Karen Peeraer

Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management

OBJECTIVE To investigate the presence and outcome of uterine vascular malformations in women with abnormal premenopausal bleeding. STUDY DESIGN In this observational study 265 consecutive patients with abnormal premenopausal bleeding were examined by the same ultrasonographer with transvaginal gray-scale ultrasonography and color Doppler imaging. A final diagnosis of uterine vascular malformation was based on ultrasonographic findings, hysteroscopy or histological findings. Patients suspected of uterine vascular malformations at ultrasonography were closely monitored. RESULTS In nine patients (3.4%) we found ultrasonographic features of uterine vascular malformations. Color Doppler imaging showed hypervascularity, marked turbulence, and low-impedance, high-velocity flow. In six patients the condition resolved spontaneously. Two patients with hydatiform mole needed chemotherapy and their condition normalized. One patient underwent a selective embolization of the uterine artery. Subsequently, five patients had uncomplicated pregnancies after resolution of the vascular malformation. CONCLUSION Uterine vascular malformations are more common than previously thought. We conclude that conservative management is a valuable option in many of the acquired pregnancy-related cases that are diagnosed with color Doppler imaging.

Preimplantation genetic screening for aneuploidy of embryos after in vitro fertilization in women aged at least 35 years: a prospective randomized trial

OBJECTIVE To test the hypothesis that patients with advanced maternal age (AMA) have a higher implantation rate (IR) after embryo transfer of embryos with a normal chromosomal pattern for the chromosomes studied with preimplantation genetic screening (PGS) compared with patients who had an embryo transfer without PGS. DESIGN Prospective randomized controlled trial (RCT). SETTING Academic tertiary setting. PATIENT(S) Patients with AMA (> or =35 years). INTERVENTION(S) In an RCT, the clinical IR per embryo transferred was compared after embryo transfer on day 5 or 6 between the PGS group (analysis of chromosomes 13, 16, 18, 21, 22, X, and Y) and the Control group without PGS. MAIN OUTCOME MEASURE(S) No differences were observed between the PGS group and the Control group for the clinical IR (15.1%; 14.9%; rate ratio 1.01; exact confidence interval [CI], 0.25-5.27), the ongoing IR (at 12 weeks) (9.4%; 14.9%), and the live born rate per embryo transferred (9.4%; 14.9%; rate ratio 0.63; exact CI, 0.08-3.37). Fewer embryos were transferred in the PGS group (1.6 +/- 0.6) than in the Control group (2.0 +/- 0.6). A normal diploid status was observed in 30.3% of the embryos screened by PGS. CONCLUSION(S) In this RCT, the results did not confirm the hypothesis that PGS results in improved reproductive outcome in patients with AMA.

Evaluation of a panel of 28 biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND At present, the only way to conclusively diagnose endometriosis is laparoscopic inspection, preferably with histological confirmation. This contributes to the delay in the diagnosis of endometriosis which is 6-11 years. So far non-invasive diagnostic approaches such as ultrasound (US), MRI or blood tests do not have sufficient diagnostic power. Our aim was to develop and validate a non-invasive diagnostic test with a high sensitivity (80% or more) for symptomatic endometriosis patients, without US evidence of endometriosis, since this is the group most in need of a non-invasive test. METHODS A total of 28 inflammatory and non-inflammatory plasma biomarkers were measured in 353 EDTA plasma samples collected at surgery from 121 controls without endometriosis at laparoscopy and from 232 women with endometriosis (minimal-mild n = 148; moderate-severe n = 84), including 175 women without preoperative US evidence of endometriosis. Surgery was done during menstrual (n = 83), follicular (n = 135) and luteal (n = 135) phases of the menstrual cycle. For analysis, the data were randomly divided into an independent training (n = 235) and a test (n = 118) data set. Statistical analysis was done using univariate and multivariate (logistic regression and least squares support vector machines (LS-SVM) approaches in training- and test data set separately to validate our findings. RESULTS In the training set, two models of four biomarkers (Model 1: annexin V, VEGF, CA-125 and glycodelin; Model 2: annexin V, VEGF, CA-125 and sICAM-1) analysed in plasma, obtained during the menstrual phase, could predict US-negative endometriosis with a high sensitivity (81-90%) and an acceptable specificity (68-81%). The same two models predicted US-negative endometriosis in the independent validation test set with a high sensitivity (82%) and an acceptable specificity (63-75%). CONCLUSIONS In plasma samples obtained during menstruation, multivariate analysis of four biomarkers (annexin V, VEGF, CA-125 and sICAM-1/or glycodelin) enabled the diagnosis of endometriosis undetectable by US with a sensitivity of 81-90% and a specificity of 63-81% in independent training- and test data set. The next step is to apply these models for preoperative prediction of endometriosis in an independent set of patients with infertility and/or pain without US evidence of endometriosis, scheduled for laparoscopy.

