Unexplained recurrent pregnancy loss and unexplained infertility: twins in disguise.

STUDY QUESTION: Is B-cell CLL/lymphoma 6 (BCL6) endometrial expression, a surrogate biomarker of endometriosis, elevated in women with unexplained recurrent pregnancy loss (uRPL) and unexplained infertility (UI) compared to fertile subjects? SUMMARY ANSWER: Endometrial BCL6 expression is elevated to a similar degree in women with uRPL and UI compared to fertile controls. WHAT IS KNOWN ALREADY: Endometriosis has been linked to the genesis of endometrial progesterone resistance and to specific nuclear proteins, including endometrial BCL6. BCL6 overexpression (immune histologic score > 1.4) has been strongly associated with poor reproductive outcomes in IVF cycles in women with UI. Our previous data have demonstrated an accuracy of 94% for diagnosing endometriosis, and BCL6 protein is elevated in the decidua of women with uRPL. STUDY DESIGN SIZE DURATION: In this case-control study, at a tertiary university teaching hospital, 110 samples (control n = 28; uRPL n = 29; UI n = 53) from pathological archives were analyzed. Timed endometrial biopsies were obtained between 2 January 2002 and 31 December 2016. PARTICIPANTS/MATERIALS SETTING METHOD: LH-timed endometrial biopsies were obtained from women with UI, uRPL (two or more consecutive losses) and normal fertile subjects during the mid-secretory phase of the menstrual cycle. Endometrial BCL6 protein levels were compared in women with UI and uRPL and fertile controls using western blot analysis and immunohistochemistry (HSCORE). MAIN RESULTS AND THE ROLE OF CHANCE: The mean age of the uRPL group was significantly higher than the others [mean (SD)] control = 32.7 (2.6); uRPL = 35.8 (3.7); UI = 32.7 (4.4); P = 0.002, ANOVA]. Seventy-nine percent of women in both subfertile groups (uRPL and UI, 65 out of 82) displayed elevated BCL6 protein levels. From these, a subset of cases with abnormal BCL6 went to laparoscopy and endometriosis was found in 9 out of 11 cases of uRPL and in 20 out of 21 cases of UI. Median BCL6 HSCORE for controls versus uRPL and UI was significantly different [median (interquartile); control = 0.3 (0.02 to 0.5); uRPL = 3 (1.9 to 3.6); UI = 2.9 (1.6 to 3.1); P < 0.0001, Kruskal-Wallis]. A significant trend in the association between the degree of infertility (fertile, uRPL and UI) and the HSCORE level (negative, medium and high) was found (P < 0.001; x 2 for trend). Western blot of representative samples from each group demonstrated similar findings based on protein levels in the whole endometrium. After running ANCOVA analysis for age difference, the BCL6 difference among groups was still significant (P-value < 0.0001). LIMITATIONS REASONS FOR CAUTION: We studied subjects with two consecutive pregnancy losses rather than the definition adopted in Europe of three losses. The findings may lack external validity in other clinical settings (e.g. low prevalence of endometriosis). WIDER IMPLICATIONS OF THE FINDINGS: Based on the data presented here, we postulate that the degree of BCL6 expression may represent a continuum of progesterone resistance and response to inflammation that occurs in women with endometriosis, yielding different degrees of infertility, from uRPL to UI. STUDY FUNDING/COMPETING INTERESTS: This study was supported by NICHD/NIH R01 HD067721 (SLY and BAL), by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior: Grant 99999.003035/2015-08 (BAL) and by CAPES/PROAP (RFS). Two authors (BAL, SLY) have licensed intellectual property for the detection of endometriosis. Dr Bruce Lessey is an unpaid scientific Advisor for CiceroDx. The other authors report no conflict of interest.

Medical or surgical treatment before embryo transfer improves outcomes in women with abnormal endometrial BCL6 expression.

