João Sabino Cunha-Filho

Age-related normograms of serum antimüllerian hormone levels in a population of infertile women: a multicenter study

OBJECTIVE To produce age-related normograms for serum antimüllerian hormone (AMH) level in infertile women without polycystic ovaries (non-PCO). DESIGN Retrospective cohort analysis. SETTING Fifteen academic reproductive centers. PATIENT(S) A total of 3,871 infertile women. INTERVENTION(S) Blood sampling for AMH level. MAIN OUTCOME MEASURE(S) Serum AMH levels and correlation between age and different percentiles of AMH. RESULT(S) Age-related normograms for the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles of AMH were produced. We found that the curves of AMH by age for the 3rd to 50th percentiles fit the model and appearance of linear relation, whereas the curves of >75th percentiles fit cubic relation. There were significant differences in AMH and FSH levels and in antral follicle count (AFC) among women aged 24-33 years, 34-38 years, and ≥39 years. Multivariate stepwise linear regression analysis of FSH, age, AFC, and the type of AMH kit as predictors of AMH level shows that all variables are independently associated with AMH level, in the following order: AFC, FSH, type of AMH kit, and age. CONCLUSION(S) Age-related normograms in non-PCO infertile women for the 3rd to 97th percentiles were produced. These normograms could provide a reference guide for the clinician to consult women with infertility. However, future validation with longitudinal data is still needed.

Up-regulation of VEGF, c-fms and COX-2 expression correlates with severity of cervical cancer precursor (CIN) lesions and invasive disease

OBJECTIVES To describe the expression of vascular endothelial growth factor (VEGF), proto-oncogene macrophage colony-stimulating factor receptor (c-fms) and cyclooxygenase-2 (COX-2) in cervical carcinogenesis and to analyze the correlation of VEGF with c-fms and COX-2 expression. METHODS In this study, 26 cases of benign cervix, 28 low-grade cervical intraepithelial neoplasia (CIN; CIN 1), 30 high-grade CIN (CIN 2/3) and 28 squamous cervical carcinomas (SCC) were examined by immunohistochemistry (IHC) and analysis was performed separately for epithelium and stroma. RESULTS Positive epithelial expressions in normal cervix, low-grade CIN, high-grade CIN and SCC were, respectively: VEGF - 11.5%, 39.3%, 53.3% and 75% (P<0.001); c-fms - 0%, 10.7%, 40% and 67.9% (P<0.001); COX-2 - 7.7%, 39.3%, 80% and 100% (P<0.001). Stromal VEGF expression was higher than epithelial expression in all CIN grades and was also associated with the lesion grade, while c-fms and COX-2 stromal expression was weak. VEGF expression was statistically correlated to c-fms and COX-2 expression in high-grade CIN (P=0.020 and P=0.027, respectively) and SCC (P=0.015 and P=0.005, respectively). CONCLUSIONS On the basis of our findings, these factors may participate in the development and progression of CIN lesions, with possible interaction of c-fms and COX-2 on VEGF expression, and may be potential molecular targets for studies of cervical cancer prevention and treatment.

Effect of phenylalanine and its metabolites on ATP diphosphohydrolase activity in synaptosomes from rat cerebral cortex

The in vitro effects of phenylalanine and some of its metabolites on ATP diphosphohydrolase (apyrase, EC 3.6.1.5) activity in synaptosomes from rat cerebral cortex were investigated. The enzyme activity in synaptosomes from rats subjected to experimental hyperphenylalaninemia (α-methylphenylalanine plus phenylalanine) was also studied. In the in vitro studies, a biphasic effect of phenylalanine on both enzyme substrates (ATP and ADP) was observed, with maximal inhibition at 2.0 mM and maximal activation at 5.0 mM. Inhibition of the enzyme activity was not due to calcium chelation. Moreover, phenylpyruvate, when compared with phenylalanine showed opposite effects on the enzyme activity, suggesting that phenylalanine and phenylpyruvate bind to two different sites on the enzyme. The other tested phenylalanine metabolites (phenyllactate, phenylacetate and phenylethylamine) had no effect on ATP diphosphohydrolase activity. In addition, we found that ATP diphosphohydrolase activity in synaptosomes from cerebral cortex of rats with chemically induced hyperphenylalaninemia was significantly enhanced by acute or chronic treatment. Since it is conceivable that ATPase-ADPase activities play an important role in neurotransmitter (ATP) metabolism, it is tempting to speculate that our results on the deleterious effects of phenylalanine and phenylpyruvate on ATP diphosphohydrolase activity may be related to the neurological dysfunction characteristics of naturally and chemically induced hyperphenylalaninemia.

