Impact of genetic polymorphisms on the degree of ovarian response to gonadotrophin stimulation in patients undergoing ICSI treatment

Abstract: Infertility is a common health problem associated with various medical, emotional, and social implications. It affects one in four couples in developing countries and one in six couples worldwide at least once during their reproductive lifetime. Intracytoplasmic sperm injection (ICSI) is the most common technique of assisted reproduction, accounting for approximately three-quarters of all infertility treatments worldwide. Despite the availability of new ovarian reserve markers and improvements in the methodologies that support personalization of In vitro fertilization (IVF) treatment protocols, an accurate definition of the modalities for applying personalized therapy to optimize efficacy and daily clinical management is still required. Genetic differences between patients are most likely the main factor responsible for different responses to the drugs. The gonadotrophin hormones, follicle-stimulating hormone (FSH) and luteinising hormone (LH), control folliculogenesis, and naturally occurring polymorphisms in genes encoding these hormones and their receptors may affect the ovarian response. However, a definite association between genetic polymorphisms and ovarian responses to gonadotrophins still needs to be determined. The purpose of this study was to detect the association between five single nucleotide polymorphisms of the following four genes follicle-stimulating hormone receptor (FSHR), anti-Mullerian hormone (AMH), luteinizing hormone/choriogonadotropin receptor (LHCGR), estrogen receptor (ESR1), and the degree of the ovarian response to gonadotrophin in Egyptian Patients undergoing IVF/ICSI therapy. The study population was Egyptian Women undergoing ICSI treatment. Two hundred and eighty women have participated in the study with mean aged 20 -35 years old. The clinical part of the study was performed in the IVF unit Sohag, Egypt starting with patient recruitment and selection. Preparatory phase and investigations before ICSI then Controlled ovarian stimulation (COS) by Long Gonadotrophin releasing hormone (GnRH) agonist protocol, patient follow-up, and samples collection. The patients were classified according to ovarian response into three groups: normal responders (retrieved oocytes=4-15) (n= 80), poor responders (retrieved oocyte 15) (n= 108). Approximately 5.0 ml of blood samples were collected from all participants in EDTA tubes and stored at -80°C until the genetic analysis to be performed in assisted reproductionand Genetics Unit, Saarland University, Germany. Genomic DNA was extracted from the blood samples, and the PCR and DNA sequencing were performed to compare the variation in the DNA sequencing between the different study groups. The quantitative PCR (qPCR) was performed to evaluate the expression level of the following genes: FSHR, AMH, LHCGR, ESR1, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) as a reference gene among the study groups. Data analysis was performed by SPSS software. The Kruskal–Wallis (H-test) and Mann-Whitney (U-test) were applied to compare the median quantitative variables between the study groups. The Spearman rank correlation was used to evaluate the association between genetic polymorphisms (rs4073366, rs6166, rs6165, rs2234693; rs17854573) and the different investigated parameters including clinical parameters e.g., age, Body mass index (BMI), hormonal parameters e.g., AMH level, FSH Level and ICSI cycle parameters e.g., dose of gonadotrophin, number of collected oocytes, number of fertilised oocytes and number of transferred embryos. Regarding the qPCR data, the comparative analysis was used to calculate the expression level of tested genes in the cases “poor/high responder” versus controls “normal responder”. The results were considered statistically significant when P-value ≤ 0.05. The data analysis of DNA sequencing showed a significant difference in the frequency of the following genotypes FSHR (rs6166), AMH (rs17854573), and ESR1 (rs2234693) in the poor responders compared to normal responders (P ≤ 0.001, P = 0.010, and P ≤ 0.001) respectively. No significant difference has been found in the frequency of LHCGR (rs4073366) and FSHR (rs6165) genotypes in patients with poor ovarian response compared to others with a normal ovarian response (P = 0.312 and P = 0.192). Besides, no significant difference has been found in the frequency of the FSHR (rs6166), FSHR (rs6165), ESR1 (rs2234693), AMH (rs17854573) or LHCGR (rs4073366) genotypes in high responders compared to normal responders (P = 0.074, P = 0.353, P = 0.060, P = 0.060 and P = 0.091 respectively). Moreover, a significant difference has been found between the poor responders and the normal responders in the total dose of gonadotropin, the number of stimulation days, the number of collected oocytes, the number of injected oocytes, the number of fertilized oocytes, and the number of embryo transfer.On the other hand, the analysis of qPCR results revealed a variation between the study groups (poor, normal, and high response) in the expression levels of FSHR (rs6166), FSHR (rs6165), AMH, LHCGR, and ESR1 gene (P ≤ 0.0001). In conclusion, The results of this study suggest that polymorphisms in the genes for key reproductive hormones (AMH, FSHR, and ESR1) in combination with the patient’s clinical characteristics and hormonal biomarkers could be used to predict the ovarian response to gonadotrophins, to personalize and adjust the dose of gonadotrophins before starting the stimulation protocol, to improve efficacy and to avoid possible complications such as cycle cancellation and OHSS; and, finally, to improve the pregnancy rate in patients undergoing ICSI treatment.Zusammenfassung: Infertilität ist ein häufiges Gesundheitsproblem, das mit verschiedenen medizinischen, emotionalen und sozialen Auswirkungen einhergeht. Es betrifft eines von vier Paaren in Entwicklungsländern und eines von sechs Paaren weltweit mindestens einmal im Laufe ihres reproduktiven Lebens. Die intrazytoplasmatische Spermieninjektion (ICSI) ist die häufigste Technik der assistierten Reproduktion und macht weltweit etwa drei Viertel aller Unfruchtbarkeitsbehandlungen aus. Obwohl neue Marker für die ovarielle Reserve zur Verfügung stehen und die Methoden zur Personalisierung der Behandlungsprotokolle für die In-vitro-Fertilisation (IVF) verbessert wurden, ist eine genaue Definition der Modalitäten für die Anwendung der personalisierten Therapie zur Optimierung der Wirksamkeit und des täglichen klinischen Managements nach wie vor erforderlich. Genetische Unterschiede zwischen den Patienten sind höchstwahrscheinlich der Hauptfaktor, der für die unterschiedlichen Reaktionen auf die Medikamente verantwortlich ist. Die Gonadotropin Hormone FSH und luteinisierendes Hormon (LH) steuern die Follikulogenese, und natürlich vorkommende Polymorphismen in Genen, die für diese Hormone und ihre Rezeptoren kodieren, können die Reaktion der Eierstöcke beeinflussen. Ein eindeutiger Zusammenhang zwischen genetischen Polymorphismen und der Reaktion der Eierstöcke auf Gonadotropine muss jedoch erst noch festgestellt werden. Ziel dieser Studie war es, den Zusammenhang zwischen fünf Einzelnukleotid-Polymorphismen der folgenden vier Gene Follikel-stimulierendes Hormon-Rezeptor (FSHR), Anti-Mullerian-Hormon (AMH), Luteinisierendes Hormon/Choriogonadotropin-Rezeptor (LHCGR), Östrogenrezeptor (ESR1) und dem Grad der ovariellen Reaktion auf Gonadotropin bei ägyptischen Patientinnen, die sich einer IVF/ICSI-Therapie unterziehen, zu ermitteln. Die Studienpopulation bestand aus ägyptischen Frauen, die sich einer ICSI-Behandlung unterzogen. Zweihundertachtzig Frauen, mit einem Mittelalter von 20 bis 35 Jahren, nahmen an dieser Studie teil. Der klinische Teil der Studie wurde in der IVF-Abteilung in Sohag, Ägypten durchgeführt. Zuerst erfolgten die Rekrutierung und Auswahl der Patientinnen, dann die Vorbereitungsphase und Untersuchungen vor ICSI danach die kontrollierte ovarielle Stimulation (COS) durch