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van der Coelen S, van der Velden J, Nadesapillai S, Braat D, Peek R, Fleischer K. Navigating fertility dilemmas across the lifespan in girls with Turner syndrome-a scoping review. Hum Reprod Update 2024:dmae005. [PMID: 38452347 DOI: 10.1093/humupd/dmae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/17/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Girls with Turner syndrome (TS) lack a partial or complete sex chromosome, which causes an accelerated decline of their ovarian reserve. Girls have to deal with several dilemmas related to their fertility, while only a limited number of them are referred to a fertility specialist and counselled about options of family planning on time. OBJECTIVE AND RATIONALE This scoping review provides an update of the literature on fertility in girls with TS throughout their lifespan and aims to propose a clinical practice guideline on fertility in TS. SEARCH METHODS Databases of PubMed, Embase, and Web of science were searched using the following key terms: Turner syndrome, fertility, puberty, pregnancy, sex-hormones, karyotype, fertility preservation, assisted reproductive techniques, and counselling, alongside relevant subject headings and synonymous terms. English language articles published since 2007 were critically reviewed. Pregnancies after using donated oocytes and data about girls with TS with Y-chromosomal content were excluded. OUTCOMES This search identified 1269 studies of which 120 were extracted for the review. The prevalence of natural conception ranged from 15% to 48% in women with 45,X/46,XX, 1% to 3% in women with 45,X, and 4% to 9% in women with other TS karyotypes. When assessing a girl's fertility potential, it was crucial to determine the karyotype in two cell lines, because hidden mosaicism may exist. In addition to karyotype, assessment of anti-Müllerian hormone (AMH) played a significant role in estimating ovarian function. Girls with AMH above the detection limit were most likely to experience spontaneous thelarche, menarche, and ongoing ovarian function during the reproductive lifespan. Fertility preservation became more routine practice: vitrification of oocytes was reported in 58 girls with TS and a median of five oocytes were preserved per stimulation. Ovarian tissue cryopreservation has demonstrated the presence of follicles in approximately 30% of girls with TS, mostly in girls with mosaic-TS, spontaneous puberty, and AMH above the detection limit. Although girls and their parents appreciated receiving counselling on fertility in TS, only one in ten girls with TS received specialized counselling. Unfamiliarity with fertility preservation techniques or uncertainties regarding the eligibility of a girl for fertility preservation constituted barriers for healthcare professionals when discussing fertility with girls with TS. WIDER IMPLICATIONS There currently is a high demand for fertility preservation techniques in girls with TS. A reliable prognostic model to determine which girls with TS might benefit from fertility preservation is lacking. Only a minority of these girls received comprehensive fertility counselling on the full spectrum of fertility, including uncertainties of fertility preservation, pregnancy risks, and alternatives, such as adoption. Fertility preservation could be a viable option for girls with TS. However, the question remains whether enough oocytes can be obtained for a realistic prospect of a live birth. It is important that girls and parents are empowered with the necessary information to make a well-informed decision.
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Affiliation(s)
- Sanne van der Coelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janielle van der Velden
- Department of Paediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sapthami Nadesapillai
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Didi Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald Peek
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, Elsendorp, The Netherlands
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Nadesapillai S, van der Velden J, van der Coelen S, Schleedoorn M, Sedney A, Spath M, Schurink M, Oerlemans A, IntHout J, Beerendonk I, Braat D, Peek R, Fleischer K. TurnerFertility trial: fertility preservation in young girls with Turner syndrome by freezing ovarian cortex tissue-a prospective intervention study. Fertil Steril 2023; 120:1048-1060. [PMID: 37549836 DOI: 10.1016/j.fertnstert.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE To evaluate which girls with Turner syndrome (TS) could benefit from fertility preservation by ovarian tissue cryopreservation on the basis of karyotype, puberty status, and hormonal data. DESIGN Prospective intervention study; participants were included between 2018 and 2020. SETTING Tertiary hospital in the Netherlands. PATIENTS In total, 106 girls with TS aged between 2 and 18 years were included. Girls with minor X chromosome deletions, Y chromosomal content, active infections, or contraindications for surgery were excluded. INTERVENTION A laparoscopic unilateral ovariectomy was performed to obtain ovarian cortical tissue for cryopreservation. One tissue fragment per participant was used to determine the number of follicles per ovary by serial sectioning and staining. Chromosome analysis was performed on lymphocytes and buccal cells. A blood sample was taken before the ovariectomy for hormonal analysis. MAIN OUTCOME MEASURES The presence of follicles in ovarian cortex tissue from girls with TS in relation to karyotype, puberty status, and hormonal data. RESULTS A unilateral ovariectomy was performed on 93 girls with TS. Complications after surgery occurred in 5 girls, including luxation of psychological symptoms in 2 girls. In 13 (14%) girls, a 46,XX cell line was found in buccal cells that was absent in lymphocytes. Follicles were observed in 30 (32%) of the 93 girls and were found mainly in girls with a 46,XX cell line in lymphocytes or buccal cells (Phi coefficient = 0.55). Spontaneous onset of puberty (Phi coefficient = 0.59), antimüllerian hormone (AMH; point-biserial correlation [r] = 0.82), inhibin B (r = 0.67), and follicle-stimulating hormone (r = -0.46) levels were also correlated strongly with the presence of follicles. Furthermore, AMH levels had a significant correlation with the number of follicles per ovary (r = 0.66). CONCLUSION Favorable predictive markers for the presence of follicles included either a 46,XX cell line, spontaneous onset of puberty, or a combination of measurable AMH and normal follicle-stimulating hormone levels. Karyotyping of two peripheral cell lines in girls with TS is recommended to reveal hidden mosaicisms. Ovarian tissue cryopreservation should be offered with caution in a research setting to those with a sufficient ovarian reserve, considering the significant loss of follicles after ovarian tissue cryopreservation and autotransplantation. Physicians should pay attention to the mental health of the girls during the whole process. CLINICAL TRIAL REGISTRATION NUMBER Trial registration number: NCT03381300- Preservation of Ovarian Cortex Tissue in Girls With Turner Syndrome - Full Text View - ClinicalTrials.gov. Registered on: December 21, 2017. First patient recruited on January 1, 2018.
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Affiliation(s)
- Sapthami Nadesapillai
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands.
| | - Janielle van der Velden
- Department of Pediatrics, Amalia's Children's Hospital, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Sanne van der Coelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Myra Schleedoorn
- Emergency Department, County Hospital Lohr am Main, Am Sommerberg, Lohr am Main, Germany
| | - Amy Sedney
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Marian Spath
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Maarten Schurink
- Department of Pediatric Surgery, Amalia's Children's Hospital, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Anke Oerlemans
- IQ Healthcare, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Joanna IntHout
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Ina Beerendonk
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Didi Braat
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Ronald Peek
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, Ripseweg, Elsendorp, the Netherlands
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Nadesapillai S, Mol F, Broer SL, Stevens Brentjens LBPM, Verhoeven MO, Heida KY, Goddijn M, van Golde RJT, Bos AME, van der Coelen S, Peek R, Braat DDM, van der Velden JAEM, Fleischer K. Reproductive Outcomes of Women with Turner Syndrome Undergoing Oocyte Vitrification: A Retrospective Multicenter Cohort Study. J Clin Med 2023; 12:6502. [PMID: 37892640 PMCID: PMC10607490 DOI: 10.3390/jcm12206502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Turner syndrome (TS) is accompanied with premature ovarian insufficiency. Oocyte vitrification is an established method to preserve fertility. However, data on the oocyte yield in women with TS who vitrify their oocytes and the return rate to utilize the oocytes are scarce. METHODS Retrospective multicenter cohort study. Data was collected from medical records of women with TS who started oocyte vitrification between 2010 and 2021. RESULTS Thirty-three women were included. The median cumulative number of vitrified oocytes was 20 per woman. Complications occurred in 4% of the cycles. Significant correlations were found between the cumulative number of vitrified oocytes and AMH (r = 0.54 and p < 0.01), AFC (r = 0.49 and p < 0.01), percentage of 46,XX cells (r = 0.49 and p < 0.01), and FSH (r = -0.65 and p < 0.01). Spontaneous (n = 8) and IVF (n = 2) pregnancies occurred in 10 women ± three years after vitrification. So far, none of the women have returned to utilize their vitrified oocytes. CONCLUSIONS Oocyte vitrification is a feasible fertility preservation option for women with TS, particularly in those with 46,XX cell lines or sufficient ovarian reserve. Multiple stimulation cycles are recommended to reach an adequate number of vitrified oocytes for pregnancy. It is too early to draw conclusions about the utilization of vitrified oocytes in women with TS.
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Affiliation(s)
- Sapthami Nadesapillai
- Department of Obstetrics and Gynecology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Femke Mol
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Center for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Simone L. Broer
- Department of Reproductive Medicine, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Linda B. P. M. Stevens Brentjens
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, 6229 ER Maastricht, The Netherlands
| | - Marieke O. Verhoeven
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Center for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Karst Y. Heida
- Dijklander Hospital, Centrum Voor Kinderwens, 1441 RN Purmerend, The Netherlands
| | - Mariëtte Goddijn
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Center for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Ron J. T. van Golde
- Department of Obstetrics and Gynecology, Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, 6229 ER Maastricht, The Netherlands
| | - Annelies M. E. Bos
- Department of Reproductive Medicine, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Sanne van der Coelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Ronald Peek
- Department of Obstetrics and Gynecology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Didi D. M. Braat
- Department of Obstetrics and Gynecology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | | | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, 5424 SM Elsendorp, The Netherlands
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Franik S, Fleischer K, Kortmann B, Stikkelbroeck NM, D’Hauwers K, Bouvattier C, Slowikowska-Hilczer J, Grunenwald S, van de Grift T, Cartault A, Richter-Unruh A, Reisch N, Thyen U, IntHout J, Claahsen-van der Grinten HL. Quality of life in men with Klinefelter syndrome: a multicentre study. Endocr Connect 2023; 12:e230111. [PMID: 37578764 PMCID: PMC10563591 DOI: 10.1530/ec-23-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/14/2023] [Indexed: 08/15/2023]
Abstract
Background Klinefelter syndrome (KS) is associated with an increased risk of lower socioeconomic status and a higher risk for morbidity and mortality, which may have a significant impact on quality of life (QOL). The objective of this study is to investigate QOL in a large European cohort of men with KS. Design Cross-sectional multicentre study. Methods Two-hundred-eighteen men with KS were recruited from 14 clinical study centres in 6 European countries which participated in the European dsd-LIFE study. Male normative data from a healthy and a psychiatric reference population were used for comparison. The validated World Health Organization (WHO) QOL (WHOQOL)-BREF questionnaire was used to investigate five main domains of quality of life (WHOQOL): global, physical, psychological, environment, and social. Results The QOL physical domain score was lower for men with KS compared to the healthy reference population (KS: 66.9; s.d. 19.4, n = 193; healthy reference population: 76.5; s.d. 16.2, n = 1324, P < 0.001) but higher compared to the psychiatric reference population (54.6; s.d. 20.6; n = 77, P < 0.001). The WHOQOL-psychological domain score was lower for men with KS compared to the healthy reference population (KS: 63.6; s.d. 17.8, n = 193; healthy reference population: 67.8; s.d. 15.6, n = 1324, P < 0.05) but higher compared to the psychiatric reference population (45.9; s.d. 26.0), n = 77, P < 0.001). The social domain score on the WHOQOL questionnaire was found to be lower in men with Klinefelter syndrome (KS) compared to the healthy reference population (KS: 60.0; s.d. 21.6, n = 193; healthy reference population: 68.2; s.d. 13.8, n = 1324, P < 0.001). However, this score was similar to that of the psychiatric reference population (61.0; s.d. 17.0, n = 77, P = 0.5). The WHO environment domain score of men with KS (70.0; s.d. 15.0, n = 193) was similar to the healthy reference population (70.5; s.d. 20.7, n = 1324) but higher compared to the psychiatric reference population (61.9; s.d. 20.8, n = 77, P = 0.002). Experienced discrimination, less social activities, and the presence of chronic health problems were associated with significantly decreased QOL in men with KS. Conclusion Overall QOL in European men with KS is significantly worse compared to a healthy European reference population. Especially, the presence of discrimination, less social activities, and chronic health problems is associated with lower physical, psychological, and social QOL. Further studies are necessary to investigate if a multidisciplinary approach may help to provide adequate counselling and psychosocial support to improve QOL.
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Affiliation(s)
- Sebastian Franik
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Barbara Kortmann
- Department of Pediatric Urology, Radboudumc, Nijmegen, The Netherlands
| | | | | | - Claire Bouvattier
- Department of Pediatric Endocrinology, Bicêtre Hospital, Paris Sud University, France
| | | | - Solange Grunenwald
- Department of Endocrinology and Metabolic Disease, Centre Hospitalier Universitaire de Toulouse, France
| | - Tim van de Grift
- Departments of Plastic Surgery and Medical Psychology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - Audrey Cartault
- Department of Pediatrics, Hospital Des Enfants, Toulouse, France
| | - Annette Richter-Unruh
- Kinderendokrinologie und Diabetologie, Universitätsklinikum Ruhr-Universität Bochum, Kinderklinik, Bochum, Germany
| | - Nicole Reisch
- Department of Endocrinology, Medizinische Klinik and Poliklinik IV, University Hospital Munich, Munich, Germany
| | - Ute Thyen
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck, Ratzeburger Allee, Lubeck, Germany
| | - Joanna IntHout
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | | | - the dsd-LIFE group
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
- Department of Pediatric Urology, Radboudumc, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
- Department of Urology, Radboudumc, Nijmegen, The Netherlands
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
- Department of Pediatric Endocrinology, Bicêtre Hospital, Paris Sud University, France
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Poland
- Department of Endocrinology and Metabolic Disease, Centre Hospitalier Universitaire de Toulouse, France
- Departments of Plastic Surgery and Medical Psychology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Department of Pediatrics, Hospital Des Enfants, Toulouse, France
- Kinderendokrinologie und Diabetologie, Universitätsklinikum Ruhr-Universität Bochum, Kinderklinik, Bochum, Germany
- Department of Endocrinology, Medizinische Klinik and Poliklinik IV, University Hospital Munich, Munich, Germany
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck, Ratzeburger Allee, Lubeck, Germany
- Department of Pediatric Endocrinology, Amalia Childrens Hospital, Radboudumc, Nijmegen, The Netherlands
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de Ligny WR, Fleischer K, Grens H, Braat DDM, de Bruin JP. The lack of evidence behind over-the-counter antioxidant supplements for male fertility patients: a scoping review. Hum Reprod Open 2023; 2023:hoad020. [PMID: 37293243 PMCID: PMC10244220 DOI: 10.1093/hropen/hoad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
STUDY QUESTION What is the evidence for over-the-counter antioxidant supplements for male infertility? SUMMARY ANSWER Less than half of over-the-counter antioxidant supplements for male fertility patients have been tested in a clinical trial, and the available clinical trials are generally of poor quality. WHAT IS KNOWN ALREADY The prevalence of male infertility is rising and, with this, the market for supplements claiming to improve male fertility is expanding. Up to now, there is limited data on the evidence for these over-the-counter supplements. STUDY DESIGN SIZE DURATION Amazon, Google Shopping and other relevant shopping websites were searched on 24 June 2022 with the following terms: 'supplements', 'antioxidants', 'vitamins', AND 'male fertility', 'male infertility', 'male subfertility', 'fertility men', 'fertility man'. All supplements with a description of ingredients in English, Dutch, French, Spanish, or German were included. Subsequently, Pubmed and Google Scholar were searched for studies that included the supplements. PARTICIPANTS/MATERIALS SETTING METHODS Inclusion criteria were supplements with antioxidant properties, of which the main purpose was to improve male fertility. Included supplements must be available without a doctor's prescription. Supplements containing plant extracts were excluded, as well as supplements of which the content or dosage was not clear. The ingredients, dosage, price and health claims of the supplements were recorded. We assessed whether substances in the supplements exceeded the recommended dietary allowance (RDA) or tolerable upper intake level (UL). All clinical trials and animal studies investigating included supplements were selected for this review. Clinical trials were assessed for risk of bias with a risk of bias tool appropriate for the study design. MAIN RESULTS AND THE ROLE OF CHANCE There were 34 eligible antioxidant supplements found, containing 48 different active substances. The average price per 30 days was 53.10 US dollars. Most of the supplements (27/34, 79%) contained substances in a dosage exceeding the recommended daily allowance (RDA). All manufacturers of the supplements made health claims related to the improvement of sperm quality or male fertility. For 13 of the 34 supplements (38%), published clinical trials were available, and for one supplement, only an animal study was found. The overall quality of the included studies was poor. Only two supplements were tested in a good quality clinical trial. LIMITATIONS REASONS FOR CAUTION As a consequence of searching shopping websites, a comprehensive search strategy could not be formulated. Most supplements were excluded because they contained plant extracts or because supplement information was not available (in an appropriate language). WIDER IMPLICATIONS OF THE FINDINGS This is the first review that gives an insight into the market of male fertility supplements as available to infertility patients and other men seeking to improve their fertility. Earlier reviews have focused only on supplements with published clinical trials. However, we show that more than half of the supplements have not been tested in a clinical trial. To our knowledge, this review is the first to assess the dosage of supplements in relation to the RDA. In agreement with the literature, we found that the evidence on male fertility supplements is generally of poor quality. This review should urge pharmaceutical companies to evaluate their products in randomized controlled trials in order to provide people with substantiated information. STUDY FUNDING/COMPETING INTERESTS The research position of W.R.d.L. is funded by an unrestricted grant from Goodlife Pharma. W.R.d.L., K.F., and J.P.d.B. are in the research team of a clinical trial on Impryl®, one of the supplements included in this review. REGISTRATION NUMBER N/A.
