The prevalence of late-follicular phase progesterone elevation and impact on the ongoing pregnancy rate after fresh and frozen blastocyst transfer. Sub-study of an RCT

The effect of late-follicular phase progesterone elevation (LFPE) during ovarian stimulation on reproductive outcomes in ART treatment remains controversial, but recent studies indicate lower pregnancy rates with rising progesterone levels. This study aims to investigate the prevalence of late-follicular phase progesterone elevation (LFPE) and possible impact on ongoing pregnancy rate after fresh or frozen blastocyst transfer in a sub-study setting of a randomised controlled trial. A total of 288 women were included (n=137 and n=151 in the fresh transfer and freeze-all group, respectively). Among these 11(3.8%) had a progesterone level ≥1.5 ng/ml, and 20(6.9%) had a progesterone level ≥1.2 ng/ml on trigger day. Spline regression analysis showed no significant effect of late follicular phase progesterone levels on ongoing pregnancy. In the multivariate regression analysis (n = 312) only age, but not progesterone level on trigger day was significantly associated with ongoing pregnancy. In conclusion, in a clinical setting with moderate gonadotrophin stimulation and well-defined trigger and fresh transfer cancellation criteria, the prevalence of women with LFPE ≥1.5 ng/ml was low and did not indicate the clinical value of routine measurement of progesterone in the late follicular phase.

Variant in the synaptonemal complex protein SYCE2 associates with pregnancy loss through effect on recombination

Two-thirds of all human conceptions are lost, in most cases before clinical detection. The lack of detailed understanding of the causes of pregnancy losses constrains focused counseling for future pregnancies. We have previously shown that a missense variant in synaptonemal complex central element protein 2 (SYCE2), in a key residue for the assembly of the synaptonemal complex backbone, associates with recombination traits. Here we show that it also increases risk of pregnancy loss in a genome-wide association analysis on 114,761 women with reported pregnancy loss. We further show that the variant associates with more random placement of crossovers and lower recombination rate in longer chromosomes but higher in the shorter ones. These results support the hypothesis that some pregnancy losses are due to failures in recombination. They further demonstrate that variants with a substantial effect on the quality of recombination can be maintained in the population.

Lifestyle and demographic associations with 47 inflammatory and vascular stress biomarkers in 9876 blood donors

BACKGROUND

The emerging use of biomarkers in research and tailored care introduces a need for information about the association between biomarkers and basic demographics and lifestyle factors revealing expectable concentrations in healthy individuals while considering general demographic differences.

METHODS

A selection of 47 biomarkers, including markers of inflammation and vascular stress, were measured in plasma samples from 9876 Danish Blood Donor Study participants. Using regression models, we examined the association between biomarkers and sex, age, Body Mass Index (BMI), and smoking.

RESULTS

Here we show that concentrations of inflammation and vascular stress biomarkers generally increase with higher age, BMI, and smoking. Sex-specific effects are observed for multiple biomarkers.

CONCLUSION

This study provides comprehensive information on concentrations of 47 plasma biomarkers in healthy individuals. The study emphasizes that knowledge about biomarker concentrations in healthy individuals is critical for improved understanding of disease pathology and for tailored care and decision support tools.

Angiogenic factors and the lectin pathway of complement in women with secondary recurrent pregnancy loss

The poor remodeling of placental spiral arteries seen in preeclampsia is also discussed to contribute to recurrent pregnancy loss (RPL) preceded by abnormal angiogenesis and excessive complement activation. Low levels of Mannose-binding-lectin (MBL), a pattern recognition molecule (PRM) of the lectin pathway, have been found in women with RPL. We propose that pregnancy loss is connected to defective angiogenesis with reperfusion damage in the placenta and decreased levels of PRM in the lectin pathway in women with RPL. In this cohort study, we investigate the angiogenic factors and the lectin complement pathway in early pregnancy and their time-dependent relationship with pregnancy outcomes in 76 women with secondary RPL (sRPL) who have at least four prior pregnancy losses and a live birth. We evaluated levels of Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Vascular Endothelial Growth Factor (VEGF), soluble fms-like tyrosine kinase-1 (sFlt-1), and the PRMs, MBL, ficolin-1, -2, -3 and an additional soluble PRM, Pentraxin-3, during the 5th, 6th, and 7th gestational weeks. Our results showed that, compared to live births, pregnancies that ended in loss were associated with elevated VEGF levels and decreased levels of the Ang-2/Ang-1 ratio. Also, increasing levels of ficolin-2 were significantly associated with pregnancy loss, with MBL showing no association. Our research suggests that women with sRPL may have inadequate placentation with impaired angiogenesis in pregnancies ending in a loss.

The impact of acute SARS-CoV-2 on testicular function including insulin-like factor 3 (INSL3) in men with mild COVID-19: A longitudinal study

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may affect the male reproductive system as it uses angiotensin-converting enzyme (ACE)2, which is expressed in testicular tissue, as an entry point into the cell. Few studies have evaluated the long-term effects of mild coronavirus disease 2019 (COVID-19) on testicular function, and insulin-like factor 3 (INSL3) levels have not previously been assessed during acute SARS-CoV-2 infection.

OBJECTIVES

The aim of the study was to assess the impact of acute SARS-CoV-2 infection on testicular function including INSL3 and the presence of SARS-CoV-2 RNA in semen in non-hospitalised men with mild COVID-19.

MATERIALS AND METHODS

This longitudinal study included 36 non-hospitalised SARS-CoV-2-positive men (median age 29 years). Inclusion was within seven days following a positive SARS-CoV-2 reverse-transcription polymerase chain reaction test. Reproductive hormone levels, semen parameters, and the presence of SARS-CoV-2 RNA in oropharyngeal and semen samples were assessed during acute SARS-CoV-2 infection (baseline) and at three- and six-month follow-up. Wilcoxon matched-pair signed-rank (two samples) test was used to assess time-related alterations in reproductive hormone levels and semen parameters.

RESULTS

Lower plasma testosterone (T) (total and calculated free (c-fT)) and higher luteinising hormone (LH) concentrations were observed during acute SARS-CoV-2 infection (baseline) compared to three- and six-month follow-up. Consequently, ratios of c-fT/LH were lower at baseline compared to three- and six-month follow-up (p < 0.001 and p = 0.003, respectively). Concomitantly, lower INSL3 concentrations were observed at baseline compared to three-month follow-up (p = 0.01). The total number of motile spermatozoa was also lower at baseline compared to six-month follow-up (p = 0.02). The alterations were detected irrespective of whether the men had experienced SARS-CoV-2-related fever episodes or not. No SARS-CoV-2 RNA was detected in semen at any time point.

DISCUSSION AND CONCLUSION

This study showed a reduction in testicular function, which was for the first time confirmed by INSL3, in men mildly affected by SARS-CoV-2 infection. The risk of transmission of SARS-CoV-2 RNA via semen seems to be low. Febrile episodes may impact testicular function, but a direct effect of SARS-CoV-2 cannot be excluded.

Psychosocial wellbeing shortly after allocation to a freeze-all strategy compared with a fresh transfer strategy in women and men: a sub-study of a randomized controlled trial

STUDY QUESTION

Is the psychosocial wellbeing affected in women and men shortly after allocation to a freeze-all strategy with postponement of embryo transfer compared to a fresh transfer strategy?

SUMMARY ANSWER

In general, psychosocial wellbeing (i.e. emotional reactions to the treatment, quality-of-life, infertility-related stress, and marital benefit) was similar in women and men allocated to a freeze-all versus those allocated to a fresh-transfer strategy 6 days after disclosure of treatment strategy (i.e. 4 days after oocyte retrieval), although women in the freeze-all group reported a slightly higher degree of depressive symptoms and mood swings compared to women in the fresh transfer group.

WHAT IS KNOWN ALREADY

The use of a freeze-all strategy, i.e. freezing of the entire embryo cohort followed by elective frozen embryo transfer in subsequent cycles has increased steadily over the past decade in assisted reproductive technology (ART). This strategy essentially eliminates the risk of ovarian hyperstimulation syndrome and has proven beneficial regarding some reproductive outcomes in subgroups of women. However, patients experience a longer time interval between oocyte retrieval and embryo transfer, hence a longer time to pregnancy, possibly adding additional stress to the ART treatment. So far, little focus has been on the possible psychosocial strains caused by postponement of embryo transfer.

STUDY DESIGN, SIZE, DURATION

This is a self-reported questionnaire based sub-study of a multicentre randomized controlled trial (RCT) including 460 women and 396 male partners initiating their first, second, or third treatment cycle of invitro fertilisation or intracytoplasmic sperm injection (ICSI) from May 2016 to September 2018. This sub-study was included in the primary project protocol and project plan for the RCT, as psychosocial wellbeing was considered a secondary outcome.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women from eight public fertility clinics in Denmark and Sweden and one private clinic in Spain were randomized in a 1:1 ratio on the day of inclusion (menstrual cycle day 2 or 3) to either a freeze-all strategy with postponement of embryo transfer to a subsequent modified natural menstrual cycle or a fresh transfer strategy with embryo transfer in the hormone stimulated cycle. Treatment allocation was blinded until the day of the ovulation trigger. Women and their male partners were asked to complete a validated self-reported questionnaire 6 days after unblinding of treatment group allocation, corresponding to 4 days after oocyte retrieval, investigating their psychosocial wellbeing related to the treatment defined as emotional reactions to the treatment, quality-of-life, infertility-related stress, and marital benefit. The questionnaire included items from the Copenhagen Multi-Centre Psychosocial Infertility (COMPI) Fertility Problem Stress Scales and the COMPI Marital Benefit Measure.

MAIN RESULTS AND THE ROLE OF CHANCE

Baseline characteristics were comparable between the two groups for both women and men. In total, response rates were 90.7% for women and 90.2% for men. In the freeze-all group, 207 women and 179 men completed the questionnaire compared with 204 women and 178 men in the fresh transfer group. Men in the two treatment groups did not differ in any of the explored aspects of psychosocial wellbeing (i.e. emotional reactions to the treatment, quality-of-life, infertility-related stress, and marital benefit) 6 days after disclosure of treatment strategy. Women in the freeze-all group reported a slightly higher degree of depressive symptoms (P = 0.045) and mood swings (P = 0.001) (i.e. variables included in 'emotional reactions to treatment') compared to women in the fresh transfer group. When adjusted for multiple testing, depressive symptoms were no longer significantly different between the two groups. No additional differences in psychosocial wellbeing were found. Self-reported quality-of-life during treatment was also rated as similar between the two groups in both women and men, but was slightly lower than they would rate their quality-of-life when not in fertility treatment.

