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Hegger S, Levy A, Koren G, Lunenfeld E, Daniel S. Exposure to Macrolides During Pregnancy and the Risk for Spontaneous Abortions: A Population-Based Retrospective Cohort Study. J Clin Pharmacol 2024. [PMID: 38804820 DOI: 10.1002/jcph.2458] [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: 06/01/2023] [Accepted: 04/20/2024] [Indexed: 05/29/2024]
Abstract
Previous studies evaluating the risk of spontaneous abortions following exposure to macrolides reported controversial results. The goal of the current study was to examine the risk for spontaneous abortions following exposure to macrolides during pregnancy. We conducted a population-based retrospective cohort study by linking three computerized databases: Clalit Health Services drug dispensation database, Soroka Medical Center (SMC) birth database, and SMC hospitalizations database. Multivariate time-varying Cox regressions were performed and adjusted for suspected confounders and known risk factors for spontaneous abortions. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated. A secondary analysis was performed to assess the association between exposure to macrolides in terms of the defined daily dose dispensed and spontaneous abortions. The study cohort included 65,457 pregnancies that ended at Soroka Medical Center between 2004 and 2009, of which 6508 (9.9%) resulted in a spontaneous abortion. A total of 825 (1.26%) pregnancies were exposed to macrolides during the exposure period. Exposure to macrolides was not associated with spontaneous abortions as a group (adjusted HR 1.00 95% CI 0.77-1.31) or as specific medications. There was no evidence of a dose-response relationship between exposure to macrolides and spontaneous abortions. In conclusion, this population-based retrospective cohort study did not detect an increased risk for spontaneous abortion following exposure to macrolides during the first trimester of pregnancy.
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Affiliation(s)
- Shani Hegger
- Department of Epidemiology, Biostatistics, and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amalia Levy
- Department of Epidemiology, Biostatistics, and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | - Sharon Daniel
- Department of Epidemiology, Biostatistics, and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Pediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Southern District, Clalit Health Services, Beer-Sheva, Israel
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Giouleka S, Tsakiridis I, Arsenaki E, Kalogiannidis I, Mamopoulos A, Papanikolaou E, Athanasiadis A, Dagklis T. Investigation and Management of Recurrent Pregnancy Loss: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2023; 78:287-301. [PMID: 37263963 DOI: 10.1097/ogx.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Importance Recurrent pregnancy loss (RPL) is one of the most frustrating clinical entities in reproductive medicine requiring not only diagnostic investigation and therapeutic intervention, but also evaluation of the risk for recurrence. Objective The aim of this study was to review and compare the most recently published major guidelines on investigation and management of RPL. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, the American Society for Reproductive Medicine, the French College of Gynecologists and Obstetricians, and the German, Austrian, and Swiss Society of Gynecology and Obstetrics on RPL was carried out. Results There is consensus among the reviewed guidelines that the mainstays of RPL investigation are a detailed personal history and screening for antiphospholipid syndrome and anatomical abnormalities of the uterus. In contrast, inherited thrombophilias, vaginal infections, and immunological and male factors of infertility are not recommended as part of a routine RPL investigation. Several differences exist regarding the necessity of the cytogenetic analysis of the products of conception, parental peripheral blood karyotyping, ovarian reserve testing, screening for thyroid disorders, diabetes or hyperhomocysteinemia, measurement of prolactin levels, and performing endometrial biopsy. Regarding the management of RPL, low-dose aspirin plus heparin is indicated for the treatment of antiphospholipid syndrome and levothyroxine for overt hypothyroidism. Genetic counseling is required in case of abnormal parental karyotype. The Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, and the French College of Gynecologists and Obstetricians guidelines provide recommendations that are similar on the management of cervical insufficiency based on the previous reproductive history. However, there is no common pathway regarding the management of subclinical hypothyroidism and the surgical repair of congenital and acquired uterine anomalies. Use of heparin for inherited thrombophilias and immunotherapy and anticoagulants for unexplained RPL are not recommended, although progesterone supplementation is suggested by the American Society for Reproductive Medicine and the German, Austrian, and Swiss Society of Gynecology and Obstetrics. Conclusions Recurrent pregnancy loss is a devastating condition for couples. Thus, it seems of paramount importance to develop consistent international practice protocols for cost-effective investigation and management of this early pregnancy complication, with the aim to improve live birth rates.
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Affiliation(s)
| | - Ioannis Tsakiridis
- Consultant in Maternal-Fetal Medicine, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elisavet Arsenaki
- Foundation Trainee Doctor, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | - Evangelos Papanikolaou
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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3
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Mirza FG, Tahlak MA, Rjeili RB, Hazari K, Ennab F, Hodgman C, Khamis AH, Atiomo W. Polycystic Ovarian Syndrome (PCOS): Does the Challenge End at Conception? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192214914. [PMID: 36429632 PMCID: PMC9690374 DOI: 10.3390/ijerph192214914] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 05/14/2023]
Abstract
Polycystic ovary syndrome (PCOS) is a prevalent condition that not only has the potential to impede conception but also represents the most common endocrine dysfunction in fertile women. It is considered a heterogeneous and multifaceted disorder, with multiple reproductive and metabolic phenotypes which differently affect the early- and long-term syndrome's risks. Undoubtedly, the impact of PCOS on infertility has attracted most of the attention of healthcare providers and investigators. However, there is growing evidence that even after conception is achieved, PCOS predisposes the parturient to several adverse pregnancy outcomes including a high risk of pregnancy-induced hypertension, spontaneous abortion, gestational diabetes, preeclampsia, and preterm birth, which increase the risks of stillbirth and neonatal death. Fetal growth abnormalities may also be more common, but the relationship is less well defined. This narrative review aims to summarize current knowledge regarding these conditions as they interplay with PCOS and concludes that although there appears to be an increase in these complications during the pregnancy of women with PCOS, there is a need for further research to clarify the possible confounding impact of obesity. Implications for clinical practice and future research are outlined.
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Affiliation(s)
- Fadi G. Mirza
- Latifa Women and Children Hospital, Dubai P.O. Box 9115, United Arab Emirates
- Department of Obstetrics and Gynaecology, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Building 14, Dubai Healthcare City, Dubai P.O. Box 505055, United Arab Emirates
- Department of Obstetrics and Gynaecology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Muna A. Tahlak
- Latifa Women and Children Hospital, Dubai P.O. Box 9115, United Arab Emirates
| | - Rachelle Bou Rjeili
- Faculty of Medicine, American University of Beirut, Beruit P.O. Box 11-0236, Lebanon
| | - Komal Hazari
- Latifa Women and Children Hospital, Dubai P.O. Box 9115, United Arab Emirates
| | - Farah Ennab
- Department of Obstetrics and Gynaecology, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Building 14, Dubai Healthcare City, Dubai P.O. Box 505055, United Arab Emirates
| | - Charlie Hodgman
- School of Biosciences, University of Nottingham, Loughborough LE12 5RD, UK
| | - Amar Hassan Khamis
- Department of Obstetrics and Gynaecology, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Building 14, Dubai Healthcare City, Dubai P.O. Box 505055, United Arab Emirates
| | - William Atiomo
- Department of Obstetrics and Gynaecology, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Building 14, Dubai Healthcare City, Dubai P.O. Box 505055, United Arab Emirates
- Correspondence:
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Brinca AT, Ramalhinho AC, Sousa Â, Oliani AH, Breitenfeld L, Passarinha LA, Gallardo E. Follicular Fluid: A Powerful Tool for the Understanding and Diagnosis of Polycystic Ovary Syndrome. Biomedicines 2022; 10:1254. [PMID: 35740276 PMCID: PMC9219683 DOI: 10.3390/biomedicines10061254] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) represents one of the leading causes of anovulatory infertility and affects 5% to 20% of women worldwide. Until today, both the subsequent etiology and pathophysiology of PCOS remain unclear, and patients with PCOS that undergo assisted reproductive techniques (ART) might present a poor to exaggerated response, low oocyte quality, ovarian hyperstimulation syndrome, as well as changes in the follicular fluid metabolites pattern. These abnormalities originate a decrease of Metaphase II (MII) oocytes and decreased rates for fertilization, cleavage, implantation, blastocyst conversion, poor egg to follicle ratio, and increased miscarriages. Focus on obtaining high-quality embryos has been taken into more consideration over the years. Nowadays, the use of metabolomic analysis in the quantification of proteins and peptides in biological matrices might predict, with more accuracy, the success in assisted reproductive technology. In this article, we review the use of human follicular fluid as the matrix in metabolomic analysis for diagnostic and ART predictor of success for PCOS patients.
