1
|
Wang J, Li L, Zhou J, Pan X, Qi Q, Sun H, Wang L. Yishen Huatan Huoxue decoction and quercetin ameliorate decidualization dysfunction in polycystic ovary syndrome: A comprehensive investigation combining clinical trial and experimental studies. Drug Discov Ther 2024; 18:117-129. [PMID: 38644207 DOI: 10.5582/ddt.2024.01003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Polycystic ovary syndrome (PCOS) is a common gynecological endocrine disorder characterized by a complex pathogenesis and limited treatment options. Yishen Huatan and Huoxue decoction (YHHD), as a traditional Chinese Medicine formula, has shown effectiveness in treating PCOS. However, the specific mechanisms by which YHHD exerts its therapeutic effects remain unclear. In this study, we performed to investigate the therapeutic effects of YHHD and quercetin on dehydroepiandrosterone-induced PCOS mice, and examine the effect of quercetin on the decidualization of T-HESCs under hyperinsulinemic conditions. The results showed that YHHD could reduce early miscarriage rates in PCOS patients and significantly improved glucose metabolism disorders, sex hormone levels, and the estrous cycles in PCOS mice. Quercetin could alleviate effect of high insulin levels and restore the low expression of insulin receptor substrate1/2 (IRS1/2) and glucose transporte 4 (GLUT4) in T-HESCs, demonstrating its potential to mitigate hyperinsulin-induced decidualization dysfunction via the GLUT4 signaling pathway mediated by IRS1/2. This study provides valuable molecular insights of YHHD and highlight the therapeutic potential of quercetin in treating decidualization dysfunction in PCOS.
Collapse
Affiliation(s)
- Jing Wang
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Lisha Li
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Jing Zhou
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Xinyao Pan
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Qing Qi
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Hongmei Sun
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Ling Wang
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| |
Collapse
|
2
|
Katalinic A, Noftz MR, Garcia-Velasco JA, Shulman LP, van den Anker JN, Strauss III JF. No additional risk of congenital anomalies after first-trimester dydrogesterone use: a systematic review and meta-analysis. Hum Reprod Open 2024; 2024:hoae004. [PMID: 38344249 PMCID: PMC10859181 DOI: 10.1093/hropen/hoae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/23/2023] [Indexed: 05/25/2024] Open
Abstract
STUDY QUESTION Is exposure to dydrogesterone a risk factor for congenital anomalies when given in the first trimester for recurrent/threatened pregnancy loss or as luteal support in assisted reproductive technology (ART)? SUMMARY ANSWER Dydrogesterone, when given in the first trimester for recurrent/threatened pregnancy loss or as luteal support in ART, is not a relevant additional risk factor for congenital anomalies. WHAT IS KNOWN ALREADY Despite large clinical trials and meta-analyses that show no association between dydrogesterone and congenital anomalies, some recently retracted publications have postulated an association with teratogenicity. Dydrogesterone is also often rated as less safe than bioidentical progestins. STUDY DESIGN SIZE DURATION A systematic review was conducted according to a pre-specified protocol with searches on Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov. The search was limited to human studies, with no restrictions on language, geographical region, or date. The search algorithm used a PICO (Population, Intervention, Comparison, Outcome)-style approach combining both simple search terms and medical subject heading terms. As congenital anomalies are mostly reported as secondary outcomes, the search term 'safety' was added. PARTICIPANTS/MATERIALS SETTING METHODS Interventional study and observational study (OS) designs were eligible for inclusion. Inclusion criteria were: women >17 years old treated for threatened miscarriage, recurrent pregnancy loss, and/or ART; the use of dydrogesterone in the first trimester compared with placebo, no treatment or other interventions; and reporting of congenital anomalies in newborns or infants ≤12 months old (primary outcome). Two authors (A.K., M.R.N.) independently extracted the following data: general study information, study population details, intervention and comparator(s), and frequencies of congenital anomalies (classification, time of determination, and type). Risk of bias focused on the reporting of congenital malformations and was assessed using the Cochrane Risk of Bias Tool Version 2 or the ROBINS-I tool. The GRADEproGDT platform was used to generate the GRADE summary of findings table. MAIN RESULTS AND THE ROLE OF CHANCE Of the 897 records retrieved during the literature search, 47 were assessed for eligibility. Nine studies were included in the final analysis: six randomized controlled trials (RCTs) and three OSs. Among the RCTs, three had a low risk and three a high risk of bias. Two of the OSs were considered to have a serious risk of bias and one with critical risk of bias and was excluded for the evidence syntheses. The eight remaining studies included a total of 5070 participants and 2680 live births from 16 countries. In the meta-analysis of RCTs only, the overall risk ratio (RR) was 0.92 [95% CI 0.55; 1.55] with low certainty. When the two OSs were included, the overall RR was 1.11 [95% CI 0.73; 1.68] with low certainty. LIMITATIONS REASONS FOR CAUTION The studies included in the analysis do not report congenital anomalies as the primary outcome; reporting of congenital anomalies was often not standardized. WIDER IMPLICATIONS OF THE FINDINGS This systematic literature review and meta-analysis provide clear reassurance to both clinicians and patients that dydrogesterone is not associated with congenital anomalies above the rate that might be expected due to environmental and genetic factors. The results of this work represent the highest current level of evidence for the question of congenital anomalies, which removes the existing uncertainty caused by poor quality and retracted studies. STUDY FUNDING/COMPETING INTERESTS Editorial support was provided by Highfield Communication Consultancy, Oxford, UK, sponsored by Abbott Products Operations AG, Allschwil, Switzerland. A.K., J.A.G.-V., L.P.S., J.N.v.d.A., and J.F.S. received honoraria from Abbott for preparation and participation in an advisory board. J.A.G.-V. received grants and lecture fees from Merck, Organon, Ferring, Gedeon Richter, and Theramex. M.R.N. has no conflicts of interest. J.N.v.d.A. and J.A.G.-V. have no other conflicts of interest. A.K. received payment from Abbott for a talk at the IVF Worldwide congress on 22 September 2023. J.F.S. has received grants from the National Institutes of Health, royalties/licences from Elsevier and Prescient Medicine (SOLVD Health), consulting fees from Burroughs Wellcome Fund (BWF) and Bayer, honoraria from Magee Women's Research Institute, Wisconsin National Primate Research Centre, University of Kansas and Oakridge National Research Laboratory, Agile, Daiichi Sankyo/American Regent, and Bayer, and travel support to attend meetings for the International Academy of Human Reproduction (IAHR). J.F.S. has patents related to diagnosis and treatment of PCOS and prediction of preterm birth. J.F.S. participates on advisory boards for SOLVD Health, Wisconsin National Primate Research Centre, and FHI360, was the past President board member of the Society for Reproductive Investigation, has a leadership role for the following organizations: Scientific Advisory Board, SOLVD Health, EAB Chair for contraceptive technology initiative, FHI360, EAB member, Wisconsin National Primate Research Centre, Advisory Board for MWRI Summit, Chair of BWF NextGen Pregnancy Research Panel, Medical Executive Committee at the Howard, and Georgeanna Jones Foundation, and is Vice President, IAHR. L.P.S. has received consulting fees from Shield Pharmaceuticals, Scynexis, Organon, Natera, Celula China, AiVF, Agile, Daiichi Sankyo, American Regent, and Medicem, honoraria from Agile, Daiichi Sankyo/American Regent, and Bayer, and travel support from BD Diagnostics. L.P.S. participates on the data safety monitoring board for Astellas and is a Chair of DSMB for fezolinetant. Abbott played no role in the funding of the study or in study design, data collection, data analysis, data interpretation, or writing of the report. TRIAL REGISTRATION NUMBER PROSPERO 2022 CRD42022356977.
Collapse
Affiliation(s)
- Alexander Katalinic
- Institute for Social Medicine and Epidemiology, University of Luebeck, Luebeck, Germany
| | - Maria R Noftz
- Institute for Social Medicine and Epidemiology, University of Luebeck, Luebeck, Germany
| | - Juan A Garcia-Velasco
- IVI RMA Global Research Alliance, Madrid, Spain
- Department of Obstetrics and Gynaecology, Rey Juan Carlos University, Madrid, Spain
| | - Lee P Shulman
- Division of Clinical Genetics, Department of Obstetrics & Gynecology, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children’s National Hospital, Washington, DC, USA
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children’s Hospital Basel, Basel, Switzerland
| | - Jerome F Strauss III
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
3
|
Patki A. Role of Dydrogesterone for Luteal Phase Support in Assisted Reproduction. Reprod Sci 2024; 31:17-29. [PMID: 37488405 DOI: 10.1007/s43032-023-01302-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
Clinical outcomes of in vitro fertilization (IVF) have significantly improved over the years with the advent of the frozen-thawed embryo transfer (FET) technique. Ovarian hyperstimulation during IVF cycles causes luteal phase deficiency, a condition of insufficient progesterone. Intramuscular or vaginal progesterone and dydrogesterone are commonly used for luteal phase support in FET. Oral dydrogesterone has a higher bioavailability than progesterone and has high specificity for progesterone receptors. Though micronized vaginal progesterone has been the preferred option, recent data suggest that oral dydrogesterone might be an alternative therapeutic option for luteal phase support to improve clinical outcomes of IVF cycles. Dydrogesterone has a good safety profile and is well tolerated. Its efficacy has been evaluated in several clinical studies and demonstrated to be non-inferior to micronized vaginal progesterone in large-scale clinical trials. Oral dydrogesterone may potentially become a preferred drug for luteal phase support in millions of women undergoing IVF.
Collapse
Affiliation(s)
- Ameet Patki
- Fertility Associates Khar, 4Th Floor, Gupte House, 81 SV Road, Khar West, Mumbai, 400052, Maharashtra, India.
- Hinduja Group of Hospitals, Khar West, Mumbai, India.
- Surya Hospital Mumbai, Mumbai, India.
| |
Collapse
|
4
|
Tetruashvili N, Domar A, Bashiri A. Prevention of Pregnancy Loss: Combining Progestogen Treatment and Psychological Support. J Clin Med 2023; 12:jcm12051827. [PMID: 36902614 PMCID: PMC10003391 DOI: 10.3390/jcm12051827] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/26/2023] [Accepted: 02/19/2023] [Indexed: 03/03/2023] Open
Abstract
Pregnancy loss can be defined as a loss before either 20 or 24 weeks of gestation (based on the first day of the last menstrual period) or the loss of an embryo or fetus less than 400 g in weight if the gestation age is unknown. Approximately 23 million pregnancy losses occur worldwide every year, equating to 15-20% of all clinically recognized pregnancies. A pregnancy loss is usually associated with physical consequences, such as early pregnancy bleeding ranging in severity from spotting to hemorrhage. However, it can also be associated with profound psychological distress, which can be felt by both partners and may include feelings of denial, shock, anxiety, depression, post-traumatic stress disorder, and suicide. Progesterone plays a key part in the maintenance of a pregnancy, and progesterone supplementation has been assessed as a preventative measure in patients at increased risk of experiencing a pregnancy loss. The primary objective of this piece is to assess the evidence for various progestogen formulations in the treatment of threatened and recurrent pregnancy loss, postulating that an optimal treatment plan would preferably include a validated psychological support tool as an adjunct to appropriate pharmacological treatment.
