Analysis of androgen receptor and anti-Müllerian hormone pathways in human granulosa cells under luteinizing hormone treatment.

BACKGROUND: The objective of this study was to determine the gene expression profiles of the androgen/androgen receptor (AR) and anti-Müllerian hormone (AMH)/ Sry-related high-mobility group box 9 (SOX9) pathways in granulosa-luteal cells from patients undergoing standard in vitro fertilization (IVF) with or without recombinant luteinizing hormone (rLH) therapy. METHODS: Levels of reproductive hormones in the pre-ovulatory follicular fluid and the expression levels of LHR (luteinizing hormone receptor), AR, SOX9, AMH, AR-associated protein 54(ARA54)and ARA70 were determined in granulosa-luteal cells by real-time reverse-transcription PCR. The effects of androgen and rLH treatments on AR and AMH expression levels were also tested in vitro using HO23 cells. RESULTS: We collected 35 an 70 granulosa cell samples from patients cycled with and without rLH supplementation, respectively. The clinical outcomes were similar in patients who received rLH therapy and those who did not, though the pre-ovulatory follicular fluid levels of androstenedione, testosterone, and estradiol were significantly higher and progesterone was lower in the rLH supplementation group. Moreover, granulosa-luteal cell mRNA levels of LHR, AR, AMH, and SOX9 were significantly higher in the rLH supplementation group relative to the group that did not receive rLH supplementation. In addition, we observed significant correlations between LHR and AR mRNA expression and among AR, AMH, and SOX9 mRNA expression in granulosa-luteal cells from patients undergoing standard IVF treatment. CONCLUSIONS: Increased expression of LHR, AR, AMH, and SOX9 is characteristic of granulosa-luteal cells from IVF/ intracytoplasmic sperm injection (ICSI) patients receiving rLH supplementation.

Comparison of the offspring sex ratio between cleavage stage embryo transfer and blastocyst transfer.

OBJECTIVE: To compare the sex ratio of offspring born after cleavage stage embryo transfer and blastocyst transfer. MATERIALS AND METHODS: In this retrospective study of embryo transfer (ET), we included 473 offspring from 446 deliveries during the period January 2002 to December 2007. Statistical analysis was performed on the sex ratio of offspring resulting from day 3 cleavage stage embryo transfer and from sequential blastocyst culture transfer. RESULTS: In total, 446 patient deliveries were included in this analysis. There were 251 singleton pregnancies, 109 twin pregnancies, and four triplet pregnancies. The total number of offspring was 473, of which 118 resulted from day 3 ETs, and 355 resulted from blastocyst ETs. At our center, the influence on the sex ratio of cleavage stage ET and blastocyst-stage ET showed a bias towards males in both cases. The overall female to male ratio for offspring resulting from day 3 ETs was not significantly higher than the same ratio for offspring resulting from blastocyst ETs (p = 0.24; odds ratio, 0.762). The female to male ratio for either singleton births or multiple deliveries was also not significantly different between day 3 ETs and blastocyst ETs. CONCLUSION: The sex ratio was influenced by cleavage stage ET and blastocyst-stage ET. In both cases, there was a bias towards males. In addition, when blastocyst ET was compared with day 3 ET, there was no further increase in the percentage of male offspring.

Significantly superior response in the right ovary compared with the left ovary after stimulation with follicle-stimulating hormone in a pituitary down-regulation regimen.

OBJECTIVE: To compare the differences between the right and left ovarian responses in patients undergoing standard in vitro fertilization (IVF) treatment. DESIGN: Prospective, observational study. SETTING: A university hospital in Taiwan. PATIENT(S): Seven hundred eighty-nine consecutive patients undergoing IVF or intracytoplasmic sperm injection. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The number of oocytes retrieved, fertilization rates, number of grade 1 zygotes and number of embryos produced, embryo arrest-free rate, and mean number of top-quality embryos on the day of transfer. RESULT(S): The number of follicles > or = 16 mm in diameter on day 2.5 versus 2.2 of human chorionic gonadotropin (hCG) administration, the number of follicles > or = 10 mm in diameter on hCG day 6.5 versus 6.1, the number of oocytes (3.6 vs. 3.0), the percentage fertilization (79.9 vs. 74.6%), and the mean number of mature oocytes and grade 1 zygotes (2.3 vs. 1.8 and 1.79 vs. 0.93, respectively), and the mean available number of top-quality embryos on transfer day 1.39 versus 0.73 were all statistically significantly greater in the right compared with the left ovary; however, the pregnancy and implantation rates were similar. CONCLUSION(S): There are statistically significant differences between the right and left ovarian responses in IVF patients with healthy ovaries, and the right ovarian responses are superior to the left ovarian responses.

