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Embryo vitrification is a standard procedure in assisted reproductive technology. Previous studies have shown that frozen embryo transfer is associated with an elevated risk of adverse maternal and neonatal outcomes. This study aimed to explore the effects of mouse blastocyst vitrification on the phenotype of vitrified-warmed blastocysts, their intrauterine and postnatal development, and the long-term metabolic health of the derived offspring. The vitrified-warmed blastocysts (IVF + VT group) exhibited reduced mitochondrial activity, increased apoptotic levels, and decreased cell numbers when compared to the fresh blastocysts (IVF group). Implantation rates, live pup rates, and crown-rump length at E18.5 were not different between the two groups. However, there was a significant decrease in fetal weight and fetal/placental weight ratio in the IVF + VT group. Furthermore, the offspring of the IVF + VT group at an age of 36 weeks had reduced whole energy consumption, impaired glucose and lipid metabolism when compared with the IVF group. Notably, RNA-seq results unveiled disturbed hepatic gene expression in the offspring from vitrified-warmed blastocysts. This study revealed the short-term negative impacts of vitrification on embryo and fetal development and the long-term influence on glucose and lipid metabolism that persist from the prenatal stage into adulthood in mice., (© 2023 Federation of American Societies for Experimental Biology.)

Study Question: Does ambient temperature exposure affect outcomes including clinical pregnancy and live birth in women undergoing IVF?, Summary Answer: Both extreme cold and hot ambient temperatures were significantly associated with adverse pregnancy outcomes of IVF cycles., What Is Known Already: Heat exposure has been linked to adverse pregnancy outcomes worldwide. However, the effect of ambient temperature on infertile women undergoing IVF treatment is unclear., Study Design, Size, Duration: A retrospective cohort study was conducted from a database of 3452 infertile women who underwent their first fresh or frozen embryo transfer in the Shanghai First Maternity and Infant Hospital from April 2016 to December 2020., Participants/materials, Setting, Methods: Daily mean ambient temperature exposure for each patient was obtained based on their residential address. Temperature-stratified multiple logistic regression analysis was performed to investigate associations between temperature exposure and pregnancy outcomes after controlling for confounders. Vulnerable sub-groups were identified using forest plots., Main Results and the Role of Chance: The clinical pregnancy rate and live birth rate were 45.7% and 37.1%, respectively. Regarding clinical pregnancy, a higher temperature during cold weather was significantly associated with a higher pregnancy rate in the period about 11 weeks before ovarian stimulation (adjusted odds ratio (aOR) = 1.102, 95% CI: 1.012-1.201). Regarding live birth, an increased temperature during cold weather was significantly related to a higher live birth rate in the period after confirmation of clinical pregnancy or biochemical pregnancy, with the aORs of 6.299 (95% CI: 3.949-10.047) or 10.486 (95% CI: 5.609-19.620), respectively. However, a higher temperature during hot weather was negatively associated with the live birth rate in the periods after confirmation of clinical pregnancy or biochemical pregnancy, with the aORs at 0.186 (95% CI: 0.121-0.285) or 0.302 (95% CI: 0.224-0.406), respectively. Moreover, the decline in live birth rates during cold and hot weather was accompanied by increased rates of early miscarriage (P < 0.05). Stratified analyses identified susceptibility characteristics among the participants., Limitations, Reasons for Caution: Climate monitoring data were used to represent individual temperature exposure levels according to the patient's residential address in the study. We were not able to obtain information of personal outdoor activity and use of indoor air conditioners in this retrospective study, which may affect actual temperature exposure., Wider Implications of the Findings: This study highlights that the ambient temperature exposure should be taken into account during IVF treatment and afterwards. There is a need to be alert to extremes in cold and hot ambient temperatures, especially during the period of follicle development and pregnancy. With this knowledge, clinicians can scientifically determine the timing of IVF treatment and reinforce patients' awareness of self-protection to minimize adverse pregnancy outcomes associated with extreme temperatures., Study Funding/competing Interest(s): This work was supported by a grant from the Clinical Research Plan of Shanghai Hospital Development Center [SHDC2020CR4080], a grant from the Science and Technology Commission of Shanghai Municipality [19411960500], and two grants from the National Natural Science Foundation of China [81871213, 81671468]. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437). B.W.M. reports consultancy for ObsEva, and research grants from Merck KGaA, Ferring and Guerbet. The other authors have no conflict of interest to declare., Trial Registration Number: N/A., (© The Author(s) 2023. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

This retrospective cohort study aimed to compare clinical outcomes following fresh or frozen embryo transfer (FET) in women with advanced reproductive age (ARA). Women aged 35-45 years who underwent their first autologous fresh or frozen cleavage stage embryo transfer cycle in the Centre for Assisted Reproduction of Shanghai First Maternity and Infant Hospital between January 2016 and December 2020 were included. The primary outcome was live birth after the first embryo transfer of the in vitro fertilization (IVF) cycle. Multiple covariates were used for propensity score matching (PSM) and generalized estimating equations were performed to examine the independent association between FET and live birth. Of the total 1453 patients, 327 patients had FET and 1126 patients had fresh ET. After the PSM procedure, 274 patients were included in each group. The live birth rate was 24.8% in the FET group and 25.2% in the fresh ET group (OR 0.98, 95% CI: 0.67-1.44, P  = 0.92). Other pregnancy, perinatal and neonatal outcomes were all comparable between the two groups. This study showed that FET did not improve live birth and other clinical outcomes as compared with fresh embryo transfer in women with ARA who underwent their first IVF cycle.

Dormant human oocytes contain a perinuclear super-organelle, called the Balbiani Body, which is not present in mature oocytes. Here, we use confocal imaging to visualize two Balbiani Body markers-mitochondria and the DEAD-box helicase DDX4-in preantral follicles isolated from a 20-year-old female patient. In primordial follicles, mitochondria were concentrated in a ring near the oocyte nucleus, while DDX4 formed adjacent micron-scale spherical condensates. In primary and secondary follicles, the mitochondria were dispersed throughout the oocyte cytoplasm, and large DDX4 condensates were not visible. Our data suggest that the Balbiani Body breaks down during the primordial to primary follicle transition, thus releasing mitochondria and soluble DDX4 protein into the oocyte cytoplasm., Competing Interests: The authors declare that there are no conflicts of interest present., (Copyright: © 2023 by the authors.)

Spermatogonial stem cells (SSCs) in the testis support the lifelong production of sperm. SSCs reside within specialized microenvironments called "niches," which are essential for SSC self-renewal and differentiation. However, our understanding of the molecular and cellular interactions between SSCs and niches remains incomplete. Here, we combine spatial transcriptomics, computational analyses, and functional assays to systematically dissect the molecular, cellular, and spatial composition of SSC niches. This allows us to spatially map the ligand-receptor (LR) interaction landscape in both mouse and human testes. Our data demonstrate that pleiotrophin regulates mouse SSC functions through syndecan receptors. We also identify ephrin-A1 as a potential niche factor that influences human SSC functions. Furthermore, we show that the spatial re-distribution of inflammation-related LR interactions underlies diabetes-induced testicular injury. Together, our study demonstrates a systems approach to dissect the complex organization of the stem cell microenvironment in health and disease., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: The target population for fertility preservation recently has been expanded from adolescents with cancer undergoing gonadotoxic chemotherapy to include transgender youth before initiating gender-affirming hormone therapy. Patients and providers may have knowledge deficits regarding options for fertility preservation, accessibility, and feasibility of its techniques, and impact of treatment on future fertility. This study describes outcomes of sperm cryopreservation in transgender male-to-female (affirmed female) youth and compares semen parameters with adolescents diagnosed with cancer., Methods: Medical records of transgender-affirmed female adolescents and adolescent males diagnosed with cancer who underwent sperm cryopreservation at the Fertility and Advanced Reproductive Medicine clinic of the University of Texas (UT) Southwestern Medical Center between March 2015 and March 2020 were reviewed. Demographic data were recorded and values for sperm parameters (volume, count, total count, motility (%), total motile) were collected. When available, hormone levels (luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol) and Tanner stages were also assessed. The two populations were compared using chi-square analysis and two-sample student's t -test. Data are presented as mean±standard deviation., Results: While semen quality parameters trended lower in transgender youth compared with adolescents with cancer, there was no statistically significant difference between groups. While four out of 18 patients in the transgender group had azoospermia, mean semen quality parameters fell within normal adult reference ranges for both groups., Conclusion: Sperm cryopreservation for transgender youth and adolescents with cancer is feasible, inexpensive, and does not result in significant treatment delays. This information can improve counseling and access to these procedures, particularly in the transgender population., Competing Interests: No competing financial interests exist., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

