Association of tubal factor infertility with elevated antibodies to Chlamydia trachomatis caseinolytic protease P.

OBJECTIVE: The objective of the study was to assess antibodies against Chlamydia trachomatis heat shock proteins (HSP) in patients with tubal factor infertility (TFI), infertility controls (IFC), and fertile controls (FC). HSPs assist organisms in surviving caustic environments such as heat. STUDY DESIGN: Twenty-one TFI, 15 IFC, and 29 FC patients were enrolled after laparoscopic tubal assessment. The titers of antibodies against C trachomatis organisms and 14 chlamydial HSPs were compared among the 3 groups. RESULTS: TFI patients developed significantly higher levels of antibodies against C trachomatis and specifically recognizing chlamydial HSP60 and caseinolytic protease (Clp) P, a subunit of the ATP-dependent Clp protease complex involved in the degradation of abnormal proteins. CONCLUSION: In addition to confirming high titers of antibodies against C trachomatis organisms and HSP60 in TFI patients, we identified a novel link of TFI with anti-ClpP antibodies. These findings may provide useful information for developing a noninvasive screening test for TFI and constructing subunit anti-C trachomatis vaccines.

Tubal anastomosis by robotic compared with outpatient minilaparotomy.

OBJECTIVE: To compare tubal anastomosis by robotic system compared with outpatient minilaparotomy. METHODS: In this retrospective case-control study, women were identified by current procedural terminology code for tubal anastomosis. We included all cases of tubal anastomosis for reversal of a prior tubal ligation by either outpatient minilaparotomy or robotic system technique. Cases performed by laparoscopy without aid of the robot were excluded. Comparisons were based on Fisher's exact, chi(2), and Wilcoxon rank sum tests. RESULTS: There were 26 cases of tubal anastomosis performed with the robot and 41 cases performed by outpatient minilaparotomy. The two groups were comparable in age, body mass index, and parity. Anesthesia time for the robotic technique (median with interquartile range) was 283 (267-290) minutes compared with 205 (170-230) minutes with outpatient minilaparotomy (P<.001). Surgical times for the robot and minilaparotomy were 229 (205-252) minutes and 181 (154-202) minutes respectively (P=.001). Hospitalization times, pregnancy, and ectopic pregnancy rates were not significantly different. The robotic technique was more costly. The median difference in costs of the procedures was $1,446 (95% confidence interval $1,112-1,812) (P<.001). The time to return to work was significantly shorter in the robotic system group by approximately 1 week (P=.013). CONCLUSION: Robotic surgery for tubal anastomosis was successfully accomplished without conversion to laparotomy. The robotic technique for tubal anastomosis required significantly prolonged surgical and anesthesia times over outpatient minilaparotomy (P

Perioperative complications in obese women vs normal-weight women who undergo vaginal surgery.

OBJECTIVE: The purpose of this study was to compare the incidence of perioperative complications in obese and normal-weight patients who undergo vaginal urogynecologic surgery. STUDY DESIGN: A retrospective cohort analysis was conducted for obese patients (body mass index, > or = 30 kg/m2) who underwent vaginal surgery and who were matched with patients with normal body mass indices (> 18.5 kg/m2 but < 30 kg/m2) by surgical procedures. Demographic information, comorbidities, and perioperative (< or = 6 weeks) complications were documented. Logistic regression analysis was used to compare the incidence of perioperative complications and to adjust for baseline differences. RESULTS: Seven hundred forty-two patients underwent vaginal surgery during the study period; 235 women were considered to have obese body mass indices. We matched 194 of these patients with normal-weight control subjects. There was no statistical difference in the proportion of subjects who had at least 1 perioperative complication (20% [obese] vs 15% [nonobese]). However, obese subjects were more likely to have an operative site infection (adjusted odds ratio, 5.5; [95% CI, 1.7-24.7]; P = .01). CONCLUSION: The overall perioperative complication rate in obese and nonobese women is low, with obesity as an independent risk factor for the development of operative site infections.

Chlamydia trachomatis antigens recognized in women with tubal factor infertility, normal fertility, and acute infection.

OBJECTIVE: To identify Chlamydia trachomatis antigens associated with tubal factor infertility and acute infection. METHODS: A C trachomatis proteome array was used to compare antibody profiles among women with tubal factor infertility, normal fertility, and acute C trachomatis infection. RESULTS: Thirteen immunodominant antigens reacted with 50% or more sera from all women (n=73). Six C trachomatis antigens were uniquely recognized in women with tubal factor infertility. Combining fragmentation of the six antigens with serum sample dilution, chlamydial antigens HSP60, CT376, CT557, and CT443 could discriminate between women with tubal factor infertility and women with normal fertility with a sensitivity of 63% (95% confidence interval [CI] 0.41-0.77) and specificity of 100% (95% CI 0.91-1), respectively. These antigens were designated as tubal factor infertility-associated antigens. However, these tubal factor antigens were unable to distinguish tubal factor infertility patients from those with acute infection. A combination of CT875 and CT147 distinguished women with acute infection from all other C trachomatis-exposed women with a detection sensitivity of 63% (95% CI 0.41-0.77) and specificity of 100% (95% CI 0.95-1), respectively. Thus, CT875 and CT147 were designated as acute infection-associated antigens. CONCLUSION: A sequential screening of antibodies against panels of C trachomatis antigens can be used to identify women with tubal factor infertility and acute C trachomatis infection. LEVEL OF EVIDENCE: II.