Collapse
Affiliation(s)
- Nana Tetruashvili
- V.I. Kulakov Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117977 Moscow, Russia
| | - Alice Domar
- Inception Fertility, Houston, TX 77081, USA
- Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA 02115, USA
| | - Asher Bashiri
- Faculty of Health Science, Ben-Gurion University of the Negev, Be’er-Sheva 84101, Israel
- Maternity C Ward & Recurrent Pregnancy Loss Prevention Clinic, Maternal Fetal Medicine and Ultrasound, Soroka University Medical Center, Be’er-Sheva 84101, Israel
- Correspondence: ; Tel.: +972-08-6400842
| |
Collapse
|
5
|
Zou W, Xie S, Liang C, Xie D, Fang J, Ouyang B, Sun L, Wang H. Medication use during pregnancy and birth defects in Hunan province, China, during 2016-2019: A cross-sectional study. Medicine (Baltimore) 2022; 101:e30907. [PMID: 36221426 PMCID: PMC9542665 DOI: 10.1097/md.0000000000030907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Safety of drug use during pregnancy attracts attentions from clinicians, pregnant woman, and even the total society. However, the studies about medication use during pregnancy and the followed birth defects (BDs) are rare in Chinese. To study condition about medication use during pregnancy and the followed BDs in Hunan province of China, here a cross-sectional study was carried out. All women using medication during pregnancy and delivering fetuses with BDs in Hunan province, China, during 2016 to 2019 were employed in this study. The descriptive analysis was carried out with Excel 2010, and the data analyses were performed by using Chi-Squared test in SPSS 16.0. After filtering, a total of 752 cases were included. In these fetuses, the males are more than females (P < .05). The severe BDs, leading to death or uncorrectable lifelong deformity, were observed for 346 times, and the other (minor) BDs were observed for 593 times. The most used drugs, categorized into pregnancy C, D, or X degrees by food and drug administration (FDA) or pharmaceutical manufacturers, mainly included anti-hyperthyroidism drugs, anti-epilepsy drugs, preventing miscarriage drugs, etc. This population-based data highlight the potential high risks for BDs from the aspect of drug use during pregnancy in Hunan province of China, and drugs with more safety, less kinds, and lower doses should be the better choice for pregnant women.
Collapse
Affiliation(s)
- Wei Zou
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
- *Correspondence: Hua Wang, Hunan Provincial Maternal and Child Health Care Hospital, 53 Xiangchun Road, Changsha, Hunan 410008, PR China (e-mail: )
| | - Shuting Xie
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
| | - Changbiao Liang
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
| | - Donghua Xie
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
| | - Junqun Fang
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
| | - Bo Ouyang
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
| | - Li Sun
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
| | - Hua Wang
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, PR China
- *Correspondence: Hua Wang, Hunan Provincial Maternal and Child Health Care Hospital, 53 Xiangchun Road, Changsha, Hunan 410008, PR China (e-mail: )
| |
Collapse
|
6
|
Effects of Dydrogesterone Tablets Combined with Zishen Yutai Pills on Threatened Abortion in Early Pregnancy and Pregnancy Outcomes. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4593637. [PMID: 35903438 PMCID: PMC9325344 DOI: 10.1155/2022/4593637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the effect of dydrogesterone tablets combined with Zishen Yutai pills on threatened abortion in early pregnancy and pregnancy outcomes. Methods This study retrospectively analyzed the clinical data of 100 patients with threatened abortion in early pregnancy who came to the Linhai Second People's Hospital/Taizhou Municipal Hospital from January 13, 2021, to January 13, 2022. According to different treatment methods, 48 patients treated with progesterone injection were assigned to the control group (CG), while 52 cases with the combined therapy of dydrogesterone tablets and Zishen Yutai pills were assigned to the observation group (OG). The two groups were compared in terms of the following parameters: treatment efficacy, whole blood high shear viscosity, hematocrit (HCT), plasma fibrinogen (FIB) level, spiral artery pulsatility index (PI), uterine spiral artery blood flow resistance index (RI), lumbar and abdominal pain relief time, hemostasis time, estrogen levels, pregnancy outcomes, neonatal adverse outcomes, and incidence of adverse reactions. Results Compared with CG, the therapeutic effect in OG was observed to be evidently better, and its pain relief time and hemostasis time in the waist and abdomen were markedly shorter. After treatment, the whole blood high shear viscosity, FIB, RI, PI, and estrogen levels of both groups improved statistically compared with those before treatment, with more significant improvements in OG compared with CG. OG was also superior to CG with markedly lower incidence of preterm birth, miscarriage, neonatal adverse outcomes, and adverse reactions and a drastically higher full-term pregnancy rate. Conclusion Zishen Yutai pill combined with dydrogesterone tablets is of remarkable therapeutic effect in treatment of early threatened abortion, which can significantly improve clinical symptoms and pregnancy outcomes of patients, with a high safety profile, which is worthy of clinical application.
Collapse
|
7
|
A critical appraisal of safety data of dydrogesterone for the support of early pregnancy: a scoping review and meta-analysis. Reprod Biomed Online 2022; 45:365-373. [DOI: 10.1016/j.rbmo.2022.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 11/23/2022]
|
8
|
Wu H, Zhang S, Lin X, He J, Wang S, Zhou P. Pregnancy-related complications and perinatal outcomes following progesterone supplementation before 20 weeks of pregnancy in spontaneously achieved singleton pregnancies: a systematic review and meta-analysis. Reprod Biol Endocrinol 2021; 19:165. [PMID: 34732210 PMCID: PMC8567546 DOI: 10.1186/s12958-021-00846-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Progesterone supplementation is widely performed in women with threatened miscarriage or a history of recurrent miscarriage; however, the effects of early progesterone supplementation on pregnancy-related complications and perinatal outcomes in later gestational weeks remain unknown. METHODS Ovid MEDLINE, the Cochrane Library, Embase and ClinicalTrials.gov were searched until April 3rd, 2021. Randomized controlled trials regarding spontaneously achieved singleton pregnancies who were treated with progestogen before 20 weeks of pregnancy and were compared with those women in unexposed control groups were selected for inclusion. We performed pairwise meta-analyses with the random-effects model. The risk of bias was assessed according to the Cochrane Collaboration tool. The primary outcomes included preeclampsia (PE), and gestational diabetes mellitus (GDM), with the results presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We identified nine eligible studies involving 6439 participants. The pooled OR of subsequent PE following early progestogen supplementation was 0.64 (95% CI 0.42-0.98, moderate quality of evidence). A lower OR for PE was observed in the progestogen group when the subgroup analysis was performed in the vaginal subgroup (OR 0.62, 95%CI 0.40-0.96). There was insufficient evidence of a difference in the rate of GDM between pregnant women with early progestogen supplementation and unexposed pregnant women (OR 1.02, 95% CI 0.79-1.32, low quality of evidence). The pooled OR of low birth weight (LBW) following oral dydrogesterone was 0.57 (95% CI 0.34-0.95, moderate quality of evidence). The results were affected by a single study and the total sample size of enrolled women did not reach the required information size. CONCLUSION Use of vaginal micronized progesterone (Utrogestan) in spontaneously achieved singleton pregnancies with threatened miscarriage before 20 weeks of pregnancy may reduce the risk of PE in later gestational weeks. Among spontaneously achieved singleton pregnancies with threatened miscarriage or a history of recurrent miscarriage, use of oral dydrogesterone before 20 weeks of pregnancy may result in a lower risk of LBW in later gestational weeks. However, the available data were not sufficient to reach definitive conclusions, which highlighted the need for future studies.
Collapse
Affiliation(s)
- Hanglin Wu
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, No. 369 Kun Peng Road, Hangzhou, 310008, Zhejiang, China
| | - Songying Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Xiaona Lin
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Jing He
- Department of Obstetrics and Gynaecology, Hangzhou Women's Hospital, No. 369 Kun Peng Road, Hangzhou, 310008, Zhejiang, China
| | - Shasha Wang
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Ping Zhou
- Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China.
