P-698 Pituitary functioning gonadotroph adenomas (FGA)-induced ovarian hyperstimulation syndrome (OHSS): results from tertiary neuroendocrine centres in the UK

Study question

There are no published series of OHSS due to FGA. What FGA features should clinicians look for during OHSS, and what treatments are effective?

Summary answer

FGA tumour size is always >10mm. Other pituitary hormones may be deficient. Surgical resection of FGA is an effective treatment for OHSS.

What is known already

Pituitary adenomas affect 1:1000 adults and are classified as functioning or non-functioning. Non-functioning pituitary adenomas do not secrete hormones, but most commonly stain histologically gonadotroph cells. Functional pituitary adenomas secrete hormones such as prolactin causing prolactinoma. However, it is rare for a pituitary tumour to cause clinical features of excessive gonadotrophins (functioning gonadotroph adenoma; FGA).

Single case reports, but no case series, have been published on the presentation of FGA-induced OHSS in women.

Surgical excision of adenomas has been reported to cause remission of symptoms, though systematic data are lacking owing to rarity of these tumours.

Study design, size, duration

National case series from tertiary neuroendocrine units in England, Wales and Scotland.

Participants/materials, setting, methods

Eight high-volume pituitary endocrine tertiary units within England, Wales and Scotland audited their records for any cases of FGA-induced OHSS; only seven patients have been identified to date. In all cases, there had been no recent exposure to assisted reproductive technologies (ART) or drugs known to induce OHSS including gonadotrophins or selective oestrogen receptor modulators (SERMS).

Main results and the role of chance

Seven cases of FGA were identified with mean age 31.6 years (range 16-48) at diagnosis. Two-of-seven women presented acutely unwell with abdominal pain, distention and palpable mass requiring oophorectomy for ovarian torsion/ruptured ovarian cyst. The remaining five women presented with abdominal pain (n = 2), thyrotoxicosis (n = 1), menstrual irregularities/galactorrhoea (n = 1) and visual disturbances (n = 1). All women experienced intermittent pelvic pain during medical attendance. Pelvic ultrasound demonstrated enlarged multiseptated ovaries (volume ranging 27-442cm3). Ascites was noted in one woman. Six women had visual field defects due to optic chiasm compression on formal assessment. Median FSH was 26.10 u/L (8.3-33), but LH was <2.5 u/L in all cases. Estradiol (E2) far exceeded the reference range in 5/7 women (2990 to > 18000pmol/L);E2 was at the upper limit of normal in the remaining 2/7 women (960-1450pmol/L). Hyperprolactinaemia, hyperthyroidism and other pituitary hormones deficiency were noted in 6/7, 1/7 and 4/7 women respectively. All FGAs were macroadenomas with diameters ranging 16-48mm. Two patients were administered a somatostatin analogue prior to surgery, but FSH, E2 and tumour size did not change. Transsphenoidal surgery was performed in 6/7 women, and always improved symptomatic and biochemical features of OHSS; however, residual FGA tumour was present post-operatively in all cases studied.

Limitations, reasons for caution

It is possible that some ‘non-functioning’ gonadotroph adenomas cause subclinical problems including menstrual irregularity and mild OHSS which were never diagnosed.

We have insufficient data to determine the prognosis for future pregnancy after FGA-induced OHSS.

This study utilised historical case-notes, so some data is missing.

Wider implications of the findings

The ‘spontaneous’ presentation of OHSS may be confusing for clinicians. We report that FGA is an important cause of spontaneous OHSS which has well-defined biochemical and radiological characteristics, which may be treated effectively in the short-to-medium with pituitary surgery. Results of this study may provide greater awareness of FGA-induced OHSS.

Trial registration number

N/A

P-456 Differential distribution of the extracellular matrix components within the human ovarian cortex and remodelling during in vitro culture

Study question

How is the extracellular matrix (ECM) network distributed within the human ovarian cortex, and how does in vitro culture alter its structure?

Summary answer

The ECM composition varies in the different layers of the ovarian cortex and is further remodelled during in vitro culture.

What is known already

The ovarian ECM is the scaffold within which follicles and stromal cells are organised. Its composition and structural properties constantly evolve to accommodate follicle development and expansion. Culturing primordial follicles within ovarian strips enables to reproduce the exact composition and stiffness of the native ECM. Yet, tissue preparation, which involves mechanical loosening, induces modifications in the ECM network and alters cell-cell contact, leading to spontaneous follicle activation. Characterising the native ovarian cortical ECM and its dynamic changes during culture will help decipher its role during folliculogenesis and improve both in vitro activation (IVA) and in vitro growth (IVG) systems.

Study design, size, duration

Fresh ovarian cortical biopsies were obtained from 6 women aged 28–38 years (mean ± SD: 32.7 ± 4.1 years) at elective caesarean section. Biopsies were cut into fragments of ∼4 × 1×0.5 mm and cultured for 0, 2, 4 or 6 days.