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Affiliation(s)
- Ana Teresa Brinca
- Health Sciences Research Centre, Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã, Portugal; (A.T.B.); (Â.S.); (L.B.)
| | - Ana Cristina Ramalhinho
- Health Sciences Research Centre, Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã, Portugal; (A.T.B.); (Â.S.); (L.B.)
- Assisted Reproduction Laboratory of Academic Hospital of Cova da Beira, 6200-251 Covilhã, Portugal;
- C4-Cloud Computing Competence Centre, University of Beira Interior, 6201-001 Covilhã, Portugal
| | - Ângela Sousa
- Health Sciences Research Centre, Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã, Portugal; (A.T.B.); (Â.S.); (L.B.)
| | - António Hélio Oliani
- Assisted Reproduction Laboratory of Academic Hospital of Cova da Beira, 6200-251 Covilhã, Portugal;
- São José do Rio Preto School of Medicine, Gynaecology and Obstetrics, São José do Rio Preto 15090-000, Brazil
| | - Luiza Breitenfeld
- Health Sciences Research Centre, Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã, Portugal; (A.T.B.); (Â.S.); (L.B.)
- C4-Cloud Computing Competence Centre, University of Beira Interior, 6201-001 Covilhã, Portugal
| | - Luís A. Passarinha
- Health Sciences Research Centre, Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã, Portugal; (A.T.B.); (Â.S.); (L.B.)
- UCIBIO–Applied Molecular Biosciences Unit, Departament of Chemistry, NOVA School of Science and Technology, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal
- Associate Laboratory i4HB-Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA de Lisboa, 2819-516 Caparica, Portugal
- Laboratório de Fármaco-Toxicologia, UBIMedical, University of Beira Interior, 6200-284 Covilhã, Portugal
| | - Eugenia Gallardo
- Health Sciences Research Centre, Faculty of Health Sciences, University of Beira Interior, 6200-506 Covilhã, Portugal; (A.T.B.); (Â.S.); (L.B.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, University of Beira Interior, 6200-284 Covilhã, Portugal
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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.
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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
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Singh N, Mishra N, Dogra Y. Do basal Luteinizing Hormone and Luteinizing Hormone/Follicle-Stimulating Hormone Ratio Have Significance in Prognosticating the Outcome of In vitro Fertilization Cycles in Polycystic Ovary Syndrome? J Hum Reprod Sci 2021; 14:21-27. [PMID: 34083988 PMCID: PMC8057154 DOI: 10.4103/jhrs.jhrs_96_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/16/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022] Open
Abstract
Context: Tonic hypersecretion of luteinizing hormone (LH) appears to impact both fertility and pregnancy outcomes in women with polycystic ovary syndrome (PCOS). Aim: Whether high basal day 2/3 serum LH levels and day 2/3 LH/follicle-stimulating hormone (FSH) ratio affect in vitro fertilization (IVF) cycle outcomes in PCOS patients undergoing controlled ovarian hyperstimulation using gonadotropin-releasing hormone (GnRH) antagonists. Settings and Design: A retrospective cohort study was conducted in Assisted Reproductive Technique Center, Department of Obstetrics and Gynaecology, at a tertiary care institute, on PCOS patients undergoing IVF/intracytoplasmic sperm injection (ICSI) using GnRH antagonist protocol with human chorionic gonadotropin trigger between January 2014 to December 2019. Methods and Material: Data related to patient's age, body mass index, day 2/3 serum FSH, serum LH, day 2/3 LH/FSH ratio, and infertility treatment-related variables were collected from the patient record files. IVF cycle characteristics, number of oocytes retrieved, number of embryos transferred were also recorded. The clinical pregnancy rate per embryo transfer was calculated. Statistical Analysis: Statistical software SPSS IBM version 24.0 was used to analyze the data. Descriptive statistics such as mean, standard deviation , and range values were calculated. To compare the difference between the groups, the paired t-test was applied for continuous variables and the Chi-square test for categorical variables. A value of P < 0.05 was considered statistically significant. Results: High basal day 2/3 LH level and day 2/3 LH/FSH ratio have no statistically significant effect on embryos formed, embryo transferred, and clinical pregnancy rate. However, fertilization rates were significantly less in these groups. Conclusion: The elevated basal day 2/3 LH and LH/FSH ratio do not impair the outcome of GnRH antagonist protocol treated IVF/ICSI cycles in PCOS women.
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Affiliation(s)
- Neeta Singh
- Department of Obstetrics and Gynaecology, ART Center, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Mishra
- Department of Obstetrics and Gynaecology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
| | - Yogita Dogra
- Department of Obstetrics and Gynaecology, ART Center, All India Institute of Medical Sciences, New Delhi, India
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7
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Vanhauwaert PS. Síndrome de ovario poliquístico e infertilidad. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Haas DM, Hathaway TJ, Ramsey PS. Progestogen for preventing miscarriage in women with recurrent miscarriage of unclear etiology. Cochrane Database Syst Rev 2019; 2019:CD003511. [PMID: 31745982 PMCID: PMC6953238 DOI: 10.1002/14651858.cd003511.pub5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Progesterone, a female sex hormone, is known to induce secretory changes in the lining of the uterus essential for successful implantation of a fertilized egg. It has been suggested that a causative factor in many cases of miscarriage may be inadequate secretion of progesterone. Therefore, clinicians use progestogens (drugs that interact with the progesterone receptors), beginning in the first trimester of pregnancy, in an attempt to prevent spontaneous miscarriage. This is an update of a review, last published in 2013. Since publication of the 2018 update of this review, we have been advised that the Ismail 2017 study is currently the subject of an investigation by the Journal of Maternal-Fetal & Neonatal Medicine. We have now moved this study from 'included studies' to 'Characteristics of studies awaiting classification' until the outcome of the investigation is known. OBJECTIVES To assess the efficacy and safety of progestogens as a preventative therapy against recurrent miscarriage. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 July 2017) and reference lists from relevant articles, attempting to contact trial authors where necessary, and contacted experts in the field for unpublished works. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing progestogens with placebo or no treatment given in an effort to prevent miscarriage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two reviewers assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Twelve trials (1,856 women) met the inclusion criteria. Eight of the included trials compared treatment with placebo and the remaining four trials compared progestogen administration with no treatment. The trials were a mix of multicenter and single-center trials, conducted in India, Jordan, UK and USA. In five trials women had had three or more consecutive miscarriages and in seven trials women had suffered two or more consecutive miscarriages. Routes, dosage and duration of progestogen treatment varied across the trials. The majority of trials were at low risk of bias for most domains. Ten trials (1684 women) contributed data to the analyses. The meta-analysis of all women, suggests that there may be a reduction in the number of miscarriages for women given progestogen supplementation compared to placebo/controls (average risk ratio (RR) 0.73, 95% confidence interval (CI) 0.54 to 1.00, 10 trials, 1684 women, moderate-quality evidence). A subgroup analysis comparing placebo-controlled versus non-placebo-controlled trials, trials of women with three or more prior miscarriages compared to women with two or more miscarriages and different routes of administration showed no clear differences between subgroups for miscarriage. None of the trials reported on any secondary maternal outcomes, including severity of morning sickness, thromboembolic events, depression, admission to a special care unit, or subsequent fertility. There was probably a slight benefit for women receiving progestogen seen in the outcome of live birth rate (RR 1.07, 95% CI 1.00 to 1.13, 6 trials, 1411 women, moderate-quality evidence). We are uncertain about the effect on the rate of preterm birth because the evidence is very low-quality (RR 1.13, 95% CI 0.53 to 2.41, 4 trials, 256 women, very low-quality evidence). No clear differences were seen for women receiving progestogen for the other secondary outcomes including neonatal death, fetal genital abnormalities or stillbirth. There may be little or no difference in the rate of low birthweight and trials did not report on the secondary child outcomes of teratogenic effects or admission to a special care unit. AUTHORS' CONCLUSIONS For women with unexplained recurrent miscarriages, supplementation with progestogen therapy may reduce the rate of miscarriage in subsequent pregnancies.
