Evaluating Chronic Endometritis in Women with Recurrent Implantation Failure and Recurrent Pregnancy Loss by Hysteroscopy and Immunohistochemistry.

STUDY OBJECTIVE: The identification of less invasive methods with acceptable diagnostic value for evaluating intrauterine abnormalities can improve the satisfaction of patients and physicians. Although hysteroscopy plus biopsy has favorable predictive and diagnostic values, limited studies have evaluated its value, and the exact value of this method is not completely understood. The aim of this study was to evaluate the prevalence of chronic endometritis in patients with recurrent implantation failure (RIF) and recurrent pregnancy loss (RPL) by hysteroscopy and immunohistochemistry. DESIGN: A cross-sectional study. SETTING: An infertility clinic at Jundishapur University Hospital, Ahvaz, Iran. PATIENTS: Women with RIF after IVF and RPL. INTERVENTIONS: Hysteroscopy on the third to fifth day after finishing the menstruation cycle and then a biopsy for immunohistochemistry by a specific monoclonal antibody against the CD138 marker. MEASUREMENTS AND MAIN RESULTS: In total, 85 patients with a mean age of 36.08 ± 5.76 years underwent hysteroscopy on the third to fifth day after finishing the menstruation cycle. At the end of hysteroscopy, a biopsy was taken and assessed using immunohistochemistry by a specific monoclonal antibody against the CD138 marker. Immunohistochemical staining findings of >5 plasma cells per 20 high-power fields were considered the gold standard. The prevalence of chronic endometritis (CE) in both groups and the diagnostic value of hysteroscopy were evaluated. All data were analyzed using the Fisher exact test and analysis of variance. The prevalence of RIF-related CE was 23.4% (11); 21.3% (10) of the cases were diagnosed by hysteroscopy. The prevalence of RPL-related CE was 36.8% (14) and 31.6% (12) based on hysteroscopy and immunohistochemistry staining, respectively. Subsequently, 10 patients (RIF/RPL-related CE with a positive hysteroscopic outcome) were selected randomly for in vitro fertilization therapy, and 3 (30%) of them eventually became pregnant. The sensitivity, specificity, and positive and negative predictive values of hysteroscopy in diagnosing CE were 86.36%, 87.30%, 70.37%, and 94.82%, respectively. CONCLUSION: Hysteroscopy is a reliable diagnostic technique in patients with RIF after in vitro fertilization and RPL that can reliably diagnose chronic endometritis.

Ultrastructural markers of tissue endometrial receptivity in patients with recurrent implantation failure.

The scanning electron microscopy of the endometrial surface epithelium during the 'implantation window' was performed in 119 patients with uterine factor of infertility or recurrent miscarriage due to endometrial hypoplasia. Ultramorphological picture of the surface endometrial epithelium was characterized by aplasia and hypoplasia of pinopodes (67.39%), dense cell - cell contacts (69.53%), heteromorphy of secretory cells (15.22%) in combination with atypia of microenvironment cells (50%) in patients with infertility. The asynchronous development of pinopodes (46.67%) and the absence of intercellular contacts separation during the 'implantation window' (84.44%) was observed in patients with recurrent miscarriage. The revealed disturbance determines the mechanisms of the blastocyst adhesion violation and trophoblast invasion in the different stages of implantation in patients with uterine factor of infertility and recurrent miscarriage.

Embryo selection with preimplantation chromosomal screening in patients with recurrent pregnancy loss.

Recurrent pregnancy loss (RPL) is a multifactorial disorder which is often challenging for both patients and providers. Guidelines for the evaluation and treatment of patients with RPL include screening for uterine abnormalities, parental chromosomes, and antiphospholipid antibodies, but approximately half of RPL patients remain unexplained. The current recommendation for patients with unexplained RPL is expectant management which offers most patients a 60 to 80% success rate over time. Genetic imbalances in the embryo, including inherited unbalanced translocations and de novo aneuploidy, are frequent causes of miscarriage. Preimplantation genetic screening (PGS) has been proposed as an effective method for selecting viable embryos for transfer that may result lower risk of miscarriage for patients with unexplained RPL and carriers of balanced translocations. The current evidence examining the use of in vitro fertilization with PGS in patients with RPL reveals variable results, due to differences in technologies used and variable patient populations. Newer approaches, which include blastocyst biopsy and the ability to screen for all 24 chromosomes, show the most promise in reducing miscarriage rates. Studies that identify which patients are most likely to benefit from PGS and include live birth rates per initiated cycles are needed before universally recommending this treatment to couples with RPL.

