Assaf Ben-Meir

At what age can human oocytes be obtained

OBJECTIVE To determine whether oocyte retrieval and in vitro maturation (IVM) is effective in girls undergoing fertility preservation before cancer treatment. DESIGN Cohort study. SETTING Tertiary university medical center. PATIENT(S) Patients <or=20 years old before gonadotoxic chemotherapy undergoing ovarian cortex cryopreservation. INTERVENTION(S) Before ovarian cortex cryopreservation, oocytes in all observed follicles were aspirated, matured in vitro, and cryopreserved. MAIN OUTCOME MEASURE(S) Maturation of oocytes. RESULT(S) One hundred seventy-nine oocytes were detected in 17/19 patients (89%) aged 5-20 years. We found 7, 8, and 17 oocytes in patients 5, 8, and 10 years old, respectively. The median number of oocytes per patient was 9 (0-37). Maturation rate was 45/133 oocytes (34%). In total, 81 oocytes were cryopreserved. We cryopreserved 4 of 12 detected, 4 of 9 detected, 1 of 8 detected, and 4 of 9 detected IVM oocytes for patients aged 5-10, 11-14, 15-17, and 18-20 years old, respectively. CONCLUSION(S) Patients undergoing ovarian cryopreservation could benefit from supplementary oocyte aspiration from the cortex. Surprisingly, oocytes were detected even in young premenarcheal girls. The number of oocytes detected, matured, and cryopreserved was not age dependent. Retrieved oocytes can be matured in vitro and cryopreserved. Because no pregnancy has yet resulted from this procedure it should be considered to be experimental. We describe the youngest patients to undergo ovum collection, IVM, and oocyte cryopreservation.

Derivation of xeno-free and GMP-grade human embryonic stem cells--platforms for future clinical applications.

Clinically compliant human embryonic stem cells (hESCs) should be developed in adherence to ethical standards, without risk of contamination by adventitious agents. Here we developed for the first time animal-component free and good manufacturing practice (GMP)-compliant hESCs. After vendor and raw material qualification, we derived xeno-free, GMP-grade feeders from umbilical cord tissue, and utilized them within a novel, xeno-free hESC culture system. We derived and characterized three hESC lines in adherence to regulations for embryo procurement, and good tissue, manufacturing and laboratory practices. To minimize freezing and thawing, we continuously expanded the lines from initial outgrowths and samples were cryopreserved as early stocks and banks. Batch release criteria included DNA-fingerprinting and HLA-typing for identity, characterization of pluripotency-associated marker expression, proliferation, karyotyping and differentiation in-vitro and in-vivo. These hESCs may be valuable for regenerative therapy. The ethical, scientific and regulatory methodology presented here may serve for development of additional clinical-grade hESCs.

Safety and efficacy of external cephalic version for women with a previous cesarean delivery

OBJECTIVE To evaluate the success and morbidity rates for attempted external cephalic version (ECV) in patients with one previous cesarean delivery (CD) and a breech-presenting fetus at term. STUDY DESIGN This is a retrospective study of outcomes of ECV at our institution for all women with one previous CD and a breech-presenting fetus at term between January 1997 and June 2005. A literature review was also performed as a Medline search (1966-2006). RESULTS ECV was attempted for 42 women with a breech-presenting fetus and previous CD. The success rate of ECV was 74.0%, and 84% of women with successful ECV delivered vaginally. All fetal and maternal outcomes were favorable. Only four Medline reports met our inclusion criteria, representing a total of 124 patients and a mean ECV success rate of 76.6%. Thus we assessed 166 cases of attempted ECV and find an average ECV success rate of 76.5% and favorable fetal and maternal outcomes. CONCLUSIONS Women with a breech-presenting fetus at term and previous CD, who desire a trial of labor, should be counseled regarding the accumulating evidence about the efficacy and apparently safety of this procedure and may be offered an ECV attempt.

Prognostic parameters for successful external cephalic version

Objective. To improve patient consultation before external cephalic version (ECV) attempt at term by defining prognostic parameters for the success of the procedure. Methods. This was a prospective observational study set in a university teaching hospital. We prospectively collected demographic and obstetric data from 603 ECV attempts at our center for the period between January 1997 and June 2005. Analysis was performed by stepwise logistic regression of the demographic and obstetric parameters. The main outcome measure was success of ECV attempt. Results. Success rates were 72.3% and 46.1% for multiparas and nulliparas, respectively. Prognostic parameters associated with successful ECV were amniotic fluid index > 7 cm, multiparity, non-frank breech, non-anterior placental location, and body mass index < 25. Conclusion. Prognostic parameters, particularly amniotic fluid index and multiparity, can help physicians in counseling parturients before deciding on ECV.