Physiopathological Aspects of Corpus Luteum Defect in Infertile Patients with Mild/Minimal Endometriosis

AbstractPurpose: We describe a physiopathological model to the luteal insufficiency of infertile patients with mild/minimal endometriosis with normal hormone measurements in the early follicular phase. Methods: We designed a case-control study with 24 patients, 14 fertile with in-phase endometrium (control group) and 10 infertile with mild/minimal endometriosis and luteal insufficiency (study group). The histologic dating of endometrium was performed during cycle days 23–25 and serum TSH, FSH, LH, prolactin, and estradiol levels were measured during the early follicular phase (cycle day 3). Progesterone serum levels were measured in three different occasions during the luteal phase. Results: Patients with out-of-phase endometrium have lower estradiol levels (P = 0.031) and decreased progesterone secretion (P = 0.012) during the late luteal phase. Serum prolactin, TSH, FSH, and LH levels were similar between the groups (P > 0.05). Conclusions: The physiopathology of luteal phase defect in infertile patients with mild/minimal endometriosis is associated with a small and large luteal cells dysfunction, characterized by abnormal follicular phase (lower estradiol serum levels) and lower progesterone LH-dependent secretion.

Luteal estradiol administration strengthens the relationship between day 3 follicle-stimulating hormone and inhibin B levels and ovarian follicular status.

OBJECTIVE To investigate whether the prevention of early follicular growth by luteal E(2) administration improves the relationship between day 3 hormone measurements and the ovarian follicular status. DESIGN Prospective, cohort study. SETTING Assisted reproductive technology unit in Clamart, France. PATIENT(S) One hundred sixty-two infertile women. INTERVENTION(S) Participants received oral 17beta-E(2), 4 mg/day, from day 20 to the next cycle day 1 (n = 81) or served as controls (n = 81). Serum E(2), inhibin B, and FSH were measured during the 3 days after E(2) discontinuation (FD1, FD2, and FD3) in E(2)-treated women and on cycle day 3 (CD3) in controls. Early antral follicles were counted at ultrasound scans on FD3 and CD3. MAIN OUTCOME MEASURE(S) Hormonal-follicular correlations on FD3 and CD3. RESULT(S) As expected, after E(2) withdrawal, inhibin B and FSH increased from FD1 to FD3 whereas E(2) decreased. Correlations between FSH and inhibin B and follicular counts were stronger on FD3 than on CD3. CONCLUSION(S) Luteal E(2) administration notably strengthens the relationship between serum FSH and inhibin B levels and the number of antral follicles on day 3. This approach may represent an alternative test of ovarian follicular status.

Premature LH and progesterone rise in intrauterine insemination cycles: analysis of related factors

Premature LH and progesterone surges are associated with different factors and hormonal modulators. The aim of the present study was (i) to investigate the clinical and laboratory factors and (ii) to highlight the importance of different stimulation protocols in associated premature LH and progesterone surges in intrauterine insemination (IUI) cycles. The study involved a retrospective investigation of 75 patients undergoing IUI for infertility treatment (135 IUI cycles) between 1996 and 2000, with initial serum LH concentrations >10 mIU/ml during ovarian stimulation. Ultrasound characteristics, follicular sizes, serum oestradiol, progesterone and LH concentrations and ovarian stimulation protocols were measured. There was a wide range of oestradiol serum concentrations (93-2245 pg/ml) and follicular size (12-25 mm). In 49.6% of cycles, the dominant follicle was <16.5 mm. Patients with >2 follicles measuring <15 mm had higher oestradiol serum concentrations (P = 0.008). Multiple regression analyses revealed no association between these variables and premature LH/progesterone surge. In conclusion, LH/progesterone surges cannot be predicted utilizing clinical parameters normally employed, e.g. ultrasound serum oestradiol assay or ovarian stimulation protocol. Patients with follicles >14 mm or more and with high numbers of small follicles and high oestradiol are at risk of a spontaneous LH surge. These variables can be used to time the administration of GnRH antagonist administration until better predictive factors are demonstrated.

