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Spitzer T, Diamond MP, Wild R, Legro R, Zhang H, Sun F, Ling S, Santoro N. The effect of improved metabolic syndrome parameters on live birth. Fertil Steril 2024:S0015-0282(24)00248-6. [PMID: 38641159 DOI: 10.1016/j.fertnstert.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To determine whether improvements in metabolic syndrome before ovarian stimulation with intrauterine insemination affects live birth among women with obesity and unexplained infertility after fertility treatment. DESIGN Secondary analysis of the randomized controlled clinical trial Improving Reproductive Fitness Through Pretreatment With Lifestyle Modification in Obese Women With Unexplained Infertility (FIT-PLESE). SUBJECTS Three hundred seventy-nine women with obesity and unexplained infertility who underwent standard infertility treatment after a lifestyle intervention. INTERVENTION The FIT-PLESE trial evaluated whether prepregnancy lifestyle interventions (diet with weight loss medication and exercise vs. exercise alone) before ovarian stimulation with intrauterine insemination improved the live birth rate among women with obesity and unexplained infertility. Utilizing FIT-PLESE data, we compared the association between improved Metabolic Syndrome (by diagnostic criteria parameters and Metabolic Syndrome Z-scores) and live birth in a subset of women who have Metabolic Syndrome. MAIN OUTCOME MEASURES Live birth by groups were compared using chi-square and Fisher's exact tests, and continuous variables were compared using Student's t-tests. Logistic regression was used to assess Metabolic Syndrome Z-score difference and live birth. RESULTS 191 study participants were diagnosed with Metabolic Syndrome at baseline. Thirty of these women exhibited a decline in the number of metabolic syndrome parameters and 33 had decline in their Metabolic Syndrome Z-scores during the preconception lifestyle intervention phase. There were no statistically significant differences in live birth among those who exhibited decline in the number of metabolic parameters compared to those who had no decline (33.3% versus 19.9%; p=0.102). Those who improved their Metabolic Syndrome Z-score had a live birth rate of 17.2% compared to 20.8% of those whose Metabolic Syndrome Z-scores were worsened or unchanged (p=0.055). CONCLUSION Analysis of the FIT-PLESE data was unable to demonstrate that women with improvement in Metabolic Syndrome prior to fertility treatment, as shown by decreased number of metabolic parameters and/or improved Metabolic Syndrome Z-scores, benefit with improved fertility and live birth outcomes.
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Affiliation(s)
- Trimble Spitzer
- Department of Gynecologic Surgery and Obstetrics. Uniformed Services University of Health Sciences, Bethesda MD, 20814 USA.
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta GA 30912, USA
| | - Robert Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City OK 73117, USA
| | - Richard Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey PA 16802, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven CT 06520, USA
| | - Fangbai Sun
- Department of Biostatistics, Yale University School of Public Health, New Haven CT 06520, USA
| | - Shen Ling
- Department of Biostatistics, Yale University School of Public Health, New Haven CT 06520, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora CO 80204, USA
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Goud PT, Goud AP, Camp OG, Bai D, Gonik B, Diamond MP, Abu-Soud HM. Chronological age enhances aging phenomena and protein nitration in oocyte. Front Endocrinol (Lausanne) 2023; 14:1251102. [PMID: 38149097 PMCID: PMC10749940 DOI: 10.3389/fendo.2023.1251102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023] Open
Abstract
Background The average age of childbearing has increased over the years contributing to infertility, miscarriages, and chromosomal abnormalities largely invoked by an age-related decline in oocyte quality. In this study, we investigate the role of nitric oxide (NO) insufficiency and protein nitration in oocyte chronological aging. Methods Mouse oocytes were retrieved from young breeders (YB, 8-14 weeks [w]), retired breeders (RB, 48-52w) and old animals (OA, 80-84w) at 13.5 and 17 hours after ovulation trigger. They were assessed for zona pellucida dissolution time (ZPDT); ooplasmic microtubule dynamics (OMD); cortical granule (CG) status and spindle morphology (SM), as markers of oocyte quality. Sibling oocytes from RB were exposed to NO supplementation and assessed for aging phenomena (AP). All oocyte cumulus complexes were subjected to fluorescence nitrotyrosine (NT) immunocytochemistry and confocal microscopy to assess morphology and protein nitration. Results At 13.5 h from hCG trigger, oocytes from RB compared to YB had significantly increased ZPDT (37.8 ± 11.9 vs 22.1 ± 4.1 seconds [s]), OMD (46.9 vs 0%), CG loss (39.4 vs 0%), and decreased normal SM (30.3 vs 81.3%), indicating premature AP that worsened among oocytes from RB at 17 hours post-hCG trigger. When exposed to SNAP, RB AP significantly decreased (ZPDT: 35.1 ± 5.5 vs 46.3 ± 8.9s, OMD: 13.3 vs 75.0% and CG loss: 50.0 vs 93.3%) and SM improved (80.0 vs 14.3%). The incidence of NT positivity was significantly higher in cumulus cells (13.5 h, 46.7 ± 4.5 vs 3.4 ± 0.7%; 17 h, 82.2 ± 2.9 vs 23.3 ± 3.6%) and oocytes (13.5 h, 57.1 vs 0%; 17 h, 100.0 vs 55.5%) from RB compared to YB. Oocytes retrieved decreased with advancing age (29.8 ± 4.1 per animal in the YB group compared to 10.2 ± 2.1 in RB and 4.0 ± 1.6 in OA). Oocytes from OA displayed increased ZPDT, major CG loss, increased OMD and spindle abnormalities, as well as pronuclear formation, confirming spontaneous meiosis to interphase transition. Conclusions Oocytes undergo zona pellucida hardening, altered spindle and ooplasmic microtubules, and premature cortical granule release, indicative of spontaneous meiosis-interphase transition, as a function of chronological aging. These changes are also associated with NO insufficiency and protein nitration and may be alleviated through supplementation with an NO-donor.
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Affiliation(s)
- Pravin T. Goud
- Laurel Fertility Center, San Francisco, CA, United States
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of California Davis Medical School, Sacramento, CA, United States
- Department of Obstetrics and Gynecology, University of California Davis Medical School, Sacramento, CA, United States
| | - Anuradha P. Goud
- Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, United States
| | - Olivia G. Camp
- Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, United States
| | - David Bai
- Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, United States
| | - Bernard Gonik
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Michael P. Diamond
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, United States
| | - Husam M. Abu-Soud
- Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, United States
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, United States
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Hosseinzadeh P, Peck JD, Burks HR, Souter I, Xing A, Craig LB, Diamond MP, Hansen KR. Follicular phase length is not related to live birth outcome in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination cycles in a multicenter trial. F S Rep 2023; 4:361-366. [PMID: 38204957 PMCID: PMC10774873 DOI: 10.1016/j.xfre.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 01/12/2024] Open
Abstract
Objective To evaluate the effect of follicular phase length (FPL) on pregnancy outcomes and endometrial thickness (ET) among women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination (OS-IUI) with clomiphene citrate, letrozole, or gonadotropins. Design Cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation randomized controlled trial. Setting Multicenter randomized controlled trial. Patients A total of 869 couples with unexplained infertility who underwent OS-IUI treatment cycles as part of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation study. Interventions FPL was evaluated as a categorical variable defined by quintiles (q1: ≤11 days, q2: 12 days, q3: 13 days, q4: 14-15 days, and q5: ≥16 days). Main outcome measures Clinical pregnancy, live birth rates, and ET. Results Decreasing FPL quintiles did not reduce clinical pregnancy or live birth rates in unadjusted or adjusted models with all treatment groups combined or when stratified by the ovarian stimulation medication. All FPL categories had significantly thinner ET compared with the 5th quintile (≥16 days) among women treated with clomiphene citrate or letrozole. Similar but diminished associations were observed among women who underwent ovarian stimulation with gonadotropins, but the observed differences were limited to those with FPL of 12 days or shorter when compared with FPL ≥16 days. Conclusions Although shorter FPL was associated with reduced ET, it was not associated with the outcomes of clinical pregnancy or live birth in women with unexplained infertility undergoing OS-IUI in all treatment groups combined. Similar patterns existed when analyses of clinical pregnancy and live birth rates were stratified by treatment. Clinical trial registration NCT01044862.
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Affiliation(s)
- Pardis Hosseinzadeh
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jennifer D. Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
- Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, Oklahoma
| | - Heather R. Burks
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Irene Souter
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Harvard Medical School, Massachusetts General Hospital Fertility Center, Boston, Massachusetts
| | - Angela Xing
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - LaTasha B. Craig
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Anchan RM, Spies JB, Zhang S, Wojdyla D, Bortoletto P, Terry K, Disler E, Milne A, Gargiulo A, Petrozza J, Brook O, Srouji S, Morton CC, Greenberg J, Wegienka G, Stewart EA, Nicholson WK, Thomas L, Venable S, Laughlin-Tommaso S, Diamond MP, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL. Long-term health-related quality of life and symptom severity following hysterectomy, myomectomy, or uterine artery embolization for the treatment of symptomatic uterine fibroids. Am J Obstet Gynecol 2023; 229:275.e1-275.e17. [PMID: 37244458 DOI: 10.1016/j.ajog.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Few studies have directly compared different surgical procedures for uterine fibroids with respect to long-term health-related quality of life outcomes and symptom improvement. OBJECTIVE We examined differences in change from baseline to 1-, 2-, and 3-year follow-up in health-related quality of life and symptom severity among patients who underwent abdominal myomectomy, laparoscopic or robotic myomectomy, abdominal hysterectomy, laparoscopic or robotic hysterectomy, or uterine artery embolization. STUDY DESIGN The COMPARE-UF registry is a multiinstitutional prospective observational cohort study of women undergoing treatment for uterine fibroids. A subset of 1384 women aged 31 to 45 years who underwent either abdominal myomectomy (n=237), laparoscopic myomectomy (n=272), abdominal hysterectomy (n=177), laparoscopic hysterectomy (n=522), or uterine artery embolization (n=176) were included in this analysis. We obtained demographics, fibroid history, and symptoms by questionnaires at enrollment and at 1, 2, and 3 years posttreatment. We used the UFS-QoL (Uterine Fibroid Symptom and Quality of Life) questionnaire to ascertain symptom severity and health-related quality of life scores among participants. To account for potential baseline differences across treatment groups, a propensity score model was used to derive overlap weights and compare total health-related quality of life and symptom severity scores after enrollment with a repeated measures model. For this health-related quality of life tool, a specific minimal clinically important difference has not been determined, but on the basis of previous research, a difference of 10 points was considered as a reasonable estimate. Use of this difference was agreed upon by the Steering Committee at the time when the analysis was planned. RESULTS At baseline, women undergoing hysterectomy and uterine artery embolization reported the lowest health-related quality of life scores and highest symptom severity scores compared with those undergoing abdominal myomectomy or laparoscopic myomectomy (P<.001). Those undergoing hysterectomy and uterine artery embolization reported the longest duration of fibroid symptoms with a mean of 6.3 years (standard deviation, 6.7; P<.001). The most common fibroid symptoms were menorrhagia (75.3%), bulk symptoms (74.2%), and bloating (73.2%). More than half (54.9%) of participants reported anemia, and 9.4% women reported a history of blood transfusion. Across all modalities, total health-related quality of life and symptom severity score markedly improved from baseline to 1-year with the largest improvement in the laparoscopic hysterectomy group (Uterine Fibroids Symptom and Quality of Life: delta= [+] 49.2; symptom severity: delta= [-] 51.3). Those undergoing abdominal myomectomy, laparoscopic myomectomy, and uterine artery embolization also demonstrated significant improvement in health-related quality of life (delta= [+]43.9, [+]32.9, [+]40.7, respectively) and symptom severity (delta= [-]41.4, [-] 31.5, [-] 38.5, respectively) at 1 year, and the improvement persisted from baseline for uterine-sparing procedures during second (Uterine Fibroids Symptom and Quality of Life: delta= [+]40.7, [+]37.4, [+]39.3 SS: delta= [-] 38.5, [-] 32.0, [-] 37.7 and third year (Uterine Fibroids Symptom and Quality of Life: delta= [+] 40.9, [+]39.9, [+]41.1 and SS: delta= [-] 33.9, [-]36.5, [-] 33.0, respectively), posttreatment intervals, however with a trend toward decline in degree of improvement from years 1 and 2. Differences from baseline were greatest for hysterectomy; however, this may reflect the relative importance of bleeding in the Uterine Fibroids Symptom and Quality of Life, rather than clinically meaningful symptom recurrence among women undergoing uterus-sparing treatments. CONCLUSION All treatment modalities were associated with significant improvements in health-related quality of life and symptom severity reduction 1-year posttreatment. However, abdominal myomectomy, laparoscopic myomectomy and uterine artery embolization indicated a gradual decline in symptom improvement and health-related quality of life by third year after the procedure.
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Affiliation(s)
- Raymond M Anchan
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Yale School of Public Health, New Haven CT.
| | - James B Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, DC
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY
| | - Kathryn Terry
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Emily Disler
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ankrish Milne
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonio Gargiulo
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Olga Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Serene Srouji
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Cynthia C Morton
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, United Kingdom
| | - James Greenberg
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Wanda K Nicholson
- Department of Obstetrics & Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | - Shannon Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA
| | - G Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Anissa I Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA; Department of Radiology, Georgetown University School of Medicine, Washington, DC
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Gavrizi SZ, Hosseinzadeh P, Brush RS, Tytanic M, Eckart E, Peck JD, Craig LB, Diamond MP, Agbaga MP, Hansen KR. Sperm very long-chain polyunsaturated fatty acids: relation to semen parameters and live birth outcome in a multicenter trial. Fertil Steril 2023; 119:753-760. [PMID: 36681262 PMCID: PMC10176595 DOI: 10.1016/j.fertnstert.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/23/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine whether the levels of sperm very long-chain polyunsaturated fatty acids (VLC-PUFAs) are correlated with sperm parameters and the outcome of live birth after conventional therapy for unexplained infertility. DESIGN Cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation randomized controlled trial. SETTING Multicenter randomized controlled trial. PATIENTS Male partners from 185 couples with unexplained infertility who provided baseline semen samples for analysis. INTERVENTION We determined the levels of VLC-PUFAs in total lipid isolated from sperm membranes using liquid chromatography-mass spectrometry/mass spectrometry analyses. MAIN OUTCOME MEASURES Sperm concentration, motility, morphology, total motile count (TMC), and live birth after standard treatment for unexplained infertility. RESULTS Total VLC-PUFA percentage was positively correlated with sperm concentration (Spearman's rank correlation (rs) 0.56, P<.0001), TMC (rs = 0.40, P<.0001), and morphology (rs = 0.26, P=.0005). After adjustment for male body mass index, age, and race, a one-standard-deviation increase in the percentage of total VLC-PUFA was associated with a 62% increase in the geometric mean (GM) of sperm concentration (GM Ratio: 1.62 [95% confidence intervals {CI}: 1.45, 1.82]) and a 43% increase in the geometric mean of TMC (GM Ratio: 1.43 [95% CI; 1.24, 1.63]). Although no evidence of association was observed for sperm motility, a positive relationship was also observed between the percentage of total VLC-PUFA and sperm morphology [adjusted incidence rate ratio (IRR) for one-standard-deviation increase in total VLC-PUFA: 1.18 (95% CI; 1.02, 1.36)]. After adjustment for female age and treatment group, the probability of a live birth outcome was 72% more likely among those in the third tertile of hydroxylated VLC-PUFA percentage than in the first tertile (RR 1.72 [95% CI; 1.01, 2.94]). CONCLUSIONS The positive correlation between sperm VLC-PUFAs percentage and sperm parameters, as well as the significant association between hydroxylated VLC-PUFA percentage and the outcome of live birth, strongly suggest that this class of fatty liquid chromatography-mass spectrometry/mass spectrometry acids is essential for normal sperm structure and function.
