Non-invasive pre-implantation genetic testing of human embryos: an emerging concept.

The accurate genetic screening of pre-implantation embryos currently entails the use of technically challenging and biologically invasive biopsies of the human embryos. Investigating a more conservative sampling approach has emerged as a timely and desired alternative. Circulating cell-free embryonic DNA is present in the blastocoel fluid and spent culture media of blastocysts, and this has lately been sought as an attractive source of genetic information. The genetic analysis of cell-free embryonic DNA has been reported, to be useful in evaluating the genetic constitution of embryos; thus, providing a potential alternative to conventional biopsy-derived pre-implantation genetic testing (PGT). In this review, we have summarized these non-invasive alternative applications of PGT and discussed their current limitations and future clinical implications.

A randomised controlled double-blind clinical trial of 17-hydroxyprogesterone caproate for the prevention of preterm birth in twin gestation (PROGESTWIN): evidence for reduced neonatal morbidity.

OBJECTIVE: To determine whether 17 alpha-hydroxyprogesterone caproate (17OHPC) prolongs gestation beyond 37 weeks of gestation (primary outcome) and reduces neonatal morbidity (secondary outcome) in twin pregnancy. DESIGN: Randomised controlled double-blind clinical trial. SETTING: Tertiary-care university medical centre. POPULATION: Unselected women with twin pregnancies. METHODS: Participants received weekly injections of 250 mg 17OHPC (n = 194) or placebo (n = 94), from 16-20 to 36 weeks of gestation. Randomisation was performed using the permuted-block randomisation method. Data were analysed on an intention-to-treat basis. MAIN OUTCOME MEASURE: Preterm birth (PTB) rate before 37 weeks of gestation. RESULTS: There were no significant differences in the average gestational age at delivery, or in the rates of PTB before 37, 32, and 28 weeks of gestation, between the two groups. The proportion of very-low-birthweight neonates (<1500 g) was significantly lower in the 17OHPC group (7.6%) compared with placebo (14.3%) (relative risk, RR 0.5; 95% confidence interval, 95% CI 0.3-0.9; P = 0.01). Progestogen-treated neonates had a significantly lower composite neonatal morbidity (19.1%) compared with placebo (30.9%) (odds ratio, OR 0.53; 95% CI 0.31-0.90; P = 0.02), with significantly lower odds for respiratory distress syndrome (14.4 versus 23.4%; OR 0.55; 95% CI 0.31-0.98; P = 0.04), retinopathy of prematurity (1.1 versus 4.6%; OR 0.21; 95% CI 0.05-0.96; P = 0.04), and culture-confirmed sepsis (3.4 versus 12.8%; OR 0.24; 95% CI 0.10-0.57; P = 0.00). CONCLUSIONS: Intramuscular 17OHPC therapy did not reduce PTB before 37 weeks of gestation in unselected twin pregnancies. Nonetheless, 17OHPC significantly reduced neonatal morbidity parameters and increased birthweight.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis.

BACKGROUND: In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB). OBJECTIVES: To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA). SEARCH STRATEGY: We searched international scientific databases, trial registration websites, and references of identified articles. SELECTION CRITERIA: Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment. DATA COLLECTION AND ANALYSIS: Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB. MAIN RESULTS: Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75). AUTHOR'S CONCLUSIONS: In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.

Inadequacy of initiating rosuvastatin then metformin on biochemical profile of polycystic ovarian syndrome patients.

BACKGROUND: Polycystic ovary syndrome (PCOS) afflicts at least 5% of women. Both metformin and statin have been used as methods to ameliorate symptoms and improve prognosis. AIM: To test the efficacy of concomitant usage of metformin and statins in PCOS patients. MATERIALS AND METHODS: This is a prospective, randomized, double-blinded, placebo controlled study. 37 patients received rosuvastatin (10 mg/day) for a period of 3 months, then the patients were randomly allocated to one of two groups: the first group (or intervention group) received rosuvastatin (10 mg/day) plus metformin (850 mg twice daily after meals), and the second group (referred to as control group hereafter) received rosuvastatin (10 mg/day) plus placebo for a period of 3 months. Biochemical and clinical data were collected at each time point. RESULTS: There were no significant differences between the intervention and control groups for baseline lipid profile (LDL, HDL, triglycerides, total cholesterol), CRP, homocysteine, DHEAS, testosterone and insulin (p > 0.05 for all variables). There were no significant differences in lipid profile, CRP, homocysteine, DHEAS, testosterone and insulin between the intervention and placebo groups at 3 and 6 months after treatment (p > 0.05 for all). Significant differences in the outcome variables of LDL, total cholesterol and FBS emerged within the intervention group, with significantly higher levels at 6 months compared to 3 months. We also did not find any significant group differences in unit change of the outcome variables between baseline and 3 months. CONCLUSIONS: We found that the combination of statin and metformin has no advantage in PCOS management. In fact, the increase of LDL, total cholesterol and FBS within the intervention group warrants reassessment of current regimens to avoid any patient harm.