| |
Collapse
|
9
|
Coomarasamy A, Harb HM, Devall AJ, Cheed V, Roberts TE, Goranitis I, Ogwulu CB, Williams HM, Gallos ID, Eapen A, Daniels JP, Ahmed A, Bender-Atik R, Bhatia K, Bottomley C, Brewin J, Choudhary M, Crosfill F, Deb S, Duncan WC, Ewer A, Hinshaw K, Holland T, Izzat F, Johns J, Lumsden MA, Manda P, Norman JE, Nunes N, Overton CE, Kriedt K, Quenby S, Rao S, Ross J, Shahid A, Underwood M, Vaithilingham N, Watkins L, Wykes C, Horne AW, Jurkovic D, Middleton LJ. Progesterone to prevent miscarriage in women with early pregnancy bleeding: the PRISM RCT. Health Technol Assess 2021; 24:1-70. [PMID: 32609084 DOI: 10.3310/hta24330] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Progesterone is essential for a healthy pregnancy. Several small trials have suggested that progesterone therapy may rescue a pregnancy in women with early pregnancy bleeding, which is a symptom that is strongly associated with miscarriage. OBJECTIVES (1) To assess the effects of vaginal micronised progesterone in women with vaginal bleeding in the first 12 weeks of pregnancy. (2) To evaluate the cost-effectiveness of progesterone in women with early pregnancy bleeding. DESIGN A multicentre, double-blind, placebo-controlled, randomised trial of progesterone in women with early pregnancy vaginal bleeding. SETTING A total of 48 hospitals in the UK. PARTICIPANTS Women aged 16-39 years with early pregnancy bleeding. INTERVENTIONS Women aged 16-39 years were randomly assigned to receive twice-daily vaginal suppositories containing either 400 mg of progesterone or a matched placebo from presentation to 16 weeks of gestation. MAIN OUTCOME MEASURES The primary outcome was live birth at ≥ 34 weeks. In addition, a within-trial cost-effectiveness analysis was conducted from an NHS and NHS/Personal Social Services perspective. RESULTS A total of 4153 women from 48 hospitals in the UK received either progesterone (n = 2079) or placebo (n = 2074). The follow-up rate for the primary outcome was 97.2% (4038 out of 4153 participants). The live birth rate was 75% (1513 out of 2025 participants) in the progesterone group and 72% (1459 out of 2013 participants) in the placebo group (relative rate 1.03, 95% confidence interval 1.00 to 1.07; p = 0.08). A significant subgroup effect (interaction test p = 0.007) was identified for prespecified subgroups by the number of previous miscarriages: none (74% in the progesterone group vs. 75% in the placebo group; relative rate 0.99, 95% confidence interval 0.95 to 1.04; p = 0.72); one or two (76% in the progesterone group vs. 72% in the placebo group; relative rate 1.05, 95% confidence interval 1.00 to 1.12; p = 0.07); and three or more (72% in the progesterone group vs. 57% in the placebo group; relative rate 1.28, 95% confidence interval 1.08 to 1.51; p = 0.004). A significant post hoc subgroup effect (interaction test p = 0.01) was identified in the subgroup of participants with early pregnancy bleeding and any number of previous miscarriage(s) (75% in the progesterone group vs. 70% in the placebo group; relative rate 1.09, 95% confidence interval 1.03 to 1.15; p = 0.003). There were no significant differences in the rate of adverse events between the groups. The results of the health economics analysis show that progesterone was more costly than placebo (£7655 vs. £7572), with a mean cost difference of £83 (adjusted mean difference £76, 95% confidence interval -£559 to £711) between the two arms. Thus, the incremental cost-effectiveness ratio of progesterone compared with placebo was estimated as £3305 per additional live birth at ≥ 34 weeks of gestation. CONCLUSIONS Progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with threatened miscarriage overall, but an important subgroup effect was identified. A conclusion on the cost-effectiveness of the PRISM trial would depend on the amount that society is willing to pay to increase the chances of an additional live birth at ≥ 34 weeks. For future work, we plan to conduct an individual participant data meta-analysis using all existing data sets. TRIAL REGISTRATION Current Controlled Trials ISRCTN14163439, EudraCT 2014-002348-42 and Integrated Research Application System (IRAS) 158326. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 33. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Arri Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Hoda M Harb
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tracy E Roberts
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ilias Goranitis
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Chidubem B Ogwulu
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen M Williams
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abey Eapen
- Carver College of Medicine, University of Iowa Health Care, Iowa City, IA, USA
| | - Jane P Daniels
- Faculty of Medicine and Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Amna Ahmed
- Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Kalsang Bhatia
- Burnley General Hospital, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Cecilia Bottomley
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Meenakshi Choudhary
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Fiona Crosfill
- Royal Preston Hospital, Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | - Shilpa Deb
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - W Colin Duncan
- Medical Research Council Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Ewer
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kim Hinshaw
- Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Thomas Holland
- St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Feras Izzat
- University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Jemma Johns
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Mary-Ann Lumsden
- Reproductive & Maternal Medicine, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Padma Manda
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jane E Norman
- Medical Research Council Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Natalie Nunes
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Isleworth, UK
| | - Caroline E Overton
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kathiuska Kriedt
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Siobhan Quenby
- Biomedical Research Unit in Reproductive Health, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sandhya Rao
- Whiston Hospital, St Helen's and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Jackie Ross
- King's College Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Anupama Shahid
- Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Martyn Underwood
- Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | | | - Linda Watkins
- Liverpool Women's Hospital, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Catherine Wykes
- East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Andrew W Horne
- Medical Research Council Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Davor Jurkovic
- University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lee J Middleton
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
10
|
Abstract
Dydrogesterone is an orally active synthetic progestogen, with a molecular structure similar to that of natural progesterone. As dydrogesterone does not inhibit ovulation at standard doses, is devoid of estrogenic or androgenic properties, and does not induce metabolic side effects, it is suitable for use throughout a woman's lifetime, from adolescence to older age, for conditions associated with altered levels of endogenous progesterone. Aside from its well established role as a component of menopausal hormone therapy, dydrogesterone is indicated in younger women for treatment of dysmenorrhea, irregular menstrual cycles, premenstrual syndrome, and threatened or recurrent miscarriage; and is effective as luteal phase support during assisted reproduction techniques. In this narrative review, evidence is examined for use of dydrogesterone across a range of disorders affecting menses and pregnancy. A case study woven into the review illustrates the clinical uses of dydrogesterone during a young woman's journey to become a mother.
Collapse
Affiliation(s)
- Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Bern, Bern, Switzerland
| |
Collapse
|
11
|
Chan DMK, Cheung KW, Ko JKY, Yung SSF, Lai SF, Lam MT, Ng DYT, Lee VCY, Li RHW, Ng EHY. Use of oral progestogen in women with threatened miscarriage in the first trimester: a randomized double-blind controlled trial. Hum Reprod 2021; 36:587-595. [PMID: 33331637 DOI: 10.1093/humrep/deaa327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/19/2020] [Indexed: 01/14/2023] Open
Abstract
STUDY QUESTION Will use of oral progestogen in women with threatened miscarriage in the first trimester reduce the miscarriage rate when compared with placebo? SUMMARY ANSWER Use of oral progestogen in women with threatened miscarriage in the first trimester did not reduce miscarriage before 20 weeks when compared with placebo. WHAT IS KNOWN ALREADY Miscarriage is a common complication of pregnancy and occurs in 15-20% of clinically recognized pregnancies. Use of vaginal progestogens is not effective in reducing miscarriage but there is still no good evidence to support use of oral progestogen for the treatment of threatened miscarriage. STUDY DESIGN, SIZE, DURATION This was a randomized double-blind controlled trial. A total of 406 women presenting with threatened miscarriage in the first trimester were recruited from 30 March 2016 to May 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS Women attending Early Pregnancy Assessment Clinics because of vaginal bleeding during the first trimester were recruited and randomly assigned to use dydrogesterone 40 mg orally, followed by 10 mg orally three times a day or placebo until 12 completed weeks of gestation or 1 week after the bleeding stopped, whichever was later. The primary outcome was the miscarriage rate before 20 weeks of gestation. MAIN RESULTS AND THE ROLE OF CHANCE The two groups of women had comparable age, BMI, number of previous miscarriages, gestation and ultrasound findings at presentation. The miscarriage rate before 20 weeks of gestation was similar in both groups, being 12.8% (26/203) in the progestogen group and 14.3% (29/203) in the placebo group (relative risk 0.897, 95% CI 0.548-1.467; P = 0.772). The live birth rate was 81.3% in the progestogen group versus 83.3% in the placebo group (P = 0.697). No significant differences were found between the two groups in terms of obstetric outcomes and side effects. LIMITATIONS, REASONS FOR CAUTION The primary outcome was the miscarriage rate, rather than the live birth rate. Women were recruited from Early Pregnancy Assessment Clinics and those with heavy vaginal bleeding might be admitted into wards directly instead of attending Early Pregnancy Assessment Clinic. The severity of vaginal bleeding was subjectively graded by women themselves. The sample size was not adequate to demonstrate a smaller difference in the miscarriage rate between the progestogen and placebo groups. We did not exclude women with multiple pregnancy, which increased the risk of miscarriage although there was only one set of twin pregnancy in the placebo group. WIDER IMPLICATIONS OF THE FINDINGS Use of oral progestogen is not recommended in women with threatened miscarriage in the first trimester. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Health and Medical Research Fund, HKSAR (reference number 12132341). All authors declared no conflict of interest. TRIAL REGISTRATION NUMBER ClinicalTrials.gov with an identifier NCT02128685. TRIAL REGISTRATION DATE 1 May 2014. DATE OF FIRST PATIENT'S ENROLMENT 30 March 2016.
Collapse
Affiliation(s)
- Diana Man Ka Chan
- Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong SAR
| | - Ka Wang Cheung
- Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong SAR
| | - Jennifer Ka Yee Ko
- Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong SAR
| | | | - Shui Fan Lai
- Department of Obstetrics & Gynaecology, Kwong Wah Hospital, Hong Kong SAR
| | - Mei Ting Lam
- Department of Obstetrics & Gynaecology, Kwong Wah Hospital, Hong Kong SAR
| | - Dorothy Yuet Tao Ng
- Department of Obstetrics & Gynaecology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR
| | - Vivian Chi Yan Lee
- Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong SAR
| | | | - Ernest Hung Yu Ng
- Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong SAR
| |
Collapse
|
12
|
Jeschke L, Santamaria CG, Meyer N, Zenclussen AC, Bartley J, Schumacher A. Early-Pregnancy Dydrogesterone Supplementation Mimicking Luteal-Phase Support in ART Patients Did Not Provoke Major Reproductive Disorders in Pregnant Mice and Their Progeny. Int J Mol Sci 2021; 22:5403. [PMID: 34065597 PMCID: PMC8161261 DOI: 10.3390/ijms22105403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/26/2023] Open
Abstract
Progestogens are frequently administered during early pregnancy to patients undergoing assisted reproductive techniques (ART) to overcome progesterone deficits following ART procedures. Orally administered dydrogesterone (DG) shows equal efficacy to other progestogens with a higher level of patient compliance. However, potential harmful effects of DG on critical pregnancy processes and on the health of the progeny are not yet completely ruled out. We treated pregnant mice with DG in the mode, duration, and doses comparable to ART patients. Subsequently, we studied DG effects on embryo implantation, placental and fetal growth, fetal-maternal circulation, fetal survival, and the uterine immune status. After birth of in utero DG-exposed progeny, we assessed their sex ratios, weight gain, and reproductive performance. Early-pregnancy DG administration did not interfere with placental and fetal development, fetal-maternal circulation, or fetal survival, and provoked only minor changes in the uterine immune compartment. DG-exposed offspring grew normally, were fertile, and showed no reproductive abnormalities with the exception of an altered spermiogram in male progeny. Notably, DG shifted the sex ratio in favor of female progeny. Even though our data may be reassuring for the use of DG in ART patients, the detrimental effects on spermatogenesis in mice warrants further investigations and may be a reason for caution for routine DG supplementation in early pregnancy.
Collapse
Affiliation(s)
- Laura Jeschke
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
| | - Clarisa Guillermina Santamaria
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| | - Nicole Meyer
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| | - Ana Claudia Zenclussen
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| | - Julia Bartley
- Reproductive Medicine and Gynecological Endocrinology, University Women’s Clinic, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany;
| | - Anne Schumacher
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| |
Collapse
|
13
|
Coomarasamy A, Gallos ID, Papadopoulou A, Dhillon-Smith RK, Al-Memar M, Brewin J, Christiansen OB, Stephenson MD, Oladapo OT, Wijeyaratne CN, Small R, Bennett PR, Regan L, Goddijn M, Devall AJ, Bourne T, Brosens JJ, Quenby S. Sporadic miscarriage: evidence to provide effective care. Lancet 2021; 397:1668-1674. [PMID: 33915095 DOI: 10.1016/s0140-6736(21)00683-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 12/19/2022]
Abstract
The physical and psychological effect of miscarriage is commonly underappreciated. The journey from diagnosis of miscarriage, through clinical management, to supportive aftercare can be challenging for women, their partners, and caregivers. Diagnostic challenges can lead to delayed or ineffective care and increased anxiety. Inaccurate diagnosis of a miscarriage can result in the unintended termination of a wanted pregnancy. Uncertainty about the therapeutic effects of interventions can lead to suboptimal care, with variations across facilities and countries. For this Series paper, we have developed recommendations for practice from a literature review, appraisal of guidelines, and expert group discussions. The recommendations are grouped into three categories: (1) diagnosis of miscarriage, (2) prevention of miscarriage in women with early pregnancy bleeding, and (3) management of miscarriage. We recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth. Early pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration. Women with the dual risk factors of early pregnancy bleeding and a history of previous miscarriage can be recommended vaginal micronised progesterone to improve the prospects of livebirth. We urge health-care funders and providers to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units.
