Association of the eukaryotic vaginal virome with prophylactic antibiotic exposure and reproductive outcomes in a subfertile population undergoing in vitro fertilisation: a prospective exploratory study.

OBJECTIVE: The objective of this study was to use high-throughput sequencing to describe the vaginal eukaryotic DNA virome in patients undergoing in vitro fertilisation (IVF) to examine associations between the vaginal virome, antibiotic exposure and IVF outcomes. DESIGN: Prospective exploratory study. SETTING: Single academic fertility centre. POPULATION: Subfertile women age 18-43 years undergoing their first IVF cycle with a fresh embryo transfer. METHODS: The primary exposure was prophylactic azithromycin or no azithromycin before IVF. A mid-vaginal swab was obtained at the time of embryo transfer for virome analysis. MAIN OUTCOME MEASURES: The primary outcomes compared between exposure groups were characteristics of vaginal virome and clinical pregnancy rates. Secondary outcomes were virome associations with number of oocytes retrieved, number of blastocysts and implantation rate. RESULTS: Twenty-six women contributed a vaginal swab before embryo transfer. There were no significant differences in IVF outcomes between azithromycin groups. There was no association between viral diversity and clinical pregnancy overall. A higher diversity of herpesviruses and α-papillomaviruses was observed in samples from the azithromycin-treated group compared with the no azithromycin group (P = 0.04). In women that received azithromycin, viral diversity was higher in the group that did not achieve clinical pregnancy compared with those who did (P = 0.06). CONCLUSIONS: We demonstrate that the vaginal eukaryotic virome in women undergoing IVF is associated with antibiotic exposure. Additionally, we demonstrate an inverse trend between viral diversity and pregnancy, with a higher number of viruses detected associated with failure to achieve clinical pregnancy in the azithromycin group. TWEETABLE ABSTRACT: Higher viral diversity is associated with prophylactic antibiotic exposure in subfertile women undergoing IVF.

Reduction of ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries.

OBJECTIVE: To report a rare case of unilateral ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries. DESIGN: Case report and literature review. SETTING: Reproductive Endocrine division in a university teaching hospital. PATIENT(S): Infertility patients undergoing IVF-ET. INTERVENTION(S): Laparoscopic reduction of adnexa 1 week after ET. MAIN OUTCOME MEASURE(S): Successful preservation of the affected adnexa. RESULT(S): Delivery of 3.324 kg male infant with preservation of the affected ovary. CONCLUSION(S): Untwisting of the affected ovary at laparoscopy without aspiration reduction of cystic masses is appropriate. The outcome of the pregnancy (even very early) in patients with torsion of the adnexa may be favorable after a laparoscopic unwinding of the affected adnexa.

Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone.

OBJECTIVE: To determine whether metformin treatment increases the ovulation and pregnancy rates in response to clomiphene citrate (CC) in women who are resistant to CC alone. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Multicenter environment. PATIENT(S): Anovulatory women with the polycystic ovary syndrome (PCOS) who were resistant to CC. INTERVENTION(S): Participants received placebo or metformin, 500 mg three times daily, for 7 weeks. Information on reproductive steroids, gonadotropins, and oral glucose tolerance testing was obtained at baseline and after treatment. Metformin or placebo was continued and CC treatment was begun at 50 mg daily for 5 days. Serum P level > or =4 ng/mL was considered to indicate ovulation. With ovulation, the daily CC dose was not changed, but with anovulation it was increased by 50 mg for the next cycle. Patients completed the study when they had had six ovulatory cycles, became pregnant, or experienced anovulation while receiving 150 mg of CC. MAIN OUTCOME MEASURE(S): Ovulation and pregnancy rates. RESULT(S): In the metformin and placebo groups, 9 of 12 participants (75%) and 4 of 15 participants (27%) ovulated, and 6 of 11 participants (55%) and 1 of 14 participants (7%) conceived, respectively. Comparisons between the groups were significant. CONCLUSION(S): In anovulatory women with PCOS who are resistant to CC, metformin use significantly increased the ovulation rate and pregnancy rate from CC treatment.

Fertility treatment in the forty and older woman.

