Mohamed A. Bedaiwy

Role of reactive oxygen species in the pathophysiology of human reproduction

OBJECTIVE To summarize the role of reactive oxygen species (ROS) in the pathophysiology of human reproduction. DESIGN Review of literature. SETTING Fertility research center and obstetrics and gynecology department in a tertiary care facility. RESULT(S) ROS plays an essential role in the pathogenesis of many reproductive processes. In male-factor infertility. oxidative stress attacks the fluidity of the sperm plasma membrane and the integrity of DNA in the sperm nucleus. Reactive oxygen species induced DNA damage may accelerate the process of germ cell apoptosis, leading to the decline in sperm counts associated with male infertility. ROS mediated female fertility disorders share many pathogenic similarities with the ones on the male side. These similarities include a potential role in the pathophysiology of endometriosis and unexplained infertility. High follicular fluid ROS levels are associated with negative IVF outcomes, particularly in smokers. Moreover, oxidative stress may be responsible in hydrosalpingeal fluid mediated embryotoxicity as well as poor in vitro embryonic development. CONCLUSION(S) High levels of ROS are detrimental to the fertility potential both in natural and assisted conception states.

Restoration of ovarian function after autotransplantation of intact frozen-thawed sheep ovaries with microvascular anastomosis

OBJECTIVE To test the feasibility of transplanting an intact frozen-thawed ovary with microvascular anastomosis of the ovarian vascular pedicle to the deep inferior epigastric vessels. DESIGN Chronic survival study. SETTING Biological Resources Unit, The Cleveland Clinic Foundation. ANIMAL(S) Adult merino ewes. INTERVENTION(S) Bilateral laparoscopic oophorectomy was performed on 17 synchronized ewes. In one group of animals (Group I, n = 11), both ovaries were cryopreserved intact with their vascular pedicles. In another group of animals (Group II, n = 6), ovarian cortical strips were prepared from each ovary and cryopreserved. After thawing, follicular viability and apoptosis rates were assessed using one ovary. The other ovary was transplanted to the abdominal wall with microvascular anastomosis (Group I). In Group II, the ovarian cortical strips were placed in the anterior abdominal wall. Ovaries were harvested after 8-10 days in situ and subjected to histological evaluation. MAIN OUTCOME MEASURE(S) Blood flow, apoptotic signals, follicular viability, serum estradiol (E(2)), follicle-stimulating hormone (FSH), and histology. RESULT(S) No significant differences were found in the mean values of apoptosis (mostly in the atretic and some secondary follicles) and follicular viability in both groups. In Group I, immediate and long-term patency were documented in 100% and 27% (3/11) of the grafts, respectively; and postoperative FSH levels were similar to preoperative values in animals with patent vessels. In Group II, postoperative FSH levels were significantly higher than the preoperative ones (P=.03). CONCLUSION(S) Transplantation of an intact frozen-thawed ovary is technically feasible. Using this approach, immediate restoration of vascular supply and ovarian hormonal functions is possible.

Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes.

OBJECTIVE: To compare the surgical outcomes of robot-assisted laparoscopic myomectomy (robot-assisted), standard laparoscopic myomectomy (laparoscopic), and open myomectomy (abdominal). METHODS: Myomectomy patients were identified from the case records of the Cleveland Clinic and stratified into three groups. Operative and immediate postoperative outcomes were compared. Data analysis was performed using analysis of variance, Kruskal-Wallis analysis of ranks, &khgr;2, and Fisher exact tests where appropriate. RESULTS: From a total of 575 myomectomies, 393 (68.3%) were abdominal, 93 (16.2%) were laparoscopic, and 89 (15.5%) were robot-assisted. The three groups were comparable regarding the size, number, and location. Significantly heavier myomas were removed in the robot-assisted group (223 [85.25, 391.50] g) compared with the laparoscopic group (96.65 [49.50, 227.25] g, P<.001) and were lower than in the abdominal group (263 [ 90.50, 449.00] g, P=.002). Higher blood loss was reported in the abdominal group compared with the other two groups, with a median (interquartile range) of blood loss in milliliters of 100 (50, 212.50), 200 (100, 437.50) and 150 (100, 200) in the laparoscopic, abdominal, and robot-assisted groups, respectively. The actual surgical time in minutes was 126 (95, 177) in the abdominal group, 155 (98, 200) in the laparoscopic group, and 181 (151, 265) in robot-assisted group (P<.001). Patients in the abdominal group had a higher median length of hospital stay of 3 (2, 3) days, compared with 1 (0, 1) day in the laparoscopic group and 1 (1, 1) days in the robot-assisted group (P<.001). CONCLUSION: Robotic-assisted myomectomy is associated with decreased blood loss and length of hospital stay compared with traditional laparoscopy and to open myomectomy. Robotic technology could improve the utilization of the laparoscopic approach for the surgical management of symptomatic myomas. LEVEL OF EVIDENCE: II

