1
|
Stenqvist A, Bungum M, Pinborg AB, Bogstad J, Englund AL, Grøndahl ML, Zedeler A, Hansson SR, Giwercman A. High sperm deoxyribonucleic acid fragmentation index is associated with an increased risk of preeclampsia following assisted reproduction treatment. Fertil Steril 2025; 123:97-104. [PMID: 39122087 DOI: 10.1016/j.fertnstert.2024.08.316] [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: 01/16/2024] [Revised: 08/05/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE To study the association between sperm deoxyribonucleic acid fragmentation index (DFI) and the odds of preeclampsia and other adverse perinatal outcomes after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment. DESIGN A prospective cohort study including infertile couples undergoing conventional IVF or ICSI treatment and their children. Data regarding preeclampsia and perinatal outcomes were derived from the Swedish National Birth Register. PATIENT(S) A total of 1,594 infertile couples undergoing IVF or ICSI treatment and their 1,660 children conceived by assisted reproduction. EXPOSURE Sperm DFI measured by Sperm Chromatin Structure Assay. MAIN OUTCOME MEASURE(S) The primary outcome was preeclampsia. The secondary outcomes were preterm birth (PTB), low birth weight, low Apgar score, and small for gestational age. RESULT(S) With a DFI level of <20% as a reference, the odds ratio (OR) of preeclampsia statistically significantly increased in the group with a DFI level of ≥20% when IVF was used as the fertilization method (OR, 2.2; 95% confidence interval, 1.1-4.4). Already at the DFI levels of ≥10%, in IVF pregnancies, the OR of preeclampsia increased in a dose-response manner, from a prevalence of 3.1% in the reference group to >10% among those with a DFI level of ≥30%. The DFI was not associated with the OR of preeclampsia in the ICSI group. In the entire cohort, a DFI level of ≥20% was associated with an increased OR of PTB (OR, 1.4; 95% confidence interval, 1.0-2.0). CONCLUSION(S) High DFI level was associated with increased odds of PTB and, in IVF pregnancies, also increased odds of preeclampsia.
Collapse
Affiliation(s)
- Amelie Stenqvist
- Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden; Reproductive Medicine Centre, Skåne University Hospital, Malmö, Sweden; Department of Obstetrics and Gynaecology, Skåne University Hospital, Malmö/Lund, Sweden.
| | - Mona Bungum
- Reproductive Medicine Centre, Skåne University Hospital, Malmö, Sweden
| | - Anja Bisgaard Pinborg
- Fertility Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jeanette Bogstad
- Fertility Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Anne Zedeler
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Stefan R Hansson
- Department of Obstetrics and Gynaecology, Skåne University Hospital, Malmö/Lund, Sweden; Obstetrics and Gynaecology, Department of Clinical Sciences Lund, Lund University, Sweden
| | - Aleksander Giwercman
- Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden; Reproductive Medicine Centre, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
2
|
Balder P, Jones C, Coward K, Yeste M. Sperm chromatin: Evaluation, epigenetic signatures and relevance for embryo development and assisted reproductive technology outcomes. Eur J Cell Biol 2024; 103:151429. [PMID: 38905808 DOI: 10.1016/j.ejcb.2024.151429] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024] Open
Abstract
Sperm chromatin is distinct from somatic cell chromatin, as a result of extensive remodeling during the final stages of spermatogenesis. In this process, the majority of histones is replaced with protamines. The chromatin is consequently highly condensed and inert, which facilitates protection of the DNA. The sperm epigenomic landscape is shaped by histone retention, histone and protamine modification, DNA methylation, and RNAs. In recent years, sperm chromatin integrity and its epigenetic marks have been increasingly studied, and the constitution of sperm chromatin is steadily being uncovered. This growing body of research prompts assessment of the frequently overlooked involvement of sperm in fertility and embryonic development. Moreover, numerous endogenous and exogenous factors are known to affect sperm chromatin, which may in turn impact the reproductive success. Concerns have been raised about the effects of assisted reproductive technology (ART) on the sperm epigenome, embryonic development and offspring health. This review examines the structure and epigenetic signatures of sperm chromatin in the context of fertility and early embryonic development. Additionally, sperm chromatin evaluation and causes of aberrant integrity are outlined. Building on the knowledge discussed in the current review, future research should aim to elucidate the intricate relationship between all aspects of sperm chromatin and embryo development. This could lead to the uncovering of new targets for treating infertility, as well as the acquisition of much needed insights into the possible reciprocal association between ART and sperm chromatin integrity.
