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To evaluate whether endometrial molecular profiles distinguish subsets of patients according to clinical characteristics, and to infer dysregulated immune networks, by measuring cytokines, chemokines, and growth factors in endometrial biopsy specimens from a cohort of infertile women with a high incidence of endometriosis.Prospective cohort study.Department of Gynecology at a university hospital.Patients undergoing laparoscopy for infertility assessment (n = 103).Endometrial biopsies were performed during surgery. Fertility outcome and clinical parameters were registered preoperatively and after 6 months.The concentrations of 48 factors in endometrial biopsy specimens were analyzed with respect to clinical status in univariate and multivariate frameworks.The concentrations of 44 factors from endometrial tissues of 74 patients were suitable for analysis. Although the tissue concentrations of interleukin (IL)15, IL-7, and interferon γ-induced protein (IP)-10 were individually lower in patients with endometriosis than in those without endometriosis, the differences were not significant after multiple comparison. However, multivariate modeling incorporating covariation showed separation between subsets of endometriotic and nonendometriotic patients, based predominantly on IP-10, monocyte chemoattractant protein-1, IL-16, and IL-18; this result was independent of cycle and fertility status. Analysis restricted to endometrial tissues from the secretory phase separated endometriotic and nonendometriotic patients by a combination of IL-15, IP-10, monocyte chemoattractant protein-1, IL-16, and IL-18. This combination suggests a uterine natural killer cell defect. We found no significant correlations between endometrial cytokines and fertility outcome.A molecular signature in endometrial tissue was able to distinguish endometriotic from nonendometriotic patients, implicating uterine natural killer cells in endometriosis.

Menopause represents the definite end of a woman's reproductive life and the onset of a persistent hypoestrogenic state. This postmenopausal period will for most women last several decades. Although mean menopausal age seems to have increased somewhat during the last century, there is a significant individual variation in age at natural menopause. With efficient contraception, women of reproductive age can now, to some extent, choose when they want to have children. As a consequence of this and other sociodemographic changes, age at first birth has increased significantly over the last 50 years. It is well documented that long before a woman enters the menopausal transition and subsequent menopause, fertility declines and finally ceases. Being able to predict when a woman will enter menopause would therefore, from a reproductive perspective, be of major interest. Several sociodemographic, morphometric, and endocrine factors are associated with age at menopause or time to menopause. Unfortunately the sensitivity and specificity of these in predicting time to or age at menopause are low. Therefore, with the exception of anti-Müllerian hormone measurements, either alone or in combination with chronological age close to menopause, there are as of now no reliable ways of predicting when a woman will enter menopause.

Research question: How does follicle distribution evolve in the human ovarian cortex between the ages of 20 and 35 years? Design: Fragments of ovarian cortex from women undergoing unilateral oophorectomy for fertility preservation were obtained for quantitative histological assessment, including recording the two-dimensional coordinates of the follicles. Data were analysed using spatial statistical methods. Results: A total of 53 ovarian cortex tissue samples, containing 1–803 follicles each, were obtained from 14 women aged 20–35 years. Primordial and transitory follicles lay in a clustered manner in the human ovarian cortex, with an average cluster radius of around 270 µm (95% confidence interval 154–377 µm; n = 49). Follicle density declined with age (P = 0.006, n = 13), and the distance from the nearest neighbouring follicle increased (P = 0.004, n = 13). Cluster radius decreased with age (P = 0.02, n = 13), but the degree of clustering tended to increase (P = 0.11, n = 13). In the majority of the samples, follicles at different stages lay in different clusters (P < 0.05, n = 13). Conclusions: This study shows that primordial and transitory follicles lie in different clusters in the human ovarian cortex. Spatio-temporal computer simulation suggests that interfollicular signals may hinder follicle loss and may therefore drive clustered follicle distribution. In clinical practice, the woman's age should be taken into account when assessing follicle density, as follicle distribution is increasingly clustered with advancing age.

The objective of this narrative review was to suggest a rational order of treatment choices in anovulatory women with polycystic ovary syndrome (PCOS), for whom a multitude of treatment options exist. In obese/overweight women with PCOS the importance of weight reduction should be stressed. Inositol, a dietary supplement with a documented effect on ovulation and without adverse effects in the doses recommended, may be suggested. Additional first-line medical alternatives include insulin sensitizers, selective estrogen receptor modulators, and aromatase inhibitors. Of these, the aromatase inhibitor letrozole and the combination of clomiphene citrate and metformin have the highest rates of ovulation and live birth. Second-line treatments are ovarian electrocautery and low-dose follicle-stimulating hormone stimulation. Controlled ovarian stimulation with in vitro fertilization, should be considered the last option as it carries a significant risk of ovarian hyperstimulation syndrome in patients with PCOS.

Introduction With increasing survival rates after treatment for cancer in prepubertal girls and women of reproductive age, an increasing focus on quality of life has emerged. Both irradiation and cytotoxic drugs can be detrimental to future fertility, consequently several treatment alternatives have been developed to spare or restore fertility in young females diagnosed with cancer. One of these options is cryopreservation of ovarian tissue before treatment and autotransplantation at a later time. Material and methods We present the Norwegian experience after 11 years of practice with ovarian tissue cryopreservation. A total of 164 patients have had ovarian tissue cryopreserved during the period 2004–2014. Fifteen patients died during the observation period. Six patients requested autotransplantation, which was performed in two women. Results Both patients conceived, one spontaneously and one after assisted reproduction due to a concomitant male factor. The pregnancies were uneventful and they each gave birth to a healthy child. Conclusions Cryopreservation with later autotransplantation of ovarian tissue should be offered to a selected group of young women with cancer.

