GnRH Analogue Research Articles

P-640 No impact of Progestin Primed Ovarian Stimulation (PPOS) on euploid blastocyst rate per cohort of metaphase-II oocytes during PGT-A cycles: a case-control study

Abstract Study question Can progestins be used to prevent spontaneous LH surge during ovarian stimulation (OS) without affecting the euploid blastocyst rate (EBR) per metaphase-II (MII) oocytes? Summary answer Progestin Primed Ovarian Stimulation (PPOS) (conducted with norethisterone acetate) and conventional-OS with GnRH-antagonist show similar EBR per MII-oocytes What is known already PPOS is a novel OS protocol based exogenous progesterone to inhibit LH surge and spontaneous ovulation as an alternative to GnRH analogues. The rationale of its use is that multiple follicular waves arise during the ovarian cycle and no spontaneous ovulation occurs during the luteal phase. PPOS effectiveness and safety have been supported lately in the literature. A recent study reported similar number of euploid blastocysts after PPOS (conducted with medroxyprogesterone acetate) versus conventional-OS with GnRH-antagonist. Study design, size, duration Case-control study involving advanced-maternal-age women undergoing ICSI with PGT-A at two private IVF centers (May-2017 to February-2020). 80 PPOS women were matched with 160 control based on maternal-age and ovarian reserve markers. Patients with poor-ovarian-reserve (AFC<3), premature-ovarian-failure, III-IV stage endometriosis, ovarian cyst, severe-male-factor, PGT-SR or PGT-M were excluded. EBR per MII-oocytes was the primary outcome. All other embryological and clinical outcomes were reported. Participants/materials, setting, methods Both groups underwent recombinant-FSH OS with GnRH-agonist ovulation trigger; the only difference was that norethisterone acetate 10mg/day was administered orally to PPOS patients starting from the second day of the menstrual cycle until trigger. The control group, instead, underwent conventional antagonist protocol. The laboratory procedures were similar in both groups: ICSI, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing to report non-mosaic aneuploidies and vitrified-warmed euploid single-embryo-transfers (SETs). Main results and the role of chance The mean fertilization rate per MII-oocytes and blastulation rate per 2PN-zygotes were similar among PPOS and control (75.5%±21.8% versus 71.7±20.7%, p = 0.1; and 56.5%±27.7% versus 53.2%±27.5%, p = 0.4, respectively). No difference was reported for the EBR per MII-oocytes among PPOS and control (15.4%±19.8% versus 14.8%±18.2%, p = 0.9). No difference was reported among the biopsied blastocysts in terms of morphological quality and day of development. A total of 47 and 86 SETs were conducted in the two groups. There was no difference in the live-birth-rates (LBR) per SET in the two groups (N = 19/47, 40.4%, 95%CI 26.7-55.7 versus N = 35/86, 40.7%, 95%CI 30.4-51.8, p = 0.9), nor in the miscarriage rate per clinical pregnancy (N = 1/20, 5%, 95%CI 0.3-26.9 versus N = 3/36, 8.3%, 95%CI 2.2-25.6, p = 0.9). At last, the cumulative-LBR among concluded cycles (i.e., LB achieved or no transferable/all transferred euploid blastocysts) was also similar (N = 19/68, 27.9%, 95%CI 18.1-40.3 versus N = 31/132, 22.0%, 95%CI 15.4-30.2, p = 0.4). Limitations, reasons for caution The main limitation is the retrospective and non-randomized design. More data are required, especially for follicle recruitment, oocyte yield, gestational and perinatal outcomes. Wider implications of the findings Norethisterone acetate-based PPOS protocol has no impact on oocyte competence when compared to conventional GnRH-antagonist OS. These promising data support further investigation on PPOS, especially in view of its reduced cost, and putative increase in patient compliance and decrease in discomfort. Trial registration number none

P-325 Evidence for dysregulation of oncogene pathways at the gene expression level in the epithelium of deep infiltrating endometriosis compared to adenomyosis

Abstract Study question How does the gene expression profile of epithelium cells differ between deep infiltrating endometriosis (DIE) and adenomyosis (FA)? Summary answer The gene expression of epithelial cells from DIE reveals a significant upregulation of the PI3K-pathway and downregulation of the RAS-pathway compared to epithelium from FA. What is known already Both DIE and FA, are histologically considered benign but have features of malignant diseases, such as a tendency for local tissue invasion. Recent next generation sequencing studies have detected driver mutations in cancer-associated genes such as PIK3CA, ARID1A, PPP2R1A and KRAS in the epithelium of DIE, as well as in KRAS in epithelium of FA. Furthermore, identical mutations in the KRAS gene were detected in coexisting adenomyotic and endometriotic lesions, supporting the theory of a common molecular mechanism. The gene expression differences between these two entities were therefore investigated in the present study. Study design, size, duration This is an experimental analysis of 7 adenomyosis and 19 DIE samples (histologically confirmed), that were formalin-fixed and paraffin-embedded (FFPE) collected between 2003 and 2018. These were provided by the tissue bank of the National Centre for Tumour Diseases (Heidelberg, Germany), in accordance with the Ethics Committee of the University of Heidelberg (approval number S-362/2017). In addition, the medical and epidemiological data of the corresponding patients were retrospectively analyzed based on the clinical data collected. Participants/materials, setting, methods For this study, the epithelia of FFPE samples were microdissected in a laser-guided fashion. After RNA extraction, the expression of 770 genes was analyzed using the nCounter Technology with the Human PanCancer Pathways Panel (Nanostring). All genes with an adjusted false discovery rate of p < 0.05 and a fold change of < 0.66 or > 1.5 were considered differentially expressed and subjected to functional annotation and clustering using DAVID bioinformatics resources. Main results and the role of chance Our analysis revealed a total of 162 differentially expressed genes, that were either significantly increased (n = 116) or decreased (n = 46) in epithelium of DIE compared to that of FA (with log2 fold changes of < 0.66 or > 1.5 and an adjusted p-value of < 0.05). Gene ontology and KEGG pathway analysis for genes with increased expression in DIE compared with FA revealed significant upregulation of genes belonging to the PI3K-pathway and the focal adhesion pathway, as well as pathways related to viral infection, endocrine resistance, and malignancy. The upregulated pathways in adenomyosis mainly included the RAS-pathway. Limitations, reasons for caution The average age of DIE patients was lower, but many of them were hormonally inactive due to GnRH analogues, which mitigates any age-related differences. Furthermore, only relative expression was studied between the groups without comparison to normal endometrium. Overall, the sample size is relatively small and further studies are needed. Wider implications of the findings The expression of different signaling pathways in the two entities could, for example, explain the different sensitivity of the two diseases to certain therapeutic approaches. While DIE responds well to therapy with the progestogen dienogest, progesterone resistance is often described in adenomyosis patients. Trial registration number not applicable