Collapse
Affiliation(s)
- Pauline Balder
- Nuffield Department of Women's and Reproductive Health, Level 3, Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK; The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, NY 10021, USA
| | - Celine Jones
- Nuffield Department of Women's and Reproductive Health, Level 3, Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Kevin Coward
- Nuffield Department of Women's and Reproductive Health, Level 3, Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
| | - Marc Yeste
- Biotechnology of Animal and Human Reproduction (TechnoSperm), Institute of Food and Agricultural Technology, University of Girona, Girona ES-17003, Spain; Unit of Cell Biology, Department of Biology, Faculty of Sciences, University of Girona, Girona ES-17003, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona ES-08010, Spain.
| |
Collapse
|
3
|
Li Y, Chang Q, Mai Q. Pregnancy and neonatal outcomes of monozygotic twins resulting from assisted reproductive technology: a 10-year retrospective study. Reprod Biol Endocrinol 2023; 21:51. [PMID: 37268975 DOI: 10.1186/s12958-023-01104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Monozygotic twins (MZTs) are associated with high risks of maternal and fetal complications. Even with the widely used elective single embryo transfer (SET), the risk of MZTs following assisted reproductive technology (ART) treatments remains. However, most studies of MZTs focused on the relevant etiology, with few studies describing pregnancy and neonatal outcomes. METHODS This retrospective cohort study included 19,081 SET cycles resulting from in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), preimplantation genetic testing (PGT) and testicular sperm aspiration (TESA) performed between January 2010 and July 2020 in a single university-based center. A total of 187 MZTs were included in this investigation. The main outcome measures were the incidence, pregnancy and neonatal outcomes of MZTs. Multivariate logistic regression analysis was performed to figure out the risk factors for pregnancy loss. RESULTS The overall rate of MZTs from ART treatment in SET cycles was 0.98%. No significant difference was found in the incidence of MZTs among the four groups (p = 0.259). The live birth rate of MZTs in the ICSI group (88.5%) was significantly more favorable than in the IVF, PGT and TESA groups (60.5%, 77.2% and 80%, respectively). IVF resulted in a significantly increased risk of pregnancy loss (39.4%) and early miscarriage (29.5%) in MZT pregnancies compared to ICSI (11.4%, 8.5%), PGT (22.7%, 16.6%) and TESA (20%, 13.3%). The total rate of twin-to-twin transfusion syndrome (TTTS) in MZTs was 2.7% (5/187); however, the TESA group had the highest rate at 20% and was significantly higher than the PGT group (p = 0.005). The four ART groups had no significant effect on the occurrence of congenital abnormalities or other neonatal outcomes in newborns from MZT pregnancies. Multivariate logistic regression analysis revealed that infertility duration, cause of infertility, the total dose of Gn used, history of miscarriages, and the number of miscarriages were not related to the risk of pregnancy loss (p > 0.05). CONCLUSIONS The rate of MZTs was similar among the four ART groups. The pregnancy loss and the early miscarriage rate of MZTs was increased in IVF patients. Neither the cause of infertility nor the history of miscarriage was correlated with the risk of pregnancy loss. MZTs in the TESA group had a higher risk of TTTS, placental effects influenced by sperm and paternally expressed genes may play a role. However, due to the small total number, studies with larger sample sizes are still needed to validate these result. Pregnancy and neonatal outcomes of MZTs after PGT treatment seem to be reassuring but the duration of the study was short, and long-term follow-up of the children is needed.
Collapse
Affiliation(s)
- Yubin Li
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiyuan Chang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingyun Mai
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
4
|
Chamayou S, Giacone F, Cannarella R, Guglielmino A. What Does Intracytoplasmic Sperm Injection Change in Embryonic Development? The Spermatozoon Contribution. J Clin Med 2023; 12:671. [PMID: 36675600 PMCID: PMC9867417 DOI: 10.3390/jcm12020671] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 12/30/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
The intracytoplasmic sperm injection (ICSI) technique was invented to solve severe male infertility due to altered sperm parameters. Nowadays, it is applied worldwide for the treatment of couple infertility. ICSI is performed with any available spermatozoon from surgery or ejaculated samples, whatever are the sperm motility, morphology or quantity. The aim of the present review was to study if embryo development and kinetics would be modified by (1) ICSI under the technical aspects, (2) the micro-injected spermatozoa in connection with male infertility. From published data, it can be seen that ICSI anticipates the zygote kinetics Furthermore, because fertilization rate is higher in ICSI compared to conventional in vitro fertilization (IVF), more blastocysts are obtained for clinical use in ICSI. Sperm and spermatozoa characteristics, such as sperm parameters, morphology and vitality, DNA content (levels of sperm DNA fragmentation, microdeletions, and chromosomal abnormalities), RNA content, epigenetics, and sperm recovery site (testicular, epididymis, and ejaculated), have an impact on fertilization and blastocyst rates and embryo kinetics in different ways. Even though ICSI is the most common solution to solve couples' infertility, the causes of male infertility are crucial in building a competent spermatozoa that will contribute to normal embryonic development and healthy offspring.
