BACKGROUND

Although female genital mutilation (FGM) does not feature in Judeo–Christian populations, it is estimated that, 100–140 million women in the world have undergone some form of FGM. Given the increasing diversity of the western populations, a review of specific complications of FGM is of paramount importance to practicing clinicians. The objective of this study is to report a case series of epidermal clitoral inclusion cysts after FGM in a Muslim population primarily from the Middle East.

METHODS

Between January 1998 and July 2009, 32 females underwent surgical removal of epidermal clitoral inclusion cysts in a tertiary referral university hospital. Data regarding age, clinical presentation, operation time, estimated blood loss, presence of intraoperative and post-operative complications, duration of admission to the hospital and long-term follow-up were extracted from the records.

RESULTS

There were 15 women (46.9%) with a definitive history of FGM, 14 (43.8%) did not know whether they had FGM or not and 3 (9.3%) had no history of FGM and were excluded from the analysis. The mean age of subjects was 28.1 years (range 5–91 years). All presented with increasing clitoral mass over a mean duration of 5.2 ± 4.1 years. The mean diameter of the cyst was 4.2 ± 2 cm. Regarding treatment, 28 subjects underwent surgical excision, and one underwent incision and drainage of a clitoral abscess. No short- or long-term complications occurred.

CONCLUSIONS

Clitoral cysts appear to be a more common complication of FGM than previously thought. Publication of studies that highlight the medical complications of FGM should be encouraged to advocate abandonment of the procedure.

BACKGROUND

Ovulation induction treatment with metformin, either alone or in combination with clomiphene citrate (CC), remains controversial even though previous randomized trials have examined this.

METHODS

A double blinded multi-centre randomized trial was undertaken including 171 women with anovulatory or oligo-ovulatory polycystic ovary syndrome. Women with high body mass index (BMI) > 32 kg/m² received placebo (‘standard care’) or metformin; women with BMI ≤ 32 kg/m² received CC (‘standard care’), metformin or both. Treatment continued for 6 months or until pregnancy was confirmed. Primary outcomes were clinical pregnancy and live birth.

RESULTS

For women with BMI > 32 kg/m², clinical pregnancy and live birth rates were 22% (7/32) and 16% (5/32) with metformin, 15% (5/33) and 6% (2/33) with placebo. For women with BMI ≤ 32 kg/m², clinical pregnancy and live birth rates were 40% (14/35) and 29% (10/35) with metformin, 39% (14/36) and 36% (13/36) with CC, 54% (19/35) and 43% (15/35) with combination metformin plus CC.

CONCLUSIONS

There is no evidence that adding metformin to ‘standard care’ is beneficial. Pregnancy and live birth rates are low in women with BMI > 32 kg/m² whatever treatment is used, with no evidence of benefit of metformin over placebo. For women with BMI ≤ 32 kg/m² there is no evidence of significant differences in outcomes whether treated with metformin, CC or both.

ClinicalTrials.gov number NCT00795808; trial protocol accepted for publication November 2005: Johnson, Aust N Z Journal Obstet Gynaecol 2006;46:141–145.

BACKGROUND

The rationale for double insemination is to create the opportunity for a longer fertilization period as follicle rupture may occur over a wide interval (~22–47 h) after hCG administration in ovarian hyperstimulation (OH) with intrauterine insemination (IUI) cycles. This randomized study evaluates the effectiveness of single versus double IUI in only OH cycles with multi-follicular development.

METHODS

We conducted a single center trial, 228 eligible patients were randomized for this study on the day of hCG. Only cycles with multi-follicular development without premature luteinization (progesterone levels >1 ng/ml on the day of hCG), were included in the study. Multi-follicular development has been defined as at least two dominant follicles reaching minimum ≥15 mm diameter in which one of them is >17 mm. OH cycles with more than five dominant follicles (>15 mm in diameter) were excluded from the study. In the single IUI group (Group 1 = 112 patients) IUI was applied 36 h after the hCG injection and in the double IUI group (Group 2 = 114 patients) the first IUI was performed 18 h after hCG administration and the second IUI was performed 40 h after hCG administration. The primary end-point is to compare live birth rates (LBRs) between single and double IUI arms.