Early pregnancy failure as a training tool for chorionic villus sampling.

OBJECTIVES: The goal of this study is to evaluate the success of a training program in chorionic villus sampling (CVS) of early pregnancy failure (EPF) for maternal-fetal medicine (MFM) fellows. METHODS: We conducted a retrospective review of a new training program in CVS for MFM fellows. Women with EPF up to 13 weeks estimated gestational age were offered inclusion in our program and counseled on alternatives. Transcervical CVS was performed for both fellow education and cytogenetic diagnosis. The primary outcome was a successful diagnosis, and the secondary outcome was cell growth by fellow experience. RESULTS: Thirty-nine patients diagnosed with EPF from December 2011 to March 2013 underwent CVS. Villi obtained via CVS yielded a diagnosis in 62% of cases. CVS samples with successful karyotype had more villi but were otherwise similar. CVS by experience showed a trend towards increased success and villi volume after the first five procedures. Abnormal results were obtained in 72% of cases, 15% of which led to changes in care. CONCLUSION: CVS of EPF is an option for the training of MFM fellows as it was acceptable to most patients, and the majority of CVS specimens yielded a karyotype diagnosis.

Predictive value of serum human chorionic gonadotropin ratio, progesterone and inhibin A for expectant management of early pregnancies of unknown location.

OBJECTIVE: To evaluate serum human chorionic gonadotropin (hCG) ratio, progesterone and inhibin A as single parameters and in combination for the prediction of spontaneous resolution of pregnancies of unknown location (PUL). STUDY DESIGN: Prospective observational study of 105 consecutive patients with a diagnosis of PUL. Serum levels of hCG, progesterone and inhibin A were determined at the first visit and after 2 days. Patients were followed clinically until a final diagnosis of spontaneously resolving PUL, viable or non-viable intrauterine pregnancy, or ectopic pregnancy with need of laparoscopic intervention had been reached. Different combinations of hCG ratio (hCG at 48 h/hCG at 0 h), s-progesterone and s-inhibin A were investigated to find the best predictor for successful expectant management. RESULTS: The final pregnancy outcomes were: 52 spontaneously resolving PUL (49.5%), 37 viable intrauterine pregnancies (35.2%), 8 non-viable intrauterine pregnancies (7.6%), 7 ectopic pregnancies (6.7%), and one molar pregnancy (1.0%). An hCG ratio<0.80 predicted spontaneously resolving PUL with positive and negative predictive values (PPV and NPV), sensitivity, and specificity of 0.98, 0.78, 0.72, and 0.99, respectively. In patients with hCG ratio ≥ 0.80, a combination of s-progesterone < 20 nmol/l and s-inhibin A < 30 pg/ml predicted spontaneously resolving PUL with PPV, NPV, sensitivity and specificity of 0.92, 0.96, 0.85, and 0.98 respectively. CONCLUSION: Our results suggest that patients with PUL and hCG ratio < 0.80 display a high probability of spontaneously resolving PUL with minimum need of follow-up. In cases of hCG ratio ≥ 0.80, a combination of s-progesterone < 20 nmol/l and s-inhibin A < 30 pg/ml, may be a reliable predictor of spontaneously resolving PUL. The safety of this approach should be tested in large prospective studies.

Candidate biomarkers for acute rejection of pregnancy after in-utero cell-based therapy in pre-immune embryos via ultrasound-guided celocentesis.