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Affiliation(s)
- David M Haas
- Indiana University School of MedicineDepartment of Obstetrics and Gynecology1001 West 10th Street, F‐5IndianapolisIndianaUSA46202
| | - Taylor J Hathaway
- Indiana University School of MedicineDepartment of Obstetrics and Gynecology1001 West 10th Street, F‐5IndianapolisIndianaUSA46202
| | - Patrick S Ramsey
- Uniformed Services University of Health SciencesDivision of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyBethesdaMDUSA
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9
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Smith PP, Dhillon-Smith RK, O'Toole E, Cooper N, Coomarasamy A, Clark TJ. Outcomes in prevention and management of miscarriage trials: a systematic review. BJOG 2019; 126:176-189. [PMID: 30461160 DOI: 10.1111/1471-0528.15528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes. OBJECTIVE To review systematically, outcomes reported in existing miscarriage trials. SEARCH STRATEGY MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester. DATA COLLECTION AND ANALYSIS Data about the study characteristics, primary, and secondary outcomes were extracted. MAIN RESULTS We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation. CONCLUSIONS Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage. TWEETABLE ABSTRACT There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.
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Affiliation(s)
- P P Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - R K Dhillon-Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - E O'Toole
- Women's Voices Involvement Panel, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nam Cooper
- Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - T J Clark
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
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Haas DM, Hathaway TJ, Ramsey PS. Progestogen for preventing miscarriage in women with recurrent miscarriage of unclear etiology. Cochrane Database Syst Rev 2018; 10:CD003511. [PMID: 30298541 PMCID: PMC6516817 DOI: 10.1002/14651858.cd003511.pub4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Progesterone, a female sex hormone, is known to induce secretory changes in the lining of the uterus essential for successful implantation of a fertilized egg. It has been suggested that a causative factor in many cases of miscarriage may be inadequate secretion of progesterone. Therefore, clinicians use progestogens (drugs that interact with the progesterone receptors), beginning in the first trimester of pregnancy, in an attempt to prevent spontaneous miscarriage. This is an update of a review, last published in 2013. OBJECTIVES To assess the efficacy and safety of progestogens as a preventative therapy against recurrent miscarriage. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 July 2017) and reference lists from relevant articles, attempting to contact trial authors where necessary, and contacted experts in the field for unpublished works. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing progestogens with placebo or no treatment given in an effort to prevent miscarriage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two reviewers assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Thirteen trials (2556 women) met the inclusion criteria. Nine of the included trials compared treatment with placebo and the remaining four trials compared progestogen administration with no treatment. The trials were a mix of multicenter and single-center trials, conducted in Egypt, India, Jordan, UK and USA. In six trials women had had three or more consecutive miscarriages and in seven trials women had suffered two or more consecutive miscarriages. Routes, dosage and duration of progestogen treatment varied across the trials. The majority of trials were at low risk of bias for most domains. Eleven trials (2359 women) contributed data to the analyses.The meta-analysis of all women, suggests that there is probably a reduction in the number of miscarriages for women given progestogen supplementation compared to placebo/controls (average risk ratio (RR) 0.69, 95% confidence interval (CI) 0.51 to 0.92, 11 trials, 2359 women, moderate-quality evidence). A subgroup analysis comparing placebo-controlled versus non-placebo-controlled trials and different routes of administration showed no differences between subgroups for miscarriage. However, there appears to be a subgroup difference for miscarriage between women with three or more prior miscarriages compared to women with two or more miscarriages, with a more pronounced effect in women with three or more prior miscarriages. However, it should be noted that there was high heterogeneity in the subgroup of women with three or more prior miscarriages.None of the trials reported on any secondary maternal outcomes, including severity of morning sickness, thromboembolic events, depression, admission to a special care unit, or subsequent fertility.There was probably a slight benefit for women receiving progestogen seen in the outcome of live birth rate (RR 1.11, 95% CI 1.00 to 1.24, 7 trials, 2086 women, moderate-quality evidence). While the rate of preterm birth is probably reduced for women receiving progestogen, this outcome was mainly driven by one trial and thus should be interpreted with great caution (RR 0.59, 95% CI 0.39 to 0.89, 5 trials, 811 women, moderate-quality evidence). No clear differences were seen for women receiving progestogen for the other secondary outcomes of neonatal death or fetal genital abnormalities. A possible reduction in stillbirth was seen, but again this outcome was driven mainly by one trial and should be interpreted with caution (RR 0.38, 95% CI 0.24 to 0.58, 3 trials, 1199 women). There may be little or no difference in the rate of low birthweight and trials did not report on the secondary child outcomes of teratogenic effects or admission to a special care unit. AUTHORS' CONCLUSIONS For women with unexplained recurrent miscarriages, supplementation with progestogen therapy probably reduces the rate of miscarriage in subsequent pregnancies.
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Affiliation(s)
- David M Haas
- Indiana University School of MedicineDepartment of Obstetrics and Gynecology1001 West 10th Street, F‐5IndianapolisUSA46202
| | - Taylor J Hathaway
- Indiana University School of MedicineDepartment of Obstetrics and Gynecology1001 West 10th Street, F‐5IndianapolisUSA46202
| | - Patrick S Ramsey
- Uniformed Services University of Health SciencesDivision of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyBethesdaUSA
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Daniel S, Rotem R, Koren G, Lunenfeld E, Levy A. Vaginal antimycotics and the risk for spontaneous abortions. Am J Obstet Gynecol 2018; 218:601.e1-601.e7. [PMID: 29510088 DOI: 10.1016/j.ajog.2018.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/18/2018] [Accepted: 02/26/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Spontaneous abortions are the most common complication of pregnancy. Clotrimazole and miconazole are widely used vaginal-antimycotic agents used for the treatment of vulvovaginal candidiasis. A previous study has suggested an increased risk of miscarriage associated with these azoles, which may lead health professionals to refrain from their use even if clinically indicated. OBJECTIVE The aim of the current study was to assess the risk for spontaneous abortions following first trimester exposure to vaginal antimycotics. STUDY DESIGN A historical cohort study was conducted including all clinically apparent pregnancies that began from January 2003 through December 2009 and admitted for birth or spontaneous abortion at Soroka Medical Center, Clalit Health Services, Beer-Sheva, Israel. A computerized database of medication dispensation was linked with 2 computerized databases containing information on births and spontaneous abortions. Time-varying Cox regression models were constructed adjusting for mother's age, diabetes mellitus, hypothyroidism, obesity, hypercoagulable or inflammatory conditions, recurrent miscarriages, intrauterine contraceptive device, ethnicity, tobacco use, and the year of admission. RESULTS A total of 65,457 pregnancies were included in the study: 58,949 (90.1%) ended with birth and 6508 (9.9%) with a spontaneous abortion. Overall, 3246 (5%) pregnancies were exposed to vaginal antimycotic medications until the 20th gestational week: 2712 (4.2%) were exposed to clotrimazole and 633 (1%) to miconazole. Exposure to vaginal antimycotics was not associated with spontaneous abortions as a group (crude hazard ratio, 1.11; 95% confidence interval, 0.96-1.29; adjusted hazard ratio, 1.11; 95% confidence interval, 0.96-1.29) and specifically for clotrimazole (adjusted hazard ratio, 1.05; 95% confidence interval, 0.89-1.25) and miconazole (adjusted hazard ratio, 1.34; 95% confidence interval, 0.99-1.80). Furthermore, no association was found between categories of dosage of vaginal antimycotics and spontaneous abortions. CONCLUSION Exposure to vaginal antimycotics was not associated with spontaneous abortions.
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Affiliation(s)
- Sharon Daniel
- Department of Public Health, Beer-Sheva, Israel; Faculty of Health Sciences, Beer-Sheva, Israel; Clalit Health Services (Southern District), Beer-Sheva, Israel
| | - Reut Rotem
- Department of Public Health, Beer-Sheva, Israel; Faculty of Health Sciences, Beer-Sheva, Israel
| | - Gideon Koren
- Faculty of Health Sciences, Beer-Sheva, Israel; Motherisk Israel and Maccabi Health Services, Tel Aviv, Israel
| | - Eitan Lunenfeld
- Department of Obstetrics and Gynecology, Beer-Sheva, Israel; Faculty of Health Sciences, Beer-Sheva, Israel; Ben-Gurion University of the Negev, Soroka Medical Center, Beer-Sheva, Israel
| | - Amalia Levy
- Department of Public Health, Beer-Sheva, Israel; Faculty of Health Sciences, Beer-Sheva, Israel.