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Affiliation(s)
- Wiep R de Ligny
- Correspondence address. Department of Reproductive Medicine, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail:
| | - Kathrin Fleischer
- Nij Geertgen Center for Reproductive Medicine, Elsendorp, The Netherlands
| | - Hilde Grens
- Center for Reproductive Medicine, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands
| | - Didi D M Braat
- Department of Reproductive Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Peter de Bruin
- Center for Reproductive Medicine, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands
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Peek R, Nadesapillai S, Thi Nguyen TY, Vassart S, Smeets D, van de Zande G, Camboni A, Braat D, van der Velden J, Donnez J, Fleischer K, Dolmans MM. Assessment of folliculogenesis in ovarian tissue from young patients with Turner syndrome using a murine xenograft model. Fertil Steril 2023:S0015-0282(23)00293-5. [PMID: 37061159 DOI: 10.1016/j.fertnstert.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE To study the impact of aneuploid granulosa and stromal cells on folliculogenesis of small ovarian follicles from mosaic Turner syndrome patients using a murine xenograft model. DESIGN Laboratory study SUBJECTS: Ovarian cortical tissue was obtained by laparoscopic surgery from 18 mosaic TS patients (aged 5-19 years) and 13 controls (aged 5-18 years). INTERVENTION Part of each tissue fragment was used to karyotype ovarian cells in non-grafted tissue by fluorescence in situ hybridization. The remaining tissue was xenografted to severe combined immunodeficient mice for 5 months. Grafted tissue was analyzed for aneuploidy, and follicle density and morphology were determined. Expression of proliferating cell nuclear antigen and anti-Müllerian hormone were investigated by immunohistochemistry. MAIN OUTCOME MEASURES The impact of aneuploid granulosa and stromal cells on folliculogenesis. Fluorescence in situ hybridization of ovarian tissue before grafting was performed to determine the level of aneuploidy in stromal cells, and oocytes and granulosa of small follicles. After xenografting the level of aneuploidy of the newly formed layers of granulosa cells was again determined in secondary and antral follicles. RESULTS Follicle density in ovarian tissue from Turner syndrome patients was significantly lower than in controls before grafting. Fluorescence in situ hybridization analysis confirmed that 101/104 oocytes from non-grafted tissue of Turner syndrome patients showed normal X chromosome content, while granulosa and stromal cells were mainly 45,X. Fragments from 12 Turner syndrome patients contained follicles at all stages after xenografting, including secondary and antral follicles. Follicle density in Turner syndrome patients and controls decreased significantly after grafting. Moreover, a shift from high to low proportions of 45,X granulosa cells was observed during folliculogenesis. Expression of PCNA in follicles from TS patients increased significantly during grafting. Secretion of AMH was impaired before grafting in peri-/postpubertal TS girls, but recovered after grafting. CONCLUSION Our study showed that small follicles from mosaic Turner syndrome patients undergo folliculogenesis, despite the presence of aneuploid granulosa and stromal cells. Ovarian tissue cryopreservation could therefore be a valid option to preserve fertility in young mosaic Turner syndrome patients if sufficient numbers of follicles are present, thus preferably before the age of 12.
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Nadesapillai S, van der Velden J, Braat D, Fleischer K, Peek R. Exploring X Chromosomal Aberrations in Ovarian Cells by using Fluorescence In Situ Hybridization. J Vis Exp 2023. [PMID: 37092819 DOI: 10.3791/64734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Millions of people worldwide deal with issues concerning fertility. Reduced fertility, or even infertility, may be due to many different causes, including genetic disorders, of which chromosomal abnormalities are the most common. Fluorescence in situ hybridization (FISH) is a well-known and frequently used method to detect chromosomal aberrations in humans. FISH is mainly used for the analysis of chromosomal abnormalities in the spermatozoa of males with numerical or structural chromosomal aberrations. Furthermore, this technique is also frequently applied in females to detect X chromosomal aberrations that are known to cause ovarian dysgenesis. However, information on the X chromosomal content of ovarian cells from females with X chromosomal aberrations in lymphocytes and/or buccal cells is still lacking. The aim of this study is to advance basic research regarding X chromosomal aberrations in females, by presenting two methods based on FISH to identify the X chromosomal content of ovarian cells. First, a method is described to determine the X chromosomal content of isolated ovarian cells (oocytes, granulosa cells, and stromal cells) in non-grafted ovarian cortex tissue from females with X chromosomal aberrations. The second method is directed at evaluating the effect of chromosomal aberrations on folliculogenesis by determining the X chromosomal content of ovarian cells of newly formed secondary and antral follicles in ovarian tissue, from females with X chromosomal aberrations after long-term grafting into immunocompromised mice. Both methods could be helpful in future research to gain insight into the reproductive potential of females with X chromosomal aberrations.
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Affiliation(s)
| | | | - Didi Braat
- Department of Obstetrics and Gynecology, Radboudumc
| | - Kathrin Fleischer
- Department of Obstetrics and Gynecology, Radboudumc; Department of Reproductive Medicine, Nij Geertgen Center for Fertility
| | - Ronald Peek
- Department of Obstetrics and Gynecology, Radboudumc
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Nadesapillai S, van der Coelen S, Goebel L, Peek R, Braat D, van der Velden A, Fleischer K, Oerlemans A. Deciding on future fertility: considerations of girls with Turner syndrome and their parents to opt for or against ovarian tissue cryopreservation. Reprod Biomed Online 2023:S1472-6483(23)00124-4. [PMID: 37062637 DOI: 10.1016/j.rbmo.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/25/2023] [Accepted: 02/23/2023] [Indexed: 03/07/2023]
Abstract
RESEARCH QUESTION What are the considerations of girls with Turner syndrome and their parents to opt for or against ovarian tissue cryopreservation (OTC)? DESIGN Semi-structured in-depth interviews were conducted with girls with Turner syndrome and their parents until data saturation was reached. Participants were recruited through purposive sampling. Data were analysed using a thematic analysis approach. RESULTS Thirteen parents and five girls who opted for OTC, and seven parents and three girls who declined OTC, were interviewed. Parents and girls mentioned that OTC offered hope, an opportunity to have genetic offspring and clarity about their current fertility status. Most participants were not afraid of the risks of surgery and trusted healthcare providers with this procedure. In contrast, families had to deal with uncertainties, owing to the lack of information on the success rate and long-term consequences of OTC in this group. Families indicated that they had to go through an important decision-making process in a short period of time, because of the limited number of participants in the OTC study. CONCLUSION A new opportunity and hope for future fertility were considerations for opting for OTC. However, OTC also came with uncertainties owing to the experimental nature of this procedure in girls with Turner syndrome. Healthcare providers could share these experiences with girls with Turner syndrome and their parents to improve fertility-preservation counselling in this group.
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Khazali S, Mondelli B, Fleischer K, Adamczyk M. Indocyanine Green tattooing for marking the caudal excision margin of a full-thickness vaginal endometriotic nodule. Facts Views Vis Obgyn 2023; 15:89-91. [PMID: 37010340 PMCID: PMC10392110 DOI: 10.52054/fvvo.15.1.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background: The use of Indocyanine Green (ICG) is well-described in oncology and more recently in benign gynaecological surgery. In this article we describe submucosal transvaginal ICG infiltration caudal to a vaginal endometriotic nodule to visualise the lower margin of excision laparoscopically.
Objectives: To demonstrates the use of submucosal ICG tattooing to mark and delineate the caudal margin of an ultra-low full thickness vaginal nodule and aid its excision laparoscopically.
Material and methods: A stepwise approach highlighting the “SOSURE” surgical technique for the excision of endometriosis and the practical use of the ICG to delineate the lowest margin of the full thickness vaginal nodule.
Main outcome measures: Laparoscopic complete excision of a 5 cm full-thickness vaginal nodule invading the right parametrium and involving the superficial muscularis layer of the rectum.
Result: ICG tattooing was helpful in identifying the lower margin of dissection of the rectovaginal space.
Conclusion: ICG tattooing of the margins of full-thickness vaginal nodules could be another use of ICG in benign gynaecology to complement the surgeon’s tactile and visual identification of the lower edge of dissection.
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Kukafka R, Logger JGM, Nelen WLDM, Braat DDM, Fleischer K, Hermens RPM. Web-based Guidance for Assisted Reproductive Technology With an Online App (myFertiCare): Quantitative Evaluation With the HOT-fit Framework. J Med Internet Res 2023; 25:e38535. [PMID: 36692928 PMCID: PMC9906312 DOI: 10.2196/38535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Assisted reproductive technologies (ARTs) are considered to be physically and mentally stressful. During their treatment trajectory, couples express high information and communication needs. They appreciate using the internet to obtain fertility-related information. In a previous study, we developed myFertiCare, an eHealth tool providing personalized information and interactive functionalities for infertile couples in order to improve patient-centered care. The app has already been successful in qualitative evaluations of usability. OBJECTIVE The aim of the current study is to quantitatively evaluate the implementation of myFertiCare by using the human, organizational, and technology-fit (HOT-fit) framework and to study the effects of using myFertiCare on couples' knowledge about infertility, their experience of the burden of infertility, and their experience of patient-centered care. With these results, implementation can be further improved, and patient-centered care can be enhanced. METHODS A quantitative study was performed based on the HOT-fit framework using validated questionnaires focusing on the human, organizational, and technology domains. Questions were added on the effect of using myFertiCare on couples' knowledge about infertility and treatment. Questions regarding the burden of infertility, the burden of infertility treatment, and the experience of patient-centeredness were based on the main items of the validated fertility quality of life (FertiQoL) and Patient-Centredness Questionnaire-Infertility questionnaires, respectively. Also, nonusers of the app were included to explore motivations for not using the app and identify opportunities for improvement. Finally, user data were analyzed to provide insight into multiple variables concerning app use. RESULTS In the human and technology domains, myFertiCare showed good system usability, high user satisfaction, and high information and interface quality. In the organizational domain, implementation was considered to be sufficient by both patients and staff. Use of the app increased knowledge about the treatment, improved coping with the treatment, and enhanced the experience of patient-centeredness. User data showed that women were the main app users and that use of the app gradually declined during the treatment trajectory. CONCLUSIONS A multi-faceted online app, myFertiCare, has been successfully evaluated quantitatively for implementation by using the HOT-fit framework. Use of the app increased knowledge about the treatment, improved coping with the treatment, and enhanced the experience of patient-centeredness. App use could be improved by creating more publicity. By providing myFertiCare, professionals in fertility care are supported in guiding patients through their treatment trajectory and in delivering patient-centered care.
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Affiliation(s)
| | - Jade G M Logger
- Department of Dermatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Willianne L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Didi D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Rosella P M Hermens
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
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11
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van der Coelen S, van der Velden J, Nadesapillai S, Peek R, Braat D, Schleedoorn M, Fleischer K, Oerlemans A. The Decision-Making Process regarding Ovarian Tissue Cryopreservation in Girls with Turner Syndrome by Patients, Parents, and Healthcare Providers: A Mixed-Methods Study. Horm Res Paediatr 2022; 95:374-383. [PMID: 35671713 PMCID: PMC9677842 DOI: 10.1159/000525374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/30/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Ovarian tissue cryopreservation (OTC) has proven to be effective in other patient groups, but the effectiveness in girls with Turner syndrome (TS) is still unclear. Guidelines for counselling about OTC in TS are lacking. The aim of this study was to gain insight into the experiences of patients, parents, and healthcare providers with the decision-making process regarding OTC in girls with TS. METHODS Within a year after counselling, a survey was sent to 132 girls with TS and their parents. Furthermore, focus groups were conducted with (1) gynaecologists with subspeciality reproductive medicine, (2) paediatric endocrinologists, (3) parents of girls aged 2-12, and (4) parents of girls aged 13-18. Transcripts were analysed using a thematic analysis approach. RESULTS The response rate of the survey was 45%. Of the survey respondents, 90% appreciated counselling regarding their future parenting options and considered it an addition to existing healthcare. Girls with TS and their parents indicated that the option of OTC raised hope for future genetic offspring and instantly made them feel that their only option was to seize this opportunity. Gynaecologists and paediatricians found it challenging to truly make families grasp a realistic perspective of OTC in girls with TS. DISCUSSION AND CONCLUSION Offering young girls with TS the possibility of fertility preservation in an experimental setting raised high hopes and led to challenges for healthcare providers in ensuring a considered decision. The appropriate moment for counselling should be tailored to the individual and discussed with patient, parents, and paediatrician.
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Affiliation(s)
- Sanne van der Coelen
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands,*Sanne van der Coelen,
| | - Janielle van der Velden
- Department of Paediatrics, Radboudumc, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Ron Peek
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Didi Braat
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Myra Schleedoorn
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Anke Oerlemans
- IQ Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
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12
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Schleedoorn MJ, Fleischer K, Braat D, Oerlemans A, van der Velden A, Peek R. Why Turner patients with 45, X monosomy should not be excluded from fertility preservation services. Reprod Biol Endocrinol 2022; 20:143. [PMID: 36138432 PMCID: PMC9494871 DOI: 10.1186/s12958-022-01015-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
In this case report, we highlight the practical dilemma, i.e. to perform ovarian tissue cryopreservation surgery in a 45, X Turner Syndrome patient or not, by reporting on the presence of follicles in a 13-year-old female diagnosed with 45, X monosomy and an unmeasurable anti-müllerian hormone serum level. We compare our results with previous research, highlight the challenges we faced in this case and provide recommendations for daily practice. Hereby, we demonstrate that excluding certain subgroups of Turner Syndrome patients (e.g. monosomy patients, and/or girls with an anti-müllerian hormone level below 2.0 ng/l) may be premature, especially based on the current state of published research data. This practical example of a challenging dilemma in the counselling of Turner Syndrome patients for fertility preservation is of interest for clinicians involved in fertility counselling and Turner Syndrome care.