PURPOSE: To determine the outcomes and logical progression of fertility treatment in women forty years and older using their own oocytes. METHODS: This was a retrospective study in which 401 completed treatment cycles in 152 women aged forty and older were reviewed. RESULTS: Assisted reproductive technology (ART) cycles (n = 58) were reviewed, comprising both in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). Intrauterine insemination (IUI) cycles (n = 343) were reviewed, consisting of 38 unstimulated natural cycle-IUI (NC-IUI), 194 clomiphene citrate-IUI (CC-IUI), and 111 injectable gonadotropins-IUI (INJ-IUI) cycles. The live birth rate of 15.5% for ART cycles was significantly higher than the live birth rate of 3.2% seen for all IUI cycles (p = 0.0007). There were no differences among treatment groups in spontaneous abortion, preterm delivery, or ectopic pregnancy rates. CONCLUSIONS: For women > or = 40 years of age who wish to use their own eggs, ART offers the best chances for conception and delivery.

Expression of BCL-2, BAX and BAK in the trophoblast layer of the term human placenta: a unique model of apoptosis within a syncytium.

The regulation of apoptosis in the syncytiotrophoblast is of particular interest because this is the only true syncytial epithelium in human cell biology. Nuclei characteristic of apoptotic cells have been localized to this syncytium especially in association with fibrin-containing fibrinoid deposits. The factors responsible for regulating cell death-like features in the trophoblast syncytium are unknown. We tested the hypothesis that fibrin was required for trophoblast apoptosis. TUNEL (terminal deoxynucleotidyltransferase-mediated dUTP end-labelling) staining to detect DNA fragmentation typical of apoptosis was performed in term human placentae revealing labelled nuclei associated with fibrin-type fibrinoid, as well as labelled nuclei in discrete areas of syncytiotrophoblast without fibrin. We also hypothesized that members of the BCL-2 family of apoptosis-associated proteins contribute to the regulation of syncytiotrophoblast apoptosis. To identify members of this protein family that might regulate trophoblast apoptosis, we assessed expression of three important members of the bcl-2 gene family. We used immunohistochemistry with monoclonal antisera against human BCL-2 and polyclonal antisera against human BAX and BAK to study paraffin-embedded sections of human term placentae (n=5) from uncomplicated pregnancies. The anti-apoptotic BCL-2 protein was expressed throughout the syncytium of normal villi with much less staining in cytotrophoblast. Staining was also seen adjacent to fibrin deposits and in syncytium overlying fibrin deposits. Expression of the pro-apoptotic BAX protein was undetectable in the syncytiotrophoblast, was expressed in rare cytotrophoblast and was prominent in connective tissue and perivascular cells within the villous core. Localization of a second pro-apoptotic protein, BAK, revealed immunoreactivity in isolated areas of intact syncytium of normal villi. Additionally, fibrin deposits were associated with intense BAK staining in both syncytiotrophoblast and cytotrophoblast. From these data, we speculate that modulation of BAK expression is one factor regulating apoptosis in human trophoblast.

Idiopathic calcinosis cutis presenting as labial lesions in children: report of two cases with literature review.

BACKGROUND: Calcinosis cutis is a general term for calcium deposition in the skin. It may be due to abnormal calcium or phosphorus metabolism, damage to the dermal collagen, or idiopathic. It has been found in the skin of many areas of the body, including the face, extremities, penis, scrotum and mons pubis. We report two cases of calcinosis cutis presenting as lesions of the labia majora in children. CASES: A 6 1/2-year-old girl presented with labial lesions of unknown etiology. There was no history of sexual abuse or trauma. Excisional biopsy was performed and histopathological evaluation showed subepithelial calcification. Follow-up laboratory evaluation revealed normal serum calcium and phosphorus levels. Screening tests for collagen vascular diseases were negative. An 8-year-old girl presented for evaluation of a "labial cyst." The lesion was first noted 6 months prior to presentation and had not resolved, despite treatment with topical creams and sitz baths. Excisional biopsy was performed and histopathological evaluation showed multiple nodules of calcified and amorphous debris surrounded by histiocytes and giant cells. CONCLUSION: We report two cases of idiopathic calcinosis cutis presenting as labial lesions in children. Because it can be mistaken for a sexually transmitted disease, recognition and proper diagnosis of this condition is essential. Additionally, work-up to rule out abnormalities of phosphorus or calcium metabolism and collagen vascular diseases may be indicated.

A combined surgical and radiologic technique for creating a functional neo-endocervical canal in a case of partial congenital cervical atresia.

