Altered microRNA and gene expression in the follicular fluid of women with polycystic ovary syndrome.

PURPOSE: To determine if microRNAs are differentially expressed in the follicular fluid of women with PCOS compared to fertile oocyte donors and identify associated altered gene expression. METHODS: Women undergoing IVF who met Rotterdam criteria for PCOS or who were fertile oocyte donors were recruited from a private IVF center. Individual follicle fluid was collected at the time of oocyte retrieval. MicroRNA analysis was performed using microarray and validated using real-time PCR on additional samples. Potential gene targets were identified and their expression analyzed by real time PCR. RESULTS: Microarray profiling of human follicular fluid revealed expression of 235 miRNAs, 29 were differentially expressed between the groups. Using PCR validation, 5 miRNAs (32, 34c, 135a, 18b, and 9) showed significantly increased expression in the PCOS group. Pathway analysis revealed genes involved in insulin regulation and inflammation. Three potential target genes were found to have significantly decreased expression in the PCOS group (interleukin 8, synaptogamin 1, and insulin receptor substrate 2). CONCLUSIONS: MicroRNAs are differentially expressed in the follicular fluid of women with PCOS when compared to fertile oocyte donors. There is also altered expression of potential target genes associated with the PCOS phenotype.

Freeze-all: enhanced outcomes with cryopreservation at the blastocyst stage versus pronuclear stage using slow-freeze techniques.

This retrospective cohort study compared outcomes from transfer of embryos cryopreserved at the pronuclear versus blastocyst stage following 'freeze-all' IVF cycles without fresh transfer for 87 consecutive IVF patients <40 years, who underwent cryopreservation of all viable embryos followed by at least one subsequent frozen embryo transfer (FET) between January 2003 and July 2007. Cryopreservation of all embryos from one oocyte retrieval was performed at either the pronuclear (1.5 mol/l propanediol and 0.1 mol/l sucrose) (group A) or blastocyst (10% glycerol) (group B) stage. Main outcome measures included survival, live birth and implantation rates. A total of 110 FET cycles were analysed. Live birth and implantation rates observed after the first FET were significantly higher (P=0.025 and P=0.002) in group B (67.7% and 40.8%) than in group A (41.1% and 21.5%) despite a higher survival rate in group A. After two FET cycles, 32.1% of group A had not conceived despite thaw of all available embryos, compared with 6.5% of group B. When freeze-all is necessary, blastocyst cryopreservation leads to higher implantation and live birth rates compared with pronuclear-stage cryopreservation despite lower survival rates. Prolonged embryo culture may allow for more optimal embryo selection.

Lipodystrophy: an unusual diagnosis in a case of oligomenorrhea and hirsutism.

BACKGROUND: Familial partial lipodystrophy, Dunnigan variety, is a rare autosomal dominant disorder caused by missense mutations in LMNA gene. Individuals are predisposed to insulin resistance and its complications, including features of polycystic ovary syndrome. CASE: A 27-year-old Hispanic woman presented with oligomenorrhea and hirsutism. Examination revealed cushingoid facies, significant hirsutism, acanthosis nigricans, and a lean body habitus. Metabolic testing identified diabetes mellitus, dyslipidemia, and steatohepatitis. A diagnosis of familial partial lipodystrophy, Dunnigan variety, was confirmed by the detection of a heterozygous p.Arg482Trp (c.1444C>T) missense mutation in the lamin A/C (LMNA) gene. Subsequently, seven female relatives were diagnosed with familial partial lipodystrophy, Dunnigan variety, four of whom had menstrual irregularities. CONCLUSION: Familial partial lipodystrophy, Dunnigan variety, can present with features similar to polycystic ovary syndrome. Diagnosis is critical because the metabolic complications of the disorder have significant morbidity.

Estrogen and progesterone metabolism in the cervix during pregnancy and parturition.

