Manejo del Síndrome de Hiperestimulación Ovárica / Management of Ovarian Hyperstimulation Syndrome

INTRODUCCIÓN: El síndrome de hiperestimulación ovárica es una respuesta exagerada del ovario a los tratamientos hormonales para estimular la formación de óvulos. OBJETIVO: Describir el caso clínico de una mujer con síndrome de hiperestimulación ovárica; revisar el abordaje, manejo, tratamiento y cómo prevenirlo. CASO CLÍNICO: Paciente femenina de 37 años, multigesta, en tratamiento con metformina por Síndrome de ovario poliquístico , que presenta infertilidad secundaria a factor tubárico, que desarrolló un cuadro moderado de síndrome de hiperestimulación ovárica como consecuencia de la aplicación de las técnicas de fertilización in vitro (Folitropina alfa humana recombinante (GONAL-F®) y Cetrolerelix (CETROTIDE®); al cuarto día del procedimiento de aspiración folicular presenta dolor pélvico intenso, disuria, deposiciones diarreicas, ecografía abdominal y vaginal evidencia líquido libre en cavidad alrededor de 1000cc, además de ovarios tanto derecho e izquierdo con volumen de 102 mL y 189 mL respectivamente. Paciente es ingresada para realizar tratamiento hidratación parenteral, Enoxaparina 40mg subcutánea, Cabergolina 0.5mg vía oral, alta a las 72 horas. DISCUSIÓN: Las claves para la prevención del síndrome de hiperestimulación ovárica son la experiencia con la terapia de inducción de la ovulación y el reconocimiento de los factores de riesgo para el síndrome de hiperestimulación ovárica. Los regímenes de inducción de la ovulación deberían ser altamente individualizados, monitorizados cuidadosamente y usando dosis y duración mínimas del tratamiento con gonadotropinas para conseguir la meta terapéutica. CONCLUSIONES: El síndrome de hiperestimulación ovárica constituye la complicación más temida durante el uso de inductores de la ovulación; el conocimiento de factores de riesgo, puede prevenir o evitar que llegue a ser de un caso severo, lo cual puede causar mayor morbilidad o hasta mortalidad. La vitrificación se convierte en la técnica que permite prevenir el síndrome de hiperestimulación ovárica, junto con esta técnica hay 2 alternativas: la inducción con análogo de la hormona liberadora de gonadotropina o el uso de agonistas dopaminérgicos.

INTRODUCTION: Ovarian hyperstimulation syndrome is an exaggerated response of the ovary to hormonal treatments to stimulate egg formation. OBJECTIVE: To describe the clinical case of a woman with ovarian hyperstimulation syndrome; to review the approach, management, treatment and how to prevent it. CLINICAL CASE: 37-year-old female patient, multigestation, under treatment with metformin for polycystic ovary syndrome, presenting infertility secondary to tubal factor, who developed a moderate picture of ovarian hyperstimulation syndrome as a consequence of the application of in vitro fertilization techniques (recombinant human follitropin alfa (GONAL-F®) and Cetrolerelix (CETROTIDE®); On the fourth day of the follicular aspiration procedure she presents intense pelvic pain, dysuria, diarrheic stools, abdominal and vaginal ultrasound shows free fluid in the cavity of about 1000cc, in addition to right and left ovaries with a volume of 102 mL and 189 mL respectively. Patient was admitted for parenteral hydration treatment, Enoxaparin 40mg subcutaneous, Cabergoline 0.5mg orally, discharged after 72 hours. DISCUSSION: The keys to prevention of ovarian hyperstimulation syndrome are experience with ovulation induction therapy and recognition of risk factors for ovarian hyperstimulation syndrome. Ovulation induction regimens should be highly individualized, carefully monitored, and using minimal doses and duration of gonadotropin therapy to achieve the therapeutic goal. CONCLUSIONS: Ovarian hyperstimulation syndrome constitutes the most feared complication during the use of ovulation inducers; knowledge of risk factors, may prevent or avoid it from becoming a severe case, which may cause increased morbidity or even mortality. Vitrification becomes the technique that allows preventing ovarian hyperstimulation syndrome, along with this technique there are 2 alternatives: induction with gonadotropin-releasing hormone analog or the use of dopaminergic agonists.

Effect of follicular size on clinical outcomes of frozen-thawed embryo transfer induced by hCG on ovulation in natural cycles / 中华妇产科杂志

