An interesting case of tripronucleate cleavage observed during live cell time-lapse imaging

Poster supported by a University Hospitals Coventry and Warwickshire PhD Fellowship, and the Centre for Reproductive Medicine.

Here, we report an interesting observation made during the first cleavage division of a tripronucleate resulting from the oocyte of a 44 year-old female undergoing standard IVF treatment, into a two-cell embryo (fig 1). Whilst conducting time lapse experiments using the Chipman Cell IQ® live cell imaging system, we recorded the fusion of the three pronuclei, followed by the formation of a “Y-shaped” centrally-located blastomere arrangement. However, rather than development into a three-cell embryo, apparent fusion of two of the blastomeres resulted in the formation of a two-cell embryo. This embryo subsequently arrested.

UHCW Research: Jaswinder Rai, Pavan Kachhwaha and Debbie Darrell

LEFTY2 inhibits endometrial receptivity by downregulating Orai1 expression and store-operated Ca2+ entry

Mol Med (2017). https://doi.org/10.1007/s00109-017-1610-9 

Early embryo development and endometrial differentiation are initially independent processes, and synchronization, imposed by a limited window of implantation, is critical for reproductive success. A putative negative regulator of endometrial receptivity is LEFTY2, a member of the transforming growth factor (TGF)-β family. LEFTY2 is highly expressed in decidualizing human endometrial stromal cells (HESCs) during the late luteal phase of the menstrual cycle, coinciding with the closure of the window of implantation. Here, we show that flushing of the uterine lumen in mice with recombinant LEFTY2 inhibits the expression of key receptivity genes, including Cox2, Bmp2, and Wnt4, and blocks embryo implantation. In Ishikawa cells, a human endometrial epithelial cell line, LEFTY2 downregulated the expression of calcium release-activated calcium channel protein 1, encoded by ORAI1, and inhibited store-operated Ca²⁺ entry (SOCE). Furthermore, LEFTY2 and the Orai1 blockers 2-APB, MRS-1845, as well as YM-58483, inhibited, whereas the Ca²⁺ ionophore, ionomycin, strongly upregulated COX2, BMP2 and WNT4 expression in decidualizing HESCs. These findings suggest that LEFTY2 closes the implantation window, at least in part, by downregulating Orai1, which in turn limits SOCE and antagonizes expression of Ca²⁺-sensitive receptivity genes.

UHCW Research: Jan J. Brosens

Hypertestosteronemia and primary infertility from a mediastinal extragonadal germ cell tumor

Case study poster on Hypertestosteronemia and primary infertility from a mediastinal extragonadal germ cell tumor from GK Dimitriadis, A Davasgaium, M Mytilinaiou, C Hewit, N Nalawade, D Sambrook and H S Randeva

RCOG statement in response to IVF postcode lottery

The number of clinical commissioning groups (CCGs) in England that offer the recommended 3 IVF cycles to eligible women under 40 has halved in the last 5 years, according to latest figures released by Fertility Fairness.

Only 12% follow national guidance, down from 24% in 2013. In contrast, the number of CCGs which have removed NHS IVF has almost doubled in the last year.

The audit of 208 CCGs also reveals the number offering just one NHS-funded IVF cycle which has risen to 61% from 49% in 2013). There are now 7 CCGs that have removed NHS IVF. In 2015, the number of CCGs offering 0 cycles lay at 1 per cent, since then this figure has tripled. 7% of CCGs are currently consulting on removing or reducing NHS fertility treatment. In addition, a league table of 17 ranked positions, so patients can see how their CCG compares to the rest of the country.

Report shows prevalence of key conditions across England

Figures released by NHS Digital provide information on the prevalence of 21 conditions, including asthma, hypertension, dementia, diabetes, and depression.

The annual report, Quality and Outcomes Framework (QOF) - Prevalence, Achievements and Exceptions Report, England 2016-17 also identifies how the prevalence of these conditions has changed since the previous year.

