SGI 2012: What'S New in Obstetrics/Gynecology and Reproductive Medicine: An Update from the Society for Gynecologic Investigation

Reproductive endocrinology & gynecology

Endometriosis was a prominent topic among the research submitted in the area of gynecology, and Olga Grechukhina from Yale University (CT, USA) was a President's New Investigator Awardee for her work in describing a novel genetic marker for endometriosis risk. The authors reported that an inherited polymorphism in a miRNA binding site (let-7 miRNA or LCS6) induces enhanced endometrial proliferation and endometriosis and could represent a potential therapeutic target for the treatment of endometriosis [1].

Among other clinical reports, a number of abstracts were related to infertility in general and to polycystic ovary syndrome in particular. Among these, a presentation by Michael Diamond (Wayne State University, MI, USA) representing the Reproductive Medicine Network and recently published in the Green JournalVas incredibly intriguing [2]. This study of 626 women with polycystic ovary syndrome represented a secondary analysis of a previously published trial comparing clomiphene citrate alone, metformin alone or clomiphene citrate plus metformin [3]. In the current report, the objective was to analyze the chance for ovulation, conception and/or live birth based upon the most recent antecedent vaginal bleeding episode. The three groups of interest were categorized as follows: after spontaneous ovulation, after an anovulatory cycle with exogenous progestin-induced withdrawal bleed and after an anovulatory cycle without exogenous progestin-induced withdrawal bleed. When assessed per ovulation, live-birth rates were 3.0% in cycles following spontaneous menses versus 5.4% in cycles following progestin-induced withdrawal bleed versus 19.7% in cycles without progestin withdrawal after an anovulatory interval. These findings call into question the standard practice of using progestin to induce a menses prior to ovulation-induction therapy, and suggest that such treatment may in fact produce adverse endometrial effects.

Yet another interesting article related to the management of infertility was presented by Daniel J Kaser (Brigham and Women's Hospital, MA, USA) who performed a secondary data analysis of the FASTT [4] and the FORT-T trials in Massachusetts (USA) [5]. The research objective was to assess the effect of moderately elevated cycle day 3 follicle stimulating hormone and estradiol levels on pregnancy outcomes in subfertile women. More than 650 women were included in the trial and women were treated with clomiphene citrate with intrauterine insemination (IUI), gonadotropins and IUI or with IVF. The results show that women with even moderately abnormal follicle stimulating hormone and estradiol levels perform poorly with either clomiphene citrate or gonadotropins with IUI, and should be counseled to move directly to IVF. This was particularly salient for older women, over the age of 40 years. This finding further stokes the debate regarding the overall utility of gonadotropin and IUI cycles given their significant multiple pregnancy risk and high expense, particularly for patients who do not have insurance coverage for fertility treatments [6].

Obstetrics & perinatology

In the area of obstetrics, the research presented at the conference was dominated by preeclampsia and preterm labor. For the latter, a President's New Investigator Award was given to Danielle Abott (King's College London, UK) for her work on cervical–vaginal fluid elafin concentrations and the risk of spontaneous preterm birth. This novel prospective study of high-risk asymptomatic women suggests that cervico-vaginal fluid elafin concentrations may be useful for the early prediction of spontaneous preterm birth prior to cervical shortening. Raised elafin concentrations may reflect a reactive response to the presence of infection rather than being a causative factor. Further study is needed to evaluate the utility of elafin to predict spontaneous preterm birth and target therapies in a larger cohort, but elafin has significant promise as a marker that may enhance or possibly supplant fetal fibronectin testing in high-risk populations [7].

Another President's New Investigator awardee was Christina M Cross (University of Cambridge, UK) for the work on melatonin's effect on the fetal brain for intrauterine growth-restricted fetuses. The authors hypothesized that, in pregnancies complicated by placental insufficiency, oxidative stress-related damage on fetal brain is due to fetal hypoxia rather than fetal undernutrition. Maternal treatment with melatonin offers a plausible target for clinical interventions against the adverse effects of complicated pregnancy on neural development, and has promise as a potential treatment in this population [8].

Basic science

While there were a large number of noteworthy basic science articles presented at the conference, one of the most riveting was delivered by a President's New Investigator awardee Yvonne White from Jonathan Tilly's group at the Massachusetts General Hospital (MA, USA). Here, the authors presented their work on the identification of oogonial stem cells from human ovaries, and the ability of these cells to produce oocytes both in vivo and with in vitro culture [9]. The potential impact of this work is considerable for two reasons. First, the notion that the ovarian follicular pool has the ability to be replenished argues against a long-established clinical dogma that a woman is born with all of the eggs she would ever have. Second, this work holds considerable promise for the future management of patients with diminished ovarian reserve, as well as for cancer patients seeking fertility preservation. A corollary of this work was recently published, and, if confirmed, sets the stage for an exciting new chapter in our understanding of ovarian physiology and in the treatment of infertile women [10].