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Affiliation(s)
- M J Schleedoorn
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - K Fleischer
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ddm Braat
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ajm Oerlemans
- Medical Ethics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Aaem van der Velden
- Paediatric Endocrinology, Radboud University Medical Centre Amalia Children's Hospital, Nijmegen, the Netherlands
| | - R Peek
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
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13
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Cornelisse S, Vos MS, Groenewoud H, Mastenbroek S, Ramos L, Braat DDM, Stalmeier PFM, Fleischer K. Womens’ preferences concerning IVF treatment: a discrete choice experiment with particular focus on embryo transfer policy. Hum Reprod Open 2022; 2022:hoac030. [PMID: 35928049 PMCID: PMC9345060 DOI: 10.1093/hropen/hoac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/02/2022] [Indexed: 11/23/2022] Open
Abstract
STUDY QUESTION What outcomes are important for women to decide on the day of embryo transfer (ET) in IVF? SUMMARY ANSWER The highest cumulative live birth rate (cLBR) per treatment was the most important treatment outcome for women undergoing an IVF treatment, regardless of the number of transfers needed until pregnancy and impact on quality of life. WHAT IS KNOWN ALREADY Cleavage stage (Day 3) and blastocyst stage (Day 5) ETs are common transfer policies in IVF. The choice for one or the other day of ET differs between clinics. From the literature, it remains unclear whether the day of transfer impacts the cLBR. Patient preferences for the day of ET have not been examined yet. STUDY DESIGN, SIZE, AND DURATION A discrete choice experiment (DCE) was performed to investigate female patients’ preferences and their values concerning various aspects of an IVF treatment, with a particular focus on ET policy. A multicenter DCE was conducted between May 2020 and June 2020 in which participants were asked to choose between different treatments. Each treatment was presented using hypothetical scenarios containing the following attributes: the probability of a healthy live birth per IVF treatment cycle, the number of embryos available for transfer (for fresh and frozen-thawed ET), the number of ETs until pregnancy and the impact of the treatment on the quality of life. PARTICIPANTS/MATERIALS, SETTING, METHODS Women (n = 445) were asked to participate in the DCE at the start of an IVF treatment cycle in 10 Dutch fertility clinics. Participating women received an online questionnaire. The attributes’ relative importance was analyzed using logistic regression analyses. MAIN RESULTS AND THE ROLE OF CHANCE A total of 164 women participated. The most important attribute chosen was the cLBR. The total number of embryos suitable for transfer also influenced women’s treatment preferences. Neither the number of transfers needed until pregnancy, nor the impact on quality of life influenced the treatment preferences in the aggregated data. For women in the older age group (age ≥36 years) and the multipara subgroup, the impact on quality of life was more relevant. Naive patients (patients with no prior experience with IVF treatment) assigned less value to the number of ETs needed until pregnancy and assigned more value to the cLBR than the patients who had experienced IVF. LIMITATIONS REASONS FOR CAUTION An important limitation of a DCE study is that not all attributes can be included, which might be relevant for making choices. Patients might make other choices in real life as the DCE scenarios presented here are hypothetical and might not exactly represent their personal situation. We tried to avoid potential bias by selecting the attributes that mattered most to the patients obtained through patient focus groups. The final selection of attributes and the assigned levels were established using the input of an expert panel of professionals and by performing a pilot study to test the validity of our questionnaire. Furthermore, because we only included women in our study, we cannot draw any conclusions on preferences for partners. WIDER IMPLICATIONS OF THE FINDINGS The results of this study may help fertility patients, clinicians, researchers and policymakers to prioritize the most important attributes in the choice for the day of ET. The present study shows that cLBR per IVF treatment is the most important outcome for women. However, currently, there is insufficient information in the literature to conclude which day of transfer is more effective regarding the cLBR. Randomized controlled trials on the subject of Day 3 versus Day 5 ETs and cLBR are needed to allow evidence-based counseling. STUDY FUNDING/COMPETING INTEREST(S) This work received no specific funding and there are no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- S Cornelisse
- Radboud University Medical Centre Department of Obstetrics and Gynaecology, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - M S Vos
- Radboud University Medical Centre Department of Obstetrics and Gynaecology, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - H Groenewoud
- Radboud University Medical Center Department of Health Evidence, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - S Mastenbroek
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, , Meibergdreef 9, 1109 AZ Amsterdam, the Netherlands
| | - L Ramos
- Radboud University Medical Centre Department of Obstetrics and Gynaecology, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - D D M Braat
- Radboud University Medical Centre Department of Obstetrics and Gynaecology, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - P F M Stalmeier
- Radboud University Medical Center Department of Health Evidence, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - K Fleischer
- Radboud University Medical Centre Department of Obstetrics and Gynaecology, , Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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14
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Balkenende EME, Dahhan T, Beerendonk CCM, Fleischer K, Stoop D, Bos AME, Lambalk CB, Schats R, Smeenk JMJ, Louwé LA, Cantineau AEP, Bruin JPD, Linn SC, van der Veen F, van Wely M, Goddijn M. Fertility preservation for women with breast cancer: a multicentre randomized controlled trial on various ovarian stimulation protocols. Hum Reprod 2022; 37:1786-1794. [PMID: 35776109 PMCID: PMC9340107 DOI: 10.1093/humrep/deac145] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/01/2022] [Indexed: 12/24/2022] Open
Abstract
STUDY QUESTION Does ovarian stimulation with the addition of tamoxifen or letrozole affect the number of cumulus-oocyte complexes (COCs) retrieved compared to standard ovarian stimulation in women with breast cancer who undergo fertility preservation? SUMMARY ANSWER Alternative ovarian stimulation protocols with tamoxifen or letrozole did not affect the number of COCs retrieved at follicle aspiration in women with breast cancer. WHAT IS KNOWN ALREADY Alternative ovarian stimulation protocols have been introduced for women with breast cancer who opt for fertility preservation by means of banking of oocytes or embryos. How these ovarian stimulation protocols compare to standard ovarian stimulation in terms of COC yield is unknown. STUDY DESIGN, SIZE, DURATION This multicentre, open-label randomized controlled superiority trial was carried out in 10 hospitals in the Netherlands and 1 hospital in Belgium between January 2014 and December 2018. We randomly assigned women with breast cancer, aged 18–43 years, who opted for banking of oocytes or embryos to one of three study arms; ovarian stimulation plus tamoxifen, ovarian stimulation plus letrozole or standard ovarian stimulation. Standard ovarian stimulation included GnRH antagonist, recombinant FSH and GnRH agonist trigger. Randomization was performed with a web-based system in a 1:1:1 ratio, stratified for oral contraception usage at start of ovarian stimulation, positive estrogen receptor (ER) status and positive lymph nodes. Patients and caregivers were not blinded to the assigned treatment. The primary outcome was number of COCs retrieved at follicle aspiration. PARTICIPANTS/MATERIALS, SETTING, METHODS During the study period, 162 women were randomly assigned to one of three interventions. Fifty-four underwent ovarian stimulation plus tamoxifen, 53 ovarian stimulation plus letrozole and 55 standard ovarian stimulation. Analysis was according to intention-to-treat principle. MAIN RESULTS AND THE ROLE OF CHANCE No differences among groups were observed in the mean (±SD) number of COCs retrieved: 12.5 (10.4) after ovarian stimulation plus tamoxifen, 14.2 (9.4) after ovarian stimulation plus letrozole and 13.6 (11.6) after standard ovarian stimulation (mean difference −1.13, 95% CI −5.70 to 3.43 for tamoxifen versus standard ovarian stimulation and 0.58, 95% CI −4.03 to 5.20 for letrozole versus standard ovarian stimulation). After adjusting for oral contraception usage at the start of ovarian stimulation, positive ER status and positive lymph nodes, the mean difference was −1.11 (95% CI −5.58 to 3.35) after ovarian stimulation plus tamoxifen versus standard ovarian stimulation and 0.30 (95% CI −4.19 to 4.78) after ovarian stimulation plus letrozole versus standard ovarian stimulation. There were also no differences in the number of oocytes or embryos banked. There was one serious adverse event after standard ovarian stimulation: one woman was admitted to the hospital because of ovarian hyperstimulation syndrome. LIMITATIONS, REASONS FOR CAUTION The available literature on which we based our hypothesis, power analysis and sample size calculation was scarce and studies were of low quality. Our study did not have sufficient power to perform subgroup analysis on follicular, luteal or random start of ovarian stimulation. WIDER IMPLICATIONS OF THE FINDINGS Our study showed that adding tamoxifen or letrozole to a standard ovarian stimulation protocol in women with breast cancer does not impact the effectiveness of fertility preservation and paves the way for high-quality long-term follow-up on breast cancer treatment outcomes and women’s future pregnancy outcomes. Our study also highlights the need for high-quality studies for all women opting for fertility preservation, as alternative ovarian stimulation protocols have been introduced to clinical practice without proper evidence. STUDY FUNDING/COMPETING INTEREST(S) The study was supported by a grant (2011.WO23.C129) of ‘Stichting Pink Ribbon’, a breast cancer fundraising charity organization in the Netherlands. M.G., C.B.L. and R.S. declared that the Center for Reproductive Medicine, Amsterdam UMC (location VUMC) has received unconditional research and educational grants from Guerbet, Merck and Ferring, not related to the presented work. C.B.L. declared a speakers fee for Inmed and Yingming. S.C.L. reports grants and non-financial support from Agendia, grants, non-financial support and other from AstraZeneca, grants from Eurocept-pharmaceuticals, grants and non-financial support from Genentech/Roche and Novartis, grants from Pfizer, grants and non-financial support from Tesaro and Immunomedics, other from Cergentis, IBM, Bayer, and Daiichi-Sankyo, outside the submitted work; In addition, S.C.L. has a patent UN23A01/P-EP pending that is unrelated to the present work. J.M.J.S. reported payments and travel grants from Merck and Ferring. C.C.M.B. reports her role as unpaid president of the National guideline committee on Fertility Preservation in women with cancer. K.F. received unrestricted grants from Merck Serono, Good Life and Ferring not related to present work. K.F. declared paid lectures for Ferring. D.S. declared former employment from Merck Sharp & Dohme (MSD). K.F. declared paid lectures for Ferring. D.S. reports grants from MSD, Gedeon Richter and Ferring paid to his institution; consulting fee payments from MSD and Merck Serono paid to his institution; speaker honoraria from MSD, Gedeon Richter, Ferring Pharmaceuticals and Merck Serono paid to his institution. D.S. has also received travel and meeting support from MSD, Gedeon Richter, Ferring Pharmaceuticals and Merck Serono. No payments are related to present work. TRIAL REGISTRATION NUMBER NTR4108. TRIAL REGISTRATION DATE 6 August 2013. DATE OF FIRST PATIENT’S ENROLMENT 30 January 2014.
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Affiliation(s)
- Eva M E Balkenende
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Taghride Dahhan
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Catharina C M Beerendonk
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dominic Stoop
- Center for Reproductive Medicine, UZ Brussel, Free University of Brussels, Brussels, Belgium.,Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Annelies M E Bos
- Department of Reproductive Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cornelis B Lambalk
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Roel Schats
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jesper M J Smeenk
- Department of Obstetrics and Gynaecology, St Elisabeth Hospital, Tilburg, The Netherlands
| | - Leonie A Louwé
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Astrid E P Cantineau
- Center for Reproductive Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Fulco van der Veen
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Madelon van Wely
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mariëtte Goddijn
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Franik S, Fleischer K, Kortmann B, Stikkelbroeck NM, D'Hauwers K, Bouvattier C, Slowikowska-Hilczer J, Grunenwald S, van de Grift T, Cartault A, Richter-Unruh A, Reisch N, Thyen U, IntHout J, Claahsen-van der Grinten HL. The impact of Klinefelter syndrome on socioeconomic status: a multicenter study. Endocr Connect 2022; 11:EC-22-0010. [PMID: 35700267 PMCID: PMC9254318 DOI: 10.1530/ec-22-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022]
Abstract
Klinefelter syndrome (KS) is associated with an increased risk of neuropsychological morbidity, such as learning disabilities, which may have a significant impact on socioeconomic status (SES). The objective of this study was to investigate the SES in men with KS and to associate this outcome with social participation, age at diagnosis, testosterone therapy and physical and mental health status. Men with KS were recruited in 14 clinical study centers in six European countries which participated in the European dsd-LIFE study. Two hundred five men with KS were eligible for inclusion. Male normative data from the European Social Surveys (ESS) were used for comparison. Data related to education, occupation, satisfaction with income and householding were collected. Compared to the ESS reference population, fewer men with KS achieved a high level of education (13% vs 25%, P < 0.001). There was a significant difference in having a paid job (55% vs 66%, P < 0.001), and the percentage of absence by sickness or disability was higher among men with KS (10% vs 3%, P < 0.001). Furthermore, satisfaction with current household's income was lower (32% vs 42%, P < 0.01). Lower scores for subjective general health were associated with lower scores for these outcomes. Men with KS achieve on average lower levels of education, occupation and report less satisfaction with income compared to the ESS reference population. The presence of health problems and lower scores of subjective general health was related to lower levels of occupation and lower satisfaction with income in men with KS.
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Affiliation(s)
- Sebastian Franik
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Barbara Kortmann
- Department of Pediatric Urology, Radboudumc, Nijmegen, The Netherlands
| | | | | | - Claire Bouvattier
- Department of Pediatric Endocrinology, Bicêtre Hospital, Paris Sud University, Paris, France
| | | | - Solange Grunenwald
- Department of Endocrinology and Metabolic Disease, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Tim van de Grift
- Departments of Plastic Surgery and Medical Psychology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Audrey Cartault
- Department of Pediatrics, Hospital des Enfants, Toulouse, France
| | - Annette Richter-Unruh
- Kinderendokrinologie und Diabetologie, Universitätsklinikum Ruhr-Universität Bochum, Kinderklinik, Bochum, Germany
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Department of Endocrinology, University Hospital Munich, Munich, Germany
| | - Ute Thyen
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck, Lubeck, Germany
| | - Joanna IntHout
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
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Van der Coelen S, Nadesapillai S, Peek R, Schleedoorn M, Braat D, Fleischer K, Van der Velden J. P-453 No major changes in ovarian function after unilateral ovariectomy in the context of ovarian tissue cryopreservation in girls with Turner syndrome. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Study question
What is the impact of unilateral ovariectomy on the ovarian function in girls with Turner syndrome (TS) undergoing ovarian tissue cryopreservation (OTC)?
Summary answer
In most girls with TS, ovarian markers remained stable up to three years after unilateral ovariectomy.
What is known already
Girls with TS have a complete or partial loss of one of the sex-chromosomes causing premature ovarian insufficiency which reduces the chances of a spontaneous pregnancy. OTC may be an option to preserve fertility at an early age to increase the chance on genetic offspring. However, this requires a unilateral ovariectomy for young girls with TS who are already subjected to an accelerated loss of ovarian reserve. Previous research in women without TS undergoing a unilateral ovariectomy has shown that the remaining ovary compensate for the function of the removed ovary with no effect on pubertal development and fertility outcome.
Study design, size, duration
This is a descriptive study of 28 girls with TS (age 5-19 years). Girls were monitored for up to three years after unilateral ovariectomy on pubertal development, and level of follicle stimulating hormone (FSH), luteinizing hormone (LH), oestrogen, Anti-Mullerian hormone (AMH) and inhibin B.
Participants/materials, setting, methods
The cohort was recruited from girls with TS undergoing OTC as part of the ongoing TurnerFertility study at a university medical centre. Follicles were found in the ovarian cortex fragments in 28 of the 86 cases. These cases were considered to have functional ovaries and were included in the study.
Main results and the role of chance
Follow-up data are not yet available for three girls because they had surgery only three months ago. Of the other 25 girls, two girls had a monosomic karyotype (45,X), fourteen were mosaic (45,X/46,XX), four had a mosaic with triple X-chromosome (45,X/47,XXX) and five girls had structural aberrations of the X chromosome. Ten girls were prepubertal at time of unilateral ovariectomy, twelve girls had a spontaneous thelarche and three girl had induced puberty. After unilateral ovariectomy, one of the 10 prepubertal girls entered puberty spontaneously and one of the prepubertal girls needed puberty induction. It is still unknown what the impact of a unilateral ovariectomy will be on the pubertal development of the other girls, due to their young age but AMH levels remained stable. 8/12 girls with spontaneous thelarche maintained a measurable AMH and FSH <20 IE/L during the median follow-up of 20 months (IQR 13-30). 4/12 girls with spontaneous thelarche before OTC needed hormone supplementation because of signs of premature ovarian insufficiency, e.g. irregular menstruations (n = 2), flushes (n = 1) and high FSH (84 IE/L; n = 1). However, these girls had unfavourable hormonal parameters before unilateral ovariectomy (e.g. AMH < 0.5 ug/L or FSH > 20 IE/L).
Limitations, reasons for caution
These results should be interpreted with caution because of the highly heterogeneous population of girls with TS. Moreover, the results should ideally be compared with age- and karyotype-matched controls to determine the natural course of ovarian function of girls with TS.
Wider implications of the findings
This cohort will be monitored for a longer period of time to observe the consequences on pubertal development, need for hormone supplementation, and eventually fertility outcome. If OTC becomes part of routine care for girls with TS, our results will be of great value in the counselling for future parenthood.
Trial registration number
NCT03381300
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Affiliation(s)
- S Van der Coelen
- Radboud University Medical Centre, Gynaecology and obstetrics , Nijmegen, The Netherlands
| | - S Nadesapillai
- Radboud University Medical Centre, Gynaecology and obstetrics , Nijmegen, The Netherlands
| | - R Peek
- Radboud University Medical Centre, Gynaecology and obstetrics , Nijmegen, The Netherlands
| | - M Schleedoorn
- Radboud University Medical Centre, Gynaecology and obstetrics , Nijmegen, The Netherlands
| | - D Braat
- Radboud University Medical Centre, Gynaecology and obstetrics , Nijmegen, The Netherlands
| | - K Fleischer
- Radboud University Medical Centre, Gynaecology and obstetrics , Nijmegen, The Netherlands
| | - J Van der Velden
- Radboud University Medical Centre , Paediatrics, Nijmegen, The Netherlands
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Nadesapillai S, Peek R, Nguyen T, Vassart S, Smeets D, Van de Zande G, Braat D, Van der Velden J, Fleischer K, Dolmans MM. O-034 Xenotransplantation of ovarian cortex tissue from young girls with Turner Syndrome in a mice model: is normal follicular development possible? Hum Reprod 2022. [DOI: 10.1093/humrep/deac104.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
Does aneuploidy of granulosa and stromal cells affect folliculogenesis of small follicles in girls with mosaic Turner Syndrome (TS)?
Summary answer
Our results showed that despite high level aneuploidy in granulosa cells of small follicles and stromal cells folliculogenesis was not affected in mosaic TS patients.
What is known already
In 2018 the TurnerFertility study was initiated to explore if ovarian tissue cryopreservation (OTC) is a viable option for TS patients to preserve their fertility at an early age. In this study, karyotyping of ovarian cells in 7 mosaic TS patients showed that the majority of oocytes had a normal X chromosomal content, while granulosa and stromal cells were aneuploid. Until now, it remains unclear if follicular development is affected, and consequently the success rate of autotransplantation after OTC in girls with TS.
Study design, size, duration
A collaboration project was initiated between Radboudumc, The Netherlands and UCLouvain, Belgium to assess folliculogenesis of small follicles in TS patients by using a xenograft mice model. Ovarian cortex tissue was obtained from 18 mosaic TS patients and 13 age-matched controls.
Participants/materials, setting, methods
After unilateral ovariectomy, one fragment of the ovarian tissue was used for research. One part of this fragment was used for fluorescence in situ hybridization (FISH) to determine the X chromosomal content of ovarian cells in non-grafted tissue. The other part was xenografted into severe combined immunodeficient mice. After 5 months, grafts were retrieved and analysed for aneuploidy by FISH. The expression of 6 proteins essential for folliculogenesis was analysed by immunohistochemistry and immunofluorescence.
Main results and the role of chance
The mean follicle density in ovarian tissue of TS patients before grafting was significantly lower compared to controls. FISH analysis showed that 97% of the oocytes in non-grafted tissue had a normal X chromosomal content. Follicles of TS patients contained mainly or exclusively 45,X granulosa cells, but different levels of X chromosome mosaicism between TS patients and between follicles of the same patient were observed.
In total, 12/18 grafts contained follicles after 5 months xenografting. Follicle density of both TS patients and controls decreased significantly after xenotransplantation. Despite the presence of high level aneuploidy in granulosa and stromal cells in the tissue before grafting, secondary and even antral follicles were observed after xenotransplantation. Remarkably, a shift from high to low percentage of 45,X granulosa cells was observed during folliculogenesis. Immunohistochemistry showed that proliferating cell nuclear antigen (PCNA) positive follicles from TS patients increased during grafting to almost 100%. Secretion of anti-Müllerian hormone by granulosa cells was impaired before grafting in peri/postpubertal TS girls, but recovered after grafting. Expression of c-kit receptor and bone morphogenetic protein 15 (BMP15) in peri/postpubertal TS patients remained abnormal after xenotransplantation, while secretion of growth differentiation factor 9 (GDF9) and kit ligand was similar to controls.
