Clinical presentation of Mullerian anomalies in a large population cohort

ongoing pregnancy rate was 96.89% and there was no difference between groups (p>0.05). CONCLUSIONS: Severe cervical erosion had negative effects on the clinical pregnancy of ICI. Supported by: None.

P-130 HUMAN PAPILLOMA VIRUS (HPV) GENOTYPING USING HPV DNA CHIP IN A POPULATION OF WOMEN UNDERGOING TREATMENT FOR INFERTILITY. J. I. Pfeffer, J. P. Taar, J. P. Kutner, P. Labourier, A. Menard, S. Zerah. ZTP IVF LAB, IVF Center Clinique de la DHUYS, Bagnolet, France; IVF Center Clinique de la DHUYS, Bagnolet, France. OBJECTIVE: The objective of the present study was to use powerful new molecular techniques (DNA chips) to determine the prevalence and the genotype of HPV infection in a population of women consulting for infertility. DESIGN: Prospective study in a Private IVF. MATERIALS AND METHODS: A prospective study was conducted on women consulting in a period of 4 months for investigation of infertility at the IVF Center Clinique de la DHUYS. One hundred and eleven consecutive women aged from 25 to 45 years (average33.3) underwent a liquid based prep cervical cytological screening combined to systematic HPV detection and genotyping. Cytology and HPV testing were performed on the same sample using a validated cytologic fixative liquid (Qualicyt). The HPV genotyping test used (Greiner bio-one, PapilloCheck) allows the simultaneous detection of 24 different HPV types: 18 high risk (HR) HPV types (16/18/31/33/35/39/ 45/51/52/53/56/58/59/66/68/70/73/82) and 6 low risk (LR) HPV types (6/11/ 40/42/43/44-55). The principle of the assay is based on the detection of a E1 fragment gene from human HPV. DNA fragments are amplified by PCR and their products are hybridized to specific DNA probe fixed on the DNA chip. Positive and negative internal controls are available for each sample on the same chip. The 111 infertile women were compared with 550 female controls aged from 25 to 45 years (average32.2) wich where routinely consulting at the same period in a regular OBGYN office of the same geographic area. For this control population, HPV testing was performed only in case of abnormal cytology. RESULTS: No cytologic abnormalities where observed in the infertile women population compared to 3,45% (19/550) of the controls. HPV screening on infertile population showed 2,7% (3/111) HPV HR positives tests (genotypes HPV39 / HPV51 / HPV56). No Low risk HPV where detected. For a french study* the prevalence of HR HPV in a sexually active population (20- 44) resulted in 15,2%. CONCLUSIONS: Using a micro array technology for genotyping HPV, we did not notice an increase of cytologic abnormalities in our women infertile population. HPV presence appear less frequently in this type of women population that are involved in a long term monogamous relationship. HPV DNA Chip allows a rapid, sensitive and specific detection of HPV infections. We suggest that this technology can now be a reliable diagnostic tool for routine tests with huge potential diagnostics applications. *Boulanger JC et al. Gynecologie Obstetrique & Fertilite, 2004,vol32, n3, p218-22. Supported by: None.

P-131 FERTILITY TREATMENT IN A PUBLIC HEALTH CARE SYSTEM IN NEW YORK CITY: A DESCRIPTION OF BELLEVUE HOSPITAL CENTER (BHC) REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY (REI) CLINIC. J. M. Knopman, S. Talebian, M. E. Fino, L. Kump, J. Quagliarello, D. A. Keegan. OB/GYN, NYU Medical Center, NY, NY. OBJECTIVE: To evaluate the patient population, care provided, and treatment outcome at the BHC REI clinic. DESIGN: Retrospective cohort. MATERIALS AND METHODS: Patients presenting to the clinic from 5/ 05-8/07 were analyzed for demographics, chief complaint, diagnosis, treatment and outcome. RESULTS: 192 patients (age: 32  6 yrs (mean  SD), range 20-46) presented in the study period. 94% (n¼181) presented with infertility. Di-