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Hackbart KS, Bender RW, Carvalho PD, Vieira LM, Dresch AR, Guenther JN, Gencoglu H, Nascimento AB, Shaver RD, Wiltbank MC. Effects of propylene glycol or elevated luteinizing hormone during follicle development on ovulation, fertilization, and early embryo development. Biol Reprod 2017; 97:550-563. [PMID: 28575154 PMCID: PMC6248555 DOI: 10.1093/biolre/iox050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 05/27/2017] [Indexed: 12/31/2022] Open
Abstract
Seventeen nonlactating Holstein cows were superovulated in a Latin-square designed experiment to determine the effects of increased propylene glycol (PROP) and luteinizing hormone (LH) during antral follicle development on ovarian function, fertilization, and early embryo quality. PROP was orally drenched every 4 h for 7 days to induce hyperinsulinemia and associated metabolic changes. LH concentrations were altered by increasing LH (3-fold) during last 2 days of superovulation. Treatment groups were as follows: (1) control-oral drenching with water plus low-LH preparation; (2) high LH(HLH)-water plus HLH preparation; (3) PROP-drenching with PROP plus low LH; (4) PROP/HLH-PROP plus HLH. PROP increased glucose (P < 0.05) and insulin (P < 0.02) concentrations at all time points analyzed. Neither PROP nor LH affected numbers of follicles > 9 mm at time of gonadotropin-releasing hormone-induced LH surge, although percentage of these follicles that ovulated was decreased by both PROP (P = 0.002) and LH (P = 0.048). In addition, PROP tended (P = 0.056) to decrease total number of ovulations. PROP reduced (P = 0.028) fertilization rate, while LH tended (P = 0.092) to increase fertilization rate. There was no effect of either PROP or LH on any measure of embryo quality including percentage of embryos that were degenerate, quality 1, or quality 1 and 2 of total structures collected or fertilized structures. These results indicate that acute elevation in insulin during the preovulatory follicular wave can decrease percentage of large follicles that ovulate, particularly when combined with increased LH, and reduce fertilization of ovulated oocytes.
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Affiliation(s)
- Katherine S Hackbart
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
- Endocrinology & Reproductive Physiology Program, University of
Wisconsin–Madison, Madison, WI, USA
| | - Robb W Bender
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Paulo D Carvalho
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Lais M Vieira
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
- University of Sao Paulo-VRA, Sao Paulo, Brazil
| | - Ana R Dresch
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Jerry N Guenther
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Hidir Gencoglu
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Anibal B Nascimento
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Randy D Shaver
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Milo C Wiltbank
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
- Endocrinology & Reproductive Physiology Program, University of
Wisconsin–Madison, Madison, WI, USA
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Daniel S, Koren G, Lunenfeld E, Bilenko N, Ratzon R, Levy A. Fetal exposure to nonsteroidal anti-inflammatory drugs and spontaneous abortions. CMAJ 2014; 186:E177-82. [PMID: 24491470 DOI: 10.1503/cmaj.130605] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Spontaneous abortion is the most common complication of pregnancy. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used during pregnancy. Published data are inconsistent regarding the risk of spontaneous abortion following exposure to NSAIDs. METHODS We performed a historical cohort study involving all women who conceived between January 2003 and December 2009 and who were admitted for delivery or spontaneous abortion at Soroka Medical Center, Clalit Health Services, Israel. A computerized database of medication dispensation was linked with 2 computerized databases containing information on births and spontaneous abortions. We constructed time-varying Cox regression models and adjusted for maternal age, diabetes mellitus, hypothyroidism, obesity, hypercoagulation or inflammatory conditions, recurrent miscarriage, in vitro fertilization of the current pregnancy, intrauterine contraceptive device, ethnic background, tobacco use and year of admission. RESULTS The cohort included 65,457 women who conceived during the study period; of these, 58,949 (90.1%) were admitted for a birth and 6508 (9.9%) for spontaneous abortion. A total of 4495 (6.9%) pregnant women were exposed to NSAIDs during the study period. Exposure to NSAIDs was not an independent risk factor for spontaneous abortion (nonselective cyclooxygenase [COX] inhibitors: adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.99-1.22; selective COX-2 inhibitors: adjusted HR 1.43, 95% CI 0.79-2.59). There was no increased risk for specific NSAID drugs, except for a significantly increased risk with exposure to indomethacin (adjusted HR 2.8, 95% CI 1.70-4.69). We found no dose-response effect. INTERPRETATION We found no increased risk of spontaneous abortion following exposure to NSAIDs. Further research is needed to assess the risk following exposure to selective COX-2 inhibitors.
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Abstract
BACKGROUND Progesterone, a female sex hormone, is known to induce secretory changes in the lining of the uterus essential for successful implantation of a fertilized egg. It has been suggested that a causative factor in many cases of miscarriage may be inadequate secretion of progesterone. Therefore, progestogens have been used, beginning in the first trimester of pregnancy, in an attempt to prevent spontaneous miscarriage. OBJECTIVES To determine the efficacy and safety of progestogens as a preventative therapy against miscarriage. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 August 2013), reference lists from relevant articles, attempting to contact authors where necessary, and contacted experts in the field for unpublished works. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing progestogens with placebo or no treatment given in an effort to prevent miscarriage. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data. MAIN RESULTS Fourteen trials (2158 women) are included. The meta-analysis of all women, regardless of gravidity and number of previous miscarriages, showed no statistically significant difference in the risk of miscarriage between progestogen and placebo or no treatment groups (Peto odds ratio (Peto OR) 0.99; 95% confidence interval (CI) 0.78 to 1.24) and no statistically significant difference in the incidence of adverse effect in either mother or baby.A subgroup analysis of placebo controlled trials did not find a difference in the rate of miscarriage with the use of progestogen (10 trials, 1028 women; Peto OR 1.15; 95% CI 0.88 to 1.50).In a subgroup analysis of four trials involving women who had recurrent miscarriages (three or more consecutive miscarriages; four trials, 225 women), progestogen treatment showed a statistically significant decrease in miscarriage rate compared to placebo or no treatment (Peto OR 0.39; 95% CI 0.21 to 0.72). However, these four trials were of poorer methodological quality. No statistically significant differences were found between the route of administration of progestogen (oral, intramuscular, vaginal) versus placebo or no treatment. No significant differences in the rates of preterm birth, neonatal death, or fetal genital anomalies/virilization were found between progestogen therapy versus placebo/control. AUTHORS' CONCLUSIONS There is no evidence to support the routine use of progestogen to prevent miscarriage in early to mid-pregnancy. However, there seems to be evidence of benefit in women with a history of recurrent miscarriage. Treatment for these women may be warranted given the reduced rates of miscarriage in the treatment group and the finding of no statistically significant difference between treatment and control groups in rates of adverse effects suffered by either mother or baby in the available evidence. Larger trials are currently underway to inform treatment for this group of women.
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Affiliation(s)
- David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, 1001 West 10th Street, F-5, Indianapolis, Indiana, USA, IN 46202
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Current Concepts and New Trends in the Diagnosis and Management of Recurrent Miscarriage. Obstet Gynecol Surv 2013; 68:445-66. [DOI: 10.1097/ogx.0b013e31828aca19] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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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
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Abstract
Polycystic ovary syndrome affects 6 to 15% of reproductive age women worldwide. It is associated with increased risk of miscarriage, gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm delivery, and birth of small for gestational age infant. Many studies on issues relating to pathophysiology and management of these complications have been published recently. These issues are being reviewed here using relevant articles retrieved from Pubmed database, especially from those published in recent past.