Comparison of in vitro fertilization versus intracytoplasmic sperm injection in extremely low oocyte retrieval cycles.

OBJECTIVE: To compare the results of IVF and intracytoplasmic sperm injection (ICSI) in extremely low oocyte retrieval cycles. DESIGN: Case-control study. SETTING: An IVF laboratory in a university hospital in Taiwan. PATIENT(S): Between January 2003 and December 2007, infertile couples with one, two, or three oocytes per retrieval were divided into two groups: 56 IVF cycles based on 28 demographic characteristics from the ICSI group. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Fertilization rate, cycle cancellation rate, clinical pregnancy rate, and implantation rate per transfer. RESULT(S): The normal fertilization rate was significantly higher after ICSI than after standard IVF (86.4% vs. 69.3%). The cycle cancellation and complete fertilization failure rates were comparable between the two groups. The clinical pregnancy rate per transfer (38.5% vs. 21.6%), implantation rate (23.5% vs. 11.1%), and live birth rate per transfer (30.8% vs. 13.7%) had a favorable trend, but no statistically significant differences, in the ICSI group compared with the IVF group. CONCLUSION(S): A higher normal fertilization rate can be achieved by ICSI in comparison with conventional IVF in extremely low oocyte retrieval cycles.

Comparison of the offspring sex ratio between fresh and vitrification-thawed blastocyst transfer.

There was a significant difference in the sex ratio between offspring from fresh and from vitrification-thawed blastocyst transfer. The live birth sex ratio influenced by the blastocyst-stage embryo transfer correlated with top-quality embryo morphology.

Comparison of the efficacy of two vaginal progesterone formulations, Crinone 8% gel and Utrogestan capsules, used for luteal support in blastocyst stage embryo transfers.

OBJECTIVE: To compare the efficacy of two vaginal progesterone formulations, Crinone gel and Utrogestan capsules, for luteal phase support in blastocyst stage embryo transfers. MATERIALS AND METHODS: We analyzed 460 consecutive cycles in patients undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI)-blastocyst transfer (BT) treatment at our institution between January 2004 and December 2007. Patients applied either Crinone 8% vaginal gel (90 mg, once daily) or Utrogestan vaginal capsules (200 mg, four times daily) for luteal supplementation. Progesterone was administered from the day of oocyte retrieval to pregnancy confirmation. Clinical pregnancy and implantation rates were the main outcome measures. RESULTS: The clinical pregnancy rate (58.7% vs. 44.3%) and implantation rate (32.04% vs. 23.89%) were significantly higher in the Crinone group compared with the Utrogestan group after IVF/ICSI-BT treatment. CONCLUSION: Luteal phase support with Crinone 8% vaginal gel (90 mg daily) resulted in better clinical pregnancy and implantation rates than Utrogestan vaginal capsules (200 mg, four times daily) in IVF/ICSI-BT cycles.

Zona-free versus laser zona-assisted hatching blastocyst transfer: a comparison of outcomes.

In unselected IVF patients, zona-free and laser zona-assisted hatching produced a comparable effect on blastocyst transfer.

Increased progesterone/estradiol ratio on the day of HCG administration adversely affects success of in vitro fertilization-embryo transfer in patients stimulated with gonadotropin-releasing hormone agonist and recombinant follicle-stimulating hormone.

OBJECTIVE: We investigated the influence of premature luteinization in in vitro fertilization using a long protocol of gonadotropin-releasing hormone agonist (GnRHa) and recombinant follicle-stimulating hormone (rFSH), taking ovarian response into account in the definition of premature luteinization. MATERIALS AND METHODS: A total of 339 cycles of controlled ovarian hyperstimulation with rFSH and GnRHa were performed in 311 infertile couples. Premature luteinization was defined as a progesterone (P) to estradiol (E2) ratio of > 1 on the day of human chorionic gonadotropin (hCG) administration. The P/E2 ratio is calculated as: P (ng/mL) 1,000/E2 (pg/mL). Clinical outcomes were compared for the prematurely luteinized and non-prematurely luteinized groups. RESULTS: The mean number of retrieved oocytes, recovered mature oocytes, embryos and top quality embryos were significantly higher in the non-prematurely luteinized group than in the prematurely luteinized group. Although fertilization rates and implantation rates were similar between the two groups, the clinical pregnancy rate was higher in the non-prematurely luteinized group than in the prematurely luteinized group. CONCLUSION: Premature luteinization, defined as late follicular P/E2 ratio of > 1 in long GnRHa cycles with rFSH stimulation, adversely affected ovarian responses and clinical outcomes. It seems unrelated to preovulatory luteinizing hormone (LH) elevation and LH/hCG content of gonadotropins and could be associated with poor ovarian response and the presence of dysmature follicles.