Participants/materials, setting, methods

Stromal cell density as well as the percentage of ECM-related protein (collagen, elastin, fibronectin, laminin) positive area in the entire cortex were quantified at each time point using histological and immunohistological analysis. Collagen and elastin contents were further quantified within each layer of the human ovarian cortex, namely the outer cortex, the mid-cortex, and the cortex-medulla junction regions.

Main results and the role of chance

Collagen content of the cortical ECM decreased from 55.5% ± 1.7% positive area at day 0 (D0) to 42.3% ± 1.1% at D6 (p = 0.001), and elastin increased from 1.1% ± 0.2% at D0 to 1.9% ± 0.1% at D6 (p = 0.001). Fibronectin and laminin remained stable. This suggests tissue loosening during culture, in accordance with the decreased stromal cell density from 3.6x106 ± 0.6 to 2.8x106 ± 0.3 cells/mm3 at D2 (p = 0.033) with no subsequent change. Moreover, collagen and elastin distribution were uneven throughout the cortex and during culture. Collagen deposition was maximal at the outer cortex and the lowest at the mid-cortex (69.4% ± 1.6% vs 53.8% ± 1.5% positive area, p < 0.001), and decreased from D0 to D2 (65.2% ± 2.0% vs 60.6% ± 2.2%, p = 0.033) then stabilised. Elastin showed the converse distribution, being most concentrated at the cortex-medulla junction (3.7% ± 0.3% vs 0.9% ± 0.2% in the outer cortex, p < 0.001), and peaked at D6 compared to D0 (3.1% ± 0.3% vs 1.3% ± 0.2%, p < 0.001). These data indicate a distinct phenotype of the ovarian cortical ECM depending on both its region and the culture period. Further characterisation of the differences in ECM architecture is ongoing.

Limitations, reasons for caution

Ovarian cortical biopsies were obtained from pregnant women undergoing caesarean sections. As such, the data obtained may not accurately reflect the ECM distribution of non-pregnant women.

Wider implications of the findings

Clarifying the composition and architecture signature of the ovarian cortical ECM will not only provide a foundation for further exploration of ovarian microenvironments, but also be of importance for understanding of ECM-follicle interactions maintaining the primordial pool and early growth stages leading to improvements in IVA and IVG.

Trial registration number

not applicable

P-424 Endometrial receptivity as determined by Endometrial Receptivity Analysis (ERA) can change after a successful live birth from a frozen embryo transfer (FET)

Study question

Endometrial receptivity as determined by Endometrial Receptivity Analysis (ERA) can change after a successful live birth from a frozen a frozen embryo transfer (FET)

Summary answer

27 of 33 patients with a previous live birth from FET had an altered endometrial receptivity profile by ERA after a subsequent unsuccessful FET.

What is known already

The endometrial window of implantation is approximately 24 hours wide with a complex interaction of autocrine, paracrine, and endocrine factors. Successful embryo implantation involves a 3-step process of apposition, adhesion, and invasion of an embryo into a receptive endometrium. The ERA was developed using the expression profile of 248 genes using Next Generation Sequencing to determine if the endometrium is receptive, early receptive, late receptive, pre-receptive or post-receptive to objectively determine the optimal timing of progesterone exposure prior to embryo transfer. Some studies have shown statistically significant improvements in live birth rates while other studies have shown no difference.

Study design, size, duration

Case series of 33 patients with successful live birth following euploid FET using 5 days of progesterone (P + 5) with subsequent unsuccessful FET using the same protocol from January 2018 – December 2020. 27 of 33 patients who repeated their ERA were found to be non-receptive using P + 5. The new ERA profile results were used for their next FET. Implantation and live birth rates were calculated.

Participants/materials, setting, methods

A single private practice fertility clinic performed 340 ERA cycles from January 2018 – December 2020 with 276 subsequent FET cycles. An observational study of 33 patients with a previous live birth using P + 5 elected to repeat their ERA cycle after an unsuccessful FET. Implantation and live birth rates were calculated for their subsequent FET after completing the repeat ERA.

Main results and the role of chance

Repeat ERA result for patients with a previous live birth using P + 5 revealed that 6 patients still needed P + 5 (18.2%) for a receptive endometrial profile, 8 patients (24.2%) needed an extra 12 hours (P + 5.5), 18 patients (54.5%) needed an extra 24 hours (P + 6) and only one patient (3.0%) needed an extra 48 hours (P + 7). No patient that repeated their ERA after a previous live birth had a post-receptive profile (P + 4 or P + 4.5) and one patient had successful live births after using 3 different ERA profiles (P + 5, P + 6 and P + 7). All patients except one had repeat ERA results that were pre-receptive with only one patient changing from P + 6 to P + 5. FET cycles using P + 5 and P + 7 had a 100% implantation and pregnancy rate, while patients using P + 5.5 had the lowest implantation rate (62.5%) and live birth rate (37.5%). Patients with an ERA profile of P + 6 had an implantation rate of 94.1% and live birth rate of 88.2%. The small number of patients in this case series make a type I error possible because of the low number of patients in each ERA profile category with insufficient power to reach statistical significance.

