Study protocol for a Developmental Epidemiological Study of Children born through Reproductive Technologies (DESCRT).

STUDY QUESTIONS: The primary objective of this study is to determine what parental factors or specific ART may influence the risk for adverse cardiometabolic outcomes among children so conceived and their parents. The secondary objective of this study is to prospectively examine the effects of infertility or ART on the intrauterine environment, obstetric and neonatal outcomes. WHAT IS KNOWN ALREADY: Pregnancies conceived with ART are at an increased risk of being affected by adverse obstetric and neonatal outcomes when compared to spontaneously conceived (SC) pregnancies among fertile women. Small cohort studies have suggested ART-conceived children may have a higher risk of long-term cardiometabolic disturbances as well. Currently, few studies have compared long-term cardiometabolic outcomes among ART-conceived children and non-IVF treated (NIFT) children, to children conceived spontaneously to parents with infertility (subfertile parents). STUDY DESIGN SIZE DURATION: The Developmental Epidemiological Study of Children born through Reproductive Technologies (DESCRT) is a prospective cohort study that aims to: establish a biobank and epidemiological cohort of children born to subfertile or infertile parents who either conceived spontaneously (without assistance) or used reproductive technologies to conceive (all offspring were from couples assessed and/or treated in the same institute); prospectively examine the effects of infertility or ART on the intrauterine environment, obstetric and neonatal outcomes; and determine what parental factors or ART may influence the cardiometabolic risk of children so conceived. Pregnancies and resultant children will be compared by mode of conception, namely offspring that were conceived without medical assistance or SC or following NIFT, IVF with fresh embryo transfer or frozen embryo transfer (FET), and by fertilization method (conventional versus ICSI). DESCRT has a Child group evaluating long-term outcomes of children as well as a Pregnancy group that will compare obstetric and neonatal outcomes of children conceived since the commencement of the study. Recruitment started in May of 2017 and is ongoing. When the study began, we estimated that ∼4000 children would be eligible for enrollment. PARTICIPANTS/MATERIALS SETTING METHODS: Eligible participants are first-trimester pregnancies (Pregnancy group) or children (Child group) born to parents who were evaluated at an infertility center in the University of California, San Francisco, CA, USA who were SC or conceived after reproductive treatments (NIFT, IVF ± ICSI, FET). Children in the Child group were conceived at UCSF and born from 2001 onwards. In the Pregnancy group, enrollment began in November of 2017.The primary outcome is the cardiometabolic health of offspring in the Child group, as measured by blood pressure and laboratory data (homeostatic model assessment for insulin resistance (HOMA-IR), oral glucose disposition). There are several secondary outcome measures, including: outcomes from parental survey response (assessing parent/child medical history since delivery-incidence of cardiometabolic adverse events), anthropomorphic measurements (BMI, waist circumference, skinfold thickness), and laboratory data (liver enzymes, lipid panel, metabolomic profiles). In the Pregnancy group, outcomes include laboratory assessments (bhCG, maternal serum analytes, soluble fms-like tyrosine kinase-1 (sFLT-1), and placental growth factor (PlGF)) and placental assessments (placental volume in the second and third trimester and placental weight at delivery). Importantly, aliquots of blood and urine are stored from parents and offspring as part of a biobank. The DESCRT cohort is unique in two ways. First, there is an extensive amount of clinical and laboratory treatment data: parental medical history and physical examination at the time of treatment, along with ovarian reserve and infertility diagnosis; and treatment specifics: for example, fertilization method, culture O2 status, embryo quality linked to each participant. These reproductive data will aid in identifying explanatory variables that may influence the primary cardiometabolic outcomes of the offspring-and their parents. Second, the DESCRT control group includes pregnancies and children SC from parents with subfertility, which may help to assess when infertility, as opposed to reproductive treatments, may be affecting offspring cardiometabolic health. STUDY FUNDING/COMPETING INTERESTS: This study is funded by the National Institutes of Health NICHD (1R01HD084380-01A1). A.J.A. is a shareholder in Carrot and consultant for Flo Health. The other authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: NCT03799107. TRIAL REGISTRATION DATE: 10 January 2019. DATE OF FIRST PATIENT'S ENROLLMENT: 10 May 2017.

Lessons from KEEPS: the Kronos Early Estrogen Prevention Study.

