Tratamiento combinado con metotrexate sistémico y resección histeroscópica en un caso de embarazo ectópico cervical / Combined treatment with sistemic methotrexate and hysteroscopic resection in a case of cervical ectopic pregnancy

El embarazo ectópico cervical es un cuadro de muy baja frecuencia y sumamente peligroso por la posibilidad de penetración de la pared por el trofoblasto hacia las arterias uterinas con compromiso de la vida de la paciente por hemorragia incontrolable y de su fertilidad futura cuando el único recurso terapéutico es la histerectomía. En la actualidad y gracias a la disponibilidad de recursos que permiten un diagnóstico precoz, son las técnicas no quirúrgicas las que constituyen la primera línea terapéutica. Se presenta el caso de una paciente de 30 años con diagnóstico de esterilidad primaria que ingresa al programa de ART, se realiza un ICSI por factor masculino que resulta en un embarazo bioquímico. Dos ciclos más tarde y durante la evaluación previa al comienzo de un nuevo ciclo luego de tratamiento con acetato de noretisterona por spotting se realiza el diagnóstico ecográfico de embarazo ectópico cervical. Fue tratada con metotrexate sistémico y al presentar sangrado se procedió a su resección por vía histeroscópica con éxito (AU)

Tratamiento combinado con metotrexate sistémico y resección histeroscópica en un caso de embarazo ectópico cervical / Combined treatment with sistemic methotrexate and hysteroscopic resection in a case of cervical ectopic pregnancy

El embarazo ectópico cervical es un cuadro de muy baja frecuencia y sumamente peligroso por la posibilidad de penetración de la pared por el trofoblasto hacia las arterias uterinas con compromiso de la vida de la paciente por hemorragia incontrolable y de su fertilidad futura cuando el único recurso terapéutico es la histerectomía. En la actualidad y gracias a la disponibilidad de recursos que permiten un diagnóstico precoz, son las técnicas no quirúrgicas las que constituyen la primera línea terapéutica. Se presenta el caso de una paciente de 30 años con diagnóstico de esterilidad primaria que ingresa al programa de ART, se realiza un ICSI por factor masculino que resulta en un embarazo bioquímico. Dos ciclos más tarde y durante la evaluación previa al comienzo de un nuevo ciclo luego de tratamiento con acetato de noretisterona por spotting se realiza el diagnóstico ecográfico de embarazo ectópico cervical. Fue tratada con metotrexate sistémico y al presentar sangrado se procedió a su resección por vía histeroscópica con éxito

Low-dose aspirin treatment improves ovarian responsiveness, uterine and ovarian blood flow velocity, implantation, and pregnancy rates in patients undergoing in vitro fertilization: a prospective, randomized, double-blind placebo-controlled assay.

OBJECTIVE: To determine the effects of low-dose aspirin on ovarian response, uterine and ovarian blood flow velocity, and implantation and pregnancy rates in patients undergoing IVF. DESIGN: Prospective, randomized, double-blind placebo-controlled assay. SETTING: Department of Reproductive Medicine, CER Medical Institute, Buenos Aires, Argentina. PATIENT(S): Two hundred ninety-eight infertile patients (mean [+/- SDI age, 35.6+/-4.09 years) undergoing IVF cycles. INTERVENTION(S): In the treatment group, 149 patients underwent controlled ovarian hyperstimulation and received a daily dose of 100 mg of aspirin. In the control group, 149 patients underwent controlled ovarian hyperstimulation in association with placebo. MAIN OUTCOME MEASURE(S): Number of follicles, number of oocytes retrieved, serum E2 levels, uterine and ovarian pulsatility index, cancellation rate, number of embryos transferred, and implantation and pregnancy rates. RESULT(S): There were statistically significant differences between the treatment group and the control group, respectively, in the number of follicles (19.8+/-7.2 versus 10.2+/-5.3), number of oocytes retrieved (16.2+/-6.7 versus 8.6+/-4.6), serum E2 levels (2,923.8+/-1,023.4 versus 1,614.3+/-791.7 pg/mL), uterine pulsatility index (1.22+/-0.34 versus 1.96+/-0.58), ovarian pulsatility index (1.18+/-0.31 versus 1.99+/-0.56), pregnancy rate (45% versus 28%), and implantation rate (17.8% versus 9.2%). CONCLUSION(S): Low-dose aspirin treatment significantly improves ovarian responsiveness, uterine and ovarian blood flow velocity, and implantation and pregnancy rates in IVF patients.