STUDY QUESTION: Is oral glucose tolerance test (OGTT) needed in all women with polycystic ovary syndrome (PCOS)?SUMMARY QNSWER: OGTT is not routinely needed in women with PCOS and BMI < 25 kg/m2.WHAT IS KNOWN ALREADY: PCOS is associated with insulin resistance and increased prevalence of prediabetes and Type 2 diabetes (T2D) which is closely linked to obesity and possibly age, ethnicity and PCOS phenotype. Several guidelines recommend OGTT upon diagnosis of PCOS and during follow-up.STUDY DESIGN, SIZE, DURATION: A Nordic cross-sectional study including 876 women.PARTICIPANTS/MATERIALS, SETTING, METHODS: The 876 Nordic women with PCOS, aged 14-57 years, were examined for T2D and prediabetes (impaired glucose tolerance [IGT] or impaired fasting glucose (IFG) by OGTT.MAIN RESULT AND THE ROLE OF CHANCE: Of all study subjects 3% (23/876) had T2D, 23% (204/876) prediabetes and 74% (649/876) had normal glucose tolerance (NGT). Increased BMI and waist circumference were significantly (P < 0.001) associated with prevalence of prediabetes and T2D. No normal-weight woman (BMI < 25 kg/m2) was diagnosed with T2D. The prevalence of BMI ≥ 25 kg/m2 was 66% (578/ 876). 91% of women (21/23) with T2D had BMI ≥ 30 kg/m2. Testosterone levels and PCOS phenotype did not predict 2-h glucose levels during OGTT after adjustment for BMI and age.LIMITATIONS, REASONS FOR CAUTION: The present study included cross-sectional data and prospective studies are needed to confirm our results. These results may not apply to populations of other ethnic origin.WIDER IMPLICATIONS OF THE FINDINGS: Routine OGTT may not be indicated in normal-weight women with PCOS.STUDY FUNDING/COMPETING INTEREST(S): None.TRIAL REGISTRATION NUMBER: N/A.

Sertoli cells have dual roles during the cells’ lifetime. In the juvenile mammal, Sertoli cells proliferate and create the structure of the testis, and during puberty they cease to proliferate and take on the adult role of supporting germ cells through spermatogenesis. Accordingly, many genes expressed in Sertoli cells during testis formation are repressed during spermatogenesis. 5-Hydroxymethylcytosine (5hmC) is a DNA modification enzymatically generated from 5mC and present in all investigated mammalian tissues at varying levels. Using mass spectrometry and immunofluorescence staining we identified a substantial Sertoli cell-specific global 5hmC increase during rat puberty. Chemical labeling, pull-down and sequencing of 5hmC-containing genomic DNA from juvenile and adult rat Sertoli cells revealed that genes that lose or gain 5hmC belong to different functional pathways and mirror the functions of the cells in the two different states. Loss of 5hmC is associated with genes involved in development and cell structure, whereas gain of 5hmC is associated with genes involved in cellular pathways pertaining to the function of the adult Sertoli cells. This redistribution during maturation shows that 5hmC is a dynamic nucleotide modification, correlated to gene expression. © The Author(s) 2017. This work is licensed under a Creative Commons Attribution 4.0 International License.

Introduction Human chorionic gonadotropin (hCG) is suggested to regulate placental angiogenesis, however, its role is incompletely understood. hCG may directly stimulate angiogenesis or influence the effect of other angiogenic factors. We examined the effect of hCG and the interplay of hCG with basic fibroblast growth factor (bFGF) and with various adipokines on proliferation of vascular endothelial cells in vitro. Methods Human umbilical vein endothelial cells (HUVEC) were incubated for 2 days with combinations of hCG, bFGF, leptin, resistin, adiponectin, IL6 and TNFα. Incorporation of radiolabelled thymidine was used to assess cell proliferation. Immunofluorescence and flow cytometry were used to examine activation of p44/42 mitogen-activated kinase (MAPK). Results hCG induced proliferation of HUVEC alone and in combination with bFGF. Cells exposed to both hCG and bFGF displayed increased activation of p44/42 MAPK as compared to hCG or bFGF alone. Increased HUVEC proliferation was observed in the presence of increasing concentrations of leptin, resistin, adiponectin, and IL6, whereas HUVEC proliferation decreased in the presence of TNFα. hCG in combination with leptin, resistin, adiponectin or IL6 stimulated HUVEC proliferation beyond the effect of hCG alone. Discussion An interplay of hCG with adipose tissue-derived factors with angiogenic properties is plausible. Thus, maternal obesity may affect placental angiogenesis in pregnancy. Conclusions hCG may directly stimulate angiogenesis. Also, hCG may indirectly stimulate angiogenesis through interplay with bFGF and adipokines.

Post-transcriptional RNA modifications were discovered several decades ago, but the reversible nature of RNA modifications has only recently been discovered. Owing to technological advances, knowledge of epitranscriptomic marks and their writers, readers and erasers has recently advanced tremendously. Here we focus on the roles of the dynamic methylation and demethylation of internal adenosines in mRNA in germ cells and pluripotent stem cells.

Objective: Our aim was to characterize peritoneal cytokine profiles in patients with infertility, with and without endometriosis, to illuminate potential differences in immune profiles that may reflect mechanistic differences between these two patient populations. Design: Cross-sectional study. Setting: University hospital and research center. Patient(s): Women undergoing laparoscopy for infertility investigation (n = 107). Intervention(s): Peritoneal fluid was collected during surgery. Clinical characteristics were registered preoperatively. Main Outcome Measure(s): We determined the concentration of 48 different cytokines from the peritoneal fluid with multiplex immunoassays. Associations between cytokines and clinical findings were assessed with logistic regression and partial least squares discriminant analyses (PLS-DA). Result(s): Concentrations of SCGF-β, IL-8, HGF, and MCP-1 were significantly higher, while IL-13 was significantly lower in the endometriosis group compared with the group without endometriosis. Multiple stepwise logistic regression identified a combination of SCGF-β, IL-13, and G-CSF concentrations that predicted the presence of endometriosis with 86% sensitivity and 67% specificity. PLS-DA identified a class of 11 cytokines (SCGF-β, HGF, IL-13, MCP-1, CTACK, MCP-3, M-CSF, LIF, IL-5, IL-9, and IFN-a2) that were more characteristic of endometriosis than nonendometriosis patients. Conclusion(s): By combining univariate and multivariate analyses, profiles of cytokines more likely to be enriched or depleted in infertility patients with endometriosis compared with those without endometriosis were identified. These findings may inform future analyses of pathophysiological mechanisms of endometriosis in infertile patients, including dysregulated Th1/Th2 response and mobilization and proliferation of hematopoietic stem cells. Keyword: Cytokine; endometriosis; infertility; peritoneal fluid; PLS-DA

