Decreased stathmin-1 expression inhibits trophoblast proliferation and invasion and is associated with recurrent miscarriage.

Fetal trophoblasts invade endometrium and establish a complex interaction with the maternal microenvironment during early pregnancy. However, the molecular mechanisms regulating trophoblast migration and invasion at the maternal-fetal interface remain poorly understood. Immunohistochemistry and immunoblotting have shown that stathmin-1 (STMN1) was down-regulated significantly in placental villi tissue and trophoblasts from patients with recurrent miscarriage. In vitro, overexpression of STMN1 promoted human trophoblast proliferation, migration, and invasion, whereas knockdown of STMN1 inhibited these processes. In addition, knockdown of STMN1 down-regulated N-cadherin and up-regulated E-cadherin in trophoblasts, whereas E-cadherin was up-regulated and N-cadherin was down-regulated in recurrent miscarriage villi tissue. Knockdown of STMN1 attenuated cytoplasmic-nuclear translocation of ß-catenin and in turn down-regulated trophoblast matrix metalloproteases. Furthermore, tumor necrosis factor-α (TNF-α) down-regulated STMN1 expression, and serum TNF-α expression correlated inversely with trophoblast STMN1 levels. Interestingly, M1 macrophage-derived TNF-α reduced trophoblast migration and invasion, and an anti-TNF-α antibody reversed this effect. Collectively, this study indicated that STMN1 may play a key role in regulating trophoblast invasion, and that impaired STMN1 expression may lead to abnormal trophoblast invasion and result in recurrent miscarriage.

Comparison of the perinatal outcome of twins conceived after assisted reproductive technologies versus those conceived naturally.

OBJECTIVE: To analyze whether twin pregnancies resulting from assisted reproductive technologies (ARTs) had an increased risk of obstetric complications or adverse neonatal outcomes. STUDY DESIGN: The obstetric and neonatal outcomes of 252 cases of twin pregnancies, including 108 cases conceived by ART and 144 cases of natural conception, delivered at our hospital between January 1, 2009, and December 31, 2011, were compared retrospectively. RESULTS: Mean maternal age in the ART group was significantly older than that of the control group (31.04 ± 3.63 vs. 28.81 ± 4.75, t = 2.88, p < 0.05). Among the gravidas (< 35 years old) the incidence of premature rupture in the ART group and the control group was statistically significant (22.09% vs. 10.48%, χ2 = 5.30, p < 0.05). The incidence of mild asphyxia of the second twin in the ART group and the control group was also statistically significant (23.53% vs. 12.20%, χ2 = 4.61, p < 0.05). However, there was no statistical difference in other maternal or neonatal complications of twins between the ART group and the control group. CONCLUSION: In this study, except for a higher incidence of morbidity, premature rupture of membranes, and mild asphyxia of the second twin, the obstetric complications or adverse neonatal outcome in the ART group were similar, which indicated that ART-conceived twin pregnancies were not at higher risk for obstetric complications or adverse neonatal outcome than were naturally conceived twin pregnancies.

Uterine micro-environment and estrogen-dependent regulation of osteopontin expression in mouse blastocyst.

Embryo implantation is a highly synchronized bioprocess between an activated blastocyst and a receptive uterus. In mice, successful implantation relies on the dynamic interplay of estrogen and progesterone; however, the key mediators downstream of these hormones that act on blastocyst competency and endometrium receptivity acquisition are largely unknown. In this study, we showed that the expression of osteopontin (OPN) in mouse blastocysts is regulated by ovarian estrogen and uterine micro-environment. OPN mRNA is up-regulated in mouse blastocyst on day 4 of pregnancy, which is associated with ovarian estrogen secretion peak. Hormone treatment in vivo demonstrated that OPN expression in a blastocyst is regulated by estrogen through an estrogen receptor (ER). Our results of the delayed and activated implantation model showed that OPN expression is induced after estrogen injection. While estrogen treatment during embryo culture in vitro showed less effect on OPN expression, the tubal ligation model on day 3 of pregnancy confirmed that the regulation of estrogen on OPN expression in blastocyst might, through some specific cytokines, have existed in a uterine micro-environment. Collectively, our study presents that estrogen regulates OPN expression and it may play an important role during embryo implantation by activating blastocyst competence and facilitating the endometrium acceptable for active blastocyst.