langwirkende GnRH-Agonisten-Protokoll.Anschließend erfolgte das Follow-up. Nach der ovariellen Reaktion wurden die Patientinnen in drei Gruppen eingeteilt: normale Responder (entnommene Eizellen = 4-15) (n = 80), schlechte Responder (entnommene Eizellen ) 15) (n = 108). Ca. 5,0 ml Blutproben wurden von allen Teilnehmerinnen in EDTA-Röhrchen gesammelt und bei -80° C, bis die genetische Analyse in der Abteilung von der assistierten Reproduktion und Genetik an der Universität des Saarlandes in Deutschland, gelagert. Genomische DNA wurde aus den Blutproben extrahiert und die PCR und die DNA-Sequenzierung wurden durchgeführt, um die Variation in der DNA- Sequenzierung zwischen den verschiedenen Studiengruppen zu vergleichen. Die quantitative PCR (qPCR) wurde durchgeführt, um das Expressionsniveau der folgenden Gene zu bewerten: FSHR, AMH, LHCGR, ESR1 und Glyceraldehyd-3-phosphat-Dehydrogenase (GAPDH) als Referenzgen in den Studiengruppen. Die Datenanalyse wurde mit der Software SPSS durchgeführt. Der Kruskal-Wallis-Test (H-Test) und der Mann-Whitney-Test (U-Test) wurden angewandt, um den Median der quantitativen Variablen zwischen den Studiengruppen zu vergleichen. Die Spearman-Rangkorrelation wurde verwendet, um den Zusammenhang zwischen dem genetischen Polymorphismus (rs4073366, rs6166, rs6165, rs2234693; rs17854573) und den verschiedenen untersuchten Parametern zu bewerten einschließlich klinischer Parameter wie Alter, Body-Mass-Index (BMI), hormoneller Parameter wie AMH-Spiegel, FSH-Spiegel und ICSI-Zyklusparameter wie Gonadotropin-Dosis, Anzahl der entnommenen Eizellen, Anzahl der befruchteten Eizellen und Anzahl der übertragenen Embryonen. In Bezug auf die qPCR-Daten wurde die vergleichende Analyse verwendet, um das Expressionsniveau der getesteten Gene in den Fällen "schlechte/hohe Responder" gegenüber den Kontrollen "normale Responder" zu berechnen. Die Ergebnisse wurden als statistisch signifikant angesehen, wenn der P-Wert ≤ 0,05 war. Die Datenanalyse der DNA-Sequenzierung zeigte einen signifikanten Unterschied bezüglich der Häufigkeit der folgenden Genotypen FSHR (rs6166), AMH (rs17854573) und ESR1 (rs2234693) bei den schlechten Respondern im Vergleich zu den normalen Respondern (P ≤ 0,001, P = 0,010 und P. ≤ 0,001). Es wurde kein signifikanter Unterschied in der Häufigkeit der Genotypen von LHCGR (rs4073366) und FSHR (rs6165) bei den schlecht ansprechenden Respondern im Vergleich zu den normalen Respondern beobachtet (P ≤ 0,312 und P = 0,192).Außerdem wurde kein signifikanter Unterschied in der Häufigkeit der Genotypen FSHR (rs6166), FSHR (rs6165), ESR1 (rs2234693) , AMH (rs17854573) oder LHCGR (rs4073366) bei den High-Respondern im Vergleich zu den normalen Respondern (P ≤ 0,074) gefunden , P ≤ 0,35 3, P ≤ 0,060, P ≤ 0,060 bzw. P ≤ 0,091 ). Darüber hinaus wurde ein signifikanter Unterschied zwischen den schlechten Respondern und den normalen Respondern bezüglich der Gesamtdosis von Gonadotropin, der Anzahl der Stimulationstage, der Anzahl der gesammelten Eizellen, der Anzahl der injizierten Eizellen, der Anzahl der befruchteten Eizellen und der Anzahl der gefunden Embryotransfer sowie die Anzahl der kryokonservierten Embryonen. Andererseits zeigte die Analyse der qPCR-Ergebnisse einen Unterschied zwischen den Studiengruppen (schlechtes, normales und hohes Ansprechen) in den Expressionsniveaus der Gene FSHR (rs6166), FSHR (rs6165), AMH, LHCGR und ESR1 (P ≤ 0,0001). Zusammenfassend zeigen die Ergebnisse dieser Studie, dass Polymorphismen in den Genen für die wichtige Fortpflanzungshormone (AMH, FSHR und ESR1) in Kombination mit den klinischen Merkmalen der Patientin und hormonellen Biomarkern verwendet werden könnten, um die ovarielle Reaktion auf Gonadotropen vorherzusagen, zu personalisieren und die Dosis von Gonadotropen vor Beginn des Stimulationsprotokolls anzupassen, um die Wirksamkeit zu verbessern und mögliche Komplikationen wie Zyklusabbruch und OHSS zu vermeiden; und schließlich zur Verbesserung der Schwangerschaftsrate bei Patientinnen, die sich einer ICSI-Behandlung unterziehen