Changes related to phosphatidylinositol 3-kinase/Akt signaling in leiomyomas: possible involvement of glycogen synthase kinase 3α and cyclin D2 in the pathophysiology

OBJECTIVE To identify changes in the expression and phosphorylation of phosphatidylinositol 3-kinase (PI3K)/Akt protein kinases controlling survival and/or apoptosis of in vitro cell cultures of uterine leiomyomas. DESIGN Establishment of paired cell cultures of leiomyoma and myometrial specimens. SETTING Hadassah gynecology research laboratory. PATIENT(S) Eleven white premenopausal women, 35 to 50 years of age, undergoing hysterectomy because of symptomatic uterine leiomyomas. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Immunochemical analysis of expression and phosphorylation of relevant PI3K/Akt and BCL2 proteins. RESULT(S) Analysis of total phosphatase and tensin homologue deleted on chromosome 10 (PTEN) and of nonphosphorylated and phosphorylated (p) PDK1, Akt, glycogen synthase kinase 3 (GSK3), FKHR, tuberin (TSC2) and hamartin (TSC1) complex, and cyclin D2 proteins indicated that [1] the level of pGSK3alpha and cyclin D2 proteins was elevated significantly in the leiomyoma compared with the normal myometrium, [2] there was a significant interaction between PTEN- PDK1 and between pAkt-pGSK3beta in the leiomyoma compared with the myometrial cells, and [3] there was a significant interaction between pAkt-pGSK3alpha in the paired leiomyoma and myometrial cultures. CONCLUSION(S) Our study suggests that the downstream signaling components of the PI3K/Akt pathway, GSK3 (a regulator of apoptosis), and cyclin D2 (a promoter of G1/S progression), as well as the significant interaction between PTEN-PDK and between pAkt-pGSK3beta, are involved in the survival and proliferation of leiomyomas.

Coenzyme Q–dependent mitochondrial respiratory chain activity in granulosa cells is reduced with aging

OBJECTIVE To examine coenzyme Q10 (CoQ10)-dependent mitochondrial respiratory chain (MRC) activity in granulosa cells (GC) with aging and examine the effect of in vitro CoQ supplementation. DESIGN Experimental study. SETTING Hospital laboratory. PATIENT(S) Ten younger (<32 years) and 10 older (>39 years) patients undergoing in vitro fertilization (IVF) treatment. INTERVENTION(S) Measurement of succinate-cytochrome c reductase (MRC complex II + III) activity in the presence and absence of CoQ1 (a soluble CoQ analog). MAIN OUTCOME MEASURE(S) MRC enzymatic activity in human GC via complex II + III measured in GC homogenate by spectrophotometry and compared with CoQ in dependent MRC complex II and citrate synthase (CS). RESULT(S) Complex II + III activity was 1.9 times higher in young patients compared with older patients (18.3 ± 5.8 and 9.6 ± 3 nmol/min/mg, respectively) whereas II and CS were not statistically significantly different. Increased II + III activity in the presence CoQ1 was observed in both groups but was statistically significantly higher in the older patients, reaching similar levels. Compared with baseline (II + III + Q/II + III), the increase was 2.47 times higher in older patients compared with young patients (6.5 ± 2.0 and 2.62 ± 0.83, respectively). CONCLUSION(S) Coenzyme Q10-dependent MRC activity in GC reduces with aging. This reduction is diminished upon in vitro CoQ1 supplementation, indicating that CoQ10 deficit is the underlying cause for the mitochondrial dysfunction. The results show that functional CoQ10 status can be assessed by measuring complex II + III activity in GC and might provide a useful monitoring tool for future clinical studies of oral CoQ10 supplementation to older patients undergoing IVF treatment.

Cesarean section upon request: is it appropriate for everybody?

Abstract The request for cesarean section without medical indication has become one of the dilemmas faced by the obstetrician. Most recent studies that compare vaginal delivery with elective cesarean section find them equally safe. This comparison is lacking in the option of trial of labor, which may result in an assisted vaginal delivery or intrapartum cesarean section, both with increased morbidity and mortality for the mother and newborn. When considering elective cesarean section, the obstetrician has to take into account improved anesthetic techniques and the decrease in morbidity and mortality after cesarean section with the trend toward patient autonomy to decide on her own treatment. On the other hand, the obstetrician has to advise his patient of the best treatment with respect to possible complications in future pregnancies, such as placental complications and increased morbidity and mortality resulting from repeated cesarean sections. The advantage of cesarean section for pelvic floor protection does not exist after three consecutive cesarean sections and equals the rate of urinary incontinence after consecutive three vaginal deliveries. In countries such as ours, where most women wish for several children, the risk-benefit balance is toward repeated spontaneous vaginal deliveries.