RESULTS

LBRs were 10.7% (12/112 patients) in the single IUI group and 12.3% (14/114) in the double IUI group and the difference was not statistically significant (P = 0.835, OR = 1.16, 95% CI: 0.51–2.64). In the unexplained infertility group the LBR was 11.1% (5/45 patients) with single IUI and 18.4% (9/49) with double IUI (P = 0.393). In the mild male factor group this rate was 10.4% (7/67) and 7.7% (5/65) in the single and double IUI groups, respectively (P = 0.764).

CONCLUSION

Our study did not find any difference in LBRs between single and double IUI groups in OH cycles with multi-follicular development. To the best of our knowledge this is the first report with this kind of study design.

The study was registered at clinicaltrials.gov: NCT 00993902.

BACKGROUND

Soluble HLA-G (sHLA-G) has been suggested as a non-invasive marker for embryo selection to improve pregnancy rates after assisted reproduction technique (ART). Our study aimed at the identification of parameters influencing the detection of sHLA-G in embryo cultures (ECs) and at the prognostic relevance of sHLA-G in a multi-centre study.

METHODS

In total 4212 EC from 2364 cycles were randomly collected from 29 German ART centres and analysed for sHLA-G by Luminex^®-based technology.

RESULTS

Among test and culture conditions, only the cleavage stage of the embryo was identified as an independent factor for sHLA-G detection (P < 0.001). Overall, sHLA-G was significantly associated with pregnancy after ART [P < 0.001; odds ratio: 2.0 (95% CI: 1.7–2.4)], suggesting that sHLA-G testing might improve the pregnancy rate from 30 to 40%. Importantly, the sHLA-G status of embryos could be associated with pregnancy after single embryo transfer [P = 0.002; odds ratio: 3.3 (95% CI: 1.5–6.8)] doubling the probability of pregnancy rate to 26% after sHLA-G testing. The patient's age, number of transferred embryos, morphological grading [EXP(B): 4.3 (95% CI: 2.1–8.9)] of embryos and sHLA-G status [EXP(B): 2.3 (95% CI: 1.8–3.1)] were independent predictors of pregnancy, with the latter two being most powerful.

CONCLUSIONS

This study provides significant evidence that the morphological scoring system is still the best strategy for the selection of embryos but that sHLA-G might be considered as a second parameter if a choice has to be made between embryos of morphologically equal quality.

BACKGROUND

It has been claimed that the risks to the child resulting from vitrification as compared with the slow-freezing technique, may be higher owing to the high concentrations of potentially toxic cryoprotectants. We therefore retrospectively compared the obstetric and neonatal outcomes in a cohort of children born after transfer of vitrified blastocysts, fresh blastocysts and slow-frozen early cleavage stage embryos.

METHODS

All children born after transfer of vitrified blastocysts (n = 106), fresh blastocysts (n = 207) and slow-frozen early cleavage stage embryos (n = 206) during the period January 2006 to May 2008 at Fertility Center Scandinavia were included. Data on obstetric and neonatal outcomes were obtained from medical records from the antenatal and delivery clinics.

RESULTS

For singletons, there were no significant differences between the groups in gestational age, mortality or birth defects. After adjustment for parity and BMI, birthweight was significantly higher in singletons born after transfer of vitrified blastocysts as compared with after transfer of fresh blastocysts (median 3560 versus 3510 g, P = 0.0311). More singletons born after transfer of fresh blastocysts were small for gestational age compared with singletons born after transfer of vitrified blastocysts (12.1 versus 3.0%, P = 0.0085). A higher rate of major post-partum haemorrhage was observed in the vitrified blastocyst group as compared with the other two groups (25.0 versus 6.0 and 7.5%).

CONCLUSIONS

No adverse neonatal outcomes were observed in children born after transfer of vitrified, as compared with fresh blastocysts or after transfer of slow-frozen early cleavage stage embryos.