PROBLEM: A maternal serum biomarker profile analysis was performed to determine potential indicators of acute rejection of pregnancy following in-utero cell-based treatments in pre-immune embryos. METHOD OF STUDY: We used an established non-human primate model for in-utero stem cell therapy at 38-42 days from fertilization. The maternal serum concentrations of nine candidate biomarkers for acute rejection of pregnancy were determined before and after the injection of different cocktails of human umbilical cord blood stem cells into the gestational sac. All animals were then followed until delivery. RESULTS: Twenty-four hours after celocentesis, two of the animals aborted. These two animals received a cocktail of haemopoietic stem cells with the highest concentration of human CD3(+) cells and showed a twofold increase in maternal serum IL-6 and a threefold increase in prolactin after the procedure. The remaining six animals delivered at term live and normal newborns and only demonstrated an increase in prolactin after the celocentesis procedure. CONCLUSION: IL-6 and prolactin are master immunoregulators with pleiotropic biological functions that have different maternal serum concentrations depending on pregnancy outcome. These findings suggest that increases in maternal serum prolactin and IL-6 concentration may be associated with acute rejection of pregnancy after in-utero stem cell therapy.

Aneuploidy detection in pigs using comparative genomic hybridization: from the oocytes to blastocysts.

Data on the frequency of aneuploidy in farm animals are lacking and there is the need for a reliable technique which is capable of detecting all chromosomes simultaneously in a single cell. With the employment of comparative genomic hybridization coupled with the whole genome amplification technique, this study brings new information regarding the aneuploidy of individual chromosomes in pigs. Focus is directed on in vivo porcine blastocysts and late morulas, 4.7% of which were found to carry chromosomal abnormality. Further, ploidy abnormalities were examined using FISH in a sample of porcine embryos. True polyploidy was relatively rare (1.6%), whilst mixoploidy was presented in 46.8% of embryos, however it was restricted to only a small number of cells per embryo. The combined data indicates that aneuploidy is not a prevalent cause of embryo mortality in pigs.

Efectos de la selección y de la superovulación en las pérdidas gestacionales de ratonas CF1 / Effects of selection and superovulation on gestational losses in CF1 mice

En un par de líneas de ratones seleccionadas para alto (s') y bajo peso (s), originadas a partir de una población no seleccionada de la cepa CF1 (t), se modificó la estructura ovárica. El diámetro de los folículos ováricos y el número de folículos y de cuerpos lúteos se incrementaron en las hembras de la línea s', sin expresarse en un mayor tamaño de camada al nacimiento, posiblemente, por un aumento de las pérdidas gestacionales. Se probó si los efectos conjuntos de la selección de peso a largo plazo y de la estimulación ovárica incrementaban las pérdidas gestacionales. Se utilizaron dos grupos de hembras por línea: sin y con estimulación ovárica (5UI de eCG y 5UI de hCG). Las hembras se sacrificaron a las 56-72 hs y a los 7 días postservicio y después de la primera parición. Se observaron los números de cuerpos lúteos (CL), embriones (E) y sitios de implantación (SI) y el tamaño de camada al nacimiento (TC). Se estimaron las pérdidas totales (PT) y las pérdidas de cuerpos lúteos (PCL), de embriones (PE) y de fetos (PF). Los promedios de CL, E, SI y TC variaron en el mismo sentido de la selección practicada y fueron significativamente mayores (P<0,05) para las hembras estimuladas, a excepción de TC. La línea s' tuvo un potencial reproductivo superior pero un mayor costo biológico (mayor PT y más tardía) cuando se la comparó con las otras líneas. La estimulación ovárica produjo menores eficiencias reproductivas totales para las tres líneas y pérdidas gestacionales mayores y más tardías, principalmente de SI. Las hembras de la línea no seleccionada (t), no estimuladas, con pesos intermedios, parieron un mayor número de crías, partiendo de un número intermedio de CL, E y SI, con una menor y más temprana mortalidad embrionaria, demostrando ser las más eficientes desde el punto de vista reproductivo y productivo.