LIMITATIONS, REASONS FOR CAUTION

Although response rates were high, selection bias cannot be excluded. As this study was an RCT, we assume that psychosocial characteristics of the participants were equally distributed in the two groups, thus it is unlikely that the identified psychosocial differences between the freeze-all and fresh transfer group were present already at baseline. Furthermore, the questionnaire was completed as a one-time assessment 4 days after oocyte retrieval, thus not reflecting the whole treatment process, whereas an assessment after the full completed treatment cycle is needed to draw firm conclusions about the psychosocial consequences of the whole waiting period. However, a question posted that late would be highly biased on whether or not a pregnancy had been achieved.

WIDER IMPLICATIONS OF THE FINDINGS

The results indicate that individuals in the freeze-all group exhibited slightly higher levels of depressive symptoms and mood swings compared to those in the fresh transfer group. Nevertheless, it is important to note that any worries related to potential emotional strains stemming from delaying embryo transfer should not overshadow the adoption of a freeze-all approach in cases where it is clinically recommended. As long as patients are provided with comprehensive information about the treatment strategy before initiating the process, it is worth emphasising that other aspects of psychosocial wellbeing were comparable between the two groups.

STUDY FUNDING/COMPETING INTEREST(S)

The study is part of the Reprounion collaborative study, co-financed by the European Union, Interreg V Öresund-Kattegat-Skagerrak. L.P. reports financial support from Merck A/S. H.S.N. reports grants from Freya Biosciences ApS, Ferring Pharmaceuticals, BioInnovation Institute, Ministry of Education, Novo Nordic Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, Ole Kirks Fond and Independent Research Fund Denmark and personal fees from Ferring Pharmaceuticals, Merck A/S, Astra Zeneca, Cook Medical, IBSA Nordic and Gedeon Richter. H.S.N is founder and chairman of the Maternity Foundation and co-developed the Safe Delivery App (non-profit). N.C.F. reports grants from Gedeon Richter, Merck A/S, Cryos International and financial support from Ferring Pharmaceuticals, Merck A/S and Gedeon Richter. N.C.F. is chairman in the steering committee for the guideline groups for The Danish Fertility Society (non-profit). P.H. reports honoraria from Merch A/S, IBSA Nordic and Gedeon Richter. A.L.M.E. reports grants and financial support from Merck A/S and Gedeon Richter. A.P. reports grants from Gedeon Richter, Ferring Pharmaceuticals, Merck A/S and personal fees from Preglem S.A., Novo Nordic Foundation, Ferring Pharmaceuticals, Gedeon Richter, Cryos International, Merch A/S, Theramex and Organon and the lend of embryoscope to the institution from Gedeon Richter. All other authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT02746562.

Genome-wide association study of placental weight identifies distinct and shared genetic influences between placental and fetal growth

A well-functioning placenta is essential for fetal and maternal health throughout pregnancy. Using placental weight as a proxy for placental growth, we report genome-wide association analyses in the fetal (n = 65,405), maternal (n = 61,228) and paternal (n = 52,392) genomes, yielding 40 independent association signals. Twenty-six signals are classified as fetal, four maternal and three fetal and maternal. A maternal parent-of-origin effect is seen near KCNQ1. Genetic correlation and colocalization analyses reveal overlap with birth weight genetics, but 12 loci are classified as predominantly or only affecting placental weight, with connections to placental development and morphology, and transport of antibodies and amino acids. Mendelian randomization analyses indicate that fetal genetically mediated higher placental weight is causally associated with preeclampsia risk and shorter gestational duration. Moreover, these analyses support the role of fetal insulin in regulating placental weight, providing a key link between fetal and placental growth.

Thyroglobulin Antibodies in Women with Recurrent Pregnancy Loss: A Systematic Review and Meta-Analysis

Background: Thyroid autoimmunity is the most prevalent autoimmune disorder among women of reproductive age and has been suggested as a risk factor in recurrent pregnancy loss (RPL)-a condition in which couples suffer several consecutive pregnancy losses, but where a cause can be identified in less than half of the cases. Most studies have focused on thyroid peroxidase antibodies (TPOAbs), not considering the presence of thyroglobulin antibodies (TgAbs). The aim of this study was to systematically assess the prevalence of TgAb positivity in women with RPL, and whether TgAb positivity was associated with the outcome of the next pregnancy. Methods: A systematic literature search of PubMed and Embase (from inception to April 29, 2023) was performed for studies reporting on TgAbs in women with RPL. The primary outcome was TgAb positivity in women with RPL compared with women without RPL, with a secondary outcome of association between TgAb positivity and the outcome of the next pregnancy. Pooled effect estimates were expressed as odds ratios (ORs) with confidence intervals [CI] using a random-effects model. The study was registered with PROSPERO (No. CRD42022310232) and adhered to the PRISMA guidelines. Results: A total of 770 studies were screened, 28 of which could be included reporting data from a total of 6868 women. The prevalence of TgAb positivity in women with RPL ranged from 3.6% to 28% compared with 2.4% to 29% in women without RPL. The OR for TgAb positivity was 1.93 ([CI 1.27-2.92]; I2 = 63%) compared with women without RPL, and for TgAbs and/or TPOAbs 2.66 ([CI 1.75-4.05]; I2 = 69%). Four studies reported on the outcome of the next pregnancy after antibody measurement with highly heterogeneous results (OR for pregnancy loss ranging from 0.99 in one study to 10.0 in the other study, and two studies reported no data eligible for meta-analysis). Consequently, a meta-analysis could not be performed. Conclusions: Women with RPL were significantly more often TgAb-positive than women without RPL. Although there was a lack of studies reporting prospective outcomes, the findings of this study support the significance of awareness about the strong association between RPL and thyroid autoimmunity.

Cohort profile: The SmartSleep Study, Denmark, combining evidence from survey, clinical and tracking data

PURPOSE

The SmartSleep Study is established to comprehensively assess the impact of night-time smartphone use on sleep patterns and health. An innovative combination of large-scale repeated survey information, high-resolution sensor-driven smartphone data, in-depth clinical examination and registry linkage allows for detailed investigations into multisystem physiological dysregulation and long-term health consequences associated with night-time smartphone use and sleep impairment.

PARTICIPANTS

The SmartSleep Study consists of three interconnected data samples, which combined include 30 673 individuals with information on smartphone use, sleep and health. Subsamples of the study population also include high-resolution tracking data (n=5927) collected via a customised app and deep clinical phenotypical data (n=245). A total of 7208 participants are followed in nationwide health registries with full data coverage and long-term follow-up.

FINDINGS TO DATE

We highlight previous findings on the relation between smartphone use and sleep in the SmartSleep Study, and we evaluate the interventional potential of the citizen science approach used in one of the data samples. We also present new results from an analysis in which we use 803 000 data points from the high-resolution tracking data to identify clusters of temporal trajectories of night-time smartphone use that characterise distinct use patterns. Based on these objective tracking data, we characterise four clusters of night-time smartphone use.

FUTURE PLANS

The unprecedented size and coverage of the SmartSleep Study allow for a comprehensive documentation of smartphone activity during the entire sleep span. The study has been expanded by linkage to nationwide registers, which allow for further investigations into the long-term health and social consequences of night-time smartphone use. We also plan new rounds of data collection in the coming years.

Cross-species comparison of pregnancy-induced GDF15

Growth differentiation factor 15 (GDF15) is a stress-induced cytokine. Although the exact physiological function of GDF15 is not yet fully comprehended, the significant elevation of circulating GDF15 levels during gestation suggests a potential role for this hormone in pregnancy. This is corroborated by genetic association studies in which GDF15 and the GDF15 receptor, GDNF family receptor alpha like (GFRAL) have been linked to morning sickness and hyperemesis gravidarum (HG) in humans. Here, we studied GDF15 biology during pregnancy in mice, rats, macaques, and humans. In contrast to macaques and humans, mice and rats exhibited an underwhelming induction in plasma GDF15 levels in response to pregnancy (∼75-fold increase in macaques vs. ∼2-fold increase in rodents). The changes in circulating GDF15 levels were corroborated by the magnitude of Gdf15 mRNA and GDF15 protein expression in placentae from mice, rats, and macaques. These species-specific findings may help guide future studies focusing on GDF15 in pregnancy and on the evaluation of pharmacological strategies to interfere with GDF15-GFRAL signaling to treat severe nausea and HG.NEW & NOTEWORTHY In the present study pregnancy-induced changes in circulating growth differentiation factor 15 (GDF15) in rodents, rhesus macaques, and humans are mapped. In sum, it is demonstrated that humans and macaques exhibit a tremendous increase in placental and circulating GDF15 during pregnancy. In contrast, GDF15 is negligibly increased in pregnant mice and rats, questioning a physiological role for GDF15 in pregnancy in rodents.

Pregnancy-Associated Bleeding and Genetics: Five Sequence Variants in the Myometrium and Progesterone Signaling Pathway are associated with postpartum hemorrhage

Bleeding in early pregnancy and postpartum hemorrhage (PPH) bear substantial risks, with the former closely associated with pregnancy loss and the latter being the foremost cause of maternal death, underscoring the severity of these complications in maternal-fetal health. Here, we investigated the genetic variation underlying aspects of pregnancy-associated bleeding and identified five loci associated with PPH through a meta-analysis of 21,512 cases and 259,500 controls. Functional annotation analysis indicated candidate genes, HAND2, TBX3, and RAP2C/FRMD7, at three loci and showed that at each locus, associated variants were located within binding sites for progesterone receptors (PGR). Furthermore, there were strong genetic correlations with birth weight, gestational duration, and uterine fibroids. Early bleeding during pregnancy (28,898 cases and 302,894 controls) yielded no genome-wide association signals, but showed strong genetic correlation with a variety of human traits, indicative of polygenic and pleiotropic effects. Our results suggest that postpartum bleeding is related to myometrium dysregulation, whereas early bleeding is a complex trait related to underlying health and possibly socioeconomic status.