Objective:To investigate the effect of follicular size on the clinical outcomes of frozen-thawed embryo transfer induced by human chorionic gonadotropin (hCG) of natural cycles on ovulation.Methods:Clinical data of 427 cycles of frozen-thawed single blastocyst transfer in Nanjing Drum Tower Hospital from January 2016 to December 2019 were retrospectively analyzed. The patients were divided into 15-16 mm group (15≤diameter≤16 mm, n=66), 16-17 mm group (16<diameter≤17 mm, n=101), 17-18 mm group (17<diameter≤18 mm, n=125), 18-20 mm group (18<diameter≤20 mm, n=109),>20 mm group (diameter>20 mm, n=26), according to the maximum follicle diameter on the induction day of hCG ovulation induction. The estradiol and luteinizing hormone (LH) levels, and clinical pregnancy rate, abortion rate and live birth rate were compared in five groups. Results:There were statistically significant differences in estradiol and LH levels among the five groups on the day of hCG induction (all P<0.05). Estradiol levels in 15-16 mm group to >20 mm group gradually increased on the day of hCG induction, and estradiol level in 15-16 mm group was significantly lower than those in 17-18 mm group, 18-20 mm group and >20 mm group (median: 1 002.3 vs 1 103.3 vs 1 171.2 vs 1 539.0 pmol/L), with statistical significances ( P=0.034, P<0.001, P=0.002). On the day of hCG induction, LH levels in 15-16 mm group to >20 mm group showed a decreasing trend, and LH level in 15-16 mm group was significantly higher than those in 17-18 mm group and >20 mm group (median: 37.73 vs 28.24 vs 24.11 U/L), with statistically significant differences ( P=0.007, P=0.006). There were no significant differences in clinical pregnancy rate, abortion rate and live birth rate in 15-16 mm group to >20 mm group (all P>0.05). Conclusion:In the natural cycle protocol of hCG induced ovulation, the small follicle group could achieve similar clinical outcomes compared with normal sized follicles in the single blastocyst transfer of frozen-thawed embryos.

Estrategias para mejorar los resultados reproductivos tras síndrome del folículo vacío: a propósito de un caso clínico

El síndrome del folículo vacío (SFV) es el fracaso total para recuperar los ovocitos después de la estimulación ovárica, a pesar de un desarrollo folicular aparentemente normal y una esteroidogénesis folicular adecuada. Se han descrito dos variantes de SFV: la forma genuina, que ocurre en presencia de niveles adecuados de hCGβ circulante o de LH en el momento de la aspiración de ovocitos, y la forma 'falsa', que se asocia a niveles séricos de hCG/LH por debajo de un umbral crítico. En nuestra paciente, tras un protocolo aceptado de estimulación ovárica con gonadotropina menopáusica humana y folitropina alfa y posterior maduración folicular con coriogonadotropina alfa no se obtuvieron cúmulos ovocitarios en la punción ecoguiada, con lo que se trató de emplear otras estrategias encaminadas a corregir esta situación. El tratamiento y el pronóstico de estas pacientes aún no se conocen bien. Se necesitan grandes estudios multicéntricos y revisiones sistemáticas para aumentar la comprensión del SFV y así, su manejo, diseñando mejores estrategias como tratamos de hacer con nuestra paciente con el empleo de doble descarga para maduración ovocitaria.

Empty follicle syndrome (EFS) is the complete failure to retrieve oocytes after ovarian stimulation, despite apparently normal follicular development and adequate follicular steroidogenesis. Two variants of EFS have been described: the genuine form, which occurs in the presence of adequate circulating βhCG or LH levels at the time of oocyte aspiration, and the 'false' form, which is associated with serum hCG/ LH levels below a critical threshold. In our patient, after an accepted protocol of ovarian stimulation with human menopausal gonadotropin and follitropin alfa and subsequent follicular maturation with choriogonadotropin alfa, no oocyte clusters were obtained in the ultrasound-guided puncture, so an attempt was made to use other strategies aimed at correcting this situation. The treatment and prognosis of these patients are still poorly understood. Large multicenter studies and systematic reviews are needed to increase understanding of EFS and thus its management, designing better strategies as we tried to do with our patient with the use of double discharge for oocyte maturation.

Ultrastructural and enzymatic alterations in the ovary of Rhodnius prolixus infected with Trypanosoma rangeli

Objective: To investigate the morphological structure of ovarian follicular cells and biochemical parameters of both ovaries and fat bodies (sites of vitellogenesis) from Rhodnius (R.) prolixus infected with Trypanosoma (T.) rangeli. Methods: Adult virgin females of R. prolixus were fed upon a membrane apparatus containing heat-inactivated citrated rabbit blood and a suspension of T. rangeli epimastigotes (Macias strain). Females from the control group and all the males received parasitefree blood. Transmission electron microscopy was used to reveal the morphological aspects of ovarian follicle cells in both control and parasite-infected groups. Protein profile, proteolytic activities and Western blotting analyses were performed in either ovary or fat body samples of control and parasite-infected groups. Results: According to the ultrastructural data, T. rangeli infection elicited a degeneration process in the ovarian follicular cells of R. prolixus. Proteolytic assays indicated a reduction in the activity of aspartic peptidases in the ovary and fat body from parasite-infected group, while a significant increase in the cysteine peptidase activity was measured in both insect organs. Additionally, immunoblotting revealed that vitellogenin was overexpressed in the ovary of parasite-infected insects. Conclusions: T. rangeli infection seems to elicit an early programmed cell death in the ovarian follicle cells as well as induces the modulation on the activities of different peptidase classes in either ovaries or fat bodies and the overexpression of the vitellogenin in the ovary of R. prolixus.

Morphology and Biochemistry of Ovulation Morfologia e bioquímica da ovulação

Abstract The process of ovulation involves multiple and iterrelated genetic, biochemical, and morphological events: cessation of the proliferation of granulosa cells, resumption of oocyte meiosis, expansion of cumulus cell-oocyte complexes, digestion of the follicle wall, and extrusion of the metaphase-II oocyte. The present narrative review examines these interrelated steps in detail. The combined or isolated roles of the folliclestimulating hormone (FSH) and luteinizing hormone (LH) are highlighted. Genes indiced by the FSH genes are relevant in the cumulus expansion, and LH-induced genes are critical for the resumption ofmeiosis and digestion of the follicle wall. A nonhuman model for follicle-wall digestion and oocyte release was provided.