Do advanced glycation end products (AGE) and the receptor for advanced glycation end products (RAGE) affect the cells of the human ovarian follicle?AGE accumulate on the surface of ovarian granulosa-lutein (GL) cells and monocytes by binding to RAGE and other receptors with possible functional effects on these cells.AGE and RAGE are expressed in granulosa and theca cells, as well as in luteinized cells derived from the ovary.In this prospective cohort study, human follicle fluid-derived cells were isolated from aspirates of ovarian follicles of women who underwent assisted reproduction treatment.Immunofluorescence microscopy and multi-colour flow cytometry were used to determine the presence of AGE and RAGE on the surface of follicular fluid-derived cells and to characterize downstream effects of RAGE activation.GL cells and ovarian monocytes were found to contain AGE and RAGE and to bind AGE-bovine serum albumin (BSA) in correlation with the patients' chronological age. AGE-BSA and BSA failed to induce significantly the cleavage of caspase-3, phosphorylation of nuclear factor-κB or the binding of annexin V (the latter was marginally increased). AGE-fibronectin was found to induce detachment of cultured GL cells in vitro.The impact of AGE and RAGE in the ovary, shown here in cells in culture, remains to be affirmed in clinical settings.The ligands of RAGE and their effects in the ovary remain uncertain but this study implies that AGEs in the form of structural long-lived extracellular matrix proteins, rather than soluble AGEs, may play a role in the decline of ovarian function during ageing.The project was funded by the Norwegian Resource Centre for Women's Health, Oslo University Hospital. The authors have no conflicts of interests.

More than 100 structurally distinct RNA modifications have been identified in all kingdoms of life.1 These post-transcriptional modifications are widely present in various RNAs, including ribosomal RNA (rRNA), transfer RNA (tRNA), messenger RNA (mRNA), long non-coding RNA (lncRNA), etc. We have shown that the methylation of N6-methyladenine (m6A) can be reversed through the discovery of the first RNA demethylase, the human fat mass and obesity-associated protein, FTO, in 2011.2 Most recently, we have identified a new mammalian RNA demethylase, ALKBH5, which is also able to remove the methyl group of m6A from RNA both in vitro and in vivo (Fig. 1A). The ALKBH5 protein colocalizes with nuclear speckles where pre-mRNA processing occurs. This protein is actively involved in mRNA export regulation, in which its demethylation activity seems to play an important role, as well as in RNA synthesis. A knockout of the Alkbh5 gene in mice resulted in impaired male fertility due to compromised spermatogenesis. Importantly, increased m6A levels were observed in mRNA isolated from the Alkbh5-knockout mouse organs compared to those from wild-type littermates. RNA-Seq results indicate aberrant gene expression in spermatogenic cells of the seminoferous tubulus of testes from Alkbh5-deficient mice, thereby showing that the loss of the m6A demethylase influences gene expression, which, in turn, leads to defects in spermatogenesis and increased apoptosis of meiotic cells. Thus, the discovery of FTO and this new RNA demethylase strongly suggests that the methylation of RNA, like DNA and histone modifications, is dynamically regulated and likely to play broad roles in mammalian cells.

Endometriosis is a common condition in women of reproductive age. In addition to pain, endometriosis may also reduce fertility. The causes of infertility in women with endometriosis may range from anatomical distortions due to adhesions and fibrosis to endocrine abnormalities and immunological disturbances. In some cases, the various pathophysiological disturbances seem to interact through mechanisms so far not fully understood. Whether surgery should be offered as a treatment option in endometriosis‐associated infertility has become controversial, partly due to its modest or undocumented effect. Medical or hormonal treatment alone has little or no effect and should only be used in conjunction with assisted reproductive technology (ART). Of the various methods of ART, intrauterine insemination, due to its simplicity, can be recommended in women with minimal or mild peritoneal endometriosis, even though insemination may yield a lower success rate than in women without endometriosis. In vitro fertilization (IVF) is an effective treatment option in less‐advanced disease stages, and the success rates are similar to the results in other causes of infertility. However, women with more advanced stages of endometriosis have lower success rates with IVF. This is the peer reviewed version of the article, which has been published in final form at https://doi.org/10.1111/aogs.13082. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving

Accepted manuscript version. Published version at http://doi.org/10.1111/aogs.12842.

Objective To study the association of maternal prepregnancy body mass index (BMI) with serum concentrations of hCG in early pregnancy. Design Cross-sectional study. Setting Oslo University Hospital, Norway, 1996–2010. Patient(s) Among 3,301 pregnancies with live-born offspring conceived after assisted reproductive techniques, 2,611 women had information on serum hCG concentrations on day 16 after ovulation induction and prepregnancy BMI: 2,110 mothers with singleton and 501 mothers with multiple pregnancy. Intervention(s) None. Main Outcome Measure(s) Human chorionic gonadotropin concentration. Result(s) Geometric mean hCG concentration was higher in multiple pregnancies (190 IU/L) than in singleton pregnancies (106 IU/L). In singleton pregnancies geometric mean serum concentration decreased from 117 IU/L in women with BMI 2 to 86 IU/L in women with BMI ≥35 kg/m 2 . In multiple pregnancies, the corresponding decrease was from 226 IU/L to 130 IU/L. There was a significant negative association of BMI with hCG concentrations log transformed in the study sample as a whole (regression coefficient −0.013), in singleton pregnancies (regression coefficient −0.012), and in multiple pregnancies (regression coefficient −0.03). Conclusion(s) Serum hCG concentrations were negatively associated with maternal prepregnancy BMI. One possible explanation may be an effect of adipose tissue–derived signaling molecules on hCG secretion by the implanting embryo.

background: Leukocyte infiltration and angiogenesis in the forming corpus luteum are prerequisites for normal ovarian function and may also underlie disorders like ovarian hyperstimulation syndrome. We examined whether ovarian angiogenesis could be affected by an interaction between granulosa-lutein (GL) cells and leukocytes. methods and results: We found that GL cells isolated from the follicular fluid synthesize and secrete the chemokine interleukin-8 (IL-8), which activates IL-8-receptor-specific Ca 2+ and p38 mitogen-activated protein kinase signalling in monocytes and induces a directed migration of these cells towards the chemical gradient. Monocytes were found to further enhance IL-8 release, which suggests that these cells promote a massive leukocyte infiltration of the forming corpus luteum. A possible utility of leukocyte infiltration is the modulation of angiogenesis. We found that GL cells induce migration and capillary tube formation by endothelial cells in vitro. Furthermore, monocytes altered the profile of angiogenic factors released by GL cells, which supports the theory that an interaction between GL cells and leukocytes regulates ovarian angiogenesis. In addition, we found a correlation between increased secretion of pro-angiogenic cytokines and number of oocytes collected during IVF, which suggests that ovarian angiogenesis is related to the clinical response during ovarian stimulation. conclusions: An intricate communication may exist between infiltrating leukocytes and ovarian GL cells during the formation of corpus luteum, affecting neo-vascularization of the luteal tissue.