PURPOSE: To evaluate the effect of medical or surgical treatment prior to embryo transfer in women with elevated endometrial BCL6 expression and suspected endometriosis in a prospective, cohort study design at a university-associated infertility clinic. METHODS: All subjects had at least 1 year of unexplained infertility (UI) and each prospectively underwent endometrial biopsy and immunostaining for the oncogene BCL6, prior to embryo transfer during an assisted reproductive technology (ART) cycle. To be included, subjects had to have an abnormal BCL6 result, defined by elevated HSCORE ≥ 1.4. Women that were pre-treated with laparoscopy or medical suppression with GnRH agonist (depot leuprolide acetate; Lupron®, Abbvie, Inc., Chicago, IL) for 2 months were compared to a group that went untreated (controls). Endpoints included implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR), and as well as cycle characteristics. Miscarriage rate were also compared between treatment and control group. RESULTS: Women in each group had similar characteristics. Those treated by medical suppression and those undergoing laparoscopy for endometriosis had a significantly higher LBR, (5/10; 50%; 95%CI 23.7 to 76.3%) and (11/21; 52.4%; 95%CI 32.4 to 71.7), respectively, compared to controls (4/54; 7.4%; 95%CI 2.9 to 17.6). An absolute benefit of 44.2% (16/31; 95%CI 24.6 to 61.2) and a number need to treat of 3 for those that received treatment (medical suppression and laparoscopy), compared to no treatment. Miscarriages were significantly more common in the control group. CONCLUSIONS: Women with suspected endometriosis and aberrant endometrial BCL6 expression have worse reproductive outcomes following embryo transfer, including a high miscarriage rate, poor IR, and low LBR and CPR compared to cycles pre-treated with medical and surgical management.

Endometrial BCL6 testing for the prediction of in vitro fertilization outcomes: a cohort study.

OBJECTIVE: To evaluate endometrial BCL6 expression as a prognostic biomarker for IVF outcome in women with unexplained infertility (UI) before ET. DESIGN: Prospective cohort study. SETTING: University-associated infertility clinic. PATIENT(S): Women with UI for >1 year. INTERVENTION(S): We studied women with UI who underwent testing for endometrial BCL6, in an LH-timed midluteal phase biopsy and completed an IVF cycle and ET. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (PR) and live birth rate per transfer was compared for women positive or negative for BCL6 expression. An abnormal BCL6 result was defined by an histologic score (>1.4). RESULT(S): Women with normal and abnormal BCL6 and those who conceived or not had similar characteristics. Women with low levels of BCL6 expression had a significantly higher clinical PR (11/17; 64.7%; 95% confidence interval [CI] 41.3-82.6) compared with women with abnormal (high) BCL6 expression (9/52; 17.3%; 95% CI 9.3-30.8). These results yield a relative risk of 0.267 (95% CI 0.13-0.53; P=.0004) for those with normal BCL6 expression, an absolute benefit of 47.4% (95% CI 22.5-72.0). Live birth rate was also significantly higher in women with low BCL6 expression (10/17; 58.8%; 95% CI 36.0-78.4) compared with women with abnormal BCL6 expression (6/52; 11.5%; 95% CI 5.4-23.0). The relative risk was 0.19 (95% CI 0.08-0.45; P=.0002), yielding an absolute benefit of 47.3% (95% CI 21.8-67.8). CONCLUSION(S): Aberrant BCL6 expression (histologic score, >1.4) was strongly associated with poor reproductive outcomes in IVF cycles in women with UI.

Luteal phase HCG support for unexplained recurrent pregnancy loss - a low hanging fruit?

Recurrent pregnancy loss (RPL) is defined by two or more failed pregnancies and accounts for only 1-5% of pregnancy failures. Treatment options for unexplained RPL (uRPL) are limited. Previous studies suggest a link between delayed implantation and pregnancy loss. Based on this, a timely signal for rescue of the corpus luteum (CL) using human chorionic gonadotrophin (HCG) could improve outcomes in women with uRPL. This retrospective cohort study included 98 subjects with uRPL: 45 underwent 135 monitored cycles without HCG support; and 53 underwent 142 cycles with a single mid-luteal HCG injection. Based on Log-rank Mantel-Cox survival curves, miscarriage rate and time to pregnancy decreased in the HCG group (P = 0.0005). Women receiving luteal HCG support had an increased chance of an ongoing pregnancy compared with those not receiving it (RR = 2.4; 95% CI 1.4-3.6; number need to treat (NNT) = 7; 95% CI 4-18). Subjects receiving HCG support had a significant absolute risk reduction (ARR) of miscarriage (P < 0.001; ARR = 11.5%; 95% CI 3.6-19.5; NNT = 9(5-27). These data suggest restoration of synchrony and CL support improves outcomes in women with RPL. Further randomized controlled trials of luteal-phase HCG in women with RPL appears warranted.