FERTILITY & STERILITYÒ

agnoses were: diminished ovarian reserve (23), endometriosis (11), male factor (10), ovulatory dysfunction (OD) (72), tubal factor (21), uterine factor (7) and unexplained (37). Diagnoses in the OD group included: PCOS, hyperprolactinemia, hypothalamic amenorrhea, and thyroid disease; 41 patients (23%) had multiple factors. Patients attempted conception for 4.5  3 yrs (range 4mos-17yrs) before seeking treatment. The number of visits varied from 1-8. The majority of patients were Hispanic (105), the others were as follows: 23 African, 30 Bengali, 25 Asian, and 11 Caucasian. TABLE 1. TREATMENT & OUTCOME

TREATMENT SURGERY MEDICAL CC CCþIUI METFORMIN THYROID MEDS PROLACTIN MEDS OUTSIDE REFERRAL

LIVE # REFERRED # COMPLETED # PREGNANT BORN 19 122 5 47 17 2 7 44

11 73 2 37 15 2 6 11

4 23 0 6 10 0 3 4

1 19 0 3 10 0 3 3

PCOS patients were offered metformin or clomiphene citrate (CC). Intrauterine insemination (IUI) with ultrasound (US) monitoring was recommended with CC, but not all patients elected monitoring. Timed intercourse þ/ weight loss was recommended to 10 patients, and 7 became pregnant. 44 patients were referred to outside centers if gonadotropins, IVF, or donor egg treatments were recommended. These procedures are not offered at BHC. 30 patients did not return after initial consultation. 4 did not receive fertility treatment as their workup uncovered underlying disorders requiring medical attention. CONCLUSIONS: Although our treatment options are limited to metformin and or CCþ/ IUI, our pregnancy rates (PR) are comparable to published data. The PR was higher with metformin vs.CCþ/IUI. Although we were unable to offer ART, we identified appropriate candidates and referred them to centers with affordable services. While we cannot offer patients all infertility treatment options at BHC, we provide treatment and referrals that lead to pregnancy. Our experience illustrates how infertility patients can be successfully diagnosed and treated in a specialized clinic within a public health care system. Supported by: None.

P-132 CLINICAL PRESENTATION OF MULLERIAN ANOMALIES IN A LARGE POPULATION COHORT. S. E. Gurtcheff, H. Hatasaka, P. Lambert, R. Empey, E. Morris, A. Hammoud. Obstetrics and Gynecology, University of Utah, Salt Lake City, UT; University of Utah, Salt Lake City, UT. OBJECTIVE: To describe the common presentations of women with Mullerian anomalies in a large series of patients. DESIGN: Retrospective cohort. MATERIALS AND METHODS: Patients with Mullerian anomalies were identified through hospital systems databases by ICD-9 codes. Chart analysis and data abstraction were performed for each patient identified. Available information was probed and the following data collected: basic demographics (age, race), nature of the anomaly, age at diagnosis, symptoms at diagnosis, method of diagnosis, associated anomalies, nature of treatment if applicable, pregnancy history and outcomes, duration of infertility if present, and general medical/surgical history. RESULTS: A true Mullerian anomaly was identified in 1,445 patients. The median age at diagnosis was 26 years. The most common reason for diagnosis was the result of an incidental finding (32.1%). The second most common reason for diagnosis was an obstetric related finding including early loss, ectopic pregnancy, antepartum or delivery complication (22.7%). Other presentations that led to diagnosis included evaluation for infertility, bleeding abnormalities, associated external anomalies at birth, pain, and difficulty wearing a tampon. Associated non-Mullerian type congenital anomalies were found in 8.5% of patients. Values by type of Mullerian anomaly are presented in the table below.

