Testosterona e gonadotrofina coriônica humana estimulam a esteroidogênese em células da granulosa de folículo pré-ovulatório de égua?

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

A curva de regressão da gonadotrofina coriônica humana é útil no diagnóstico precoce da neoplasia trofoblástica gestacional pós-molar?

OBJETIVO: avaliar a utilidade da curva de regressão normal da gonadotrofina coriônica humana (hCG) no diagnóstico precoce de neoplasia trofoblástica gestacional pós-molar (NTG). MÉTODOS: estudo longitudinal, incluindo 105 pacientes com mola hidatiforme completa (MHC) acompanhadas no Centro de Doenças Trofoblásticas de Botucatu, entre 1998 e 2005. Os títulos da hCG sérica foram mensurados quinzenalmente em todas as pacientes. Curvas individuais de regressão da hCG das 105 pacientes foram estabelecidas. A comparação entre a curva de regressão normal estabelecida em nosso serviço com as curvas individuais da hCG foi usada no rastreamento e diagnóstico (platô/ascensão) de NTG. O número de semanas pós-esvaziamento quando a hCG excedeu o limite normal foi comparado com o número semanas em que a hCG apresentou platô/ascensão. RESULTADOS: das 105 pacientes com MHC, 80 apresentaram remissão espontânea (RE) e 25 desenvolveram NTG. Das 80 pacientes com RE, 7 (8,7%) apresentaram, inicialmente, dosagem da hCG acima do normal, mas, no devido tempo, alcançaram a remissão. Todas as 25 pacientes com NTG apresentaram desvio da curva normal da hCG em 3,8±2,5 semanas e mostraram platô ou ascensão em 8,4±2,9 semanas (p<0,001). CONCLUSÕES: a curva de regressão normal da hCG pós-molar pode ser útil para diagnóstico de NTG.

Molar Pregnancy in Adolescents

OBJECTIVE: To describe the clinical presentation of hydatidiform molar pregnancy in women under the age of 20 years. In addition, we sought to understand if this adolescent population manifests differences in clinical factors compared to an adult population that may affect outcome.STUDY DESIGN: We used a database from the New England Trophoblastic Disease Center to analyze clinical data from all women followed for molar pregnancy between 1970 and 2009 with complete follow-up information. This population was stratified by age and clinical parameters including presenting signs, molar histology and development of gestational trophoblastic neoplasia (GTN). Univariable and multivariable logistic regression was employed to discern clinical factors that associated with adolescent age. The Partners Human Research Committee approved this study.RESULTS: We identified 1,494 women diagnosed with hydatidiform mole (HM), of which 220 (14.7%) were adolescents defined as age <20 years. The most common presenting clinical signs were vaginal bleeding and an enlarged uterus compared to dates. Median gestational age at diagnosis was 13.4 weeks, not different from that in the adult population. Similarly, no difference in presenting human chorionic gonadotropin was observed between the adult and adolescent populations. Adolescents presented with a significant overrepresentation of complete mole (86% vs. 75%, p < 0.001) compared to adults. Complete mole was associated with a heightened risk of developing GTN (OR 2.6, 95% CI 1.9-3.5), and despite the association of complete mole with young maternal age, univariable analysis showed no difference in the rate of GTN observed between adolescents and adults (24% vs. 30%, p = 0.08). Multivariable analysis controlling for molar histology demonstrated that adolescent age was associated with a decreased risk of GTN (hazard ratio 0.67, 95% CI 0.48 0.93).CONCLUSION: Adolescents account for a substantial proportion of the population with HM. They commonly present with vaginal bleeding. Though this population develops a complete mole with a higher frequency than adults, adolescents appear to have a significantly decreased risk of developing GTN. (J Reprod Med 2012; 57:225-230)

Gestational Trophoblastic Neoplasia Following Molar Ectopic Pregnancy A Case Report

