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WORLD UNIVERSITY DIRECTORY is the one and only largest database of world educational institutions.

WORLD UNIVERSITY DIRECTORY has the World's largest online database of universities, polytechnics, colleges, schools and online universities across globe. Discover the complete list of universities, and other educational institutions available in North America, South America, Europe, Asia, Australia, New Zealand, rest of the world and online.

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1Universidade Federal do Rio de Janeiro     
Universidade Federal do Rio de Janeiro
Category: University
Brazil
South America, America
2Brock University     
Brock University
Category: University
Canada
North America, America
3Kuwait University      
Kuwait University
Category: University
Kuwait
Middle East , Asia
4Universite Bordeaux 1     
Universite Bordeaux 1
Category: University
France
Western Europe, Europe
5Australian National University     
Australian National University
Category: University
Australia
Australia and New Zealand, Oceanic
6RMIT University     
RMIT University
Category: University
Australia
Australia and New Zealand, Oceanic
7University of Cambridge     
University of Cambridge
Category: University
United Kingdom
Northern Europe, Europe
8University of Oxford     
University of Oxford
Category: University
United Kingdom
Northern Europe, Europe
9Stanford University    
Stanford University
Category: University
United States
North America, America
10Harvard University    
Harvard University
Category: University
United States
North America, America
11Massey University    
Massey University
Category: University
New Zealand
Australia and New Zealand, Oceanic
12University of Auckland    
University of Auckland
Category: University
New Zealand
Australia and New Zealand, Oceanic

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Hourly News Update -
Human Reproduction - recent issues

Human Reproduction - RSS feed of recent issues (covers the latest 3 issues, including the current issue)

Genetic variations in the 3'-untranslated region of SLC18A2 are associated with serum FSH concentration in polycystic ovary syndrome patients and regulate gene expression in vitro

STUDY QUESTION

Are genetic variations at the human solute carrier family 18 member A2 (SLC18A2) locus associated with the etiology of polycystic ovary syndrome (PCOS) and/or with follicle stimulating hormone (FSH) levels and insulin secretion in PCOS?

SUMMARY ANSWER

We found two common genetic variants in the 3'-untranslated region of SLC18A2 (rs363282 and rs363238) that are associated with serum FSH concentration in the PCOS group.

WHAT IS KNOWN ALREADY

SLC18A2 is a vesicular monoamine transporter that is essential in dopamine regulation. Dopamine can negatively regulate FSH and insulin secretion through the D2 receptor.

STUDY DESIGN, SIZE, DURATION

This study was a cross-sectional examination in women with PCOS (n = 319) and controls (n = 220) from China.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The PCOS patients were diagnosed based on the criteria of the Androgen Excess Society, including clinical and/or biochemical signs of hyperandrogenemia plus oligoamenorrhea or polycystic ovaries. Controls had regular menstrual cycles and no hyperandrogenism or other endocrine disorders related to PCOS. Tag single nucleotide polymorphisms (SNPs) were selected based on resequencing data in 48 PCOS patients and linkage disequilibrium analysis. Allele frequencies for variants (rs363282 and rs363238) were examined in PCOS cases and controls along with their relationship to quantitative traits. The samples were further divided into two subgroups for association analysis: AA + AG group and GG group (rs363282), CC + AC group and AA group (rs363238). The functional effects of SLC18A2 variants were measured by luciferase assay. The gene expression of SLC18A2 was compared with the NCBI's Gene Expression Omnibus datasets.

MAIN RESULTS AND THE ROLE OF CHANCE

Two common genetic variants in the 3'-untranslated region (rs363282 and rs363238) are associated with serum FSH in the PCOS group (P= 0.005 and P= 0.001, respectively), while no associations were found in controls. Functional studies showed that minor alleles of the two variants (rs363282-G and rs363238-A) had significantly lower luciferase activities than rs363282-A (P= 0.009) and rs363238-C (P = 0.009).

LIMITATIONS, REASONS FOR CAUTION

Results were not validated in another independent cohort, though we provided functional evidence of the two SNPs. Because of limited condition, more specific parameters, including ovarian follicle count and anti-Müllerian hormone were not included and relationship between SLC18A2 and these parameters cannot be evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

We found a novel association between two genetic variants in SLC18A2 and FSH levels in PCOS patients. These findings might indicate a novel regulatory mechanism in follicular development and maturation in PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (grant numbers 81571501 and 81270747), National Basic Research Program of China (grant number 2015CB943300). No competing interests declared.

Posted on 19 August 2016 | 10:17 am

Is underage abortion associated with adverse outcomes in early adulthood? A longitudinal birth cohort study up to 25 years of age

STUDY QUESTION

Is underage abortion associated with adverse socioeconomic and health outcomes in early adulthood when compared with underage delivery?

SUMMARY ANSWER

Underage abortion was not found to be associated with mental health problems in early adulthood, and socioeconomic outcomes were better among those who experienced abortion compared with those who gave birth.

WHAT IS KNOWN ALREADY

Teenage motherhood has been linked with numerous adverse outcomes in later life, including low educational levels and poor physical and mental health. Whether abortion at a young age predisposes to similar consequences is not clear.

STUDY DESIGN, SIZE, DURATION

This nationwide, retrospective cohort study from Finland, included all women born in 1987 (n = 29 041) and followed until 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analysed socioeconomic, psychiatric and risk-taking-related health outcomes up to 25 years of age after underage (<18 years) abortion (n = 1041, 3.6%) and after childbirth (n = 394, 1.4%). Before and after conception analyses within the study groups were performed to further examine the association between abortion and adverse health outcomes. A group with no pregnancies up to 20 years of age (n = 25 312, 88.0%) served as an external reference group.

MAIN RESULTS AND THE ROLE OF CHANCE

We found no significant differences between the underage abortion and the childbirth group regarding risks of psychiatric disorders (adjusted odds ratio 0.96 [0.67–1.40]) or suffering from intentional or unintentional poisoning by medications or drugs (1.06 [0.57–1.98]). Compared with those who gave birth, girls who underwent abortion were less likely to achieve only a low educational level (0.41 [95% confidence interval 0.31–0.54]) or to be welfare-dependent (0.31 [0.22–0.45]), but more likely to suffer from injuries (1.51 [1.09–2.10]). Compared with the external control group, both pregnancy groups were disadvantaged already prior to the pregnancy. Psychiatric disorders and risk-taking-related health outcomes, including injury, were increased in the abortion group and in the childbirth group similarly on both sides of the pregnancy.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study remains a limitation. The identification of study subjects in order to collect additional data was not allowed for ethical reasons. Therefore further confounding factors, such as the intentionality of the pregnancy, could not be checked.

WIDER IMPLICATIONS OF THE FINDINGS

Previous studies have found that abortion is not harmful to mental health in the majority of adult women. Our study adds to the current understanding in suggesting that this is also the case concerning underage girls. Furthermore, women with a history of underage abortion had better socioeconomic outcomes compared with those who gave birth. These findings can be generalized to settings of high-quality social and health-care services, where abortion is accessible and affordable to all citizens. Social and health-care professionals who care for and counsel underage girls facing unplanned pregnancy should acknowledge this information.

STUDY FUNDING/COMPETING INTEREST(S)

This study was financially supported by the Finnish Cultural Foundation and the Päivikki and Sakari Sohlberg Foundation. The researchers are independent of funders and the funders had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication. The authors have no competing interests.

Posted on 19 August 2016 | 10:17 am

Female digit length ratio (2D:4D) and time-to-pregnancy

STUDY QUESTION

Is the female 2th- to 4th-finger ratio (2D:4D) associated with fecundity as measured by time-to-pregnancy (TTP)?

SUMMARY ANSWER

Our study does not support an association between female 2D:4D and TTP.

WHAT IS KNOWN ALREADY

The 2th- to 4th-finger ratio (2D:4D) has been proposed as a potential indicator of greater androgen exposure during fetal development. Women exposed in utero to unbalanced steroid hormones may have impaired fecundity in the adulthood. Fecundity is often measured by TTP, an epidemiological tool commonly used to assess the impact of environmental factors in human conception.

STUDY DESIGN, SIZE, DURATION

The Maternal-Infant Research on Environmental Chemicals (MIREC) Study is a pregnancy and birth cohort of 2001 women recruited before 14 weeks of gestation in 10 cities across Canada between 2008 and 2011. The present analysis is part of MIREC-CD Plus, a follow-up study in a subsample of some 800 MIREC mothers and their children from 2012 to 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

TTP and maternal characteristics were collected from questionnaires administered during the first trimester of pregnancy as part of the MIREC study. Digital pictures of the ventral surface of both hands were obtained in the MIREC mothers at the MIREC-CD Plus follow-up study. The 2D:4D was calculated as the ratio of the second and fourth fingers of each hand. The exposure of interest was the 2D:4D of the women categorized by tertiles, or dichotomized as ≥1 (index finger longer than the ring finger) or <1 (ring finger longer than the index finger, implying greater androgen exposure during fetal development). The final sample included 696 mothers. Statistical analyses included discrete-time Cox proportional hazard models, allowing adjustment for potential confounding factors.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no evidence of diminished/increased fecundability according to the 2D:4D, neither on the right nor on the left hand. In our analysis by tertiles, the smallest 2D:4D (i.e. higher androgen exposure during fetal life) resulted in FORs higher than 1 (i.e. shorter TTP) in both hands, although this was not statistically significant (FOR 1.19 [95% CI 0.93, 1.51] in the right hand and 1.16 [95% CI 0.91, 1.47] in the left hand). In the dichotomous analysis, 2D:4D <1 resulted in FORs higher than 1 (i.e. shorter TTP), but this was also not statistically significant (FOR 1.08 [95% CI 0.88, 1.33] in the right hand and 1.14 [95% CI 0.92, 1.42] in the left hand). Our large sample size resulted in a high statistical power to exclude an association between female 2D:4D and TTP.

LIMITATIONS, REASONS FOR CAUTION

The MIREC Study is a cohort of pregnant women, and therefore, women with infertility were excluded by design from our study.

WIDER IMPLICATIONS OF THE FINDINGS

Our data do not provide evidence for an association between female 2D:4D and fecundity as measured by TTP. Whether the female 2D:4D is a marker of in utero androgen exposure and whether it is associated with fecundity have yet to be determined.

STUDY FUNDING/COMPETING INTEREST

The MIREC Study was funded by Health Canada's Chemicals Management Plan, the Canadian Institute of Health Research (CIHR grant # MOP - 81285), and the Ontario Ministry of the Environment. MIREC-CD Plus was funded by Health Canada's Chemicals Management Plan Research Fund. The 2D:4D component was funded by a research grant from the CIHR-Quebec Training Network in Perinatal Research (QTNPR). M.P. Vélez was supported by a CIHR Fellowship Award, and a QTNPR scholarship. P. Monnier is supported by the Research Institute of the McGill University Health Centre. W.D Fraser is supported by a CIHR Canada Research Chair. There are no conflicts of interest to declare.

Posted on 19 August 2016 | 10:17 am

Urinary paracetamol and time-to-pregnancy

STUDY QUESTION

Is preconception urinary paracetamol (acetaminophen) associated with time-to-pregnancy (TTP)?

SUMMARY ANSWER

Higher urinary paracetamol concentrations among male partners were associated with a longer TTP.

WHAT IS KNOWN ALREADY

Paracetamol is a commonly used analgesic among women and men of all ages. As metabolites of select chemicals used in the manufacturing of polyurethane foam, dyes and various industrial products, as well as a common medicinal product, paracetamol and its primary metabolite p-aminophenol, are ubiquitous in the environment. Studies investigating the relationship between adult urinary concentrations of paracetamol and TTP are lacking.

STUDY DESIGN, SIZE, DURATION

This prospective cohort included 501 couples discontinuing contraception for the purposes of attempting conception during the years 2005–2009 and residing in Michigan or Texas, USA.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Total urinary paracetamol, its metabolite para-aminophenol (p-aminophenol), and a summary measure of both urinary biomarkers were quantified by ultra-performance liquid chromatography coupled with an electrospray triple quadrupole mass spectrometry (UPLC-ESI-MS/MS). Female partners used the Clearblue® digital home test to confirm pregnancy. Cox's proportional odds models for discrete survival time were used to estimate fecundability odds ratios (FORs) and 95% confidence intervals (CIs), adjusting for age, body mass index (BMI), urinary creatinine, preconception smoking status, race/ethnicity and household income. Models were further adjusted for hypothyroidism and hypertension as an attempt to account for possible indications of paracetamol medication use. FOR estimates <1.0 denote a longer TTP (diminished fecundity). Models were performed to examine urinary concentrations of paracetamol as a continuous and variable or categorized into quartiles. In light of TTP being a couple-dependent outcome, models were first performed for females and males, modeled separately, and then modeled for couples with each partner's concentrations being adjusted for the other.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 501 enrolled couples, 347 (69%) had an human chorionic gonadotrophin confirmed pregnancy. Urinary concentrations of paracetamol were lowest among females and males who achieved pregnancy and p-aminophenol concentrations were lowest among those not achieving pregnancy. Urinary paracetamol concentrations were higher among female than male partners (Median = 26.6 and 13.2 ng/ml, respectively; P < 0.0001). After adjustment for age, BMI, urinary creatinine, preconception smoking status, race/ethnicity and household income, the highest quartile of male urinary paracetamol was associated with a longer TTP [FOR = 0.67; 95% CI = (0.47, 0.95)]. This association remained after adjustment for chronic health conditions, hypothyroidism and hypertension and female partner's urinary paracetamol concentration [FOR = 0.65; 95% CI = (0.45, 0.94)]. No associations were observed between female or male partners' urinary concentrations of paracetamol or of its metabolite p-aminophenol when urinary concentrations were modeled continuously.

LIMITATIONS, REASONS FOR CAUTION

Only a single spot urine was available for analysis despite the short-lived nature of paracetamol. Additionally, participants were not asked to provide information on indication of use for paracetamol medications; any underlying conditions for the paracetamol use would have been potential confounders.

WIDER IMPLICATIONS OF THE FINDINGS

If corroborated with more robust studies, findings from our exploratory analysis may have both clinical and public health relevance among reproductive aged individuals, including those trying for pregnancy, given the prevalent use of paracetamol/acetaminophen medications and the ubiquitous nature of paracetamol in the environment.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the National Institutes of Health, Intramural Research Program, and Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts N01-HD-3-3355; N01-HD-3-3356; NOH-HD-3-3358; HHSN27500001/HHSN27500001). None of the authors have any conflicts to declare.

Posted on 19 August 2016 | 10:17 am

A nested case-control study of prenatal vanadium exposure and low birthweight

STUDY QUESTION

Is prenatal vanadium exposure associated with adverse birth outcomes?

SUMMARY ANSWER

The odds of low birthweight (LBW) are increased 2.23-fold in mothers with a urinary vanadium of ≥2.91 μg/g creatinine compared with that in mothers with a urinary vanadium of ≤1.42 μg/g creatinine.

WHAT IS KNOWN ALREADY

Human exposure to vanadium occurs through intake of food, water and polluted air. Vanadium has been suggested to have fetotoxicity and developmental toxicity in animal studies, and epidemiological studies have reported an association between a decrease in birthweight and vanadium exposure estimated from particulate matter.

STUDY DESIGN, SIZE, DURATION

A nested case–control study involving 816 study participants (204 LBW cases and 612 matched controls) was conducted with data from the prospective Healthy Baby Cohort between 2012 and 2014 in the province of Hubei, China.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Vanadium concentrations in 816 maternal urine samples collected before delivery [the median gestational age was 39 weeks (range 27–42 weeks)] were measured by inductively coupled plasma mass spectrometry. Information on the infants' birth outcomes was obtained from medical records. Conditional logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs).

MAIN RESULTS AND THE ROLE OF CHANCE

The median urinary vanadium concentration of the cases was much higher than that of the controls (3.04 μg/g creatinine versus 1.93 μg/g creatinine). The results revealed a significant positive trend between the odds of LBW and level of maternal urinary vanadium [relative to the lowest tertile; adjusted OR = 1.69 (95% CI: 0.92, 3.10) for the medium tertile; adjusted OR = 2.23 (95% CI: 1.23, 4.05) for the highest tertile; P-trend = 0.02]. Additionally, the association was not modified by maternal age (P for heterogeneity = 0.70) or infant gender (P for heterogeneity = 0.21).

LIMITATIONS, REASONS FOR CAUTION

The maternal urine sample was collected before labor, and the maternal urinary vanadium levels measured at one point in time may not accurately reflect the vanadium burden during the entire pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study can enrich the biological monitoring data on urinary vanadium in pregnant women; and may be evidence that vanadium may affect fetal development.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (21437002, 81372959 and 81402649), the R&D Special Fund for Public Welfare Industry (Environment) (201309048) and the Fundamental Research Funds for the Central Universities, HUST (2016YXZD043). The authors have no conflicts of interest to declare.

Posted on 19 August 2016 | 10:17 am

Interleukin-1 receptor antagonist mediates toll-like receptor 3-induced inhibition of trophoblast adhesion to endometrial cells in vitro

STUDY QUESTION

Is interleukin-1 receptor antagonist (IL-1RA) involved in the toll-like receptor 3 (TLR 3)-induced inhibition of trophoblast cells' adhesion to endometrial cells in vitro?

SUMMARY ANSWER

IL-1RA mediates the TLR 3-induced inhibition of trophoblast cells' adhesion to endometrial cells in vitro.

WHAT IS KNOWN ALREADY

It is well documented that endometrial TLR 3 activation leads to impairment of trophoblast binding to endometrial cells in vitro. IL-1RA is known as an anti-implantation factor, as its injection significantly reduced implantation rates in mice by an effect on endometrial receptivity.

STUDY DESIGN, SIZE, DURATION

Poly I:C was used as a TLR3 specific ligand and endometrial cells were either treated or not with Poly I:C (treated versus control) in vitro. IL-1RA was applied to block IL-1 signal transduction. IL-1RA was knocked down by Accell Human IL1RN siRNA. Flagellin was used to stimulate TLR 5. SP600125 (JNK) was applied to inhibit the mitogen-activated protein kinases (MAPK) pathway. BAY11 -7082 was used to inhibit the nuclear factor-B (NF-B) pathway. The experiments were performed in three replicates on three separate days.

PARTICIPANTS/MATERIALS, SETTING, METHODS

An in vitro assay was developed using RL95-2 (an endometrial cell line) and JAr (a trophoblast cell line) cells. Initially, the production of IL-1RA in RL95-2 cells in response to TLR 3 activation was measured. To determine whether the TLR 3-induced inhibition of trophoblast binding was mediated through IL-1RA: (i) we evaluated the effect of IL-1RA on the attachment of trophoblast cells to endometrial cells; (ii) we knocked down TLR3-induced IL-1RA gene expression by IL-1RA Small interfering RNA (siRNA) and evaluated trophoblast attachment to endometrial cells. Finally, to clarify through which pathway TLR 3-induced inhibition of trophoblast binding occurs: (i) activation of NF-B and MAPK was detected by transfecting the cells with secreted placental alkaline phosphatase reporter plasmids bearing promoter sequences for each transcription factor; (ii) the inhibitors for NF-B and MAPK were used to block signaling; (iii) it was then investigated whether addition of these inhibitors could restore the TLR 3-induced impairment of trophoblast attachment to the endometrial cells.

MAIN RESULTS AND THE ROLE OF CHANCE

Our results showed that addition of polyinosinic:polycytidylic acid (Poly I:C) to RL95-2 cells significantly increased the production of IL-1RA (P < 0.05). Addition of human recombinant IL-1RA to RL95-2 cells remarkably decreased the adhesion rate of trophoblast cells to endometrial cells (P < 0.05). In addition, suppression of TLR3-induced IL-1RA gene expression in RL95-2 cells significantly restored trophoblast cells attachment to endometrial cells in the presence of Poly I:C (P < 0.05). Only TLR3 and not TLR5 induced MAPK activation (P < 0.05). TLR3 ligation did not affect NF-B activation. Of NF-kB and MAPK inhibitors, only MAPK's inhibitor could achieve restoration of spheroid adhesion to endometrial cells (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

This study has been only done in vitro. Future in vivo studies will confirm our data.

WIDER IMPLICATIONS OF THE FINDINGS

The findings of this study have a potential clinical application in introducing IL-1RA as one of the diagnostic infertility markers in the endometrium, which can affect the process of embryo adhesion at the time of implantation. Moreover, based on the novel data obtained in the current study, blocking and regulating the MAPK pathway by its inhibitors can be used as a new strategy to prevent and treat virus-induced infertility cases in ART techniques.

STUDY FUNDING/COMPETING INTEREST

This study was partially funded by a Marie Curie IIF-253948 grant to I.C. and was partially funded by the author's institutions. The authors have no conflict of interest to declare.

Posted on 19 August 2016 | 10:17 am

Obesity-induced oocyte mitochondrial defects are partially prevented and rescued by supplementation with co-enzyme Q10 in a mouse model

STUDY QUESTION

Does supplementation with co-enzyme Q10 (CoQ10) improve the oocyte mitochondrial abnormalities associated with obesity in mice?

SUMMARY ANSWER

In an obese mouse model, CoQ10 improves the mitochondrial function of oocytes.

WHAT IS KNOWN ALREADY

Obesity impairs oocyte quality. Oocytes from mice fed a high-fat/high-sugar (HF/HS) diet have abnormalities in mitochondrial distribution and function and in meiotic progression.

STUDY DESIGN, SIZE, DURATION

Mice were randomly assigned to a normal, chow diet or an isocaloric HF/HS diet for 12 weeks. After 6 weeks on the diet, half of the mice receiving a normal diet and half of the mice receiving a HF/HS diet were randomly assigned to receive CoQ10 supplementation injections for the remaining 6 weeks.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Dietary intervention was initiated on C57Bl6 female mice at 4 weeks of age, CoQ10 versus vehicle injections were assigned at 10 weeks, and assays were conducted at 16 weeks of age. Mice were super-ovulated, and oocytes were collected and stained to assess mitochondrial distribution, quantify reactive oxygen species (ROS), assess meiotic spindle formation, and measure metabolites. In vitro fertilization was performed, and blastocyst embryos were transferred into control mice. Oocyte number, fertilization rate, blastulation rate and implantation rate were compared between the four cohorts. Bivariate statistics were performed appropriately.

MAIN RESULTS AND THE ROLE OF CHANCE

HF/HS mice weighed significantly more than normal diet mice (29 versus 22 g, P< 0.001). CoQ10 supplementation did not influence weight. Levels of ATP, citrate, and phosphocreatine were lower and ROS levels were higher in HF/HS mice than in controls (P< 0.001). CoQ10 supplementation significantly increased the levels of metabolites and decreased ROS levels in oocytes from normal diet mice but not in oocytes from HF/HS mice. However, CoQ10 completely prevented the mitochondrial distribution abnormalities observed in the HF/HS mice. Overall, CoQ10 supplementation significantly increased the percentage of normal spindle and chromosome alignment (92.3 versus 80.2%, P= 0.039). In the sub-analysis by diet, the difference did not reach statistical significance. When undergoing IVF, there were no statistically significant differences in the number of mature oocytes, the fertilization rate, blastocyst formation rates, implantation rates, resorption rates or litter size between HF/HS mice receiving CoQ10 or vehicle injections.

LIMITATIONS, REASONS FOR CAUTION

Experiments were limited to one species and strain of mice. The majority of experiments were performed after ovulation induction, which may not represent natural cycle fertility.

WIDER IMPLICATIONS OF THE FINDINGS

Improvement in oocyte mitochondrial distribution and function of normal, chow-fed mice and HF/HS-fed mice demonstrates the importance of CoQ10 and the efficiency of the mitochondrial respiratory chain in oocyte competence. Clinical studies are now needed to evaluate the therapeutic potential of CoQ10 in women's reproductive health.

STUDY FUNDING/COMPETING INTEREST(S)

C.E.B. received support from the National Research Training Program in Reproductive Medicine sponsored by the National Institute of Health (T32 HD040135-13) and the Scientific Advisory Board of Vivere Health. K.H.M received support from the American Diabetes Association and the National Institute of Health (R01 HD083895). There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

This study is not a clinical trial.

Posted on 19 August 2016 | 10:17 am

Prevalence of infertility and help seeking among 15 000 women and men

STUDY QUESTION

What is the prevalence of infertility and of help seeking among women and men in Britain?

SUMMARY ANSWER

One in eight women and one in ten men aged 16–74 years had experienced infertility, defined by unsuccessfully attempting pregnancy for a year or longer, and little more than half of these people sought medical or professional help.

WHAT IS KNOWN ALREADY

Estimates of infertility and help seeking in Britain vary widely and are not easily comparable because of different definitions and study populations.

STUDY DESIGN, SIZE, DURATION

A cross-sectional population survey was conducted between 2010 and 2012 with a sample of 15 162 women and men aged 16–74 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants completed the Natsal-3 questionnaire, using computer-assisted personal interviewing (CAPI) and computer-assisted self-interview (CASI).

MAIN RESULTS AND THE ROLE OF CHANCE

The reported prevalence of infertility was 12.5% (CI 95% 11.7–13.3) among women and 10.1% (CI 95% 9.2–11.1) among men. Increased prevalence was associated with later cohabitation with a partner, higher socio-economic status and, for those who had a child, becoming parents at older ages. The reported prevalence of help seeking was 57.3% (CI 95% 53.6–61.0) among women and 53.2% (CI 95% 48.1–58.1) among men. Help seekers were more likely to be better educated and in higher status occupations and, among those who had a child, to have become parents later in life.

LIMITATIONS, REASONS FOR CAUTION

These data are cross-sectional so it is not possible to establish temporality or infer causality. Self-reported data may be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

The study provides estimates of infertility and help seeking in Britain and the results indicate that the prevalence of infertility is higher among those delaying parenthood. Those with higher educational qualifications and occupational status are more likely to consult with medical professionals for fertility problems than others and these inequalities in help seeking should be considered by clinical practice and public health.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by grants from the Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health. AMJ is a Governor of the Wellcome Trust. Other authors have no competing interests.

Posted on 19 August 2016 | 10:17 am

Young women's psychological distress after a diagnosis of polycystic ovary syndrome or endometriosis

STUDY QUESTION

Do young women with polycystic ovary syndrome (PCOS) or endometriosis report more psychological distress than their peers without a history of these conditions?

SUMMARY ANSWER

Young women (aged 18–23 years) with PCOS or endometriosis had a greater risk of moderate to severe psychological distress than women without a history of these conditions.

WHAT IS KNOWN ALREADY

Psychological distress appears common among women with PCOS and endometriosis. However, population-based studies that examine the psychological outcomes for adolescents and young women are generally absent from the literature.

STUDY DESIGN, SIZE, DURATION

This is a secondary analysis of data collected from 17 015 young, Australian women participating in a national, longitudinal cohort study. Women were first surveyed in 2012–2013 when they were aged 18–23 years. In 2014, women completed the second survey when they were aged 19–24 years and 11324 (67%) women responded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analysed data from 11 238 women who participated in both Surveys 1 and 2 and who responded to questions about PCOS and endometriosis. Using logistic regression, we compared the odds of moderate to severe psychological distress at Surveys 1 and 2 for women reporting a recent diagnosis (within the last 12 months) of PCOS or endometriosis and women with a pre-existing diagnosis, with that for women without a history of these conditions.

MAIN RESULTS AND THE ROLE OF CHANCE

At Survey 2, around 60% of women reporting a diagnosis of PCOS or endometriosis had moderate to severe levels of psychological distress. Compared to women without a history of these conditions, the odds of moderate to severe psychological distress at Survey 2 were significantly higher for women recently diagnosed with PCOS [Adjusted Odds Ratio (AOR) = 1.62, 95% CI = 1.21–2.18] or endometriosis (AOR= 1.77; 95% CI = 1.20–2.63) and for women with a pre-existing diagnosis of PCOS (AOR = 1.57, 95% CI = 1.30–1.89) or endometriosis (AOR = 1.61; 95% CI = 1.26–2.06). Women recently diagnosed with PCOS or endometriosis also had a greater likelihood of moderate to severe distress in the year prior to their diagnosis. The association between PCOS and psychological distress was attenuated when adjusting for BMI, but hormonal contraceptive use did not attenuate the risk of distress among the women with PCOS or endometriosis.

LIMITATIONS, REASONS FOR CAUTION

All data were self-reported and, therefore, the diagnoses of PCOS or endometriosis were not confirmed by a medical practitioner.

WIDER IMPLICATIONS OF THE FINDINGS

Health professionals should be aware of the potential psychosocial and healthcare needs among young women with these conditions, particularly women with PCOS who are obese. While hormonal contraceptives may help to regulate the hormonal aspects of these conditions, they do not appear to reduce women's psychological distress. Because psychological distress among the young women in this study remained elevated even after diagnosis, this supports the need for multidisciplinary health care to help women adjust to their diagnosis and treatment regimens and facilitate positive, long-term mental health outcomes. Future research that examines medical and psychosocial sources of distress for young women with PCOS and endometriosis is needed.

STUDY FUNDING/COMPETING INTEREST(S)

I.J.R. was supported by an Australian National Health and Medical Research Council Centre for Research Excellence (grant number: APP1000986). G.D.M. is funded by the Australian Research Council Future Fellowship (FT120100812). The Australian Longitudinal Study on Women's Health is funded by the Australian Government Department of Health. H.T. is supported by an Australian National Health and Medical Research Council Practitioner Fellowship. The authors declare that no competing interests exist. Trial registration number: N/A.

Posted on 19 August 2016 | 10:17 am

Online sperm donation: a survey of the demographic characteristics, motivations, preferences and experiences of sperm donors on a connection website

STUDY QUESTION

What are the demographic characteristics, motivations, preferences and experiences of heterosexual, gay and bisexual sperm donors on a connection website (i.e. a website that facilitates direct contact between donors and recipients of gametes)?

SUMMARY ANSWER

This demographically diverse group of men was donating for altruistic reasons and perceived the website as providing greater choice over donation arrangements: approximately one third favoured anonymous donation, most of whom were heterosexual, whilst gay and bisexual donors were more likely to be in contact with children conceived with their sperm.

WHAT IS KNOWN ALREADY

Despite substantially more sperm donors being registered on connection websites than with clinics, there has been very little research on this population. Current understanding of the impact of sexual orientation on donors' attitudes is also limited.

STUDY DESIGN, SIZE, DURATION

An online survey was conducted over 7 weeks with 383 men registered as sperm donors with Pride Angel, a large UK-based connection website for donors and recipients of sperm.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey obtained data on participants' demographic characteristics and their motivations, preferences and experiences regarding online sperm donation, including attitudes towards contact with offspring. Differences according to participants' sexual orientation were examined.

MAIN RESULTS AND THE ROLE OF CHANCE

Most participants (80.4%, 308) were heterosexual, 10.5% (40) were gay and 9.1% (35) were bisexual; ages ranged from 18 to 69 years (median = 36, mean = 37.3, SD = 9.7). A greater proportion of gay and bisexual men desired open-identity donation (P < 0.005) and contact with offspring (P <0.005) than heterosexual men. Approximately one third (28.7%, 110) had donated sperm; 18.3% (70) had conceived at least one child, of whom a minority (25.7%, 18) were currently in contact with the child, comprising significantly more gay and bisexual than heterosexual men (P = 0.001). Heterosexual men were most likely to state a preference for natural insemination, although the large majority (94.3%, 66) of donors who had conceived children had used artificial insemination.

LIMITATIONS, REASONS FOR CAUTION

Findings may not be representative of all sperm donors using connection websites because members of only one website participated and participants were, by necessity, a self-selected sample.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first comprehensive study of donors who connect with recipients via the internet, including a substantial number who have donated and conceived children. The findings indicate that sexual orientation may influence men's donation preferences and raise policy issues concerning donor recruitment and the incorporation of online sperm donation into clinical practice.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Wellcome Trust (097857/Z/11/Z). E.T. is the co-founder of Pride Angel; the remaining authors have no conflicts of interest.