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Affiliation(s)
- Sarah Z Gavrizi
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Pardis Hosseinzadeh
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma.
| | - Richard Steven Brush
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Dean A. McGee Eye Institute, Oklahoma City, Oklahoma
| | - Madison Tytanic
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Dean A. McGee Eye Institute, Oklahoma City, Oklahoma
| | - Erin Eckart
- Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, Oklahoma
| | - Jennifer D Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma; Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, Oklahoma
| | - LaTasha B Craig
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Michael P Diamond
- Department of Obstetrics and Gynaecology, Augusta University, Augusta, Georgia
| | - Martin-Paul Agbaga
- Department of Cell Biology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma; Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Dean A. McGee Eye Institute, Oklahoma City, Oklahoma
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Villar L, Tralik B, Diamond MP, Allon M, Maldonado I, Dozortsev DI. Ovulation and birth after administration of progesterone trigger-two case reports. J Assist Reprod Genet 2023; 40:1037-1044. [PMID: 36808579 PMCID: PMC10239420 DOI: 10.1007/s10815-023-02750-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
PURPOSE To determine whether using progesterone as a trigger of a gonadotropin surge will induce ovulation and a competent corpus luteum. METHODS Patients were administered 5 or 10 mg of progesterone intramuscularly when the leading follicle reached preovulatory size. RESULTS We demonstrate that progesterone injections result in classical ultrasonographic hallmarks of ovulation about 48 h later and the formation of a corpus luteum competent to support pregnancy. CONCLUSION Our results support further exploration of using progesterone to trigger a gonadotropin surge in assisted human reproduction.
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Affiliation(s)
- Lina Villar
- CITMER Medicina Reproductiva, Mexico City, Mexico
| | - Beata Tralik
- Advanced Fertility Center of Texas, Houston, TX, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Michael Allon
- Advanced Fertility Center of Texas, Houston, TX, USA
| | | | - Dmitri I Dozortsev
- CITMER Medicina Reproductiva, Mexico City, Mexico.
- Advanced Fertility Center of Texas, Houston, TX, USA.
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Anchan RM, Wojdyla D, Bortoletto P, Terry K, Disler E, Milne A, Gargiulo A, Petrozza J, Brook O, Srouji S, Morton CC, Greenberg J, Wegienka G, Stewart EA, Nicholson WK, Thomas L, Venable S, Laughlin-Tommaso S, Diamond MP, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL, Spies JB. A Comparative Analysis of Health-Related Quality of Life 1 Year Following Myomectomy or Uterine Artery Embolization: Findings from the COMPARE-UF Registry. J Womens Health (Larchmt) 2023; 32:423-433. [PMID: 36637808 PMCID: PMC10079244 DOI: 10.1089/jwh.2022.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: To compare 12-month post-treatment health-related quality of life (HR-QoL) and symptom severity (SS) changes among patients with symptomatic uterine fibroids (SUF) not seeking fertility and undergo a hysterectomy, abdominal myomectomy (AM), or uterine artery embolization (UAE). Materials and Methods: The Comparing Options for Management: Patient-Centered Results for Uterine Fibroids (COMPARE-UF) Registry is a multi-institutional prospective observational cohort study of patients treated for SUF. A subset of 1465 women 31-45 years of age, who underwent either hysterectomy (n = 741), AM (n = 446), or UAE (n = 155) were included in this analysis. Demographics, fibroid history, and symptoms were obtained by baseline questionnaires and at 1 year post-treatment. Results were stratified by all treatments and propensity score weighting to adjust for differences in baseline characteristics. Results: Women undergoing UAE reported the lowest baseline HR-QoL and highest SS scores (mean = 40.6 [standard deviation (SD) = 23.8]; 62.3 [SD = 24.2]) followed by hysterectomy (44.3 [24.3]; 59.8 [SD = 24.1]). At 12 months, women who underwent a hysterectomy experienced the largest change in both HR-QoL (48.7 [26.2]) and SS (51.9 [25.6]) followed by other uterine-sparing treatments. Propensity score weighting revealed all treatments produced substantial improvement, with hysterectomy patients reporting the highest HR-QoL score (92.0 [17.8]) compared with myomectomy (86.7 [17.2]) and UAE (82.6 [21.5]) (p < 0.0001). Similarly, hysterectomy patients reported the lowest SS scores (8.2 [15.1]) compared with myomectomy (16.5 [15.1]) and UAE (19.6 [17.5]) (p < 0.0001). Conclusion: All procedures showed improvement in HR-QoL and reduction in SS score at 12 months, hysterectomy showing maximum improvement. Of importance, at 12 months, patients who underwent either a myomectomy or UAE reported comparable symptom relief and HR-QoL. Clinicaltrials.Gov Identifier: NCT02260752.
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Affiliation(s)
- Raymond M. Anchan
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Kathryn Terry
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Disler
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ankrish Milne
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olga Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Serene Srouji
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cynthia C. Morton
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - James Greenberg
- Department of Obstetrics, Gynecology, and Reproductive Biology, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | | | - Wanda K. Nicholson
- Department of Obstetrics and Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Shannon Laughlin-Tommaso
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
| | - G. Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Erica E. Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anissa I. Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren A. Wise
- Slone Epidemiology Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - James B. Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, District of Columbia, USA
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8
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Awonuga AO, Camp OG, Abu-Soud HM, Rappolee DA, Puscheck EE, Diamond MP. Determinants of Embryo Implantation: Roles of the Endometrium and Embryo in Implantation Success. Reprod Sci 2023:10.1007/s43032-023-01224-w. [PMID: 36988904 DOI: 10.1007/s43032-023-01224-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023]
Abstract
Both uterine endometrium and embryo contribute to implantation success. However, their relative role in the implantation success is still a matter for debate, as are the roles of endometrial receptivity analysis (ERA), endometrial scratch (ES), endometrial microbiome, and intrauterine or intravenous measures that are currently advocated to improve the implantation success. There is insufficient evidence to suggest that the endometrium is more important than the embryo in determining the implantation success and the utility of these measures, especially when euploid embryos are transferred is limited. Although embryo implantation on epithelium other than the endometrium is a very rare event, evidence suggests that embryo implantation and growth is not limited to the endometrium alone. Embryos can implant and develop to result in livebirths on epithelium that lacks the typical endometrial development present at implantation. Currently, the role of embryo euploidy in implantation success is underappreciated. At a minimum, it is the author's opinion that until robust, definitive studies are conducted that demonstrate benefit, reproductive endocrinologists and infertility specialist should be prudent in the way they counsel patients about the utility of ERA, ES, and other measures in improving implantation success.
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Affiliation(s)
- Awoniyi O Awonuga
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA.
- Kindbody Fertility, 26400 W 12 Mile Road, Ste. 140D, Southfield, MI, 48034, USA.
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, 26400 West 12 Mile Road, Suite 140, Southfield, MI, 48034, USA.
| | - Olivia G Camp
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
| | - Husam M Abu-Soud
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Daniel A Rappolee
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Physiology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
- Reproductive Stress, Inc., 135 Lake Shore Rd, Grosse Pointe Farms, MI, USA
| | - Elizabeth E Puscheck
- Department of Ob/Gyn, CS Mott Center for Human Growth and Development, Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI, USA
- Reproductive Stress, Inc., 135 Lake Shore Rd, Grosse Pointe Farms, MI, USA
- InVia Fertility, 2718 W Roscoe St Suite 500, Chicago, IL, 60618, USA
- InVia Fertility, 1585 N. Barrington Road, Suite 406, Doctor's Building Two, Hoffman Estates, IL, 60169, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, 1120 15Th Street, CJ‑1036, Augusta, GA, 30912, USA
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9
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Dougherty MP, Poch AM, Chorich LP, Hawkins ZA, Xu H, Roman RA, Liu H, Brakta S, Taylor HS, Knight J, Kim HG, Diamond MP, Layman LC. Unexplained Female Infertility Associated with Genetic Disease Variants. N Engl J Med 2023; 388:1055-1056. [PMID: 36920765 PMCID: PMC10134047 DOI: 10.1056/nejmc2211539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
| | | | - Lynn P Chorich
- Medical College of Georgia at Augusta University, Augusta, GA
| | - Zoe A Hawkins
- Medical College of Georgia at Augusta University, Augusta, GA
| | - Hongyan Xu
- Medical College of Georgia at Augusta University, Augusta, GA
| | - Robert A Roman
- Medical College of Georgia at Augusta University, Augusta, GA
| | - Haitao Liu
- Medical College of Georgia at Augusta University, Augusta, GA
| | - Soumia Brakta
- Medical College of Georgia at Augusta University, Augusta, GA
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10
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Lutfi H, Kirsch-Mangu TK, Fletcher-King NM, Ruden DM, Diamond MP, Saed GM. Epigenetics: new insights into postoperative adhesion development. Minerva Obstet Gynecol 2022:S2724-606X.22.05158-2. [PMID: 36222785 DOI: 10.23736/s2724-606x.22.05158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND The link between post-operative adhesion development and epigenetic modifications is important in understanding the mechanism behind their formation. The purpose of this study was to determine whether epigenetic differences exist between primary fibroblasts of normal peritoneum and adhesion tissues isolated from the same patient(s). METHODS DNA from fibroblasts isolated from normal peritoneum and adhesion tissues was isolated using Qiagen's EZ1 Advanced Kit. Methylation patterns of genes were quantified and compared in both cell lines using the Infinium Human Methylation 27 Beadchip system. RESULTS A total of 7364 genes had been found to manifest significantly different DNA methylation levels in adhesion fibroblasts as compared to normal peritoneal fibroblasts (p<0.01). A total of 1685 genes were found to have increased DNA methylation by 50% in adhesion compared to peritoneal fibroblasts, and were enriched in Gene Ontology categories, Glycoprotein, and Defense Response. Furthermore, 1287 genes were found to have decreased DNA methylation patterns with enriched Gene Ontology categories, "Homeobox", and Transcription Factor Activity in adhesion fibroblasts. CONCLUSIONS Epigenetic differences in fibroblasts isolated from normal peritoneum and adhesion tissues were observed. Future studies focusing on the precise role of these genes in the development of post operative adhesions will allow us to more fully appreciate regulatory mechanisms leading to adhesion development, thereby establishing targets for therapeutic interventions to prevent or limit adhesion development.
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Affiliation(s)
- Hala Lutfi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, USA
| | - Thea K Kirsch-Mangu
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nicole M Fletcher-King
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, USA
| | - Douglas M Ruden
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia Augusta University, Augusta, GA, USA
| | - Ghassan M Saed
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, USA -
- Karmanos Cancer Center, Detroit, MI, USA
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11
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Seungdamrong AM, Pal L, Kuokkanen S, Lieman H, Wild RA, Sun F, Zhang H, Diamond MP, Legro RS, Santoro N. RELATIONSHIP OF ANTITHYROID ANTIBODIES AND TSH TO INFERTILITY PHENOTYPES AND OUTCOMES. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.08.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Cardozo ER, Alvero RJ, Diamond MP, Santoro N, Bavan B. MORE RISK THAN REWARD: A COST ANALYSIS OF THE AMIGOS TRIAL. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.09.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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13
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Kim AS, Eckart E, Peck JD, Campbell A, Maxwell J, Diamond MP, Steiner AZ, Coutifaris C, Cedars MI, Santoro N, Zhang H, Hansen KR. INCIDENCE OF PREGNANCY LOSS IN WOMEN UNDERGOING INFERTILITY TREATMENT. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.08.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Plowden TC, Mumford SL, Wild RA, Cedars MI, Steiner AZ, Franasiak JM, Diamond MP, Santoro N. Probability of Pregnancy With Mono vs Multiple Folliculogenesis in Women With Unexplained Infertility. J Endocr Soc 2022; 7:bvac142. [PMID: 36447958 PMCID: PMC9692188 DOI: 10.1210/jendso/bvac142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Indexed: 12/25/2022] Open
Abstract
Context Ovarian stimulation (OS) increases pregnancy rates but can cause multiple folliculogenesis and multiple pregnancy. Objective To determine whether the probability of pregnancy differs in OS cycles with mono- vs multifolliculogenesis in women with unexplained infertility (UI). Design Secondary analysis of a multicenter, randomized controlled trial: Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation with 3 treatment arms: gonadotropins, clomiphene, or letrozole, combined with intrauterine insemination. Women were categorized as having either 1 or ≥ 2 mature follicles (≥ 16 mm). Relative risk (RR) and 95% CIs for clinical pregnancy and live birth by number of follicles were estimated using generalized linear models adjusted for age, body mass index, years of infertility, and history of prior live birth. Setting 12 US-based clinical sites. Participants Normally cycling women aged 18 to 40 years with a normal uterine cavity and at least 1 patent fallopian tube. Male partners with ≥ 5 million total motile sperm. Interventions Gonadotropins, clomiphene, or letrozole with insemination. Main Outcome Measures Clinical pregnancy rates (CPR) and live birth rates (LBR). Results A single mature follicle > 16 mm resulted in lower CPR (RR, 0.70; 95% CI, 0.54-0.90) and LBR (RR, 0.67; 95% CI, 0.51-0.89) compared with ≥ 2 mature follicles. When stratified by treatment modality, no association of follicle number with CPR or LBR was observed for letrozole or clomiphene, but women using gonadotropins had lower CPR and LBR with monofolliculogenesis. Conclusion In couples undergoing gonadotropin treatment for UI, monofolliculogenesis following OS is related to a lower rate of live birth.