Objective. To test whether the clinical efficiency of recombinant FSH (rFSH) and highly purified human menotrophin (hMG) differs in terms of pregnancy and live birth rates during the first treatment cycle of IVF or ICSI. Design. Prospective cohort study. Setting. Department of Gynecology and Obstetrics, Rikshospitalet, Oslo University Hospital. Study population. Records of 1,136 infertile couples undergoing their first IVF (n = 682) or ICSI (n = 454) treatments were reviewed. The effect of hMG and rFSH was analyzed for the IVF and ICSI groups separately. Methods. Patients received long term down-regulation with GnRH agonist and controlled ovarian hyperstimulation with hMG or rFSH. Oocytes were fertilized by IVF or ICSI. Embryos were transferred on Day 2. Main outcome measures. Primary outcome measures were pregnancy and live birth rates, secondary outcome measures were duration of treatment, doses of hMG or rFSH applied, number of oocytes retrieved and the number and quality of embryos obtained. Results. Similar pregnancy and live birth rates were observed with hMG and rFSH. Compared to hMG, treatment cycles with rFSH were characterized by significantly shorter stimulation, lower gonadotrophin consumption, and increased number of oocytes and embryos. Conclusion. We conclude that rFSH and hMG are equivalent in terms of clinical efficacy.

Routine morphological scoring systems in assisted reproduction treatment are based on parameters that presumably correlate with the biological quality of gametes and embryos, including chromosome abnormalities. Maternal age is a key factor predicting pregnancy and live birth, and it is therefore of considerable interest to identify age-related indicators of oocyte and embryo quality in assisted reproduction treatment. The purpose of this study was to examine whether routine morphological scoring systems reflect age-related impact on oocyte and embryo quality among 4587 couples undergoing their first assisted reproduction treatment. This study assessed over 43,000 oocytes, 25,000 embryos and 7900 transferred embryos and analysed the associations among the following parameters: number of oocytes retrieved, oocyte quality, including maturity, fertilization rates, embryo quality, based on morphological features, and treatment outcome. Advanced chronological age was found to be associated with fewer oocytes retrieved, fewer embryos available for cryopreservation, as well as lower pregnancy, implantation, live birth rates and a higher miscarriage rate. No age-related correlation was found between fertilization rates, oocyte or embryo quality. Routinely-used morphological scoring systems, such as assessment of blastomere count, shape and fragmentation, fail to reflect age-related impact on oocyte and embryo quality.

Tissue reorganization during ovulation and corpus luteum formation involves a coordinated action of matrix metalloproteinases (MMPs) and tissue MMP inhibitors (TIMPs). In this study we investigated the cellular source of ovarian MMPs and TIMPs. Cells isolated from the preovulatory human follicle were cultured after immunobead depletion of CD45-expressing cells, which allowed differential assessment of leukocyte and granulosa-lutein cell fractions. Secretion of MMP-9 by follicular fluid-derived cells was associated with the presence of leukocytes. Granulosa-lutein cells synthesized low levels of MMP-9 but failed to secrete this enzyme that presumably accumulated in the cytoplasm, indicated by an increased MMP-9 expression of luteinized cells in sectioned midluteal phase corpora lutea. Synthesis and secretion of TIMP by follicular fluid-derived cells was associated with granulosa-lutein cells. TIMPs derived by granulosa-lutein cells failed to inhibit MMP-related pericellular proteolysis. The findings support a two-cell model of periovulatory MMP/TIMP release, in which leukocytes secrete MMPs and granulosa-lutein cells release TIMP, suggesting that there exists an intriguing interaction among cells that intertwingle during ovulation and corpus luteum formation.

Problem Peri-ovulatory migration of leukocytes towards the follicle plays an important role during corpus luteum formation. In this study, we examined the secretion of the neutrophil chemoattractant interleukin (IL)-8 by ovarian GL cells and the role of monocytes in IL-8 secretion. Method of study Granulosa-lutein cells were isolated from the pre-ovulatory follicle. After depletion of contaminating leukocytes, GL cells were co-cultured with the myelo-monocytic cell line THP-1. Intracellular IL-8 accumulation, IL-8 secretion, and chemotactic activity of cell culture media were examined. Results Intracellular IL-8 was predominantly localized in the endoplasmatic reticulum-Golgi both in GL cells and in THP-1 cells. In co-cultured cells, intracellular IL-8-specific immunofluorescence and IL-8 secretion were increased compared with either GL cells or THP-1 cells that were cultured alone. Conditioned cell culture media from GL cells and THP-1 cells induced directed cell migration by neutrophils. Conclusion Human GL cells constitutively synthesize IL-8. An increased IL-8 secretion by co-cultured GL cells and THP-1 cells suggest that GL cells and monocytes mutually induce chemokine secretion. An initial interaction between GL cells and ovarian leukocytes may therefore contribute to an increased chemokine release and leukocyte recruitment to the forming corpus luteum.

Maternal-to-zygotic transition (MZT) is essential for the formation of a new individual, but is still poorly understood despite recent progress in analysis of gene expression and DNA methylation in early embryogenesis1–9. Dynamic histone modifications may have important roles in MZT10–13, but direct measurements of chromatin states have been hindered by technical difficulties in profiling histone modifications from small quantities of cells. Recent improvements allow for 500 cell-equivalents of chromatin per reaction, but require 10,000 cells for initial steps14 or require a highly specialized microfluidics device that is not readily available15. We developed a micro-scale chromatin immunoprecipitation and sequencing (μChlP-seq) method, which we used to profile genome-wide histone H3 lysine methylation (H3K4me3) and acetylation (H3K27ac) in mouse immature and metaphase II oocytes and in 2-cell and 8-cell embryos. Notably, we show that ~22% of the oocyte genome is associated with broad H3K4me3 domains that are anti-correlated with DNA methylation. The H3K4me3 signal becomes confined to transcriptional-start-site regions in 2-cell embryos, concomitant with the onset of major zygotic genome activation. Active removal of broad H3K4me3 domains by the lysine demethylases KDM5A and KDM5B is required for normal zygotic genome activation and is essential for early embryo development. Our results provide insight into the onset of the developmental program in mouse embryos and demonstrate a role for broad H3K4me3 domains in MZT.

