Chlorination by-products in drinking water and menstrual cycle function

Urinary biomarkers of drinking-water disinfection byproducts in relation to diminished ovarian reserve risk: A case-control study from the TREE cohort

BACKGROUND

Disinfection byproducts (DBPs) as ovarian toxicants have been documented in toxicological studies. However, no human studies have explored the effects of exposure to DBPs on diminished ovarian reserve (DOR).

OBJECTIVE

To assess whether urinary biomarkers of exposure to drinking-water DBPs were associated with DOR risk.

METHODS

A total of 311 women undergoing assisted reproductive technology were diagnosed with DOR in the Tongji Reproductive and Environmental (TREE) cohort from December 2018 to August 2021. The cases were matched to the controls with normal ovarian reserve function by age in a ratio of 1:1. Urinary trichloroacetic acid (TCAA) and dichloroacetic acid (DCAA) were quantified as biomarkers of drinking-water DBP exposures. The conditional logistic regression and restricted cubic spline (RCS) were used to explore urinary biomarkers of drinking-water DBP exposures in associations with the risk of DOR.

RESULTS

Elevated urinary DCAA levels were associated with higher DOR risk [adjusted odds ratio (OR) = 1.87; 95 % confidence interval (CI): 1.16, 3.03 for the highest vs. lowest quartiles; P for trend = 0.016]. The association was confirmed in the RCS model, with a linear dose-response curve (P for overall association = 0.029 and P for non-linear association = 0.708). The subgroup analysis by age and body mass index (BMI) showed that urinary DCAA in association with DOR risk was observed among women ≥35 years old and leaner women (BMI < 24 kg/m2), but the group differences were not statistically significant. Moreover, a U-shaped dose-response curve between urinary TCAA and DOR risk was estimated in the RCS model (P for overall association = 0.011 and P for non-linear association = 0.004).

CONCLUSIONS

Exposure to drinking-water DBPs may contribute to the risk of DOR among women undergoing assisted reproductive technology.

Phthalate metabolites in urine and follicular fluid in relation to menstrual cycle characteristics in women seeking fertility assistance

BACKGROUND

Phthalates have been shown to disrupt the estrous cycle in animal studies. However, epidemiological research investigating their associations with menstrual cycle characteristics is limited.

OBJECTIVE

To explore the relationships between phthalate exposure and menstrual cycle characteristics among women seeking fertility assistance.

METHODS

We determined the levels of eight phthalate metabolites in both follicular fluid (FF) and urine specimens collected from 441 women in the Tongji Reproductive and Environmental (TREE) cohort, using high-performance liquid chromatography and tandem mass spectrometry. Information about menstrual cycle parameters was obtained through a questionnaire. The impacts of individual and joint exposure to phthalates on menstrual cycle characteristics were assessed using multivariable linear regression, Poisson regression, and quantile g-computation approaches.

RESULTS

After adjusting for relevant covariates, we found that per log10-unit increase in mono(2-ethylhexyl) phthalate (MEHP) level in urine specimens was associated with a decrease of 0.20 days (95 % CI: -0.37, -0.03) in bleeding duration. We also observed that mono(2-ethyl-5-carboxypentyl) phthalate (MECPP) and the sum of di(2-ethylhexyl) phthalate (DEHP) metabolites (∑DEHP) concentrations in FF samples were inversely related to cycle length [β = -1.92 (95 % CI: -3.10, -0.75) and -1.87 (95 % CI: -3.56, -0.19), respectively]. However, we generally observed null associations between phthalate metabolites and irregular cycle, dysmenorrhea, hypomenorrhea, or cycle length variation. Furthermore, we also found that phthalate metabolite mixtures in FF and urine were generally unrelated to menstrual cycle characteristics.

CONCLUSION

Our findings suggest that some DEHP metabolites in FF and urine are inversely associated with menstrual cycle length and menstrual bleeding duration in women attending a fertility center.

Associations between Urinary Concentrations of Disinfection Byproducts and in Vitro Fertilization Outcomes: A Prospective Cohort Study in China

BACKGROUND

Experimental studies show that disinfection byproducts (DBPs) can inhibit oocyte maturation, decrease fertilization capacity, and impair embryo development, but human evidence is lacking.

OBJECTIVES

We aimed to evaluate the associations between exposure to drinking water DBPs and in vitro fertilization (IVF) outcomes.

METHODS

The study included 1,048 women undergoing assisted reproductive technology (ART) treatment between December 2018 and January 2020 from a prospective cohort study, the Tongji Reproductive and Environmental study in Wuhan, China. Exposure to DBPs was assessed by dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) in up to four urine samples, which were collected on the day of both enrollment and oocyte retrieval. Multivariable generalized linear mixed models, accounting for multiple IVF cycles per woman, were applied to evaluate the associations between urinary biomarkers of DBP exposures and IVF outcomes. Stratified analyses were used to explore the potential effect modifiers.