[Luteal letrozole administration decreases serum estrogen level but not the risk of ovarian hyperstimulation syndrome].

OBJECTIVE: To explore the efficiency of using aromatase inhibitors during luteal phase in in vitro fertilization IVF stimulated cycles for patients at high risk for ovarian hyperstimulation syndrome (OHSS). METHODS: A total of 139 infertile women undergoing assisted reproductive technique with high risk for OHSS were enrolled in this clinical trial. In the treatment group 43 patients received five consecutive doses of aromatase inhibitors (letrozole) and support therapy combined with embryo cryopreservation. In the control group 96 patients received support therapy alone. All the patients were evaluated clinically, echographically, hematologically and tested for their steroid hormone. RESULTS: There was significantly lower estrogen level in the treatment group 2, 5 and 8 days after oocyte retrieval compared with the control group (P<0.001), There was no significant difference in luteinizing hormone and progesterone levels 2, 5 and 8 days after oocyte retrieval in the treatment group and control group (P>0.05). There were 7 cases of severe OHSS in the treatment group and 18 cases of severe OHSS in the control group. The rate of severe OHSS was not significantly different in the treatment group and control group (P=0.12). No side effect was reported in either group. CONCLUSION: Treatment with letrzolein luteal phase decreases serum estrogen levels of patients after oocyte retrieval,but it couldn't reduce the risk of severe OHSS.

Temporal and spatial regulation of ezrin-radixin-moesin-binding phosphoprotein-50-kDa (EBP50) during embryo implantation in mouse uterus.

Embryo implantation is a crucial process for successful pregnancy. To date, the mechanism of embryo implantation remains unclear. Ezrin-radixin-moesin-binding protein-50-kDa (EBP50) is a scaffold protein, which has been shown to play an important role in cancer development. Embryo implantation and cancer follow a similar progression. Thus, in this article, we utilized immunohistochemical staining and western blot analyses to examine the spatiotemporal expression and regulation of EBP50 both in the mouse uterus during embryo implantation as well as in other related models. We found that EBP50 was detected in epithelial cells in all of the groups used in our study. During the peri-implantation period, EBP50 mainly localized in apical membranes. At the implantation site (IS) on day 5 (D5) of pregnancy, EBP50 was mainly expressed in the nuclei of stroma cells, whereas from day 6 to day 8 (D6–D8) of pregnancy, the expression of EBP50 was noted in the cytoplasm of decidual cells. The expression of EBP50 was not significantly different in the pseudopregnant uterus and decreased in the uteri subjected to activation of delayed implantation. Artificial decidualization also decreased EBP50 expression. Thus, the expression levels and location were affected by active blastocysts and decidualization during the window of implantation.

[Ovarian torsion after controlled ovarian hyperstimulation: 5 cases report and clinical analysis].

OBJECTIVE: To evaluate the characteristics and treatment of ovary torsion after controlled ovarian hyperstimulation. METHODS: Between Jan.2008 and Dec.2011, 5 cases with ovary torsion who underwent ovarian hyperstimulation were retrospectively studied. RESULTS: Five cases presented intermittent lower abdominal from 1 to 38 days after oocyte retrieval. Enlargement of ovary and decreased or absent venous and/or arterial flow were demonstrated by Doppler sonography. Two torsions at left side, two torsions at right side, and one on bilateral side were observed. Three cases give up embryo transplantation, 2 cases were pregnant after surgical treatment. One case with partial torsion was successfully treated with simple conservative treatment. Two cases with complete torsion were performed adnexectomy by laparotomy. One case with complete torsion with early pregnancy was managed by laparoscopic adnexectomy. One case with chemical pregnancy was managed by laparoscopic detorsion for left side and excision for right side. Postoperative pathology of ovary tissue all confirmed haemorrhage and necrosis. CONCLUSIONS: Ovary torsion might occur after controlled ovarian hyperstimulation. The early management on ovary torsion will be benefit for preserving ovarian function.

[Expression of estrogen receptor, progesterone receptor and integrin alphaVbeta3 in endometrium of patients with luteinized unruptured follicle.].