Loss of Endometrial Sodium Glucose Cotransporter SGLT1 is Detrimental to Embryo Survival and Fetal Growth in Pregnancy

Sci Rep. 2017 Oct 3;7(1):12612. doi: 10.1038/s41598-017-11674-3.

Embryo implantation requires a hospitable uterine environment. A key metabolic change that occurs during the peri-implantation period, and throughout early pregnancy, is the rise in endometrial glycogen content. Glycogen accumulation requires prior cellular uptake of glucose. Here we show that both human and murine endometrial epithelial cells express the high affinity Na+-coupled glucose carrier SGLT1. Ussing chamber experiments revealed electrogenic glucose transport across the endometrium in wild type (Slc5a1 +/+) but not in SGLT1 deficient (Slc5a1 -/-) mice. Endometrial glycogen content, litter size and weight of offspring at birth were significantly lower in Slc5a1 -/- mice. In humans, SLC5A1 expression was upregulated upon decidualization of primary endometrial stromal cells. Endometrial SLC5A1 expression during the implantation window was attenuated in patients with recurrent pregnancy loss when compared with control subjects. Our findings reveal a novel mechanism establishing adequate endometrial glycogen stores for pregnancy. Disruption of this histiotrophic pathway leads to adverse pregnancy outcome.

UHCW Research: Durairaj RRP and Barros FSV

EP04.37: Fetal persistent left superior vena cava: a case report and review of the literature

Ultrasound in Obstetrics & Gynecology; London50.S1 (Sep 2017): 279-279.

We present a case of a fetal persistent left superior vena cava (PLSVC). A 34-year-old primigravida underwent a successful round of in vitro fertilisation. She was normally fit and well, the only medical history to note was loop excision of transformation zone six years prior to pregnancy. She had normal booking bloods and low risk Trisomy screening. However, her PAPP-A MoM came back at 0.21. At the twenty week anomaly scan she was found to have an abnormal four chamber heart view, and so was referred to the fetal medicine department where a discordance in atrial size was found and also an abnormal three vessel view. Therefore, she was referred to a tertiary centre. Here at 22⁺⁴ the fetus was found to have PLSVC draining into the coronary sinus. There were no obvious valvar or ventricular septal defects. As no other anatomical abnormalities were detected the couple deferred the decision for invasive testing. The pregnancy is still ongoing and further fetal medicine scans have been arranged. PLSVC has a prevalence of 0.3-0.5% of the general population and is thought to arise due to an in utero failure of development of the left cardinal vein. 60% of cases are associated with intra-cardiac anomalies and 37% of cases are associated with extra-cardiac anomalies. 12.5% of cases had a chromosomal abnormality. 21% of cases with isolated PLSVC can develop coarctation, therefore, follow-up scans are necessary in utero. Survival rates for isolated PLSVC are high as often the venous blood returns to the right atrium. 

UHCW Research: L.J. Ewington and P. Parthasarathy

Measuring impact of chemotherapy upon AMH and fertility in breast cancer and lymphoma patients relative to normal controls- 5-year multicentre study

Fertility and Sterility , Volume 108 , Issue 3 , e31

Reproductive age women with malignancy have lower AMH than controls even before starting chemotherapy. Our study confirmed strong correlation between pre-chemotherapy AMH and post-chemotherapy AMH (measured at 1 and 5-year) in young women diagnosed with breast cancer.

Low/undetectable serum AMH concentration 12 months after starting chemotherapy does not exclude future pregnancy. There is an unmet need for fertility consultation and preservation in young women diagnosed with cancer.

UHCW Research: T Ghobara

Sexual health, reproductive health and HIV: a review of commissioning

This report from Public Health England outlines the findings of a 2016 survey, carried out jointly with the Association of Directors of Public Health, which aimed to gain a clear picture of the commissioning arrangements for sexual health, reproductive health and HIV services. The survey found that whilst there has been progress in improving services and the development of collaborative approaches there is also evidence of structural concerns which have the potential to impede effective commissioning. Key findings from the survey highlight the fragmentation of commissioning, barriers to access for those at greatest risk, increasing financial pressures and patient demand, and workforce concerns.

