Amir Mor

Recent advances in the field of ovarian tissue cryopreservation and opportunities for research

PurposeThe purpose of this study was to summarize the latest advances and successes in the field of ovarian tissue cryopreservation while identifying gaps in current knowledge that suggest opportunities for future research.MethodsA systematic review was performed according to PRISMA guidelines for all relevant full-text articles in PubMed published in English that reviewed or studied historical or current advancements in ovarian tissue cryopreservation and auto-transplantation techniques.ResultsOvarian tissue auto-transplantation in post-pubertal women is capable of restoring fertility with over 80 live births currently reported with a corresponding pregnancy rate of 23 to 37%. The recently reported successes of live births from transplants, both in orthotopic and heterotopic locations, as well as the emerging methods of in vitro maturation (IVM), in vitro culture of primordial follicles, and possibility of in vitro activation (IVA) suggest new fertility options for many women and girls. Vitrification, as an ovarian tissue cryopreservation technique, has also demonstrated successful live births and may be a more cost-effective method to freezing with less tissue injury. Further, transplantation via the artificial ovary with an extracellular tissue matrix (ECTM) scaffolding as well as the effects of sphingosine-1-phosphate (SIP) and fibrin modified with heparin-binding peptide (HBP), heparin, and a vascular endothelial growth factor (VEGF) have demonstrated important advancements in fertility preservation. As a fertility preservation method, ovarian tissue cryopreservation and auto-transplantation are currently considered experimental, but future research may pave the way for these modalities to become a standard of care for women facing the prospect of sterility from ovarian damage.

Molecular characterization of the human microbiome from a reproductive perspective

The process of reproduction inherently poses unique microbial challenges because it requires the transfer of gametes from one individual to the other, meanwhile preserving the integrity of the gametes and individuals from harmful microbes during the process. Advances in molecular biology techniques have expanded our understanding of the natural organisms living on and in our bodies, including those inhabiting the reproductive tract. Over the past two decades accumulating evidence has shown that the human microbiome is tightly related to health and disease states involving the different body systems, including the reproductive system. Here we introduce the science involved in the study of the human microbiome. We examine common methods currently used to characterize the human microbiome as an inseparable part of the reproductive system. Finally, we consider a few limitations, clinical implications, and the critical need for additional research in the field of human fertility.

Acute presentation of gestational diabetes insipidus with pre‐eclampsia complicated by cerebral vasoconstriction: A case report and review of the published work

Gestational diabetes insipidus (GDI) is a rare, self‐limited complication of pregnancy. As it is related to excess placental vasopressinase enzyme activity, which is metabolized in the liver, GDI is more common in pregnancies complicated by conditions associated with liver dysfunction. We present a case of a 41‐year‐old woman at 38 weeks’ gestation who presented with pre‐eclampsia with severe features, including impaired liver function and renal insufficiency. Following cesarean section she was diagnosed with GDI, which was further complicated by cerebral vasoconstriction as demonstrated by magnetic resonance angiography. This case raises the possibility that cerebral vasoconstriction may be related to the cause of GDI. A high index of suspicion of GDI should be maintained in patients who present with typical signs and symptoms, especially in the setting of pregnancy complications associated with liver dysfunction.

Alpha-fetoprotein as a tool to distinguish amniotic fluid from urine, vaginal discharge, and semen.

OBJECTIVE: To estimate whether alpha-fetoprotein (AFP) can be used to distinguish amniotic fluid absorbed in sanitary pads from other similarly absorbed substances (semen, urine, and normal vaginal discharge). METHODS: A prospective cohort study. Urine and amniotic fluid specimens were collected from 52 pregnant women admitted for labor. Semen specimens were collected from 17 men undergoing infertility evaluation. Alpha-fetoprotein concentrations were measured directly from urine, amniotic fluid, and semen and from pads instilled with samples from these specimens. Alpha-fetoprotein concentrations were also measured from pads absorbed with normal vaginal discharge collected from 27 pregnant women. RESULTS: Alpha-fetoprotein levels in amniotic fluid (245.38±21.03 ng/mL, n=52) were significantly higher than those measured in maternal urine (0.84±0.17 ng/mL, n=52, P<.001), or semen (1.52±0.35 ng/mL, n=17, P<.001). The same trend was seen when AFP was extracted from pads: amniotic fluid levels (19.44±1.98 ng/mL, n=52) were significantly higher than those of urine (undetectable, n=52), semen (undetectable, n=17), or normal vaginal discharge (0.53±0.16 ng/mL, n=27, P<.001). Receiver operator characteristic curve analysis demonstrated 96.2% sensitivity and 100% specificity for distinguishing the presence of amniotic fluid from normal vaginal discharge on sanitary pads (cutoff 3.88 ng/mL, area under the curve 0.99). CONCLUSION: When the diagnosis of rupture of membranes is in doubt, AFP levels can assist in differentiating amniotic fluid from other bodily fluids. A method that utilizes sanitary pads and an assay for AFP quantification may be an accurate and convenient way to confirm the diagnosis of rupture of membranes. LEVEL OF EVIDENCE: II