RESULTS

The included 1,048 women underwent 1,136 IVF cycles, with 960 (91.6%), 84 (8.0%), and 4 (0.4%) women contributing one cycle, two cycles, and three cycles, respectively. We found that elevated quartiles of urinary DCAA and TCAA concentrations were associated with reduced numbers of total oocytes and metaphase II oocytes and that urinary DCAA concentrations with a lower proportion of best-quality embryos (all p for trends < 0.05 ). Moreover, elevated quartiles of urinary DCAA concentrations were associated with decreased proportions of successful implantation, clinical pregnancy, and live birth (14%, 15%, and 15% decreases in adjusted means comparing the extreme quartiles, respectively; all p for trends < 0.05 ). Stratification analyses showed that the inverse associations of urinary TCAA concentrations with multiple IVF outcomes were stronger among women ≥ 30 y of age (p for interactions < 0.05 ).

DISCUSSION

Exposure to drinking water DBPs was inversely associated with some IVF outcomes among women undergoing ART treatment. Further study is necessary to confirm our findings. https://doi.org/10.1289/EHP12447.

Associations between drinking water disinfection byproducts and menstrual cycle characteristics: A cross-sectional study among women attending an infertility clinic

Disinfection byproducts (DBPs) have been shown to alter ovarian steroidogenesis and cause estrous cyclicity disturbance and prolongation in experimental studies, however human studies are lacking. We aimed to evaluate the cross-sectional associations between drinking water DBPs and menstrual cycle characteristics. A total of 1078 women attending an infertility clinic in Wuhan, China were included between December 2018 and January 2020. Characteristics of menstrual cycle were collected by questionnaires. Concentrations of dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) were measured in urine as biomarkers of drinking water DBPs. Multivariate logistic and linear regression models were used to evaluate the associations between urinary DCAA and TCAA concentrations and menstrual cycle characteristics. Higher urinary DCAA concentrations were associated with increased odds ratios (ORs) of irregular menstrual cycle (OR = 1.80; 95% CI: 0.97, 3.33 for the highest vs. lowest quartile; P for trend = 0.05) and long menstrual cycle (OR = 1.62; 95% CI: 0.97, 2.70 for the highest vs. lowest quartile; P for trend = 0.06), as well as prolonged variation in cycle length (β = 1.27 days; 95% CI: -0.11, 2.66 for the highest vs. lowest quartile; P for trend = 0.04). Higher urinary TCAA concentrations were associated with prolonged bleeding duration (β = 0.23 days; 95% CI: -0.06, 0.51 for the highest vs. lowest quartile; P for trend = 0.07). These results suggest that exposure to drinking water DBPs is associated with menstrual cycle disturbances. These findings are warranted to confirm in other studies.

Urinary biomarkers of exposure to drinking water disinfection byproducts and ovarian reserve: A cross-sectional study in China

Experimental studies have demonstrated that disinfection byproducts (DBPs) can cause ovarian toxicity including inhibition of antral follicle growth and disruption of steroidogenesis, but there is a paucity of human evidence. We aimed to investigate whether urinary biomarkers of exposure to drinking water DBPs were associated with ovarian reserve. The present study included 956 women attending an infertility clinic in Wuhan, China from December 2018 to January 2020. Antral follicle count (AFC), ovarian volume (OV), anti-Mullerian hormone (AMH), and follicle-stimulating hormone (FSH) were measured as indicators of ovarian reserve. Urinary dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) were assessed as potential biomarkers of drinking water DBP exposures. Multivariate linear and Poisson regression models were applied to estimate the associations of urinary DCAA and TCAA concentrations with indicators of ovarian reserve. Elevated urinary DCAA and TCAA levels were monotonically associated with reduced total AFC (- 5.98%; 95% CI: - 10.30%, - 1.44% in DCAA and - 12.98%; 95% CI: - 17.00%, - 8.76% in TCAA comparing the extreme tertiles; both P for trends ≤ 0.01), and the former was only observed in right AFC but not in left AFC, whereas the latter was estimated for both right and left AFC. Moreover, elevated urinary TCAA levels were monotonically associated with decreased AMH (- 14.09%; 95% CI: - 24.79%, - 1.86% comparing the extreme tertiles; P for trend = 0.03). These negative associations were still observed for the exposure biomarkers modeled as continuous variables. Our findings suggest that exposure to drinking water DBPs may be associated with decreased ovarian reserve.

Impact of chloroform exposures on reproductive and developmental outcomes: A systematic review of the scientific literature

AIMS

We assessed the animal and epidemiological data to determine if chloroform exposure causes developmental and/or reproductive toxicity.