The utilization of pre-implantation genetic testing in the absence of governance: a real-time experience.

To create a diagnostic document describing the utilization of pre-implantation genetic testing (PGT) in the absence of monitoring and regulation. Retrospective cohort study of couples undergoing PGT between 2004 and 2007 in Lebanon. The clinical indications for 192 PGT cycles performed during the study period were gender selection (96.3%), chromosomal aneuploidy (3.1%), and balanced translocation (0.5%). When gender selection was sought, the selection of a son was desired in 94.1% of cases. Of couples undergoing PGT for sex selection, 16.2% were childless, 8.6% had one child of the opposite gender, 28.1% had two same-gender children, 29.7% had three same-gender children, and 11.9% had four or more. Our findings demonstrate the morally questionable consequences of self-regulated systems in which physicians are the sole gatekeepers of norms and ethics.

Idiopathic premature ovarian failure: what is the most suitable ovarian stimulation protocol?

OBJECTIVE: To evaluate the ovarian response to ovarian stimulation in women with idiopathic premature ovarian failure (POF) in a prospective, controlled, and sequential crossover pilot study. MATERIALS AND METHODS: Ten women with idiopathic premature ovarian failure and normal karyotype were included in the study. Phase I was comprised of three consecutive control cycles consisting each of estrogen progestin sequential therapy. Phase II was comprised of three consecutive treatment cycles combining the use of gonadotropin-releasing hormone agonist (GnRHa) in the background of estrogen priming, followed by gonadotropin ovarian stimulation and corticosteroid immunosuppression. RESULTS: Ovulation rates in the treatment cycles (0/10; 0%) did not differ from control cycles (0/10; 0%). CONCLUSIONS: The findings of this pilot study showed that the combination of estrogen priming, corticosteroid immune-suppression, GnRHa pituitary desensitization, and followed by gonadotropin ovarian stimulation is ineffective in restoring ovarian function in women with idiopathic POF.

The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study.

OBJECTIVE: To determine the effect of fasting during the month of Ramadan on the rate of preterm delivery (PTD). DESIGN: A prospective cohort study of women with singleton pregnancies who elected to fast and matched controls. SETTING: Four medical centres in Beirut, Lebanon. POPULATION: Women presenting for prenatal care (20-34 weeks of gestation) during the month of Ramadan, September 2008. METHODS: Data were collected prospectively. The frequency of PTD was evaluated in relation to the duration of fasting and the stage of gestation at the time of fasting. MAIN OUTCOME MEASURES: The primary endpoint was the percentage of pregnant women who had PTD, defined as delivery before 37 completed weeks of gestation. RESULTS: A total of 468 women were approached, of whom 402 were included in the study. There were no differences in smoking history and employment. There was no difference in the proportion of women who had PTD at <37 weeks (10.4% versus 10.4%) or PTD at <32 weeks (1.5% versus 0.5%) in the Ramadan-fasted group and the controls, respectively. The PTD rate was also similar in those who fasted before or during the third trimester. The mean birthweight was lower (3094 ± 467 g versus 3202 ± 473 g, P = 0.024) and the rate of ketosis and ketonuria was higher in the Ramadan-fasted women. On multivariate stepwise logistic regression analysis, fasting was not associated with an increased risk of PTD (odds ratio 0.72; 95% confidence interval 0.34-1.54; P = 0.397). The only factor that had a significant effect on the PTD rate was body mass index (odds ratio 0.43; 95% confidence interval 0.20-0.93; P = 0.033). CONCLUSIONS: Fasting during the month of Ramadan does not seem to increase the baseline risk of preterm delivery in pregnant women regardless of the gestational age during which this practice is observed.

Induction of final follicle maturation with a gonadotropin-releasing hormone agonist in women at risk of ovarian hyperstimulation syndrome undergoing gonadotropin stimulation and intrauterine insemination: proof-of-concept study.