The Kronos Early Estrogen Prevention Study (KEEPS) was a randomized, double-blind, placebo-controlled trial designed to determine the effects of hormone treatments (menopausal hormone treatments [MHTs]) on the progression of carotid intima-medial thickness (CIMT) in recently menopausal women. Participants less than 3 years from menopause and without a history of overt cardiovascular disease (CVD), defined as no clinical CVD events and coronary artery calcium < 50 Agatston units, received either oral conjugated equine estrogens (0.45 mg/day) or transdermal 17ß-estradiol (50 µg/day), both with progesterone (200 mg/day for 12 days/month), or placebo pills and patches for 4 years. Although MHT did not decrease the age-related increase in CIMT, KEEPS provided other important insights about MHT effects. Both MHTs versus placebo reduced the severity of menopausal symptoms and maintained bone density, but differed in efficacy regarding mood/anxiety, sleep, sexual function, and deposition of ß-amyloid in the brain. Additionally, genetic variants in enzymes for metabolism and uptake of estrogen affected the efficacy of MHT for some aspects of symptom relief. KEEPS provides important information for use of MHT in clinical practice, including type, dose, and mode of delivery of MHT recently after menopause, and how genetic variants in hormone metabolism may affect MHT efficacy on specific outcomes.

Antral follicle count recovery in women with menses after treatment with and without gonadotropin-releasing hormone agonist use during chemotherapy for breast cancer.

PURPOSE: After chemotherapy for breast cancer, most women will recover some ovarian function, but the timing and extent of this recovery are poorly understood. We studied post-chemotherapy ovarian recovery in women with and without a history of ovarian suppression during chemotherapy. METHODS: Reproductive age breast cancer patients who were seen prior to chemotherapy for fertility preservation consult were consented for follow-up ovarian function assessment (every 3-6 months after chemotherapy) with antral follicle count (AFC) in this prospective cohort study. We restricted our analysis to those with menses present after chemotherapy. Box plots were used to demonstrate the change in follow-up AFC versus time elapsed after chemotherapy. A mixed effects regression model was used to assess differences in AFC. RESULTS: Eighty-eight patients with a history of newly diagnosed breast cancer were included. Forty-five patients (51%) had ovarian suppression with GnRH agonist (GnRHa) during chemotherapy. AFC recovery appeared to plateau at 1 year after completing chemotherapy at a median of 40% of pre-chemotherapy AFC. After adjustment for age, initial AFC, cyclophosphamide exposure, combined hormonal contraceptive (CHC) use, and tamoxifen use, AFC recovered faster and to a greater degree for those women who underwent GnRHa therapy for ovarian protection during chemotherapy (P = 0.032). CONCLUSIONS: Women with menses after chemotherapy for breast cancer appear to recover their full potential AFC 1 year after their last chemotherapy dose. Treatment with GnRHa during chemotherapy is associated with a higher degree of AFC recovery. The findings of this study can aid in counseling patients prior to chemotherapy about expectations for ovarian recovery and planning post-treatment fertility preservation care to maximize reproductive potential when pre-treatment fertility preservation care is not possible or has limited oocyte yield.

Association of ethnicity, Fitzpatrick skin type, and hirsutism: A retrospective cross-sectional study of women with polycystic ovarian syndrome.

BACKGROUND: The complex interplay between ethnicity, Fitzpatrick skin type (FST), and hirsutism in patients with polycystic ovarian syndrome (PCOS) is poorly understood. OBJECTIVE: In this cross-sectional, retrospective analysis, we examined the prevalence, severity, and distribution of hirsutism with clinician-rated site-specific and total modified Ferriman-Gallwey (mFG) visual scoring in a diverse cohort of American patients with PCOS. METHODS: Independent analyses were conducted on the basis of patient-reported FST ratings and ethnicity. RESULTS: In this PCOS cohort, a correlation was found between hirsutism and ethnicity and the highest prevalence of hirsutism and total mFG scores was observed in Hispanic, Middle Eastern, African American, and South Asian patients. A positive correlation between hirsutism and FST was also observed with an increasing prevalence of hirsutism in the group of patients with higher FSTs. Significant trends in the anatomic distribution of hirsutism were observed between ethnic groups as well. A higher facial mFG score was found in African American patients but higher mFG scores in the truncal and extremity regions were observed in Middle Eastern patients. Truncal hirsutism was also associated with higher FSTs. CONCLUSIONS: Ethnicity and FST may be important variables in both the quantitative and qualitative presentations of hirsutism in women with PCOS and should be considered in the diagnostic evaluation of any patient who is suspected of having the condition. Previously published studies that examined ethnicity, FST, and hirsutism in homogeneous cohorts limited comparison and generalizability but the strength of this study lies in its detailed analysis within a single large and diverse PCOS cohort. Validated studies are needed to determine whether clinical criteria for hirsutism should be adjusted for ethnicity and FST in the PCOS population and particularly within diverse cohorts and patients of mixed ancestry.