The ovarian structure was modified as a consequence of weight selection in a pair of mouse lines selected for high (s') and low weight (s). Lines were founded from an unselected population of CF1 strain (t). The follicle diameter and the number of the ovarian follicles and the corpora lutea were higher in s' females, but they did not reach a larger litter size at birth, may be, by an increase in the gestational losses. In these lines, the co-effects of long-term weight selection and ovarian stimulation were tested to evaluate if they increased gestational losses. Two groups of females per line were employed: without and with ovarian stimulation (5UI of eCG and 5UI of hCG). Females were slaughtered at 56-72hs and at 7 days post-breeding and after first parturition. The number of corpora lutea (CL), embryos (E) and implantation sites (SI), and litter size at birth (TC) were observed. Total losses (PT) and corpora lutea (PCL), embryo (PE) and fetus (PF) losses were estimated. Mean CL, E, SI and TC varied in the same direction of the selection made and they were significantly higher (P<0.05) in stimulated females, though not for TC. Line s' had a higher reproductive potential but a greater biological cost (higher and later gestational mortality) when compared with the other lines. Ovarian stimulation produced lower total reproductive efficiencies for the three lines and higher and later gestational losses, mainly for implantation sites. Females from unselected line (t), without ovarian stimulation, with intermediate weights, bore larger litters, starting from an intermediate number of CL, E and SI, with a lower and earlier embryo mortality, showing to be the most efficient from a reproductive and productive point of view.

Defective endometrial prostaglandin synthesis identified in patients with repeated implantation failure undergoing in vitro fertilization.

OBJECTIVE: To define the role of prostaglandins (PG) in the endometrium of patients with repeated failure of embryo implantation. Prostaglandins are produced after the sequential oxidation of arachidonic acid by cyclooxygenases (COX-1 and COX-2) and terminal PG synthases. DESIGN: Case-control study. SETTING: In vitro fertilization unit at a university hospital. PATIENT(S): Thirty-four women, comprising of 19 patients with repeated IVF failure and 15 controls with proven fertility. INTERVENTION(S): Endometrial expression levels of the enzymes responsible for the PG synthesis were compared between the two groups. MAIN OUTCOME MEASURE(S): Cytosolic phospholipase A2 (cPLA2alpha) expression and activity were assessed by Western blot. Expression of cyclooxygenase-2, secretory phospholipase A2 group IIA, V, and IB (sPLA2-IIA, sPLA2-V, sPLA2-IB), glypican-1, PG E synthase, PG E receptors, and lysophosphatidic acid receptor 3 (LPA3) was measured by real-time polymerase chain reaction (PCR). Localization of COX-2, sPLA2-IIA, and LPA3 within the secretory endometrium was detected by immunohistochemistry. RESULT(S): Patients displaying recurrent implantation failure expressed reduced levels of cPLA2alpha and COX-2 compared with controls. In response to this deficiency, sPLA2-IIA was found to be overexpressed. Interestingly, LPA3, which is known to converge on the cPLA2-arachidonic acid-COX-PG signaling pathway, was also decreased in these patients. CONCLUSION(S): Prostaglandin synthesis appears to be disrupted in patients with repeated IVF failure compared with fertile controls. We therefore suggest that reduced PG synthesis in the human endometrium may lead to poor endometrial receptivity.

Comprehensive chromosome screening of polar bodies and blastocysts from couples experiencing repeated implantation failure.

OBJECTIVE: To identify and transfer cytogenetically normal embryos after screening all chromosomes of first and second polar bodies (PBs) or trophectoderm samples with the use of comparative genomic hybridization. DESIGN: Clinical research study. SETTING: In vitro fertilization clinic referring samples to a specialist preimplantation genetic diagnosis laboratory. PATIENT(S): Thirty-two couples with repeated implantation failure. INTERVENTION(S): Zygotes from patients with repeated implantation failure and poor response to ovarian stimulation underwent PB biopsy. Patients with repeated implantation failure who were candidates for blastocyst transfer received trophectoderm biopsy. Zygotes or blastocysts were vitrified while chromosome analysis took place. Euploid embryos were transferred during a subsequent cycle. MAIN OUTCOME MEASURE(S): Cytogenetic status and implantation and pregnancy rates. RESULT(S): The oocyte and blastocyst aneuploidy rates were 65.5% and 45.2%, respectively. Abnormalities affecting all chromosomes were detected. Implantation and pregnancy rates for the patients with PB biopsy were 11.5% and 21.4%, respectively, whereas for patients receiving blastocyst analysis they were 58.3% and 69.2%. CONCLUSION(S): Initial results for patients of advanced maternal age (39.8 years) with repeated implantation failure and poor ovarian response were encouraging. However, further study is required to confirm whether or not screening is beneficial. Blastocyst analysis was associated with high pregnancy rates, suggesting that comprehensive chromosome screening may assist patients with repeated implantation failure capable of producing blastocysts in achieving pregnancies.