P-432 Gonadal function and fertility preservation in girls with Hodgkin lymphoma treated according to the EURONET-PHL-C2 Protocol: the fertility add-on study

Abstract Study question What is the gonadotoxic potential of the EURONET-PHL-C2 treatment protocol for female childhood Hodgkin lymphoma patients, and how frequently are co-treatments to preserve fertility applied? Summary answer Treatment-induced amenorrhea (72%) persisted in > 10% of cases. Results on AMH are available by April 2023. Fertility preserving (co-)treatments were applied in 27% of patients. What is known already Current treatment for childhood Hodgkin lymphoma (HL) is highly effective with survival rates exceeding 90%. However, HL treatment affects gonadal function and HL survivors were proven to be at risk of premature ovarian insufficiency. In effort to reduce late effects, treatment protocols were adapted and toxic procarbazine was successfully omitted. The current EuroNET-PHL-C2 protocol aims to reduce use of radiotherapy by intensifying chemotherapy. The cumulative dose of cyclophosphamide is increased by 25% in the intensified treatment-arm, the impact of this change in therapeutic protocol on gonadal function is currently unknown. Therefore, a fertility study was incorporated in the EuroNET-PHL-C2 study. Study design, size, duration This international, prospective, multicenter cohort study is embedded in the EuroNET-PHL-C2 study, an European phase-3 treatment study evaluating the effectivity of HL treatment with OEPA-COPDAC (OEPA: vincristine sulfate (oncovin), etoposide, prednisolone and doxorubicin (adriamycin); COPDAC: cyclophosphamide, vincristine sulfate (oncovin), prednisone and dacarbazine) versus OEPA-DECOPDAC (DECOPDAC: COPDAC with additional doxorubicin and etoposide) in a randomized setting. In the present fertility add-on study, 205 (104 girls, 101 boys) patients were included between January 2017 and September 2021. Participants/materials, setting, methods Female patients, aged <18 years, treated according to the EuroNet-PHL-C2 protocol for classical HL, were recruited across 18 sites (the Netherlands, Belgium, Germany, Austria, Czech Republic). All parents and patients (aged ≥12 years old) provided written informed consent. Serum AMH levels and menstrual cycle were evaluated over time (at diagnosis, during- and directly after treatment, 2 years post-diagnosis) and compared between OEPA-COPDAC and OEPA-DECOPDAC treatment groups. Moreover, use of available fertility preservation treatments was evaluated. Main results and the role of chance In the present analysis, 100 girls were included of whom 88 completed 2 years of follow up. Median age at diagnosis was 15 years (7-18), 8 girls were prepubertal and 92 post pubertal (87% postmenarchal). 17 girls were diagnosed at an early stage of HL (TL1) and 83 in more advanced stages (TL2/TL3, 66% received COPDAC and 33% DECOPDAC). 5 patients (5%) were irradiated in the pelvic area. Of the 46 postmenarchal girls who did not receive hormonal contraceptives during treatment, 33 (72%) experienced treatment-induced amenorrhea, at least 4 (12%) had persisting amenorrhea at 2 years post-diagnosis. 4 girls (22%) who stopped taking hormonal contraceptives after treatment had no (return of) spontaneous cycle. 2 girls (2%) underwent ovariopexy. 4 girls cryopreserved oocytes before treatment and 12 cryopreserved ovarian tissue (OTC). 15 (15%) received GnRH analogues as a co-treatment. Data on AMH-levels up to 2 years post-diagnosis will be available by April 2023. Change in AMH will be evaluated, comparing number of received chemotherapy-cycles (3/4/6), DECOPDAC versus COPDAC and pubertal stage at time of diagnosis. Additional analyses will be performed to assess the impact of applied fertility preservation methods on gonadal function (i.e. AMH levels after OTC or receiving GnRH agonist). Limitations, reasons for caution The current analysis included data up to 2 years post-diagnosis. Potential recovery or late emerging effects of treatment remain unknown. The studied population comprises young girls with diagnosis of HL often concurring with pubertal transition, during which AMH levels naturally rise. SD z-scored will be used to analyze AMH results. Wider implications of the findings The fertility add-on study is the first study to prospectively evaluate reproductive markers in children treated for HL. Study results are highly valuable to determine effect of the proposed new treatment regimen for childhood HL on fertility . Trial registration number Clinicaltrials NCT02684708; EudraCT number 2012-004053-88

P-761 Live-birth and neonatal outcomes from BEYOND, a randomised controlled trial comparing efficacy and safety of individualised follitropin delta dosing in GnRH agonist versus antagonist protocols