Gonadotropin-releasing hormone analog cotreatment for preservation of ovarian function during gonadotoxic chemotherapy: a systematic review and meta-analysis.

OBJECTIVE To determine whether gonadotropin-releasing hormone (GnRH) analog cotreatment with chemotherapy provides better reproductive outcomes for women at risk of premature ovarian failure (POF) as a side-effect of gonadotoxic chemotherapy. DESIGN Systematic review and meta-analysis. SETTING University-affiliated research centers. PATIENT(S) None. INTERVENTION(S) Electronic and manual searches (e.g., MEDLINE, EMBASE, CENTRAL) up to January 2010 were performed to identify randomized controlled trials (RCTs) comparing GnRH cotreatment with chemotherapy alone in premenopausal women. MAIN OUTCOME MEASURE(S) Incidence of POF after treatment, incidence of women with resumption of ovulation, POF after an initial normal cycle, normal cycles but abnormal markers of ovarian reserve, spontaneous occurrence of pregnancy after treatment, and time to reestablishment of menstruation; data also extracted to allow for an intention-to-treat analysis. RESULT(S) Twenty-eight RCTs were identified, but only six met the inclusion criteria. Data were only available for the incidence of women with new onset of POF, resumption of ovulation, and occurrence of pregnancy. The incidence of POF or resumption of ovulation both demonstrated a statistically significant difference in favor of the GnRH cotreatment. The occurrence of spontaneous pregnancy showed no statistically significant difference between GnRH cotreatment and the control groups. CONCLUSION(S) Evidence from RCTs suggests a potential benefit of GnRH cotreatment with chemotherapy in premenopausal women, with higher rates of spontaneous resumption of menses and ovulation but not improvement in pregnancy rates. Data relating to study quality and possible bias for the majority of the outcomes in this review were not available, denoting possible selective reporting of trial data.

Heterotopic autotransplantation of the ovary with microvascular anastomosis: A novel surgical technique

OBJECTIVE To test the feasibility of transplanting an entire ovary with anastomosis of the ovarian vascular pedicle. DESIGN Long-term survival study. SETTING Biological Resources Unit, Cleveland Clinic Foundation. ANIMAL(S) Five adult, nonpregnant ewes. INTERVENTION(S) Laparoscopic bilateral oophorectomy was performed. Ovaries were autotransplanted into the abdominal wall, and microsurgical vascular anastomosis of the ovarian to the inferior epigastric vessels was performed. The transplant was removed and evaluated after 7 +/- 1 days. MAIN OUTCOME MEASURE(S) Blood flow, serum E2 and FSH levels, and histologic characteristics. RESULT(S) At follow-up three transplants were viable; they showed no signs of necrosis, and patency of the vascular anastomosis was confirmed. Serum E2 levels did not change significantly after transplantation in the patent vessel group (155.3 +/- 46.1 vs. 125.7 +/- 44.6 pg/mL) or the nonpatent vessel group (99 vs. 158 pg/mL). Serum FSH level in the patent vessel group did not change significantly from before to after transplantation (70.6 +/- 37.2 ng/mL vs. 95.1 +/- 17.7 ng/mL), whereas a large increase in FSH level was observed in the nonpatent vessel group (52.3 ng/mL vs. 522 ng/mL). The patent vessel group had significantly more follicles after transplantation than did the nonpatent vessel group (6 +/- 1 vs. 1 +/- 1). CONCLUSION(S) In conjunction with improved protocols for cryopreservation, ovarian autotransplantation with vascular anastomosis may be superior to current ovarian tissue banking and grafting techniques.