Prevalence of Coronary Artery Lesion(S) in Pati ents Aged 40-50 Years Undergoing Rheumatic Valvular Surgery

Objective: To determine the prevalence of coronary artery disease in patients undergoing valve surgery for rheumatic heart disease between age 40-50 years, usefulness, and indication of pre-operative coronary angiography. Methods: This is an observational prospective study that took place in 2 hospitals (National Heart Institute and Nasser Institute) within the period starting from January 2013 to January 2015. We included 454 rheumatic patients that were admitted for elective primary mitral, aortic or double valve surgery, and that had a coronary angiogram in their regular preoperative workup. All coronary angiographies were performed by injecting right and left coronaries by using 80-100 ml of iodinated contrast to obtain the standard views of both right and left coronaries using Philips or Siemens machines in both hospitals. Coronary artery disease (CAD) of 50% is considered to be a positive finding. Results: There was no correlation between rheumatic heart disease in this age group and CAD as only 1.76% had the significant stenosis. Male gender, family history of CAD, age above 45yrs, hypertension, and smoking showed significant correlation with the CAD in this study. Conclusion: Our results suggest that the overall prevalence of coronary artery disease in patients undergoing rheumatic valve surgery in our population is not comparable with the prevalence reported in international data. So, multicenter studies are needed in developing countries to set their own guidelines. Therefore, our study can be the nucleus for these guidelines in our country

The diagnostic accuracy of intraoperative frozen section biopsy for diagnosis of sentinel lymph node metastasis in breast cancer patients: a meta-analysis

: Sentinel lymph node (SLN) sampling is important for evaluating the nodal stage of breast cancer when the axillary nodes are clinically free of metastasis. The intraoperative frozen section (IFS) of SLN is used for lymph node assessment. This meta-analysis aims to provide evidence about the diagnostic accuracy and the applicability of IFS of SLN in breast cancer patients. Data were collected by searching PubMed, Cochrane, Scopus, and Web of Science electronic databases for trials matching our eligibility criteria. The statistical analysis included the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and pooled studies' diagnostic odds ratio outcomes. The analyses were conducted using the Open Meta-analyst software. This meta-analysis pooled the results of 110 studies. The overall sensitivity of IFS for SLN metastasis was 74.7%; 95% CI [72.0, 77.2], P < 0.001. It was 31.4% 95% CI [25.2, 38.3], P < 0.001 for the micro-metastasis, and 90.2%; 95% CI [86.5, 93.0], P < 0.001 for the macro-metastasis. The overall specificity was 99.4%; 95% CI [99.2, 99.6], P < 0.001. The overall positive likelihood ratio was 121.4; 95% CI [87.9, 167.6], P < 0.001, and the overall negative likelihood ratio was 0.226; 95% CI [0.186, 0.274], P < 0.001. The overall diagnostic odds ratio of IFS for diagnosing SLN metastasis was 569.5; 95% CI [404.2, 802.4], P < 0.001. The intraoperative frozen section of SLN has good sensitivity for diagnosing breast cancer macro-metastasis. However, the sensitivity is low for micro-metastasis. The specificity is very satisfactory