CONTEXT: Experimental and clinical studies in a variety of nonprimate species demonstrate that progesterone withdrawal leads to changes in gene expression that initiate parturition at term. Mice deficient in 5alpha-reductase type I fail to undergo cervical ripening at term despite the timely onset of luteolysis and progesterone withdrawal in blood. OBJECTIVE: Our objective was to test the hypothesis that estrogen and progesterone metabolism is regulated in cervical tissues during pregnancy, even in species in which parturition is not characterized by progesterone withdrawal in blood. DESIGN: Estradiol and progesterone metabolism was quantified in intact cervical tissues from nonpregnant and pregnant women at term before or after labor. SETTING: The study was conducted at a university hospital. PATIENTS: Tissues were obtained from five nonpregnant and 21 pregnant women (nine before labor and 12 in labor). MAIN OUTCOME MEASURES: Enzyme activity measurements, Northern blot analysis, quantitative real-time RT-PCR, and immunohistochemistry were used to quantify steroid hormone metabolizing enzymes in cervical and myometrial tissues. RESULTS: During pregnancy, 17beta-hydroxysteroid dehydrogenase type 2 was induced in glandular epithelial cells to catalyze the conversion of estradiol to estrone and stroma-derived 20alpha-hydroxyprogesterone to progesterone. During parturition, 17beta-hydroxysteroid dehydrogenase type 2 was down-regulated in endocervical cells, thereby creating a microenvironment favorable for cervical ripening. CONCLUSIONS: Together, the data indicate that cervical ripening during parturition involves localized regulation of estrogen and progesterone metabolism through a complex relationship between cervical epithelium and stroma, and that steroid hormone metabolism in cervical tissues from pregnant women is unique from that in mice.

Abnormal bleeding in adolescents.

Abnormal bleeding is a common clinical problem in adolescents, with the vast majority of cases resulting from anovulatory menstrual cycles. Although most episodes of abnormal vaginal bleeding do not cause acute medical complications, bleeding can be traumatic for young patients and their families. Health care providers with a solid knowledge of menstrual physiology and a thorough approach to differential diagnosis can evaluate and appropriately manage adolescents. In this article, we review the maturation of the hypothalamic ovarian axis, the most frequent etiologies of abnormal bleeding, as well as other less common causes and discuss diagnosis and treatment modalities.

Single blastocyst transfer: a prospective randomized trial.

OBJECTIVE: To determine the efficacy of single blastocyst transfer. DESIGN: Prospective randomized trial. SETTING: Private assisted reproductive technology unit. PATIENT(S): Forty-eight women undergoing IVF-embryo transfer with day 3 FSH 12 mm in diameter on day of hCG administration. INTERVENTION(S): Embryo culture to the blastocyst stage in sequential media G1/G2 followed by transfer of either one or two blastocysts. MAIN OUTCOME MEASURE(S): Implantation rate, ongoing pregnancy rate, and twinning. RESULT(S): The transfer of a single blastocyst resulted in an implantation and ongoing pregnancy rate of 60.9% with no twins. The transfer of two blastocysts resulted in an implantation rate of 56%, an ongoing pregnancy rate of 76% with a 47.4% incidence of twins. CONCLUSION(S): Single blastocyst transfer is an effective method of eliminating multiple births while maintaining high pregnancy rates in this selected group of patients.

Association of abnormal ovarian reserve parameters with a higher incidence of aneuploid blastocysts.