Understanding how gene regulatory elements influence ovarian follicle development has important implications in clinically relevant settings. This includes understanding decreased fertility with age and understanding the short-lived graft function commonly observed after ovarian tissue cryopreservation and subsequent autologous transplantation as a fertility preservation treatment. The Assay for Transposase Accessible Chromatin by sequencing (ATAC-seq) is a powerful tool to identify distal and proximal regulatory elements important for activity-dependent gene regulation and hormonal and environmental responses such as those involved in germ cell maturation and human fertility. Original ATAC protocols were optimized for fresh cells, a major barrier to implementing this technique for clinical tissue samples which are more often than not frozen and stored. While recent advances have improved data obtained from stored samples, this technique has yet to be applied to human ovarian follicles, perhaps due to the difficulty in isolating follicles in sufficient quantities from stored clinical samples. Further, it remains unknown whether the process of cryopreservation affects the quality of the data obtained from ovarian follicles. Here, we generate ATAC-seq data sets from matched fresh and cryopreserved human ovarian follicles. We find that data obtained from cryopreserved samples are of reduced quality but consistent with data obtained from fresh samples, suggesting that the act of cryopreservation does not significantly affect biological interpretation of chromatin accessibility data. Our study encourages the use of this method to uncover the role of chromatin regulation in a number of clinical settings with the ultimate goal of improving fertility., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.)

In assisted reproductive technology treatment, diminished ovarian reserve (DOR) is a condition of utmost clinical and scientific relevance because of its negative influence on patient outcomes. The current methods of infertility treatment may be unsuitable for many women with DOR, which support the need for development of additional approaches to achieve fertility restoration. Various techniques have been tried to improve the quality and increase the quantity of oocytes in DOR patients, including mitochondrial transfer, activation of primordial follicles, in vitro culture of follicles, and regeneration of oocytes from various stem cells. Herein, we review the science behind these experimental reproductive technologies and their potential use to date in clinical studies for infertility treatment in women with DOR., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Early cumulus cell removal combined with early rescue intracytoplasmic sperm injection (ICSI) has been widely practiced in many in vitro fertilization (IVF) centers in China in order to avoid total fertilization failure. However, uncertainty remains whether the pregnancy and neonatal outcomes are associated with early cumulus cell removal., Objectives: To investigate if early cumulus cell removal alone after 4 hours co-incubation of gametes (4 h group), has detrimental effect on the pregnancy and neonatal outcomes in patients undergoing IVF, through a comparison with conventional cumulus cell removal after 20 hours of insemination (20 h group)., Methods: This retrospective cohort study included 1784 patients who underwent their first fresh cleavage stage embryo transfer at the Centre for Assisted Reproduction of Shanghai First Maternity and Infant Hospital from June 2016 to December 2018 (4 h group, n=570; 20 h group, n=1214). A logistic regression analysis was performed to examine the independent association between early cumulus cell removal and pregnancy outcomes after adjustment for potential confounders. The neonatal outcomes between the two groups were compared., Results: When compared with the 20 h group, the 4 h group had similar pregnancy outcomes, including rates for biochemical pregnancy, clinical pregnancy, ongoing pregnancy, miscarriage, ectopic pregnancy, multiple pregnancy, live birth. There were 1073 infants delivered after embryo transfer (4 h group, n=337; 20 h group, n=736). Outcomes in both groups were similar for both singleton and twin gestations, including preterm birth rate and very preterm birth rate, mean birth weight, mean gestational age, sex ratio at birth and rate of congenital birth defects. In addition, findings pertaining to singleton gestations were also similar in the two groups for Z-scores (gestational age- and sex-adjusted birth weight), rates of small for gestational age, very small for gestational age, large for gestational age and very large for gestational age infants., Conclusions: In this study early cumulus cell removal alone was not associated with adverse pregnancy and neonatal outcomes. From this perspective, early cumulus cell removal to assess for a potential early rescue ICSI is therefore considered to be a safe option in patients undergoing IVF., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kong, Yin, Tang, Zhu, Bukulmez, Chen and Teng.)

Objective: This prospective study aimed to assess the effect of short-acting gonadotropin-releasing hormone agonist (GnRHa) administration on pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles., Methods: Patients who planned to have FET in Peking Union Medical College Hospital (China) were recruited for this study and randomly assigned into two groups. Patients in the experimental group (n = 460) received triptorelin acetate on the day of embryo transfer along with routine luteal support. Patients in the control group (n = 433) only received luteal support. One dose (0.1 mg) of a short-acting GnRHa was administered on the day of blastocyte transfer. The rates for clinical pregnancy, biochemical pregnancy, implantation, miscarriage, and ectopic pregnancy were compared between the groups., Results: There were no significant differences in the number and quality of blastocytes transferred between the two groups. In the experimental and control groups, the clinical pregnancy rate was 56.3% and 50.58%, the biochemical pregnancy rate was 15.78% and 18.94%, and the median implantation rate was 39.98% and 38.01%, respectively, with no significant difference between the groups. Biochemical pregnancy and abortion and the ectopic pregnancy rate were not significantly different between the two groups., Conclusion: In FET cycles, a GnRHa does not affect the pregnancy outcome.

Objective: To assess whether primary care specialists' demographics, specialty, and knowledge of preimplantation genetic testing for monogenic disorders (PGT-M) influence their practice patterns., Design: Cross-sectional survey study., Setting: Academic medical center., Patients: Not applicable., Interventions: None., Main Outcome Measures: Objective PGT-M knowledge, subjective comfort with PGT-related topics, PGT care practices (discussions/referrals), and PGT-M implementation barriers., Results: Our survey had 145 respondents: 65 obstetrician/gynecologists, 36 internists, and 44 pediatricians. Overall, 88% believed that patients at a risk of passing on genetic disorders should be provided PGT-M information. However, few discussed PGT-M with their patients (24%) or referred them for testing (23%). Over half (63%) believed that the lack of physician knowledge was a barrier to PGT use. In terms of subjective comfort with PGT, only 1 in 5 physicians felt familiar enough with the topic to answer patient questions. There were higher odds of discussing (odds ratio, 3.21; 95% confidence interval, 1.75-5.87) or referring for PGT (odds ratio, 2.52; 95% confidence interval, 1.41-4.51) for each additional 0.5 correct answers to PGT knowledge-related questions. The odds of referring patients for PGT-M were the highest among obstetrician/gynecologists compared with those among the internists and pediatricians., Conclusions: Physician specialty and PGT knowledge were associated with PGT-M care delivery practices. Although most specialists believed in equipping at-risk patients with PGT-M information, <1 in 4 discussed or referred patients for PGT. The low levels of PGT-related care among providers may be owed to inadequate knowledge of and comfort with the topic. An opportunity to promote greater understanding of PGT-M among primary care specialists exists and can in turn improve the use of referrals to PGT-M services., (© 2021 The Authors.)