VARICOCELECTOMY IMPROVES INTRAUTERINE INSEMINATION SUCCESS RATES IN MEN WITH VARICOCELE

PURPOSE We determined whether varicocele treatment before intrauterine insemination significantly affects intrauterine insemination success rates. MATERIALS AND METHODS A total of 58 infertile couples, of whom the women had normal evaluations and men had abnormal semen analyses and a history of varicocele, were included in this study. They were identified after reviewing the charts of all women undergoing intrauterine insemination for male factor infertility at our center. Of the men 24 participated in 63 intrauterine insemination cycles without varicocele treatment, while in the remaining 34 varicocele was treated before a total of 101 intrauterine insemination cycles. Variables associated with pregnancy or live birth were analyzed using repeat measures logistic regression with generalized estimating equation techniques. An initial stepwise generalized estimating equation was performed without including varicocele treatment status. Subsequently varicocele treatment status and the significant associated factors were included in analysis. The semen characteristics of untreated and treated varicocele groups were compared with repeat measures analysis of variance. RESULTS On pre-wash semen analysis patients with untreated varicocele had significantly higher mean motility plus or minus standard error than patients whose varicoceles were treated (48.6% +/- 2.3% versus 38.1% +/- 1.8%, p = 0.02). However, no statistically significant difference was noted in the mean post-wash total motile sperm count in the treated and untreated groups (7.2 +/- 1.0 versus 14.8 +/- 2.6, p = 0.1). Despite these findings the pregnancy and live birth rates per cycle were significantly higher in patients in whom varicocele was treated than in those without varicocele treatment (11.8% versus 6.3%, p = 0.04 and 11.8% versus 1.6%, p = 0.007, respectively). CONCLUSIONS Varicocele treatment may not improve semen characteristics in all men but it appears to improve pregnancy and live birth rates among couples undergoing intrauterine insemination for male factor infertility. A functional factor not measured on routine semen analysis may affect pregnancy rates in this setting. Men should be screened for varicocele before intrauterine insemination is initiated for male factor infertility.

Minimally invasive management-of uterine fibroids

Purpose of review Many minimally invasive techniques have recently been introduced for the management of uterine fibroids. The purpose of this review is to analyse recent data for techniques that are used to manage uterine fibroids. Recent findings Laparoscopic myomectomy has provided a minimally invasive alternative to laparotomy for intramural and subserous myomata. However, this technique is still the subject of debate. With good surgical experience, the risk of perioperative complications is comparable with conventional surgery. Laparoscopic myomectomy is associated with faster postoperative recovery, and could potentially reduce the risk of postoperative adhesions compared with laparotomy. Spontaneous uterine rupture, although uncommon after laparoscopic myomectomy, is still a concern. The risk of recurrence seems to be higher after laparoscopic myomectomy than after myomectomy performed by laparotomy. Uterine artery embolization is another new and attractive treatment for patients with symptomatic fibroids. Uterine artery embolization provides excellent relief for abnormal bleeding, pelvic pain, and bulk-related symptoms. Early reports show that uterine artery embolization is associated with normal reproductive and obstetric functions. This technique is associated with a shorter hospital stay and a rapid recovery time. Summary Laparoscopic myomectomy and uterine artery embolization are being performed more than ever. Current evidence proves the safety, reliability and reproducibility of both procedures. However, prospective randomized controlled trials comparing both procedures with conventional myomectomy are needed.

Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease

OBJECTIVE To present our initial experience in laparoscopic surgery for benign adnexal disease performed exclusively through an umbilical incision using a single three-channel port and flexible laparoscopic instrumentation. DESIGN Case report. SETTING Tertiary-care referral center. PATIENT(S) Since November, 2008, we have performed single-port laparoscopic surgery in nine patients diagnosed with benign adnexal disease. Patients with adnexal masses or endometriosis and a body mass index of <35 kg/m(2) were selected. INTERVENTION(S) Laparoendoscopic single-site (LESS) surgery. In each case, a multichannel port was inserted into the peritoneum through a 1.5-2.0-centimeter umbilical incision. MAIN OUTCOME MEASURES Feasibility, postoperative pain score, age, BMI, estimated blood loss. RESULT(S) Eight of nine cases were completed successfully, without conversion to a standard laparoscopic approach or to laparotomy. An additional 3 mm extraumbilical port was required in one patient with stage 4 endometriosis. Seven out of nine patients had earlier abdominal surgery. The operative blood loss ranged from minimal to 75 mL. Duration of hospital stay was <24 hours in all cases. Minimal use of postoperative narcotics was required, and no intraoperative complications occurred. CONCLUSION(S) The LESS surgery for benign adnexal disease is feasible in patients with or without earlier surgery. Additional investigation is needed to evaluate the safety and long-term outcomes of this new approach.

