J.A. Land

Elevated Levels of Basal Estradiol-17β Predict Poor Response in Patients with Normal Basal Levels of Follicle-Stimulating Hormone Undergoing In Vitro Fertilization

OBJECTIVEnTo evaluate whether the predictive ability of a normal FSH level on cycle day 3 can be enhanced by levels of estradiol-17beta (E2) on cycle day 3.nnnDESIGNnProspective cohort study.nnnSETTINGnUniversity hospital-based, tertiary care infertility center.nnnPATIENT(S)nTwo hundred thirty-one consecutively seen patients who attended the center for their first IVF attempt.nnnINTERVENTION(S)nBlood samples were collected on day 3 of the cycle preceding IVF; IVF was performed in all patients.nnnMAIN OUTCOME MEASURE(S)nPatients age, number of ampules of hMG, cancellation rate, number of oocytes, fertilization rate, and clinical pregnancy rate.nnnRESULT(S)nIn patients with elevated FSH levels on cycle day 3, a low oocyte yield was achieved (7 versus 11) and a high number of ampules of hMG was necessary (56 versus 33). Their cancellation rate was high (67% versus 16%). In patients with normal basal FSH levels, high E2 levels predicted a high cancellation rate (56%, versus 13% in patients with low E2 levels) and a low oocyte yield (9, versus 11 in patients with low E2 levels). Patients with both normal FSH levels and low E2 levels on cycle day 3 fared best.nnnCONCLUSION(S)nThe basal E2 level on cycle day 3 is a useful prognosticator of response to stimulation in IVF patients with normal basal FSH levels.

Effect of oxygen concentration on in vitro fertilization and embryo culture in the human and the mouse

OBJECTIVEnTo compare the effect of culturing oocytes, zygotes and embryos under low (5%) versus ambient (20%) oxygen conditions on human IVF results and on mouse blastocyst formation.nnnDESIGNnA prospective, randomized study of 257 consecutive IVF treatment cycles in 186 couples undergoing oocyte retrieval for various reasons of infertility. Gametes and resulting embryos after IVF were alternately allocated to fertilization and culture either under a gas phase of 5% CO2/90% N2/5% O2, or 5% CO2/95% air (20% O2). Oocytes and embryos from randomly bred and hybrid mouse strains were randomly allocated to culture under either of the two gas phases.nnnSETTINGnA university hospital-based IVF-ET program.nnnMAIN OUTCOME MEASUREnIn the human, rates of fertilization, embryonic development at the time of embryo replacement (42 to 46 hours after insemination), pregnancy, and implantation were compared. In the mouse, the rates of blastocyst formation were compared.nnnRESULTSnClinical pregnancies occurred in 24.2% versus 19.4% of retrievals when culture took place under low oxygen versus ambient oxygen conditions. Fertilization, embryonic development, pregnancy, and implantation rates did not differ significantly between the groups. Slightly higher blastocyst rates occurred when mouse embryos from hybrid strains were cultured under low oxygen compared with culture under ambient oxygen conditions, whereas no such difference in blastocyst rates was found in randomly bred mouse embryos.nnnCONCLUSIONSnThis study failed to demonstrate any improvement in human IVF results associated with the use of a gas mixture of 5% CO2/90% N2/5% O2 during the first two days of development compared with the use of 5% CO2 in air.

Chlamydia antibody testing and diagnosing tubal pathology in subfertile women: an individual patient data meta-analysis

BACKGROUNDnThe Chlamydia IgG antibody test (CAT) shows considerable variations in reported estimates of test accuracy, partly because of the use of different assays and cut-off values. The aim of this study was to reassess the accuracy of CAT in diagnosing tubal pathology by individual patient data (IPD) meta-analysis for three different CAT assays.nnnMETHODSnWe approached authors of primary studies that used micro-immunofluorescence tests (MIF), immunofluorescence tests (IF) or enzyme-linked immunosorbent assay tests (ELISA). Using the obtained IPD, we performed pooled receiver operator characteristics analysis and logistic regression analysis with a random effects model to compare the three assays. Tubal pathology was defined as either any tubal obstruction or bilateral tubal obstruction.nnnRESULTSnWe acquired data of 14 primary studies containing data of 6191 women, of which data of 3453 women were available for analysis. The areas under the curve for ELISA, IF and MIF were 0.64, 0.65 and 0.75, respectively (P-value < 0.001) for any tubal pathology and 0.66, 0.66 and 0.77, respectively (P-value = 0.01) for bilateral tubal pathology.nnnCONCLUSIONSnIn Chlamydia antibody testing, MIF is superior in the assessment of tubal pathology. In the initial screen for tubal pathology MIF should therefore be the test of first choice.