Ovarian hyperstimulation syndrome and complications of ART

This article reviews serious clinical complications related to assisted reproductive technology (ART) procedures (ovarian stimulation and oocyte aspiration), including ovarian hyperstimulation syndrome (OHSS), bleeding and infection. These complications are rare, but can be severe and even life-threatening. It is important that general practitioners and gynaecologists are aware of these complications, because they will often be the first to be contacted by patients. Similarly, patients should be counselled before starting ART procedures that iatrogenic complications can be associated with ovarian stimulation and/or oocyte aspiration.

Why We Need a Noninvasive Diagnostic Test for Minimal to Mild Endometriosis with a High Sensitivity

tion has oft en been criticized, there is currently no better method available. Th e stage of endometriosis is positively correlated with the degree of subfertility, but not or not as clearly with the degree of pelvic pain [4–6] . Surgical excision of endometriosis, even in mild stage disease, is an eff ective treatment for both endometriosis-associated subfertility and pain. Th e spontaneous pregnancy rate following surgery is negatively correlated with the degree of endometriosis [4] . Th e degree of pain relief following surgery is more pronounced in women with mild to severe endometriosis than in women with minimal endometriosis [7–9] . Current medical therapy of endometriosis is based on hormonal suppression and is eff ective for pain but useless for endometriosis-associated subfertility [5] . Since most women with endometriosis are of reproductive age, the active or passive desire to become pregnant later in life is an important issue. Early diagnosis of endometriosis in women who try to conceive should enable gynecologists to detect and excise endometriosis before the disease has progressed to a moderate to severe stage, in order to preserve or improve fertility as much as possible. In the presence of subfertility with a history of cyclic or chronic pelvic pain, combined with a clinical examination that is positive for pain, and an ultrasound positive for ovarian endometriotic cysts or deep endometriotic nodules, the probability of endometriosis is so high Endometriosis is defi ned as the presence of endometrial-like tissue outside the uterus, is associated with a chronic infl ammatory reaction in the pelvis and oft en results in subfertility and pain. Endometriosis occurs mainly in women of reproductive age (16–50 years), is estrogen-sensitive, and has a progressive character in at least 50%, but the rate and risk factors for progression are unpredictable and unknown, respectively. Th e diagnosis of endometriosis can be suspected in women with a history of dysmenorrhea, deep dyspareunia, chronic pelvic pain with or without subfertility, although it is possible that endometriosis is completely asymptomatic. In speculo inspection of cervix and vagina may show a small cervical diameter [1] , lateral cervical displacement [2] and rarely blue discoloration suggestive for cervical or vaginal endometriosis. Clinical abdominal and bimanual pelvic examination, preferably during the menstrual period, may reveal a painful lower abdomen, painful adnexal masses, painful uterosacral ligaments, and painful mobilization of the uterus. Vaginal ultrasound is an adequate diagnostic method to detect ovarian endometriotic cysts and deeply infi ltrative endometriotic noduli, but does not rule out peritoneal endometriosis or endometriosis-associated adhesions. Endometriosis is classifi ed in four stages: minimal, mild, moderate and severe [3] . Although this classifi caPublished online: May 4, 2006

Pregnancy after ICSI with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome: a case report and review of the literature

This study presents a case of intracytoplasmic sperm injection (ICSI) with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome. Semen analysis of the patient suffering from immotile cilia syndrome revealed an extreme oligoasthenoteratozoospermia (OAT: count <1.4 x 10(6)/ml, 0% motility and 3% normal morphology). Electron microscopy of sperm flagella showed the absence of inner and outer dynein arms. During the ICSI cycle, the hypo-osmotic swelling test (HOS) was used for the identification of viable spermatozoa in the pool of immotile spermatozoa for ICSI. A normal fertilization rate was found in eight out of the 12 oocytes. A first fresh double embryo transfer resulted in a late miscarriage at 21 weeks. A second healthy singleton pregnancy occurred after transfer of two frozen-thawed embryos from the same ICSI procedure. Although only one successful ICSI case of the immotile cilia syndrome combined with HOS is described here, HOS might be a simple but valuable tool to obtain normal fertilization and pregnancy for patients suffering from immotile spermatozoa.