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Affiliation(s)
- Torie C Plowden
- Correspondence: Torie Comeaux Plowden, MD, Department of Gynecologic Surgery and Obstetrics, 2817 Reilly Road, Fort Bragg, NC 28310.
| | - Sunni L Mumford
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD 20892, USA
| | - Robert A Wild
- Department of Obstetrics and Gynecology, OUHSC, Oklahoma City, OK 73117, USA
| | - Marcelle I Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94158, CA, USA
| | | | - Jason M Franasiak
- RMA New Jersey, Thomas Jefferson University, Basking Ridge, NJ 07920, USA
| | | | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO 80045, USA
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15
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Baker KC, Steiner AZ, Hansen KR, Barnhart KT, Cedars MI, Legro RS, Diamond MP, Krawetz SA, Usadi R, Baker VL, Coward RM, Sun F, Wild R, Masson P, Smith JF, Santoro N, Zhang H. Poor reproducibility of percentage of normally shaped sperm using the World Health Organization Fifth Edition strict grading criteria. F S Rep 2022; 3:110-115. [PMID: 35789726 PMCID: PMC9250115 DOI: 10.1016/j.xfre.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 12/03/2022] Open
Abstract
Objective To determine the reproducibility of the World Health Organization Fifth Edition (WHO5) strict grading methodology by comparing the percentage of morphologically normal sperm (PNS) recorded by the core laboratory with results obtained at the fertility centers participating in a multisite clinical trial. Design Secondary cohort analysis of data from the Males, Antioxidants, and Infertility trial. Setting Fertility centers. Patients Semen values of 171 men participating in a multicenter, double-blind, randomized, placebo-controlled trial evaluating the effect of antioxidants on male fertility. Interventions Not applicable. Main Outcome Measures Strict morphology expressed as PNS as determined at each fertility center and the core central laboratory for the same semen sample. Results No correlation was found in the PNS values for the same semen sample between the core laboratory and fertility center laboratories either as a group or by individual site. Interobserver agreement was similarly low (κ = 0.05 and 0.15) between the core and fertility laboratories as a group for strict morphology, categorized by the WHO5 lower reference limits of 4% and 0, respectively. Moderate agreement was found between the core and 2 individual fertility laboratories for the cutoff value of 0 (κ = 0.42 and 0.57). The remainder of the comparisons demonstrated poor to fair agreement. Conclusions Strict morphology grading using the WHO5 methodology demonstrated overall poor reproducibility among a cohort of experienced fertility laboratories. This lack of correlation and agreement in the PNS values calls into question the reproducibility, and thereby the potential applicability, of sperm strict morphology testing.
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Affiliation(s)
- Karen C Baker
- Division of Urology, Duke University, Durham, North Carolina
| | - Anne Z Steiner
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcelle I Cedars
- Department of Obstetrics and Gynecology, University of California-San Francisco, San Francisco, California
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology & Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Rebecca Usadi
- Department of Reproductive Endocrinology and Infertility, Atrium Health, Charlotte, North Carolina
| | - Valerie L Baker
- Department of Gynecology and Obstetrics, Johns Hopkins University, Lutherville, Maryland
| | - R Matthew Coward
- Department of Urology, University of North Carolina, Chapel Hill, North Carolina
| | - Fangbai Sun
- Department of Biostatistics, Yale School of Public Health, New Haven Connecticut
| | - Robert Wild
- Department of Obstetrics and Gynecology, Biostatistics and Epidemiology University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Puneet Masson
- Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James F Smith
- Department of Urology, University of California-San Francisco, San Francisco, California
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado
| | - Heping Zhang
- Collaborative Center for Statistics in Science, Yale School of Public Health, New Haven, Connecticut
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16
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Wiseman D, Hanzlik JA, Richardson JA, Shelton JM, Evers BM, Diamond MP, Brown R, Mazzucco DC. Development of a Chronic Canine Ovariohysterectomy Model to Evaluate Vaginal Cuff Healing Using Two Closure Systems. Surg Innov 2022; 29:183-194. [PMID: 34414835 DOI: 10.1177/15533506211039307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose. This study established a suitable animal model of ovariohysterectomy; characterized the course and pattern of vaginal healing after ovariohysterectomy; and compared healing obtained after closure of the vaginal cuff with a novel cuff-closure device (Zip-stitch® clips) and VICRYL® sutures. Research Design and Study Sample. This prospective, randomized, controlled, blinded animal study was conducted in 27 mongrel hounds according to an IACUC-approved protocol. Each animal underwent ovariohysterectomy followed by vaginal cuff closure with Zip-stitch or VICRYL. At two or six weeks, animals were sacrificed for gross and histological analysis. Data Collection. The primary endpoint was the difference in the fraction of vaginal cuff healed six weeks after application of the closure device. Secondary endpoints included histopathologic cellular and tissue responses, including inflammation, necrosis, infection, and vascular and muscle changes. Results. In the test group, there were two distinct locations where fibrotic or granular tissue fusion between the anterior and posterior vaginal walls was observed: in tissue "captured" by a clip or in tissue around the clip. The fraction of the vaginal cuff healed was similar in animals treated with Zip-stitch clips and those treated with sutures at six weeks (68±10% vs 67±18%; P=.148, test for non-inferiority) after surgery. The test article performed similarly or better than the control article in terms of the intensity or extent of the secondary endpoints. Conclusions. Subject to further confirmation, this study supports Zip-stitch clips as a method to maintain immediate post-operative approximation of the vaginal cuff leading to healing but did not achieve statistical significance in its primary endpoint.
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Affiliation(s)
| | | | - James A Richardson
- Department of Pathology, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John M Shelton
- Department of Internal Medicine, Histo Pathology Division, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bret M Evers
- Department of Pathology, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael P Diamond
- Wayne State University School of Medicine, Grosse Pointe Shores, MI, USA
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17
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Spitzer TL, Trussell JC, Coward RM, Hansen KR, Barnhart KT, Cedars MI, Diamond MP, Krawetz SA, Sun F, Zhang H, Santoro N, Steiner AZ. Biomarkers of Stress and Male Fertility. Reprod Sci 2022; 29:1262-1270. [PMID: 35106743 PMCID: PMC9078052 DOI: 10.1007/s43032-022-00853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/08/2022] [Indexed: 11/25/2022]
Abstract
To study if stress, as measured by salivary alpha-amylase and cortisol, negatively impacts male fertility, as measured by semen parameters, pregnancy, and live birth rates. Prospective, cohort study of men enrolled in the Males, Antioxidants, and Infertility (MOXI) trial. One-hundred twelve infertile men provided first-morning salivary and semen samples at baseline. Salivary samples were analyzed for alpha-amylase and cortisol. Couples attempted to conceive naturally (months 1-3) and with clomiphene citrate/intrauterine insemination (months 4-6). The association between stress-related biomarkers and semen parameters including DNA fragmentation was assessed using linear regression models adjusting for male age. Salivary levels were dichotomized at the 80th percentile. Pregnancy/live birth rates in couples in the upper quintile were compared to remaining subjects using chi-square testing. Salivary levels of alpha-amylase were not associated with semen parameters or DNA fragmentation. Salivary cortisol levels were not correlated with DNA fragmentation or normal morphology. For every 1-unit increase in salivary cortisol, total sperm count increased by 13.9 million (95% CI: 2.5, 25.3) and total motile sperm count increased by 9.9 million (95% CI: 3.2-16.6). Couple pregnancy rates and live birth rates did not differ for males in the highest quintile of alpha-amylase (27% and 28%, p = 0.96; 23% and 21%, p = 0.87) or cortisol (40% and 26%, p = 0.22; 35% and 19%, p = 0.12), compared to males with lower values. Physiologic measures of high stress may not harm but actually improve semen parameters among men with male-factor infertility.
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Affiliation(s)
- Trimble L Spitzer
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA, 23708, USA.
| | - J C Trussell
- Department of Urology, State University of New York Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - R Matthew Coward
- Department of Urology, UNC School of Medicine, 2113 Physicians Office Building CB#7235, Chapel Hill, NC, 27599-7235, USA
- UNC Fertility, 7920 ACC Blvd #300, Raleigh, NC, 27617, USA
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK, 73104, USA
| | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Marcelle I Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, CA, 94143, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, 30912, USA
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology, Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, 48202, USA
| | - Fangbai Sun
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, CO, 80204, USA
| | - Anne Z Steiner
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, 27713, USA
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18
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Vitek W, Oh J, Mbowe O, Thurston SW, Christianson MS, Styer AK, Polotsky AJ, Diamond MP, Cedars MI. Preconception ovarian reserve and placenta-mediated pregnancy complications among infertile women. Pregnancy Hypertens 2022; 27:193-196. [PMID: 35131729 PMCID: PMC8922433 DOI: 10.1016/j.preghy.2022.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/25/2022]
Abstract
RESEARCH QUESTION Are preconception ovarian reserve markers, such as Anti-Mullerian hormone and antral follicle count, associated with preeclampsia and placenta mediated pregnancy complications among women with unexplained infertility who conceive with superovulation? DESIGN This is a secondary analysis of women with unexplained infertility who had a singleton live birth after enrollment in the Analysis of Multiple Intrauterine Gestations after Ovarian Stimulation (AMIGOS) trial that randomized couples to superovulation with letrozole, clomiphene, or gonadotropins with insemination for up to 4 cycles. RESULTS Compared to controls (N = 156), women who developed preeclampsia (N = 17) had lower Anti-Mullerian hormone levels (2.24 ± 1.20 vs. 2.89 ± 2.32, p = 0.07) and lower antral follicle count (18 ± 7.67 vs. 21 ± 11.43, p = 0.16); though these differences were not statistically significant. There was no relationship between Anti-Mullerian hormone (OR: 1.00, 95% CI: 0.76-1.25) or antral follicle count (OR: 0.98, 95% CI 0.93-1.04) with preeclampsia and between Anti-Mullerian hormone (OR: 1.00, 95% CI: 0.83-1.17) and antral follicle count (OR: 1.00, 95% CI: 0.97-1.04) with placenta medicated pregnancy complications after adjusting for age, BMI and race. CONCLUSIONS Preconception ovarian reserve markers are not associated with preeclampsia and placenta mediated pregnancy complications among women with unexplained infertility who conceive with superovulation with insemination.
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Affiliation(s)
- Wendy Vitek
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Jinhee Oh
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Omar Mbowe
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sally W. Thurston
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | | | | | | | - Marcelle I. Cedars
- University of California San Francisco Medical Center, San Francisco, CA
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Wallace K, Stewart EA, Wise LA, Nicholson WK, Parry JP, Zhang S, Laughlin-Tommaso S, Jacoby V, Anchan RM, Diamond MP, Venable S, Shiflett A, Wegienka GR, Maxwell GL, Wojdyla D, Myers ER, Marsh E. Anxiety, Depression, and Quality of Life After Procedural Intervention for Uterine Fibroids. J Womens Health (Larchmt) 2022; 31:415-424. [PMID: 34101502 PMCID: PMC8972021 DOI: 10.1089/jwh.2020.8915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Background: Quality of life (QOL) and psychological health has been reported to be decreased among women with gynecological conditions such as uterine fibroids (UFs). Materials and Methods: Women enrolled in the Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry, receiving procedural therapy for symptomatic UFs, were eligible for this analysis if they completed a series of health-related QOL surveys administered at three time points (baseline, 6-12 weeks postprocedure, and 1 year postprocedure; n = 1486). Ethical approval for this study was obtained at each recruiting site and the coordinating center (NCT02260752, clinicaltrials.gov). Results: More than 26% (n = 393) of women reported moderate anxiety/depression on the baseline anxiety/depression domain of the Euro-QOL 5-dimension instrument. At both the 6-12 weeks and 1-year postprocedural follow-up, there was significant improvement in the UF QOL symptom severity score (p < 0.001, p < 0.001), the total UF symptom QOL score (p < 0.001, p < 0.001), and the Euro-QOL 5-dimension visual analog scale (p < 0.001, p = 0.004) compared with the preprocedural baseline scores. The reporting of anxiety/depression decreased by 66.4% among women who were at baseline, whereas 5.6% of women previously reporting no anxiety/depression reported anxiety/depression at the 1-year follow-up. Conclusion: UF symptoms were more severe among women reporting anxiety/depression at baseline. At the 1-year follow-up, health-related QOL scores improved among all women and the prevalence of anxiety/depression decreased in most, but not all women, whereas severity of anxiety/depression worsened in a small percentage of women (5.6%). Overall, these results suggest that UF treatment improves symptoms of anxiety/depression associated with symptomatic UFs.
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Affiliation(s)
- Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA.,Address correspondence to: Kedra Wallace, PhD, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216, USA
| | | | - Lauren A. Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Wanda Kay Nicholson
- Center for Women's Health Research, Department of Obstetrics and Gynecology, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - John Preston Parry
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | | | - Vanessa Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California at San Francisco, San Francisco, California, USA
| | - Raymond M. Anchan
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
| | | | - Amber Shiflett
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ganesa R. Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - George Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Erica Marsh
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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20
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Souter I, Sun F, Zhang H, Diamond MP, Legro RS, Wild RA, Hansen KR, Santoro N. A personalized medicine approach to ovulation induction/ovarian stimulation: development of a predictive model and online calculator from level-I evidence. Fertil Steril 2022; 117:408-418. [PMID: 35125179 PMCID: PMC8985501 DOI: 10.1016/j.fertnstert.2021.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To estimate the probability of clinical or multiple pregnancy during ovulation induction (OI)/ovarian stimulation (OS). DESIGN Secondary analysis of two multicenter randomized clinical trials (combined). SETTING Multicenter. PATIENTS A total of 750 women with polycystic ovary syndrome and 900 women with unexplained infertility. INTERVENTIONS Ovulation induction/OS with either timed intercourse (polycystic ovary syndrome) or intrauterine insemination. MAIN OUTCOME MEASURES Clinical and multiple pregnancy rates/cycle, cumulative pregnancy rates. Age, body mass index, parity, diagnosis, medication, markers of ovarian reserve, and ovarian response were considered in multivariable regression models for clinical, multiple, and cumulative pregnancy rates. Receiver operating characteristic curves were created for clinical and multiple pregnancy rates. RESULTS Younger patient and partner age, treatment type, lower body mass index, and medication dose were all associated with clinical pregnancy. Variables associated with multiple pregnancy included the abovementioned variables (except age), in addition to diagnosis, parity, higher antral follicle count, antimüllerian hormone levels, and ovarian response. Gonadotropin use was associated with multiple pregnancy, with progressively increasing odds ratios (cycles 1-4). Receiver operating characteristic curves indicated the model's predictive power to be fair for clinical pregnancy (areas under the curve [95% confidence interval {CI}]: 0.78 [0.75-0.81] for cycle 1 and 0.70 [0.64-0.75] for cycle 4) and good-to-excellent for multiple pregnancy (areas under the curve [95% CI]: 0.78 [0.72-0.84] for cycle 1 and 0.86 [0.78-0.93] for cycle 4). Partner age, lower medication dose, parity, antimüllerian hormone levels, and diagnosis were associated with cumulative pregnancy rates. CONCLUSIONS Using the majority of the factors known to predict the outcome of OI/OS cycles, we constructed an easy-to-use formula that may predict individualized chances of clinical and multiple pregnancy for commonly used fertility treatments (https://pregnancyprediction.medicine.yale.edu/CalDirect.html). CLINICAL TRIAL REGISTRATION NUMBERS Assessing Multiple Intrauterine Gestations after Ovulation Stimulation NCT01044862; PPCOSII NCT00719186.