Role of nuclear progesterone receptor isoforms in uterine pathophysiology

BACKGROUND Progesterone is a key hormonal regulator of the female reproductive system. It plays a major role to prepare the uterus for implantation and in the establishment and maintenance of pregnancy. Actions of progesterone on the uterine tissues (endometrium, myometrium and cervix) are mediated by the combined effects of two progesterone receptor (PR) isoforms, designated PR-A and PR-B. Both receptors function primarily as ligand-activated transcription factors. Progesterone action on the uterine tissues is qualitatively and quantitatively determined by the relative levels and transcriptional activities of PR-A and PR-B. The transcriptional activity of the PR isoforms is affected by specific transcriptional coregulators and by PR post-translational modifications that affect gene promoter targeting. In this context, appropriate temporal and cell-specific expression and function of PR-A and PR-B are critical for normal uterine function. METHODS Relevant studies describing the role of PRs in uterine physiology and pathology (endometriosis, uterine leiomyoma, endometrial cancer, cervical cancer and recurrent pregnancy loss) were comprehensively searched using PubMed, Cochrane Library, Web of Science, and Google Scholar and critically reviewed. RESULTS Progesterone, acting through PR-A and PR-B, regulates the development and function of the endometrium and induces changes in cells essential for implantation and the establishment and maintenance of pregnancy. During pregnancy, progesterone via the PRs promotes myometrial relaxation and cervical closure. Withdrawal of PR-mediated progesterone signaling triggers menstruation and parturition. PR-mediated progesterone signaling is anti-mitogenic in endometrial epithelial cells, and as such, mitigates the tropic effects of estrogen on eutopic normal endometrium, and on ectopic implants in endometriosis. Similarly, ligand-activated PRs function as tumor suppressors in endometrial cancer cells through inhibition of key cellular signaling pathways required for growth. In contrast, progesterone via PR activation appears to increase leiomyoma growth. The exact role of PRs in cervical cancer is unclear. PRs regulate implantation and therefore aberrant PR function may be implicated in recurrent pregnancy loss (RPL). PRs likely regulate key immunogenic factors involved in RPL. However, the exact role of PRs in the pathophysiology of RPL and the use of progesterone for therapeutic benefit remains uncertain. CONCLUSIONS PRs are key mediators of progesterone action in uterine tissues and are essential for normal uterine function. Aberrant PR function (due to abnormal expression and/or function) is a major cause of uterine pathophysiology. Further investigation of the underlying mechanisms of PR isoform action in the uterus is required, as this knowledge will afford the opportunity to create progestin/PR-based therapeutics to treat various uterine pathologies.

Fertility preservation and pregnancy outcome after malignancy

Purpose of review The overall survival and cure rates of patients with childhood and adult malignancies have improved dramatically, but cancer treatment can be associated with diminished reproductive potential. However, research on the preservation of fertility in these patients has given patients new options. This article discusses the mechanisms of reproductive failure after cancer therapy and the currently available fertility preservation strategies. Recent findings Ovarian transposition is still a viable option if radiotherapy is to be used alone. Modifications in assisted reproductive technology that decrease peak estradiol levels are ideal for breast cancer survivors. Embryo freezing technology offers excellent pregnancy rates. Oocyte freezing is available for women without a partner, but there is more limited experience with this technique. Understanding the concepts of graft function after the autotransplantation of frozen–thawed ovarian tissue has resulted in great strides in the technical requirements for success. Summary Gonadotropin-releasing hormone analogues are the only available medical protection means for gonadotoxic chemotherapy. Assisted reproductive technology offers excellent results, but the protocols require a delay in implementing chemotherapy. Despite recent reports of embryo development after the transplantation of cryopreserved–thawed ovarian tissue, clinical experience is limited and the technique remains experimental. Abbreviations ART: assisted reproductive technology; FSH: follicle-stimulating hormone; GnRH: gonadotropin-releasing hormone; IVF: in-vitro fertilization; POF: premature ovarian failure.