Expression of androgen receptor co-regulators in the testes of men with azoospermia.

OBJECTIVE: To elucidate the physiologic and pathologic roles of androgen receptor (AR) and co-regulators in human testes with obstructive azoospermia or nonobstructive azoospermia. DESIGN: Prospective laboratory and clinical study. SETTING: Infertility clinic at Chang Gung Memorial Hospital. PATIENT(S): Twenty-seven men with obstructive azoospermia and 24 men with nonobstructive azoospermia. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Expression of AR and AR co-regulators was determined in testicular specimens and were analyzed using reverse transcription polymerase chain reaction (PCR) and immunohistochemical staining techniques. RESULT(S): Most of the AR co-regulators were expressed at similar levels in specimens obtained from men with nonobstructive and obstructive azoospermia. However, the levels of expression of ARA54 mRNA were significantly lower and ARA55 mRNA was significantly higher in specimens from men with nonobstructive than obstructive azoospermia. In specimens from men with obstructive and nonobstructive azoospermia, AR immunostaining was detected in Sertoli, Leydig, and peritubular myoid cells. ARA55 immunostaining was detected in peritubular myoid and endothelial cells of blood vessels. Interestingly, nuclear ARA54 immunostaining was detected in the late stage germ cells of specimens from men with obstructive azoospermia but in the somatic cells of specimens from men with nonobstructive azoospermia. CONCLUSION(S): These results demonstrated that the decreased expression of ARA54 and increased expression of ARA55 is a feature of nonobstructive azoospermia. In addition, the differential localization of ARA54 may play an important role in testicular development and spermatogenesis in humans.

VEGF, IVF clinical variables and ovarian hyperstimulation syndrome: a prospective study of the preimplantation luteal phase.

OBJECTIVE: To explore the relationships between vascular endothelial growth factor (VEGF) levels in the preimplantation luteal phase and ovarian response, embryonic development, pregnancy outcome and occurrence of ovarian hyperstimulation syndrome (OHSS) in women undergoing in vitro fertilization (IVF). STUDY DESIGN: The level of total VEGF in peritoneal fluid and serum was determined in 61 consecutive women undergoing day 3 tubal embryo transfer via laparoscopy. A MEDLINE search of the literature for 1996 to 2003 was conducted to review the relationship between VEGF levels and clinical variables at different time points during the IVF treatment cycle. RESULTS: No correlation existed between total VEGF levels and patient age, estradiol production, number of oocytes retrieved, embryo development or pregnancy outcome. There was no significant difference between the 12 patients who developed OHSS and the 49 who did not. A literature review yielded inconclusive results. CONCLUSION: A single measurement of total VEGF obtained from the serum or peritoneal fluid during the preimplantation luteal phase adds little to the clinical assessment of IVF response or to predicting the risk of OHSS. Large-scale studies at different times during the IVF cycle are needed to better define its potential use as a biomarker.

Expression of inhibin-activin subunits, follistatin and smads in granulosa-luteal cells collected at oocyte retrieval.

PURPOSE: To examine the expression of inhibin-activin subunits, follistatin, and Smads 2, 3 and 4 in granulosa-luteal cells at the time of oocyte retrieval. METHODS: Quantitative reverse transcriptase-polymerase chain reaction was performed to quantify the mRNA expression of the investigated genes: inhibin alpha-subunit, inhibin-activin betaA- and betaB-subunits, follistatin, and Smads 2, 3 and 4. RESULTS: alpha-, betaA- and betaB-subunits of inhibin-activin, and follistatin were all well expressed in granulosa-luteal cells obtained from either dominant or cohort follicles. alpha-subunits strongly correlated with Smad2 (p < 0.001). betaA-subunit significantly correlated with Smad4, p < 0.001. betaB-subunit significantly correlated with Smad2, p = 0.002, and follistatin expression strongly correlated with the expression of Smads 2 and 4 (p < 0.001 and = 0.007 respectively). CONCLUSIONS: We found, for the first time that inhibin-activin betaB-subunit mRNA was well expressed in human granulosa-luteal cells obtained from either dominant or cohort follicles. alpha-, betaA- and betaB-subunits and follistatin correlated with Smads to varied degrees, suggesting the active roles of the above genes at the time of oocyte retrieval.