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Affiliation(s)
- Irene Souter
- Department of Obstetrics/Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Fangbai Sun
- Collaborative Center for Statistics, Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Heping Zhang
- Collaborative Center for Statistics, Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Schiences Center, Oklahoma City, Oklahoma
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Schiences Center, Oklahoma City, Oklahoma
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
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21
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Gavrizi SZ, Arya S, Peck JD, Knudtson JF, Diamond MP, Wild RA, Hansen KR. High-Sensitivity C-Reactive Protein (hS-CRP) levels and pregnancy outcomes in women with unexplained infertility after ovarian stimulation with intrauterine-insemination (OS-IUI) in a multi-center trial. F S Rep 2022; 3:57-62. [PMID: 35386508 PMCID: PMC8978106 DOI: 10.1016/j.xfre.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/04/2022] Open
Abstract
Objective To determine if chronic inflammation, assessed by basal high-sensitivity C-reactive protein (hs-CRP) levels, is associated with pregnancy outcomes in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Design Prospective cohort analysis of the Reproductive Medicine Network’s Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial. Setting Multicenter university-based randomized controlled trial. Patient(s) A total of 781 couples with unexplained infertility. Intervention(s) Secondary analysis. Main Outcome Measure(s) Adjusted risk ratios of live birth, clinical pregnancy, and pregnancy loss rates by hs-CRP levels. Result(s) Associations between hs-CRP levels and clinical pregnancy rates were not observed after adjustment for baseline body mass index. There were fewer live births among women with higher hs-CRP levels, although confidence intervals crossed 1.0. The risk of pregnancy loss was greater in women with increased hs-CRP levels (1–3 mg/L: risk ratio [RR], 1.67; 95% confidence interval [CI], 1.00–2.79; >3–10 mg/L: RR, 1.84; 95% CI, 1.06–3.20; and >10 mg/L: RR, 2.14; 95% CI, 1.05–4.36 compared to women with hs-CRP <1 mg/L). Conclusion(s) This investigation suggests that chronic inflammation may increase the risk of pregnancy loss but not impact the clinical pregnancy rate in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Associations between inflammation and pregnancy outcomes in women with infertility merit further investigation. Clinical Trial Registration Number clinicaltrials.gov NCT01044862.
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22
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Wessel JA, Danhof NA, van Eekelen R, Diamond MP, Legro RS, Peeraer K, D’Hooghe TM, Erdem M, Dankert T, Cohlen BJ, Thyagaraju C, Mol BWJ, Showell M, van Wely M, Mochtar MH, Wang R. OUP accepted manuscript. Hum Reprod Update 2022; 28:733-746. [PMID: 35587030 PMCID: PMC9434229 DOI: 10.1093/humupd/dmac021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intrauterine insemination with ovarian stimulation (IUI-OS) is a first-line treatment for unexplained infertility. Gonadotrophins, letrozole and clomiphene citrate (CC) are commonly used agents during IUI-OS and have been compared in multiple aggregate data meta-analyses, with substantial heterogeneity and no analysis on time-to-event outcomes. Individual participant data meta-analysis (IPD-MA) is considered the gold standard for evidence synthesis as it can offset inadequate reporting of individual studies by obtaining the IPD, and allows analyses on treatment–covariate interactions to identify couples who benefit most from a particular treatment. OBJECTIVE AND RATIONALE We performed this IPD-MA to compare the effectiveness and safety of ovarian stimulation with gonadotrophins, letrozole and CC and to explore treatment–covariate interactions for important baseline characteristics in couples undergoing IUI. SEARCH METHODS We searched electronic databases including MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO from their inception to 28 June 2021. We included randomized controlled trials (RCTs) comparing IUI-OS with gonadotrophins, letrozole and CC among couples with unexplained infertility. We contacted the authors of eligible RCTs to share the IPD and established the IUI IPD-MA Collaboration. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. Secondary outcomes were other reproductive outcomes, including time to conception leading to live birth. We performed a one-stage random effects IPD-MA. OUTCOMES Seven of 22 (31.8%) eligible RCTs provided IPD of 2495 couples (62.4% of the 3997 couples participating in 22 RCTs), of which 2411 had unexplained infertility and were included in this IPD-MA. Six RCTs (n = 1511) compared gonadotrophins with CC, and one (n = 900) compared gonadotrophins, letrozole and CC. Moderate-certainty evidence showed that gonadotrophins increased the live birth rate compared to CC (6 RCTs, 2058 women, RR 1.30, 95% CI 1.12–1.51, I2 = 26%). Low-certainty evidence showed that gonadotrophins may also increase the multiple pregnancy rate compared to CC (6 RCTs, 2058 women, RR 2.17, 95% CI 1.33–3.54, I2 = 69%). Heterogeneity on multiple pregnancy could be explained by differences in gonadotrophin starting dose and choice of cancellation criteria. Post-hoc sensitivity analysis on RCTs with a low starting dose of gonadotrophins (≤75 IU) confirmed increased live birth rates compared to CC (5 RCTs, 1457 women, RR 1.26, 95% CI 1.05–1.51), but analysis on only RCTs with stricter cancellation criteria showed inconclusive evidence on live birth (4 RCTs, 1238 women, RR 1.15, 95% CI 0.94–1.41). For multiple pregnancy, both sensitivity analyses showed inconclusive findings between gonadotrophins and CC (RR 0.94, 95% CI 0.45–1.96; RR 0.81, 95% CI 0.32–2.03, respectively). Moderate certainty evidence showed that gonadotrophins reduced the time to conception leading to a live birth when compared to CC (6 RCTs, 2058 women, HR 1.37, 95% CI 1.15–1.63, I2 = 22%). No strong evidence on the treatment–covariate (female age, BMI or primary versus secondary infertility) interactions was found. WIDER IMPLICATIONS In couples with unexplained infertility undergoing IUI-OS, gonadotrophins increased the chance of a live birth and reduced the time to conception compared to CC, at the cost of a higher multiple pregnancy rate, when not differentiating strategies on cancellation criteria or the starting dose. The treatment effects did not seem to differ in women of different age, BMI or primary versus secondary infertility. In a modern practice where a lower starting dose and stricter cancellation criteria are in place, effectiveness and safety of different agents seem both acceptable, and therefore intervention availability, cost and patients’ preferences should factor in the clinical decision-making. As the evidence for comparisons to letrozole is based on one RCT providing IPD, further RCTs comparing letrozole and other interventions for unexplained infertility are needed.
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Affiliation(s)
- J A Wessel
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N A Danhof
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R van Eekelen
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA 30912, USA
| | - R S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, PA 17033, USA
| | - K Peeraer
- UZ Leuven, Leuven University Fertility Center, Leuven 3000, Belgium
| | - T M D’Hooghe
- Merck Healthcare KGaA, Darmstadt 64293, Germany
- Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven/University of Leuven, Leuven 3000, Belgium
- Department of Obstetrics and Gynecology, Yale University, New Haven, CT 06520, USA
| | - M Erdem
- Faculty of Medicine, Department of Obstetrics & Gynecology, Gazi University, Ankara 06560, Turkey
| | - T Dankert
- Department of Obstetrics and Gynecology, Rijnstate Hospital Arnhem, 06560 Ankara, The Netherlands
| | - B J Cohlen
- Department of Obstetrics and Gynaecology, Isala Fertility Center, 8025 AB Zwolle, The Netherlands
| | - C Thyagaraju
- Department of OBG, Jawaharlal Institute of Postgraduate Medical education and Research (JIPMER), Pondicherry 605006, India
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
- Aberdeen Centre for Women’s Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - M Showell
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland 1142, New Zealand
| | - M van Wely
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M H Mochtar
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R Wang
- Correspondence address. Department of Obstetrics and Gynaecology, Monash University, Level 5, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. E-mail:
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23
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Legro RS, Hansen KR, Diamond MP, Steiner AZ, Coutifaris C, Cedars MI, Hoeger KM, Usadi R, Johnstone EB, Haisenleder DJ, Wild RA, Barnhart KT, Mersereau J, Trussell JC, Krawetz SA, Kris-Etherton PM, Sarwer DB, Santoro N, Eisenberg E, Huang H, Zhang H. Effects of preconception lifestyle intervention in infertile women with obesity: The FIT-PLESE randomized controlled trial. PLoS Med 2022; 19:e1003883. [PMID: 35041662 PMCID: PMC8765626 DOI: 10.1371/journal.pmed.1003883] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 12/03/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Women with obesity and infertility are counseled to lose weight prior to conception and infertility treatment to improve pregnancy rates and birth outcomes, although confirmatory evidence from randomized trials is lacking. We assessed whether a preconception intensive lifestyle intervention with acute weight loss is superior to a weight neutral intervention at achieving a healthy live birth. METHODS AND FINDINGS In this open-label, randomized controlled study (FIT-PLESE), 379 women with obesity (BMI ≥ 30 kg/m2) and unexplained infertility were randomly assigned in a 1:1 ratio to 2 preconception lifestyle modification groups lasting 16 weeks, between July 2015 and July 2018 (final follow-up September 2019) followed by infertility therapy. The primary outcome was the healthy live birth (term infant of normal weight without major anomalies) incidence. This was conducted at 9 academic health centers across the United States. The intensive group underwent increased physical activity and weight loss (target 7%) through meal replacements and medication (Orlistat) compared to a standard group with increased physical activity alone without weight loss. This was followed by standardized empiric infertility treatment consisting of 3 cycles of ovarian stimulation/intrauterine insemination. Outcomes of any resulting pregnancy were tracked. Among 191 women randomized to standard lifestyle group, 40 dropped out of the study before conception; among 188 women randomized to intensive lifestyle group, 31 dropped out of the study before conception. All the randomized women were included in the intent-to-treat analysis for primary outcome of a healthy live birth. There were no significant differences in the incidence of healthy live births [standard 29/191(15.2%), intensive 23/188(12.2%), rate ratio 0.81 (0.48 to 1.34), P = 0.40]. Intensive had significant weight loss compared to standard (-6.6 ± 5.4% versus -0.3 ± 3.2%, P < 0.001). There were improvements in metabolic health, including a marked decrease in incidence of the metabolic syndrome (baseline to 16 weeks: standard: 53.6% to 49.4%, intensive 52.8% to 32.2%, P = 0.003). Gastrointestinal side effects were significantly more common in intensive. There was a higher, but nonsignificant, first trimester pregnancy loss in the intensive group (33.3% versus 23.7% in standard, 95% rate ratio 1.40, 95% confidence interval [CI]: 0.79 to 2.50). The main limitations of the study are the limited power of the study to detect rare complications and the design difficulty in finding an adequate time matched control intervention, as the standard exercise intervention may have potentially been helpful or harmful. CONCLUSIONS A preconception intensive lifestyle intervention for weight loss did not improve fertility or birth outcomes compared to an exercise intervention without targeted weight loss. Improvement in metabolic health may not translate into improved female fecundity. TRIAL REGISTRATION ClinicalTrials.gov NCT02432209.
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Affiliation(s)
- Richard S. Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- * E-mail:
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, United States of America
| | - Anne Z. Steiner
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Marcelle I. Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California, United States of America
| | - Kathleen M. Hoeger
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York, United States of America
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina, United States of America
| | - Erica B. Johnstone
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Daniel J. Haisenleder
- Ligand Core Laboratory, University of Virginia Center for Research in Reproduction, Charlottesville, Virginia, United States of America
| | - Robert A. Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Kurt T. Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jennifer Mersereau
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - J. C. Trussell
- Department of Urology, SUNY Upstate University Hospital, Syracuse, New York, United States of America
| | - Stephen A. Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, United States of America
| | - Penny M. Kris-Etherton
- Department of Nutritional Sciences, Penn State College of Health and Human Development, Pennsylvania, United States of America
| | - David B. Sarwer
- Center for Obesity Research and Education, College of Public Health, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Esther Eisenberg
- Fertility and Infertility Branch, NICHD, Rockville, Maryland, United States of America
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut, United States of America
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut, United States of America
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Dozortsev DI, Diamond MP. Two peas from the same pod: vanishing follicles and postmature oocytes. Fertil Steril 2021; 117:40-41. [PMID: 34753599 DOI: 10.1016/j.fertnstert.2021.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/04/2022]
Affiliation(s)
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
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25
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Knudtson JF, Sun F, Coward RM, Hansen KR, Barnhart KT, Smith J, Legro RS, Diamond MP, Krawetz SA, Zhang H, Usadi R, Baker VL, Santoro N, Steiner AZ. The relationship of plasma antioxidant levels to semen parameters: the Males, Antioxidants, and Infertility (MOXI) randomized clinical trial. J Assist Reprod Genet 2021; 38:3005-3013. [PMID: 34455507 PMCID: PMC8609082 DOI: 10.1007/s10815-021-02301-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/12/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The understanding of the role of plasma antioxidant levels in male fertility in the USA is limited. In a secondary analysis of the Males, Antioxidants, and Infertility (MOXI) randomized clinical trial, we sought to determine whether serum levels of vitamin E (α-tocopherol), zinc, and selenium were correlated with semen parameters and couple fertility outcomes. METHODS This study is a secondary analysis of the MOXI clinical trial. The primary endpoints in this secondary analysis include semen parameters, and DNA fragmentation and clinical outcomes including pregnancy and live birth. Analyses were completed using Wilcoxon's rank-sum test and linear regression models. RESULTS At baseline, the analysis included plasma labs for vitamin E (n = 131), selenium (n = 124), and zinc (n = 128). All baseline plasma values were in the normal ranges. There was no association between selenium, zinc, or vitamin E levels and semen parameters or DNA fragmentation. Baseline antioxidant levels in the male partners did not predict pregnancy or live birth among all couples. Among those randomized to placebo, baseline male antioxidant levels did not differ between those couples with live birth and those that did not conceive or have a live birth. CONCLUSIONS Among men attending fertility centers in the USA, who have sufficient plasma antioxidant levels of zinc, selenium, or vitamin E, no association was observed between vitamins and semen parameters or clinical outcomes in couples with male infertility. Higher levels of antioxidants among men with circulating antioxidants in the normal range do not appear to confer benefit on semen parameters or male fertility.