Limitations, reasons for caution

Implantation rate for the clinic during the study period was 75% and live birth rate of 68% using euploid embryos. Our high baseline implantation and live birth rates, coupled with low numbers of patients in this observational study, make these results less generalizable to the IVF population at large.

Wider implications of the findings

It is widely accepted that ERA results are reproducible and do not change during a woman’s reproductive life. These results suggest that some women may have an altered window of receptivity after both successful and unsuccessful FET cycles. It may be reasonable to repeat ERA cycles for carefully selected patients.

Trial registration number

N/A

Comparing the accuracy of two diagnostic methods for detection of light Schistosoma haematobium infection in an elimination setting in Wolaita Zone, South Western Ethiopia

Reagent urinalysis dipstick and filtration have been recommended diagnostic methods for the detection of urogenital schistosomiasis. However, the accurate diagnosis of light infections using these methods presents a major challenge. This study evaluates the diagnosis accuracy of light infection with Schistosoma haematobium in study participants living in Wolaita Zone, an area targeted for sustainable control of Schistosomiasis, and ultimately interrupt transmission. Urine samples were collected from children and adults in surveys carried out during baseline and longitudinal sentinel site surveys conducted from 2018 to 2020. All urine samples were tested using a reagent urinalysis dipstick test (Haemastix) to detect microhaematuria with reference urine filtration technique as a proxy for S. haematobium infection. Sensitivity and specificity were determined in diagnosing urogenital schistosomiasis. Cohen’s Kappa statistics was done for the agreement of these diagnostic methods. A total of 12,102 participants were enrolled in the current baseline study. Among them, 285 (2.35%) samples tested positive for microhaematuria and 21 (0.20%) positive for S. haematobium eggs. A total of 4,357 samples were examined in year 1 and year 2 using urine dipsticks, and urine filtration 172 (3.95%) and 2 (0.05%) were positive for microhaematuria and S. haematobium eggs. The reagent urinalysis dipsticks showed the highest sensitivity and specificity for diagnosing light intensity of infection,100% (95% CI:85.18–100.00) and 97.4% (95% CI: 97.10–97.60), respectively. There is a slight agreement between the two methods (Kappa = 0.09, 95% CI: 0.01–0.18). The present study revealed very low prevalence and light intensity of S. haematobium infections. The study also highlights that the dipstick test is considered a useful adjunct diagnostic tool for population-based control of urogenital schistosomiasis.

Assessment of the efficacy of clofazimine alone and in combination with primary agents against Mycobacterium tuberculosis in vitro

OBJECTIVES

The chemotherapeutic regimens of drug-susceptible (DS)-tuberculosis (TB) patients comprise four primary anti-TB drugs; rifampicin (RMP), isoniazid (INH), ethambutol (EMB) and pyrazinamide (PZA), administered for six-to-nine months. These drug regimens target the various microbial populations that include actively-replicating (AR), slow-replicating (SR) and non-replicating (NR) organisms. Clofazimine (CFZ) has showed benefit in shortening DS-TB treatment in vivo from six to four months when used in combination with this regimen in murine models of experimental infection. However, its antimicrobial efficacy when used in combination with the primary drugs against the various microbial populations of Mycobacterium tuberculosis has not been demonstrated.

METHODS

In the current in vitro study, the inhibitory and bactericidal activities of CFZ in combination with the primary anti-TB drugs, RMP, INH and EMB against the AR and SR organisms in planktonic and biofilm-forming cultures, respectively, were evaluated by fractional inhibitory concentration index (FICI) and fractional bactericidal concentration index (FBCI) determinations, using the Loewe Additivity Model.

RESULTS

In planktonic cultures, CFZ demonstrated synergistic growth inhibitory activity in combination with RMP and INH individually and collectively. With respect to bactericidal activity, CFZ exhibited synergistic activity only in a two-drug combination with RMP. However, in biofilm-forming cultures, all CFZ-containing anti-TB drug combinations exhibited synergistic inhibitory and bactericidal effects, particularly in combination with RIF and INH.

CONCLUSION

Clofazimine exhibited synergistic effects in combination with primary anti-TB drugs against both planktonic and biofilm-forming cultures, showing potential benefit in augmenting treatment outcome when used during standard TB chemotherapy.

