INTRODUCTION:Cervical cytology remains a critical screening tool for cervical cancer. While various factors can influence cytology quality, the effect of lubricant type used during specimen collection has been previously studied with inconclusive results. This study aimed to evaluate the impact of surgical lubricant on cervical cytology results and elucidate risk factors associated with unsatisfactory results. We hypothesized that switching from a carbomer-containing lubricant to a noncarbomer, water-soluble lubricant would improve specimen adequacy in cervical cytology. MATERIALS AND METHODS:A retrospective chart review was performed examining patient cytologic results from January to December 2017 at a single academic institution. After historical rates of unsatisfactory cytology were higher than acceptable standards, the practice changed lubricant formulation from a carbomer containing lubricant to a noncarbomer, water soluble lubricant. Demographic data and treatment characteristics were collected for eligible patients. Matched analysis was performed to examine factors associated with an unsatisfactory cytology result. RESULTS:After the change in lubricant, there was a significant decline in the rates of unsatisfactory cytology from 9.6% to 5.7%, P = 0.01. This decline was also observed when patients were matched based on menopausal status, personal history of gynecologic malignancy, pregnancy status, and cytology specimen type (10.0% to 4.8%, P = 0.001). CONCLUSIONS:Change in lubricant from a carbomer containing to noncarbomer, water soluble product was associated with a statistically significant decline in the rates of unsatisfactory cytology. Although prior data have had mixed results as to the etiology of unsatisfactory cytology, we feel that this directly contributed to the high rates observed at our institution.

An ongoing interest in environmental exposures and female fertility has led to an increasing number of studies focusing on endocrine- disrupting chemicals (EDCs). Both natural and synthetic compounds have the ability to impact reproductive health by altering the structure and/or function of genes and proteins that facilitate normal ovarian and endometrial functions. This mini-review aims to summarize the effects of some of the most common EDCs on female fertility, including the effects of pesticides and plasticizer alternatives (phthalates, bisphenol A), based on available data in human studies. A literature search was performed using the key words " pesticides, fertility, reproduction, plasticizers, bisphenol A, phthalate, miscarriage, and in vitro fertilization."The data supporting EDCs' role in female infertility remain limited, but existing evidence suggests that exposure may have an adverse impact. Accumulating evidence in animal studies provides important insights into the mechanisms underlying EDC effects. As dose-response dynamics are better elucidated, understanding the effects of EDCs on female fertility will help in the development of guidelines for both industry and individuals. (Fertil Steril Rep (R) 2022;3:86-90. (c) 2022 by American Society for Reproductive Medicine.)

Objective: To investigate whether there is a difference in live-birth gender rates in blastocyst-stage frozen-thawed embryo transfers (FETs) compared with those in cleavage-stage FETs. Design: Retrospective cohort study. Setting: Academic medical center. Patient(s): All women with recorded live births who underwent FET at either the blastocyst or cleavage stage, reported to the Society for Assisted Reproductive Technology during 2004-2013. Intervention(s): None. Main Outcome Measure(s): The primary outcome was live-birth gender rates. Demographic criteria were also collected. The chi-square analyses were used for bivariate associations, and multiple logistic regression models were used for adjusted associations, with all twosided P< .05 considered statistically significant. Result(s): A statistically significant increase was noted in the number of live male births after blastocyst-stage FET compared with that after cleavage-stage FET (51.9% vs. 50.5%). After controlling for potential confounders including age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03, 1.08), body mass index (OR, 1.08; 95% CI, 1.04, 1.12), and male factor infertility (OR, 1.06; 95% CI, 1.03, 1.08), the increase in male live births after blastocyst-stage FET remained statistically significant. Conclusion(s): In patients undergoing FETs, blastocyst-stage transfers are associated with higher male gender live-birth rates compared with cleavage-stage transfers. (Fertil Steril Rep (R) 2021;2:161-5. (c) 2021 by American Society for Reproductive Medicine.)