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TABLE 1. Mullerian anomaly cohort

Diagnosis

Percent with nonMullerian associated anomalies

Number of cases

Percent of total

Median age at diagnosis (years)

572 128 400 12

39.6% 8.9% 27.7% 0.8%

27 29 26 27

Incidental Infertility Incidental Incidental

3.7% 3.1% 8.8% 0%

114 89 6 48

7.9% 6.2% 0.4% 3.3%

26 25 24 21

Incidental Incidental Infertility Pain

21.9% 18% 0% 4.2%

16

1.1%

21

Difficulty with tampon use Amenorrhea Incidental

12.5%

Uterine septum Arcuate uterus Bicornuate uterus Bicornuate uterus versus uterine septum Unicornuate uterus Uterine didelphys T shaped uterus Longitudinal vaginal septum (without uterine anomaly) Transverse vaginal septum (without uterine anomaly) Mullerian agenesis Totals

Most common presenting symptom

60 4.2% 17 1445 cases 100% 26 years

30% 8.5%

CONCLUSIONS: In our study population, Mullerian anomalies were often diagnosed incidentally. Directed efforts to diagnose Mullerian anomalies at a younger age would allow for appropriate counseling and intervention prior to a woman’s reproductive life. Supported by: Divisional.

P-133 APPLICATIONS OF NOVEL, NON-INVASIVE IMAGING TECHNIQUES TO THE UTERUS OF RHESUS MACAQUES: MEASURING VASCULAR PARAMETERS. C. V. Bishop, I. Tagge, X. Li, J. Lindner, R. Stouffer, O. Slayden. Division of Reproductive Sciences, ONPRC, Oregon Health & Science University, Beaverton, OR; Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR; Department of Cardiology, Oregon Health & Science University, Portland, OR; Division of Reproductive Sciences, ONPRC, & OBGYN, Oregon Health & Science University, Beaverton, OR. OBJECTIVE: To develop novel imaging techniques for non-invasive studies quantifying vascular parameters in the primate uterus. DESIGN: Female rhesus macaques with normal cycles (n ¼ 3) were imaged by contrast enhanced (CE)-ultrasound on day 3-7 of the natural luteal phase. Similar monkeys were treated with a controlled ovarian stimulation (COS) protocol to stimulate high levels of P and then imaged by abdominal Dynamic Contrast Enhanced -Magnetic Resonance Imaging (DCE-MRI) 5-7 days after follicle aspiration. MATERIALS AND METHODS: CE-ultrasound was conducted on the uterus of each animal by low-power (MI¼0.2) multipulse phase- and amplitude-modulation technique (CPS, Siemens) during IV administration of Definity microbubble contrast agent (Bristol-Myers Squibb Medical Imaging). Image sets were acquired for approximately 10 seconds after a brief highpower (MI¼1.0) sequence used to eliminated microbubbles from the ultrasound sector. Microbubble replenishment data were then fit to a 1-exponential function to derive relative microvascular blood velocity and volume in different uterine regions. For DCE-MRI, monkeys were subjected to a COS protocol (Wolf et al. Biol Reprod 71:486-93) with recombinant human FSH and LH (Organon, Merck Serono), the GnRH antagonist Acyline (NICHD) and hCG (Merck Serono). Oocytes were aspirated via laparoscopic surgery 36 h post-hCG. DCE-MRI images were acquired using the Trio 3T system (Siemens) by T1-weighted 3D gradient recalled-echo imaging with high spatiotemporal resolution before, during, and after IV infusion of Prohance, (Bracco Diagnostics, Inc) a low molecular weight gadoteridol contrast reagent (CR). Pharmacokinetic analyses were used to estimate the CR transfer rate constant through different regions of interest. RESULTS: CE-ultrasound revealed that during the luteal phase, blood flow was 11-fold higher in the myometrium than in the endometrium. Within the endometrium, blood flow was greatest in the basalis zone. DCE-MRI during COS cycles with high P indicated that vascular flow through the myometrium was over 100-fold greater than through the endometrium.

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Abstracts

CONCLUSIONS: CE-ultrasound and DCE-MRI are valuable, non-invasive techniques to measure uterine vascular flow and for the first time permit localized measurement of blood flow within uterine compartments. Supported by: Oregon Opportunity Fund 0927-48101-22, HD18185 (Proj. 3), HD055744 (Proj 3), RR00163.