Collapse
Affiliation(s)
- Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Rima K Dhillon-Smith
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Maya Al-Memar
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Jane Brewin
- Tommy's Charity, Laurence Pountney Hill, London, UK
| | - Ole B Christiansen
- Centre for Recurrent Pregnancy Loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
| | - Mary D Stephenson
- University of Illinois Recurrent Pregnancy Loss Program, Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL, USA
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | | | - Rachel Small
- Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Phillip R Bennett
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Lesley Regan
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Tom Bourne
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK; KU Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Jan J Brosens
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Warwick, UK; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Siobhan Quenby
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Warwick, UK; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
14
|
Devall AJ, Papadopoulou A, Podesek M, Haas DM, Price MJ, Coomarasamy A, Gallos ID. Progestogens for preventing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013792. [PMID: 33872382 PMCID: PMC8406671 DOI: 10.1002/14651858.cd013792.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime, and 15% to 20% of pregnancies ending in a miscarriage. Progesterone has an important role in maintaining a pregnancy, and supplementation with different progestogens in early pregnancy has been attempted to rescue a pregnancy in women with early pregnancy bleeding (threatened miscarriage), and to prevent miscarriages in asymptomatic women who have a history of three or more previous miscarriages (recurrent miscarriage). OBJECTIVES To estimate the relative effectiveness and safety profiles for the different progestogen treatments for threatened and recurrent miscarriage, and provide rankings of the available treatments according to their effectiveness, safety, and side-effect profile. SEARCH METHODS We searched the following databases up to 15 December 2020: Cochrane Central Register of Controlled Trials, Ovid MEDLINE(R), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of progestogen treatment for the prevention of miscarriage. Cluster-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded quasi- and non-randomised trials. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We performed pairwise meta-analyses and indirect comparisons, where possible, to determine the relative effects of all available treatments, but due to the limited number of included studies only direct or indirect comparisons were possible. We estimated the relative effects for the primary outcome of live birth and the secondary outcomes including miscarriage (< 24 weeks of gestation), preterm birth (< 37 weeks of gestation), stillbirth, ectopic pregnancy, congenital abnormalities, and adverse drug events. Relative effects for all outcomes are reported separately by the type of miscarriage (threatened and recurrent miscarriage). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS Our meta-analysis included seven randomised trials involving 5,682 women, and all provided data for meta-analysis. All trials were conducted in hospital settings. Across seven trials (14 treatment arms), the following treatments were used: three arms (21%) used vaginal micronized progesterone; three arms (21%) used dydrogesterone; one arm (7%) used oral micronized progesterone; one arm (7%) used 17-α-hydroxyprogesterone, and six arms (43%) used placebo. Women with threatened miscarriage Based on the relative effects from the pairwise meta-analysis, vaginal micronized progesterone (two trials, 4090 women, risk ratio (RR) 1.03, 95% confidence interval (CI) 1.00 to 1.07, high-certainty evidence), and dydrogesterone (one trial, 406 women, RR 0.98, 95% CI 0.89 to 1.07, moderate-certainty evidence) probably make little or no difference to the live birth rate when compared with placebo for women with threatened miscarriage. No data are available to assess the effectiveness of 17-α-hydroxyprogesterone or oral micronized progesterone for the outcome of live birth in women with threatened miscarriage. The pre-specified subgroup analysis by number of previous miscarriages is only possible for vaginal micronized progesterone in women with threatened miscarriage. In women with no previous miscarriages and early pregnancy bleeding, there is probably little or no improvement in the live birth rate (RR 0.99, 95% CI 0.95 to 1.04, high-certainty evidence) when treated with vaginal micronized progesterone compared to placebo. However, for women with one or more previous miscarriages and early pregnancy bleeding, vaginal micronized progesterone increases the live birth rate compared to placebo (RR 1.08, 95% CI 1.02 to 1.15, high-certainty evidence). Women with recurrent miscarriage Based on the results from one trial (826 women) vaginal micronized progesterone (RR 1.04, 95% CI 0.95 to 1.15, high-certainty evidence) probably makes little or no difference to the live birth rate when compared with placebo for women with recurrent miscarriage. The evidence for dydrogesterone compared with placebo for women with recurrent miscarriage is of very low-certainty evidence, therefore the effects remain unclear. No data are available to assess the effectiveness of 17-α-hydroxyprogesterone or oral micronized progesterone for the outcome of live birth in women with recurrent miscarriage. Additional outcomes All progestogen treatments have a wide range of effects on the other pre-specified outcomes (miscarriage (< 24 weeks of gestation), preterm birth (< 37 weeks of gestation), stillbirth, ectopic pregnancy) in comparison to placebo for both threatened and recurrent miscarriage. Moderate- and low-certainty evidence with a wide range of effects suggests that there is probably no difference in congenital abnormalities and adverse drug events with vaginal micronized progesterone for threatened (congenital abnormalities RR 1.00, 95% CI 0.68 to 1.46, moderate-certainty evidence; adverse drug events RR 1.07 95% CI 0.81 to 1.39, moderate-certainty evidence) or recurrent miscarriage (congenital abnormalities 0.75, 95% CI 0.31 to 1.85, low-certainty evidence; adverse drug events RR 1.46, 95% CI 0.93 to 2.29, moderate-certainty evidence) compared with placebo. There are limited data and very low-certainty evidence on congenital abnormalities and adverse drug events for the other progestogens. AUTHORS' CONCLUSIONS The overall available evidence suggests that progestogens probably make little or no difference to live birth rate for women with threatened or recurrent miscarriage. However, vaginal micronized progesterone may increase the live birth rate for women with a history of one or more previous miscarriages and early pregnancy bleeding, with likely no difference in adverse events. There is still uncertainty over the effectiveness and safety of alternative progestogen treatments for threatened and recurrent miscarriage.
Collapse
Affiliation(s)
- Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Marcelina Podesek
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
15
|
Zhao H, He W, Yang Z. A pairwise and network meta-analysis comparing the efficacy and safety of progestogens in threatened abortion. Int J Gynaecol Obstet 2021; 156:383-393. [PMID: 33864694 DOI: 10.1002/ijgo.13707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/18/2021] [Accepted: 04/12/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Progesterone is widely used to prevent threatened miscarriage. OBJECTIVE To determine the efficacy and safety of progestogens in the treatment of threatened miscarriage. SEARCH STRATEGY PubMed, Cochrane Library, EMBASE, CNKI, CBM, and WanFang databases were searched for randomized controlled trials (RCTs) published from the date of inception of the database to August 2020. The search terms included "abortion, threatened," "progesterone," and "progestogens." SELECTION CRITERIA A network meta-analysis was conducted of all the RCTs on threatened abortion so far to compare the efficacy and safety of different progestogens in the treatment of threatened abortion. DATA COLLECTION AND ANALYSIS Odds ratios for dichotomous data with 95% confidence intervals were calculated and the data were pooled using a random-effects model. The surface under the cumulative ranking area (SUCRA) was calculated for efficacy and safety with different interventions. MAIN RESULTS A total of 59 RCTs with 10 424 participants were included. Oral dydrogesterone (DYD) had the lowest risk of miscarriage (SUCRA 100.0%), followed by vaginal progesterone (SUCRA 67.9%). Oral micronized progesterone had the highest risk of miscarriage (SUCRA 15.7%). CONCLUSION Oral DYD is effective in the treatment of threatened miscarriage. The results of the present study can help patients make informed decisions about treatment options for threatened miscarriage.
Collapse
Affiliation(s)
- Hongqiong Zhao
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei He
- Department of Gastroenterology, Chongqing Southeast Hospital, Chongqing, China
| | - Zhu Yang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
16
|
Koren G, Barer Y, Cem Kaplan Y. Fetal safety of medications used in treating infertility. Expert Rev Clin Pharmacol 2020; 13:991-1000. [PMID: 32815747 DOI: 10.1080/17512433.2020.1803738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The medications used in assisted reproduction are given before and during early pregnancy, and hence, they may potentially result in adverse fetal effects. In this review we present an updated account of their fetal safety and discuss methodological challenges in interpretation of existing data. AREAS COVERED The fetal safety/risks of clomiphene citrate, aromatase inhibitors, metformin, gonadotropins and progestins are discussed. We searched PubMed, EMBASE, Cochrane, Google, and Google Scholar from inception to 30 April 2020 for publications pertinent to our topic. EXPERT OPINION There are several major challenges in studying fetal safety of medications used in assisted reproduction. The fact is that the rates of congenital malformations among infertile women giving birth spontaneously is higher than the rates among healthy women conceiving spontaneously. In most clinical studies of assisted reproduction, the primary endpoint is the success in inducing pregnancy, neglecting to report pregnancy outcome and adverse neonatal event. As an example for this reality, it has been estimated that between 1977 and 2005 around 10 million pregnancies were treated with dydrogesterone (DYD), yet till 2019 only very few studies, with a total sample size of less than 600 were reported with regards to fetal safety.
Collapse
Affiliation(s)
- Gideon Koren
- Adelson Faculty of Medicine, Ariel University , Ariel, Israel.,Department of pharmacology, Motherisk Israel.s , Turkey
| | - Yael Barer
- Maccabi Health Services , Tel Aviv, Turkey
| | - Yusuf Cem Kaplan
- Teratology Information Center, Terafar-Izmir Katip Celebi University , Izmir, Turkey.,Department of Pharmacology, Faculty of Medicine, Izmir Katip Celebi University , Izmir, Turkey
| |
Collapse
|
17
|
Yan Y, Chen Z, Yang Y, Zheng X, Zou M, Cheng G, Yuan Z. Efficacy of progesterone on threatened miscarriage: an updated meta-analysis of randomized trials. Arch Gynecol Obstet 2020; 303:27-36. [PMID: 32989508 DOI: 10.1007/s00404-020-05808-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The efficacy of progesterone supplementation in the treatment of threatened miscarriage is controversial. This meta-analysis was to evaluate the correlation between progesterone and improving pregnancy outcomes in women with threatened miscarriage. METHODS We searched PubMed, EMBASE, and the Cochrane Library for relevant randomized controlled trials (RCTs) to demonstrate the efficacy of progesterone on the threatened miscarriage pregnancy. The outcomes were miscarriage, preterm birth, and live birth. RESULTS Nine RCTs comparing 4907 patients were included in this study. Compared with placebo or no treatment, progesterone supplementation had a relationship with a reduction in the rate of miscarriage [RR 0.70 95% Cl (0.52, 0.94)]. There was no significant difference between progesterone supplementation and placebo or no treatment in preterm birth [RR 0.87 95% Cl (0.52, 1.47) and live birth (RR 1.02 95% Cl (0.98, 1.07)]. CONCLUSION Progesterone supplementation did not significantly improve the incidence of preterm and live birth, so progesterone treatment of threatened miscarriage may be unhelpful.