Same-day confirmation of intrauterine pregnancy failure in women with first- and early second-trimester bleeding

OBJECTIVE To determine if alpha-fetoprotein (AFP) concentration in vaginal blood, in the setting of dissolved fetal tissue, is significantly higher than its concentration in the maternal serum. DESIGN A prospective cohort study. SETTING Medical center. PATIENT(S) Four groups of women were evaluated: 1) with missed/incomplete miscarriage with vaginal bleeding; 2) with threatened miscarriage; 3) with vaginal bleeding during cerclage placement; and 4) undergoing dilation and curettage (D&C). INTERVENTIONS(S) None. MAIN OUTCOME MEASURE(S) In each patient, AFP concentration in the vaginal blood or in the liquid component of the evacuated products of conception (POC; D&C group) was compared with the AFP concentration in the maternal serum. RESULT(S) The median (range) concentration ratios of AFP in vaginal blood (or POC) to AFP in maternal serum were 24.5 (5.1-8,620) and 957 (4.6-24,216) for the missed/incomplete (n = 30) and the D&C (n = 22) groups, respectively, whereas they were only 1.2 (0.4-13.4) and 1.01 (0.7-1.5) for the threatened miscarriage (n = 15) and cerclage (n = 9) groups, respectively. Receiver operating characteristic (ROC) analysis demonstrated 100% sensitivity and 86.7% specificity for the detection of the passage of fetal tissue (ratio 4.3, area under the ROC curve 0.96). CONCLUSION(S) Higher concentrations of AFP in vaginal blood than in maternal serum may indicate the presence of dissolved fetal tissue (i.e., confirming a failed pregnancy).

Fetal proximal humeral epiphysis as an indicator of term gestation in different ethnic groups

Abstract Objectives: Accurate pregnancy dating is critical for appropriate clinical management. Our aim was to determine the time of appearance of proximal humeral epiphysis (PHE), consistency of its appearance among ethnic groups and whether 3D imaging helps with its visualization. Methods: A cross-sectional study was done on 360 patients with 563 scans in different ethnic groups between August 2013 and July 2015. Inclusion criteria were singleton pregnancies (34–40+  weeks of gestation), well dated by <20 weeks sonogram. Results: PHE was not seen at 34 (n = 44) or 35 weeks (n = 36) and was present at gestational ages 36 (n = 3), 37 (n = 126), 38 (n = 96), 39 (n = 100) and 40 weeks (n = 28) in 2%, 12%, 51%, 75% and 100%, respectively. PHE was seen in 20 of 50 (60%) African–Americans, 22 of 61 (64%) south Asians, 41 of 72 (57%) Caucasians, 45 of 86 (48%) Hispanics and 41 of 80 (49%) Asians. Conclusion: Appearance of PHE did increase with gestational age, prior to 40 weeks, it was not uniformly present and was seen as early as 36 weeks independent of ethnic group.

A Novel Rapid Bedside Test for Rupture of Membranes [25I]

INTRODUCTION: Our objective was to evaluate the ability of a pad containing an immunoassay for alpha-fetoprotein (AFP) to detect amniotic fluid (AF) leakage to serve as a rapid and simple one-step bedside test. METHODS: A prospective cohort study. Pads containing a qualitative immunoassay for AFP (detection threshold of 20 ng/mL) were used. The study group was pads worn by 200 pregnant women with confirmed rupture of membranes. Three controls were evaluated: 1) Pads worn by 70 pregnant women with intact membranes who had no vaginal bleeding; 2) Additional pads instilled with urine specimens obtained from the 270 women described above (200 cases and the 70 women in group 1); 3) Pads instilled with semen collected from 40 men seen in an infertility clinic. RESULTS: All 200 pads that absorbed AF had positive results. Among the pads from the 70 women with intact membranes, only 36 absorbed a sufficient amount of normal vaginal discharge to activate the colorimetric reaction, and they all had negative results. The colorimetric reaction was either not activated or failed to complete in the remaining 34 pads. All 270 pads that absorbed urine, and all 40 pads with semen, had negative results. CONCLUSION: A qualitative immunoassay for AFP, embedded in a pad, appears to be a reliable bedside test for distinguishing amniotic fluid leakage from normal vaginal discharge, urine, or semen. This assay, based on the same principle as a home urine pregnancy test, has the potential to be a rapid and simple one-step bedside or home test for ROM.