'It's like taking a bit of masculinity away from you': towards a theoretical understanding of men's experiences of infertility

Sociology of Health & Illness; Oxford39.6 (Jul 2017): 878-892.

In the UK, nearly half of all cases of infertility involve a 'male-factor'. Yet, little empirical work has explored how men as men negotiate this terrain. Three interrelated concepts; 'hegemonic masculinity', 'embodied masculinity' and the linkages between 'masculinities' and male help-seeking, provide the theoretical framework that guided a qualitative study conducted with 22 men experiencing infertility. The paper explores men's propensity to delay their help-seeking in relation to infertility despite their desire for children. It also demonstrates how, in the context of infertility, the male body can be defined as both a failed entity in itself (unable to father a child) and a subordinated social entity (unable to measure up to hegemonic ideals) that characterises men's masculine identities. The paper also illustrates how men appear willing to accept responsibility for their infertility and adopt aspects of hitherto subordinate masculine practice. This does not, however, constitute the total unravelling of well understood and accepted expressions of masculinity. Finally, the paper demonstrates how infertility is perceived as having the potential to fracture current and even future relationships. Moreover, regardless of how well men measured up to other hegemonic ideals, ultimately they can do little to counteract the threat of other (fertile) men.

UHCW Research: Tarek Ghobara

‘Vaginal seeding’ birth trend could do more harm than good, say experts

The potential benefits of vaginal seeding do not outweigh the risks, according to a group of doctors who reviewed the available evidence published in BJOG: An International Journal of Obstetrics and Gynaecology.

Vaginal seeding is the practice of exposing babies born by caesarean section to their mother’s vaginal fluids in order to expose them to bacteria that may help to build their immunity against some chronic conditions, such as asthma and allergies. This involves taking a swab of vaginal fluid and applying it to the baby’s eyes, face and skin after birth.

Immigration health surcharge: removal of assisted conception services

Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017.

As a result, from 21 August 2017, assisted conception services will no longer be included in the scope of services available for free for those who pay the immigration health surcharge. CCGs should update their online and publicly available policies in this area, to ensure potential users of these services are aware of the changes. Further information can be found in the explanatory memorandum for these regulations. 

Gene editing used to repair diseased genes in embryos

"Deadly gene mutations removed from human embryos in landmark study," reports The Guardian. Researchers have used a gene-editing technique to repair faults in DNA that can cause the often-fatal heart condition, hypertrophic cardiomyopathy.

This inherited heart condition is caused by a genetic change (mutation) in one or more genes. Babies born with hypertrophic cardiomyopathy have diseased and stiff heart muscles, which can lead to sudden unexpected death in childhood and in young athletes; often because they don't realise they have the condition and so put their heart under strain when exercising.

In this latest study researchers used a technique called CRISPR-cas9 to target and then remove faulty genes. CRISPR-cas9 acts like a pair of molecular scissors, allowing scientists to cut out certain sections of DNA. The technique has attracted a great deal of excitement in the scientific community since it was released in 2014. But as yet, there have been no practical applications for human health.

Effect of endometrial injury on reproductive outcome in assisted reproduction: An observational study

Human Reproduction. Conference: 32nd Annual Meeting of the European Society of Human Reproduction and Embryology. Finland. Conference Start: 20160703. Conference End: 20160706. 31 (pp i284), 2016. Date of Publication: July 2016.

To analyse the effect of endometrial injury before IVF or ICSI on clinical pregnancy outcome. Summary answer: Endometrial scratching performed before IVF/ICSI increased clinical pregnancy outcome in the second attempt of IVF/ICSI, unlike overall comparison.

UHCW Research: Garg N.; Harthshone G.; Ghobara T.; Rai J.; Keay S.; Agarwal R.