Background: The effects of ambient air pollutants on adverse pregnancy outcomes have been reported. However, studies about air pollutants exposure and pregnancy outcomes in patients undergoing IVF were limited and inconclusive. To date Shanghai has been the only city in China to implement a compulsory single embryo transfer policy for all patients undergoing their first embryo transfer procedure effective from January 2019. We aimed to investigate the associations between exposure to ambient air pollutants and biochemical pregnancy and live births, and to identify potential vulnerability characteristics of patients undergoing IVF in Shanghai, China., Methods: A retrospective cohort study was conducted on 2766 infertile patients aged ≤ 45 years who underwent first fresh or frozen-thawed cleavage stage embryo transfer in the Shanghai First Maternity and Infant Hospital during April 2016 and December 2019. Daily average ambient levels of six air pollutants (PM 2.5 , PM 10 , NO 2 , SO 2 , CO and O 3 max-8h) were obtained from fixed air monitors located in closest proximity to patients' residences. The cumulative average level was calculated during three different exposure periods (period1: three months before oocyte retrieval to serum hCG test; period 2: from serum hCG test to live birth outcome; period 3: from three months before oocyte retrieval to live birth). Multiple logistic regression model was performed to investigate associations between exposure to ambient air pollutants and pregnancy outcomes. Stratified analyses were conducted to explore the potential effects modifier., Results: The biochemical pregnancy rate and live birth rate were 54.2% and 36.4%, respectively. The ambient NO 2 exposure was significantly associated with a 14% lower pregnancy rate during period 1 (aOR = 0.86, 95%CI: 0.75-0.99). The ambient PM 10 was related to significantly increased risk of lowering live birth rate among the patients during period 3 [aOR = 0.88(0.79-0.99)]. Stratified analysis showed that ambient PM 10 was also significantly associated with a reduced pregnancy rate (aOR = 0.82, 95% CI: 0.69-0.97) in patients who underwent single embryo transfer during period 1. Subjects who underwent single embryo transfer also had a decreased likelihood of a live birth when exposed to ambient SO 2 and O 3 during period 3 [aOR = 0.74(0.57-0.95), and 0.92 (0.83-0.98), respectively]. Moreover, O 3 exposure was associated with decreased live birth rates in patients living in non-urban areas. Sensitivity analyses indicated robust negative association between PM 10 exposure and live birth outcomes., Conclusions: Our study suggested that exposure to ambient air pollutants, in particular NO 2 and PM 10 , was associated with an increased risk of lower rates of pregnancy and live birth respectively in patients undergoing IVF. Stratified analyses indicated that ambient SO 2 and O 3 levels were related to adverse pregnancy outcomes in some subgroups of IVF patients in this study. Notably, patients who underwent single embryo transfer were more susceptible to ambient air pollution exposure. Thus, prospective cohort studies are needed to investigate the underlying mechanisms and the susceptibility windows for women undergoing IVF treatment., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Although it is well appreciated that ovarian stimulation protocols for in vitro fertilization (IVF) alter endometrial receptivity, the precise cellular mechanisms are not known. To gain insights into potential mechanisms by which different ovarian stimulation protocols alter the endometrium, we compared histologic and gene expression profiles of endometrium from women undergoing conventional ovarian stimulation for IVF (C-IVF) with those undergoing minimal stimulation with clomiphene citrate (MS-IVF). Sixteen women undergoing MS-IVF (n = 8) or C-IVF (n = 8) were recruited for endometrial biopsy at the time of oocyte retrieval. Endometrial glands were large, tortuous, and secretory with C-IVF but small and undifferentiated with MS-IVF. Whereas RNA sequencing did not reveal changes in estrogen receptor or its co-regulators or classic proliferation associated genes in MS-IVF, together with immunohistochemistry, Wnt signaling was disrupted in endometrium from MS-IVF cycles with significant upregulation of Wnt inhibitors. Secreted frizzled-related protein 1 (sFRP1) was increased fourfold (p < 0.01), and sFRP4 was upregulated sixfold (p < 0.01) relative to C-IVF. Further these proteins were localized to subepithelial endometrial stroma. These data indicate that MS-IVF protocols with CC do not seem to impact endometrial estrogen signaling as much as would be expected from the reported antiestrogenic properties of CC. Rather, the findings of this study highlight Wnt signaling as a major factor for endometrial development during IVF cycles.

Introduction: Obesity is an epidemic affecting more than one-third of adults in the United States. Obese women experience decreased fertility, explained in part by oocyte quality. Since follicular fluid (FF) provides an important microenvironment for oocyte growth, we sought to evaluate the effect of increased body weight on FF levels of 11 metabolic hormones and fatty acid metabolism., Methods: The FF was collected from 25 women (10 normal weight, 10 overweight, and 5 obese) with diminished ovarian reserve undergoing in vitro fertilization (IVF) following a minimal stimulation protocol. Hormone levels were determined by multiplex immunoassay using the MAGPIX (Luminex, Austin, Texas) instrument. Fatty acid metabolites were determined using gas and ultra-high pressure liquid chromatography coupled with mass spectrometry., Results: Levels of hormones related to glucose and energy homeostasis and regulation of fat stores (insulin, glucagon, glucagon-like peptide-1, C-peptide, and leptin) were increased significantly in FF from obese women compared to FF from nonobese(normal weight and overweight) women. Interestingly, FF levels of branched-chain amino acids (BCAA) isoleucine, leucine, and valine as well as uric acid, isocaproic acid, butanoic acid, tyrosine, threonine, glycine, and methionine correlated positively with body mass index., Conclusion: This pilot study demonstrates significant alterations in the FF milieu of obese women undergoing IVF, which may contribute to the decreased fecundity of obese women. Although the impact of this environment on oocyte and embryo development is not fully realized, these changes may also lead to imprinting at the genomic level and long-term sequelae on offspring.

Premature follicular rupture during in vitro fertilization (IVF) is a well-known culprit for cycle cancellation. We sought to evaluate whether a single oral dose of ibuprofen will have an effect on the follicular fluid (FF) levels of inflammatory markers involved in ovulation. This is a prospective within-subjects study following nine patients undergoing IVF. Every patient underwent a first cycle of minimal stimulation IVF followed by a second cycle using the same stimulation protocol, except one oral dose of ibuprofen 800 mg was administered 15-18 h post-trigger injection. FF was obtained during oocyte retrievals of both cycles and analyzed for levels of selected inflammatory markers. A total of 27 cytokines and 9 matrix metalloproteinases (MMPs) were tested. Results demonstrate significantly decreased levels of interleukin (IL)-6, IL-8, granulocyte-colony stimulating factor (G-CSF), eotaxin, MMP3, MMP7, MMP12, and MMP13 in FF of cycles where ibuprofen was administered. However, other cytokines levels, such IL-1 and vascular endothelial growth factor (VEGF), were similar with or without ibuprofen. Levels of MMPs described to be involved in ovulation, namely MMP-2 and MMP-9, were either undetectable or unchanged by ibuprofen, respectively. In conclusion, our data show that one dose of ibuprofen administered orally the day after trigger injection revealed a significant impact on the FF inflammatory milieu. Abbreviations: IVF: in vitro fertilization; MMP: matrix metalloproteinase; IL: interleukins; FF: follicular fluid; VEGF: vascular endothelial growth factor; NSAIDS: non-steroidal anti-inflammatories; POR: poor ovarian response; AMH: anti-Mullerian hormone; TAFC: total antral follicle count; HMG: human menopausal gonadotropin; hCG: human chorionic gonadotropin; COX: cyclooxygenase enzymes; PGH2: prostaglandin H2; RANTES: regulated on activation, normal T expressed and secreted; NF-κb: nuclear factor kappa-light-chain-enhancer of activated B cells.

Objective: Minimal stimulation IVF is a treatment option that uses clomiphene citrate (CC). We sought to evaluate how CC impacts endometrial thickness during minimal stimulation IVF cycles., Methods: We retrospectively analyzed a cohort of 230 cycles in 119 poor ovarian response patients. The IVF cycles were studied in three groups: 130 minimal stimulation cycles, 29 mild stimulation cycles, and 30 conventional high dose gonadotropin releasing hormone (GnRH) antagonist cycles. Thirty-three minimal stimulation IVF patients had 41 frozen embryo transfers (FET) which allowed us to study whether the CC effects were prolonged., Results: Endometrial thickness in the minimal stimulation group was significantly lower than the mild and conventional stimulation groups (7.3±2.2mm versus 11.4±3.3mm versus 12.9±3.8mm, respectively, p <0.0001). In patients who underwent minimal stimulation IVF followed by FET, significantly thicker endometrial thickness was achieved during their FET cycles as compared to their minimal stimulation cycles (7.95±2.1mm versus 10.3±1.8mm, p <0.0001)., Conclusion: We concluded that endometrial thickness is impacted during minimal stimulation IVF cycles. Since negative effects on endometrial thickness are not observed in the patients' subsequent FET cycle, a freeze-all approach is justified to mitigate adverse endometrial effects of CC in minimal stimulation IVF cycles.