OBJECTIVE: To investigate endometrium receptivity in patients with luteinized unruptured follicle (LUF) by measuring the expression of estrogen receptor (ER), progesterone receptor (PR) and integrin alphaVbeta3 in the endometrium. METHODS: From May 2007 to Nov. 2007, 17 infertile women with LUF were selected as LUF group matched with 13 infertile cases with normal ovulation as control group. They all underwent frozen-thawed embryo transfer in Reproductive Medicine Center, Renmin Hospital of Wuhan University. Endometrial tissue in anterior and posterior wall of uterus of LUF group and control group were biopsied by a small curettage between 7 and 11 days after luteinizing hormone (LH) surge. The expression of ER, PR and integrin alphaVbeta3 in endometrium were detected by immunohistochemistry staining. The level of estrogen and progesterone were measured by chemiluminescence assay. Then, the relationship between alphaVbeta3 expression in endometrium and the level of estrogen/progesterone were analyzed in LUF patients. RESULTS: (1) There was no remarkable difference in the level of estrogen between LUF [(656 +/- 299) pmol/L] and control group [(727 +/- 275) pmol/L, P > 0.05]. However, the level of progesterone were (23 +/- 8) nmol/L in LUF group and (35 +/- 10) nmol/L in control group, which reached statistical difference (P < 0.01). (2) The expression of ER, PR in endometrium of LUF patients were 183.9 +/- 2.4 and 168 +/- 3, which were significantly higher than 109.4 +/- 6.3 and 106 +/- 4 in control group (P < 0.01). The expression of integrin alphaVbeta3 in endometrium of 115 +/- 11 in LUF group were significantly lower than 191 +/- 9 in control group (P < 0.01). (4) In LUF group, the expression of alphaVbeta3 in endometrium was correlated positively with the level of progesterone (r = 0.77, P < 0.01) and irrelevant with the level of estrogen (r = 0.01, P > 0.05). CONCLUSION: The higher expression of estrogen and progesterone and lower expression of integrin alphaVbeta3 might confer impaired receptivity of endometrium and interfere with embryo implantation.

[Indications and clinical outcomes of half-ICSI in 99 cases].

OBJECTIVE: To determine an optimal insemination technique for patients suspected of high risk of fertilization failure and undergoing assisted reproduction treatment. METHODS: Ninety-nine couples were treated by conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in one cycle (half-ICSI) by dividing the sibling oocytes in halves. The clinical and laboratory data were analyzed, and the rates of fertilization, cleavage, good embryos and clinical pregnancy were compared between different fertilization methods. RESULTS: In the half-ICSI group, the fertilization rate of ICSI (80.5%) was significantly higher than that of IVF (42.9%) (P < 0.01), and so were the rates of complete fertilization failure (21.2%) and low fertilization (16.2%) of IVF than those of ICSI (0 and 3.0%). No significant differences were observed in the rates of cleavage and good-quality embryos between the two groups (P > 0.05). CONCLUSION: ICSI can help to avoid complete fertilization failure, achieve more high quality embryos for transfer and improve the rate of pregnancy for patients with high risk of fertilization failure.

Spontaneous ovarian hyperstimulation syndrome: Report of two cases.

BACKGROUND: Spontaneous ovarian hyperstimulation syndrome (sOHSS) is extremely rare. It can be divided into four types according to its clinical manifestations and follicle stimulating hormone receptor mutations. CASE SUMMARY: Here we report two cases of sOHSS in Chinese women, one with a singleton gestation developing sOHSS in the first trimester who conceived naturally and the other with a twin pregnancy developing sOHSS in the second trimester after a thawed embryo transfer cycle. Both patients were admitted to the hospital with abdominal distension, ascites, and enlarged ovaries. Conservative treatment was the primary option of management. The first patient had spontaneous onset labor at 40 wk of gestation and underwent an uncomplicated vaginal delivery of a male newborn. The second patient delivered a female baby and a male baby by caesarean section at 35 wk and 1 d of gestation. CONCLUSION: Patients with a history of ovarian hyperstimulation syndrome should be closely monitored. Single embryo transfer might reduce the risk of this rare syndrome.

Flexible GnRH Antagonist Protocol versus Progestin-primed Ovarian Stimulation (PPOS) Protocol in Patients with Polycystic Ovary Syndrome: Comparison of Clinical Outcomes and Ovarian Response.