The CD14 functional gene polymorphism -260 C>T is not involved in either the susceptibility to Chlamydia trachomatis infection or the development of tubal pathology

BackgroundThe functional polymorphism -260 C>T in the LPS sensing TLR4 co-receptor CD14 gene enhances the transcriptional activity and results in a higher CD14 receptor density. Individuals carrying the T/T genotype also have significantly higher serum levels of soluble CD14. The T allele of this polymorphism has recently been linked to Chlamydia pneumoniae infection. We investigated the role of the CD14 -260 C>T polymorphism in the susceptibility to and severity (defined as subfertility and/or tubal pathology) of C. trachomatis infection in Dutch Caucasian women.MethodsThe different CD14 -260 C>T genotypes were assessed by PCR-based RFLP analysis in three cohorts: 1) A cohort (n = 576) of women attending a STD clinic, 2) a cohort (n = 253) of women with subfertility, and 3) an ethnically matched control cohort (n = 170). The following variables were used in the analysis: In cohort 1 the CT-DNA status, CT IgG serology status, self-reported symptoms and in cohort 2, the CT IgG serology status and the tubal status at laparoscopy.ResultsIn the control cohort the CC, CT and TT genotype distribution was: 28.2%, 48.2%, and 23.5% respectively. No differences were found in the overall prevalence of CD14 -260 genotypes (28.1%, 50.7%, and 21.2%) in cohort 1 when compared to the control cohort. Also no differences were observed in women with or without CT-DNA, with or without serological CT responses, with or without symptoms, or in combinations of these three variables. In subfertile women with tubal pathology (cohort 2, n = 50) the genotype distribution was 28.0%, 48.0%, and 24.0% and in subfertile women without tubal pathology (n = 203), 27.6%, 49.3% and 23.2%. The genotype distribution was unchanged when CT IgG status was introduced in the analyses.ConclusionThe CD14 -260 C>T genotype distributions were identical in all three cohorts, showing that this polymorphism is not involved in the susceptibility to or severity of sequelae of C. trachomatis infection.

TLR9 KO MICE, HAPLOTYPES AND CPG INDICES IN CHLAMYDIA TRACHOMATIS INFECTION

Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndrome undergoing percutaneous coronary intervention. Clopidogrel, in combination with aspirin, is associated with improvement in longterm vascular clinical outcomes in these patients and is currently the antiplatelet standard of care. However, a significant number of patients still experience secondary ischemic thrombotic events due to potential insufficient platelet inhibition or noncompliance. Therefore, the development of better and safer antiplatelet agents is of the utmost priority. Indeed, oral antiplatelet agents, such as aspirin in the ISIS-2 study and clopidogrel in the COMMIT mega trial, in moderate doses are among the very few classes of drugs that reduce absolute mortality in patients after acute vascular thrombotic events. Prasugrel (CS-747; LY-640315), an experimental third-generation oral thienopyridine, is a specific, irreversible antagonist of the platelet adenosine diphosphate P2Y(12) receptor. Preclinical and early phase clinical studies have shown that prasugrel has greater antiplatelet potency, lower variability in platelet response and faster onset of inhibition than clopidogrel. However, the doses of the drug chosen for further prasugrel developments are much higher (about 2.5-2.7 times higher) than those of conventional clopidogrel regimen(s). The recent TRITON trial assessed head-to-head prasugrel versus clopidogrel, both in addition to aspirin, and led to numerous controversies with regard to the fairness of the trial design, interpretation of its results, and the suitability of the high maintenance prasugrel dose for chronic preventive human use. We critically review various aspects of prasugrel development, focusing on the discrepancies between the official interpretation of the results and actual findings. We conclude that the benefits of prasugrel are exaggerated and that the risks are underestimated. Very careful maintenance dose selection and a flawless long-term safety profile for the new agents will become the keys to the success of future oral antiplatelet drug development.