Psychological stress and reproductive aging among pre-menopausal women.

BACKGROUND: Life history models suggest that biological preparation for current versus longer term reproduction is favored in environments of adversity. In this context, we present a model of reproductive aging in which environmental adversity is proposed to increase the number of growing follicles at the cost of hastening the depletion of the ovarian reserve over time. We evaluated this model by examining psychological stress in relation to reproductive aging indexed by antral follicle count (AFC), a marker of total ovarian reserve. We hypothesized that stress would be related to (i) higher AFC in younger women, reflecting greater reproductive readiness as well as (ii) greater AFC loss across women, reflecting more accelerated reproductive aging. METHODS: In a multi-ethnic, community sample of 979 participants [ages 25-45 (mean (standard deviation) = 35.2 (5.5)); 27.5% Caucasian] in the Ovarian Aging study, an investigation of the correlates of reproductive aging, the interaction of age-x-stress was assessed in relation to AFC to determine whether AFC and AFC loss varied across women experiencing differing levels of stress. Stress was assessed by the perceived stress scale and AFC was assessed by summing the total number of antral follicles visible by transvaginal ultrasound. RESULTS: In linear regression examining AFC as the dependent variable, covariates (race/ethnicity, socio-economic status, menarcheal age, hormone-containing medication for birth control, parity, cigarette smoking, bodymass index, waist-to-hip ratio) and age were entered on step 1, stress on step 2 and the interaction term (age-x-stress) on step 3. On step 3, significant main effects showed that older age was related to lower AFC (b = -0.882, P = 0.000) and greater stress was related to higher AFC (b = 0.545, P = 0.005). Follow-up analyses showed that the main effect of stress on AFC was present in the younger women only. A significant interaction term (b = -0.036, P = 0.031) showed the relationship between age and AFC varied as function of stress. When the sample was divided into tertiles of stress, the average follicle loss was -0.781, -0.842 and -0.994 follicles/year in the low-, mid- and high-stress groups, respectively. CONCLUSIONS: Psychological stress was related to higher AFC among younger women and greater AFC decline across women, suggesting that greater stress may enhance reproductive readiness in the short term at the cost of accelerating reproductive aging in the long term. Findings are preliminary, however, due to the cross-sectional nature of the current study.

Human oocyte maturation is dependent on LH-stimulated accumulation of the epidermal growth factor-like growth factor, amphiregulin.

BACKGROUND: The LH surge promotes ovulation via activation of multiple signaling networks in the ovarian follicle. Studies in animal models have shown the importance of LH-induced activation of the epidermal growth factor (EGF)signaling network in critical peri-ovulatory events. We investigated the biological significance of regulatory mechanisms mediated by EGF-like growth factors during LH stimulation in humans. METHODS: We characterized the EGF signaling network in mature human ovarian follicles using in vivo and in vitro approaches. Amphiregulin (AREG) levels were measured in 119 follicular fluid (FF) samples from IVF/ICSI patients. Biological activity of human FF was assessed using in vitro oocyte maturation, cumulus expansion and cell mitogenic assays. RESULTS: AREG is the most abundant EGF-like growth factor accumulating in the FF of mature follicles of hCG-stimulated patients. No AREG was detected before the LH surge or before hCG stimulation of granulosa cells in vitro, demonstrating that the accumulation of AREG requires gonadotrophin stimulation. Epiregulin and betacellulin mRNA were detected in both human mural and cumulus granulosa cells, although at significantly lower levels than AREG. FF from stimulated follicles causes cumulus expansion and oocyte maturation in a reconstitution assay. Immunodepletion of AREG abolishes the ability of FF to stimulate expansion (P < 0.0001) and oocyte maturation (P < 0.05), confirming the biological activity of AREG. Conversely, mitogenic activity of FF remained after depletion of AREG, indicating that other mitogens accumulate in FF. FF from follicles yielding an immature germinal vesicle oocyte or from an oocyte that develops into an aberrant embryo contains lower AREG levels than that from follicles yielding a healthy oocyte (P = 0.008). CONCLUSIONS: EGF-like growth factors play a role in critical peri-ovulatory events in humans, and AREG accumulation is a useful marker of gonadotrophin stimulation and oocyte competence.

