Effect of estradiol on oocyte development.

OBJECTIVE: To determine whether elevated serum estradiol (E(2)) concentrations in oocyte donors affect assisted reproduction outcome. METHOD: In a retrospective cohort study of 58 consecutive oocyte donation cycles, donors were stratified into 2 groups according to E(2) concentration, group 1 (n=32; E(2)2000 pg/mL [range, 2062-6957 pg/mL]). Data were analyzed using the t test and chi(2) test. RESULTS: Donors in group 1 produced significantly less oocytes than donors in group 2 (19.3+/-1.7 vs 12.0+/-1.4; P<0.001), and recipients of oocytes from group 1 had significantly fewer numbers of embryos available for transfer (10.4+/-1.1 vs 6.4+/-0.8; P=0.003). However, the mean number (3.3) of embryos transferred and the pregnancy rate were the same in both groups. CONCLUSION: Elevated estradiol concentration in oocyte donors did not affect pregnancy outcome, suggesting that estradiol levels in donors do not affect oocyte development.

Familial aggregation of endometriosis in the Yale Series.

OBJECTIVE: To investigate the familial aggregation and the risk of endometriosis among the female relatives of women with endometriosis. We also compared the epidemiologic characteristics of women with and without family history of endometriosis. PATIENT(S): A total of 485 women with endometriosis and 197 infertile women without endometriosis underwent surgical investigation between August 1996 and February 2002. MAIN OUTCOME MEASURE(S): The relative risk of endometriosis in a first-degree relative and the association between potential risk factors was estimated by chi2 and by crude adjusted odds ratios (95% CI). RESULTS: Endometriosis was identified in 9.5% of first-degree relatives of women with endometriosis versus only 1% of controls. The odds ratio for endometriosis in a first-degree relative was 10.21 (95% CI 2.45-42.5; P<0.001). In 3.9% of cases women with endometriosis reported that their mother had been diagnosed with endometriosis and 5.6% of cases that at least one sister had been diagnosed. Compared to the control group the odds ratio for the mother having endometriosis (7.99, 95% CI 1.06-60.1) or at least one sister having (11.55, 95% CI 1.56-85.59) were significantly elevated. Among women with endometriosis who reported a family history of endometriosis, and women with endometriosis who did not report a family history of endometriosis, there were no differences in demographic characteristics, body habitus, or menstrual parameters. CONCLUSION(S): Women with endometriosis have a tenfold increased risk of endometriosis in their first-degree relatives.

Epidemiological characteristics in women with and without endometriosis in the Yale series.

OBJECTIVE: The association between demographic factors, menstrual and reproductive characteristics, and clinical profile for women with endometriosis was analyzed in a retrospective case-control study. METHODS: Over a 6-year period, 535 women with endometriosis and 200 infertile women without endometriosis, studied by laparoscopy or laparotomy, were evaluated. Information was then collected in a uniform manner from the patients' medical records. Statistical methods included chi(2) and Mann-Whitney U test. RESULTS: The factors associated with an increased risk for endometriosis include lower body weight, alcohol use (chi(2) = 8.8; P < 0.003), early menarche (chi(2) = 5.08; P < 0.024), shorter cycle length (chi(2) = 13.06; P < 0.001), and heavier menstrual cycles. Pelvic pain was present in 79.1% of women with endometriosis, dysmenorrhea in 70.2%, and dyspareunia in 49.5%. These symptoms were statistically significantly higher in comparison with the infertile women without endometriosis (P < 0.001). Moreover, we found that women with endometriosis had fewer prior pregnancies, elective abortions and ectopic pregnancies compared to women seeking care for infertility, who did not have endometriosis. Interestingly, women with endometriosis were significantly more likely to report a family history of cancer compared to women in control group (chi(2) = 78.2; P < 0.001). CONCLUSIONS: Body habitus, personal habits and menstrual characteristics are all strongly associated with the development of endometriosis. There may also be an association between family history of cancer and the development of endometriosis.

Role of gonadotropin-releasing hormone antagonists in poor responders.