Abstract Study question What are the live birth and neonatal outcomes following an individualised follitropin delta dosing regimen in either a long GnRH agonist or GnRH antagonist protocol? Summary answer Live birth rates and neonatal outcomes were similar, supporting the efficacy and safety of follitropin delta in both GnRH agonist and antagonist protocols. What is known already Follitropin delta is used for ovarian stimulation and is administered as a fixed daily dose, individualised based on bodyweight and anti-Müllerian (AMH) levels. Registrational trials for follitropin delta used a GnRH antagonist protocol. Preliminary study data shows that individualized follitropin delta is efficacious when used with a long GnRH agonist protocol (RAINBOW trial); however, there is no comparative data for the effects on live birth rates and neonatal outcomes with individualised follitropin delta in a long GnRH agonist versus an antagonist protocol. Study design, size, duration This RCT compared the efficacy and safety of individualised follitropin delta dosing using a long GnRH agonist versus an antagonist protocol and was conducted between May 2019 and February 2022. The trial was designed to describe potential differences in the number of oocytes retrieved between the two GnRH analogue protocols (reported separately). A total of 437 participants were randomised, with a post-trial follow-up period to 4 weeks after birth to record birth and neonatal outcomes. Participants/materials, setting, methods Participants were 18–40 years old with AMH ≤35 pmol/L, undergoing their first ovarian stimulation cycle for IVF/ICSI at specialist reproductive health clinics in Austria, Denmark, Israel, Italy, the Netherlands, Norway and Switzerland.Live birth rates were compared using a logistic regression model with age and AMH at screening as factors. Multiple imputation was used for randomised subjects withdrawing before start of stimulation. Subjects with transfer cancellation due to COVID-19 related reasons were excluded. Main results and the role of chance All participants had a single blastocyst transferred, except two participants ≥38 years in the agonist group who received a double transfer resulting in one dichorionic diamniotic pregnancy for one subject, complicated by maternal hypertension and preterm birth at 33 weeks. All 133 participants with ongoing pregnancies (138 fetuses) were included in this post-trial follow-up analysis. Late pregnancy losses (after confirmed ongoing pregnancy) were similar in the agonist and antagonist groups (2.7% and 1.7%). There were 130 live births (agonist group: 75 neonates [67 singletons; 4 sets of twins]; antagonist group: 60 neonates [58 singletons; 1 set of twins]). Estimated live-birth rates were 35.8% and 28.7% in the agonist and antagonist groups, respectively, per started cycle (treatment difference 7.15%; 95% CI: –2.02; 16.31; p = 0.1265). There were two neonatal deaths in the agonist group – a set of monochorionic twins born at gestational age 24 weeks + 2 days died shortly after birth due to prematurity. The two treatment groups were comparable with respect to neonatal health data for singletons and twins, and incidence of congenital malformations (2.7% and 3.3%, respectively). Neonatal admissions to intensive care units were similar for both groups (10 and six neonates, respectively). Limitations, reasons for caution Double blastocyst transfer was permitted for participants ≥38 years with no good-quality blastocysts. Neonatal health is dependent on singleton/twin status. Outcomes of transfers with cryopreserved blastocysts were not followed up – the cumulative live birth rates and neonatal outcomes after cryo-transfer are not known. Wider implications of the findings The safety profile of individualised follitropin delta dosing was similar in GnRH agonist and antagonist protocols. Live birth rates following individualised follitropin delta were also similar for both GnRH protocols. There were no safety concerns with respect to the neonatal health after ovarian stimulation with follitropin delta. Trial registration number ClinicalTrials.gov identifier: NCT03809429; EudraCT number: 2017-002783-40

Efficacy of Degarelix in the Neoadjuvant Setting in Managing Locally Advanced Prostate Cancer.

Background Prostate cancer holds a substantial presence in the global cancer landscape, and a considerable proportion of diagnoses occur at late stages, particularly in India. Management of locally advanced prostate cancer necessitates a multimodal treatment strategy. A critical part of this strategy is neoadjuvant androgen deprivation therapy, typically administered via luteinizing hormone-releasing hormone (LHRH) analogs. This study explores the potential of an alternative approach: neoadjuvant therapy with degarelix, an LHRH antagonist, and its impact on perioperative and postoperative outcomes in patients undergoing radical prostatectomy for locally advanced or high-risk prostate cancer. Methodology We conducted a retrospective, non-randomized clinical study at Apollo Hospitals in Chennai, India. Patients diagnosed with locally advanced or high-risk prostate cancer who underwent radical prostatectomy were included. Participants were patients treated with neoadjuvant degarelix and subsequent radical prostatectomy between March 2020 and June 2022. We excluded patients receiving radical radiotherapy, those switching from LHRH agonists to antagonists, and those contraindicated for androgen deprivation therapy due to existing comorbidities. For comparison, we selected a group from the institutional database who received conventional treatment (i.e., without neoadjuvant therapy). Results The study compared two groups, each with 32 patients. The groups had no significant difference in total operative duration and console times. The postoperative pathological assessment showed significantly lower margin positivity rates and notable pathological downstaging in the group receiving neoadjuvant degarelix compared to the control group. The incidence of node positivity, prostate-specific antigen levels at three months postoperative, and number of pads used per day at one month did not differ significantly between the two groups. Conclusions Our study suggests that neoadjuvant degarelix could notably enhance patient outcomes in locally advanced prostate cancer management. The benefits include improved symptom control, significant reductions in margin positivity rates, and facilitated surgical procedures. Neoadjuvant degarelix therapy could potentially enhance the feasibility of the surgical intervention in locally advanced prostate cancer management, thus suggesting a promising pathway for improved patient care.