Endometrial receptivity defects during IVF cycles with and without letrozole.

BACKGROUND: Our aim was to study ways to improve IVF success rates in women with suspected endometrial receptivity defects. METHODS: We conducted a retrospective cohort study examining the effect of letrozole (aromatase inhibitor) on integrin expression as a marker of endometrial receptivity. We compared IVF outcomes in 97 infertile women who had undergone ανß3 integrin assessment by immunohistochemistry in mid-luteal endometrial biopsies. Of 79 women undergoing standard IVF, 29 (36.7%) lacked normal integrin expression. Eighteen other women with low integrin were studied after receiving letrozole during early IVF stimulation. An independent set of ανß3 integrin-negative patients (n = 15) who had undergone repeat endometrial biopsy for integrin testing while taking letrozole were re-evaluated. RESULTS: Clinical pregnancy and delivery rates were higher in women with normal ανß3 integrin expression compared with those who were integrin negative [20/50 (40%) versus 4/29 (13.8%); P = 0.02 and 19/50 (38%) versus 2/29 (7%); P < 0.01, respectively]. In 18 women who received letrozole early in IVF, 11 conceived (61.1%; P < 0.001) compared with integrin-negative patients who did not receive letrozole. In integrin-negative women who were rebiopsied on letrozole, 66.7% reverted to normal integrin expression. Positive endometrial aromatase immunostaining using a polyclonal antibody was a common finding in infertile patients compared with controls. CONCLUSIONS: Lack of endometrial ανß3 integrin expression is associated with a poor prognosis for IVF that might be improved with letrozole co-treatment. Prospective studies are needed to confirm and extend these findings but the data suggest that aromatase expression may contribute to implantation failure in some women.

Creation of a neovagina by the Vecchietti procedure in a patient with corrected high imperforate anus.

BACKGROUND: Vaginal atresia is often associated with high imperforate anus. Because the commonly used methods of surgical vaginal creation (eg, McIndoe, intestinal segment interposition) may adversely affect urinary and fecal continence, the less-invasive Vecchietti procedure was selected for a young adult with a successfully corrected high imperforate anus. METHODS: A 21-year-old was born with a high imperforate anus, vaginal atresia, right hemi-uterus, and left renal agenesis. A colostomy was done at birth, a pull-through procedure at 9 months, and a stoma closure 3 months later. At age 13, an obstructed and dilated right hemiuterus and fallopian tube were resected. A laparoscopic version of the Vecchietti procedure was used for creation of a neovagina. RESULTS: After the patient had been in the hospital for 2 days, traction was gradually advanced every other day in the office. At 2 weeks postoperatively, the bead was removed revealing a 7-cm vagina. Further elongation was achieved using the Frank method, while continence remained intact. CONCLUSION: The Vecchietti procedure is an attractive, minimally invasive alternative for creation of a neovagina in patients at risk for compromise to their vesico-anorectal continence.

Effect of short-term diet and exercise on hormone levels and menses in obese, infertile women.

OBJECTIVE: To improve serum metabolic and endocrine measures known to influence fecundity. STUDY DESIGN: Twelve infertile, obese women were enrolled in a 12-week program of diet and exercise. Subjects underwent baseline testing for estrone (E1), estradiol (E2), testosterone (T), luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), prolactin, fasting leptin, dehydroepiandrosterone sulfate (DHEAS), C-reactive protein (CRP) and total cholesterol. Glucose and insulin levels were measured fasting and 2 hours after a 75-g glucose load. Subjects attended three 1-hour exercise sessions per week and received instructions for a 1,200- to 1,300-kcal/day diet. Serum tests and body mass index (BMI) were remeasured after 12 weeks. Intermenstrual intervals were also recorded. At 24 weeks, subjects rated compliance with diet and exercise. Main outcome measures included change in serum variables, BMI and intermenstrual interval. RESULTS: BMI, total cholesterol and E1/E2 ratio significantly decreased over 12 weeks (mean difference +/- SEM, 2.06 +/- 0.51 kg/m2, 25.91 +/- 4.33 mg/dL and 0.7 +/- 0.22, respectively). No significant differences were noted for all other measures. Ten of the 12 subjects (83%) showed menstrual improvement, with 8 becoming eumenorrheic. CONCLUSION: Favorable metabolic and menstrual changes are possible in obese, infertile women after 12 weeks of diet and exercise.