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Affiliation(s)
| | | | - Thozhukat Sathyapalan
- Department of Academic Endocrinology, Diabetes and Metabolism, Hull York Medical School, Hull, United Kingdom
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Orvieto R, Meltcer S, Liberty G, Rabinson J, Anteby EY, Nahum R. Does day-3 LH/FSH ratio influence in vitro fertilization outcome in PCOS patients undergoing controlled ovarian hyperstimulation with different GnRH-analogue? Gynecol Endocrinol 2012; 28:422-4. [PMID: 22578028 DOI: 10.3109/09513590.2011.633661] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an attempt to evaluate whether high basal day-3 luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio affects IVF cycle outcome in polycystic ovary syndrome (PCOS) patients undergoing ovarian stimulation with either GnRH-agonist (n = 47) or antagonist (n = 104), we studied 151 IVF cycles: 119 in patients with basal LH/FSH <2 and 32 in patients with LH/FSH ≥ 2. The PCOS with high LH/FSH ratio achieved a non-significantly higher pregnancy rate using the GnRH-agonist (50% vs 17.9%, p = 0.2; respectively), as compared to the GnRH-antagonist protocols, probably due to the ability of the long GnRH-agonist protocol to induce a prolong and sustained reduction of the high basal LH milieu and avert its detrimental effect on oocyte quality and implantation potential.
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Affiliation(s)
- Raoul Orvieto
- Infertility and IVF Unit, Barzilai Medical Center, Ashkelon and Ben Gurion University of Negev, Beer Sheva, Israel.
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Araki T, Elias R, Rosenwaks Z, Poretsky L. Achieving a successful pregnancy in women with polycystic ovary syndrome. Endocrinol Metab Clin North Am 2011; 40:865-94. [PMID: 22108285 DOI: 10.1016/j.ecl.2011.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a disease of complex and still poorly understood cause and of variable phenotypes. It is characterized by anovulation, hyperandrogenism, and polycystic ovaries. Infertility is commonly present. A variety of methods has been used successfully to achieve pregnancy in women with PCOS. Maintenance of pregnancy is complicated by a higher rate of premature spontaneous abortions and high risk of gestational diabetes, hypertension, and preeclampsia. However, with careful monitoring and treatment, the outcome of pregnancy in most women with PCOS is excellent.
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Affiliation(s)
- Takako Araki
- Division of Endocrinology and Metabolism, Beth Israel Medical Center and Albert Einstein College of Medicine, NY 10003, USA
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Musters AM, Repping S, Korevaar JC, Mastenbroek S, Limpens J, van der Veen F, Goddijn M. Pregnancy outcome after preimplantation genetic screening or natural conception in couples with unexplained recurrent miscarriage: a systematic review of the best available evidence. Fertil Steril 2011; 95:2153-7, 2157.e1-3. [PMID: 21215967 DOI: 10.1016/j.fertnstert.2010.12.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 11/04/2010] [Accepted: 12/13/2010] [Indexed: 11/25/2022]
Abstract
The objective of this systematic review was to assess live birth rates and miscarriage rates after preimplantation genetic screening or natural conception for unexplained recurrent miscarriage. There were no randomized controlled trials or comparative studies found on this topic. Until data from randomized controlled trials become available, this review summarizes the best available evidence of the efficacy of preimplantation genetic screening vs. natural conception.
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Affiliation(s)
- Anna M Musters
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, University of Amsterdam, Amsterdam, the Netherlands.
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Affiliation(s)
- D Ware Branch
- University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA.
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Abstract
BACKGROUND Progesterone, a female sex hormone, is known to induce secretory changes in the lining of the uterus essential for successful implantation of a fertilised egg. It has been suggested that a causative factor in many cases of miscarriage may be inadequate secretion of progesterone. Therefore, progestogens have been used, beginning in the first trimester of pregnancy, in an attempt to prevent spontaneous miscarriage. OBJECTIVES To determine the efficacy and safety of progestogens as a preventative therapy against miscarriage. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to June 2006), EMBASE (1980 to June 2006), CINAHL (1982 to June 2006), NHMRC Clinical Trials Register (June 2006) and Meta-Register (June 2006). We searched references from relevant articles, attempting to contact authors where necessary, and contacted experts in the field for unpublished works. SELECTION CRITERIA Randomised or quasi-randomized controlled trials comparing progestogens with placebo or no treatment given in an effort to prevent miscarriage. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data. MAIN RESULTS Fifteen trials (2118 women) are included. The meta-analysis of all women, regardless of gravidity and number of previous miscarriages, showed no statistically significant difference in the risk of miscarriage between progestogen and placebo or no treatment groups (Peto odds ratio (Peto OR) 0.98; 95% confidence interval (CI) 0.78 to 1.24) and no statistically significant difference in the incidence of adverse effect in either mother or baby. In a subgroup analysis of three trials involving women who had recurrent miscarriages (three or more consecutive miscarriages), progestogen treatment showed a statistically significant decrease in miscarriage rate compared to placebo or no treatment (Peto OR 0.38; 95% CI 0.20 to 0.70). No statistically significant differences were found between the route of administration of progestogen (oral, intramuscular, vaginal) versus placebo or no treatment. AUTHORS' CONCLUSIONS There is no evidence to support the routine use of progestogen to prevent miscarriage in early to mid-pregnancy. However, there seems to be evidence of benefit in women with a history of recurrent miscarriage. Treatment for these women may be warranted given the reduced rates of miscarriage in the treatment group and the finding of no statistically significant difference between treatment and control groups in rates of adverse effects suffered by either mother or baby in the available evidence. Larger trials are currently underway to inform treatment for this group of women.
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Affiliation(s)
- David M Haas
- Indiana University School of Medicine, Wishard Memorial Hospital, 1001 West 10th Street, F-5, Indianapolis, IN 46202, USA
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24
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Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril 2008; 89:505-22. [DOI: 10.1016/j.fertnstert.2007.09.041] [Citation(s) in RCA: 563] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 09/18/2007] [Accepted: 09/18/2007] [Indexed: 12/16/2022]
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Cocksedge KA, Li TC, Saravelos SH, Metwally M. A reappraisal of the role of polycystic ovary syndrome in recurrent miscarriage. Reprod Biomed Online 2008; 17:151-60. [DOI: 10.1016/s1472-6483(10)60304-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Fetal wastage has many causes, but genetic factors are by far the most common. The earlier the pregnancy loss occurs, the greater the likelihood of genetic causation. Among first trimester abortions, 50% to 80% show chromosomal abnormalities, usually aneuploidy. This is greater than all other causes combined. Chromosomal numerical abnormalities can be recurrent and sporadic; failure to take this into account is a major pitfall in many reports addressing causation. Moreover, many causes of fetal wastage that are traditionally considered to be "nongenetic" are actually the result of perturbations of gene products-proteins. Among nongenetic causes of first trimester fetal wastage, the best established are thyroid abnormities; antifetal antibodies; and the inherited and acquired thrombophilias. The latter are more established in the second trimester. Uterine anomalies can lead to second trimester losses. Infections seem uncommon, and alloimmune causes are not validated.
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Affiliation(s)
- Joe Leigh Simpson
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.
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Vulpoi C, Lecomte C, Guilloteau D, Lecomte P. Ageing and reproduction: is polycystic ovary syndrome an exception? ANNALES D'ENDOCRINOLOGIE 2007; 68:45-50. [PMID: 17316546 DOI: 10.1016/j.ando.2006.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 11/13/2006] [Accepted: 12/20/2006] [Indexed: 10/22/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is a frequent cause of infertility. Despite an impressive number of reports, few have evaluated the influence of age upon fertility. We present the outcomes of three infertile women with PCOS who achieved spontaneous pregnancies when ageing. CASE REPORTS Three patients with PCOS were monitored for more than 20 years. PCOS was confirmed by clinical data (oligo/amenorrhoea, infertility, hirsutism), hormonal measures and ovarian ultrasonography. All three infertile patients were treated for several years using numerous ovulation induction protocols with varying responses. When ageing, they gained more regular cycles and spontaneously became pregnant at 39, 40 1/2 and 36 years of age, more than 5 years after induction treatment was stopped, and in spite of increasing weight in each of them. CONCLUSIONS These clinical observations suggest improved fertility in some PCOS ageing women. The positive impact of ageing on cycle regularisation in PCOS has recently been claimed but the fertility outcome was not evaluated. Ovary ageing results in diminution of the follicular cohort in both normal and PCOS women, associated with decreased inhibin B and anti-müllerian hormone (AMH) levels. Lower inhibin B levels induce FSH enhancement, with a rise in FSH rate per follicle which may determine better follicle maturation, regular and ovulatory cycles in PCOS ageing women. The best proof of this improved fertility was the occurrence of spontaneous pregnancies which never occurred previously.