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Affiliation(s)
- Jennifer F Knudtson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, Texas; and Aspire Fertility, San Antonio, TX, USA.
| | - Fangbai Sun
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - R Matthew Coward
- Department of Urology, University of North Carolina, Chapel Hill, NC, USA
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - James Smith
- Department of Urology, University of California- San Francisco, San Francisco, CA, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology & Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Heping Zhang
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Rebecca Usadi
- Department of Reproductive Endocrinology and Infertility, Atrium Health, Charlotte, NC, USA
| | - Valerie L Baker
- Department of Gynecology and Obstetrics, Division of Reproductive Endocrinology and Infertility, Johns Hopkins University, Lutherville, MD, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anne Z Steiner
- Department of Reproductive Endocrinology and Infertility, Duke University School of Medicine, Durham, NC, USA
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Eisenberg E, Legro RS, Diamond MP, Huang H, O’Brien LM, Smith YR, Coutifaris C, Hansen KR, Santoro N, Zhang H. Sleep Habits of Women With Infertility. J Clin Endocrinol Metab 2021; 106:e4414-e4426. [PMID: 34180998 PMCID: PMC8530742 DOI: 10.1210/clinem/dgab474] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Indexed: 01/30/2023]
Abstract
CONTEXT Sleep plays important roles in metabolic and reproductive function, and polycystic ovary syndrome (PCOS) is associated with sleep disturbances, including increased prevalence of obstructive sleep apnea. OBJECTIVE We sought to evaluate sleep parameters in infertile women with PCOS compared with women with unexplained infertility (UI) and identify risk factors for disturbed sleep. METHODS At private and academic ambulatory gynecology and infertility practices, we evaluated a prospective cohort of women diagnosed with PCOS or UI from 2 randomized clinical trials. We included 1603 infertile women enrolled in 2 concurrent randomized clinical trials. The main outcome measures were self-reported sleep measures. RESULTS Sleep duration <6 hours (6.1% vs 2.7%; P < .001), habitual snoring (37.8% vs 19.0%; P < .001), and clinical sleepiness (12.0% vs 8.6%; P < .026) were more common in women with PCOS than those with UI. After adjusting for covariates, PCOS and elevated fasting insulin were associated (P = .010) with clinical symptoms of obstructive sleep apnea (OSA) diagnosis, whereas PCOS, elevated insulin (P = .003), WC >88 cm (P = .003), and current smoking (P = .012) were associated with habitual snoring. Clinical depression score (P < .001) and PCOS diagnosis (P = .002) were associated with perceived daytime sleepiness. Short sleep duration and clinical symptoms of OSA were not associated with conception and live birth rates. CONCLUSION Infertile women with PCOS more commonly report sleep disturbances than those with UI. Markers of insulin resistance are associated with previous diagnosis of OSA, habitual snoring, and short sleep duration. The presence of clinical symptoms of OSA or short sleep duration does not affect fertility treatment response.
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Affiliation(s)
- Esther Eisenberg
- Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20817, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA 16802, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA 30912, USA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
| | - Louise M O’Brien
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Yolanda R Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
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Wang A, Wang S, Owens CD, Vora JB, Diamond MP. Health Care Costs and Treatment Patterns Associated with Uterine Fibroids and Heavy Menstrual Bleeding: A Claims Analysis. J Womens Health (Larchmt) 2021; 31:856-863. [PMID: 34591695 PMCID: PMC9245789 DOI: 10.1089/jwh.2020.8983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Heavy menstrual bleeding (HMB) is one of the most common distressing complications of uterine fibroids (UF); however, data on the health care costs for treatments in women experiencing HMB associated with UF are lacking. The objective of this study was to compare the direct costs and treatments patterns for women diagnosed with UF+HMB, UF only, and HMB only in the United States. Materials and Methods: The study design was retrospective matched cohort study using claims data. Women, aged 18–51 years, comprising four cohorts (HMB only, UF only, UF+HMB, and controls) were identified in the IBM MarketScan® Commercial Claims and Encounters Database (October 1, 2007‒September 30, 2018) and matched by demographics and Charlson Comorbidity Index score. Baseline characteristics and treatments during the 12 months post-diagnosis were summarized descriptively. Costs (2018 U.S. dollars) during the post-diagnosis year were compared using analysis of variance. Results: Before matching, women with UF+HMB represented 54% of UF cases. Following diagnosis, 32% in the matched UF+HMB cohort had no treatment, 49% underwent surgeries/procedures with (12%) or without (37%) medications, and 18% received medications only. The mean all-cause total costs for UF+HMB ($16,762) exceeded that for UF only by 24% ($13,506) and HMB only by 50% ($11,135), and almost tripled the mean cost for the control cohort ($6,691) (all, p < 0.001). The mean diagnosis-related costs were significantly higher for UF+HMB ($8,741) than for UF only ($4,550) and HMB only ($3,081) (all, p < 0.0001). Surgery/procedure costs comprised 80% of diagnosis-related medical costs for UF+HMB. Conclusions: UF with HMB were associated with significant economic burden, driven primarily by surgical/procedural costs and treatment patterns.
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Affiliation(s)
- Alice Wang
- AbbVie, Inc., North Chicago, Illinois, USA
| | | | | | | | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
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Rios JS, Coward RM, Hansen KR, Barnhart KT, Cedars MI, Legro RS, Diamond MP, Krawetz SA, Usadi R, Baker VL, Sun F, Wild R, Smith JF, Santoro N, Zhang H, Steiner AZ. Sperm deoxyribonucleic acid fragmentation: predictors, fertility outcomes, and assays among infertile males. F S Rep 2021; 2:282-288. [PMID: 34553152 PMCID: PMC8441563 DOI: 10.1016/j.xfre.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To examine the factors associated with increased deoxyribonucleic acid fragmentation index (DFI), evaluate the pregnancy outcomes of men with increased DFI, and compare three independent DFI assays. Design Secondary analysis. Setting Nine US-based fertility centers. Patient(s) Infertile men (N = 147) with sperm concentration ≤15 × 106/mL, motility ≤40%, or normal morphology ≤4% were enrolled. The female partners were ovulatory, ≤40 years old, and had documented tubal patency. Intervention(s) At a baseline visit, the men provided a semen sample. The couples attempted conception without assistance for 3 months and with ovarian stimulation and intrauterine insemination in the subsequent 3 months. Main Outcome Measure(s) The DFI was analyzed using the sperm chromatin structure assay (SCSA) with increased DFI defined as >30%. The predictors of increased DFI were determined by a multivariable linear regression model. The pregnancy outcomes were compared using the χ2 test. The independent DFI assays (SCSA, deoxynucleotidyl transferase-mediated dUTP nick end labeling, and Comet) were compared with Pearson and Spearman correlations. Result(s) The 19% of men with increased DFI were older (36.0 vs. 33.0 years) and had lower total sperm motility (38.2% ± 20.5% vs. 45.2% ± 15.6%). Increased male age was found to be a significant predictor of DFI (0.75, 95% confidence interval [0.06, 1.45]). Increased DFI was not associated with conception or live birth. There was a modest correlation of the deoxynucleotidyl transferase-mediated dUTP nick end labeling assay with the SCSA (r = 0.34) and Comet assay (r = 0.19). Conclusion(s) Older age was associated with increased DFI among infertile men. The DFI assays were only weakly correlated, indicating a standard definition of DFI is needed to truly interrogate how sperm deoxyribonucleic acid fragmentation impacts male fertility.
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Affiliation(s)
- Julie S Rios
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Karl R Hansen
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Kurt T Barnhart
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Marcelle I Cedars
- University of California San Francisco School of Medicine, San Francisco, California
| | - Richard S Legro
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | | | | | | | | | - Fangbai Sun
- Yale School of Public Health, New Haven, Connecticut
| | - Robert Wild
- University of North Carolina, Chapel Hill, North Carolina
| | - James F Smith
- University of California San Francisco School of Medicine, San Francisco, California
| | | | - Heping Zhang
- Yale School of Public Health, New Haven, Connecticut
| | - Anne Z Steiner
- Duke University School of Medicine, Durham, North Carolina
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Awonuga AO, Chatzicharalampous C, Thakur M, Rambhatla A, Qadri F, Awonuga M, Saed G, Diamond MP. Genetic and Epidemiological Similarities, and Differences Between Postoperative Intraperitoneal Adhesion Development and Other Benign Fibro-proliferative Disorders. Reprod Sci 2021; 29:3055-3077. [PMID: 34515982 DOI: 10.1007/s43032-021-00726-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/22/2021] [Indexed: 12/11/2022]
Abstract
Intraperitoneal adhesions complicate over half of abdominal-pelvic surgeries with immediate, short, and long-term sequelae of major healthcare concern. The pathogenesis of adhesion development is similar to the pathogenesis of wound healing in all tissues, which if unchecked result in production of fibrotic conditions. Given the similarities, we explore the published literature to highlight the similarities in the pathogenesis of intra-abdominal adhesion development (IPAD) and other fibrotic diseases such as keloids, endometriosis, uterine fibroids, bronchopulmonary dysplasia, and pulmonary, intraperitoneal, and retroperitoneal fibrosis. Following a literature search using PubMed database for all relevant English language articles up to November 2020, we reviewed relevant articles addressing the genetic and epidemiological similarities and differences in the pathogenesis and pathobiology of fibrotic diseases. We found genetic and epidemiological similarities and differences between the pathobiology of postoperative IPAD and other diseases that involve altered fibroblast-derived cells. We also found several genes and single nucleotide polymorphisms that are up- or downregulated and whose products directly or indirectly increase the propensity for postoperative adhesion development and other fibrotic diseases. An understanding of the similarities in pathophysiology of adhesion development and other fibrotic diseases contributes to a greater understanding of IPAD and these disease processes. At a very fundamental level, blocking changes in the expression or function of genes necessary for the transformation of normal to altered fibroblasts may curtail adhesion formation and other fibrotic disease since this is a prerequisite for their development. Similarly, applying measures to induce apoptosis of altered fibroblast may do the same; however, apoptosis should be at a desired level to simultaneously ameliorate development of fibrotic diseases while allowing for normal healing. Scientists may use such information to develop pharmacologic interventions for those most at risk for developing these fibrotic conditions.
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Affiliation(s)
- Awoniyi O Awonuga
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
| | - Charalampos Chatzicharalampous
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Mili Thakur
- Reproductive Genomics Program, The Fertility Center, Grand Rapids, MI, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Anupama Rambhatla
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Farnoosh Qadri
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Modupe Awonuga
- Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University, 1355 Bogue Street, East Lansing, MI, USA
| | - Ghassan Saed
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, 1120 15th Street, CJ-1036, Augusta, GA, 30912, USA
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30
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Hosseinzadeh P, Peck JD, Burks HR, Souter I, Craig LB, Diamond MP, Hansen KR. FOLLICULAR PHASE LENGTH (FPL) AND PREGNANCY OUTCOME IN WOMEN WITH UNEXPLAINED INFERTILITY UNDERGOING OVARIAN STIMULATION WITH INTRAUTERINE INSEMINATION (OS-IUI) CYCLES IN A MULTICENTER TRIAL. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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31
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Gavrizi SZ, Anderson Z, Peck JD, Burks HR, Diamond MP, Hansen KR. EFFECT OF PREMATURELY ELEVATED LATE FOLLICULAR PROGESTERONE ON PREGNANCY OUTCOMES FOLLOWING OVARIAN STIMULATION-INTRAUTERINE INSEMINATION FOR UNEXPLAINED INFERTILITY. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Gavrizi SZ, Peck JD, Eckart E, Agbaga MP, Tytanic M, Craig LB, Diamond MP, Hansen KR. SPERM VERY LONG CHAIN POLYUNSATURATED FATTY ACID (VLC-PUFA) CONCENTRATION: RELATION TO SEMEN PARAMETERS AND LIVE-BIRTH OUTCOME IN A MULTICENTER TRIAL. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Barnhart KT, Hansen KR, Stephenson MD, Usadi R, Steiner AZ, Cedars MI, Jungheim ES, Hoeger KM, Krawetz SA, Mills B, Alston M, Coutifaris C, Senapati S, Sonalkar S, Diamond MP, Wild RA, Rosen M, Sammel MD, Santoro N, Eisenberg E, Huang H, Zhang H. Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial. JAMA 2021; 326:390-400. [PMID: 34342619 PMCID: PMC8335579 DOI: 10.1001/jama.2021.10767] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Women with an early nonviable pregnancy of unknown location are at high risk of ectopic pregnancy and its inherent morbidity and mortality. Successful and timely resolution of the gestation, while minimizing unscheduled interventions, are important priorities. OBJECTIVE To determine if active management is more effective in achieving pregnancy resolution than expectant management and whether the use of empirical methotrexate is noninferior to uterine evacuation followed by methotrexate if needed. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial recruited 255 hemodynamically stable women with a diagnosed persisting pregnancy of unknown location between July 25, 2014, and June 4, 2019, in 12 medical centers in the United States (final follow up, August 19, 2019). INTERVENTIONS Eligible patients were randomized in a 1:1:1 ratio to expectant management (n = 86), active management with uterine evacuation followed by methotrexate if needed (n = 87), or active management with empirical methotrexate using a 2-dose protocol (n = 82). MAIN OUTCOMES AND MEASURES The primary outcome was successful resolution of the pregnancy without change from initial strategy. The primary hypothesis tested for superiority of the active groups combined vs expectant management, and a secondary hypothesis tested for noninferiority of empirical methotrexate compared with uterine evacuation with methotrexate as needed using a noninferiority margin of -12%. RESULTS Among 255 patients who were randomized (median age, 31 years; interquartile range, 27-36 years), 253 (99.2%) completed the trial. Ninety-nine patients (39%) declined their randomized allocation (26.7% declined expectant management, 48.3% declined uterine evacuation, and 41.5% declined empirical methotrexate) and crossed over to a different group. Compared with patients randomized to receive expectant management (n = 86), women randomized to receive active management (n = 169) were significantly more likely to experience successful pregnancy resolution without change in their initial management strategy (51.5% vs 36.0%; difference, 15.4% [95% CI, 2.8% to 28.1%]; rate ratio, 1.43 [95% CI, 1.04 to 1.96]). Among active management strategies, empirical methotrexate was noninferior to uterine evacuation followed by methotrexate if needed with regard to successful pregnancy resolution without change in management strategy (54.9% vs 48.3%; difference, 6.6% [1-sided 97.5% CI, -8.4% to ∞]). The most common adverse event was vaginal bleeding for all of the 3 management groups (44.2%-52.9%). CONCLUSIONS AND RELEVANCE Among patients with a persisting pregnancy of unknown location, patients randomized to receive active management, compared with those randomized to receive expectant management, more frequently achieved successful pregnancy resolution without change from the initial management strategy. The substantial crossover between groups should be considered when interpreting the results. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02152696.