Collapse
Affiliation(s)
- Yuying Yan
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, 110016, Liaoning, China
| | - Zeping Chen
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, 110016, Liaoning, China
| | - Ying Yang
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, 110016, Liaoning, China
| | - Xinkuo Zheng
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, 110016, Liaoning, China
| | - Meijuan Zou
- Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, 110016, Liaoning, China
| | - Gang Cheng
- Department of Pharmaceutical Sciences, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, 110016, Liaoning, China.
| | - Zhenting Yuan
- No. 230 Hospital of P.L.A., 19 Shijing Street, Dandong, 118000, Liaoning, China.
| |
Collapse
|
18
|
Devall AJ, Coomarasamy A. Sporadic pregnancy loss and recurrent miscarriage. Best Pract Res Clin Obstet Gynaecol 2020; 69:30-39. [PMID: 32978069 DOI: 10.1016/j.bpobgyn.2020.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
Progesterone is essential for the maintenance of pregnancy, and progesterone deficiency is associated with miscarriage. The subject of whether progesterone supplementation in early pregnancy can prevent miscarriage has been a long-standing research question and has been investigated and debated in the medical literature for over 70 years. During this time, several different progestogens have been synthesised and tested for the prevention of miscarriage. In this chapter, we describe the prior evidence alongside the latest research using micronized natural progesterone as well as synthetic progestogens, which were used to treat both recurrent and threatened miscarriage. The totality of evidence indicates that women with a past history of miscarriage who present with bleeding in early pregnancy may benefit from the use of vaginal micronized progesterone. The clinical implications of the findings are discussed.
Collapse
Affiliation(s)
- Adam J Devall
- Tommy's National Centre for Miscarriage Research, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, College of Medical and Dental Sciences, University of Birmingham, UK.
| |
Collapse
|
19
|
Li L, Zhang Y, Tan H, Bai Y, Fang F, Faramand A, Chong W, Hai Y. Effect of progestogen for women with threatened miscarriage: a systematic review and meta‐analysis. BJOG 2020; 127:1055-1063. [PMID: 32324957 DOI: 10.1111/1471-0528.16261] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 02/05/2023]
Affiliation(s)
- L Li
- West China Hospital Sichuan University Chengdu Sichuan China
| | - Y Zhang
- West China Hospital Sichuan University Chengdu Sichuan China
- Clinical Research Centre Affiliated Hospital of Chengdu University Chengdu Sichuan China
| | - H Tan
- West China Hospital Sichuan University Chengdu Sichuan China
| | - Y Bai
- West China Second University Hospital Sichuan University Chengdu Sichuan China
| | - F Fang
- West China Hospital Sichuan University Chengdu Sichuan China
| | - A Faramand
- University of Pittsburgh Medical Center University of Pittsburgh Pittsburgh PA USA
| | - W Chong
- Sidney Kimmel Medical College Thomas Jefferson University Philadelphia PA USA
| | - Y Hai
- Department of Surgery Zucker School of Medicine at Hofstra/Northwell New York NY USA
| |
Collapse
|
20
|
Arab H, Alharbi AJ, Oraif A, Sagr E, Al Madani H, Abduljabbar H, Bajouh OS, Faden Y, Sabr Y. The Role Of Progestogens In Threatened And Idiopathic Recurrent Miscarriage. Int J Womens Health 2019; 11:589-596. [PMID: 31807086 PMCID: PMC6848983 DOI: 10.2147/ijwh.s224159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/25/2019] [Indexed: 12/13/2022] Open
Abstract
It is well known that progesterone plays a major role in the maintenance of pregnancy, particularly during the early stages, as it is responsible for preparing the endometrium for implantation and maintenance of the gestational sac. The management of pregnant women at risk of a threatened or idiopathic recurrent miscarriage is complex and critical. Therefore, a group of obstetricians and gynecologists practicing in Saudi Arabia gathered to update the 2014 Saudi guidelines for threatened and recurrent miscarriage management. In preparation, a literature review was conducted to explore the role of oral, vaginal, and injectable progestogens: this was used as a basis to develop position statements to guide and standardize practice across Saudi Arabia.
Collapse
Affiliation(s)
- Hisham Arab
- Obstetrics and Gynecology Department, Dr. Arab Medical Center, Jeddah, Saudi Arabia
| | - Ahmed Jaber Alharbi
- Obstetrics and Gynecology Department, Ibinsina Medical Private College, Jeddah, Saudi Arabia
| | - Ayman Oraif
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Emad Sagr
- Obstetrics and Gynecology Department, The International Medical Center, Jeddah, Saudi Arabia
| | - Hana Al Madani
- Obstetrics and Gynecology Department, Maternity Hospital - King Saud Medical City, Riyadh, Saudi Arabia
| | - Hassan Abduljabbar
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Sadeak Bajouh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Yaser Faden
- Department of Obstetrics and Gynecology, King Saud bin Abdulaziz University for Health Sciences - Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Yasser Sabr
- Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| |
Collapse
|
21
|
Azizi R, Ahmadi M, Danaii S, Abdollahi-Fard S, Mosapour P, Eghbal-Fard S, Dolati S, Kamrani A, Rahnama B, Mehdizadeh A, Jadidi-Niaragh F, Yousefi B, Yousefi M. Cyclosporine A improves pregnancy outcomes in women with recurrent pregnancy loss and elevated Th1/Th2 ratio. J Cell Physiol 2019; 234:19039-19047. [PMID: 30924169 DOI: 10.1002/jcp.28543] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 12/20/2022]
Abstract
Recurrent pregnancy loss (RPL) is a one of the most common obstetrical complications. Since, the successful pregnancy occurs in T helper 2 (Th2)-dominant situation and since, Th1 type immunity is related to pregnancy failure, we investigated the effects of cyclosporine on Th1 and Th2 cells in RPL women. Totally, 76 RPL patients (38 women as treated group and 38 as control group) were included in this study. Flow cytometry was utilized to analyze the frequency of Th1 and Th2 in blood samples. Also, real-time polymerase chain reaction was carried out to assess the messenger RNA (mRNA) expression of transcription factors and enzyme-linked immunosorbent assay was used to evaluate Th1 and Th2 related cytokines. Significant decrease in Th1 frequency (p = 0.0004), Th1/Th2 ratio (p < 0.0001), T-bet mRNA expression (p < 0.0001), interferon-γ (p = 0.0007), and tumor necrosis factor α (p = 0.0002) secretion level were observed in cyclosporine group. Moreover, significant increase in Th2 frequency (p < 0.0001), mRNA expression of GATA binding protein 3 (p = 0.0001), and interleukin 10 secretion level (p = 0.0027) was also evident in treated group. At the end of the investigation, 31 (81.5%) patients in cyclosporine-treated group had successful childbirth when compared with 16 (42.1%) women in control group (p = 0.0001). Given this, cyclosporine treatment for RPL patients with elevated Th1/Th2 ratio can result in improved pregnancy outcome.
Collapse
Affiliation(s)
- Ramyar Azizi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Majid Ahmadi
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Student's Research Committee, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahla Danaii
- Gynecology Department, Eastern Azerbaijan ACECR ART Center, Eastern Azerbaijan Branch of ACECR, Tabriz, Iran
| | - Sedigheh Abdollahi-Fard
- Gynecology Department, Eastern Azerbaijan ACECR ART Center, Eastern Azerbaijan Branch of ACECR, Tabriz, Iran
| | - Parisa Mosapour
- Gynecology Department, Eastern Azerbaijan ACECR ART Center, Eastern Azerbaijan Branch of ACECR, Tabriz, Iran
| | - Shadi Eghbal-Fard
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanam Dolati
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.,Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Kamrani
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Badrossadat Rahnama
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Mehdizadeh
- Endocrine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farhad Jadidi-Niaragh
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Bahman Yousefi
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
22
|
Wang XX, Luo Q, Bai WP. Efficacy of progesterone on threatened miscarriage: Difference in drug types. J Obstet Gynaecol Res 2019; 45:794-802. [PMID: 30632226 DOI: 10.1111/jog.13909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 12/08/2018] [Indexed: 11/28/2022]
Abstract
AIM To investigate whether treatment with progesterone would decrease the incidence of miscarriage in women who faced threatened miscarriage. METHODS Randomized controlled trials (RCT) were identified by searching PubMed, Embase, Cochrane Library and Web of Science. Trials were included if they compared progesterone with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage. Pregnant prophylaxis drugs were not included without strict progesterone type, language and progesterone management. The primary outcome was the incidence of miscarriage. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI). RESULTS Eight RCT including 845 women who faced threatened miscarriage were analyzed. Pooled data from the eight trials showed that women with threatened miscarriage who were randomized to the progesterone group had a lower risk of threatened miscarriage (RR = 0.64, 95% CI 0.48-0.85). Dydrogesterone was shown to have a lower risk of miscarriage (RR = 0.49, 95% CI 0.33-0.75) than natural progesterone (RR = 0.69, 95% CI 0.40-1.19). Oral management was demonstrated to have a lower risk of miscarriage (RR = 0.55, 95% CI 0.38-0.79) compared with vaginal administration (RR = 0.58, 95% CI 0.28-1.21). CONCLUSION Our findings show that progesterone agents are effective in reducing the incidence of miscarriage in threatened miscarriage. Dydrogesterone, but not natural progesterone, was associated with a lower risk of miscarriage. Given the limitations of the studies included in our meta-analysis, it is difficult to recommend route and dose of progesterone therapy. Further head-to-head trials of gestational weeks and long-time follow-up are required.
