Dynamics of IGF signalling during the ovulatory peak in women undergoing ovarian stimulation.

CONTEXT: IGF signalling is known to affect human ovarian follicular function during growth and development. However, the role of the IGF system is unknown during the ovulatory peak, which is characterized by profound changes in granulosa cell (GCs) mitosis and function. OBJECTIVE: How is the IGF system expressed and regulated during the midcycle surge in women? DESIGN: Follicular fluid (FF) and granulosa cells (GCs) were collected during the ovulatory peak from two specific time-points. One sample was obtained before oocyte pick up (OPU): before ovulation trigger (OT) (T = 0 h) or at 12, 17, or 32 h after OT, and one sample was obtained at OPU 36 h after OT. SETTING: University hospital. PATIENTS/PARTICIPANTS: Fifty women undergoing ovarian stimulation were included. MAIN OUTCOME MEASURE: Gene expression profiles were assessed by microarray analysis of GCs. IGF-related proteins in the FF were assessed by using immunoassays or by determination of activity with a proteinase assay. RESULTS: Expression of proteins promoting IGF activity (i.e., IGF2, PAPPA, and IRS1) together with proliferation markers were downregulated on a transcriptional level in GCs after OT, whereas proteins inhibiting the IGF signal (i.e., IGFBPs, IGF2R, and STC1) were upregulated. STC1 gene expression and protein levels were greatly upregulated after OT with a parallel steep downregulation of PAPP-A proteolytic activity. CONCLUSIONS: These data suggest that downregulation of IGF signalling mediated by increased STC1 expression is instrumental for the sudden cessation in GC proliferation and onset of differentiation during the ovulatory peak.

Letrozole in fertility treatment.

This review describes the current evidence regarding the putative indications of letrozole (LTZ) in fertility treatment. Prior to intrauterine insemination, LTZ is recommended in women with normogonadotrophic oligo-anovulation. In ovulatory women, LTZ is equal to clomiphene and may be used instead of exogenous gonadotrophin. LTZ may be used as co-treatment in poor responders prior to in vitro fertilization/intracytoplasmic sperm injection. In addition, LTZ prior to frozen-thawed embryo transfer is increasingly used in women with normogonadotrophic oligo-anovulation.

Proteome of fluid from human ovarian small antral follicles reveals insights in folliculogenesis and oocyte maturation.

STUDY QUESTION: Is it possible to identify by mass spectrometry a wider range of proteins and key proteins involved in folliculogenesis and oocyte growth and development by studying follicular fluid (FF) from human small antral follicles (hSAF)? SUMMARY ANSWER: The largest number of proteins currently reported in human FF was identified in this study analysing hSAF where several proteins showed a strong relationship with follicular developmental processes. WHAT IS KNOWN ALREADY: Protein composition of human ovarian FF constitutes the microenvironment for oocyte development. Previous proteomics studies have analysed fluids from pre-ovulatory follicles, where large numbers of plasma constituents are transferred through the follicular basal membrane. This attenuates the detection of low abundant proteins, however, the basal membrane of small antral follicles is less permeable, making it possible to detect a large number of proteins, and thereby offering further insights in folliculogenesis. STUDY DESIGN, SIZE, DURATION: Proteins in FF from unstimulated hSAF (size 6.1 ± 0.4 mm) were characterised by mass spectrometry, supported by high-throughput and targeted proteomics and bioinformatics. The FF protein profiles from hSAF containing oocytes, capable or not of maturing to metaphase II of the second meiotic division during an IVM (n = 13, from 6 women), were also analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS: We collected FF from hSAF of ovaries that had been surgically removed from 31 women (∼28.5 years old) undergoing unilateral ovariectomy for fertility preservation. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 2461 proteins were identified, of which 1108 identified for the first time in FF. Of the identified proteins, 24 were related to follicular regulatory processes. A total of 35 and 65 proteins were down- and up-regulated, respectively, in fluid from hSAF surrounding oocytes capable of maturing (to MII). We found that changes at the protein level occur already in FF from small antral follicles related to subsequent oocyte maturation. LIMITATIONS, REASONS FOR CAUTION: A possible limitation of our study is the uncertainty of the proportion of the sampled follicles that are undergoing atresia. Although the FF samples were carefully aspirated and processed to remove possible contaminants, we cannot ensure the absence of some proteins derived from cellular lysis provoked by technical reasons. WIDER IMPLICATIONS OF THE FINDINGS: This study is, to our knowledge, the first proteomics characterisation of FF from hSAF obtained from women in their natural menstrual cycle. We demonstrated that the analysis by mass spectrometry of FF from hSAF allows the identification of a greater number of proteins compared to the results obtained from previous analyses of larger follicles. Significant differences found at the protein level in hSAF fluid could predict the ability of the enclosed oocyte to sustain meiotic resumption. If this can be confirmed in further studies, it demonstrates that the viability of the oocyte is determined early on in follicular development and this may open up new pathways for augmenting or attenuating subsequent oocyte viability in the pre-ovulatory follicle ready to undergo ovulation. STUDY FUNDING/COMPETING INTEREST(S): The authors thank the financial support from ReproUnion, which is funded by the Interreg V EU programme. No conflict of interest was reported by the authors. TRIAL REGISTRATION NUMBER: N/A.