Posted on 19 August 2016 | 10:17 am

Effects of fertility education on knowledge, desires and anxiety among the reproductive-aged population: findings from a randomized controlled trial

STUDY QUESTION

What are the effects of fertility education on knowledge, childbearing desires and anxiety?

SUMMARY ANSWER

Providing fertility information contributed to greater knowledge, but increased anxiety.

WHAT IS KNOWN ALREADY

Past studies have found that exposure to educational material improved fertility awareness and changed desires toward childbearing and its timing. Existing educational websites with evidence-based medical information provided in a non-judgmental manner have received favorable responses from reproductive-aged men and women.

STUDY DESIGN, SIZE, DURATION

This three-armed (one intervention and two control groups), randomized controlled trial was conducted using online social research panels (SRPs) in Japan in January 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1455 participants (726 men and 729 women) between 20 and 39 years of age who hoped to have (more) children in the future were block-randomized and exposed to one of three information brochures: fertility education (intervention group), intake of folic acid during pregnancy (control group 1) or governmental financial support for pregnancy and childbirth (control group 2). Fertility knowledge was measured with the Japanese version of the Cardiff Fertility Knowledge Scale (CFKS-J). Knowledge, child-number and child-timing desires, subjective anxiety (i.e. whether participants felt anxiety [primary outcome]), and scores on the State-Trait Anxiety Inventory were assessed immediately after exposure. Non-inferiority comparisons were performed on subjective anxiety with non-inferiority declared if the upper limit of the two-sided 95% confidence interval (CI) for risk difference did not exceed a margin of 0.15. This test for non-inferiority was only performed for subjective anxiety; all the other variables were tests of superiority.

MAIN RESULTS AND THE ROLE OF CHANCE

Posttest scores on the CFKS-J (mean, SD) were higher in the intervention group than that of the control groups: intervention versus Control 1 and versus Control 2: 52.8 (28.8) versus 40.9 (26.2) (P< 0.001) versus 45.1 (27.1) (P = 0.003) among men and 64.6 (26.0) versus 50.8 (26.9) (P< 0.001) versus 53.0 (26.4) (P< 0.001) among women.

The percentage of participants who felt subjective anxiety after exposure to the intervention brochure was significantly higher than that of the control groups: intervention versus Control 1 and versus Control 2: 32.6 versus 17.8% (risk difference [RD] = 0.149, 95% CI: 0.073–0.225) versus 14.5% (RD = 0.182, 95% CI: 0.108–0.256) among men, and 50.2 versus 26.3% (RD = 0.239, 95% CI: 0.155–0.322) versus 14.0% (RD = 0.362, 95% CI: 0.286–0.439) among women. Non-inferiority of the intervention was inconclusive (i.e. the CI included 0.15) among men whereas inferiority was declared among women. The incidence of anxiety was higher in the intervention group than that of the control groups especially among men aged 30 and older and among women aged 25 and older. No difference existed in childbearing desires between groups after exposure.

LIMITATIONS, REASONS FOR CAUTION

The possibility of selection bias associated with the use of SRPs (higher socioeconomic status and education) and volunteer bias toward those more interested in fertility may limit the generalizability of these findings.

WIDER IMPLICATIONS OF THE FINDINGS

In addition to education targeting a younger generation, psychological approaches are needed to alleviate possible anxiety caused by fertility information.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by National Center for Child Health and Development, Seiiku Medical Study Grant (24-6), the Daiwa Foundation Small Grants and Grant-in-Aid for JSPS Fellows (26-1591). No competing interest declared.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry. Trial registration number, 000016168.

TRIAL REGISTRATION DATE

13 January 2015.

DATE OF FIRST PATIENT'S ENROLMENT

15 January 2015.

Posted on 19 August 2016 | 10:17 am

Hysteroscopic proximal tubal occlusion versus laparoscopic salpingectomy as a treatment for hydrosalpinges prior to IVF or ICSI: an RCT

STUDY QUESTION

Does hysteroscopic proximal tubal occlusion by intratubal devices as a treatment for hydrosalpinges result in comparable ongoing pregnancy rates following IVF/ICSI when compared with laparoscopic salpingectomy?

SUMMARY ANSWER

Hysteroscopic proximal tubal occlusion by intratubal devices is inferior to laparoscopic salpingectomy in the treatment of hydrosalpinges in women undergoing IVF/ICSI with respect to ongoing pregnancy rates.

WHAT IS KNOWN ALREADY

It is known that women with hydrosalpinges undergoing IVF have poorer pregnancy outcomes compared with women with other forms of tubal infertility. In these women, both laparoscopic salpingectomy and laparoscopic proximal tubal ligation are known to improve IVF outcomes. At present, it is unclear whether a less-invasive hysteroscopic treatment with intratubal devices leads to similar ongoing pregnancy rates following IVF when compared with laparoscopic salpingectomy.

STUDY DESIGN, SIZE, DURATION

A two-centre, randomized, controlled, non-inferiority trial. Between October 2009 and December 2014 a total of 85 women were included in this study; of whom, 42 were randomized to hysteroscopic proximal occlusion by intratubal device placement and 43 were randomized to laparoscopic salpingectomy. Randomization was based on a computer-generated randomization list. The study was unblinded. The primary outcome was ongoing pregnancy rate, defined as a fetal heartbeat on ultrasound beyond 10-week gestation following one IVF/ICSI treatment (fresh and frozen–thawed embryo transfers).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied women aged 18–41 years, with uni- or bilateral ultrasound visible hydrosalpinges who were scheduled for an IVF/ICSI treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

The ongoing pregnancy rates per patient according to the intention-to-treat principle were 11/42 (26.2%) after hysteroscopic proximal occlusion by intratubal devices (intervention group) versus 24/43 (55.8%) after laparoscopic salpingectomy (control group) (P = 0.008) [absolute difference: 26.1%; 95% confidence interval (CI): 0.5–51.7, relative risk (RR): 0.56; 95% CI: 0.31–1.03, P = 0.01]. In the per protocol analysis, the ongoing pregnancy rate per patient following hysteroscopic proximal occlusion by intratubal devices was 9/27 (33.3%) compared with 19/32 (59.4%) following laparoscopic salpingectomy (P = 0.067) (absolute difference: 29.6%; 95% CI: 7.1 to 49.1, RR: 0.47; 95% CI: 0.27–0.83, P = 0.062).

LIMITATIONS, REASONS FOR CAUTION

Masking participants and investigators would be difficult due to the nature of both interventions. Since we had objective outcome measurements, we withheld sham procedures, leaving the study unblinded. Furthermore, our low sample size resulted in wide CIs. A larger sample size would result in a more accurate treatment effect; however, this was non-feasible for recruitment and inclusion.

WIDER IMPLICATIONS OF THE FINDINGS

In the treatment of hydrosalpinges prior to IVF/ICSI, hysteroscopic proximal occlusion by intratubal devices is inferior to laparoscopic salpingectomy.

STUDY FUNDING/COMPETING INTEREST(S)

The intratubal devices were received from Conceptus, Inc., San Carlos, CA, USA, which was acquired by Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ, USA in 2013. Conceptus, Inc./Bayer HealthCare Pharmaceuticals, Inc. had no role in the study design, data collection and analyses, decision to publish or preparation of the manuscript. The study as a whole was funded by the SWOG (foundation for scientific investigation in obstetrics and gynaecology of the VU University Medical Centre, Amsterdam, the Netherlands). P.G.A.H. has received non-financial support from Conceptus, Inc. during the conduct of this study. He has received grants from Ferring B.V., Merck Serono and Abbott outside the submitted work. M.H.E. has received personal fees from Smith and Nephew and IQ Medical Ventures outside the submitted work.

TRIAL REGISTRATION NUMBER

The Dutch Trial Register: NTR 2073.

TRIAL REGISTRATION DATE

October 21, 2009.

DATE OF FIRST PATIENT'S ENROLMENT

October 26, 2009.

Posted on 19 August 2016 | 10:17 am

RCT to evaluate the influence of adjuvant medical treatment of peritoneal endometriosis on the outcome of IVF

STUDY QUESTION

Does a 3-month adjuvant hormonal treatment of mild peritoneal endometriosis after laparoscopic surgery influence the outcome of IVF stimulation in terms of number of mature oocytes obtained per cycle?

SUMMARY ANSWER

Complementary medical treatment of mild peritoneal endometriosis does not influence the number of oocytes per treatment cycle.

WHAT IS KNOWN ALREADY

Endometriosis is a disease known to be related to infertility. However, the influence of superficial endometriosis—and its treatment—is still a matter of debate.

STUDY DESIGN, SIZE, DURATION

A prospective controlled, randomized, open label trial was performed between February 2012 and March 2014 and embryological and clinical outcomes were measured. Patients with laparoscopically diagnosed peritoneal endometriosis (n= 120) were treated by laser surgery after which they were sequentially randomized by computer-generated allocation to one of the two groups. The primary outcome of the trial was the number of Metaphase II (MII) oocytes. Sample size was chosen to detect a difference of two MII oocytes with a power of 80%. The control group (Group B) received the classical long protocol IVF stimulation, whereas the research group (Group A) had an additional pituitary suppression, of 3 months using a long-acting GnRH agonist, prior to IVF.

PARTICIPANTS/ MATERIALS, SETTING, METHODS

A total of 120 patients were included in the study, 61 of them in the study group and 59 patients in the control group. One patient of the control group was lost to follow up leading to 58 evaluable patients.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no difference in terms of the number of MII oocytes obtained per cycle: 8.2 in both groups (difference in MII between A and B: 0.07 [–1.89; 2.04] 95% confidence interval (CI)). Pregnancy rate did not differ, being 39.3% for Group A (24 out of 61 patients) versus 39.7% for Group B (23 out of 58 patients) (95% CI around difference in pregnancy rate between A and B: –0.31% [–17.96%; 17.86%]). However, a significantly (P = 0.025) lower dose of FSH (2561 IU for Group A and 2303 IU for Group B, 95% CI around difference in FSH between B and A: –258.6 IU [–483.4 IU; –33.8 IU]) and a significantly (P = 0.004) shorter stimulation period (Group A 12.3 days and Group B 11.3 days, 95% CI around difference in stimulation period between B and A: –1.03 days [–1.73 days; –0.33 days]) were needed to reach adequate follicle maturation in the control group.

LIMITATIONS, REASON FOR CAUTION

The validity of this study is limited to mild peritoneal endometriosis, and does not apply to ovarian endometriosis, which is also commonly seen in infertility patients.

WIDER IMPLICATIONS OF THE FINDINGS

There is no indication for complementary medical treatment of peritoneal endometriosis in terms of IVF outcome. On the contrary, stimulation takes longer and requires a higher amount of medication.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this clinical trial in the IVF Center, AZ Jan Palfijn, Ghent. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

EudraCT nr: 2012-000784-25.

TRIAL REGISTRATION DATE

First registration on 29 February 2012 and re-entered on 23 August 2012, NCT01682642 (due to a change of staff).

DATE OF FIRST PATIENT'S ENROLLMENT

8 March 2012.

Posted on 19 August 2016 | 10:17 am

Reduced homeobox protein MSX1 in human endometrial tissue is linked to infertility

STUDY QUESTION

Is protein expression of the muscle segment homeobox gene family member MSX1 altered in the human secretory endometrium by cell type, developmental stage or fertility?

SUMMARY ANSWER

MSX1 protein levels, normally elevated in the secretory phase endometrium, were significantly reduced in endometrial biopsies obtained from women of infertile couples.

WHAT IS KNOWN ALREADY

Molecular changes in the endometrium are important for fertility in both animals and humans. Msx1 is expressed in the preimplantation mouse uterus and regulates uterine receptivity for implantation. The MSX protein persists a short time, after its message has been down-regulated. Microarray analysis of the human endometrium reveals a similar pattern of MSX1 mRNA expression that peaks before the receptive period, with depressed expression at implantation. Targeted deletion of uterine Msx1 and Msx2 in mice prevents the loss of epithelial cell polarity during implantation and causes infertility.

STUDY DESIGN, SIZE DURATION

MSX1 mRNA and cell type-specific levels of MSX1 protein were quantified from two retrospective cohorts during the human endometrial cycle. MSX1 protein expression patterns were compared between fertile and infertile couples. Selected samples were dual-labeled by immunofluorescence microscopy to localize E-cadherin and β-catenin in epithelial cells.

PARTICIPANTS/MATERIALS, SETTING METHODS

MSX1 mRNA was quantified by PCR in endometrium from hysterectomies (n = 14) determined by endometrial dating to be in the late-proliferative (cycle days 10–13), early-secretory (cycle days 14–19) or mid-secretory (cycle days 20–24) phase. MSX1 protein was localized using high-throughput, semi-quantitative immunohistochemistry with sectioned endometrial biopsy tissues from fertile (n = 89) and infertile (n = 89) couples. Image analysis measured stain intensity specifically within the luminal epithelium, glands and stroma during the early-, mid- and late- (cycle days 25–28) secretory phases.

MAIN RESULTS AND THE ROLE OF CHANCE

MSX1 transcript increased 5-fold (P < 0.05) between the late-proliferative and early secretory phase and was then down-regulated (P < 0.05) prior to receptivity for implantation. In fertile patients, MSX1 protein displayed strong nuclear localization in the luminal epithelium and glands, while it was weakly expressed in nuclei of the stroma. MSX1 protein levels accumulated throughout the secretory phase in all endometrial cellular compartments. MSX1 protein decreased (P < 0.05) in the glands between mid- and late-secretory phases. However, infertile patients demonstrated a broad reduction (P < 0.001) of MSX1 accumulation in all cell types throughout the secretory phase that was most pronounced (~3-fold) in stroma and glands. Infertility was associated with persistent co-localization of E-cadherin and β-catenin in epithelial cell junctions in the mid- and late-secretory phases.

LIMITATIONS, REASONS FOR CAUTION

Details of the infertility diagnoses and other patient demographic data were not available. Therefore, patients with uterine abnormalities (Mullerian) could not be distinguished from other sources of infertility. Antibody against human MSX2 is not available, limiting the study to MSX1. However, both RNAs in the human endometrium are similarly regulated. In mice, Msx1 and Msx2 are imperative for murine embryo implantation, with Msx2 compensating for genetic ablation of Msx1 through its up-regulation in a knockout model.

WIDER IMPLICATIONS OF THE FINDINGS

This investigation establishes that the MSX1 homeobox protein accumulation is associated with the secretory phase in endometrium of fertile couples, and is widely disrupted in infertile patients. It is the first study to examine MSX1 protein localization in the human endometrium, and supported by genetic findings in mice, suggests that genes regulated by MSX1 are linked to the loss of epithelial cell polarity required for uterine receptivity during implantation.

STUDY FUNDING/COMPETING INTERESTS

This research was supported by the NICHD National Cooperative Reproductive Medicine Network grant HD039005 (M.P.D.), NIH grants HD068524 (S.K.D.), HD071408 (D.R.A., M.P.D.), and HL128628 (S.D.), the Intramural Research Program of the NICHD, March of Dimes (S.K.D., S.D.) and JSPS KAKENHI grant 26112506 (Y.H.). There were no conflicts or competing interests.

Posted on 19 August 2016 | 10:17 am

Dienogest mediates midkine suppression in endometriosis

STUDY QUESTION

What are the effects of dienogest (DNG) on midkine (MK) production in women with endometriosis?

SUMMARY ANSWER

DNG-mediated down-regulation of MK in vivo and in vitro.

WHAT IS KNOWN ALREADY

DNG is an oral progestin that alleviates painful symptoms of women with endometriosis with a favourable tolerability and safety profile. Its effects on MK, a growth factor that plays an important role in endometriosis, have not yet been investigated.

STUDY DESIGN, SIZE, DURATION

Prospective in vivo study on 283 patients subjected to laparoscopy for benign pathologies in a University hospital and in vitro cultures of primary endometrial stromal cells (ESC) from 6 of these women with histologically confirmed endometriosis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

MK concentrations in the peritoneal fluid (PF) of women were measured by ELISA and compared based on endometriosis status and the use of DNG. A subsequent in vitro analysis with ESC was used to confirm the direct influence of DNG and other progestins including, norethisterone acetate (NETA) and medroxyprogesterone acetate (MPA) on MK mRNA production.

MAIN RESULTS AND THE ROLE OF CHANCE

The final study population consisted of 253 women. Of these, 165 suffered from endometriosis, with 62 of them taking DNG (DNG group) and 103 taking no hormone treatment (non-DNG group) during at least 3 months before surgery. Another 88 women were endometriosis free (non-endometriosis group). The concentration of MK was highest in the PF of women in the non-DNG group (median 5.26 ng/ml, IQR 2.74–8.46). Significantly lower concentrations were found in the non-endometriosis group (median 3.51 ng/ml, IQR: 1.90–7.53, P = 0.028). The lowest concentrations were found in the DNG group (median 2.44 ng/ml, IQR: 1.12–4.70, P < 0.0001 versus non-DNG group, P = 0.048 versus non-endometriosis group). The treatment of primary cultured ESC with DNG (10–5 M) suppressed MK mRNA production (P = 0.016), whereas MPA (P = 0.109) and NETA (P = 0.422) at same concentrations did not show a similar effect.

LIMITATIONS, REASONS FOR CAUTION

The non-randomized design of the study.

WIDER IMPLICATIONS OF THE FINDINGS

These findings could indicate a direct effect of DNG on endometriotic cells that could contribute to its effectiveness in the treatment of this disease.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from Swiss National Science Foundation (Grant No. 320030_140774). M.D.M. has received fees for speaking at scientific meetings from Bayer. The other authors have no conflicts of interest to declare.

The authors state that the manufacturer of dienogest has in no way influenced the performance or outcomes of this study.

Posted on 19 August 2016 | 10:17 am

The Fertility Quality of Life Questionnaire (FertiQoL) Relational subscale: psychometric properties and discriminant validity across gender

STUDY QUESTION

Is the Fertility Quality of Life Questionnaire (FertiQoL)—Relational Scale a valid measure to assess the relational domain regarding quality of life in women and men undergoing infertility treatment?

SUMMARY ANSWER

The FertiQoL-Relational scale (FertiQoL-REL) showed good psychometric properties and captured core aspects of couple relationships.

WHAT IS KNOWN ALREADY

FertiQoL has become a gold standard for the assessment of infertility-related quality of life in patients undergoing assisted reproduction treatment (ART). Despite its growing importance, no previous studies have examined the convergent validity of the FertiQoL-REL and its discriminant validity across gender.

STUDY DESIGN, SIZE, DURATION

Baseline cross-sectional data as part of a longitudinal study of infertile couples undergoing an ART between February 2013 and January 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Five hundred and eighty-nine patients (301 females and 288 males), prior to starting an ART in a private clinic, filled in the Fertility Quality of Life Questionnaire (FertiQoL) and several measures of the marital relationship (Dyadic Adjustment Scale, Marital Commitment Inventory and ENRICH Marital Satisfaction Scale) and infertility-related distress (Fertility Problem Inventory).

MAIN RESULTS AND THE ROLE OF CHANCE

Confirmatory factor analysis showed that the FertiQoL four-factor solution provided a good fit for the observed data. Reliability of the FertiQoL-REL was higher for women than men. Significant correlations between the FertiQoL-REL scores and all the other measures of marital relationship were found for both women and men. FertiQoL-REL scores did not differ significantly in women and men. The FertiQoL-REL was able to differentiate subjects as regards the Dyadic Adjustment Scale and ENRICH Marital Satisfaction Scale threshold.

LIMITATIONS, REASONS FOR CAUTION

Findings are limited because the data were obtained from only one Italian private clinic.

WIDER IMPLICATIONS OF THE FINDINGS

FertiQoL-REL threshold scores are useful for identifying those patients undergoing ART who are more likely to report poor or good relationship quality. Clinicians should tailor their counselling strategies to the positive qualities in a couple's relationship, so as to reinforce the overall quality of life, especially among women, and to support patients in tackling the psychological burden, so that they can either continue treatment or choose discontinuation.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by funds provided by Centro Andros S.r.l., Palermo, Italy. The authors declare no financial or commercial conflicts of interest in this study.

TRIAL REGISTRATION NUMBER

Not necessary.

Posted on 19 August 2016 | 10:17 am

Ovarian hyperstimulation syndrome: review and new classification criteria for reporting in clinical trials

STUDY QUESTION

What is an objective approach that employs measurable and reproducible physiologic changes as the basis for the classification of ovarian hyperstimulation syndrome (OHSS) in order to facilitate more accurate reporting of incidence rates within and across clinical trials?

SUMMARY ANSWER

The OHSS flow diagram is an objective approach that will facilitate consistent capture, classification and reporting of OHSS within and across clinical trials.

WHAT IS KNOWN ALREADY

OHSS is a potentially life-threatening iatrogenic complication of the early luteal phase and/or early pregnancy after ovulation induction (OI) or ovarian stimulation (OS). The clinical picture of OHSS (the constellation of symptoms associated with each stage of the disease) is highly variable, hampering its appropriate classification in clinical trials. Although some degree of ovarian hyperstimulation is normal after stimulation, the point at which symptoms transition from those anticipated to those of a disease state is nebulous.

STUDY DESIGN, SIZE, DURATION

An OHSS working group, comprised of subject matter experts and clinical researchers who have significantly contributed to the field of fertility, was convened in April and November 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The OHSS working group was tasked with reaching a consensus on the definition and the classification of OHSS for reporting in clinical trials. The group engaged in targeted discussion regarding the scientific background of OHSS, the criteria proposed for the definition and the rationale for universal adoption. An agreement was reached after discussion with all members.

MAIN RESULTS AND THE ROLE OF CHANCE

One of the following conditions must be met prior to making the diagnosis of OHSS in the context of a clinical trial: (i) the subject has undergone OS (either controlled OS or OI) AND has received a trigger shot for final oocyte maturation (e.g. hCG, GnRH agonist [GnRHa] or kisspeptin) followed by either fresh transfer or segmentation (cryopreservation of embryos) or (ii) the subject has undergone OS or OI AND has a positive pregnancy test. All study patients who develop symptoms of OHSS should undergo a thorough examination. An OHSS flow diagram was designed to be implemented for all subjects with pelvic or abdominal complaints, such as lower abdominal discomfort or distention, nausea, vomiting and diarrhea, and/or for subjects suspected of having OHSS. The diagnosis of OHSS should be based on the flow diagram.

LIMITATIONS, REASONS FOR CAUTION

This classification system is primarily intended to address the needs of the clinical investigator undertaking clinical trials in the field of OS and may not be applicable for the use in clinical practice or with OHSS occurring under natural circumstances.

WIDER IMPLICATIONS OF THE FINDINGS

The proposed OHSS classification system will enable an accurate estimate of the incidence and severity of OHSS within and across clinical trials performed in women with infertility.

STUDY FUNDING/COMPETING INTERESTS

Financial support for the advisory group meetings was provided by Merck & Co., Inc., Kenilworth, NJ, USA. P.H. reports unrestricted research grants from MSD, Merck and Ferring, and honoraria for lectures from MSD, Merck and IBSA. S.M.N. reports that he has received fees and grant support from the following companies (in alphabetic order): Beckman Coulter, Besins, EMD Serono, Ferring Pharmaceuticals, Finox, MSD and Roche Diagnostics over the previous 5 years. P.D., C.C.C., J.L.F., H.M.F., and P.L. report no relationships that present a potential conflict of interest. B.C.T. reports: grants and honorarium from Merck Serono; unrestricted research grants, travel grants and honorarium, and participation in a company-sponsored speaker's bureau from Merck Sharp & Dohme; grants, travel grants, honoraria and advisory board membership from IBSA; travel grants from Ferring; and advisory board membership from Ovascience. L.B.S. reports current employment with Merck & Co, Inc., Kenilworth, NJ, USA, and owns stock in the company. K.G. and B.J.S. report prior employment with Merck & Co., Inc., Kenilworth, NJ, USA, and own stock in the company. All reported that competing interests are outside the submitted work. No other relationships or activities exist that could appear to have influenced the submitted work.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 19 August 2016 | 10:17 am

No change in live birthweight of IVF singleton deliveries over an 18-year period despite significant clinical and laboratory changes

STUDY QUESTION

Has live birthweight changed over 18 years of autologous fresh and frozen IVF?

SUMMARY ANSWER

Regardless of changes in clinical care and laboratory practice over 18 years, birthweight has remained stable.

WHAT IS KNOWN ALREADY

Birthweight has historically been used as a marker of neonatal health. Frozen embryo transfers lead to heavier live birthweights compared with fresh embryo transfers.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included 7295 singletons from autologous fresh (n = 6265) and frozen (n = 1030) IVF cycles from 1996 to 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients undergoing autologous IVF cycles between 1996 and 2013 resulting in a singleton live born with a birthweight recorded were included. One-way ANOVA and t-tests compared mean live birthweight in fresh and frozen cycles in 6-month increments over 18 years. Linear regression analysis was performed to investigate predictors of birthweight.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean birthweight after fresh (3283 ± 601 g) and frozen (3462 ± 621 g) cycles were significantly different (P < 0.001). ANOVA demonstrated no significant difference in mean weight from fresh or frozen cycles over 6-month intervals. No difference in weight was noted between Days 3 and 5 transfers or between ICSI and standard IVF. No difference was found across known changes when comparing media, laboratory location, cryopreservation method or gonadotrophins.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the small number of frozen low birthweight neonates.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that changes in IVF practice, with the exception of fresh or frozen embryo transfer, have little impact on mean live birthweight.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. The authors have no conflicting interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 19 August 2016 | 10:17 am

Klinefelter syndrome and fertility: sperm preservation should not be offered to children with Klinefelter syndrome

STUDY QUESTION

Should fertility preservation be offered to children with Klinefelter syndrome (KS)?

SUMMARY ANSWER

Current evidence shows that fertility preservation should not be offered to adolescents with KS younger than 16 years because of lower retrieval rates for germ cells by testicular sperm extraction (TESE) compared with retrieval rates for adolescents and adults between 16 and 30 years.

WHAT IS KNOWN ALREADY

KS, the most common chromosomal disorder in men leading to non-obstructive azoospermia, is caused by the presence of at least one additional X chromosome. The onset of puberty in adolescents with KS leads to progressive degeneration of the testicular environment. The impact of the subsequent tissue degeneration on fertility potential of patients with KS is unknown, but in previous literature it has been suggested that fertility preservation should be started in adolescents as early as possible. However spermatozoa can be found by TESE in about 50% of adults with KS despite severe testicular degeneration. This review discusses the current evidence for fertility preservation in children and adolescents and possible prognostic markers for fertility treatment in KS.

STUDY DESIGN, SIZE, DURATION

An extensive literature search was conducted, searching Pubmed, Embase, Cinahl and Web of Science from origin until April 2016 for ‘Klinefelter syndrome’ and ‘fertility’ and various synonyms. Titles and abstracts have been scanned manually by the authors for eligibility.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total 76 studies were found to be eligible for inclusion in this review. Information from the papers was extracted separately by two authors.

MAIN RESULTS AND THE ROLE OF CHANCE

Various studies have shown that pre-pubertal children with KS already have a reduced number of germ cells despite a normal hormonal profile during childhood. The presence of spermatozoa in the ejaculate of adolescents with KS is extremely rare. Using TESE, the retrieval rates of spermatozoa for adolescents younger than 16 years old are much lower (0–20%) compared with those for adolescents and young adults between 16 and 30 years old (40–70%). Although spermatogonia can be found by TESE in about half of the peri-pubertal adolescents, there are currently no clinically functional techniques for their future use. Children and adolescents need to be informed that early fertility preservation before the age of 16 cannot guarantee fertility later in life and may even reduce the chances for offspring by removing functional immature germ cells which may possibly develop into spermatozoa after puberty. Furthermore, except for the age of patients with KS, there are no identified factors that can reliably be used as a predictive marker for fertility preservation.

LIMITATIONS, REASONS FOR CAUTION

Most of the evidence presented in this review is based on studies including a small number of adolescents with KS. Therefore, the studies may have been underpowered to detect clinically significant differences for their various outcomes, especially for potential predictive factors for fertility preservation, such as hormone levels. Furthermore, the population of patients with KS diagnosed during childhood might be different from the adult population with KS where the diagnosis is based on infertility. Results based on comparisons between the two groups must be interpreted with caution.

WIDER IMPLICATIONS OF THE FINDINGS

Despite the limitations, this review summarizes the current evidence for managing fertility preservation in patients with KS to provide optimal health care.

STUDY FUNDING/COMPETING INTERESTS

There was no funding for this study. S.F., Y.H., K.D., W.L.M.N., D.S., H.L.C.–v.d.G. and L.R. declare to have no conflicts of interests. D.D.M.B. reports grants from Merck Serono, grants from Ferring and grants from MSD, outside the submitted work. K.F. reports personal fees from MSD (commercial sponsor), personal fees from Ferring (commercial sponsor), grants from Merck-Serono (commercial sponsor), grants from Ferring (commercial sponsor) and grants from MSD (commercial sponsor), outside the submitted work.

Posted on 19 August 2016 | 10:17 am

Advanced maternal age causes adverse programming of mouse blastocysts leading to altered growth and impaired cardiometabolic health in post-natal life

STUDY QUESTION

Does advanced maternal age (AMA) in mice affect cardiometabolic health during post-natal life in offspring derived from an assisted reproduction technology (ART) procedure?

SUMMARY ANSWER

Offspring derived from blastocysts collected from aged female mice displayed impaired body weight gain, blood pressure, glucose metabolism and organ allometry during post-natal life compared with offspring derived from blastocysts from young females; since all blastocysts were transferred to normalized young mothers, this effect is independent of maternal pregnancy conditions.

WHAT IS KNOWN ALREADY

Although studies in mice have shown that AMA can affect body weight and behaviour of offspring derived from natural reproduction, data on the effects of AMA on offspring cardiometabolic health during post-natal development are not available. Given the increasing use of ART to alleviate infertility in women of AMA, it is pivotal to develop ART–AMA models addressing the effects of maternal aging on offspring health.

STUDY DESIGN, SIZE, DURATION

Blastocysts from old (34–39 weeks) or young (8–9 weeks) C57BL/6 females mated with young CBA males (13–15 weeks) were either subjected to differential cell staining (inner cell mass and trophectoderm) or underwent embryo transfer (ET) into young MF1 surrogates (8–9 weeks) to produce young (Young-ET, 9 litters) and old (Old-ET, 10 litters) embryo-derived offspring. Offspring health monitoring was carried out for 30 weeks.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All animals were fed with standard chow. Blood pressure was measured at post-natal Weeks 9, 15 and 21, and at post-natal Week 30 a glucose tolerance test (GTT) was performed. Two days after the GTT mice were killed for organ allometry. Blastocyst cell allocation variables were evaluated by T-test and developmental data were analysed with a multilevel random effects regression model.

MAIN RESULTS AND THE ROLE OF CHANCE

The total number of cells in blastocysts from aged mice was decreased (P < 0.05) relative to young mice due to a lower number of cells in the trophectoderm (mean ± SEM: 34.5 ± 2.1 versus 29.6 ± 1.0). Weekly body weight did not differ in male offspring, but an increase in body weight from Week 13 onwards was observed in Old-ET females (final body weight at post-natal Week 30: 38.5 ± 0.8 versus 33.4 ± 0.8 g, P < 0.05). Blood pressure was increased in Old-ET offspring at Weeks 9–15 in males (Week 9: 108.5 ± 3.13 versus 100.8 ± 1.5 mmHg, Week 15: 112.9 ± 3.2 versus 103.4 ± 2.1 mmHg) and Week 15 in females (115.9 ± 3.7 versus 102.8 ± 0.7 mmHg; all P < 0.05 versus Young-ET). The GTT results and organ allometry were not affected in male offspring. In contrast, Old-ET females displayed a greater (P < 0.05) peak glucose concentration at 30 min during the GTT (21.1 ± 0.4 versus 17.8 ± 1.16 mmol/l) and their spleen weight (88.2 ± 2.6 ± 105.1 ± 4.6 mg) and several organ:body weight ratios (g/g x 103) were decreased (P < 0.05 versus Young-ET), including the heart (3.7 ± 0.06 versus 4.4 ± 0.08), lungs (4.4 ± 0.1 versus 5.0 ± 0.1), spleen (2.4 ± 0.06 versus 3.2 ± 0.1) and liver (36.4 ± 0.6 versus 39.1 ± 0.9).