Purpose: To investigate possible differences between unexplained and stage I endometriosis-associated infertility in ICSI cycles conducted after low fertilization (

BACKGROUND: Down-regulation with GnRH agonist has been suggested to result in a profound suppression of LH bioactivity, reduced estradiol synthesis, and thus impaired IVF and pregnancy outcome. The aims of this study were: (i) to assess the usefulness of serum LH measurement on stimulation day 1 as a predictor of ovarian response, conception and pregnancy outcome in patients treated with long-term down-regulation with GnRH agonist and recombinant FSH, and (ii) to define the best threshold LH value, if any, to discriminate between women with different outcomes of IVF. METHODS: Records of 2625 cycles in 1652 infertile women undergoing IVF (n 5 1856) and/or ICSI (n 5 769) treatment were reviewed. RESULTS: The range of LH concentrations on stimulation day 1 overlapped among non-conception cycles, conception cycles, ongoing pregnancies and early pregnancy losses. Receiver operating characteristic (ROC) analysis showed that serum LH concentrations on stimulation day 1 were unable to discriminate between conception and non-conception cycles (AUCROC 5 0.51; 95% CI: 0.49‐0.54) or ongoing pregnancies versus early pregnancy loss groups (AUCROC 5 0.52; 95% CI: 0.47‐0.57). Stratification for various low serum levels of LH did not reveal significant differences with respect to conception or pregnancy outcome among different LH levels on stimulation day 1. CONCLUSIONS: Serum LH concentration on stimulation day 1 cannot predict ovarian response, conception and pregnancy outcome in women receiving long-term down-regulation during assisted reproduction treatment.

Underweight and overweight may affect reproduction and interfere with treatment of infertility. The purpose of this report is to describe the independent effect of body weight on treatment with IVF and ICSI.Records of 5019 IVF or ICSI treatments in 2660 couples were reviewed. The influence of body mass index (BMI) on treatment outcome was examined, after accounting for differences in age and infertility diagnosis.The cumulative live birth rate within three treatment cycles was 41.4% [95% confidence interval (CI) 32.1-50.7] in obese women with BMIor =30 kg/m2 and 50.3 (95% CI 47.0-53.7) in normal weight women with BMI 18.5-24.9 kg/m2. Obesity was associated with an increased risk of early pregnancy loss occurring before 6 weeks gestation. Positive correlation between BMI and gonadotrophin requirement during stimulation and negative correlation between BMI and number of collected oocytes were observed. Underweight (BMI18.5 kg/m2) was not related to an impaired outcome of IVF or ICSI.Obesity is associated with lower chances for live birth after IVF and ICSI and with an impaired response to ovarian stimulation.

Preimplantation mouse embryos simultaneously express receptors for leptin and leukemia inhibitory factor (LIF), both of which trigger activation of STAT3 (Signal Transducer and Activator of Transcription) protein. To examine the joint effects of leptin and LIF on embryonic development, we studied preimplantation development and activation of STAT3 signaling of mouse embryos after exposure to leptin and/or LIF in vitro. Two-cell mouse embryos (Day 2) were cultured in the presence of leptin and/or LIF. Significantly fewer leptin-exposed than control embryos hatched by Day 5 and by Day 6 of development. In addition, cells of leptin-exposed Day 5 blastocysts showed a higher rate of DNA fragmentation, which is a sign of apoptosis. Leukemia inhibitory factor alone had no effect on the rates of embryonic development or DNA fragmentation. Simultaneous exposure of embryos to leptin and LIF increased the proportion of hatching embryos and decreased the rate of apoptosis compared to embryos exposed to leptin only. Leptin treatment was associated with an increased phospho-STAT3-specific immunofluorescence in the cell membrane of blastocysts, which was not observed in LIF-exposed embryos. In conclusion, LIF modifies the effect of leptin during preimplantation embryo development in mice, presumably by interfering with activation of STAT3 signaling.

ALKBH4, an AlkB homologue in the 2-oxoglutarate and Fe2+ dependent hydroxylase family, has previously been shown to regulate the level of monomethylated lysine-84 in actin and thereby indirectly influences the ability of non-muscular myosin II to bind actin filaments. ALKBH4 modulates fundamental processes including cytokinesis and cell motility, and its depletion is lethal during early preimplantation embryo stage. The aim of this study was to investigate the effect of ALKBH4 deficiency in a physiological context, using inducible Alkbh4 knockout mice. Here, we report that ALKBH4 is essential for the development of spermatocytes during the prophase of meiosis, and that ALKBH4 depletion leads to insufficient establishment of the synaptonemal complex. We also show that ALKBH4 is localized in nucleolar structures of Sertoli cells, spermatogonia and primary spermatocytes.

Objective To study whether maternal age is associated with serum concentration of human chorionic gonadotropin in early pregnancy. Design Cross-sectional study. Setting Oslo University Hospital in Oslo, Norway. Population All vital pregnancies in gestational week 8 conceived by in vitro fertilization between February 1996 and February 2013 (n = 4472). Methods Serum concentrations of human chorionic gonadotropin were measured on day 12 after embryo transfer/day 16 following ovulation induction. Trends in geometric means of human chorionic gonadotropin concentrations by maternal age group were tested by linear regression analysis. We also studied the association of maternal age (years) with log-transformed human chorionic gonadotropin concentrations, and adjustments were made for number of embryos transferred, method of in vitro fertilization and year (period) of embryo transfer. Main outcome measure Serum concentration of human chorionic gonadotropin. Results Geometric mean concentrations of human chorionic gonadotropin decreased with increasing maternal age (p = 0.024, test for trend by weighted linear regression). Also, we estimated a significant negative association of maternal age with log-transformed human chorionic gonadotropin concentrations (adjusted regression coefficient −0.011, standard error 0.003, p