OBJECTIVE: To evaluate the role of GnRH antagonists in poor-responder protocols. DESIGN: Literature review. CONCLUSION(S): The optimum stimulation protocol for poor responders is unknown. Although many IVF programs currently use GnRH antagonists for poor responders, there have been only four prospective, randomized trials comparing GnRH antagonists to alternate protocols. None of these studies had sufficient power to evaluate a difference in pregnancy rates (PRs), and in all four cases, IVF outcomes were comparable. Nevertheless, interest in the use of GnRH antagonists in poor responders has continued. GnRH antagonists may be associated with simpler stimulation protocols, lower gonadotropin requirements, reduced patient costs, and shorter downtimes between consecutive cycles. However, the greatest advantage of GnRH antagonists may lie in the ability to assess ovarian reserves immediately prior to deciding whether or not to initiate gonadotropin stimulation. The ability to respond to cycle-to-cycle variation in antral follicle counts may allow the optimization of oocyte yield and reduce cycle cancellation rates. It remains to be seen if this approach (initiating gonadotropins only in cycles where an adequate antral follicle count is present) also translates into higher clinical PRs for poor responders.

Impact of duration and dose of gonadotrophins on IVF outcomes.

In order to examine whether the duration of the follicular phase and changes in daily gonadotrophin dosages impact IVF outcome, a retrospective analysis of women who underwent oocyte retrieval and fresh embryo transfer was performed. Among the parameters assessed were the number of days of gonadotrophin stimulation, changes in the daily dosage of gonadotrophins, total ampoules of gonadotrophins, embryo implantation rates, clinical pregnancy rates and ongoing pregnancy rates. The number of days of gonadotrophin stimulation, as determined by standard follicular size criteria did not appear to influence IVF outcomes. There was no significant difference in pregnancy rates between women who were stimulated for <9 days, 10-11 days or >12 days. When grouped by amount of starting daily dose of gonadotrophins there was a significant inverse relationship between gonadotrophin requirements and pregnancy rates (P=0.02). The data suggest that the success of an IVF cycle depends on the ovaries' ability to develop follicles of the appropriate size, not the speed at which the ovaries perform this function.

p16, retinoblastoma (pRb), and cyclin D1 protein expression in human endometriotic and adenomyotic lesions.

OBJECTIVE: To investigate the expression of p16, retinoblastoma (pRb), and cyclin D1 oncoproteins in endometriomas and adenomyosis. DESIGN: Immunohistochemical study for p16, pRb, and cyclin D1 proteins in formalin-fixed paraffin-embedded endometriotic and adenomyotic tissues. SETTING: University hospital. PATIENT(S): Tissues from 25 women with endometriomas and 31 women with adenomyosis were evaluated. INTERVENTION(S): Tissue samples were collected during gynecologic surgery and confirmed by histology to have endometriosis or adenomyosis. Nuclear expression of p16, pRb, and cyclin D1 proteins was examined by immunohistochemistry. MAIN OUTCOME MEASURE(S): Distribution and intensity of immunostaining. RESULT(S): In the proliferative phase of the cycle, p16 was detected in 77% of adenomyosis tissues but in only 15% of endometriosis tissues. Moreover, in adenomyosis samples positive for p16, 100% of the adenomyotic cells expressed p16, whereas only 10%-20% of endometriosis cells from positive cases expressed p16. In contrast, pRb was detected in 28% of endometriosis cases but not in any adenomyotic tissues. Cyclin D1 was absent in both endometriotic and adenomyotic tissue samples. CONCLUSION(S): Differences in oncoprotein expression between endometriotic and adenomyotic tissues provide further evidence that the pathogenesis of endometriosis is different from that of adenomyosis.

Endometriosis associated with Stage IA clear cell ovarian carcinoma in a woman with IVF-ET treatments in the Yale Series.