Polycystic ovary syndrome (PCOS) is one of the most common causes of infertility in women. Progestin-primed ovarian stimulation (PPOS) protocol, which used oral progestin to prevent premature luteinizing hormone (LH) surges in ovarian stimulation, has been proved to be effective and safe in patients with PCOS. The aim of the present study was to compare the efficacy of PPOS protocol with that of the traditional gonadotropin-releasing hormone (GnRH) antagonist protocol in patients with PCOS. A total of 157 patients undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) were recruited into this study. The patients were divided into two groups by the stimulation protocols: the GnRH antagonist protocol group and the PPOS protocol group. There was no significant difference in the clinical characteristics between the two groups. Dose and duration of gonadotropin were higher in the PPOS protocol group. Estradiol levels on the day of human chorionic gonadotropin (hCG) administration were significantly lower in the PPOS protocol group. Fertilization rates and the number of good quality embryos were similar between the two groups. Remarkably, we found 6 patients with moderate ovarian hyperstimulation syndrome (OHSS) in the GnRH antagonist protocol group but 0 in the PPOS protocol group. A total of 127 women completed their frozen embryo transfer (FET) cycles. There were no significant differences between the two groups in terms of clinical pregnancy rate per transfer, implantation rate, first-trimester miscarriage rate and on-going pregnancy rate per transfer. To conclude, PPOS protocol decreased the incidence of OHSS without adversely affecting clinical outcomes in patients with PCOS.

Acetyl-L-carnitine: An effective antioxidant against cryo-damage on human spermatozoa with asthenospermia.

A variety of natural and artificial cryoprotectant extenders have been explored to enhance sperm recovery following cryopreservation-thawing process. The current investigation is aimed at evaluating the effect of acetyl-L-carnitine on human spermatozoa and reactive species oxygen (ROS) level after freezing-thawing process. The spermatozoa were collected from 35 male patients diagnosed as having asthenospermia. The cryopreservation of human spermatozoa treated with acetyl-L-carnitine at different concentrations (group B: 2.5 mmol/L, group C: 7.5 mmol/L, group D: 15 mmol/L) was compared with control (group A: no acetyl-L-carnitine given). For the frozen-thawed spermatozoa, the viability, motility and DNA integrity were measured by comet assay, acrosome integrity by FITC-PNA staining and ROS level was determined in each group. The results showed that there were no significant differences in motility and viability between group A and group B, while the motility and viability of spermatozoa in group C and group D were significantly increased as compared with those in group A. As compared with group A, the values for DNA integrity parameters including comet rate (CR), tail DNA percentage (TD), tail length (TL) and Oliver tail moment (OTM) were significantly reduced in group C and group D. Group C and group D also displayed a higher proportion of intact acrosome than group A. No significant difference in ROS level was found between group A and group B, while with the increase in acetyl-L-carnitine concentration, the ROS level in groups C and D was significantly reduced as compared with that in group A. In conclusion, acetyl-L-carnitine at a concentration of 7.5 mmol/L is an effective antioxidant against cryo-damage on post-thawed human spermatozoa.

Reproductive outcome of septate uterus after hysteroscopic treatment with neodymium:YAG laser.

OBJECTIVE: The aim of this study was to assess fertility outcome and obstetrical prognosis of 46 patients after hysteroscopic section of uterine septa with neodysmium:yttrium-aluminum-garnet (Nd:YAG) laser. BACKGROUND DATA: Approximately 15-25% of spontaneous miscarriages are related to Müllerian fusion defects, most of which are associated with uterine septa. Operative hysteroscopy is a safe and effective treatment for uterine septa. METHODS: Forty-six sterile patients with septate uterus received hysteroscopic metroplasty with Nd:YAG laser. Forty-one patients with incomplete septate uterus were under the guidance of B-ultrasonography, while the other 5 patients with complete septate uterus were treated by laparoscopy. RESULTS: The metroplasty was successfully conducted in 45 patients, with a success rate of 98% (45 /46). Postoperative follow-up examinations of 28 patients revealed pregnancy within 12 months in 20 patients, 16 of whom acquired term delivery. The pregnancy rate within 1 year was 71%. CONCLUSION: Hysteroscopic treatment of septate uterus with Nd:YAG laser is effective. The cervix may not be excessively dilated, the intraoperative bleeding can be thoroughly controlled, and the procedure under local anesthesia is relatively safe.

Oxidative Stress: Placenta Function and Dysfunction.