Limitations, reasons for caution
In this study, only ovarian tissue of mosaic TS patients was examined, because the chances of finding ovarian follicles in this subgroup is considerably higher than in other TS patients. Subtle effects of reduced expression of c-kit receptor and BMP15 on folliculogenesis might have gone unnoticed.
Wider implications of the findings
Small follicles of mosaic TS patients are able to grow to secondary and antral follicles, despite the presence of aneuploid granulosa and stromal cells before grafting. Therefore, OTC could be a realistic option for young mosaic TS patients to preserve their fertility provided that sufficient numbers of follicles are present.
Trial registration number
NCT03381300
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Affiliation(s)
- S Nadesapillai
- Radboud University Medical Center, Obstetrics and Gynaecology , Nijmegen, The Netherlands
| | - R Peek
- Radboud University Medical Center, Obstetrics and Gynaecology , Nijmegen, The Netherlands
| | - T Nguyen
- Université Catholique de Louvain, Gynecology Research Unit- Institut de Recherche Expérimentale et Clinique, Brussels , Belgium
| | - S Vassart
- Université Catholique de Louvain, Gynecology Research Unit- Institut de Recherche Expérimentale et Clinique, Brussels , Belgium
| | - D Smeets
- Radboud University Medical Center, Human Genetics , Nijmegen, The Netherlands
| | - G Van de Zande
- Radboud University Medical Center, Human Genetics , Nijmegen, The Netherlands
| | - D Braat
- Radboud University Medical Center, Obstetrics and Gynaecology , Nijmegen, The Netherlands
| | - J Van der Velden
- Radboud University Medical Center, Amalia Children's Hospital , Nijmegen, The Netherlands
| | - K Fleischer
- Radboud University Medical Center, Obstetrics and Gynaecology , Nijmegen, The Netherlands
| | - M M Dolmans
- Université Catholique de Louvain, Gynecology Research Unit- Institut de Recherche Expérimentale et Clinique, Brussels , Belgium
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Fleischer K, Nadesapillai S, Van der Velden J, Schleedoorn M, Van der Coelen S, Braat D, Peek R. P-485 The TurnerFertility study: data on fertility preservation (FP) by ovarian tissue cryopreservation (OTC) in young girls with Turner syndrome (TS). Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
Which girls with TS could benefit from FP by OTC, based on the presence of follicles in relation to karyotype, clinical and hormonal data?
Summary answer
Girls with TS who have favourable predictive parameters (e.g 46,XX cell line, a measurable AMH or spontaneous puberty) could benefit from FP by OTC.
What is known already
Infertility due to premature ovarian insufficiency is a major concern for girls with TS and their parents. Physicians are often asked about possible options to preserve their fertility. However, evidence for successful FP by OTC in these girls is lacking. Without evidence on the effectiveness of OTC in TS girls, it should only be offered in a research setting.
Study design, size, duration
A national prospective exploratory intervention study. Ovarian cortex will be obtained after unilateral ovariectomy from 106 girls with TS aged 2-18 years. Patients will be included between 2017 and 2022.
Participants/materials, setting, methods
All girls with TS who have completed the diagnostic work up of TS were included. After unilateral ovariectomy, one fragment of the ovarian cortex was used to determine the number of follicles by serial sectioning and staining. Karyotyping of ovarian cells, lymphocytes, buccal cells and urine cells was performed by Fluorescence in situ hybridization (FISH). Blood samples obtained before oophorectomy and during the yearly clinical visit after oophorectomy will provide information on hormonal parameters.
Main results and the role of chance
Currently, we have received 106 informed consent forms and 86 TS patients (age 3-19) had a unilateral ovariectomy. Oocytes were found in 32,6% (n = 28; age 5-19) of which 11 were prepubertal, 16 had a spontaneous puberty, 22 had numerical chromosome X aberrations, of whom one 45,X monosomy and 6 had structural chromosome X aberrations. In 6 patients with structural aberrations we found a low follicle density. In 24/28 patients AMH was measurable (0.1 - 4.79µg/L) and 25/28 patients had a FSH below 15 E/L.
FISH was used to karyotype the ovarian cortex cells of 12 patients with a numerical aberration and revealed that 112 of the 119 oocytes (94,1%) had a normal X-chromosomal content. Granulosa cells were largely 45,X, but showed different levels of X chromosome mosaicism, not only between patients but also between individual follicles of the same patient. Despite the level of aneuploidy (0–80%) of ovarian stromal cells, no obvious morphological/histological abnormalities were observed in the ovarian cortex tissue.
Hormone values and the chromosome pattern were found to be predictive parameters for the presence of follicles. The chance of finding follicles in girls with a 46,XX cell line was three times higher than in girls without a 46,XX cell line.
Limitations, reasons for caution
The final analysis will be performed when the dataset of 106 TS girls is completed. Further research is necessary to determine the effects of ovarian mosaicism on folliculogenesis, i.e. are follicles capable to grow to antral stages, and to elucidate if OTC is an effective method for FP in TS.
Wider implications of the findings
A combination of clinical, hormonal and karyotypic data could provide predictive parameters to define which girls with TS might benefit from fertility preservation. These parameters could help physicians during FP counselling to determine if OTC is an option for a certain girl with TS.
Trial registration number
NCT03381300
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Affiliation(s)
- K Fleischer
- Radboud University Medical Center, Department of Obstetrics and Gynaecology , Nijmegen, The Netherlands
| | - S Nadesapillai
- Radboudumc, Obstetrics & Gynaecology , Nijmegen, The Netherlands
| | - J Van der Velden
- Radboudumc, Obstetrics & Gynaecology , Nijmegen, The Netherlands
| | - M Schleedoorn
- Radboudumc, Obstetrics & Gynaecology , Nijmegen, The Netherlands
| | - S Van der Coelen
- Radboudumc, Obstetrics & Gynaecology , Nijmegen, The Netherlands
| | - D Braat
- Radboudumc, Obstetrics & Gynaecology , Nijmegen, The Netherlands
| | - R Peek
- Radboudumc, Obstetrics & Gynaecology , Nijmegen, The Netherlands
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Smits RM, Xavier MJ, Oud MS, Astuti GDN, Meijerink AM, de Vries PF, Holt GS, Alobaidi BKS, Batty LE, Khazeeva G, Sablauskas K, Vissers LELM, Gilissen C, Fleischer K, Braat DDM, Ramos L, Veltman JA. De novo mutations in children born after medical assisted reproduction. Hum Reprod 2022; 37:1360-1369. [PMID: 35413117 PMCID: PMC9156847 DOI: 10.1093/humrep/deac068] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/08/2022] [Indexed: 01/23/2023] Open
Abstract
STUDY QUESTION Are there more de novo mutations (DNMs) present in the genomes of children born through medical assisted reproduction (MAR) compared to spontaneously conceived children? SUMMARY ANSWER In this pilot study, no statistically significant difference was observed in the number of DNMs observed in the genomes of MAR children versus spontaneously conceived children. WHAT IS KNOWN ALREADY DNMs are known to play a major role in sporadic disorders with reduced fitness such as severe developmental disorders, including intellectual disability and epilepsy. Advanced paternal age is known to place offspring at increased disease risk, amongst others by increasing the number of DNMs in their genome. There are very few studies reporting on the effect of MAR on the number of DNMs in the offspring, especially when male infertility is known to be affecting the potential fathers. With delayed parenthood an ongoing epidemiological trend in the 21st century, there are more children born from fathers of advanced age and more children born through MAR every day. STUDY DESIGN, SIZE, DURATION This observational pilot study was conducted from January 2015 to March 2019 in the tertiary care centre at Radboud University Medical Center. We included a total of 53 children and their respective parents, forming 49 trios (mother, father and child) and two quartets (mother, father and two siblings). One group of children was born after spontaneous conception (n = 18); a second group of children born after IVF (n = 17) and a third group of children born after ICSI combined with testicular sperm extraction (ICSI-TESE) (n = 18). In this pilot study, we also subdivided each group by paternal age, resulting in a subgroup of children born to younger fathers (<35 years of age at conception) and older fathers (>45 years of age at conception). PARTICIPANTS/MATERIALS, SETTING, METHODS Whole-genome sequencing (WGS) was performed on all parent-offspring trios to identify DNMs. For 34 of 53 trios/quartets, WGS was performed twice to independently detect and validate the presence of DNMs. Quality of WGS-based DNM calling was independently assessed by targeted Sanger sequencing. MAIN RESULTS AND THE ROLE OF CHANCE No significant differences were observed in the number of DNMs per child for the different methods of conception, independent of parental age at conception (multi-factorial ANOVA, f(2) = 0.17, P-value = 0.85). As expected, a clear paternal age effect was observed after adjusting for method of conception and maternal age at conception (multiple regression model, t = 5.636, P-value = 8.97 × 10-7), with on average 71 DNMs in the genomes of children born to young fathers (<35 years of age) and an average of 94 DNMs in the genomes of children born to older fathers (>45 years of age). LIMITATIONS, REASONS FOR CAUTION This is a pilot study and other small-scale studies have recently reported contrasting results. Larger unbiased studies are required to confirm or falsify these results. WIDER IMPLICATIONS OF THE FINDINGS This pilot study did not show an effect for the method of conception on the number of DNMs per genome in offspring. Given the role that DNMs play in disease risk, this negative result is good news for IVF and ICSI-TESE born children, if replicated in a larger cohort. STUDY FUNDING/COMPETING INTEREST(S) This research was funded by the Netherlands Organisation for Scientific Research (918-15-667) and by an Investigator Award in Science from the Wellcome Trust (209451). The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- R M Smits
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, the Netherlands
| | - M J Xavier
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - M S Oud
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, the Netherlands
| | - G D N Astuti
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, the Netherlands
| | - A M Meijerink
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, the Netherlands
| | - P F de Vries
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, the Netherlands
| | - G S Holt
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - B K S Alobaidi
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - L E Batty
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - G Khazeeva
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - K Sablauskas
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - L E L M Vissers
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, the Netherlands
| | - C Gilissen
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - K Fleischer
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, the Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, the Netherlands
| | - L Ramos
- Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, the Netherlands
| | - J A Veltman
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Abstract
BACKGROUND The inability to have children affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to half of the infertility cases with between 25% to 87% of male subfertility considered to be due to the effect of oxidative stress. Oral supplementation with antioxidants is thought to improve sperm quality by reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments, however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain. We compared the benefits and risks of different antioxidants used for male subfertility. OBJECTIVES To evaluate the effectiveness and safety of supplementary oral antioxidants in subfertile men. SEARCH METHODS The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, and two trial registers were searched on 15 February 2021, together with reference checking and contact with experts in the field to identify additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment, or treatment with another antioxidant, among subfertile men of a couple attending a reproductive clinic. We excluded studies comparing antioxidants with fertility drugs alone and studies that included men with idiopathic infertility and normal semen parameters or fertile men attending a fertility clinic because of female partner infertility. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary review outcome was live birth. Clinical pregnancy, adverse events and sperm parameters were secondary outcomes. MAIN RESULTS We included 90 studies with a total population of 10,303 subfertile men, aged between 18 and 65 years, part of a couple who had been referred to a fertility clinic and some of whom were undergoing medically assisted reproduction (MAR). Investigators compared and combined 20 different oral antioxidants. The evidence was of 'low' to 'very low' certainty: the main limitation was that out of the 67 included studies in the meta-analysis only 20 studies reported clinical pregnancy, and of those 12 reported on live birth. The evidence is current up to February 2021. Live birth: antioxidants may lead to increased live birth rates (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.07 to 1.91, P = 0.02, 12 RCTs, 1283 men, I2 = 44%, very low-certainty evidence). Results in the studies contributing to the analysis of live birth rate suggest that if the baseline chance of live birth following placebo or no treatment is assumed to be 16%, the chance following the use of antioxidants is estimated to be between 17% and 27%. However, this result was based on only 246 live births from 1283 couples in 12 small or medium-sized studies. When studies at high risk of bias were removed from the analysis, there was no evidence of increased live birth (Peto OR 1.22, 95% CI 0.85 to 1.75, 827 men, 8 RCTs, P = 0.27, I2 = 32%). Clinical pregnancy rate: antioxidants may lead to increased clinical pregnancy rates (OR 1.89, 95% CI 1.45 to 2.47, P < 0.00001, 20 RCTs, 1706 men, I2 = 3%, low-certainty evidence) compared with placebo or no treatment. This suggests that, in the studies contributing to the analysis of clinical pregnancy, if the baseline chance of clinical pregnancy following placebo or no treatment is assumed to be 15%, the chance following the use of antioxidants is estimated to be between 20% and 30%. This result was based on 327 clinical pregnancies from 1706 couples in 20 small studies. Adverse events Miscarriage: only six studies reported on this outcome and the event rate was very low. No evidence of a difference in miscarriage rate was found between the antioxidant and placebo or no treatment group (OR 1.46, 95% CI 0.75 to 2.83, P = 0.27, 6 RCTs, 664 men, I2 = 35%, very low-certainty evidence). The findings suggest that in a population of subfertile couples, with male factor infertility, with an expected miscarriage rate of 5%, the risk of miscarriage following the use of an antioxidant would be between 4% and 13%. Gastrointestinal: antioxidants may lead to an increase in mild gastrointestinal discomfort when compared with placebo or no treatment (OR 2.70, 95% CI 1.46 to 4.99, P = 0.002, 16 RCTs, 1355 men, I2 = 40%, low-certainty evidence). This suggests that if the chance of gastrointestinal discomfort following placebo or no treatment is assumed to be 2%, the chance following the use of antioxidants is estimated to be between 2% and 7%. However, this result was based on a low event rate of 46 out of 1355 men in 16 small or medium-sized studies, and the certainty of the evidence was rated low and heterogeneity was high. We were unable to draw conclusions from the antioxidant versus antioxidant comparison as insufficient studies compared the same interventions. AUTHORS' CONCLUSIONS In this review, there is very low-certainty evidence from 12 small or medium-sized randomised controlled trials suggesting that antioxidant supplementation in subfertile males may improve live birth rates for couples attending fertility clinics. Low-certainty evidence suggests that clinical pregnancy rates may increase. There is no evidence of increased risk of miscarriage, however antioxidants may give more mild gastrointestinal discomfort, based on very low-certainty evidence. Subfertile couples should be advised that overall, the current evidence is inconclusive based on serious risk of bias due to poor reporting of methods of randomisation, failure to report on the clinical outcomes live birth rate and clinical pregnancy, often unclear or even high attrition, and also imprecision due to often low event rates and small overall sample sizes. Further large well-designed randomised placebo-controlled trials studying infertile men and reporting on pregnancy and live births are still required to clarify the exact role of antioxidants.