Does the Timing of Appearance of the Fetal Proximal Humeral Epiphysis Differ Between Ethnic Groups? [23M]

INTRODUCTION: Accurate determination of the expected date of delivery is critical since clinical management is often determined by gestational age. Previous studies have suggested that the appearance of the ossification center in the proximal humeral epiphysis (PHE) may be a reliable indicator of term gestation, and appears around 38 weeks of gestation. Our aim was to determine if the sonographic appearance of fetal PHE correlates with gestational age, and is consistent among various ethnic groups. METHODS: A prospective observational study of 563 patients between August 2013 and June 2015. Inclusion criteria: Singleton pregnancies at >34 weeks of gestation, well dated by first trimester sonogram. Pregnancies with skeletal dysplasia, congenital malformation, or unclear dating were excluded. RESULTS: PHE was not seen in any patients at 34 and 35 weeks, and was present in only 2.2% of patients at 36 weeks across different ethnic groups. The appearance of PHE in the full cohort at gestational ages 37, 38 weeks, 39 weeks, and 40 weeks was 11.9%, 51%, 75% and 100% respectively. No significant differences between ethnic groups were noted in the appearance of PHE. CONCLUSION: We found a relatively high prevalence of PHE in women at 39 weeks or above with no differences between ethnic groups. This suggests that the appearance of PHE can be used as a reliable indicator of term gestation independent of ethnic group, and may be useful for patients with poor dating who present for care in the late third trimester.

A Simple and Fast Approach to Confirm Pregnancy Failure in First Trimester Bleeding [8Q]

INTRODUCTION: A failing pregnancy may present with vaginal bleeding and the passage of fetal tissue. Alpha-fetoprotein (AFP) concentration in fetal serum is at least 1000 times higher than it is in maternal serum. The objective of this study was to determine if vaginal blood mixed with fetal tissue has a relatively higher concentration of AFP than vaginal blood in the case of a threatened abortion. METHODS: The study group was women with incomplete abortion or with missed abortion that started to have vaginal bleeding. The control group was women with threatened abortion (ie, not passing fetal tissue and with a fetal heartbeat). In each group, every womans maternal serum AFP concentration was compared to the AFP concentration in the vaginal blood. Values were expressed as mean±SEM. Paired t test was used. RESULTS: In the study group (17 women), the mean AFP concentration in blood sampled from the vagina was 17,043±11,048 ng/mL vs 11±2.7 ng/mL in the maternal serum (P<.001). In the control group (9 women), the mean AFP concentration in the blood sampled from the vagina was 71 ± 18 ng/mL vs 112 ± 32 ng/mL in the maternal serum (P=.1). In the study group, the AFP concentration in the vaginal blood was 8–8,620 times higher than in the maternal serum, whereas in the control group the ratio was around 1 (range 0.37–1.36). CONCLUSION: AFP concentration in vaginal blood that is at least 8 times higher than AFP concentration in maternal serum may indicate a passage or dissolving fetal tissue (ie, pregnancy failure).

A Sanitary Pad for Self-Assessment of Rupture of Membranes.

BACKGROUND: Multistep immunoassay kits for the diagnosis of rupture of membranes are relatively complex and are not designed to be used by pregnant women themselves. These kits require procedural steps of specimen extraction and preparation. We evaluated the ability of a sanitary pad containing a qualitative immunoassay for alpha-fetoprotein (AFP) to serve as a one-step self-test to detect amniotic fluid leakage. TECHNIQUE: Four sets of pads were evaluated. The pads in the study set were worn by 288 pregnant women with confirmed rupture of membranes. Three controls were evaluated: 1) pads worn by 93 pregnant women with intact membranes, 2) additional pads instilled with urine specimens obtained from the 381 women described previously (study set plus control set 1), and 3) pads instilled with semen collected from 40 men. EXPERIENCE: All 288 pads that absorbed amniotic fluid had positive results. Approximately half of the pads absorbed with normal vaginal discharge had a sufficient amount to yield valid results, which were all negative. All 381 pads with instilled urine and all 40 pads with instilled semen had negative results. CONCLUSION: An immunoassay for AFP, embedded in a pad, appears to be a feasible and reproducible self-test for the detection of rupture of membranes.