Pregnancy Loss and the Risk of Myocardial Infarction, Stroke, and All-Cause Mortality: A Nationwide Partner Comparison Cohort Study

Background Pregnancy loss has been associated with myocardial infarction, stroke, and all-cause mortality in women through unknown mechanisms. The aim of this study was to examine these associations in women and their male partners. Methods and Results In this register-based cohort study, all people born between 1957 and 1997, residing in Denmark between 1977 and 2017, and with a registered partner of the opposite sex were eligible for inclusion. Male partners through cohabitation, marriage, or paternity constituted the male cohort. Exposure to pregnancy loss was categorized as follows: 0, 1, 2, or ≥3 pregnancy losses. The outcomes of interest were myocardial infarction, stroke, and all-cause mortality. The Cox proportional hazards model estimated hazard ratios (HRs), adjusted for age, calendar year, parity, and parental history of myocardial infarction or stroke. During follow-up, 1 112 507 women experienced 4463 events of myocardial infarction compared with 13 838 events among 1 120 029 male partners. With the no pregnancy loss group as reference, the adjusted HRs of myocardial infarction in the female cohort after 1, 2, and ≥3 pregnancy losses were as follows: 1.1 (95% CI, 1.0-1.2), 1.3 (95% CI, 1.1-1.5), and 1.4 (95% CI, 1.1-1.8), respectively. In the male partner cohort, the corresponding estimates were 1.0 (95% CI, 1.0-1.1), 1.1 (95% CI, 1.0-1.2), and 1.0 (95% CI, 0.8-1.2), respectively. The outcome of stroke showed similar results. Pregnancy loss was not significantly associated with increased mortality in either sex. Conclusions Pregnancy loss or stillbirth was significantly associated with myocardial infarction and stroke in women but not their male partners. Pregnancy loss or stillbirth was not significantly associated with all-cause mortality in women or male partners.

Biopsy-free profiling of the uterine immune system in patients with recurrent pregnancy loss and unexplained infertility

RESEARCH QUESTION

What are the differences in menstrual blood lymphocytes between controls, patients with recurrent pregnancy loss (RPL) and patients with unexplained infertility (uINF)?

DESIGN

Prospective study including 46 healthy controls, 28 RPL and 11 uINF patients. A feasibility study compared lymphocyte compositions of endometrial biopsies and menstrual blood collected during the first 48 h of menstruation in seven controls. In all patients, peripheral and menstrual blood from the first and subsequent 24 h were analysed separately by flow cytometry, focusing on the main lymphocyte populations and natural killer (NK) cell subsets.

RESULTS

The first 24 h of menstrual blood resembles the uterine immune milieu as tested by endometrial biopsy. RPL patients showed significantly higher menstrual blood CD56+ NK cell numbers than controls (mean ± SD: 31.13 ± 7.52% versus 36.73 ± 5.4%, P = 0.002). Menstrual blood CD56dimCD16bright NK cells within the CD56+ NK cell population were decreased in RPL (16.34 ± 14.65%, P = 0.011) and uINF (15.7 ± 5.91%, P = 0.02) patients versus control (20.42 ± 11.53%). uINF patients had the lowest menstrual blood CD3+ T cell counts (38.81 ± 5.04%, control versus uINF: P = 0.01) and cytotoxicity receptors NKp46 and NKG2D on CD56brightCD16dim cells were higher in uINF (68.12 ± 11.84%, P = 0.006; 45.99 ± 13.83%, P = 0.01, respectively) and RPL (NKp46: 66.21 ± 15.36%, P = 0.009) patients versus controls. RPL and uINF patients had higher peripheral CD56+ NK cell counts versus controls (11.42 ± 4.05%, P = 0.021; 12.86 ± 4.29%, P = 0.009 versus 8.4 ± 3.5%).

CONCLUSIONS

Compared with controls, RPL and uINF patients had a different menstrual blood-NK-subtype profile, indicating an altered cytotoxicity. In future studies, this non-invasive analysis might enable identification and monitoring of patients receiving immunomodulatory medications.

'You're never pregnant in the same way again': prior early pregnancy loss influences need for health care and support in subsequent pregnancy

STUDY QUESTION

What are couples' needs for health care and support in a subsequent pregnancy after prior early pregnancy loss (PL) and how do needs change across the pregnancy?

SUMMARY ANSWER

Couples described unmet needs for pregnancy care in the first 20 weeks of pregnancy and were more satisfied with the care provided during the remainder of the pregnancy.

WHAT IS KNOWN ALREADY

Despite early PL being common (∼25% of pregnancies), there is a paucity of research to guide practice to optimize treatment and support future pregnancies. There has been low priority for the issue in research and a pervasive acceptance that couples should 'just try again' after experiencing PL. Women with prior PL report increased anxiety during the first trimester of pregnancy compared to those without previous PL. No longitudinal studies explore what couples' needs are throughout the pregnancy and how these needs shift across time.

STUDY DESIGN SIZE DURATION

This was a qualitative longitudinal dyadic (joint) interview study. In total, 15 couples who were pregnant after a prior PL were interviewed four times over their pregnancy. Couples were recruited from the Copenhagen Pregnancy Loss Cohort Research Programme. Interviews were held in person at the hospital or university, or online. Interviews ranged from 20 to 91 min (mean = 54 min).

PARTICIPANTS/MATERIALS SETTING METHODS

Inclusion criteria included couples with one to two prior early PL(s) who self-reported a new pregnancy and were willing to be interviewed together and in English. Couples were interviewed four times: after a positive pregnancy test and once in each trimester. Interviews were transcribed and data were analysed using thematic analysis to compare and contrast needs of the couples at each of the four time periods in the pregnancy and across the entire pregnancy. One same-sex couple and 14 heterosexual couples participated.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples' needs were categorized into two main longitudinal themes across the pregnancy, divided by the 20-week scan. Within each longitudinal theme, there were two themes to represent each time period. In the longitudinal theme 'The first 20 weeks: a 'scary' gap in care' there were two themes: Positive pregnancy test: 'Tell them it's not the same pregnancy' and First trimester: 'We craved that someone was taking care of us'. The standard pregnancy care offered in the public healthcare system in Denmark includes a scan at 12 and 20 weeks. While all couples wished for additional access to scans and monitoring of the foetus in early pregnancy to provide reassurance and detect problems early, they described considerable variation in the referrals and care they were offered. Both partners expressed a high degree of worry and anxiety about the pregnancy, with pregnant women in particular describing 'surviv[ing] from scan to scan' in the early weeks. Couples took scans wherever offered or paid for comfort scans, but this resulted in fragmented care. Instead, they wished for continuity in care, and acknowledgement and sensitivity that a pregnancy after PL is not the same as a first pregnancy. In the longitudinal theme 'The second 20 weeks: Safety in the care system' there were two themes: Second trimester: 'I think we are in good hands' and Third trimester: 'It's more of a 'nice to know' everything is OK than a 'need to know'. Couples reported their distress was lower and overall needs for care were met during this time. They expressed general satisfaction with regular or extended antenatal support although, as in the first 20 weeks, additional acknowledgement and sensitivity regarding their history of PL was desired. Couples said they felt more secure given that they had access to a 24-hour telephone support by midwife/nurse if they had any concerns or questions.

LIMITATIONS REASONS FOR CAUTION

Participants were self-selected from an ongoing cohort study of patients presenting at hospital with PL. Single women were not included in the study. This study was limited to data collection in Denmark; however, other countries with public healthcare systems may have similar offerings with regard to their provision of antenatal care, care provided in recurrent pregnancy loss (RPL) clinics and the availability of private scans.

WIDER IMPLICATIONS OF THE FINDINGS

The findings underscore that an early PL creates an increased need for monitoring and care in a subsequent pregnancy. This study highlights a gap in pregnancy care for those with a history of PL given that their need for monitoring and support is high in the early weeks of a new pregnancy before they have access to antenatal care, and before they have had multiple PLs and can be referred to the RPL unit.

STUDY FUNDING/COMPETING INTERESTS

This project has received funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 101028172 for E.K. The Copenhagen Pregnancy Loss Cohort is funded by a grant from the BioInnovation Institute Foundation. H.S.N. has received scientific grants from Freya Biosciences, Ferring Pharmaceuticals, BioInnovation Institute, Ministry of Education, Novo Nordisk Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, Ole Kirks Fond, and Independent Research Fund Denmark. H.S.N. received personal payment or honoraria for lectures and presentations from Ferring Pharmaceuticals, Merck, Astra Zeneca, Cook Medical, Gedeon Richter, and Ibsa Nordic. All other authors declare no competing interests.

Antibiotic-free vaginal microbiota transplant with donor engraftment, dysbiosis resolution and live birth after recurrent pregnancy loss: a proof of concept case study

Background

Vaginal dysbiosis covers imbalances in the vaginal microbiota, defined by altered composition of bacteria, viruses, and fungi and is associated with euploid pregnancy losses, premature birth, infertility, or bacterial vaginosis. A large proportion of women who have vaginal dysbiosis do not experience any symptoms. Antibiotics are the traditional treatment, recently combined with local probiotics in some cases. Vaginal Microbiota Transplantation (VMT) with eubiotic vaginal bacterial microbiota after antibiotic eradication of pathogens has successfully been performed in a case study with five patients, but no VMT has been performed without the use of antibiotics.

Methods

This is a proof of concept case study. The patient was found to have vaginal dysbiosis at the RPL clinic at Copenhagen University Hospital Hvidovre, Denmark on the 23rd of June 2021. She was offered and accepted to receive experimental treatment in the form of a VMT as a compassionate use case. VMT is the transfer of cervicovaginal secretions (CVS) from a healthy donor with a Lactobacillus-dominant vaginal microbiome to a recipient with a dysbiotic vaginal microbiome. CVS is a mixture of e.g., mucus, bacteria, metabolites present in the vaginal canal. Potential donors were thoroughly screened for the absence of STIs, and the most suitable donor sample for the specific patient in this study was determined via an in vitro microbiome competition assay.

Findings

A 30-year-old patient with one livebirth and a complicated pregnancy history of two stillbirths and 1 s trimester pregnancy loss in gestational weeks 27 (2019), 17 (2020) and 23 (2020) respectively with complaints of vaginal irritation and discharge that had aggravated in all her pregnancies. Her vaginal microbiome composition showed a 90% dominance of Gardnerella spp. After one VMT there was a complete shift in microbiome composition to 81.2% L. crispatus and 9% L. jensenii with a concurrent resolvement of vaginal symptoms. Single nucleotide polymorphism-analysis confirmed her microbiome to be of donor origin and it remain stable now 1.5 years after the VMT. Five months after the VMT she became pregnant and has successfully delivered a healthy baby at term.

Interpretation

Here we report a successful VMT with confirmed donor strain engraftment followed by a successful pregnancy and delivery after a series of late pregnancy losses/stillbirths. Findings suggest that VMT is a potential treatment for severe vaginal dysbiosis. Further, larger studies are required.

Funding

The study was partially funded (i.e., analysis costs) by Freya Biosciences Aps, Fruebjergvej, 2100 Copenhagen, Denmark.

The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia

BACKGROUND

Postpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions.

METHODS

Between August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and "health extension workers," 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario.

RESULTS

Baseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2-35.1 compared to 1·8; 95% CI - 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3-18.3 compared to 3.1; 95% CI - 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0-15.0).

CONCLUSION

The Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality.

TRIAL REGISTRATION

Clinicaltrial.gov Identifier NCT01945931. September 5, 2013.