Fate and transport in environmental quality

Changes in pollutant concentrations in environmental media occur both from pollutant transport in water or air and from local processes, such as adsorption, degradation, precipitation, straining, and so on. The terms "fate and transport" and "transport and fate" reflect the coupling of moving with the carrier media and biogeochemical processes describing local transformations or interactions. The Journal of Environmental Quality (JEQ) was one of the first to publish papers on fate and transport (F&T). This paper is a minireview written to commemorate the 50th anniversary of JEQ and show how the research interests, methodology, and public attention have been reflected in fate and transport publications in JEQ during the last 40 years. We report the statistics showing how the representation of different pollutant groups in papers changed with time. Major focus areas have included the effect of solution composition on F&T and concurrent F&T, the role of organic matter, and the relative role of different F&T pathways. The role of temporal and spatial heterogeneity has been studied at different scales. The value of long-term F&T studies and developments in modeling as the F&T research approach was amply demonstrated. Fate and transport studies have been an essential part of conservation measure evaluation and comparison and ecological risk assessment. For 50 years, JEQ has delivered new insights, methods, and applications related to F&T science. The importance of its service to society is recognized, and we look forward to new generations of F&T researchers presenting their contributions in JEQ.

P–720 Prevalence of Female Infertility in the UK Armed Forces

Study question

What is the prevalence of female infertility among UK military personnel and does it differ from the Metropolitan Police Service (MPS) and civilian populations?

Summary answer

Prevalence of self-reported infertility was higher in servicewomen (31.7%) and female MPS officers (36.3%) than in civilian women (24.4%).

What is known already

Arduous employment is associated with numerous potential occupational hazards and behaviours that may be relevant to fertility. These include physical and psychological stress, smoking, alcohol drinking and other lifestyle factors. A preliminarily report in 2016 indicated that UK servicewomen over 30 years of age were more likely to present with fertility problems compared with reported civilian infertility data for age-matched women. Few previous studies have compared infertility prevalence of servicewomen with civilians, and none have compared infertility prevalence with other occupations.

Study design, size, duration

A cross-sectional study was undertaken in 2019 to determine prevalence of infertility. All eligible UK servicewomen (14,650) and MPS officers (8,262) aged 18–60 years were invited to participate with sisters of participants recruited as controls using a snowball technique. Data including pregnancy history, time to each pregnancy and self-reported infertility risk-factors were collected using an online questionnaire. We estimated a sample of 4898 servicewomen would give a precision of 1% around infertility prevalence estimates.

Participants/materials, setting, methods

The questionnaire was developed, piloted and adapted for electronic distribution. The occupational groups were invited by email to complete the questionnaire on three occasions. Prevalence of infertility was defined as the proportion of women at risk of pregnancy who had not become pregnant within 12 months. Only women with pregnancy outcomes, or fully tested for fertility (12 months or more of exposure), were included in the denominator.

Main results and the role of chance

Participants included 4806 (33%) women serving in the UK Armed Forces, 1237 (15%) female MPS officers and 435 (estimated 8%) non-military, non-MPS sisters (biological, half, step or adopted) of both groups. 98.4% of responses were complete. Prevalence of self-reported 12-month infertility was 31.7% (95% CI 29.9–33.5) in servicewomen, 36.3% (95% CI 33.1–39.7) in MPS officers and 24.4% (95% CI 19.6–29.8) in civilian women. Age, history of polycystic ovary syndrome, endometriosis, fibroids, tubal and pelvic surgery, hysterectomy and a short General Health Questionnaire (GHQ 12) score of > 4 (suggesting a minor psychiatric disorder) were associated with infertility and adjusted for in logistic regression models to estimate odds ratios. The adjusted odds ratio (aOR) of infertility in servicewomen was 1.0 (95% CI 0.8–1.2) compared with MPS officers and 1.5 (95% CI 1.1–2.0) in both servicewomen and MPS officers compared with sisters.

Limitations, reasons for caution

The major limitation is the low response rate, particularly in the two control groups, potentially resulting in response bias. Prevalence of infertility could have been further over-estimated if fertile women are more likely to have left the military or MPS. There is scope for residual confounding.

Wider implications of the findings: Further analyses will explore the key risk factors to identify what aspects of these occupations contribute to infertility and which may be modifiable. Future cohort studies would be helpful to extend the understanding of the influence of occupation on infertility.

Trial registration number

Not applicable

P–758 The efficacy, safety and proven security of microSecure vitrification offers “peace of mind” and reliability during a global pandemic

Study question

Under deadly pandemic conditions involving the novel SARS-CoV–2 corona virus, could biopsied blastocysts be safely cryopreserved, stored and utilized for subsequent warming cycles?

Summary answer

Blastocysts were securely stored, effectively warmed and safely transferred to yield normal pregnancy outcomes under uncertain laboratory conditions subject to unprecedented policy changes.

What is known already

By April 2020, every IVF lab worldwide was implementing deep cleaning/disinfecting procedures in their laboratory and patient-contact areas, thorough hand-washing policies and mandatory PPE to reduce the chance of contact transmission and spread of the potentially deadly SARS-CoV–2 coronavirus. Furthermore, we know that safeguards like oil overlay culture dishes and pipetting dilution factors provide insurance against possible contamination. However, knowing that the trophectoderm of blastocysts possessed the ACE–2 binding receptor, potential concern existed regarding the continuation of laser zona opening and biopsy procedures that could possibly expose cryopreserved embryos to the coronavirus in liquid nitrogen storage (vapor or liquid).