Collapse
Affiliation(s)
- Sandrine Chamayou
- Centro HERA—Unità di Medicina della Riproduzione, Via Barriera del Bosco, 51/53, Sant’Agata li Battiati, 95030 Catania, Italy
| | - Filippo Giacone
- Centro HERA—Unità di Medicina della Riproduzione, Via Barriera del Bosco, 51/53, Sant’Agata li Battiati, 95030 Catania, Italy
| | - Rossella Cannarella
- Glickman Urological & Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Antonino Guglielmino
- Centro HERA—Unità di Medicina della Riproduzione, Via Barriera del Bosco, 51/53, Sant’Agata li Battiati, 95030 Catania, Italy
| |
Collapse
|
5
|
van Duijn L, Hoek J, Rousian M, Baart EB, Willemsen SP, Laven JSE, Steegers-Theunissen RPM, Schoenmakers S. Prenatal growth trajectories and birth outcomes after frozen-thawed extended culture embryo transfer and fresh embryo transfer: the Rotterdam Periconception Cohort. Reprod Biomed Online 2021; 43:279-287. [PMID: 34092521 DOI: 10.1016/j.rbmo.2021.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/30/2022]
Abstract
RESEARCH QUESTION Are there differences in prenatal growth trajectories and birth outcomes between singleton pregnancies conceived after IVF treatment with frozen-thawed extended culture embryo transfer at day 5, fresh embryo transfer at day 3 or naturally conceived pregnancies? DESIGN From a prospective hospital-based cohort, 859 singleton pregnancies were selected, including 133 conceived after IVF with frozen-thawed embryo transfer, 276 after fresh embryo transfer, and 450 naturally conceived pregnancies. Longitudinal 3D ultrasound scans were performed at 7, 9 and 11 weeks of gestation for offline crown-rump length (CRL) and embryonic volume measurements. Second trimester estimated fetal weight was based on growth parameters obtained during the routine fetal anomaly scan at 20 weeks of gestation. Birth outcome data were collected from medical records. RESULTS No differences regarding embryonic growth trajectories were observed between frozen-thawed and fresh embryo transfer. Birthweight percentiles after fresh embryo transfer were lower than after frozen-thawed embryo transfer (38.0 versus 48.0; P = 0.046, respectively). The prevalence of non-iatrogenic preterm birth (PTB) was significantly lower in pregnancies resulting from fresh embryo transfer compared with frozen-thawed embryo transfer (4.7% versus 10.9%; P = 0.026, respectively). Compared with naturally conceived pregnancies, birthweight percentiles and percentage of non-iatrogenic PTB were significantly lower in pregnancies after fresh embryo transfer and gestational age at birth was significantly higher. CONCLUSIONS This study shows that embryonic growth is comparable between singleton pregnancies conceived after fresh and frozen-thawed embryo transfer. The lower relative birthweight and PTB rate in pregnancies after fresh embryo transfer than after frozen-thawed embryo transfer and naturally conceived pregnancies warrants further investigation.