Using basic science to design a clinical trial: baseline characteristics of women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS).

Observational and epidemiological studies suggest that menopausal hormone therapy (MHT) reduces cardiovascular disease (CVD) risk. However, results from prospective trials showed neutral or adverse effects most likely due to differences in participant demographics, such as age, timing of initiation of treatment, and preexisting cardiovascular disease, which reflected in part the lack of basic science information on mechanisms of action of hormones on the vasculature at the time clinical trials were designed. The Kronos Early Estrogen Replacement Study (KEEPS) is a prospective, randomized, controlled trial designed, using findings from basic science studies, to test the hypothesis that MHT when initiated early in menopause reduces progression of atherosclerosis. KEEPS participants are younger, healthier, and within 3 years of menopause thus matching more closely demographics of women in prior observational and epidemiological studies than women in the Women's Health Initiative hormone trials. KEEPS will provide information relevant to the critical timing hypothesis for MHT use in reducing risk for CVD.

Methylenetetrahydrofolate reductase C677T and A1298C variants do not affect ongoing pregnancy rates following IVF.

BACKGROUND: There is concern that IVF could compromise normal imprinting and methylation of DNA. Methylenetetrahydrofolate reductase (MTHFR) regulates the flow of folic acid-derived, one-carbon moieties for methylation and is critical to early embryonic development. Therefore, we hypothesized that common polymorphisms in MTHFR could associate with IVF outcome. METHODS: MTHFR C677T and A1298C polymorphism genotyping was performed on 374 subjects for this study, representing 197 couples undergoing IVF in a university setting from July 2005 to January 2006. Analysis of variance (ANOVA), chi-square and/or multivariate analyses were used to assess whether these polymorphisms are associated with embryo quality or with ongoing pregnancy or spontaneous abortion rates. RESULTS: Allele frequencies for C677T ( p=0.67, q=0.33) and A1298C ( p=0.71, q=0.29) were in Hardy-Weinberg equilibrium. The C677T and A1298C variants, either alone or in combination, did not associate with embryo quality or short-term pregnancy outcome. CONCLUSIONS: The common polymorphisms in MTHFR are not associated with embryo quality, as defined by cell number or fragmentation score, or with short-term pregnancy outcomes. Therefore, in our population in which women receive adequate folic acid, MTHFR genotypes are not informative in explaining IVF failure. Further studies, however, examining birth outcomes and the other enzymes in the folic acid pathway are warranted.

The prevalence of upper lip hair in black and white girls during puberty: a new standard.

In order to develop standards for upper lip hair in adolescent girls, 4693 observations in 856 black and white subjects were made over 9 years. Up to 2 years after menarche, 90% of girls had no upper lip hair. More than 2 years after menarche, 48.8% of black girls and 9.0% of white girls had small amounts of upper lip hair. This may be more significant in adolescent girls than in older women.

N5 endometrial stromal cell line: a model system to study decidual prolactin gene expression.