Equipoise and the duty of care in clinical research: a philosophical response to our critics.

Franklin G. Miller and colleagues have stimulated renewed interest in research ethics through their work criticizing clinical equipoise. Over three years and some twenty articles, they have also worked to articulate a positive alternative view on norms governing the conduct of clinical research. Shared presuppositions underlie the positive and critical dimensions of Miller and colleagues' work. However, recognizing that constructive contributions to the field ought to enjoy priority, we presently scrutinize the constructive dimension of their work. We argue that it is wanting in several respects.

Flexible versus rigid intrauterine insemination catheters: a prospective, randomized, controlled study.

OBJECTIVE: To prospectively compare pregnancy rates for couples undergoing IUI by a single healthcare provider with random assignment to either rigid (Tomcat; Kendall Sovereign, Mansfield, MA) or flexible (Soft Pass; Cook, Spencer, IN) catheters. DESIGN: Randomized, controlled study. SETTING: Tertiary care infertility practice. PATIENT(S): One hundred infertile women enrolled from a single infertility practice who met the inclusion and exclusion criteria for IUI were enrolled. Of the 100 patients, 95 underwent ovarian stimulation before IUI: 35 with clomiphene citrate alone, 60 with clomiphene citrate combined with a single dose of gonadotropins. INTERVENTION(S): Timed IUI was performed with either rigid (Tomcat) or flexible (Cook) insemination catheters. MAIN OUTCOME MEASURE(S): Pregnancy rate per cycle. RESULT(S): No differences were noted between groups for the following: age, length of infertility, day-3 FSH level, number of prior IUI cycles, total motile sperm count, days of abstinence, infertility diagnoses, insemination ratings, and stimulation protocols. No difference in pregnancy rates was observed between rigid and flexible catheter groups. CONCLUSION(S): There is no statistically significant difference between flexible and rigid catheters for IUI.

Assisted reproductive technology (ART) in the upstate: reducing the risks of multiple births.

Multiple pregnancies from ART procedures are all too common. Efforts to reduce high-order multiple pregnancies will require both social and medical reforms. In lieu of a legislative agenda to reduce multiple pregnancies in the United States, efforts must come from the personnel within the individual ART clinics. The approach to the problem includes accepting a lower pregnancy rate than otherwise might be obtainable, if the observed rate of high-order multiple pregnancies is above a certain threshold. Expanding the opportunities for ART reimbursement will ultimately address this problem in the United States, but until then, it is a problem that will not go away without commitment and resolve.

Rehabilitating equipoise.

When may a physician legitimately offer enrollment in a randomized clinical trial (RCT) to her patient? Two answers to this question have had a profound impact on the research ethics literature. Equipoise, as originated by Charles Fried, which we term Fried's equipoise (FE), stipulates that a physician may offer trial enrollment to her patient only when the physician is genuinely uncertain as to the preferred treatment. Clinical equipoise (CE), originated by Benjamin Freedman, requires that there exist a state of honest, professional disagreement in the community of expert practitioners as to the preferred treatment. FE and CE are widely understood as competing concepts. We argue that FE and CE offer separable and, in themselves, incomplete justifications for the conduct of clinical trials. FE articulates conditions under which the fiduciary duties of physician to patient may be upheld in the conduct of research. CE sets out a standard for the social approval of research by institutional review boards. Viewed this way, FE and CE are not necessarily competing notions, but rather address complementary moral concerns.

Will the real Charles Fried please stand up?

In response to the preceding commentary by Jerry Menikoff in this issue of the Journal, the authors argue that Fried's central concern is not that randomized clinical trials (RCTs) are conducted without consent, but rather that various aspects of the design and conduct of RCTs are in tension with physicians' duties of personal care to their patients. Although Fried does argue that the existence of equipoise cannot justify failure to obtain consent from research subjects, informed consent by itself does not supplant ill subjects' rights to personalized judgment and care embodied in Fried's equipoise.