Introduction Exogenous FSH administration to achieve supraphysiologic serum levels for multifollicular recruitment is a mainstay of modern invitro fertilization (IVF). Initial dosing and subsequent titration of these medications to optimize ovarian response is one of the most onerous and expensive parts of IVF for both the patient and the physician. Yet, it is still considered part of the art of assisted reproductive technology (ART), meaning there are no definitive data or clear guidelines on how to dose and titrate these medications. In addition, patient response to these medications can be unpredictable. While there are some data on excessive use of gonadotropins and detrimental Exogenous FSH is the catalyst controlling controlled ovarian stimulation (COS), with high dosing being associated with negative outcomes. A retrospective cohort study of COS cycles was performed to determine the effect dosing and BMI has on serum FSH levels and to determine if serum FSH levels are associated with changes in live birth rates. In this study, 397 GnRH suppressive cycles were analyzed. Serum FSH levels were measured every 48-72 hours throughout COS and the change (delta) in serum FSH levels from baseline was calculated. Elevated day 3 serum FSH levels were significantly associated with decreased live births (OR: 0.86; 95%CI: 0.78 0.94, p = 0.002), while antral follicle count (OR: 01.077; 95%CI: 1.028 1.128, p = 0.002), number of oocytes retrieved (OR: 1.053; 95%CI: 1.002 1.107, p = 0.04), and number of embryos transferred (OR: 1.292; 95%CI: 1.284 1.301, p < 0.001) were significantly associated with an increased birth rate. Elevated delta FSH and maximum serum FSH significantly (p < 0.001) correlated with a decrease in live births. Increased BMI significantly reduced serum FSH levels, suggesting BMI should be considered when calculating FSH dose. Overall, maximum serum FSH and elevated serum delta FSH levels were associated with lower live birth rates supporting a rationale for measuring serum FSH during COS.

In the first trimester of human pregnancy, low oxygen tension or hypoxia is essential for proper placentation and placenta function. Low oxygen levels and activation of signaling pathways have been implicated as critical mediators in the promotion of trophoblast differentiation, migration, and invasion with inappropriate changes in oxygen tension and aberrant Notch signaling both individually reported as causative to abnormal placentation. Despite crosstalk between hypoxia and Notch signaling in multiple cell types, the relationship between hypoxia and Notch in first trimester trophoblast function is not understood. To determine how a low oxygen environment impacts Notch signaling and cellular motility, we utilized the human first trimester trophoblast cell line, HTR-8/SVneo. Gene set enrichment and ontology analyses identified pathways involved in angiogenesis, Notch and cellular migration as upregulated in HTR-8/SVneo cells exposed to hypoxic conditions. DAPT, a γ-secretase inhibitor that inhibits Notch activation, was used to interrogate the crosstalk between Notch and hypoxia pathways in HTR-8/SVneo cells. We found that hypoxia requires Notch activation to mediate HTR-8/SVneo cell migration, but not invasion. To determine if our in vitro findings were associated with preeclampsia, we analyzed the second trimester chorionic villous sampling (CVS) samples and third trimester placentas. We found a significant decrease in expression of migration and invasion genes in CVS from preeclamptic pregnancies and significantly lower levels of JAG1 in placentas from pregnancies with early-onset preeclampsia with severe features. Our data support a role for Notch in mediating hypoxia-induced trophoblast migration, which may contribute to preeclampsia development.

Embryo implantation requires a receptive endometrium under the influence of tightly regulated endocrine signaling from both the embryo and the corpus luteum. Research has found that after IVF, additional support for the endometrium with exogenous progesterone improves implantation and subsequent live birth rates. The purpose of this study is to investigate the potential benefit of a short acting GnRH agonist (GnRHa), leuprolide acetate, for support of the luteal phase endometrium prior to embryo implantation in IVF. We hypothesize that GnRHa administration at time of blastocyst transfer in the mid-luteal phase of an ART cycle improves pregnancy and live birth rates. This is an interim analysis of a randomized double-blinded, placebo-controlled study conducted at a single university-affiliated institution between 2016 and 2021. Eligible women, ages 18-40 undergoing IVF with subsequent day 5 fresh ET or frozen embryo transfer (FET), were randomized to receive either a single subcutaneous injection of 40U (2g) of leuprolide acetate or saline placebo, administered on the day of embryo transfer (ET). The primary outcome was live birth rate. Biochemical pregnancy, clinical pregnancy and pregnancy loss rates were also compared. Chi-square statistical analysis was performed for comparisons between groups. To date, two hundred seventy-two cycles were included in the study, of which 103 were IVF-fresh ET and 169 were FET. One hundred thirty-nine cycles cycles were randomized to receive GnRHa at time of ET, and 133 cycles were randomized to placebo. Among fresh ET cycles, subjects receiving GnRHa had a live birth rate of 35.8% (19/53), as compared with 22% (11/50) in the placebo group (p<0.184). Pregnancy loss rate (defined as [#Clinical Pregnancies-#Live Births] /#Clinical Pregnancies) was 26.9% (7/26) in the GnRHa group vs. 45% (9/20) in the placebo group (p<0.335). Similar non-significant trends were noted in FET cycles, with a live birth rate of 39.5% (34/86) in subjects receiving GnRHa vs. 32.5% (27/83) in the placebo group (p<0.431), and a pregnancy loss rate of 15% (6/40) with GnRHa vs. 27% (10/37) with placebo (p<0.308). To our knowledge, this is the first RCT designed to evaluate the utility of leuprolide acetate at time of day 5 ET. Our interim analysis found that GnRHa at time of ET was associated with non-significant trends towards increased live birth rates and decreased pregnancy loss rates in both fresh and frozen ET cycles. This is an ongoing study. No adverse events or side effects were identified.