BACKGROUND: Ectopic molar pregnancy is a gestational trophoblastic disease (GTD) of rare occurrence and therefore not always remembered as a diagnostic possibility.CASE: We describe a case of molar ectopic pregnancy in a primiparous woman who developed gestational trophoblastic neoplasia and required chemotherapy to achieve remission.CONCLUSION This case stresses the important role of histopathologic examination in establishing a diagnosis of ectopic molar pregnancy. Moreover, close follow-up of human chorionic gonadotropin levels is required when a GTD is suspected. (J Reprod Med 2008;53:579-582)

Características das Curvas de Regressão da Gonadotrofina Coriônica Pós-mola Hidatiforme Completa

Objetivos: construir a curva de regressão do b-hCG pós-mola hidatiforme completa (MHC) com remissão espontânea e comparar com a curva de regressão pós-MHC com tumor trofoblástico gestacional (TTG). Análise comparativa da curva de regressão do b-hCG das portadoras de MHC, acompanhadas no Serviço, com a curva de regressão observada por outros autores1-3. Métodos: foi realizada avaliação clínica e laboratorial (dosagem sérica de b-hCG), na admissão e no segmento pós-molar, de todas as pacientes com MHC, atendidas entre 1990 e 1998 no Hospital das Clínicas de Botucatu - Unesp. O resultado da determinação seriada do b-hCG foi analisado em curvas log de regressão. A evolução da curva de regressão do b-hCG foi analisada e comparada em MHC com remissão espontânea e MHC com TTG numa curva log de regressão, com intervalo de confiança de 95%. A curva log de regressão do grupo de remissão espontânea foi comparada com curvas consideradas padrão1,2. Foram construídas curvas log individuais de todas as pacientes e classificadas de acordo com os quatro tipos de curva (I, II, III e IV), propostos para o seguimento pós-molar³. Resultados: 61 pacientes com MHC tiveram seguimento pós-molar completo, 50 (82%) apresentaram remissão espontânea e 11 (18%) desenvolveram TTG. No grupo de pacientes com MHC e remissão espontânea, o tempo para alcançar a normalização dos níveis do b-hCG, após o esvaziamento molar, foi até 20 semanas. As pacientes que desenvolveram TTG apresentaram desvio precoce da curva de regressão normal do b-hCG, 4 a 6 semanas após o esvaziamento molar. Nestas pacientes, a quimioterapia foi introduzida em média na 9ª semana pós-esvaziamento molar. Conclusões: a curva de regressão do b-hCG pós-MHC com remissão espontânea apresentou declínio log exponencial, semelhante ao observado por outros autores1,2, e diferente das MHC com TTG. Foram identificados três tipos de curvas de regressão do b-hCG, semelhantes aos de Goldstein³, I, II e IV, e outros dois tipos diferentes de regressão do b-hCG: V (regressão normal) e VI (regressão anormal).

Use of oocyte transfer in a commercial breeding program for mares with reproductive abnormalities

In some mares with lesions of the reproductive tract, embryo collection and survival rates are low or collection of embryos is not feasible. For these mares, oocyte transfer has been proposed as a method to induce pregnancies. In this report, a method for oocyte transfer in mares and results of oocyte transfer performed over 2 breeding seasons, using mares with long histories of subfertility and various reproductive lesions, are described.Human chorionic gonadotropin or an implant containing a gonadotropin-releasing hormone analog was used to initiate follicular and oocyte maturation. Oocytes were collected by means of transvaginal ultrasound-guided follicular aspiration. Following follicular aspiration, cumulus oocyte complexes were evaluated for cumulus expansion and signs of atresia; immature oocytes were cultured in vitro to allow maturation. The recipient's ovary and uterine tube (oviduct) were exposed through a flank laparotomy with the horse standing, and the oocyte was slowly deposited within the oviduct. Oocyte transfer was attempted in 38 mares between 9 and 30 years old during 2 successive breeding seasons. All mares had a history of reproductive failure while in breeding and embryo transfer programs. Twenty pregnancies were induced. Fourteen of the pregnant mares delivered live foals. Results suggest that oocyte transfer can be a successful method for inducing pregnancy in subfertile mares in a commercial setting..