Collapse
Affiliation(s)
- Xiao-Xue Wang
- Department of Gynecology and Obstetrics, Capital Medical University Affiliated Shijitan Hospital, Beijing, China
| | - Qing Luo
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Public Health, Xiamen University, Xiamen, China
| | - Wen-Pei Bai
- Department of Gynecology and Obstetrics, Capital Medical University Affiliated Shijitan Hospital, Beijing, China
| |
Collapse
|
23
|
Griesinger G, Blockeel C, Tournaye H. Oral dydrogesterone for luteal phase support in fresh in vitro fertilization cycles: a new standard? Fertil Steril 2018; 109:756-762. [PMID: 29778368 DOI: 10.1016/j.fertnstert.2018.03.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 01/20/2023]
Abstract
Oral dydrogesterone has been used for luteal phase support on an empirical basis since the early days of in vitro fertilization (IVF) treatment. Systematic comparisons of oral dydrogesterone with vaginal progesterone, so far considered to be the standard of care, started to appear in the middle 2000s. Recently, a large, randomized, double-blind, double-dummy phase III trial on the use of daily 30 mg oral dydrogesterone versus daily 600 mg micronized vaginal progesterone for LPS in IVF was published. This company-sponsored trial confirmed the efficacy findings from previous independent researchers and firmly established the noninferiority of daily 30 mg oral dydrogesterone for luteal phase support. Despite oral administration and first pass through the liver, dydrogesterone was as well tolerated as vaginal progesterone in safety analyses. Moreover, no new fetal safety concerns have arisen from that trial. Given the widespread preference of women for an oral compound, dydrogesterone may well become the new standard for luteal phase support in fresh embryo transfer IVF cycles.
Collapse
Affiliation(s)
- Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Luebeck, Germany.
| | - Christophe Blockeel
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Herman Tournaye
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| |
Collapse
|
24
|
Abstract
BACKGROUND Miscarriage is a common complication encountered during pregnancy. It is defined as spontaneous pregnancy loss before 20 weeks' gestation. Progesterone's physiological role is to prepare the uterus for the implantation of the embryo, enhance uterine quiescence and suppress uterine contractions, hence, it may play a role in preventing rejection of the embryo. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. This update of the Cochrane Review first published in 2007, and previously updated in 2011, investigates the evidence base for this practice. OBJECTIVES To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (8 August 2017) and reference lists of retrieved trials. SELECTION CRITERIA Randomised, quasi-randomised or cluster-randomised controlled trials, that compared progestogen with placebo, no treatment or any other treatment for the treatment of threatened miscarriage in women carrying singleton pregnancy. DATA COLLECTION AND ANALYSIS At least two review authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data and graded the body of evidence. MAIN RESULTS We included seven trials (involving 696 participants) in this update of the review. The included trials were conducted in different countries, covering the full spectrum of the World Bank's economic classification, which enhances the applicability of evidence drawn from this review. Two trials were conducted in Germany and Italy which are high-income countries, while four trials were conducted in upper-middle income countries; two in Iran, one in Malaysia and the fourth in Turkey, and the seventh trial was conducted in Jordan, which is a lower-middle income country. In six trials all the participants met the inclusion criteria and in the seventh study, we included in the meta-analysis only the subgroup of participants who met the inclusion criteria. We assessed the body of evidence for the main outcomes using the GRADE tool and the quality of the evidence ranged from very low to moderate. Downgrading of evidence was based on the high risk of bias in six of the seven included trials and a small number of events and wide confidence intervals for some outcomes.Treatment of miscarriage with progestogens compared to placebo or no treatment probably reduces the risk of miscarriage; (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.47 to 0.87; 7 trials; 696 women; moderate-quality evidence). Treatment with oral progestogen compared to no treatment also probably reduces the miscarriage rate (RR 0.57, 95% CI 0.38 to 0.85; 3 trials; 408 women; moderate-quality evidence). However treatment with vaginal progesterone compared to placebo, probably has little or no effect in reducing the miscarriage rate (RR 0.75, 95% CI 0.47 to 1.21; 4 trials; 288 women; moderate-quality evidence). The subgroup interaction test indicated no difference according to route of administration between the oral and vaginal subgroups of progesterone.Treatment of preterm birth with the use of progestogens compared to placebo or no treatment may have little or no effect in reducing the rate of preterm birth (RR 0.86, 95% CI 0.52 to 1.44; 5 trials; 588 women; low-quality evidence).We are uncertain if treatment of threatened miscarriage with progestogens compared to placebo or no treatment has any effect on the rate of congenital abnormalities because the quality of the evidence is very low (RR 0.70, 95% CI 0.10 to 4.82; 2 trials; 337 infants; very-low quality evidence). AUTHORS' CONCLUSIONS The results of this Cochrane Review suggest that progestogens are probably effective in the treatment of threatened miscarriage but may have little or no effect in the rate of preterm birth. The evidence on congenital abnormalities is uncertain, because the quality of the evidence for this outcome was based on only two small trials with very few events and was found to be of very low quality.
Collapse
Affiliation(s)
- Hayfaa A Wahabi
- King Saud UniversityChair of Evidence‐Based Healthcare and Knowledge TranslationRiyadhSaudi Arabia11451
| | - Amel A Fayed
- Princess Nourah Bint Abdulrahman UniversityCollege of Medicine, Clinical DepartmentKhurais RoadKing Abdulaziz Medical CityRiyadhSaudi Arabia22490
| | - Samia A Esmaeil
- King Saud UniversityDepartment of Family and Community MedicineRiyadhSaudi Arabia
| | | | | |
Collapse
|
25
|
Schumacher A, Dauven D, Zenclussen AC. Progesterone-driven local regulatory T cell induction does not prevent fetal loss in the CBA/J×DBA/2J abortion-prone model. Am J Reprod Immunol 2017; 77. [PMID: 28224721 DOI: 10.1111/aji.12626] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/06/2016] [Indexed: 11/27/2022] Open
Abstract
PROBLEM Best known for its endocrine and immunologic properties, progesterone (P4) is a pivotal player for pregnancy success. However, the immunologic actions underlying P4 protection are not completely understood. Here, we investigated whether P4 application in a murine abortion-prone combination regulates regulatory T cells (Treg) and dendritic cells (DCs) and thereby affects pregnancy outcome. METHOD OF STUDY Progesterone or vehicle was applied to DBA/2J-mated CBA/J abortion-prone animals in early pregnancy. On gestation day 10, peripheral and local DC and Treg numbers were analyzed and pregnancy outcome was determined. RESULTS Progesterone application provoked a significant increase in the uterine Treg pool but did not alter the abortion rate. Moreover, no significant changes could be observed in peripheral Treg levels and DC numbers after P4 application. CONCLUSIONS Our findings suggest that P4-induced local Treg elevation is not sufficient to overcome fetal rejection in this specific model of disturbed fetal tolerance.
Collapse
Affiliation(s)
- Anne Schumacher
- Department of Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| | - Dominique Dauven
- Department of Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| | - Ana C Zenclussen
- Department of Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| |
Collapse
|
26
|
The Influence of Oral Dydrogesterone and Vaginal Progesterone on Threatened Abortion: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3616875. [PMID: 29392134 PMCID: PMC5748117 DOI: 10.1155/2017/3616875] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/24/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022]
Abstract
Objective To conduct systematic analyses to evaluate the efficacy of progesterone therapy for the prevention of miscarriages in pregnant women experiencing threatened abortion. Methods In November 2016, we performed a systematic literature search and identified 51 articles in PubMed, Embase, and Cochrane databases. We identified nine randomized trials that included 913 pregnant women (including 322 treated with oral dydrogesterone, 213 treated with vaginal progesterone, and 378 control subjects) who met the selection criteria. Results The incidence of miscarriage was significantly lower in the total progesterone group than in the control group (13.0% versus 21.7%; odds ratio, 0.53; 95% confidence interval (CI), 0.36 to 0.78; P = 0.001; I2, 0%). Moreover, the incidence of miscarriage was significantly lower in the oral dydrogesterone group than in the control group (11.7% versus 22.6%; odds ratio, 0.43; 95% CI, 0.26 to 0.71; P = 0.001; I2, 0%) and was lower in the vaginal progesterone group than in the control group, although this difference was nonsignificant (15.4% versus 20.3%; odds ratio, 0.72; 95% CI, 0.39 to 1.34; P = 0.30; I2, 0%). However, the incidence of miscarriage was not different between the oral dydrogesterone and vaginal progesterone groups. Conclusion Progesterone therapy, especially oral dydrogesterone, can effectively prevent miscarriage in pregnant women experiencing threatened abortion.
Collapse
|
27
|
Xin Q, Kong S, Yan J, Qiu J, He B, Zhou C, Ni Z, Bao H, Huang L, Lu J, Xia G, Liu X, Chen ZJ, Wang C, Wang H. Polycomb subunit BMI1 determines uterine progesterone responsiveness essential for normal embryo implantation. J Clin Invest 2017; 128:175-189. [PMID: 29202468 DOI: 10.1172/jci92862] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 10/17/2017] [Indexed: 12/19/2022] Open
Abstract
Natural and synthetic progestogens have been commonly used to prevent recurrent pregnancy loss in women with inadequate progesterone secretion or reduced progesterone sensitivity. However, the clinical efficacy of progesterone and its analogs for maintaining pregnancy is variable. Additionally, the underlying cause of impaired endometrial progesterone responsiveness during early pregnancy remains unknown. Here, we demonstrated that uterine-selective depletion of BMI1, a key component of the polycomb repressive complex-1 (PRC1), hampers uterine progesterone responsiveness and derails normal uterine receptivity, resulting in implantation failure in mice. We further uncovered genetic and biochemical evidence that BMI1 interacts with the progesterone receptor (PR) and the E3 ligase E6AP in a polycomb complex-independent manner and regulates the PR ubiquitination that is essential for normal progesterone responsiveness. A close association of aberrantly low endometrial BMI1 expression with restrained PR responsiveness in women who had previously had a miscarriage indicated that the role of BMI1 in endometrial PR function is conserved in mice and in humans. In addition to uncovering a potential regulatory mechanism of BMI1 that ensures normal endometrial progesterone responsiveness during early pregnancy, our findings have the potential to help clarify the underlying causes of spontaneous pregnancy loss in women.