During pregnancy, the placenta is a site of active oxygen metabolism that continuously generates oxidative stress (OS). Overproduction of reactive oxygen species and reactive nitrogen species can destroy normal placental functions. Therefore, the feto-placental unit generates abundant antioxidants to keep OS under control. Properly controlled oxidative species have been proven to serve as indispensable cellular signal messengers by regulating gene expression and downstream cellular activities. OS also plays an important immunoregulatory role during pregnancy. Oxidative disorder and immune disturbances are associated with adverse pregnancy outcomes such as spontaneous abortion, preeclampsia and intrauterine growth restriction. In this review, we introduce recent studies revealing basal functions and regulatory roles of placental OS in metabolism and immunity. The relationships between OS- and pregnancy-related disorders are also discussed.

IL-17 Induces Fetal Loss in a CBA/J×BALB/c Mouse Model, and an Anti-IL-17 Antibody Prevents Fetal Loss in a CBA/J×DBA/2 Mouse Model.

PROBLEM: Many researchers have demonstrated that the expression of interleukin-17(IL-17) is higher in spontaneous abortion. However, whether Th17 cells are an independent factor in inducing abortion is not known. METHOD OF STUDY: This study investigated the effect of exogenous recombinant IL-17 and an anti-IL-17 antibody in a normal and an abortion mouse model using flow cytometry, enzyme-linked immunosorbent assay, real-time PCR, and Western blot. RESULTS: Th17 cells and the related factors, IL-17 and RORγt, were significantly upregulated in abortion mice, and Treg cells and the related factor, Foxp3, were downregulated. Intraperitoneal injection of recombinant IL (rIL)-17 induced fetal loss in a normal mouse model, and an anti-IL-17 antibody prevented fetal loss in an abortion mouse model. CONCLUSION: This study confirmed an imbalance of the Th17/Treg paradigm in abortion mice and IL-17 as a risk factor of fetal loss. An anti-IL-17 antibody may prevent abortion.

The Immunogenicity of CRISP1 Plasmid-Based Contraceptive Vaccine can be Improved When Using Chitosan Nanoparticles as the Carrier.

PROBLEM: To evaluate the effectiveness and security of a contraceptive vaccine using plasmid DNA encoding mouse CRISP1 as antigen and chitosan nanoparticles as the carrier. METHOD OF STUDY: Chitosan-pcDNA3.1-mCRISP1 Nanoparticles (CS-DNA NPs) were prepared and characterized in terms of morphology, zeta potential, polydispersity index, and binding capacity of pDNA. The cytotoxicity and gene transfer capability of CS-DNA NPs were assessed in COS-7 cells compared to Lipofectamine 2000(™) . Four groups of mice received three injections of 0.9% normal saline, pcDNA3.1 vector, pcDNA3.1-CRISP1, or CS-DNA NPs, respectively. ELISA was used to examine the immune responses. Fertility and mean litter size were analyzed by natural mating. RESULTS: CS-DNA NPs have a spherical or elliptical shape with a mean diameter of 189.3 nm, positive zeta potential, and good DNA condensation. It also showed high DNAse resistance and good transfection efficiency without cell toxicity. The titers of anti-mCRISP1 antibodies from CS-DNA NP-immunized mice were significantly higher than that of pcDNA3.1-CRISP1 group. Male and female CS-DNA NP-immunized animals were recognized with a statistically significant reduction in their fertility compared with pcDNA3.1-CRISP1-immunized mice. CONCLUSION: This study demonstrated that using chitosan-DNA nanoparticles as the carrier can improve the immunogenicity of mCRISP1 DNA contraceptive vaccine with good security.

Patients with cervical Ureaplasma Urealyticum and Chlamydia Trachomatis infection undergoing IVF/ICSI-ET: The need for new paradigm.

Genital tract infections with ureaplasma urealyticum (UU) and chlamydia trachomatis (CT) are the most frequent sexually-transmitted disease worldwide. UU and CT infections are considered to be the leading cause for infertility and adverse pregnancy outcomes. However, little is known about the specific effect of cervical UU and CT infections on the etiology of female infertility, as well as the pregnancy outcomes of the patients undergoing in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET). In order to find the association between cervical UU and/or CT infection and pregnancy outcomes, we conducted a retrospective case-control study on the patients undergoing IVF/ICSI-ET with cervical UU and/or CT infection. A total of 2208 patients who received IVF/ICSI-ET were enrolled in this study. Data on the general conditions, pregnancy history and clinical pregnant outcomes were analyzed in terms of the cervical UU and CT detection. Our results revealed that cervical UU and CT infections were the risk factors for ectopic pregnancy and tubal factor-induced infertility. Moreover, the pregnancy rate, abortion rate, ectopic pregnancy rate and premature birth rate in patients with UU and/or CT infections showed no significant difference when compared with the control group. We recommend that cervical UU and CT detection should be an optional item for infertility patients and clinical UU detection should differentiate the subtypes of cervical UU. Positive cervical UU and CT infections should not be taken as strict contraindications for IVF/ICSI-ET.