Anxiety and depression in women with asthma prior to fertility treatment

Objective

We investigate symptoms of anxiety and depression among women with asthma prior to fertility treatment.

Methods

This is a cross-sectional study of women screened for eligibility to the PRO-ART study (RCT of omalizumab versus placebo in asthmatic women undergoing fertility treatment (NCT03727971)). All participants were scheduled for in vitro fertilization (IVF) treatment at four public fertility clinics in Denmark. Data on demographics and asthma control (ACQ-5) were obtained. Symptoms of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS-A and D, respectively) and defined as being present on both subscales if a score >7 was obtained. Spirometry, diagnostic asthma test, and measurement of fractional exhaled nitric oxide (FeNO) were conducted.

Results

A total of 109 women with asthma were included (mean age 31.8 ± 4.6 and BMI 25.5 ± 4.6). Most women had male factor infertility (36.4%) or unexplained infertility (35.5%). Twenty-two percent of the patients reported uncontrolled asthma (ACQ-5 score > 1.5). The mean HADS-A and HADS-D scores were 6.0 ± 3.8 (95% CI 5.3-6.7) and 2.5 ± 2.2 (95% CI 2.1-3.0), respectively. Thirty (28.0%) women reported anxiety symptoms, and four (3.7%) had concomitant depressive symptoms. Uncontrolled asthma was significantly associated with both depressive (p = 0.04) and anxiety symptoms (p = 0.03).

Conclusions

More than 25% of women with asthma prior to fertility treatment had self-reported symptoms of anxiety, and just below 5% had self-reported depressive symptoms, possibly related to uncontrolled asthma.

Deficit of homozygosity among 1.52 million individuals and genetic causes of recessive lethality

Genotypes causing pregnancy loss and perinatal mortality are depleted among living individuals and are therefore difficult to find. To explore genetic causes of recessive lethality, we searched for sequence variants with deficit of homozygosity among 1.52 million individuals from six European populations. In this study, we identified 25 genes harboring protein-altering sequence variants with a strong deficit of homozygosity (10% or less of predicted homozygotes). Sequence variants in 12 of the genes cause Mendelian disease under a recessive mode of inheritance, two under a dominant mode, but variants in the remaining 11 have not been reported to cause disease. Sequence variants with a strong deficit of homozygosity are over-represented among genes essential for growth of human cell lines and genes orthologous to mouse genes known to affect viability. The function of these genes gives insight into the genetics of intrauterine lethality. We also identified 1077 genes with homozygous predicted loss-of-function genotypes not previously described, bringing the total set of genes completely knocked out in humans to 4785.

Danish translation, cross-cultural adaptation, and electronic migration of the World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonisation Project Endometriosis Patient Questionnaire

Objectives

This study aims to translate and cross-culturally adapt the standard version of the World Endometriosis Research Foundation (WERF) EPHect Endometriosis Patient Questionnaire (EPQ) into Danish and to ensure equivalence of a Danish electronic version.

Methods

The translation, cultural adaption, and electronic migration followed recommendations from the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the Critical Path Institute. Ten women with endometriosis were enrolled for cognitive debriefing of the paper version (pEPQ) after translation and back translation. The questionnaire was then migrated into an electronic version (eEPQ) and subsequently tested for usability and measurement equivalence by five women with endometriosis.

Results

Cross-cultural alterations were needed for medical terms, response options for ethnicity, the educational system, and measurement units. Thirteen questions were altered after back translation, while 21 underwent minor changes after cognitive debriefing. After testing the eEPQ, 13 questions were altered. Questions tested for measurement equivalence across the two modes of administration were found comparable. The median time-to-complete the pEPQ and eEPQ was 62 min (range: 29–110) and 63 min (range: 31–88), respectively. General comments included the questionnaire being relevant but long and repetitive.

Conclusions

We find the the Danish pEPQ and eEPQ similar and comparable to the original English instrument. However, attention must be drawn to questions regarding measurement units, ethnicity, and educational systems before cross-country comparison. The Danish pEPQ and eEPQ are suitable for obtaining subjective data on women with endometriosis.

Cell-free fetal DNA for genetic evaluation in Copenhagen Pregnancy Loss Study (COPL): a prospective cohort study

BACKGROUND

One in four pregnancies end in a pregnancy loss. Although the effect on couples is well documented, evidence-based treatments and prediction models are absent. Fetal aneuploidy is associated with a higher chance of a next successful pregnancy compared with euploid pregnancy loss in which underlying maternal conditions might be causal. Ploidy diagnostics are therefore advantageous but challenging as they require collection of the pregnancy tissue. Cell-free fetal DNA (cffDNA) from maternal blood has the potential for evaluation of fetal ploidy status, but no large-scale validation of the method has been done.

METHODS

In this prospective cohort study, women with a pregnancy loss were recruited as a part of the Copenhagen Pregnancy Loss (COPL) study from three gynaecological clinics at public hospitals in Denmark. Women were eligible for inclusion if older than 18 years with a pregnancy loss before gestational age 22 weeks (ie, 154 days) and with an intrauterine pregnancy confirmed by ultrasound (including anembryonic sac), and women with pregnancies of unknown location or molar pregnancies were excluded. Maternal blood was collected while pregnancy tissue was still in situ or within 24 h after pregnancy tissue had passed and was analysed by genome-wide sequencing of cffDNA. Direct sequencing of the pregnancy tissue was done as reference.

FINDINGS

We included 1000 consecutive women, at the time of a pregnancy loss diagnosis, between Nov 12, 2020, and May 1, 2022. Results from the first 333 women with a pregnancy loss (recruited between Nov 12, 2020, and Aug 14, 2021) were used to evaluate the validity of cffDNA-based testing. Results from the other 667 women were included to evaluate cffDNA performance and result distribution in a larger cohort of 1000 women in total. Gestational age of fetus ranged from 35-149 days (mean of 70·5 days [SD 16·5], or 10 weeks plus 1 day). The cffDNA-based test had a sensitivity for aneuploidy detection of 85% (95% CI 79-90) and a specificity of 93% (95% CI 88-96) compared with direct sequencing of the pregnancy tissue. Among 1000 cffDNA-based test results, 446 (45%) were euploid, 405 (41%) aneuploid, 37 (4%) had multiple aneuploidies, and 112 (11%) were inconclusive. 105 (32%) of 333 women either did not manage to collect the pregnancy tissue or collected a sample classified as unknown tissue giving a high risk of being maternal.

INTERPRETATION

This validation of cffDNA-based testing in pregnancy loss shows the potential and feasibility of the method to distinguish euploid and aneuploid pregnancy loss for improved clinical management and benefit of future reproductive medicine and women's health research.

FUNDING

Ole Kirks Foundation, BioInnovation Institute Foundation, and the Novo Nordisk Foundation.

Night-time smartphone use, sleep duration, sleep quality, and menstrual disturbances in young adult women: A population-based study with high-resolution tracking data

Study Objectives

To explore the relationship among night-time smartphone use, sleep duration, sleep quality, and menstrual disturbances in young adult women.

Methods

Women aged 18-40 years were included in the SmartSleep Study in which they objectively tracked their smartphone use via the SmartSleep app between self-reported sleep onset and offset times (n = 764) and responded to a survey (n = 1068), which included background characteristics, sleep duration, sleep quality (Karolinska Sleep Questionnaire), and menstrual characteristics (International Federation of Gynecology and Obstetrics' definitions).

Results

The median tracking time was four nights (interquartile range: 2-8). Higher frequency (p = .05) and longer duration (p = .02) of night-time smartphone use were associated with long sleep duration (≥9 h), but not with poor sleep quality or short sleep duration (<7 h). Short sleep duration was associated with menstrual disturbances (OR = 1.84, 95% confidence interval [CI] = 1.09 to 3.04) and irregular menstruation (OR = 2.17, 95% CI = 1.08 to 4.10), and poor sleep quality was associated with menstrual disturbances (OR = 1.43, 95% CI = 1.19 to 1.71), irregular menstruation (OR = 1.34, 95% CI = 1.04 to 1.72), prolonged bleedings (OR = 2.50, 95% CI = 1.44 to 4.43) and short-cycle duration (OR = 1.40, 95% CI = 1.06 to 1.84). Neither duration nor frequency of night-time smartphone use was associated with menstrual disturbances.

Conclusions

Night-time smartphone use was associated with longer sleep duration, but not with menstrual disturbances in adult women. Short sleep duration and sleep quality were associated with menstrual disturbances. Further investigation of the effects of night-time smartphone use on sleep and female reproductive function in large prospective studies is needed.

Low-grade inflammation is negatively associated with live birth in women undergoing IVF

RESEARCH QUESTION

Is low-grade inflammation, detected by C-reactive protein (CRP), a marker of IVF outcome addressing both blastocyst quality and pregnancy outcome?

DESIGN

This sub-study of a multicentre randomized controlled trial included 440 women undergoing IVF treatment with a gonadotrophin-releasing hormone (GnRH) antagonist protocol. Serum CRP was measured on cycle day 2-3 (baseline) and on the day of ovulation triggering. The association between CRP concentrations and reproductive outcomes (number of retrieved oocytes, number of good-quality blastocysts, pregnancy, pregnancy loss and live birth), were analysed, adjusting for relevant confounders.

RESULTS

A negative association was found between higher baseline CRP concentrations and live birth rate (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62-0.96, P = 0.02) and higher CRP concentrations at baseline were associated with pregnancy loss among women who conceived (OR 1.37, 95% CI 1.07-1.76, P = 0.01). When testing for a specific cut-off, CRP concentrations above 2.34 (the highest quartile) were more likely to be associated with pregnancy loss (P = 0.02) and a lower chance of live birth (P = 0.04) compared with the lowest quartile. No associations were found between CRP concentrations and pregnancy outcomes on the day of ovulation triggering, and there were no associations between CRP concentrations and the number of good-quality blastocysts.

CONCLUSIONS

Higher CRP concentrations at cycle day 2-3, before starting ovarian stimulation, are negatively associated with chance of live birth, possibly because of an increased risk of pregnancy loss. No association was found between the number of good-quality blastocysts and CRP concentration. More studies are needed to investigate the impact of low-grade inflammation.

Anti-Müllerian Hormone and live birth in unexplained recurrent pregnancy loss

RESEARCH QUESTION

Is anti-Müllerian hormone (AMH) associated with live birth rate (LBR) in women with unexplained recurrent pregnancy loss (RPL)?

DESIGN

Cohort study of women with unexplained RPL attending the RPL Unit, Copenhagen University Hospital, Denmark, between 2015 and 2021. AMH concentration was assessed upon referral, and LBR in the next pregnancy. RPL was defined as three or more consecutive pregnancy losses. Regression analyses were adjusted for age, number of previous losses, body mass index, smoking, treatment with assisted reproductive technology (ART) and RPL treatments.