Androgenic and antiandrogenic effects and expression of androgen receptor in mouse embryonic stem cells.

OBJECTIVE: To investigate the effects of androgen and antiandrogen and the expression of androgen receptor on mouse embryonic stem cells (ESCs) and the inner cell mass. DESIGN: Controlled laboratory study. SETTING: Academic university hospital. ANIMAL(S): Blastocysts from mice developed at the Institute for Cancer Research and 129/Sv mice embryonic stem cell line. INTERVENTION(S): Cultured mouse ESCs were exposed to testosterone (T), dihydrotestosterone (DHT), or the antiandrogen nilutamide. MAIN OUTCOME MEASURE(S): Immunohistochemistry for androgen receptor (AR), quantitative real-time polymerase chain reaction analysis, cell colorimetric assays, and Western blot analysis. RESULT(S): Androgen receptor messenger RNA (mRNA) was first detected both in the inner cell mass from blastocysts and in undifferentiated ESCs. It increased stage-dependently during ESC differentiation. Although both T and DHT had marginal effects on AR mRNA expression level and cell growth in vitro, the nonsteroidal antiandrogen nilutamide significantly stimulated ESC growth and induced Akt expression. The enhancing effects of nilutamide on mouse ESCs indicated that the Akt pathway may be involved in nilutamide-promoted ESC growth. CONCLUSION(S): These findings provide the first evidence of the existence of AR in ESCs. During differentiation, the expression level of AR was increased in a stage-dependent but not a ligand-dependent manner. Nilutamide promoted cell growth and increased Akt expression in ESCs.

Concomitant pelvic organ prolapse surgery with TVT procedure.

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior-posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12-42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.

Adverse effects of retinoic acid on embryo development and the selective expression of retinoic acid receptors in mouse blastocysts.

BACKGROUND: All-trans retinoic acid (RA), the oxidative metabolite of vitamin A, is essential for normal development. In addition, high levels of RA are teratogenic in many species. We have previously shown that excess RA results in immediate effects on the preimplantation embryo and on blastocyst development. This study was conducted to clarify the long-term survival of mouse blastocyst and the effect of RA on gene expression. METHODS AND RESULTS: Using an in vitro model, we identified the immediate adverse impact of RA on mouse blastocyst development. This involved an inhibition of cell proliferation and growth retardation. Using an in vivo model, we also identified the resorption of postimplanted blastocysts that had been treated with excess RA. Analysis of RA-mediated gene induction was also included. The retinoic acid receptors RARalpha and RARgamma were constitutively expressed in the blastocyst and the inner cell mass, whereas RARbeta was induced upon RA treatment. CONCLUSIONS: This is the first evidence to show the impacts of RA on mouse blastocysts in vitro and any carry-over effects in the uterus. There is a retardation of early postimplantation blastocyst development and then subsequent blastocyst death. Our findings also show that there is some degree of selective induction of retinoic acid receptors when excess RA is administered to the blastocysts.

Preemptive analgesia installation during gynecologic laparoscopy: a randomized trial.

STUDY OBJECTIVE: To evaluate the efficacy of intraoperative infusion of bupivacaine solution for the relief of pain after operative gynecologic laparoscopy. DESIGN: Prospective, double-blind, randomized, controlled trial (Canadian Task Force classification I4). SETTING: Tertiary teaching hospital. PATIENTS: Ninety-one women aged 16 to 69 years who underwent gynecologic laparoscopic surgery from November 2002 through November 2003. INTERVENTIONS: Group A (n = 30): intraperitoneal infusion of a mixture of 10 mL of 0.5% bupivacaine (50 mg) with epinephrine (1:500) in 40 mL of Ringer's lactate solution postoperatively. Group B (n = 30): the same mixture solution infusion preoperatively and postoperatively (total 100 mg bupivacaine). Group C (n = 31): placebo. MEASUREMENTS AND MAIN RESULTS: Shoulder tip pain (STP), abdominal parietal pain (APP), and abdominal visceral pain (AVP) were recorded on a visual analog scale at 2, 4, 8, 16, and 24 hours postoperatively. A total of 79 patients fulfilled the study criteria. The overall incidence of STP was 60.8%. Abdominal visceral pain in group B was significantly less than in group C at 2 and 4 hours postoperatively (p = .011 and p = .010, respectively). No statistically significant difference was found in length of hospital stay, postoperative meperidine consumption, or side effects. CONCLUSION: Intraperitoneal bupivacaine administration both immediately after placement of trocars and at the end of surgery was found to be effective in reducing the intensity of AVP but not in reducing STP, APP, or postoperative analgesia consumption after nonadvanced gynecologic laparoscopic procedures. The duration of the analgesic effect of bupivacaine instilled into the peritoneal cavity did not exceed 8 hours and probably was not dose related.