RESULTS AND DISCUSSION

Initial scoping identified developmental toxicity as the primary area of concern. At levels producing maternal toxicity in rats and mice, chloroform caused decrements in fetal weights and associated delays in ossification. In a single mouse inhalation study, exposure to a high concentration of chloroform was associated with small fetuses and increased cleft palate. However, oral exposure of mice to chloroform at a dose 4 times higher was negative for cleft palate; multiple inhalation studies in rats were also negative. Epidemiologic data on low birth weight and small for gestational age were generally equivocal, preventing conclusions from being drawn for humans. The animal data also show evidence of very early (peri-implantation) total litter losses at very high exposure levels. This effect is likely maternally mediated rather than a direct effect on the offspring. Finally, the epidemiologic data indicate a possible association of higher chloroform exposure with lower risk of preterm birth (<37 weeks gestation).

CONCLUSIONS

The available animal data suggest that exposures lower than those causing maternal toxicity should be without developmental effects in the offspring. Also, most studies in humans rely on group-level geographic exposure data, providing only weak epidemiologic evidence for an association with development outcomes and fail to establish a causal role for chloroform in the induction of adverse developmental outcomes at environmentally relevant concentrations.

Method to assess component contribution to toxicity of complex mixtures: Assessment of puberty acquisition in rats exposed to disinfection byproducts

A method based on regression modeling was developed to discern the contribution of component chemicals to the toxicity of highly complex, environmentally realistic mixtures of disinfection byproducts (DBPs). Chemical disinfection of drinking water forms DBP mixtures. Because of concerns about possible reproductive and developmental toxicity, a whole mixture (WM) of DBPs produced by chlorination of a water concentrate was administered as drinking water to Sprague-Dawley (S-D) rats in a multigenerational study. Age of puberty acquisition, i.e., preputial separation (PPS) and vaginal opening (VO), was examined in male and female offspring, respectively. When compared to controls, a slight, but statistically significant delay in puberty acquisition was observed in females but not in males. WM-induced differences in the age at puberty acquisition were compared to those reported in S-D rats administered either a defined mixture (DM) of nine regulated DBPs or individual DBPs. Regression models were developed using individual animal data on age at PPS or VO from the DM study. Puberty acquisition data reported in the WM and individual DBP studies were then compared with the DM models. The delay in puberty acquisition observed in the WM-treated female rats could not be distinguished from delays predicted by the DM regression model, suggesting that the nine regulated DBPs in the DM might account for much of the delay observed in the WM. This method is applicable to mixtures of other types of chemicals and other endpoints.

Overview of Disinfection By-products and Associated Health Effects

The presence of chemical compounds formed as disinfection by-products (DBPs) is widespread in developed countries, and virtually whole populations are exposed to these chemicals through ingestion, inhalation, or dermal absorption from drinking water and swimming pools. Epidemiological evidence has shown a consistent association between long-term exposure to trihalomethanes and the risk of bladder cancer, although the causal nature of the association is not conclusive. Evidence concerning other cancer sites is insufficient or mixed. Numerous studies have evaluated reproductive implications, including sperm quality, time to pregnancy, menstrual cycle, and pregnancy outcomes such as fetal loss, fetal growth, preterm delivery, and congenital malformation. The body of evidence suggests only minor effects from high exposure during pregnancy on fetal growth indices such as small for gestational age (SGA) at birth. Populations highly exposed to swimming pools such as pool workers and professional swimmers show a higher prevalence of respiratory symptoms and asthma, respectively, although the direction of the association, and thus causality, is not clear among professional swimmers. The risk of asthma, wheezing, eczema, and other respiratory outcomes among children attending swimming pools has been the object of extensive research. Early studies suggested a positive association, while subsequent larger studies found no correlations or showed a protective association. Future research should develop methods to evaluate the effects of the DBP mixture and the interaction with personal characteristics (e.g., genetics, lifestyle), clarify the association between swimming pools and respiratory health, evaluate the occurrence of DBPs in low- and middle-income countries, and evaluate outcomes suggested by animal studies that have not been considered in epidemiological investigations.

Overview of Emerging Contaminants and Associated Human Health Effects

In recent decades, because of significant progress in the analysis and detection of trace pollutants, emerging contaminants have been discovered and quantified in living beings and diverse environmental substances; however, the adverse effects of environmental exposure on the general population are largely unknown. This review summarizes the conclusions of the comprehensive epidemic literature and representative case reports relevant to emerging contaminants and the human body to address concerns about potential harmful health effects in the general population. The most prevalent emerging contaminants include perfluorinated compounds, water disinfection byproducts, gasoline additives, manufactured nanomaterials, human and veterinary pharmaceuticals, and UV-filters. Rare but statistically meaningful connections have been reported for a number of contaminants and cancer and reproductive risks. Because of contradictions in the outcomes of some investigations and the limited number of articles, no significant conclusions regarding the relationship between adverse effects on humans and extents of exposure can be drawn at this time. Here, we report that the current evidence is not conclusive and comprehensive and suggest prospective cohort studies in the future to evaluate the associations between human health outcomes and emerging environmental contaminants.

