David L. Olive

HOXA10 is expressed in response to sex steroids at the time of implantation in the human endometrium.

Hox genes are well-known transcriptional regulators that play an essential role in directing embryonic development. Mice that are homozygous for a targeted disruption of the Hoxa10 gene exhibit uterine factor infertility. We have recently demonstrated that HOXA10 is expressed in the adult human uterus. To examine expression of HOXA10 during the menstrual cycle, Northern blot analysis and in situ hybridization were performed. Expression of HOXA10 dramatically increased during the midsecretory phase of the menstrual cycle, corresponding to the time of implantation and increase in circulating progesterone. Expression of HOXA10 in cultured endometrial cells was stimulated by estrogen or progesterone. Stimulation of HOXA10 by progesterone was concentration-dependent within the physiologic range, and the effect of estrogen was inhibited by cycloheximide. These results identify sex steroids as novel regulators of HOX gene expression. HOXA10 may have an important function in regulating endometrial development during the menstrual cycle and in establishing conditions necessary for implantation in the human.

The effect of endometriosis on implantation : results from the Yale University in vitro fertilization and embryo transfer program

OBJECTIVE To investigate the effect of endometriosis on implantation. DESIGN Case-control study from Yale University IVF-ET program. PATIENTS Two hundred eighty-four consecutive IVF cycles were analyzed retrospectively. Patients with endometriosis only (n = 35; 89 cycles) were compared with an age-matched control group with tubal infertility (n = 70; 147 cycles) and also to a group with unexplained infertility (n = 15; 48 cycles). Data from the endometriosis group was analyzed further in subgroups of minimal-mild (43 cycles) and moderate-severe (46 cycles). RESULTS No difference was found in the number and the quality of oocytes retrieved and fertilization rates between the endometriosis, the tubal infertility, and the unexplained infertility groups. The quality and the number of embryos transferred in each group were comparable. A trend toward reduced pregnancy rate per transfer (14.8%) in the endometriosis versus tubal or unexplained infertility groups (25.7% and 23.3%, respectively) was observed. Implantation rate (gestational sac per transferred embryo) was significantly lower in the endometriosis versus the tubal infertility group (3.9% versus 8.1%; unexplained infertility group, 7.2%). Analysis of first cycles only across all groups revealed that the implantation rate also was significantly lower in the endometriosis versus the tubal infertility group (3.1% versus 9%; unexplained infertility group, 6.7%). Within the endometriosis group, although the pregnancy rate per cycle and per transfer were similar in subgroups, patients with minimal-mild endometriosis had the lowest implantation rate. CONCLUSION We conclude that, in patients with endometriosis, implantation rate is low. Abnormal implantation, which may be secondary to endometrial dysfunction or embryotoxic environment, is a factor in endometriosis-associated subfertility.

Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization- embryo transfer

OBJECTIVE To determine the effect of hydrosalpinx on the establishment of pregnancy after IVF-ET. DESIGN Metaanalysis. SETTING University medical center. PATIENT(S) AND INTERVENTION(S) All published reports (n=13) and abstracts (n=10) in English that examined the relation between hydrosalpinx and IVF-ET were included in the analysis. The metaanalysis was performed by first calculating the odds ratios for each trial and then combining them to obtain a pooled estimate of the odds ratio and a 95% confidence interval. MAIN OUTCOME MEASURE(S) Clinical pregnancy. RESULT(S) A total of 5,569 cycles was reviewed in the group without hydrosalpinx, and a total of 1,144 was reviewed in the group with hydrosalpinx. The clinical pregnancy rate was approximately 50% lower in patients who had hydrosalpinx. Similarly, the implantation rate was decreased by 50%. These effects were observed also in thawed ET cycles. The abortion rate was more than twofold higher in patients who had hydrosalpinx. CONCLUSION(S) This metaanalysis suggests that hydrosalpinx is associated with a reduced chance of implantation and an increased risk of pregnancy loss.

Monocyte chemotactic protein-1 concentration in peritoneal fluid of women with endometriosis and its modulation of expression in mesothelial cells☆