Collapse
Affiliation(s)
- Qiliang Xin
- State Key Laboratory of Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, China
| | - Shuangbo Kong
- Reproductive Medical Center, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China.,Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Junhao Yan
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated with Shandong University, Jinan, China
| | - Jingtao Qiu
- Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Bo He
- Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Chan Zhou
- Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Zhangli Ni
- Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Haili Bao
- Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Lin Huang
- Reproductive Medical Center, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China.,Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Jinhua Lu
- Reproductive Medical Center, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China.,Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| | - Guoliang Xia
- State Key Laboratory of Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, China
| | - Xicheng Liu
- National Institute of Biological Sciences, Beijing, China
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated with Shandong University, Jinan, China
| | - Chao Wang
- State Key Laboratory of Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, China
| | - Haibin Wang
- Reproductive Medical Center, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China.,Fujian Provincial Key Laboratory of Reproductive Health Research, Medical College of Xiamen University, Xiamen, Fujian, China
| |
Collapse
|
28
|
Given JE, Loane M, Luteijn JM, Morris JK, de Jong van den Berg LTW, Garne E, Addor MC, Barisic I, de Walle H, Gatt M, Klungsoyr K, Khoshnood B, Latos-Bielenska A, Nelen V, Neville AJ, O'Mahony M, Pierini A, Tucker D, Wiesel A, Dolk H. EUROmediCAT signal detection: an evaluation of selected congenital anomaly-medication associations. Br J Clin Pharmacol 2016; 82:1094-109. [PMID: 27028286 PMCID: PMC5137835 DOI: 10.1111/bcp.12947] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 12/30/2022] Open
Abstract
AIMS To evaluate congenital anomaly (CA)-medication exposure associations produced by the new EUROmediCAT signal detection system and determine which require further investigation. METHODS Data from 15 EUROCAT registries (1995-2011) with medication exposures at the chemical substance (5th level of Anatomic Therapeutic Chemical classification) and chemical subgroup (4th level) were analysed using a 50% false detection rate. After excluding antiepileptics, antidiabetics, antiasthmatics and SSRIs/psycholeptics already under investigation, 27 associations were evaluated. If evidence for a signal persisted after data validation, a literature review was conducted for prior evidence of human teratogenicity. RESULTS Thirteen out of 27 CA-medication exposure signals, based on 389 exposed cases, passed data validation. There was some prior evidence in the literature to support six signals (gastroschisis and levonorgestrel/ethinylestradiol (OR 4.10, 95% CI 1.70-8.53; congenital heart disease/pulmonary valve stenosis and nucleoside/tide reverse transcriptase inhibitors (OR 5.01, 95% CI 1.99-14.20/OR 28.20, 95% CI 4.63-122.24); complete absence of a limb and pregnen (4) derivatives (OR 6.60, 95% CI 1.70-22.93); hypospadias and pregnadien derivatives (OR 1.40, 95% CI 1.10-1.76); hypospadias and synthetic ovulation stimulants (OR 1.89, 95% CI 1.28-2.70). Antipropulsives produced a signal for syndactyly while the literature revealed a signal for hypospadias. There was no prior evidence to support the remaining six signals involving the ordinary salt combinations, propulsives, bulk-forming laxatives, hydrazinophthalazine derivatives, gonadotropin releasing hormone analogues and selective serotonin agonists. CONCLUSION Signals which strengthened prior evidence should be prioritized for further investigation, and independent evidence sought to confirm the remaining signals. Some chance associations are expected and confounding by indication is possible.
Collapse
Affiliation(s)
- Joanne E Given
- Centre for Maternal, Fetal and Infant Research, Institute of Nursing and Health Research, Ulster University, United Kingdom
| | - Maria Loane
- Centre for Maternal, Fetal and Infant Research, Institute of Nursing and Health Research, Ulster University, United Kingdom
| | - Johannes M Luteijn
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom
| | - Joan K Morris
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom
| | | | - Ester Garne
- Paediatric Department, Hospital Lillebaelt, Kolding, Denmark
| | | | - Ingeborg Barisic
- Department of Medical Genetics and Reproductive Health, Children's University Hospital Zagreb, Croatia
| | - Hermien de Walle
- Eurocat Northern Netherlands, University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, the Netherlands
| | - Miriam Gatt
- Department of Health Information and Research, Guardamangia, Malta
| | - Kari Klungsoyr
- Medical Birth Registry of Norway, the Norwegian Institute of Public Health and Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Babak Khoshnood
- Paris Registry of Congenital Anomalies, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Biostatistics and Epidemiology, INSERM U1153, Maternité de Port-Royal, PARIS, France
| | - Anna Latos-Bielenska
- Polish Registry of Congenital Malformations, Department of Medical Genetics, Poznan, Poland
| | - Vera Nelen
- Provinciaal Instituut voor Hygiene (PIH), Antwerp, Belgium
| | - Amanda J Neville
- IMER Registry (Emilia Romagna Registry of Birth Defects), Centre for Clinical and Epidemiological Research, University of Ferrara and Azienda Ospedaliero Univerisitarion di Ferrara, Italy
| | | | - Anna Pierini
- Epidemiology and Health Promotion Macro-Area Working Group, Unit of Environmental Epidemiology and Disease Registries, CNR Institute of Clinical Physiology, Pisa, Italy
| | - David Tucker
- CARIS - Congenital Anomaly Register and Information Service for Wales, Public Health Wales, Swansea, United Kingdom
| | - Awi Wiesel
- Mainz Model Birth Registry, University Children's Hospital Mainz, Germany
| | - Helen Dolk
- Centre for Maternal, Fetal and Infant Research, Institute of Nursing and Health Research, Ulster University, United Kingdom.
| |
Collapse
|
29
|
Chan DMK, Cheung KW, Yung SSF, Lee VCY, Li RHW, Ng EHY. A randomized double-blind controlled trial of the use of dydrogesterone in women with threatened miscarriage in the first trimester: study protocol for a randomized controlled trial. Trials 2016; 17:408. [PMID: 27534747 PMCID: PMC4989484 DOI: 10.1186/s13063-016-1509-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 07/15/2016] [Indexed: 11/17/2022] Open
Abstract
Background Miscarriage is a common complication of pregnancy occurring in 15–20 % of all clinically recognized pregnancies. Currently, there is still no good scientific evidence to support the routine use of progestogens for the treatment of threatened miscarriage because the existing studies were not large enough to show a significant difference and some of them were not randomized or double-blind. Methods This is a double-blind, randomized controlled trial. A total of 400 patients presenting with first-trimester threatened miscarriage will be enrolled. They will be randomized to take dydrogesterone 40 mg per os, followed by 10 mg per os three times a day or placebo until twelve completed weeks of gestation or 1 week after the bleeding has stopped, whichever is longer. The primary outcome is the percentage of miscarriage before 20 weeks of gestation. Discussion We postulate that the dydrogesterone therapy will significantly reduce the risk of miscarriage in women with threatened miscarriage. Trial registration This study is registered at ClinicalTrials.gov, NCT02128685. Registered on 29 April 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1509-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Diana Man Ka Chan
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China.
| | - Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Sofie Shuk Fei Yung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Vivian Chi Yan Lee
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Raymond Hang Wun Li
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Ernest Hung Yu Ng
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| |
Collapse
|
30
|
Saharkhiz N, Zamaniyan M, Salehpour S, Zadehmodarres S, Hoseini S, Cheraghi L, Seif S, Baheiraei N. A comparative study of dydrogesterone and micronized progesterone for luteal phase support during in vitro fertilization (IVF) cycles. Gynecol Endocrinol 2016; 32:213-7. [PMID: 26486011 DOI: 10.3109/09513590.2015.1110136] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of the present study was to compare the efficacy, tolerability and patients' satisfaction after the use of oral dydrogesterone with vaginal micronized progesterone for luteal-phase support (LPS) among infertile women undergoing in vitro fertilization (IVF). A total of 210 women (aged 20-40 years old) with a history of infertility, who underwent controlled ovarian stimulation for fresh intra-cytoplasmic sperm injection-embryo transfer cycles, were included in the study. Consequently, they were randomized to receive LPS with dydrogesterone 20 mg twice daily (n = 96) or micronized progesterone 400 mg twice daily at the day of oocyte retrieval (n = 114). The clinical success rate (31% versus 33%; p = 0.888), miscarriage rate (5.0% versus 3.0%; p = 0.721), ongoing pregnancy rate (30.0% versus 30.0%; p = 1.000), implantation (22.0% versus 24.0%; p = 0.254) and multiple pregnancy rate (5.30% versus 7.20%; p = 0.394) were comparable among the two groups. Serum progesterone levels were significantly lower among the patients receiving dydrogesterone than the control group (13.62 ± 13.83 ng/ml versus 20.66 ± 18.09 ng/ml; p = 0.001). However, there was no statistically significant difference regarding the patients' satisfaction (p = 0.825) and tolerability (0.790) between the two groups. Our results showed that oral dydrogesterone (40 mg/day) is as effective as vaginal micronized progesterone considering its clinical outcomes and patients' satisfaction and tolerability, for LPS among women undergoing IVF.
Collapse
Affiliation(s)
- Nasrin Saharkhiz
- a Preventive Gynecology Research Center (PGRC) , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Marzieh Zamaniyan
- a Preventive Gynecology Research Center (PGRC) , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Saghar Salehpour
- a Preventive Gynecology Research Center (PGRC) , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Shahrzad Zadehmodarres
- a Preventive Gynecology Research Center (PGRC) , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Sedighe Hoseini
- a Preventive Gynecology Research Center (PGRC) , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Leila Cheraghi
- b Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Samira Seif
- c Department of Veterinary Theriogenology and Obstetric , Tehran University of Medical Sciences , Tehran , Iran , and
| | - Nafiseh Baheiraei
- d Department of Anatomy , Faculty of Medical Sciences, Tarbiat Modares University , Tehran , Iran
| |
Collapse
|
31
|
Abstract
Successful oocyte implantation and a favorable pregnancy outcome rely on optimal progesterone levels. Therefore, progesterone deficiencies associated with infertility and miscarriage have commonly been treated with progestogens that mimic the activity of progesterone. Among those is dydrogesterone, an oral retrosteroid with a structure closely related to that of progesterone yet with a greater bioavailability and higher selectivity for the progesterone receptor. This review describes the efficacy of dydrogesterone for the treatment of threatened and recurrent miscarriage, and infertility due to luteal phase insufficiency. Data from clinical trials evaluating dydrogesterone in assisted reproductive technology are also discussed. Prospective clinical trials, systematic reviews and meta-analyses have demonstrated that dydrogesterone significantly improves pregnancy outcomes in women with threatened miscarriage or with a history of miscarriage. Although this is not yet a registered indication, dydrogesterone was as effective as vaginal micronized progesterone for luteal phase support in the setting of assisted reproductive technology. The safety and tolerability of dydrogesterone treatment in pregnant women are also briefly addressed and the data support a well-established and favorable benefit-risk profile.
Collapse
Affiliation(s)
- Fadi Ghazi Mirza
- a American University of Beirut Medical Center, Department of Obstetrics and Gynecology , Beirut , Lebanon
| | - Ameet Patki
- b Fertility Associates , Mumbai , India , and
| | | |
Collapse
|
32
|
Schindler AE, Carp H, Druckmann R, Genazzani AR, Huber J, Pasqualini J, Schweppe KW, Szekeres-Bartho J. European Progestin Club Guidelines for prevention and treatment of threatened or recurrent (habitual) miscarriage with progestogens. Gynecol Endocrinol 2015; 31:447-9. [PMID: 25976550 DOI: 10.3109/09513590.2015.1017459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This guideline has been developed based on studied and clinical investigations. Therefore, it appears to be appropriate to use all the available evidence, which are very encouraging, in a summarized form to propose guidelines by a group of European experts in order to give the gynecologists, obstetricians and reproductive medicine specialists have direction with regard to the prevention or treatment of miscarriage for the benefit of the endangered pregnancies. There are a number of statements, opinions and guidelines already published for this topic, which are not entirely in agreement.