Anti-estrogenic activity formation potential assessment and precursor analysis in reclaimed water during chlorination

Chlorination was reported to increase the anti-estrogenic activity in reclaimed water from domestic wastewater treatment plants, which may add to the risk of reclaimed water reuse. In order to assess the anti-estrogenic disinfection by-product (DBP) precursors, the anti-estrogenic activity formation potential (AEAFP) during chlorination was studied. Firstly, the conditions for the experimental measurement of AEAFP were determined. A 24-h chlorination experiment was applied for AEAFP measurement. After chlorination, dechlorination using reductive reagents led to significant loss of anti-estrogenic activity formation. In addition, as the presence of ammonia nitrogen and other major chlorine consumers would result in lower anti-estrogenic activity formation, a basic chlorine dose of 3× DOC (mg-Cl2 L(-1)) was adequate for completely transforming the anti-estrogenic DBP precursors while an extra chlorine dose of 8× ammonia-nitrogen + 5× nitrite-nitrogen (mg-Cl2 L(-1)) should be added when there was a high level of ammonia nitrogen and nitrite nitrogen in the reclaimed water. Therefore, 24-h chlorination without dechlorination or using only non-reductive quenching reagents (e.g. ammonium) for dechlorination and a total chlorine dose of 3× DOC + 8× ammonia nitrogen + 5× nitrite nitrogen (mg-Cl2 L(-1)) should be fulfilled for the AEAFP measurement. Moreover, the AEAFP (0.2-2.1 mg-TAM L(-1)) of the reclaimed water samples (n = 20) were further analyzed. The AEAFP was highly correlated to UV254 and the fluorescence volume in excitation emission matrix fluorescence spectrum which can be used as surrogates to indicate the level of the AEAFP and assess the precursors in reclaimed water.

The impact of environmental and occupational exposures on reproductive health

Environmental exposures during critical periods of susceptibility in utero may result in lifelong or intergenerational adverse health effects. Most chemicals in commercial use in the United States have not been tested for possible developmental toxicity to fetuses, infants, and children. Environmental and occupational exposures can result in adverse effects on female and male reproduction. Nurses can identify at-risk patients, provide education about the impact of chemical toxicants, and empower women to take precautionary action.

Characterization and identification of antiestrogenic products of phenylalanine chlorination

Recent studies have reported that chlorination increased the antiestrogenic activity of wastewater, suggesting that disinfection by-products (DBPs) formed during chlorination is a potential and important source of endocrine-disruptor. However, antiestrogenic DBPs have not been identified. In this study, the antiestrogenic activity after aqueous chlorination of phenylalanine solution was evaluated by yeast two-hybrid assay and antiestrogenic DBPs were also identified and characterized. For the first time, aqueous chlorination of phenylalanine was found to form antiestrogenic DBPs when the antiestrogenic activity of chlorinated phenylalanine solution (0.5 mmol L(-1)) increased from undetectable to 57 mumol-tamoxifen (TAM) L(-1) with the increase in chlorine doses from 0 to 0.5 mmol-Cl2 L(-1). This level decreased sharply when chlorine addition went over 0.5 mmol-Cl2 L(-1). By fractionating DBPs of chlorinated phenylalanine solution into different fractions via semipreparative liquid chromatography, a key fraction with high antiestrogenic activity was discovered and collected. Based on analyses of mass spectrometry (MS) and nuclear magnetic resonance (NMR), the compound involved in this fraction (21 mg) was determined to be 2,4-diphenylcrotonaldehyde, which is newly identified as a relatively high antiestrogenic chemical.

Public health interpretation of trihalomethane blood levels in the United States: NHANES 1999-2004

Trihalomethanes (THMs) can form as byproducts during drinking water disinfection, which is crucial for limiting human exposure to disease-causing pathogens. The US Environmental Protection Agency (USEPA), recognizing both the importance of water disinfection for public health protection and potential risks associated with THM exposure, developed disinfection byproduct rules with the parallel goals of ensuring safe drinking water and limiting the levels of THMs in public water systems. The National Health and Nutrition Examination Survey (NHANES) THM blood data can be used as a means for assessing US population exposures to THMs; biomonitoring equivalents (BEs) can provide human health risk-based context to those data. In this paper, we examine the blood THM levels in the 1999-2004 NHANES data to (i) determine weighted population percentiles of blood THMs, (ii) explore whether gender and/or age are associated with blood THM levels, (iii) determine whether temporal trends can be discerned over the 6-year timeframe, and (iv) draw comparisons between population THM blood levels and BEs. A statistically significant decrease in blood chloroform levels was observed across the 1999-2004 time period. Age-related differences in blood chloroform levels were not consistent and no gender-related differences in blood chloroform levels were observed. The concentrations of all four THMs in the blood of US residents from the 2003 to 2004 NHANES dataset are below BEs consistent with the current US EPA reference doses. For bromodichloromethane and dibromochloromethane, the measured median blood concentrations in the United States are within the BEs for the 10(-6) and 10(-4) cancer risk range, whereas measured values for bromoform generally fall below the 10(-6) cancer risk range. These assessments indicate that general population blood concentrations of THMs are in a range considered to be a low to medium priority for risk assessment follow-up, according to the guidelines for interpretation of biomonitoring data using BEs.