Prolactin gene expression in extrapituitary tissues, such as decidua and lymphocytes, is regulated by a distinct promoter approximately 6 kb upstream of the pituitary prolactin gene transcription start site. Here we describe studies in a human endometrial stromal cell line, N5, that was immortalized by transfection with an SV40 mutant and which expresses the prolactin gene driven by the extrapituitary promoter. The N5 cells have phenotypic features of primary cultures of decidualized human endometrial stromal cells and secrete low levels of prolactin and insulin-like growth factor binding protein-1 (IGFBP-1), both of which are markers of decidualized endometrial stromal cells. As in primary cultures of endometrial stromal cells, treatment of N5 cells with progesterone and estradiol alone or in combination with prostaglandin E2 stimulated the synthesis and release of prolactin. Transient transfection of the N5 cells with an expression vector containing - 2927/ + 66 bp of the decidual prolactin promoter coupled to a luciferase reporter gene resulted in a 20 to 25-fold increase in luciferase activity, a magnitude similar to that which occurs in primary cultures of endometrial stromal cells decidualized in vitro by treatment with progesterone and estradiol. Luciferase expression levels were similar in untreated N5 cells and N5 cells treated with progesterone and estradiol. Taken together, these results indicate that the N5 human endometrial stromal cell line has phenotypic characteristics of normal decidualized stromal cells and is a useful model to study regulation of decidual prolactin gene expression.

Successful non-surgical management of a heterotopic abdominal pregnancy following embryo transfer with cryopreserved-thawed embryos.

Heterotopic pregnancy is an increasingly common complication of assisted reproductive technology. Abdominal pregnancy is a rare and life-threatening form of ectopic pregnancy that can present as the extrauterine portion of a heterotopic pregnancy. We present the case of a cryopreserved-thawed embryo transfer that resulted in a simultaneous intrauterine and abdominal pregnancy first recognized at 10 weeks gestation. Ultrasound-guided transvaginal injection of potassium chloride into the abdominal pregnancy resulted in asystole and spontaneous resorption of the ectopic fetus, while the intrauterine pregnancy continued and resulted in a liveborn vaginal delivery at full term. Selective embryo reduction using a non-surgical approach in a haemodynamically stable patient can therefore be considered in the management of heterotopic abdominal pregnancy if diagnosed relatively early.

Embryo cryopreservation.

Cryopreservation stands as an ongoing evolution in the field of assisted reproductive technologies. Face with increasing numbers of fertilized oocytes and early embryos, cryopreservation avails the ART program of a useful means to preserve embryos for future use without exposing patients to the risks of multiple pregnancies. This article examines some of the clinical and laboratory issues critical to a successful cryopreservation program.

Efficacy of treatment for unexplained infertility.

OBJECTIVE: To analyze the efficacy and cost-effectiveness of alternative treatments for unexplained infertility. DESIGN: Retrospective analysis of 45 published reports. SETTING: Clinical practices. PATIENT(S): Couples who met criteria for unexplained infertility. Women with Stage I or Stage II endometriosis were included. INTERVENTION(S): Observation; clomiphene citrate (CC); gonadotropins (hMG); IUI; and GIFT and IVF. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate. RESULT(S): Combined pregnancy rates per initiated cycle, adjusted for study quality, were as follows: no treatment = 1.3%-4.1%; IUI = 3.8%; CC = 5.6%; CC + IUI = 8.3%; hMG = 7.7%; hMG + IUI = 17.1%; IVF = 20.7%; GIFT = 27.0%. The estimated cost per pregnancy was $10,000 for CC + IUI, $17,000 for hMG + IUI, and $50,000 for IVF. CONCLUSION(S): Clomiphene citrate + IUI is a cost-effective treatment for unexplained infertility. If this treatment fails, hMG + IUI and assisted reproduction are efficacious therapeutic options.

Identification of allelic variants in the follicle-stimulating hormone receptor genes of females with or without hypergonadotropic amenorrhea.

OBJECTIVE: To determine whether women with idiopathic hypergonadotropic amenorrhea have unique alterations in the FSH receptor gene that could account for reduced activity. DESIGN: Compare FSH receptor genes of affected women with normally menstruating control subjects. SETTING: Center for Reproductive Health and university departments. PATIENT(S): Fourteen female subjects, including four normally menstruating controls; four sibling sisters, two of whom developed premature ovarian failure (POF); four patients with POF; one patient with 46,XX gonadal dysgenesis (GD); and one patient with hypogonadotropic hypogonadism. INTERVENTION(S): Blood samples were collected. MAIN OUTCOME MEASURE(S): Restriction fragment length polymorphism (RFLP) analysis, single-stranded conformation polymorphism analysis, gel electrophoretic mobility of amplified genomic DNA, and FSH receptor gene sequence. RESULT(S): The DNA sequencing revealed allelic variants in one RFLP-positive control. There were two silent variants and one missense variant that resulted in a change from Asp to Gly at position 334 from the start Met in the amino acid sequence. Six of 10 subjects, including controls and patients with POF and GD, had an allelic variant in which A was changed to G at position 919 which caused Thr307 to be changed to Ala. CONCLUSION(S): Allelic variants in the FSH receptor gene occur commonly in control subjects and affected patients.

