Claire Bourgain

Effect of ovarian stimulation with recombinant follicle-stimulating hormone, gonadotropin releasing hormone antagonists, and human chorionic gonadotropin on endometrial maturation on the day of oocyte pick-up

OBJECTIVE To assess the effect of ovarian stimulation with recombinant FSH, GnRH antagonists, and hCG on endometrial maturation on the day of oocyte pick-up. DESIGN Prospective study. SETTING Tertiary referral center. PATIENT(S) Fifty-five women undergoing controlled ovarian hyperstimulation for IVF/intracytoplasmic sperm injection (ICSI). INTERVENTION(S) [1] Ovarian stimulation with recombinant FSH, starting on day 2 of the cycle and GnRH antagonist, starting after a median of 6 days of recombinant FSH stimulation (range, 5-12 days); [2] hCG administration for ovulation induction; and [3] aspirational biopsy of endometrium at oocyte pick-up. MAIN OUTCOME MEASURE(S) Endometrial histology at oocyte pick-up by Noyes criteria. RESULT(S) Advancement of endometrial maturation (2.5 +/- 0.1 days) as compared to the expected chronological date was observed in all antagonist cycles at oocyte retrieval. Endometrial advancement at oocyte pick-up increased in line with values of LH at initiation of stimulation and the duration of recombinant FSH treatment before the antagonist was started. CONCLUSION(S) The higher the values of LH at initiation of stimulation and the longer the duration of recombinant FSH treatment before the antagonist is started, the more advanced the endometrial maturation at oocyte pick-up.

Endometrial evaluation by aspiration biopsy on the day of oocyte retrieval in the embryo transfer cycles in patients with serum progesterone rise during the follicular phase

OBJECTIVE To investigate the effect of subtle serum P rise before hCG administration on endometrial maturation in stimulated cycles. DESIGN Case-control study. SETTING Tertiary referral center. PATIENT(S) Twenty patients with serum P < or = 0.9 ng/mL (group I) (conversion to SI unit, 3.180), 20 patients with premature P rise (> or = 1.1 ng/mL, group II), and 20 patients with normal serum P (group III). INTERVENTION(S) Patients in groups I and II underwent endometrial aspiration biopsies on the day of oocyte retrieval in the ET cycles themselves. Patients in group III, without endometrial biopsies, were chosen as controls. MAIN OUTCOME MEASURE(S) Comparison of endometrial maturation, correlation between endometrial dating and cumulative P exposure, and/or number of days of P > or = 1.1 ng/mL and comparison of clinical outcome. RESULT(S) Groups I and II showed a secretory activity of the endometrium. In group II, the endometrial dating correlated neither with P exposure nor with the number of days of subtle P rise. Clinical pregnancies were observed in both groups but none in cases with endometrium advanced > 3 days. Similar pregnancy and implantation rates were observed between groups I and III. CONCLUSION(S) These data suggest that an endometrial aspiration biopsy performed on the day of oocyte retrieval may be used to assess endometrial receptivity in patients with serum P rise.

Human Oocytes Reversibly Arrested in Prophase I by Phosphodiesterase Type 3 Inhibitor In Vitro

Abstract This study addresses the role of cAMP hydrolytic isoenzyme phosphodiesterase type 3 (PDE 3) modulation on human oocyte maturation in vitro. Presence of phosphodiesterase type 3 A (PDE 3A) mRNA was confirmed in human germinal vesicle-stage (GV) oocytes. Making use of a selective PDE 3 inhibitor, Org 9935 (10 μM), oocytes retrieved from immature follicles were arrested in prophase I with a high efficiency for up to 72 h. Cumulus oocyte complexes (COCs) were retrieved in the follicular phase of the cycle before or after exposure to endogenous LH or hCG administration in vivo and randomly distributed into maturation medium with or without the PDE 3 inhibitor. Previous exposure of small follicles to LH activity in vivo had no influence on the arresting capacity of the PDE 3 inhibitor. Reversal from pharmacological arrest leads to a progression through meiosis in a normal time frame with formation of a well-aligned metaphase plate. Ultrastructure analysis of COC derived from follicles between 8 and 12 mm showed that the induced extension of prophase I arrest in vitro resulted in cytoplasm changes but not in apparent nuclear changes during culture.

Cryopreserved-thawed human embryo transfer: spontaneous natural cycle is superior to human chorionic gonadotropin-induced natural cycle.