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Affiliation(s)
- Wiep de Ligny
- Department of Gynaecology and Obstetrics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Roos M Smits
- Department of Gynaecology and Obstetrics, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Kathrin Fleischer
- Department of Gynaecology and Obstetrics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Marian G Showell
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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van Hoogenhuijze NE, van Eekelen R, Mol F, Schipper I, Groenewoud ER, Traas MAF, Janssen CAH, Teklenburg G, de Bruin JP, van Oppenraaij RHF, Maas JWM, Moll E, Fleischer K, van Hooff MHA, de Koning CH, Cantineau AEP, Lambalk CB, Verberg M, van Heusden AM, Manger AP, van Rumste MME, van der Voet LF, Pieterse QD, Visser J, Brinkhuis EA, den Hartog JE, Glas MW, Klijn NF, van der Zanden M, Bandell ML, Boxmeer JC, van Disseldorp J, Smeenk J, van Wely M, Eijkemans MJC, Torrance HL, Broekmans FJM. Economic evaluation of endometrial scratching before the second IVF/ICSI treatment: a cost-effectiveness analysis of a randomized controlled trial (SCRaTCH trial). Hum Reprod 2022; 37:254-263. [PMID: 34864993 PMCID: PMC8804332 DOI: 10.1093/humrep/deab261] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 10/12/2021] [Indexed: 11/22/2022] Open
Abstract
STUDY QUESTION Is a single endometrial scratch prior to the second fresh IVF/ICSI treatment cost-effective compared to no scratch, when evaluated over a 12-month follow-up period? SUMMARY ANSWER The incremental cost-effectiveness ratio (ICER) for an endometrial scratch was €6524 per additional live birth, but due to uncertainty regarding the increase in live birth rate this has to be interpreted with caution. WHAT IS KNOWN ALREADY Endometrial scratching is thought to improve the chances of success in couples with previously failed embryo implantation in IVF/ICSI treatment. It has been widely implemented in daily practice, despite the lack of conclusive evidence of its effectiveness and without investigating whether scratching allows for a cost-effective method to reduce the number of IVF/ICSI cycles needed to achieve a live birth. STUDY DESIGN, SIZE, DURATION This economic evaluation is based on a multicentre randomized controlled trial carried out in the Netherlands (SCRaTCH trial) that compared a single scratch prior to the second IVF/ICSI treatment with no scratch in couples with a failed full first IVF/ICSI cycle. Follow-up was 12 months after randomization.Economic evaluation was performed from a healthcare and societal perspective by taking both direct medical costs and lost productivity costs into account. It was performed for the primary outcome of biochemical pregnancy leading to live birth after 12 months of follow-up as well as the secondary outcome of live birth after the second fresh IVF/ICSI treatment (i.e. the first after randomization). To allow for worldwide interpretation of the data, cost level scenario analysis and sensitivity analysis was performed. PARTICIPANTS/MATERIALS, SETTING, METHODS From January 2016 until July 2018, 933 women with a failed first IVF/ICSI cycle were included in the trial. Data on treatment and pregnancy were recorded up until 12 months after randomization, and the resulting live birth outcomes (even if after 12 months) were also recorded.Total costs were calculated for the second fresh IVF/ICSI treatment and for the full 12 month period for each participant. We included costs of all treatments, medication, complications and lost productivity costs. Cost-effectiveness analysis was carried out by calculating ICERs for scratch compared to control. Bootstrap resampling was used to estimate the uncertainty around cost and effect differences and ICERs. In the sensitivity and scenario analyses, various unit costs for a single scratch were introduced, amongst them, unit costs as they apply for the United Kingdom (UK). MAIN RESULTS AND THE ROLE OF CHANCE More live births occurred in the scratch group, but this also came with increased costs over a 12-month period. The estimated chance of a live birth after 12 months of follow-up was 44.1% in the scratch group compared to 39.3% in the control group (risk difference 4.8%, 95% CI -1.6% to +11.2%). The mean costs were on average €283 (95% CI: -€299 to €810) higher in the scratch group so that the point average ICER was €5846 per additional live birth. The ICER estimate was surrounded with a high level of uncertainty, as indicated by the fact that the cost-effectiveness acceptability curve (CEAC) showed that there is an 80% chance that endometrial scratching is cost-effective if society is willing to pay ∼€17 500 for each additional live birth. LIMITATIONS, REASONS FOR CAUTION There was a high uncertainty surrounding the effects, mainly in the clinical effect, i.e. the difference in the chance of live birth, which meant that a single straightforward conclusion could not be ascertained as for now. WIDER IMPLICATIONS OF THE FINDINGS This is the first formal cost-effectiveness analysis of endometrial scratching in women undergoing IVF/ICSI treatment. The results presented in this manuscript cannot provide a clear-cut expenditure for one additional birth, but they do allow for estimating costs per additional live birth in different scenarios once the clinical effectiveness of scratching is known. As the SCRaTCH trial was the only trial with a follow-up of 12 months, it allows for the most complete estimation of costs to date. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by ZonMW, the Dutch organization for funding healthcare research. A.E.P.C., F.J.M.B., E.R.G. and C.B. L. reported having received fees or grants during, but outside of, this trial. TRIAL REGISTRATION NUMBER Netherlands Trial Register (NL5193/NTR 5342).
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Affiliation(s)
- N E van Hoogenhuijze
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R van Eekelen
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology—NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - F Mol
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Reproduction and Development, Amsterdam, The Netherlands
| | - I Schipper
- Division of Reproductive Endocrinology and Infertility, Department Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Noordwest Ziekenhuisgroep, Den Helder, The Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - C A H Janssen
- Department of Gynaecology, Groene Hart Hospital, Gouda, The Netherlands
| | - G Teklenburg
- Isala Fertility Clinic, Isala Hospital, Zwolle, The Netherlands
| | - J P de Bruin
- Department of Gynaecology and Obstetrics, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | - J W M Maas
- Department of Gynaecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - E Moll
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - K Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M H A van Hooff
- Department of Gynaecology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - C H de Koning
- Department of Gynaecology, Tergooi Hospital, Hilversum, The Netherlands
| | - A E P Cantineau
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M Verberg
- Fertility Clinic, Fertility Clinic Twente, Hengelo, The Netherlands
| | - A M van Heusden
- Fertility Clinic, Medisch Centrum Kinderwens, Leiderdorp, The Netherlands
| | - A P Manger
- Department of Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - L F van der Voet
- Department of Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - Q D Pieterse
- Fertility Center, Haga Hospital, The Hague, The Netherlands
| | - J Visser
- Department of Gynaecology and Obstetrics, Amphia Hospital, Breda, The Netherlands
| | - E A Brinkhuis
- Department of Gynaecology and Obstetrics, Meander Hospital, Amersfoort, The Netherlands
| | - J E den Hartog
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, The Netherlands
| | - M W Glas
- Fertility Clinic, Wilhelmina Hospital Assen, Assen, The Netherlands
| | - N F Klijn
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M van der Zanden
- Department of Gynaecology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - M L Bandell
- Department of Gynaecology, Albert Schweitzer Hospital, Sliedrecht, The Netherlands
| | - J C Boxmeer
- Department of Gynaecology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - J van Disseldorp
- Department of Gynaecology and Obstetrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Smeenk
- Department of Reproductive Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - M van Wely
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology—NVOG Consortium 2.0, Amsterdam, The Netherlands
| | - M J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H L Torrance
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - F J M Broekmans
- Department of Gynaecology and Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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22
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Oud MS, Smits RM, Smith HE, Mastrorosa FK, Holt GS, Houston BJ, de Vries PF, Alobaidi BKS, Batty LE, Ismail H, Greenwood J, Sheth H, Mikulasova A, Astuti GDN, Gilissen C, McEleny K, Turner H, Coxhead J, Cockell S, Braat DDM, Fleischer K, D’Hauwers KWM, Schaafsma E, Nagirnaja L, Conrad DF, Friedrich C, Kliesch S, Aston KI, Riera-Escamilla A, Krausz C, Gonzaga-Jauregui C, Santibanez-Koref M, Elliott DJ, Vissers LELM, Tüttelmann F, O’Bryan MK, Ramos L, Xavier MJ, van der Heijden GW, Veltman JA. A de novo paradigm for male infertility. Nat Commun 2022; 13:154. [PMID: 35013161 PMCID: PMC8748898 DOI: 10.1038/s41467-021-27132-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
De novo mutations are known to play a prominent role in sporadic disorders with reduced fitness. We hypothesize that de novo mutations play an important role in severe male infertility and explain a portion of the genetic causes of this understudied disorder. To test this hypothesis, we utilize trio-based exome sequencing in a cohort of 185 infertile males and their unaffected parents. Following a systematic analysis, 29 of 145 rare (MAF < 0.1%) protein-altering de novo mutations are classified as possibly causative of the male infertility phenotype. We observed a significant enrichment of loss-of-function de novo mutations in loss-of-function-intolerant genes (p-value = 1.00 × 10-5) in infertile men compared to controls. Additionally, we detected a significant increase in predicted pathogenic de novo missense mutations affecting missense-intolerant genes (p-value = 5.01 × 10-4) in contrast to predicted benign de novo mutations. One gene we identify, RBM5, is an essential regulator of male germ cell pre-mRNA splicing and has been previously implicated in male infertility in mice. In a follow-up study, 6 rare pathogenic missense mutations affecting this gene are observed in a cohort of 2,506 infertile patients, whilst we find no such mutations in a cohort of 5,784 fertile men (p-value = 0.03). Our results provide evidence for the role of de novo mutations in severe male infertility and point to new candidate genes affecting fertility.
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Affiliation(s)
- M. S. Oud
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands
| | - R. M. Smits
- grid.10417.330000 0004 0444 9382Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - H. E. Smith
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - F. K. Mastrorosa
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - G. S. Holt
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - B. J. Houston
- grid.1008.90000 0001 2179 088XSchool of BioSciences, Faculty of Science, The University of Melbourne, Parkville, VIC Australia
| | - P. F. de Vries
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands
| | - B. K. S. Alobaidi
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - L. E. Batty
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - H. Ismail
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J. Greenwood
- grid.420004.20000 0004 0444 2244Department of Genetic Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - H. Sheth
- Foundation for Research in Genetics and Endocrinology, Institute of Human Genetics, Ahmedabad, India
| | - A. Mikulasova
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - G. D. N. Astuti
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands ,grid.412032.60000 0001 0744 0787Division of Human Genetics, Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - C. Gilissen
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - K. McEleny
- grid.420004.20000 0004 0444 2244Newcastle Fertility Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - H. Turner
- grid.420004.20000 0004 0444 2244Department of Cellular Pathology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - J. Coxhead
- grid.1006.70000 0001 0462 7212Genomics Core Facility, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - S. Cockell
- Bioinformatics Support Unit, Faculty of Medical Sciences New, castle University, Newcastle upon Tyne, UK
| | - D. D. M. Braat
- grid.10417.330000 0004 0444 9382Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - K. Fleischer
- grid.10417.330000 0004 0444 9382Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - K. W. M. D’Hauwers
- grid.10417.330000 0004 0444 9382Department of Urology, Radboudumc, Nijmegen, The Netherlands
| | - E. Schaafsma
- grid.10417.330000 0004 0444 9382Department of Pathology, Radboudumc, Nijmegen, The Netherlands
| | | | - L. Nagirnaja
- grid.5288.70000 0000 9758 5690Division of Genetics, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR USA
| | - D. F. Conrad
- grid.5288.70000 0000 9758 5690Division of Genetics, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR USA
| | - C. Friedrich
- grid.5949.10000 0001 2172 9288Institute of Reproductive Genetics, University of Münster, Münster, Germany
| | - S. Kliesch
- grid.16149.3b0000 0004 0551 4246Centre of Reproductive Medicine and Andrology, Department of Clinical and Surgical Andrology, University Hospital Münster, Münster, Germany
| | - K. I. Aston
- grid.223827.e0000 0001 2193 0096Department of Surgery, Division of Urology, University of Utah School of Medicine, Salt Lake City, UT USA
| | - A. Riera-Escamilla
- grid.418813.70000 0004 1767 1951Andrology Department, Fundació Puigvert, Universitat Autònoma de Barcelona, Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Barcelona, Catalonia Spain
| | - C. Krausz
- grid.8404.80000 0004 1757 2304Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - C. Gonzaga-Jauregui
- grid.418961.30000 0004 0472 2713Regeneron Genetics Center, Tarrytown, NY USA
| | - M. Santibanez-Koref
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - D. J. Elliott
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - L. E. L. M. Vissers
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands
| | - F. Tüttelmann
- grid.5949.10000 0001 2172 9288Institute of Reproductive Genetics, University of Münster, Münster, Germany
| | - M. K. O’Bryan
- grid.1008.90000 0001 2179 088XSchool of BioSciences, Faculty of Science, The University of Melbourne, Parkville, VIC Australia
| | - L. Ramos
- grid.10417.330000 0004 0444 9382Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - M. J. Xavier
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - G. W. van der Heijden
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands ,grid.10417.330000 0004 0444 9382Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - J. A. Veltman
- grid.1006.70000 0001 0462 7212Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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23
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Coelen SVD, Schleedoorn M, Nadesapillai S, Peek R, Braat D, Velden JVD, Fleischer K, Oerlemans A. O-185 Evaluation of the decision-making process of girls with Turner syndrome and their parents considering ovarian tissue cryopreservation. Hum Reprod 2021. [DOI: 10.1093/humrep/deab127.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
What are the experiences with the decision-making process of girls with Turner syndrome (TS) considering ovarian tissue cryopreservation (OTC), their parents and healthcare providers?
Summary answer
Offering a new option to preserve fertility in TS caused unrealistic hope leading to challenges for healthcare providers to fulfil the ideal of informed consent.
What is known already
Due to premature ovarian insufficiency, girls with TS have only a small chance of genetic offspring. OTC might increase these odds. Healthcare providers and scientist are still cautious in offering OTC to girls with TS because of the many uncertainties regarding OTC in this patient group. Hence, OTC is now offered to girls with TS between 2 and 18 years old in a research setting: the TurnerFertility study.
Study design, size, duration
A retrospective qualitative study consisting of a survey and focus groups. Within a year after counselling, families (n = 132) received a survey with 30 questions regarding their experiences with the decision-making process and also an invitation for a focus group. The focus groups were conducted between January and October 2019 and lasted 51-84 minutes. The topic lists were based on literature research and survey results. Results were analysed following a thematic analysis approach.
Participants/materials, setting, methods
This is a sub-study of the prospective intervention study within an academical medical centre. Focus groups were composed through purposive sampling. Focus group 1 (FG1) consisted of five gynaecologists involved in counselling, FG2 with seven paediatricians who referred girls for counselling, FG3 with nine parents of girls with TS between 2 and 12 years old and FG4 with three parents of girls with TS between 13 and 17 years old.
Main results and the role of chance
90% of survey respondents appreciated counselling regarding fertility options and considered it an enrichment of existing healthcare. The individual consultation was rated as most contributing by 66% of the survey respondents, followed by the information meeting (37%) and decision aid (3%). The focus groups revealed that many had not discussed options for future parenthood with a healthcare provider before. Girls with TS and their parents indicated that the option of OTC raised hope for future genetic offspring, and at once made them feel like they had no choice but to take this chance. The small chance of success did not influence the decision for families who opted for OTC. Some parents who had to decide for their young daughter accepted OTC to give their daughter the option to decide herself whether to make use of the cryopreserved tissue later in life. Gynaecologists found it challenging to truly make families grasp a realistic perspective of OTC in TS and the associated mental and physical risks. Gynaecologists and paediatricians struggled with conflicting moral principles of non-maleficence against respect for autonomy: healthcare providers recognized the scientific relevance for the TS population, while it felt inconsistent with the disproportionate burden for some individual patients.
Limitations, reasons for caution
Because there was no validated survey for this topic in TS, we developed a survey based on literature research and experiences of a dedicated TS team. Among the survey responders and focus group participants a greater proportion decided for OTC compared to the overall counselled group (75% vs 60%).
Wider implications of the findings
This study gives insight in the issues to consider when implementing new technologies regarding fertility, in which parents have to decide for their child, where it is expected that anticipated decision regret plays a major role, or where healthcare providers experience conflicting duties as scientist and physician.
Trial registration number
not applicable
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Affiliation(s)
- S. Van der Coelen
- Radboud University Medical Centre, Reproductive medicine, Nijmegen, The Netherlands
| | - M Schleedoorn
- Radboud University Medical Centre, Reproductive medicine, Nijmegen, The Netherlands
| | - S Nadesapillai
- Radboud University Medical Centre, Reproductive medicine, Nijmegen, The Netherlands
| | - R Peek
- Radboud University Medical Centre, Reproductive medicine, Nijmegen, The Netherlands
| | - D Braat
- Radboud University Medical Centre, Gynaecology and obstetrics, Nijmegen, The Netherlands
| | - J. Van der Velden
- Radboud University Medical Centre- Amalia Children’s Hospital, Pediatrics, Nijmegen, The Netherlands
| | - K Fleischer
- The Fertility Partnership-VivaNeo Center, Reproductive Medicine, Düsseldorf, Germany
| | - A Oerlemans
- Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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24
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Sparidaens EM, Hermens RPM, Braat DDM, Nelen WLDM, Fleischer K. Web-Based Guidance Through Assisted Reproductive Technology (myFertiCare): Patient-Centered App Development and Qualitative Evaluation. J Med Internet Res 2021; 23:e25389. [PMID: 34342591 PMCID: PMC8371479 DOI: 10.2196/25389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/07/2021] [Accepted: 04/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Providing patient-centered fertility care is known to improve quality of life and can reduce anxiety and depression. In a previous study, we established the need for a web-based app providing personalized information and interactive functionalities among couples undergoing intracytoplasmic sperm injection with surgically retrieved sperm. OBJECTIVE This study aimed to design, develop, and qualitatively evaluate a multifaceted web-based app for infertile couples undergoing intracytoplasmic sperm injection with surgically retrieved sperm during their treatment trajectory. METHODS The web-based app was developed in three phases: (1) we established a patient-centered functional design, (2) developed the app in collaboration with medical and technical professionals, and (3) qualitatively evaluated the app among couples using a think-aloud method. RESULTS The basis of the app is the couple's visualized treatment trajectory. The app provides personalized and interactive functionalities; for example, customized information and communication options. During qualitative evaluation, myFertiCare was highly appreciated and received a median score of 8 out of 10. The main improvements made upon conclusion of the think-aloud sessions were related to faster login and easier app navigation. CONCLUSIONS A patient-centered web-based app aimed at guiding couples through their fertility treatment course was systematically designed, developed, and positively evaluated by patients and medical and technical professionals.