A 42-year-old woman with Stage IA, grade 3 clear cell ovarian carcinoma arising within an endometrioma after multiple ovarian stimulation attempts was a unique case from a total of 900 patients who underwent laparoscopy for infertility and pelvic pain between 1996 and 2002 at Yale University. Her previous treatments included two laparoscopic cystectomies for left ovarian endometriomas and four cycles of IVF-ET that resulted in one miscarriage and two successful pregnancies. Although it has been suggested that controlled ovarian hyperstimulation may predispose to the development of ovarian cancer, more recent studies postulate a protective effect if fertility treatments ultimately result in successful pregnancy. Our unusual case serves as a reminder that clear cell adenocarcinoma may coexist with endometriosis, and that parity does not necessarily protect infertility patients against the development of ovarian cancer.

Sequential embryo assessment outperforms investigator-driven morphological assessment at selecting a good quality blastocyst.

Two selection methods (morphology-only and a sequential embryo assessment algorithm) were compared within the same IVF clinic to determine which method best identifies the embryos on day 3 that will develop into the highest quality on day 5. The sequential embryo assessment algorithm was significantly better at selecting the best embryo and selecting a blastocyst compared with the morphology-only method.

Immunohistochemical expression of p53, MDM2, and p21Waf1 oncoproteins in endometriomas but not adenomyosis.

OBJECTIVE: p53, MDM2, and p21Waf1 are oncoproteins that regulate the cell cycle. The purpose of this study was to examine the distribution of p53, MDM2, and p21Waf1 oncoprotein expression in endometriomas and in adenomyosis. METHODS: Tissue samples from 25 women with pathologically confirmed endometriomas and 31 women with pathologically confirmed adenomyosis were analyzed. Expression of p53, MDM2, and p21Waf1 oncoproteins was assessed by immunohistochemical nuclear staining. RESULTS: p53, MDM2, and p21Waf1 expression were detected in 20%, 60%, and 80% of endometrioma tissue samples, respectively. All endometrioma tissue samples expressing p53 also tested positive for both MDM2 and p21Waf1. MDM2 expression was significantly higher in the proliferative than in the secretory phase of the cycle. In contrast, all 31 adenomyosis tissue samples were negative for p53, MDM2, and p21Waf1 expression. CONCLUSION: The expression of p53, MDM2, and p21Waf1 suggests a role for these oncoproteins in the regulation of endometrioma cell growth, but not in adenomyosis.

Elevations in peritoneal fluid macrophage migration inhibitory factor are independent of the depth of invasion or stage of endometriosis.

OBJECTIVE: To quantify levels of macrophage migration inhibitory factor (MIF) in the peritoneal fluid (PF) of women with endometriosis, and to correlate these levels with the extent of disease. DESIGN: Controlled clinical study. SETTING: Academic medical center. PATIENT(S): Peritoneal fluid samples were collected during laparoscopic surgery in 60 women with endometriosis and 16 controls undergoing tubal ligation; 52 of the women with endometriosis had received no hormonal treatment in the 6 months prior to surgery, while 8 were using gonadotropin-releasing hormone (GnRH) agonists. MAIN OUTCOME MEASURE(S): Peritoneal fluid migration inhibitory factor (PF MIF) levels. RESULT(S): Women with endometriosis had significantly higher PF MIF levels (10.8 +/- 0.9 ng/mL) than controls (3.0 +/- 0.7 ng/mL). However, no correlation existed between MIF levels and the stage of disease (r = 0.05) or the depth of endometriotic invasion (r = 0.08). Moreover, treatment with a GnRH agonist did not suppress PF MIF levels. Peritoneal fluid MIF levels did not vary significantly between the proliferative and secretory phases of the cycle, and did not distinguish women with endometriosis-associated infertility from women with endometriosis-associated pain. CONCLUSION(S): Peritoneal fluid migration inhibitory factor levels are markedly elevated in women with endometriosis but are independent of the extent of disease.

Apoptosis and differential expression of apoptosis-related proteins in endometriotic glandular and stromal cells.