Current treatments for endometriosis in South Korea: an analysis of nationwide data from 2010 to 2019

While a wide range of treatments, including medical therapies and surgery, are used to manage endometriosis, the characteristics and treatment status of patients who received these treatments have not been investigated in Korea. This study analyzed the Korean Health Insurance Review & Assessment Service—National Patient Sample (HIRA-NPS) data from 2010 to 2019 with 7530 patients diagnosed with endometriosis. Annual trends in the types of visit and surgery, medication prescriptions and associated costs were investigated. The analysis showed that surgery slightly decreased among the types of utilized healthcare services (2010: 16.3, 2019: 12.7), dienogest prescription rapidly increased due to national health insurance coverage from 2013 (2013: 12.1, 2019: 36.0), and the use of gonadotrophin-releasing hormone analogues decreased (2010: 33.6, 2019: 16.4). There was no significant change in total and outpatient costs per person over time. Regarding endometriosis treatment, conservative treatment mainly based on prescribed medications has been gradually replacing surgery. Particularly, the listing of dienogest for national health insurance coverage might have affected the trend. However, there were no significant changes in terms of total and medication costs per person.

Fertility and fertility preservation in women

Advances in the treatment of cancer and in reproductive medicine make it possible for many patients to start their family planning even after cytotoxic therapy. Depending on the age of the patient, the planned oncological therapy and its urgency, various methods can be used to preserve the fertility of affected women. Presentation of facts about fertility, as well as information about fertility-preserving methods for women, so that they can be discussed with and offered to patients. Presentation and discussion of basic research, clinical data, and expert recommendations on fertility and fertility preservation. Well-established fertility-protective techniques now exist for women that offer arealistic chance of subsequent pregnancy. These include transposition of the gonads prior to radiotherapy, gonadal protection with gonadotropin-releasing hormone (GnRH) analogues and cryopreservation of fertilized and unfertilized oocytes, as well as cryopreservation of ovarian tissue. Fertility-protective techniques are an integral part of oncological treatments for prepubertal girls and patients of reproductive age. The various measures must be discussed individually with the patient as part of amultimodal concept. Prompt and timely collaboration with aspecialized center is essential.

Leiomyoma with Isolated Foam Cell Vasculopathy: A Case Report

ABSTRACT Foam cell vasculopathy is an obliterating type of vasculitis characterized by fibrinoid necrosis, sub-intimal foam cell deposition, vessel wall hyalinosis, and lymphocytic infiltrate. Isolated intra-tumoral foam cell vasculitis is rare and similar changes have been reported in a leiomyoma attributed to treatment with tranexamic acid and gonadotropin-releasing hormone (GnRH) analogs. A 68-year-old hypertensive and diabetic female (P2L2) presented with vaginal spotting and vague abdominal pain. An ultrasound abdomen showed an anterior wall fibroid measuring 5 × 4 cm. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Microscopic sections from the leiomyoma showed multiple foci of obliterating vasculitis, along with fibrinoid necrosis, sub-intimal foam cell deposition, and hyalinosis. There was no involvement of the endometrium, cervix, or ovaries. There were no pulmonary, skin, or renal lesions, or history of systemic vasculitis, and treatment by tranexamic acid or GnRH analogs. This prompted a diagnosis of idiopathic intra-tumoral foam cell vasculitis. This finding has been documented previously in three instances, namely, within a renal angiomyolipoma, cerebral Hodgkin’s lymphoma, and a gastrointestinal stromal tumor; the present case provides the first-ever documentation of isolated intra-tumoral acute atherosis-like/foam cell vasculopathy in leiomyoma.

Impact of ovulation inducers on ovarian artery in mares: pulsatility and resistivity indexes

A failure of vascular development in reproductive organs may be the cause of several dysfunctions during the estrous cycle and gestation. Therefore, it is important to evaluate the in vivo influences of ovarian vaso- irrigation on ovulation. The ovarian follicles need an adequate blood supply for oxygen, nutrients, and hormones, besides eliminating CO2 and other metabolites (Bruno et al. Animal Reproduction. 2009; 6, 2:371-379). Transrectal ultrasonography (US) with color, power, and spectral Doppler US has been used to study blood flow and ovarian perfusion in mares (Acosta et al. Biology of Reproduction. 2004b; 71, 2: 502-507). Studies have shown a daily increase in vascularization of the wall of the dominant follicle as it approaches the day of ovulation (Gastal et al. Animal Reproduction Science. 2007; 102, 3-4: 314-321); However, a few hours before ovulation, an abrupt decrease in blood perfusion of the follicular wall has been detected (Ginther et al. Journal of Equine Veterinary Science. 2007a; 27, 1: 20-27). The drugs most used as ovulation inducers in horses are human chorionic gonadotropin (hCG) and analogues of gonadotropin-releasing hormone (GnRH), such as deslorelin (Chavatte & Palmer Equine Veterinary Education. 1998; 10, 26-30). Using different ovulation inducers, this study aimed to evaluate changes in ovarian arteryblood flow after induction of ovulation in mares with follicles ≥ 35mm diameter. Twenty-eight estrous cycles were followed, randomly and equally distributed: GI: control mares without treatment; GII: 1000 IU IV of hCG; GIII: 750µl IV of deslorelin; GIV: 250µg IM of hysterelin. The ovarian artery pulsatility and resistivity indexes (PI and RI) were measured. Thereafter, estrous cycles were followed every 12 hours from time 0 (induction) until ovulation using B-mode US and spectral mode Doppler US of ovarian arteries. Statistical analysis was performed with ANOVA, a p-value of <0.05 was considered significant. No statistical difference was found in PI between groups (p=0.1297) of at the different evaluation times. When the times of analysis were compared separately between the groups, no statistical difference was found between 0h (p= 0.7092), 12h (p= 0.5148), 24h (p=0.2642), and 36h (p=0.582). Similarly, the RI did not differ between the groups analyzed (p= 0.1397), regardless of the time of evaluation, nor between the timepoints analyzed separately between 0h (p= 0.5049), 12h (p= 0.7334), 24h (p=0.3589) and 36h (p=0.1621). It can be concluded that although an increase in vascularization of the wall of the dominant follicle occurred, the PI and RI of the ovarian artery were not influenced by any ovulation inducer of the pre-ovulatory follicles.