RESULTS

A total of 629 women were included; 507 (80.6%) became pregnant after referral. Pregnancy rates were similar for women with low and high AMH compared to women with medium AMH (81.9, 80.3 and 79.7%, respectively) (low AMH: adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 0.84-2.47, P = 0.18; high AMH: aOR 0.98, 95% CI 0.59-1.64, P = 0.95). AMH concentrations were not associated with live birth. LBR was 59.5% in women with low AMH, 66.1% with medium AMH and 65.1% with high AMH (low AMH: aOR 0.68, 95% CI 0.41-1.11, P = 0.12, high AMH: aOR 0.96, 95% CI 0.59-1.56, P = 0.87). Live birth was lower in ART pregnancies (aOR 0.57, 95% CI 0.33-0.97, P = 0.04) and with higher numbers of previous losses (aOR 0.81, 95% CI 0.68-0.95, P = 0.01).

CONCLUSION

In women with unexplained RPL, AMH was not associated with the chances of live birth in the next pregnancy. Screening for AMH in all women with RPL is not supported by current evidence. The chance of live birth among women with unexplained RPL achieving pregnancy by ART was low and needs to be confirmed and explored in future studies.

Endometriosis is associated with pregnancy loss: a nationwide historical cohort study

OBJECTIVE

To study whether endometriosis is associated with pregnancy loss and recurrent pregnancy loss (RPL).

DESIGN

Nationwide historical cohort study with a nested case-control analysis.

SETTING

National health registers.

PATIENT(S)

A total of 29,563 women born between 1957 and 1997 were identified in the national health registers, diagnosed with endometriosis between 1977 and 2017, and age-matched 1:10 with 295,630 women without endometriosis. The number of pregnancy losses was assessed, and data were analyzed with conditional logistic regression.

INTERVENTION(S)

Endometriosis (International Classification of Diseases, 8th Revision, 62530-62539, and International Classification of Diseases, 10th Revision, DN80.0-9).

MAIN OUTCOME MEASURE(S)

The primary outcomes of interest were the numbers of pregnancy losses categorized as 0, 1, 2, and ≥ 3 losses, unadjusted and adjusted for gravidity, and RPL. The secondary outcome measures were the predefined types of pregnancy losses. Pregnancy loss was defined as the spontaneous demise of a pregnancy until 22 weeks of gestation. Primary RPL was defined as 3 or more consecutive pregnancy losses with no prior live birth or stillbirth, and secondary RPL was defined as 1 or more births followed by 3 or more consecutive losses.

RESULT(S)

A total of 18.9%, 3.9%, and 2.1% of ever-pregnant women with endometriosis had 1, 2, and ≥ 3 pregnancy losses compared with 17.3%, 3.5%, and 1.5% of the women without endometriosis, corresponding to the odds ratios of 1.13 (95% confidence interval, 1.09-1.17), 1.18 (1.10-1.26), and 1.44 (1.31-1.59), respectively. When adjusted also for gravidity, the corresponding results were 1.37 (95% confidence interval, 1.32-1.42), 1.75 (1.62-1.89), and 2.57 (2.31-2.85), respectively. The following predefined subgroups of RPL were positively associated with endometriosis: primary; secondary; secondary after giving birth to a boy; after a complicated delivery; and ≥ 3 pregnancy losses before the age of 30 years. Six endometriosis subgroup analyses found an association between endometriosis and pregnancy loss. These analyses were women diagnosed in the 4 decades between 1977 and 2017, women with adenomyosis, and women with adenomyosis only.

CONCLUSION(S)

This nationwide cohort study found endometriosis to be associated with pregnancy loss and RPL, and the association strengthened with an increasing number of losses.

ESHRE guideline: recurrent pregnancy loss: an update in 2022

STUDY QUESTION

What are the updates for the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature from 2017 to 2022?

SUMMARY ANSWER

The guideline development group (GDG) updated 11 existing recommendations on investigations and treatments for RPL, and how care should be organized, and added one new recommendation on adenomyosis investigation in women with RPL.

WHAT IS KNOWN ALREADY

A previous ESHRE guideline on RPL was published in 2017 and needs to be updated.

STUDY DESIGN SIZE DURATION

The guideline was developed and updated according to the structured methodology for development and update of ESHRE guidelines. The literature searches were updated, and assessments of relevant new evidence were performed. Relevant papers published between 31 March 2017 and 28 February 2022 and written in English were included. Cumulative live birth rate, live birth rate, and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were updated and discussed until consensus was reached within the GDG. A stakeholder review was organized after the updated draft was finalized. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The new version of the guideline provides 39 recommendations on risk factors, prevention, and investigation in couples with RPL, and 38 recommendations on treatments. These includes 62 evidence-based recommendations-of which 33 were formulated as strong recommendations and 29 as conditional-and 15 good practice points. Of the evidence-based recommendations, 12 (19.4%) were supported by moderate-quality evidence. The remaining recommendations were supported by low (34 recommendations; 54.8%), or very low-quality evidence (16 recommendations; 25.8%). Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions those investigations and treatments that should not be used for couples with RPL.

LIMITATIONS REASONS FOR CAUTION

The guidelines have been updated; however, several investigations and treatments currently offered to couples with RPL have not been well studied; for most of these investigations and treatments, a recommendation against using the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in RPL, based on the best and most recent evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. Still, the absence of a unified definition of RPL is one of the most critical consequences of the limited scientific evidence in the field.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment.O.B.C. reports being a member of the executive board of the European Society for Reproductive Immunology and has received payment for honoraria for giving lectures about RPL in Australia in 2020. M.G. reports unconditional research and educational grant received by the Centre for Reproductive Medicine, Amsterdam UMC from Guerbet, Merck and Ferring, not related to the presented work. S.L. reports position funding from EXAMENLAB Ltd. and ownership interest by stock or partnership of EXAMENLAB Ltd (CEO). S.Q. reports being a deputy director of Tommy's National centre for miscarriage research, with payment received by the institution for research, staff time, and consumables for research. H.S.N. reports grants with payment to institution from Freya Biosciences ApS, Ferring Pharmaceuticals, BioInnovation Institute, the Danish ministry of Education, Novo Nordic Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, Ole Kirks Fond, and Independent Research Fund Denmark and speakers' fees for lectures from Ferring Pharmaceuticals, Merck A/S, Astra Zeneca, IBSA Nordic and Cook Medical. She also reports to be an unpaid founder and chairman of a maternity foundation. M.-L.v.d.H. received small honoraria for lectures on RPL care. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained.Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.).

Chronic endometritis - is it time to clarify diagnostic criteria?

Chronic endometritis is a persistent, low-intensity inflammation of endometrial mucosa, characterized by the infiltration of plasma cells into the endometrial stroma This immunological alteration is thought to be a consequence of a bacterial infection. For a long time, chronic endometritis was poorly investigated and rarely considered in clinical practice because it is either asymptomatic or presents with no specific symptoms. Its association with adverse effects on fertility and retrospectively reported effectiveness of antibiotic treatment were the main reasons for a growing interest in this endometrial pathology. Chronic endometritis is now a hot topic in recurrent pregnancy loss and recurrent implantation failure research. Nevertheless, there are still no recommendations to include chronic endometritis investigation in a clinical evaluation of infertile patients. The uncertain role of this condition is an effect of significant differences in study results presented by different research groups. One important reason for these inconsistent findings is a lack of standardised chronic endometritis diagnostic methods. We present a review of the literature, focusing on the currently available chronic endometritis diagnostic techniques. The review is subdivided into three parts concerning the diagnostic accuracy of three main diagnostic modalities. Histopathological examination of endometrial tissue, hysteroscopic evaluation of uterine cavity and identification of the bacterial factor. In conclusion, it is of great importance to establish a consensus on the diagnostic criteria for chronic endometritis. This is the only way to enhance international cooperation and create well-design multicenter studies to evidence the role of this endometrial pathology in infertility.

Pregnancy Loss and Cardiovascular Diseases in Women: Recent Findings and Potential Mechanisms

PURPOSE OF REVIEW

Pregnancy loss (PL) has been acknowledged by the American Heart Association as a risk factor for cardiovascular diseases (CVD) later in life. This review aims to sum up recent findings (< ~ 5 years), concerning the link between PL and CVD.

RECENT FINDINGS

The association between PL and risk of CVD increased with increasing number of PLs and is inversely correlated to maternal age, indicating that the association concerns euploid PLs. Likely mechanisms leading to PL and an increased risk of CVD include endothelial dysfunction, a pro-inflammatory state, antiphospholipid syndrome, autoimmunity, and genetic predisposition. PL as an independent risk factor for CVD constitutes an obvious gateway for a more targeted approach to future research, prevention, and treatment. Future research should clarify the following questions to which the answers are still unknown: whether PL is (a) directly causing the increased risk of CVD or (b) sharing pathophysiological mechanisms also leading to CVD.

Asthma Is Associated With Pregnancy Loss and Recurrent Pregnancy Loss: A Nationwide Cohort Study

BACKGROUND

Women with asthma appear to have an increased risk of pregnancy loss (PL). The impact of asthma on recurrent pregnancy loss (RPL), defined as 3 consecutive losses, is, however, unknown.

OBJECTIVE

The aim of this study was to investigate whether having asthma before or during the fertile age is associated with PL and RPL.

METHODS

Based on Danish national health registers, we identified all women aged 6 to 45 years with at least 2 filled prescriptions of an antiasthma drug during the period 1977 to 2019. Women with asthma were compared with women without asthma. Pregnancy outcomes were retrieved for both groups from national health registers. Logistic regression with adjustment for the year of birth and educational level provided odds ratios (ORs) for the number of PLs. Subgroup analyses were conducted for early-onset (age 6-15 years), adult-onset (age 16-39 years), and late-onset (age 40-45 years) asthma. Lastly, we compared uncontrolled asthma (defined as ≥ 400 doses of a short-acting beta-2 agonist in a year) to controlled asthma (defined as < 400 doses of a short-acting beta-2 agonist in a year).

RESULTS

In a population of 1,309,786 women, we identified 128,553 women with asthma and 1,297,233 women without asthma. Compared with nonasthmatic women, women with asthma had ORs for 1, 2, and 3 or more PLs of 1.05 (95% CI 1.03-1.07), 1.09 (95% CI 1.05-1.13), and 1.18 (95% CI1.11-1.24), respectively, and for RPL of 1.19 (95% CI 1.12-1.27). In women with early-onset asthma, the OR of 3 or more PLs was 1.47 (95% CI 1.24-1.72). For women classified as having uncontrolled asthma compared with controlled asthma, we found a significant OR of 1.60 (95% CI 1.16-2.16) for 3 or more PLs.