Glucocorticoid supplementation during ovarian stimulation for IVF or ICSI

Cochrane Database Syst Rev. 2017 Mar 27;3:CD004752. doi: 10.1002/14651858.CD004752.pub2. [Epub ahead of print]

The safety and effectiveness of glucocorticoid administration in women undergoing controlled ovarian hyperstimulation for IVF/ICSI cycles (until the day of oocyte retrieval) is unclear due to the small number of studies and low event rates. Whilst glucocorticoids possible increase the clinical pregnancy rate, there may be little or no impact on live birth rate. More research is needed.

UHCW Research: S. D. Keay

Innovation In Regulation

The Human Fertilisation and Embryology Authority (HFEA) and the Human Tissue Authority (HTA) have published documents showing how their approach to regulation supports innovation.

• HFEA strategy
• HTA strategy

Reprogramming of the retinoic acid pathway in decidualizing human endometrial stromal cells

PLOS One March 2, 2017 http://dx.doi.org/10.1371/journal.pone.0173035

Upon breaching of the endometrial surface epithelium, the implanting embryo embeds in the decidualizing stroma. Retinoic acid (RA), a metabolite of vitamin A, is an important morphogen during embryonic and fetal development, although the role of the RA pathway in the surrounding decidual cells is not understood. Here we show that decidual transformation of human endometrial stromal cells (HESCs) results in profound reprogramming of the RA signaling and metabolism pathways.

UHCW Research: Jan J Brosens

Multi-Resolution Cell Orientation Congruence Descriptors for Epithelium Segmentation in Endometrial Histology Images

Medical Image Analysis. Available online 22 January 2017

It has been recently shown that recurrent miscarriage can be caused by abnormally high ratio of number of uterine natural killer (UNK) cells to the number of stromal cells in human female uterus lining. Due to high workload, the counting of UNK and stromal cells needs to be automated using computer algorithms. However, stromal cells are very similar in appearance to epithelial cells which must be excluded in the counting process. To exclude the epithelial cells from the counting process it is necessary to identify epithelial regions. There are two types of epithelial layers that can be encountered in the endometrium: luminal epithelium and glandular epithelium. To the best of our knowledge, there is no existing method that addresses the segmentation of both types of epithelium simultaneously in endometrial histology images. In this paper, we propose a multi-resolution Cell Orientation Congruence (COCo) descriptor which exploits the fact that neighbouring epithelial cells exhibit similarity in terms of their orientations. Our experimental results show that the proposed descriptors yield accurate results in simultaneously segmenting both luminal and glandular epithelium.

UHCW Research: Nasir M. Rajpoot

An altered endometrial CD8 tissue resident memory T cell population in recurrent miscarriage

Scientific Reports 7, Article number: 41335 (2017) doi:10.1038/srep41335

When trying to conceive 1% of couples have recurrent miscarriages, defined as three or more consecutive pregnancy losses. This is not accounted for by the known incidence of chromosomal aneuploidy in miscarriage, and it has been suggested that there is an immunological aetiology. The endometrial mucosa is populated by a variety of immune cells which in addition to providing host pathogen immunity must facilitate pregnancy. Here we characterise the endometrial CD8-T cell population during the embryonic window of implantation and find that the majority of cells are tissue resident memory T cells with high levels of CD69 and CD103 expression, proteins that prevent cells egress. We demonstrate that unexplained recurrent miscarriage is associated with significantly decreased expression of the T-cell co-receptor CD8 and tissue residency marker CD69. These cells differ from those found in control women, with less expression of CD127 indicating a lack of homeostatic cell control through IL-7 signalling. Nevertheless this population is resident in the endometrium of women who have RM, more than three months after the last miscarriage, indicating that the memory CD8-T cell population is altered in RM patients. This is the first evidence of a differing pre-pregnancy phenotype in endometrial immune cells in RM.

UHCW Research:, J. Brosens and S. Quenby

Ulipristal acetate, fibroids and pregnancy

Answer to the question Is there any evidence to support the use of ulipristal acetate in women with large fibroids with the aim of reducing the size of the fibroid prior to pregnancy? posted to the RCOG query bank.