Expression of protease nexin-1 and plasminogen activators during follicular growth and the periovulatory period in cattle

Extracellular matrix remodeling occurs during ovarian follicular development, mediated by plasminogen activators (PAs) and PA inhibitors including protease nexin-1 (PN-1). In the present study we measured expression/activity of the PA system in bovine follicles at different stages of development by timed collection of ovaries during the first follicular wave and during the periovulatory period, and in follicles collected from an abattoir. The abundance of mRNA encoding PN-1, tissue-type PA (tPA), urokinase (uPA) and PA inhibitor-1 (PAI-1) were initially upregulated by human chorionic gonadotropin (hCG) in bovine preovulatory follicular wall homogenates. PN-1, PAI-1 and tPA mRNA expression then decreased near the expected time of ovulation, whereas uPA mRNA levels remained high. PN-1 concentration in follicular fluid (FF) decreased and reached the lowest level at the time of ovulation, whereas plasmin activity in FF increased significantly after hCG. Follicles collected from the abattoir were classified as non-atretic, early-atretic or atretic based on FF estradiol and progesterone content: PN-1 protein levels in FF were significantly higher in non-atretic than in atretic follicles, and plasmin activity was correspondingly higher in the atretic follicles. No changes in PN-1 levels in FF were observed during the growth of pre-deviation follicles early in a follicular wave. These results indicate that PN-1 may be involved in the process of atresia in non-ovulatory dominant follicles and the prevention of precocious proteolysis in periovulatory follicles.

Respostas endócrinas e ovarianas associadas com o folículo dominante da primeira onda folicular em ovelhas sincronizadas com CIDR ou PGF2alfa

Os efeitos de prostaglandina (PGF2a) vs CIDR e eCG (gonadotrofina coriônica eqüina) na dinâmica folicular da primeira onda e sua relação com as concentrações plasmáticas de P4 e E2 foram investigadas em ovelhas cíclicas. Foram utilizadas 14 fêmeas ovinas da raça Bergamascia; o Grupo 1 (G1) foi submetido a duas aplicações de PGF2alfa e o Grupo 2 (G2), tratado com CIDR durante 14 dias, sendo que, no momento de sua retirada, administraram-se 500 UI de eCG. A dinâmica folicular ovariana foi monitorada por meio de ultra-som. Monitoraram-se todos os folículos > 2mm e mapeou-se sua posição diariamente, observando-se o desenvolvimento individual de cada folículo. Desde o dia anterior à aplicação da segunda dose de PGF2alfa (G1) e desde a administração de eCG (G2) até o décimo dia do ciclo estral, foram coletadas amostras de sangue para análise de P4 e E2. Houve diferença significativa nas concentrações plasmáticas de P4 e E2 entre os tratamentos. A sincronização de estro e ovulação, utilizando CIDR + 500 UI de eCG, incrementou a quantidade de folículos recrutados, além de aumentar o diâmetro máximo e a taxa de crescimento dos folículos grandes na primeira onda folicular.

Ovulation synchronization following commercial application of ultrasound-guided follicle ablation during the estrous cycle in mares

A regimen of progesterone plus estradiol (P&E) was used as a standard for ovarian synchronization to test the efficacy and evaluate the commercial application of ultrasound-guided follicle ablation as a non-steroidal alternative for ovulation synchronization in mares. Recipient mares at a private embryo transfer facility were at unknown stages of the estrous cycle at the start of the experiment on Day 1 when they were randomly assigned to an ablation group (n = 18-21 mares) or to a ME group (n = 20-21 mares). In the ablation group, mares were lightly sedated and all follicles > 10 mm were removed by transvaginal ultrasound-guided follicle aspiration. In the ME group, a combination of progesterone (150 mg) plus estradiol (10 mg) prepared in safflower oil was given daily (im) for 10 d. Two doses of prostaglandin FZ, (PGF, 10 mg/dose, im) were given 12 h apart on Day 5 in the ablation group, or a single dose on Day 10 in the ME group. Human chorionic gonadotropin (hCG, 2500 IU/mare, im) was given at a fixed time, 6 and 10 d after PGF treatment in the ablation and ME groups, respectively, with the expectation of a follicle > 30 mm at the time of treatment. In both the ablation and P&E groups, transrectal ultrasonography was done at the start of the study (Day 1) and again on the day of hCG treatment and daily thereafter to determine the presence of a CL, measure diameter of the largest follicle and detect ovulation. The mean interval from the start of the study and from PGF treatment to ovulation was shorter (P < 0.0001) in the ablation group (13.7 and 9.7 d, respectively) compared to the P&E group (22.3 and 13.2 d, respectively). Following fixed-day treatment with hCG after PGF treatment, the degree of ovulation synchronization was not different (P > 0.05) between the ablation and P&E groups within a 2-d (56 and 70%) or 4-d (83% and 90%) period. Although ultrasound-guided follicle ablation may not be practical in all circumstances, it excluded the conventional 10-d regimen of progesterone and estradiol and was considered an efficacious and feasible, non-steroidal alternative for ovulation synchronization in mares during the estrous cycle. (C 2007 Elsevier B.V. All rights reserved.