BACKGROUND

Ewing sarcoma (EWS) is a highly metastatic malignancy in young patients. Ovarian cryopreservation is often an option for fertility preservation in cancer patients of reproductive age, specifically in minors. Thus, the possibility of ovarian involvement in EWS needs to be elucidated.

METHODS

Eight patients aged 13–20 years with EWS participated in the study. Ovarian samples were fixed and prepared for light microscopy, and frozen in liquid nitrogen for RNA extraction followed by RT–PCR. Histological studies, including immunostaining for the adhesion receptor CD99, were used to detect histopathological features. Sensitive molecular methods were used to detect translocations causing the formation of tumor-specific EWS–Friend leukemia virus integration site 1 fusion gene (EWS-FLI1).

RESULTS

In seven patients, there was no evidence of EWS in the ovaries from pathological/molecular studies. However, in one patient, the RT–PCR showed the EWS translocation, although there was no pathological evidence.

CONCLUSIONS

Ovarian involvement is possible in EWS. Therefore, in patients with EWS ovarian tissue should be examined for traces of malignancy at both the pathological and molecular levels prior to the grafting of cryopreserved tissue in order to minimize the risk of reseeding the cancer.

BACKGROUND

The aim of the present study was to evaluate the implication of male factor, in terms of sperm DNA oxidation and fragmentation, and Y chromosome microdeletions in recurrent spontaneous abortion (RSA) of unknown origin in a strictly selected cohort.

METHODS

A prospective cohort study was carried out in a private university-affiliated setting. Three groups, each comprised of 30 males, were compared. The first was formed by healthy and fertile sperm donors (SD) with normal sperm parameters (control group), the second by men presenting severe oligozoospermia (SO) without RSA history, and the third by men from couples who had experienced idiopathic RSA. Frequency of Y chromosome microdeletions and mean sperm DNA fragmentation and oxidation were determined.

RESULTS

Y chromosome microdeletions were not detected in any of the males enrolled in the study. Moreover, sperm DNA oxidation measurements were not demonstrated to be relevant to RSA. Interestingly, sperm DNA fragmentation was higher in the SO group than in the RSA and the SD groups, and also higher in the RSA group compared with the SD group, but lacked an adequate predictive power to be employed as a discriminative test of RSA condition.

CONCLUSIONS

Sperm DNA features and Y chromosome microdeletions do not seem to be related to RSA of unknown origin. Other molecular features of sperm should be studied to determine their possible influence on RSA.

Clinicaltrials.gov reference: nCT00447395.

BACKGROUND

The aim of our research was to create a fertility status awareness tool (FertiSTAT) that would enable women to gain personalized guidance about reducing risks to their fertility and seeking timely fertility medical advice based on their own lifestyle and reproductive profile.

METHODS

Independent risk factors associated with female fertility impairment were identified. Associations between risk indicator and fertility status were examined in 1073 women who completed the Fertility Risk Factors Survey (FRFS) online or in pregnancy termination, antenatal or infertility clinics in the UK, consisting of the FertiSTAT indicators; 49.58% (n = 532) were currently pregnant (78.82% ≥12 weeks pregnant) and 15.66% (n = 168) were currently infertile (trying to conceive >12 or 6 months if >34 years of age).

RESULTS

Twenty-two risk factors were identified from the literature review and expert Delphi consultation. Prevalence of risk factors in the validation sample was similar to general population. Most risks were independently associated with fertility status in logistic regressions and in the expected direction. Discriminant analysis demonstrated that the set of FertiSTAT indicators could correctly classify whether women were currently pregnant or infertile [²(19) = 204.209, P < 0.001] with a correct classification rate for the overall sample of 85.8% (326/380), 91.0% (n = 243/267) for the currently pregnant and 73.5% (n = 83/113) for the currently infertile.

CONCLUSIONS

The main result was the generation of a self-administered, multifactorial tool that can enable women to get personalized fertility guidance. This research and the FertiSTAT provide foundational work for public health campaigns to increase awareness about fertility health.