Quality of service modeling for green scheduling in Clouds

International audienceBest known Cloud providers propose services under constraints of Service Level Agreement (SLA) definitions.The SLAs are composed of different Quality of Service (QoS) rules promised by the provider. Thus, the QoSin Clouds becomes more and more important. Precise definitions and metrics have to be explained. Thisarticle proposes an overview of Cloud QoS parameters as well as their classification, but also it defines usablemetrics to evaluate QoS parameters. Moreover, the defined QoS metrics are measurable and reusable in anyscheduling approach for Clouds. Energy consumption is an inherent objective in Cloud Computing, thus, it isalso considered. For evaluation purposes, two uncommon QoS parameters: Dynamism and Robustness are takeninto account in different Cloud virtual machines scheduling approaches. Validation is done through comparisonof common scheduling algorithms, including a genetic algorithm (GA), in terms of QoS parameters evolutionin time. Simulation results have shown that including various QoS parameters allows a deeper schedulingalgorithms analysi

Analysis of entropy generation in biomimetic electroosmotic nanofluid pumping through a curved channel with Joule dissipation

Biomimetic designs are increasingly filtering into new areas of technology in recent years. Such systems exploit characteristics intrinsic to nature to achieve enhanced adaptivity and efficiency in engineering applications. Peristaltic propulsion is an example of such characteristics and in the current article it is explored as a feasible mechanism for deployment in electrokinetic pumping of nanofluids through a curved distensible conduit as a model for a bioinspired smart device. The unsteady mass, momentum, energy and nanoparticle concentration conservation equations for a Newtonian aqueous ionic fluid under an axial electrical field are formulated and simplified using lubrication approximations and low zeta potential (Debye H¨uckel linearization). A dilute nanofluid is assumed with Brownian motion and thermophoretic body forces present. The reduced non-dimensional conservation equations are solved with the symbolic software, Mathematica 9 via the NDSolve algorithm for velocity, temperature, nano-particle concentration distributions for low zeta potential. An entropy generation analysis is also conducted. The influence of curvature parameter, maximum electroosmotic velocity (Helmholtz-Smoluchowski velocity), inverse EDL thickness parameter, zeta potential ratio and Joule heating parameter on transport characteristics is evaluated with the aid of graphs and contour plots. Temperature profiles are elevated with positive Joule heating and reduced with negative Joule heating whereas the opposite behaviour is observed for the nano-particle concentrations

Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic

Introduction Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality. Methods Prospective cohort study in 109 institutions in 41 countries. Inclusion criteria: children &lt;18 years who were newly diagnosed with or undergoing active treatment for acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms tumour, glioma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, medulloblastoma and neuroblastoma. Of 2327 cases, 2118 patients were included in the study. The primary outcome measure was all-cause mortality at 30 days, 90 days and 12 months. Results All-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3-11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); p&lt;0.001), lower middle income (OR 3.32 (95% CI 1.96 to 5.61); p&lt;0.001) and upper middle income (OR 3.49 (95% CI 2.02 to 6.03); p&lt;0.001) country status and chemotherapy (OR 0.55 (95% CI 0.36 to 0.86); p=0.008) and immunotherapy (OR 0.27 (95% CI 0.08 to 0.91); p=0.035) within 30 days from MDT plan. Multivariable analysis revealed laboratory-confirmed SARS-CoV-2 infection (OR 5.33 (95% CI 1.19 to 23.84); p=0.029) was associated with 30-day mortality. Conclusions Children with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Triboelectric Nanogenerator versus Piezoelectric Generator at Low Frequency (\u3c4 Hz): A Quantitative Comparison

© 2020 The Author(s) Triboelectric nanogenerators (TENGs) and piezoelectric generators (PGs) are generally considered the two most common approaches for harvesting ambient mechanical energy that is ubiquitous in our everyday life. The main difference between the two generators lies in their respective working frequency range. Despite the remarkable progress, there has been no quantitative studies on the operating frequency band of the two generators at frequency values below 4 Hz, typical of human motion. Here, the two generators are systematically compared based on their energy harvesting capabilities below 4 Hz. Unlike PGs, the TENG demonstrates higher power performance and is almost independent of the operating frequency, making it highly efficient for multi-frequency operation. In addition, PGs were shown to be inapplicable for charging capacitors when a rectifier was attached to the system. The results of this work reveal the tremendous potential of flexible TENGs for harvesting energy at low frequency