (p = 0.277). Myoma had elevated levels of Gal-1 compared to myometrium (p = 0.007) and leiomyosarcoma (p < 0.0001). CONCLUSION: MUC1 and Gal-1 might be useful for evaluating the potential of leiomyoma to transform into leiomyosarcoma and, therefore, help in risk-adapted consultation and adjusted treatment.

Common 677C-->T mutation of the 5,10-methylenetetrahydrofolate reductase gene affects follicular estradiol synthesis.

OBJECTIVE: To investigate the influence of the 5,10-methylenetetrahydrofolate reductase 677C-->T mutation on the E(2) synthesis in human granulosa cells (GCs). DESIGN: In vitro cell culture study. SETTING: Research laboratory of a university hospital. PATIENT(S): Follicular fluids (n = 139) and GCs (n = 66) were obtained from patients undergoing controlled ovarian hyperstimulation for IVF with or without ICSI. INTERVENTION(S): Granulosa cells were cultured for a total of 5 days. On day 3, the cells either were stimulated with recombinant (r-) FSH or r-LH (80 IU/L for 48 h) or were sham stimulated. MAIN OUTCOME MEASURE(S): Estradiol and protein content were measured in the pooled follicular fluids of each individual. At the end of each GC-culturing period, the concentrations of E(2) were measured in the supernatants of triplicate cultures by immunoassays. The 5,10-methylenetetrahydrofolate reductase 677C-->T genotype was determined by RFLP analysis. RESULT(S): The E(2)-protein ratio of homozygous T/T carriers was significantly lower compared with that of homozygous C/C individuals. Furthermore, basal and r-FSH- as well as r-LH-stimulated E(2) synthesis of GC obtained from homozygous T/T patients was significantly reduced, compared with GC from heterozygous C/T and homozygous C/C subjects. CONCLUSION(S): Decreased E(2) in follicular fluid and decreased E(2) synthesis of GC from homozygous T/T individuals suggest that reduced follicular E(2) is a result of impaired E(2) production of human GC.