OBJECTIVE To assess whether there is a difference in the ongoing pregnancy rate after transferring frozen-thawed embryos in natural cycles with spontaneous LH-P rise compared with natural cycles controlled by hCG for final oocyte maturation and ovulation. DESIGN Randomized controlled trial. SETTING Tertiary referral center. PATIENT(S) A total of 168 patients were assigned randomly to undergo frozen ET on day 3 from October 2007 until November 2008. Finally, analysis was performed in 124 patients; 61 belonged to the spontaneous LH group and 63 to the hCG group. INTERVENTION(S) In the spontaneous LH group the transfer was planned 5 days after the LH surge. In the hCG group, the cryopreserve ET was planned 5 days after the administration of 5000 IU of hCG, when an endometrial thickness of ≥7 mm and a follicle of ≥17 mm were present on ultrasound examination. MAIN OUTCOME MEASURE(S) Ongoing pregnancy rate. RESULT(S) The study was terminated early, when a prespecified interim analysis found a significantly higher ongoing pregnancy rate in the spontaneous LH group as compared with the hCG group (31.1% vs. 14.3%; difference 16.9%, 95% confidence interval 4.4%-28.8%). CONCLUSION(S) The results suggest the superiority of the natural cycle as compared with the natural cycle controlled by hCG administration in cryothawed ET cycles.

Dialogue between Blastocyst hCG and Endometrial LH/hCG Receptor: Which Role in Implantation?

The specific interaction of blastocyst-derived human chorionic gonadotropin (hCG) and endometrial LH/hCG-R constitutes a fundamental component of the molecular dialogue at the materno-fetal interface. From our observations and studies from other groups, hCG was indeed shown to play a significant role in implantation and tolerance of the embryo, decidual differentiation and remodeling, as well as in placentation. The profile pattern of LH/hCG-R expression by endometrial epithelium correlates with the theoretical timing of the implantation window. Studies are currently being conducted in assisted medical procreation and in an animal model of implantation to establish the index of LH/hCG-R expression as a new biomarker of uterine receptivity for embryo implantation.

Endometrial hormone receptors and proliferation index in the periovulatory phase of stimulated embryo transfer cycles in comparison with natural cycles and relation to clinical pregnancy outcome

OBJECTIVE To investigate the endometrial steroid receptors and proliferation index in GnRH analogue/hMG-stimulated cycles in comparison with natural cycles and their relation to clinical pregnancy outcome. DESIGN Prospective observational study. SETTING Tertiary referral center. PATIENT(S) Twenty-seven stimulated patients with GnRH agonist and hMG. Twenty normo-ovulatory patients were the natural cycle controls. INTERVENTION(S) Endometrial aspiration biopsies: in stimulated cycles on the day of oocyte retrieval within the ET cycle (Day OPU) (n = 20) or 2 days later (Day OPU + 2) (n = 7); in natural cycles on the natural day of ovulation (Day NO) (n = 10) or on the day of ovulation + 2 (Day NO + 2) (n = 10). MAIN OUTCOME MEASURE(S) Comparison of endometrial maturation, estrogen (ER) and P receptor (PR), and proliferation index by immunohistochemistry in natural and stimulated cycles, correlation with pregnancy outcome in stimulated cycles. RESULT(S) Stimulated cycles Day OPU showed significantly advanced endometrial maturation compared to natural cycles Day NO; stromal ER and glandular and stromal PR staining was lower in stimulated than in natural cycles, but higher on Day OPU than on Day NO + 2; proliferation index was lower in all stimulated cycles. Steroid receptors and proliferation index in stimulated cycles were unrelated to clinical pregnancy occurrence. CONCLUSION(S) Compared to natural cycles, ovarian stimulation induced an imbalance in endometrial ER and PR and led to a profound antimitotic effect in the peri-ovulatory phase. These parameters were, however, not predictive of clinical pregnancy in cycles with ET.

Ovulation induction disrupts luteal phase function.

Abnormalities in the luteal phase have been detected in virtually all the stimulation protocols used in in vitro fertilization, on both the hormonal and endometrial levels. Supraphysiological follicular or luteal sex steroid serum concentrations, altered estradiol: progesterone (E2/P) ratio, and disturbed luteinizing hormone pituitary secretion leading to corpus luteum insufficiency or a direct drug effect have been postulated as the main etiologic factors. Luteinizing hormone supports corpus luteum function, and low LH levels have been described after human menopausal gonadotropin treatment, after gonadotropin‐releasing hormone (GnRH)‐agonist treatment, or after GnRH‐antagonist treatment. These low luteal LH levels may lead to an insufficient corpus luteum function and consequently to a shortened luteal phase or to the low luteal progesterone concentrations frequently described after ovulation induction. A direct effect of the GnRH agonist or GnRH antagonist on human corpus luteum or on human endometrium and thus on endometrial receptivity cannot be excluded, as GnRH receptors have been described in both compartments. Endometrial histology has revealed a wide range of abnormalities during the various stimulation protocols. In GnRH‐agonist cycles, mid‐luteal biopsies have revealed increased glandulo‐stromal dyssynchrony and delay in endometrial development, strong positivity of endometrial glands for progesterone receptors, decreased αvβ3‐integrin subunit expression, and earlier appearance of surface epithelium pinopodes. These factors suggest a shift forwards of the implantation window. Progesterone supplementation improves endometrial histology, and its necessity has been well established, at least in cycles using GnRH agonists.