Analysis of the incidence of central precocious puberty treated with gonadotropin-releasing hormone analogs. Impact of the COVID-19 pandemic

Introduction. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, consultations of girls with idiopathic central precocious puberty (ICPP) increased in several countries, but there were no data from Argentina. This increase may be related to changes in lifestyle and stress levels resulting from the lockdown, which particularly affected the child population. Objectives. 1) To describe the progression of the incidence of ICPP requiring inhibition of the hypothalamic-pituitary-gonadal (HPG) axis in girls between 2010 and 2021 in a cohort from the Metropolitan Area of Buenos Aires. 2) To compare the characteristics of girls diagnosed with ICPP during the pandemic with those of a control group. Methods. Interrupted time-series and case-control study. Results. The annual incidence remained stable between 2010 and 2017. Since 2017, it increased to an average of 59.9% (95% CI: 18.6-115.5) and appears to have accelerated during the pandemic. We found an association between ICPP and requiring inhibitory treatment between June 1st, 2020 and May 31st, 2021 and 2 variables: maternal age at menarche (OR: 0.46, 95% CI: 0.28-0.77) and family history of ICPP (OR: 4.42, 95% CI: 1.16-16.86). Conclusion. We evidenced a significant increase in the incidence of ICPP with requirement of HPG axis inhibition since 2017. Increased exposure to various environmental triggers during the COVID-19 pandemic may have had a greater influence in girls with some genetic predisposition.

Precocious puberty in relation to the COVID-19 pandemic. A survey among Argentine pediatric endocrinologists

Introduction. Puberty is manifested initially by the onset of secondary sexual characteristics as a result of hormonal changes that progressively lead to complete sexual maturity. In Argentina and worldwide, the lockdown resulting from the SARS-CoV-2 pandemic may have interfered in the onset and timing of pubertal development. Objective. To describe the perception of pediatric endocrinologists in Argentina regarding consultations for suspected precocious and/or rapidly progressive puberty during the pandemic. Materials and methods. Descriptive, observational, cross-sectional study. Anonymous survey among pediatric endocrinologists members of the Sociedad Argentina de Pediatría and/or the Asociación de Endocrinología Pediátrica Argentina administered in December 2021. Results. Out of 144 pediatric endocrinologists, 83 completed the survey (rate of response: 58%). All of them considered that consultation for precocious or early puberty increased, either in terms of early thelarche (84%), early pubarche (26%), and/or precocious puberty (95%). Ninety-nine percent agreed that this has occurred to a greater extent in girls. All survey respondents also consider that the diagnosis of central precocious puberty has increased. In total, 96.4% of respondents consider that the number of patients treated with GnRH analogs has increased. Conclusion. Our results about the perception of pediatric endocrinologists are consistent with data published in other regions on the increase in the diagnosis of precocious puberty during the COVID-19 pandemic. We underscore the need to develop national registries of central precocious puberty, and to disseminate the evidence for a timely detection and management.

The GnRH analogue Decapeptyl was able to induce ovulation in cyclic jennies

The aim of this study was to assess the ability of the GnRH analogue decapeptyl to induce ovulation of jennies in oestrus. Most of the northern hemisphere donkey breeds are faced with the risk of extinction (Camillo et al. J Equine Vet Sci 2018;65:44-49), thus donkey reproduction is considered an emerging branch of theriogenology and the management of induction of ovulation is a crucial point to set up preservation protocols (Carluccio et al. Theriogenology 2007;68:914-919; Camillo et al. Anim Reprod Sci 2014;151:56-60). In this study six Amiata jennies aged between 3 and 10 years, cyclic, in good general health and with a body condition score of ¾ were employed (Vall et al. in: Pearson, et al. Ed., 2003:93–102). For four consecutive cycles, jennies’ ovarian activity was routinely monitored; ultrasound examination was performed daily from the evidence of a follicle diameter ≥27 mm until ovulation. Upon reaching a follicular diameter ≥32±2 mm (hour 0), estrous jennies were treated alternatively with 100 mg Decapeptyl, sc, (DEC) or the equivalent volume of saline, sc, (CTRL) and examined ultrasonographically at hours 14, 24, 38, 42, 48, 62 and every 24 hours until ovulation. The experimental design was a 2 × 2 (with two replicates) Latin square. Induction of ovulation was considered successful if ovulation occurred between hours24 and 48 from treatment. An independent sample Student T Test and a Fisher Exact Test were performed to compare mean ovulation hour and ovulatory rates between DEC and CTRL groups, respectively. A forward stepwise multivariable logistic regression model based on the Wald statistics criterion of a P value smaller than 0.05 was used to establish significant predictors (group, jenny, and cycle number) for ovulation after treatment. Eleven/12 and 12/12 cycles resulted in ovulation for DEC and CTRL groups, respectively. Mean±SD ovulation time after treatment was 47.1±21.0 and 66.8±25.9 hours for DEC and CTRL respectively (P=0.059). Ovulation rates between 24h and 48h were 10/12 (83.3%) and 2/12 (16.7%) for DEC and CTRL respectively (P=0.003). Decapeptyl-treated jennies had a 25 times higher probability to ovulate between hours 24 and 48 than controls (P=0.003), while there were no jenny and cycle effects on the ovulatory rate. The results of this study show how Decapeptyl successfully induced ovulation in jennies, similarly to other GnRH analogs previously evaluated (Canisso et al. Vet Clin North Am Equine Pract 2019;35:607-642). Acknowledgments: The authors are grateful to Ente Terre Regionali Toscane for funding and for providing the jennies.