Study design, size, duration

Between March 8 and December 22, 2020, 508 patients performed FET cycles involving the use of single (n = 490) or dual (n = 18) euploid microSecure vitrified blastocysts. In this retrospective analysis, we compared clinical pregnancy outcomes to a 5 year dataset (2015–2019) encompassing 2768 single and 272 dual embryo transfer FET cycles. All blastocysts were vitrified using a closed microSecure system and Innovative Cryoenterprise (ICE; NJ, USA) non-DMSO, glycerol-EG solutions. Differences were assessed by Chi-square analysis (p < 0.05).

Participants/materials, setting, methods

Deep cleaning was performed with Simple Green Pro3+ Virucide in non-lab areas (e.g., ET rooms, waiting room) and 6% H2O2 & OoSafe solutions to disinfect lab surfaces and equipment. Group embryo cultures were performed in MCO–5M humidified incubators under low oxygen tri-gas conditions with varying CO2 levels (5.3–6.0%; pH = 7.3–7.35) using 25µl droplets of LifeGlobal medium+7.5%LGPS+1%sodium hyaluronate, before changing to 10µl droplet/GPS dishes post-biopsy. FET cycles involved 4-step sucrose dilutions and transvaginal ultrasound-guided embryo transfers.

Main results and the role of chance

While ICSI fertilization rates were unchanged in 2020 (79.4% 2PN vs 77.3%), blastocyst utilization rates tended to be slightly lower than past years (56.4% vs 59.9%) but within an acceptable range. Of 529 blastocysts warmed, 527 (99.7%) survived completely for transfer, being comparable to the 99.4% experienced over 5 years. Furthermore, there was no differences detected in single embryo transfer pregnancy outcomes. The implantation and ongoing clinical pregnancy/live birth rates were 69% and 66.53% compared to 70.4% and 65.1%, respectively. Under pandemic conditions we did not observe an increase in biochemical pregnancies (10.3%) nor spontaneous miscarriage rates (7.8%). Although it is possible that our rigorous disinfection practices could have attributed to lower blastocyst production, the viability of those embryos was not compromised. Importantly, we were able to feel comfortable performing micromanipulation and cryopreservation procedures throughout the year knowing that we were effectively eliminating possible vertical transmission of coronavirus to an exposed trophectoderm layer in cryostorage by applying mircoSecure vitrification. Post-FET clinical check-ups revealed no patient reporting any fever or other Covid–19 symptoms in the weeks following their transfers. We are fortunate to say that our Lab staff, physicians and patients have remained healthy throughout 2020.

Limitations, reasons for caution

Blastocyst survival and viability are independent of possible viral exposure. Previously, the risk of disease transmission via liquid nitrogen or vapor exposure was considered highly unlikely (Pomeroy et al., 2010), but that was at a time when embryos were primarily zona-enclosed. Today’s ART standards have us re-evaluating safer approaches.

Wider implications of the findings: We have effectively mitigated avoiding performing zona opening procedures by employing our standard practice of aseptic, closed vitrification. In combination with standard preventative measures (PPE, hand hygiene, distance awareness) and routine deep cleaning practices, we sustained a contamination-free environment and healthy patients, capable of sustaining high levels of pregnancy success.

Trial registration number

Not applicable

P–437 The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool

Study question

Does high-dose testosterone therapy affect the stage distribution, morphological health and DNA damage repair capacity of human ovarian follicles and their survival in vitro?

Summary answer

Testosterone exposure is associated with reduced follicle growth activation, reduced follicle health and increased DNA damage: these further deteriorate after six days of culture. What is known already: Androgens have diverse actions within the ovary, however, there is a lack of information regarding the long-term effects of high-dose testosterone on ovarian function and reproductive potential. Cumulus-oocyte complexes recovered from transgender men have been successfully matured in-vitro but little is known regarding the impact of this gender affirming endocrine therapy on the primordial follicle pool. Study design, size, duration: Whole ovaries were obtained from four transgender men aged 25–36 years with informed consent at oophorectomy. All patients had received 1000mg testosterone undecanoate intramuscularly at 12–16 week intervals for a minimum of 4 years pre-operatively. Cortical tissues were dissected into small pieces (≈1x1x0.5mm) and either immediately fixed for histological analysis or cultured for 6 days. Testosterone-treated ovaries were compared to cortical biopsies from age-matched healthy women obtained at caesarean section (n = 4, age 26–36). Participants/materials, setting, methods: Follicle number, classification of developmental stage and morphology were evaluated by histological analysis of ovarian cortical tissue from day 0 and 6 days post culture. Immunohistochemical analysis included γH2AX as a marker of DNA damage, and meiotic recombination 11 (MRE11), ataxia telangiectasia mutated (ATM) and Rad51 as DNA repair proteins. A total of 3802 follicles from testosterone exposed and 878 from control ovaries were analysed. Main results and the role of chance: At day 0 (D0), transgender tissue had a higher proportion of non-growing follicles (92.7±1.7%) compared to control (85.4±6.2%, p &lt; 0.05) but a lower proportion of morphologically healthy follicles (non-growing 59%, primary 61%, secondary 36%; vs 83%, 75%, 80% in controls, all p &lt; 0.005). After 6 days in culture, the proportion of growing follicles increased (51.3% vs 46.5%) but follicle health further declined (all stages p &lt; 0.005).