BACKGROUND

This study was designed to assess the impact of different ovarian tissue transplantation sites on the follicular pool and ovarian tissue integrity after short-term grafting, since there is no consensus in the literature as to the optimal grafting site in experimental models.

METHODS

Frozen-thawed ovarian tissue from eight patients was grafted for 1 or 3 weeks to the peritoneum, inside the ovarian bursa, under the skin and into the muscle of 16 nude mice. Assessment of follicular density and follicle classification was carried out by histological analysis. Proliferative activity was evidenced by immunostaining with anti-Ki-67 antibodies, and fibrotic areas were analyzed by morphometry on histological slides.

RESULTS

One week post-transplantation, the proportion of Ki-67-positive primordial follicles was higher (20–42%) than in controls (1.7%), demonstrating follicular activation in all four sites. Despite this activation, primordial follicles were still found 3 weeks post-grafting, (34.1–66.9% of the follicle population), most of them quiescent, as indicated by the absence of Ki-67 immunostaining. Cryopreservation and grafting resulted in extensive fibrosis in the stroma. This fibrosis was significantly less pronounced in intramuscular (IM) grafts, representing 18.8% of the surface versus 44.7–60.5% for other sites, after 3 weeks of grafting.

CONCLUSIONS

All four grafting sites equally supported early follicular growth and preserved some quiescent follicles after short-term frozen-thawed human ovarian tissue transplantation. The extensive fibrosis observed does not appear to have a major impact on early follicle development, but its long-term effects must be investigated. The graft environment may be implicated in the preservation of the stroma, as suggested by a lower degree of fibrosis in the IM site.

BACKGROUND

The cystic fibrosis transmembrane conductance regulator (CFTR) plays a critical role in electrolyte and fluid transport in epithelial cells, and women with cystic fibrosis (CF), caused by CFTR gene mutations, have a higher incidence of infertility.

METHODS

In the present study, we investigated the expression of CFTR in porcine oviduct and its functional role in oviductal HCO₃^– secretion and embryo development with RT–PCR, western blot, patch-clamp, short-circuit current (I_sc), pH measurement and embryo culture.

RESULTS

RT–PCR and western blot analysis showed the expression of CFTR mRNA and protein in the oviduct with its localization demonstrated by immunohistochemstry. The whole-cell patch-clamp recording revealed a forskolin (FSK)-activated current with electrophysiological and pharmacological characteristics of CFTR. The I_sc measurement showed that FSK-stimulated an increase in the I_sc, which could be significantly reduced by CFTR inhibitor or removal of both CO₂ and HCO₃^–. pH measurement showed a FSK stimulated alkalization at the apical surface, which could be inhibited by CFTR inhibitor, indicating CFTR-mediated HCO₃^– secretion. Mouse embryo development from 2-cell to morula or blastocyst stage was significantly inhibited in the absence of HCO₃^– or when co-cultured with HCO₃^– secretion-deficient CFTR mutant cells as compared with the wild-type. RT–PCR, western blot and immunostaining showed the expression of soluble adenylate cyclase (sAC), the known HCO₃^– sensor, in embryos. Treatment with its inhibitors, 2-hydroxyestradiol and KH7, prevented the HCO₃^– dependent embryo development.

CONCLUSION

The present results suggest that CFTR-mediated oviductal HCO₃^– secretion may be vital for sAC-dependent early embryo development, a defect of which may contribute to the reduced fertility seen in women with CF.

BACKGROUND

The aim of this study was to evaluate protein expression profile and quantify the proteins present in follicular fluid (FF) samples from women with endometriosis and pregnant women without endometriosis.

METHODS

A prospective case–control study was carried out including women with Stage III or IV endometriosis (Group I) and pregnant women without endometriosis (Group II), both at the maximum age of 35 years. Women were submitted to controlled ovarian stimulation for in vitro fertilization, and FF was collected after ultrasound-guided ovarian aspiration. FF from both ovaries was pooled, and patient samples were pooled according to Group I or II. Pooled protein samples were separated and analyzed by MudPIT (multidimensional protein identification technology followed by Expression^E and label-free quantification with ProteinLynxGlobalServer 2.4v, Identity^E and Expression^E software).