OBJECTIVE:To determine if women with human immunodeficiency virus (HIV) undergoing pelvic reconstructive surgery (PRS) have an increased risk of perioperative and postoperative complications compared with HIV-negative controls.STUDY DESIGN:Multicenter, retrospective matched cohort study of patients with and without HIV infection who underwent PRS between 2006 and 2016. Cases were identified using International Classification of Disease, 9th edition Clinical Modification and 10th edition Clinical Modification and current procedural terminology (CPT) codes encompassing HIV diagnoses and pelvic reconstructive surgeries. Controls were identified as patients without HIV who underwent similar procedures, performed by the same surgeon during the same 1-year period as surgeries performed on patients with HIV. Cases were matched to controls at a ratio of 1:3. The primary outcome was composite complication rate within 1 year of surgery.RESULTS:Sixty-three patients with HIV and 187 controls were identified. There was no difference in the composite complication rate between women with HIV and HIV-negative women (36.5% vs 30.0%, P = 0.15) over 1 year. However, 19.1% of patients with HIV compared with 5.4% controls had Clavien Dindo Grade I complications (P = 0.002), and 11.1% of HIV patients had urinary retention within 6 weeks of surgery compared with 3.2% of controls (P = 0.02). After multivariable logistic regression used to adjust for confounders, living with HIV was not associated with an increased risk of complications.CONCLUSIONS:Patients living with HIV are not at an increased risk of complications within 1 year of PRS compared with patients without HIV.

Interleukin-33 (IL-33) is an IL-1 family cytokine with pleiotropic effects on diverse cell types. Dysregulated IL-33 signaling has been implicated in pregnancy-related disorders, including preeclampsia and recurrent pregnancy loss, and in ovarian function in women undergoing controlled ovarian stimulation for in vitro fertilization. To date, expression of IL-33 and its receptor subunit, ST2, in the female reproductive tract remains poorly characterized. We identify IL-33-expressing oocytes surrounded by ST2-expressing granulosa cells at all stages of follicular development, in addition to IL-33+ and ST2+ non-endothelial cells in the ovarian stroma and theca layer in ovaries from adult mice. These expression patterns are similar in estrus- and diestrus-stage adults and in pubescent mice, suggesting a role for IL-33 signaling in ovarian function throughout development and in the estrous cycle. In the uterus, we find expression of IL-33 and ST2 in glandular and luminal epithelia during estrus and at the initiation of pregnancy. Uterine IL-33 expression was modulated by the estrous cycle and was reduced in pubescent females. Last, superovulation increases transcripts for IL-33 and the soluble form of ST2 (sST2) in ovaries, and for IL-33 in uteri. Collectively, our findings lay the foundation for studies identifying cell type-specific requirements for IL-33/ST2 signaling in the establishment and maintenance of mouse pregnancy.