Pregnancy after human donor oocyte cryopreservation and thawing in association with intracytoplasmic sperm injection in a patient with ovarian failure.

OBJECTIVE: To describe a pregnancy after human donor oocyte cryopreservation in association with intracytoplasmic sperm injection in a patient with ovarian failure. SETTING: Department of Reproductive Medicine, CER Medical Institute, Buenos Aires, Argentina. PATIENT: A 48-year-old patient with ovarian failure. RESULTS: Ten donated oocytes were cryopreserved. Survival after thawing was 30%. Three oocytes were microinjected, and two embryos were obtained. The fertilization rate was 66%, and embryo development was 100%. Both embryos were transferred to a patient who had received hormonal replacement therapy. The attempt was successful, and a pregnancy was achieved after the transfer. CONCLUSION: In association with intracytoplasmic sperm injection, an adequate technique of freezing and thawing of human oocytes might achieve encouraging results in ART programs.

Male immunologic infertility: sperm performance on in vitro fertilization.

OBJECTIVE: To analyze sperm performance in a group of patients with male immunologic infertility treated with IVF-ET. DESIGN: Retrospective clinical study. SETTING: Patients attending a private IVF clinic. PATIENT(S): The study group comprised seven men with significant levels of surface-bound antisperm antibodies treated in nine IVF cycles. The control group comprised nine couples with female tubal infertility and no indication of male factor infertility treated on the same cycle. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Fertilization rate, early embryonic development, implantation, and clinical pregnancy rate (PR). RESULT(S): Forty-six (44.2%) of 104 inseminated oocytes were fertilized in the study group compared with 65 (84.4%) of 77 in the control group, which was a significant difference. Surface-bound antisperm antibodies significantly inhibited early embryonic cleavage in the study group (13 [28.3%] of 46 embryos with at least 3 blastomeres) compared with the control group (41 [63.1%] of 65 embryos, with at least 3 blastomeres). The percentage of good-quality embryos (grades 1 and 2) was similar in the study and control groups (71.7% and 78.5%, respectively). The percentage of poor-quality embryos (grade 4 and two pronuclei) was higher in the study group compared with the control group (13.9% versus 9.2%, respectively); however, the difference was not significant. The implantation rate and clinical PR were lower in the study group (3% and 11%, respectively) compared with the control group (9.5% and 44%, respectively), but the difference was not statistically significant. CONCLUSION(S): The fertilization rate and early embryonic cleavage of human embryos was found to be reduced significantly in patients with high levels of surface-bound antisperm antibodies. Moreover, embryonic quality and the PR may be compromised by the presence of significant levels of surface-bound antisperm antibodies.

Interleukin-1 beta levels in human embryo culture supernatants and their predictive value for pregnancy.

Interleukin 1 (IL-1) is possibly one factor produced by the embryo that might have a role in the maternal immunological recognition of pregnancy. The purpose of this study was to identify an embryo-related factor suitable for prediction of pregnancy during IVF procedures. For this purpose, IL-1 beta levels were measured in 21 samples of human embryo culture-conditioned media. The average number of embryos per sample was 5 +/- 1. Simultaneously, 16 cell culture media containing 10% autologous serum but no embryos were tested as controls. IL-1 beta levels were measured using the ELISA technique, and the biological activity of IL-1 was measured by means of a C3H/HeJ mice thymocyte proliferation assay. The average IL-1 beta level +/- S.E.M. was 49 +/- 7 pg/ml in embryo culture-conditioned media and 12 +/- 2 pg/ml in controls (P < 0.001). The average IL-1 beta level in embryo culture-conditioned media from viable pregnancy cycles was 82 +/- 6 pg/ml (n = 8), while in those cases that did not result in viable pregnancies the IL-1 beta level was significantly lower (28 +/- 4 pg/ml, n = 13, P < 0.001). The IL-1 activity of embryo culture-conditioned media, measured by [3H]thymidine incorporation in thymocytes was increased, compared with control media (442 +/- 51 counts/min vs. 337 +/- 13 counts/min, P < 0.05), and the highest values corresponded to media containing those embryos that resulted in pregnancies (589 +/- 41 counts/min, P < 0.01 vs. controls). We conclude that the determination of the levels of this cytokine in embryo culture-conditioned media might be a predictive parameter for pregnancies in patients undergoing IVF-ET.