Resumo O processo de ovulação envolve modificações genéticas, bioquímicas e morfológicas múltiplas e interrelacionadas: suspensão da proliferação das células da granulosa, reinício da meiose do oócito, expansão das células do complexo cumulus-oócito, digestão da parede folicular, e extrusão do oócito. Esta revisão narrativa examina em detalhes cada um desses eventos e os principais genes e proteínas envolvidos. Mais importante, a ação combinada ou isolada do hormônio folículo-estimulante (HFE) e do hormônio luteinizante (HL) é destacada. Detalha-se o papel do HFE na expansão do cumulus e do HL na digestão da parede folicular, permitindo a extrusão do oócito na superfície ovariana. Proveu-se um modelo não humano para explicar a digestão da parede folicular.

Primordial follicle activation as new treatment for primary ovarian insufficiency / 대한생식의학회지

Primordial follicle activation is a process in which individual primordial follicles leave their dormant state and enter a growth phase. While existing hormone stimulation strategies targeted the growing follicles, the remaining dormant primordial follicles were ruled out from clinical use. Recently, in vitro activation (IVA), which is a method for controlling primordial follicle activation, has provided an innovative technology for primary ovarian insufficiency (POI) patients. IVA was developed based on Hippo signaling and phosphatase and tensin homolog (PTEN)/phosphatidylinositol-3-kinase (PI3K)/protein kinase B (AKT)/forkhead box O3 (FOXO3) signaling modulation. With this method, dormant primordial follicles are activated to enter growth phase and developed into competent oocytes. IVA has been successfully applied in POI patients who only have a few remaining remnant primordial follicles in the ovary, and healthy pregnancies and deliveries have been reported. IVA may also provide a promising option for fertility preservation in cancer patients and prepubertal girls whose fertility preservation choices are limited to tissue cryopreservation. Here, we review the basic mechanisms, translational studies, and current clinical results for IVA. Limitations and further study requirements that could potentially optimize IVA for future use will also be discussed.

Differential gene expression analysis of human cumulus cells / 대한생식의학회지

OBJECTIVE: This study was performed to explore the possibility that each oocyte and its surrounding cumulus cells might have different genetic expression patterns that could affect human reproduction. METHODS: Differential gene expression analysis was performed for 10 clusters of cumulus cells obtained from 10 cumulus-oocyte complexes from 10 patients. Same procedures related to oocyte maturation, microinjection, and microarray analyses were performed for each group of cumulus cells. Two differential gene expression analyses were performed: one for the outcome of clinical pregnancy and one for the outcome of live birth. RESULTS: Significant genes resulting from these analyses were selected and the top 20 affected pathways in each group were analyzed. Circadian entrainment is determined to be the most affected pathway for clinical pregnancy, and proteoglycans in cancer pathway is the most affected pathway for live birth. Circadian entrainment is also amongst the 12 pathways that are found to be in top 20 affected pathways for both outcomes, and has both lowest p-value and highest number of times found count. CONCLUSION: Although further confirmatory studies are necessary, findings of this study suggest that these pathways, especially circadian entrainment in cumulus cells, may be essential for embryo development and pregnancy.

Consequences of chemotherapeutic agents on primordial follicles and future clinical applications

The ovarian reserve is necessary for female fertility and endocrine health. Commonly used cancer therapies diminish the ovarian reserve, thus, resulting in primary ovarian insufficiency, which clinically presents as infertility and endocrine dysfunction. Prepubertal children who have undergone cancer therapies often experience delayed puberty or cannot initiate puberty and require endocrine support to maintain a normal life. Thus, developing an effective intervention to prevent loss of the ovarian reserve is an unmet need for these cancer patients. The selection of adjuvant therapies to protect the ovarian reserve against cancer therapies underlies the mechanism of loss of primordial follicles (PFs). Several theories have been proposed to explain the loss of PFs. The “burn out” theory postulates that chemotherapeutic agents activate dormant PFs through an activation pathway. Another theory posits that chemotherapeutic agents destroy PFs through an “apoptotic pathway” due to high sensitivity to DNA damage. However, the mechanisms causing loss of the ovarian reserve remains largely speculative. Here, we review current literature in this area and consider the mechanisms of how gonadotoxic therapies deplete PFs in the ovarian reserve.