LIMITATIONS, REASONS FOR CAUTION

Results from experimental animal models cannot be extrapolated to humans. Nevertheless, they are valuable to develop conceptual models that can produce hypotheses for eventual testing in the target species (i.e. humans).

WIDER IMPLICATIONS OF THE FINDINGS

Our data show that offspring from mouse embryos from aged mothers can develop altered phenotypes during post-natal development compared with embryos from young mothers. Because all embryos were transferred into young mothers for the duration of pregnancy to normalize the maternal in vivo environment, our findings indicate that adverse programming via AMA is already established at the blastocyst stage. Whilst human embryos display increased aneuploidy compared with mouse, we believe our data have implications for women of AMA undergoing assisted reproduction, including surrogacy programmes.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported through the European Union FP7-CP-FP Epihealth programme (278418) to T.P.F. and the BBSRC (BB/F007450/1) to T.P.F. The authors have no conflicts of interest to declare.

Posted on 19 August 2016 | 10:17 am

Treatment with human, recombinant FSH improves sperm DNA fragmentation in idiopathic infertile men depending on the FSH receptor polymorphism p.N680S: a pharmacogenetic study

STUDY QUESTION

Does the sperm DNA fragmentation index (DFI) improve depending on the FSH receptor (FSHR) genotype as assessed by the nonsynonymous polymorphisms rs6166 (p.N680S) after 3 months of recombinant FSH treatment in men with idiopathic infertility?

SUMMARY ANSWER

FSH treatment significantly improves sperm DFI only in idiopathic infertile men with the p.N680S homozygous N FSHR.

WHAT IS KNOWN ALREADY

FSH, fundamental for spermatogenesis, is empirically used to treat male idiopathic infertility and several studies suggest that DFI could be a candidate predictor of response to FSH treatment, in terms of probability to conceive. Furthermore, it is known that the FSHR single nucleotide polymorphism (SNP) rs6166 (p.N680S) influences ovarian response in women and testicular volume in men.

STUDY DESIGN, SIZE AND DURATION

A multicenter, longitudinal, prospective, open-label, two-arm clinical trial was performed. Subjects enrolled were idiopathic infertile men who received 150 IU recombinant human FSH s.c. every other day for 12 weeks and were followed-up for a further 12 weeks after FSH withdrawal. Patients were evaluated at baseline, at the end of treatment and at the end of follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eighty-nine men with idiopathic infertility carrier of the FSHR p.N680S homozygous N or S genotype, FSH ≤ 8 IU/l and DFI >15%, were enrolled. A total of 66 patients had DFI analysis completed on at least two visits. DFI was evaluated in one laboratory by TUNEL/PI (propidium iodide) assay coupled to flow cytometry, resolving two different fractions of sperm, namely the ‘brighter’ and ‘dimmer’ sperm DFI fractions.

MAIN RESULTS AND THE ROLE OF CHANCE

Thirty-eight men (57.6%) were carriers of the p.N680S homozygous N and 28 (42.4%) of the homozygous S FSHR. Sperm concentration/number was highly heterogeneous and both groups included men ranging from severe oligozoospermia to normozoospermia. Total DFI was significantly lower at the end of the study in homozygous carriers of the p.N680S N versus p.N680S S allele (P = 0.008). Total DFI decreased significantly from baseline to the end of the study (P = 0.021) only in carriers of the p.N680S homozygous N polymorphism, and this decrease involved the sperm population containing vital sperm (i.e. brighter sperm) (P = 0.008). The dimmer sperm DFI fraction, including only nonvital sperm, was significantly larger in p.N680S S homozygous patients than in homozygous N men (P = 0.018). Total DFI was inversely related to total sperm number (P = 0.020) and progressive sperm motility (P = 0.014). When patients were further stratified according to sperm concentration (normoozospermic versus oligozoospermic) or -211G>T polymorphism in the FSHB gene (rs10835638) (homozygous G versus others), the significant improvement of sperm DFI in FSHR p.N680S homozygous N men was independent of sperm concentration and associated with the homozygous FSHB -211G>T homozygous G genotype.

LIMITATIONS, REASONS FOR CAUTION

The statistical power of the study is 86.9% with alpha error 0.05. This is the first pharmacogenetic study suggesting that FSH treatment induces a significant improvement of total DFI in men carriers of the p.N680S homozygous N FSHR; however, the results need to be confirmed in larger studies using a personalized FSH dosage and treatment duration.

WIDER IMPLICATIONS OF THE FINDINGS

The evaluation of sperm DFI as a surrogate marker of sperm quality, and of the FSHR SNP rs6166 (p.N680S), might be useful to predict the response to FSH treatment in men with idiopathic infertility.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by an unrestricted grant to M.S. and H.M.B. from Merck Serono that provided the drug used in the study. MS received additional grants from Merck Serono and IBSA as well as honoraria from Merck Serono. The remaining authors declare that no conflicts of interest are present.

TRIAL REGISTRATION NUMBER

EudraCT number 2010-020240-35.

Posted on 19 August 2016 | 10:17 am

Fertility, pregnancy and gynecological outcomes after fetoscopic surgery for congenital diaphragmatic hernia

STUDY QUESTION

What is the impact of fetoscopic surgery for isolated Congenital Diaphragmatic Hernia (CDH) on future reproductive and gynecological outcomes?

SUMMARY ANSWER

We did not observe an increase of obstetric or gynecological problems after fetoscopic surgery nor was there an increased risk for subsequent infertility.

WHAT IS KNOWN ALREADY

The reproductive and gynecological outcomes of patients undergoing open maternal-fetal surgery are known. The most relevant counseling items are the elevated risk for uterine dehiscence and rupture (up to 14%).

STUDY DESIGN, SIZE, DURATION

Bi-centric study over a 10-year period including 371 women carrying a fetus with isolated CDH either managed expectantly (n = 167) or operated in utero (n = 204).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Consenting patients filled out a survey with 23 questions (2 open and 21 multiple choice). Questionnaires were custom designed to obtain information on subsequent reproductive or gynecological problems as well as psychological impact.

MAIN RESULTS AND THE ROLE OF CHANCE

The response rate was 40% (147/371). More women in the FETO group attempted a subsequent pregnancy: 70% (62/89) when compared with 47% (27/58) in controls (P = 0.009). This coincided with a longer follow-up in the FETO group (76 versus 59 months; P < 0.001) and a lower survival rate in the index pregnancy (53 versus 72%; P = 0.028). There was no difference in the number of nulliparous or parous women, neither in the conception rate. In total, there were 129 subsequent pregnancies. Nobody reported secondary fertility problems. Four women in the FETO group and one in the control reported a congenital anomaly in a subsequent pregnancy. Twenty-one pregnancies were reported with at least one complication (FETO: 23% (14/60), controls 27% (7/26)). During delivery or in the post-partum period 11 patients reported at least 1 complication (FETO 17% (10/59), controls 4% (1/24)). New onset gynecological problems occurred in 14 participants (10%). None of these events were more likely in one or the other group. Psychological and emotional impacts were frequent in both the FETO (41%) and the control groups (46%) (P = 0.691).

LIMITATIONS, REASONS FOR CAUTION

The response rate was 40% (147/371), less than desired. The use of unvalidated self-reported outcomes may skew exact determination of the nature and severity of medical complications. The number of observations for uncommon events was low. The mean follow-up period to detect gynecological complications may be too short.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first evidence that fetoscopic surgery for CDH does not compromise future reproductive potential or obstetrical outcome when compared with expectant management. A pregnancy complicated by a serious congenital birth defect, such as CDH, frequently has a measurable psychological impact.

STUDY FUNDING/COMPETING INTEREST

The authors have no conflicts to declare. J.D. receives a fundamental clinical research grant of the Fonds Wetenschappelijk Onderzoek - Vlaanderen (FWO; 18.01207). A.C.E. is supported by the Erasmus+Program of the European Union (Framework agreement number 2013-0040; contract 1011990). This was presented at the 61st meeting of the Society of Gynaecologic Investigation, in Florence, March 2014 (F-111).

Posted on 19 August 2016 | 10:17 am

Ninety-five orthotopic transplantations in 74 women of ovarian tissue after cytotoxic treatment in a fertility preservation network: tissue activity, pregnancy and delivery rates

STUDY QUESTION

What is the success rate in terms of ovarian activity (menstrual cycles) as well as pregnancy and delivery rates 1 year after orthotopic ovarian transplantations conducted in a three-country network?

SUMMARY ANSWER

In 49 women with a follow-up >1 year after transplantation, the ovaries were active in 67% of cases and the pregnancy and delivery rates were 33 and 25%, respectively.

WHAT IS KNOWN ALREADY

Cryopreservation of ovarian tissue in advance of cytotoxic therapies and later transplantation of the tissue is being performed increasingly often, and the total success rates in terms of pregnancy and delivery have been described in case series. However, published case series have not allowed either a more detailed analysis of patients with premature ovarian insufficiency (POI) or calculation of success rates based on the parameter ‘tissue activity’.

STUDY DESIGN, SIZE, DURATION

Retrospective analysis of 95 orthotopic transplantations in 74 patients who had been treated for cancer, performed in the FertiPROTEKT network from 2008 to June 2015. Of those 95 transplantations, a first subgroup (Subgroup 1) was defined for further analysis, including 49 women with a follow-up period >1 year after transplantation. Of those 49 women, a second subgroup (Subgroup 5) was further analysed, including 40 women who were transplanted for the first time and who were diagnosed with POI before transplantation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Transplantation was performed in 16 centres and data were transferred to the FertiPROTEKT registry. The transplantations were carried out after oncological treatment had been completed and after a remission period of at least 2 years. Tissue was transplanted orthotopically, either into or onto the residual ovaries or into a pelvic peritoneal pocket. The success rates were defined as tissue activity (menstrual cycles) after 1 year (primary outcome) and as pregnancies and deliveries achieved.

MAIN RESULTS AND THE ROLE OF CHANCE

The average age of all transplanted 74 women was 31 ± 5.9 years at the time of cryopreservation and 35 ± 5.2 at the time of transplantation. Twenty-one pregnancies and 17 deliveries were recorded. In Subgroup 1, tissue was cryopreserved at the age of 30 ± 5.6 and transplanted at 34 ± 4.9 years. Ovaries remained active 1 year after transplantation in 67% of cases (n = 33/49), the pregnancy rate was 33% (n = 16/49) and the delivery rate was 25% (n = 12/49). In Subgroup 5, tissue was cryopreserved at the age 30 ± 5.9 years and transplanted at 34 ± 5.2 years. Ovaries remained active 1 year after transplantation in 63% of cases (n = 25/40), the pregnancy rate was 28% (n = 11/40) and the delivery rate was 23% (n = 9/40). The success rates were age dependant with higher success in women who cryopreserved at a younger age. In Subgroup 5, tissue was exclusively transplanted into the ovary in 10% (n = 4/40) of women and into a peritoneal pocket in 75% (n = 30/40), resulting in spontaneous conceptions in 91% of patients (n = 10/11).

LIMITATIONS, REASONS FOR CAUTION

The data were drawn from a retrospective analysis. The cryopreservation and transplantation techniques used have changed during the study period. The tissue was stored in many tissue banks and many surgeons were involved, leading to heterogeneity of the procedures. However, this does reflect the realistic situation in many countries. Although patients with POI were evaluated before transplantation to allow specific analysis of the transplanted tissue itself, the possibility cannot be excluded that residual ovarian tissue was also reactivated.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest case series worldwide to date and it confirms that cryopreservation and transplantation of ovarian tissue can be a successful option for preserving fertility. Persistent tissue activity 12 months after transplantation suggests that the pregnancy and delivery rates may increase further in the future. As transplantation into the peritoneum results in a high success rate, this approach may be an alternative to transplantation into the ovary. However, in order to establish the best transplantation site, a randomized study is required.

STUDY FUNDING/COMPETING INTEREST

This study was in part funded from the Deutsche Forschungsgemeinschaft (# DI 1525) and the Wilhelm Sander Foundation (2012.127.1) and did not receive any funding from a commercial company. No competing interests.

TRIAL REGISTRATION NUMBER

None.

Posted on 19 August 2016 | 10:17 am

Prediction model for obtaining spermatozoa with testicular sperm extraction in men with non-obstructive azoospermia

STUDY QUESTION

Can an externally validated model, based on biological variables, be developed to predict successful sperm retrieval with testicular sperm extraction (TESE) in men with non-obstructive azoospermia (NOA) using a large nationwide cohort?

SUMMARY ANSWER

Our prediction model including six variables was able to make a good distinction between men with a good chance and men with a poor chance of obtaining spermatozoa with TESE.

WHAT IS KNOWN ALREADY

Using ICSI in combination with TESE even men suffering from NOA are able to father their own biological child. Only in approximately half of the patients with NOA can testicular sperm be retrieved successfully. The few models that have been developed to predict the chance of obtaining spermatozoa with TESE were based on small datasets and none of them have been validated externally.

STUDY DESIGN, SIZE, DURATION

We performed a retrospective nationwide cohort study. Data from 1371 TESE procedures were collected between June 2007 and June 2015 in the two fertility centres.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All men with NOA undergoing their first TESE procedure as part of a fertility treatment were included. The primary end-point was the presence of one or more spermatozoa (regardless of their motility) in the testicular biopsies.

We constructed a model for the prediction of successful sperm retrieval, using univariable and multivariable binary logistic regression analysis and the dataset from one centre. This model was then validated using the dataset from the other centre. The area under the receiver-operating characteristic curve (AUC) was calculated and model calibration was assessed.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 599 (43.7%) successful sperm retrievals after a first TESE procedure. The prediction model, built after multivariable logistic regression analysis, demonstrated that higher male age, higher levels of serum testosterone and lower levels of FSH and LH were predictive for successful sperm retrieval. Diagnosis of idiopathic NOA and the presence of an azoospermia factor c gene deletion were predictive for unsuccessful sperm retrieval. The AUC was 0.69 (95% confidence interval (CI): 0.66–0.72). The difference between the mean observed chance and the mean predicted chance was <2.0% in all groups, indicating good calibration. In validation, the model had moderate discriminative capacity (AUC 0.65, 95% CI: 0.62–0.72) and moderate calibration: the predicted probability never differed by more than 9.2% of the mean observed probability.

LIMITATIONS, REASONS FOR CAUTION

The percentage of men with Klinefelter syndrome among men diagnosed with NOA is expected to be higher than in our study population, which is a potential selection bias. The ability of the sperm retrieved to fertilize an oocyte and produce a live birth was not tested.

WIDER IMPLICATIONS OF THE FINDINGS

This model can help in clinical decision-making in men with NOA by reliably predicting the chance of obtaining spermatozoa with TESE.

STUDY FUNDING/COMPETING INTEREST

This study was partly supported by an unconditional grant from Merck Serono (to D.D.M.B. and K.F.) and by the Department of Obstetrics and Gynaecology of Radboud University Medical Center, Nijmegen, The Netherlands, the Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, The Netherlands, and the Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands. Merck Serono had no influence in concept, design nor elaboration of this study.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 19 August 2016 | 10:17 am

Prediction model for live birth in ICSI using testicular extracted sperm

STUDY QUESTION

Which parameters have a predictive value for live birth in couples undergoing ICSI after successful testicular sperm extraction (TESE-ICSI)?

SUMMARY ANSWER

Female age, a first or subsequent started TESE-ICSI cycle, male LH, male testosterone, motility of the spermatozoa during the ICSI procedure and the initial male diagnosis before performing TESE were identified as relevant and independent parameters for live birth after TESE-ICSI.

WHAT IS KNOWN ALREADY

In reproductive medicine prediction models are used frequently to predict treatment success, but no prediction model currently exists for live birth after TESE-ICSI.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study between 2007 and 2015 in two academic hospitals including 1559 TESE-ICSI cycles. The prediction model was developed using data from one centre and validation was performed with data from the second centre.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included couples undergoing ICSI treatment with surgically retrieved sperm from the testis for the first time. In the development set we included 526 couples undergoing 1006 TESE-ICSI cycles. In the validation set we included 289 couples undergoing 553 TESE-ICSI cycles. Multivariable logistic regression models were constructed in a stepwise fashion (P < 0.2 for entry). The external validation was based on discrimination and calibration.

MAIN RESULTS AND THE ROLE OF CHANCE

We included 224 couples (22.3%) with a live birth in the development set. The occurrence of a live birth was associated with lower female age, first TESE-ICSI cycle, lower male LH, higher male testosterone, the use of motile spermatozoa for ICSI and having obstructive azoospermia as an initial suspected diagnosis. The area under the receiver operating characteristic (ROC) curve was 0.62. From validation data, the model had moderate discriminative capacity (c-statistic 0.67, 95% confidence interval: 0.62–0.72) but calibrated well, with a range from 0.06 to 0.56 in calculated probabilities.

LIMITATIONS, REASONS FOR CAUTION

We had a lack of data about the motility of spermatozoa during TESE, therefore, we used motility of the spermatozoa used for ICSI after freeze-thawing, information which is only available during treatment. We had to exclude data on paternal BMI in the model because too many missing values in the validation data hindered testing. We did not include a histologic diagnosis, which would have made our data set less heterogeneous and, finally, our model may not be applicable in centres which have a different policy for the indication for performing sperm extraction. The prognostic value of the model is limited because of a low ‘area under the curve’.

WIDER IMPLICATIONS OF THE FINDINGS

This model enables the differentiation between couples with a low or high chance to reach a live birth using TESE-ICSI. As such it can aid in the counselling of patients and in clinical decision-making.

STUDY FUNDING/COMPETING INTEREST(S)

This study was partly supported by an unconditional grant from Merck Serono (to D.D.M.B. and K.F.) and by the Department of Obstetrics and Gynaecology of Radboud University Medical Center, Nijmegen, The Netherlands, the Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, The Netherlands, and the Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands. Merck Serono had no influence in concept, design, nor elaboration of this study.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 19 August 2016 | 10:17 am

Nomogram to predict live birth rate after fertility-sparing surgery for borderline ovarian tumours

STUDY QUESTION

Can a nomogram be used to predict the individual probability of live birth (LB) in women with borderline ovarian tumours (BOTs) receiving primary fertility-sparing surgery?

SUMMARY ANSWER

A nomogram built according to the woman's age, histological subtype (serous versus mucinous), type of ovarian surgical treatment and FIGO stage can accurately predict the probability of LB in women with BOT.

WHAT IS KNOWN ALREADY

Current prediction models determine the probability of pregnancy after medically assisted reproduction (MAR) and form the basis of patient counselling to guide the decision as to whether to consider in vitro fertilization but do not take into account prediction of the LB rate.

STUDY DESIGN, SIZE, DURATION

This was a retrospective multi-centre study including 187 women with fertility-sparing surgery for BOT diagnosed between January 1980 and December 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A multivariate logistic regression analysis of selected factors and a nomogram to predict the subsequent LB rate was constructed. A bootstrapping technique was used for internal validation.

MAIN RESULTS AND THE ROLE OF CHANCE

Fifty-one women had LB (27.3%). Taking into account multiple pregnancies, the overall LB rate was 40.1% (75/187). Federation International of Gynaecology and Obstetric (FIGO) stage, age at diagnosis, histological subtype and surgery type were included in the nomogram. The predictive model had an AUC of 0.742 (95% CI, 0.644–0.825) and 0.72 (95% CI, 0.621–0.805) before and after the 200 repetitions of bootstrap sample corrections, respectively, and showed a good calibration.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study cannot exclude all biases. Our nomogram is based on simple criteria, but did not take into account the evaluation of ovarian reserve. It demonstrates a fair relevance, but requires external validation before routine use.

WIDER IMPLICATIONS OF THE FINDINGS

Clinicians are increasingly interested in such tools to support the patient in making an informed decision about treatment options. This nomogram contributes to the decision-making by defining simple risk factors of poor LB probability that can help identify good candidates for MAR.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Posted on 5 August 2016 | 5:14 am

Endometriosis-related infertility: ovarian endometrioma per se is not associated with presentation for infertility

STUDY QUESTION

Is there an association between the endometriosis phenotype and presentation with infertility?

SUMMARY ANSWER

In a population of operated patients with histologically proven endometriosis, ovarian endometrioma (OMA) per se is not associated with an increased risk of presentation with infertility, while previous surgery for endometriosis was identified as a risk factor for infertility.

WHAT IS KNOWN ALREADY

The increased prevalence of endometriosis among subfertile women indicates that endometriosis impairs reproduction for reasons that are not completely understood.

STUDY DESIGN, SIZE, DURATION

This was an observational, cross-sectional study using data prospectively collected in all non-pregnant patients aged between 18 and 42 years, who were surgically explored for benign gynaecological conditions at our institution between January 2004 and March 2013. For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon during the month preceding surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Surgery was performed in 2208 patients, of which 2066 signed their informed consent. Of the 1059 women with a visual diagnosis of endometriosis, 870 had histologically proven endometriosis and complete treatment for their endometriotic lesions, including 307 who presented with infertility. Univariate analysis and multiple logistic regression analysis were performed to determine factors associated with infertility.

MAIN RESULTS AND THE ROLE OF CHANCE

The following variables were identified as risk factors for endometriosis-related infertility: age >32 years (odds ratio [OR] = 1.9; 95% confidence interval [CI]: 1.4–2.4), previous surgery for endometriosis (OR = 1.9; 95% CI: 1.3–2.2), as well as peritoneal superficial endometriosis (OR = 3.1; 95% CI: 1.9–4.9); Conversely, previous pregnancy was associated with a lower rate of infertility (OR = 0.7; 95% CI: 0.6–0.9 and OR = 0.6; 95% CI: 0.4–0.9, respectively). OMA is not selected as a significant risk factor for infertility.

LIMITATIONS, REASON FOR CAUTION

The selection of our study population was based on a surgical diagnosis. We cannot exclude that infertile women with OMA associated with a diminished ovarian reserve, as assessed during their infertility work-up, were referred less frequently to surgery and might therefore be underrepresented. In addition we cannot exclude that our group of infertile women present associated other causes of infertility.

WIDER IMPLICATIONS OF THE FINDINGS

Identification of risk and preventive factors of endometriosis-related infertility can help improve clinical and surgical management of endometriosis in the setting of infertility.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

None.

Posted on 5 August 2016 | 5:14 am

Self-reported onset of puberty and subsequent semen quality and reproductive hormones in healthy young men

STUDY QUESTION

Is there an association between pubertal onset and subsequent reproductive health in young men?

SUMMARY ANSWER

Self-reported later onset of puberty was associated with reduced semen quality and altered serum levels of reproductive hormones among 1068 healthy, young Danish men.

WHAT IS KNOWN ALREADY

The long-term effects of variations in the onset of male puberty on subsequent reproduction remain largely unstudied.

STUDY DESIGN, SIZE, DURATION

In a cross-sectional study, young healthy Danish men were approached when they attended a compulsory medical examination to determine their fitness for military service from 2008 to 2012.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

A total of 1068 healthy, young Danish men (mean age 19 years) participated. They were asked to assess whether onset of penile and testicular growth, development of pubic hair and voice break occurred earlier, at the same time as or later than their peers. Their semen quality (semen volume, sperm concentration, total sperm count and percentages of motile and morphologically normal spermatozoa) and serum concentrations of sex hormones (LH, FSH, total testosterone, SHBG, inhibin B) and testicular size were determined.

MAIN RESULTS AND THE ROLE OF CHANCE

The response rate was 29%. Of the 1068 men who then participated, 652 answered the questions about penile growth and pubic hair development and were therefore included in the analysis. Self-reported later onset of puberty was associated with a 25% reduction in sperm concentration (95% CI –41%; –4%), a 40% reduction in total sperm count (–55%; –21%), a 1.6% age point reduction in morphological normal spermatozoa (–2.9; –0.3) and a 1.6 ml reduction in testicular size (–2.4 and –0.8 ml), after adjustment for confounders. Self-reported later onset of puberty was also associated with a 9% (3%; 15%) reduction in free testosterone and a 16% (2%; 31%) increase in FSH, after adjustment for confounders.

LIMITATIONS, REASON FOR CAUTION

Our study was cross-sectional and reverse causality cannot be ruled out. In addition, we cannot rule out the possibility that the men with late puberty onset had not yet fully matured although most were in Tanner stage 5.

WIDER IMPLICATIONS OF THE FINDINGS

Approximately 15% of young Danish men have self-reported later onset of puberty than their peers. We found poorer testicular function in young men with a history of later pubertal development, suggesting that timing of pubertal onset may be a fundamental marker of male reproductive health. However, we cannot exclude the possibility that these men had not fully matured at the time of examination and therefore their semen quality may yet improve, which makes follow-up important.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the Danish Council for Strategic Research, Program Commission on Health, Food and Welfare (project number 2101-08-0058), Rigshospitalet (grants 961506336 and R42-A1326), European Union, DEER (grant agreement no 212844), the Danish Ministry of Health and the Danish Environmental Protection Agency and Kirsten and Freddy Johansens Foundation (grant 95-103-72087). There are no competing interests.

Posted on 5 August 2016 | 5:14 am

Ovarian injury during cryopreservation and transplantation in mice: a comparative study between cryoinjury and ischemic injury

STUDY QUESTION

What is the main cause of ovarian injury during cryopreservation and transplantation in mice: cryoinjury or ischemic injury?

SUMMARY ANSWER

Post-transplantation ischemia is the main cause of ovarian injury during cryopreservation and transplantation for restoring ovarian function.

WHAT IS KNOWN ALREADY

During cryopreservation and the transplantation of ovaries, cryoinjury and ischemic injury inevitably occur, which has a detrimental effect on ovarian quality and reserve.

STUDY DESIGN, SIZE, DURATION

A total of 80 B6D2F1 female mice were randomly allocated to 2 control and 6 experimental groups according to the presence or the absence of transplantation (n = 10/group). The control groups consisted of fresh or vitrified-warmed controls that had the whole ovary fixed without transplantation (fresh and vitri-con, respectively). The experimental groups were further divided according to the presence of vitrification (fresh or vitrified-warmed) and the transplantation period (2 [D2], 7 [D7] or 21 [D21] days).

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the control groups, fresh and vitrified-warmed ovaries were immediately fixed after the collection (fresh) and the vitrification-warming process (vitrification control, vitri-con), respectively. Of those experimental groups, three were auto-transplanted with fresh whole ovary (FrOT; FrOT-D2, FrOT-D7 and FrOT-D21). For the other three groups, the ovaries were harvested and stored in liquid nitrogen for 1 week after vitrification and then warmed to auto-transplant the vitrified whole ovaries (vitrified ovary [VtOT]; VtOT-D2, VtOT-D7 and VtOT-D21). After 2, 7 or 21 days of grafting, the grafts and blood sera were collected for analysis by hematoxylin–eosin staining, terminal deoxynucleotidyl transferase dUTP nick end labeling assay, CD31 immunohistochemistry and follicle-stimulating hormone enzyme-linked immunosorbent assay.

MAIN RESULTS AND THE ROLE OF CHANCE

The vitrification-warming procedure decreased the proportion of intact follicles (Grade 1, G1) (vitri-con 50.3% versus fresh 64.2%) but there was a larger decrease due to ischemic injury after transplantation (FrOT-D2: 42.5%). The percentage of apoptotic follicles was significantly increased in the vitrified-warmed ovary group compared with the fresh control, but it increased more after transplantation without vitrification (fresh: 0.9%, vitri-con: 6.0% and FrOT-D2: 26.8%). The mean number of follicles per section and percentage of CD31-positive area significantly decreased after vitrification but decreased to a larger extent after transplantation (number of follicles, fresh: 30.3 ± 3.6, vitri-con: 20.6 ± 2.9, FrOT-D2: 17.9 ± 2.1; CD31-positive area, fresh: 10.6 ± 1.3%, vitri-con: 5.7 ± 0.9% and FrOT-D2: 4.2 ± 0.4%). Regarding the G1 follicle ratio and CD31-positive area per graft, only the FrOT groups significantly recovered with time after transplantation (G1 follicle ratio, FrOT-D2: 42.5%, FrOT-D7: 56.1% and FrOT-D21: 70.7%; CD31-positive area, FrOT-D2: 4.2 ± 0.4%, FrOT-D7: 5.4 ± 0.6% and FrOT-D21: 7.5 ± 0.8%). Although there was no significant difference between the two transplantation groups at each evaluation, the serum follicle-stimulating hormone level of both groups significantly decreased over time.

LIMITATIONS AND REASONS FOR CAUTION

It is unclear how far these results can be extrapolated from mice to the human ovary.

WIDER IMPLICATIONS OF THE FINDINGS

Minimizing ischemic injury should be the first priority rather than preventing cryoinjury alone, and decreasing the combination of cryoinjury and ischemic injury is necessary to improve ovarian quality after cryopreservation and transplantation.

STUDY FUNDING/COMPETING INTEREST

This study was supported by a grant of the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (HI12C0055). The authors have no conflict of interest to declare.

Posted on 5 August 2016 | 5:14 am

Sexual and physical abuse and gynecologic disorders

STUDY QUESTION

Is sexual and/or physical abuse history associated with incident endometriosis diagnosis or other gynecologic disorders among premenopausal women undergoing diagnostic and/or therapeutic laparoscopy or laparotomy regardless of clinical indication?

SUMMARY ANSWER

No association was observed between either a history of sexual or physical abuse and risk of endometriosis, ovarian cysts or fibroids; however, a history of physical abuse was associated with a higher likelihood of adhesions after taking into account important confounding and mediating factors.

WHAT IS KNOWN ALREADY

Sexual and physical abuse may alter neuroendocrine-immune processes leading to a higher risk for endometriosis and other noninfectious gynecologic disorders, but few studies have assessed abuse history prior to diagnosis.

STUDY DESIGN, SIZE, DURATION

The study population for these analyses includes the ENDO Study (2007–2009) operative cohort: 473 women, ages 18–44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of the 14 surgical centers located in Salt Lake City, UT, USA or San Francisco, CA, USA. Women with a history of surgically confirmed endometriosis were excluded.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

Prior to surgery, women completed standardized abuse questionnaires. Relative risk (RR) of incident endometriosis, uterine fibroids, adhesions or ovarian cysts by abuse history were estimated, adjusting for age, race/ethnicity, education, marital status, smoking, gravidity and recruitment site. We assessed whether a history of chronic pelvic pain, depression, or STIs explained any relationships via mediation analyses.

MAIN RESULTS AND ROLE OF CHANCE

43 and 39% of women reported experiencing sexual and physical abuse. No association was observed between either a history of sexual or physical abuse, versus no history, and risk of endometriosis (aRR: 1.00 [95% confidence interval (CI): 0.80–1.25]); aRR: 0.83 [95% CI: 0.65–1.06]), ovarian cysts (aRR: 0.67 [95% CI: 0.39–1.15]); aRR: 0.60 [95% CI: 0.34–1.09]) or fibroids (aRR: 1.25 [95% CI: 0.85–1.83]); aRR: 1.36 [95% CI: 0.92–2.01]). Conversely, a history of physical abuse, versus no history, was associated with higher risk of adhesions (aRR: 2.39 [95% CI: 1.18–4.85]). We found no indication that the effect of abuse on women's adhesion risk could be explained by a history of chronic pelvic pain, depression or STIs.