OBJECTIVE To investigate monocyte chemotactic protein-1 concentrations in the peritoneal fluid (PF) of women with or without endometriosis, then assess peritoneal mesothelial cells as a potential source of monocyte chemotactic protein-1. DESIGN Prospective study. SETTING University medical center. PATIENT(S) Women with (n = 60) or without (n = 18) endometriosis. INTERVENTION(S) First monocyte chemotactic protein-1 levels in PF were measured, then mesothelial cells in culture were treated with cytokines. MAIN OUTCOME MEASURE(S) In PF and culture supernatants, monocyte chemotactic protein-1 was measured by ELISA. In vitro monocyte chemotactic protein-1 messenger RNA expression was evaluated by Northern analysis. RESULT(S) The median concentration of monocyte chemotactic protein-1 in PF of control women was 137 pg/mL (conversion factor to SI unit, 0.115; range, 12 to 418 pg/mL); that of women with moderate endometriosis was 205 pg/mL (range 65 to 6,000 pg/mL); and that of those with severe endometriosis was 1,165 pg/mL (0 to 2,602 pg/mL). Within the moderate to severe endometriosis group, monocyte chemotactic protein-1 levels were higher in women with untreated endometriosis (354 pg/mL range 0 to 6,000 pg/mL) than in women receiving GnRH agonist (128 pg/mL, range 0 to 216 pg/mL). In the control group, monocyte chemotactic protein-1 levels were higher in the proliferative phase than in the secretory phase. Mesothelial cells produced constitutively monocyte chemotactic protein-1; moreover, both interleukin-1 alpha and tumor necrosis factor-alpha induced higher levels of monocyte chemotactic protein-1. CONCLUSION(S) Levels of monocyte chemotactic protein-1 in PF were higher during the proliferative phase than secretory phase of control women and increased in moderate to severe endometriosis. The regulated expression of monocyte chemotactic protein-1 may recruit macrophages into PF and contribute to the pathogenesis of endometriosis.

Peritoneal macrophages and infertility: the association between cell number and pelvic pathology

Increased numbers of peritoneal macrophages have been repeatedly associated with infertility. Because the factors contributing to this intraperitoneal exudate are unknown, this study was carried out to determine which anatomic or endocrinologic abnormalities in infertile women might be associated with an increase in leukocyte numbers. The peritoneal fluid from 103 women was analyzed. Nonparametric data analysis demonstrated significantly greater cell counts in infertile women with endometriosis, compared with other infertile women (P less than 0.01) or fertile control subjects (P less than 0.005). Multiple regression analysis was then used to determine the relationship of individual variables to cell number without the influence of confounding factors. These data demonstrate that the best correlation with elevated macrophage number is in women who have infertility and no mechanical fertility factors (of which mild endometriosis is a subgroup). Thus, an increase in peritoneal macrophage number is not restricted to women with endometriosis but, rather, is seen in a subset of infertile women generally without mechanical or endocrinologic infertility factors.

Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids

Conservative surgical options for uterine myomata traditionally were abdominal myomectomy, laparoscopic myomectomy, and, more recently, myolysis. Each of these procedures has distinct advantages, but also apparent disadvantages. We attempted to introduce an additional option for conservative surgical treatment of fibroids by freezing the structures, a procedure termed cryomyolysis. In this pilot study, 14 women were pretreated with a gonadotropin-releasing hormone (GnRH) agonist for a minimum of 2 months preoperatively to minimize uterine and myoma size. Cryomyolysis was performed and the GnRH agonist was discontinued. Magnetic resonance imaging scans were performed in 10 of the 14 women after GnRH agonist treatment but before surgery, and 4 months postoperatively. Total uterine volume ranged from 41.3 to 1134.8 ml preoperatively, and 49.5 to 1320 ml postoperatively (mean increase 22% after discontinuation of GnRH agonist). Normal uterine volume ranged from 35.6 to 548.7 ml preoperatively and 45.1 to 729.6 ml postoperatively (mean increase 40%); however, myoma volume showed a mean decrease of 6% (range -87-28%). Analysis of only frozen myomata revealed a mean volume decrease of 10%. Cryomyolysis maintains at or slightly reduces these lesions to post-GnRH agonist size, and all other uterine tissue returns to pretreatment size. We believe cryomyolysis may be an effective conservative surgical approach to uterine fibroids.

OFFICE MICROLAPAROSCOPY UNDER LOCAL ANESTHESIA FOR CHRONIC PELVIC PAIN

STUDY OBJECTIVE To investigate the utility, tolerance, and costs associated with a program of office laparoscopy under local anesthesia using fiberoptic microlaparoscopes (<2 mm) and accessory instrumentation (<2 mm) for the evaluation of patients with chronic pelvic pain (CPP). DESIGN Prospective, nonselected cohort study. SETTING Office-based free-standing faculty practice at a tertiary care referral center. PATIENTS All women with a history of CPP from February to June 1995 who required diagnostic laparoscopy were compared with a cohort of patients undergoing in office diagnostic laparoscopy for the evaluation of infertility during the same period. INTERVENTIONS All patients underwent diagnostic office microlaparoscopy under local anesthesia (OLULA) with supplemental intravenous sedation, as well as conscious pain mapping. MEASUREMENTS AND MAIN RESULTS A specific questionnaire was developed to follow all aspects of patient acceptance and tolerance of the procedures, and all patients were queried preoperatively, and 30 minutes and 1 week postoperatively. Pain was evaluated with a modification of the McGill pain inventory. A subset of questions evaluated the length of time until usual activities were resumed, anxiety level, and general acceptance of the procedure including set-up, operative time, and recovery time until discharge. Overall, there was a high degree of patient acceptance and satisfaction with OLULA; however, women with CPP experienced greater intraoperative and postoperative pain than those with infertility. Some patients with CPP had a generalized visceral hypersensitivity to pain; all areas of the pelvis and bowel were sensitive, and pain was not completely blocked with local anesthesia. Average procedure length was similar for the two groups. Patients with CPP required greater postoperative analgesia and took longer to return to work. Conscious pain mapping identified a focal source of pain in three patients and generalized visceral hypersensitivity in a majority of patients with CPP. Neither of these were found in patients with infertility. Compared with traditional laparoscopy there was almost an 80% reduction in costs. CONCLUSION Office laparoscopy under local anesthesia is safe and effective for the evaluation of patients with CPP and is less expensive than traditional laparoscopy. Although the procedure is better tolerated by women undergoing infertility evaluation, it was well tolerated by both groups. Conscious pain mapping helps identify potential areas of pelvic pain and helps further characterize patients with CPP.