Effects of high-fat diet exposure on glucolipid metabolism and ovarian function in offspring of female rats / 中国医师杂志

Objective@#To explore the effects of high-fat diet exposure on glucolipid metabolism and ovarian function in offspring of female Sprague Dawley rats.@*Methods@#Female and male rats were mated in cages at a ratio of 2∶1. Pregnant mice were collected and randomly divided into normal feed group (control group) and high-fat and high-glucose feed group (observation group). Female offspring were selected as the research object. After the offspring entering the stage of sexual maturity, the blood was taken from abdominal aorta artery. The contents of serum related factors were determined by automatic biochemical analyzer and enzyme linked immunosorbent assay (ELISA) kit. Hematoxylin-eosin staining (HE) was used to directly observe the distribution and quantity of liver tissue and the quantity and structure of ovarian follicles.@*Results@#Compared with the normal control group, the body weight, blood glucose, blood lipids and fat coefficient in high-fat diet rats were significantly increased (P<0.05). The secretions of estradiol (E2), follicle stimulating hormone (FSH) and luteinizing hormone (LH) in the ovary were significantly reduced (P<0.05). HE slices showed that compared with the normal control group, there were fat vacuoles in the cytoplasm of hepatocytes, the increase of hepatocyte arrangement gap, the number of adipocytes and the diameter of fat droplets in the observation group. The quantities of primordial follicles and primary follicles in the ovary showed increasing trend in high-fat diet group, and the diameter of follicles was decreased.@*Conclusions@#High-fat and high glucose diet may cause abnormal glucolipid metabolism. It is speculated that high fat diet may cause ovary to be surrounded by fat through fat accumulation in the abdomen and buttocks of female offspring, which directly leads to dysfunction.

Effects of high-fat diet exposure on glucolipid metabolism and ovarian function in offspring of female rats / 中国医师杂志

Objective To explore the effects of high-fat diet exposure on glucolipid metabolism and ovarian function in offspring of female Sprague Dawley rats.Methods Female and male rats were mated in cages at a ratio of 2∶ 1.Pregnant mice were collected and randomly divided into normal feed group (control group) and high-fat and high-glucose feed group (observation group).Female offspring were selected as the research object.After the offspring entering the stage of sexual maturity,the blood was taken from abdominal aorta artery.The contents of serum related factors were determined by automatic biochemical analyzer and enzyme linked immunosorbent assay (ELISA) kit.Hematoxylin-eosin staining (HE) was used to directly observe the distribution and quantity of liver tissue and the quantity and structure of ovarian follicles.Results Compared with the normal control group,the body weight,blood glucose,blood lipids and fat coefficient in high-fat diet rats were significantly increased (P ＜ 0.05).The secretions of estradiol (E2),follicle stimulating hormone (FSH) and luteinizing hormone (LH) in the ovary were significantly reduced (P ＜ 0.05).HE slices showed that compared with the normal control group,there were fat vacuoles in the cytoplasm of hepatocytes,the increase of hepatocyte arrangement gap,the number of adipocytes and the diameter of fat droplets in the observation group.The quantities of primordial follicles and primary follicles in the ovary showed increasing trend in high-fat diet group,and the diameter of follicles was decreased.Condusions High-fat and high glucose diet may cause abnormal glucolipid metabolism.It is speculated that high fat diet may cause ovary to be surrounded by fat through fat accumulation in the abdomen and buttocks of female offspring,which directly leads to dysfunction.

Insulin effect during a Heatsynch protocol in dairy cows / Efeito da insulina durante um protocolo Heatsynch em vacas leiteiras

ABSTRACT: The objective of this study was to evaluate the effect of exogenous insulin administration on follicular growth, estrus presentation and conception rate during a protocol of ovulation synchronization. Dairy cows were subjected to the Heatsynch protocol, with the insertion of an intravaginal device containing 1.9 g of progesterone (CIDR) and an intramuscular injection containing 2.5 mg of GnRH on day 0. On day 7, the CIDR was removed and subjects were given 12.5 mg of dinoprost. Also on day 7, Insulin Group (IG, n = 21) animals received a subcutaneous injection containing 0.25 IU / kg of recombinant human insulin and the control group (CG, n = 25) received a 0.9% NaCl injection. On day 8, an injection of 0.5 mg of estradiol cypionate was administered to all cows. Animals were inseminated 12 hours after estrus presentation or at day 10 at fixed time. Follicular development was evaluated on days 7, 9, and 10 using transrectal ultrasonography, estrus presentation was observed between days 8 and 10, and conception rate was evaluated 30 days after AI. There were no differences in growth rate, follicular diameter, estrus presentation, and conception rate. Therefore, application of a single dose of insulin does not promoted an increase in follicular size, estrus presentation and conception rate in dairy cows.

RESUMO: O objetivo deste estudo foi avaliar o efeito da administração exógena de insulina sobre crescimento folicular, apresentação de cio e taxa de concepção durante um protocolo de sincronização da ovulação. As vacas holandês lactantes foram submetidas ao protocolo Heatsynch, com inserção do dispositivo intravaginal contendo 1,9 g de progesterona (CIDR) no dia 0 e uma injeção intramuscular de 2,5 mg de GnRH. No dia 7, o CIDR foi removido e foi aplicado 12,5 mg de dinoprost. Ainda no dia 7, os animais do Grupo Insulina (IG, n = 21) receberam uma injeção subcutânea de 0,25 UI / kg de insulina humana recombinante e o grupo controle (CG, n = 25) recebeu uma injeção de NaCl 0,9%. No dia 8 foi aplicado 0,5 mg de cipionato de estradiol em todas as vacas. Animais foram inseminados 12 horas após a apresentação de cio ou no dia 10 em tempo fixo. O desenvolvimento folicular foi avaliado nos dias 7, 9 e 10 por ultrassonografia transretal, a apresentação de cio foi observada entre os dias 8 e 10 e a taxa de prenhez/IA foi avaliada 30 dias após a IA. Não houve diferença quanto a taxa de crescimento e diâmetro folicular, apresentação de cio e taxa de concepção. A aplicação de uma dose única de insulina não promove o incremento no tamanho folicular, apresentação de cio e taxa de prenhez/IA em vacas de leite.