LIMITATIONS, REASONS FOR CAUTION

Limitations to our study include inquiries on childhood physical but not sexual abuse. Additionally, we did not inquire about childhood or adulthood emotional support systems, found to buffer the negative impact of stress on gynecologic health.

WIDER IMPLICATIONS OF THE FINDINGS

Abuse may be associated with some but not all gynecologic disorders with neuroendocrine-inflammatory origin. High prevalence of abuse reporting supports the need for care providers to screen for abuse and initiate appropriate follow-up.

STUDY FUNDING/COMPETING INTERESTS

Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

Posted on 5 August 2016 | 5:14 am

Vitamin D deficiency and pregnancy rates following frozen-thawed embryo transfer: a prospective cohort study

STUDY QUESTION

What is the effect of vitamin D deficiency on the pregnancy rates following frozen embryo transfer (FET)?.

SUMMARY ANSWER

Vitamin D deficiency does not affect pregnancy rates in FET cycles.

WHAT IS KNOWN ALREADY

Although there is evidence that the potential impact of vitamin D deficiency on reproductive outcome may be mediated through a detrimental effect on oocyte or embryo quality, the rationale of our design was based on evidence derived from basic science, suggesting that vitamin D may have a key role in endometrial receptivity and implantation. Only few retrospective clinical studies have been published to date with conflicting results.

STUDY DESIGN, SIZE, DURATION

This study is the first prospective observational cohort study from the Centre for Reproductive Medicine at the University Hospital of Brussels. The duration of the study was 1 year.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 280 consecutive patients, who had at least one blastocyst frozen and were planned for a FET, were enrolled in the study following detailed information and signing of a written informed consent. Serum analysis of 25-OH vitamin D was measured on the day of embryo transfer, and the impact of vitamin deficiency was investigated on reproductive outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

Among all patients, 45.3% (n = 127) had vitamin D deficiency (<20 ng/ml), and 54.6% (n = 153) had vitamin D levels ≥20 ng/ml. Positive human chorionic gonadotrophin rates were similar among patients with vitamin D deficiency and women with total serum 25-OH vitamin D levels ≥20 ng/ml (40.9 versus 48.3%, P = 0.2). Similarly, no difference was found in clinical pregnancy rates in women with vitamin D deficiency [32.2% (41/127)] compared with those with higher vitamin D levels [37.9% (58/153)]; P = 0.3. When analyzing the results according to different thresholds, as proposed by the Endocrine Society, clinical pregnancy rates were comparable between vitamin D deficient (<20 ng/ml), vitamin D insufficient (20–30 ng/ml) and vitamin D replete women (≥30 ng/ml) [32.3% (41/127) versus 39.5% (36/91) versus 35.5% (22/62), respectively, P = 0.54]. Multivariate logistic regression analysis showed that vitamin D status is not related to pregnancy outcome.

LIMITATIONS, REASONS FOR CAUTION

Ethnicity in relation to vitamin D status was not assessed, given that the vast majority of patients included in our study were Caucasian, whereas we did only assess 25-OH vitamin D levels and not bioavailable vitamin D. Furthermore, although we failed to find a difference between vitamin D deficient women and women with vitamin D levels ≥20 ng/ml, we need to underscore that our study was powered to detect a difference of 15% in clinical pregnancy rates.

WIDER IMPLICATIONS OF THE FINDINGS

Vitamin D deficiency does not significantly impair pregnancy rates among infertile women undergoing frozen–thawed cycles. The measurement of vitamin D levels in this population should not be routinely recommended.

STUDY FUNDING/COMPETING INTERESTS

No external funding was used for this study. No conflicts of interest are declared.

Posted on 5 August 2016 | 5:14 am

Women's adjustment trajectories during IVF and impact on mental health 11-17 years later

STUDY QUESTION

Do patients present different adjustment trajectories during and after IVF treatment?

SUMMARY ANSWER

Most women show resilient trajectories during and after IVF treatment but 37% show temporary or chronic maladjustment during IVF and 10% are maladjusted 11–17 years after treatment.

WHAT IS KNOWN ALREADY

Research on patient psychosocial adjustment during treatment has contributed to identifying the most distressful stages of IVF treatment and profiling patients at risk for emotional maladjustment at these specific stages. This knowledge is currently driving the deliverance of psychosocial care at fertility clinics by tailoring it to patients' risk profiles and specific treatment stages. However, current care does not take into consideration how individuals adjust across the entire treatment pathway. This can be assessed by profiling individual adjustment trajectories.

STUDY DESIGN, SIZE, DURATION

A longitudinal cohort study with five assessment moments that combines data from two different studies, the STRESSIVF and OMEGA projects. Participants enrolled in the STRESSIVF study (started IVF in 1998–2000) were assessed before and after the first IVF treatment cycle and 6 months and 2.5 years after the last IVF cycle. A subset participated in the OMEGA project (started IVF in 1995–2000) and reported on their mental health 11–17 years after treatment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Three hundred and forty-eight women participated in the STRESSIVF project and 108 of these in the OMEGA. Anxiety was measured with the State and Trait Anxiety Inventory, depression with the Beck Depression Inventory and mental health with the Mental Health Inventory. Latent class growth mixed modelling was carried out to identify distinct anxiety and depression trajectories over the four STRESSIVF study assessment moments. Multinominal logistic regressions were conducted to investigate predictors of trajectory membership, and stepwise linear regressions were performed to investigate if adjustment trajectories predicted mental health 11–17 years after IVF treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 67 and 86% of women showed normal levels of anxiety and depression, respectively, throughout treatment (resilient trajectories), 24 and 33% experienced anxiety and depression only during treatment (recovery trajectories), 4.6 and 4.9% experienced anxiety and depression only after treatment (delayed trajectories), and 4.3% showed chronic anxiety (chronic trajectory, not identified for depression). Non-resilient trajectories were associated with unsuccessful treatment, marital dissatisfaction, lack of social support and negative infertility cognitions. One in 10 women had a delayed or chronic trajectory and these trajectories predicted serious mental health impairment 11–17 years after treatment.

LIMITATIONS, REASONS FOR CAUTION

The study only focuses on women. In the OMEGA project adjustment was assessed using a mental health measure. Although we could investigate how trajectories predicted mental health, it would have been preferable to map anxiety and depression trajectories up to 11–17 years after treatment. Missing analysis showed selective dropout from the study but this was accounted for by using mixed models and imputation procedures. Finally, data on other life stressors were not collected; therefore any contribution from these events cannot be assessed.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility health-care providers have been called upon considering their responsibility in supporting patients in the aftermath of treatment. Results show it is possible to profile different groups of at-risk women at the start of the treatment and tailor psychosocial support to risk profile to promote health adjustment during treatment and thereafter.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a grant from the Dutch Cancer Society (2006-3631) and the Praeventiefonds (28-3012). No competing interests exist.

Posted on 5 August 2016 | 5:14 am

Intent to treat analysis of in vitro fertilization and preimplantation genetic screening versus expectant management in patients with recurrent pregnancy loss

STUDY QUESTION

In an intent to treat analysis, are clinical outcomes improved in recurrent pregnancy loss (RPL) patients undergoing IVF and preimplantation genetic screening (PGS) compared with patients who are expectantly managed (EM)?

SUMMARY ANSWER

Among all attempts at PGS or EM among RPL patients, clinical outcomes including pregnancy rate, live birth (LB) rate and clinical miscarriage (CM) rate were similar.

WHAT IS KNOWN ALREADY

The standard of care for management of patients with RPL is EM. Due to the prevalence of aneuploidy in CM, PGS has been proposed as an alternate strategy for reducing CM rates and improving LB rates.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of 300 RPL patients treated between 2009 and 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among two academic fertility centers, 112 RPL patients desired PGS and 188 patients chose EM. Main outcomes measured were pregnancy rate and LB per attempt and CM rate per pregnancy. One attempt was defined as an IVF cycle followed by a fresh embryo transfer or a frozen embryo transfer (PGS group) and 6 months trying to conceive (EM group).

MAIN RESULTS AND THE ROLE OF CHANCE

In the IVF group, 168 retrievals were performed and 38 cycles canceled their planned PGS. Cycles in which PGS was intended but cancelled had a significantly lower LB rate (15 versus 36%, P = 0.01) and higher CM rate (50 versus 14%, P < 0.01) compared with cycles that completed PGS despite similar maternal ages. Of the 130 completed PGS cycles, 74% (n = 96) yielded at least one euploid embryo. Clinical pregnancy rate per euploid embryo transfer was 72% and LB rate per euploid embryo transfer was 57%. Among all attempts at PGS or EM, clinical outcomes were similar. Median time to pregnancy was 6.5 months in the PGS group and 3.0 months in the EM group.

LIMITATIONS, REASONS FOR CAUTION

The largest limitation is the retrospective study design, in which patients who elected for IVF/PGS may have had different clinical prognoses than patients who elected for expectant management. In addition, the definition of one attempt at conception for PGS and EM groups was different between the groups and can introduce potential confounders. For example, it was not confirmed that patients in the EM group were trying to conceive for each month of the 6-month period.

WIDER IMPLICATIONS OF THE FINDING

Success rates with PGS are limited by the high incidence of cycles that intend but cancel PGS or cycles that do not reach transfer. Counseling RPL patients on their treatment options should include not only success rates with PGS per euploid embryo transferred, but also LB rate per initiated PGS cycle. Furthermore, patients who express an urgency to conceive should be counseled that PGS may not accelerate time to conception.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

N/A.

TRIAL REGISTRATION DATE

N/A.

DATE OF FIRST PATIENT'S ENROLLMENT

N/A.

Posted on 5 August 2016 | 5:14 am

Impact of vitrification on the mitochondrial activity and redox homeostasis of human oocyte

STUDY QUESTION

Do the extreme conditions of vitrification affect mitochondrial health and reactive oxygen species (ROS) levels of human oocytes?

SUMMARY ANSWER

Vitrification of discarded human oocytes shifts the intracellular redox potential towards oxidation but does not alter the mitochondrial potential or intracellular ROS levels.

WHAT IS KNOWN ALREADY

Recent studies have reflected increased ROS levels in warmed young oocytes and have highlighted the temporal dynamic loss of mitochondrial potential that could, therefore, lead to a decrease in ATP production, impairing embryo development. Mitochondrial function can also be evaluated in vivo by the FAD/NAD(P)H autofluorescence ratio, which reflects the respiratory chain activity and is considered as a marker of the intracellular redox state.

STUDY DESIGN, SIZE, DURATION

A total of 629 discarded Metaphase II (MII) oocytes collected from June 2013 to April 2014 were included in this control (fresh oocytes, n= 270) versus treatment (vitrified oocytes, n= 359) study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Discarded MII oocytes were donated to research by young (<27 years old) and reproductively aged (>36 years old) women who underwent ovarian stimulation for IVF at a university-affiliated private fertility clinic. Redox state was assessed by measuring the FAD/NAD(P)H autofluorescence ratio, while ROS and mitochondrial activity were reported by in vivo labelling with carboxy-H2DCFDA and JC-1, respectively.

MAIN RESULTS AND THE ROLE OF CHANCE

Young and aged oocytes showed high and similar survival rates (81.8 versus 83.1%, not significant). Confocal microscopy revealed that the FAD/NAD(P)H ratio was significantly higher in vitrified oocytes than in fresh oocytes, suggesting a significant shift towards the oxidized state in oocytes after vitrification, regardless of the maternal age. Mitochondrial distribution was not affected by vitrification. Furthermore, it was not possible to resolve any difference in mitochondrial potential using JC-1 potentiometric dye or in reactive oxygen species (ROS) production (assessed with H2-DCFDA staining) between fresh and vitrified oocytes. Therefore, measurement of intracellular redox potential by autofluorescence imaging may be a more sensitive method to assess oxidative stress or mitochondrial demise in human oocytes because it showed a higher resolving power than JC-1 staining and displayed less variability than H2-DCFDA staining.

LIMITATIONS, REASONS FOR CAUTION

Owing to sample availability, MII discarded oocytes (in vitro matured oocytes and unfertilized oocytes 20 h after ICSI) were included in the study. These discarded oocytes do not necessarily reflect the physiological condition of the MII human oocyte.

WIDER IMPLICATIONS OF THE FINDINGS

Although vitrified oocytes yield comparable clinical outcomes compared with fresh oocytes, lower cleavage and blastocyst rates can be observed during in vitro culture. Data here obtained suggest that the redox state of human oocytes could be affected by vitrification. Therefore, the importance of adding protective antioxidant molecules to the vitrification solution and to the post-warming culture medium to improve embryo cleavage deserves some research.

STUDY FUNDING/COMPETING INTEREST(S)

This research project was supported by the Valencian Government (Val+i+D program, M.N.-C.), INCLIVA Foundation for health research (G.S.-A.) and by the University of L'Aquila and Regione Abruzzo (‘Reti per l'Alta Formazione’ – P.O.F.S.E. Abruzzo 2007–2013 G.D.E.). No conflicts of interest were declared.

Posted on 5 August 2016 | 5:14 am

Hospital admission for hyperemesis gravidarum: a nationwide study of occurrence, reoccurrence and risk factors among 8.2 million pregnancies

STUDY QUESTION

What are the maternal risk factors for hyperemesis gravidarum (HG) hospital admission, readmission and reoccurrence in a following pregnancy?

SUMMARY ANSWER

Young age, less socioeconomic deprivation, nulliparity, Asian or Black ethnicity, female fetus, multiple pregnancy, history of HG in a previous pregnancy, thyroid and parathyroid dysfunction, hypercholesterolemia and Type 1 diabetes are all risk factors for HG.

WHAT IS KNOWN ALREADY

Women with Black or Asian ethnicity, of young age, carrying multiple babies or singleton females, with Type 1 diabetes or with a history of HG were previously reported to be at higher risk of developing HG; however, most evidence is from small studies. Little is known about associations with other comorbidities and there is controversy over other risk factors such as parity. Estimates of HG prevalence vary and there is a little understanding of the risks of HG readmission in a current pregnancy and reoccurrence rates in subsequent pregnancies, all of which are needed for planning measures to reduce onset or worsening of the condition.

STUDY DESIGN, SIZE, DURATION

We performed a population-based cohort study of pregnancies ending in live births and stillbirths using prospectively recorded secondary care records (Hospital Episode Statistics) from England. We analysed those computerized and anonymized clinical records from over 5.3 million women who had one or more pregnancies between 1997 and 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We obtained 8 215 538 pregnancies from 5 329 101 women of reproductive age, with a total of 186 800 HG admissions occurring during 121 885 pregnancies. Multivariate logistic regression with generalized estimating equations was employed to estimate odds ratios (aOR) to assess sociodemographic, pregnancy and comorbidity risk factors for HG onset, HG readmission within a pregnancy and reoccurrence in a subsequent pregnancy.

MAIN RESULTS AND THE ROLE OF CHANCE

Being younger, from a less socioeconomically deprived status, of Asian or Black ethnicity, carrying a female fetus or having a multiple pregnancy all significantly increased HG and readmission risk but only ethnicity increased reoccurrence. Comorbidities most strongly associated with HG were parathyroid dysfunction (aOR = 3.83, 95% confidence interval 2.28–6.44), hypercholesterolemia (aOR = 2.54, 1.88–3.44), Type 1 diabetes (aOR = 1.95, 1.82–2.09), and thyroid dysfunction (aOR = 1.85, 1.74–1.96). History of HG was the strongest independent risk factor (aOR = 4.74, 4.46–5.05). Women with higher parity had a lower risk of HG compared with nulliparous women (aOR = 0.90, 0.89–0.91), which was not explained by women with HG curtailing further pregnancies.

LIMITATIONS, REASONS FOR CAUTION

Although this represents the largest population-based study worldwide on the topic, the results could have been biased by residual and unmeasured confounding considering that some potential important risk factors such as smoking, BMI or prenatal care could not be measured with these data. Underestimation of non-routinely screened comorbidities such as hypercholesterolemia or thyroid dysfunction could also be a cause of selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

The estimated prevalence of 1.5% from our study was similar to the average prevalence reported in the literature and the representativeness of our data has been validated by comparison to national statistics. Also the prevalence of comorbidities was mostly similar to other studies estimating these in the UK and other developed countries. Women with Black or Asian ethnicity, of young age, carrying multiple babies or singleton females, with Type 1 diabetes or with history of HG were confirmed to be at higher risk of HG with an unprecedented higher statistical power. We showed for the first time that socioeconomic status interacts with maternal age, that hypercholesterolemia is a potential risk factor for HG and that carrying multiple females increases risk of hyperemesis compared with multiple males. We also provided robust evidence for the association of parity with HG. Earlier recognition and management of symptoms via gynaecology day-case units or general practitioner services can inform prevention and control of consequent hospital admissions.

STUDY FUNDING/COMPETING INTEREST(S)

The work was founded by The Rosetrees Trust and the Stoneygate Trust. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. C.N.-P. reports personal fees from Sanofi Aventis, Warner Chilcott, Leo Pharma, UCB and Falk, outside the submitted work and she is one of the co-developers of the RCOG Green Top Guideline on HG; all other authors did not report any potential conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 5 August 2016 | 5:14 am

Couples with non-obstructive azoospermia are interested in future treatments with artificial gametes

STUDY QUESTION

Would couples diagnosed with non-obstructive azoospermia (NOA) consider two future treatments with artificial gametes (AGs) as alternatives for testicular sperm extraction followed by ICSI (TESE-ICSI)?

SUMMARY ANSWER

Most couples with NOA (89%) would opt for treatment with AGs before attempting TESE-ICSI and/or after failed TESE-ICSI.

WHAT IS KNOWN ALREADY

Couples with NOA who undergo TESE-ICSI have a 25% chance of conceiving a child. Two future treatments that are being developed are ‘ICSI with artificial sperm formed from somatic cells’ (ICSI with AGs) and ‘natural conception after autotransplantation of in vitro proliferated spermatogonial stem cells’ (natural conception with AGs). It is unknown what treatment preferences patients have.

STUDY DESIGN, SIZE, DURATION

A cross-sectional survey conducted in 2012–2013, addressing all 921 couples diagnosed with NOA and treated with TESE-ICSI in Dutch fertility clinics between 2007 and 2012. The coded questionnaires were sent by mail and followed up with two reminders.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We developed the questionnaire based on a literature review and previous qualitative interviews, and included treatment preference and the valuation of nine treatment characteristics. We assessed reliability of the questionnaires and calculated mean importance scores (MISs: 0–10) of each treatment characteristic. We assessed which patient and treatment characteristics were associated with a couple's hypothetical treatment preference using binominal regression.

MAIN RESULTS AND THE ROLE OF CHANCE

The vast majority (89%) of the 494 responding couples (response rate: 54%) would potentially opt for AGs as a first and/or a last resort treatment option. More specifically, as a first treatment couples were likely (67%) to prefer natural conception with AGs over TESE-ICSI and less likely to prefer ICSI with AGs over TESE-ICSI (34%). After failed TESE-ICSI, the majority of couples (75%) would want to attempt ICSI with AGs as a last resort option. The most important characteristics of treatment were safety for children (MIS: 8.2), pregnancy rates (MIS: 7.7) and curing infertility (MIS: 6.8). Costs, burden, naturalness and technological sophistication were of about equal importance (MIS: 3.1–4.0). The majority of patients rated conception at home and moral acceptability as not important (MIS: 1.7 and 0.8, respectively), but the importance attributed to these variables did still affect patients' likeliness to opt for AGs.

LIMITATIONS AND REASONS FOR CAUTION

Couples with NOA not opting for TESE-ICSI were not included and might have other perspectives. Couples' hypothetical choices for AGs might differ from their actual choices once data on the costs, safety and pregnancy rates become available from these new treatment options.

WIDER IMPLICATIONS OF THE FINDINGS

The interest of couples with NOA in potential future treatments with AGs encourages further pre-clinical research. Priority setting for research and future decision-making on clinical application of AGs should take all characteristics important to patients into account.

STUDY FUNDING/COMPETING INTEREST(S)

The authors report no financial or other conflict of interest relevant to the subject of this article.

Posted on 5 August 2016 | 5:14 am

Pregnancy and birth outcomes following fresh or vitrified embryo transfer according to blastocyst morphology and expansion stage, and culturing strategy for delayed development

STUDY QUESTION

How do live birth rates (LBRs), following fresh and vitrified/warmed embryo transfer, compare according to morphological grade, developmental stage and culturing strategy of human blastocysts in vitro?

SUMMARY ANSWER

Equivalent LBRs were obtained after fresh embryo transfer and after vitrified/warmed embryo transfer of blastocysts of top or non-top quality, while vitrification after prolonged embryo culture of blastocysts with delayed development had a positive impact on LBR.

WHAT IS KNOWN ALREADY

Blastocyst morphology correlates with clinical outcome; however, few data are available on vitrified/warmed embryo transfer using non-top quality blastocysts. The aim of this study was to determine clinical outcomes of non-top quality blastocysts and blastocysts with delayed development that underwent vitrified/warmed embryo transfer.

STUDY DESIGN, SIZE, DURATION

This retrospective, single-centre study (conducted January 2009 to June 2013) compared 1010 fresh embryo transfer and 1270 vitrified/warmed embryo transfer of blastocysts originating from the same stimulation cycle. Furthermore, 636 fresh embryo transfers and 304 vitrified/warmed embryo transfer after delayed expansion or blastulation in the same period were also analysed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Clinical outcomes after fresh and vitrified/warmed embryo transfer according to blastocyst morphology were compared in both groups.

MAIN RESULTS AND THE ROLE OF CHANCE

Similar LBRs after fresh embryo transfer or after vitrified/warmed embryo transfer of top or non-top quality blastocysts were observed. A statistically significant improvement in clinical outcomes was obtained after vitrified/warmed embryo transfer of Day 5 embryos with delayed expansion or blastulation when applying prolonged culture. Our study suggests that vitrification of non-top quality blastocysts as well as delayed cavitating and blastulating Day 5 embryos should be considered in autologous IVF cycles.

LIMITATIONS AND REASONS FOR CAUTION

Given that the present retrospective study used aseptic vitrification of blastocysts, the results, particularly the survival rates, may not be fully applicable to other vitrification protocols. The retrospective nature of the study has to be mentioned.

WIDER IMPLICATIONS OF THE FINDINGS

Restriction of vitrification to top quality blastocysts may result in discarding potentially viable embryos.

STUDY FUNDING AND COMPETING INTEREST(S)

This study was not externally funded. There are no conflicts of interest to declare.

Posted on 5 August 2016 | 5:14 am

Endometrial preparation: effect of estrogen dose and administration route on reproductive outcomes in oocyte donation cycles with fresh embryo transfer

STUDY QUESTION

Is there a difference in live birth rates following endometrial preparation with either a constant or increasing estrogen dose in fresh embryo transfer from oocyte donation cycles?

SUMMARY ANSWER

There is no difference in live birth rates between a constant dose versus an increasing dose of estrogen after fresh embryo transfer in oocyte donation cycles with oral or transdermal supplementation.

WHAT IS KNOWN ALREADY

Endometrial preparation (EP) with estrogen and progesterone, and embryo-endometrial synchronicity are determinant for adequate embryo implantation. Estrogen is crucial and different exogenous administration patterns could imply variations on EP. Moreover, estrogen undergoes metabolization by the intestines and liver when administered orally, an effect that is bypassed by transdermal administration. Information on the effect of replacement patterns and route of administration of E on reproductive outcomes of women undergoing fresh embryo transfer from oocyte donation cycles is scarce.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study including 8362 embryo transfers following ICSI, corresponding to 8254 patients, between October 2010 and March 2015. A total of 5593 (66.9%) patients received an increasing E dose (ID) (oral: 2 mg/day day(d)1–7, 4 mg days d8–12, 6 mg d13-embryo transfer; transdermal: 75 µg/3 days on d1–6, 150 µg/3 days d7-embryo transfer) while 2769 (33.1%) received a constant dose (CD) of estrogen (oral: 6 mg/day 1-embryo transfer; transdermal: 150 µg/3 days d1-embryo transfer). Embryos were generated by ICSI with fresh or vitrified donor oocytes fertilized with either fresh or frozen sperm from either the couple partner or donor.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cohort allocation was not related to patient characteristics; instead it reflected an internal policy change in E administration. Effect of estrogen dose (ID versus CD) on biochemical, clinical, ongoing and live birth rates, stratified by administration route, was analyzed by univariate and multivariate analysis adjusted by donor and recipient demographic and cycle characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

No difference in live birth rate was found between CD and ID for oral (33.0 versus 32.5%, P = 0.81) and transdermal (35.3 versus 33.5%, P = 0.33) supplementation. Biochemical pregnancy rate was higher in CD than ID (53.7 versus 47.5%, P < 0.001) when patients received oral supplementation. Adjusted analysis confirmed that oral administration had a greater impact on biochemical pregnancy rates than transdermal (odds ratio (OR) 1.28; 95% confidence interval (CI) 1.11–1.48, P = 0.001 versus OR 1.13; 95% CI 1.00–1.30, P = 0.055). Sub-analysis of transfers between day 12 and 15 of estrogen supplementation showed no difference between CD and ID in pregnancy outcomes. Demographic variables and cycle characteristics were comparable between both groups. Moreover, the use of the oocyte donation model reduces confounding factors related to oocyte age, embryo aneuploidy, and embryo quality.

LIMITATIONS, REASONS FOR CAUTION

The greatest limitation of this study is its retrospective nature. On the other hand, this study was performed using donated oocytes; although this is unlikely to affect the results, we cannot exclude the possibility that a high quality female gamete responds differently to endometrial state in comparison to a patient's own oocytes.

WIDER IMPLICATIONS OF THE FINDINGS

In fresh embryo transfer from oocyte donation cycles, changes in the protocol of E replacement do not seem to have an impact on clinical outcomes and performance; for this reason estrogen replacement protocols can be adjusted to the patient's characteristics and preferences as well as to the most cost effective strategy.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Posted on 5 August 2016 | 5:14 am

Trends and determinants of IUD use in the USA, 2002-2012

STUDY QUESTION

What factors and subgroups have propelled the recent increase in intrauterine device (IUD) use in the USA?

SUMMARY ANSWER

The increase in IUD use, from 1.8 to 9.5% in the USA between 2002 and 2012, was driven primarily by a marked uptake among parous women who intended to have more children.

WHAT IS KNOWN ALREADY

Recent data suggest an unprecedented increase in IUD use among women in the USA, yet less is known about how this increase has affected the overall proportion of women, at risk of unintended pregnancy, who are using contraception and which social and economic groups are involved.

STUDY DESIGN, SIZE, DURATION

Data are drawn from the 2002 and 2011–2013 National Surveys of Family Growth. The surveys were based on cross-sectional, national samples of women of 15–44 years of age in the USA. Women responded to in-person interviews, which lasted an average of 80 min. The response rate was 80% in 2002 and 73% in 2011–2013. The sample included 7643 completed interviews in 2002 and 5601 interviews in 2011–2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study was limited to women at risk of unintended pregnancy, i.e. women who were sexually active in the previous 3 months (using contraception or not); it excludes women who were sterile, currently pregnant or trying to conceive. Altogether, 5181 women were at risk in the 2002 sample and 3681 were at risk in the 2012 sample. We used descriptive statistics to investigate trends in contraceptive use patterns by women's sociodemographic characteristics between 2002 and 2012 and used logistic regression to identify current predictors of IUD use in 2012.

MAIN RESULTS AND THE ROLE OF CHANCE

IUD use increased from 1.8% in 2002 to 9.5% in 2012 (P < 0.001). The surge was especially marked among parous women who intended to have more children (4.2% in 2002 to 19.3% in 2012; P < 0.001); it occurred to a lesser extent among parous women who did not intend to have more children (2.0–9.7% P < 0.001), suggesting that IUDs are more often used for spacing than for ending childbearing in the USA. The most important predictors of IUD use in 2012 were age, parity and intent to have children. Dissatisfaction with a previous method was also associated with IUD use (adjusted odds ratio = 1.89, P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

As with all cross-sectional studies, causal inference is limited. Data are self-reported, but the survey had a high response rate and rigorous quality controls.

WIDER IMPLICATION OF THE FINDINGS

This study shows promising trends in the use of highly effective contraceptive methods in the USA, which may help to explain recently reported declines in unintended pregnancy in the USA.

STUDY FUNDING/COMPETING INTERESTS

Caroline Moreau was supported by the William Robertson endowment funds. The work of Hannah Lantos and William Mosher on this analysis was supported by the Department of Population Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health. The authors declare that no conflict of interest exists.

Posted on 5 August 2016 | 5:14 am

Examining the psychosocial determinants of women's decisions to delay childbearing

STUDY QUESTION

What are the psychosocial determinants of women's intentions to delay childbearing until after 35 years?

SUMMARY ANSWER

Attitudes, pressure from important others, perceived self-confidence and anticipated regret all influence the decision-making process of women aged 18–30 years to defer their attempts to conceive their first child until 35+ years.

WHAT IS KNOWN ALREADY

Research has consistently demonstrated that, for many women, the decision to delay childbearing can lead to ‘unintentional childlessness’ due to a failure to consider the impact of age-related fertility decline. A large body of literature has also found strong links between age-related involuntary infertility and negative psychological impacts, including an increased prevalence of anxiety, depression, guilt, stigma and poor mental health.

STUDY DESIGN, SIZE, DURATION

The study initially conducted focus groups designed to ascertain important beliefs informing participants' intentions to delay childbearing. A subsequent larger-scale quantitative questionnaire followed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants (n = 358) were female, aged between 18 and 30 years, lived in Australia, identified as being open to the idea of having children, were heterosexual, had not already had children, were not already pregnant, and had not received a diagnosis of medical infertility prior to participating.

MAIN RESULTS AND THE ROLE OF CHANCE

Hierarchical multiple regression analyses showed strong support for psychosocial predictors of attitude, pressure from others and perceived self-confidence as predictors of women's intentions to delay childbearing, accounting for 59% of total variance. The extended model that included anticipated regret, accounted for a significant additional 4.4% variance in intention to delay childbearing past the age of 35 years.

LIMITATIONS, REASONS FOR CAUTION

Proportionally more participants were younger, Caucasian, and were university students, thus limiting the generalizability of results to the wider Australian community. Future research in this domain is recommended to adopt a prospective design and incorporate a measure of behaviour to investigate the link between intentions to delay childbearing and future fertility behaviour.

WIDER IMPLICATIONS OF THE FINDINGS

This research augments our understanding of the decision-making process and key beliefs underlying the decision to delay childbearing. Further efforts are needed to advise young women to investigate their fertility options during the peak of their reproductive years in order to prevent negative psychological consequences associated with unintentional childlessness.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Posted on 5 August 2016 | 5:14 am

Pharmacodynamics and safety of the novel selective progesterone receptor modulator vilaprisan: a double-blind, randomized, placebo-controlled phase 1 trial in healthy women

STUDY QUESTION

Does administration of vilaprisan (VPR) to healthy women for 12 weeks reduce menstrual bleeding?

SUMMARY ANSWER

In this 12-week proof-of-concept phase 1 trial, most women (30/33, 90%) who received VPR at daily doses of 1–5 mg reported the absence of menstrual bleeding.

WHAT IS KNOWN ALREADY

Vilaprisan (BAY 1002670) is a novel, highly potent selective progesterone receptor modulator that markedly reduces the growth of human leiomyoma tissue in a preclinical model of uterine fibroids (UFs).