Effect of chlorination on the estrogenic/antiestrogenic activities of biologically treated wastewater

Chlorination is widely used in wastewater reclamation, however harmful disinfection byproducts (DBPs) may be formed during disinfection. These DBPs are considered as a potential and important source of endocrine-disruption. In this study, the effects of chlorination on estrogenic and antiestrogenic activities in biologically treated wastewater were evaluated by yeast two-hybrid assay. For the first time, chlorination was found to increase the antiestrogenic activity of wastewater notably and decrease the estrogenic activity. By fractionating dissolved organic matter (DOM) in wastewater into different fractions, it was found that the polar compounds (PC) fraction of DOM was the key fraction involved in increasing antiestrogenic activity during chlorination of wastewater. Furthermore, fluorescence spectroscopy analysis on different fractions of soluble organic compounds in wastewater suggested that the PC fraction contained most of the aromatic amino acids and humic/fulvic acid, which were then demonstrated as the precursors of antiestrogenic DBPs through chlorination experiments of tryptophan, humic acid, and tannic acid.

Female reproductive disorders: the roles of endocrine-disrupting compounds and developmental timing

OBJECTIVE

To evaluate the possible role of endocrine-disrupting compounds (EDCs) on female reproductive disorders emphasizing developmental plasticity and the complexity of endocrine-dependent ontogeny of reproductive organs. Declining conception rates and the high incidence of female reproductive disruptions warrant evaluation of the impact of EDCs on female reproductive health.

DESIGN

Publications related to the contribution of EDCs to disorders of the ovary (aneuploidy, polycystic ovary syndrome, and altered cyclicity), uterus (endometriosis, uterine fibroids, fetal growth restriction, and pregnancy loss), breast (breast cancer, reduced duration of lactation), and pubertal timing were identified, reviewed, and summarized at a workshop.

CONCLUSION(S)

The data reviewed illustrate that EDCs contribute to numerous human female reproductive disorders and emphasize the sensitivity of early life-stage exposures. Many research gaps are identified that limit full understanding of the contribution of EDCs to female reproductive problems. Moreover, there is an urgent need to reduce the incidence of these reproductive disorders, which can be addressed by correlative studies on early life exposure and adult reproductive dysfunction together with tools to assess the specific exposures and methods to block their effects. This review of the EDC literature as it relates to female health provides an important platform on which women's health can be improved.

Proceedings of the Summit on Environmental Challenges to Reproductive Health and Fertility: executive summary

The 2007 Summit on Environmental Challenges to Reproductive Health and Fertility convened scientists, health care professionals, community groups, political representatives, and the media to hear presentations on the impact of environmental contaminants on reproductive health and fertility, and to discuss opportunities to improve health through research, education, communication, and policy. Environmental reproductive health focuses on exposures to environmental contaminants, particularly during critical periods of development, and their potential effects on future reproductive health, including conception, fertility, pregnancy, adolescent development, and adult health. Approximately 87,000 chemical substances are registered for commercial use in the United States, with ubiquitous human exposures to environmental contaminants in air, water, food, and consumer products. Exposures during critical windows of susceptibility may result in adverse effects with lifelong and even intergenerational health impacts. Effects can include impaired development and function of the reproductive tract and permanently altered gene expression, leading to metabolic and hormonal disorders, reduced fertility and fecundity, and illnesses such as testicular, prostate, uterine, and cervical cancers later in life. This executive summary reviews effects of pre- and postnatal exposures on male and female reproductive health, and provides a series of recommendations for advancing the field in the areas of research, policy, health care, and community action.

Science linking environmental contaminant exposures with fertility and reproductive health impacts in the adult female

STUDY OBJECTIVE

To broadly review the recent literature linking environmental factors and adult female reproductive health for the UCSF-CHE Summit on Environmental Challenges to Reproductive Health and Fertility.

DESIGN

Reviewed articles indexed in PubMed from 1999-2007 addressing environment and puberty, menstrual and ovarian function, fertility, and menopause.