OBJECTIVE: To evaluate the reproductive performance and safety of gonadotropin-stimulated intrauterine insemination (IUI) cycles in women at risk for ovarian hyperstimulation syndrome (OHSS) when final follicle maturation was induced using a gonadotropin-releasing hormone (GnRH) agonist. MATERIALS AND METHODS: Thirty-three women presenting with a history of cancelled ovarian stimulation for fear of OHSS, underwent repeat gonadotropin ovarian stimulation for IUI. They were all found to be at high-risk for OHSS once more, and were counseled to receive a GnRH agonist to trigger final follicle maturation before insemination. GnRH agonist trigger of ovulation (triptorelin) was given subcutaneously every 12 hours in three repeated doses: 0.3, 0.2, 0.2 mg, respectively. RESULTS: Induction with the agonist was associated with a 30.3% take-home pregnancy rate and 20% miscarriage rate. Multiple pregnancy rates were 26.7%. There were no reported cases of clinically significant moderate/severe ovarian hyperstimulation syndrome. CONCLUSIONS: The use of a GnRH agonist to trigger final follicle maturation in stimulated cycles of hyper responders was associated with a favorable reproductive outcome and no incidence of OHSS. The rate of multiple pregnancies nevertheless was found to be uncontrollably elevated, raising serious concerns regarding the safety of this protocol in standard clinical practice in the context of IUI.

Char Syndrome a novel mutation and new insights: A clinical report.

Transcription Factor AP-2 Beta (TFAP2B) functions in the differentiation of neural crest cell derivatives and contributes to the embryogenesis of the ductus arteriosus. Mutations of TFAP2B produces Char syndrome. Char syndrome is an autosomal dominant disorder comprising facial dysmorphism, hand anomalies, and patent ductus arteriosus (PDA). In this report, we describe a proband with a de novo TFAP2B frameshift mutation c.650delG p.(Gly217Alafs*32) in the basic domain. The proband presented mainly with musculoskeletal features of Char syndrome. No PDA was identified at presentation suggesting that this syndrome may prove to be phenotypically heterogeneous. This report will help illustrate the genotype/phenotype correlation of TAFB2 mutations and better delineate the clinical features in Char syndrome.

A randomised comparison of patient satisfaction with vaginal and sublingual misoprostol for induction of labour at term.

OBJECTIVE: To compare patient satisfaction with two routes of misoprostol for term labour induction. DESIGN: Prospective randomised trial. SETTING: Tertiary care hospital. POPULATION: A total of 170 women admitted at > or = 37 weeks of gestation for induction of labour. METHODS: Women were randomised to receive 50 micrograms of either sublingual or vaginal misoprostol. MAIN OUTCOME MEASURES: Patient satisfaction with the route of administration. RESULTS: Despite a similar proportion reporting the labour induction as more painful than expected in both groups, a significantly lower proportion mentioned that the pelvic examinations were very painful in the sublingual group (19.7 versus 36.1%, relative risk [RR] 0.5, 95% CI 0.3-0.9). Request for analgesia was similar in both groups. More women in the sublingual group thought that the labour experience was better than expected (RR 2.0, 95% CI 1.2-3.3), had a positive attitude towards induction in subsequent pregnancies (RR 1.6, 95% CI 1.1-2.3) and preferred the same route in subsequent pregnancies (RR 3.1, 95% CI 2.2-4.5). Mean number of misoprostol doses, oxytocin augmentation, tachysystole and hyperstimulation, induction to vaginal delivery interval, vaginal delivery after a single dose, vaginal birth within 12 and 24 hours, and caesarean delivery rates were similar in both groups. CONCLUSION: Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.

Alpha 2-macroglobulin production by the human endometrium.

