Increased implantation rate after intrauterine infusion of a small volume of human chorionic gonadotropin at the time of embryo transfer: a randomized, double-blind controlled study.

PURPOSE: Intrauterine human chorionic gonadotropin (hCG) infusion at the time of embryo transfer (ET) has resulted in controversial results. We evaluated the effects of intrauterine infusion of a small volume of hCG at the time of ET in fresh and frozen-thawed cycles. METHODS: Infertile women scheduled for ET with either fresh or frozen-thawed cycles were enrolled and randomized into two groups (n = 100 each): an hCG group, who received 500 IU of hCG in 10 µL culture medium infused into the uterine cavity using a soft catheter 4 min before ET; and a control group, who received 10 µL of culture medium alone by the same technique. The primary outcome was the implantation rate. The secondary outcomes were clinical pregnancy and live birth rate. RESULTS: Two hundred infertile women aged 18-43 years, undergoing fresh or frozen-thawed ET were enrolled, regardless of any previous transfer cycles. The implantation rate was significantly higher in the hCG group compared with the control group (28.8% vs. 18.2%, p = 0.030). The clinical pregnancy rates were similar in both groups (42% vs. 30%, p = 0.077). The live birth rates were also similar (29% and 23% in the hCG and control group, respectively). CONCLUSIONS: Intrauterine infusion of a small volume of hCG at the time of ET can significantly improve the implantation rate, while the clinical pregnancy rate may only be improved in younger patients (aged < 40 years). This technique may thus be of benefit to patients undergoing clinical infertility treatment.

Outcomes of follicle-stimulating hormone priming and nonpriming in in vitro maturation of oocytes in infertile women with polycystic ovarian syndrome: a single-blinded randomized study.

BACKGROUND/AIMS: Follicle-stimulating hormone (FSH) priming has been studied in in vitro matured oocytes for oocyte maturation rate, embryo quality, and pregnancy rate with discouraging results. This study aimed to initiate FSH stimulation later, i.e. on day 6, to prolong natural endometrial priming and promote oocyte maturation. METHODS: Forty polycystic ovarian syndrome (PCOS) patients were enrolled into a single, blinded (investigator), randomized, controlled study, and randomly allocated to group 1 (no FSH priming) or group 2 (day 6 recombinant FSH priming). Oocytes were retrieved after human chorionic gonadotropin injection on day 10. After 27 or 51 h of incubation, only mature oocytes were denuded and fertilized by intracytoplasmic sperm injection. Two day 3 embryos were transferred in most patients. Rates of oocyte maturation, cleavage, and pregnancy were compared. RESULTS: The oocyte maturation rates within 51 h were 62.6 and 72.7% in groups 1 and 2, respectively (p < 0.01). The embryo cleavage rate was significantly higher in group 2 than in group 1 (77.3 vs. 63.6%, p < 0.05). The pregnancy rate was higher in group 1 than in group 2 (50 vs. 30%, p > 0.05). CONCLUSION: FSH priming is beneficial for promotion of the maturation and quality of oocytes, leading to a higher embryo cleavage rate and lower rate of pregnancy loss.

Androgens modulate the morphological characteristics of human endometrial stromal cells decidualized in vitro.

The activated androgen receptor (AR) in decidualizing human endometrial stromal cells (HESCs) regulates genes involved in cytoskeletal organization, cell motility, and cell cycle progression. Androgens also enhance the secretion of prolactin, a widely used marker of decidualized HESCs. The purpose of the present study was to investigate the direct effects of androgens on the ultrastructural changes associated with decidual transformation of HESCs. Primary HESC cultures were established and propagated, and confluent cultures were decidualized for 6 days with 8-bromoadenosine 3',5'-cyclic monophosphate (8-br-cAMP) and progesterone (P4) in the presence or absence of dihydrotestosterone (DHT). Phase-contrast image analysis demonstrated that DHT increases the shape index of decidualizing cells, which was reversed upon cotreatment with the AR antagonist flutamide. Electron microscopy demonstrated that DHT enhances many of the ultrastructural changes induced by 8-br-cAMP and P4 in HESCs. Decidualizing cells are characterized by an abundant cytoplasm, multiple cell surface projections and, unlike undifferentiated HESCs, form 2 or more cell layers. The DHT further stimulated cytoplasmic expansion, lipid droplet formation, the production of an abundant extracellular matrix, and gap junction formation in decidualized HESCs. The present study demonstrates that androgen signaling has an impact on the morphological and ultrastructural changes associated with the decidual process. Our findings show that androgens promote the development and expansion of cytoplasmic organelles and gap junctions in decidualizing HESCs. These results suggest that androgens in early pregnancy play an important role in promoting the cellular transformation associated with decidualization.