Combination of a tension-free vaginal tape procedure and laparoscopic-assisted vaginal hysterectomy for the treatment of benign uterine disease associated with stress urinary incontinence.

BACKGROUND: Women undergoing hysterectomy for benign uterine disease (BUD) may experience stress urinary incontinence (SUI). We performed tension-free vaginal tape (TVT) procedure and laparoscopic-assisted vaginal hysterectomy (LAVH) simultaneously and assessed the feasibility and efficacy of TVT performed under general anesthesia and the resultant anti-incontinence effects following the combined procedures. METHODS: Between March, 2000 and March, 2002 inclusively, 63 patients, who suffered from both BUD and SUI, underwent LAVH and TVT. Preoperative evaluation included history-taking, physical examination and ultrasonography. One-hour pad test, multichannel urodynamics and urinary questionnaire were conducted preoperatively and postoperatively. Details about surgical procedures undertaken, hospitalization and urinary problems in the follow-up period were recorded. RESULTS: 50 patients completed the study with a mean follow-up period of 34 (25-48) months. The mean age was 49 (39-67) years and mean parity 3 (2-6). The mean surgical duration was 163 (95-240) minutes and blood loss 284 (100-1,500) milliliters. Mean duration of hospital stay was 5.5 days and bladder drainage 1.9 days. Three patients suffered bladder perforation and one patient was complicated with excess blood loss. Postoperative urinary problems included transient urine retention, de novo frequency/urgency symptoms and voiding difficultly. CONCLUSIONS: The efficacy of concomitant TVT in LAVH procedure remained satisfactory in treatment of SUI associated with BUD. Both procedures reflect the benefits of less-invasive surgery. So the combination of LAVH and TVT is probably a good alternative for the patient who needs to undergo hysterectomy and anti-incontinence surgery simultaneously.

Effects of retinoic acid on the inner cell mass in mouse blastocysts.

This is the first evidence that excess retinoic acid has a direct cellular response from proliferation to cell death (apoptosis) and affects in vitro development in mouse inner cell mass.

Management of polypropylene mesh erosion after intravaginal midurethral sling operation for female stress urinary incontinence.

The intravaginal midurethral sling operations have become a trend to treat female stress urinary incontinence. Cases of complications requiring surgical revision are rarely reported. We report on seven patients with complications necessitating surgery. Six patients with vaginal erosion were treated with transvaginal excision of migrated tape and fibrotic tissues around the vaginal wall, and one patient with bladder erosion was treated with suprapubic minimal laparotomy and transvaginal partial excision of the tension-free vaginal tape (TVT). The incidence of polypropylene mesh erosion was 1.1% in this study. All patients recovered well from our surgical intervention, except the bladder erosion patient who needed anticholinergic medication to treat postoperative urgency and urge incontinence.

The role of the preoperative serum carcinoembryonic antigen level in early-stage adenocarcinoma of the uterine cervix.

OBJECTIVE: The purpose of the study was to identify the relationship between preoperative serum levels of carcinoembryonic antigen (CEA) and clinicopathological variables in early-stage adenocarcinoma of the uterine cervix. METHODS: From February 1990 to August 2002, 117 patients with surgically treated early-stage cervical adenocarcinoma that had had preoperative serum CEA evaluations were retrospectively reviewed. The cut-off value for CEA, based on the manufacturer's recommendations, was 5 ng/ml. For an evaluation of the relationship between the clinicopathological factors and increased levels of serum tumor markers, the Chi-Square/Fisher's exact test and logistic regression were used for univariate and multivariate analysis, respectively. RESULTS: The mean age of the patients was 46 years (range, 21-78). Of the 117 patients, 28 had preoperative serum CEA levels greater than 5 ng/ml. In a univariate analysis, the increased marker was associated with a larger tumor size, presence of lymphovascular invasion, and deeper cervical wall invasion. However, in a multivariate analysis, the preoperative CEA level had a significant impact on the determination of the depth of stromal invasion (OR 4.12, 95% CI 1.97-8.68, P < 0.001). CONCLUSION: In early-stage cervical adenocarcinoma, preoperative serum CEA levels seem to be useful in estimating the depth of cervical stromal invasion. Assessment of tumor antigen CEA levels should be integrated with the routine examination in the work-up of patients with adenocarcinoma of the uterine cervix.