BACKGROUND: To elucidate possible differences between unexplained and minimal peritoneal endometriosisassociated infertility, we studied their outcome in natural cycle IVF (NIVF). METHODS: A prospective cohort study was carried out on unexplained (33 couples), minimal peritoneal endometriosis-associated (30 couples) and tubal factor (24 couples) infertility in 223 NIVF cycles, using human chorionic gonadotrophin (HCG) for ovulation induction. RESULTS: During the first NIVF attempt, follicular and luteal phase oestradiol, FSH, LH and progesterone concentrations, as well as endometrial thickness and follicular diameter were similar among the three groups. Periovulatory follicular growth monitored from day of HCG administration to oocyte aspiration was significantly lowered in unexplained infertility compared with minimal endometriosis-associated and tubal factor infertility. The fertilization rate, clinical pregnancy rate per initiated cycle, per successful oocyte retrieval and per embryo transfer, in minimal endometriosis (80.0, 10.4, 16.0 and 23.5% respectively) were similar to that in tubal factor infertility patients (68.6, 5.8, 11.4 and 16.0%) but significantly higher (P < 0.05) than that of the unexplained infertility group (62.2, 2.6, 5.4 and 8.7%). CONCLUSIONS: The significant reduction in follicular periovulatory growth, fertilization and pregnancy rates in unexplained infertility compared with minimal peritoneal endometriosis patients may be explained by sub-optimal follicular development with possibly reduced oocyte quality, intrinsic embryo quality factors or by impaired implantation. From a clinical point of view, NIVF is less suited to unexplained infertility treatment, but might represent an interesting treatment option for minimal peritoneal endometriosisassociated infertility.

We studied the in vitro response to insulin of granulosa-lutein cells derived from patients with polycystic ovary syndrome (PCOS) and clinically defined insulin resistance. Insulin sensitivity was assessed by continuous infusion of glucose with model assessment test (CIGMA). Insulin resistant (PCOS-IR; n = 8), noninsulin resistant (PCOS-NIR; n = 9) patients with PCOS, and women with tubal factor infertility (TF; n = 8) underwent controlled ovarian stimulation with long-term gonadotropin-releasing hormone (GnRH) agonist, recombinant follicle stimulating hormone (FSH), and in vitro fertilization. Primary cultures of granulosa-lutein cells were incubated with insulin (10, 100, 500 ng/ml) and/or luteinizing hormone (LH) (10, 100 ng/ml) in the presence of low density lipoprotein (100 micrograms/ml). The progesterone and lactate accumulation were measured in the culture medium. LH potently stimulated the progesterone secretion in all groups. Insulin alone had no effect on progesterone release in any of the groups, but stimulated lactate formation in the PCOS-NIR and TF groups. Insulin augmented the effect of LH on progesterone secretion selectively in the PCOS-NIR group. The expression of the insulin receptor was determined by Western blotting in separate cultures of granulosa-lutein cells, and showed receptor down-regulation in the PCOS-IR patients. We infer that the in vitro effect of insulin on progesterone and lactate release by granulosa-lutein cells is impaired in insulin resistant PCOS patients.

Background. Experience with polycystic ovary syndrome shows that insulin resistance is related to early pregnancy loss. This association was examined by comparing pregnancy outcome in obese and lean women. Methods. A cohort of 383 patients conceiving after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) was studied. Ovarian stimulation was achieved by GnRHa and FSH or hMG ( n =362), by FSH or hMG alone ( n =16), or by clomiphene citrate and FSH or hMG ( n =5). Luteal phase was supported with progesterone. Pregnancies were defined by >10 IU/l plasma s-hCG on day 14. Ultrasound scan on week 6 and week 12 confirmed fetal viability. Results. Lean group (body mass index [BMI]

The early decline and loss of female fertility in humans and other species represents an evolutionary paradox. Despite being born with a vast stock of oocytes, females encounter an exhaustion of ovarian reserve and sterility half way through their natural lives. Female reproductive ageing has been proposed to proceed as an ongoing decline in ovarian reserve, determined by remaining ovarian follicle number. However, despite extensive modelling, the respective contributions of intra-, inter-, and extra-ovarian signalling have not been fully characterised. It remains unclear whether reproductive ageing progresses simply as a pre-determined function of remaining ovarian follicles, or as an age-dependent process in humans. Here, we have analysed ovarian response to hormonal stimulation in women who have undergone surgical removal of a single ovary, in order to investigate the relative contributions of intra-, inter, and extra-ovarian signalling on reproductive ageing. Our data show that in unilaterally oophorectomised women, ovarian response to follicle stimulating hormone (FSH) declines beyond levels predicted by a total ovarian follicle pool model of reproductive ageing. Maintenance of ovarian function later in reproductive life, despite the removal of half of the total ovarian reserve, suggests a role for an extra-ovarian age-dependent regulation of reproductive decline. This highlights the need for further work to identify signalling factors that communicate age-related signals between the soma and the germline.

Objective To assess whether men with reduced semen quality exhibit genetic variants in the genes coding for the messenger RNA methylation erasers FTO and ALKBH5. Design DNA of men undergoing infertility work-up was extracted and the FTO and ALKBH5 genes were sequenced. Statistical analysis was used to study the correlation between the identified ALKBH5 and FTO variants and sperm quality. Setting University hospital infertility clinic. Patient(s) Semen samples from 77 unselected men that had been referred to Oslo University Hospital for routine semen analysis as part of infertility work-up. Intervention(s) Not applicable. Main Outcome Measure(s) Immunohistochemistry and Western blot were used to confirm the presence of ALKBH5 and FTO in human testis. DNA extraction from samples was followed by Illumina MiSeq amplicon high throughput sequencing and sequence alignment. Variant calling was carried out using GATK's UnifiedGenotyper. Standard semen parameter analysis was performed according to World Health Organization guidelines. Result(s) We found an FTO genetic variant to be associated with reduced semen quality. We also identified two FTO missense variants, one mutation (p.Cys326Ser) was located in the important linker between the two protein domains; the other mutation (p.Ser256Asn) was situated in a flexible loop able to interact with other molecules. Conclusion(s) The discovery of two missense mutations with potentially detrimental effect on the functionality of the methylation eraser protein FTO, as well as a genetic variant of the same protein that is associated with altered semen quality could suggest that aberrant demethylation of messenger RNA is a factor involved in reduced male fertility.