Chlamydia trachomatis IgG seropositivity is associated with lower natural conception rates in ovulatory subfertile women without visible tubal pathology

BACKGROUNDnThe relation between Chlamydia trachomatis infection and subsequent tubal damage is widely recognized. As such, C. trachomatis antibody (CAT) testing can be used to triage women for immediate tubal testing with hysterosalpingography (HSG) or laparoscopy. However, once invasive tubal testing has ruled out tubal pathology, CAT serology status is ignored, as its clinical significance is currently unknown. This study aimed to determine whether positive CAT serology is associated with lower spontaneous pregnancy rates in women in whom HSG and/or diagnostic laparoscopy showed no visible tubal pathology.nnnMETHODSnWe studied ovulatory women in whom HSG or laparoscopy showed patent tubes. Women were tested for C. trachomatis immunoglobulin G (IgG) antibodies with either micro-immunofluorescence (MIF) or an ELISA. CAT serology was positive if the MIF titre was ≥ 1:32 or if the ELISA index was >1.1. The proportion of couples pregnant without treatment was estimated at 12 months of follow-up. Time to pregnancy was considered censored at the date of the last contact when the woman was not pregnant or at the start of treatment. The association between CAT positivity and an ongoing pregnancy was evaluated with Cox regression analyses.nnnRESULTSnOf the 1882 included women without visible tubal pathology, 338 (18%) had a treatment-independent pregnancy within 1 year [estimated cumulative pregnancy rate 31%; 95% confidence interval (CI): 27-35%]. Because of differential censoring after 9 months of follow-up, regression analyses were limited to the first 9 months after tubal testing. Positive C. trachomatis IgG serology was associated with a statistically significant 33% lower probability of an ongoing pregnancy [adjusted fecundity rate ratio 0.66 (95% CI 0.49-0.89)].nnnCONCLUSIONSnEven after HSG or laparoscopy has shown no visible tubal pathology, subfertile women with a positive CAT have lower pregnancy chances than CAT negative women. After external validation, this finding could be incorporated into existing prognostic models.

The Flemish Giant, reflections on the defense against endometriosis, inspired by Professor Emeritus Ivo A. Brosens

Reproductive research benefits from combining animal and clinical studies. In Leuven, rabbits have constituted an animal model for many reproductive disorders, especially for those that involved surgical treatment. Much of what has been learned from animal experiments has been applied to human clinical reproductive research soon after. In this manuscript we wish to address the problem of the constant intra-abdominal battle between the menstrual aggressor and the peritoneal defense. From all published evidence we may conclude that endometriosis appears to be a dynamic disease, especially in the early phase, with subtle, atypical lesions emerging and vanishing again. In the end however the peritoneal defense system will prevail and the disease will be contained in the majority of patients. When doing repeat laparoscopies in young patients one should be prepared to encounter more advanced histological types of lesions, which not necessarily do have to indicate more advanced stages of the disease: the classical, blue and black powderburn spots and blueberry lesions reflect the extinguishing phase of the dynamic endometriotic process, and herald its inactivated histological end-stage. The dynamic phase of the disease may involve a varying interval of each patients life, and medical suppression of the activity of the implants during this interval may lead one to conclude erroneously that treatment has been effective. If subsequently (after the end of medical suppression of the activity of the lesions) ovarian activity resumes and the lesions are stimulated again by ovarian steroids, their productive activity returns. Recurrence of disease may be diagnosed if at that stage a laparoscopy would be performed, whereas in reality only reactivation of temporarily obscured lesions did occur. The suppressed, dormant (but never absent) lesions produce mucus again, desquamation occurs, and reaction by the surrounding tissue. The inflammatory response, the local hyperemia and the neogenesis of vessels accentuate the presence of previously invisible endometriosis lesions and make them visible again. Endometriosis resumes its temporarily halted natural course of development, tissue remodeling occurs again, the battle between the aggressor and the defense resumes and waxing and waning of the several types of lesions, red, white and black, can be found again.

Risk of Colorectal Cancer After Ovarian Stimulation for In Vitro Fertilization.