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Affiliation(s)
- Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mary D Stephenson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina
| | - Anne Z Steiner
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill
| | - Marcelle I Cedars
- Department of Obstetrics and Gynecology, University of California at San Francisco
| | - Emily S Jungheim
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Kathleen M Hoeger
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Benjie Mills
- Department of Obstetrics & Gynecology, Prisma Health, University of South Carolina School of Medicine-Greenville
| | - Meredith Alston
- Department of Obstetrics and Gynecology, University of Colorado and Denver Health Medical Center, Denver
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suneeta Senapati
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mitchell Rosen
- Department of Obstetrics and Gynecology, University of California at San Francisco
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver
| | - Esther Eisenberg
- Fertility and Infertility Branch, National Institute of Child Health and Human Development, Rockville, Maryland
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut
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Dozortsev DI, Pellicer A, Diamond MP. Oscillations of estradiol and gonadotropins are a missing link to solving the mystery of mono-ovulation in humans. Fertil Steril 2021; 116:630-632. [PMID: 34303510 DOI: 10.1016/j.fertnstert.2021.05.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 10/20/2022]
Affiliation(s)
| | - Antonio Pellicer
- Instituto Valenciano de Infertilidad, Rome, Italy; Instituto de Investigacion Sanitaria La Fever, Valencia, Spain
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia
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35
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Engmann L, Sun F, Legro RS, Diamond MP, Zhang H, Santoro N. Factors associated with study protocol adherence and bio banking participation in reproductive medicine clinical trials and their relationship to live birth. Hum Reprod 2021; 35:2819-2831. [PMID: 33190149 DOI: 10.1093/humrep/deaa232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/14/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What demographic and baseline characteristics are predictive of adherence to reproductive medicine clinical trial protocols, live birth or participation in genetic studies? SUMMARY ANSWER Race, BMI and lower income are associated with likelihood of non-adherent to reproductive medicine clinical trial protocols, while race influences collection of biological samples and non-adherent to study protocols is associated with lower probability of live birth. WHAT IS KNOWN ALREADY Although aspects of adherence to study protocol have previously been evaluated as individual factors in infertile women, the factors that affect overall non-adherent to study protocol have not been previously evaluated. STUDY DESIGN, SIZE, DURATION A secondary data analysis of 1650 participants from two prospective multicenter, double-blind controlled studies was carried out: Pregnancy in Polycystic Ovary Syndrome II (PPCOS II) and Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS). PARTICIPANTS/MATERIALS, SETTING, METHODS The participants were women aged 18-40 years old with either polycystic ovary syndrome (PCOS) with ovulatory dysfunction in combination with either hyperandrogenemia and/or polycystic ovarian morphology (PPCOS II), or regular ovulatory cycles with unexplained infertility (AMIGOS). The study was carried out in 14 clinical sites in the USA. Non-adherence to clinical trial protocol was chosen as the primary outcome for this analysis. To evaluate whether demographic and baseline characteristics were predictive of adherence to study protocols, live birth or participation in blood sampling for DNA and repository, and pregnancy registry, these putative factors were compared between the outcome measures. Logistic regression was used to establish a prediction model using the putative predictors introduced above. MAIN RESULTS AND THE ROLE OF CHANCE Women who self-identified as African American or Asian and those with higher BMI and lower household income were less likely to adhere to protocol. Non-adherence to the study protocol was associated with a lower probability of live birth (odds ratio: 0.180, 95% CI: 0.120, 0.272, P < 0.001). African Americans or Asians were less likely to participate in optional study DNA collection compared to Whites. Participants who were African American or with high annual income or from the Southwest sites or had PCOS were less likely to participate in the blood repository studies. LIMITATIONS, REASONS FOR CAUTION Race and ethnicity were self-reported and such self-classification to strict race and ethnicity may not always be representative of a whole racial or ethnic group. This study included two US multicenter trials and therefore the findings may not be extrapolated to international trials. WIDER IMPLICATIONS OF THE FINDINGS Identification of populations with low participation is an important initial step, as further investigation can develop specific measures to improve adherence to study protocols and participation in biospecimen banking and thereby extend the representativeness of reproductive medicine clinical trial findings. STUDY FUNDING/COMPETING INTEREST(S) Supported by NIH Eunice Kennedy Shriver NICHD Grants: U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936, U10HD055925, PPCOSII: U10 HD27049, U10 HD38992, U10 HD055925, U10 HD39005, U10 HD38998, U10 HD055936, U10 HD055942, U10 HD055944; Clinical Reproductive Endocrine Scientist Training Program (CREST): R25HD075737. Outside this study, M.P.D. received NIH/NIHCD research grant and R.S.L. received research grant from Ferring and was consultant for Bayer, Kindex, Odega, Millendo and AbbVie. TRIAL REGISTRATION NUMBER ClinicalTrials.gov number: NCT00719186; NCT01044862.
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Affiliation(s)
- Lawrence Engmann
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Fangbai Sun
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, PA, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
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Hansen KR, Peck JD, Coward RM, Wild RA, Trussell JC, Krawetz SA, Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Santoro N, Zhang H. Intrauterine insemination performance characteristics and post-processing total motile sperm count in relation to live birth for couples with unexplained infertility in a randomised, multicentre clinical trial. Hum Reprod 2021; 35:1296-1305. [PMID: 32432326 DOI: 10.1093/humrep/deaa027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/28/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Are intrauterine insemination (IUI) performance characteristics and post-processing total motile sperm count (TMC) related to live birth rate in couples with unexplained infertility? SUMMARY ANSWER Patient discomfort with IUI and lower inseminate TMC were associated with a reduced live birth rate, while time from hCG injection to IUI, sperm preparation method and ultrasound guidance for IUI were not associated with live birth success. WHAT IS ALREADY KNOWN We previously determined that some baseline characteristics of couples with unexplained infertility, including female age, duration of infertility, history of prior loss and income, were related to live birth rate across a course of ovarian stimulation and IUI treatment. However, the relationship between treatment outcomes and per-cycle characteristics, including ultrasound guidance for IUI, timing of IUI relative to hCG injection, difficult or painful IUI and inseminate TMC, are controversial, and most prior investigations have not evaluated live birth outcome. STUDY DESIGN, SIZE, DURATION This was a secondary analyses of 2462 cycles from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. This prospective, randomised, multicentre clinical trial determined live birth rates following IUI after ovarian stimulation with clomiphene citrate, letrozole or gonadotropins in 854 couples with unexplained infertility. It was conducted between 2011 and 2014, and couples could undergo up to four consecutive treatment cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS AMIGOS was an NIH-sponsored Reproductive Medicine Network trial conducted at 12 clinical sites. Participants were women with unexplained infertility who were between 18 and 40 years of age. Cluster-weighted generalised estimating equations (GEE), which account for informative clustering of multiple IUI treatment cycles within the same patient, were used to determine associations between IUI performance characteristics, including inseminate TMC, and live birth rate. Efficiency curves were also generated to examine the relationship between inseminate TMC and live birth rate. MAIN RESULTS AND THE ROLE OF CHANCE After adjustment for treatment group and baseline factors previously associated with live birth across a course of OS-IUI treatment, patient discomfort during the IUI procedure was associated with a reduction in live birth rate (aRR 0.40 (0.16-0.96)). Time from hCG trigger injection to IUI was not significantly associated with outcome. Higher TMC was associated with greater live birth rate (TMC 15.1-20.0 million (14.8%) compared to ≤5 million (5.5%)) (aRR 2.09 (1.31-3.33)). However, live births did occur with TMC ≤ 1 million (5.1%). LIMITATIONS, REASONS FOR CAUTION This investigation is a secondary analysis, and AMIGOS was not designed to address the present question. Since timed intercourse was allowed as part of the AMIGOS trial, we cannot rule out the possibility that any given pregnancy resulted from intercourse rather than IUI. WIDER IMPLICATIONS OF THE FINDINGS Most factors associated with the performance of IUI were not significantly related to obtaining live birth. Our findings suggest that higher TMC inseminated leads to an increase in live birth rate up to TMC ~20 million. However, there may be no reasonable threshold below which live birth is not possible with IUI. STUDY FUNDING/COMPETING INTEREST(S) Funding was received through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD077680, U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10 HD055925. This research was made possible by funding by the American Recovery and Reinvestment Act. Dr Hansen reports grants from NIH/NICHD and Yale University during the conduct of the study, grants from Roche Diagnostics and grants from Ferring International Pharmascience Center US outside the submitted work. Dr Peck reports support from Ferring Pharmaceuticals outside the submitted work. Dr Coward has nothing to disclose. Dr Wild reports grants from NICHD during the conduct of the study. Dr Trussell has nothing to disclose. Dr Krawetz reports grants from NICHD during the conduct of the study, grants from Merck and support from Taylor and Frances and from Springer, outside the submitted work. Dr Diamond reports grants from NIH/NICHD, Yale University, during the conduct of the study and support from Advanced Reproductive Care AbbVie, Bayer and ObsEva, outside the submitted work. Dr Legro reports support from Bayer, Kindex, Odega, Millendo and AbbVie and grants and support from Ferring, outside the submitted work. Dr Coutifaris reports grants from NICHD/NIH and personal fees from American Society for Reproductive Medicine, outside the submitted work. Dr Alvero has nothing to disclose. Dr Robinson reports grants from NIH during the conduct of the study. Dr Casson has nothing to disclose. Dr Christman reports grants from NICHD during the conduct of the study. Dr Santoro reports grants from NIH during the conduct of the study. Dr Zhang reports grants from NIH during the conduct of the study and support from Shangdong University outside the submitted work. TRIAL REGISTRATION NUMBER n/a.
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Affiliation(s)
- Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA
| | - Jennifer D Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA.,Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, OK 73104, USA
| | - R Matthew Coward
- Department of Urology, UNC School of Medicine, 2113 Physicians Office Building CB#7235, Chapel Hill, NC 27599-7235, USA.,UNC Fertility, 7920 ACC Blvd #300, Raleigh, NC 27617, USA
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA.,Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, OK 73104, USA
| | - J C Trussell
- Department of Urology, Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA.,Department of Obstetrics and Gynecology, Augusta University, Augusta, GA 30912, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA 17033, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO 80045, USA.,Department of Obstetrics and Gynecology, Stanford University, Sunnyvale, CA 94087, USA
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, TX 78229, USA
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, VT 05446, USA.,Northeastern Reproductive Medicine, 105 W View Rd, #302, Colchester, VT 05446, USA
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Obstetrics and Gynecology, University of Florida College of Medicine, PO Box 100294, Gainesville, FL 32610, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
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Dozortsev DI, Diamond MP. Luteinizing hormone-independent rise of progesterone as the physiological trigger of the ovulatory gonadotropins surge in the human. Fertil Steril 2021; 114:191-199. [PMID: 32741458 DOI: 10.1016/j.fertnstert.2020.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 02/09/2023]
Abstract
The current ovarian cycle paradigm postulates that ovulation is triggered by a critically sustained elevation of estradiol. However, an in-depth look into the published data reveals considerable uncertainty about the relative roles of progesterone and estradiol in the ovulation process.This review provides compelling evidences that the role of estradiol in ovulation has been misinterpreted and that the true physiological trigger of ovulation is a luteinizing hormone-independent preovulatory progesterone surge in the circulation to approximately 0.5 ng/mL. Furthermore, the current work reconciles the ability of progesterone to trigger ovulation, with its well-established ability to block ovulation during pregnancy, or when administered in the form of a synthetic progestin in birth control formulations and with experimental data that estradiol benzoate triggers ovulation in the complete absence of progesterone.
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Wegienka G, Stewart EA, Nicholson WK, Zhang S, Li F, Thomas L, Spies JB, Venable S, Laughlin-Tommaso S, Diamond MP, Anchan RM, Maxwell GL, Marsh EE, Myers ER, Vines AI, Wise LA, Wallace K, Jacoby VL. Black Women Are More Likely Than White Women to Schedule a Uterine-Sparing Treatment for Leiomyomas. J Womens Health (Larchmt) 2021; 30:355-366. [PMID: 33524308 DOI: 10.1089/jwh.2020.8634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: To evaluate differences in the proportion of uterine fibroid (UF) treatments that are uterine-sparing between Black women and White women and identify factors that could explain disparities. Methods: Women at age 18-54 years who were enrolled from 10 clinical sites in the United States into the Comparing Options for Management: Patient-Centered Results for UFs (COMPARE-UF) treatment registry completed questionnaires before their UF procedure. UF symptoms and quality of life were assessed by questionnaires. Details on UF imaging and treatment (hysterectomy, myomectomy, or uterine artery embolization [UAE]) were collected from each patient's medical record. Random-effects logistic regression was used to assess the association between race and the odds of having a uterine-sparing procedure versus hysterectomy. Subgroup analyses compared each uterine-sparing procedure with hysterectomy. Results: In this cohort of 1141 White women and 1196 Black women, Black women tended to be younger (median 41.0 vs. 42.0 years) and report worse symptoms, pain, and function on every scale compared with White women. Black women were more likely to have had a prior UF treatment compared with White women (22.8% vs. 14.6%). White women had more hysterectomies (43.6% vs. 32.2%) and myomectomies (50.9% vs. 50.2%) versus Black women. Black women had more UAEs (15.1% vs. 4.7%) than White women. After adjusting for clinical site and other variables, Black women had greater odds than White women of having a myomectomy (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.63-3.56) or a UAE versus hysterectomy (OR = 4.24, 95% CI = 2.41-7.46). Conclusion: In these participants, Black women were more likely to schedule a uterine-sparing UF treatment and a nonsurgical UF treatment than their White counterparts; this may not be true for all women. Longer comparative effectiveness studies are needed to inform women about the durability of UF treatments. Greater understanding of factors influencing treatment selection is needed as are studies that include women without access to tertiary care centers. Clinical Trial Registration: Clinicaltrials.gov, NCT02260752 (enrollment start: November 2015).