Preliminary analysis of hormonal and seminal sperm parameters of subfertile and fertile stallions treated with the GnRH agonist lecirelin

Subfertility is relatively common in stallions and few treatments are available to improve the semen characteristics of affected animals. The GnRH therapy, however, has been reported to improve sperm quality in individual clinical cases. The aim of this study was to evaluate therapeutical effects of daily GnRH analogue lecirelin treatment on sperm characteristics of fertile and subfertile stallions and to assess differences in the endocrine response among groups. Stallions were divided into untreated (n=3), fertile control (n=4) and subfertile (n=4) groups. Fertile and sub-fertile stallions received saline or 0.05 mg lecirelin, respectively, daily for 60 days and were evaluated for >90 days post-treatment. Ejaculates were collected biweekly, but semen and serum samples were evaluated weekly. Fertile stallions were characterized as having normal seminal parameters and a 75% conception rate. Subfertile stallions had low total and progressive motility (< 50% and 20%, respectively), sperm count, abnormal morphology (>30% of major defects), and ≈20% conception rate in the previous breeding season. Testicular response was assessed by determination of the concentrations of testosterone and estrone sulphate (interstitial compartment), anti-Müllerian hormone (AMH) and inhibin-B (tubular compartment) and correlated with sperm kinetics and production. Sperm kinetics were evaluated by CASA (IVOS Version 12 Hamilton Thorne Research, MA, USA), sperm concentration by Neubauer hemocytometer (Optik Labor®, Lancing, England), serum concentrations of inhibin- B, AMH and estrone sulfate weredetermined by ELISA and testosterone by RIA. Data were analyzed by ANOVA for repeated measures. In the subfertile group, testosterone concentrations decreased from week 0 to 6 (667 vs 302 pg/ml, respectively P<0.05), but tended to recover 1 month after treatment ceased (469 to 977pg/ml, respectively, P<0.08). Concentrations of all hormones were positively correlated with one another and with total sperm number (P<0.01), the highest between inhibin-B and estrone sulphate (R2=0.72) (P<0.01). No statistically significant effects on other hormones or semen characteristics were detected irrespective of group. Despite non statistical difference between groups, it is important to note that total sperm number increased by 60% 30 days after the beginning of the treatment and remained elevated by the end of the evaluation period in the fertile group. These data suggest that the treatment increased sperm production, but further investigations are underway. In conclusion, lecirelin treatment did not affect hormonal and seminal parameters in treated stallions, and did not affect testicular function. The correlation between hormones and sperm output indicates that these hormones are potentially valuable biomarkers for testicular function. Acknowledgements: São Paulo Research Foundation (FAPESP, grant #2019/01119-8 and #2022/03405-0), John P. Hughes Endowment and Clinical Endocrinology Laboratory, UC-Davis.

Effects of different semen extenders on sperm motility and pregnancy rates in donkeys

Semen quality is highly associated with the success of artificial insemination (AI). The characteristics of semen preserved at room temperature will be influenced by various factors. The semen extender provides sufficient energy for sperm, maintains pH and osmotic pressure stability, inhibits the reproduction of microorganisms and thus prolongs the survival time of sperm. We investigated effects of extender type on semen motility and pregnancy rates in donkeys. Five Yangyuan jacks and 1000 Yangyuan jennies were included in the study. Semen was collected by artificial vagina and filtered to remove impurities. The sperm motility (i.e., total and progressive) and concentration were determined by computer-assisted sperm analysis. Biggers, Whitter and Whittingham (BWW), Brackett and Oliphant medium (BO), Human Tubal Fluid (HTF) and Beltsville Thawing Solution (BTS), were semen extenders from other animal species, CAU-A and CAU-B were diluents independently developed by our laboratory. Firstly, the semen was diluted with CAU-B in a ratio of 1:2 (v/v, sperm: CAU-B). After mixing, the semen was centrifuged at 1500rpm for 10 min. The precipitation was retained and added to each tube. Then, the prewarmed extenders were slowly added along the tube wall and mixed by gentle shaking. After cooling to 17°C, diluted semen was placed in an incubator, mixed every 8h, and the sperm motility was analyzed. Meanwhile, we used transrectal palpation andB-mode ultrasound to determine ovarian activity of jennies. Upon detection of a 30-35 mm follicle, jennies were treated with the GnRH analogue deslorelin (GnRH-D) and inseminated with fresh semen diluted appropriately. The pregnancy rate of jennies was evaluated 20 days after ovulation. Statistical analysis was performed by ANOVA. Values are given as mean ± standard error. When diluted semen was stored at 17°C, the motility decreased with the increase of storage time extender. After 16h, sperm in BWW, BTS, BO and HTF extender were all dead. After 48h storage, the motility of sperm in CAU-A (mean 36.14 ± 6.12%) was lower (p < 0.05) than that in CAU-B (53.87 ± 16.25%). Pregnancy rates after insemination with semen diluted in CAU-A, CAU-B, BWW and BO were 30.53%, 34.77%, 29.37% and 30.96%, respectively, and there was no significant difference among groups (p>0.05). However, the pregnancy rate of semen diluted by CAU-B, which contains raffinose and fructose was slightly higher than that of the other groups. In conclusion, the results show that extension of donkey semen in CAU-B extender resulted in a slightly although not significantly improved pregnancy rate. This suggests that the semen extender is important for both, sperm viability and fertilization. This finding may be of significance for breeding and reproduction of donkeys and other equid species.