BACKGROUND & AIMSnApart from lifestyle factors, sex hormones also seem to have a role in the etiology of colorectal cancer. This raises interest in the possible effects of fertility drugs, especially because the use of ovarian stimulation for in vitro fertilization (IVF) has strongly increased over the past decades.nnnMETHODSnIn 1996, a nationwide cohort study was set up to examine cancer risk in a population that included 19,158 women who received ovarian stimulation for IVF (IVF group) and 5950 women who underwent subfertility treatments other than IVF (non-IVF group). Cancer incidence was ascertained through linkage with the Netherlands Cancer Registry. Colorectal cancer risk in the IVF group was compared with those in the general population and in the non-IVF group.nnnRESULTSnAfter a median follow-up of 21 years, 109 colorectal cancers were observed. Compared with the general population, risk of colorectal cancer was not increased in the IVF group (standardized incidence ratio, 1.00; 95% confidence interval [CI], 0.80-1.23), and was significantly decreased in the non-IVF group (standardized incidence ratio, 0.58; 95% CI, 0.36-0.88). Women in the IVF group had a significant increase in risk compared with women in the non-IVF group (multivariable-adjusted hazard ratio, 1.80; 95% CI, 1.10-2.94). No trend emerged with more IVF cycles or more ampules of gonadotropins administered. Colorectal cancer risk did not increase with longer follow-up periods.nnnCONCLUSIONSnAlthough women who receive ovarian stimulation for IVF do not have an increased risk for colorectal cancer compared with the general population, findings from our nationwide cohort study indicate that their risk is increased compared with women who received subfertility treatments other than IVF. Further research is warranted to examine whether ovarian stimulation for IVF contributes to development of colorectal cancer.

A revised prediction model for natural conception

One of the aims in reproductive medicine is to differentiate between couples that have favourable chances of conceiving naturally and those that do not. Since the development of the prediction model of Hunault, characteristics of the subfertile population have changed. The objective of this analysis was to assess whether additional predictors can refine the Hunault model and extend its applicability. Consecutive subfertile couples with unexplained and mild male subfertility presenting in fertility clinics were asked to participate in a prospective cohort study. We constructed a multivariable prediction model with the predictors from the Hunault model and new potential predictors. The primary outcome, natural conception leading to an ongoing pregnancy, was observed in 1053 women of the 5184 included couples (20%). All predictors of the Hunault model were selected into the revised model plus an additional seven (womans body mass index, cycle length, basal FSH levels, tubal status,history of previous pregnancies in the current relationship (ongoing pregnancies after natural conception, fertility treatment or miscarriages), semen volume, and semen morphology. Predictions from the revised model seem to concur better with observed pregnancy rates compared with the Hunault model; c-statistic of 0.71 (95% CI 0.69 to 0.73) compared with 0.59 (95% CI 0.57 to 0.61).

P3.024 Comparison of Chlamydia Trachomatis Antibodies in Vaginal Mucosa and Serum in Women a Fertility Clinic and an STI-Clinic

Background The common asymptomatic nature of Chlamydia infections and consequential PIDs plus the delayed appearance of any damaging effect thereof on the reproductive tract hamper timely interventions for individuals prone to complications. In infertile women, Chlamydia antibodies in serum relate to tubal pathology and lower conception rates. The current ‘proof of principle study’ aimed to assess whether Chlamydia antibodies are detectable in easier, non-invasive vaginal mucosa samples, and if these could predict the risk for complications. Patients and Method We compared outcomes of Chlamydia antibody tests in serum and vaginal swabs in two groups: (a) 77 women attending a fertility clinic, of whom 25 tested positive for anti-chlamydia IgG in serum and (b) 107 women visiting an STI centre, including 30 Chlamydia PCR-positive subjects. The presence of IgG/IgA antibodies was compared (Kappa-test) and determinants investigated (regression). Results In women in the STI clinic, active Chlamydia infections were linked to both IgG and IgA antibodies in serum (p < 0.001) and IgA in vaginal mucosa (p < 0.001), but not IgG in mucosa; mucosa-IgA correlated with IgG in serum (p = 0.001). In women in the fertility clinic, IgG in vaginal mucosal material had a stronger correlation with IgG in serum (p = 0.02) than IgA in mucosa (p = 0.06). Women with tubal pathology or Chlamydia history more commonly had IgG in serum and IgA in vaginal mucosa (both p < 0.001), whereas this link was weaker for mucosa-IgG (p = 0.03); for tubal pathology alone mucosa-IgA had a higher Kappa than serum-IgG (0.41 versus 0.36). Discussion Chlamydia IgG/IgA are detectable in vaginal mucosal material. IgG antibodies in serum had stronger associations with current or past Chlamydia infections. However, IgA antibodies in vaginal mucosa also showed associations with (past) infection and complications. IgA presence in vaginal mucosa might indicate an on-going hidden Chlamydia infection in the upper genital tract, and warrants further epidemiological studies.