Effect of a dienogest for an experimental three-dimensional endometrial culture model for endometriosis.

The pathogenesis of endometriosis remains poorly understood at least in part because early stages of the disease process are difficult to investigate. Previous studies have proposed a three-dimensional fibrin matrix culture model to study human endometriosis. We examined the ultrastructural features of the endometriosis in this model and assessed the effect of a progestin on endometrial outgrowth and apoptosis in this culture system. Endometrial explants were placed in three-dimensional fibrin matrix culture and treated with and without various concentrations of the progestin dienogest. By the second week, endometrial gland-like formation was established in outgrowths both attached to and at a distance from the explants. These cells formed a combination of clumps and tubular monolayers surrounding a central cavity. Electron microscopy demonstrated that these cells are polarized with microvilli on the apical surface, desmosome-like structures, and basement membrane; features consistent with glandular epithelial cells. Outgrowth of endometrial stromal cells and glandular formation was impaired in response to dienogest in a dose-dependent manner. Our study shows that the human endometrial explants cultured in three-dimensional fibrin matrix establish outgrowths that ultrastructurally resemble ectopic endometrial implants. This model may provide insight into the cellular processes leading to endometriosis formation and enables screening of therapeutic compounds.

Androgen signaling in decidualizing human endometrial stromal cells enhances resistance to oxidative stress.

OBJECTIVE: To investigate the effect of androgens on the expression of genes involved in oxidative stress resistance in decidualized human endometrial stromal cells (HESCs). DESIGN: In vitro experiment. SETTING: University hospital. PATIENT(S): Premenopausal women undergoing hysterectomy for uterine fibroids. INTERVENTION(S): Human endometrial stromal cells isolated from hysterectomy specimens were decidualized with 8-bromo-cyclic adenosine monophosphate (8-br-cAMP) and P in the presence or absence of dihydrotestosterone (DHT) at various concentrations. Hydrogen peroxide was used as a source of reactive oxygen species. MAIN OUTCOME MEASURE(S): Prolactin secretion, apoptosis, FOXO1, and the free radical scavengers superoxide dismutase 2 (SOD2) and SOD1 protein expression. RESULT(S): Prolactin production was induced in HESCs in response to 8-br-cAMP and P. Dihydrotestosterone further enhanced the secretion of PRL in cells treated with 8-br-cAMP plus P. The effect of DHT was blocked by the antiandrogen flutamide. Dihydrotestosterone enhanced resistance to oxidative stress-induced apoptosis on decidualized HESCs. Moreover, DHT enhanced FOXO1 expression in parallel with increased SOD2 protein but not with SOD1. CONCLUSION(S): Androgens might play a critical role in the decidualization process at the time of embryo implantation and trophoblast invasion by promoting resistance to oxidative stress.

Efficacy of mefenamic acid and hyoscine for pain relief during saline infusion sonohysterography in infertile women: a double blind randomized controlled trial.

OBJECTIVES: To evaluate the efficacy and level of satisfaction from mefenamic acid and hyoscine when used for pain relief during saline infusion sonohysterography. STUDY DESIGN: In this double blind randomized controlled trial, 141 nulliparous women were allocated to receive 500 mg of mefenamic acid, 10mg of hyoscine or a placebo, which was packed in the same outer capsule. Saline infusion sonohysterography (SIS) was performed 30 min later by one operator. Pain and satisfaction scores were evaluated using a 10 cm visual analog scale. Baseline characteristics, pain and satisfaction scores were compared among the three groups. Pain scores were recorded before, after catheter insertion, during, immediately after, and 30 min after the procedure. RESULTS: No statistically significant differences were found in baseline characteristics, pain and satisfaction scores among the three groups. Maximum pain during SIS was 4.40 ± 3.34, 4.67 ± 3.14 and 4.85 ± 3.19 in the mefenamic acid, hyoscine and placebo groups respectively. There was a 31.1% prevalence of intrauterine abnormality and the most frequent finding was endometrial polyp. CONCLUSION: There is no benefit in using mefenamic acid and hyoscine in the prevention of pain occurring from SIS.

Intravenous nitroglycerin for controlled cord traction in the management of retained placenta.