Background: Androgenic compounds have been implicated in induction of endometrial atrophy yet the mechanisms of androgen effects on human endometrium have not been well studied. We hypothesized that androgens may promote their endometrial effects via modulation of progesterone receptor (PR) expression., Methods: Proliferative phase endometrial samples were collected at the time of hysterectomy. We evaluated the effect of the potent androgen 5α-dihydrotestosterone (DHT) on endometrial PR expression by treating human endometrial explants, endometrial stromal cells, and Ishikawa cells with DHT. Ishikawa cells were also treated with DHT ± the androgen receptor (AR) blocker flutamide. The PR-B, total PR messenger RNA (mRNA), and PR protein expression were assessed. Expression of cyclin D1 and D2 was checked as markers of cell proliferation., Results: As expected, estradiol induced PR expression in isolated stromal cells, endometrial epithelial cells, and tissue explants. The DHT treatment also resulted in increased PR expression in endometrial explants and Ishikawa cells but not in stromal cells. Further, protein levels of both nuclear PR isoforms (PR-A and PR-B) were induced with the DHT treatment. Although flutamide treatment alone did not affect PR expression, flutamide diminished androgen-induced upregulation of PR in both endometrial explants and Ishikawa cells. Although estradiol induced both cyclin D1 and cyclin D2 mRNA, DHT did not induce these markers of cell proliferation., Conclusion: Androgens may mediate endometrial effects through upregulation of PR gene and protein expression. Endometrial PR upregulation by androgens is mediated, at least in part, through AR.

As women are increasingly delaying childbearing into their 30s and beyond, diminished ovarian reserve (DOR) and advanced reproductive age (ARA) patients are bound to become a large proportion of all assisted reproductive technology practices. Traditional controlled ovarian stimulation (COS) protocols for DOR and/or ARA have had some limited success, but pregnancy rates are lower and cycle cancellation rates are higher than their younger counterparts with normal ovarian reserve. Though many physicians have a selection of favorite standard protocols that they use, patients with DOR may require closer monitoring and customization of the treatment cycle to address the common problems that come with low ovarian reserve. Frequent issues that surface in women with DOR and/or ARA include poor follicular response, premature luteinizing hormone surge, and poor embryo quality. Limited published evidence exists to guide treatment for DOR. However, use of minimal or mild doses of gonadotropins, avoidance of severe pituitary suppression, and consideration for luteal phase stimulation and a "freeze all" approach are possible customized treatment options that can be considered for such patients who have failed more traditional COS protocols., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Up to 15% of all couples of reproductive age are diagnosed with subfertility and about one-third of those will have male factor infertility as a contributing factor. Intracytoplasmic sperm injection (ICSI) has proven to be invaluable for couples with severely compromised semen parameters. Since its introduction into the clinical practice in 1992, the indications for ICSI were dramatically expanded to include various patient populations with normal or mildly abnormal semen parameters. Moreover, some fertility programs choose to perform ICSI for all of their patients needing assisted reproductive technologies. By all means, the male factor indications for ICSI are not well defined, apart from its absolute utility with surgically obtained spermatozoa in the presence of low motility, or in cases of severe defects with sperm concentration and motility. Based on current evidence, ICSI is not indicated for routine use. Its adoption for previous history of total fertilization failure, in vitro oocyte maturation, cryopreserved oocytes, polyploidy prevention, poor-quality oocytes, diminished ovarian reserve, and advanced reproductive age are not supported by current evidence, albeit further research with well-designed studies is warranted. Finally, from a biological standpoint ICSI is considered to be more invasive, more energy consuming for the oocyte itself and its adverse genetic and epigenetic effects cannot be ruled out. Although more studies are needed to clarify definitive indications for ICSI, many of its current applications can be deemed empiric at this time., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Potential roles of gonadotropin-releasing hormone (GnRH) antagonists on GnRH/GnRH receptor systems and their effects on the extrapituitary tissues are largely elusive. In this narrated review, we summarized the systemic effects of GnRH antagonists on ovary, endometrium, embryo implantation, placental development, fetal teratogenicity, reproductive tissue cancer cells, and heart while briefly reviewing the GnRH and GnRH receptor system. GnRH antagonists may have direct effects on ovarian granulosa cells. Data are conflicting regarding their effects on endometrial receptivity. The GnRH antagonists may potentially have detrimental effect on early placentation by decreasing the invasive ability of cytotrophoblasts if the exposure to them occurs during early pregnancy. The GnRH antagonists were not found to increase the rates of congenital malformations. Comparative clinical data are required to explore their systemic effects on various extrapituitary tissues such as on cardiac function in the long term as well as their potential use in other human cancers that express GnRH receptors.

Obesity has grown to epidemic proportions, and currently nearly half of the reproductive-age women are overweight or obese. Risks, success rates, and economic aspects of infertility treatments in obese women have been extensively investigated. Unfavorable ovarian stimulation characteristics like increased gonadotropin consumption, fewer selected follicles, and lower number of retrieved oocytes have been observed in obese women undergoing assisted reproductive technologies (ART). There seems to be a strong association between increased body mass index and lower pregnancy and live-birth rates and increased miscarriage rate. Coexisting factors like age and polycystic ovary syndrome status have also been blamed for these adverse effects. The mechanisms underlying those adverse outcomes, whether ovarian or endometrial, still remain to be fully elucidated. Moreover, maternal, perinatal, and neonatal complications have also been reported to be higher in obese pregnant women. Hence in some countries strict restrictions exist for access to elective fertility treatment in obese women. However, it is controversial if these policies are socially and ethically acceptable. Furthermore, because weight reduction is not an easy task, it may lead to the decreased probability of conception due to the advancing reproductive age for many obese women. Thus weight reduction should be encouraged and patients counseled accordingly, but whether restriction for fertility treatment is implemented in obese women remains a matter of debate. There remains much to be known regarding the association between obesity and ART., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

A number of microRNAs (miRNAs), including miR-200 family, are aberrantly expressed in endometriosis and endometrial cancer. Here we assessed the expression and functional aspects of miR-200c in endometrial tissues (N = 52) from normal endometrial biopsies (N = 15), endometrial tissues including those exposed to hormonal therapies (N = 20), and grade I-III endometrial cancer (N = 17). miR-200c expression was elevated in normal endometrial biopsies from mid- and late-luteal phase, and in endometrial tumors as compared to endometrial tissues from peri- and postmenopausal period (P < .05) and its pattern of temporal expression displayed an inverse relationship with the expression of ZEBs. The expression of E-cadherin (CDH1) varied, but expressed at low levels, specifically in endometrial tissues and endometrial tumors. The endometrial expression of ZEBs and CDH1 in patients who were exposed to Depo-Provera and gonadotropin-releasing hormone agonist GnRHa displayed a trend toward lower expression as compared to proliferative phase; however, treatment of Ishikawa cells with 17β-estradiol, progesterone, and medroxy progesterone acetate had modest effects on the expression of miR-200c and ZEBs without affecting CDH1 expression. Gain of function of miR-200c in Ishikawa cells repressed ZEBs, as well as VEGFA, FLT1, IKKβ, and KLF9 expression at transcriptional and translational levels through direct interaction with their respective 3'untranslated regions and increased the rate of their proliferation. These results indicated that endometrial miR-200c expression undergoes dynamic changes during transition from normal into cancerous states; possibly influenced by hormonal milieu and by targeting the expression of specific genes with key regulatory functions in cellular transformation, inflammation, and angiogenesis may influence these events during normal and disease progression.