[Forensic-medical evaluation of medical care errors in obstetric-gynecological practice].

The authors show the necessity of elaboration and practical application of normative documents (standards) and forensic-medical criterions of assessment of defects in obstetric-gynecological medical aid. The examples of the above assessment are given in the article.

Endometrial thickness and pregnancy outcome after intrauterine insemination.

OBJECTIVES: To investigate whether endometrial thickness on the day of hCG administration is a predictor of intrauterine insemination (IUI) success. DESIGN: A retrospective study. PATIENT(S): Two hundred forty-nine women undergoing IUI cycles. SETTING: University hospital-based infertility center. INTERVENTION(S): Endometrial thickness on the day of hCG administration, cycle parameters, and sperm quality were compared between pregnant and nonpregnant patients. A similar comparison was made between ongoing pregnancies and those that resulted in a loss. MAIN OUTCOME MEASURE(S): Endometrial thickness versus IUI outcome. RESULT(S): The overall pregnancy rate was 15%. Mean (+/- standard deviation) endometrial thickness on the day of hCG administration was significantly greater in cycles where pregnancy was achieved (10.1 +/- 3.0 vs. 7.7 +/- 3.5). In the univariate analysis, the following variables affected the pregnancy rate: the woman's age, duration of infertility, the number of IUI cycles, the number of follicles, the diameter of the dominant follicle, the duration of follicle maturation, and sperm count, motility, and morphology. In the multivariate analysis, the strongest predictor of IUI success was the number of IUI cycles. The woman's age was negatively associated with pregnancy outcome, while endometrial thickness and the total motile sperm count were positively associated with pregnancy outcome. CONCLUSION(S): The results of the present study suggest that clinicians providing IUI for infertile couples must pay close attention to endometrial development as well as to follicle growth and sperm motility.

Prognostic factors in oocyte donation: an analysis through egg-sharing recipient pairs showing a discordant outcome.

OBJECTIVE: To analyze prognostic factors that are associated with a discordant outcome in egg recipients sharing oocytes from the same donor. DESIGN: Matched case-control single-center study. SETTING: Private infertility clinic. PATIENT(S): Four hundred forty-four recipients (222 pairs) sharing oocytes from the same donor and showing a discordant outcome. INTERVENTION(S): Controlled ovarian hyperstimulation of egg donors, oocyte donation, intracytoplasmic sperm injection, and ET in egg recipients. MAIN OUTCOME MEASURE(S): Recipient age, obstetric (gravidity, parity) and gynecologic variables (previous uterine surgery, uterine fibroids, uterine malformations, endometriosis, history of tubal infertility), previous oocyte donation cycles, duration of E(2) replacement, received cumulus-oocyte complexes, mature (MII) oocytes, fertilized oocytes, transferred embryos, mean embryo score, transfer difficulty, and semen parameters. RESULT(S): No significant differences were found in the above-mentioned prognostic factors between the study and control groups. CONCLUSION(S): Recipient- and cycle-related prognostic factors investigated in our study were not associated with a discordant outcome in recipient pairs sharing oocytes from the same donor. Other possible prognostic factors involving oocyte donor heterogeneity, embryo aneuploidy rates, male factor infertility, and endometrial receptivity should be further investigated.

Low endometrial volume may predict early pregnancy loss in women undergoing in vitro fertilization.

PURPOSE: To evaluate the role of 3-D US measurement of the endometrium during early IVF-pregnancy and before the appearance of gestational sac in the prediction of pregnancies outcome. METHODS: 60 pregnant women following IVF treatment were included in the study. The women underwent transvaginal 3D US measurements of endometrial volume and thickness on day 15-17 post ET. Patients were followed and classified according to pregnancy outcome into 2 further groups. The group with early pregnancy loss and the group with ongoing pregnancy. RESULTS: While no differences were observed between those who miscarried and those who did not in gestational age, endometrial thickness or volume, spontaneous early pregnancy loss was significantly higher in patients with endometrial volume <2 mL as compared to those with endometrial volume >2 mL. CONCLUSIONS: 3-D US measurement of endometrial volume of less than 2 mL during early IVF pregnancy and prior to the appearance of gestational sac is a powerful predictor of pregnancy loss.