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Affiliation(s)
- Ganesa Wegienka
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Elizabeth A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wanda K Nicholson
- Department of Obstetrics and Gynecology, Center for Women's Health Research, and Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Fan Li
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - James B Spies
- Department of Radiology, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | | | - Shannon Laughlin-Tommaso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, USA
| | - Raymond M Anchan
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - George Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Erica E Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anissa I Vines
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren A Wise
- Slone Epidemiology Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vanessa L Jacoby
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
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Johns DA, Garza-Leal JG, Diamond MP, Harris M. Post-Ablation Cavity Evaluation: A Prospective Multicenter Observational Clinical Study to Evaluate Hysteroscopic Access to the Uterine Cavity 4 Years After Water Vapor Endometrial Ablation for the Treatment of Heavy Menstrual Bleeding. Obstet Gynecol Surv 2021. [DOI: 10.1097/ogx.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Park YD, Linder DF, Pope J, Flamini JR, Moretz K, Diamond MP, Long SA. Long-term efficacy and safety of cannabidiol (CBD) in children with treatment-resistant epilepsy: Results from a state-based expanded access program. Epilepsy Behav 2020; 112:107474. [PMID: 33181893 DOI: 10.1016/j.yebeh.2020.107474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION An intermediate-sized, multicenter, expanded-access study was opened in 2015 through the support of the State of Georgia. This study provided children with treatment-resistant epilepsy (TRE) access to plant-derived highly purified cannabidiol (CBD; Epidiolex® in the US; Epidyolex® in the EU; 100 mg/mL oral solution). These children had failed to achieve seizure freedom with available treatment options and were ineligible to participate in randomized controlled trials that only included patients with Lennox-Gastaut and Dravet syndromes. METHODS Cannabidiol safety, changes in seizure type, frequency, and seizure-free days were evaluated for children aged 1-18 years (at time of consent) as an adjunctive treatment for 36 months. The study consisted of a two-month baseline period, a titration period, treatment period, and optional titration period, which occurred after ≥26 weeks of treatment. Cannabidiol treatment was administered up to a targeted dose of 25 mg/kg/day, with an optional secondary treatment up to 50 mg/kg/day. Daily seizure type, seizure frequency, and seizure-free days were recorded in a Web-based diary, and changes in these outcomes were recorded and analyzed for the duration of the study. The occurrence of adverse events (AEs) was also recorded. RESULTS The median percentage change in seizures for 45 patients in Months 3, 6, 12, 18, 24, and 36 showed a statistically significant (p < 0.001) reduction in major seizures (ranging from 54 to 72% at various time points) and all seizures (61-70%) compared with baseline. A mean increase in seizure-free days per 28 days was >5 in all treatment periods after Month 2, and an average increase of 7.52 (p < 0.001) seizure-free days per 28 days was observed at the end of follow-up compared with baseline. All patients experienced ≥1 AE. Children who transitioned to the optional secondary treatment (high-dose group) reported more AEs before increasing their dose to >25.0 mg/kg/day compared with the low-dose group. However, the average rate of AEs was significantly lower after moving to a high-dose regimen (p = 0.004). Twelve children reported 20 serious AEs, none of which were considered related to CBD. CONCLUSIONS This study supports CBD as an adjunctive treatment for children with TRE. Treatment was well tolerated in doses up to 50 mg/kg/day. Patients who did not achieve desired results at a dose of ≤25.0 mg/kg/day reported more AEs when CBD dose increased to >25.0 mg/kg/day. Decreases in major seizure frequency and an increase in seizure-free days compared with baseline were reported during treatment. This supports the efficacy and tolerability of CBD for mixed seizure etiologies.
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Affiliation(s)
- Yong D Park
- Augusta University, Augusta, GA, United States.
| | | | - Jamie Pope
- Augusta University, Augusta, GA, United States.
| | | | - Katherine Moretz
- Memorial Health University Medical Center, Savannah, GA, United States
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Dozortsev DI, Pellicer A, Diamond MP. Premature progesterone rise as a trigger of polycystic ovarian syndrome. Fertil Steril 2020; 114:943-944. [PMID: 33036794 DOI: 10.1016/j.fertnstert.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/07/2020] [Indexed: 11/19/2022]
Affiliation(s)
| | - Antonio Pellicer
- Instituto Valenciano de Infertilidad (IVI), Rome, Italy; Instituto de Investigacíon Sanitaria La Fe, Valencia, Spain
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
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Vitek W, Sun F, Hoeger KM, Santoro N, Diamond MP, Zhang H, Legro RS. Short-term weight change and live birth among women with unexplained infertility and polycystic ovary syndrome undergoing ovulation induction. Fertil Steril 2020; 114:1032-1039. [PMID: 33036790 DOI: 10.1016/j.fertnstert.2020.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine if short-term weight change among women with unexplained infertility (UI) and polycystic ovary syndrome (PCOS) undergoing ovulation induction is associated with live birth. DESIGN Secondary analysis of randomized trials. SETTING Multicenter fertility trial sites. PATIENT(S) A total of 900 women with UI and 750 women with PCOS. MAIN OUTCOME MEASURE(S) Live birth. INTERVENTION(S) Weight assessment at enrollment and start of up to 4-5 cycles of clomiphene, letrozole, or gonadotropins and intrauterine insemination for women with UI and clomiphene or letrozole with regular intercourse for women with PCOS. RESULT(S) Weight data were available for 856 women with UI and 697 women with PCOS. Mean weight change was -0.2 ± 0.3 kg among women with UI and +2.2 ± 0.2 kg among women with PCOS and did not differ based on treatment allocation. There were 115 women with PCOS (16.4%) who gained ≥3 kg. Increased body mass index and three or more cycles were associated with weight gain in women with PCOS. There was no difference in live birth rate among women with PCOS and ≥3 kg weight gain and women with PCOS who did not gain weight. CONCLUSION(S) Women with PCOS gained an average of 2.2 kg regardless of the medication received, whereas women with UI experienced no short-term weight change during ovulation induction. Weight gain in women with PCOS was not associated with live birth rate.
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Affiliation(s)
- Wendy Vitek
- University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | - Fangbai Sun
- Yale School of Public Health, New Haven, Connecticut
| | - Kathleen M Hoeger
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | | | - Heping Zhang
- Yale School of Public Health, New Haven, Connecticut
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Moffat SD, An Y, Resnick SM, Diamond MP, Ferrucci L. Longitudinal Change in Cortisol Levels Across the Adult Life Span. J Gerontol A Biol Sci Med Sci 2020; 75:394-400. [PMID: 31714574 DOI: 10.1093/gerona/gly279] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cortisol is a key stress hormone implicated in the pathogenesis of many age-related diseases. Longitudinal information on cortisol exposure has been restricted to animal models and a small number of human studies. The purpose of the present study was to quantify longitudinal change in cortisol across the adult life span. METHODS We conducted a prospective longitudinal study of 24-hour urinary free cortisol excretion from ages 20 to 90 years and older. Participants were 1,814 men and women from the Baltimore Longitudinal Study of Aging who provided a total of 5,527 urine specimens for analysis. The average duration of longitudinal follow-up was 6.6 years. The primary outcome measure was 24-hour urinary free cortisol to creatinine ratio (UFC/Cr) as determined by liquid chromatography/mass spectrometry. RESULTS UFC/Cr follows a U-shaped pattern across the life span with decreases in UFC/Cr in the 20s and 30s, relative stability in the 40s and 50s, and increases thereafter. This pattern of change was robust with respect to adjustment for several potential confounding factors. CONCLUSIONS Age-related changes in cortisol exposure raise important questions about the potential protective or exacerbating role of cortisol exposure in predicting medical, physiological, and behavioral outcomes.
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Affiliation(s)
- Scott D Moffat
- Department of Psychology, Georgia Institute of Technology, Atlanta
| | - Yang An
- Laboratory of Behavioral Neuroscience, National Institute on Aging, Baltimore, Maryland
| | - Susan M Resnick
- Laboratory of Behavioral Neuroscience, National Institute on Aging, Baltimore, Maryland
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Georgia Regents University, Augusta
| | - Luigi Ferrucci
- Longitudinal Studies Section, National Institute on Aging, Baltimore
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Johns DA, Garza-Leal JG, Diamond MP, Harris M. Post-Ablation Cavity Evaluation: A Prospective Multicenter Observational Clinical Study to Evaluate Hysteroscopic Access to the Uterine Cavity 4 Years after Water Vapor Endometrial Ablation for the Treatment of Heavy Menstrual Bleeding. J Minim Invasive Gynecol 2020; 27:1273-1280. [DOI: 10.1016/j.jmig.2019.09.775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 11/25/2022]
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Chiu YH, Stensrud MJ, Dahabreh IJ, Rinaudo P, Diamond MP, Hsu J, Hernández-Díaz S, Hernán MA. The Effect of Prenatal Treatments on Offspring Events in the Presence of Competing Events: An Application to a Randomized Trial of Fertility Therapies. Epidemiology 2020; 31:636-643. [PMID: 32501812 PMCID: PMC7755108 DOI: 10.1097/ede.0000000000001222] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
When studying the effect of a prenatal treatment on events in the offspring, failure to produce a live birth is a competing event for events in the offspring. A common approach to handle this competing event is reporting both the treatment-specific probabilities of live births and of the event of interest among live births. However, when the treatment affects the competing event, the latter probability cannot be interpreted as the causal effect among live births. Here we provide guidance for researchers interested in the effects of prenatal treatments on events in the offspring in the presence of the competing event "no live birth." We review the total effect of treatment on a composite event and the total effect of treatment on the event of interest. These causal effects are helpful for decision making but are agnostic about the pathways through which treatment affects the event of interest. Therefore, based on recent work, we also review three causal effects that explicitly consider the pathways through which treatment may affect the event of interest in the presence of competing events: the direct effect of treatment on the event of interest under an intervention to eliminate the competing event, the separable direct and indirect effects of treatment on the event of interest, and the effect of treatment in the principal stratum of those who would have had a live birth irrespective of treatment choice. As an illustrative example, we use a randomized trial of fertility treatments and risk of neonatal complications.
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Affiliation(s)
- Yu-Han Chiu
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA
- Mongan Institute, Massachusetts General Hospital, Boston,
MA
| | - Mats J. Stensrud
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA
| | - Issa J. Dahabreh
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA
- Department of Health Services Policy and Practice, Center
for Evidence Synthesis in Health, School of Public Health, Brown University, Box
G-121-8, Providence, RI
- Department of Epidemiology, School of Public Health, Brown
University, Providence, RI
| | - Paolo Rinaudo
- Center for Reproductive Health, Department of Obstetrics,
Gynecology, and Reproductive Sciences, University of California, San Francisco,
CA
| | - Michael P. Diamond
- Department of Obstetrics & Gynecology, Medical College
of Georgia, Augusta University, Augusta, GA
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Boston,
MA
- Department of Health Care Policy, Harvard Medical School,
Boston, MA
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA
| | - Miguel A. Hernán
- Department of Epidemiology, Harvard T.H. Chan School of
Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of
Public Health, Boston, MA
- Harvard-MIT Division of Health Sciences and Technology,
Boston, MA
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Quaas AM, Gavrizi SZ, Peck JD, Diamond MP, Hansen KR. ENDOMETRIAL THICKNESS FOLLOWING OVARIAN STIMULATION WITH GONADOTROPIN, CLOMIPHENE, OR LETROZOLE FOR UNEXPLAINED INFERTILITY, AND ASSOCIATION WITH TREATMENT OUTCOMES. Fertil Steril 2020. [DOI: 10.1016/j.fertnstert.2020.08.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Stewart EA, Diamond MP, Williams ARW, Carr BR, Myers ER, Feldman RA, Elger W, Mattia-Goldberg C, Schwefel BM, Chwalisz K. Safety and efficacy of the selective progesterone receptor modulator asoprisnil for heavy menstrual bleeding with uterine fibroids: pooled analysis of two 12-month, placebo-controlled, randomized trials. Hum Reprod 2020; 34:623-634. [PMID: 30865281 DOI: 10.1093/humrep/dez007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/28/2018] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Can asoprisnil, a selective progesterone receptor modulator, provide clinically meaningful improvements in heavy menstrual bleeding (HMB) associated with uterine fibroids with an acceptable safety profile? SUMMARY ANSWER Uninterrupted treatment with asoprisnil for 12 months effectively controlled HMB and reduced fibroid and uterine volume with few adverse events. WHAT IS KNOWN ALREADY In a 3-month study, asoprisnil (5, 10 and 25 mg) suppressed uterine bleeding, reduced fibroid and uterine volume, and improved hematological parameters in a dose-dependent manner. STUDY DESIGN, SIZE, DURATION In two Phase 3, double-blind, randomized, placebo-controlled, multicentre studies, women received oral asoprisnil 10 mg, asoprisnil 25 mg or placebo (2:2:1) once daily for up to 12 months. PARTICIPANTS/MATERIALS, SETTING, METHODS Premenopausal women ≥18 years of age in North America with HMB associated with uterine fibroids were included (N = 907). The primary efficacy endpoint was the percentage of women who met all three predefined criteria at 12 months or the final month for patients who prematurely discontinued: (1) ≥50% reduction in monthly blood loss (MBL) by menstrual pictogram, (2) hemoglobin concentration ≥11 g/dL or an increase of ≥1 g/dL, and (3) no interventional therapy for uterine fibroids. Secondary efficacy endpoints included changes in other menstrual bleeding parameters, volume of the largest fibroids, uterine volume and health-related quality of life (HRQL). MAIN RESULTS AND THE ROLE OF CHANCE In all, 90% and 93% of women in the asoprisnil 10-mg and 25-mg groups, respectively, and 35% of women in the placebo group met the primary endpoint (P < 0.001). Similar results were observed at month 6 (P < 0.001). The percentage of women who achieved amenorrhea in any specified month ranged from 66-78% in the asoprisnil 10-mg group and 83-93% in the asoprisnil 25-mg group, significantly higher than with placebo (3-12%, P < 0.001). Hemoglobin increased rapidly (by month 2) with asoprisnil treatment and was significantly higher versus placebo throughout treatment. The primary fibroid and uterine volumes were significantly reduced from baseline through month 12 with asoprisnil 10 mg (median changes up to -48% and -28%, respectively) and 25 mg (median changes up to -63% and -39%, respectively) versus placebo (median changes up to +16% and +13%, respectively; all P < 0.001). Dose-dependent, significant improvements in HRQL (Uterine Fibroid Symptom and Quality of Life instrument) were observed with asoprisnil treatment. Asoprisnil was generally well tolerated. Endometrial biopsies indicated dose- and time-dependent decreases in proliferative patterns and increases in quiescent or minimally stimulated endometrium at month 12 of treatment. Although not statistically significantly different at month 6, mean endometrial thickness at month 12 increased by ~2 mm in both asoprisnil groups compared with placebo (P < 0.01). This effect was associated with cystic changes in the endometrium on MRI and ultrasonography, which led to invasive diagnostic and therapeutic procedures in some asoprisnil-treated women. LIMITATIONS, REASONS FOR CAUTION Most study participants were black; few Asian and Hispanic women participated. The study duration may have been insufficient to fully characterize the endometrial effects. WIDER IMPLICATIONS OF THE FINDINGS Daily uninterrupted treatment with asoprisnil was highly effective in controlling menstrual bleeding, improving anemia, reducing fibroid and uterine volume, and increasing HRQL in women with HMB associated with uterine fibroids. However, this treatment led to an increase in endometrial thickness and invasive diagnostic and therapeutic procedures, with potential unknown consequences. STUDY FUNDING/COMPETING INTEREST(S) This trial was funded by AbbVie Inc. (prior sponsors: TAP Pharmaceutical Products Inc., Abbott Laboratories). E.A. Stewart was a site investigator in the Phase 2 study of asoprisnil and consulted for TAP during the design and conduct of these studies while at Harvard Medical School and Brigham and Women's Hospital. She received support from National Institutes of Health grants HD063312, HS023418 and HD074711 and research funding, paid to Mayo Clinic for patient care costs related to an NIH-funded trial from InSightec Ltd. She consulted for AbbVie, Allergan, Bayer HealthCare AG, Gynesonics, and Welltwigs. She received royalties from UpToDate and the Med Learning Group. M.P. Diamond received research funding for the conduct of the studies paid to the institution and consulted for AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution from Bayer and ObsEva. A.R.W. Williams consulted for TAP and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr consulted for and received research funding from AbbVie. E.R. Myers consulted for AbbVie, Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was co-inventor of several patents related to asoprisnil. C. Mattia-Goldberg is a former employee of AbbVie and may own AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie and may own AbbVie stock or stock options. TRIAL REGISTRATION NUMBER NCT00152269, NCT00160381 (clinicaltrials.gov). TRIAL REGISTRATION DATE 7 September 2005; 8 September 2005. DATE OF FIRST PATIENT’S ENROLMENT 12 September 2002; 6 September 2002.
