Robert R. Greb

Male smokers have a decreased success rate for in vitro fertilization and intracytoplasmic sperm injection

OBJECTIVE Smoking by one or both partners can adversely affect IVF outcome. We investigated whether smoking may also play a role in the success rate of intracytoplasmic sperm injection (ICSI), in which initial steps of fertilization are bypassed. DESIGN Three hundred one couples (ICSI: 153, IVF: 148) participated in 415 treatment cycles (ICSI: 202, IVF: 213). One hundred thirty-nine men were habitual smokers (ICSI: 71, IVF: 68). Seventy-seven women were smokers (ICSI: 41, IVF: 36). Multiple nominal regression analyses of various steps of assisted reproduction included smoking status, age, semen parameters, and number of embryos transferred. SETTINGS Reproductive and andrology unit of the university. PATIENT(S) Three hundred one couples seeking fertility treatment. INTERVENTION(S) Assisted reproduction by in vitro fertilization (IVF) or ICSI. MAIN OUTCOME MEASURE(S) Clinical pregnancy. RESULT(S) Intracytoplasmic sperm injection success (clinical pregnancy) in women with smoking male partners was 22% and was 38% with nonsmoking partners. Similar results were seen for IVF, with 18% vs. 32%. Multinominal logistic regression analysis revealed smoking in men to be a significant predictor of ICSI outcome, along with female age and the number of embryos transferred, whereas clinical pregnancies after IVF were dependent on smoking in men, number of embryos transferred, sperm motility, and female age. Female smoking influenced the number of oocytes retrieved and the fertilization rate of oocytes in IVF but not in ICSI. The odds ratio for failure of ICSI for male smokers in comparison to male nonsmokers was 2.95 (IVF: 2.65). CONCLUSION(S) Smoking by males decreases the success rates of assisted reproduction procedures, not only in IVF, but also in ICSI. Apart from putative adverse effects during fertilization, altered DNA in spermatozoa might hamper development of the embryo.

Analysis of cyclooxygenase-2 expression in human breast cancer: high throughput tissue microarray analysis

PurposeThe objective of this study was to evaluate breast carcinomas for the expression of cyclooxygenase-2 (Cox-2) using a tissue microarray (TMA) and to determine its clinical and prognostic relevance.MethodsWe analyzed Cox-2 expression in 600 samples from 200 breast carcinomas immunohistochemically performing TMA technology and semiquantitative analysis. Results were correlated with various clinicopathological variables and follow-up data. Expression of estrogen receptor, progesterone receptor, Ki-67, and Her-2/neu-oncogene was analyzed and correlated with Cox-2 status.ResultsWe observed a moderate or strong cytoplasmic staining for Cox-2 in 78 (40.6%) of breast carcinomas. Increased Cox-2 expression corresponded to higher pT stage (P=0.038), amplification of Her-2/neu (P=0.032), lymphovascular invasion (P=0.006), a high MIB-1 labeling index (LI) (P<0.001), and histological grading (P=0.013). We also observed an inverse relationship between strong Cox-2 expression and estrogen and progesterone receptor content of tumors (P=0.037 and P=0.010). However, we could not demonstrate a significant association between Cox-2 staining and overall survival or disease free survival time.ConclusionsThese results suggest that Cox-2 expression is significantly associated with less differentiated and more aggressive breast carcinomas and might therefore be a useful prognostic indicator as well as a target for therapy.

Clinical use of GnRH analogues

GnRH agonists were initially designed to provide agents with more potent stimulatory action than native GnRH. Their prolonged administration, however, results in a brief period of increased gonadotrophin synthesis and release, followed by a more prolonged decrease of pituitary hormone secretion. This paradoxical action, known as desensitization, has turned out to be clinically useful in the treatment of several sex hormonedependent conditions. More recently, GnRH antagonists inducing immediate reduction of gonadotrophin levels have been introduced in clinical practice. GnRH analogues may be applied for the treatment of various disorders to prevent the hormonedependent development or progression of benign conditions (e.g. uterine fibroids, menorrhagia, endometriosis and central precocious puberty) or malignant tumours (breast, ovarian, endometrial and prostate carcinoma). In addition, the inhibitory effect on hypophysial gonadotrophin secretion was broadly introduced in controlled ovarian hyperstimulation (COH) regimens for assisted reproductive techniques (ARTs). Oestrogen withdrawal symptoms and costs, however, can limit their long-term use. In this review we describe the spectrum of use of modern synthetic GnRH analogues in benign and malignant gynaecological disorders.

