R.L. Gustofson

Converse Regulatory Functions of Estrogen Receptor-α and -β Subtypes Expressed in Hypothalamic Gonadotropin-Releasing Hormone Neurons

Estradiol (E(2)) acts as a potent feedback molecule between the ovary and hypothalamic GnRH neurons, and exerts both positive and negative regulatory actions on GnRH synthesis and secretion. However, the extent to which these actions are mediated by estrogen receptors (ERs) expressed in GnRH neurons has been controversial. In this study, Single-cell RT-PCR revealed the expression of both ERalpha and ERbeta isoforms in cultured fetal and adult rat hypothalamic GnRH neurons. Both ERalpha and ERbeta or individual ERs were expressed in 94% of cultured fetal GnRH neurons. In adult female rats at diestrus, 68% of GnRH neurons expressed ERs, followed by 54% in estrus and 19% in proestrus. Expression of individual ERs was found in 24% of adult male GnRH neurons. ERalpha exerted marked G(i)-mediated inhibitory effects on spontaneous action potential (AP) firing, cAMP production, and pulsatile GnRH secretion, indicating its capacity for negative regulation of GnRH neuronal function. In contrast, increased E(2) concentration and ERbeta agonists increase the rate of AP firing, GnRH secretion, and cAMP production, consistent with ERbeta-dependent positive regulation of GnRH secretion. Consonant with the coupling of ERalpha to pertussis toxin-sensitive G(i/o) proteins, E(2) also activates G protein-activated inwardly rectifying potassium channels, decreasing membrane excitability and slowing the firing of spontaneous APs in hypothalamic GnRH neurons. These findings demonstrate that the dual actions of E(2) on GnRH neuronal membrane excitability, cAMP production, and GnRH secretion are mediated by the dose-dependent activation of ERalpha and ERbeta expressed in hypothalamic GnRH neurons.

Association of abnormal ovarian reserve parameters with a higher incidence of aneuploid blastocysts.

OBJECTIVE: To estimate the relationship between hormonal parameters of diminished ovarian reserve and the incidence of aneuploid blastocysts. METHODS: This prospective cohort trial was performed in a private in vitro fertilization clinic. Three hundred seventy-two patients underwent in vitro fertilization with blastocyst biopsy and aneuploidy screening of all 23 chromosome pairs. Patients were divided into groups based on baseline hormonal ovarian reserve. Group 1 included normal ovarian reserve (n=279) and group 2 included diminished ovarian reserve with day 2 or 3 follicle-stimulating hormone (FSH) more than 10 milli-international units/mL, antimüllerian hormone 1 ng/mL or less (n=93), or both. Patients with diminished ovarian reserves were further subdivided into three groups. Group A included FSH more than 10 milli-international units and antimüllerian hormone 1 ng/mL or less (n=25); group B included FSH more than 10 milli-international units/mL and antimüllerian hormone more than 1 ng/mL (n=34); and group C included antimüllerian hormone 1 ng/mL or less and day 3 FSH less than 10 milli-international units/L (n=34). RESULTS: Group 2 (diminished ovarian reserve) had a higher percentage of aneuploid blastocysts (66% compared with 51.7%; P<.05) and all aneuploid blastocyst cycles (35.1% compared with 14.3%; P<.001) than group 1 (normal ovarian reserve). However, implantation rates after transfer of euploid blastocysts were similar (69% compared with 61.7%; not significant). The highest percentage of aneuploid blastocysts among diminished ovarian reserve patients was in group A (abnormal FSH and antimüllerian hormone) compared with groups B and C (77.2% compared with 58.5% compared with 58.8%; P<.05). Implantation rates also were no different among the diminished ovarian reserve subgroups (68% compared with 71% compared with 66.7%; not significant). CONCLUSIONS: Infertility patients with hormonal evidence of diminished ovarian reserve have a significantly higher percentage of aneuploid blastocysts. The combination of abnormal serum FSH and antimüllerian hormone correlated with the greatest rate of embryonic aneuploidy. Regardless of ovarian reserve parameters, transfer of euploid blastocysts resulted in equivalent implantation potential. LEVEL OF EVIDENCE: II

Does methotrexate administration for ectopic pregnancy after in vitro fertilization impact ovarian reserve or ovarian responsiveness