Progesterone-dependent decidualization of the human endometrium is mediated by cAMP.

Progesterone is a key factor in regulating endometrial cell decidualization, but the signal transduction pathways involved in mediating the effects of progesterone are not known. A role of the cAMP pathway in decidualization has been suggested by in vitro studies demonstrating that cAMP agonists can stimulate decidualization, in the absence of sex steroids. In this article, we have used an in vitro culture model of progesterone-dependent decidualization of human endometrial stromal cells to examine whether progesterone-induced decidualization is associated with activation of the cAMP signal transduction pathway in which the prolactin gene expression is a marker of decidualization. Following a lag period of approx 3 d, progesterone induced prolactin secretion and elevated intracellular cAMP levels. By d 15, cAMP and prolactin levels were approx 10- and 60-fold greater, respectively, than those on d 3. Changes in cAMP levels showed a positive correlation with prolactin secretion. Prostaglandin E2 (PGE2), which enhances progesterone-dependent decidualization, also increased both prolactin secretion and cAMP levels approx two- to fourfold on d 15 compared with d 3, whereas PGE2 alone, which does not induce decidualization, did not stimulate prolactin secretion or intracellular cAMP accumulation. Conversely, all-trans retinoic acid, which attenuates progesterone-dependent decidualization, significantly (p < 0.05) decreased both prolactin secretion and cAMP levels. Furthermore, the protein kinase A (PKA) inhibitor, 8-bromoadenosine-3',5'-cyclic monophosphorothioate, significantly (p < 0.05) suppressed progesterone-dependent prolactin expression. Since activation of the PGE2 receptor subtype EP2 stimulates adenylate cyclase, reverse transcription-polymerase chain reaction (RT-PCR) analysis of endometrial cells was undertaken. Expression of EP2 mRNA was induced in cells treated with progesterone and estradiol alone or with PGE2, compared with untreated controls. The data suggest that the cAMP signal transduction cascade is activated during progesterone-dependent decidualization.

Birth of a western lowland gorilla (Gorilla gorilla gorilla) following in vitro fertilization and embryo transfer.

A 21-year-old multiparous female exhibiting 31-41 day menstrual cycles was given hFSH (225 IU/day, Metrodin 75, from cycle day 3 through 9 (menses = day 1) and hCG (10,000 IU, Profasi, on day 10 to stimulate follicular development. At 35 h after hCG, under isoflurane (AErrane) anesthesia, follicles were aspirated by controlled suction under transvaginal ultrasound guidance. Metaphase II oocytes (n = 11) were placed in modified human tubal fluid (mHTF, 100 microliters) medium under oil at 37 degrees C in humidified 5% CO2. Frozen semen, collected by voluntary ejaculation, was thawed (70 degrees C H2O bath, 6 sec), diluted slowly, centrifuged, and resuspended in mHTF, and 160,000 motile spermatozoa/ml were added at 6 h after oocyte recovery. At 21 h postinsemination (p.i.) eight oocytes were at the two-cell stage, five were cryopreserved, and three were cultured to the six- to eight-cell stage in mHTF with granulosa cells before transcervical uterine transfer at 47 h p.i. using a Teflon catheter. Micronized progesterone (400 mg/d) was orally administered for 10 weeks posttransfer (p.t.). Ultrasound examination revealed a single fetus at 15 weeks p.t., and unassisted delivery of a live 1.37 kg female infant occurred at 29 weeks. Am. J. Primatol. 41:247-260, 1997.

Retinoic acid suppresses in-vitro decidualization of human endometrial stromal cells.