Collapse
Affiliation(s)
- Adolf E Schindler
- Institute for Medical Research and Education, University Clinic , Essen , Germany
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Acupuncture and clomiphene citrate for live birth in polycystic ovary syndrome: study design of a randomized controlled trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:527303. [PMID: 24023577 PMCID: PMC3762180 DOI: 10.1155/2013/527303] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 05/29/2013] [Accepted: 07/01/2013] [Indexed: 12/31/2022]
Abstract
Acupuncture is an alternative therapy to induce ovulation in women with polycystic ovary syndrome (PCOS), but there is no study reporting the live birth rate following ovulation induction by acupuncture or its potential as an adjuvant treatment to clomiphene citrate (CC). We assess the efficacy of acupuncture with or without CC in achieving live births among 1000 PCOS women in Mainland China. This paper reports the methodology of an ongoing multicenter randomized controlled trial. The randomization scheme is coordinated through the central mechanism and stratified by the participating sites. Participants will be randomized into one of the four treatment arms: (A) true acupuncture and CC, (B) control acupuncture and CC, (C) true acupuncture and placebo CC, and (D) control acupuncture and placebo CC. To ensure the quality and integrity of the trial we have developed a unique multinational team of investigators and Data and Safety Monitoring Board. Up to the end of April 2013, 326 subjects were recruited. In conclusion, the success of this trial will allow us to evaluate the additional benefit of acupuncture beyond the first line medicine for fertility treatment in PCOS women in an unbiased manner.
Collapse
|
34
|
Abstract
The endocrinology of human pregnancy involves endocrine and metabolic changes that result from physiological alterations at the boundary between mother and fetus. Progesterone and oestrogen have a great role along with other hormones. The controversies of use of progestogen and others are discussed in this chapter. Progesterone has been shown to stimulate the secretion of Th2 and reduces the secretion of Th1 cytokines which maintains pregnancy. Supportive care in early pregnancy is associated with a significant beneficial effect on pregnancy outcome. Prophylactic hormonal supplementation can be recommended for all assisted reproduction techniques cycles. Preterm labor can be prevented by the use of progestogen. The route of administration plays an important role in the drug's safety and efficacy profile in different trimesters of pregnancy. Thyroid disorders have a great impact on pregnancy outcome and needs to be monitored and treated accordingly. Method of locating review: Pubmed, scopus
Collapse
Affiliation(s)
- Pratap Kumar
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | | |
Collapse
|
35
|
Murtaza UI, Ortmann MJ, Mando-Vandrick J, Lee ASD. Management of first-trimester complications in the emergency department. Am J Health Syst Pharm 2013; 70:99-111. [DOI: 10.2146/ajhp120069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Umbreen I. Murtaza
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Melinda J. Ortmann
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | | | - Amy S. D. Lee
- Department of Gynecology-Obstetrics, The Johns Hopkins Hospital, Baltimore
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| |
Collapse
|
36
|
Abstract
The objective of this systematic review was to assess whether the orally acting progestagen, dydrogesterone lowers the incidence of miscarriage in women with threatened miscarriage. A computerized search was performed in Medline, Embase, and Ovid Medline for original reports with the product name 'Duphaston' or 'dydrogesterone', and limited to clinical human data. Twenty-one reports of dydrogesterone treatment were identified with 1380 patients. Five randomized trials were identified, including 660 women who fulfilled the criteria for meta-analysis. The number of subsequent miscarriages or continuing pregnancies per randomized woman was compared in women receiving dydrogesterone compared to standard bed rest or placebo intervention. There was a 13% (44/335) miscarriage rate after dydrogesterone administration compared to 24% in control women [odds ratio for miscarriage 0.47, (CI = 0.31-0.7), 11% absolute reduction in the miscarriage rate]. The adverse and side effects were summarized in all 21 reports, and seemed to be minimal. Although all the predictive and confounding factors could not be controlled for, the results of this systematic review show a significant reduction of 47% in the odds for miscarriage when dydrogesterone is compared to standard care indicating a real treatment effect.
Collapse
Affiliation(s)
- Howard Carp
- Department of Obstetrics & Gynecology, Sheba Medical Center, Tel Hashomer, Israel.
| |
Collapse
|
37
|
Abstract
BACKGROUND Threatened miscarriage occurs in 10% to 15% of all pregnancies. Vaginal spotting or bleeding during early gestation is common, with nearly half of those pregnancies resulting in pregnancy loss. To date, there is no effective preventive treatment for threatened miscarriage. Chinese herbal medicines have been widely used in Asian countries for centuries and have become a popular alternative to Western medicines in recent years. Many studies claim to show that they can prevent miscarriage. However, there has been no systematic evaluation of the effectiveness of Chinese herbal medicines for threatened miscarriage. OBJECTIVES To review the therapeutic effects of Chinese herbal medicines for the treatment of threatened miscarriage. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012), Chinese Biomedical Database (1978 to 31 January 2012), China Journal Net (1915 to 31 January 2012), China National Knowledge Infrastructure (1915 to 31 January 2012), WanFang Database (1980 to 31 January 2012), Chinese Clinical Trial Registry (31 January 2012), EMBASE (1980 to 31 January 2012), CINAHL (31 January 2012), PubMed (1980 to 31 January 2012), Wiley InterScience (1966 to 31 January 2012), International Clinical Trials Registry Platform (31 January 2012) and reference lists of retrieved studies. We also contacted organisations, individual experts working in the field, and medicinal herb manufacturers. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that compared Chinese herbal medicines (alone or combined with other pharmaceuticals) with placebo, no treatment (including bed rest), or other pharmaceuticals as treatments for threatened miscarriage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all the studies for inclusion in the review, assessed risk of bias and extracted the data. Data were checked for accuracy. MAIN RESULTS In total, we included 44 randomised clinical trials with 5100 participants in the review.We did not identify any trials which used placebo or no treatment (including bed rest) as a control.The rate of effectiveness (continuation of pregnancy after 28 weeks of gestation) was not significantly different between the Chinese herbal medicines alone group compared with the group of women receiving Western medicines alone (average risk ratio (RR) 1.23; 95% confidence interval (CI) 0.96 to 1.57; one trial, 60 women).Chinese herbal medicines combined with Western medicines were more effective than Western medicines alone to continue the pregnancy beyond 28 weeks of gestation (average RR 1.28; 95% CI 1.18 to 1.38; five trials, 550 women). AUTHORS' CONCLUSIONS There was insufficient evidence to assess the effectiveness of Chinese herbal medicines alone for treating threatened miscarriage.A combination of Chinese herbal and Western medicines was more effective than Western medicines alone for treating threatened miscarriage. However, the quality of the included studies was poor. More high quality studies are necessary to further evaluate the effectiveness of Chinese herbal medicines for threatened miscarriage.
Collapse
Affiliation(s)
- Lu Li
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | | | | |
Collapse
|
38
|
Use of progestogens in pregnant and infertile patients. Arch Gynecol Obstet 2012; 286:495-503. [PMID: 22543698 DOI: 10.1007/s00404-012-2340-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
Abstract
Progesterone is an essential hormone in the occurence and maintenance of pregnancy. Natural or synthetic progestogens are commonly used in pregnant patients or patients undergoing infertility treatments for various indications. Most frequently put indications for the use of progestogens in these patient populations are the prevention of spontaneous preterm birth, the prevention of pregnancy loss in pregnancies with an unexplained recurrent pregnancy loss and in patients with threatened abortion. It is also used in pregnant women undergoing nonobstetric surgery, for infertility or recurrent pregnancy loss that is thought to be due to luteal phase defect or as a luteal support in stimulated IVF cycles. We aimed to review the current evidence for the use of progestogens in each of these settings.
Collapse
|
39
|
Abstract
BACKGROUND Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. OBJECTIVES To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011) and bibliographies of all located articles for any additional studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage. DATA COLLECTION AND ANALYSIS At least two authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data. Data were checked for accuracy. MAIN RESULTS We included four studies (421 participants) in the meta-analysis. In three studies all the participants met the inclusion criteria and in the fourth study, we included only the subgroup of participants who met the inclusion criteria in the meta-analysis. There was evidence of a reduction in the rate of spontaneous miscarriage with the use of progestogens compared to placebo or no treatment (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35 to 0.79). There was no increase in the rate of antepartum haemorrhage (RR 0.76; 95% CI 0.30 to 1.94), or pregnancy-induced hypertension (RR 1.00; 95% CI 0.54 to 1.88) for the mother. The rate of congenital abnormalities was no different between the newborns of the mothers who received progestogens and those who did not (RR 0.70; 95% CI 0.10 to 4.82). AUTHORS' CONCLUSIONS The data from this review suggest that the use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy-induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn. However, the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion.
Collapse
Affiliation(s)
- Hayfaa A Wahabi
- Chair of Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia, 11451
| | | | | | | |
Collapse
|
40
|
Schindler AE. Progestogens for treatment and prevention of pregnancy disorders. Horm Mol Biol Clin Investig 2010; 3:453-60. [PMID: 25961219 DOI: 10.1515/hmbci.2010.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 12/15/2010] [Indexed: 11/15/2022]
Abstract
Progesterone appears to be the dominant hormone not only establishing a proper secretory endometrial development but also adequate decidualization to establish pregnancy and sustain pregnancy development. Progesterone is the natural immunoregulator to control the maternal immune system and not to reject the allogeneic fetus. There are two sources of progesterone: corpus luteum first and placenta later. Three progestogens can be used in pregnancy: (i) progesterone (per os, intravaginal and intramuscular), (ii) dydrogesterone (per os), and (iii) 17α-hydroxyprogesterone caproate (intramuscular). There are three indications, for which these progestogens can be clinically used either for treatment or prevention: (i) first trimester threatened and recurrent (habitual) abortion, (ii) premature labor/premature birth, and (iii) pre-eclampsia (hypertension in pregnancy). The available data are limited and only partially randomized. In threatened abortion the use of progesterone, dydrogesterone and 17α-hydroxyprogesterone caproate leads to a significant improved outcome, when at the time of threatened abortion a viable fetus has been ascertained by ultrasound. For prevention of recurrent abortion there are also some data indicating a significant effect compared with women without progestogen treatment. Prevention of preterm birth by progestogens (progesterone vaginally, orally and 17α-hydroxyprogesterone caproate intramuscularly) was significantly effective. The main study groups include pregnant women with a previous history of premature birth. However, also in women with shortened cervix use of progesterone seems to be helpful. The studies done so far in women with risk factors for pre-eclampsia or established pre-eclampsia were based on parenteral progesterone application. However, new studies are urgently needed.
Collapse
|