RESULT(S)

The strongest evidence of environmental contaminant exposures interfering with healthy reproductive function in adult females is for heavy metals, particularly lead. Compounds that can influence hormone function, including pesticides and persistent pollutants, are also associated with risk. The pattern of effects for these endocrine-active compounds is often complex, with no clear dose response, but alterations in function and poor reproductive health outcomes are observed. From a clinical perspective, most modifiable risk appears to be associated with exposures in unique populations (contaminated fish consumers) or occupational groups (farmworkers). Many compounds have demonstrated increased risks for reproductive health impairment in women, but the literature is largely cross-sectional in nature and too sparse or inconclusive to support causal inference.

CONCLUSION(S)

Reproductive function in adult females is impaired by lead exposure. Pesticides and persistent pollutants can alter hormone function resulting in adverse reproductive health effects. Coordinated research is needed to address contaminant effects across the life span.

Proceedings of the Summit on Environmental Challenges to Reproductive Health and Fertility: executive summary

The 2007 Summit on Environmental Challenges to Reproductive Health and Fertility convened scientists, health care professionals, community groups, political representatives, and the media to hear presentations on the impact of environmental contaminants on reproductive health and fertility, and to discuss opportunities to improve health through research, education, communication, and policy. Environmental reproductive health focuses on exposures to environmental contaminants, particularly during critical periods of development, and their potential effects on future reproductive health, including conception, fertility, pregnancy, adolescent development, and adult health. Approximately 87,000 chemical substances are registered for commercial use in the United States, with ubiquitous human exposures to environmental contaminants in air, water, food, and consumer products. Exposures during critical windows of susceptibility may result in adverse effects with lifelong and even intergenerational health impacts. Effects can include impaired development and function of the reproductive tract and permanently altered gene expression, leading to metabolic and hormonal disorders, reduced fertility and fecundity, and illnesses such as testicular, prostate, uterine, and cervical cancers later in life. This executive summary reviews effects of pre- and postnatal exposures on male and female reproductive health, and provides a series of recommendations for advancing the field in the areas of research, policy, health care, and community action.

Research issues underlying the four-lab study: integrated disinfection by-products mixtures research

Chemical disinfection of drinking water is a major public health triumph of the 20th century, resulting in significant decreases in morbidity and mortality from waterborne diseases. Disinfection by-products (DBP) are chemicals formed by the reaction of oxidizing disinfectants with inorganic and organic materials in the source water. To address potential health concerns that cannot be answered directly by toxicological research on individual DBPs or defined DBP mixtures, scientists residing within the various organizations of the U.S. Environmental Protection Agency's Office of Research and Development (the National Health and Environmental Effects Research Laboratory, the National Risk Management Research Laboratory, the National Exposure Research Laboratory, and the National Center for Environmental Assessment) engaged in joint investigation of environmentally realistic complex mixtures of DBP. Research on complex mixtures of DBP is motivated by three factors: (a) DBP exposure is ubiquitous to all segments of the population; (b) some positive epidemiologic studies are suggestive of potential developmental, reproductive, or carcinogenic health effects in humans exposed to DBP; and (c) significant amounts of the material that makes up the total organic halide portion of the DBP have not been identified. The goal of the Integrated Disinfection Byproducts Mixtures Research Project (the 4Lab Study) is provision of sound, defensible, experimental data on environmentally relevant mixtures of DBP and an improved estimation of the potential health risks associated with exposure to the mixtures of DBP formed during disinfection of drinking water. A phased research plan was developed and implemented. The present series of articles provides the results from the first series of experiments.

Accuracy of reporting of menstrual cycle length

There are many studies based on self-reported menstrual cycle length, yet little is known about the validity of this measure. The authors used data collected in 1990 from 352 women born in Chicago, Illinois, aged 37-39 years. Women reported their usual cycle length and behavioral and reproductive characteristics at study enrollment and then completed daily menstrual diaries for up to 6 months. The authors compared this observed cycle length (geometric mean) with the reported length by using kappa coefficients. To assess systematic effects, they performed linear regression of the difference between reported and observed cycle length. Agreement between observed and reported cycle length was moderate. The crude overall kappa coefficient was 0.33; the kappa adjusted for within-woman sampling variability was 0.45 (95% confidence interval: 0.36, 0.55). On average, women overestimated their cycle length by 0.7 days (95% confidence interval: 0.3, 1.0). Reporting by sexually active women and women with a history of infertility was more accurate. Parity, body mass index, prior medical evaluation for irregular cycles, and exercise were all associated with systematic reporting differences. Studies that rely on self-reported cycle length could be prone to artifactual findings because of systematic covariate effects on reporting.