All-trans retinoic acid (RA) has potent effects on cell differentiation and gene expression. Previous studies have demonstrated that human endometrial stromal cells express mRNA for retinoic acid receptors (RARs) and cellular RA-binding protein-II (CRABP-II). We examined whether RA regulates stromal cell differentiation (decidualization), a critical process in preparation of the uterus for blastocyst implantation. Decidualization was induced by incubating cultured stromal cells with medroxyprogesterone acetate (MPA) and oestradiol. Decidualization was defined by the induction of prolactin, insulin-like growth factor binding protein-1 (IGFBP-1), appearance of a differentiated phenotype and changes in fibronectin expression. RA treatment significantly (P < 0.05) suppressed prolactin and IGFBP-1 production associated with stromal cells decidualization. The formation of differentiated cells was inhibited by RA, and consistent with maintenance of the undifferentiated phenotype, fibronectin mRNA content was approximately 3.5-times greater than in the absence of RA. Upon induction of decidualization, the expression of mRNA for the major RA receptor sub-types (RAR-alpha, -beta and -gamma) was maintained while the relative amounts of CRABP-II mRNA progressively decreased with differentiation. With RA treatment, RAR-alpha and RAR-gamma mRNA concentrations were approximately 70 and 25% respectively of those in cells decidualized in the absence of RA. The effects of RA appear to be partially mediated by inhibition of cAMP action. RA suppressed intracellular cAMP concentrations induced by MPA and oestradiol to approximately 35% of those in cells without RA. Addition of 50 microM dibutyryl cAMP to stromal cells treated with MPA and oestradiol only partially reversed the suppression of decidualization and prolactin release by RA. In summary, we have demonstrated that in-vitro decidualization of human endometrial stromal cells induced by MPA and oestradiol treatment is suppressed by RA.

Success of donor oocyte in in vitro fertilization-embryo transfer in recipients with and without premature ovarian failure.

OBJECTIVE: To compare the effectiveness of donor oocyte in IVF-ET in patients with premature ovarian failure (POF) versus those (non-POF) with other indications for donor oocyte IVF-ET. DESIGN: Retrospective comparative clinical study. SETTING: University-based IVF-ET facility. PATIENTS: Eighty-six donor oocyte IVF-ET cycles from 32 POF patients (39 cycles) and 38 non-POF patients (47 cycles). INTERVENTIONS: Fertile oocyte donors, age 19 to 38 years, were given luteal phase GnRH agonist, gonadotropins, and HCG. Recipients were given transdermal 17 beta-E2 and P in oil. MAIN OUTCOME MEASURES: Donor and recipient age, characteristics of controlled ovarian hyperstimulation, oocytes retrieved, embryos frozen and transferred, and percentage with male factor infertility, fertilization rate, implantation rate, and clinical pregnancy rate (PR) per cycle and per transfer. RESULTS: Given limitations of sample size, there were no detectable differences in clinical PR per cycle and per transfer, fertilization rate, and implantation rate between POF and non-POF groups despite recognizable differences in recipient age and degree of male factor infertility. CONCLUSIONS: Donor oocyte IVF-ET success rates were not different in patients with and without POF. Age-related changes in oocyte quality, rather than uterine senescence, is a major factor for the age-related decline in fertility.

Up-regulation of the human prolactin receptor in the endometrium.

In humans, uterine endometrial stromal cells differentiate (decidualize) into decidual cells that express prolactin (PRL). Decidual PRL expression continues throughout pregnancy, thus decidual cells lining fetal membranes of term placenta synthesize and secrete PRL. To examine the hypothesis that PRL may play an autocrine role in the decidual cells, we examined the expression of the PRL receptor (PRL-R) during in vitro decidualization of stromal cells and in term decidua. In endometrial stromal cells decidualized by treatment with 1 µM medroxyprogesterone and 10 nM estradiol for 3, 6, and 9 d, respectively, a 12.7 kb PRL-R transcript increased 3-3.5-fold, 16.5-17-fold, and 23.5-24-fold, respectively, compared with untreated controls, in duplicate experiments. Progesterone-dependent PRL-R and PRL expression were stimulated by 1 µ/M prostaglandin E(2). Term decidua expressed the long form of the PRL-R and five major PRL-R transcripts (12.7, 9.7, 7.0, 3.6, and 2.8 kb). In contrast, human liver expressed two major transcripts (12.7 and 9.7 kb) while hepG2 cells expressed a single 7.0-kb-sized transcript. These studies demonstrate that PRL-R expression is stimulated upon progesterone-induced PRL gene expression in endometrial stromal cells supporting the hypothesis that PRL may have an autocrine effect in the endometrium and decidua.