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Affiliation(s)
- C Vulpoi
- Endocrine Unit, Medicine B, University Hospital Bretonneau, 2 bis, boulevard Tonnellé, 37047 Tours cedex 1, France
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Khattab S, Mohsen IA, Foutouh IA, Ramadan A, Moaz M, Al-Inany H. Metformin reduces abortion in pregnant women with polycystic ovary syndrome. Gynecol Endocrinol 2006; 22:680-4. [PMID: 17162710 DOI: 10.1080/09513590601010508] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Women with polycystic ovary syndrome (PCOS) are considered to be at increased risk of miscarriage. Since metformin has beneficial effects on the risk factors contributing to first-trimester abortion in PCOS patients, we hypothesized that metformin - owing to its metabolic, endocrine, vascular and anti-inflammatory effects - may reduce the incidence of first-trimester abortion in PCOS women. MATERIALS AND METHODS A prospective cohort study was set up to determine the beneficial effects of metformin on PCOS patients during pregnancy. Two hundred non-diabetic PCOS patients were evaluated while undergoing assisted reproduction. One hundred and twenty patients became pregnant while taking metformin, and continued taking metformin at a dose of 1000-2000 mg daily throughout pregnancy. Eighty women who discontinued metformin use at the time of conception or during pregnancy comprised the control group. RESULTS Both groups were similar with respect to all background characteristics (age, body mass index, waist/hip ratio, follicle-stimulating hormone, luteinizing hormone, estradiol and dehydroepiandrosterone sulfate levels). Rates of early pregnancy loss in the metformin group were 11.6% compared with 36.3% in the control group (p < 0.0001; odds ratio = 0.23, 95% confidence interval 0.11-0.42). CONCLUSIONS Administration of metformin throughout pregnancy to women with PCOS was associated with a marked and significant reduction in the rate of early pregnancy loss.
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Affiliation(s)
- Sherif Khattab
- Misr International Infertility & IVF Center, Misr International Hospital, Department of Obstetrics & Gynecology, Cairo University, Cairo, Egypt
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Abstract
PURPOSE OF REVIEW The majority of investigations and treatments offered to women with recurrent pregnancy loss are not evidence-based. In this review a critical analysis is given of the current management of recurrent pregnancy loss often recommended in meta-analyses and guidelines. RECENT FINDINGS Our knowledge of genetic, endocrine, thrombophilic and immunological causes of recurrent pregnancy loss has been improved significantly, primarily by the introduction of modern laboratory techniques. Most clinical trials in this area, however, are still subject to serious methodological flaws. SUMMARY At present, the clinician must base their clinical practice on the few high-quality observational studies and intervention trials available rather than on meta-analyses, as there is a scarcity of good clinical trials. More high-quality clinical studies are urgently needed in this area.
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Chung MT, Tsai YC, Chen SH, Loo TC, Tang HH, Lin LY. Influence of pituitary suppression with triphasic or monophasic oral contraceptives on the outcome of in vitro fertilization and embryo transfer. J Assist Reprod Genet 2006; 23:343-6. [PMID: 16912930 DOI: 10.1007/s10815-006-9056-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 07/11/2006] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare the clinical outcome of IVF treatment after pituitary suppression with two different oral contraceptives (OCs). METHODS 65 patients who received IVF treatment was classified into 2 groups based on the difference of OCs they used for pituitary suppression before ovarian hyperstimulation. Group 1 included 36 patients who received monophasic OCs. Group 2 included 29 patients who received triphastic OCs. Both groups received the OCs from the 5th day of the cycle for consecutive 21 days. The hormone profiles after OCs and clinical outcome of IVF treatment were compared between two groups. Two-sample t-tests and X2 tests were used for statistical analyses. P < 0.05 was considered statistically significant. RESULTS The mean age and basal hormone profiles were comparable between two groups. After ovulation suppression with different OCs, the day 2 FSH and LH value revealed statistically significant difference between two groups(4.2+/-1.8 vs 6.0+/-2.6; 2.7+/-2.0 vs 4.2+/-3.3 respectively). The numbers of oocyte per retrieval and fertilization rate were comparable between two groups, but higher quality embryos as revealed by the cleavage speed were noted in the triphastic OCs group. Although statistically not significant, higher implantation rate and pregnancy rate were also noted in the triphastic OCs group. CONCLUSIONS Different OCs for pituitary suppression can result in different hormone profiles. Ovulation induction in IVF treatment should be individualized according to these hormone changes to achieve the optimal clinical outcome. Triphastic OCs exceeds monophastic OCs in producing good quality embryo in IVF-ET treatment.
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Affiliation(s)
- Ming-Ting Chung
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Chimei Medical Center, Yung-Kang City, Tainan, Taiwan
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Abstract
Many human conceptions are genetically abnormal and end in miscarriage, which is the commonest complication of pregnancy. Recurrent miscarriage, the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. It is associated with psychological morbidity, and has often proven to be frustrating for both patient and clinician. A third of women attending specialist clinics are clinically depressed, and one in five have levels of anxiety that are similar to those in psychiatric outpatient populations. Many conventional beliefs about the cause and treatment of women with recurrent miscarriage have not withstood scrutiny, but progress has been made. Research has emphasised the importance of recurrent miscarriage in the range of reproductive failure linking subfertility and late pregnancy complications and has allowed us to reject practice based on anecdotal evidence in favour of evidence-based management.
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Affiliation(s)
- Raj Rai
- Department of Obstetrics and Gynaecology, St Mary's Campus, Imperial College London, Mint Wing, South Wharf Road, London W2 1PG, UK
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Dias S, McNamee R, Vail A. Evidence of improving quality of reporting of randomized controlled trials in subfertility. Hum Reprod 2006; 21:2617-27. [PMID: 16793995 DOI: 10.1093/humrep/del236] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The quality of randomized controlled trials (RCTs) in subfertility and their suitability for inclusion in meta-analyses have been assessed in the past and found to be insufficient. Our aim was to assess whether this quality has improved over time, particularly since the publication of the Consolidated Standards of Reporting Trials (CONSORT) statement, and to assess what proportion of trials could be included in the meta-analyses of pregnancy outcomes such as those included in Cochrane Reviews. METHODS A selection of subfertility trials published in 1990, 1996 and 2002 was collected from the Cochrane Menstrual Disorder and Subfertility Group (MDSG) database. Only trials published in English as full journal articles, claiming to be randomized and reporting on pregnancy outcomes, were included. RESULTS One hundred and sixty-four trials met our inclusion criteria. Twenty-four (15%) were found not to be randomized, despite claims, and only 10 trials (6%) provided adequate details on the methods of randomization and allocation concealment. Of these, only three had sufficient details extractable to allow for an intention-to-treat analysis of the outcome 'live birth'. CONCLUSIONS Although an improvement in some subfertility-specific issues was observed, the quality of reporting of RCTs still needs to improve to make them suitable for inclusion in meta-analyses such as those in the Cochrane Library.
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Affiliation(s)
- Sofia Dias
- Biostatistics Group, University of Manchester, Manchester, UK.
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34
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Hart R, Norman R. Polycystic ovarian syndrome--prognosis and outcomes. Best Pract Res Clin Obstet Gynaecol 2006; 20:751-78. [PMID: 16766228 DOI: 10.1016/j.bpobgyn.2006.04.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Polycystic ovarian syndrome (PCOS) is a condition that is present in 5-6% of women of reproductive age. It has potentially profound implications for women with regard to anovulatory infertility and symptoms related to elevated androgen levels. In addition, in later life women are prone to significant health problems related to hyperinsulinaemia, with an excess risk for diabetes and cardiovascular risk factors. Evidence suggests that the adverse features of PCOS can be ameliorated with lifestyle intervention, such as diet and exercise, while further short-term benefits related to ovulation and cardiac risk factors may be derived from medication with metformin. Evidence for the long-term use of metformin to protect against adverse cardiovascular outcomes and for the use of metformin throughout pregnancy to reduce the risk of miscarriage, gestational diabetes, pre-eclampsia and fetal macrosomia is still lacking.
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Affiliation(s)
- Roger Hart
- UWA School of Women's and Infants' Health, University of Western Australia, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA 6008, Australia.