DNA damage was assessed by expression of γH2AX. At D0, the proportion of oocytes showing DNA damage was significantly higher in transgender non-growing follicles (48.1±12.5%, vs 12.3±0.25%, p &lt; 0.005). After culture, γH2AX expression increased in both transgender (p &lt; 0.005) and controls (p &lt; 0.005) but remained higher in transgender oocytes (non-growing 72.2%, primary 71.7% vs 27.3%, 46.2%, all p &lt; 0.05). At D0, there was no difference in expression of DNA repair enzymes ATM and RAD51 between transgender and control oocytes, and increased expression of MRE11 in control non-growing follicles (p &lt; 0.05). Post-culture, there was a significant increase in ATM expression in transgender non-growing oocytes compared to control (98.5% vs 77.8%, p &lt; 0.05) and a less marked decline in RAD51 expression(p &lt; 0.05). The expression of MRE–11 in control non-growing oocytes dramatically declined (100% to 58.2%, p &lt; 0.05), unlike in transgender tissue where expression was comparable to D0.

Limitations, reasons for caution

A large number of follicles have been analysed, but only from a small number of ovaries. DNA damage at D0 and after 6 days of culture may not reflect DNA damage and repair capacity at later stages of follicle growth. The effect of duration of testosterone treatment was not investigated.

Wider implications of the findings: These data indicate that high circulating concentrations of testosterone have previously unrecognised effects on the primordial and small-growing follicles of the ovary. These results may have implications for transgender men receiving gender-affirming therapy prior to considering pregnancy or fertility preservation measures.

Trial registration number

n/a

P-437 The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool

Study question

Does high-dose testosterone therapy affect the stage distribution, morphological health and DNA damage repair capacity of human ovarian follicles and their survival in vitro?

Summary answer

Testosterone exposure is associated with reduced follicle growth activation, reduced follicle health and increased DNA damage: these further deteriorate after six days of culture. 

What is known already

Androgens have diverse actions within the ovary, however, there is a lack of information regarding the long-term effects of high-dose testosterone on ovarian function and reproductive potential. Cumulus-oocyte complexes recovered from transgender men have been successfully matured in-vitro but little is known regarding the impact of this gender affirming endocrine therapy on the primordial follicle pool

Study design, size, duration

Whole ovaries were obtained from four transgender men aged 25-36 years with informed consent at oophorectomy. All patients had received 1000mg testosterone undecanoate intramuscularly at 12-16 week intervals for a minimum of 4 years pre-operatively. Cortical tissues were dissected into small pieces (≈1x1x0.5mm) and either immediately fixed for histological analysis or cultured for 6 days. Testosterone-treated ovaries were compared to cortical biopsies from age-matched healthy women obtained at caesarean section (n = 4, age 26-36). 

Participants/materials, setting, methods

Follicle number, classification of developmental stage and morphology were evaluated by histological analysis of ovarian cortical tissue from day 0 and 6 days post culture. Immunohistochemical analysis included γH2AX as a marker of DNA damage, and meiotic recombination 11 (MRE11), ataxia telangiectasia mutated (ATM) and Rad51 as DNA repair proteins. A total of 3802 follicles from testosterone exposed and 878 from control ovaries were analysed. 

Main results and the role of chance

At day 0 (D0), transgender tissue had a higher proportion of non-growing follicles (92.7±1.7%) compared to control (85.4±6.2%, p &lt; 0.05) but a lower proportion of morphologically healthy follicles (non-growing 59%, primary 61%, secondary 36%; vs 83%, 75%, 80% in controls, all p &lt; 0.005). After 6 days in culture, the proportion of growing follicles increased (51.3% vs 46.5%) but follicle health further declined (all stages p &lt; 0.005).

DNA damage was assessed by expression of γH2AX. At D0, the proportion of oocytes showing DNA damage was significantly higher in transgender non-growing follicles (48.1±12.5%, vs 12.3±0.25%, p &lt; 0.005). After culture, γH2AX expression increased in both transgender (p &lt; 0.005) and controls (p &lt; 0.005) but remained higher in transgender oocytes (non-growing 72.2%, primary 71.7% vs 27.3%, 46.2%, all p &lt; 0.05). 