Culture media influenced laboratory outcomes but not neonatal birth weight in assisted reproductive technology.

Whether the type of culture media utilized in assisted reproductive technology has impacts on laboratory outcomes and birth weight of newborns in in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) was investigated. A total of 673 patients undergoing IVF/ICSI and giving birth to live singletons after fresh embryo transfer on day 3 from Jan. 1, 2010 to Dec. 31, 2012 were included. Three types of culture media were used during this period: Quinn's Advantage (QA), Single Step Medium (SSM), and Continuous Single Culture medium (CSC). Fertilization rate (FR), normal fertilization rate (NFR), cleavage rate (CR), normal cleavage rate (NCR), good-quality embryo rate (GQER) and neonatal birth weight were compared using one-way ANOVA and χ (2) tests. Multiple linear regression analysis was performed to determine the impact of culture media on laboratory outcomes and birth weight. In IVF cycles, GQER was significantly decreased in SSM medium group as compared with QA or CSC media groups (63.6% vs. 69.0% in QA; vs. 71.3% in CSC, P=0.011). In ICSI cycles, FR, NFR and CR were significantly lower in CSC medium group than in other two media groups. No significant difference was observed in neonatal birthweight among the three groups (P=0.759). Multiple linear regression analyses confirmed that the type of culture medium was correlated with FR, NFR, CR and GQER, but not with neonatal birth weight. The type of culture media had potential influences on laboratory outcomes but did not exhibit an impact on the birth weight of singletons in ART.

Immunogenicity study of plasmid DNA encoding mouse cysteine-rich secretory protein-1 (mCRISP1) as a contraceptive vaccine.

PROBLEM: To examine the immunocontraceptive properties of the plasmid pcDNA-mCRISP1 and compare them to the corresponding recombinant mCRISP1 (r-mCRISP1). METHOD OF STUDY: RT-PCR and indirect immunofluorescence were performed to observe the mCRISP1 protein expression in COS-7 cells. Three groups of mice received three injections of r-mCRISP1, pcDNA-mCRISP1 or pcDNA vector, respectively. ELISA and Western blot were used to examine the immune responses and immunoreactivity of antisera. Sperm-egg penetration assay was performed to examine the effect of anti-mCRISP1 antibodies in vitro fertilization of mouse oocytes. Fertility and mean litter size were analysed by natural mating. Histological analysis was carried out to look for potential immunopathologic effects of the antibodies. RESULTS: COS-7 cells transfected with pcDNA-mCRISP1 present the expression of mCRISP1. Both r-mCRISP1 and pcDNA-mCRISP1 raised an immune response against r-mCRISP1 protein and native CRISP1 in mouse sperm. The titres of anti-mCRISP1 antibodies from DNA immunized mice were significantly lower than that of r-mCRISP1 immunized mice, but it lasted relatively longer. Male and female pcDNA-mCRISP1 injected animals presented a statistically significant reduction in their fertility with no signs of immunopathologic effects. CONCLUSION: These studies demonstrated the feasibility of generating an immune response to mCRISP1 protein by DNA vaccine and pcDNA-mCRISP1 plasmid causing significant anti-fertility potential.

Folic acid supplementation as adjunctive treatment premature ejaculation.

Selective serotonin re-uptake inhibitors (SSRIs), has been increasingly used for the treatment of premature ejaculation over the past 5 years. It was reported that folic acid plays important roles in synthesis of 5-HT. Therefore, we hypothesize that folic acid supplementation may cures premature ejaculation by the same mechanism of interacting with monoamine neurotransmitters in brain, to be the replacement of RRSIs. Folic acid supplementation cures premature ejaculation more safely. These new views will help to understand the diagnosis and treatment methods for premature ejaculation.