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Affiliation(s)
- Ellen Marie Sparidaens
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rosella P M Hermens
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, Netherlands
| | - Didi D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willianne L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kathrin Fleischer
- The Fertility Partnership Center of Reproductive Medicine, Düsseldorf, Germany
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25
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van Hoogenhuijze NE, Mol F, Laven JSE, Groenewoud ER, Traas MAF, Janssen CAH, Teklenburg G, de Bruin JP, van Oppenraaij RHF, Maas JWM, Moll E, Fleischer K, van Hooff MHA, de Koning CH, Cantineau AEP, Lambalk CB, Verberg M, van Heusden AM, Manger AP, van Rumste MME, van der Voet LF, Pieterse QD, Visser J, Brinkhuis EA, den Hartog JE, Glas MW, Klijn NF, van der Meer S, Bandell ML, Boxmeer JC, van Disseldorp J, Smeenk J, van Wely M, Eijkemans MJC, Torrance HL, Broekmans FJM. Endometrial scratching in women with one failed IVF/ICSI cycle-outcomes of a randomised controlled trial (SCRaTCH). Hum Reprod 2021; 36:87-98. [PMID: 33289528 PMCID: PMC7801792 DOI: 10.1093/humrep/deaa268] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
STUDY QUESTION Does endometrial scratching in women with one failed IVF/ICSI treatment affect the chance of a live birth of the subsequent fresh IVF/ICSI cycle? SUMMARY ANSWER In this study, 4.6% more live births were observed in the scratch group, with a likely certainty range between −0.7% and +9.9%. WHAT IS KNOWN ALREADY Since the first suggestion that endometrial scratching might improve embryo implantation during IVF/ICSI, many clinical trials have been conducted. However, due to limitations in sample size and study quality, it remains unclear whether endometrial scratching improves IVF/ICSI outcomes. STUDY DESIGN, SIZE, DURATION The SCRaTCH trial was a non-blinded randomised controlled trial in women with one unsuccessful IVF/ICSI cycle and assessed whether a single endometrial scratch using an endometrial biopsy catheter would lead to a higher live birth rate after the subsequent IVF/ICSI treatment compared to no scratch. The study took place in 8 academic and 24 general hospitals. Participants were randomised between January 2016 and July 2018 by a web-based randomisation programme. Secondary outcomes included cumulative 12-month ongoing pregnancy leading to live birth rate. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with one previous failed IVF/ICSI treatment and planning a second fresh IVF/ICSI treatment were eligible. In total, 933 participants out of 1065 eligibles were included (participation rate 88%). MAIN RESULTS AND THE ROLE OF CHANCE After the fresh transfer, 4.6% more live births were observed in the scratch compared to control group (110/465 versus 88/461, respectively, risk ratio (RR) 1.24 [95% CI 0.96–1.59]). These data are consistent with a true difference of between −0.7% and +9.9% (95% CI), indicating that while the largest proportion of the 95% CI is positive, scratching could have no or even a small negative effect. Biochemical pregnancy loss and miscarriage rate did not differ between the two groups: in the scratch group 27/153 biochemical pregnancy losses and 14/126 miscarriages occurred, while this was 19/130 and 17/111 for the control group (RR 1.21 (95% CI 0.71–2.07) and RR 0.73 (95% CI 0.38–1.40), respectively). After 12 months of follow-up, 5.1% more live births were observed in the scratch group (202/467 versus 178/466), of which the true difference most likely lies between −1.2% and +11.4% (95% CI). LIMITATIONS, REASONS FOR CAUTION This study was not blinded. Knowledge of allocation may have been an incentive for participants allocated to the scratch group to continue treatment in situations where they may otherwise have cancelled or stopped. In addition, this study was powered to detect a difference in live birth rate of 9%. WIDER IMPLICATIONS OF THE FINDINGS The results of this study are an incentive for further assessment of the efficacy and clinical implications of endometrial scratching. If a true effect exists, it may be smaller than previously anticipated or may be limited to specific groups of women undergoing IVF/ICSI. Studying this will require larger sample sizes, which will be provided by the ongoing international individual participant data-analysis (PROSPERO CRD42017079120). At present, endometrial scratching should not be performed outside of clinical trials. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by ZonMW, the Dutch organisation for funding healthcare research. J.S.E. Laven reports grants and personal fees from AnshLabs (Webster, Tx, USA), Ferring (Hoofddorp, The Netherlands) and Ministry of Health (CIBG, The Hague, The Netherlands) outside the submitted work. A.E.P. Cantineau reports ‘other’ from Ferring BV, personal fees from Up to date Hyperthecosis, ‘other’ from Theramex BV, outside the submitted work. E.R. Groenewoud reports grants from Titus Health Care during the conduct of the study. A.M. van Heusden reports personal fees from Merck Serono, personal fees from Ferring, personal fees from Goodlife, outside the submitted work. F.J.M. Broekmans reports personal fees as Member of the external advisory board for Ferring BV, The Netherlands, personal fees as Member of the external advisory board for Merck Serono, The Netherlands, personal fees as Member of the external advisory for Gedeon Richter, Belgium, personal fees from Educational activities for Ferring BV, The Netherlands, grants from Research support grant Merck Serono, grants from Research support grant Ferring, personal fees from Advisory and consultancy work Roche, outside the submitted work. C.B. Lambalk reports grants from Ferring, grants from Merck, grants from Guerbet, outside the submitted work. TRIAL REGISTRATION NUMBER Registered in the Netherlands Trial Register (NL5193/NTR 5342). TRIAL REGISTRATION DATE 31 July 2015. DATE OF FIRST PATIENT’S ENROLMENT 26 January 2016.
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Affiliation(s)
- N E van Hoogenhuijze
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - F Mol
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - J S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus Medical Centre Rotterdam, 3015 GD, Rotterdam, the Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology & Reproductive Medicine, Noordwest Ziekenhuisgroep, 1782 GZ, Den Helder, the Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, 7334 DZ, Apeldoorn, the Netherlands
| | - C A H Janssen
- Department of Gynaecology, Groene Hart Hospital, 2803 HH, Gouda, the Netherlands
| | - G Teklenburg
- Isala Fertility Clinic, Isala Hospital, 8025 AB, Zwolle, the Netherlands
| | - J P de Bruin
- Department of Gynaecology & Obstetrics, Jeroen Bosch Hospital, 5223 GZ, Den Bosch, the Netherlands
| | - R H F van Oppenraaij
- Department of Gynaecology, Maasstad Hospital, 3079 DZ, Rotterdam, the Netherlands
| | - J W M Maas
- Department of Gynaecology, Maxima Medical Centre, 5504 DB, Veldhoven, the Netherlands
| | - E Moll
- Department of Gynaecology, Onze Lieve Vrouwe Gasthuis, 1061 AE, Amsterdam, the Netherlands
| | - K Fleischer
- Department of Obstetrics & Gynaecology, Radboud University Medical Centre, 6525 GA, Nijmegen, the Netherlands
| | - M H A van Hooff
- Department of Gynaecology, Franciscus Gasthuis en Vlietland, 3045 PM, Rotterdam, the Netherlands
| | - C H de Koning
- Department of Gynaecology, Tergooi Hospital, 1213 XZ, Hilversum, the Netherlands
| | - A E P Cantineau
- University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, the Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - M Verberg
- Fertility Clinic, Fertility Clinic Twente, 7556 BN, Hengelo, the Netherlands
| | - A M van Heusden
- Fertility Clinic, Medisch Centrum Kinderwens, 2353 GA, Leiderdorp, the Netherlands
| | - A P Manger
- Department of Gynaecology, Diakonessenhuis, 3582 KE, Utrecht, the Netherlands
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, 5623 EJ, Eindhoven, the Netherlands
| | - L F van der Voet
- Department of Gynaecology, Deventer Hospital, 7416 SE, Deventer, the Netherlands
| | - Q D Pieterse
- Fertility Center, Haga Hospital, 2545 AA, The Hague, the Netherlands
| | - J Visser
- Department of Gynaecology & Obstetrics, Amphia Hospital, 4818 CK, Breda, the Netherlands
| | - E A Brinkhuis
- Department of Gynaecology & Obstetrics, Meander Hospital, 3813 TZ, Amersfoort, the Netherlands
| | - J E den Hartog
- Department of Obstetrics & Gynaecology, Maastricht University Medical Centre, 6229 HX, Maastricht, the Netherlands
| | - M W Glas
- Fertility clinic, Wilhelmina Hospital Assen, 9401 RK, Assen, the Netherlands
| | - N F Klijn
- Department of Gynaecology, Leiden University Medical Centre, 2333 ZA, Leiden, the Netherlands
| | - S van der Meer
- Department of Gynaecology, Haaglanden Medical Centre, 2512 VA, The Hague, the Netherlands
| | - M L Bandell
- Department of Gynaecology, Albert Schweitzer Hospital, 3364 DA, Sliedrecht,the Netherlands
| | - J C Boxmeer
- Department of Gynaecology, Reinier de Graaf Gasthuis, 2625 AD, Delft, the Netherlands
| | - J van Disseldorp
- Department of Gynaecology & Obstetrics, St. Antonius Hospital, 3435 CM, Nieuwegein, the Netherlands
| | - J Smeenk
- Department of Reproductive Medicine, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, the Netherlands
| | - M van Wely
- Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology - NVOG Consortium 2.0
| | - M J C Eijkemans
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands.,Julius Centre for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - H L Torrance
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
| | - F J M Broekmans
- Department of Gynaecology & Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands
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Schleedoorn MJ, Mulder BH, Braat DDM, Beerendonk CCM, Peek R, Nelen WLDM, Van Leeuwen E, Van der Velden AAEM, Fleischer K, Turner Fertility Expert Panel OBOT. International consensus: ovarian tissue cryopreservation in young Turner syndrome patients: outcomes of an ethical Delphi study including 55 experts from 16 different countries. Hum Reprod 2021; 35:1061-1072. [PMID: 32348471 PMCID: PMC7493129 DOI: 10.1093/humrep/deaa007] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/09/2020] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION What is the standpoint of an international expert panel on ovarian tissue cryopreservation (OTC) in young females with Turner syndrome (TS)? SUMMARY ANSWER The expert panel states that OTC should be offered to young females with TS, but under strict conditions only. WHAT IS KNOWN ALREADY OTC is already an option for preserving the fertility of young females at risk of iatrogenic primary ovarian insufficiency (POI). Offering OTC to females with a genetic cause of POI could be the next step. One of the most common genetic disorders related to POI is TS. Due to an early depletion of the ovarian reserve, most females with TS are confronted with infertility before reaching adulthood. However, before offering OTC as an experimental fertility preservation option to young females with TS, medical and ethical concerns need to be addressed. STUDY DESIGN, SIZE, DURATION A three-round ethical Delphi study was conducted to systematically discuss whether the expected benefits exceed the expected negative consequences of OTC in young females with TS. The aim was to reach group consensus and form an international standpoint based on selected key statements. The study took place between February and December 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS Anonymous panel selection was based on expertise in TS, fertility preservation or medical ethics. A mixed panel of 12 gynaecologists, 13 (paediatric) endocrinologists, 10 medical ethicists and 20 patient representatives from 16 different countries gave consent to participate in this international Delphi study. In the first two rounds, experts were asked to rate and rank 38 statements regarding OTC in females with TS. Participants were offered the possibility to adjust their opinions after repetitive feedback. The selection of key statements was based on strict inclusion criteria. MAIN RESULTS AND THE ROLE OF CHANCE A total of 46 participants completed the first Delphi round (response rate 84%). Based on strict selection criteria, six key statements were selected, and 13 statements were discarded. The remaining 19 statements and two additional statements submitted by the expert panel were re-evaluated in the second round by 41 participants (response rate 75%). The analysis of the second survey resulted in the inclusion of two additional key statements. After the approval of these eight key statements, the majority of the expert panel (96%) believed that OTC should be offered to young females with TS, but in a safe and controlled research setting first, with proper counselling and informed consent procedures, before offering this procedure in routine care. The remaining participants (4%) did not object but did not respond despite several reminders. LIMITATIONS, REASONS FOR CAUTION The anonymous nature of this study may have led to lack of accountability. The selection of experts was based on their willingness to participate. The fact that not all panellists took part in all rounds may have resulted in selection bias. WIDER IMPLICATIONS OF THE FINDINGS This international standpoint is the first step in the global acceptance of OTC in females with TS. Future collaborative research with a focus on efficacy and safety and long-term follow-up is urgently needed. Furthermore, we recommend an international register for fertility preservation procedures in females with TS. STUDY FUNDING/COMPETING INTEREST(S) Unconditional funding (A16-1395) was received from Merck B.V., The Netherlands. The authors declare that they have no conflict of interest.
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Affiliation(s)
- M J Schleedoorn
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - B H Mulder
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - D D M Braat
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C C M Beerendonk
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R Peek
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - W L D M Nelen
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E Van Leeuwen
- Medical Ethics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - A A E M Van der Velden
- Paediatric Endocrinology, Radboud University Medical Centre Amalia Children's Hospital, Nijmegen, The Netherlands
| | - K Fleischer
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Walls B, Mazilkin AA, Mukhamedov BO, Ionov A, Smirnova IA, Ponomareva AV, Fleischer K, Kozlovskaya NA, Shulyatev DA, Abrikosov IA, Shvets IV, Bozhko SI. Nanodomain structure of single crystalline nickel oxide. Sci Rep 2021; 11:3496. [PMID: 33568704 PMCID: PMC7875979 DOI: 10.1038/s41598-021-82070-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/30/2020] [Indexed: 11/25/2022] Open
Abstract
In this work we present a comprehensive study of the domain structure of a nickel oxide single crystal grown by floating zone melting and suggest a correlation between point defects and the observed domain structure. The properties and structure of domains dictate the dynamics of resistive switching, water splitting and gas sensing, to name but a few. Investigating the correlation between point defects and domain structure can provide a deeper understanding of their formation and structure, which potentially allows one to tailor domain structure and the dynamics of the aforementioned applications. A range of inhomogeneities are observed by diffraction and microscopy techniques. X-ray and low-energy electron diffraction reveal domains on the submicron- and nanometer-scales, respectively. In turn, these domains are visualised by atomic force and scanning tunneling microscopy (STM), respectively. A comprehensive transmission electron microscopy (TEM) study reveals inhomogeneities ranging from domains of varying size, misorientation of domains, variation of the lattice constant and bending of lattice planes. X-ray photoelectron spectroscopy and electron energy-loss spectroscopy indicate the crystal is Ni deficient. Density functional theory calculations—considering the spatial and electronic disturbance induced by the favourable nickel vacancy—reveal a nanoscale distortion comparable to STM and TEM observations. The different inhomogeneities are understood in terms of the structural relaxation induced by ordering of nickel vacancies, which is predicted to be favourable.
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Affiliation(s)
- B Walls
- School of Physics and Centre for Research on Adaptive Nanostructures and Nanodevices (CRANN), Trinity College Dublin, Dublin 2, Ireland.
| | - A A Mazilkin
- Institute of Solid State Physics, Russian Academy of Sciences, Chernogolovka, Russia
| | - B O Mukhamedov
- Materials Modeling and Development Laboratory, NUST MISIS, Leninskiy prosp, 4, Moscow, Russia, 199049
| | - A Ionov
- Institute of Solid State Physics, Russian Academy of Sciences, Chernogolovka, Russia
| | - I A Smirnova
- Institute of Solid State Physics, Russian Academy of Sciences, Chernogolovka, Russia
| | - A V Ponomareva
- Materials Modeling and Development Laboratory, NUST MISIS, Leninskiy prosp, 4, Moscow, Russia, 199049
| | - K Fleischer
- School of Physical Sciences, Dublin City University, Dublin 9, Ireland
| | - N A Kozlovskaya
- Materials Modeling and Development Laboratory, NUST MISIS, Leninskiy prosp, 4, Moscow, Russia, 199049
| | - D A Shulyatev
- Materials Modeling and Development Laboratory, NUST MISIS, Leninskiy prosp, 4, Moscow, Russia, 199049
| | - I A Abrikosov
- Department of Physics, Chemistry and Biology (IFM), Linköping University, 58183, Linköping, Sweden.
| | - I V Shvets
- School of Physics and Centre for Research on Adaptive Nanostructures and Nanodevices (CRANN), Trinity College Dublin, Dublin 2, Ireland
| | - S I Bozhko
- Institute of Solid State Physics, Russian Academy of Sciences, Chernogolovka, Russia
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Nadesapillai S, van der Velden J, Braat D, Peek R, Fleischer K. The challenge of defining predictive parameters for fertility preservation counseling in young females with Turner syndrome. Acta Obstet Gynecol Scand 2021; 100:1155-1156. [PMID: 33554331 DOI: 10.1111/aogs.14094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/28/2020] [Accepted: 01/09/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Sapthami Nadesapillai
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Didi Braat
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ron Peek
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands.,The Fertility Partnership-VivaNeo Center of Reproductive Medicine, Düsseldorf, Germany
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Cornelisse S, Ramos L, Arends B, Brink-van der Vlugt JJ, de Bruin JP, Curfs MH, Derhaag J, van Dongen A, van Echten-Arends J, Groenewoud ER, Maas JW, Pieterse Q, van Santbrink EJ, Slappendel E, Traas MA, Visser J, Vergouw CG, Verhoeve HR, van der Westerlaken LA, Wurth Y, van der Zanden M, Braat DD, van Wely M, Mastenbroek S, Fleischer K. Comparing the cumulative live birth rate of cleavage-stage versus blastocyst-stage embryo transfers between IVF cycles: a study protocol for a multicentre randomised controlled superiority trial (the ToF trial). BMJ Open 2021; 11:e042395. [PMID: 33441363 PMCID: PMC7812106 DOI: 10.1136/bmjopen-2020-042395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION In vitro fertilisation (IVF) has evolved as an intervention of choice to help couples with infertility to conceive. In the last decade, a strategy change in the day of embryo transfer has been developed. Many IVF centres choose nowadays to transfer at later stages of embryo development, for example, transferring embryos at blastocyst stage instead of cleavage stage. However, it still is not known which embryo transfer policy in IVF is more efficient in terms of cumulative live birth rate (cLBR), following a fresh and the subsequent frozen-thawed transfers after one oocyte retrieval. Furthermore, studies reporting on obstetric and neonatal outcomes from both transfer policies are limited. METHODS AND ANALYSIS We have set up a multicentre randomised superiority trial in the Netherlands, named the Three or Fivetrial. We plan to include 1200 women with an indication for IVF with at least four embryos available on day 2 after the oocyte retrieval. Women are randomly allocated to either (1) control group: embryo transfer on day 3 and cryopreservation of supernumerary good-quality embryos on day 3 or 4, or (2) intervention group: embryo transfer on day 5 and cryopreservation of supernumerary good-quality embryos on day 5 or 6. The primary outcome is the cLBR per oocyte retrieval. Secondary outcomes include LBR following fresh transfer, multiple pregnancy rate and time until pregnancy leading a live birth. We will also assess the obstetric and neonatal outcomes, costs and patients' treatment burden. ETHICS AND DISSEMINATION The study protocol has been approved by the Central Committee on Research involving Human Subjects in the Netherlands in June 2018 (CCMO NL 64060.000.18). The results of this trial will be submitted for publication in international peer-reviewed and in open access journals. TRIAL REGISTRATION NUMBER Netherlands Trial Register (NL 6857).