Ovarian stimulation and assisted reproductive technology outcomes in women transplanted with cryopreserved ovarian tissue: a systematic review.

OBJECTIVE: To systematically review reproductive outcomes of assisted reproductive technology (ART) treatment in women transplanted with frozen-thawed ovarian tissue. DESIGN: Systematic review in accordance with guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). SETTING: Not applicable. PATIENT(S): Women undergoing ovarian tissue transplantation (OTT) and subsequent ART. INTERVENTION(S): Literature search in PubMed and Scopus databases. MAIN OUTCOME MEASURE(S): Time from OTT to initiation of ART, stimulation protocol, and conventional ART outcome measures. RESULT(S): Twenty studies (including 15 case reports), specifying ART treatments and outcomes of 40 women undergoing OTT were identified. Multiple stimulation protocols were applied, with the modified natural cycle as the most frequently used. In total, 195 ART cycles were performed (4.0 cycles per patient) resulting in 1.5 follicles and 1.0 mature oocyte retrieved per cycle. Empty follicle rates ranged from 23% to 35% in the three largest cohort studies. Twenty-five women (62.5%) had one or more pregnancies, of which 28.6% were lost, resulting in a total of 20 live births (22 children). Overall the pregnancy rates varied from 3.9% to 19.3% and live-birth rates from 3.9% to 14.0% per cycle in the three cohort studies. Fertility treatment was initiated shortly after OTT in some centers, while others awaited natural conception before embarking on ART treatment. CONCLUSION(S): The reported pregnancy and live-birth rates for women undergoing OTT and ART were considerably lower than those of the general in vitro fertilization (IVF) population, corresponding to patients with poor ovarian reserve. In general, ART outcomes are underreported, and there is a lack of consensus regarding the timing of ART in relation to OTT and the type of ovarian stimulation protocol.

Progressive changes in human follicular fluid composition over the course of ovulation: quantitative proteomic analyses.

Follicular fluid (FF) acts as a vehicle for paracrine signalling between somatic cells of the follicle and the oocyte. To investigate changes in the protein composition of FF during ovulation, we conducted a prospective cohort study including 25 women undergoing fertility treatment. Follicular fluid was aspirated either before or 12, 17, 32 or 36 h after induction of ovulation (five patients per time point). Liquid chromatography-mass spectrometry was used to identify and quantify FF proteins. In total, 400 proteins were identified and the levels of 40 proteins changed significantly across ovulation, evaluated by analysis of covariance (adjusted p < 0.05) and on-off expression patterns. The majority peaked after 12-17 h, e.g., AREG (p < 0.0001), TNFAIP6 (p < 0.0001), and LDHB (p = 0.0316), while some increased to peak after 36 h e.g., ACPP (p < 0.0001), TIMP1 (p < 0.0001) and SERPINE1 (p = 0.0002). Collectively, this study highlights proteins and pathways of importance for ovulation and oocyte competence in humans.

Human granulosa cells function as innate immune cells executing an inflammatory reaction during ovulation: a microarray analysis.