Subfertility due to chronic anovulation is common in women with polycystic ovary syndrome (PCOS) and is often treated with IVF. Women with PCOS have an increased ovarian follicle and oocyte count, increased ovarian reserve and/or a slower rate of follicle atresia. If so, one would expect women with PCOS to display a delayed reduction in fertility with advancing age as compared with eumenorrheic women.To test this hypothesis, we compared oocyte count and live birth rates among two groups undergoing IVF, 500 women with PCOS and 500 eumenorrheic women with infertility due to tubal factor only.Across the age range of 22-41 years, oocyte count and live birth rates remained stable in women with PCOS. In the eumenorrheic comparison group, these parameters decreased significantly with age.Women with PCOS display sustained fertility with advancing age as compared with infertile eumenorrheic women.

Surgical eradication of minimal and mild endometriosis has been shown to increase the birth rate both spontaneously and after intrauterine insemination. This study from a reproductive medicine unit at a referral university hospital examined whether surgical eradication of minimal and mild endometriosis prior to IVF improved the treatment outcome. Records of infertile patients with minimal and mild endometriosis (American Society for Reproductive Medicine stages I and II) with no prior IVF/intracytoplasmic sperm injection (ICSI) treatments were analysed. During the first treatment cycle, women who had undergone complete removal (n=399) of endometriotic lesions experienced, compared with women with diagnostic laparoscopy only (n=262), a significantly improved implantation rate (30.9% versus 23.9%, P=0.02), pregnancy rate (40.1% versus 29.4%, P=0.004) and live-birth rate per ovum retrieval (27.7% versus 20.6%, P=0.04). Surgical removal of minimal and mild endometriotic lesions also gave shorter time to first pregnancy and a higher cumulative pregnancy rate. The study shows that women with stages I and II endometriosis undergoing IVF/ICSI have significantly shorter time to pregnancy and higher live-birth rate if all visible endometriosis is completely eliminated at the time of diagnostic surgery. Surgical elimination of minimal and mild endometriosis has been shown to increase the birth rate both spontaneously and after intrauterine insemination. In this study from a reproductive medicine unit at a referral university hospital, we examined whether surgical elimination of minimal and mild endometriosis prior to IVF improved the outcome of this treatment as well. During the first IVF treatment cycle, women who had undergone complete surgical removal of endometriosis experienced, compared with women who still had their endometriosis, an improved rate of embryo implantation, pregnancy rate and live birth rate per ovum retrieval. Surgical removal of minimal and mild endometriotic lesions also gave shorter time to first pregnancy and a higher cumulative pregnancy rate. In summary, our study shows that women with minimal and mild endometriosis undergoing IVF have shorter time to pregnancy and higher live-birth rate if all visible endometriosis is completely eliminated before the start of treatment.

Surgery, chemotherapy and radiation, but also long-term hormonal treatment may cause reduced gonadal function in male cancer patients. The germinal epithelium is more vulnerable to cytotoxic damage than the Leydig cells, which implies that subfertility/infertility is a more frequent side effect of cancer treatment than endocrine hypogonadism.This review article is based on clinical experience and literature retrieved from PubMed.The degree of gonadal damage depends on the type of chemotherapy and the cumulative dose; with alkylating substances and procarbazine being the most gonadotoxic agents. The testicle is one of the most radiosensitive organs, and the damage depends on the radiation dose. Testicle damage may be caused by direct radiation of the testicles or scattered radiation from radiated adjacent tissue. Freezing of semen should be discussed with and offered to all men below 55 years that are about to undergo cancer treatment that may cause reduced fertility. Men surviving cancer who experience unwanted childlessness should be offered examination, advice and possibly assisted fertilization as part of the rehabilitation. Especially after intensive chemotherapy and high dose cranial radiation therapy the patient should be examined regularly throughout life with respect to premature endocrine hypogonadism.

BACKGROUND: Cells isolated from the periovulatory ovarian follicle are often used as a model of ovarian steroidogenesis and corpus luteum formation. The follicular fluid-derived cell (FFDC) population is, however, heterogeneous and in addition to granulosa–lutein cells, non-steroidogenic cells are also present. These non-steroidogenic cells, especially the immune cells, may have important biological functions in this model. Here, we describe a method to isolate FFDC, characterize the phenotype of the immune cells and deplete immune cells from FFDC. METHODS AND RESULTS: Follicular fluid aspirated transvaginally during IVF was clarified by centrifugation and enzymatic dispersion, labelled for leukocyte-specific markers and analysed by flow cytometry. Leukocytes constituted 22% of FFDC and expressed macrophage/dendritic cell, monocyte and lymphocyte markers. Leukocytes were depleted with anti-CD45-conjugated immunobeads, resulting in an FFDC population with

In Norway, assisted reproduction has been regulated by law since 1987, but the in vitro fertilization (IVF)-clinics are free to decide the number of embryos transferred. During the 1990ies, the number of embryos replaced was reduced from three to two. Triplets almost disappeared, but the twinning rate remained unchanged. According to the latest national data, 27.5 % of the deliveries following IVF and intracytoplasmic sperm injection (ICSI) in 2002 were multiple births. In our hospital, 23.9 % of the deliveries following IVF/ICSI in 2003 were multiple births. To reduce the multiple pregnancy rate, eSET was introduced as a routine in patients with a high probability to become pregnant in November 2004.The results of eSET from the beginning of November 2004 until July 2005 are presented. All three inclusion criteria for eSET had to be fulfilled: 1) ageor= 35 years, 2) first or second treatment, 3) at least one top quality embryo.163 out of 644 treatment cycles fulfilled all three criteria for eSET. For 54 (33 %) of the treated women, the treatment has resulted in live births or ongoing pregnancies, compared to 23 % of the treatments with two transferred embryos. The overall pregnancy rate was only slightly decreased (32.4 %) compared to before implementation of eSET (34 %). In the eSET group, 60 % of the patients had embryos available for cryopreservation. The cumulative pregnancy rate per started treatment cycle is expected to increase when pregnancies following transfer of frozen-thawed embryos are included. The overall twinning rate was reduced to 18.1 %. It should be possible to reduce the twinning rate further by for example raising the age-limit for eSET. An optimal trade-off between cumulative ongoing pregnancy rate and twinning rate could more easily be obtained if the Norwegian IVF-clinics and authorities establish an eSET policy.