STUDY DESIGN, SIZE, DURATION

In this double-blind, parallel-group study, of the 163 healthy women enrolled 73 were randomized to daily VPR 0.1 mg (n = 12), 0.5 mg (n = 12), 1 mg (n = 13), 2 mg (n = 12), 5 mg (n = 12) or placebo tablets (n = 12) for 12 weeks. Participants were followed up until the start of the second menstrual bleeding after the end of treatment. Trial simulations were used to determine the minimum sample size required to estimate the non-bleeding rate (i.e. self-assessed bleeding intensity of ‘none’ or ‘spotting’) using Bayesian dose–response estimation with incorporated prior information. It was estimated that 48 participants in the per-protocol analysis population would be sufficient.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 18–45 years who had been sterilized by tubal ligation were enrolled between November 2011 and May 2012. Participants kept a daily diary of bleeding intensity. Blood and urine samples were taken, and transvaginal ultrasound was performed before treatment, during treatment and follow-up. Endometrial biopsies were obtained during the pretreatment cycle, at the end of the treatment period and during the follow-up phase. The primary outcome was the estimated dose–response curve of the observed non-bleeding rate during Days 10–84 of treatment, excluding the endometrial biopsy day and 2 days after biopsy. Secondary outcomes included return of bleeding during follow-up, size of follicle-like structures and serum hormone levels. Safety assessments included adverse events (AEs), endometrial thickness and histology, laboratory parameters, vital signs and 12-lead electrocardiography.

MAIN RESULTS AND THE ROLE OF CHANCE

All 73 randomized participants received at least one dose of study medication and were included in safety analyses; six participants were excluded from the per-protocol analyses. A total of 69 completed the study. Observed non-bleeding rates increased with VPR dose: 0.1 mg (0%; 90% confidence interval [CI]: 0–23.8), 0.5 mg (27.3%; 90% CI: 7.9–56.4), 1 mg (80.0%; 90% CI: 49.3–96.3), 2 mg (100%; 90% CI: 77.9–100), 5 mg (90.9%; 90% CI: 63.6–99.5), compared with 0% (90% CI: 0–22.1) in the placebo group. Maximal non-bleeding rates were reached at doses of 2 mg and higher. Return of menstrual bleeding was observed in all women ≤52 days after VPR discontinuation. No treatment-emergent critical endometrial findings occurred. Follicular growth was not suppressed and minimum average estradiol levels remained above 40 pg/ml. No serious treatment-emergent AEs or study discontinuations due to AEs were reported. Clinically relevant changes in laboratory parameters or vital signs were not evident.

LIMITATIONS, REASONS FOR CAUTION

The results of this small proof-of-concept study will need to be confirmed in larger trials in patients with UFs to establish the potential therapeutic benefits and safety of VPR.

WIDER IMPLICATIONS OF THE FINDINGS

The high rates of non-bleeding (80–100% at VPR doses of 1–5 mg) support further evaluation of VPR in patients with UFs and heavy menstrual bleeding.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Bayer Pharma AG. B.S., A.K., M.-H.S.M., C.S. and B.R. are employees of Bayer Pharma AG. B.S., A.K. and M.-H.S.M. are listed as inventors of an issued patent related to this work, and received payment for this from Bayer Pharma AG. D.B. is the founder of Biokinetic Europe Ltd, UK, which received funding for this study from Bayer Pharma AG. M.K. is an employee of Nuvisan GmbH, Germany, which received funding for this study from Bayer Pharma AG.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT01816815.

TRIAL REGISTRATION DATE

20 March 2013.

DATE OF FIRST PATIENT'S ENROLMENT

28 November 2011.

Posted on 5 August 2016 | 5:14 am

Development and validation of the FertiMed questionnaire assessing patients' experiences with hormonal fertility medication

STUDY QUESTION

Can a valid and reliable questionnaire be developed to assess patients' experiences with all of the characteristics of hormonal fertility medication valued by them?

SUMMARY ANSWER

The FertiMed questionnaire is a valid and reliable tool that assesses patients' experiences with all medication characteristics valued by them and that can be used for all hormonal fertility medications, irrespective of their route of administration.

WHAT IS KNOWN ALREADY

Hormonal fertility medications cause emotional strain and differ in their dosage regime and route of administration, although they often have comparable effectiveness. Medication experiences of former patients would be informative for medication choices. A recent literature review showed that there is no trustworthy tool to compare patients' experiences of medications with differing routes of administration, regarding all medication characteristics which patients value.

STUDY DESIGN, SIZE, DURATION

The items of the new FertiMed questionnaire were generated by literature review and 23 patient interviews. In 2013, 411 IVF-patients were asked to retrospectively complete the FertiMed questionnaire to assess 1 out of the 8 different medications used for ovarian stimulation, induction of pituitary quiescence, ovulation triggering or luteal support.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 276 patients (on average 35 per medication) from 2 university fertility clinics (Belgium, the Netherlands) completed the FertiMed questionnaire (67% response rate). The FertiMed questionnaire questioned whether items were valued by patients and whether these items were experienced while using the assessed medication. Hence, the final outcome ‘Experiences with Valued Aspects Scores’ (EVAS) combined importance and experience ratings. The content and face validity, reliability, feasibility and discriminative potential of the FertiMed questionnaire were tested and changes were made accordingly.

MAIN RESULTS AND THE ROLE OF CHANCE

Patient interviews defined 51 items relevant to seven medication characteristics previously proved to be important to patients. Item analysis deleted 10 items. The combined results from the reliability and content validity analysis identified 10 characteristics instead of 7. The final FertiMed questionnaire was valid (Adapted Goodness of Fit Index = 0.95) and all but one characteristic (‘ease of use: disturbance’) could be assessed reliably (Cronbach's α > 0.60). The EVAS per characteristic differed between the medications inducing pituitary quiescence (P = 0.001).

LIMITATIONS, REASON FOR CAUTION

As all eight medications prescribed in the recruiting clinics were questioned, sample sizes per medication were rather small for presenting EVAS per medication and for testing the discriminative potential of the FertiMed questionnaire.

WIDER IMPLICATION OF THE FINDINGS

The FertiMed questionnaire can be used for all hormonal fertility medications to assess in a valid and reliable way whether patients experience what they value regarding 10 medication characteristics (e.g. side effects and ease of use). Future randomized controlled trials (RCT) comparing medications could include the FertiMed questionnaire as a Patient Reported Experience Measure (PREM). Insights from these RCTs could be used to develop evidence-based decision aids aiming to facilitate shared physician–patient medication choices.

STUDY FUNDING/COMPETING INTERESTS

Funding was received from the University of Leuven and Amsterdam University Medical Centre. E.A.F.D. holds a postdoctoral fellowship of the Research Foundation of Flanders. T.D. was appointed Vice-President and Head Global Medical Affairs Fertility at Merck (Darmstadt, Germany) on 1 October 2015. The reported project was initiated and finished before this date. The other authors had no conflicts of interest to declare.

Posted on 5 August 2016 | 5:14 am

Pharmacokinetics, pharmacodynamics, safety and tolerability of an intravaginal ring releasing anastrozole and levonorgestrel in healthy premenopausal women: a Phase 1 randomized controlled trial

STUDY QUESTION

What are suitable doses of the aromatase inhibitor anastrozole (ATZ) and the progestin levonorgestrel (LNG), when delivered to the systemic circulation by an intravaginal ring (IVR), for further clinical development as a potential new therapy for the treatment of endometriosis?

SUMMARY ANSWER

Anticipated targets for pharmacokinetics, pharmacodynamics and safety/tolerability were achieved for both drug components of the IVR at the doses investigated, supporting selection of the doses to be investigated in Phase 2 studies.

WHAT IS KNOWN ALREADY

Aromatase is a key enzyme in the biosynthesis of estrogens and is known to increase local levels of estradiol (E2) at extragonadal sites. Up-regulation of aromatase expression has been demonstrated in endometriotic lesions and the use of oral aromatase inhibitors has been shown to reduce endometriosis-associated pelvic pain in small-scale clinical trials.

STUDY DESIGN, SIZE, DURATION

This Phase 1, randomized, multicentre, parallel-group, three-arm, open-label study assessed the pharmacokinetics, pharmacodynamics, safety and tolerability of various IVRs intended for systemic drug delivery. After screening, healthy, ovulating women aged 18–35 years were randomized to use IVRs releasing one of the three ATZ/LNG dose combinations (in vitro nominal daily drug release rates on Day 29: ATZ/LNG 500 µg/20 µg [low dose], ATZ/LNG 1000 µg/30 µg [mid dose] or ATZ/LNG 1500 µg/40 µg [high dose]) for two consecutive 28-day wearing periods without a treatment break.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Sixty women were included in the per protocol set. The primary variables were plasma concentrations of ATZ and LNG at the end of each treatment period and the mean size of largest follicle-like structures (FLSs) over 56 days. Serum concentrations of several hormones were also evaluated, with emphasis on E2 levels.

MAIN RESULTS AND THE ROLE OF CHANCE

At the end of the first treatment period, geometric mean plasma concentrations of LNG and ATZ, respectively, were 0.228 and 12.5 µg/l for the low dose, 0.269 and 19.8 µg/l for the mid dose and 0.384 and 37.3 µg/l for the high dose; results were similar at the end of the second treatment period. Over the entire treatment period, mean FLS sizes were higher in all three treatment groups than during the pretreatment cycle; more women in the mid- and high-dose groups had FLSs of at least 30 mm (32–45%) than those in the low-dose group (14–24%). Changes in the mean size of FLSs were similar to those reported for low-dose progestin-only oral contraceptives and generally resolved during the 2-month treatment period. Serum E2 levels were decreased, but only one woman in each of the mid- and high-dose groups, and no woman in the low-dose group, had a serum E2 level below 20 pg/ml in both cycles. All ATZ and LNG combinations showed good tolerability.

LIMITATIONS, REASONS FOR CAUTION

This was an exploratory study; no formal power calculation was performed.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this first-in-human study of the ATZ/LNG IVR facilitated the selection of ATZ and LNG doses to be investigated in the Phase 2 studies of patients with endometriosis.

STUDY FUNDING/COMPETING INTEREST

The study was funded by Bayer Pharma AG. T.R. is an employee of DINOX GmbH, which received funding from Bayer Pharma AG to perform this study. M.-H.S.-M., K.W., R.N., S.K., J.K., H.S. and B.R. are or have been employees of Bayer Pharma AG. H.S. is a named inventor on EP 2 552 404 B1, a patent application relating to this work.

TRIAL REGISTRATION NUMBER

EudraCT number: 2011-005620-18.

TRIAL REGISTRATION DATE

16 November 2011.

DATE OF FIRST PATIENT'S ENROLMENT

14 March 2012.

Posted on 5 August 2016 | 5:14 am

Charged iron particles, components of space radiation, destroy ovarian follicles

STUDY QUESTION

Do charged iron particles, components of space radiation, cause premature ovarian failure?

SUMMARY ANSWER

Exposure to charged iron particles causes ovarian DNA damage, oxidative damage and apoptosis, resulting in premature ovarian failure.

WHAT IS KNOWN ALREADY

The ovary is very sensitive to follicle destruction by low linear energy transfer (LET) radiation, such as X-rays and -rays. However, it is completely unknown whether high-LET radiation, such as charged iron particles, also destroys ovarian follicles.

STUDY DESIGN, SIZE, DURATION

Twelve week old C57BL/6J female mice were exposed to single doses of 0, 5, 30 or 50 cGy (n = 8/group) charged iron particles (LET = 179 keV/µm) at energy of 600 MeV/u. Two groups were irradiated at the highest dose, one fed AIN-93M chow and the other fed AIN-93M chow supplemented with 150 mg/kg diet alpha lipoic acid (ALA).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We quantified the numbers of ovarian follicles, measured serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) concentrations, and analyzed histone H2AX phosphorylation, oxidative damage and apoptosis markers in the ovarian follicles.

MAIN RESULTS AND THE ROLE OF CHANCE

H2AX phosphorylation, lipid peroxidation, protein nitration and apoptosis were highly induced in ovarian follicles at 6 h and remained increased 1 week after irradiation. As a result, numbers of healthy ovarian follicles were significantly and dose-dependently depleted at 1 and 8 weeks post-irradiation, with 57, 84 and 99% decreases in primordial follicles at 8 weeks at the 5, 30 and 50 cGy doses, respectively (P < 0.05 versus 0 cGy). Consistent with near-total depletion of ovarian follicles in the 50 cGy group, serum concentrations of FSH and LH were significantly elevated at 8 weeks. Dietary supplementation with ALA partially prevented the adverse ovarian effects of 50 cGy iron particles.

LIMITATIONS, REASONS FOR CAUTION

About 21% of the estimated radiation dose from exposure to galactic cosmic rays during a multi-year Mars mission will be due to high-LET particles, of which iron is only one. The effects of galactic cosmic rays, which contain a mixture of multiple charged particles, as well as protons, neutrons, and helium ions, may differ from the effects of iron alone.

WIDER IMPLICATIONS OF THE FINDINGS

We show for the first time that charged high-LET ions are highly damaging to the ovary even at low doses, causing premature ovarian failure. In addition to raising concerns for female astronauts, these findings raise concerns for ovarian damage due to clinical uses of high-LET particles for cancer treatment. In addition to causing infertility, premature ovarian failure has adverse implications for the functions of heart, brain, bone and muscle later in life.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a National Aeronautics and Space Administration grant NNX14AC50G to U.L. B.M. was partially supported by a National Space Biomedical Research Institute First Award, PF04302. Additional support was received from the University of California Irvine Center for Occupational and Environmental Health. The authors have no conflicts of interests.

Posted on 5 August 2016 | 5:14 am

Age-related differences in the sonographic characteristics of endometriomas

STUDY QUESTION

Do sonographic characteristics of ovarian endometriomas vary with age in premenopausal women?

SUMMARY ANSWER

With increasing age, multilocular cysts and cysts with papillations and other solid components become more common whereas ground glass echogenicity of cyst fluid becomes less common.

WHAT IS KNOWN ALREADY

Expectant or medical management of women with endometriomas is now accepted. Therefore, the accuracy of non-invasive diagnosis of these cysts is pivotal. A clinically relevant question is whether the sonographic characteristics of ovarian endometriomas are the same irrespective of the age of the woman.

STUDY DESIGN, SIZE, DURATION

This is a secondary analysis of cross-sectional data in the International Ovarian Tumor Analysis (IOTA) database. The database contains clinical and ultrasound information collected pre-operatively between 1999 and 2012 from 5914 patients with adnexal masses in 24 ultrasound centres in 10 countries.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There were 1005 histologically confirmed endometriomas in adult premenopausal patients found in the database and these were used in our analysis. The following ultrasound variables (defined using IOTA terminology) were used to describe the ultrasound appearance of the endometriomas: tender mass at ultrasound, largest diameter of lesion, tumour type (unilocular, unilocular-solid, multilocular, multilocular-solid, solid), echogenicity of cyst content, presence of papillations, number of papillations, height (mm) of largest papillation, presence and proportion of solid tissue and number of cyst locules, as well as vascularity in papillations and colour content of the tumour scan (colour score) on colour or power Doppler ultrasounds. Results are reported as median difference or odds ratio (OR) per 10 years increase in age.

MAIN RESULTS AND THE ROLE OF CHANCE

Maximal lesion diameter did not vary substantially with age (+1.3 mm difference per 10 years increase in age, 95% confidence interval (CI) –1.4 to 4.0). Tender mass at scan was less common in the older the woman (OR 0.75, 95% CI 0.63–0.89), as were unilocular cysts relative to multilocular cysts (OR 0.70, 95% CI 0.57–0.85) and to lesions with solid components (OR 0.61, 95% CI 0.48–0.77), and ground glass echogenicity relative to homogeneous low-level echogenicity (OR 0.74, 95% CI 0.58–0.94) and other types of echogenicity of cyst contents (OR 0.64, 95% CI 0.50–0.81). Papillations were more common the older the woman (OR 1.65, 95% CI 1.24–2.21), but their height and vascularization showed no clear relation to age.

LIMITATIONS, REASONS FOR CAUTION

It is a limitation that we have little clinical information on the women included, e.g. previous surgery or medical treatment for endometriosis. It is important to emphasize that we do not know the age of the endometrioma itself and that our study is not longitudinal and so does not describe changes in endometriomas over time. The differences in the ultrasound appearance of endometriomas between women of different ages might be explained by previous surgery or medical treatment and might not be an effect of age per se.

WIDER IMPLICATIONS OF THE FINDINGS

Awareness of physicians that the ultrasound appearance of endometriomas differs between women of different ages may facilitate a correct diagnosis of endometrioma.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported in part by the Regione Autonoma della Sardegna (project code CPR-24750). B.V.C., A.C. and D.T. are supported by the Fund for Scientific Research Flanders, Belgium (FWO). The authors declare that there is no conflict of interest.

Posted on 5 August 2016 | 5:14 am

Morphological, ultrastructural and functional imaging of frozen/thawed and vitrified/warmed human ovarian tissue retrieved from oncological patients

STUDY QUESTION

Which is the best method for human ovarian tissue cryopreservation: slow freezing/rapid thawing (SF/RT) or vitrification/warming (V/W)?

SUMMARY ANSWER

The conventional SF/RT protocol used in this study seems to better preserve the morpho-functional status of human cryopreserved ovarian tissue than the used open carrier V/W protocol.

WHAT IS KNOWN ALREADY

Cryopreservation of human ovarian tissue is generally performed using the SF/RT method. However, reduction in the follicular pool and stroma damage are often observed. An emerging alternative procedure is represented by V/W which seems to allow the maintenance of the morphological integrity of the stroma.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study including six patients affected by oncological diseases and enrolled from January to December 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Ovarian tissue was laparoscopically harvested from the right and left ovaries and was cryopreserved using a routinary SF/RT protocol or a V/W method, involving tissue incubation in two solutions (containing propylene glycol, ethylene glycol and sucrose at different concentrations) and vitrification in an open system. For each patient, three pieces from each ovary were collected at the time of laparoscopy (fresh tissue) and after storage (SF/RT or V/W) and processed for light microscopy (LM) and transmission electron microscopy (TEM), to assess the morphological and ultrastructural features of follicles and stroma, and for laser scanning confocal microscopy (LSCM), to determine the functional energetic/redox stroma status. The preservation status of SF/RT and V/W ovarian tissues was compared with that of fresh ones, as well as between them.

MAIN RESULTS AND THE ROLE OF CHANCE

By LM and TEM, SF/RT and V/W samples showed cryodamage of small entity. Interstitial oedema and increased stromal cell vacuolization and chromatin clumping were observed in SF/RT samples; in contrast, V/W samples showed oocyte nuclei with slightly thickened chromatin and irregular shapes. The functional imaging analysis by LSCM revealed that the mitochondrial activity and intracellular reactive oxygen species levels were reduced both in SF/RT and in V/W samples compared with fresh samples. The study also showed progressive dysfunction of the mitochondrial activity going from the outer to the inner serial section of the ovarian cortex. The reduction of mitochondrial activity of V/W samples compared with fresh samples was significantly higher in the inner section than in the outer section.

LIMITATIONS, REASONS FOR CAUTION

The results report the bioenergetic and oxidative status assessment of fresh and cryopreserved human ovarian tissue by LSCM, a technique recently applied to tissue samples. The use of LSCM on human ovarian tissues after SF/RT or V/W is a new application that requires validation. The procedures for mitochondrial staining with functional probes and fixing are not yet standardized. Xenografting of the cryopreserved ovarian tissue in severe combined immunodeficient mice and in vitro culture have not yet been performed.

WIDER IMPLICATIONS OF THE FINDINGS

The identification of a cryopreservation method able to maintain the morpho-functional integrity of the ovarian tissue and a number of follicles comparable with those observed in fresh tissue might optimize results in clinical practice, in terms of recovery, duration of ovarian function and increased delivery outcomes after replanting. The SF/RT protocol allowed better morpho-functional tissue integrity than the V/W procedure.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by Fondazione del Monte di Bologna e Ravenna, Italy. Dr N.A.M. was granted by the project ONEV MIUR PONa3 00134-n.254/R&C 18 5 2011 and the project GR-2011-02351396 (Ministry of Health, Young Researchers Grant 2011/2012). There are no competing interests.

TRIAL REGISTRATION NUMBER

Clinical trial 74/2001/0 (approved:13 2 2002): ‘Pilot study on cryopreservation of human ovarian tissue: morphological and immunohistochemical analysis before and after cryopreservation’.

Posted on 5 August 2016 | 5:14 am

The association of low ovarian reserve with cardiovascular disease risk: a cross-sectional population-based study

STUDY QUESTION

Is there a relationship between serum anti-Müllerian hormone (AMH) level and cardiovascular disease (CVD) risk in premenopausal women?

SUMMARY ANSWER

There are indications that premenopausal women with very low ovarian reserve may have an unfavorable CVD risk profile.

WHAT IS KNOWN ALREADY

Age at menopause is frequently linked to CVD occurrence. AMH is produced by ovarian antral follicles and provides a measure of remaining ovarian reserve Literature on whether AMH is related to CVD risk is still scarce and heterogeneous.

STUDY DESIGN, SIZE, DURATION

Cross-sectional study in 2338 women (age range of 20–57 years) from the general population, participating in the Doetinchem Cohort Study between 1993 and 1997.

PARTICIPANTS/MATERIALS, SETTING, METHODS

CVD risk was compared between 2338 premenopausal women in different AMH level-categories, with adjustment for confounders. CVD risk was assessed through levels of systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol and glucose, in addition to a summed score of CVD risk factors. Among other factors, analyses were corrected for smoking, oral contraceptive use and BMI.

MAIN RESULTS AND THE ROLE OF CHANCE

The relationship of serum AMH levels with CVD risk factor outcomes was nonlinear. Women with AMH levels <0.16 µg/l had 0.11 (95% confidence intervals (CIs) 0.01; 0.21) more metabolic risk factors compared with women with AMH levels ≥0.16 µg/l. There was no association of individual risk factor levels with AMH levels, besides a tendency towards lower total cholesterol levels of 0.11 mmol/l (95% CI –0.23; 0.01) in women with AMH levels <0.002 µg/l compared with women with AMH levels ≥0.16 µg/l. Although not statistically significant, these effect sizes were larger in women below 40 years of age.

LIMITATIONS, REASONS FOR CAUTION

Causality and temporality of the studied association cannot be addressed here. Moreover, the clinical and statistical significance of the results of this exploratory study should be interpreted with caution due to the absence of adjustment for multiple statistical testing.

WIDER IMPLICATIONS OF THE FINDINGS

This population-based study supports previous findings that premenopausal women with very low AMH levels may have an increased CVD risk. It lays the groundwork for future research to focus on this group of women. Longitudinal studies with more sensitive AMH assays may furthermore help better understand the implications of these results.

STUDY FUNDING/COMPETING INTEREST

No financial support was received for this research or manuscript. The Doetinchem Cohort Study is conducted and funded by the Dutch National Institute for Public Health and the Environment F.J.M.B. has received fees and grant support from Merck Serono, Gedeon Richter, Ferring BV and Roche.

TRIAL REGISTRATION NUMBER

N/A.

Posted on 5 August 2016 | 5:14 am

Basal serum progesterone and history of elevated progesterone on the day of hCG administration are significant predictors of late follicular progesterone elevation in GnRH antagonist IVF cycles

STUDY QUESTION

Are there any baseline predictors of progesterone elevation (PE) on the day of human chorionic gonadotrophin (hCG) which are not associated with the intensity of ovarian stimulation in women undergoing in vitro fertilization (IVF) using follicle stimulating hormone (FSH) and gonadotrophin-releasing hormone (GnRH) antagonists?

SUMMARY ANSWER

Basal (Day 2 of the menstrual cycle) serum progesterone concentration and history of PE are baseline variables that can predict the occurrence of PE on the day of hCG independently of the intensity of ovarian stimulation.

WHAT IS KNOWN ALREADY

PE on the day of hCG is associated with the magnitude of the ovarian response to stimulation. For this reason, it has been hypothesized that milder ovarian stimulation might reduce the probability of PE. However, given the fact that the number of oocytes retrieved is associated with the probability of live birth, such a strategy should be considered only in patients that are at high risk of PE on the day of hCG.

STUDY DESIGN, SIZE, DURATION

This is a retrospective analysis of a cohort of fresh IVF/ICSI cycles (n = 1702) performed in a single IVF centre during the period 2001–2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients in whom ovarian stimulation was performed with FSH and GnRH antagonists and with basal FSH <14.0 mIU/ml, progesterone (P) ≤1.6 ng/ml and estradiol (E2) ≤80 pg/ml on the same day (prior to the initiation of stimulation) were considered eligible. PE was defined as serum progesterone concentration >1.5 ng/ml. Pre-stimulation characteristics of patients and basal hormonal profile were assessed for their ability to predict the occurrence of PE after ovarian stimulation through generalized estimating equation univariable and multivariable regression analyses, controlling for the effect of ovarian stimulation. Furthermore, a secondary analysis in a subset of patients with multiple IVF cycles explored whether the occurrence of PE in one of the previous cycles included in this study is associated with a significantly higher occurrence of PE elevation in subsequent cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

Univariable regression analyses showed that female age (OR: 0.97; 95% CI: 0.94–0.99), basal FSH (OR: 0.85; 95% CI: 0.79–0.92) and basal P (OR: 4.20; 95% CI: 2.47–7.12) were baseline variables that could significantly predict PE on the day of hCG. When these variables were entered in the same model as covariates, only basal FSH (OR: 0.86; 95% CI: 0.80–0.94) and basal P (OR: 3.83; 95% CI: 2.24–6.56) could still predict the occurrence of PE. Basal P (OR: 6.30; 95% CI: 3.35–11.82) was the only variable that could significantly predict the occurrence of PE on the day of hCG after adjusting for the intensity of ovarian stimulation. The secondary analysis revealed that history of PE on the day of hCG in a previous cycle was also strongly associated with an increased risk of PE in a subsequent cycle.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective analysis and although the effect of the most important confounders was controlled for in the multivariable analysis, the presence of residual bias cannot be excluded.

WIDER IMPLICATIONS OF THE FINDINGS

The findings of this study might help clinicians identify patients at high risk for late follicular PE and alter the management of their cycle.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 5 August 2016 | 5:14 am

The influence of social factors on gender health

Male births exceed female births by 5–6% (for a sex ratio at birth of 1.05–1.06) while a women's life expectancy, on a global scale, is about 6 years longer. Thus within various age groups the male:female ratio changes over time. Until age 50 years men outnumber women; thereafter their numbers show a sharp decline. Consequently at age 80 years, there are many more women than men. An estimated 25% of this male excess mortality is due to biological causes, the rest being explained by behavioural, cultural and environmental factors. For both women and men, the main health risks related to lifestyle are smoking, alcohol, unhealthy diet and physical inactivity. In the year 2010, overweight (BMI: 25–29 kg/m2) and obesity (BMI: >30 kg/m2) were responsible for over 3 million deaths, with similar relative risks in men and women for overweight and obesity. Smoking and alcohol are the major causes of the global gender gap in mortality. For women in some parts of the world however pregnancy is also hazardous. On a global scale, in 2013 about 300 000 deaths were related to pregnancy, with sub-Saharan Africa registering the highest maternal mortality: over 500 maternal deaths per 100 000 births. Additional woman's health risks arise from gender discrimination, including sex-selective abortion, violence against women and early child marriage. Providers should be aware of the effect that these risks can have on both reproductive and general health.

Posted on 5 August 2016 | 5:14 am

Vitamin D deficiency and low ionized calcium are linked with semen quality and sex steroid levels in infertile men

STUDY QUESTION

Are low vitamin D levels linked with semen quality and sex steroids in infertile men?

SUMMARY ANSWER

Infertile men with vitamin D deficiency had lower sperm motility, total numbers of motile sperm, Inhibin B, sex-hormone-binding-globulin (SHBG) and testosterone/estradiol ratio, but higher levels of free sex steroids, than infertile men with normal vitamin D levels.

WHAT IS KNOWN ALREADY

Low vitamin D levels have been associated with decreased sperm motility in healthy men, but a relationship between vitamin D and calcium with semen quality and especially sex steroids has not been sufficiently described in infertile men.

STUDY DESIGN, SIZE, DURATION

This study comprises baseline characteristics of 1427 infertile men screened from 2011 to 2014 for inclusion in a randomized clinical trial, the Copenhagen-Bone-Gonadal Study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total 1427 infertile men, consecutively referred to our tertiary andrological centre for fertility workup, underwent a physical examination and had semen quality assessed based on two samples and blood analysed for serum testosterone, SHBG, estradiol, inhibin B, luteinizing hormone, follicle-stimulating hormone (FSH), 25-hydroxyvitamin D (25-OHD), ionized calcium (Ca2+) and karyotype. There were 179 men excluded due to serious comorbidities or anabolic steroid usage, leaving 1248 patients for analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

Men with 25-OHD >75 nmol/l had higher sperm motility and 66 and 111% higher total numbers of motile spermatozoa after 45 and 262 min, respectively, than men with 25-OHD <25 nmol/l (all P < 0.05). SHBG levels and testosterone/estradiol ratios were 15 and 14% lower, respectively, while free testosterone and estradiol ratios were 6 and 13% higher, respectively, in men with 25-OHD <25 nmol/l (all P < 0.05). Men with lower Ca2+ levels had higher progressive sperm motility and inhibin B/FSH ratio but lower testosterone/estradiol ratio (all P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

All outcomes presented are predefined end-points but inferral of causality is compromised by the descriptive study design. It remains to be shown whether the links between vitamin D, calcium, semen quality and sex steroids in infertile men are causal.

WIDER IMPLICATIONS OF THE FINDINGS

The associations between vitamin D deficiency and low calcium with semen quality and sex steroids support the existence of a cross-link between regulators of calcium homeostasis and gonadal function in infertile men.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by the Danish Agency for Science, Technology and Innovation, Hørslev Fonden, Danish Cancer Society and Novo Nordisk Foundation. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

NCT01304927.

DATE OF TRIAL REGISTRATION

25 February 2011.

DATE OF ENROLMENT OF FIRST PATIENT

8 March 2011.

Posted on 5 August 2016 | 5:14 am

Assisted reproductive technology in Europe, 2012: results generated from European registers by ESHRE

STUDY QUESTION

The 16th European IVF-monitoring (EIM) report presents the data of the treatments involving assisted reproductive technology (ART) and intrauterine insemination (IUI) initiated in Europe during 2012: are there any changes compared with previous years?

SUMMARY ANSWER

Despite some fluctuations in the number of countries reporting data, the overall number of ART cycles has continued to increase year by year, the pregnancy rates (PRs) in 2012 remained stable compared with those reported in 2011, and the number of transfers with multiple embryos (3+) and the multiple delivery rates were lower than ever before.

WHAT IS KNOWN ALREADY

Since 1997, ART data in Europe have been collected and re-ported in 15 manuscripts, published in Human Reproduction.

STUDY DESIGN, SIZE, DURATION

Retrospective data collection of European ART data by the EIM Consortium for the European Society of Human Reproduction and Embryology (ESHRE). Data for cycles between 1 January and 31 December 2012 were collected from National Registers, when existing, or on a voluntary basis by personal information.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From 34 countries (+1 compared with 2011), 1111 clinics reported 640 144 treatment cycles including 139 978 of IVF, 312 600 of ICSI, 139 558 of frozen embryo replacement (FER), 33 605 of egg donation (ED), 421 of in vitro maturation, 8433 of preimplantation genetic diagnosis/preimplantation genetic screening and 5549 of frozen oocyte replacements (FOR). European data on intrauterine insemination using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 1126 IUI labs in 24 countries. A total of 175 028 IUI-H and 43 497 IUI-D cycles were included.