Early luteal phase endocrine profile is affected by the mode of triggering final oocyte maturation and the luteal phase support used in recombinant follicle-stimulating hormone-gonadotropin-releasing hormone antagonist in vitro fertilization cycles.

OBJECTIVE To assess endocrine differences during early luteal phase according to mode of triggering final oocyte maturation with or without luteal phase support (LPS). DESIGN A prospective randomized study. SETTING University center for reproductive medicine. PATIENT(S) Four oocyte donors each underwent four consecutive cycles. INTERVENTION(S) To avoid interpatient variation, each donor underwent the same stimulation regimen. However, different modes of triggering final oocyte maturation and LPS were administered: A) 10,000 IU hCG and standard LPS; B) GnRH agonist (GnRHa; 0.2 mg triptorelin), and 35 hours later 1,500 IU hCG, and standard LPS; C) GnRH agonist (0.2 mg triptorelin) and standard LPS; and D) GnRH agonist (0.2 mg triptorelin) without LPS. MAIN OUTCOME MEASURE(S) Blood sampling was performed on the day of ovulation trigger, ovulation trigger + 1 day, and ovum pick-up + 5 days. Serum E2, FSH, LH, and P were measured. RESULT(S) The early luteal phase steroid levels following GnRHa trigger and modified luteal phase support (B) were similar to those seen after hCG trigger (A). However, significant differences were seen between groups A and B compared with C and D, as well as between groups C and D. CONCLUSION(S) Administration of a single bolus of GnRHa effectively induced LH and FSH surges in oocyte donors stimulated with recombinant FSH and cotreated with a GnRH antagonist. However, gonadotropin and steroid levels differed significantly according to the type of luteal phase support used after GnRHa trigger. EUROPEAN COMMUNITY CLINICAL TRIAL SYSTEM (EUDRACT) NUMBER 2009-009429-26.

Ex-vivo oocyte retrieval for fertility preservation

OBJECTIVE To report a novel fertility preservation strategy in a woman with recurrent serous borderline ovarian tumor in the conserved ovary involving ex-vivo retrieval of in vivo matured oocytes and subsequent embryo cryopreservation. DESIGN Case report. SETTING Tertiary infertility care unit. PATIENT(S) A 27-year-old woman presented for follow-up visit with a history of borderline serous adenocarcinoma treated conservatively with left oophorectomy and fertility-sparing laparoscopic staging. Ultrasound scan revealed a recurrent disease in the right ovary. INTERVENTION(S) Ex-vivo retrieval of mature oocytes after ovarian stimulation. MAIN OUTCOME MEASURE(S) Fertility preservation. RESULT(S) The patient underwent ovarian stimulation followed by a laparotomy and oophorectomy on the day of oocyte retrieval. A puncture of the follicles was performed in the operating theatre with a maximum ischemia time of 14 minutes. Eleven mature oocytes were aspirating, resulting in seven zygotes for cryopreservation. CONCLUSION(S) Mature oocytes can be successfully retrieved ex-vivo from the oophorectomy specimen after a controlled ovarian hyperstimulation (COH) protocol. This method provides a possible strategy for fertility preservation in patients with recurrent ovarian cancer without the risk of cancer cells spillage associated with the standard transvaginal oocyte retrieval.

The reliability of the histological diagnosis of endometritis in asymptomatic IVF cases: a multicenter observer study

BACKGROUND Chronic endometritis is associated with abnormal uterine bleeding, recurrent abortion and infertility. It is a subtle condition, and therefore is difficult to diagnose. The diagnosis is ultimately based on the presence of plasma cells in the endometrial stroma on histopathological examination. Literature on the reproducibility of the diagnosis of chronic endometritis is lacking. Therefore, the aim of the current study was to assess the interobserver agreement of two pathologists in diagnosing chronic endometritis in asymptomatic, infertile patients. METHODS In the context of a randomized controlled trial, an endometrial biopsy was taken during a screening hysteroscopy prior to IVF. All endometrial samples were independently examined by two pathologist. The slides diagnosed with chronic endometritis were replenished with a random sample of the remaining slides up to a total of 100, then exchanged between the two pathologists and reassessed. RESULTS Of the 678 patients who underwent hysteroscopy, 19 patients were diagnosed with at least possible chronic endometritis (2.8%). Perfect agreement between the pathologists, before and after inclusion of 13 slides with additional immunohistochemistry staining, was found in 88 and 86% of reviews, respectively. The interobserver agreement was substantial, with kappa-values of 0.55 and 0.66, respectively. CONCLUSIONS The interobserver agreement in diagnosing chronic endometritis in asymptomatic infertile patients was found to be substantial. Although the diagnostic reliability is sufficient with the methods in the present study, the low prevalence and unknown clinical significance of endometritis warrants further study.