In this study we assessed how insulin resistance affects pregnancy rates in infertile women with the polycystic ovary syndrome (PCOS) treated with laparoscopic ovarian electrocautery. Sixty-four PCOS women were included in the study in a consecutive fashion. Following the CIGMA (continuous infusion of glucose with model assessment) test, 28 women were classified as insulin resistant and 36 women as non-insulin resistant. After the ovarian electrocautery patients were observed for 12-18 months. If pregnancy did not ensue, they were referred for one or more cycles of in vitro fertilization (IVF). Following ovarian electrocautery the non-insulin-resistant women more frequently achieved a regular menstrual cycle and ovulation than the insulin-resistant PCOS women. Consequently 18 (50%) of the non-insulin-resistant PCOS women achieved a pregnancy versus only five (18%) of women in the insulin-resistant PCOS group. Following treatment with both ovarian electrocautery and IVF, 27 (75%) of the non-insulin resistant PCOS women achieved a successful pregnancy, while 13 (46%) of the insulin-resistant PCOS group achieved this. In conclusion, insulin resistance may be an important marker of a poor outcome of treatment in PCOS infertility. Further studies are needed to evaluate the possible effect of treatment alternatives to alleviate the unfavorable influences of insulin resistance and hyperinsulinemia on ovulation induction in PCOS women.

Metformin effectively restores insulin sensitivity in insulin-resistant women with polycystic ovary syndrome (PCOS). We examined whether metformin, given prior to and during ovarian stimulation for in vitro fertilization (IVF), altered follicle stimulating hormone (FSH) requirement and increased the number of collected oocytes in these women. Seventeen insulin-resistant women with PCOS were recruited to our IVF unit to receive two consecutive cycles of ovarian stimulation with or without metformin co-treatment, the order of treatments being randomized using a table of random numbers. Metformin treatment (1500 mg/day) started 3 weeks before downregulation with buserelin acetate and was continued throughout ovarian stimulation with human recombinant FSH. Nine women completed both cycles, the results of eight women being excluded because of pregnancy after the first cycle (n = 4) or because the protocol of the study was not followed (n = 4). Mean total FSH dose was 2301 IU (range 1500-6563 IU) in metformin cycles and 2174 IU (range 1200-3900 IU) in parallel control cycles, while the mean number of collected oocytes was 8.6 (range 2-28) and 4.6 (range 1-16), respectively. Bayesian analysis showed probabilities of 0.05 that metformin reduces FSH requirement by at least 10%, and of 0.61 that at least 10% more oocytes are collected after metformin co-treatment. Co-administration of metformin is therefore likely to increase the number of oocytes collected after ovarian stimulation in insulin-resistant women with PCOS but is unlikely to reduce the requirement for FSH.

Objective To study whether maternal age is associated with serum concentration of human chorionic gonadotropin in early pregnancy. Design Cross-sectional study. Setting Oslo University Hospital in Oslo, Norway. Population All vital pregnancies in gestational week 8 conceived by in vitro fertilization between February 1996 and February 2013 (n = 4472). Methods Serum concentrations of human chorionic gonadotropin were measured on day 12 after embryo transfer/day 16 following ovulation induction. Trends in geometric means of human chorionic gonadotropin concentrations by maternal age group were tested by linear regression analysis. We also studied the association of maternal age (years) with log-transformed human chorionic gonadotropin concentrations, and adjustments were made for number of embryos transferred, method of in vitro fertilization and year (period) of embryo transfer. Main outcome measure Serum concentration of human chorionic gonadotropin. Results Geometric mean concentrations of human chorionic gonadotropin decreased with increasing maternal age (p = 0.024, test for trend by weighted linear regression). Also, we estimated a significant negative association of maternal age with log-transformed human chorionic gonadotropin concentrations (adjusted regression coefficient −0.011, standard error 0.003, p

The impact of insulin resistance on the outcome of IVF or intracytoplasmic sperm injection (ICSI) in women with polycystic ovarian syndrome (PCOS) was examined. Insulin sensitivity was measured by the continuous infusion of glucose with model assessment (CIGMA) test. Insulin-resistant (n = 26) and non-insulin-resistant women (n = 30) with PCOS underwent a total of 100 cycles of long-term down-regulation with buserelin acetate, stimulation with human recombinant FSH, and IVF or ICSI. Blood samples were taken throughout ovarian stimulation for hormone assays. Insulin-resistant and non-insulin-resistant women had similar concentrations of FSH, LH, testosterone and androstenedione throughout stimulation, but insulin-resistant women had hyperinsulinaemia and lower sex hormone binding globulin concentrations. Insulin-resistant women also had lower oestradiol concentrations during stimulation and required higher FSH doses, but these differences disappeared after controlling for the higher body weight in the group of insulin-resistant women. Groups had similar number of oocytes collected, similar implantation and pregnancy rates, and the incidence of ovarian hyperstimulation syndrome was also similar. Obesity, independent of hyperinsulinaemia, was related to a lower oocyte count and increased FSH requirement. It is concluded that in PCOS women receiving long-term down-regulation and stimulation with recombinant FSH, insulin resistance is neither related to hormone levels nor to IVF outcome. Obesity, independent of insulin resistance, is associated with relative gonadotrophin resistance.

To investigate the clinical importance of leptin's intraovarian effects, we studied the concentration of leptin and leptin binding activity in the plasma and in the follicular fluid of PCOS patients (n=20; median BMI: 27.1 kg/m2, range 19.7-36.3) undergoing controlled ovarian stimulation with long-term GnRH agonist, recombinant FSH, and in vitro fertilization. Follicular fluid and blood samples were collected during follicle aspiration for IVF. Total leptin concentration was measured by radioimmunoassay, and specific leptin binding activity was accessed by a gel filtration column assay. Follicular fluid and plasma leptin levels were similar (median 1135 pmol/l vs. 1409 pmol/l; p=0.81). Follicular fluid to plasma leptin ratio was independently associated with cumulative FSH dose (r=0.63; p=0.006) and insulin resistance index (r=-0.45; p=0.04). Specific leptin binding activity was higher in the plasma than in the follicular fluid [median 7.94% vs. 3.49%; p0.001]. When multivariate analysis was used to predict FSH consumption, only follicular fluid leptin levels were significantly associated with cumulative FSH dose (r=0.46; p=0.04). We infer that at least in part by increased intrafollicular leptin levels, obesity directly affects ovarian function in PCOS, and may induce a relative resistance to gonadotropin stimulation. This intraovarian effect of leptin can be even more profound because of low leptin binding activity in the preovulatory follicle of obese patients.