alpha 2-Macroglobulin (A2M) is a broad spectrum plasma protease inhibitor previously described in uterine effluents and recently demonstrated to bind and possibly modulate the functions of cytokines. As cytokines, proteases, and protease inhibitors are important in implantation and endometrial physiology, we sought to investigate and characterize the pattern of production of A2M in the endometrium. Endometrial tissues from different phases of the menstrual cycle were analyzed for A2M production. Tissues were incubated in methionine-free Minimum Essential Medium with [35S]methionine for 12 h at 37 C in 5% CO2. Conditioned media were immunoprecipitated with a polyclonal antibody to human A2M. Recovered proteins were resolved under reducing and nonreducing conditions by 5% sodium dodecyl sulfate-polyacrylamide gel electrophoresis and analyzed by autoradiography. Immunohistochemistry was performed on both cryostat sections of OCT-embedded tissue and formalin-fixed paraffin-embedded tissue. The intensity of staining was evaluated, and a histochemical score was assigned. Comparisons between histochemical scores were performed using the nonparametric Wilcoxon rank sum test. Immunoprecipitation with A2M antibody yielded a single 320-kilodalton protein band under nonreducing conditions and a single 182-kilodalton band under reducing conditions. Both physical and immunological properties of the recovered protein were consistent with A2M. A2M was identified in all endometrial samples and represented approximately 2% of the total radiolabeled proteins produced. Immunohistochemical analysis revealed prominent stromal, but no glandular, staining for A2M throughout the menstrual cycle. The stromal staining in secretory endometrial samples was significantly more intense than that in proliferative samples. In the proliferative phase, staining was more intense in the spongiosum and basalis layers, and less intense in the superficial compactum layer. In the secretory phase, it remained very intense in the spongiosum, but less so in the basalis layer. These findings indicate that A2M is predominantly produced by the stromal component of endometrial tissue. This production is menstrual cycle dependent, with zonal differences in A2M expression within the endometrium, which may indicate a functional significance relevant to the process of implantation that merits further investigation.

Localization of the expression of complement component 3 in the human endometrium by in situ hybridization.

C3 production by the human endometrium has been previously described. The objective of the current study was to localize the site of expression and regulation of the third component of complement, C3, in the endometrium. Eight secretory and eight proliferative archival endometrial samples from hysterectomy and endometrial biopsy specimens were used for in situ hybridization analysis. This analysis was performed with a radiolabeled riboprobe synthesized from a 736-bp template representing sequence 1944-2680 of the human C3 complementary DNA. Duplicate sections were hybridized with sense and antisense riboprobes. Resultant autoradiograms were analyzed qualitatively by light- and darkfield microscopy. In proliferative endometrium, minimal expression of C3 was observed and was limited to a few stromal patches and glands throughout the section. In the secretory samples, prominent C3 expression was observed in both the glands and stroma of the basalis layer. Endometrial lymphocytes did not express C3. Endometrial stromal and glandular cells express the C3 gene. Endometrial lymphocytes did not express C3, but other nondistinct lymphoid elements scattered in the stroma may be expressing C3. There was a visibly more intense expression of C3 in the basalis layer of the secretory endometrium than in proliferative endometrium. The spatial and temporal pattern of C3 expression may have implications in normal menstrual physiology and in the immunological response of the endometrium to the invading trophoblast during placentation.

The harmonic scalpel: an intraoperative complication.

BACKGROUND: The harmonic scalpel is an ultrasonically activated surgical instrument for tissue dissection. Despite its expanding surgical applications, there are no reports about associated complications. CASE: A 35-year-old woman sustained injury to the sigmoid colon from the use of the harmonic scalpel during laparoscopic lysis of pelvic adhesions. The injury was identified and repaired laparoscopically in a primary fashion with no subsequent sequelae. CONCLUSION: Acoustic energy coupling and overheating of the laparosonic blade extender sheath occur with bending of the instrument. This can happen with steering of the blade extender during laparoscopic surgery and may increase the exposure risk of adjacent tissues to injury.

Imperforate hymen: report of an unusual familial occurrence.

BACKGROUND: Although imperforate hymen occurs in approximately 0.1% of female newborns, familial occurrence of imperforate hymen has been reported only once. CASES: We report two families in which imperforate hymen was diagnosed in three siblings of each family. One family is described in detail; the patients were two postmenarchal young women and one premenarchal girl. CONCLUSION: Imperforate hymen usually occurs sporadically but can be familial. We advise screening all female newborns and children for vaginal patency, especially family members of an affected child. Identification of other families with a similar problem might point to a specific mode of inheritance.

High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war.

OBJECTIVE: To evaluate the value of selective laparotomy in pregnant women with penetrating abdominal injuries. METHODS: A retrospective survey was carried out at our center over 16 years of civil war, extending from 1975 to 1991. Fourteen pregnant women had uterine injuries secondary to high-velocity abdominal penetrating trauma. The corresponding management was evaluated carefully with respect to maternal and fetal outcomes. RESULTS: Two maternal deaths occurred, neither resulting solely from intra-abdominal injuries. Visceral injuries were present when the entrance of the missile was in either the upper abdomen or the back. When the entry site was anterior and below the uterine fundus, visceral injuries were absent in all six women upon surgical exploration. Perinatal deaths occurred in half of the cases and were due to maternal shock or uteroplacental or direct fetal injury. Immediate cesarean delivery was performed because of either limited surgical field exposure, fetal injury, or distress. Three patients explored were managed by delaying delivery. All later delivered vaginally with successful fetal outcomes in all three. CONCLUSION: Selective laparotomy may be considered in pregnant women with anterior penetrating abdominal trauma, as the likelihood of intra-abdominal injuries may be predicted based on the location of the penetrating wound.