MAIN RESULTS AND THE ROLE OF CHANCE

In 18 countries where all clinics reported to their ART register, a total of 369 081 ART cycles were performed in a population of around 295 million inhabitants, corresponding to 1252 cycles per million inhabitants (range 325–2732 cycles per million inhabitants). For all IVF cycles, the clinical PRs per aspiration and per transfer were stable with 29.4 (29.1% in 2011) and 33.8% (33.2% in 2011), respectively. For ICSI, the corresponding rates also were stable with 27.8 (27.9% in 2011) and 32.3% (31.8% in 2011). In FER cycles, the PR per thawing/warming increased to 23.1% (21.3% in 2011). In ED cycles, the PR per fresh transfer increased to 48.4% (45.8% in 2011) and to 35.9% (33.6% in 2011) per thawed transfer, while it was 45.1% for transfers after FOR. The delivery rate after IUI remained stable, at 8.5% (8.3% in 2011) after IUI-H and 12.0% (12.2% in 2011) after IUI-D. In IVF and ICSI cycles, 1, 2, 3 and 4+ embryos were transferred in 30.2, 55.4, 13.3 and 1.1% of the cycles, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (added together) were 82.1, 17.3 and 0.6%, respectively, resulting in a total multiple delivery rate of 17.9% compared with 19.2% in 2011 and 20.6% in 2010. In FER cycles, the multiple delivery rate was 12.5% (12.2% twins and 0.3% triplets). Twin and triplet delivery rates associated with IUI cycles were 9.0%/0.4% and 7.2%/0.5%, following treatment with husband and donor semen, respectively.

LIMITATIONS, REASONS FOR CAUTION

The method of reporting varies among countries, and registers from a number of countries have been unable to provide some of the relevant data such as initiated cycles and deliveries. As long as data are incomplete and generated through different methods of collection, results should be interpreted with caution.

WIDER IMPLICATIONS OF THE FINDINGS

The 16th ESHRE report on ART shows a continuing expansion of the number of treatment cycles in Europe, with more than 640 000 cycles reported in 2012 with an increasing contribution to birthrate in many countries. However, the need to improve and standardize the national registries, and to establish validation methodologies remains manifest.

STUDY FUNDING/COMPETING INTERESTS

The study has no external funding; all costs are covered by ESHRE. There are no competing interests.

Posted on 5 August 2016 | 5:14 am

Maternal first trimester serum levels of free-beta human chorionic gonadotrophin and male genital anomalies

STUDY QUESTION

Are maternal first trimester levels of serum free-beta hCG associated with the development of hypospadias or undescended testis (UDT) in boys?

SUMMARY ANSWER

Overall, first trimester maternal levels of serum free-beta hCG are not associated with hypospadias or UDT. However, elevated levels were found in severe phenotypes (proximal hypospadias and bilateral UDT) suggesting an altered pathway of hormonal release in early pregnancy.

WHAT IS KNOWN ALREADY

Human chorionic gonadotrophin peaks in first trimester of pregnancy stimulating fetal testosterone production, which is key to normal male genital development. Endocrine-disrupting insults early in pregnancy have been associated with increased risk of common genital anomalies in males such as hypospadias and UDT. One plausible etiological pathway is altered release of hCG.

STUDY DESIGN, SIZE, DURATION

We conducted a record-linkage study of two separate populations of women attending first trimester aneuploidy screening in two Australian states, New South Wales (NSW) and Western Australia (WA), in 2006–2009 and 2001–2003, respectively.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Included were women who gave birth to a singleton live born male infant. There were 12 099 boys from NSW and 10 518 from WA included, of whom 90 and 77 had hypospadias; and 107 and 109 UDT, respectively. Serum levels of free-beta hCG were ascertained from laboratory databases and combined with relevant birth outcomes and congenital anomalies via record linkage of laboratory, birth, congenital anomalies and hospital data. Median and quartile levels of gestational age specific free-beta hCG multiple of the median (MoM) were compared between affected and unaffected boys. Logistic regression was used to evaluate the association between levels of free-beta hCG MoM and hypospadias or UDT, stratified by suspected placental dysfunction and co-existing anomalies. Where relevant, pooled analysis was conducted.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no difference in median hCG levels amongst women with an infant with hypospadias (NSW = 0.88 MoM, P = 0.83; WA = 0.84 MoM, P = 0.76) or UDT (NSW = 0.89 MoM, P = 0.54; WA = 0.95 MoM, P = 0.95), compared with women with an unaffected boy (NSW = 0.92 MoM; WA = 0.88 MoM). Low (<25th centile) or high (>75th centile) hCG levels were not associated with hypospadias or UDT, nor when stratifying by suspected placental dysfunction and co-existing anomalies. However, there was a tendency towards high levels for severe types, although confidence intervals were wide. When combining NSW and WA results, high hCG MoM levels (>75th centile) were associated with increased risk of proximal hypospadias (odds ratio (OR) 4.34; 95% CI: 1.08–17.4) and bilateral UDT (OR 2.86; 95% CI: 1.02–8.03).

LIMITATIONS, REASONS FOR CAUTION

There were only small numbers of proximal hypospadias and bilateral UDT in both cohorts and although we conducted pooled analyses, results reported on these should be interpreted with caution. Gestational age by ultrasound may have been inaccurately estimated in small and large for gestational age fetuses affecting hCG MoM calculation in those pregnancies. Despite the reliability of our datasets in identifying adverse pregnancy outcomes, we did not have pathology information to confirm tissue lesions in the placenta and therefore our composite outcome should be considered as a proxy for placental dysfunction.

WIDER IMPLICATIONS OF THE FINDINGS

This is one of the largest population-based studies examining the association between maternal first trimester serum levels of free-beta hCG and genital anomalies—hypospadias and UDT; and the first to compare specific phenotypes by severity. Overall, our findings does not support the hypothesis that alteration in maternal hCG levels is associated with the development of male genital anomalies; however, high hCG free-beta levels found in severe types suggest different underlying etiology involving higher production and secretion of hCG. These findings require further exploration and replication.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the National Health and Medical Research Council (NHMRC) grant APP1047263. N.N. is supported by a NHMRC Career Development Fellowship APP1067066. C.B. was supported by a NHMRC Principal Research Fellowship #634341. The funding agencies had no role in the design, analysis, interpretation or reporting of the findings. There are no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 5 August 2016 | 5:14 am

Nuclear and mitochondrial DNA in blastocoele fluid and embryo culture medium: evidence and potential clinical use

The ability to screen embryos for aneuploidy or inherited disorders in a minimally invasive manner may represent a major advancement for the future of embryo viability assessment. Recent studies have demonstrated that both blastocoele fluid and embryo culture medium contain genetic material, which can be isolated and subjected to downstream genetic analysis. The blastocoele fluid may represent an alternative source of nuclear DNA for aneuploidy testing, although the degree to which the isolated genetic material is solely representative of the developing embryo is currently unclear. In addition to nuclear DNA, mitochondrial DNA (mtDNA) can be detected in the embryo culture medium. Currently, the origin of this nuclear and mtDNA has not been fully evaluated and there are several potential sources of contamination that may contribute to the genetic material detected in the culture medium. There is however evidence that the mtDNA content of the culture medium is related to embryo fragmentation levels and its presence is predictive of blastulation, indicating that embryo development may influence the levels of genetic material detected. If the levels of genetic material are strongly related to aspects of embryo quality, then this may be a novel biomarker of embryo viability. If the genetic material does have an embryo origin, the mechanisms by which DNA may be released into the blastocoele fluid and embryo culture medium are unknown, although apoptosis may play a role. While the presence of this genetic material is an exciting discovery, the DNA in the blastocoele fluid and embryo culture medium appears to be of low yield and integrity, which makes it challenging to study. Further research aimed at assessing the methodologies used for both isolating and analysing this genetic material, as well as tracing its origin, are needed in order to evaluate its potential for clinical use. Should such methodologies prove to be routinely successful and the DNA recovered demonstrated to be embryonic in origin, then they may be used in a minimally invasive and less technical methodology for genetic analysis and embryo viability assessment than those currently available.

Posted on 5 August 2016 | 5:14 am

Copy number variation analysis detects novel candidate genes involved in follicular growth and oocyte maturation in a cohort of premature ovarian failure cases

STUDY QUESTION

Can spontaneous premature ovarian failure (POF) patients derived from population-based biobanks reveal the association between copy number variations (CNVs) and POF?

SUMMARY ANSWER

CNVs can hamper the functional capacity of ovaries by disrupting key genes and pathways essential for proper ovarian function.

WHAT IS KNOWN ALREADY

POF is defined as the cessation of ovarian function before the age of 40 years. POF is a major reason for female infertility, although its cause remains largely unknown.

STUDY DESIGN, SIZE, DURATION

The current retrospective CNV study included 301 spontaneous POF patients and 3188 control individuals registered between 2003 and 2014 at Estonian Genome Center at the University of Tartu (EGCUT) biobank.

PARTICIPANTS/MATERIALS, SETTING, METHODS

DNA samples from 301 spontaneous POF patients were genotyped by Illumina HumanCoreExome (258 samples) and HumanOmniExpress (43 samples) BeadChip arrays. Genotype and phenotype information was drawn from the EGCUT for the 3188 control population samples, previously genotyped with HumanCNV370 and HumanOmniExpress BeadChip arrays. All identified CNVs were subjected to functional enrichment studies for highlighting the POF pathogenesis. Real-time quantitative PCR was used to validate a subset of CNVs. Whole-exome sequencing was performed on six patients carrying hemizygous deletions that encompass genes essential for meiosis or folliculogenesis.

MAIN RESULTS AND THE ROLE OF CHANCE

Eleven novel microdeletions and microduplications that encompass genes relevant to POF were identified. For example, FMN2 (1q43) and SGOL2 (2q33.1) are essential for meiotic progression, while TBP (6q27), SCARB1 (12q24.31), BNC1 (15q25) and ARFGAP3 (22q13.2) are involved in follicular growth and oocyte maturation. The importance of recently discovered hemizygous microdeletions of meiotic genes SYCE1 (10q26.3) and CPEB1 (15q25.2) in POF patients was also corroborated.

LIMITATIONS, REASONS FOR CAUTION

This is a descriptive analysis and no functional studies were performed. Anamnestic data obtained from population-based biobank lacked clinical, biological (hormone levels) or ultrasonographical data, and spontaneous POF was predicted retrospectively by excluding known extraovarian causes for premature menopause.

WIDER IMPLICATIONS OF THE FINDINGS

The present study, with high number of spontaneous POF cases, provides novel data on associations between the genomic aberrations and premature menopause of ovarian cause and demonstrates that population-based biobanks are powerful source of biological samples and clinical data to reveal novel genetic lesions associated with human reproductive health and disease, including POF.

STUDY FUNDING/COMPETING INTEREST

This study was supported by the Estonian Ministry of Education and Research (IUT20-43, IUT20-60, IUT34-16, SF0180027s10 and 9205), Enterprise Estonia (EU30020 and EU48695), Eureka's EUROSTARS programme (NOTED, EU41564), grants from European Union's FP7 Marie Curie Industry-Academia Partnerships and Pathways (IAPP, SARM, |EU324509) and Horizon 2020 innovation programme (WIDENLIFE, 692065), Academy of Finland and the Sigrid Juselius Foundation.

Posted on 5 August 2016 | 5:14 am

Anti-Müllerian hormone in seminal plasma and serum: association with sperm count and sperm motility

STUDY QUESTION

Is anti-Müllerian hormone (AMH) in seminal plasma and serum associated with sperm count and sperm motility?

SUMMARY ANSWER

AMH in seminal plasma is positively associated with sperm concentration, total sperm count, and progressive sperm motility, while no association was found between serum AMH levels and semen characteristics.

WHAT IS KNOWN ALREADY

AMH is secreted by the Sertoli cells and is detectable in both serum and seminal plasma in adult men. It has been suggested as a marker of spermatogenesis, however, its function in the adult male is largely unknown.

STUDY DESIGN, SIZE, DURATION

Participants were recruited in between 2008 and 2013, from the general population (n = 94) and from couples with female factor infertility in a fertility clinic (n = 32). AMH data were available for 126 participants.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mean age of the participants was 36 years, and BMI was between 19 and 39 kg/m2. Semen quality was evaluated by semen analysis according to the World Health Organization, and AMH levels were measured in seminal plasma. Blood samples were analyzed for AMH, total testosterone, FSH, LH, and inhibin B. AMH analysis was performed using the improved Beckman Coulter method.

MAIN RESULTS AND THE ROLE OF CHANCE

The central 95% intervals of AMH concentrations were 2–2812 pmol/l in seminal plasma and 15–134 pmol/l in serum. Total AMH (pmol/ejaculate) in seminal plasma was positively associated with sperm concentration (B = 0.177, P< 0.001) and total sperm count (B = 0.212, P< 0.001) when adjusted for age, BMI, time of abstinence, and positively associated with progressive sperm motility (B = 6.762, P = 0.001) when adjusted for age, BMI, time of abstinence, and site of sample collection. No association was found between serum AMH and semen characteristics. Serum levels of inhibin B were positively correlated with total AMH in seminal plasma (B = 18.52, P< 0.001) and concentration of AMH in serum (B = 0.507, P< 0.001).

LIMITATIONS, REASONS FOR CAUTION

Participants were recruited both from the general population and from a fertility clinic. This may limit the applicability to men in the general population.

WIDER IMPLICATIONS OF THE FINDINGS

The AMH levels found in this study show large inter-individual variation, especially in seminal plasma. AMH in seminal plasma may serve as a marker of sperm production, however, in the lower range the predictive value is low.

STUDY FUNDING/COMPETING INTEREST(S)

All funding for this study was received from Oslo and Akershus University College of Applied Sciences. The authors have no conflicts of interest to declare.

Posted on 5 August 2016 | 5:14 am

Parental disclosure to offspring created with oocyte donation: intentions versus reality

STUDY QUESTION

Do parents with children created through oocyte donation (OD) follow through with their original intentions regarding disclosure to their offspring, and if not, why not?

SUMMARY ANSWER

Although 43% of this study population had disclosed to their offspring as intended, 39% had delayed disclosure because of uncertainty about how and when to disclose.

WHAT IS KNOWN ALREADY

Previous research studies have primarily investigated the intentions of families regarding disclosure to offspring conceived with gamete donation, but have not focused on what actually occurs in the disclosure process.

STUDY DESIGN, SIZE, DURATION

Data from 72 subjects were collected utilizing a 52-item questionnaire developed by the authors from January to May 2012. This cross-sectional hypothesis-generating pilot study utilized descriptive statistics, including frequency and percentiles in order to characterize survey responses.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 459 families who delivered a child (or children) after using OD between 1992 and 2003 were invited by mail to participate. The parents were invited to a 1-day, professionally led seminar on issues about oocyte-donation and disclosure. The study, performed at a large university-based fertility clinic, included 72 parents, representing 46 families and 66 children ranging in age from 7 to 19 years.

MAIN RESULTS AND THE ROLE OF CHANCE

The findings indicate that 43% of the study population disclosed to their offspring as intended, 39% still intend to disclose, 9% are uncertain and 9% do not plan to disclose at any time. The average age of children at the time of disclosure was 5.5 years. The average age of children at the time of data collection was 13 years. Primary reasons for disclosure were the child's right to know, the desire to be open and honest, and the notion that family secrets are harmful. For families who still intend to disclose, the average age of the offspring was 11 years and primary reasons for delayed disclosure included ‘never finding the right time’ and uncertainty about how and when to disclose. An unanticipated finding was that delayed disclosure among those who intend to tell offspring resulted in heightened levels of parental anxiety about disclosing to older children. Demographic data showed no associations with disclosure or non-disclosure to offspring. The response rate to participation was 12%.

LIMITATIONS, REASONS FOR CAUTION

Limitations of this study include a low response rate due to potential participants being lost to follow-up and to the possibility that families choosing non-disclosure did not respond to the invitation. This lack of a more effective recruitment strategy may have resulted in the smaller, self-selected study population. Additional limitations included the lack of heterogeneity of our population, any confounding factors the seminars may have had on the choice to participate in the study and on responses to the questionnaire, and the lack of a specified anxiety measurement.

WIDER IMPLICATIONS OF THE FINDINGS

Families disclosing to children by the age of 8 reported the lowest levels of conflict regarding the disclosure process and the highest levels of satisfaction at having disclosed early. The findings are consistent with, and add to, a growing body of literature on disclosure in donor-assisted reproduction. The authors recommend that fertility programs and mental health providers better assist OD parents with disclosure issues by recommending early disclosure for those who plan to tell, and by providing on-going follow-up and support to ensure that disclosure decisions are implemented as originally intended.

STUDY FUNDING/COMPETING INTERESTS

Partial study funding was received from an educational grant from Ferring Pharmaceuticals, Inc. There are no conflicts of interest to declare.

Posted on 5 August 2016 | 5:14 am

What threshold values of antral follicle count and serum AMH levels should be considered for oocyte cryopreservation after in vitro maturation?

STUDY QUESTION

What threshold values of ultrasonographic antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels should be considered for ensuring the cryopreservation of sufficient number of in vitro matured (IVM) oocytes, in cancer patients seeking fertility preservation (FP)?

SUMMARY ANSWER

AFC and serum AMH values >20 follicles and 3.7 ng/ml, respectively, are required for obtaining at least 10 IVM oocytes for cryopreservation.

WHAT IS KNOWN ALREADY

IVM of cumulus oocyte complexes (COCs) followed by oocyte cryopreservation has emerged recently as an option for urgent FP. Recent data have reported that, in healthy patients, 8–20 cryopreserved oocytes after ovarian stimulation would maximize the chance of obtaining a live birth. Although both AFC and AMH have been reported as predictive factors of IVM success in infertile patients with polycystic ovary syndrome (PCOS), there is a dramatic lack of data regarding the values of these parameters in oncological patients as candidates for FP.

STUDY DESIGN, SIZE, DURATION

From January 2009 to April 2015, we prospectively studied 340 cancer patients, aged 18–41 years, as candidates for oocyte cryopreservation following IVM.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients had AFC and AMH measurements, 48–72 h before oocyte retrieval, regardless of the phase of the cycle. COCs were recovered under ultrasound guidance 36 h after hCG priming. Logistic regression allowed the determination of threshold values of AFC and AMH, for obtaining at least 8, 10 or 15 matures oocytes frozen after the IVM procedure. Similar analyses were performed for a final number of mature oocytes ≤2.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 340 cancer patients included, 300 were diagnosed with breast cancers, 14 had hematological malignancies and 26 underwent the procedure for others indications. Overall, the mean age of the population was 31.8 ± 4.5 years. Mean AFC and serum AMH levels were 21.7 ± 13.3 follicles and 4.4 ± 3.8 ng/ml, respectively. IVM was performed in equal proportions during the follicular or luteal phase of the cycle (49 and 51%, respectively). Statistical analysis showed that AFC and AMH values above 28 follicles and 3.9 ng/ml, 20 follicles and 3.7 ng/ml and 19 follicles and 3.5 ng/ml are required, respectively, for obtaining at least 15, 10 or 8 frozen IVM oocytes with a sensitivity ranging from 0.82 to 0.90. On the contrary, ≤2 IVM oocytes were cryopreserved when AFC and AMH were <19 follicles and 3.0 ng/ml, respectively.

LIMITATIONS, REASONS FOR CAUTION

Although the potential of cryopreserved IVM oocytes from cancer patients remains unknown, data obtained from infertile PCOS women have shown a dramatically reduced competence of these oocytes when compared with that of oocytes recovered after ovarian stimulation. As a consequence, the optimal number of IVM oocytes frozen in candidates for FP is currently unpredictable.

WIDER IMPLICATIONS OF THE FINDINGS

Cryopreservation of oocytes after IVM should be considered in the FP strategy when ovarian stimulation is unfeasible, in particular when markers of the follicular ovarian status are at a relatively high range. Further investigation is needed to objectively assess the real potential of these IVM oocytes after cryopreservation. Therefore, even when a good COCs yield is expected, we should systematically encourage IVM in combination with ovarian tissue cryopreservation.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for the present study. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 10 June 2016 | 6:45 am

Does BPA alter steroid hormone synthesis in human granulosa cells in vitro?

STUDY QUESTION

Does Bisphenol A (BPA) impair steroid hormone production in human luteinized granulosa cells in vitro?

SUMMARY ANSWER

At supra-physiological concentrations, BPA alters progesterone and estradiol synthesis in vitro and significantly reduces the mRNA and protein expression levels of three genes encoding steroidogenesis enzymes.

WHAT IS KNOWN ALREADY

In IVF patients, the effects of BPA exposure on cycle outcome are controversial. Previous animal studies have shown that granulosa cell steroid hormone synthesis is compromised after BPA exposure, but their findings have been difficult to replicate in humans due, in part, to the low availability of discarded biological material.

STUDY DESIGN, SIZE, DURATION

Luteinized granulosa cells obtained from 44 fertile and infertile patients undergoing in vitro fertilization were cultured for 48 h with different concentrations of BPA (0, 0.2, 0.02, 2.0, 20 µg/ml).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Culture medium and total RNA extracted from the luteinized granulosa cells were examined for estradiol and progesterone levels as well as mRNA and protein expression of steroidogenesis enzymes, using enzyme immunoassays, real-time PCR and western blots.

MAIN RESULTS AND THE ROLE OF CHANCE

Treatment of granulosa cells with 2 or 20 µg/ml BPA for 48 h resulted in significantly lower progesterone biosynthesis (P < 0.005 and <0.001, respectively). Estradiol production was significantly altered only after incubation with 20 µg/ml of BPA (P < 0.001). These concentrations also significantly reduced the mRNA levels of 3β-hydroxysteroid dehydrogenase (3β-HSD), CYP11A1 and CYP19A1 without affecting StAR and 17β-hydroxysteroid dehydrogenase mRNA expression. Similarly, 3β-HSD, CYP11A1 and CYP19A1 protein levels were reduced after administration of 20 µg/ml BPA. Lower BPA concentrations similar to, and up to 100 times, the concentrations measured in human follicular fluid, serum and urine did not alter steroidogenesis in primary granulosa cell cultures.

LIMITATIONS, REASONS FOR CAUTION

This was an in vitro study investigating the effects of acute exposure (48 h) of BPA on discarded material. As such, the model may not accurately reflect the effect of BPA on the physiological events of follicular steroid hormone synthesis in vivo.

WIDER IMPLICATIONS OF THE FINDINGS

Our results show that in vitro exposure to BPA at low doses does not affect granulosa cells steroidogenesis. Combined with recent in vivo studies, these data can be reassuring but further studies are needed to assess the effects of chronic exposure to BPA on ovarian steroidogenesis.

STUDY FUNDING AND COMPETING INTEREST(S)

This study was supported by grant number 1936/12 from the Israeli Science Foundation (ISF). The authors have no conflict of interest.

Posted on 10 June 2016 | 6:45 am

IVM in need of clear definitions

Oocyte in vitro maturation (IVM) involves the achievement of the process of oocyte maturation in vitro. Clinically, it was introduced several decades ago as a potentially more patient-friendly and less expensive assisted reproductive technology (ART) approach, as immature oocytes collected from mid-antral follicles can be matured in vitro without prior gonadotrophin stimulation. However, IVM oocytes are developmentally less competent compared with oocytes matured in vivo, a fact that has encouraged the use of short FSH priming and/or hCG triggering in IVM cycles. These alternatives have generated much confusion about the definition and clinical outcome of IVM, also among ART specialists, especially because hCG triggering can support maturation in vivo even in follicles of 10–13 mm in diameter. In a recent manuscript, a team of IVM specialists propose that IVM should include any ART approach involving ‘the collection of oocyte from small and intermediate sized follicles’ even after hCG or GnRH triggering. It is more than predictable that other scientists and clinicians with an interest in IVM will object to such a definition, believing that semantically and operatively IVM should not be associated with pharmacological interventions aimed at promoting or achieving maturation in vivo, although partially.

Posted on 10 June 2016 | 6:45 am

Anti-Müllerian hormone promotes pre-antral follicle growth, but inhibits antral follicle maturation and dominant follicle selection in primates

STUDY QUESTION

What are the direct effects and physiological role of anti-Müllerian hormone (AMH) during primate follicular development and function at specific stages of folliculogenesis?

SUMMARY ANSWER

AMH actions in the primate ovary may be stage-dependent, directly promoting pre-antral follicle growth while inhibiting antral follicle maturation and dominant follicle selection.

WHAT IS KNOWN ALREADY

AMH is expressed in the adult ovary, particularly in developing follicles. Studies in mice suggest that AMH suppresses pre-antral follicle growth in vitro, and inhibits primordial follicle recruitment and FSH-stimulated antral follicle steroidogenesis.

STUDY DESIGN, SIZE, DURATION

For in vitro study, secondary follicles were isolated from ovaries of 12 rhesus macaques and cultured for 5 weeks. For in vivo study, intraovarian infusion was conducted on five monkeys for the entire follicular phase during two spontaneous menstrual cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

For in vitro study, individual follicles were cultured in a 5% O2 environment, in alpha minimum essential medium supplemented with recombinant human FSH. Follicles were randomly assigned to treatments of recombinant human AMH protein or neutralizing anti-human AMH antibody (AMH-Ab). Follicle survival, growth, steroid production, steroidogenic enzyme expression, and oocyte maturation were assessed. For in vivo study, ovaries were infused with control vehicle or AMH-Ab during the follicular phase of the menstrual cycle. Cycle length, serum steroid levels, and antral follicle growth were evaluated.

MAIN RESULTS AND THE ROLE OF CHANCE

AMH exposure during culture weeks 0–3 (pre-antral stage) promoted, while AMH-Ab delayed, antrum formation of growing follicles compared with controls. AMH treatment during culture weeks 3–5 (antral stage) decreased (P < 0.05) estradiol (E2) production, as well as the mRNA expression of cytochrome P450 family 19 subfamily A polypeptide 1, by antral follicles relative to controls, whereas AMH-Ab increased (P < 0.05) follicular mRNA levels of the enzyme. Intraovarian infusion of AMH-Ab during the follicular phase of the menstrual cycle increased (P < 0.05) the average levels of serum E2 compared with those of the control cycles. Three of the five AMH-Ab-treated ovaries displayed multiple (n = 2–9) medium-to-large (2–8 mm) antral follicles at the mid-cycle E2 peak, whereas only one large (4–7 mm) antral follicle was observed in all monkeys during their control cycles. The average levels of serum progesterone were higher (P < 0.05) during the luteal phase of cycles following the AMH-Ab infusion relative to the vehicle infusion.

LIMITATIONS, REASONS FOR CAUTION

The in vitro study of AMH actions on cultured individual macaque follicles was limited to the interval from the secondary to small antral stage. A sequential study design was used for in vivo experiments, which may limit the power of the study.

WIDER IMPLICATIONS OF THE FINDINGS

The current study provides novel information on direct actions and role of AMH during primate follicular development, and selection of a dominant follicle by the late follicular phase of the menstrual cycle. We hypothesize that AMH acts positively on follicular growth during the pre-antral stage in primates, but negatively impacts antral follicle maturation, which is different from what is reported in the mouse model.

STUDY FUNDING/COMPETING INTEREST(S)

NIH NICHD R01HD082208, NIH ORWH/NICHD K12HD043488 (BIRCWH), NIH OD P51OD011092 (ONPRC), Collins Medical Trust. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 10 June 2016 | 6:45 am

Age-related infertility and unexplained infertility: an intricate clinical dilemma

A diagnosis of unexplained infertility is commonly made when clinical investigations fail to identify any obvious barriers to conception. As a consequence, unexplained infertility includes several heterogeneous conditions, one being women with age-related infertility. However, the latter represent a peculiar and different situation. Women with age-related infertility may have a different prognosis and may benefit from different treatments. Unfortunately, since fecundity declines with age, discerning between unexplained infertility and age-related infertility becomes more and more difficult as the woman's age increases. In this opinion, with the use of a mathematical model we show that the rate of false positive diagnoses of unexplained infertility increases rapidly after 35 years of age. Using a threshold of 2 years of unfruitful, regular unprotected intercourse, this rate exceeds 50% in women starting pregnancy seeking after 37 years. The scenario is much worse using a threshold of 1 year. From a clinical perspective, extrapolating results obtained in a population of young women with unexplained infertility to those with age-related infertility is not justified. It is noteworthy that, if Assisted Reproductive Technologies are unable to overcome age-related infertility, the older women erroneously labeled with unexplained infertility may receive inappropriate therapies. These may expose women to unjustified risks and waste financial resources. Unfortunately, the available literature about older women is scanty and does not provide valid evidence. Randomized controlled trials aimed at identifying the most suitable clinical management of older women with a normal infertility work-up are pressingly needed.

Posted on 10 June 2016 | 6:45 am

Neonatal health including congenital malformation risk of 1072 children born after vitrified embryo transfer

STUDY QUESTION

Does vitrification of Day 3 and Day 5 embryos adversely affect birth outcomes of singletons and twins in comparison with peers born after fresh embryo transfer?

SUMMARY ANSWER

Neonatal health parameters, including the prevalence of congenital malformations, in singletons and twins born after embryo vitrification are similar to or slightly better than after fresh embryo transfer.

WHAT IS ALREADY KNOWN

Although vitrification, rather than slow-freezing, of embryos is routine practice nowadays, convincing evidence regarding the safety for the offspring is sparse. Literature data comprise results from mostly small-sized studies or studies including only Day 3 or only Day 5 vitrified embryo transfers. Overall, better or comparable perinatal outcomes, in terms of higher birthweight and lower risk for small-for-gestational age or for low birthweight, have been reported for singletons born after vitrified embryo transfer compared with fresh embryo transfer. According to the single available study with sufficient sample size, the congenital malformation rate was found to be comparable after vitrified and fresh embryo transfers.

STUDY DESIGN, SIZE, DURATION

Data were collected from 960 cycles after transfer of embryos vitrified on Day 3 (n = 457) or Day 5 (n = 503) and from 1644 cycles after fresh embryo transfer on Day 3 (n = 853) or Day 5 (n = 791), performed between 2008 and 2013 at the Centre for Reproductive Medicine of the university hospital UZ Brussel. Outcome measures were neonatal health in terms of birthweight, small-for-gestational age, prematurity rate, perinatal death and major/minor/total malformation rate.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Perinatal health parameters of 11 stillborns and 1061 live borns (827 singletons and 234 twins) in the vitrified group and of 28 stillborns and 1838 live borns (1374 singletons and 464 twins) in the fresh embryo group are reported. Within 3 months after birth, children in the two study groups were assessed clinically with special attention to congenital malformations by a paediatrician blinded to the type of embryo transfer. Data were analysed by multiple linear and logistic regression, adjusted for treatment variables and maternal characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

Mothers to infants in the vitrified group were on average slightly older and more often suffering from pregnancy-related hypertensive disorders than mothers to infants in the fresh transfer group. Singletons born after vitrification showed a higher birthweight standard deviation score (SDS) (–0.4 versus –0.7; 95% confidence interval (CI): 0.0–0.3, P = 0.001) and a lower small-for-gestational age rate (AOR: 0.55; 95% CI: 0.34–0.90) in comparison with peers born after fresh embryo transfer. Preterm birth rate and perinatal death rate were comparable between the two groups (AOR: 0.91; 95% CI: 0.57–1.43 and AOR: 0.97; 95% CI: 0.40–2.36). In twins, neonatal outcomes including birthweight SDS, small-for-gestational age and prematurity rates were comparable in the vitrified and the fresh groups, when adjusted for confounders. Furthermore, the rate of major congenital malformations in live borns was comparable between the vitrified group and the fresh group, both in singletons (2.6 versus 2.8%; AOR: 0.91; 95% CI: 0.47–1.78) and in twins (2.4 versus 2.7%; AOR: 0.51; 95% CI: 0.05–5.72). Also, the total malformation rate in the vitrified group (3.4%; 95% CI: 2.4–4.8) did not differ from the rate in the fresh embryo group (3.9%; 95% CI: 3.1–5.0). The embryonic stage at vitrification or fresh transfer (cleavage-stage embryo or blastocyst) did not influence the birth characteristics or malformation rate.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of this study is the rather small twin group. Therefore, the outcome results for twins should be interpreted cautiously.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides evidence that transfer of vitrified Day 3 and Day 5 embryos does not adversely affect the neonatal health of the offspring in comparison with transfer of fresh embryos. Furthermore, neonatal outcomes were not different after transfer of vitrified blastocysts compared with transfer of vitrified cleavage-stage embryos.