Effects of Zishen Yutai Pills on expression of Bcl-2 and Bax in rat model of diminished ovarian reserve / 重庆医学

Objective To investigate the effect of Zishen Yutai Pills on follicle apoptosis and related protein expression in diminished ovarian reserve(DOR) rat model induced by tripterygium glycosides.Methods Forty rats were divided into the control group,model group,progynova group,and Zishen Yutai Pills high and low dose groups,8 cases in each group.Tripterygium Wilfordii Glycosides Tablets were given by gavage for establishing the rat DOR model.Then the HE staining was used to detect the pathological morphology of rat ovary.All levels of follicles were counted.Expression levels of Bcl-2 and Bax protein in follicle and ovarian stroma of each group were detected by using the immunohistochemical method.Results Compared to the control group,the number of great and small follicles in the model control group was decreased,number of atretic follicles was increased,Bcl-2 expression in all kinds of follicles was decreased,and Bax expression was increased,the differences were statistically significant(P＜0.05).Compared to the model group,the number of great and small follicles in the Zishen Yutai Pills high and low dose groups and progynova group was increased,number of atretic follicles was decreased,the Bcl-2 expression in great and small follicles was significantly increased and the Bax expression was significantly decreased,the differences were statistically significant(P＜0.05).Conclusion Zishen Yutai Pills can inhibit the premature and too fast follicles apoptosis by upregulating the expression of Bcl-2 protein and down-regulating the expression of Bax protein,thus plays the effect for treating DOR.

Estudo da vascularização folicular e do corpo lúteo de éguas cíclicas tratadas com extrato de pituitária equina utilizando ultrassom Doppler colorido / Study of follicular and corpus luteum vascularization in mares treated with Equine Pituitary Extract using ultrasound color Doppler

Informações sobre a vascularização da parede folicular e do corpo lúteo equino, associadas à superovulação, são escassas. Com o objetivo de avaliar o efeito superovulatório do extrato de pituitária equina (EPE) no fluxo sanguíneo folicular e luteal, foram utilizadas seis éguas Puro Sangue Árabe, em dois ciclos estrais (controle e tratamento). As éguas foram monitoradas diariamente por ultrassonografia modo B, até que os folículos atingissem diâmetro de 23mm (desvio). No ciclo tratamento, as éguas receberam 8mg de EPE, uma vez ao dia, por via IM, até que dois ou mais folículos atingissem o diâmetro entre 32 e 35mm. A ovulação foi induzida com acetato de deslorelina, quando os folículos atingiram, no mínimo, 35mm. No momento do desvio folicular, da indução da ovulação e do último exame pré-ovulatório, foi utilizada a ultrassonografia modo B para medir o diâmetro dos folículos e, no oitavo dia pós-ovulação, para a área do corpo lúteo (CL). Utilizou-se também ultrassonografia com Doppler colorido para avaliar a perfusão sanguínea da parede folicular e do parênquima luteal. No ciclo controle, foi realizado o mesmo procedimento, exceto pelo uso do EPE. Os dados foram submetidos à análise de variância, com nível de significância de 5%. Não foi observado efeito do EPE sobre o número de ovulações, o diâmetro dos folículos, a vascularização da parede folicular e a concentração sérica de estrógeno. Os animais, tratados ou não, apresentaram CLs funcionais, não havendo diferença na área do parênquima ou da vascularização luteal, nem na concentração sérica de progesterona, no oitavo dia após a ovulação. Foi observado que o EPE proporcionou um maior número de folículos subordinados no momento da indução da ovulação do folículo dominante (P ≤ 0,05). Embora esses folículos não tenham chegado a ovular, concluiu-se que o EPE atuou no crescimento de folículos, que podem ser utilizados em outras biotécnicas, como a transferência de oócitos, com maior aproveitamento da reserva folicular de ovários equinos.(AU)

Knowledge about follicle and corpus luteum vascularization associated with superovulation in mares is scarce. Aiming to evaluate the effect of equine pituitary extract (EPE) on superovulation, the experiment was conducted using six mares Purebred Arabian in two estrous cycles (control and treatment). The mares were synchronized, and monitored daily by ultrasound B mode until the follicles reached diameter ≤ 23 mm (deviation). In the treatment cycle, from the deviation, mares received 8 mg of EPE, once a day, intramuscularly, until two or more follicles reached a diameter between 32 and 35 mm. Ovulation was induced with deslorelin acetate when follicles reached at least 35 mm. At the time of follicular deviation, induction of ovulation and final preovulatory exam, it was used B-mode ultrasound to measure the diameter of follicles and on the eighth day after ovulation to measure the area of the corpus luteum (CL); color Doppler was also used to assess blood perfusion of the follicle wall and luteal parenchyma. In the control cycle was performed the same procedure except for the use of EPE. Data were subjected to analysis of variance, with 5% significance level. There was no effect of EPE on ovulation number, diameter of follicles, vascularity of the follicular wall and serum estrogen concentration. The animals treated or not, showed functional CLs, with no difference in parenchymal area or luteal vascularization, or in serum progesterone concentration on the eighth day after ovulation. It was observed that the EPE provided a greater number of subordinate follicles at the time of induction of ovulation of the dominant follicle. Although these follicles have failed to ovulate, it was concluded that EPE influenced the follicles growth, and it can be used in other biotechnologies, with greater utilization of equine ovarian follicular reserve.(AU)