Determination of IL-1 and IL-6 levels in human embryo culture-conditioned media.

PROBLEM: The aim of this study was to evaluate the presence of interleukin-1 (IL-1) and IL-6 in 24-hour human embryo culture-conditioned media (HECCM) and to find any embryo-related factor(s) to predict pregnancy during IVF procedure. METHOD: IL-1 beta and IL-6 levels were measured in 36 samples of HECCM and 17 cell culture medial that had not been exposed to embryos, which were used as controls. Both cytokine levels were measured by the ELISA technique, using commercially available kits. RESULTS AND CONCLUSIONS: We found an average IL-1 beta level +/- SEM of 82 +/- 4 pg/ml (n = 11) in HECCM from viable pregnancies and a significantly lower value, 14 +/- 2 pg/ ml (n = 25, P < 0.001), in HECCM from embryos that did not lead to viable pregnancies. In control medial the average IL-1 beta level was 11 +/- 1 pg/ml (n = 17), (P < 0.001 vs. HECCM from viable pregnancies). In contrast IL-6 levels were undetectable in all samples analyzed. Judging by our results we suggest that measurement of IL-1 level in HECCM could be a useful parameter for predicting implantation in techniques of assisted reproduction.

Citoquinas embrionarias y su posible uso como parámetro predictivo en técnicas de IVF / Embryonic cytokines and its possible use as prediction parameter in IVF techniques

El objetivo del presente trabajo fue evaluar los niveles de IL-1 e IL-6 en sobrenadantes de distinto número de embriones humanos de 24 horas en relación con la viabilidad de los embarazos, con el fin de determinar su posible utilidad como test predictivo en las prácticas de fertilización asistida. Para ello se analizaron 36 muestras de medios condicionados de cultivo de embriones humanos (MCCEH) de 24 horas y 17 medios controles (medios de cultivo igualmente adicionados con 10 por ciento de suero autólogo pero sin contacto con embriones). Se observó que los MCCEH de embriones que luego de ser transferidos produjeron embarazos viables tuvieron los valores más altos de IL-1b (82 ñ 4 pg/ml, n=11) con respecto a aquellos que no produjeron embarazos viables (14 ñ 2 pg/ml, n=25) p<0,001 y significativamente mayores a los medio controles (11 ñ 1 pg/ml, n=17). Estas diferencias en los niveles de IL-1ß fueron igualmente significativas al analizar los resultados obtenidos de acuerdo al número de embriones por muestra. La evaluación de los niveles de IL-6 sin embargo no dio resultados comparables a los obtenidos en la determinación de IL-1ß, puesto que los valores hallados fueron extremadamente bajos (= 20 pg/ml). Estos resultados indican que la determinación de los niveles de IL-1ß en MCCEH podría ser un buen parámetro predictivo en pacientes sometidas a técnicas de fertilización asistida (AU)

Citoquinas embrionarias y su posible uso como parámetro predictivo en técnicas de IVF / Embryonic cytokines and its possible use as prediction parameter in IVF techniques