OBJECTIVE: To recanalize the endocervical canal in a patient with partial congenital cervical atresia. DESIGN: Case report. SETTING: University hospital. PATIENT: A 16-year-old girl referred with a history of primary amenorrhea, polycystic ovaries, and intermittent abdominal pain. Physical examination revealed a normal vagina and external cervical os, but magnetic resonance imaging revealed a solid endocervical tract. INTERVENTION(S): At laparotomy the endometrial cavity was accessed transfundally and outlined by injection of water-soluble contrast. A trocar needle was guided transvaginally into the uterus, the tract was dilated, and a 12F stent was placed. Oral contraceptives (OCs) and antibiotics were continued postoperatively. MAIN OUTCOME MEASURE(S): Hysterosalpingography and clinical follow-up. RESULT(S): The operation and postoperative course were uneventful. Withdrawal bleeding occurred at 8 weeks, after discontinuation of the OCs, at which time the stent was expelled. Later follow-up revealed recurrent narrowing, and the stent was replaced for 14 more weeks. After stent removal, regular menses continued (7 months to date). CONCLUSION: In select cases of congenital cervical atresia, recanalization may be safely performed with the use of the combined surgical-radiologic technique described, with good short-term outcome.

Analysis of apoptosis and expression of bcl-2 gene family members in the human and baboon ovary.

Recent data support a role for apoptosis, under tight regulatory control by bcl-2, oxidative stress response, tumor suppressor, and CASP gene family members, in mediating granulosa cell demise during follicular atresia in the rodent and avian ovary. Herein we evaluated the occurrence of apoptosis in the human and baboon ovary relative to follicular health status, and analyzed expression of several cell death genes in these tissues. In situlocalization of DNA strand breaks in fixed human and baboon ovarian tissue sections indicated that apoptosis was essentially restricted to granulosa cells of atretic antral follicles. Biochemical analysis of DNA oligonucleosomes in individual follicles isolated from baboon ovaries during the ovulatory phase revealed the presence of apoptotic DNA fragments in subordinate but not dominant follicles, thus substantiating the in situ labeling studies. Messenger RNA transcripts encoded by the bax death susceptibility gene, the bcl-xlong survival gene, the bcl-xshort pro-apoptosis gene, the p53 tumor suppressor gene, and two members of the CASP gene family (CASP-2/Ich-1, CASP-3/CPP32), were detected by Northern blot analysis of total RNA prepared either from human ovaries or from Percoll-purified granulosa-lutein cells obtained from patients undergoing assisted reproductive technologies. Lastly, immunohistochemical localization of the BAX death-susceptibility protein in the human ovary revealed abundant expression in granulosa cells of early atretic follicles, whereas BAX protein was extremely low or non-detectable in healthy or grossly-atretic follicles. We conclude that apoptosis occurs during, and is probably responsible for, folicular atresia in the human and baboon ovary. Moreover, apoptosis in the human ovary is likely controlled by altered expression of the same cohort of cell death regulatory factors recently implicated as primary determinants of apoptosis induction or suppression in the rodent ovary.

Ablation of bcl-2 gene expression decreases the numbers of oocytes and primordial follicles established in the post-natal female mouse gonad.

Oocyte loss, either directly through attrition (germ cell death) or indirectly through follicular atresia (somatic or granulosa cell death), is a fundamental event associated with defining the time of normal or premature reproductive senescence in females. Although apoptosis has been reported to function as the underlying mechanism responsible for death of both germ cells and somatic cells in the ovary, the final molecular steps which commit ovarian cells to death have not been fully elucidated. To examine if death repressor activity of the bcl-2 gene product is important for germ cell survival, we conducted studies using a Bcl-2 loss-of-function (bcl-2 -/-) transgenic mouse model. Histological analyses revealed that ovaries collected from bcl-2 -/- mice possessed numerous aberrantly formed primordial follicle-like structures containing a single layer of granulosa cells without an oocyte. Additionally, the total number of primordial follicles present which contained a healthy oocyte was markedly reduced in bcl-2 -/- mice as compared to heterozygote (bcl-2 -/+) or wild-type (bcl-2 +/+) mice, suggesting that expression of the bcl-2 death repressor gene is critical for endowment of a normal complement of germ cells and primordial follicles in the mammalian ovary.