How polymorphic markers contribute to genetic diseases in different populations? The study of inhibin A for premature ovarian insufficiency / Como os marcadores polimórficos contribuem para as doenças genéticas em diferentes populações? O estudo da inibina A para insuficiência ovariana prematura

ABSTRACT Objective To verify the incidence of the G679A mutation in exon 2 of the gene inhibin alpha (INHA), in women with secondary amenorrhea and diagnosis of premature ovarian insufficiency, and in controls. Methods A 5mL sample of peripheral blood was collected from all study participants in an EDTA tube and was used for DNA extraction. For the patient group, 5mL of blood were also collected in a tube containing heparin for karyotype, and 5mL were collected in a dry tube for follicle stimulant hormone dosage. All patient and control samples were initially submitted to analysis of the G679A variant in exon 2 of the INHA gene by PCR-RFLP technique. Samples from patients with premature ovarian insufficiency after PCR-RFLP were submitted to Sanger sequencing of the encoding exons 2 and 3. Sequencing was performed on ABI 3500 GeneticAnalyzer equipment and the results were evaluated by SeqA and Variant Reporter software. Results Samples of 70 women with premature ovarian insufficiency and 97 fertile controls were evaluated. The G769A variant was found in only one patient in the Premature Ovarian Insufficiency Group and in no control, and it appears to be rare in Brazilian patients with premature ovarian insufficiency. This polymorphism was previously associated to premature ovarian insufficiency in several populations worldwide. Conclusion There is genetic heterogeneity regarding the INHA gene in different populations, and among the causes of premature ovarian insufficiency.

RESUMO Objetivo Verificar a incidência da mutação G679A no éxon 2 do gene da inibina alfa (INHA) em mulheres com amenorreia secundária e diagnóstico de insuficiência ovariana prematura e em controles. Métodos Uma amostra de 5mL de sangue periférico foi coletada de todos os participantes do estudo em tubo de EDTA e utilizada para a extração de DNA. Para o grupo de pacientes, foram coletados também 5mL de sangue em tubo contendo heparina para realização de cariótipo, e 5mL um tubo seco para dosagem de hormônio folículo-estimulante. As amostras de pacientes e controles foram inicialmente submetidas à análise da variante G679A no éxon 2 do gene INHA pela técnica de PCR-RFLP. As amostras de pacientes com insuficiência ovariana prematura após PCR-RFLP foram submetidas ao sequenciamento de Sanger dos éxons codantes 2 e 3. O sequenciamento foi realizado em equipamento ABI 3500 GeneticAnalyzer, e os resultados foram avaliados pelos programas SeqA and Variant Reporter. Resultados Foram avaliadas amostras de 70 mulheres com insuficiência ovariana prematura e de 97 controles férteis. A variante G769A foi encontrada em apenas uma paciente do Grupo Insuficiência Ovariana Prematura e em nenhum controle, e parece ser rara nas pacientes brasileiras com insuficiência ovariana prematura. Este polimorfismo foi previamente associado à insuficiência ovariana prematura em diversas populações no mundo. Conclusão O estudo evidenciou que há heterogeneidade genética quanto ao INHA em diferentes populações e entre as causas de insuficiência ovariana prematura.

Determinación de la reserva ovárica mediante el recuento de folículos antrales en mujeres en edad reproductiva / Association between antral follicle count and age in fertile women

Background: Age plays a crucial role in women fertility and is related with a decreased oocyte quality and quantity. The evidence for this asseveration comes from data obtained in infertile women. However there is a paucity of studies in patients with proven fertility evaluating ovarian reserve and its decline with time. Aim: To measure antral follicle count (AFC) in probed fertile patients and to create a distribution chart based on variables that may affect its natural decline. Material and Methods: Observational prospective study. A transvaginal ultrasound was made between menstrual cycle days 3 and 5, evaluating AFC in 100 patients, followed during a year. Results: Median antral follicle count media was 14.5 (interval 3 to 26). There was a lineal decline of AFC with age. Women with hypertension and type 2 diabetes mellitus had significantly less follicles. However, a multiple regression analysis showed that only women's age was a significant predictor of AFC (R2 = 0.84). Conclusions: There was a lineal relationship between AFC and age in women with probed fertility.