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Affiliation(s)
- Simone Cornelisse
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Liliana Ramos
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Brigitte Arends
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Jan Peter de Bruin
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, 's-Hertogenbosch, North Brabant, The Netherlands
| | - Max Hjn Curfs
- Department of Obstetrics and Gynecology, Isala Fertility Centre, Zwolle, Overijssel, The Netherlands
| | - Josien Derhaag
- Department of Reproductive Medicine, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Angelique van Dongen
- Department of Obstetrics and Gynaecology, Hospital Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Jannie van Echten-Arends
- Department of Obstetrics and Gynaecology, Section of Reproductive Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Eva R Groenewoud
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Northwest Hospital Group, Den Helder, North Holland, The Netherlands
| | - Jacques Wm Maas
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, North Brabant, The Netherlands
| | - Quirine Pieterse
- Department of Obstetrics and Gynaecology, Haga Hospital, the Hague, South Holland, The Netherlands
| | | | - Els Slappendel
- Fertility Clinic, Nij Geertgen, Elsendorp, North Brabant, The Netherlands
| | - Maaike Af Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, Gelderland, The Netherlands
| | - Jantien Visser
- Department of Obstetrics and Gynaecology, Amphia Hospital, Breda, North Brabant, The Netherlands
| | - Carlijn G Vergouw
- Department of Reproductive Medicine, Amsterdam UMC Location VUmc, Amsterdam, North Holland, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, North Holland, The Netherlands
| | | | - Yvonne Wurth
- Department of Reproductive Medicine, Elisabeth-TweeSteden Hospital, Tilburg, North Brabant, The Netherlands
| | - Moniek van der Zanden
- Department of Obstetrics and Gynaecology, Haaglanden Medical Centre, the Hague, South Holland, The Netherlands
| | - Didi Dm Braat
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Madelon van Wely
- Centre for Reproductive Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sebastiaan Mastenbroek
- Centre for Reproductive Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Kathrin Fleischer
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Fertility Centre, MVZ TFP-VivaNeo, Düsseldorf, Germany
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Nadesapillai S, van der Velden J, Smeets D, van de Zande G, Braat D, Fleischer K, Peek R. Why are some patients with 45,X Turner syndrome fertile? A young girl with classical 45,X Turner syndrome and a cryptic mosaicism in the ovary. Fertil Steril 2020; 115:1280-1287. [PMID: 33342535 DOI: 10.1016/j.fertnstert.2020.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To report a case of a young girl initially diagnosed with exclusively 45,X Turner syndrome (TS), but with a cryptic mosaicism in the ovary. DESIGN Case report. SETTING Radboud University Medical Center in the Netherlands. PATIENT(S) A 14-year-old girl with TS showing an exclusively 45,X cell line in lymphocytes, buccal cells, and urine cells in the presence of ovarian follicles. INTERVENTION(S) Laparoscopic unilateral oophorectomy was performed to obtain ovarian cortex tissue for fertility preservation purposes. One cortex fragment was used to determine the number of follicles by serial sectioning and staining, to perform fluorescence in situ hybridization (FISH) analysis and an in vitro growth (IVG) assay. MAIN OUTCOME MEASURE(S) FISH analysis of ovarian cells and the capacity of unilaminar follicles to develop to secondary follicles. RESULT(S) FISH analysis revealed that most oocytes had a normal tetraploid X chromosomal content, the stromal cell compartment had both 45,X and 47,XXX cell lines, and all follicular granulosa cells had a 45,X karyotype. IVG assay showed that unilaminar follicles were capable of maturing to secondary follicles, but that the granulosa layers and membrana granulosa were distorted. CONCLUSION(S) We report a case where follicles were found in a girl with monosomic TS, in the presence of a cryptic mosaicism. Karyotyping of extraovarian cells was not predictive of the karyotype of ovarian cells in the same patient. Despite the presence of normal oocytes, our observation that all analyzed follicles contained exclusively 45,X granulosa cells embedded in mosaic 45,X/47,XXX stromal tissue may have functional consequences for follicular development. CLINICAL TRIAL REGISTRATION NUMBER NCT03381300.
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Affiliation(s)
- Sapthami Nadesapillai
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Dominique Smeets
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Guillaume van de Zande
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Didi Braat
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands; The Fertility Partnership-VivaNeo Center of Reproductive Medicine, Düsseldorf, Germany
| | - Ronald Peek
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
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Sparidaens EM, Braat DDM, van den Berg M, D'Hauwers KWM, Fleischer K, Nelen WLDM. Informational needs of couples undergoing intracytoplasmic sperm injection with surgical sperm retrieval: A qualitative study. Eur J Obstet Gynecol Reprod Biol 2020; 255:177-182. [PMID: 33166938 DOI: 10.1016/j.ejogrb.2020.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Infertile couples consider patient information a very important dimension of patient-centred care. Although testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI) has long been offered to infertile couples, little is known about couples' informational needs. The aim of this study was to identify the informational needs of couples undergoing TESE and ICSI, including information content and the channels providing the information as a first step to improve patient-centred care. STUDY DESIGN We conducted a qualitative study consisting of semi-structured interviews with 11 couples. The topic guide was based on a literature review and interviews with an expert panel. The number of interviews was determined with data saturation. The data were analysed using a constant comparative method. RESULTS The couples needed information about many topics. They considered information about the success rates of the treatment, an explanation of the treatment procedure, and other patient experiences the most important. Regarding information channels, the couples preferred face-to-face information, but they also valued a leaflet, website, or an online application, especially when it is personalized or providing interactive functionalities. CONCLUSION We obtained in-depth insight into the information needs of couples undergoing TESE and ICSI. The results of this study give fertility clinics an opportunity to develop patient information that meets the needs of their patients and thus improve patient-centred fertility care.
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Affiliation(s)
- Ellen Marie Sparidaens
- Department of Obstetrics and Gynaecology (Route 791), Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Didi D M Braat
- Department of Obstetrics and Gynaecology (Route 791), Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Michelle van den Berg
- Department of Obstetrics and Gynaecology (Route 791), Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Kathleen W M D'Hauwers
- Department of Urology (Route 725), Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology (Route 791), Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, the Netherlands.
| | - Willianne L D M Nelen
- Department of Obstetrics and Gynaecology (Route 791), Radboud University Medical Center, P.O. Box 9101, 6500HB Nijmegen, the Netherlands.
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Nadesapillai S, Smeets D, van de Zande G, van der Velden J, Peek R, Fleischer K. Fertility preservation in Turner Syndrome: The first case of a young girl with 45,X Monosomy, where FISH analysis revealed that most oocytes had a normal tetraploid X chromosomal content. Geburtshilfe Frauenheilkd 2020. [DOI: 10.1055/s-0040-1718351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
| | - D Smeets
- Department of Human Genetics, Radboud University Medical Centre Nimwegen
| | - G van de Zande
- Department of Human Genetics, Radboud University Medical Centre Nimwegen
| | - J van der Velden
- Radboud University Medical Centre Nimwegen, Amalia Children’s Hospital
| | - R Peek
- Radboud University Medical Centre Nimwegen, Reproductive Medicine
| | - K Fleischer
- Radboud University Medical Centre Nimwegen, Reproductive Medicine
- MVZ Kinderwunsch Düsseldorf
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Peek R, Schleedoorn M, Smeets D, van de Zande G, Groenman F, Braat D, van der Velden J, Fleischer K. Ovarian follicles of young patients with Turner's syndrome contain normal oocytes but monosomic 45,X granulosa cells. Hum Reprod 2020; 34:1686-1696. [PMID: 31398245 PMCID: PMC6736193 DOI: 10.1093/humrep/dez135] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION What is the X chromosomal content of oocytes and granulosa cells of primordial/primary (small) follicles and stromal cells in ovaries of young patients with Turner's syndrome (TS)? SUMMARY ANSWER Small ovarian follicles were detected in one-half of the patients studied, and X chromosome analysis revealed that most oocytes were normal, granulosa cells were largely monosomic, while stromal cells showed a high level of mosaicism. WHAT IS KNOWN ALREADY Most women with TS experience a premature reduction or complete loss of fertility due to an accelerated loss of gametes. To determine whether fertility preservation in this group of patients is feasible, there is a strong need for information on the X chromosomal content of ovarian follicular and stromal cells. STUDY DESIGN, SIZE, DURATION Small follicles (<50 μm) and stromal cells were isolated from ovarian tissue of young TS patients and analysed for their X chromosomal content. In addition to ovarian cells, several other cell types from the same patients were analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS After unilateral ovariectomy, ovarian cortex tissue was obtained from 10 TS patients (aged 2-18 years) with numerical abnormalities of the X chromosome. Ovarian cortex fragments were prepared and cryopreserved. One fragment from each patient was thawed and enzymatically digested to obtain stromal cells and primordial/primary follicles. Stromal cells, granulosa cells and oocytes were analysed by FISH using an X chromosome-specific probe. Extra-ovarian cells (lymphocytes, buccal cells and urine cells) of the same patients were also analysed by FISH. Ovarian tissue used as control was obtained from individuals undergoing oophorectomy as part of their gender affirming surgery. MAIN RESULTS AND THE ROLE OF CHANCE Ovarian follicles were detected in 5 of the 10 patients studied. A method was developed to determine the X chromosomal content of meiosis I arrested oocytes from small follicles. This revealed that 42 of the 46 oocytes (91%) that were analysed had a normal X chromosomal content. Granulosa cells were largely 45,X but showed different levels of X chromosome mosaicism between patients and between follicles of the same patient. Despite the presence of a low percentage (10-45%) of 46,XX ovarian cortex stromal cells, normal macroscopic ovarian morphology was observed. The level of mosaicism in lymphocytes, buccal cells or urine-derived cells was not predictive for mosaicism in ovarian cells. LIMITATIONS, REASONS FOR CAUTION The results are based on a small number (n = 5) of TS patient samples but provide evidence that the majority of oocytes have a normal X chromosomal content and that follicles from the same patient can differ with respect to the level of mosaicism of their granulosa cells. The functional consequences of these observations require further investigation. WIDER IMPLICATIONS OF THE FINDINGS The results indicate that despite normal ovarian and follicular morphology, stromal cells and granulosa cells of small follicles in patients with TS may display a high level of mosaicism. Furthermore, the level of mosaicism in ovarian cells cannot be predicted from the analysis of extra-ovarian tissue. These findings should be considered by physicians when offering cryopreservation of ovarian tissue as an option for fertility preservation in young TS patients. STUDY FUNDING/COMPETING INTEREST(S) Unconditional funding was received from Merck B.V. The Netherlands (Number A16-1395) and the foundation 'Radboud Oncologie Fonds' (Number KUN 00007682). The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER NCT03381300.
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Affiliation(s)
- Ronald Peek
- Department of Obstetrics and Gynecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Myra Schleedoorn
- Department of Obstetrics and Gynecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Dominique Smeets
- Department of Human Genetics, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Guillaume van de Zande
- Department of Human Genetics, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Freek Groenman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Obstetrics and Gynecology, Amsterdam Reproduction and Development, De Boelelaan 1117 Amsterdam, The Netherlands
| | - Didi Braat
- Department of Obstetrics and Gynecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Janielle van der Velden
- Amalia Children's Hospital, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Cornelisse S, Zagers M, Kostova E, Fleischer K, van Wely M, Mastenbroek S. Preimplantation genetic testing for aneuploidies (abnormal number of chromosomes) in in vitro fertilisation. Cochrane Database Syst Rev 2020; 9:CD005291. [PMID: 32898291 PMCID: PMC8094272 DOI: 10.1002/14651858.cd005291.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI), selection of the most competent embryo(s) for transfer is based on morphological criteria. However, many women do not achieve a pregnancy even after 'good quality' embryo transfer. One of the presumed causes is that such morphologically normal embryos have an abnormal number of chromosomes (aneuploidies). Preimplantation genetic testing for aneuploidies (PGT-A), formerly known as preimplantation genetic screening (PGS), was therefore developed as an alternative method to select embryos for transfer in IVF. In PGT-A, the polar body or one or a few cells of the embryo are obtained by biopsy and tested. Only polar bodies and embryos that show a normal number of chromosomes are transferred. The first generation of PGT-A, using cleavage-stage biopsy and fluorescence in situ hybridisation (FISH) for the genetic analysis, was demonstrated to be ineffective in improving live birth rates. Since then, new PGT-A methodologies have been developed that perform the biopsy procedure at other stages of development and use different methods for genetic analysis. Whether or not PGT-A improves IVF outcomes and is beneficial to patients has remained controversial. OBJECTIVES To evaluate the effectiveness and safety of PGT-A in women undergoing an IVF treatment. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in September 2019 and checked the references of appropriate papers. SELECTION CRITERIA All randomised controlled trials (RCTs) reporting data on clinical outcomes in participants undergoing IVF with PGT-A versus IVF without PGT-A were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed risk of bias, and extracted study data. The primary outcome was the cumulative live birth rate (cLBR). Secondary outcomes were live birth rate (LBR) after the first embryo transfer, miscarriage rate, ongoing pregnancy rate, clinical pregnancy rate, multiple pregnancy rate, proportion of women reaching an embryo transfer, and mean number of embryos per transfer. MAIN RESULTS We included 13 trials involving 2794 women. The quality of the evidence ranged from low to moderate. The main limitations were imprecision, inconsistency, and risk of publication bias. IVF with PGT-A versus IVF without PGT-A with the use of genome-wide analyses Polar body biopsy One trial used polar body biopsy with array comparative genomic hybridisation (aCGH). It is uncertain whether the addition of PGT-A by polar body biopsy increases the cLBR compared to IVF without PGT-A (odds ratio (OR) 1.05, 95% confidence interval (CI) 0.66 to 1.66, 1 RCT, N = 396, low-quality evidence). The evidence suggests that for the observed cLBR of 24% in the control group, the chance of live birth following the results of one IVF cycle with PGT-A is between 17% and 34%. It is uncertain whether the LBR after the first embryo transfer improves with PGT-A by polar body biopsy (OR 1.10, 95% CI 0.68 to 1.79, 1 RCT, N = 396, low-quality evidence). PGT-A with polar body biopsy may reduce miscarriage rate (OR 0.45, 95% CI 0.23 to 0.88, 1 RCT, N = 396, low-quality evidence). No data on ongoing pregnancy rate were available. The effect of PGT-A by polar body biopsy on improving clinical pregnancy rate is uncertain (OR 0.77, 95% CI 0.50 to 1.16, 1 RCT, N = 396, low-quality evidence). Blastocyst stage biopsy One trial used blastocyst stage biopsy with next-generation sequencing. It is uncertain whether IVF with the addition of PGT-A by blastocyst stage biopsy increases cLBR compared to IVF without PGT-A, since no data were available. It is uncertain if LBR after the first embryo transfer improves with PGT-A with blastocyst stage biopsy (OR 0.93, 95% CI 0.69 to 1.27, 1 RCT, N = 661, low-quality evidence). It is uncertain whether PGT-A with blastocyst stage biopsy reduces miscarriage rate (OR 0.89, 95% CI 0.52 to 1.54, 1 RCT, N = 661, low-quality evidence). No data on ongoing pregnancy rate or clinical pregnancy rate were available. IVF with PGT-A versus IVF without PGT-A with the use of FISH for the genetic analysis Eleven trials were included in this comparison. It is uncertain whether IVF with addition of PGT-A increases cLBR (OR 0.59, 95% CI 0.35 to 1.01, 1 RCT, N = 408, low-quality evidence). The evidence suggests that for the observed average cLBR of 29% in the control group, the chance of live birth following the results of one IVF cycle with PGT-A is between 12% and 29%. PGT-A performed with FISH probably reduces live births after the first transfer compared to the control group (OR 0.62, 95% CI 0.43 to 0.91, 10 RCTs, N = 1680, I² = 54%, moderate-quality evidence). The evidence suggests that for the observed average LBR per first transfer of 31% in the control group, the chance of live birth after the first embryo transfer with PGT-A is between 16% and 29%. There is probably little or no difference in miscarriage rate between PGT-A and the control group (OR 1.03, 95%, CI 0.75 to 1.41; 10 RCTs, N = 1680, I² = 16%; moderate-quality evidence). The addition of PGT-A may reduce ongoing pregnancy rate (OR 0.68, 95% CI 0.51 to 0.90, 5 RCTs, N = 1121, I² = 60%, low-quality evidence) and probably reduces clinical pregnancies (OR 0.60, 95% CI 0.45 to 0.81, 5 RCTs, N = 1131; I² = 0%, moderate-quality evidence). AUTHORS' CONCLUSIONS There is insufficient good-quality evidence of a difference in cumulative live birth rate, live birth rate after the first embryo transfer, or miscarriage rate between IVF with and IVF without PGT-A as currently performed. No data were available on ongoing pregnancy rates. The effect of PGT-A on clinical pregnancy rate is uncertain. Women need to be aware that it is uncertain whether PGT-A with the use of genome-wide analyses is an effective addition to IVF, especially in view of the invasiveness and costs involved in PGT-A. PGT-A using FISH for the genetic analysis is probably harmful. The currently available evidence is insufficient to support PGT-A in routine clinical practice.