Successful implantation requires synchronous development of the embryo and endometrium. Euploid embryos fail to implant in about ⅓ of IVF cycles, which may be attributable to a non-receptive endometrium. The endometrial receptivity array (ERA) has emerged as a diagnostic tool to identify receptive endometrium and to guide timing of embryo transfer. While studies have shown the utility of ERA testing in a natural cycle, the impact of endometrial stimulation with exogenous estrogen (E) and progesterone (P) on ERA results are not well understood. The objective of this study was to investigate whether cycle parameters obtained during a programmed endometrial stimulation cycle can predict abnormal ERA results. Retrospective cohort study. We reviewed the records of all women who underwent a mock frozen-thawed embryo transfer (FET) cycle and ERA testing (n= 88) at a university-affiliated IVF clinic from 2017-2019. All women received endometrial preparation with exogenous oral estradiol (E2). Exogenous P was administered once endometrial thickness reached ≥8 mm. Endometrial biopsy for ERA testing was performed on the sixth day of exogenous P. Study measures included patients' age, BMI, number of previous failed embryo transfers, maximum (max) serum P level, max P dose, max endometrial thickness (MET), duration of E exposure, max serum E2 level, and ERA result. Multivariable logistic regression models and resulting odds ratios (OR) with 95% confidence intervals (CI) were used to test for measure association, where stepwise AIC selection criteria was applied to determine the optimal model. All reported p-values are 2-sided and a p-value < 0.05 was considered statistically significant. Mean (SD) age was 36.3 (4.2) years and median (Q1, Q3) BMI was 26.3 (22.0, 28.5) kg/m2. Of the 88 ERA tests performed, 21 (23.9%) were receptive and 67 (76.1%) were non-receptive. A full multivariable model for predicting non-receptive ERA results showed that the total number of transfers prior to ERA (OR [95% CI]: 0.81 [0.5, 1.31], p=0.40), MET (OR 0.97 [0.74, 1.27], p=0.83), age (OR 0.98 [0.85, 1.12], p=0.83), and duration of E exposure (OR 1.05 [0.91, 1.21], p=0.51) were not significant factors. Based on the reduced, optimized multivariable model, the odds of having a non-receptive ERA result decreased by 0.54 per 25 mg increase of P dose (OR [95% CI]: 0.46 [0.24, 0.87], p=0.016), increased by 0.31 per 100 pg/ml increase in max E2 level (OR 1.31 [1.03, 1.68], p=0.030) and increased by 0.13 per unit increase in BMI (OR 1.13[1.01, 1.26], p=0.039), when also adjusting for max serum P, max dose of P, max serum E2 level, and BMI. Our data suggests total number of transfers prior to ERA, MET, age and duration of E exposure do not predict ERA results. However, when modeled together, serum P level, P dose, serum E2 and BMI can be used to predict ERA results. Since implantation failure may be a result of a non-receptive endometrium in programmed FET cycles, studies with a larger sample size are needed to determine if cycle parameters can help providers determine who may benefit from ERA.

Purpose: To determine the effect of ruptured ectopic pregnancies on the rate of future intrauterine pregnancies.Materials and Methods: This was a retrospective study of patients at a University-affiliated hospital with a history of an ectopic pregnancy between January 1991 to December 2016. All patients that underwent a salpingectomy for a tubal ectopic pregnancy were considered for this study. Intrauterine pregnancy rates for patients with a history of a ruptured ectopic pregnancy were compared to those with non-ruptured ectopic pregnancies. Fisher’s exact test was used for analysis.Results: During the study period, 77 patients met the inclusion criteria. In this cohort, 14 patients with a history of a tubal ruptured ectopic pregnancy had achieved pregnancy within 12 months, compared to 24 patients in the non-ruptured group (52% vs 48%, p = 0.81). The rate of intrauterine pregnancies, compared to repeat ectopic pregnancy, in both the ruptured and non-ruptured group, was 71% (p > 0.99).Conclusion(s): Ruptured ectopic pregnancies did not adversely affect the rate of intrauterine pregnancy within 12 months of rupture when compared to non-ruptured ectopic pregnancies.