Integrated disinfection by-products research: assessing reproductive and developmental risks posed by complex disinfection by-product mixtures

This article presents a toxicologically-based risk assessment strategy for identifying the individual components or fractions of a complex mixture that are associated with its toxicity. The strategy relies on conventional component-based mixtures risk approaches such as dose addition, response addition, and analyses of interactions. Developmental toxicity data from two drinking-water concentrates containing disinfection by-products (DBP) mixtures were used to illustrate the strategy. The results of this study showed that future studies of DBP concentrates using the Chernoff-Kavlock bioassay need to consider evaluating DBP that are concentrated more than 130-fold and using a rat strain that is more sensitive to chemically-induced pregnancy loss than Sprague-Dawley rats. The results support the planned experimental design of a multigeneration reproductive and developmental study of DBP concentrates. Finally, this article discusses the need for a systematic evaluation of DBP concentrates obtained from multiple source waters and treatment types. The development of such a database could be useful in evaluating whether a specific DBP concentrate is sufficiently similar to tested combinations of source waters and treatment alternatives so that health risks for the former may be estimated using data on the latter.

Effects of bromodichloromethane on ex vivo and in vitro luteal function and bromodichloromethane tissue dosimetry in the pregnant F344 rat

Bromodichloromethane (BDCM), a drinking water disinfection by-product, causes pregnancy loss, i.e. full-litter resorption, in F344 rats when treated during the luteinizing hormone (LH)-dependent period. This effect is associated with reduced maternal serum progesterone (P) and LH levels, suggesting that BDCM disrupts secretion of LH. To test the hypothesis that BDCM also affects luteal responsiveness to LH, we used ex vivo and in vitro approaches. For the ex vivo study (i.e., in vivo exposure followed by in vitro assessment), dams were dosed by gavage on gestation days (GD) 6-9 (plug day=GD 0) at 0 or 100 mg/kg/d. One hour after the GD-9 dose, rats were killed, blood was collected, and tissue concentrations of BDCM were assessed. Corpora lutea (CL) were incubated with or without hCG, an LH agonist, to stimulate P secretion. For the in vitro study, CL were pooled from untreated F344 rats on GD 9 and cultured with BDCM at 0, 0.01, 0.10 or 3.0 mM. BDCM was found at highest concentrations in adrenal, ovarian, adipose, and hypothalamic tissues. BDCM treatment decreased serum P and LH levels in vivo. Ex vivo, however, BDCM-exposed CL showed >2-fold increases in P secretion relative to controls. Both control and BDCM-exposed CL displayed a 2.4-fold increase in P secretion in response to hCG challenge. In contrast, in vitro exposures reduced CL responsiveness in a dose-related fashion while baseline levels were unaffected. It is unclear if the ex vivo 'rebound' reflects the removal of the CL from a possible direct inhibitory influence of BDCM, or a response to diminished LH stimulation in vivo. Thus, these data suggest that BDCM disrupts pregnancy in F344 rats via two modes: disruption of LH secretion, and disruption of the CL's ability to respond to LH.

Updated weight of evidence for an association between adverse reproductive and developmental effects and exposure to disinfection by-products

Disinfection by-products (DBP) are produced when water is treated with chemical disinfectants. Some toxicological and epidemiological studies suggest an association between DBP exposure and adverse reproductive and developmental effects. In a previous critical review, [Graves, C.G., Matanoski, G.M., Tardiff, R.G., 2001. Weight of evidence for an association between adverse reproductive and developmental effects and exposure to disinfection by-products: a critical review. Regul. Toxicol. Pharmacol. 34, (2) 103-124] evaluated the weight of evidence for this exposure and these effects. This investigation updates the previous evaluation and considers all toxicological and epidemiological evidence since the earlier review and reassesses the weight-of-evidence for all of the data on the various effects, outcome by outcome. The updated toxicity weight of evidence found little indication of previously unreported reproductive or developmental toxicity. In particular, the recently published findings of an exceptionally well conducted cohort study of broad scope found no impact of chlorination by-products on the highly controversial outcome of spontaneous abortion, unlike predecessor studies of more limited methodology, leading the authors to recommend no further epidemiologic pursuit for this hypothesis since the cohort was scrutinized very closely and dispelled any concern of such an association. The updated epidemiologic weight of evidence demonstrated that no association with DBP exposure exists for over a dozen outcomes including low and very low birth weight, preterm delivery, some specific congenital anomalies, and neonatal death. The analysis found inconsistent or very weak results for all congenital anomalies/birth defects, all central nervous system anomalies, neural tube defects, and spontaneous abortion. As in the previous article, the updated weight of evidence suggested a positive association with DBP exposure and some measure of growth retardation such as intrauterine growth retardation, small for gestational age, term low birth weight, and small body length or head circumference. Exposure assessment in most epidemiological studies remains inadequate to definitively demonstrate any association of small magnitude.

Menstrual cycle characteristics: associations with fertility and spontaneous abortion

BACKGROUND

Epidemiologists often use menstrual cycle patterns as indicators of endocrine function in environmental and occupational studies, yet few studies have considered whether menstrual cycle characteristics are associated with fertility or pregnancy outcome.