At D0, there was no difference in expression of DNA repair enzymes ATM and RAD51 between transgender and control oocytes, and increased expression of MRE11 in control non-growing follicles (p &lt; 0.05). Post-culture, there was a significant increase in ATM expression in transgender non-growing oocytes compared to control (98.5% vs 77.8%, p &lt; 0.05) and a less marked decline in RAD51 expression(p &lt; 0.05). The expression of MRE-11 in control non-growing oocytes dramatically declined (100% to 58.2%, p &lt; 0.05), unlike in transgender tissue where expression was comparable to D0.

Limitations, reasons for caution

A large number of follicles have been analysed, but only from a small number of ovaries. DNA damage at D0 and after 6 days of culture may not reflect DNA damage and repair capacity at later stages of follicle growth. The effect of duration of testosterone treatment was not investigated.

Wider implications of the findings

These data indicate that high circulating concentrations of testosterone have previously unrecognised effects on the primordial and small-growing follicles of the ovary. These results may have implications for transgender men receiving gender-affirming therapy prior to considering pregnancy or fertility preservation measures. 

Trial registration number

n/a

A comparison of porewater chemistry between intact, afforested and restored raised and blanket bogs

Afforestation is a significant cause of global peatland degradation. In some regions, afforested bogs are now undergoing clear-felling and restoration, often known as forest-to-bog restoration. We studied differences in water-table depth (WTD) and porewater chemistry between intact, afforested, and restored bogs at a raised bog and blanket bog location. Solute concentrations and principal component analysis suggested that water-table drawdown and higher electrical conductivity (EC) and ammonium (NH₄-N) concentrations were associated with afforestation. In contrast, higher dissolved organic carbon (DOC) and phosphate (PO₄-P) concentrations were associated with deforestation. Drying-rewetting cycles influenced seasonal variability in solute concentrations, particularly in shallower porewater at the raised bog location. WTD was significantly deeper in the oldest raised bog restoration site (~9 years post-restoration) than the intact bog (mean difference = 6.2 cm). However, WTD in the oldest blanket bog restoration site (~17 years post-restoration), where furrows had been blocked, was comparable to the intact bog (mean difference = 1.2 cm). When averaged for all porewater depths, NH₄-N concentrations were significantly higher in the afforested than the intact sites (mean difference = 0.77 mg L^-1) whereas significant differences between the oldest restoration sites and the intact sites included higher PO₄-P (mean difference = 70 μg L^-1) in the raised bog and higher DOC (mean difference = 5.6 mg L^-1), EC (mean difference = 19 μS cm^-1) and lower SUVA₂₅₄ (mean difference = 0.13 L mg^-1 m^-1) in the blanket bog. Results indicate felled waste (brash) may be a significant source of soluble C and PO₄-P. Mean porewater PO₄-P concentrations were between two and five times higher in furrows and drains in which brash had accumulated compared to other locations in the same sites where brash had not accumulated. Creating and maintaining brash-free buffer zones may therefore minimise freshwater impacts.

Soil-transmitted helminths and schistosome infections in Ethiopia: a systematic review of progress in their control over the past 20 years

Background

Ethiopia has set the ambitious national targets of eliminating soil-transmitted helminths (STH) and schistosomiasis (SCH) as public health problems by 2020, and breaking their transmission by 2025. This systematic review was performed to provide insight into the progress made by the national STH and SCH control programme purposed with reaching these targets.

Methods

Studies published on STH and SCH in Ethiopia were searched for using Web of Science, PubMed, Scopus, and the resulting references of selected studies. Prevalence and intensity were analysed, stratified by region, age, and diagnostics.

Results

A total of 231 papers published between 2000 and 2020 were included. Over the past two decades, Trichuris trichiura (TT) infection has shown the most statistically significant decrease (93%, p < 0.0001), followed by Schistosoma mansoni (SM) (69%, p < 0.0001), Ascaris lumbricoides (AL) (67%, p < 0.0001) and Schistosoma haematobium (83%, p = 0.038) infections. Geographically, parasite burden has only consistently shown a significant reduction in the Southern Nations, Nationalities and Peoples’ Region of Ethiopia, where AL, TT, hookworm and SM significantly decreased by 80% (p = 0.006), 95% (p = 0.005), 98% (p = 0.009) and 87% (p = 0.031), respectively. Prevalence of STH was highest among adults across all species, contrary to typical age-infection profiles for TT and AL that peak among school-aged children. Expanding treatment to the whole community would target reservoirs of adult and preschool-aged infection within the community, assisting Ethiopia in reaching their national transmission break targets. There was substantial heterogeneity in diagnostic methods used across studies, the majority of which predominantly used single-slide Kato–Katz. This low slide frequency provides poor diagnostic sensitivity, particularly in low endemic settings.

Conclusion

The prevalence of STH and SCH in Ethiopia has decreased over time due to the strategic use of anthelmintics. Both standardising and increasing the sensitivity of the diagnostics used, alongside the ubiquitous use of parasite intensity with prevalence, would enable a more accurate and comparable understanding of Ethiopia’s epidemiological progress. Further work is needed on community-wide surveillance in order to understand the burden and subsequent need for treatment among those outside of the standard school-based control program.