OBJECTIVE: Apoptosis is an important regulator of eutopic endometrial function. Endometriosis, the growth of endometrial tissue outside the uterus, could result from increased cellular proliferation or decreased apoptosis in response to appropriate stimuli. The objective of this study was to evaluate the rate of apoptosis and the expression of apoptosis-related Bcl-2 and Bax proteins in endometriotic tissues within the glandular and stromal compartments, according to the phase of the menstrual cycle and the stage of disease. METHODS: Ovarian endometriosis samples were evaluated in 75 women who had surgery at a university hospital. Apoptotic cells were detected with the use of the dUTP nick-end labeling (TUNEL) assay. Bcl-2 and Bax expression were assessed by immunohistochemical techniques. RESULTS: The percentage of apoptotic cells was significantly higher in endometriotic stromal cells (73.3%) compared with glandular cells (48%; P =.002). In contrast, the expression of the apoptosis-related proteins Bcl-2 and Bax was significantly lower in the endometriotic stroma (17.3% for both) than in the glandular epithelium (38.6% and 41.3%, respectively; P <.004). No significant menstrual cycle phase-dependent changes or endometriosis stage-related changes were observed in TUNEL, Bcl-2, or Bax positivity within ovarian endometriotic tissues. CONCLUSION: Apoptosis occurs in ovarian endometriotic lesions at significantly higher levels in the stroma than the glandular epithelium. However, Bcl-2 and Bax proteins are distributed preferentially in glandular epithelial cells. The apoptotic rate as well as Bcl-2 and Bax expression in ovarian endometriotic cells were not affected by the stage of endometriosis or the phase of the menstrual cycle.

Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case-control study.

OBJECTIVE: To investigate whether conservative surgery on ovarian endometriomas before an IVF cycle improves fertility outcomes. DESIGN: Retrospective, matched case-control study. SETTING: Two academic IVF programs. PATIENT(S): One hundred eighty-nine women with endometriomas who underwent IVF treatment: 56 women proceeded directly to IVF, and 133 first underwent conservative ovarian surgery. INTERVENTION(S): Controlled ovarian hyperstimulation and IVF-ET. MAIN OUTCOME MEASURE(S): Response to gonadotropins, fertilization, implantation, and pregnancy rates. RESULT(S): Aside from lower peak E(2) levels on the day of hCG and a higher total FSH dose in women previously operated for an endometrioma, no significant differences were found between the two groups in the different IVF variables analyzed. CONCLUSION(S): Laparoscopic cystectomy for endometriomas before commencing an IVF cycle does not improve fertility outcomes. Proceeding directly to controlled ovarian hyperstimulation in women with asymptomatic ovarian endometriomas might reduce the time to pregnancy, the costs of treatment, and the hypothetical complications of laparoscopic surgery. Conversely, conservative surgical treatment of ovarian endometriomas in symptomatic women does not impair IVF or intracytoplasmic sperm injection success rates.

Altered expression of interleukin-18 in the peritoneal fluid of women with endometriosis.

OBJECTIVE: Peritoneal fluid (PF) inflammatory factors may participate in the pathogenesis of endometriosis. The aim of this study was to investigate PF interleukin (IL)-18 levels in women with and without endometriosis. DESIGN: Controlled clinical study. SETTING: Women undergoing laparoscopy at a university hospital. PATIENT(S): Fifty women with previously untreated endometriosis, 8 women on GnRH agonists for endometriosis, and 18 control women with normal pelvic anatomy who were undergoing tubal ligation. INTERVENTION(S): Peritoneal fluid IL-18 levels as measured by ELISA. MAIN OUTCOME MEASURE(S): Peritoneal fluid IL-18 levels. RESULT(S): Peritoneal fluid IL-18 levels were significantly higher in women with previously untreated endometriosis (mean +/- SEM, 91.1 +/- 6.5 pg/mL) than in control women (59.4 +/- 2.0 pg/mL). Interestingly, women with superficial (100.0 +/- 10.2 pg/mL) and deep peritoneal implants (94.0 +/- 10.8 pg/mL) had significantly higher PF IL-18 levels than did women with endometriomas (57.8 +/- 1.8 pg/mL). Similarly, women with stage I-II endometriosis (97.3 +/- 8.0 pg/mL), but not women with stage III-IV endometriosis (74.9 +/- 9.9 pg/mL), had significantly higher PF IL-18 levels than did control women. Peritoneal fluid IL-18 levels were significantly higher in the luteal phase than in the follicular phase but did not discriminate between women with pelvic pain or infertility. CONCLUSION(S): Peritoneal fluid IL-18 is elevated in women with peritoneal, minimal- to mild-stage endometriosis.