Follicular Fluid High Density Lipoprotein-associated Sphingosine 1-Phosphate Is a Novel Mediator of Ovarian Angiogenesis

Angiogenesis plays an important role in the development of the ovarian follicle and its subsequent transition into the corpus luteum. Accordingly, follicular fluid is a rich source of mitogenic and angiogenic factors such as basic fibroblast growth factor and vascular endothelial growth factor secreted by granulosa cells. In the present study, we show that follicular fluid deprived of basic fibroblast growth factor or vascular endothelial growth factor by means of thermal denaturation or antibody neutralization retains its capacity to stimulate endothelial proliferation and angiogenesis. Mass spectrometric analysis of chromatographic fractions stimulating endothelial growth obtained from follicular fluid revealed that the heat-stable mitogenic activity is identical with the subfraction α of high density lipoproteins purified from follicular fluid (FF-HDL). Further investigations demonstrated that sphingosine 1-phosphate (S1P), one of the lysophospholipids associated with HDL, accounts for the capacity of this lipoprotein to stimulate endothelial growth and the formation of new vessels. Activation of mitogen-activated protein kinase (p42/44ERK1/2), protein kinase C, and protein kinase Akt represent signaling pathways utilized by FF-HDL and S1P to induce endothelial proliferation and angiogenesis. We conclude that FF-HDL represents a novel mitogenic and angiogenic factor present in follicular fluid and that S1P is one of the FF-HDL lipid components accounting for this activity.

Pharmacogenetics in ovarian stimulation – current concepts and future options

Tailoring ovarian stimulation to the individual patient can be challenging because the ovarian response varies substantially between patients. Pharmacogenetics has emerged as a new area of research to improve the balance between desired and undesired actions of drugs, based upon the genetic predisposition of the individual patient. Clinical studies have demonstrated that the p.N680S polymorphism of the FSH-receptor gene determines the ovarian response to FSH stimulation in patients undergoing IVF. In homozygous Ser(680)/Ser(680) type women, the FSH receptor appears to be more resistant to FSH action even in normal menstrual cycles. Therefore, genotyping of patients scheduled for ovarian stimulation could be an attractive tool to individualize FSH dosing according to genetic differences in ovarian sensitivity. More clinical studies are warranted to investigate the usefulness of genotyping for the p.N680S polymorphism as a routine diagnostic test before ovarian stimulation.

A prospective randomized placebo-controlled study of the effect of acupuncture in infertile patients with severe oligoasthenozoospermia

In this first prospective, randomized, single-blind, placebo-controlled study, 28 infertile patients with severe oligoasthenozoospermia received acupuncture according to the principles of traditional Chinese medicine (TCM) and 29 infertile patients received placebo acupuncture. A significantly higher percentage of motile sperm (World Health Organization categories A-C), but no effect on sperm concentration, was found after acupuncture compared with placebo acupuncture.

Lipoprotein (a) and other prothrombotic risk factors in Caucasian women with unexplained recurrent miscarriage Results of a multicentre case-control study

From 1998 to 2003, 133 Caucasian women aged 17-40 years (median 29 years) suffering from unexplained recurrent miscarriage (uRM) were consecutively enrolled. In patients and 133 age-matched healthy controls prothrombotic risk factors (factor V (FV) G1691A, factor II (FII) G20210A, MTHFR T677T, 4G/5G plasminogen activator inhibitor (PAI)-1, lipoprotein (Lp) (a), protein C (PC), protein S (PS), antithrombin (AT), antiphospholipid/anticardiolipin (APA/ACA) antibodies) as well as associated environmental conditions (smoking and obesity) were investigated. 70 (52.6%) of the patients had at least one prothrombotic risk factor compared with 26 control women (19.5%; p<0.0001). Body mass index (BMI; p=0.78) and smoking habits (p=0.44) did not differ significantly between the groups investigated. Upon univariate analysis the heterozygous FV mutation, Lp(a) > 30 mg/dL, increased APA/ACA and BMI > 25 kg/m(2) in combination with a prothrombotic risk factor were found to be significantly associated with uRM. In multivariate analysis, increased Lp(a) (odds ratio (OR): 4.7/95% confidence interval (CI): 2.0-10.7), the FV mutation (OR:3.8/CI:1.4-10.7), and increased APA/ACA (OR: 4.5/CI: 1.1-17.7) had independent associations with uRM.