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Affiliation(s)
- Shrita M Patel
- Division of Endocrinology, Diabetes, and Metabolism, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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36
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Christiansen OB, Nielsen HS, Kolte AM. Future directions of failed implantation and recurrent miscarriage research. Reprod Biomed Online 2006; 13:71-83. [PMID: 16820113 DOI: 10.1016/s1472-6483(10)62018-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recurrent implantation failure is today the major reason for women completing several IVF/intracytoplasmic sperm injection attempts without having achieved a child, and is probably also the explanation for many cases of unexplained infertility. Most causes of recurrent miscarriage are still poorly elucidated, but from a theoretical point of view recurrent implantation failure and recurrent miscarriage are suggested to have partly overlapping causes. Recent research has indeed documented that both syndromes can be caused by the same embryonic chromosomal abnormalities and the same maternal endocrine, thrombophilic and immunological disturbances. Consequently, many treatments attempting to normalize these abnormalities have been tested or are currently used in women with both recurrent implantation failure and recurrent miscarriage. However, no treatment for the two syndromes is at the moment sufficiently documented to justify its routine use. In this review, an overview is given regarding present knowledge about causes that may be common for recurrent implantation failure and recurrent miscarriage, and suggestions are put forward for future research that may significantly improve understanding and treatment options for the syndromes.
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Affiliation(s)
- Ole B Christiansen
- Fertility Clinic 4071, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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37
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Abstract
PURPOSE OF REVIEW This article reviews new concepts in the aetiology of recurrent miscarriage, presents new outcome data and evaluates new modalities of treatment for unexplained recurrent miscarriage. RECENT FINDINGS Preimplantation genetic diagnosis has been considered an option for couples who have structural chromosomal abnormalities or unexplained recurrent miscarriage. The association between thrombophilias and adverse pregnancy outcome is further reviewed. In relation to this, there is increasing support for the use of thromboprophylaxis in improving pregnancy outcome in women with inherited thrombophilias. Nonrandomized studies have shown that the reduction in insulin levels with metformin in insulin-resistant individuals may reduce miscarriage risk by restoring normal haemostasis and improving the endometrial milieu. With respect to immunological concepts there is now evidence to suggest that, in addition to a suppression of maternal cell-mediated immunity, some elements of the innate immune system are activated in successful pregnancies. SUMMARY With the exception of aspirin and heparin for the prevention of recurrent miscarriage in women with the antiphospholipid syndrome, no other suggested therapies for this heterogeneous group of patients have been evaluated in randomized controlled trials. These include thromboprophylaxis for inherited thrombophilias and use of insulin sensitizers in women with insulin resistance and/or polycystic ovarian syndrome. The role of the innate immune system in pregnancy was recently highlighted, and use of nonspecific therapies to suppress the maternal immune response to pregnancy should be reassessed.
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Affiliation(s)
- Belinda Carrington
- Department of Obstetrics and Gynaecology, Imperial College, St. Mary's Campus, London, UK.
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38
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Abstract
Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophic hypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Pulsatile GnRH has the same effectiveness as gonadotrophins and the advantage of the low multiple pregnancy rate. In polycystic ovary syndrome (PCOS), the first treatment choice is clomiphene citrate. With this drug, in properly selected patients, the cumulative pregnancy rate approaches that of normal women. Low-dose protocols of FSH are the second line of treatment, effective in inducing monofollicular development. Laparoscopic ovarian drilling can be an alternative but not as a first choice treatment in clomiphene-resistant patients. Other treatments, such as pulsatile GnRH and GnRH agonists, are hardly used today in PCOS. However, in obese women with PCOS, weight loss and exercise should be recommended as the first line of therapy. Newer agents including aromatase inhibitors and insulin sensitizers, although promising, need further evaluation.
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Affiliation(s)
- Ioannis E Messinis
- Department of Obstetrics and Gynaecology, University of Thessalia, Medical School, Larissa, Greece.
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Christiansen OB, Nybo Andersen AM, Bosch E, Daya S, Delves PJ, Hviid TV, Kutteh WH, Laird SM, Li TC, van der Ven K. Evidence-based investigations and treatments of recurrent pregnancy loss. Fertil Steril 2005; 83:821-39. [PMID: 15820784 DOI: 10.1016/j.fertnstert.2004.12.018] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Revised: 12/14/2004] [Accepted: 12/14/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To give an overview of currently used investigations and treatments offered to women with recurrent pregnancy loss (RPL) and, from an evidence-based point of view, to evaluate the usefulness of these interventions. DESIGN Ten experts on epidemiologic, genetic, anatomic, endocrinologic, thrombophilic, immunologic, and immunogenetic aspects of RPL discussed methodologic problems threatening the validity of research in RPL during and after an international workshop on the evidence-based management of RPL. CONCLUSION(S) Most RPL patients have several risk factors for miscarriage, and an extensive investigation for all major factors should always be undertaken. There is an urgent need for agreement concerning the thresholds for detecting what is normal and abnormal, irrespective of whether laboratory tests or uterine abnormalities are concerned. A series of lifestyle factors should be reported in future studies of RPL because they might modify the effect of laboratory or anatomic risk factors. More and larger randomized controlled trials, including trials of surgical procedures, are urgently needed, and to achieve this objective multiple centers have to collaborate. Current meta-analyses evaluating the efficacy of treatments of RPL are generally pooling very heterogeneous patient populations and treatments. It is recommended that future meta-analyses look at subsets of patients and treatment protocols that are more combinable.
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Affiliation(s)
- Ole B Christiansen
- Fertility Clinic 4071, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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40
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Checa MA, Requena A, Salvador C, Tur R, Callejo J, Espinós JJ, Fábregues F, Herrero J. Insulin-sensitizing agents: use in pregnancy and as therapy in polycystic ovary syndrome. Hum Reprod Update 2005; 11:375-90. [PMID: 15878899 DOI: 10.1093/humupd/dmi015] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Treatment with insulin-sensitizing agents is a relatively recent therapeutic strategy in women with polycystic ovary syndrome (PCOS) and insulin resistance. The key areas addressed in this review include PCOS and the development of type 2 diabetes mellitus and gestational diabetes, as well as the use of insulin-sensitizing agents, particularly metformin, in the management of infertility in obese and non-obese PCOS women. Treatment with metformin in PCOS women undergoing IVF and the use of metformin during gestation will be discussed. The challenge for the health care professional should be the appropriate utilization of pharmacotherapies to improve insulin sensitivity and lower circulating insulin levels resulting in beneficial changes in PCOS phenotype. Further research into the potential role of other insulin-sensitizing agents, such as pioglitazone and rosiglitazone, in the treatment of infertile women with PCOS is needed.
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Affiliation(s)
- M A Checa
- Department of Obstetrics and Gynecology, Hospital Universitari del Mar, Universitat Autónoma de Barcelona, Barcelona, Spain.
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41
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Abstract
BACKGROUND Miscarriage is pregnancy loss before 23 weeks of gestational age and it happens in 10% to 15% of pregnancies depending on maternal age and parity. It is associated with chromosomal defects in about a half or two thirds of cases. Many interventions have been used to prevent miscarriage but bed rest is probably the most commonly prescribed especially in cases of threatened miscarriage and history of previous miscarriage. Since the etiology of miscarriage in most of the cases is not related to an excess of activity, it is unlikely that bed rest could be an effective strategy to reduce spontaneous miscarriage. OBJECTIVES To evaluate the effect of prescription of bed rest during pregnancy to prevent miscarriage in women at high risk of miscarriage. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2004). In addition, we searched The Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, POPLINE, LILACS and EMBASE. SELECTION CRITERIA We included all published, unpublished and ongoing randomized trials with reported data which compare clinical outcomes in pregnant women who were prescribed bed rest in hospital or at home for preventing miscarriage compared with alternative care or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently assessed the methodological quality of included trials using the methods described in the Cochrane Reviewers' Handbook. Studies were included irrespective of their methodological quality. MAIN RESULTS Only two studies including 84 women were identified. There was no statistically significant difference in the risk of miscarriage in the bed rest group versus the no bed rest group (placebo or other treatment) (relative risk (RR) 1.54, 95% confidence interval (CI) 0.92 to 2.58). Neither bed rest in hospital nor bed rest at home showed a significant difference in the prevention of miscarriage. There was a higher risk of miscarriage in those women in the bed rest group than in those in the human chorionic gonadotrophin therapy group with no bed rest (RR 2.50, 95% CI 1.22 to 5.11). It seems that the small number of participants included in these studies is a main factor to make this analysis inconclusive. AUTHORS' CONCLUSIONS There is insufficient evidence of high quality that supports a policy of bed rest in order to prevent miscarriage in women with confirmed fetal viability and vaginal bleeding in first half of pregnancy.