Combined mRNA microarray and proteomic analysis of eutopic endometrium of women with and without endometriosis

BACKGROUND An early semi-invasive diagnosis of endometriosis has the potential to allow early treatment and minimize disease progression but no such test is available at present. Our aim was to perform a combined mRNA microarray and proteomic analysis on the same eutopic endometrium sample obtained from patients with and without endometriosis. METHODS mRNA and protein fractions were extracted from 49 endometrial biopsies obtained from women with laparoscopically proven presence (n= 31) or absence (n= 18) of endometriosis during the early luteal (n= 27) or menstrual phase (n= 22) and analyzed using microarray and proteomic surface enhanced laser desorption ionization-time of flight mass spectrometry, respectively. Proteomic data were analyzed using a least squares-support vector machines (LS-SVM) model built on 70% (training set) and 30% of the samples (test set). RESULTS mRNA analysis of eutopic endometrium did not show any differentially expressed genes in women with endometriosis when compared with controls, regardless of endometriosis stage or cycle phase. mRNA was differentially expressed (P< 0.05) in women with (925 genes) and without endometriosis (1087 genes) during the menstrual phase when compared with the early luteal phase. Proteomic analysis based on five peptide peaks [2072 mass/charge (m/z); 2973 m/z; 3623 m/z; 3680 m/z and 21133 m/z] using an LS-SVM model applied on the luteal phase endometrium training set allowed the diagnosis of endometriosis (sensitivity, 91; 95% confidence interval (CI): 74-98; specificity, 80; 95% CI: 66-97 and positive predictive value, 87.9%; negative predictive value, 84.8%) in the test set. CONCLUSION mRNA expression of eutopic endometrium was comparable in women with and without endometriosis but different in menstrual endometrium when compared with luteal endometrium in women with endometriosis. Proteomic analysis of luteal phase endometrium allowed the diagnosis of endometriosis with high sensitivity and specificity in training and test sets. A potential limitation of our study is the fact that our control group included women with a normal pelvis as well as women with concurrent pelvic disease (e.g. fibroids, benign ovarian cysts, hydrosalpinges), which may have contributed to the comparable mRNA expression profile in the eutopic endometrium of women with endometriosis and controls.

Proteomics analysis of plasma for early diagnosis of endometriosis

OBJECTIVE: To test the hypothesis that differential surface-enhanced laser desorption/ionization time-of-flight mass spectrometry protein or peptide expression in plasma can be used in infertile women with or without pelvic pain to predict the presence of laparoscopically and histologically confirmed endometriosis, especially in the subpopulation with a normal preoperative gynecologic ultrasound examination. METHODS: Surface-enhanced laser desorption/ionization time-of-flight mass spectrometry analysis was performed on 254 plasma samples obtained from 89 women without endometriosis and 165 women with endometriosis (histologically confirmed) undergoing laparoscopies for infertility with or without pelvic pain. Data were analyzed using least squares support vector machines and were divided randomly (100 times) into a training data set (70%) and a test data set (30%). RESULTS: Minimal-to-mild endometriosis was best predicted (sensitivity 75%, 95% confidence interval [CI] 63–89; specificity 86%, 95% CI 71–94; positive predictive value 83.6%, negative predictive value 78.3%) using a model based on five peptide and protein peaks (range 4.898–14.698 m/z) in menstrual phase samples. Moderate-to-severe endometriosis was best predicted (sensitivity 98%, 95% CI 84–100; specificity 81%, 95% CI 67–92; positive predictive value 74.4%, negative predictive value 98.6%) using a model based on five other peptide and protein peaks (range 2.189–7.457 m/z) in luteal phase samples. The peak with the highest intensity (2.189 m/z) was identified as a fibrinogen &bgr;-chain peptide. Ultrasonography-negative endometriosis was best predicted (sensitivity 88%, 95% CI 73–100; specificity 84%, 95% CI 71–96) using a model based on five peptide peaks (range 2.058–42.065 m/z) in menstrual phase samples. CONCLUSION: A noninvasive test using proteomic analysis of plasma samples obtained during the menstrual phase enabled the diagnosis of endometriosis undetectable by ultrasonography with high sensitivity and specificity. LEVEL OF EVIDENCE: II

Vitrification of cleavage stage day 3 embryos results in higher live birth rates than conventional slow freezing: a RCT