Enhanced oestradiol secretion briefly after embryo transfer in conception cycles from IVF.

The hypothesis was tested that conception cycles (CC) resulting from IVF can be distinguished from non-conception cycles (NC) by differences in corpora lutea function that are detectable at the earliest stage of embryo implantation. Luteal oestradiol secretion was analysed retrospectively in 409 ovarian stimulation cycles of 296 patients from the day of embryo transfer until 14 days after embryo transfer (ET+14) in IVF/intracytoplasmic sperm injection (ICSI) cycles. Human chorionic gonadotrophin (HCG) was administered in 330 of 409 cycles in addition to vaginal progesterone in all cycles. Differences in serum oestradiol concentrations between CC and NC increased from day ET+1 onward and became statistically significant on days ET+4 through ET+14, with higher oestradiol concentrations in CC compared with NC. Even though exogenous HCG administration prevented the fall in luteal oestradiol concentrations after ET+4 both in CC and NC, increasing differences in oestradiol concentrations between CC and NC after embryo transfer were observed in both groups of HCG-supplemented and non-supplemented cycles. It is concluded that luteal oestradiol secretion is affected at the earliest stage of embryo implantation. The putative early signal to the corpus luteum associated with embryo attachment and early implantation appears to be superimposed onto the effect of exogenous luteal HCG administration and is clearly distinguishable as early as 4 days after embryo transfer in conception cycles.

Serum estradiol and progesterone in the mid-luteal phase predict clinical pregnancy outcome in IVF/ICSI cycles

Abstract In this prospective study, we tested the hypothesis if E2 and P serum levels significantly differ during the luteal phase following in vitro-fertilization/intracytoplasmic sperm injection (IVF/ICSI) therapy in conception (CC) versus non-conception (NC) cycles, and their potential in the prediction of pregnancy at the earliest point in time. Serum was sampled from the day of embryo transfer (ET) and throughout the luteal phase until ET + 14 from patients consecutively enrolling for IVF/ICSI therapy. The luteal phase was supported by vaginal P suppositories only, clinical pregnancies were detected by ultrasound and followed up until the 20th week. Overall pregnancy rate was 30.9% constituting the two study groups of CC (n = 22) and NC cycles (n = 49). Significantly, higher E2 (3326 ± 804 versus 1072 ± 233 pmol/l, p = 0.014) and P (244 ± 68 versus 73 ± 10 nmol/l, p = 0.023) were present in CC versus NC from as early as ET + 7. In the CC group, patients with ongoing pregnancies (CC-OG) as compared with miscarriages (CC-MC) had significantly higher E2 and P from ET + 7, predicting ongoing pregnancy in receiver operator characteristics analysis.

Molecular mechanisms contributing to the pathogenesis of endometriosis.

Endometriosis was first described by Rokitansky in 1860, yet it remains an enigmatic disease. Endometriosis is a common but complex gynecological syndrome of unknown pathogenesis that affects 5–15% of women of reproductive age. It is commonly accompanied by debilitating symptoms of dysmenorrhea, pelvic pain and reduced fertility. The natural history of endometriosis is poorly understood. Although it is widely believed to be a progressive disease, the data are fraught with problems. Risk factors or facilitating factors for the disease are not well understood. Nevertheless, in the last 5 years there has been an explosion of knowledge in clinical and basic science. Multiple theories of the histogenesis of endometriosis exist, of which the implantation hypothesis established by Sampson is the most widely accepted one (Figures 1 and 2). Retrograde menstruation and intraperitoneal spillage of viable endometrial cells occur frequently in menstruating women, and müllerian tract outflow obstruction is associated with an increased prevalence of endometriosis. Because retrograde menstruation is seen in almost all cycling women, endometriosis is postulated to develop as a result of the coexistence of a defect in the clearance of the menstrual efflux from pelvic peritoneal surfaces, possibly involving the immune system. There is still an ongoing debate as to whether endometriosis might also be established by hormone-dependent transformation of peritoneum to müllerian-type epithelium – the metaplasia theory. Environmental factors and patterns of inheritance may also contribute to the establishment and course of this disease. Alternatively, intrinsic molecular aberrations in pelvic endometriotic implants were proposed to contribute to the development and maintenance of endometriosis. In this article, aspects of the molecular mechanisms of the pathogenesis of endometriosis, which might become a therapeutic target in the future, are reviewed.