STUDY FUNDING/COMPETING INTERESTS

Educational grants for establishing and organizing the data collection have come from IBSA, Ferring, Organon, Shering-Plough and Merck. Merck Belgium funded the data collection for outcomes after vitrification between 2012 and 2015. All co-authors, except M.B., declared no conflict of interest. M.B. has received consultancy fees from Organon, Serono Symposia and Merck.

Posted on 10 June 2016 | 6:45 am

Can IVF influence human evolution?

IVF, a procedure in which pharmacological and technological manipulation is used to promote pregnancy, offers help to infertile couples by circumventing selection at the most fundamental level. Fertility is clearly one of the key fitness-promoting drivers in all forms of sexually reproducing life, and fertilization and pregnancy are fundamental evolutionary processes that involve a range of pre- and post-zygotic screening mechanisms. Here, we discuss the various selection and screening factors involved in fertilization and pregnancy and assess IVF practices in light of these factors. We then focus on the possible consequences of these differences in selection pressures, mainly at the individual but also at the population level, to evaluate whether changes in the reproducing genotype can affect human evolution. The aim of the article is not to argue for or against IVF, but to address aspects of assisted reproduction in an evolutionary context.

Posted on 10 June 2016 | 6:45 am

Survey of 243 ART patients having made a final disposition decision about their surplus cryopreserved embryos: the crucial role of symbolic embryo representation

STUDY QUESTION

In couples who have chosen and confirmed the fate of surplus frozen embryos, which factors influence their decision, with a special emphasis on their symbolic representation of the embryo(s)?

SUMMARY ANSWER

Embryo representation and gamete donation use significantly influence the fate of surplus cryopreserved embryos.

WHAT IS KNOWN ALREADY

Previous studies report difficulties for couples to decide whether or not to continue storing their frozen embryo(s) and different factors have been already highlighted which influence their decision, including embryo conceptualization, information and support provided by the medical institution, quality of embryo(s) and life events. Little is known, however, about couples who definitely decided to stop their parental project and finalized the process of decision-making about the fate of their cryopreserved embryo(s).

STUDY DESIGN, SIZE, DURATION

This prospective study was conducted over a period of 3 years (2007–2010) and included IVF/ICSI patients with surplus frozen embryos, who made a final embryo disposition decision. Among the 280 eligible IVF/ICSI patients, 247 agreed to participate in the study. According to the available options, 91 persons chose to ‘stop cryopreservation’, 77 chose donation to ‘research’ and 48 ‘embryo donation’ to infertile couples. Furthermore, 31 participants who chose embryo donation for a parental project were refused by the center as not compatible with their mandatory medical conditions. Among them, 27 participants then selected donation to research as a new option and were included in a fourth group: ‘donation to research after Refusal of Embryo Donation for parental project’ or ‘research-RED’ (n = 27). Four participants chose ‘stop cryopreservation’, however, given the small number of subjects this latter group was not included in the analysis. In all, 243 participants who made a final choice concerning the fate of their cryopreserved embryos were included in this study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were sent a letter of invitation to a semi-structured interview of 30 min with a psychologist. Interviews were conducted separately for each partner, including a questionnaire with a common part and a specific part, according to the chosen option, and allowing a quantitative evaluation. A multivariate logistic regression model was used to assess the link between their embryo representation and their decision about their embryos' fate.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjustment for age, gender, gamete donation, number of children and the different embryo representations, a choice to ‘stop cryopreservation’ is more frequent if the embryo is represented as a child [odds ratio (OR) adjusted = 3.29, 95% confidence interval (CI) = 1.62–6.66], P = 0.0009. Representing the embryo as a project prompts patients to choose ‘donation to research’ [OR adjusted = 3.76, 95% CI = 1.56–9.06], P = 0.0032. Respondents are more likely to choose ‘embryo donation’ if they represent the embryo as a potential person [OR adjusted = 3.77, 95% CI = 1.45–9.80], P = 0.0064. Furthermore, patients who benefited from gamete donation are ~10 times more likely to donate their embryos to another couple [OR adjusted = 10.62, 95% CI = 3.99–28.30], P < 0.0001. For more than half the participants (57%) the decision-making was easy, however, deciding to stop cryopreservation was significantly more difficult than choosing research or embryo donation (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

Socio-economic status, moral and religious affiliations are known to influence the choice of couples but analyzing these factors was not an aim of the present study.

WIDER IMPLICATIONS OF THE FINDINGS

When couples definitely decide to stop their parental project, the embryo symbolic representation remains the main factor that influences the fate of their frozen embryo(s). Moreover, this representation can evolve when influenced by external events and information provided. In order to support patients who are making this difficult decision, it could be helpful to explore this symbolic representation early in the IVF/ICSI procedure, before surplus embryo freezing, as a new tool enhancing the accuracy of counseling.

STUDY FUNDING/COMPETING INTEREST(S)

this study was supported by a grant from the ‘Agence de la biomedicine (ABM)’, the national regulatory ART agency, under the authority of the French Ministry of Health. The authors have no conflict of interest to declare.

Posted on 10 June 2016 | 6:45 am

Halofuginone suppresses growth of human uterine leiomyoma cells in a mouse xenograft model

STUDY QUESTION

Does halofuginone (HF) inhibit the growth of human uterine leiomyoma cells in a mouse xenograft model?

SUMMARY ANSWER

HF suppresses the growth of human uterine leiomyoma cells in a mouse xenograft model through inhibiting cell proliferation and inducing apoptosis.

WHAT IS KNOWN ALREADY

Uterine leiomyomas are the most common benign tumors of the female reproductive tract. HF can suppress the growth of human uterine leiomyoma cells in vitro. The mouse xenograft model reflects the characteristics of human leiomyomas.

STUDY DESIGN, SIZE, DURATION

Primary leiomyoma smooth muscle cells from eight patients were xenografted under the renal capsule of adult, ovariectomized NOD-scid IL2Rnull mice (NSG). Mice were treated with two different doses of HF or vehicle for 4 weeks with six to eight mice per group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mouse body weight measurements and immunohistochemical analysis of body organs were carried out to assess the safety of HF treatment. Xenografted tumors were measured and analyzed for cellular and molecular changes induced by HF. Ovarian steroid hormone receptors were evaluated for possible modulation by HF.

MAIN RESULTS AND THE ROLE OF CHANCE

Treatment of mice carrying human UL xenografts with HF at 0.25 or 0.50 mg/kg body weight for 4 weeks resulted in a 35–40% (P < 0.05) reduction in tumor volume. The HF-induced volume reduction was accompanied by increased apoptosis and decreased cell proliferation. In contrast, there was no significant change in the collagen content either at the transcript or protein level between UL xenografts in control and HF groups. HF treatment did not change the expression level of ovarian steroid hormone receptors. No adverse pathological effects were observed in other tissues from mice undergoing treatment at these doses.

LIMITATIONS, REASONS FOR CAUTION

While this study did test the effects of HF on human leiomyoma cells in an in vivo model, HF was administered to mice whose tolerance and metabolism of the drug may differ from that in humans. Also, the longer term effects of HF treatment are yet unclear.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study showing the effectiveness of HF in reducing UL tumor growth by interfering with the main cellular processes regulating cell proliferation and apoptosis are in agreement with previous studies on the effects of HF on other fibrotic diseases. HF can be considered as a candidate for reducing the size of leiomyomas, particularly prior to surgery.

STUDY FUNDING/COMPETING INTEREST(S)

This project was funded by NIH PO1HD057877 and R01 HD064402. Authors report no competing interests.

Posted on 10 June 2016 | 6:45 am

Shorter anogenital distance correlates with the severity of hypospadias in pre-pubertal boys

STUDY QUESTION

Do pre-pubertal boys with hypospadias have a shorter anogenital distance (AGD) than boys with normal genitalia?

SUMMARY ANSWER

AGD is significantly shorter in boys with hypospadias and decreases with the severity of hypospadias.

WHAT IS KNOWN ALREADY

Animal studies have shown that androgen disruption and exposure to endocrine disrupting chemicals during a critical time period in early gestation, termed the male programming window (MPW), result in hypospadias and reduced AGD; and the severity of hypospadias correlates with the reduction in AGD. However, this correlation has not been established in humans.

STUDY DESIGN, SIZE, DURATION

A prospective descriptive study involving measurement of AGD in pre-pubertal boys (n = 458) presenting to our pediatric urology clinic with hypospadias and normal genitalia was performed over a period of 3 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

AGD was measured in pre-pubertal boys from 5 months to 14 years of age presenting to our clinic with hypospadias (n = 180: four were excluded) and compared with randomly selected boys with normal genitalia (controls, n = 274). Three variants of AGD, from the midpoint of the anus to base of the scrotum (AGD-AS), to the anterior base of penis (AGD-1) and to the posterior base of penis (AGD-2), were measured and assessed for correlation with the severity of hypospadias. Severity of hypospadias was classified as anterior, middle and posterior according to the meatal location.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant difference in weight (P = 0.123), age (P = 0.162) or height (P = 0.591) between the two groups was observed. Only AGD-AS was significantly shorter in boys with hypospadias compared with controls (mean ± SD: 40.6 ± 9.7 mm versus 45.6 ± 9.4 mm, P < 0.001). This relation persisted after adjusting AGD for weight, height and age (β = 0.016, 95% confidence interval: 0.10–0.21; P < 0.001). The Spearman test showed a significant negative correlation for the severity of hypospadias with all the three AGD measures. Analysis of variance between anterior, middle and posterior subgroups showed a significant reduction in mean AGD-AS (P = 0.003) and AGD-2 (P = 0.008).

LIMITATIONS, REASONS FOR CAUTION

No data were collected pertaining to in utero exposure to endocrine disrupting chemicals (EDCs) or cigarette smoke, or current diet and environmental exposure to EDCs, which may have influenced the AGD. Family history of genital malformation and use of IVF were not known. There may have been a selection bias as only boys presenting to our clinic were included.

WIDER IMPLICATIONS OF THE FINDINGS

The findings suggest that prenatal androgens during early gestation influence development of the male reproductive system and support the existence of a MPW in humans. Of the three AGDs, AGD-AS may be the most reliable biomarker of this in utero androgen action. However, no direct link to any specific exposure leading to shortened AGD in pre-pubertal boys with hypospadias could be determined. Further large scale multi-center studies are needed to understand this association better.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was from the Hypospadias Foundation. No conflicts of interest to disclose.

Posted on 10 June 2016 | 6:45 am

Does anti-Müllerian hormone predict menopause in the general population? Results of a prospective ongoing cohort study

STUDY QUESTION

Do ovarian reserve tests (ORTs) predict age at natural menopause (ANM) in a cohort of healthy women with a regular menstrual cycle?

SUMMARY ANSWER

Of the ORTs researched, anti-Müllerian hormone (AMH) alone predicts age at menopause. However, its predictive value decreased with increasing age of the woman, prediction intervals were broad and extreme ages at menopause could not be predicted.

WHAT IS KNOWN ALREADY

A fixed interval is hypothesized to exist between ANM and age at loss of natural fertility. Therefore, if it is possible to predict ANM, one could identify women destined for early menopause and thus at higher risk for age-related subfertility. Of ORTs researched in the prediction of ANM, AMH is the most promising one.

STUDY DESIGN, STUDY SIZE AND DURATION

A long-term, extended follow-up study was conducted, results of the first follow-up round were previously published. Two hundred and sixty-five normo-ovulatory women (21–46 years) were included between 1992 and 2001, 49 women (18.5%) could not be reached in the current follow-up round.

PARTICIPANTS, SETTING, METHODS

Two hundred and sixty-five healthy normo-ovulatory women were included, recruited in an Academic hospital. We measured baseline AMH, follicle-stimulating hormone and the antral follicle count (AFC). At follow-up (2009 and 2013), menopausal status was determined via questionnaires. Cox regression analysis calculated time to menopause (TTM) using age and ORT. A check of (non-) proportionality of the predictive effect of AMH was performed. A Weibull survival model was used in order to predict individual ANM.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 155 women were available for analyses. Eighty-one women (37.5%) had become post-menopausal during follow-up. Univariable Cox regression analysis demonstrated age and ORTs to be significantly correlated with TTM. Multivariable Cox regression analysis, adjusting for baseline age and smoking; however, demonstrated AMH alone to be an independent predictor of TTM (Hazard Ratio 0.70, 95% Confidence Interval 0.56–0.86, P-value <0.001). A (non-)proportionality analysis of AMH over time demonstrated AMH's predictive effect to decline over time.

LIMITATIONS, REASON FOR CAUTION

The observed predictive effect of AMH became less strong with increasing age of the woman. Individual AMH-based age at menopause predictions did not cover the full range of menopausal ages, but did reduce the variation around the predicted ANM from 20 to 10.1 years.

WIDER IMPLICATIONS OF THE FINDINGS

Age-specific AMH levels are predictive for ANM. Unlike in our previous publication however, a declining AMH effect with increasing age was observed. This declining AMH effect is in line with recent long-term follow-up data published by others. Moreover, the accompanying predictive inaccuracy observed in individual age at menopause predictions based on AMH, makes this marker currently unsuitable for use in clinical practice.

STUDY FUNDING/COMPETING INTERESTS

No external funds were used for this study. M.D., M.J.C.E, S.L.B., G.J.S. and I.A.J.R. have nothing to declare. J.S.E.L. has received fees and grant support from the following companies (in alphabetical order): Ferring, Merck-Serono, MSD, Organon, Serono and Schering Plough. F.J.M.B. receives monetary compensation: member of the external advisory board for Merck Serono, the Netherlands; consultancy work for Gedeon Richter, Belgium; educational activities for Ferring BV, the Netherlands; strategic cooperation with Roche on automated AMH assay development.

Posted on 10 June 2016 | 6:45 am

TET enzymes are successively expressed during human spermatogenesis and their expression level is pivotal for male fertility

STUDY QUESTION

Are ten-eleven-translocation (TET) 1–3 family enzymes involved in human spermatogenesis and do they impact male fertility?

SUMMARY ANSWER

TET1, TET2 and TET3 are successively expressed at different stages of human spermatogenesis, and their expression levels associate with male fertility.

WHAT IS KNOWN ALREADY

Spermatogenesis is a complex cell differentiation process accompanied by a drastic epigenetic remodeling. TET1–3 dioxygenases are essential for active DNA demethylation in the paternal pronucleus and in embryonic stem cells.

STUDY DESIGN, SIZE, DURATION

Expression of TET1–3 mRNAs and proteinss and 5-hydroxymethylcytosine (5-hmC) proteins were analyzed in human testis tissues from men with obstructive azoospermia and exhibiting histologically normal spermatogenesis. Ejaculated spermatozoa from normozoospermic healthy volunteers, the ‘controls’ (TET1: n = 58; TET2–3: n = 63), and subfertile men who participated with their female partners in an ICSI-program, the ‘patients’ (TET1: n = 66; TET2–3: n = 64), were analyzed concerning the stored TET13 mRNAs, and the values were correlated to semen parameters and ICSI-outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Testis sections were used for in situ hybridization (ISH) and immunohistochemical (IHC) studies to determine TET1–3 mRNA and protein expression, and for immunofluorescence (IF) detection of 5-hmC. Sperm samples from controls were analyzed by western blot, immunocytochemistry (ICC) and RT–PCR concerning the presence of non-degraded TET1–3 protein and mRNA. Sperm samples from controls and patients were used for quantitative TET1–3 mRNA analyses (reverse transcription–polymerase chain reaction) and for comparative statistical evaluations under consideration of semen parameters and ICSI-outcome (pregnancy).

MAIN RESULTS AND THE ROLE OF CHANCE

During human spermatogenesis TET1–3 proteins are successively expressed: TET2 is expressed in the cytoplasm of late pachytene spermatocytes of Stage V, TET1 starts to be expressed in the nuclei of Step 1 round spermatids at Stage I, and TET3 starts to be expressed in the nuclei of Step 3 round spermatids at Stage III. Five-hmC appears only in Step 5 elongated spermatids. All three TETs are still detectable at the mRNA and protein level in sperm cells in considerable amounts. Control men generally exhibited higher levels of TET1–3 in sperm. TET1- and TET3-mRNA levels in sperm were significantly negatively correlated with age (P = 0.0025 and P = 0.0343) and positively correlated with progressive sperm motility (P = 0.0007 and P = 0.018). All TETs showed a significant association with sperm concentration (P < 0.03). Patients diagnosed with oligozoospermia and/or asthenozoospermia (TET1: n = 35; TET2–3: n = 32) showed significantly reduced TET1–3 in sperm in comparison to controls (P = 0.003, P = 0.041 and P = 0.028), but not compared with normozoospermic patients. Levels of TET3 in sperm was significantly associated with high-fertilization rates (P = 0.009). Concerning ICSI-outcome, the lowest levels of TET1–3 mRNAs in sperm were found in the non-pregnant group. Increased TET2 in sperm was significantly associated with pregnancy (P = 0.006).

LIMITATIONS, REASONS FOR CAUTION

Our results concerning the association of the mRNA level of TETs in ejaculated sperm cells to different fertility parameters are descriptive. Further studies clarifying the reasons for decreased TET1–3 levels in subfertile men and their effect on their sperm methylome are essential.

WIDER IMPLICATIONS OF THE FINDINGS

The study gives a substantial indication that in human spermiogenesis, an active DNA demethylation process occurs with an involvement of TET enzymes, and that the level of TET1–3 expression is pivotal for male fertility.

STUDY FUNDING

Research grant from the German Research Foundation (DFG) to U.S. (SCHA1531/1-1 and SCHA1531/2-1).

COMPETING INTEREST(S)

None.

Posted on 10 June 2016 | 6:45 am

The clinical performance of the M4 decision support model to triage women with a pregnancy of unknown location as at low or high risk of complications

STUDY QUESTION

What are the adverse outcomes associated with using the M4 model in everyday clinical practice for women with pregnancy of unknown location (PUL)?

SUMMARY ANSWER

There were 17/835 (2.0%) adverse events and no serious adverse events associated with the performance of the M4 model in clinical practice.

WHAT IS KNOWN ALREADY

The M4 model has previously been shown to stratify women classified as a PUL as at low or high risk of complications with a good level of test performance. The triage performance of the M4 model is better than single measurements of serum progesterone or the hCG ratio (serum hCG at 48 h/hCG at presentation).

STUDY DESIGN, SIZE, DURATION

A prospective multi-centre cohort study of 1022 women with a PUL carried out between August 2012 and December 2013 across 2 university teaching hospitals and 1 district general hospital.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women presenting with a PUL to the early pregnancy units of the three hospitals were recruited. The final outcome for PUL was either a failed PUL (FPUL), intrauterine pregnancy (IUP) or ectopic pregnancy (EP) (including persistent PUL (PPUL)), with EP and PPUL considered high-risk PUL. Their hCG results at 0 and 48 h were entered into the M4 model algorithm. If the risk of EP was ≥5%, the PUL was predicted to be high-risk and the participant was asked to re-attend 48 h later for a repeat hCG and transvaginal ultrasound scan by a senior clinician. If the PUL was classified as ‘low risk, likely failed PUL’, the participant was asked to perform a urinary pregnancy test 2 weeks later. If the PUL was classified as ‘low risk, likely intrauterine’, the participant was scheduled for a repeat scan in 1 week. Deviations from the management protocol were recorded as either an ‘unscheduled visit (participant reason)’, ‘unscheduled visit (clinician reason)’ or ‘differences in timing (blood test/ultrasound)’. Adverse events were assessed using definitions outlined in the UK Good Clinical Practice Guidelines' document.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 835 (82%) women classified as a PUL were managed according to the M4 model (9 met the exclusion criteria, 69 were lost to follow-up, 109 had no hCG result at 48 h). Of these, 443 (53%) had a final outcome of FPUL, 298 (36%) an IUP and 94 (11%) an EP. The M4 model predicted 70% (585/835) PUL as low risk, of which 568 (97%) were confirmed as FPUL or IUP. Of the 17 EP and PPUL misclassified as low risk, 5 had expectant management, 7 medical management with methotrexate and 5 surgical intervention.

Nineteen PUL had an unscheduled visit (participant reason), 38 PUL had an unscheduled visit (clinician reason) and 68 PUL had deviations from protocol due to a difference in timing (blood test/ultrasound).

Adverse events were reported in 26 PUL and 1 participant had a serious adverse event. A total of 17/26 (65%) adverse events were misclassifications of a high risk PUL as low risk by the M4 model, while 5/26 (19%) adverse events were related to incorrect clinical decisions. Four of the 26 adverse events (15%) were secondary to unscheduled admissions for pain/bleeding. The serious adverse event was due to an incorrect clinical decision.

LIMITATIONS, REASONS FOR CAUTION

A limitation of the study was that 69/1022 (7%) of PUL were lost to follow-up. A 48 h hCG level was missing for 109/1022 (11%) participants.

WIDER IMPLICATIONS OF THE FINDINGS

The low number of adverse events (2.0%) suggests that expectant management of PUL using the M4 prediction model is safe. The model is an effective way of triaging women with a PUL as being at high- and low-risk of complications and rationalizing follow-up. The multi-centre design of the study is more likely to make the performance of the M4 model generalizable in other populations.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 10 June 2016 | 6:45 am

The medical and ethical challenges of fertility preservation in teenage girls: a case series of sickle cell anaemia patients prior to bone marrow transplant

Cryopreservation of oocytes has been proposed as a way of storing gametes in young patients at high risk of infertility and premature ovarian failure. Recent advances in cryobiology have yielded promising results, leading to oocyte cryopreservation becoming a mainstay of fertility preservation. In this case series, we describe the feasibility of performing ovarian stimulation, and the ethical challenges faced, in teenage girls, aged 14–18 years, prior to undergoing bone marrow transplant for sickle cell anaemia. All eight consecutive cases completed ovarian stimulation and oocyte retrieval with mature oocytes being found and cryopreserved for each patient. The mean dose of gonadotrophin stimulation was 2134.38 IU (95% CI 1593.34–2675.4) and the mean duration of treatment was 11 days (95% CI 10.02–11.98). The mean number of oocytes retrieved was 14.88 (95% CI 7.39–22.36), of which a mean of 12.13 (95% CI 4.72–19.54) oocytes were mature and cryopreserved. There was one case of moderate ovarian hyperstimulation syndrome that required hospital admission for supportive treatment. Oocyte cryopreservation is a technique that can be successfully employed after the retrieval of mature oocytes from the peripubertal ovary, restoring hope to these patients, and their families, of having their own genetic children in the future.

Posted on 10 June 2016 | 6:45 am

Bisphenol A in culture media and plastic consumables used for ART

STUDY QUESTION

Do the embryo culture media and plastic materials used during assisted reproductive technology (ART) laboratory procedures expose embryos to bisphenol A (BPA)?

SUMMARY ANSWER

BPA was not detected in embryo culture media or protein supplements at concentrations above those encountered in normal patient serum and follicular fluids.

WHAT IS KNOWN ALREADY

BPA is strongly suspected of altering the epigenome during mammalian development. Medical devices have been shown to be a source of BPA exposure in adult and neonatal intensive care units.

STUDY DESIGN, SIZE, DURATION

An analytical study of ART culture media and plastic labware products was performed under conditions close to routine practice and if BPA was detected, tests were carried out under more stringent conditions.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two single-step embryo culture media, two sequential media and three different protein supplements [a purified human serum albumin (HSA), a synthetic serum substitute, and a recombinant HSA] were tested for BPA. Thirty-three different plastic consumables, used from oocyte collection through to embryo transfer, were tested for their ability to leach BPA into their surrounding environment.

BPA concentrations were measured according to a previously described liquid chromatography/mass spectrometry method. This method is linear over the calibration range from 0.5 to 100 ng/ml using a linear model weighted by 1/X² and validated in terms of selectivity, linearity, repeatability, reproducibility and limit of quantification (0.5 ng/ml).

MAIN RESULTS AND THE ROLE OF CHANCE

Neither the culture media nor the protein supplements were shown to contain detectable levels of BPA. None of the plastic materials leached BPA into the surrounding medium at levels higher than the upper limit detected previously in serum and follicular fluids in women (about 2 ng/ml). However, the plastic of the three tested strippers used for oocyte denudation/embryo handling did contain BPA. Two of these strippers are made with polycarbonate, a plastic whose synthesis is known to require BPA.

LIMITATIONS, REASONS FOR CAUTION

This study is limited to the ART media and materials tested here and using a BPA assay with a limit of quantification at 0.5 ng/ml. A minimum volume was required for testing, and one type of plastic labware could not be tested in conditions identical to those in routine use.

WIDER IMPLICATIONS OF THE FINDINGS

Although we demonstrated that some plastic materials used in ART contain BPA, under routine conditions none appear capable of leaching BPA at levels higher than those from maternal internal exposure. However, BPA is strongly suspected of altering the epigenome. Since important epigenetic modifications occur in the early embryonic stage, it is questionable whether plastics that contain BPA, polycarbonate in particular, should be used in the manufacture of plastic consumables for ART procedures.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the Agence de Biomédecine (AOR 2012) and by a grant from the French Ministry of Health (Clinical Research Hospital Program 2012; no.12-018-0560). The authors declared no competing interest.

Posted on 10 June 2016 | 6:45 am

Personality in women with endometriosis: temperament and character dimensions and pelvic pain

STUDY QUESTION

Is pelvic pain due to endometriosis associated with temperament and character dimensions?

SUMMARY ANSWER

Women with endometriosis and pelvic pain do not clearly exhibit a specific personality profile; however, personality is associated with pelvic pain perception.

WHAT IS KNOWN ALREADY

There is research evidence suggesting that endometriosis patients with pelvic pain are more likely to present psychological disruption. Little is known about the association between subjective factors, such as personality traits, and pelvic pain.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study (N = 133) is part of a larger research on the association between endometriosis and several psychological variables carried out between 2012 and 2014.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

The participants were 82 endometriosis patients and 51 healthy controls. Endometriosis patients indicated on a dichotomous scale (yes/no) whether they were suffering from pelvic pain and were divided in two study groups: painful endometriosis group (N = 58) and pain-free endometriosis group (N = 24). The severity of pelvic pain (chronic pelvic pain, dysmenorrhoea, dyspareunia, and dyschezia) was rated on a 0–10 point numerical rating scale. All participants completed a 240-item psychometric test (TCI-R) evaluating personality in terms of temperament and character dimensions.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with painful endometriosis had lower novelty seeking compared with the control group (P = 0.017) and higher harm avoidance (P = 0.007) and lower exploratory excitability (P = 0.034) and responsibility (P = 0.027) compared with the pain-free endometriosis group, as well as higher fatigability compared with the pain-free endometriosis group (P = 0.001) and the control group (P = 0.032). Higher harm avoidance (B = 0.081; P = 0.002) and lower self-directedness (B = –0.053; P = 0.015) were associated with a greater severity of chronic pelvic pain.

LIMITATIONS, REASONS FOR CAUTION

These study findings should be taken cautiously for several methodological reasons such as small sample size, differences in group sizes and cultural homogeneity. More research is needed to further investigate the association between personality and pelvic pain related to endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest new avenues for future research and treatment of endometriosis. The association between the severity of chronic pelvic pain and personality may help clarify the lack of a direct correlation between pain severity and the type and stage of endometriosis, as well as the inconsistencies in patients' response to medical and/or surgical treatment. Therapeutic strategies should be specifically targeted on individual women and involve an integrated approach to the treatment of chronic pelvic pain related to endometriosis.

STUDY FUNDING/COMPETING INTERESTS

There was no external funding for this study and the authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable to this study.

Posted on 10 June 2016 | 6:45 am

Antioxidants improve mouse preimplantation embryo development and viability

STUDY QUESTION

What is the effect of three antioxidants (acetyl-L-carnitine, N-acetyl-L-cysteine and α-lipoic acid), when used individually and in combination, on mouse embryo development in culture, and subsequent fetal development post-transfer?

SUMMARY ANSWER

A combination of antioxidants resulted in significant increases in blastocyst cell number, maintained intracellular glutathione (GSH) levels, supported earlier cleavage times from 5-cell stage to expanded blastocyst, and improved fetal developmental irrespective of incubator oxygen concentration.

WHAT IS KNOWN ALREADY

Acetyl-L-carnitine, N-acetyl-L-cysteine and α-lipoic acid have been shown to have beneficial effects individually in several tissues, and most recently on developing embryos, in the presence of oxidative stress.

STUDY DESIGN, SIZE, DURATION

Morphokinetics of mouse embryos were quantitated using time-lapse imaging. GSH levels in pronucleate oocytes were measured. Blastocysts underwent differential nuclear staining for inner cell mass and trophectoderm cells or were transferred to recipient females to assess implantation and fetal development.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Pronucleate oocytes from F1 mice were cultured in 5 or 20% oxygen either individually or in groups of 10, in media G1/G2, in the presence or absence of 10 µM acetyl-L-carnitine /10 µM N-acetyl-L-cysteine /5 µM α-lipoic acid, either individually or in combination. Controls were embryos cultured without antioxidants. Intracellular levels of reduced glutathione were quantitated in pronucleate oocytes. Embryo development and viability were analysed through time-lapse microscopy and embryo transfers.

MAIN RESULTS AND THE ROLE OF CHANCE

Antioxidants significantly increased mouse blastocyst cell numbers compared with control when used individually (P< 0.05) and to a greater effect when all three were used in combination (P< 0.01) in 20% oxygen. The combination of antioxidants resulted in faster development rates to 5-cell cleavage stage, which continued until the expanded blastocyst stage when cultured in 20% oxygen. The beneficial effects of combining the antioxidants were greater for embryos cultured individually as opposed to in groups of 10 and for those embryos cultured in 20% compared to 5% oxygen. Levels of GSH were significantly decreased in control embryos that were incubated in the absence of antioxidants in 20% oxygen (P< 0.01), compared with in vivo flushed embryos. However, when embryos were cultured with antioxidants the level of GSH was not different to that of in vivo developed embryos. Embryos cultured in the presence of antioxidants in 20% oxygen and transferred resulted in significantly longer crown-rump length (11.6 ± 0.1 mm versus 11.3 ± 0.1 mm; P< 0.01), heavier fetuses (209.8 ± 11.8 mg versus 183.9 ± 5.9 mg; P< 0.05) and heavier placentas (103.5 ± 3.1 mg versus 93.6 ± 2.7 mg; P< 0.01) compared with controls (all data are mean ± SEM). Further, a post-implantation benefit of the antioxidant combination was also evident after culture in 5% oxygen.

LIMITATIONS, REASONS FOR CAUTION

Embryo development and implantation was only examined in the mouse.

WIDER IMPLICATIONS OF THE FINDINGS

These findings show that a combination of antioxidants in the culture media has a highly beneficial effect on mouse preimplantation embryo development in vitro and on subsequent fetal development post-transfer. These data indicate a potential role for the inclusion of specific antioxidant combinations in human embryo culture media irrespective of oxygen concentration. However, before application to human embryos, a proper evaluation of this approach in prospective, preferably randomized, trials will be required.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by a research grant from Vitrolife AB (Sweden). The authors have no conflict of interest to declare.

Posted on 10 June 2016 | 6:45 am

Survival and growth of isolated pre-antral follicles from human ovarian medulla tissue during long-term 3D culture

STUDY QUESTION

Can human pre-antral follicles isolated enzymatically from surplus medulla tissue survive and grow in vitro during long-term 3D culture?

SUMMARY ANSWER

Secondary human follicles can develop to small antral follicles and remain hormonally active in an alginate-encapsulation culture system for more than 30 days.

WHAT IS KNOWN ALREADY

Ovarian tissue cryopreservation followed by transplantation is a promising fertility preservation approach for cancer patients. However, transplantation of cryopreserved tissue to patients may carry the risk of re-implanting malignant cells. Grafting of follicles enzymatically isolated from ovarian tissue or developing a method for follicular culture and maturation in vitro may provide fertility to such patients without the risk of reintroducing the malignancy. However, the growth of pre-antral follicles isolated by enzymatic digestion from medulla tissue during long-term culture has received only little attention.