CONCLUSIONS

We found a significant positive association between asthma and number of PLs and RPLs. Early-onset asthma and uncontrolled asthma were more strongly associated with PL than adult-onset and late-onset asthma and controlled asthma.

Pregnancy loss and risk of multiple sclerosis and autoimmune neurological disorder: A nationwide cohort study

Background

The loss of one or more pregnancies before viability (i.e. pregnancy loss or miscarriage), has been linked to an increased risk of diseases later in life such as myocardial infarction and stroke. Recurrent pregnancy loss (i.e. three consecutive pregnancy losses) and multiple sclerosis have both been linked to immunological traits, which could predispose to both occurrences. The objective of the current study was to investigate if pregnancy loss is associated with later autoimmune neurological disease.

Methods

This register-based cohort study, included the Danish female population age 12 or older between 1977–2017. Women were grouped hierarchically: 0, 1, 2, ≥3 pregnancy losses, primary recurrent pregnancy loss (i.e. not preceded by a delivery), and secondary recurrent pregnancy loss (i.e. preceded by a delivery). The main outcome was multiple sclerosis and additional outcomes were amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis. Bayesian Poisson regression estimated incidence rate ratios [IRR] and 95% credible intervals [CI] adjusted for year, age, live births, family history of an outcome, and education.

Results

After 40,380,194 years of follow-up, multiple sclerosis was diagnosed among 7,667 out of 1,513,544 included women (0.5%), median age at diagnosis 34.2 years (IQR 27.4–41.4 years), and median age at symptom onset 31.2 years (IQR 24.8–38.2). The adjusted IRR of multiple sclerosis after 1 pregnancy loss was: 1.03 (95% CI 0.95–1.11), 2 losses: 1.02 (95% CI 0.86–1.20), ≥3 non-consecutive losses: 0.81 (95% CI 0.51–1.24), primary recurrent pregnancy loss: 1.18 (95% CI 0.84–1.60), secondary recurrent pregnancy loss: 1.16 (95% CI 0.81–1.63), as compared to women with no pregnancy losses. Seven sensitivity analyses and analyses for additional outcomes did not show significantly elevated adjusted risk estimates.

Conclusions

In this nationwide study, pregnancy loss was not significantly associated with autoimmune neurological disorder.

OUP accepted manuscript

STUDY QUESTION

What is the microbiome profile across different body sites in relation to the normal menstrual cycle (with and without hormonal contraception), recurrent pregnancy loss (RPL) (before and during pregnancy, pregnancy loss or birth) and endometriosis (before, during and after surgery)? How do these profiles interact with genetics, environmental exposures, immunological and endocrine biomarkers?

WHAT IS KNOWN ALREADY

The microbiome is a key factor influencing human health and disease in areas as diverse as immune functioning, gastrointestinal disease and mental and metabolic disorders. There is mounting evidence to suggest that the reproductive microbiome may be influential in general and reproductive health, fertility and pregnancy outcomes.

STUDY DESIGN, SIZE, DURATION

This is a prospective, longitudinal, observational study using a systems biology approach in three cohorts totalling 920 participants. Since microbiome profiles by shot-gun sequencing have never been investigated in healthy controls during varying phases of the menstrual cycle, patients with RPL and patients with endometriosis, no formal sample size calculation can be performed. The study period is from 2017 to 2024 and allows for longitudinal profiling of study participants to enable deeper understanding of the role of the microbiome and of host–microbe interactions in reproductive health.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants in each cohort are as follows: Part 1 MiMens—150 healthy women with or without hormonal contraception; Part 2 MiRPL—200 couples with RPL, 50 healthy couples with prior uncomplicated pregnancy and 150 newborns; Part 3 MiEndo—120 patients with endometriosis requiring surgery with or without hormonal treatment. Microbiome profiles from saliva, faeces, rectal mucosa, vaginal fluid and endometrium will be studied, as well as the Omics profile, endocrine disrupting chemicals and endocrine and immune factors in blood, hair, saliva and urine. Pregnancy loss products, seminal microbiome, HLA types, endometriotic tissue and genetic risk and comprehensive questionnaire data will also be studied, where appropriate. Correlations with mental and physical health will be evaluated.

STUDY FUNDING/COMPETING INTEREST(S)

This work is supported by funding from Ferring Pharmaceuticals ([#MiHSN01] to H.S.N., M.C.K., M.E.M., L.E.V., L.E., I.S.-K., F.B., L.W.H., E.F. and M.H.), Rigshospitalet’s Research Funds ([#E-22614-01 and #E-22614-02] to M.C.K. and [#E-22222-06] to S.B.), Niels and Desiree Yde’s Foundation (S.B., endocrine analyses [#2015-2784]), the Musikforlæggerne Agnes and Knut Mørk’s Foundation (S.B., endocrine and immune analyses [#35108-001]) and Oda and Hans Svenningsen’s Foundation ([#F-22614-08] to H.S.N.). Medical writing assistance with this manuscript was provided by Caroline Loat, PhD, and funded by Ferring Pharmaceuticals. H.S.N. reports personal fees from Ferring Pharmaceuticals, Merck Denmark A/S, Ibsa Nordic, Astra Zeneca and Cook Medical outside the submitted work. K.W. is a full-time employee of Ferring Pharmaceuticals. No other conflicts are reported.

TRIAL REGISTRATION NUMBER

N/A

TRIAL REGISTRATION DATE

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DATE OF FIRST PATIENT’S ENROLMENT

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[Presence of SARS-CoV-2 in semen and the impact of COVID-19 on the male reproductive system]

This article reviews the current studies published on the transmission of SARS-CoV-2 in semen and the potential effect of COVID-19 on male fertility. The aim was to provide insight into different possible mechanisms of involvement of the male reproductive system by SARS-CoV-2 infection and to evaluate the studies investigating the presence of virus in semen. It is concluded that the likelihood of SARS-CoV-2 transmission through semen is low and that COVID-19 may negatively affect semen parameters, but that the impairment is probably short-termed.

RUBIC (ReproUnion Biobank and Infertility Cohort): A binational clinical foundation to study risk factors, life course, and treatment of infertility and infertility-related morbidity

BACKGROUND

Infertility affects 15%-25% of all couples during their reproductive life span. It is a significant societal and public health problem with potential psychological, social, and economic consequences. Furthermore, infertility has been linked to adverse long-term health outcomes. Despite the advanced diagnostic and therapeutic techniques available, approximately 30% of infertile couples do not obtain a live birth after fertility treatment. For these couples, there are no further options to increase their chances of a successful pregnancy and live birth.

OBJECTIVES

Three overall questions will be studied: (1) What are the risk factors and natural life courses of infertility, early embryonic loss, and adverse pregnancy outcomes? (2) Can we develop new diagnostic and prognostic biomarkers for fecundity and treatment success? And (3) what are the health characteristics of women and men in infertile couples at the time of fertility treatment and during long-term follow-up?

MATERIAL AND METHODS

ReproUnion Biobank and Infertility Cohort (RUBIC) is established as an add-on to the routine fertility management at Copenhagen University Hospital Departments in the Capital Region of Denmark and Reproductive Medicine Centre at Skåne University Hospital in Sweden. The aim is to include a total of 5000 couples equally distributed between Denmark and Sweden. The first patients were enrolled in June 2020. All eligible infertile couples are prospectively asked to participate in the project. Participants complete an extensive questionnaire and undergo a physical examination and collection of biospecimens (blood, urine, hair, saliva, rectal swabs, feces, semen, endometrial biopsies, and vaginal swabs). After the cohort is established, the couples will be linked to the Danish and Swedish national registers to obtain information on parental, perinatal, childhood, and adult life histories, including disease and medication history. This will enable us to understand the causes of infertility and identify novel therapeutic options for this important societal problem.

P–097 The impact of SARS-CoV–2 on male gonadal function. A longitudinal study

Study question

Can severe acute respiratory syndrome coronavirus 2 (SARS-CoV–2) be detected in the semen of SARS-CoV–2 positive men, and does SARS-CoV–2 infection affect male reproductive function?

Summary answer

No SARS-CoV–2 RNA was detected in semen. An impact of SARS-CoV–2 infection on semen quality and reproductive hormone profile awaits evaluation at 3 + 6 months follow-up.

What is known already

SARS-CoV–2 may use angiotensin-converting enzyme (ACE)2 as an entry point into the cell. As ACE2 is expressed in testicular tissue, it has been speculated that SARS-CoV–2 may affect the male reproductive system. A cohort study including 38 male COVID–19 patients showed that SARS-CoV–2 was present in the semen of six patients (15.8%) [Li et al., 2020]. Later studies including a total of 223 patients have not provided evidence of transmission of SARS-CoV–2 via semen. There are to date no available longitudinal studies on semen quality following SARS-CoV–2 infection.

Study design, size, duration

Longitudinal cohort study including 50 non-hospitalized men from the general population in the Capital Region of Denmark. All participants had a confirmed SARS-CoV–2 infection by reverse-transcription polymerase chain reaction (RT-PCR) on oropharyngeal swab material within the last week. The presence of SARS-CoV–2 in semen samples by RT-PCR, semen parameters and reproductive hormone profile were assessed at inclusion and at 3 + 6 months follow-up. SARS-CoV–2 antibody levels were assessed 3–5 weeks after inclusion.

Participants/materials, setting, methods

SARS-CoV–2-positive males (age 18–60 years) were included. Oropharyngeal and semen samples were tested by RT-PCR applying the E-Sarbeco primers and probe published by Corman et al. 2020 and adapted to TaqMan Fast Virus 1-step master mix and LightCycler 480 as previously reported by Jørgensen et al. 2020. SARS-CoV–2 antibodies were detected using the serological immunoassay from Shenzhen YHLO Biotech on the iFlash 1800. Semen quality parameters were analysed according to World Health Organisation (WHO) standards.

Main results and the role of chance

To date, 25 men with a mean age of 35 years have been included in the study. SARS-CoV–2 RNA could not be detected in the semen samples of any of the 25 men at the time of inclusion. Twenty-one of the 25 men (84,0%) had a same day RT-PCR-confirmed SARS-CoV–2 infection in an oropharyngeal swab. RT-PCR cycle threshold (ct) values were distributed as follows: four (19,0%) were strongly positive (ct < 25), 16 (76,2%) intermediately positive (ct 25–35) and one (4,8%) weakly positive (ct 35–45). The four men without PCR-confirmed SARS-CoV–2 infection all had a positive IgG response to SARS-CoV–2 at the time of inclusion. Longitudinal semen and reproductive hormone profiles analyses will be performed. Further studies are needed to prove whether SARS-CoV–2 can be transmitted to the male reproductive tract and whether SARS-CoV–2 infection may cause alterations of spermatogenesis and endocrine function.