HCG versus histrelin acetate: ovulation inducing agents in mares (Equus caballus) in a commercial breeding program in Uruguay

Hormonal control of ovulation timing is an effective tool to optimize reproductive management and reduce costs in equine breeding programs. Few studies have evaluated the efficacy of GnRH analog histrelin as an ovulation inducer agent. This study aimed to compare the efficacy of human chorionic gonadotrophin (hCG) and histrelin as ovulation inducers in young, adult, and old mares during spring and summer. Reproductive records of 321 estrous cycles of 125 mares, mean age 9.8±0.37 years, range 1.5–24 years, between 360-600 kg body weight, and body condition ≥3 (1/5), were evaluated during spring (151 cycles) and summer (170 cycles). Mares were kept in the field and fed alfalfa hay, balanced concentrate feed and ad-libitum water. The ovaries, uterus, and cervix underwent transrectal examination and ultrasonography daily. When only one dominant follicle of 35 mm and endometrial edema compatible with estrus were reached, ovulation was induced. Each cycle was monitored every two to six hours until ovulation, 24h after induction. Cycles were randomly allotted in two groups; G1 (n=106 cycles): 1500 IU hCG (IV); G2 (n=215 cycles): 250 μg histrelin acetate (IM). A total of 119 cycles were from young (<8 years), 93 from adults (8-15 years), and 109 from old mares (>15 years). Cycles of mares ovulating within 24-48hafter treatment were considered to have responded to the inducer, and those ovulating before 24h and after 48h were excluded from the experiment. Inducer agents, season (spring or summer), and mare age were independent factors, and ovulation between 24-48h was considered the dependent factor. Data were analyzed through Fisher's exact test. The significance level was defined as P<0.05. From the 321 induced cycles, 254 (79.1%) ovulated within 24-48h, 20 (6.2%) before 24h, and 47 (14.6%) after 48h. There were no differences (P=0.2414) in the average response time between G1 (37.2h±3,5) and G2 (39.3h±4,5). The ovulatory response between G1 and G2 did not differ in spring (84.1% versus 90.7%, P=0.2627) and summer (79.2% versus 85.4%, P=0.3534). Independent of the inducer, the season did not influence the ovulation response in the different mare ages (spring P=0.1489; summer P=0.2992). No differences (P=0.896) were found between drugs in young and adult mares. However, old mares had a higher percentage of ovulatory response in spring and summer to histrelin (n=76) than to hCG (n=24) (89.5% versus 45.8%, P<0.0001). In conclusion, histrelin is more effective and accurate in inducing ovulation in old mares (>15 years) than hCG throughout the breeding season.

Systemic Therapy of Premenopausal Patients with Early Stage Hormone Receptor-Positive, HER2-Negative Breast Cancer - Controversies and Standards in Healthcare.

In patients with existing ovarian function, there are some special aspects to adjuvant endocrine therapy in premenopausal patients with hormone receptor-positive, HER2-negative (HR pos./HER2 neg.) breast cancer. Treatment options include tamoxifen with or without a GnRH analog, and aromatase inhibitors with a GnRH analog. Furthermore, ovarian function is affected by previous chemotherapy. Both aromatase inhibitors (+GnRH analogs) and GnRH analogs in combination with tamoxifen are supposed to be indicated for patients at increased risk of recurrence. However, national and international guidelines and therapy recommendations do not provide a clear definition of intermediate or high risk; as a result, therapy decisions are often made for each patient on an individual basis. This is also reflected in the considerable variability at national and international levels, e.g., with regard to the use of aromatase inhibitors + GnRH analogs. This review summarizes the data on completed studies (e.g., SOFT, TEXT, EBCTCG meta-analyses) and the current multigene testing studies (TailorX, RxPonder, ADAPT), discusses the rationale for current studies (e.g., CLEAR-B), and looks ahead to future questions.

Gonadotropins and Sex Steroid Hormones in Captive-Reared Small Yellow Croaker (Larimichthys polyactis) and Their Role in Female Reproductive Dysfunction.

The seed production of small yellow croaker (SYC) is constrained by reproductive dysfunction in captive-reared females. Reproductive dysfunction is closely linked to endocrine reproductive mechanisms. To better understand the reproductive dysfunction in captive broodstock, functional characterization of gonadotropins (GtHs: follicle stimulating hormone β subunit, fshβ; luteinizing hormone β subunit, lhβ; and glycoprotein α subunit, gpα) and sex steroids (17β-estradiol, E2; testosterone, T; progesterone; P) was performed using qRT-PCR, ELISA, in vivo, and in-vitro assay. The pituitary GtHs and gonadal steroids levels were significantly higher in ripen fish of both sexes. However, changes in lhβ and E2 levels in females were not significant in the developing and ripen stages. Furthermore, GtHs and steroids levels were lower in females compared to males throughout the reproductive cycle. In vivo administration of gonadotropin releasing hormone analogue (GnRHa) significantly increased the expression of GtHs in both dose- and time-related manners. The lower and higher doses of GnRHa led to successful spawning in male and female SYC, respectively. Sex steroids in vitro significantly inhibited the expression of lhβ in female SYC. Overall, GtHs were shown to play a vital role in final gonadal maturation, while steroids promoted negative feedback in the regulation of pituitary GtHs. Lower levels of GtHs and steroids might be key components in the reproductive dysfunction of captive-reared female SYC.