Purpose of Review: The true impact of the current sperm DNA fragmentation testing needs further scrutiny to assess whether clinically meaningful information is conveyed., Recent Findings: Various studies have suggested different or no threshold values with assorted tests for the percentage of DNA fragmentation in the ejaculated sperm above which natural conception, fertilization or embryo development and/or clinical pregnancy rates are compromised. Current DNA fragmentation assessment methods provide very little specific information on the nature and severity of the DNA damage detected. Although sperm DNA fragmentation is associated with lower pregnancy rates through natural conception or intrauterine insemination, it does not seem to affect intracytoplasmic sperm injection outcome. Although animal studies demonstrated adverse reproductive effects of sperm DNA fragmentation, any conclusive evidence in humans is yet to be demonstrated. It is not clear whether interventions aimed at enrichment of sperm with decreased DNA fragmentation are effective in preventing the potential adverse effects of sperm DNA fragmentation in humans. Major concern about the use of sperm DNA integrity tests as prognostic parameters is that the direct evaluation of DNA fragmentation in individual sperm fertilizing the oocyte is not possible., Summary: The lack of consensus in defining a clinically relevant standard DNA fragmentation test with a meaningful cut-off level brings challenges in implementing the routine use of sperm DNA integrity assessment in daily practice.

Objective: To evaluate the effect of increasing female obesity on response to and outcome of assisted reproductive technology (ART) treatment., Design: Historical cohort study., Setting: Clinic-based data., Patient(s): A total of 152,500 ART cycle starts from the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System for 2007-2008, limited to women with documented height and grouped by body mass index (BMI, [weight/height(2)])., Intervention(s): None., Main Outcome Measure(s): Cycle cancellation overall, cycle cancellation due to low response, treatment failure (not pregnant vs. pregnant), and pregnancy failure (fetal loss or stillbirth vs. live birth), as adjusted odds ratios and 95% confidence intervals, with cycles among normal-weight women as the reference group., Result(s): Cycle cancellation overall and cancellation due to low response using autologous oocytes significantly paralleled increasing BMI. The odds of treatment failure rose significantly with autologous-fresh cycles, from 1.03 for cycles among overweight women (BMI 25.0-29.9) to 1.53 for cycles among women with BMIs ≥ 50.0 kg/m(2). Likewise, the odds of pregnancy failure were most significant with increasing BMI among women with autologous-fresh cycles, increasing from 1.10 for cycles to overweight women to 2.29 for cycles to women with BMI ≥ 50.0 kg/m(2)., Conclusion(s): These results indicate significantly higher odds of cycle cancellation. In addition, treatment and pregnancy failures with increasing obesity significantly increased starting with overweight women., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Gonadotropin-releasing hormone (GnRH) receptors are not only detected in the central nervous system but also in tissues such as ovary, endometrium, breast, gastrointestinal system, placenta and malignant tumors of ovary and breast. The direct role of GnRH-antagonists in ovarian function, implantation, cancer pathogenesis and treatment is under extensive investigation. This study reviews the biochemistry and molecular and cellular biology of GnRH-antagonists as well as GnRH types and their receptors., Recent Findings: The best clinical evidence with GnRH-antagonists has accumulated in controlled ovarian hyperstimulation protocols for prevention of premature luteinizing hormone surge (cetrorelix, ganirelix) and in the treatment of advanced-stage prostate cancer (abarelix and degarelix). GnRH-GnRH receptor pathways may have a role in the embryo implantation. The controversy still exists whether GnRH antagonist protocols result in slightly decreased clinical pregnancy rates compared with the GnRH agonist protocols. GnRH-antagonists could be used in the near future to treat some cancer types that express GnRH receptors., Summary: GnRH-antagonists have various clinical applications in gynecology, reproductive medicine, urology and oncology. The emergence of well tolerated, orally active GnRH-antagonists may provide an alternative to long-term injections and is likely to have a major impact on the utility of GnRH analogues in the treatment of human diseases.

Objective: To examine codified state policies related to infertility and assess their implications for cancer patients. Lack of insurance is often identified as a barrier to use of fertility preservation (FP) services., Design: None., Setting: A keyword search was developed to identify statutes and administrative regulations of insurance coverage for FP in the United States., Patient(s): N/A., Intervention(s): N/A., Main Outcome Measure(s): Laws addressing the general population but pertaining to FP were compiled using Lexis-Nexis. Data were analyzed by reviewing the "plain meaning" of the text, legislative/administrative history, and annotated case law. Legal reasoning and common rules of statutory construction and legislative interpretation were used., Result(s): Fifteen states (29.4%) had laws relating to insurance coverage for infertility or in vitro fertilization (IVF) procedures and two states (CA and IL) specifically excluded IVF from a mandatory offer of coverage. No state laws or regulations addressed insurance coverage for FP methods specific to cancer patients., Conclusion(s): There is an argument for policies that require coverage for FP for cancer survivors before treatment., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effects of a gonadotropin-releasing hormone antagonist (GnRH-ANT) on the expression of anti-Müllerian Hormone (AMH) and aromatase (via the exon CYP19IIa promoter), in cultured human granulosa cells (hGCs) and the human granulosa cell line (HGL5)., Design: Primary cell cultures of hGCs and culture of HGL5 cells., Setting: Academic center., Patient(s): Women undergoing IVF because of male factor, tubal infertility, or donor eggs., Intervention(s): hGCs and HGL5 cells were treated with a GnRH-ANT (1 nM and 1 μM) alone or in combination with cAMP (1 mM). Media was collected and stored at -80°C until assayed., Main Outcome Measure(s): mRNA levels of CYP19 IIa, AMH, steroidogenic factor 1 (SF-1) and liver receptor homologue-1 (LRH-1) were determined by quantitative polymerase chain reaction. ELISA was used to determined estradiol (E(2)) levels in the culture media. Pooled results from triplicate experiments were analyzed using one-way analysis of variance with Student-Newman-Keuls multiple-comparison methods., Result(s): The GnRH-ANT decreased the expressions of CYP19 IIa, AMH, SF-1, and LRH-1. cAMP induced aromatase and AMH expression. Cotreatment with cAMP and GnRH-ANT caused a dose-dependent suppression of AMH and CYP19 IIa mRNA. A GnRH agonist (GnRH-A) increased the mRNA expressions of CYP 19 IIa and AMH. The GnRH-ANT decreased E(2) production in cultured hGCs., Conclusion(s): GnRH-ANTs, in addition to their central suppressive effects on the pituitary, may have a direct effect on ovarian granulosa cells with inhibition of aromatase and AMH expression. Furthermore, the inhibitory effect could be mediated via suppression of SF-1 and LRH-1, and may play a role in estrogen-mediated ovarian folliculogenesis., (Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if the anti-Müllerian hormone (AMH), a proposed marker of ovarian aging, decreases with repetitive oocyte donation., Design: Retrospective cohort., Setting: Academic., Patient(s): Thirty-six young women who underwent three to seven oocyte donation cycles., Intervention(s): Assessor blind determination of AMH levels from serum samples collected during each treatment cycle., Main Outcome Measure(s): Cycle trends of serum AMH levels., Result(s): The AMH was the only predictor of oocyte yield in the first cycles. The AMH was negatively associated with donor age and follicle stimulating hormone (FSH) dose used. Serum AMH levels did not show any decrease per treatment cycle basis and per maximum number of oocyte donation cycles performed per woman. Whereas donors who underwent six cycles showed increasing AMH levels when controlled for studied covariates, the slopes of the multiple regression curves were not significantly different from donors who underwent three, four, and five cycles. Clinical outcome assessed by FSH dose/number of oocytes ratio did not show significant change over repetitive cycles. Intercycle variation of AMH in all patients over three cycles was found to be 12.5%, which was within the reported intermenstrual range., Conclusion(s): Serum AMH levels do not decrease over repetitive oocyte donation cycles, which may imply that accelerated ovarian aging may not occur in oocyte donors., (Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Endometriosis is a complex trait with significant environmental and genetic influences that are likely to affect its phenotype. Natural history of the disease varies from one individual to another. The gold standard of surgical diagnosis is limited in accuracy by visibility and recognition of lesions by the attending surgeon. Several lines of evidence suggest that pelvic endometriosis results from the reflux of viable endometrial tissue through the fallopian tubes. Endometriosis is an inflammatory disease that nuclear factor kappa B pathway may play an important role in its pathogenesis. Endometriotic lesions demonstrate increased aromatase expression in association with increased cyclo-oxygenase-2 expression, especially in red lesions which represent earlier stages of inflammation. Estrogen and progesterone receptor expressions vary according to the morphology and the inflammatory status of the endometriotic lesions. Normal endometrial tissue fragments can adhere and implant to peritoneum. Aromatase expression, a possible intrinsic survival factor for endometrial tissue, is inducible in human endometrial fragments by androstenedione at physiological concentrations found in peritoneal fluid. Inflammatory response to ectopic endometrial tissue, which may vary in each individual seems to be important in disease progression. Current therapies for endometriosis include surgical and medical approaches aimed at cytoreduction or hormonal suppression. However, the disease have tendency to recur in many symptomatic women. Although new management approaches are emerging, properly designed clinical trials are desperately needed in treatment of pain and subfertility associated with endometriosis. Future studies should also focus on identifying risk population to develop preventive strategies, since the treatment of endometriosis is costly and challenging.