STUDY DESIGN, SIZE, DURATION

Two to ten human pre-antral follicles were encapsulated together within an alginate bead and cultured with or without ovarian interstitial tissue for either 7 days or >30 days. Follicles were cultured in either 20% oxygen or 5% oxygen or encapsulated in a lower concentration of alginate together with a lower concentration of FSH in high oxygen.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 395 pre-antral follicles from 16 cancer patients, aged 9–37 years, were co-cultured for either 7 days or >30 days. A proportion of follicle (64) were removed from culture on Day 7 and assessed for viability using confocal fluorescence microscopy following calcein-AM and ethidium homodimer-1 staining or histology. The remaining follicles (331) were continued in culture for >30 days then assessed for survival and growth. Anti-Müllerian hormone (AMH) and estradiol levels were quantified in the medium.

MAIN RESULTS AND THE ROLE OF CHANCE

An optimized protocol for isolation of intact healthy pre-antral follicles from ovarian medulla was developed. After 7 days of culture, secondary follicles had a significantly higher survival rates compared with primary and primordial follicles (70 versus <38%). Primordial and primary follicles did not develop into the antral follicle stage. In contrast, secondary follicles continued to develop in all culture conditions examined. Based on growth rate and morphology, four distinct cohorts of surviving follicles, ‘fast growth’, ‘slow growth’, ‘no growth’ and ‘extruded oocyte’ were identified. From Day 1 to Day 30, the mean diameter of follicles increased from 184 ± 35 to 661 ± 120 μm (significant from Day 18), 145 ± 19 to 318 ± 68 μm and 136 ± 15 to 162 ± 25 μm (mean ± SD) in the ‘fast growth’, ‘slow growth’ and ‘no growth’ patterns, respectively. The fast growth follicles also contained a larger diameter oocyte than other follicle groups. From the pre-antral follicle to antral stage, follicles became steroidogenically active and secretion of AMH and estradiol increased. No significant difference between the follicles cultured with or without ovarian interstitial tissue was observed.

LIMITATIONS, REASONS FOR CAUTION

The number of surviving follicles at the end of study was low in each of the culture conditions therefore whether there is a benefit with any of the conditions is difficult to ascertain. Multiple pre-antral follicles were cultured within the same alginate bead which may affect the in vitro development of the secondary follicles.

WIDER IMPLICATIONS OF THE FINDINGS

These findings show that pre-antral follicles, isolated enzymatically from surplus medulla tissue that is normally discarded, possess a developmental potential which may be used to devise safer fertility preservation methods for patients who are at high risk of malignant contamination of their ovarian tissue.

STUDY FUNDING/COMPETING INTEREST(S)

The Child Cancer Foundation in Denmark (2012–26) and the EU interregional project ReproHigh are thanked for having funded this study; and the Key Program of Medical Science and Technology Innovation of Nanjing Military Area Command in China (14ZX06; 11Z010). They had no role in the study design, collection and analysis of data, data interpretation or in writing the report. The authors have no conflicts of interest to disclose.

Posted on 10 June 2016 | 6:45 am

Expression of Syncytin 1 (HERV-W), in the preimplantation human blastocyst, embryonic stem cells and trophoblast cells derived in vitro

STUDY QUESTION

As Syncytin 1 (human endogenous retrovirus (HERV-W)) is crucial for human embryo placentation is it expressed during preimplantation embryo development?

SUMMARY ANSWER

Syncytin 1 was expressed mainly in trophoblast cells of the blastocyst particularly in cells underlying the inner cell mass (ICM).

WHAT IS KNOWN ALREADY

Syncytin 1 (along with HERV-FRD or Syncytin 2) is expressed in first-trimester placenta and required for cell–cell fusion to enable formation of syncytiotrophoblast and effective placentation.

STUDY DESIGN, SIZE AND DURATION

Preimplantation human embryos donated for research were cultured in vitro and protein expression of Syncytin 1 at the blastocyst stage of development investigated. Comparisons were made with protein (Syncytin 1) and mRNA (Syncytin 1 and 2) expression in human embryonic stem cells (hESCs) undergoing differentiation to trophoblast-like cells in vitro. In total, 10 blastocysts (x3 or 4 replicates) were analysed and 4 hESC lines. The study was terminated after consistent observations of embryos were made.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Donated embryos were thawed and cultured to blastocyst, fixed with 4% w/v paraformaldehyde. Syncytin 1 protein expression was determined by immunofluorescent localisation and confocal microscopy. Additionally, hESCs were differentiated to trophoblast-like cells in standard and conditioned culture medium with growth factors (bone morphogenetic protein 4 (BMP4) or fibroblast growth factor 4 (FGF4) and assessed for mRNA (Syncytin 1 and 2) by quantitative polymerase chain reaction (qPCR) and protein expression by immunolocalization and western blot.

MAIN RESULTS AND ROLE OF CHANCE

Syncytin 1 was expressed in cytoplasm and on the cell surface of some trophoblast cells, and consistently the trophectoderm underlying the ICM of the blastocyst. There was weak but consistent expression of Syncytin 1 in cells on the periphery of the ICM also displaying pluripotency antibody marker (Tra-1-60). Three-dimensional reconstruction of confocal slice data provided good visualization of expression. The time course of expression of Syncytin 1 was replicated in hESCs differentiated in vitro confirming the embryo observations and providing statistically significant differences in protein and mRNA level (P= 0.002) and (P< 0.05), respectively.

LIMITATION, REASONS FOR CAUTION

Culture of a limited number of embryos to blastocyst in vitro may not replicate the range and quality of development in situ. Probes (antibodies, PCR) were tested for specificity, but might have non-specific reactions.

WIDER IMPLICATIONS OF FINDINGS

Syncytin expression is a prerequisite for embryo implantation and placentation. Understanding when expression first occurs during embryo development may be informative for understanding conditions of abnormal gestations such as pre-clampsia.

STUDY FUNDING/COMPETING INTERESTS

The study was supported partly by an ERASMUS training grant and grant G0801059 from the Medical Research Council, U.K. There were no competing interests.

Posted on 10 June 2016 | 6:45 am

Intrauterine human chorionic gonadotropin infusion in oocyte donors promotes endometrial synchrony and induction of early decidual markers for stromal survival: a randomized clinical trial

STUDY QUESTION

Does a single intrauterine infusion of human chorionic gonadotropin (hCG) at the time corresponding to a Day 3 embryo transfer in oocyte donors induce favorable molecular changes in the endometrium for embryo implantation?

SUMMARY ANSWER

Intrauterine hCG was associated with endometrial synchronization between endometrial glands and stroma following ovarian stimulation and the induction of early decidual markers associated with stromal cell survival.

WHAT IS KNOWN ALREADY

The clinical potential for increasing IVF success rates using an intrauterine hCG infusion prior to embryo transfer remains unclear based on previously reported positive and non-significant findings. However, infusion of CG in the non-human primate increases the expression of pro-survival early decidual markers important for endometrial receptivity, including α-smooth muscle actin (α-SMA) and NOTCH1.

STUDY DESIGN, SIZE, DURATION

Oocyte donors (n=15) were randomly assigned to receive an intrauterine infusion of 500 IU hCG (n=7) or embryo culture media vehicle (n=8) 3 days following oocyte retrieval during their donor stimulation cycle. Endometrial biopsies were performed 2 days later, followed by either RNA isolation or tissue fixation in formalin and paraffin embedding.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Reverse transcription of total RNA from endometrial biopsies generated cDNA, which was used for analysis in the endometrial receptivity array (ERA; n = 5/group) or quantitative RT–PCR to determine relative expression of ESR1, PGR, C3 and NOTCH1. Tissue sections were stained with hematoxylin and eosin followed by blinded staging analysis for dating of endometrial glands and stroma. Immunostaining for ESR1, PGR, α-SMA, C3 and NOTCH1 was performed to determine their tissue localization.

MAIN RESULTS AND THE ROLE OF CHANCE

Intrauterine hCG infusion was associated with endometrial synchrony and reprograming of stromal development following ovarian stimulation. ESR1 and PGR were significantly elevated in the endometrium of hCG-treated patients, consistent with earlier staging. The ERA did not predict an overall positive impact of intrauterine hCG on endometrial receptivity. However, ACTA2, encoding α-SMA was significantly increased in response to intrauterine hCG. Similar to the hCG-treated non-human primate, sub-epithelial and peri-vascular α-SMA expression was induced in women following hCG infusion. Other known targets of hCG in the baboon were also found to be increased, including C3 and NOTCH1, which have known roles in endometrial receptivity.

LIMITATIONS, REASONS FOR CAUTION

This study differs from our previous work in the hCG-treated non-human primate along with clinical studies in infertile patients. Specifically, we performed a single intrauterine infusion in oocyte donors instead of either continuous hCG via an osmotic mini-pump in the baboon or infusion followed by blastocyst-derived hCG in infertile women undergoing embryo transfer. Therefore, the full impact of intrauterine hCG in promoting endometrial receptivity may not have been evident.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest a potential clinical benefit for intrauterine hCG prior to embryo transfer on Day 3 in counteracting endometrial dyssynchrony from ovarian stimulation and promoting expression of markers important for stromal survival. Finally, there were no obvious negative effects of intrauterine hCG treatment.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this work was provided by NICHD R01 HD042280 (A.T.F.) and NICHD F30 HD082951 (M.R.S.). C.S. and P.D.-G are co-inventors of the patented ERA, which is owned by IGENOMIX SL and was used in this study, and C.S. is a shareholder in IGENOMIX SL. M.R.-A. is employed by IGENOMIX SL. No other authors have any conflicts of interest to report.

TRIAL REGISTRATION NUMBER

This study was registered with ClinicalTrials.gov (NCT01786252).

TRIAL REGISTRATION DATE

5 February 2013.

DATE OF FIRST PATIENT'S ENROLLMENT

10 May 2013.

Posted on 10 June 2016 | 6:45 am

Platelet-derived TGF-{beta}1 mediates the down-modulation of NKG2D expression and may be responsible for impaired natural killer (NK) cytotoxicity in women with endometriosis

STUDY QUESTION

Does platelet-derived transforming growth factor-β1 (TGF-β1) have any role in the reduced cytotoxicity of natural killer (NK) cells in women with endometriosis?

SUMMARY ANSWER

Platelet-derived TGF-β1 suppresses the expression of NK Group 2, Member D (NKG2D) on NK cells, resulting in reduced cytotoxicity in women with endometriosis, but neutralization of TGF-β1 reverses the reduction.

WHAT IS KNOWN ALREADY

NK cells are cytotoxic lymphocytes that play an important role in peritoneal immune surveillance, and their function is known to be impaired in women with endometriosis. There is increased platelet aggregation in endometriotic lesions and increased platelet activation rate in the peripheral blood in women with endometriosis, yet activated platelets release copiousTGF-β1, which is known to be a potent immunosuppressive molecule that suppresses NK cell function and NKG2D expression.

STUDY DESIGN, SIZE, DURATION

Cross-sectional clinical studies of 30 women with endometriosis and 33 women without endometriosis and in vitro experimentation with and without TGF-β1 blockade.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Peritoneal fluid (PF) samples from premenopausal women with endometriosis and age- and menstrual phase-matched controls were collected. Platelet count, white blood cell (WBC) count, mean platelet volume (MPV), platelet activation rate, TGF-β1 concentration, expression levels of NKG2D on NK cells in the PF were evaluated. The apoptosis of freshly isolated NK cells treated with PF from women with endometriosis, the NK cytotoxicity and NKG2D expression treated with PF in the presence or absence of an anti-TGF-β1 antibody were also determined.

MAIN RESULTS AND THE ROLE OF CHANCE

The platelet count, WBC count, MPV, platelet activation rate and the TGF-β1 concentration in the PF from women with endometriosis were significantly elevated when compared with those of women without endometriosis. The TGF-β1 concentration correlated positively with the platelet activation rate (r = 0.59, P < 0.01), suggesting that activated platelets are responsible, at least in part, for the increased TGF-β1 concentration. The cytotoxicity of freshly isolated NK cells treated with PF of women with endometriosis is significantly reduced when compared with that of women without endometriosis. Both the platelet activation rate and the TGF-β1 concentration in the PF correlated negatively with the NKG2D expression in NK cells isolated from the PF (r = –0.36, P < 0.01, and r = –0.45, P < 0.01, respectively). In addition, the NKG2D expression level and the cytotoxicity in freshly isolated NK cells were found to be significantly reduced if co-cultured with PF from women with endometriosis, but the TGF-β1 blockade effectively reverses the reduction.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by the cross-sectional nature of the study.

WIDER IMPLICATIONS OF THE FINDINGS

NKG2D is known to potently activate NK cells, so potent that it even overrides inhibitory signals transduced by other inhibitory receptors. This is the first time we demonstrate that platelet-derived TGF-β1 may be responsible for reduced NKG2D expression as well as reduced cytotoxicity of NK cells in women with endometriosis. This study provides yet another piece of evidence that platelets play critical roles in the development of endometriosis, and anti-platelet treatment should improve NK cell functionality in treating endometriosis. Equally important, this study highlights the critical role of the lesion microenvironment in shaping NK cell-mediated anti-endometriotic immunity.

STUDY FUNDING/COMPETING INTERESTS

This research was supported in part by grants 81270676 (S.-W.G.), 81471434 (S.-W.G.), 81530040 (S.-W.G.), and 81370695 (X.L.) from the National Natural Science Foundation of China, and grant 2013ZYJB0019 (X.L.) from Shanghai Municipal Commission of Health and Family Planning. None of the authors has anything to disclose.

Posted on 10 June 2016 | 6:45 am

Self-collected dried blood spots as a tool for measuring ovarian reserve in young female cancer survivors

STUDY QUESTION

Are female young cancer survivors (YCS) able to self-collect high-quality dried blood spots (DBSs) at home to provide biospecimens for studying ovarian reserve?

SUMMARY ANSWER

YCS can self-collect high-quality DBS specimens in non-clinical settings, and anti-Mullerian hormone (AMH) levels can be assayed in such specimens.

WHAT IS KNOWN ALREADY

Large-scale biosample collection is a barrier to studying ovarian reserve in YCS. DBS collected by research personnel has high acceptability. AMH levels measured in DBS are highly correlated with those measured by serum-based methods.

STUDY DESIGN, SIZE, DURATION

In a prospective cohort study, YCS were recruited to self-collect DBS samples. AMH levels were assayed in 112 samples.

PARTICIPANTS/MATERIALS, SETTING, METHODS

YCS participants, ages 18–44, were recruited from a nationwide longitudinal cohort and DBS collection materials were posted to them. AMH levels were assayed by the Ansh DBS AMH ELISA and compared according to participant characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 163 potential participants, 123 (75%) were enrolled. Of those enrolled, 112 (91%) were able to complete DBS self-collection and submit mailed samples adequate for measuring AMH. Participants (mean age 31.6 [SD 5.5]) were 85% white, 87% college graduates and 46% reported higher income. Common cancer types were lymphoma and leukemia (34%), breast cancer (30%) and thyroid or skin cancer (8%). The geometric mean (95% confidence interval) AMH level in DBS samples was 0.24 ng/ml (0.16–0.36). In adjusted analysis, AMH levels for survivors of breast cancer (0.02 ng/ml [0.01–0.07]) or leukemia/lymphoma (0.03 ng/ml [0.01–0.08]) were lower than the levels in thyroid or skin cancer survivors (0.12 ng/ml [0.03–0.44]). Pelvic radiation remained associated with lower AMH levels (0.20 ng/ml [0.10–0.40] in unexposed versus 0.02 ng/ml [0.01–0.06] in exposed). Amenorrheic survivors had AMH levels (0.02 ng/ml [0.01–0.06]) that were lower than those of YCS with 7–9 (0.09 ng/ml [0.03–0.32]) or ≥10 (0.17 ng/ml [0.08–0.37]) menstrual periods in the past year.

LIMITATIONS, REASONS FOR CAUTION

The results are generalizable to a population of highly educated, higher income YCS. It is unclear how generalizable the results are to other populations.

WIDER IMPLICATIONS OF THE FINDINGS

Self-collected DBS is a patient-friendly and minimally invasive tool for studying ovarian reserve in geographically diverse populations.

STUDY FUNDING/COMPETING INTERESTS

Research related to the development of this paper was supported by the National Institutes of Health, grants UL1 RR024926 pilot and HD080952-02, and by the American Cancer Society MRSG-08-110-01-CCE. The authors report no competing interests.

Posted on 10 June 2016 | 6:45 am

A prospective cohort study of endometriosis and subsequent risk of infertility

STUDY QUESTION

Is there a temporal relationship between endometriosis and infertility?

SUMMARY ANSWER

Endometriosis is associated with a higher risk of subsequent infertility, but only among women age <35 years.

WHAT IS KNOWN ALREADY

Endometriosis is the most commonly observed gynecologic pathology among infertile women undergoing laparoscopic examination. Whether endometriosis is a cause of infertility or an incidental discovery during the infertility examination is unknown.

STUDY DESIGN, SIZE, DURATION

This study included data collected from 58 427 married premenopausal female nurses <40 years of age from 1989 to 2005, who are participants of the Nurses' Health Study II prospective cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Our exposure was laparoscopically confirmed endometriosis. Multivariate Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for infertility risk (defined as attempting to conceive for >12 months) among women with and without endometriosis.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified 4612 incident cases of infertility due to any cause over 362 219 person-years of follow-up. Compared with women without a history of endometriosis, women with endometriosis had an age-adjusted 2-fold increased risk of incident infertility (HR = 2.12, 95% CI = 1.76–2.56) that attenuated slightly after accounting for parity. The relationship with endometriosis was only observed among women <35 years of age (multivariate HR <35 years = 1.77, 95% CI = 1.46–2.14; multivariate HR 35–39 years = 1.20, 95% CI = 0.94–1.53; P-interaction = 0.008). Risk of primary versus secondary infertility was similar subsequent to endometriosis diagnosis. Among women with primary infertility, 50% became parous after the endometriosis diagnosis, and among all women with endometriosis, 83% were parous by age 40 years.

LIMITATIONS, REASONS FOR CAUTION

We did not have information on participants' intentions to conceive, but by restricting the analytic population to married women we increased the likelihood that pregnancies were planned (and therefore infertility would be recognized). Women in our cohort with undiagnosed asymptomatic endometriosis will be misclassified as unexposed. However, the small proportion of these women are diluted among the >50 000 women accurately classified as endometriosis-free, minimizing the impact of exposure misclassification on the effect estimates.

WIDER IMPLICATIONS OF THE FINDINGS

This study supports a temporal association between endometriosis and infertility risk. Our prospective analysis indicates a possible detection bias in previous studies, with our findings suggesting that the infertility risk posed by endometriosis is about half the estimates observed in cross-sectional analyses.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the National Institutes of Health (grant numbers: UM1 CA176726, HD52473, HD57210, T32DK007703, T32HD060454, K01DK103720). We have no competing interests to declare.

Posted on 10 June 2016 | 6:45 am

International Committee for Monitoring Assisted Reproductive Technologies world report: Assisted Reproductive Technology 2008, 2009 and 2010

STUDY QUESTION

What were utilization, outcomes and practices in assisted reproductive technology (ART) globally in 2008, 2009 and 2010?

SUMMARY ANSWER

Global utilization and effectiveness remained relatively constant despite marked variations among countries, while the rate of single and frozen embryo transfers (FETs) increased with a concomitant slight reduction in multiple birth rates.

WHAT IS KNOWN ALREADY

ART is widely practised in all regions of the world. Monitoring utilization, an approximation of availability and access, as well as effectiveness and safety is an important component of universal access to reproductive health.

STUDY DESIGN, SIZE, DURATION

This is a retrospective, cross-sectional survey on utilization, effectiveness and safety of ART procedures performed globally from 2008 to 2010.

PARTICIPANTS, SETTING, METHODS

Between 58 and 61 countries submitted data from a total of nearly 2500 ART clinics each year. Aggregate country data were processed and analyzed based on forms and methods developed by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART). Results are presented at country, regional and global level.

MAIN RESULTS AND THE ROLE OF CHANCE

For the years 2008, 2009 and 2010, >4 461 309 ART cycles were initiated, resulting in an estimated 1 144 858 babies born. The number of aspirations increased by 6.4% between 2008 and 2010, while FET cycles increased by 27.6%. Globally, ART utilization remained relatively constant at 436 cycles/million in 2008 and 474 cycles/million population in 2010, but with a wide country range of 8–4775 cycles/million population. ICSI remained constant at around 66% of non-donor aspiration cycles. The IVF/ICSI combined delivery rate (DR) per fresh aspiration was 19.8% in 2008; 19.7% in 2009 and 20.0% in 2010, with corresponding DRs for FET of 18.8, 19.7 and 20.7%. In fresh non-donor cycles, single embryo transfer increased from 25.7% in 2008 to 30.0% in 2010, while the average number of embryos transferred fell from 2.1 to 1.9, again with wide regional variation. The rates of twin deliveries following fresh non-donor transfers were, in 2008, 2009 and 2010, 21.8, 20.5 and 20.4%, respectively, with a corresponding triplet rate of 1.3, 1.0 and 1.1%. Fresh IVF and ICSI carried a perinatal mortality rate per 1000 births of 22.8 (2008), 19.2 (2009) and 21.0 (2010), compared with 15.1, 12.8 and 14.6/1000 births following FET in the same periods of observation. The proportion of women aged 40 years or older undergoing non-donor ART increased from 20.8 to 23.2% from 2008 to 2010.

LIMITATIONS, REASON FOR CAUTION

The data presented are reliant on the quality and completeness of data submitted by individual countries. This report covers approximately two-thirds of the world ART activity.

WIDER IMPLICATIONS OF FINDINGS

The ICMART World Reports provide the most comprehensive global statistical census and review of ART utilization, effectiveness, safety and quality. While ART treatment continues to increase globally, the wide disparities in access to treatment and embryo transfer practices warrant attention by clinicians and policy makers.

STUDY FUNDING/COMPETING INTEREST(S)

The authors declare no conflict of interest and no specific support from any organizations in relation to this manuscript. ICMART acknowledges financial support from the following organizations: American Society for Reproductive Medicine; European Society for Human Reproduction and Embryology; Fertility Society of Australia; Japan Society for Reproductive Medicine; Japan Society of Fertilization and Implantation; Red Latinoamericana de Reproduccion Asistida; Society for Assisted Reproductive Technology; Government of Canada (Research grant), Ferring Pharmaceuticals (Grant unrelated to World Reports).

TRIAL REGISTRATION

not applicable.

Posted on 10 June 2016 | 6:45 am

A randomized controlled, non-inferiority trial of modified natural versus artificial cycle for cryo-thawed embryo transfer

STUDY QUESTION

Are live birth rates (LBRs) after artificial cycle frozen-thawed embryo transfer (AC-FET) non-inferior to LBRs after modified natural cycle frozen-thawed embryo transfer (mNC-FET)?

SUMMARY ANSWER

AC-FET is non-inferior to mNC-FET with regard to LBRs, clinical and ongoing pregnancy rates (OPRs) but AC-FET does result in higher cancellation rates.

WHAT IS ALREADY KNOWN

Pooling prior retrospective studies of AC-FET and mNC-FET results in comparable pregnancy and LBRs. However, these results have not yet been confirmed by a prospective randomized trial.

STUDY DESIGN, SIZE AND DURATION

In this non-inferiority prospective randomized controlled trial (acronym ‘ANTARCTICA’ trial), conducted from February 2009 to April 2014, 1032 patients were included of which 959 were available for analysis. The primary outcome of the study was live birth. Secondary outcomes were clinical and ongoing pregnancy, cycle cancellation and endometrium thickness. A cost-efficiency analysis was performed.

PARTICIPANT/MATERIALS, SETTING, METHODS

This study was conducted in both secondary and tertiary fertility centres in the Netherlands. Patients included in this study had to be 18–40 years old, had to have a regular menstruation cycle between 26 and 35 days and frozen-thawed embryos to be transferred had to derive from one of the first three IVF or IVF–ICSI treatment cycles. Patients with a uterine anomaly, a contraindication for one of the prescribed medications in this study or patients undergoing a donor gamete procedure were excluded from participation. Patients were randomized based on a 1:1 allocation to either one cycle of mNC-FET or AC-FET. All embryos were cryopreserved using a slow-freeze technique.

MAIN RESULTS AND THE ROLE OF CHANCE

LBR after mNC-FET was 11.5% (57/495) versus 8.8% in AC-FET (41/464) resulting in an absolute difference in LBR of –0.027 in favour of mNC-FET (95% confidence interval (CI) –0.065–0.012; P = 0.171). Clinical pregnancy occurred in 94/495 (19.0%) patients in mNC-FET versus 75/464 (16.0%) patients in AC-FET (odds ratio (OR) 0.8, 95% CI 0.6–1.1, P = 0.25). 57/495 (11.5%) mNC-FET resulted in ongoing pregnancy versus 45/464 (9.6%) AC-FET (OR 0.7, 95% CI 0.5–1.1, P = 0.15). 2 test confirmed the lack of superiority. Significantly more cycles were cancelled in AC-FET (124/464 versus 101/495, OR 1.4, 95% CI 1.1–1.9, P = 0.02). The costs of each of the endometrial preparation methods were comparable (617.50 per cycle in NC-FET versus 625.73 per cycle in AC-FET, P = 0.54).

LIMITATIONS, REASONS FOR CAUTION

The minimum of 1150 patients required for adequate statistical power was not achieved. Moreover, LBRs were lower than anticipated in the sample size calculation.

WIDER IMPLICATIONS OF THE FINDINGS

LBRs after AC-FET were not inferior to those achieved by mNC-FET. No significant differences in clinical and OPR were observed. The costs of both treatment approaches were comparable.

STUDY FUNDING/COMPETING INTEREST(S)

An educational grant was received during the conduct of this study. Merck Sharpe Dohme had no influence on the design, execution and analyses of this study. E.R.G. received an education grant by Merck Sharpe Dohme (MSD) during the conduct of the present study. B.J.C. reports grants from MSD during the conduct of the study. A.H. reports grants from MSD and Ferring BV the Netherlands and personal fees from MSD. Grants from ZonMW, the Dutch Organization for Health Research and Development. J.S.E.L. reports grants from Ferring, MSD, Organon, Merck Serono and Schering-Plough during the conduct of the study. F.J.M.B. receives monetary compensation as member of the external advisory board for Merck Serono, consultancy work for Gedeon Richter, educational activities for Ferring BV, research cooperation with Ansh Labs and a strategic cooperation with Roche on automated anti Mullerian hormone assay development. N.S.M. reports receiving monetary compensations for external advisory and speaking work for Ferring BV, MSD, Anecova and Merck Serono during the conduct of the study. All reported competing interests are outside the submitted work. No other relationships or activities that could appear to have influenced the submitted work.

TRIAL REGISTRATION NUMBER

Netherlands trial register, number NTR 1586.

TRIAL REGISTRATION DATE

13 January 2009.

FIRST PATIENT INCLUDED

20 April 2009.

Posted on 10 June 2016 | 6:45 am

Infertility treatment and children's longitudinal growth between birth and 3 years of age

STUDY QUESTION

Does early childhood growth from birth through to 3 years of age differ by mode of conception?

SUMMARY ANSWER

Findings suggest early childhood growth was comparable for children irrespective of infertility treatment, but twins conceived with ovulation induction with or without intrauterine insemination (OI/IUI) were slightly smaller than twins conceived without treatment.

WHAT IS KNOWN ALREADY

Although studies have found that babies conceived with infertility treatment are born lighter and earlier than infants conceived without treatment, little research especially for non-assisted reproductive technology (ART) treatments has focused on their continued growth during early childhood.

STUDY DESIGN, SIZE, DURATION

Upstate KIDS recruited infants born (2008–2010) to resident upstate New York mothers. Infants were sampled based on birth certificate indication of infertility treatment; specifically, for every singleton conceived by infertility treatment, three singletons without infertility treatment were recruited and matched on region of birth. All multiple births irrespective of treatment were also recruited. Children were prospectively followed, returning questionnaires every 4–6 months until 3 years of age. In total, 3905 singletons, 1129 sets of multiples (96% of whom were twins) enrolled into the study. Analyses included 3440 (88%) singletons (969 conceived with treatment; specifically, 433 with ART and 535 with OI/IUI) and 991 (88%) sets of multiples (439 conceived with treatment; specifically 233 with ART and 206 with OI/IUI) with growth data available.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers reported infertility treatment use at baseline and children's height and weight from pediatric visits. Self-reported use of ART was previously verified by linkage with the US Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database. Mixed linear models with cubic splines accounting for age and age–gender interactions were used to estimate mean differences in growth from birth to 3 years by infertility treatment status and adjusting for maternal age, race, education, private insurance, smoking status during pregnancy, maternal pre-pregnancy and paternal body mass indices (BMI).

MAIN RESULTS AND THE ROLE OF CHANCE

Compared with singletons conceived without treatment (n = 2471), singletons conceived by infertility treatment (433 by assisted reproductive technologies (ART), 535 by OI/IUI and 1 unknown specific type) did not differ in growth. Compared with twins not conceived with treatment (n = 1076), twins conceived with OI/IUI (n = 368) weighed slightly less over follow-up (122 g). They were also proportionally smaller for their length (–0.17 weight-for-length z-score units). No differences in mean size over the 3 years were observed for twins conceived by ART, though some evidence of rapid weight gain from birth to 4 months (adjusted OR 1.08; 95% CI: 1.00–1.16) suggestive of catch up growth was observed.

LIMITATIONS, REASONS FOR CAUTION

Participants from upstate New York may not be representative of US infants. Although accounted for in statistical analysis, attrition during follow-up may have limited power to detect small differences.

WIDER IMPLICATIONS OF THE FINDINGS

This study is the first to prospectively track the growth of children conceived with and without infertility treatment in the USA, including a substantial number of twins. Our findings are similar to what was previously observed in the ART literature outside of the states.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts #HHSN275201200005C, #HHSN267200700019C). Authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Posted on 10 June 2016 | 6:45 am

Clinical definition paper on in vitro maturation of human oocytes

In vitro maturation (IVM) of human oocytes is a reproductive technique which has been practiced for 25 years and is gaining popularity. However, the techniques used for IVM differ substantially across clinics and they result in extremely variable pregnancy rates, partially due to some of these differences in protocols. Such differences include the use in some cycles of hCG triggering prior to oocyte retrieval and the use of a few days of gonadotrophin treatment to support moderate follicle growth. Other important factors are patient selection (including those with polycystic ovaries or decreased ovarian reserve), the number of embryos transferred and cleavage-stage embryo or blastocyst transfer. There are also substantial differences of opinion among clinicians regarding IVM and what it implies. Due to the large variation in protocols, a decision was made to write this paper in an attempt to introduce uniformity when comparing treatments and outcomes of IVM. A clinical definition of IVM was developed: The retrieval of oocytes from small and intermediate sized follicles in an ovary before the largest follicle has surpassed 13 mm in mean diameter. The use of short gonadotrophin stimulation should be acknowledged. However, it should be stated that metaphase II oocytes also have the potential to be collected at that time in the cycles associated with either hCG or GnRH agonist priming. Many feel this is not IVM because some mature oocytes are retrieved, therefore, we recommend renaming this procedure either natural cycle IVF or modified natural cycle IVF (if gonadotrophin stimulation is given) with early triggering, combined with IVM. The percentage as well as the absolute number of mature oocytes at retrieval should be indicated. The use of these titles will allow transparency when comparing results of IVM cycles.

Posted on 10 June 2016 | 6:45 am

Santa Claus in the fertility clinic

Posted on 10 June 2016 | 6:45 am