Limitations, reasons for caution

Strengths of this study are the unselected population of men examined within a week after confirmed SARS-CoV–2 infection and the follow-up of semen parameters and endocrine profile. Limitations are the limited sample size and the fact that semen quality was not known before the participants were diagnosed with COVID–19.

Wider implications of the findings: Knowledge of viral detection and semen persistence of SARS-CoV–2 is essential for clinical practice and public health. There is a need for evidence-based counselling on the impact of SARS-CoV–2 infection for patients undergoing assisted reproduction technology and patients who have a need for semen cryopreservation.

Trial registration number

H–20027362

P–493 Couples joint narratives of coping with and making sense of recurrent pregnancy loss: a dyadic interview study

Study question

What are couples’ joint narratives of coping with, and making sense of recurrent pregnancy loss?

Summary answer

Couples can become stuck in patterns of communication and coping roles that may be dissatisfying and not reflect the complexity of their experience of RPL.

What is known already

Fertility problems such as recurrent pregnancy loss (RPL) are unique health issues because they are a couple problem, in that they involve a blocked parenthood goal for both members of the couple regardless of the cause or source of the fertility issue.

Previous research has focused on the psychosocial impact on the individual or examined gender differences in men and women’s response to RPL. Research suggests that couples’ relationships are impacted, but few examine this issue in interviews with couples as participants. We need appropriate study designs to examine and understand the couple’s experience and process on a dyadic level.

Study design, size, duration

This was a qualitative study using dyadic interviews and analysis. This method facilitates a co-construction of meaning and joint narrative between couples through sharing and comparing their experience in a conjoint dyadic interview.

Thirteen couples who were referred to the RPL program, in Rigshospitalet, Copenhagen, Denmark were interviewed over a two-month period in 2017–2018. Interviews were held at Rigshospitalet and ranged between 81 and 109 minutes (average 91 minutes). Participants/materials, setting, methods: Inclusion criteria included: heterosexual couples with at least three pregnancy losses (PL) under 12 weeks gestation with no children/one child and willing to be interviewed in English. Thirty invitations were sent to couples who met the inclusion criteria and 15 couples contacted the interviewer to schedule an interview. Semi-structured dyadic interviews were conducted in person with 13 couples. Data was analyzed using dyadic analysis with a focus on common themes in co-constructed meaning across couples.

Main results and the role of chance

On average, participants had been in their relationship for 8.4 years, experienced three PLs (range three–six), with most recent PL occurring 4.3 months before the interview.

Couples described becoming stuck in patterns of communication and in rigid roles of coping and relating (e.g., the optimist, the emotional one) that could be dissatisfying and not meet their needs and not reflect the nuances and complexity of their experience of RPL. Common roles included the “optimist” versus the “pessimist”, the “talker” versus the “listener” and the “emotional” versus the “rational / problem solver”. While these roles were rooted in some truth of their experience, the rigidity of these roles did not create space and flexibility for the full spectrum of their reactions and experience. For example, a woman said, “I hope for him to be the pessimist so I get to be the optimist sometimes” and several men shared the depth of their grief for the first time.

The interviews were a way to highlight and create a new dynamic by allowing couples to respond to and correct their partner’s assumptions about their experience or role (e.g., “that’s not how I feel all the time”) and try new ways of communicating.

Limitations, reasons for caution

The findings cannot be generalized to all couples who have experienced RPL given the study design. Whilst dyadic interviews allow for a fuller, more nuanced narrative account, couples may omit some of their experience in the interview due to social desirability.

Wider implications of the findings: This study provides a better understanding of the complexity of communication patterns and roles in couples with RPL that can improve provision of support and counselling.

Dyadic interviews can provide opportunities for couples to communicate differently and break out of dissatisfying patterns while creating common ground and generating shared meaning.

Trial registration number

N/A

Feelings of guilt and loss of control dominate in stress and depression inventories from women with recurrent pregnancy loss

PURPOSE

Which feelings on the major depression inventory (MDI) and the perceived stress scale (PSS) are predominant among women with recurrent pregnancy loss (RPL)?

MATERIALS AND METHODS

Prospective cohort study of women with RPL referred to the tertiary RPL Unit at Copenhagen University Hospital, Rigshospitalet, Denmark, from 2010-2013. All women answered the MDI and PSS at time of referral.

RESULTS

In total, 298 women completed the MDI and the PSS, of which 162 had primary RPL and 136 secondary RPL. The most common feelings were low in energy (42%), loss of interest (35%), sadness (35%), and guilt (29%). Twenty-six (8.6%) women fulfilled the criteria for moderate to severe depression. Of the remaining 272 women, nine felt that life was not worth living. Among all women feeling angered of things outside their control (35%) and unable to control important things (27%) were predominant. Women with primary RPL compared to secondary RPL more often felt less self-confident and that life wasn't worth living (p = 0.007 and p = 0.002).

CONCLUSIONS

Feelings of guilt and loss of control were predominant in women with RPL. Women with primary RPL could represent a particularly sensitive group. Addressing these specific feelings could help treating the psychological aspects of RPL.

In vitro fertilisation (IVF) versus intracytoplasmic sperm injection (ICSI) in patients without severe male factor infertility: study protocol for the randomised, controlled, multicentre trial INVICSI

INTRODUCTION

Over the last decades, the use of intracytoplasmic sperm injection (ICSI) has increased, even among patients without male factor infertility. The increase has happened even though there is no evidence to support that ICSI results in higher live birth rates compared with conventional in vitro fertilisation (IVF) in cases with nonmale factor infertility. The lack of robust evidence on an advantage of using ICSI over conventional IVF in these patients is problematic since ICSI is more invasive, complex and requires additional resources, time and effort. Therefore, the primary objective of the IVF versus ICSI (INVICSI) study is to determine whether ICSI is superior to standard IVF in patients without severe male factor infertility. The primary outcome measure is first live birth from fresh and frozen-thawed transfers after one stimulated cycle. Secondary outcomes include fertilisation rate, ongoing pregnancy rate, birth weight and congenital anomalies.

METHODS AND ANALYSIS

This is a two-armed, multicentre, randomised, controlled trial. In total, 824 couples/women with infertility without severe male factor will be recruited and allocated randomly into two groups (IVF or ICSI) in a 1:1 ratio. Participants will be randomised in variable block sizes and stratified by trial site and age. The main inclusion criteria are (1) no prior IVF/ICSI treatment, (2) male partner sperm with an expected count of minimum 2 million progressive motile spermatozoa following density gradient purification on the day of oocyte pick up and (3) age of the woman between 18 and 42 years.

ETHICS AND DISSEMINATION

The study will be performed in accordance with the ethical principles in the Helsinki Declaration. The study is approved by the Scientific Ethical Committee of the Capital Region of Denmark. Study findings will be presented, irrespectively of results at international conferences and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04128904. Pre-results.

Using Social Media for Qualitative Health Research in Danish Women of Reproductive Age: Online Focus Group Study on Facebook

BACKGROUND

Social media platforms provide new possibilities within health research. With Facebook being the largest social network in the world, it constitutes a potential platform for recruitment and data collection from women of reproductive age. Women in Denmark and in other Western countries postpone motherhood and risk infertility due to their advanced age when they try to conceive. To date, no study has explored Danish women's reflections on the timing of motherhood within a social media setting.

OBJECTIVE

The aim of this study was to explore the challenges and opportunities of using Facebook as a platform for qualitative health research in Danish women of reproductive age.

METHODS

This study was a qualitative study based on 3 online focus groups on Facebook with 26 Danish women of reproductive age discussing the timing of motherhood in January 2020.

RESULTS

Conducting online focus groups on Facebook was successful in this study as the web-based approach was found suitable for developing qualitative data with women of reproductive age and made recruitment easy and free of charge. All participants found participating in an online focus group to be a positive experience. More than half of the women participating in the online focus groups found it advantageous to meet on Facebook instead of meeting face-to-face.

CONCLUSIONS

Conducting online focus groups on Facebook is a suitable method to access qualitative data from women of reproductive age. Participants were positive toward being a part of an online focus group. Online focus groups on social media have the potential to give women of reproductive age a voice in the debate of motherhood.

Chance of live birth: a nationwide, registry-based cohort study

STUDY QUESTION

Does the sequence of prior pregnancy events (pregnancy losses, live births, ectopic pregnancies, molar pregnancy and still birth), obstetric complications and maternal age affect chance of live birth in the next pregnancy and are prior events predictive for the outcome?

SUMMARY ANSWER

The sequence of pregnancy outcomes is significantly associated with chance of live birth; however, pregnancy history and age are insufficient to predict the outcome of an individual woman's next pregnancy.

WHAT IS KNOWN ALREADY

Adverse pregnancy outcomes decrease the chance of live birth in the next pregnancy, whereas the impact of prior live births is less clear.

STUDY DESIGN, SIZE, DURATION

Nationwide, registry-based cohort study of 1 285 230 women with a total of 2 722 441 pregnancies from 1977 to 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women living in Denmark in the study period with at least one pregnancy in either the Danish Medical Birth Registry or the Danish National Patient Registry. Data were analysed using logistic regression with a robust covariance model to account for women with more than one pregnancy. Model discrimination and calibration were ascertained using 20% of the women in the cohort randomly selected as an internal validation set.

MAIN RESULTS AND THE ROLE OF CHANCE

Obstetric complications, still birth, ectopic pregnancies and pregnancy losses had a negative effect on the chance of live birth in the next pregnancy. Consecutive, identical pregnancy outcomes (pregnancy losses, live births or ectopic pregnancies) immediately preceding the next pregnancy had a larger impact than the total number of any outcome. Model discrimination was modest (C-index = 0.60, positive predictive value = 0.45), but the models were well calibrated.

LIMITATIONS, REASONS FOR CAUTION

While prior pregnancy outcomes and their sequence significantly influenced the chance of live birth, the discriminative abilities of the predictive models demonstrate clearly that pregnancy history and maternal age are insufficient to reliably predict the outcome of a given pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

Prior pregnancy history has a significant impact on the chance of live birth in the next pregnancy. However, the results emphasize that only taking age and number of losses into account does not predict if a pregnancy will end as a live birth or not. A better understanding of biological determinants for pregnancy outcomes is urgently needed.

STUDY FUNDING/COMPETING INTEREST(S)

The work was supported by the Novo Nordisk Foundation, Ole Kirk Foundation and Rigshospitalet's Research Foundation. The authors have no financial relationships that could appear to have influenced the work.

TRIAL REGISTRATION NUMBER

N/A.