Pulmonary benign metastasizing leiomyoma in patients aged 45 years and younger: clinical features and novelty in treatment

BackgroundPulmonary benign metastasizing leiomyoma (PBML) is the most common extrauterine spread of uterine leiomyoma, and its biological behavior is traditionally thought to be hormone dependent. Studies on older PBML patients have been previously reported, but limited literature has been published regarding the clinical features and treatment of PBML in young women.MethodsA total of 65 cases of PBML in women aged 45 years and younger were reviewed, including 56 cases selected from PubMed and 9 cases from our hospital. The clinical characteristics and management of these patients were analyzed.ResultsThe median age of all the patients at diagnosis was 39.0 years. PBML most commonly presented as bilateral solid lesions (60.9%), with other rare imaging manifestations. The median interval time from a pertinent gynecologic procedure to diagnosis was 6.0 years. A total of 16.7% of patients received careful observation, and all achieved stable status in a median follow-up time of 18.0 months. A total of 71.4% of patients were administered anti-estrogen therapies, including surgical castration (33.3%), gonadotropin-releasing hormone analog (23.8%) and anti-estrogen drugs (14.3%). Eight of 42 patients underwent surgical resection of metastatic lesions. Patients who underwent curative surgery for the removal of pulmonary lesions combined with adjuvant anti-estrogen therapies had favorable outcomes compared with those who only underwent surgical resection. The disease control rates of surgical castration, gonadotropin-releasing hormone analog, and anti-estrogen drugs were 85.7%, 90.0%, and 50.0%, respectively. For two patients, sirolimus (rapamycin) achieved successful relief of symptoms and control of pulmonary lesions without lowering hormone levels and causing estrogen deficiency symptoms.ConclusionsIn the absence of standard treatment guidelines for PBML, maintaining a low-estrogen environment using different kinds of antiestrogen therapies has been the mainstream strategy and has satisfying curative effects. A wait-and-see strategy might be an option, but therapeutic approaches must be contemplated when complications or symptoms progress. For PBML in young women, the negative effect on ovarian function of anti-estrogen treatment, especially surgical castration, should be considered. Sirolimus might be a new treatment option for young PBML patients, especially for those who want to preserve ovarian function.

Reproductive Performance of Female Rabbits Inseminated with Extenders Supplemented with GnRH Analogue Entrapped in Chitosan-Based Nanoparticles.

Rabbit is a reflexively ovulating species. Accordingly, in the practice of artificial insemination (AI) ovulation must be induced via exogenous GnRH (Gonadotropin-Releasing Hormone) administration, which may be performed intramuscularly, subcutaneously, or intravaginally. Unfortunately, the bioavailability of the GnRH analogue when added to the extender is lower due to the proteolytic activity in the seminal plasma and the poor permeability of the vaginal mucosa. The aim of the study was to refine the practice of AI practice in rabbits by replacing parenteral GnRH analogue administration (subcutaneous, intravenous, or intramuscular injection) with intravaginal application, while reducing its concentration in the diluent. Extenders containing the buserelin acetate in chitosan-dextran sulphate and chitosan-alginate nanoparticles were designed and 356 females were inseminated. Reproductive performance of females inseminated with the two experimental extenders, receiving 4 μg of buserelin acetate intravaginally per doe, was compared with that in the control group, the does of which were inseminated with the extender without the GnRH analogue and induced to ovulate with 1 μg of buserelin acetate administered intramuscularly. The entrapment efficiency of the chitosan-dextran sulphate complex was higher than that of chitosan-alginate. However, females inseminated with both systems showed similar reproductive performance. We conclude that both nanoencapsulation systems are an efficient way of intravaginal ovulation induction, allowing a reduction in the level of the GnRH analogue normally used in seminal doses from 15-25 μg to 4 μg.

Application of the "echo-synch protocol" to advance pregnancy onset in ewe lambs at the first reproductive season.

This study assessed the efficacy and economic impact of a reproductive protocol based on repeated ultrasound scanning (US) associated with the use of GnRH to advance pregnancy onset in ewe lambs. Prepubertal ewe lambs (n = 133) were divided into three weight groups (High: HW n = 35; Medium: MW n = 65; Low: LW n = 33). Thereafter, animals were randomly allocated into two subgroups: GnRH, ewe lambs treated with GnRH analog and then exposed to rams; CTR, ewe lambs exposed to rams only. CTR groups were joined with rams as a single flock. GnRH groups were kept separate from rams receiving a single dose of gonadorelin (40 μg/head) and then were evaluated after a week of US. Animals showing corpora lutea received an injection of PGF2α analog (100 μg/head) and then were joined with rams. The remaining ewe lambs received a second dose of gonadorelin and were kept separate from the rams. After another week, animals were checked again and the ones showing corpora lutea were injected with the PGF2α analog, while the others received a third injection of gonadorelin. On the same day, all the animals were joined with rams. Pregnancies were confirmed within 30 days by US. The efficacy of the protocol was determined by assessing differences in the number of days required to achieve pregnancy rates of 25, 50, and 75% and in the total costs and incomes from birth to the end of first lactation within the groups. The GnRH-MW group showed the best performances in reaching the threshold pregnancy rates of 25, 50, and 75%, but the effect of treatment was significant only at the 25% threshold (p < 0.01). Both low groups displayed an overall poorer performance at 50 and 75% thresholds than medium and high-weight groups (p = 0.01 and p < 0.01, respectively). The GnRH administration did not advance pregnancy onset in GnRH-HW compared with CTR-HW. In the balance between costs and income, the HW-CTR and MW-GnRH groups showed higher gross margins than the other groups. Using the US/GnRH protocol in ewe lambs appears technically and economically effective in animals that have not reached the optimal weight at the first breeding season, advancing ewe lambs' pregnncies and increasing farm profitability.