Diagnosis of 5α-reductase type 2 deficiency: Contribution of anti-Müllerian hormone evaluation

Aim: To evaluate anti-Müllerian hormone (AMH) levels in patients with clinical and molecular diagnosis of 5α-reductase 2 deficiency. Patients and methods: Data from 14 patients whose age ranged from 21 days to 29 years were analyzed according to age and pubertal stage. Sexual ambiguity was rated as Prader III in 11 patients. LH, FSH, testosterone (T), dihydrotestosterone (DHT) and AMH serum levels were measured in all but two patients, who had been previously submitted to gonadectomy; T and DHT were also measured in 20 age-matched controls. Results: Gonadotropin levels were normal in all but one patient who retained gonads (six of whom had reached puberty) and T/DHT ratio was elevated in all patients when compared to controls. All prepubertal patients had AMH levels < -1 SD for age, while most pubertal patients had AMH levels compatible with pubertal stage. Conclusions: Prepubertal patients with 5α-reductase 2 deficiency have AMH values in the lower part of the normal range. These data indicate that T does not need to be converted to DHT to inhibit AMH secretion by Sertoli cells. © Freund Publishing House Ltd., London.

Uso da suplementação de LH recombinante na estimulação ovariana com protocolos de FSH recombinante e agonistas do GnRH: Uma revisão da literatura

The purpose of this review was to assess the efficacy of recombinant LH (r-LH) supplementation for controlled ovarian stimulation in recombinant FSH (r-FSH) and GnRH-agonist (GnRH-a) protocol for IVF/ICSI cycles. Search strategies included on-line surveys of databases from 1990 to 2006. Four trials fulfilled the inclusion criteria (Lisi et al. 2002, Humaidan et al. 2004, Marrs et al. 2004, Tarlatzis et al. 2006). When the review was carried out advantages were observed for the r-LH supplementation protocol with respect to a fewer days of stimulation, a fewer total amount of r-FSH administered and a higher serum estradiol levels on the day of hCG administration. However, these differences were not observed in number of oocyte retrieved, number of mature oocytes, clinical pregnancy per oocyte retrieval, implantation and miscarriage rates. Nevertheless, more randomized controlled trials are necessary before evidence-based recommendations regarding exogenous r-LH supplementation in ovarian stimulation protocols with r-FSH and GnRH-a for assisted reproduction treatment can be provided.

O emprego de hormônio luteinizante recombinante associado ao hormônio folículo-estimulante recombinante nos protocolos de estimulação ovariana com antagonista do GnRH

The purpose of this investigation was to verify the efficacy of recombinant LH supplementation for controlled ovarian stimulation in GnRH-antagonist protocol for assisted reproductive technologies cycles. Search strategies included on-line surveys of databases from 1990 to 2006. In this review and meta-analysis, the observed advantages for the LH supplementation protocol were a higher serum estradiol levels on the day of hCG administration and a higher number of mature oocytes. However, there were no differences observed in the total amount of r-FSH administered, days of stimulation, number of oocyte retrieved, the clinical pregnancy rate per oocyte retrieval, the implantation rate and miscarriage rate. This result demonstrates that the association of r-LH with r-FSH may prevent any decrease in estradiol after antagonist administration and a significant higher number of mature oocytes was obtained. Nevertheless, additional randomized controlled trials are needed confirm these observations.