El objetivo del presente trabajo fue evaluar los niveles de IL-1 e IL-6 en sobrenadantes de distinto número de embriones humanos de 24 horas en relación con la viabilidad de los embarazos, con el fin de determinar su posible utilidad como test predictivo en las prácticas de fertilización asistida. Para ello se analizaron 36 muestras de medios condicionados de cultivo de embriones humanos (MCCEH) de 24 horas y 17 medios controles (medios de cultivo igualmente adicionados con 10 por ciento de suero autólogo pero sin contacto con embriones). Se observó que los MCCEH de embriones que luego de ser transferidos produjeron embarazos viables tuvieron los valores más altos de IL-1b (82 ñ 4 pg/ml, n=11) con respecto a aquellos que no produjeron embarazos viables (14 ñ 2 pg/ml, n=25) p<0,001 y significativamente mayores a los medio controles (11 ñ 1 pg/ml, n=17). Estas diferencias en los niveles de IL-1ß fueron igualmente significativas al analizar los resultados obtenidos de acuerdo al número de embriones por muestra. La evaluación de los niveles de IL-6 sin embargo no dio resultados comparables a los obtenidos en la determinación de IL-1ß, puesto que los valores hallados fueron extremadamente bajos (= 20 pg/ml). Estos resultados indican que la determinación de los niveles de IL-1ß en MCCEH podría ser un buen parámetro predictivo en pacientes sometidas a técnicas de fertilización asistida

Regulation of the steroidogenic response of cultured human granulosa cells: effects of serum and 25-hydroxycholesterol.

OBJECTIVE: To examine the effect of serum and 25-hydroxycholesterol on steroidogenesis in cultured human granulosa cells from women undergoing assisted fertilization. DESIGN: Retrospective. SETTING: Private Fertility Clinic and National Research Institute. PATIENTS: Women undergoing IVF-ET or GIFT programs. RESULTS: In serum-free medium P production decreased significantly with culture time (2, 4, 6, and 8 days: 566 +/- 128, 161 +/- 50, 71 +/- 16, and 36 +/- 7 ng/mL P, respectively; conversion factor to SI unit, 3.180; mean +/- SEM). The addition of 25-hydroxycholesterol (10 micrograms/mL), a substrate for steroidogenesis, did not prevent the decrease in P levels. However, P production was greater in the presence of this substrate at all times. The presence of fetal bovine serum (10% FBS) in the cultures allowed the maintenance of 75% of P production with respect to the initial time considered (at which maximal P values are detected). Cultured granulosa cells treated with 10 ng/mL LH in the presence of FBS showed an increase in the percentage of stimulation with culture time (2, 4, and 7 days: 2.4%; 54.8%, and 55.1%, respectively). This effect was not observed when 25-hydroxycholesterol was added to the cultures. Similar results to that obtained by LH were attained when steroidogenesis was stimulated with 0.1 mM dibutyryl cyclic adenosine 3':5' monophosphate (cAMP). In addition, cAMP production in response to 100 ng/mL LH in the presence of 0.1 mM methyl-isobutyl-xanthine decreased with culture time, showing a time dependency similar to that observed for P. CONCLUSION: Our results demonstrate that the decrease in granulosa cell steroidogenic activity with culture time is inhibited by serum but not by 25-hydroxycholesterol, suggesting that other factors despite LH and cholesterol are necessary to support the luteal function.

Improvement of clinical pregnancy rate and implantation rate of in-vitro fertilization-embryo transfer patients by using methylprednisone.

A prospective non-randomized study was undertaken to test whether immunosuppression improves implantation and pregnancy rates in an in-vitro fertilization-embryo transfer (IVF-ET) programme in patients with tubal factor infertility. Treatment involved ovarian stimulation, transvaginal oocyte retrieval, IVF-ET, and assessment of short-term administration of large doses of corticosteroids (60 mg of methyl-prednisone x 4 days). When compared to the group that did not receive immunosuppressive doses of methylprednisone (group A; mean age 31.85 +/- 4.09 years), those subjects who were treated (group A2) showed a statistically significant increase in pregnancy (P < 0.01) and take home baby rate (P < 0.01). Similar results were observed in subjects who received corticosteroids in their first IVF-ET attempt (group B; mean age 34.32 +/- 4.98 years). Our results suggest that immunosuppressive doses of corticosteroids administered for a short period of time to patients undergoing IVF-ET could significantly improve the implantation and pregnancy rates. Possible mechanisms of action of corticosteroids are proposed.