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Affiliation(s)
- Alicia Aleman
- School of Medicine ‐ University of UruguayPreventive Medicine3051 Alfredo NavarroMontevideoUruguay11600
| | - Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy (IECS)Department of Mother and Child Health ResearchBuenos AiresArgentina
| | - José M Belizán
- Institute for Clinical Effectiveness and Health Policy (IECS)Department of Mother and Child Health ResearchBuenos AiresArgentina
| | - Eduardo Bergel
- World Health OrganizationStatistics and Informatics Services, Reproductive Health and ResearchGeneva 27Switzerland1211
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42
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Abstract
Recurrent miscarriage, the occurrence of three consecutive first-trimester losses of pregnancy, affects 1% of women. The purported causes of recurrent miscarriage include chromosomal abnormalities, thrombophilia, metabolic disorders, anatomical causes and immune factors. At present, the only recommended investigations are testing for lupus anticoagulant and anticardiolipin antibody levels (to diagnose antiphospholipid syndrome, an acquired thrombophilia) and the karyotyping of both parents for chromosomal abnormalities. Women with antiphospholipid syndrome should be offered treatment with aspirin and low molecular weight heparin. Couples with chromosomal abnormalities should be referred to a clinical geneticist with whom the options of prenatal diagnosis, pre-implantation genetic diagnosis, donor gametes and adoption in subsequent pregnancies should be discussed. Couples with unexplained recurrent miscarriage should be offered appropriate emotional support and reassurance that they have a good prognosis for future pregnancies.
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Affiliation(s)
- Andrew W Horne
- Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK.
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44
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van der Spuy ZM, Dyer SJ. The pathogenesis of infertility and early pregnancy loss in polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol 2005; 18:755-71. [PMID: 15380145 DOI: 10.1016/j.bpobgyn.2004.06.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Women with polycystic ovary syndrome (PCOS) frequently present with reproductive dysfunction. Ovarian function might be disturbed, with resultant abnormal folliculogenesis and steroidogenesis and, although it is difficult to define the exact pathogenesis of anovulation, many possible mechanisms have been postulated. Folliculogenesis in anovulatory women with PCOS is characterized by failure of dominance and the ovary has multiple small follicles, which are arrested but capable of steroidogenesis. Abnormalities in gonadotrophin and insulin secretion and disordered paracrine function have been identified. Women with PCOS have an increased prevalence of miscarriage, both after spontaneous and induced ovulation. Hypersecretion of LH, hyperandrogenaemia and hyperinsulinaemia have all been investigated as possible causes of PCOS. It is likely that these factors are interlinked and together might result in disordered ovarian and endometrial function. Multiple other possible abnormalities have been postulated as contributory factors in the reproductive failure. These include decreased plasminogen activator inhibitor activity, endothelial dysfunction and obesity. Ideally, therapy should target the underlying disorders but at present data are inadequate and further investigations are essential before therapeutic recommendations are truly based on an understanding of the pathophysiology.
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Affiliation(s)
- Zephne M van der Spuy
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town/Groote Schuur Hospital, Anzio Road, Observatory 7935, Cape Town, South Africa.
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45
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von Wolff M, Strowitzki T. Habituelle Aborte—ein multifaktorielles Krankheitsbild. GYNAKOLOGISCHE ENDOKRINOLOGIE 2005. [DOI: 10.1007/s10304-004-0095-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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46
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Symposium. Evidence based management of anovulation. HUM FERTIL 2004; 7:183-208. [PMID: 15590572 DOI: 10.1080/14647270400006895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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47
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Ozturk O, Saridogan E, Jauniaux E. Drug intervention in early pregnancy after assisted reproductive technology. Reprod Biomed Online 2004; 9:452-65. [PMID: 15511349 DOI: 10.1016/s1472-6483(10)61283-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Implantation in humans is a complex, closely regulated, highly selective and relatively poorly understood process. Humans have the highest rate of miscarriage in mammals and various pharmacological manipulations have been used to minimize pregnancy losses in both spontaneous pregnancies and pregnancies resulting from assisted reproduction technology. The widespread application of protocols using numerous drugs in assisted reproduction treatment has led to an increasing number of pregnancies exposed to these drugs. The vast majority of these protocols have been based on data from a few observational and often retrospective clinical studies. This paper reviews the recent literature on drug interventions in early pregnancy after assisted reproduction treatment. It is concluded that there are still numerous issues about the safety of most drugs for both the women and their fetus. In many cases, the benefits are theoretical and the possible long-term side-effects are untested. There is an urgent need for more epidemiological studies and randomized controlled trials to explore the use, efficacy and side-effects of both old and new drugs in early pregnancy after assisted reproduction treatment.
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MESH Headings
- Abortion, Habitual/etiology
- Abortion, Habitual/therapy
- Abortion, Spontaneous/epidemiology
- Abortion, Spontaneous/etiology
- Abortion, Spontaneous/prevention & control
- Antibodies, Antiphospholipid/blood
- Antiphospholipid Syndrome/complications
- Endometriosis/complications
- Endometriosis/therapy
- Female
- Humans
- Hyperprolactinemia/complications
- Hyperprolactinemia/physiopathology
- Hyperprolactinemia/therapy
- Infertility, Female/etiology
- Infertility, Female/immunology
- Infertility, Female/therapy
- Luteal Phase/physiology
- Oxidative Stress
- Polycystic Ovary Syndrome/complications
- Polycystic Ovary Syndrome/therapy
- Pregnancy
- Pregnancy Maintenance/drug effects
- Reproductive Techniques, Assisted
- Uterus/blood supply
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Affiliation(s)
- Ozkan Ozturk
- Academic Department of Obstetrics and Gynaecology, University College London Hospitals, 86-96 Chenies Mews, London, WC1E 6HX, UK
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48
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Hart R, Hickey M, Franks S. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol 2004; 18:671-83. [PMID: 15380140 DOI: 10.1016/j.bpobgyn.2004.05.001] [Citation(s) in RCA: 183] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Polycystic ovarian morphology is seen on ultrasound in approximately 22% of women. Polycystic ovary syndrome (PCOS) is a common and perplexing endocrine disorder of women in their reproductive years, with a prevalence of up to 10%. Clinical expression of the syndrome varies but commonly includes menstrual cycle disturbance, hyperandrogenism, insulin resistance and obesity. Recently, the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine (ESHRE/ASRM) achieved a new consensus regarding the definition of PCOS. This is now defined as the presence of any two of the following three criteria: (i) polycystic ovaries; (ii) oligo-/anovulation; and/or (iii) clinical or biochemical evidence of hyperandrogenism. This revised definition provides an international framework for the clinical assessment of PCOS and for future research and collaboration.
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Affiliation(s)
- Roger Hart
- UWA School of Women's and Infants' Health, King Edward Memorial Hospital, University of Western Australia, 375 Bagot Road, WA 6008 Subiaco, Perth, Australia.
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49
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Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81:19-25. [PMID: 14711538 DOI: 10.1016/j.fertnstert.2003.10.004] [Citation(s) in RCA: 3763] [Impact Index Per Article: 188.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since the 1990 National Institutes of Health-sponsored conference on polycystic ovary syndrome (PCOS), it has become appreciated that the syndrome encompasses a broader spectrum of signs and symptoms of ovarian dysfunction than those defined by the original diagnostic criteria. The 2003 Rotterdam consensus workshop concluded that PCOS is a syndrome of ovarian dysfunction along with the cardinal features hyperandrogenism and polycystic ovary (PCO) morphology. PCOS remains a syndrome, and as such no single diagnostic criterion (such as hyperandrogenism or PCO) is sufficient for clinical diagnosis. Its clinical manifestations may include menstrual irregularities, signs of androgen excess, and obesity. Insulin resistance and elevated serum LH levels are also common features in PCOS. PCOS is associated with an increased risk of type 2 diabetes and cardiovascular events.
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50
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Milsom SR, Sowter MC, Carter MA, Knox BS, Gunn AJ. LH levels in women with polycystic ovarian syndrome: have modern assays made them irrelevant? BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02528.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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