GnRH agonist versus GnRH antagonist in poor ovarian responders: A meta-analysis

The aim of this meta-analysis was to compare the efficacy of gonadotrophin antagonist (GnRH-ant) versus GnRH agonist (GnRHa) as coadjuvant therapy for ovarian stimulation in poor ovarian responders in IVF/intracytoplasmic sperm injection cycles. Search strategies included on-line surveys of databases such as MEDLINE, EMBASE and others. A fixed effects model was used for odds ratio (OR) and effect size (weighted mean difference, WMD). Six trials fulfilled the inclusion criteria (randomized controlled trials). There was no difference between GnRH-ant and GnRHa (long and flare-up protocols) with respect to cycle cancellation rate, number of mature oocytes and clinical pregnancy rate per cycle initiated, per oocyte retrieval and per embryo transfer. When the mete-analysis was applied to the two trials that had used GnRH-ant versus long protocols of GnRHa, a significantly higher number of retrieved oocytes was observed in the GnRH-ant protocols [P = 0.018; WMD: 1.12 (0.18, 2.05)]. However, when the meta-analysis was applied to the four trials that had used GnRH-ant versus flare-up protocols, a significantly higher number of retrieved oocytes (P = 0.032; WMD: -0.51, 95% CI -0.99, -0.04) was observed in the GnRHa protocols. Nevertheless, additional randomized controlled trials with better planning are needed to confirm these results.

Laser-assisted hatching of cryopreserved-thawed embryos by thinning one quarter of the zona

Laser-assisted hatching is little documented in the literature regarding its efficacy in cryopreserved-thawed (CT) embryo transfer cycles. The aim of the present study was to evaluate in a randomized manner the efficacy of thinning one quarter of the zona pellucida of CT embryos to a depth of 50-80% of the original thickness, via laser treatment (the qLZT-AH procedure), in improving implantation and pregnancy rates. Two populations were studied: population I, patients who had all their supernumerary embryos cryopreserved, regardless of their morphology, and population II, patients at risk of ovarian hyperstimulation syndrome who had all their embryos cryopreserved. Artificial and natural protocols were used for the embryo transfers. A total of 350 laser-thinned CT embryos were compared with 352 intact zona embryos. No difference in implantation or pregnancy rate was found after using qLZT-AH in either population. These findings suggest that qLZT-AH should not be routinely performed in cryopreserved embryo programmes.

Recombinant LH supplementation to recombinant FSH during induced ovarian stimulation in the GnRH-antagonist protocol: A meta-analysis

This study aims to compare the efficacy of recombinant LH (rLH) supplementation for ovarian stimulation in gonadotrophin-releasing hormone-antagonist protocol for IVF/intracytoplasmic sperm injection cycles. Search strategies included online surveys of databases. The fixed effects model was used for odds ratio (OR) and effect size (weighted mean difference, WMD). Five trials fulfilled the inclusion criteria. When the meta-analysis was carried out, advantages were observed for the LH supplementation protocol with respect to higher serum oestradiol concentrations on the day of human chorionic gonadotrophin administration (P < 0.0001; WMD: 514, 95% CI 368, 660) and higher number of mature oocytes (P = 0.0098; WMD: 0.88, 95% CI 0.21, 1.54). However, these differences were not observed in the total amount of recombinant FSH (rFSH) administered, days of stimulation, number of oocytes retrieved, the clinical pregnancy rate per oocyte retrieval, the implantation rate and miscarriage rate. This result demonstrates that the association of rLH with rFSH may prevent any decrease in oestradiol after antagonist administration and that a significantly higher number of mature oocytes was available for laboratory work. Nevertheless, it failed to show any statistically significant difference in clinically significant end-points in IVF (implantation and pregnancy rates). Additional randomized controlled trials are needed to confirm these results further. © 2007 Published by Reproductive Healthcare Ltd.