The benefit of human chorionic gonadotropin supplementation throughout the secretory phase of frozen-thawed embryo transfer cycles

OBJECTIVE To assess whether supplementation with hCG throughout the secretory phase of hormonally modulated cycles of frozen-thawed embryos might positively affect the outcome of such cycles. DESIGN Prospective, randomized controlled trial. SETTING University teaching hospital. PATIENT(S) Patients undergoing frozen-thawed embryo transfer cycles. INTERVENTION(S) Patients were randomly divided into two groups by the last digit of their identification number. Group A received our standard protocol for endometrial preparation, whereas group B patients were given an additional 250 microg of recombinant hCG on day of P initiation, the day of embryo transfer, and 6 days later. Throughout the cycle, and to compare between the groups, serial ultrasound examinations and hormonal tests of E(2) and P serum levels were obtained. MAIN OUTCOME MEASURE(S) Implantation and clinical pregnancy rates (PR). RESULT(S) One hundred sixty-five patients were enrolled in this study, 78 in the control group and 87 in the hCG-treated group. Progesterone levels and endometrial thickness were similar throughout the cycle in both groups. The E(2) level was significantly higher in group B on the day of embryo transfer and 6 days later. The PRs did not differ between the two groups (28.2% and 32.2% for groups A and B, respectively). Similarly, the implantation rates were comparable between the groups (12.7% and 14.9%, respectively). CONCLUSION(S) No advantage was found concerning PR and implantation rate by supplementing the secretory phase with hCG in patients undergoing transfer of frozen-thawed embryo in hormonally modulated cycles.

All-trans-retinoic acid mediates changes in PI3K and retinoic acid signaling proteins of leiomyomas

OBJECTIVE To detect changes induced by all-trans-retinoic acid (ATRA) on the expression and activation of target proteins of the retinoic acid (RA) and PI3K/Akt pathways involved in leiomyoma growth. DESIGN A study on human tissue cultures. SETTING Hadassah University Hospital. PATIENT(S) Premenopausal women with uterine leiomyomas. INTERVENTION(S) Paired cultures of normal myometrium and leiomyomas, from women undergoing hysterectomy, were obtained. MAIN OUTCOME MEASURE(S) The effect of ATRA was examined on the expression and phosphorylation of relevant RA, PI3K/Akt, and Bcl2 proteins (immunochemical analysis), cell proliferation, cell cycle distribution, and apoptosis. RESULT(S) Applying our cell culture model, we demonstrated that ATRA induced changes in the expression and activation of the RA and PI3K/Akt pathway proteins in leiomyoma cells, with significant increases of alcohol dehydrogenase 1 and cyclin D2 protein levels. In part of the leiomyoma cells, ATRA induced a relative increase of Bax (proapoptotic) as well as a relative decrease of phosphorylated glycogen synthase kinase 3β (proapoptotic). CONCLUSION(S) Our results highlight the involvement of ATRA in the RA and PI3K/Akt pathways, whose specific signaling products may influence the outcome of leiomyoma growth by regulating cell proliferation, apoptosis, and survival. These results might be useful for the on-going research into alternative methods for treating and preventing this disorder.

Surgical versus medical treatment for secondary post‐partum hemorrhage

Background. Secondary post‐partum hemorrhage (PPH) is defined as any abnormal bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally. Treatment usually falls into one of the two categories: surgical evacuation of the uterus or medical treatment. Objective. To compare the two different clinical approaches and the implications on future fertility. Study design. A retrospective study. Setting. From 1990 to 2002, 168 women diagnosed with late PPH were admitted to the Hadassah Medical Centers in Jerusalem. The cases were divided into two groups according to the planned initial treatment: primary surgical treatment vs. primary medical treatment. Results. Primary surgical treatment was associated with significantly more primary negative events (p = 0.01). After the primary event, primary surgical treatment was associated with fewer future deliveries (p = 0.04) and resulted in increased rate of secondary infertility of borderline significance (p = 0.06). Conclusions. Our results show that secondary PPH is related to high rates of immediate and long‐term complications. It is possible that a conservative medical approach for secondary PPH may be superior to surgical treatment.