Complex translocation (8;12;21): a new variant of t(8;21) in acute myeloid leukemia.

Variants of the t(8;21)(q22;q22) involving chromosomes 8, 21, and other chromosomes account for approximately 3% of all t(8;21)(q22;q22) in acute myeloid leukemia (AML) patients. In this paper, we report a case of AML-M2 with a t(8;12;21)(q22;p12 approximately p13;q22) associated with chromosomal abnormalities, including loss of the Y chromosome and trisomy 8q22 approximately qter. Using a dual-color fluorescence in situ hybridization (FISH) analysis with ETO and AML1 probes, we demonstrated an ETO/AML1 fusion signal on the derivative chromosome 8. Using whole painting probes for chromosomes 8 and 12, we demonstrated a three-way translocation, t(8;12;21)(q22;p12 approximately p13;q22). Reverse transcription polymerase chain reaction (RT-PCR) analysis showed the presence of AML1/ETO fusion transcript. The present case highlights the importance of the combination of approaches, i.e., standard karyotyping, FISH, and RT-PCR, for the detection of variants of t(8;21)(q22;q22), shedding light on region 8q22 approximately qter which could harbor potential genes responsible for leukemogenesis.

Tamoxifen and ovarian cysts: a prospective study.

PURPOSE: To prospectively follow a group of women with breast cancer on tamoxifen for the development of ovarian cysts. METHODS: 72 women were followed every 6 months with pelvic examination and vaginal ultrasound. Chi square and Student's t-test were used for statistical analysis. RESULTS: The duration of treatment was 31.5+/-20 months. The mean age was 51.2+/-9.8 years. 55.6% were post-menopausal. Out of 72 women, 18 (25%) developed ovarian cysts. The mean age of women who developed ovarian cysts was significantly lower than in those who did not (47.0+/-7.0 and 52.5+/-10.2 years, respectively, P=0.03), however, the mean duration of treatment was not significantly different (33.3+/-17.4 and 29.3+/-20 months, respectively, P=0.45). Out of 32, 14 (43.8%) pre-menopausal and out of 40, 4 (10%) post-menopausal women developed ovarian cysts (P=0.003). They developed the cysts after an average duration of 33.3+/-18 and 50.7+/-6.2 months, respectively (P=0.7). The average diameter of the cysts was 2.8+/-1.2 cm. All cysts were simple except for one pre-menopausal women. All the cysts in post-menopausal women resolved spontaneously. One pre-menopausal patient had a multi-loculated cyst, was operated and had a serious cystadenoma. In nine patients, the cysts resolved spontaneously and in three after discontinuation of tamoxifen, and one patient was lost to follow-up. All cysts were asymptomatic. CONCLUSION: Ovarian cysts frequently develop in women with breast cancer on tamoxifen. The majority of the cysts resolve spontaneously, therefore an expectant management with follow-up ultrasonography is recommended.

Ear length: a potential sonographic marker for Down syndrome.

OBJECTIVES: The purpose of this study was to determine if antenatal sonographic determination of fetal ear length is a useful screening method for identification of fetuses with Down syndrome. METHODS: Ear length measurements were recorded in 418 fetuses undergoing ultrasound scanning between 20 and 28 weeks of gestation. Four trisomy 21 and six trisomy 18 fetuses were identified by karyotyping. The relationship between ear length and gestational age in the normal population was determined by linear regression analysis: expected ear length = -6.000 + 1.075 gestational age. The ability of measured-to-expected ear length cut-off ratios to discriminate between affected and non-affected fetuses was assessed. RESULTS: The mean ear length and measured-to-expected ear length ratios were significantly lower in the affected group as compared to the normal one. A measured-to-expected ear length ratio of less than 0.8 was 75.0% sensitive and 98.8% specific in detecting Down syndrome fetuses, and resulted in an 8.5% positive predictive value in the general population. CONCLUSIONS: This preliminary study suggests that antenatal ear length measurements might be a promising sonographic screening method for the detection of Down syndrome in the second trimester of pregnancy.