Purpose of Review: Observational studies have reported small but increased risk of birth defects associated with assisted reproductive technology (ART) pregnancies. We intend to review the current data on this issue to provide essential information for patient counseling., Recent Findings: There is lack of consensus on whether ART per se increases the risk of birth defects, genetic and imprinting disorders, mostly due to the bias inherent to the observational studies, which suggest 30-40% increased risk of birth defects with ART. Recent reports suggest that apparent risks for adverse outcome following ART may be largely related to parental infertility-linked factors. Criteria used to define birth defects bring challenges as well., Summary: All couples undergoing these procedures should be counseled about the current information suggesting elevated risks of birth defects, genetic abnormalities and imprinting disorders associated with infertility and the infertility treatment with ART. In order to elucidate the controversy whether ART is associated with adverse outcome in the offspring, a multinational collaborative effort is needed, as the required sample size is between 10 000 and 84 000 or more.

MicroRNAs (miRNAs) which regulate gene expression stability displayed an aberrant expression profile in ectopic endometrium (ECE) as compared to eutopic (EUE) and normal endometrium (NE). We assessed the expression of miR-17-5p, miR-23a, miR-23b and miR-542-3p, their predicted target genes, steroidogenic acute regulatory protein, aromatase and cyclooxygenase-2, and influence of ovarian steroids on their expression in endometrial stromal (ESC) and glandular epithelial cells (GEC). The results indicated a lower expression of miR-23b and miR-542-3p and higher level of miR-17-5p in paired ECE and EUE as compared with NE. These levels were elevated and inversely correlated with the level of expression of their respective target genes in ECE. The expression of these miRNAs and genes was differentially regulated by 17beta- estradiol, medroxyprogesterone acetate, ICI-182780 and RU-486, or their respective combinations in ESC and GEC. We concluded that altered expression of specific miRNAs in ECE, affecting the stability of their target genes expression, has direct implications in pathogenesis of endometriosis.

The interactions between ovarian germ and somatic cells and expression of several intraovarian autocrine/paracrine regulators are major contributing factors in the ovary. These intraovarian mediators regulate various ovarian cellular activities including cell growth, differentiation, and apoptosis, which are critical in follicular development. MicroRNAs (miRNAs) have emerged as key components of posttranscriptional gene expression. Recent evidence generated in mice implicates the regulatory function of miRNAs in oocyte maturation and ovarian follicular development. In the human, miRNAs may target specific gene expression in granulosa cells and participate in establishment and progression of ovarian cancer. Here, we review the currently available information on the expression and potential regulatory functions of miRNAs in the ovary under normal and pathologic conditions. Understanding the underlying mechanisms of how ovarian germ cell and somatic cell miRNAs are regulated and identifying their specific target genes and their functions may lead to the development of strategies to achieve target-specific gene regulation for the prevention and treatment of various ovarian disorders.

Context: Up-regulation of aromatase expression in endometrial cells disseminated into the peritoneal cavity may enhance their survival via local estrogen synthesis, which may lead to endometriosis. The factors that mediate induction of aromatase in the endometrium are not well defined, but increased expression of steroidogenic factor (SF)-1 may play a role., Objective: The objective of the study was to determine whether androstenedione (A4), the predominant sex steroid in peritoneal fluid, regulates endometrial aromatase expression., Design: This was a cell/tissue culture study., Setting: The study was conducted at an academic center., Methods: Quantitative real-time PCR, HPLC, and chromatin immunoprecipitation were used in this study., Results: Treatment of cultured human endometrial explants and stromal cells with A4 (10 nm) significantly up-regulated expression of aromatase mRNA transcripts containing exon IIa at their 5'-ends. In endometrial stromal cells and the human endometrial surface epithelial (HES) cell line, induction of aromatase mRNA by A4 was associated with increased expression of SF-1. In HES cells, tritiated A4 was metabolized to estradiol, testosterone (T), dihydrotestosterone, and androstanediol. Both estradiol and T, but not nonaromatizable androgens, up-regulated aromatase and SF-1 mRNA in HES cells. Chromatin immunoprecipitation revealed that A4 enhanced recruitment of SF-1 to its response element (-136 bp) upstream of CYP19 exon IIa. This, together with the findings that both estrogen receptor antagonist, ICI 182,780, and aromatase inhibitor, fadrozole, suppressed A4 and T induction of aromatase and SF-1 mRNA, indicates that the inductive effects of A4 and T are mediated by their conversion to estrogens., Conclusions: Exposure of endometrial cells to A4 may enhance CYP19 gene expression through its aromatization to estrogens.

Aberrant up-regulation of aromatase in eutopic endometrium and implants from women with endometriosis has been reported. Aromatase induction may be mediated by increased cyclooxygenase-2 (COX-2). Recently, we demonstrated that progesterone receptor (PR)-A and PR-B serve an antiinflammatory role in the uterus by antagonizing nuclear factor kappaB activation and COX-2 expression. PR-C, which antagonizes PR-B, is up-regulated by inflammation. Although estrogen receptor alpha (ERalpha) is implicated in endometriosis, an antiinflammatory role of ERbeta has been suggested. We examined stage-specific expression of aromatase, COX-2, ER, and PR isoform expression in eutopic endometrium, implants, peritoneum, and endometrioma samples from endometriosis patients. Endometrial and peritoneal biopsies were obtained from unaffected women and those with fibroids. Aromatase expression in eutopic endometrium from endometriosis patients was significantly increased compared with controls. Aromatase expression in endometriosis implants was markedly increased compared with eutopic endometrium. Aromatase mRNA levels were increased significantly in red implants relative to black implants and endometrioma cyst capsule. Moreover, COX-2 expression was increased in implants and in eutopic endometrium of women with endometriosis as compared with control endometrium. As observed for aromatase mRNA, the highest levels of COX-2 mRNA were found in red implants. The ratio of ERbeta/ERalpha mRNA was significantly elevated in endometriomas compared with endometriosis implants and eutopic endometrium. Expression of PR-C mRNA relative to PR-A and PR-B mRNA was significantly increased in endometriomas compared with eutopic and control endometrium. PR-A protein was barely detectable in endometriomas. Thus, whereas PR-C may enhance disease progression, up-regulation of ERbeta may play an antiinflammatory and opposing role.

Objective: To analyze the potential association between serum cetrorelix levels and clinical pregnancy outcome in patients who had undergone assisted reproduction cycles with a GnRH antagonist cetrorelix acetate 3-mg injection., Design: Retrospective case-control study., Setting: University-affiliated private-assisted reproduction center., Patient(s): 130 IVF and intracytoplasmic sperm injection first cycles, treated with the same cetrorelix acetate protocol, in two matched groups according to whether the cycle resulted in clinical pregnancy (n = 56) or not (n = 74)., Intervention(s): Cetrorelix acetate administration at 3 mg in a sandwich protocol., Main Outcome Measure(s): Serum cetrorelix concentrations on the day of hCG administration with regard to clinical pregnancy outcome, pre- versus post-hCG percent change in serum E(2) levels and implantation rates., Result(s): The cetrorelix serum concentrations were in the range of 0.29 to 5.12 ng/mL. The comparisons between groups with and without clinical pregnancy revealed comparable serum cetrorelix levels. There was no significant correlation between the serum cetrorelix concentrations and percent change in pre- versus post-hCG serum E(2) levels. Serum cetrorelix levels were comparable among patients with various implantation rates., Conclusion(s): Although a wide range of serum cetrorelix levels could be detected during a GnRH antagonist cycle, these levels were comparable in patients with and without clinical pregnancies.