Clinical monitoring of serum sex hormones during normal menstrual follicle growth cycle / 中华检验医学杂志

Objective To study the changes of six sex hormones corresponding to the follicle growth during the normal menstrual cycle of Chinese women.Methods Thirty Chinese women with regular menstrual period and average age of (28.8±3.2) years were selected for the study by Peking Union Medical College Hospital in September,2010.Growth of follicles was monitored by using transvaginal sonography.Six sex hormones,including follicle-stimulating hormone (FSH),luteinizing hormone (LH),estradiol (E2),progesterone (P),testosterone (T),and prolactin (PRL) were measured by chemoluminescence immunoassay every day during a menstrual cycle.Nonparametric statistical analysis was used.ResultsMenstrual cycle of all the patients was in the range of 25 to 39 d,with mean of (29.5 ± 3.1) d.Length of follicular phase and luteal phase was 15.3 and 14.4 d,respectively.Number of days from antral follicle to emergence of dominant follicle,and from the latter to ovulation,was 6.2 and 8.9 d,respectively.Average diameter of preovulatory follicle was 19.33 mm.Both FSH and LH reached peak on the day before ovulation.P started to increase before ovulation and remained at a high plateau from 6th to 9th day after ovulation.Both PRL and T reached peak after ovulation,near the end of a menstrual cycle.Conclusions A small rise of LH and P emerges just 1 to 2 d before ovulation,indicating the maturing of follicle.PRL and T shows cyclic changes as follicle grows.Therefore,PRL and T levels should be measured in the early follicle phases in the clinical practice so that leading the impact of menstrual cycle minimal.

Evaluation of ovarian structures using computerized microtomography

ABSTRACT Visualization and clear understanding of the ovarian structures are important in determining the stage of oestrus, helping to diagnose several pathologies and supporting advances in reproductive technologies. In this research, computerized microtomography (microCT) was used to explore and characterize the ovarian structure of seven mammalian species. Ovaries of rats, female dog, queens, cows, mares, sows and a female donkey were used. After microCT scanning, the same samples were prepared for histologic evaluation, used here as a validation criterion. It was possible to distinguish regions of the cortex and medulla, visualize the morphology and distribution of blood vessels, clearly observe corpus luteum and antral follicles, and visualize oocytes inside some antral follicles. This is the first report using microCT to explore and compare ovarian structures in several domestic mammals. MicroCT revealed great potential for the evaluation of ovarian structures. This research open prospects for the use of computerized tomography (CT) as a non-invasive approach to studying ovarian structures in live animals, which may be especially attractive for scientific study of development of ovarian structures and/or ovarian pathologies in small animals' models.

The association of follicular fluid volume with human oolemma stretchability during intracytoplasmic sperm injection / 대한생식의학회지

OBJECTIVE: Oocyte degeneration often occurs after intracytoplasmic sperm injection (ICSI), and the risk factor is low-quality oocytes. The follicular fluid (FF) provides a crucial microenvironment for oocyte development. We investigated the relationships between the FF volume aspirated from individual follicles and oocyte retrieval, oocyte maturity, oolemma stretchability, fertilization, and development. METHODS: This retrospective study included data obtained from 229 ICSI cycles. Ovarian stimulation was performed according to a gonadotropin-releasing hormone antagonist protocol. Each follicle was individually aspirated and divided into six groups according to FF volume (<1.0, 1.0 to <2.0, 2.0 to <3.0, 3.0 to <4.0, 4.0 to <5.0, and ≥5.0 mL). Oolemma stretchability during ICSI was evaluated using a mechanical stimulus for oolemma penetration, that is, the stretchability was assessed by oolemma penetration with aspiration (high stretchability) or without aspiration (low stretchability). RESULTS: Oocyte retrieval rates were significantly lower in the <1.0 mL group than in the ≥1.0 mL groups (46.0% [86/187] vs. 67.5%–74.3% [172/255 to 124/167], respectively; p<0.01). Low oolemma stretchability was significantly more common in the <1.0 mL group than in the ≥1.0 mL groups during ICSI (22.0% [13/59] vs. 5.8%–9.4% [6/104 to 13/139], respectively; p=0.018). There was a relationship between FF volume and oolemma stretchability. However, there were no significant differences in the rates of fertilization, cleavage, ≥7 cells at day 3, and blastocyst development among all groups. CONCLUSION: FF volume is potentially associated with the stretchability of metaphase II oolemma during ICSI. Regarding oolemma stretchability, ensuring a uniform follicular size during ovarian stimulation is crucial to obtain good-quality oocytes.

Recuento de folículos antrales como predictor de la respuesta ovárica / Antral follicle counts as a predictor of ovarian response

Objetivo: Evaluar la relación entre el número de folículos antrales en condiciones basales y la cantidad de ovocitos recuperados luego del tratamiento de estimulación ovárica, y establecer el rol del recuento de folículos antrales mediante ecografía como predictor de la respuesta ovárica. Como propósito secundario, se examinó la correlación del recuento de folículos antrales con la edad de las pacientes y el éxito del tratamiento. Materiales y métodos: Entre enero y marzo de 2015 se estudió retrospectivamente a 40 candidatas a punción aspiración folicular, que se habían realizado una ecografía transvaginal con recuento de folículos antrales antes de la estimulación. Se tomaron en cuenta solo los folículos que medían entre 3 y 8 mm. Todas las pacientes recibieron estimulación hormonal y monitoreo ecográfico y hormonal en sangre hasta la punción aspiración de folículos. Resultados: Se observó una importante correlación inversa entre la edad de las pacientes y el recuento de los folículos antrales y una correlación inversa muy marcada entre la edad y la recuperación de ovocitos. También se constató una muy importante correlación positiva entre el recuento de folículos antrales y la cantidad de ovocitos recuperados en la aspiración transvaginal. El número reducido de pacientes limitó el análisis del éxito del tratamiento. Conclusión: El recuento de folículos antrales permite predecir la respuesta ovárica y la cantidad de ovocitos recuperados mediante punción folicular. Debido a su bajo costo, alto rendimiento diagnóstico y fácil acceso y realización, el recuento ovárico folicular mediante ecografía debería ser considerado la prueba de reserva ovárica de primera elección