RESULTS

A total of 416 proteins or randomic sequence were identified, 62 proteins differentially expressed between Groups I and II. One (1.6%) was expressed at a higher level and 36 (58.1%) were uniquely expressed in Group I, whereas 8 (12.9%) were expressed at a higher level and 17 (27.4%) were uniquely expressed in Group II. Of all these, 15 (24.2%) are related to binding, 1 (1.6%) to immune response, 8 (12.9%) to cell division, 3 (4.8%) to cellular metabolism, 16 (25.8%) to general function and 19 (30.6%) do not yet present an identified function.

CONCLUSIONS

Protein expression profiles of patients with and without endometriosis identified at least 64 proteins differentially expressed, which may be related to the physiopathology of endometriosis. These proteins may additionally be useful in determining potential biomarkers for diagnostics, as well as for therapeutic intervention in women with infertility due to endometriosis.

BACKGROUND

During implantation, the embryo adheres to the endometrium via cell adhesion molecules (CAMs) present on blastocyst trophectoderm and endometrial epithelial cells. CAMs, including integrins and extracellular matrix (ECM) ligands, are most likely regulated by hormones, cytokines and growth factors. We hypothesized first that activin A affects the adhesive properties of trophoblast cells and second that alterations in dimeric activin A levels in the uterine cavity could disrupt adhesion, thereby causing implantation failure.

METHODS

This study examined effects of activin A on trophoblast cell adhesion and measured activin A levels in secretory phase uterine washings from women with and without endometriosis (EOS). Activin receptor expression on trophoblast (HTR8) cells was examined by RT–PCR, and adhesive molecules measured by integrin antibody and cell–matrix adhesion assays. Dimeric activin A was measured (enzyme-linked immunosorbent assay) in uterine washings (14 controls and 23 EOS), and βA-subunit localization was verified in endometrial tissues.

RESULTS

Activin receptors are expressed by HTR8 cells. Activin A activated Smad2 in a concentration-dependent manner which was blocked by an activin receptor inhibitor (SB431542). Following activin A treatment (50 ng/ml for 24 h), trophoblast cell surface integrins 1 2 3 5, β1, β2, β4 and vβ5 were decreased, as was cell binding to the ECM ligands, fibronectin, collagen IV and collagen I (P < 0.05). Activin A was detected in 56.5% of EOS and 21.4% of control washings, with measured levels from 42 to 8481 pg/ml (not significantly different).

CONCLUSIONS

Decreased trophoblast CAM production and adhesion could be caused by dysregulated local activin A levels and may contribute to implantation failure. This could explain, in part, the infertility observed in women with EOS.

BACKGROUND

It has been identified that human epididymal protease inhibitor (EPPIN) plays a critical role in sperm function and male fertility. The aim of this study was to determine whether variants of the EPPIN gene are risk factors for idiopathic male infertility.

METHODS

All subjects, including 473 idiopathic infertile men and 198 fertile controls, underwent complete historical and physical examinations. Each subject donated 5 ml of peripheral blood for genomic DNA extraction and serum testosterone evaluation and an ejaculate for semen analysis. The semen analysis was performed by computer-assisted semen analysis system. The serum testosterone level was evaluated by radioimmunoassay. Four tagging single-nucleotide polymorphisms were analyzed by polymerase chain reaction–restriction fragment length polymorphism.

RESULTS

We have demonstrated a significant decreased risk of idiopathic infertility with abnormal semen parameters in association with the variant rs2231829, and an increased risk of idiopathic infertility with abnormal semen parameters in association with the variant rs11594. However, among men with normal semen parameters, there were no differences in risk for these genotypes. Furthermore, no significant differences were found for the other variants, rs6124715 and rs2227290, on the risk of male infertility with normal or abnormal semen parameters. Similar serum testosterone levels among different EPPIN genotypes were observed for each group.

CONCLUSIONS

These results suggest that different variants in the EPPIN gene may have different relationships with idiopathic male infertility and men carrying these variants have a decreased or increased risk of abnormal semen parameters associated with male infertility.