P-134 IDENTIFICATION OF DNA-REGULATORY ELEMENTS IN THE PITUITARYADENYLATE CYCLASE-ACTIVATING POLYPEPTIDE (PACAP) GENE PROMOTER WHICH CONFER GnRH RESPONSIVENESS. R. L. Thomas, C. M. Muncy, L. M. Halvorson. Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX. OBJECTIVE: Initially identified as a hypothalamic releasing factor, PACAP has subsequently been discovered to have widespread distribution and function in the reproductive system, including the regulation of gonadotropin biosynthesis and secretion. Previous studies in our laboratory have demonstrated marked induction of PACAP gene expression by GnRH attributable, in part, to CRE and AP-1 sites within region -402 to -77 of the promoter (unpublished data). Loss of GnRH responsiveness was also noted with deletion of nucleotides -915 to -402 in the PACAP promoter. The objective of these studies was to identify additional GnRH-responsive promoter elements in this second region. DESIGN: GnRH-mediated transcription of the PACAP gene was analyzed in vitro. MATERIALS AND METHODS: PCR was used to generate sequential 5’ deletions in the PACAP promoter which were subcloned into the pGL3 luciferase expression vector. Using Lipofectamine, gonadotrope-derived LbT2 cells were transiently transfected with the PACAP expression constructs followed by treatment with 100nM GnRH or vehicle for 6 hours prior to harvest. Luciferase activity was measured using the Dual-Luciferase Reporter Kit (Promega, Madison, WI). Statistical analysis was performed by one-way ANOVA followed by the Student-Newman-Keuls Method using the SigmaStat 2.03 software with significance set at p<0.05. RESULTS: -915/þ906 PACAP promoter activity was markedly upregulated by GnRH (approximately 35-fold vs. control). Transient transfection of 5’ deletion truncations of the rat PACAP gene promoter demonstrated a significant loss of GnRH-stimulated rat PACAP promoter activity between two regions. Deletion from position -915 to -818 blunted the GnRH response to 71 % of the full length construct (Region A) (p<0.05) with a further loss of GnRH-responsiveness with deletion between positions -488 and -402 (Region B) (65% versus 46%, p<0.05). By sequence homology, Region A contains a c-ets cis-element and Region B contains an AP-1 regulatory region, both known to be downstream mediators of GnRH activation. CONCLUSIONS: Our results have identified two regions of the PACAP gene promoter which contribute to GnRH-mediated expression. We hope to isolate the specific cis-elements in these regions by point mutation analysis. As PACAP modulates gonadotropin gene expression, this information may provide insight into both normal and abnormal gonadotrope function. Supported by: R01 HD048699. P-135 TRANSVAGINAL HYDRO-LAPAROSCOPY IS ASSOCIATED WITH A LOW COMPLICATION RATE. S. Marr, M. Bloechle. Fertility Center at Kaiser Wilhelm Memorial Church, Berlin, Germany. OBJECTIVE: To evaluate the complication rate of Transvaginal HydroLaparoscopy in the diagnostic work-up of infertility. Transumbilical laparoscopy (TUL) considered as the gold standard of diagnosing tubal patency and function has several side effects such as abdominal discomfort and pain in the shoulder region mainly due to the use of CO2 needed for the distension of the abdominal cavity. Furthermore, general anesthesia with assisted ventilation is needed and visible scares, even small, from the skin incision made for the insertion of trocars remain. Transvaginal Hydro-Laparoscopy (TVHL) has been proposed as a new approach of diagnosing tubal function and patency avoiding the side effects of TUL. DESIGN: Retrospective analysis of the complication rate of 487 TVHL performed as out patient procedures from october 2005 to april 2008. MATERIALS AND METHODS: The study concerned 487 women (average age of 32.6  5.3 years with a range of 21-44 years) who underwent TVHL under propofol analgesia at the Fertility Center at Kaiser Wilhelm Memorial Church in Berlin from October 2005 to April 2008. Indications for TVHL were primary and secondary infertility. Exclusion

Vol. 90, Suppl 1, September 2008