Inhibition of CD44 N- and O-linked glycosylation decreases endometrial cell lines attachment to peritoneal mesothelial cells.

The attachment of endometrial epithelial cells (EECs) and endometrial stromal cells (ESCs) to peritoneal mesothelial cells (PMCs) with and without inhibition of N- and O-linked glycosylation, the viability of EECs and ESCs, and the expression of CD44 surface density were evaluated. Inhibition of CD44 N- and O-linked glycosylation by using tunicamycin and/or B-GalNAc statistically significantly inhibited endometrial cell attachment to peritoneal mesothelial cells, suggesting a role in establishment of early endometriotic lesions.

Genome-wide identification of Chlamydia trachomatis antigens associated with tubal factor infertility.

OBJECTIVE: To identify Chlamydia trachomatis antigens that can be used to differentially diagnose tubal factor infertility in comparison with previously reported heat shock protein 60. DESIGN: In vitro study. SETTING: Academic medical center. PATIENT(S): Infertile women with and without tubal pathology diagnosed laparoscopically. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Antibody responses to C. trachomatis in infertile women with or without tubal pathologies using a C. trachomatis genome-wide proteome array. RESULT(S): Comparison of the antibody profiles revealed 30 C. trachomatis antigens that were preferentially recognized in women with tubal factor infertility, with a detection sensitivity and specificity of 80.6% and 56.5%, respectively, 10 of which showed 100% specificity. A combination of CT443 and CT381 antigens yielded the highest detection sensitivity (67.7%) while maintaining 100% specificity. CONCLUSION(S): These findings have demonstrated that antibodies to CT443 and CT381, when used in combination, have higher sensitivity and specificity in predicting tubal factor infertility than other indicators for tubal factor infertility, such as heat shock protein 60 antibodies (35.5%, 100%) or hysterosalpingogram (65%, 83%). Using a panel of C. trachomatis antigens to serologically diagnose tubal factor infertility can save the patients from undertaking expensive and invasive procedures for determining tubal pathology and choosing treatment plans.

In vitro fertilization outcomes in Hispanics versus non-Hispanic whites.

The in vitro fertilization (IVF) outcomes, including clinical intrauterine gestation rate and live birth rate, between Hispanic and non-Hispanic white women were compared, and there were no differences. Hispanics were more likely to have a diagnosis of tubal factor infertility, whereas non-Hispanic white women were more likely to have endometriosis as their infertility diagnosis.

Serum beta human chorionic gonadotropin levels can inform outcome counseling after in vitro fertilization.

The predictive value of serum beta hCG level for fetal cardiac motion and pregnancy outcome after IVF was evaluated. The serum hCG level 12 days after ET is a useful predictor of subsequent presence of fetal cardiac activity and live birth and may assist clinicians in counseling patients regarding their IVF outcome.

Risk factors for prolapse development in white, black, and Hispanic women.

OBJECTIVES: : This study aimed to examine the risk factors for prevalence and incidence of pelvic organ prolapse (POP) in whites, Hispanics, and blacks. METHODS: : This is a secondary analysis of the Women's Health Initiative (WHI) Estrogen plus Progestin Clinical Trial (E + P). Of the original E + P trial population of 16,608, 12,667 women (78.3%; 11,194 whites, 804 blacks, and 669 Hispanics) were included in the final study sample and evaluated during the 5-year period. The outcomes evaluated were any prolapse (WHI prolapse grades 1-3) and WHI prolapse grade 2 or 3. Descriptive analyses, logistic regression, and proportional hazard modeling were performed. RESULTS: : Increasing parity correlates with increasing WHI prolapse grades (0-3) in whites and blacks but not Hispanics. The incidence of grade 2 or 3 POP increased by 250% in white women with 1 child (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.68-3.71) in comparison to nulliparous women and grew with higher parity. For blacks, a weak association between the parity and grade 2 or 3 POP was noted only in women who had 5 or more kids (HR, 10.41; 95% CI, 1.38-78.77). Blacks were less likely (HR, 0.53; 95% CI, 0.40-0.71) to develop grade 2 or 3 POP compared with whites. For grade 2 or 3 POP, age was found to be a risk factor in whites (odds ratio [OR], 1.03; 95% CI, 1.02-1.04) only and body mass index (≥25 kg/m, <30 kg/m) in whites (OR, 1.64; 95% CI, 1.34-2.02) and Hispanics (OR, 2.87; 95% CI, 1.03-2.02). CONCLUSIONS: : White women are at a much greater risk for developing grade 2 or 3 POP compared with blacks. Parity correlates most strongly with the risk of prolapse development in whites and possibly in grand multiparous blacks.

Reviews: in vitro models to study the pathogenesis of endometriosis.