Failed fertilization: is it predictable?

PURPOSE OF REVIEW: The purpose of this review is to critically examine the ability of screening tests to predict fertilization failure. RECENT FINDINGS: Failed fertilization occurs in 5-10% of in-vitro fertilization cycles and 2-3% of intracytoplasmic sperm injection cycles. Failed fertilization may result from impaired spermatozoa, oocyte deficiencies or defects in the in-vitro sperm/oocyte medium. In the in-vitro fertilization setting most cases are caused by male factor deficiencies, whereas failure of oocyte activation is the most common cause of failed fertilization after intracytoplasmic sperm injection. Although the standard semen analysis has limited ability to predict fertilization failure, strict sperm morphology criteria, sperm-zona binding ratios and zona pellucida induced acrosome reaction tests provide increased capacity to avoid this outcome. The quality of the semen sample on the day of oocyte retrieval and fertilization performance in previous in-vitro fertilization cycles may also guide the appropriate use of intracytoplasmic sperm injection. However, the routine use of the latter technique in cases of non-male factor infertility is contraindicated. SUMMARY: The ever improving techniques highlighted in this analysis offer improved ability to predict failed fertilization.

Increased pregnancy-associated plasma protein-A (PAPP-A) concentrations in peritoneal fluid of women with endometriosis.

PROBLEM: Pregnancy-associated plasma protein-A (PAPP-A) belongs to a group of glycoproteins isolated from extracts of human placenta. Healthy ovarian and uterine tissues are also known to express PAPP-A. We hypothesized that PAPP-A levels might also be elevated in the peritoneal fluid (PF) of women with endometriosis, and examined variations in PF PAPP-A during the menstrual cycle and with the severity of the disease. METHOD OF STUDY: PF PAPP-A were measured in 60 women with endometriosis and 38 women without endometriosis using a high-sensitivity immunofluorometric assay. RESULTS: We found that the mean level of PAPP-A was higher in PF from patients with endometriosis than controls (p = 0.003). Furthermore, significant correlation was found between the stages of endometriosis and the levels of PAPP-A in these patients (r = 0.39, p = 0.009). The concentrations of PAPP-A in PF were significantly higher in the secretory phase than the proliferative phase of the menstrual cycle in both women with and without endometriosis (p = 0.009 and P = 0.002, respectively). Finally, among the controls, women undergoing tubal ligation had significantly lower mean PF levels of PAPP-A than women with infertility or pelvic pain (p = 0.001). CONCLUSION: We conclude that PF levels of PAPP-A vary during the menstrual cycle, and are highest in the secretory phase. We also find that PF PAPP-A levels are significantly increased in women with endometriosis, and that the degree of elevation corresponds to the extent of disease.

Inverse correlation between peritoneal fluid leptin concentrations and the extent of endometriosis.