Objective:To evalúate the relationship between the number of antral follicles under basal conditions and the number of oocytes retrieved after ovarían stimulation treatment, to establish the role of antral count follicles by ultrasonography as a predictor of ovarían response. Secondary objective: to assess the correlation of antral follicle count with the age of patients and the success of treatment. Materials and methods: This is a retrospective cohort study, between January and March 2015, assessing 40 women undergoing transvaginal ultrasonography guided follicular aspiration. Trans-vaginal ultrasonography follicle count was performed prior to antral follicles stimulation, (follicles measuring between 3 and 8 mm were taken into account), they also received hormonal stimulation, ultrasonography and hormonal monitoring blood until the follicle aspiration. Results: A strong inverse correlation between patient age and antral follicle count and a very strong inverse correlation between age and oocyte retrieval was observed. A very strong positive correlation between the antral follicle count and the number of oocytes retrieved in the transvaginal aspiration was also observed. The small number of patients limited the analysis linked to the success of treatment. Conclusion: The antral follicle count had significant associations with ovarían response and the number of oocytes retrieved. The antral follicles count by ultrasonography should be considerad the first choice of test of ovarían reserve because of its low cost, good performance and accessibility

Variabilidade da contagem automática tridimensional de folículos ovarianos durante o ciclo menstrual / Variability of Three-dimensional Automatic Ovarian Follicle Count in Menstrual Cycle

Objetivos Avaliar a variabilidade da contagem automática tridimensional dos folículos ovarianos que mediram 2 a 6 mm e 2 a 10 mm durante o ciclo menstrual. Verificar se este exame pode ser aplicado fora da fase folicular precoce do ciclo. Método Prospectivo observacional. Foram incluídas todas as pacientes inférteis submetidas à monitorização da ovulação de 20 de abril de 2013 a 30 de outubro de 2014, com18 a 35 anos; IMC de 18 a 25 kg/m2, eumenorréicas; semhistória de cirurgia ovariana e sem alterações nas dosagens do TSH, prolactina, insulina e glicemia. Foram excluídas aquelas que apresentaram cistos ovarianos e as que faltaram algum dia da monitorização. A contagem ultrassonográfica dos folículos foi feita pelo modo 3D com Sono AVC na fase folicular precoce, folicular media, periovulatória e lútea do ciclo. Resultados Quarenta e cinco mulheres foram incluídas. Houve diferença entre as médias das contagens dos folículos com 2 a 6 mm (p = 0,001) e 2 a 10 mm (p = 0,003) pelo teste de Friedman que avaliou conjuntamente as quatro fases do ciclo. Quando se aplicou o teste t-Student pareado, houve aumento significativo na contagem dos folículos de 2 a 6 mm quando se comparou a contagem desses folículos na fase folicular média e periovulatória com a contagem da fase lútea. Não houve diferença significante entre a contagem destes folículos pequenos nas fases folicular precoce, média e periovulatória. Conclusões A variação da contagem automática tridimensional dos folículos de 2 a 6 mm, nas fases folicular precoce, folicular média e periovulatória, não mostrou significância estatística. Houve uma variação significativa da contagem automática 3D dos folículos ovarianos de 2 a 10 mmdurante o ciclo. A variabilidade significativa da contagem dos folículos de 2 a 10 mm durante o ciclo não permite que este exame seja realizado fora da fase folicular precoce.

Objective To evaluate the variability of three-dimensional automatic counts of ovarian follicles measuring 2-6 to 2-10 mm during the menstrual cycle and to determine if this test can be applied outside the early follicular phase of the menstrual cycle. Methods in a prospective observational study, serial transvaginal ultrasound scans were performed from April 20, 2013, to October 30, 2014, on infertile patients. Inclusion criteria: age between 18 and 35 years, BMI 18-25 kg/m2, regular menstrual cycles, no history of ovarian surgery and no hormonal changes in TSH, prolactin, fasting insulin or glucose. We excluded patients with ovarian cysts or who did not complete one or more days of the serial transvaginal ultrasound scans. The follicle count was performed in 3D mode ultrasound with a Sono AVC system. Visits were scheduled for the early follicular, mid-follicular, periovulatory and luteal phases of the menstrual cycle. Results Forty-five women were included. The Friedman test showed that the total number of follicles measuring 2-6 mmvaried significantly (p = 0.001) across the four periods of the menstrual cycle. The Paired Student t-test showed a significant increase in 2-6 mm follicle count from the mid-follicular and periovulatory phase to the luteal phase. We found no significant intra-cycle variation between the small follicles (2-6 mm) in the early follicular, mid-follicular and periovulatory phases. The Friedman test showed that the total number of follicles measuring 2-10 mm varied significantly (p = 0.003) across the menstrual cycle. Conclusions The variation of three-dimensional automatic counts of 2-6 mm follicles in the early follicular, mid-follicular and periovulatory phases was not statistically significant. The significant variability in the counts of follicles measuring 2-10 mm across the menstrual cycle does not permit this examination to be performed side the early follicular phase.