At the start of pregnancy, trophoblasts (TBs) migrate and invade into the decidua and remodel the spiral arteries in physiologic hypoxic conditions (1-3% O2). Persistent hypoxia secondary to a defect in remodeling of the maternal arteries is proposed to lead to a failure to increase oxygen tension, leading to poor placental perfusion and pregnancy complications, such as preeclampsia (PE). The objectives of this study are to determine how exposure to hypoxia impacts gene expression and cellular motility of first trimester TBs, and to assess if expression of migration-associated genes is dysregulated in 2nd trimester chorionic villous samples (CVS) from PE pregnancies relative to CVS from healthy pregnancies. Laboratory in vitro studies using the first-trimester TB cell line, HTR-8/SVneo (HTR-8). RNA-sequencing (RNA-seq) of HTR-8 cells and CVS. HTR-8 cells were exposed to hypoxia (2.5% O2) or normoxia (21% O2) for 6hrs and RNA-seq was performed. Significant differentially expressed genes (SDEGs) and upregulated Gene Ontology (GO) cellular pathways were identified. To determine if gene expression changes were associated with changes in cellular response, transwell assays were performed to assess HTR-8 cell migration and invasion after exposure to 2.5% O2 or 21% O2 for 6hrs and 24hrs. For transwell migration assays (n=6), number of migrated cells through culture inserts were counted. For invasion assays (n=6), number of cells that invaded into Matrigel and collagen I matrices were counted. Means were compared using unpaired t tests and statistical significance was defined as p <0.05. To determine if changes in gene expression induced by exposure of HTR-8 to 2.5% O2 were present in 2nd trimester CVS from PE pregnancies relative to healthy pregnancies, CVS were collected and analyzed under an IRB approved protocol. RNA-seq of CVS from PE (n=2) and healthy (n=4) pregnancies was performed and DEGs were identified. GO analysis showed that exposure of HTR-8 to 2.5% O2 for 6hrs upregulated cellular migration pathways. SDEGs included genes involved in TB migration and invasion (MMP9, TIMP1, and PAPPA), as well as genes involved in tumor migration and invasion (ACTA2, MFAP4, SNAI2, SLCO4A1, GDF15, KLF5, ZBTB20, and ZNF703). HTR-8 cell migration and invasion, through both collagen I and Matrigel matrices, was significantly increased after exposure to 2.5% O2 for 24hrs but not 6hrs. Analysis of RNA-seq data from CVS of PE and healthy pregnancies identified 17 significant DEGs, 4 of which (FAT2, SPON2, RASGRF2, and SCLO4A1) were decreased in CVS from PE pregnancies and are involved in cellular migration and invasion. Exposure of 1st trimester TBs to physiologic hypoxic conditions induces expression of genes associated with cellular migration and invasion and increases 1st trimester TB migration and invasion in vitro. Decreased expression of migration and invasion genes in CVS from PE pregnancies may impair TB migration and invasion in the 2nd trimester of pregnancy, resulting in inadequate spiral artery transformation and prolonged hypoxia, preceding the development of PE.

OBJECTIVE:To investigate whether there is a difference in the ectopic/heterotopic pregnancy rate of blastocyst-stage frozen-thawed embryo transfers (FETs) compared with that of cleavage-stage FETs. DESIGN:A retrospective cohort study. SETTING:Not applicable. PATIENTS:Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619), as reported to the Society for Assisted Reproductive Technology from 2004 to 2013. INTERVENTIONS:None. MAIN OUTCOME MEASURES:Pregnancy outcomes, specifically ectopic pregnancy rates and heterotopic pregnancy rates. RESULTS:Among those who became pregnant, there was a significantly lower incidence of ectopic/heterotopic pregnancies in blastocyst-stage FETs versus that in cleavage-stage FETs (0.8% vs. 1.1%). The differences in ectopic/heterotopic pregnancy rates remained statistically significant after controlling for confounders such as tubal factor infertility and number of embryos transferred. CONCLUSIONS:Blastocyst-stage FET was associated with a lower ectopic/heterotopic pregnancy rate compared with cleavage-stage FET.

Background: The hormonal changes which occur leading up to menopause have been described in multiple cross-sectional and longitudinal studies. Results from these studies document the occurrence of marked alterations in pituitary-hypothalamic function, along with the changes in the ovary, which play a role in the etiology of menopause. However, the role of pituitary-hypothalamic function in the menopausal transition (MT) has been generally overlooked. Methods: Literature searches were performed using PubMed, Scopus, and Medline, for articles with content related to menopause and the MT. The searches were restricted to English language observational studies and reviews of human studies and clinical trials. Results: During the MT, in addition to a reduction in the number of ovarian follicles, there is a marked reduction in the sensitivity of the central nervous system to both the positive and negative feedback effects of estrogen. These changes in sensitivity explain menstrual irregularities and systemic systems which are present in the time before the final menstrual period. Although the timing of menopause is difficult to predict, broad patterns in hormonal changes are seen, including a slow drop in inhibin B levels, followed by a monotropic rise in follicle-stimulating hormone during the late reproductive period. The MT is marked by irregular cycles with unpredictable luteinizing hormone levels and unpredictable ovulation. The levels of estrogen remain stable, or are even elevated through most of the MT, and levels of estrogen do not begin to decrease until late in the MT. The Stages of Reproductive Aging Workshop guidelines have improved the homogeneity of classifications in studies. Conclusions: On the basis of longitudinal hormone studies, it is clear that desensitization of the hypothalamic-pituitary-ovarian feedback loop plays an important role, in addition to a decrease in follicle number and insensitivity of remaining follicles to the positive feedback of estrogen, to trigger ovulation. Further studies in humans are needed to elucidate the mechanisms responsible for these perimenopausal changes if proper therapeutic modalities for the symptoms associated with menopause can be developed.