OBJECTIVE: To estimate the relationship between hormonal parameters of diminished ovarian reserve and the incidence of aneuploid blastocysts. METHODS: This prospective cohort trial was performed in a private in vitro fertilization clinic. Three hundred seventy-two patients underwent in vitro fertilization with blastocyst biopsy and aneuploidy screening of all 23 chromosome pairs. Patients were divided into groups based on baseline hormonal ovarian reserve. Group 1 included normal ovarian reserve (n=279) and group 2 included diminished ovarian reserve with day 2 or 3 follicle-stimulating hormone (FSH) more than 10 milli-international units/mL, antimüllerian hormone 1 ng/mL or less (n=93), or both. Patients with diminished ovarian reserves were further subdivided into three groups. Group A included FSH more than 10 milli-international units and antimüllerian hormone 1 ng/mL or less (n=25); group B included FSH more than 10 milli-international units/mL and antimüllerian hormone more than 1 ng/mL (n=34); and group C included antimüllerian hormone 1 ng/mL or less and day 3 FSH less than 10 milli-international units/L (n=34). RESULTS: Group 2 (diminished ovarian reserve) had a higher percentage of aneuploid blastocysts (66% compared with 51.7%; P<.05) and all aneuploid blastocyst cycles (35.1% compared with 14.3%; P<.001) than group 1 (normal ovarian reserve). However, implantation rates after transfer of euploid blastocysts were similar (69% compared with 61.7%; not significant). The highest percentage of aneuploid blastocysts among diminished ovarian reserve patients was in group A (abnormal FSH and antimüllerian hormone) compared with groups B and C (77.2% compared with 58.5% compared with 58.8%; P<.05). Implantation rates also were no different among the diminished ovarian reserve subgroups (68% compared with 71% compared with 66.7%; not significant). CONCLUSIONS: Infertility patients with hormonal evidence of diminished ovarian reserve have a significantly higher percentage of aneuploid blastocysts. The combination of abnormal serum FSH and antimüllerian hormone correlated with the greatest rate of embryonic aneuploidy. Regardless of ovarian reserve parameters, transfer of euploid blastocysts resulted in equivalent implantation potential. LEVEL OF EVIDENCE: II.

Does endometrial integrin expression in endometriosis patients predict enhanced in vitro fertilization cycle outcomes after prolonged GnRH agonist therapy?

OBJECTIVE: To determine whether endometrial expression of the integrin alpha(v)beta(3) vitronectin can predict which endometriosis patient subgroup will benefit from pre-IVF cycle prolonged GnRH agonist (GnRHa) therapy. DESIGN: Prospective randomized institutional review board approved pilot trial. SETTING: Private assisted reproductive technology program. PATIENT(S): IVF candidates with regular menses, surgically confirmed endometriosis, and normal ovarian reserve. INTERVENTION(S): All patients underwent endometrial biopsy 9 to 11 days post-LH surge to evaluate alpha(v)beta(3) integrin expression. Patients were randomized either to receive depot leuprolide acetate 3.75 mg every 28 days for three doses before controlled ovarian hyperstimulation (COH) or to proceed directly to COH and IVF. Group 1: integrin-positive controls (N = 12); group 2: integrin-positive administered prolonged GnRHa (N = 8). Group A: integrin-negative controls (N = 7); group B: integrin-negative administered prolonged GnRHa (N = 9). MAIN OUTCOME MEASURE(S): COH responses, ongoing pregnancy and implantation rates. RESULTS: There were no significant effects of GnRH agonist treatment in either of the integrin expression strata regarding ongoing pregnancy or implantation rates, although these outcomes were more frequent in group 2 vs. 1 (62.5% vs. 41.6% and 35% vs. 20.6%, respectively). This effect may have because of limited sample size. The value of a negative integrin biopsy in predicting an ongoing pregnancy after prolonged GnRH agonist therapy was only 44.4%. CONCLUSION(S): Endometrial alpha(v)beta(3) integrin expression did not predict which endometriosis patients would benefit from prolonged GnRHa therapy before IVF.

Management of poor responders: can outcomes be improved with a novel gonadotropin-releasing hormone antagonist/letrozole protocol?