METHODS

We prospectively studied 470 women to determine whether cycle length or bleed length were associated with fertility or spontaneous abortion. Women completed daily diaries with information on menstrual bleeding, intercourse, birth control use, and covariates. For each menstrual cycle, women collected at least 2 urine samples, which were assayed for human chorionic gonadotropin to define early pregnancies. Women were followed for 1 year or until the end of a clinical pregnancy.

RESULTS

Cycles with lengths of 30 to 31 days preceded cycles with the highest fecundity. Shorter cycles were less likely to be followed by conception (fecundity ratio [FR] = 0.6; 95% confidence interval [CI] = 0.4-1.0). Compared with 30- to 31-day cycles, conceptions after shorter and longer cycles were more likely to be spontaneously aborted (for shorter cycles, odds ratio [OR] = 3.0 [95% CI = 0.9-9.6] and for longer cycles, OR = 3.0 [0.9-10.6]). Cycles with 5 days of menstrual bleeding had the highest fecundity. Cycles with up to 4 days of bleeding had lower fecundity (for bleed lengths of 4 days, FR = 0.5 [0.3-0.8] and for bleed lengths less than 4 days, FR = 0.6 [0.3-0.9]). Spontaneous abortion was less likely after bleeds greater than 5 days (OR = 0.4 [0.1-1.1]) when compared with 5-day bleeds.

CONCLUSIONS

Menstrual cycle characteristics appear to be associated with fertility and spontaneous abortion.

Exposure to organochlorine compounds and effects on ovarian function

BACKGROUND

Some chemicals appear to have hormonally active properties in animals, but data in humans are sparse. Therefore, we examined ovarian function in relation to organochlorine compound levels.

METHODS

During 1997-1999, 50 Southeast Asian immigrant women of reproductive age collected urine samples daily. These samples were assayed for metabolites of estrogen and progesterone, and the women's menstrual cycle parameters were assessed. Organochlorine compounds (including DDT, its metabolite DDE, and 10 polychlorinated biphenyl [PCB] congeners) were measured in serum.

RESULTS

All samples had detectable DDT and DDE, with mean levels higher than typical U.S. populations. Mean cycle length was approximately 4 days shorter at the highest quartile concentration of DDT or DDE compared with the lowest. After adjustment for lipid levels, age, parity, and tubal ligation, and exclusion of a particularly long cycle, the decrements were attenuated to less than 1 day, with wide confidence intervals (CIs). The adjusted mean luteal phase length was shorter by approximately 1.5 days at the highest quartile of DDT (95% CI = -2.6 to -0.30) or DDE (-2.6 to -0.20). With each doubling of the DDE level, cycle length decreased 1.1 day (-2.4 to 0.23) and luteal phase length decreased 0.6 days (-1.1 to -0.2). Progesterone metabolite levels during the luteal phase were consistently decreased with higher DDE concentration. PCB levels were not generally associated with cycle length or hormone parameters after adjustment, and they did not alter the DDE associations when included in the same models.

CONCLUSIONS

This study indicates a potential effect of DDE on ovarian function, which may influence other end points such as fertility, pregnancy, and reproductive cancers.

The effect of boiling water on disinfection by-product exposure

Chloraminated and chlorinated waters containing bromide were used to determine the impact of boiling on disinfection by-product (DBP) concentrations. No significant changes were detected in the concentrations of the dihalogenated haloacetic acids (DXAAs) (i.e., dichloro-, bromochloro-, dibromoacetic acid) upon boiling of chloraminated water, whereas the levels of the trihalogenated haloacetic acids (TXAAs) (i.e., trichloro- (TCAA), bromodichloro- (BDCAA), dibromochloroacetic acid (DBCAA)) decreased over time (e.g., 9-37% for TCAA). Increased DXAA concentrations (58-68%) were detected in the boiled chlorinated sample, which likely resulted from residual chlorine reacting with DXAA precursors. TCAA concentration was unchanged after boiling chlorinated water for 1 min, but a 30% reduction was observed after 5 min of boiling. BDCAA concentrations decreased 57% upon boiling for 1 min and were completely removed after 2 min of boiling, whereas DBCAA was removed after boiling chlorinated water for 1 min. Trihalomethane concentrations were reduced in both chloraminated (74-98%) and chlorinated (64-98%) water upon boiling. Boiling chloraminated water for 1 min reduced chloroform concentration by 75%. Chloroform was reduced by only 34% in chlorinated water after a 1 min boil, which indicates that simultaneous formation and volatilization of chloroform was occurring. Most of the remaining DBPs (e.g. haloketones, chloral hydrate, haloacetonitriles) were removed by at least 90% after 1 min of boiling in both samples. These data suggest that other mechanisms (e.g., hydrolysis) may have been responsible for removal of the non-volatile DBPs and further highlight the importance of examining individual species when estimating thermal effects on DBP concentrations.