Insulin and insulin-like growth factor I stimulate the proliferation of human ovarian theca-interstitial cells

OBJECTIVE To determine whether insulin and insulin-like growth factor I (IGF-I) affect the proliferation of human theca-interstitial cells. DESIGN In vitro assays. SETTING University laboratory. PATIENT(S) Premenopausal women undergoing oophorectomy for benign conditions. INTERVENTION(S) Purified theca-interstitial cells were cultured in chemically defined media with or without insulin and IGF-I. MAIN OUTCOME MEASURE(S) The proliferation of cells was evaluated by determination of [3H] thymidine incorporation and cell counting. RESULT(S) Insulin and IGF-I stimulated DNA synthesis by theca-interstitial cells in a dose-dependent fashion. Insulin-like growth factor I had a greater potency than did insulin. The effects of both approached, but did not reach, the level of DNA synthesis observed in cultures exposed to 10% fetal bovine serum. Direct counting of theca-interstitial cells revealed that IGF-I significantly increased the total number of cells (36% above control), whereas insulin induced a modest and statistically nonsignificant increase in the cell number (14% above control). CONCLUSION(S) The present results support the hypothesis that insulin and IGF-I promote the mitotic activity of theca-interstitial cells. These effects may represent mechanisms that lead to hyperplasia of the thecal/stromal compartment in polycystic ovary syndrome.

Seveso Women's Health Study : a study of the effects of 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin on reproductive health

Although reproductive effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposure have been reported in numerous investigations of animals, studies of this association in humans are limited. In 1976, an explosion in Seveso, Italy exposed the surrounding population to among the highest levels of TCDD recorded in humans. The relatively pure exposure to TCDD and the ability to quantify individual level TCDD exposure from sera collected in 1976 for the Seveso cohort affords a unique opportunity to evaluate the potential dose-response relationship between TCDD exposure and a spectrum of reproductive endpoints. The Seveso Womens Health Study (SWHS) is the first comprehensive study of the reproductive health of a human population exposed to TCDD. The primary objectives of the study are to investigate the relationship of TCDD and the following endpoints: (1) endometriosis; (2) menstrual cycle characteristics; (3) age at menarche; (4) birth outcomes of pregnancies conceived after 1976; (5) time to conception and clinical infertility; and (6) age at menopause. Included in the SWHS cohort are women who were 0-40 yr old in 1976, who have adequate stored sera collected between 1976 and 1980, and who resided in Zones A or B at the time of the accident. All women were interviewed extensively about their reproductive and pregnancy history and had a blood draw. For an eligible subset of women, a pelvic exam and transvaginal ultrasound were conducted and a menstrual diary was completed. More than 95% of the women were located 20 yr after the accident and roughly 80% of the cohort agreed to participate. Data collection was completed in July 1998, serum TCDD analysis of samples for analysis of endometriosis as a nested case-control study was completed in October 1998, and statistical analysis of these data should be completed in early 1999. Serum samples are now being analyzed in order to relate TCDD levels with the remaining reproductive outcomes.

Sonographic uterine predictors of pregnancy in women undergoing ovulation induction for assisted reproductive treatments

OBJECTIVE To determine preovulatory uterine sonographic predictors of pregnancy in women undergoing ovulation induction for assisted reproductive treatments. DESIGN Prospective evaluation of uterine sonographic and vascular flow profiles in women stimulated with leuprolide acetate and hMG. SETTING Private fertility center and tertiary-care academic center. PATIENTS Ninety-six women underwent 102 cycles of ovulation induction for IVF (46), GIFT (20), and zygote intrafallopian transfer (36). MAIN OUTCOME MEASURES Endometrial texture, thickness, resistance index at the first branch of uterine artery, diastolic blood flow, and pregnancy outcome (no conception, spontaneous abortion, and delivery). RESULTS Triple-lined pattern was predominant in women who delivered liveborn infants (P < 0.005). Endometrial pattern and diastolic blood flow were the only predictive markers of term pregnancy (P < 0.001 and P < 0.05, respectively). CONCLUSION Preovulatory triple-lined sonographic endometrial texture and the presence of end diastole blood velocities at the first branch of uterine artery are the most important uterine predictors of conception.