STUDY QUESTION Is the live birth rate (LBR) per embryo thawed/warmed higher when Day 3 cleavage stage embryos are cryopreserved by vitrification compared with slow freezing? SUMMARY ANSWER The LBR per embryo thawed/warmed was higher after vitrification than after slow freezing on Day 3, based on better embryo survival, quality and availability of embryos in the vitrification group. WHAT IS KNOWN ALREADY Post-thawing survival rate of cleavage-stage embryos has been reported to be higher after vitrification than after slow freezing. STUDY DESIGN, SIZE, DURATION This RCT was performed in an academic tertiary center between September 2011 and March 2013. If supernumerary embryos were available on Day 3, patients were randomized at the time of cryopreservation using a computerized system to determine a simple allocation to the vitrification group or the slow freezing group and all embryos were frozen with the same technique. The primary outcome of this study was the LBR per embryo thawed/warmed. Power calculation revealed that 184 thawed embryos were needed in each group (β = 0.8, α < 0.05) to test the hypothesis that the LBR per embryo thawed/warmed was significantly higher (16%) after vitrification than after slow freezing (6%). PARTICIPANTS/MATERIALS, SETTING, METHODS Patients <40 years old undergoing their first oocyte retrieval (OR), with embryo transfer and with supernumerary embryos on Day 3, were randomized. Day 3 embryos with ≥6 cells, <25% fragmentation and morphologically equal blastomeres were cryopreserved by slow freezing (using 1,2-propanediol and 0.1 M sucrose as cryoprotectant) or by closed vitrification using commercially available freezing/vitrification media. Survival was defined as ≥50% cells were intact after thawing. Thawed embryos were further cultured overnight. In total, 307 patients were randomized to slow freezing (155 patients, 480 embryos) or vitrification (152 patients, 495 embryos). MAIN RESULTS AND THE ROLE OF CHANCE By March 2013, 200 embryos were thawed after slow freezing in 95 cycles for 79 patients and 217 embryos were warmed after vitrification in 121 cycles in 90 patients. The LBR per embryo thawed/warmed was significantly higher after vitrification (16.1% (35/217)) than after slow freezing (5.0% (10/200); P < 0.0022; relative risk (RR) 3.23; 95% confidence interval (CI) 1.64-6.35). Similarly, the implantation rate per embryo thawed/warmed was higher after vitrification (20.7% (45/217) than after slow freezing (7.5% (15/200); P = 0.0012; RR 2.76; CI 1.59-4.81). The survival rate was significantly higher after vitrification (84.3% (183/217) than after slow freezing (52.5% (105/200); P < 0.0001). Significantly more embryos were fully intact after vitrification (75.4% (138/183) than after slow freezing (28.6% (30/105); P < 0.0001). The number of transfers was significantly higher after vitrification (90.1% (109/121)) than after slow freezing (73.7% (70/95); P = 0.0024). LIMITATIONS, REASONS FOR CAUTION Survival rates in the slow freezing group were low in this study. Additional RCTs are needed to compare reproductive outcome after vitrification and after slow freezing with 1,2-propanediol and 0.2 M sucrose, since this method has been reported to have better survival than the method used in our study. Our findings are only applicable to the specific slow freezing cryopreservation medium used in our study, and not to any other commercially available media. WIDER IMPLICATIONS OF THE FINDINGS When compared with slow freezing using 1,2-propanediol and 0.1 M sucrose as cryoprotectant, vitrification of Day 3 cleavage stage embryos resulted in a higher LBR per embryo warmed, and may therefore result into a higher cumulative delivery rate after one oocyte retrieval. STUDY FUNDING/COMPETING INTERESTS None. TRIAL REGISTRATION NUMBER NCT02013024.

ENDOMETRIOSIS AND ASSISTED REPRODUCTION: THE ROLE FOR REPRODUCTIVE SURGERY?

Purpose of review The aim of this review paper is to discuss the relationship between endometriosis and assisted reproductive technology. More specifically, the following clinically relevant issues will be discussed. (1) Does the presence of endometriosis affect the outcome of assisted reproductive technology? (2) Does surgical treatment for endometriosis prior to or after assisted reproductive technology treatment affect the outcome of assisted reproductive technology? (3) Is assisted reproductive technology a risk factor for the recurrence of endometriosis after medical or surgical therapy? Recent findings The review is based on recently published review papers/meta-analyses or international guidelines as published by the European Society of Human Reproduction or the American Society of Reproductive Medicine, updated with a selective review of recent papers searching PubMed with the key words ‘Endometriosis’, ‘Assisted Reproduction’, ‘IVF’, ‘IUI’ and ‘Reproductive Surgery’. Summary At the end of this review, a practical proposal for the clinical management of women with endometriosis-associated subfertility is proposed, based on our own experience.