OBJECTIVE: To compare the efficacy of a microdose GnRH agonist flare (ML) with a GnRH antagonist/letrozole (AL) protocol before IVF-ET in poor responders. DESIGN: Prospective controlled trial. SETTING: Private assisted reproductive technology center. PATIENT(S): Five hundred thirty-four infertile women classified as past or potential poor responders based on clinic-specific criteria. INTERVENTION(S): Poor responders were prospectively assigned to an ML or AL protocol in a 2:1 ratio, respectively. MAIN OUTCOME MEASURE(S): Results of controlled ovarian hyperstimulation and implantation and ongoing pregnancy rates. RESULT(S): Patient characteristics were similar between the two protocol groups. There were no significant differences in mean age, number of oocytes, fertilization rates, number of embryos transferred, or embryo score. Peak E(2) levels were significantly lower in the AL group. Ongoing pregnancy rates were significantly higher in the ML group (52% vs. 37%). Trends toward increased implantation and lower cancellation rates were also noted, but these did not reach statistical significance. CONCLUSION(S): Quantitative results of stimulation between the ML and AL protocols were equivalent with the exception of peak E(2) levels. However, the higher ongoing pregnancy rates and trend toward superior implantation rates would suggest that ML represents a preferred approach for the poor responder. An increased sample size would be necessary to verify these findings.

The incidence of aberrant endometrial alphavbeta(3) vitronectin expression in a high risk infertility population: could prolonged GnRH agonist therapy play a role?

PURPOSE: Evaluate the incidence of aberrant endometrial integrin (alphavbeta(3) vitronectin) expression in patients at high risk for implantation defects. MATERIALS AND METHODS: Retrospective case-control trial of 74 consecutive infertile patients with prior failed IVF cycles despite good embryo quality and/or endometriosis who underwent endometrial biopsy 9-11 days after an LH surge to assess the presence or absence of alphavbeta(3) vitronectin. Patients were separated into two groups for analysis based on the presence (Gr. A) or absence (Gr. B) of integrin expression. A subset of Gr. B patients (86.1%) was treated with a 2 month course of a GnRH agonist prior to IVF (Gr. B1). No Gr. A patients were so treated. RESULTS: Absent alphavbeta(3) vitronectin expression was noted in 48.6% of patients evaluated. A trend towards more severe endometriosis was noted in Gr. B (57.1 vs 31.5%). Responses to controlled ovarian hyperstimulation and IVF cycle outcomes including ongoing pregnancy rates were similar between Gr. B1 patients untreated Gr. A controls (55.6 vs 63.9%). CONCLUSIONS: A high incidence of absent endometrial alphavbeta(3) vitronectin expression is noted in patients at increased risk for implantation defects. Prolonged GnRH agonist therapy prior to an IVF cycle resulted in outcomes similar to untreated controls with positive expression.

Effect of myomectomy on the outcome of assisted reproductive technologies.

OBJECTIVE: To evaluate the impact of myomectomy on in vitro fertilization-embryo transfer (IVF-ET) and oocyte donation cycle outcome. DESIGN: Retrospective case-controlled study of consecutive fresh IVF-ET and oocyte donation patients during a 2-year interval. SETTING: Private assisted reproductive technology (ART) center. PATIENT(S): Patients with submucosal leiomyomata resected hysteroscopically (group A: 15 oocyte donor recipients; group 1 = 31 IVF-ET patients) and those with intramural components or strictly intramural leiomyomata that distorted or impinged upon the endometrial cavity resected at laparotomy (group B = 26 oocyte donor recipients; group 2 = 29 IVF-ET patients). INTERVENTION(S): Precycle hysteroscopic or abdominal myomectomy and subsequent fresh IVF-ET or oocyte donation. MAIN OUTCOME MEASURE(S): Results of controlled ovarian hyperstimulation as well as ongoing pregnancy and implantation rates were evaluated in comparison with contemporaneous patient groups without such lesions (group C = 552 oocyte donor recipients; group 3: 896 IVF-ET patients). RESULT(S): As would be expected, the mean number and size of leiomyomata were significantly larger in patients who underwent abdominal myomectomy. However, neither ongoing pregnancy nor implantation rates were significantly different in comparison with controls among either oocyte donor recipients (group A: 86.7%, 57.8%; group B: 84.6%, 55.2%; group C 77%, 49.1%). The findings were similar for those undergoing IVF-ET in comparison with controls (group 1: 61%, 24%; group 2: 52%, 26%; group 3: 53%, 23%). CONCLUSION(S): Precycle resection of appropriately selected clinically significant leiomyomata results in IVF-ET or oocyte donation cycle outcomes that are similar to controls.