Objective: To define and validate metrics of embryo progression and morphology during extended embryo culture and to compare the effects of early cleavage (EC) vs. blastulation stages on clinical pregnancy., Design: Retrospective observational study., Setting: University-affiliated assisted reproduction center., Patient(s): One thousand two hundred ninety-two intracytoplasmic sperm injection and 842 IVF blastocyst-transfer cycles., Intervention(s): The embryo progression index (EPI) was calculated as the area under the curve of total cell number (TCN) over time, by using observed TCN for cleavage-stage embryos and estimated blastocyst TCN according to morphology. The EPI from days 1-3 measured early cleavage, and blastulation was assessed by EPI over extended embryo culture. Blastocyst morphology was converted into numerical blastocyst quality scores (BQSs). Receiver operating characteristic curve analysis was used to evaluate predictors for clinical pregnancy., Main Outcome Measure(s): Clinical pregnancy., Result(s): Per-cycle mean EPI and mean BQS for all embryos developing into blastocysts, as well as mean BQS of the transferred embryos, were significant predictors of clinical pregnancy in intracytoplasmic sperm injection and IVF cycles. Mean EPI for days 1-3 did not predict outcome., Conclusion(s): Early cleavage is a putative marker of embryo quality. Late-stage embryo development is more sensitive and specific in predicting clinical pregnancy than is early cleavage, supporting the use of extended embryo culture for embryo selection. The embryo progression index and BQS may also be used for this purpose.

Objective: To determine whether women with hydrosalpinx would have diminished endometrial HOXA10 expression and whether salpingectomy would reverse HOXA10 suppression. The homeobox gene HOXA10 is a transcription factor that is necessary for embryo implantation; its expression in human endometrium correlates with receptivity and implantation. Increased endometrial HOXA10 expression may be one mechanism by which salpingectomy results in increased implantation rates in IVF., Design: Prospective clinical trial., Setting: Academic medical center., Patient(s): Women with unilateral or bilateral hydrosalpinx., Intervention(s): Expression of HOXA10 was examined prospectively during the midluteal phase in endometrium obtained from infertile women (n = 9) with hydrosalpinges before and after salpingectomy, as well as from fertile controls (n = 6). Quantitative HOXA10 mRNA expression was determined by real-time reverse-transcription polymerase chain reaction, and HOXA10 protein expression was determined by immunohistochemistry., Main Outcome Measure(s): Expression of HOXA10 mRNA and protein., Result(s): Expression of HOXA10 mRNA was significantly lower in infertile women with hydrosalpinges, compared with the case of fertile controls. Salpingectomy resulted in a statistically significant, 15-fold increase in endometrial HOXA10 expression. Immunohistochemical analysis confirmed the quantitative real-time reverse-transcription polymerase chain reaction findings. Increased HOXA10 expression was evident in both glandular epithelial cells and endometrial stroma., Conclusion(s): HOXA10 is necessary for implantation. Here, we demonstrate decreased HOXA10 expression in response to hydrosalpinx fluid as a potential molecular mechanism for diminished implantation rates. Salpingectomy restores endometrial HOXA10 expression. This may be one mechanism by which salpingectomy results in augmented implantation rates in IVF.

The outcome of a novel protocol utilizing precycle gonadotrophin-releasing hormone (GnRH) antagonist administration and LH activity support with microdose recombinant human chorionic gonadotrophin (HCG) was compared to GnRH agonist long protocol used in patients undergoing their first ICSI (n=707) or IVF (n=571) cycles, which had resulted in one or two blastocyst transfers. In GnRH antagonist cycles, cetrorelix acetate (3 mg) was administered s.c. 4 days before FSH stimulation and a repeat dose was given when the lead follicular diameter was 13-14 mm. LH support was provided by recombinant HCG (2.5 microg). Embryo progression and blastulation were evaluated using embryo progression indices and blastocyst quality scores. The tested protocol demonstrated reduced implantation and clinical pregnancy rates as compared with GnRH agonist long protocol, although the embryo progression and blastulation parameters and blastocyst quality were comparable among the groups. Logistic regression models further supported the significant negative impact of GnRH antagonist/microdose HCG protocol on clinical pregnancy rates in both ICSI and IVF patients. Assisted reproduction cycles with fresh blastocyst transfers utilizing precycle GnRH antagonist administration and microdose HCG support resulted in lower implantation and clinical pregnancy rates as compared with GnRH agonist cycles, although the embryo progression and blastulation parameters were comparable.

Uterine myomas are the most common solid pelvic tumors in women and the primary indication for hysterectomy. Most of the myomas are asymptomatic. The most common symptoms associated with uterine myomas are abnormal uterine bleeding and pelvic discomfort mostly caused by the mass effect. Vaginal bleeding may lead to iron deficiency anemia. Uterine myomas have a significant role in reproductive dysfunction, although a causal relationship between infertility and intramural or subserosal myomas not disturbing the uterine cavity has not been established clearly. Nevertheless myomas, especially the tumors distorting the uterine cavity, are associated with infertility and spontaneous miscarriage. In addition, the myomas may be the potential cause for numerous obstetric complications, especially if they are located adjacent to placenta. The transformation of myomas to leiomyosarcomas is a very rare event. Leiomyosarcomas may be suspected in postmenopausal women with rapidly growing symptomatic solid pelvic mass. Despite the high prevalence of these tumors, there is paucity of data available regarding the natural clinical history of myomas.

Background: The presence of hydrosalpinges is associated with lower implantation and pregnancy rates in women undergoing IVF-embryo transfer, while salpingectomy improves these parameters. Although the mechanism by which hydrosalpinges affects fertility is not entirely understood, an adverse effect on endometrial receptivity has been postulated. In this study, we hypothesized that the adverse effects of hydrosalpinges on fertility may be in part mediated by inappropriate endometrial expression of leukaemia inhibitory factor (LIF), a cytokine implicated in implantation., Methods: In order to test our hypothesis, we prospectively examined the expression of LIF during the window of implantation in the endometrium of infertile women (n = 10) with hydrosalpinges prior to and following salpingectomy and of fertile controls (n = 10) by Western blotting and immunohistochemistry., Results: LIF expression was significantly lower in infertile women with hydrosalpinges compared with fertile controls (P < 0.05). Salpingectomy resulted in an increase in LIF expression in eight out of 10 women with hydrosalpinges. LIF levels were increased by 231 +/-49% (mean +/- SEM) following salpingectomy. Immunohistochemical analysis confirmed the Western blot findings. The increased LIF immunoreactivity was predominantly localized to luminal and glandular epithelial cells., Conclusions: Our findings suggest that observed benefit from salpingectomy in infertile women with hydrosalpinges may be in part mediated by the up-regulation of endometrial LIF expression.

Although the diagnosis of luteal phase defect (LPD) has been described convincingly in the research setting, it remains a controversial clinical entity. Apart from many uncertainties that surround the diagnosis of LPD, there is no convincing evidence that LPD is associated with infertility and recurrent abortion. Once diagnosed, the treatment options are empiric and include those that are recommended for unexplained infertility. The efforts to diagnose LPD in patients who have infertility or recurrent abortion are not justified.

Purpose of Review: Various methods have been proposed and are currently used in the assessment of ovarian reserve in order to predict the outcome in assisted reproduction. This review focuses on the current information regarding the ovarian reserve markers and tests, an active area of research., Recent Findings: Female age alone is a rough parameter for assessing ovarian reserve. The basal follicle stimulating hormone level is not adequately sensitive to predict poor outcome and the same is true for other basal parameters, including basal estradiol, the follicle stimulating hormone/luteinizing hormone ratio, and inhibin-B levels. The clomiphene citrate challenge test has a low sensitivity but this sensitivity is greater than that of basal follicle stimulating hormone. The value of other hormonal dynamic tests remains to be determined. Among the ultrasound markers the total antral follicle count seems to be promising. Ovarian biopsy in this assessment is controversial. History of poor response to ovarian stimulation is a strong indicator for declining ovarian function., Summary: There is currently no clinically useful predictive test sufficiently accurate and distinct in time from controlled ovarian stimulation to assess ovarian reserve accurately. Further research is warranted to validate the ovarian reserve tests in the general population and in populations with different causes of infertility.