Supportive care in patients with cancer during the COVID-19 pandemic

Cancer care has been profoundly impacted by the global pandemic of severe acute respiratory syndrome coronavirus 2 disease (coronavirus disease 2019, COVID-19), resulting in unprecedented challenges. Supportive care is an essential component of cancer treatment, seeking to prevent and manage chemotherapy complications such as febrile neutropenia, anaemia, thrombocytopenia/bleeding, thromboembolic events and nausea/vomiting, all of which are common causes of hospitalisation. These adverse events are an essential consideration under routine patient management, but particularly so during a pandemic, a setting in which clinicians aim to minimise patients' risk of infection and need for hospital visits. Professional medical oncology societies have been providing updated guidelines to support health care professionals with the management, treatment and supportive care needs of their patients with cancer under the threat of COVID-19. This paper aims to review the recommendations made by the most prominent medical oncology societies for devising and modifying supportive care strategies during the pandemic.

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Cancer care has been profoundly impacted by the global pandemic of COVID-19, resulting in unprecedented challenges.

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Oncology societies have updated guidelines for the supportive care needs of patients with cancer under the threat of COVID-19.

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This paper reviews recommendations from prominent oncology societies for providing supportive care during the pandemic.

Molecular evidence of hybridization between pig and human Ascaris indicates an interbred species complex infecting humans

Human ascariasis is a major neglected tropical disease caused by the nematode Ascaris lumbricoides. We report a 296 megabase (Mb) reference-quality genome comprised of 17,902 protein-coding genes derived from a single, representative Ascaris worm. An additional 68 worms were collected from 60 human hosts in Kenyan villages where pig husbandry is rare. Notably, the majority of these worms (63/68) possessed mitochondrial genomes that clustered closer to the pig parasite Ascaris suum than to A. lumbricoides. Comparative phylogenomic analyses identified over 11 million nuclear-encoded SNPs but just two distinct genetic types that had recombined across the genomes analyzed. The nuclear genomes had extensive heterozygosity, and all samples existed as genetic mosaics with either A. suum-like or A. lumbricoides-like inheritance patterns supporting a highly interbred Ascaris species genetic complex. As no barriers appear to exist for anthroponotic transmission of these 'hybrid' worms, a one-health approach to control the spread of human ascariasis will be necessary.

Clinical summary guide: reproduction in women with previous abdominopelvic radiotherapy or total body irradiation

STUDY QUESTION

What is the evidence to guide the management of women who wish to conceive following abdominopelvic radiotherapy (AP RT) or total body irradiation (TBI)?

SUMMARY ANSWER

Pregnancy is possible, even following higher doses of post-pubertal uterine radiation exposure; however, it is associated with adverse reproductive sequelae and pregnancies must be managed in a high-risk obstetric unit.

WHAT IS KNOWN ALREADY

In addition to primary ovarian insufficiency, female survivors who are treated with AP RT and TBI are at risk of damage to the uterus. This may impact on its function and manifest as adverse reproductive sequelae.

STUDY DESIGN SIZE DURATION

A review of the literature was carried out and a multidisciplinary working group provided expert opinion regarding assessment of the uterus and obstetric management.

PARTICIPANTS/MATERIALS SETTING METHODS

Reproductive outcomes for postpubertal women with uterine radiation exposure in the form of AP RT or TBI were reviewed. This included Pubmed listed peer-reviewed publications from 1990 to 2019, and limited to English language..

MAIN RESULTS AND THE ROLE OF CHANCE

The prepubertal uterus is much more vulnerable to the effects of radiation than after puberty. Almost all available information about the impact of radiation on the uterus comes from studies of radiation exposure during childhood or adolescence.An uncomplicated pregnancy is possible, even with doses as high as 54 Gy. Therefore, tumour treatment doses alone cannot at present be used to accurately predict uterine damage.

LIMITATIONS REASONS FOR CAUTION

Much of the data cannot be readily extrapolated to adult women who have had uterine radiation and the publications concerning adult women treated with AP RT are largely limited to case reports.

WIDER IMPLICATIONS OF THE FINDINGS

This analysis offers clinical guidance and assists with patient counselling. It is important to include patients who have undergone AP RT or TBI in prospective studies to provide further evidence regarding uterine function, pregnancy outcomes and correlation of imaging with clinical outcomes.

STUDY FUNDING/COMPETING INTERESTS

This study received no funding and there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Brief review: Cardiac complications and platelet activation in COVID-19 infection

COVID-19 pneumonia, much like that of bacterial and viral community-acquired pneumonia before it, is accompanied by a high rate of cardio- and cerebrovascular events that are associated with an increased risk of complications and a greater mortality. Although the mechanisms underlying the pathogenesis of these adverse events are not entirely clear and may be multifactorial, platelets appear to have a prominent aetiologic role and this, together with an overview of the clinical evidence, forms the basis of this short review.