Meditation and mindfulness reduce perceived stress in women with recurrent pregnancy loss: a randomized controlled trial

RESEARCH QUESTION

Can participating in a tailored 7-week meditation and mindfulness programme with additional standard supportive care versus standard supportive care only reduce perceived stress for women with recurrent pregnancy loss (RPL)?

DESIGN

A two-armed randomized controlled trial (RCT) with 12-month follow-up. In total 76 patients were enrolled and randomly assigned to either standard supportive care or to a 7-week meditation and mindfulness programme led by an instructor in addition to standard supportive care.

RESULTS

At intervention completion (after 7 weeks), perceived stress decreased significantly both in the intervention group (P = 0.001) and in the control group (P = 0.006). The decrease in perceived stress in the intervention group was significantly larger (P = 0.027) compared with the control group. At the 12-month follow-up perceived stress was still significantly decreased in both groups compared with baseline (P < 0.0001 in the intervention group and P = 0.002 in the control group).

CONCLUSION

This first RCT of a tailored meditation and mindfulness intervention for women with RPL documents that a 7-week daily at-home meditation and mindfulness programme combined with group sessions reduced perceived stress significantly more than a standard supportive care programme. Future studies should address the most effective format and the 'dose' needed for an impact on perceived stress levels.

Stress and depression among women and men who have experienced recurrent pregnancy loss: focusing on both sexes

RESEARCH QUESTION

Are women and men suffering from recurrent pregnancy loss (RPL) more affected by psychological stress and depression than the general population?

DESIGN

Cross-sectional study investigating the prevalence of stress and depression in women and men with RPL seen in the Danish national RPL Unit. Data were collected between 2015-2018. All newly referred couples were asked to complete the Major Depression Index (MDI) and Cohen's Perceived Stress Scale (PSS). The scores of both sexes were compared with scores from relevant cohorts of men and women from the general population.

RESULTS

In total, 412 women with RPL (82% response rate) and 281 male partners (60% response rate) were included. Depression: 5/281 (1.8%) of men with RPL had moderate/severe depression vs. 5/253 (2.0%) of men in the comparison group (relative risk (RR) 0.90; 95% CI 0.26-3.07, p=0.99). Among women with RPL, 34/412 (8.3%) had a moderate/severe depression vs. 2.2% in the comparison group (RR 3.74; 95% CI 2.40-5.83, p<0.001). High stress levels were found in 30/281 men with RPL (10.7%) vs. 15.8% in the comparison group (co-habiting men) (RR 0.67; 95% CI 0.48-0.94, p=0.017). High stress level was found among 110/384 (28.6%) of RPL-women vs. 420/1813 (23.2%) of comparison women (RR 1.24; 95% CI 1.03-1.48, p=0.026). Both MDI and PSS scores, respectively, for a woman and a man in an RPL couple were significantly correlated.

CONCLUSION

Male partners in RPL couples did not have increased prevalence of stress and depression compared with other men but we confirmed our previous finding of significantly increased frequencies among women with RPL.

Dysbiosis of the Human Oral Microbiome During the Menstrual Cycle and Vulnerability to the External Exposures of Smoking and Dietary Sugar

Physiological hormonal fluctuations exert endogenous pressures on the structure and function of the human microbiome. As such, the menstrual cycle may selectively disrupt the homeostasis of the resident oral microbiome, thus compromising oral health. Hence, the aim of the present study was to structurally and functionally profile the salivary microbiome of 103 women in reproductive age with regular menstrual cycle, while evaluating the modifying influences of hormonal contraceptives, sex hormones, diet, and smoking. Whole saliva was sampled during the menstrual, follicular, and luteal phases (n = 309) of the cycle, and the participants reported questionnaire-based data concerning their life habits and oral or systemic health. No significant differences in alpha-diversity or phase-specific clustering of the overall microbiome were observed. Nevertheless, the salivary abundances of genera Campylobacter, Haemophilus, Prevotella, and Oribacterium varied throughout the cycle, and a higher species-richness was observed during the luteal phase. While the overall community structure maintained relatively intact, its functional properties were drastically affected. In particular, 11 functional modules were differentially abundant throughout the menstrual cycle, including pentose phosphate metabolism, and biosynthesis of cobalamin and neurotransmitter gamma-aminobutyric acid. The menstrual cycle phase, but not oral contraceptive usage, was accountable for greater variations in the metabolic pathways of the salivary microbiome. Further co-risk factor analysis demonstrated that Prevotella and Veillonella were increased in current smokers, whereas high dietary sugar consumption modified the richness and diversity of the microbiome during the cycle. This is the first large study to systematically address dysbiotic variations of the oral microbiome during the course of menstrual cycle, and document the additive effect of smoking and sugar consumption as environmental risk factors. It reveals the structural resilience and functional adaptability of the oral microbiome to the endogenous hormonal pressures of the menstrual cycle, while revealing its vulnerability to the exogenous exposures of diet and smoking.

HLA-DRB1 polymorphism in recurrent pregnancy loss: New evidence for an association to HLA-DRB1*07

Many cases of recurrent pregnancy loss (RPL) defined as ≥3 consecutive pregnancy losses are suggested to be caused by an aberrant maternal immune response against the fetus or trophoblast. Human leukocyte antigen (HLA)-DRB1 and -DQB1 polymorphisms are associated with most autoimmune disorders and studies of HLA-DBB1 polymorphism in RPL patients are thus relevant. In previous studies, the HLA-DRB1*03 allele was found with increased prevalence in RPL patients. We wanted to clarify whether HLA-DRB1 alleles indeed were associated with RPL among women of Caucasian descent. A total of 1078 women with unexplained RPL and 2066 bone marrow donors were HLA-DRB1-typed and subsets were also HLA-DQB1 typed. All patients were initially HLA-DRB1-typed by DNA-based low-resolution techniques and subsets of patients and all controls were typed by high-resolution techniques. Among patients, the HLA-DRB1*07 allele frequency was significantly increased compared with controls; OR 1.29 (95 % CI 1.09-1.52), p < 0.0025; after correction for multiple comparisons pc = 0.031. The HLA-DRB1*07/*07 genotype was highly increased in patients with RPL compared with controls: OR 2.27 (1.31-3.93), p = 0.0027. The frequency of the HLA-DRB1*07 phenotype in RPL patients had increased significantly (p = 0.002) in three studies from our group published 1994-2021. The allele frequency of HLA-DRB1*03 was not increased in RPL patients compared with controls; OR 0.96 (0.83-1.12). In conclusion, the previous association between HLA-DRB1*03 and RPL could not be confirmed in our study whereas an association to HLA-DRB1*07 was detected for the first time. Since the latter association is a new finding, it should be confirmed in future studies.

SARS-CoV-2 in first trimester pregnancy: a cohort study

Study question

Does maternal infection with SARS-CoV-2 in first trimester pregnancy have an impact on the fetal development as measured by nuchal translucency thickness and pregnancy loss?

Summary answer

Nuchal translucency thickness at the first trimester scan was not significantly different in pregnant women with versus without SARS-CoV-2 infection in early pregnancy and there was no significant increased risk of pregnancy loss in women with SARS-CoV-2 infection in the first trimester.

What is known already

Pregnant women are more vulnerable to viral infections. Previous coronavirus epidemics have been associated with increased maternal morbidity, mortality and adverse obstetric outcomes. Currently, no evidence exists regarding possible effects of SARS-CoV-2 in first trimester pregnancies.

Study design, size, duration

Cohort study of 1,019 women with a double test taken between Feb. 17 and Apr. 23, 2020, as a part of the combined first trimester risk assessment, and 36 women with a first trimester pregnancy loss between Apr. 14 and May 21, 2020, prior to the double test. The study period was during the first SARS-CoV-2 epidemic wave in Denmark.

Participants/materials, setting, methods

Cohort 1 included pregnant women with a double test taken within the study period. The excess serum from each double test was analyzed for SARS-CoV-2 antibodies. Results were correlated to the nuchal translucency thickness and the number of pregnancy losses before or at the time of the first trimester scan. Cohort 2 included women with a pregnancy loss before the gestational age for double test sample. Serum from a blood test taken the day the pregnancy loss was identified was analyzed for SARS-CoV-2 antibodies. The study was conducted at a public university hospital serving approximately 12% of pregnant women and births in Denmark. All participants in the study provided written informed consent.

Main results and the role of chance

Eighteen (1.8%) women had SARS-CoV-2 antibodies in the serum from the double test suggestive of SARS-CoV-2 infection in early pregnancy. There was no significant difference in nuchal translucency thickness for women testing positive for previous SARS-CoV-2 infection (n = 18) versus negative (n = 994) (p = 0.62). There was no significant increased risk of pregnancy loss for women with positive antibodies (n = 1) (OR 3.4, 0.08-24.3 95% CI, p = 0.27). None of the women had been hospitalized due to SARS-CoV-2 infection. None of the women with pregnancy loss prior to the double test (Cohort 2) had SARS-CoV-2 antibodies.

Limitations, reasons for caution

These results may only apply to similar populations and to patients who do not require hospitalization due to SARS-CoV-2 infection. A limitation of the study is that only 1.8% of the study population had SARS-CoV-2 antibodies suggestive of previous infection.

Wider implication of the findings

Maternal SARS-CoV-2 infection had no effect on the nuchal translucency thickness and there was no significant increased risk of pregnancy loss for women with SARS-CoV-2 infection in first trimester pregnancy. Evidence concerning Covid-19 in pregnancy is still limited. These data indicate that infection with SARS-CoV-2 in not hospitalized women does not pose a significant threat in first trimester pregnancies. Follow up studies are needed to establish any risk to a fetus exposed to maternal SARS-CoV-2 infection.

Study funding/competing interest(s)

Prof. Henriette Svarre Nielsen (HSN) and colleagues received a grant from the Danish Government for research of Covid-19 among pregnant women. The Danish government was not involved in the study design, data collection, analysis, interpretation of data, writing of the report or decision to submit the paper for publication. AI, JOL, JBR, DMS, JEF, and ERH received funding from a Novo Nordisk Foundation (NNF) Young Investigator Grant (NNF15OC0016662) and a Danish National Science Foundation Center Grant (6110-00344B). AI received a Novo Scholarship. JOL is funded by an NNF Pregraduate Fellowship (NNF19OC0058982). DW is funded by the NNF (NNF18SA0034956, NNF14CC0001, NNF17OC0027594). AMK is funded by a grant from the Rigshospitalet’s research fund. Henriette Svarre Nielsen has received speakeŕs fees from Ferring Pharmaceuticals, Merck Denmark A/S and Ibsa Nordic (outside the submitted work). Nina la Cour Freiesleben has received a grant from Gedeon Richter (outside the submitted work). Astrid Marie Kolte has received speakeŕs from Merck (outside the submitted work). The other authors did not report any potential conflicts of interest.