Our objective was to assess the effects of intramural and subserous fibroids on intracytoplasmic sperm injection (ICSI) in a retrospective case-control study of 108 women with uterine fibroids and 324 controls. The fibroids were located and measured by transvaginal ultrasound performed just before the ICSI cycle and all patients had normal endometrial scan. Seventy-three women had intramural and 35 women had subserous fibroids and the maximum diameter in any patient ranged from 0.5-10 cm. The number of fibroids in a patient ranged from 1-8. The first cycle outcome was compared with an age and body mass index matched 324 ICSI patients/cycles. All couples had male factor infertility. The ICSI cycles of patients with intramural and subserous fibroids were comparable in terms of the days of ovarian stimulation, the total dose of gonadotropin used, estradiol level on day of hCG administration, the number of metaphase II oocytes retrieved, fertilization and cleavage rates, number and quality of embryos developed and transferred. The implantation and clinical pregnancy rates were similar. We conclude that the presence of intramural and subserous fibroids does not adversely effect clinical pregnancy and implantation rates in patients undergoing ICSI.

In order to investigate the effect of hormone replacement therapy (HRT) on plasma homocysteine and C-reactive protein (CRP) levels 46 healthy postmenopausal women were prospectively enrolled. HRT, which was either 0.625 mg/day conjugated equine estrogen (CEE) plus 2.5 mg/day medroxyprogesterone acetate (MPA) or 0.625 mg/day CEE alone were administered. After 6 months, estrogen alone significantly increased serum CRP concentrations (p = 0.039), however, estrogen plus progesterone therapy did not significantly alter serum CRP levels. Both regimens significantly decreased plasma homocysteine levels (CEE group p = 0.034, CEE+MPA group p = 0.007). It was concluded that the reduction in plasma homocysteine levels with both regimens might contribute to the cardiovascular benefit of HRT and the CRP raising effect of estrogen might be partially prevented by the addition of progesterone., (Copyright 2002 S. Karger AG, Basel)

Objectives: To investigate the effects of estrogen and estrogen plus progesterone replacement therapy on left ventricular systolic and diastolic function parameters in healthy postmenopausal women., Methods: Forty-six healthy consecutive postmenopausal women were prospectively enrolled. Hormone replacement therapy (HRT), which was either 0.625 mg/day conjugated equine estrogen (CEE) alone, or with 2.5 mg/day medroxyprogesterone acetate (MPA) was administered depending on the hysterectomy status. Left ventricular systolic and diastolic function parameters were evaluated with echocardiography before and after 6 months of HRT. The paired t-test was used for statistical analysis., Results: Estrogen or estrogen plus progesterone did not significantly alter the left ventricular dimensions and systolic function parameters. However, significant improvements were noted in several diastolic function parameters including late diastolic mitral flow velocity, ratio of early to late mitral flow velocity and isovolumic relaxation time (P=0.003, P=0.001 and P=0.005, respectively, for the CEE group; all P<0.001 for the CEE+MPA group)., Conclusions: Estrogen or estrogen plus progesterone replacement therapy may significantly improve left ventricular diastolic functions in healthy postmenopausal women.

Background: We aimed to assess whether salpingectomy in women with communicating hydrosalpinges influenced endometrial receptivity., Methods: The inclusion criteria were: women with communicating hydrosalpinges, absence of other confounding infertility factors and aged <40 years. Patients were scheduled for laparoscopy during the putative window of implantation (cycle days 19-21). In patients in whom salpingectomy was decided upon due to the severity of tubal disease (n = 10), an intra-operative endometrial biopsy was performed. Post-treatment endometrial sampling was done between day 19-21 of the fourth consecutive cycle. Pre-treatment and post-treatment samples were assessed by both conventional histologic criteria and alpha(v)beta3 integrin immunostaining, where histological score (HSCORE) was used for quantification., Results: Despite normal histological maturation assessed by conventional criteria, 8/10 hydrosalpinx cases yielded an epithelial HSCORE of <0.7, which was below the accepted threshold. Following salpingectomy, luminal endometrial epithelium demonstrated a significantly increased alpha(v)beta3 integrin expression (Wilcoxon's signed rank test, P = 0.017). Although the mean HSCORE for glandular epithelia improved, it failed to reach statistical significance. Ultrasound visible hydrosalpinges (n = 5) and non-visible cases (n = 5) were also compared. However, neither the pre-treatment integrin expression, nor the postoperative improvement were significantly different between these groups., Conclusions: We conclude that the surgical treatment of communicating hydrosalpinges may improve endometrial receptivity as assessed by alpha(v)beta3 integrin expression. Women with hydrosalpinges may undergo endometrial evaluation by the molecular markers of implantation, such as alpha(v)beta3 integrin. This evaluation may be decisive in determining the optimal management of cases, and may also be used to assess the efficacy of the treatment. The expression of the implantation markers should be correlated with implantation and clinical pregnancy rates in IVF-embryo transfer programs.

Background: Hormone replacement therapy (HRT) is associated with reduced cardiovascular risk, but the underlying mechanism(s) are not fully understood. This study investigated the effects of a 6-month course of HRT on cardiac autonomic function parameters assessed by heart rate variability (HRV) in postmenopausal women., Methods: Forty-six healthy postmenopausal women (age 48 +/- 5, range 40-60) with normal baseline electrocardiogram and negative exercise testing were enrolled. HRT, which was either 0.625 mg/day conjugated equine estrogen (CEE) plus 2.5 mg/day medroxyprogesterone acetate or 0.625 mg/day CEE alone were administered depending on hysterectomy status. Power spectral analysis of HRV was performed to calculate the low frequency component in absolute (LF) and normalized units (LF nu), high frequency component in absolute (HF), and normalized units (HF nu), and the LF/HF ratio. The standard deviation of RR intervals (SDNN) was calculated from the time series of RR intervals., Results: A 6-month course of HRT did not significantly alter resting heart rate (P > 0.05). The LF/HF ratio and LF nu significantly decreased after HRT (P = 0.022 and P = 0.032), whereas a significant increase was noted in the HF component of HRV (P = 0.043), indicating an improvement in cardiac autonomic function. The SDNN value, which was 28.8 +/- 11.8 ms before HRT significantly increased to 35.4 +/- 16.7 ms after 6 months (P = 0.011)., Conclusion: Our results indicate that a 6-month course of HRT may significantly improve cardiac autonomic function parameters, a finding that could at least partly explain the potential cardioprotective effect(s) of HRT.

Background: The aim of the study was to investigate the effects of hormone replacement therapy (HRT) on myocardial repolarization characteristics in postmenopausal women without coronary artery disease., Methods: Fifty-one consecutive healthy postmenopausal women (age 48 +/- 5) with negative exercise stress testing were prospectively enrolled into the study. Standard 12-lead electrocardiograms were obtained to evaluate the effects of 6 months of HRT on QT intervals, corrected QT intervals (QTcmax and QTcmin), QT dispersion (QTd), and corrected QTd (QTcd). Hormone regimens were continuous 0.625 mg/day conjugated equine estrogen (CEE) plus 2.5 mg/day medroxyprogesterone acetate (MPA) or 0.625 mg/day CEE alone depending on the hysterectomy status., Results: Although not statistically significant, CEE alone or in combination with MPA increased QTmax and QTmin values. However, the increase in QTmin was greater than the increase in QTmax, which resulted in statistically significant shortening of QTd (P = 0.007 in CEE and P < 0.001 in CEE + MPA groups). There was a significant prolongation of QTcmin values after 6 months in patients assigned to the CEE group (P = 0.001). The QTcd values were significantly shortened by HRT with both regimens (for CEE group 49 +/- 13 ms vs 38 +/- 13 ms, P = 0.01; for CEE + MPA group 49 +/- 14 ms vs 36 +/- 13, P < 0.001)., Conclusion: HRT significantly decreased the QTd and QTcd in postmenopausal women without coronary artery disease, independent of the addition of MPA to the regimen. This improvement in myocardial repolarization may be one of the mechanisms of the favorable effects of HRT on cardiovascular system. However, the clinical implications of the shortening of QTd in postmenopausal women with HRT must be clarified.