Collapse
Affiliation(s)
- Linette van Duijn
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jeffrey Hoek
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Melek Rousian
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Esther B Baart
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Sten P Willemsen
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Sam Schoenmakers
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
6
|
van Marion ES, Speksnijder JP, Hoek J, Boellaard WPA, Dinkelman-Smit M, Chavli EA, Steegers-Theunissen RPM, Laven JSE, Baart EB. Time-lapse imaging of human embryos fertilized with testicular sperm reveals an impact on the first embryonic cell cycle. Biol Reprod 2021; 104:1218-1227. [PMID: 33690817 PMCID: PMC8181962 DOI: 10.1093/biolre/ioab031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
Testicular sperm is increasingly used during in vitro fertilization treatment. Testicular sperm has the ability to fertilize the oocyte after intracytoplasmic sperm injection (ICSI), but they have not undergone maturation during epididymal transport. Testicular sperm differs from ejaculated sperm in terms of chromatin maturity, incidence of DNA damage, and RNA content. It is not fully understood what the biological impact is of using testicular sperm, on fertilization, preimplantation embryo development, and postimplantation development. Our goal was to investigate differences in human preimplantation embryo development after ICSI using testicular sperm (TESE-ICSI) and ejaculated sperm. We used time-lapse embryo culture to study these possible differences. Embryos (n = 639) originating from 208 couples undergoing TESE-ICSI treatment were studied and compared to embryos (n = 866) originating from 243 couples undergoing ICSI treatment with ejaculated sperm. Using statistical analysis with linear mixed models, we observed that pronuclei appeared 0.55 h earlier in TESE-ICSI embryos, after which the pronuclear stage lasted 0.55 h longer. Also, significantly more TESE-ICSI embryos showed direct unequal cleavage from the 1-cell stage to the 3-cell stage. TESE-ICSI embryos proceeded faster through the cleavage divisions to the 5- and the 6-cell stage, but this effect disappeared when we adjusted our model for maternal factors. In conclusion, sperm origin affects embryo development during the first embryonic cell cycle, but not developmental kinetics to the 8-cell stage. Our results provide insight into the biological differences between testicular and ejaculated sperm and their impact during human fertilization.
Collapse
Affiliation(s)
- E S van Marion
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J P Speksnijder
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J Hoek
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - W P A Boellaard
- Department of Urology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Dinkelman-Smit
- Department of Urology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - E A Chavli
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - R P M Steegers-Theunissen
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - E B Baart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Developmental Biology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Hoek J, Boellaard WPA, van Marion ES, Willemsen SP, Baart EB, Steegers-Theunissen RPM, Schoenmakers S. The impact of the origin of surgical sperm retrieval on placental and embryonic development: The Rotterdam Periconception cohort. Andrology 2020; 9:599-609. [PMID: 33207074 PMCID: PMC7986236 DOI: 10.1111/andr.12943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/17/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In patients with azoospermia, pregnancy can be achieved after surgical techniques using sperm retrieved from the testis or epididymis, which can impact on DNA integrity and epigenetics. DNA of the fetus and placenta is equally derived from both parents; however, genes important for placental development are expressed from the paternal alleles. Therefore, the origin of sperm may affect fetal and placental development. OBJECTIVES To investigate whether first-trimester trajectories of embryonic and placental development of pregnancies conceived after intracytoplasmic sperm injection (ICSI) with testicular sperm extraction (TESE) or microsurgical epididymal sperm aspiration (MESA), are different from pregnancies after ICSI with ejaculated sperm or natural conceptions. MATERIALS AND METHODS A total of 147 singleton ICSI pregnancies, including pregnancies conceived after TESE (n = 23), MESA (n = 25) and ejaculated sperm (n = 99), and 380 naturally conceived and 140 after IVF treatment without ICSI were selected from the prospective Rotterdam periconception cohort. Crown-rump length (CRL), embryonic volume (EV), Carnegie stages, and placental volume (PV) at 7, 9, and 11 weeks of gestation were measured using 3D ultrasound and virtual reality technology. RESULTS Linear mixed model analysis showed no differences in trajectories of CRL, EV, and Carnegie stages between pregnancies conceived after ICSI with testicular, epididymal, and ejaculated sperm. A significantly positive association was demonstrated for PV between pregnancies conceived after TESE-ICSI (adjusted beta: 0.28(95%CI: 0.05-0.50)) versus ICSI with ejaculated sperm. Retransformation to original values showed that the PV of pregnancies after TESE-ICSI is 14.6% (95%CI: 1.4%-25.5%) larger at 11 weeks of gestation compared to ICSI pregnancies conceived with ejaculated sperm. DISCUSSION AND CONCLUSION Here we demonstrate that the first-trimester growth trajectory of the placenta is increased in pregnancies conceived after TESE-ICSI compared to those conceived after ICSI with ejaculated sperm. Findings are discussed in the light of known differences in sperm DNA integrity, epigenetics, and placental gene expression.
Collapse
Affiliation(s)
- Jeffrey Hoek
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Willem P A Boellaard
- Department of Urology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Eva S van Marion
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sten P Willemsen
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Biostatistics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Esther B Baart
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Sam Schoenmakers
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|