BACKGROUND: The role of leptin in reproductive processes has received increasing attention. Because leptin has intrinsic angiogenic properties, may be induced by inflammatory cytokines and induces matrix metalloproteinases, we examined peritoneal fluid (PF) leptin concentrations in women with endometriosis. METHODS: PF samples were collected from 60 women undergoing laparoscopy for endometriosis, and 18 controls undergoing tubal sterilization. Fifty of the women with endometriosis had received no prior hormonal treatment, while 10 with moderate- severe endometriosis were using GnRH agonists. RESULTS: Women with untreated endometriosis had significantly higher (mean +/- SD) PF leptin levels (34.9 +/- 7.9 ng/ml) than controls (17.9 +/- 4.1 ng/ml; P < 0.001). However, PF leptin levels were inversely correlated with the stage of disease (r = -0.62; P < 0.001). Nevertheless, women with stage III-IV endometriosis maintained significantly higher PF leptin levels (26.3 +/- 4.8 ng/ml; P < 0.001) than controls. Although PF leptin levels were significantly higher in the secretory versus proliferative phase of the menstrual cycle, they remained higher in both phases in women with untreated endometriosis. PF leptin levels in women on GnRH agonists were similar to controls. CONCLUSIONS: PF leptin levels are elevated in women with endometriosis, but inversely correlated with extent of disease. These findings suggest a potential role for leptin in the pathogenesis of peritoneal endometriosis.

Medical management of endometriosis-associated pain.

In the coming years, basic science research into the mechanisms of endometriosis development and persistence almost certainly will open new avenues for treatment. A wide armamentarium of medical therapies already exists, however. The efficacy of most of these methods in reducing endometriosis-associated pain is well established. The choice of which to use depends largely on patient preference after an appropriate discussion of risks, side effects, and cost. Typically, oral contraceptives and NSAIDs are first-line therapy because of their low cost and mild side effects (Box 6). Because of its greater potential for suppressing endometrial development, consideration should be given to prescribing a low-dose monophasic oral contraceptive continuously. If adequate relief is not obtained or if side effects prove intolerable, consideration should be given to the use of progestins (oral, intramuscular, or IUD) or a GnRH agonist with immediate add-back therapy. Progestins are less expensive, but GnRH agonists with add-back may be better tolerated. If none of these medications proves beneficial or if side effects are too pronounced, then repeat surgery is warranted. The surgery may have analgesic value and serves to reconfirm the diagnosis. Finally, if endometriosis is identified at the time of surgery, then consideration should be given to prescribing medical therapy postoperatively.

Twenty-year history of endometriosis-associated pelvic pain: too much surgery or not enough?

A 36-year-old woman with a 20-year history of endometriosis-associated pelvic pain was a unique case from a total of 700 patients with endometriosis recently evaluated at Yale University. Her previous treatments included 11 surgical procedures related to pelvic pain or endometriosis. Multiple recurrences of endometriosis were documented. Although clearly an unusual case, our patient highlights the importance of using even the most advanced surgical techniques judiciously.

Increased levels of interleukin-15 in the peritoneal fluid of women with endometriosis: inverse correlation with stage and depth of invasion.

BACKGROUND: Interleukin (IL)-15 is a novel cytokine with immunoregulatory and angiogenic properties. We compared IL-15 levels in the peritoneal fluid (PF) of women with and without endometriosis. METHODS: PF samples were obtained from 55 women with endometriosis (23 with superficial peritoneal implants, 19 with deep endometriotic implants and 13 with ovarian endometriomas). Eighteen women with normal pelvic anatomy undergoing tubal sterilization served as controls. RESULTS: PF IL-15 concentrations were increased in women with endometriosis (2.7 +/- 0.5 pg/ml) versus controls (2.1 +/- 0.3 pg/ml; P < 0.001). However, IL-15 levels were higher in women with superficial peritoneal implants (2.9 +/- 0.5 pg/ml) than women with deep endometriotic implants (2.6 +/- 0.4 pg/ml; P = 0.01) or ovarian endometriomas (2.2 +/- 0.4 pg/ml; P < 0.001). IL-15 was also higher in women with deep implants than in those with endometriomas (P < 0.05). PF IL-15 correlated inversely with both depth of invasion (r = -0.52) and the stage of endometriosis (r = -0.42). PF IL-15 levels demonstrated little variation during the menstrual cycle, and did not discriminate between women with infertility or pelvic pain. CONCLUSION: PF IL-15 levels are increased in women with endometriosis. However, IL-15 levels are inversely correlated with the depth of invasion and disease stage, suggesting a possible role for this cytokine in the early pathogenesis of endometriosis.