OBJECTIVE To evaluate the effects of methotrexate (MTX) on the future fertility of women undergoing IVF by comparing ovarian reserve and ovarian responsiveness in the IVF cycle before and after an ectopic pregnancy (EP) treated with MTX. DESIGN Retrospective cohort study. SETTING Private reproductive endocrinology and infertility practice. PATIENT(S) Sixty-six women undergoing IVF before and after receiving MTX for an EP. INTERVENTION(S) Methotrexate administration and ovarian stimulation. MAIN OUTCOME MEASURE(S) Markers of ovarian reserve (day 3 FSH, antral follicle count), measures of ovarian responsiveness (duration of stimulation, peak E2 level, total dose of gonadotropins, number of oocytes retrieved, fertilization rate), and time from MTX administration to subsequent IVF cycle. RESULT(S) There were no differences after MTX administration in body mass index (BMI), FSH, or antral follicle count. A greater dose of gonadotropins was used in the cycle after MTX, but there were no differences in numbers of oocytes retrieved or high quality embryos transferred. As expected, there was a slight increase in age in the subsequent IVF cycle. The pregnancy rates (PR) were comparable to the average PRs within the practice when combining all age groups. CONCLUSION(S) Methotrexate remains the first line of therapy for medical management of asymptomatic EP and does not compromise ovarian reserve, ovarian responsiveness, or IVF success in subsequent cycles.

Does endometrial integrin expression in endometriosis patients predict enhanced in vitro fertilization cycle outcomes after prolonged GnRH agonist therapy

OBJECTIVE To determine whether endometrial expression of the integrin alpha(v)beta(3) vitronectin can predict which endometriosis patient subgroup will benefit from pre-IVF cycle prolonged GnRH agonist (GnRHa) therapy. DESIGN Prospective randomized institutional review board approved pilot trial. SETTING Private assisted reproductive technology program. PATIENT(S) IVF candidates with regular menses, surgically confirmed endometriosis, and normal ovarian reserve. INTERVENTION(S) All patients underwent endometrial biopsy 9 to 11 days post-LH surge to evaluate alpha(v)beta(3) integrin expression. Patients were randomized either to receive depot leuprolide acetate 3.75 mg every 28 days for three doses before controlled ovarian hyperstimulation (COH) or to proceed directly to COH and IVF. Group 1: integrin-positive controls (N = 12); group 2: integrin-positive administered prolonged GnRHa (N = 8). Group A: integrin-negative controls (N = 7); group B: integrin-negative administered prolonged GnRHa (N = 9). MAIN OUTCOME MEASURE(S) COH responses, ongoing pregnancy and implantation rates. RESULTS There were no significant effects of GnRH agonist treatment in either of the integrin expression strata regarding ongoing pregnancy or implantation rates, although these outcomes were more frequent in group 2 vs. 1 (62.5% vs. 41.6% and 35% vs. 20.6%, respectively). This effect may have because of limited sample size. The value of a negative integrin biopsy in predicting an ongoing pregnancy after prolonged GnRH agonist therapy was only 44.4%. CONCLUSION(S) Endometrial alpha(v)beta(3) integrin expression did not predict which endometriosis patients would benefit from prolonged GnRHa therapy before IVF.

GnRH agonist administration prior to embryo transfer in freeze-all cycles of patients with endometriosis or aberrant endometrial integrin expression

Prolonged gonadotrophin-releasing hormone agonist (GnRHa) administration before IVF with fresh embryo transfer to patients with endometriosis or aberrant endometrial integrin expression (-integrin) improves outcomes but may suppress ovarian response and prevents elective cryopreservation of all embryos. This retrospective cohort pilot study evaluates freeze-all cycles with subsequent prolonged GnRHa before embryo transfer in these populations. Patients from 2010 to 2015 who met inclusion criteria and received a long-acting GnRHa every 28 days twice before FET were evaluated. A subset underwent comprehensive chromosomal screening (CCS) after trophectoderm biopsy. Three groups were identified: Group 1: + CCS, +endometriosis (20 patients, 20 transfers); Group 2: +CCS, -integrin (12 patients, 13 transfers); Group 3: no CCS, +endometriosis or -integrin (10 patients, 12 transfers); Group 4: all transfers after CCS for descriptive comparison only (n = 2809). Baseline characteristics were similar among Groups 1-3 except that the mean surgery to oocyte aspiration interval was longer for Group 1 than Group 3. Implantation and ongoing pregnancy rates were statistically similar among the three groups and compared favourably to Group 4. A non-significant trend towards improved outcomes was noted in Group 1. Prolonged GnRHa after freeze-all in these patients avoids excessive ovarian suppression and results in excellent outcomes.

Ultrasound-Guided Embryo Transfer

The complexity of in vitro fertilization is culminated in the embryo transfer. Failure to achieve a successful transfer can negate the effort of the entire process. Any method to facilitate an easier transfer with higher pregnancy rates is considered a necessary step. Ultrasound-guided embryo transfer has become integrated in most IVF centers because of its ease of use, reassurance of proper embryo placement, and improved pregnancy rates.