OBJECTIVE: To determine the effect of 200 µg of intravenous nitroglycerin in the release of retained placenta by controlled cord traction. METHODS: In this randomized controlled study, 40 women with a placenta retained for 30 minutes received intravenously 200 µg of nitroglycerin or a normal saline solution before umbilical cord traction was initiated. The rates of successful removal of the retained placenta in the study (n=20) and control (n=20) groups were compared, as were blood pressure, pulse rate, blood loss, and adverse effects. RESULTS: The placenta was released in only 15% and 20% of the participants in the study and control group, respectively. The remainder of the participants required general anesthesia and manual removal of the retained placenta regardless of group assignation. Blood pressure fell in significantly more women in the study group, but there were no differences in estimated blood loss or minor adverse effects. CONCLUSION: Intravenously administered nitroglycerin did not facilitate the release of retained placenta by umbilical cord traction. However, cord traction may be performed longer than 30 minutes to attempt releasing the placenta before operative manual removal is initiated.

Comparison between sperm treated with pentoxifylline and 2-deoxyadenosine using hypo-osmotic swelling test.

OBJECTIVE: To compare the percentage of sperm tail membrane swelling under hypo-osmotic conditions between sperm treated with pentoxifylline and 2-deoxyadenosine. DESIGN: Experimental in vitro study. MATERIAL AND METHOD: Thirty normal semen samples from male partners of infertile couples were collected. After sperm preparation by two-layer Percoll gradient method, each sperm sample was divided into three specimens. Pentoxifylline and 2-deoxyadenosine were separately added into two specimens, while the third specimen was used as a control. Hypo-osmotic swelling test was performed in all specimens. Percentage of swollen spermatozoa in each specimen was evaluated. RESULTS: The mean percentage of swollen spermatozoa in the semen samples supplemented with pentoxifylline and 2-deoxyadenosine were both significantly higher than those in the control (82.8 +/- 7.7 and 83.0 +/- 9.5 vs 70.8 +/- 12.7; p < 0.001). There was no significant differences of swollen spermatozoa between pentoxifylline and 2-deoxyadenosine (p = 0.898). CONCLUSION: Addition of pentoxifylline and 2-deoxyadenosine to the sperm prepared by the two-layer Percoll gradient method can almost equally enhance the sperm membrane integrity. Therefore, it may be beneficial to add these compounds to sperm preparation for use in assisted reproduction.

Comparison of the accuracy of fetal weight estimation using clinical and sonographic methods.

OBJECTIVES: 1. To compare the accuracy of clinical and sonographic estimations of fetal weight in pregnant women. 2. To determine the contributing factors that may affect the accuracy of these two methods. STUDY DESIGN: Prospective study. MATERIAL AND METHOD: 297 pregnant women who were admitted at labor room, Siriraj Hospital during the period of January 6 to February 26, 2004 were enrolled. The fetal weight was estimated clinically by the physicians, then blindly followed by sonographic estimation within 24 hours before delivery. The mean absolute error was calculated from the absolute of the difference between the estimated fetal weight and the actual birth weight of each method. Main outcome measurements were simple error, absolute error, absolute percentage error, and accuracy within 10% of actual birth weight. RESULTS: The accuracy of clinical estimation of fetal weight was similar to sonographic estimation. The accuracy within 10% of both methods were 66.7 (95% CI 61.3, 72.0) and 65.3 (95% CI 60.1, 71.0), respectively. The estimation by both methods tend to be underestimated with the mean of absolute error 264.7 +/- 299.6 and 265.0 +/- 236.3 grams, respectively, and the mean of percentage error 9.0 +/- 9.7 and 8.6 +/- 6.9% of actual birth weight. The accuracy amongst possible contributing factors were compared and analyzed. The only one factor effect the accuracy significantly was actual birth weight < 2,500 grams in clinical estimation (P < 0.05). Sensitivity and specificity for prediction of birth weight lower than 2,500 grams was 82.6, 94.2% by clinical and 64.4, 97.6% by sonographic estimation. The positive predictive value and negative predictive value of both methods were 54.3, 98.5% and 82.9, 93.9%, respectively, while the efficacy was 93.3 and 92.6%. CONCLUSIONS: Intrapartum clinical estimation of fetal weight was accurate as sonographic estimation, while the mean of error in grams or in percentage of birth weight were indifferent. The low-birth weight influenced the accuracy of clinical estimation significantly. However, clinical estimation is good enough for screening of the low-birth weight because of its high sensitivity and negative predictive value.