Ovulation has been compared to a local inflammatory reaction. We performed an in silico study on a unique, PCR validated, transcriptome microarray study to evaluate if known inflammatory mechanisms operate during ovulation. The granulosa cells were obtained in paired samples at two different time points during ovulation (just before and 36 hours after ovulation induction) from nine women receiving fertility treatment. A total of 259 genes related to inflammation became significantly upregulated during ovulation (2-80 fold, p<0.05), while specific leukocyte markers were absent. The genes and pathway analysis indicated NF-KB-, MAPK- and JAK/STAT signalling (p<1.0E-10) as the major pathways involved in danger recognition and cytokine signalling to initiate inflammation. Upregulated genes further encoded enzymes in eicosanoid production, chemo-attractants, coagulation factors, cell proliferation factors involved in tissue repair, and anti-inflammatory factors to resolve the inflammation again. We conclude that granulosa cells, without involvement from the innate immune system, can orchestrate ovulation as a complete sterile inflammatory reaction.

Time from referral to ovarian tissue cryopreservation in a cohort of Danish women.

INTRODUCTION: Young women with a cancer diagnosis often have very little time to decide whether or not to commence fertility-preserving strategies before initiating potentially sterilizing cancer treatment. Minimizing the interval from opting for fertility preservation to completion of the procedure will reduce the potential risk of delaying cancer treatment. In the current study, we have evaluated the period of time from referral to ovarian tissue cryopreservation (OTC) to actual freezing of the tissue in a cohort of Danish women. MATERIAL AND METHODS: The study population comprised 277 consecutive patients with both malignant and nonmalignant diseases referred for OTC from four centers in the Danish network. Statistical analysis was conducted to analyze the impact of age, diagnosis, and referring center on the time from OTC-referral to OTC. A literature search for "random start" protocols for controlled ovarian stimulation (COS) for fertility preservation in cancer patients was performed. RESULTS: The time from OTC-referral to OTC was significantly influenced by diagnosis, age, and referring center. Women with malignant diseases other than breast cancer, such as sarcomas, pelvic cancers, and hematological cancers, experienced a significantly shorter interval to OTC (5 days) than women with breast cancer (7 days) and nonmalignant diseases including systemic, ovarian, and hereditary conditions (13-17.5 days). Women over the age of 30 years experienced a significantly longer time to OTC (P < 0.03), and the diagnosis determined the length of the interval (P < 0.001). According to the literature, fertility preservation by oocyte vitrification requires 13-14 days, as the average time for 1 round of COS was 11 days and oocyte collection can be performed 2 days later. CONCLUSIONS: It is in the interest of both cancer patients and clinicians to perform fertility preservation as quickly and safely as possible. In a Danish setting, OTC provides a short interval of around 6 days from the patient choosing this option to completion of the procedure. This is considerably less time than what is needed to perform COS and oocyte vitrification, and therefore OTC might be considered the preferred choice of fertility preservation when urgency is needed.

Establishment of ultrasound as a diagnostic aid in the referral of patients with abdominal pain in an emergency department - a pilot study.

PURPOSE: Ultrasonography is a noninvasive, cheap, and fast way of assessing abdominal pain in an emergency department. Many physicians working in emergency departments do not have pre-existing ultrasound experience. The purpose of this study was to investigate the ability of first-year internship doctors to perform a reliable ultrasound examination on patients with abdominal pain in an emergency setting. MATERIALS AND METHODS: This study took place in an emergency department in Denmark. Following a 1-day ultrasound introduction course, three doctors without prior ultrasound experience scanned 45 patients during a 2-month period. The applicability of the examinations was evaluated by subsequent control examination: computed tomography, operation, or ultrasound by a trained radiologist or gynecologist or, in cases where the patient was immediately discharged, by ultrasound image evaluation. RESULTS: In 14 out of 21 patients with a control examination, there was diagnostic agreement between the project ultrasound examination and the control. Image evaluation of all patients showed useful images of the gallbladder, kidneys, liver, abdominal aorta, and urinary bladder, but no useful images for either the pancreas or colon. CONCLUSION: With only little formal training, it is possible for first-year internship doctors to correctly visualize some abdominal organs with ultrasonography. However, a longer study time frame, including more patients, and an ultrasound course specifically designed for the purpose of use in an emergency department, is needed to enhance the results.