Several in vitro models that attempt to replicate the intraperitoneal environment have been developed to study the pathogenesis of endometriosis. The chicken chorioallantotic membrane has been used, but it has not been well characterized and may introduce some species specific variables. In vitro models using human tissues include amniotic membrane, human peritoneal explants, and cell culture monolayers. These models have been used to qualitatively, quantitatively, and temporally assess attachment of endometrial cells to peritoneal mesothelial and subsequent transmesothelial invasion. These models have also been used to assess the role of cytokines in the development of the early endometriotic lesion. Two- and three dimensional invasion chamber models have been utilized to assess endometrial cell interactions with peritoneal mesothelial cells and the extracellular matrix. Invasion models are also useful to evaluate novel therapeutic approaches. This review will focus on the above models to assist reproductive scientists interested in the pathogenesis of endometriosis.

Alcohol consumption and risk of ductal carcinoma in situ of the breast in a cohort of postmenopausal women.

BACKGROUND: Observational studies have commonly linked higher alcohol consumption with a modest increase in invasive breast cancer risk, but cohort studies have not examined alcohol intake in relation to ductal carcinoma in situ (DCIS). METHODS: The association between adulthood alcohol consumption assessed at baseline and subsequent DCIS risk was examined in a cohort of postmenopausal women participating in the Women's Health Initiative clinical trials, in which mammography was protocol-mandated. Alcohol intake was assessed by a semiquantitative food-frequency questionnaire. Reported DCIS cases were verified by central pathology report review. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals. RESULTS: The cohort consisted of 63,822 women with information on alcohol intake, among whom 489 cases of DCIS were ascertained after a median follow-up of 8.0 years. For the primary analysis, invasive breast cancer was treated as a competing risk, and follow-up time was censored at the date of diagnosis of invasive breast cancer. After adjustment for covariates, the hazard ratio for DCIS among women who consumed 14 or more servings of alcohol per week, relative to nondrinkers, was 0.87 (95% confidence interval, 0.50-1.51). In addition, alcohol intake was not associated with risk of either high-grade or low-/moderate-grade DCIS. CONCLUSIONS: In this large cohort study of postmenopausal women, alcohol consumption was not associated with risk of DCIS. IMPACT: If other studies confirm our findings, this would suggest that alcohol may have an effect later in the carcinogenic process.

Optimizing success with donor insemination.

Artificial insemination with donor sperm yields pregnancy rates similar to the general fertile population with the woman's age being the best predictor for success. This article reviews the indications for donor insemination and the current American Society for Reproductive Medicine guidelines for screening both the donors and recipients. For most women, timing the insemination the day after detecting the LH surge with a urinary ovulation predictor kit gives the best results. The addition of clomiphene or letrozole provided no benefit in women with regular menstrual cycles. Superovulation with FSH or hMG did significantly increase the fecundity rate but at a much greater cost and risk of multiple pregnancy and ovarian hyperstimulation syndrome. Intrauterine insemination has been shown to be superior to intracervical insemination in most studies. Adding a second insemination doesn't appear to significantly improve upon the pregnancy rates to justify the additional cost and inconvenience. Fallopian sperm perfusion has shown promise in preliminary studies. The different techniques of sperm processing are reviewed but no technique was clearly better.

Treatment strategies for endometriosis.

BACKGROUND: Endometriosis is a common chronic disease that causes symptoms of pain and infertility. The pain syndrome can be quite incapacitating. The pain symptoms usually originate in the reproductive organs but can also involve the urinary or intestinal tracts if endometriosis implantation has occurred there. The presentation and physical appearance of endometriosis is extremely variable and can be characterized by a chronic intraperitoneal inflammatory process and adhesions. The only definitive diagnostic technique is laparoscopy. OBJECTIVE: To review current literature on the treatment strategies for endometriosis. METHODS: Review of Pubmed, Cochrane database and Medline for current review articles and studies regarding the current treatment strategies for endometriosis. RESULTS: Initial treatment is surgical or medical. Medical therapy is often used as a first-line therapy and can also be used in conjunction with those patients who undergo surgical therapy for pain. No medical therapy has proven effective for infertility. Medical therapy consists mostly of hormonal suppressive therapy in which the medication causes a downregulation of the hypothalamus-pituitary-ovarian pathway. Non-steroidal anti-inflammatory drugs and oral contraceptives are often used as an initial approach even without a definitive diagnosis. Progestins, such as oral norethindrone and depot medroxyprogesterone, are effective while using them but have a high recurrence rate. The norgestrol intrauterine device is also quite effective at relieving pain associated with endometriosis, especially pain arising during menses as well as from lesions in the rectovaginal tissue. Gonadotropin-releasing hormone agonists induce a pseudomenopausal state and have significant side effects, such as hot flashes and genital atrophy. 'Add-back' therapy with a progestin has been shown to relieve most of these drug related symptoms. Gonadotropin-releasing hormone agonists are also very effective at relieving symptoms of pain during treatment but are also associated with a high recurrence rate. New drug therapies that are under investigation are aromatase inhibitors and immunomodulators. Furthermore, new delivery systems are being investigated that may also improve the patient response.