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Affiliation(s)
- E A Stewart
- Departments of Obstetrics & Gynecology and Surgery, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - M P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, GA, USA
| | - A R W Williams
- Department of Pathology, University of Edinburgh, Edinburgh, UK
| | - B R Carr
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E R Myers
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC, USA
| | | | - W Elger
- Evestra GmbH, Berlin-Dahlem, Germany
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Ludwin A, Coelho Neto MA, Ludwin I, Nastri CO, Costa W, Acién M, Alcazar JL, Benacerraf B, Condous G, DeCherney A, De Wilde RL, Diamond MP, Emanuel MH, Guerriero S, Hurd W, Levine D, Lindheim S, Pellicer A, Petraglia F, Saridogan E, Martins WP. Congenital Uterine Malformation by Experts (CUME): diagnostic criteria for T-shaped uterus. Ultrasound Obstet Gynecol 2020; 55:815-829. [PMID: 31432589 DOI: 10.1002/uog.20845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/23/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify uterine measurements that are reliable and accurate to distinguish between T-shaped and normal/arcuate uterus, and define T-shaped uterus, using Congenital Uterine Malformation by Experts (CUME) methodology, which uses as reference standard the decision made most often by several independent experts. METHODS This was a prospectively planned multirater reliability/agreement and diagnostic accuracy study, performed between November 2017 and December 2018, using a sample of 100 three-dimensional (3D) datasets of different uteri with lateral uterine cavity indentations, acquired from consecutive women between 2014 and 2016. Fifteen representative experts (five clinicians, five surgeons and five sonologists), blinded to each others' opinions, examined anonymized images of the coronal plane of each uterus and provided their independent opinion as to whether it was T-shaped or normal/arcuate; this formed the basis of the CUME reference standard, with the decision made most often (i.e. that chosen by eight or more of the 15 experts) for each uterus being considered the correct diagnosis for that uterus. Two other experienced observers, also blinded to the opinions of the other experts, then performed independently 15 sonographic measurements, using the original 3D datasets of each uterus. Agreement between the diagnoses made by the 15 experts was assessed using kappa and percent agreement. The interobserver reliability of measurements was assessed using the concordance correlation coefficient (CCC). The diagnostic test accuracy was assessed using the area under the receiver-operating-characteristics curve (AUC) and the best cut-off value was assessed by calculating Youden's index, according to the CUME reference standard. Sensitivity, specificity, negative and positive likelihood ratios (LR- and LR+) and post-test probability were calculated. RESULTS According to the CUME reference standard, there were 20 T-shaped and 80 normal/arcuate uteri. Individual experts recognized between 5 and 35 (median, 19) T-shaped uteri on subjective judgment. The agreement among experts was 82% (kappa = 0.43). Three of the 15 sonographic measurements were identified as having good diagnostic test accuracy, according to the CUME reference standard: lateral indentation angle (AUC = 0.95), lateral internal indentation depth (AUC = 0.92) and T-angle (AUC = 0.87). Of these, T-angle had the best interobserver reproducibility (CCC = 0.87 vs 0.82 vs 0.62 for T-angle vs lateral indentation depth vs lateral indentation angle). The best cut-off values for these measurements were: lateral indentation angle ≤ 130° (sensitivity, 80%; specificity, 96%; LR+, 21.3; LR-, 0.21), lateral indentation depth ≥ 7 mm (sensitivity, 95%; specificity, 77.5%; LR+, 4.2; LR-, 0.06) and T-angle ≤ 40° (sensitivity, 80%; specificity, 87.5%; LR+, 6.4; LR-, 0.23). Most of the experts diagnosed the uterus as being T-shaped in 0% (0/56) of cases when none of these three criteria was met, in 10% (2/20) of cases when only one criterion was met, in 50% (5/10) of cases when two of the three criteria were met, and in 93% (13/14) of cases when all three criteria were met. CONCLUSIONS The diagnosis of T-shaped uterus is not easy; the agreement among experts was only moderate and the judgement of individual experts was commonly insufficient for accurate diagnosis. The three sonographic measurements with cut-offs that we identified (lateral internal indentation depth ≥ 7 mm, lateral indentation angle ≤ 130° and T-angle ≤ 40°) had good diagnostic test accuracy and fair-to-moderate reliability and, when applied in combination, they provided high post-test probability for T-shaped uterus. In the absence of other anomalies, we suggest considering a uterus to be normal when none or only one criterion is met, borderline when two criteria are met, and T-shaped when all three criteria are met. These three CUME criteria for defining T-shaped uterus may aid in determination of its prevalence, clinical implications and best management and in the assessment of post-surgical morphologic outcome. The CUME definition of T-shaped uterus may help in the development of interventional randomized controlled trials and observational studies and in the diagnosis of uterine morphology in everyday practice, and could be adopted by guidelines on uterine anomalies to enrich their classification systems. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - W Costa
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - M Acién
- San Juan University Hospital/Miguel Hernández University, Alicante, Spain
| | - J L Alcazar
- Department of Obstetrics and Gynecology, University of Navarra, Pamplona, Spain
| | | | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - A DeCherney
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - R-L De Wilde
- Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, GA, USA
| | - M H Emanuel
- Department of Gynaecology and Reproductive Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Gynaecology, University Hospital Ghent, Ghent, Belgium
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | - W Hurd
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - D Levine
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - S Lindheim
- Department of Obstetrics & Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
| | - A Pellicer
- Instituto Valenciano de Infertilidad, Valencia, Spain
| | | | - E Saridogan
- University College London Hospital, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
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Legro RS, Diamond MP, Coutifaris C, Schlaff WD, Alvero R, Casson P, Christman GM, Rosen RM, Cedars MI, Hansen KR, Robinson R, Baker V, Usadi R, Dodson WC, Estes SJ, Kunselman A, Stetter C, Barnhart KT, Coward RM, Trussell JC, Krawetz SA, Santoro N, Huang H, Zhang H, Eisenberg E. Pregnancy registry: three-year follow-up of children conceived from letrozole, clomiphene, or gonadotropins. Fertil Steril 2020; 113:1005-1013. [PMID: 32386612 DOI: 10.1016/j.fertnstert.2019.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the development of children conceived from non-IVF infertility treatments consisting of gonadotropins, clomiphene, or letrozole. DESIGN Prospective cohort study. SETTING U.S. academic health centers. PATIENT(S) Children of women with polycystic ovary syndrome who conceived with letrozole (LTZ) or clomiphene (CC) in the PPCOS II study or women with unexplained infertility (AMIGOS study) who conceived with LTZ, CC, or gonadotropin (GN). INTERVENTION(S) Longitudinal annual follow-up from birth to age 3. MAIN OUTCOME MEASURE(S) Scores from Ages and Stages Developmental Questionnaire (ASQ), MacArthur-Bates Communicative Development Inventory (MCDI), and annual growth. RESULT(S) One hundred eighty-five children from 160 families participated in at least one follow-up evaluation from the two infertility trials. Most multiple gestations in the follow-up study resulted from GN treatment (n = 14) followed by CC (n = 6) and LTZ (n = 3). There were no significant differences among the three groups at any time point with respect to abnormal scores on the ASQ. On the MCDI Words and Gestures, the LTZ group scored significantly higher than the GN group for most items (phrases, early gestures, later gestures, and total gestures). Children in the CC group scored significantly higher than the GN group for the later gestures and total gestures items. CONCLUSION(S) Differences in growth and cognitive developmental rates among children conceived with first-line infertility therapies, including LTZ, are relatively minor and likely due to differences in multiple pregnancy rates.
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Affiliation(s)
- Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William D Schlaff
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - R Mitchell Rosen
- Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, California
| | - Karl R Hansen
- Department of Obstetrics and Gynecology University of Oklahoma, Oklahoma City, Oklahoma
| | - Randal Robinson
- Department of Obstetrics and Gynecology, University of Texas at San Antonio, San Antonio, Texas
| | - Valerie Baker
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina
| | - William C Dodson
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Stephanie J Estes
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Christina Stetter
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - R Matthew Coward
- Department of Urology, University of North Carolina, Raleigh, North Carolina; UNC Fertility LLC, Raleigh, North Carolina
| | - J C Trussell
- Department of Urology, SUNY Upstate University Hospital, Syracuse, New York
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Esther Eisenberg
- Fertility and Infertility Branch, National Institute of Child Health and Human Development, Rockville, Maryland
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Halassy S, Mikhael S, Chorich LP, Tam KB, Diamond MP, Burkholder AB, Hall JE, Korach KS, Layman LC. SUN-738 Establishing the Link Between Genetic Variations of Estrogen Receptor 2 and Unexplained Infertility. J Endocr Soc 2020. [PMCID: PMC7208208 DOI: 10.1210/jendso/bvaa046.855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Unexplained or idiopathic infertility comprises approximately 30% of couples who present with infertility. This has led to investigations seeking to determine the cause(s) of this important diagnosis of exclusion. Estrogen’s role in reproduction has been well- established. Estrogens bind to two hormone receptors (namely estrogen receptor-alpha and estrogen receptor-beta), which are distributed differentially throughout the body. Specifically, the estrogen receptor-beta, coded by the Estrogen Receptor 2 (ESR2) gene, is highly expressed in granulosa cells and growing follicles. The one female patient reported with an ESR2 mutation presented with hypergonadotropic hypogonadism. However, subfertility with inefficient ovulation and resistance to exogenous ovulatory stimulation is seen in an ESR2 knockout mouse model. We therefore hypothesized that less severe ESR2 variants could lead to a normal female phenotype and pubertal development but could be a cause subfertility.
Methods: DNA samples from 200 women with unexplained infertility were obtained from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial, which investigated optimal ovulation induction medications for unexplained infertility. These samples were subjected to targeted next-generation sequencing (NGS) for the ESR2 gene. Likely pathogenic variants that occurred with a minor allele frequency of < 0.01 in the gnomAD database and a Combined Annotation Dependent Depletion (CADD) score of > 20 were selected for confirmation by Sanger sequencing.
Results: From the 200 patient samples, five heterozygous missense variants and one heterozygous in-frame deletion identified by targeted NGS were confirmed by Sanger sequencing. Further studies will need to be performed in vitro to confirm the likely pathogenicity of these variants.
Conclusion: These studies raise the possibility that If these variants in ESR2 that impair estrogen signaling, they could be a potential newly recognized etiology of unexplained infertility in women with unexplained infertility.
Conclusion: These studies raise the possibility that variants in ESR2 that impair estrogen signaling could be a potential newly recognized etiology of unexplained infertility in women.
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Affiliation(s)
| | - Sasha Mikhael
- Medical College of Georgia at Augusta University, Augusta, GA, USA
| | | | | | | | - Adam B Burkholder
- National Institute of Environmental Health Sciences/National Institute of Health, Research Triangle Park, NC, USA
| | - Janet Elizabeth Hall
- National Institute of Environmental Health Sciences/National Institute of Health, Research Triangle Park, NC, USA
| | - Kenneth Steven Korach
- National Institute of Environmental Health Sciences/National Institute of Health, Research Triangle Park, NC, USA
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