T helper (Th)1, Th2, and Th17 interleukin pathways in infertile patients with minimal/mild endometriosis

In the present study, interleukin (IL)-10, IL-12, IL-17, and IL-23 levels were measured in serum and peritoneal fluid of women with minimal or mild endometriosis and compared with levels in controls without endometriosis. Higher IL-23 levels were encountered in the peritoneal fluid of women with endometriosis, suggesting a possible role of this cytokine in these womens infertility.

The effect of the levonorgestrel-releasing intrauterine system and the copper intrauterine device on subendometrial microvascularization and uterine artery blood flow

OBJECTIVE To evaluate the effect of the levonorgestrel intrauterine system (LNG-IUS) and TCU 380A on the subendometrial vascularization and the uterine artery blood flow during the midluteal phase. DESIGN Prospective clinical trial. SETTING Teaching hospital. PATIENT(S) The trial included 27 patients who received the LNG-IUS compared with 25 patients who received the TCU 380A. INTERVENTION(S) The subendometrial blood flow was evaluated using power Doppler analysis, uterine artery pulsatility index (PI), and resistance index (RI) just before inserting the intrauterine device in the midluteal phase and 3 months after. MAIN OUTCOME MEASUREMENT(S) Power Doppler analysis, PI, RI, and endometrial thickness. RESULT(S) There were no significant differences in subendometrial vascularization between the groups. Pulsatility index and RI variability (before and after) increased and endometrial thickness reduced in LNG-IUS users. We used the multiple logistic regression model to examine the potential confounding bias (age and parity). The LNG-IUS was independently associated with increased PI. CONCLUSION(S) No subendometrial microvascularization difference was found between the groups. It is the first direct evidence that LNG-IUS reduced uterine artery blood flow, even after controlling for age and parity.

Subendometrial microvascularization and uterine artery blood flow in IUD-induced side effects (levonorgestrel intrauterine system and copper intrauterine device)

BACKGROUND A better understanding of the uterine and endometrial vascularization in intrauterine device (IUD)-induced side effects is clearly of paramount importance in terms of both physiological and pathophysiological changes and may permit assessment for future therapeutic treatments. The aim of the study was to quantify the subendometrial microvascularization and uterine artery blood flow in IUD-induced side effects using power Doppler analysis as well as pulsatility index (PI) and resistance index (RI) in the exact midluteal phase 3 months after IUD insertion. There were 27 patients using the levonorgestrel-releasing intrauterine system and 25 patients using TCu 380A. STUDY DESIGN This study has a prospective clinical trial design. RESULTS There is an increased subendometrial blood flow in patients with severe dysmenorrhea and/or bleeding, after controlling for IUD type, age and parity. Moreover, the PI and RI were not different in such women. CONCLUSION The results provide new data on the bleeding patterns related to these IUD types that may be relevant during contraception use. This method could be used as a prognostic factor to better evaluate women for the risk of developing dysmenorrhea and/or bleeding after IUD insertion.

Hormonal manipulations in the luteal phase to coordinate subsequent antral follicle growth during ovarian stimulation

During the early follicular phase in the menstrual cycle, antral follicle sizes are often markedly heterogeneous. These follicular size discrepancies may, at least in part, result from the early exposure of FSH-sensitive follicles to gradient FSH concentrations during the preceding luteal phase. In addition, they potentially affect the results of ovarian stimulation. Indeed, pre-existing follicle size discrepancies may encumber coordinated follicular growth during ovarian stimulation, thereby reducing the number of follicles that reach maturation at once. To investigate this issue, three clinical studies were conducted to test the hypothesis that luteal FSH suppression could coordinate follicular growth. First, luteal FSH concentrations were artificially lowered by administering physiological oestradiol doses and measured follicular characteristics on the subsequent day 3. Second, it was verified whether luteal oestradiol administration could promote the coordination of follicular growth during ovarian stimulation and improve its results. Third, the effects of premenstrual gonadotrophin-releasing hormone (GnRH) antagonist administration on follicular characteristics were assessed during the early follicular phase. The results showed that luteal FSH suppression by either oestradiol or GnRH antagonist administration reduces the size and improves the homogeneity of early antral follicles during the early follicular phase, an effect that persists during ovarian stimulation. Coordination of follicular development may optimize ovarian response to short GnRH agonist and antagonist protocols, and constitutes an attractive approach to improving their outcome.