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Affiliation(s)
- Simone Cornelisse
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Miriam Zagers
- Center for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Elena Kostova
- Center for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
- MVZ TFP-VivaNeo Kinderwunschzentrum, Düsseldorf, Germany
| | - Madelon van Wely
- Center for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sebastiaan Mastenbroek
- Center for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Leijdekkers JA, Eijkemans MJC, van Tilborg TC, Oudshoorn SC, van Golde RJT, Hoek A, Lambalk CB, de Bruin JP, Fleischer K, Mochtar MH, Kuchenbecker WKH, Laven JSE, Mol BWJ, Torrance HL, Broekmans FJM. Cumulative live birth rates in low-prognosis women. Hum Reprod 2020; 34:1030-1041. [PMID: 31125412 PMCID: PMC6555622 DOI: 10.1093/humrep/dez051] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/10/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Do cumulative live birth rates (CLBRs) over multiple IVF/ICSI cycles confirm the low prognosis in women stratified according to the POSEIDON criteria? SUMMARY ANSWER The CLBR of low-prognosis women is ~56% over 18 months of IVF/ICSI treatment and varies between the POSEIDON groups, which is primarily attributable to the impact of female age. WHAT IS KNOWN ALREADY The POSEIDON group recently proposed a new stratification for low-prognosis women in IVF/ICSI treatment, with the aim to define more homogenous populations for clinical trials and stimulate a patient-tailored therapeutic approach. These new criteria combine qualitative and quantitative parameters to create four groups of low-prognosis women with supposedly similar biologic characteristics. STUDY DESIGN, SIZE, DURATION This study analyzed the data of a Dutch multicenter observational cohort study including 551 low-prognosis women, aged <44 years, who initiated IVF/ICSI treatment between 2011 and 2014 and were treated with a fixed FSH dose of 150 IU/day in the first treatment cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS Low-prognosis women were categorized into one of the POSEIDON groups based on their age (younger or older than 35 years), anti-Müllerian hormone (AMH) level (above or below 0.96 ng/ml), and the ovarian response (poor or suboptimal) in their first cycle of standard stimulation. The primary outcome was the CLBR over multiple complete IVF/ICSI cycles, including all subsequent fresh and frozen-thawed embryo transfers, within 18 months of treatment. Cumulative incidence curves were obtained using an optimistic and a conservative analytic approach. MAIN RESULTS AND THE ROLE OF CHANCE The CLBR of the low-prognosis women was on average ~56% over 18 months of IVF/ICSI treatment. Younger unexpected poor (n = 38) and suboptimal (n = 179) responders had a CLBR of ~65% and ~68%, respectively, and younger expected poor responders (n = 65) had a CLBR of ~59%. The CLBR of older unexpected poor (n = 41) and suboptimal responders (n = 102) was ~42% and ~54%, respectively, and of older expected poor responders (n = 126) ~39%. For comparison, the CLBR of younger (n = 164) and older (n = 78) normal responders with an adequate ovarian reserve was ~72% and ~58% over 18 months of treatment, respectively. No large differences were observed in the number of fresh treatment cycles between the POSEIDON groups, with an average of two fresh cycles per woman within 18 months of follow-up. LIMITATIONS, REASONS FOR CAUTION Small numbers in some (sub)groups reduced the precision of the estimates. However, our findings provide the first relevant indication of the CLBR of low-prognosis women in the POSEIDON groups. Small FSH dose adjustments between cycles were allowed, inducing therapeutic disparity. Yet, this is in accordance with current daily practice and increases the generalizability of our findings. WIDER IMPLICATIONS OF THE FINDINGS The CLBRs vary between the POSEIDON groups. This heterogeneity is primarily determined by a woman's age, reflecting the importance of oocyte quality. In younger women, current IVF/ICSI treatment reaches relatively high CLBR over multiple complete cycles, despite reduced quantitative parameters. In older women, the CLBR remains relatively low over multiple complete cycles, due to the co-occurring decline in quantitative and qualitative parameters. As no effective interventions exist to counteract this decline, clinical management currently relies on proper counselling. STUDY FUNDING/COMPETING INTEREST(S) No external funds were obtained for this study. J.A.L. is supported by a Research Fellowship grant and received an unrestricted personal grant from Merck BV. S.C.O., T.C.v.T., and H.L.T. received an unrestricted personal grant from Merck BV. C.B.L. received research grants from Merck, Ferring, and Guerbet. K.F. received unrestricted research grants from Merck Serono, Ferring, and GoodLife. She also received fees for lectures and consultancy from Ferring and GoodLife. A.H. declares that the Department of Obstetrics and Gynaecology, University Medical Centre Groningen received an unrestricted research grant from Ferring Pharmaceuticals BV, the Netherlands. J.S.E.L. has received unrestricted research grants from Ferring, Zon-MW, and The Dutch Heart Association. He also received travel grants and consultancy fees from Danone, Euroscreen, Ferring, AnshLabs, and Titus Healthcare. B.W.J.M. is supported by an National Health and Medical Research Council Practitioner Fellowship (GNT1082548) and reports consultancy work for ObsEva, Merck, and Guerbet. He also received a research grant from Merck BV and travel support from Guerbet. F.J.M.B. received monetary compensation as a member of the external advisory board for Merck Serono (the Netherlands) and Ferring Pharmaceuticals BV (the Netherlands) for advisory work for Gedeon Richter (Belgium) and Roche Diagnostics on automated AMH assay development, and for a research cooperation with Ansh Labs (USA). All other authors have nothing to declare. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Jori A Leijdekkers
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Marinus J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Theodora C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Simone C Oudshoorn
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Ron J T van Golde
- Department of Reproductive Medicine, Maastricht University Medical Centre, P. Debyelaan 25, HX Maastricht, The Netherlands
| | - Annemieke Hoek
- Centre for Reproductive Medicine, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, GZ Groningen, The Netherlands
| | - Cornelis B Lambalk
- Centre for Reproductive Medicine, Amsterdam University Medical Centre, Free University of Amsterdam, De Boelelaan, HV Amsterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Henri Dunantstraat 1, GZ 's-Hertogenbosch, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, GA Nijmegen, T he Netherlands
| | - Monique H Mochtar
- Centre for Reproductive Medicine, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Walter K H Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Clinics, Dokter Spanjaardweg 27-29, 8025 BT Zwolle, The Netherlands
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Scenic Blvd & Wellington Road, Clayton, VIC, Australia
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
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Koedooder R, Singer M, Schoenmakers S, Savelkoul PHM, Morré SA, de Jonge JD, Poort L, Cuypers WJSS, Beckers NGM, Broekmans FJM, Cohlen BJ, den Hartog JE, Fleischer K, Lambalk CB, Smeenk JMJS, Budding AE, Laven JSE. The vaginal microbiome as a predictor for outcome of in vitro fertilization with or without intracytoplasmic sperm injection: a prospective study. Hum Reprod 2020; 34:1042-1054. [PMID: 31119299 DOI: 10.1093/humrep/dez065] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/21/2019] [Accepted: 03/01/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Is the presence or absence of certain vaginal bacteria associated with failure or success to become pregnant after an in vitro fertilization (IVF) or IVF with intracytoplasmic sperm injection (IVF-ICSI) treatment? SUMMARY ANSWER Microbiome profiling with the use of interspace profiling (IS-pro) technique enables stratification of the chance of becoming pregnant prior to the start of an IVF or IVF-ICSI treatment. WHAT IS KNOWN ALREADY Live-birth rates for an IVF or IVF-ICSI treatment vary between 25 and 35% per cycle and it is difficult to predict who will or will not get pregnant after embryo transfer (ET). Recently, it was suggested that the composition of the vaginal microbiota prior to treatment might predict pregnancy outcome. Analysis of the vaginal microbiome prior to treatment might, therefore, offer an opportunity to improve the success rate of IVF or IVF-ICSI. STUDY DESIGN, SIZE, DURATION In a prospective cohort study, 303 women (age, 20-42 years) undergoing IVF or IVF-ICSI treatment in the Netherlands were included between June 2015 and March 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS Study subjects provided a vaginal sample before the start of the IVF or IVF-ICSI procedure. The vaginal microbiota composition was determined using the IS-pro technique. IS-pro is a eubacterial technique based on the detection and categorization of the length of the 16S-23S rRNA gene interspace region. Microbiome profiles were assigned to community state types based on the dominant bacterial species. The predictive accuracy of the microbiome profiles for IVF and IVF-ICSI outcome of fresh ET was evaluated by a combined prediction model based on a small number of bacterial species. From this cohort, a model was built to predict outcome of fertility treatment. This model was externally validated in a cohort of 50 women who were undergoing IVF or IVF-ICSI treatment between March 2018 and May 2018 in the Dutch division of the MVZ VivaNeo Kinderwunschzentrum Düsseldorf, Germany. MAIN RESULTS AND THE ROLE OF CHANCE In total, the vaginal microbiota of 192 women who underwent a fresh ET could be analysed. Women with a low percentage of Lactobacillus in their vaginal sample were less likely to have a successful embryo implantation. The prediction model identified a subgroup of women (17.7%, n = 34) who had a low chance to become pregnant following fresh ET. This failure was correctly predicted in 32 out of 34 women based on the vaginal microbiota composition, resulting in a predictive accuracy of 94% (sensitivity, 26%; specificity, 97%). Additionally, the degree of dominance of Lactobacillus crispatus was an important factor in predicting pregnancy. Women who had a favourable profile as well as <60% L. crispatus had a high chance of pregnancy: more than half of these women (50 out of 95) became pregnant. In the external validation cohort, none of the women who had a negative prediction (low chance of pregnancy) became pregnant. LIMITATIONS, REASONS FOR CAUTION Because our study uses a well-defined study population, the results will be limited to the IVF or IVF-ICSI population. Whether these results can be extrapolated to the general population trying to achieve pregnancy without ART cannot be determined from these data. WIDER IMPLICATIONS OF THE FINDINGS Our results indicate that vaginal microbiome profiling using the IS-pro technique enables stratification of the chance of becoming pregnant prior to the start of an IVF or IVF-ICSI treatment. Knowledge of their vaginal microbiota may enable couples to make a more balanced decision regarding timing and continuation of their IVF or IVF-ICSI treatment cycles. STUDY FUNDING/COMPETING INTEREST(S) This study was financed by NGI Pre-Seed 2014-2016, RedMedTech Discovery Fund 2014-2017, STW Valorisation grant 1 2014-2015, STW Take-off early phase trajectory 2015-2016 and Eurostars VALBIOME grant (reference number: 8884). The employer of W.J.S.S.C. has in collaboration with ARTPred acquired a MIND subsidy to cover part of the costs of this collaboration project. The following grants are received but not used to finance this study: grants from Innovatie Prestatie Contract, MIT Haalbaarheid, other from Dutch R&D tax credit WBSO, RedMedTech Discovery Fund, (J.D.d.J.). Grants from Ferring (J.S.E.L., K.F., C.B.L. and J.M.J.S.S.), Merck Serono (K.F. and C.B.L.), Dutch Heart Foundation (J.S.E.L.), Metagenics Inc. (J.S.E.L.), GoodLife (K.F.), Guerbet (C.B.L.). R.K. is employed by ARTPred B.V. during her PhD at Erasmus Medical Centre (MC). S.A.M. has a 100% University appointment. I.S.P.H.M.S., S.A.M. and A.E.B. are co-owners of IS-Diagnostics Ltd. J.D.d.J. is co-owner of ARTPred B.V., from which he reports personal fees. P.H.M.S. reports non-financial support from ARTPred B.V. P.H.M.S., J.D.d.J. and A.E.B. have obtained patents `Microbial population analysis' (9506109) and `Microbial population analysis' (20170159108), both licenced to ARTPred B.V. J.D.d.J. and A.E.B. report patent applications `Method and kit for predicting the outcome of an assisted reproductive technology procedure' (392EPP0) and patent `Method and kit for altering the outcome of an assisted reproductive technology procedure' by ARTPred. W.J.S.S.C. received personal consultancy and educational fees from Goodlife Fertility B.V. J.S.E.L. reports personal consultancy fees from ARTPred B.V., Titus Health B.V., Danone, Euroscreen and Roche during the conduct of the study. J.S.E.L. and N.G.M.B. are co-applicants on an Erasmus MC patent (New method and kit for prediction success of in vitro fertilization) licenced to ARTPred B.V. F.J.M.B. reports personal fees from Advisory Board Ferring, Advisory Board Merck Serono, Advisory Board Gedeon Richter and personal fees from Educational activities for Ferring, outside the submitted work. K.F. reports personal fees from Ferring (commercial sponsor) and personal fees from GoodLife (commercial sponsor). C.B.L. received speakers' fee from Ferring. J.M.J.S.S. reports personal fees and other from Merck Serono and personal fees from Ferring, unrelated to the submitted paper. The other authors declare that they have no competing interests. TRIAL REGISTRATION NUMBER ISRCTN83157250. Registered 17 August 2018. Retrospectively registered.
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Affiliation(s)
- R Koedooder
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre (UMC), Wytemaweg, CN Rotterdam, The Netherlands
| | - M Singer
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan, HZ Amsterdam, The Netherlands
| | - S Schoenmakers
- Division Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Wytemaweg, CN Rotterdam
| | - P H M Savelkoul
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan, HZ Amsterdam, The Netherlands.,Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, P. Debyelaan, HX Maastricht, The Netherlands
| | - S A Morré
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan, HZ Amsterdam, The Netherlands.,Institute of Public Health Genomics, Department of Genetics and Cell Biology, Research Institute GROW, Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - J D de Jonge
- ARTPred B.V., Kruisweg, NC Hoofddorp, The Netherlands
| | - L Poort
- IS-Diagnostics Ltd, Department of Medical Microbiology and Infection Control, Amsterdam UMC, VUmc, Science park, XG Amsterdam, The Netherlands
| | - W J S S Cuypers
- Dutch Division, MVZ VivaNeo Kinderwunschzentrum Düsseldorf GmbH, Völklinger Straße 4, Düsseldorf, Germany
| | - N G M Beckers
- VivaNeo Medisch Centrum Kinderwens, Simon Smitweg, GA Leiderdorp, The Netherlands
| | - F J M Broekmans
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Heidelberglaan, CX Utrecht, The Netherlands
| | - B J Cohlen
- Isala Voortplantingscentrum, Isala Kliniek, Dokter Spanjaardweg, BT Zwolle, The Netherlands
| | - J E den Hartog
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Maastricht Universitair Medisch Centrum+, P. Debyelaan, HX Maastricht, The Netherlands
| | - K Fleischer
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein, HB Nijmegen, The Netherlands
| | - C B Lambalk
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, location VUmc, De Boelelaan, HV Amsterdam, The Netherlands
| | - J M J S Smeenk
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Sint Elisabeth Ziekenhuis, Hilvarenbeekseweg, GC Tilburg, The Netherlands
| | - A E Budding
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan, HZ Amsterdam, The Netherlands.,IS-Diagnostics Ltd, Department of Medical Microbiology and Infection Control, Amsterdam UMC, VUmc, Science park, XG Amsterdam, The Netherlands
| | - J S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre (UMC), Wytemaweg, CN Rotterdam, The Netherlands
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Abstract
Pelvic organ prolapse describes the loss of support and subsequent descent of pelvic organs into the vagina. It is common, affecting up to 50% of parous women, and can be accompanied by a number of burdening symptoms. Prolapse has been thrown into the spotlight secondary to mesh-related complications. There are a number of effective treatment options to consider when managing pelvic organ prolapse and most do not require mesh. Patients' choice, comorbidities and likelihood of treatment success should be considered when making decisions about their care. Vaginal mesh surgery is currently on hold in the UK and even prior to this there has been a reduction both in the number of all prolapse surgeries and the number of women seeking surgery to manage their symptoms. This article reviews the current evidence for the management of pelvic organ prolapse, providing an update on the current state of mesh in prolapse surgery and summarises the key evidence points derived from the literature.
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Affiliation(s)
- K Fleischer
- Ashford and St Peter's NHS Foundation Trust, London, UK
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Smits R, D'Hauwers K, IntHout J, Braat D, Fleischer K. Impact of a nutritional supplement (Impryl) on male fertility: study protocol of a multicentre, randomised, double-blind, placebo-controlled clinical trial (SUppleMent Male fERtility, SUMMER trial). BMJ Open 2020; 10:e035069. [PMID: 32616489 PMCID: PMC7333867 DOI: 10.1136/bmjopen-2019-035069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/23/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Infertility is a worldwide problem and about 10%-15% of all couples will be affected by the inability to have children. In approximately 50% of infertile couples, a male factor is involved. Most of the male infertile cases are characterised as 'idiopathic', except for a small percentage of cases which are causative by a genetic aetiology. In the past decade, the role of oxidative stress related to sperm quality has been researched thoroughly and estimated to be the problem in 25%-87% of male infertility cases. Impryl is a nutritional supplement which works on the metabolic system and the regulation of oxidative stress by activating the 1-carbon cycle and therefore recycling of homocysteine. We hypothesise that the nutritional supplement Impryl in men of infertile couples might improve the ongoing pregnancy rate. METHODS AND ANALYSIS We designed a multicentre, randomised, double-blind, placebo-controlled clinical trial. We aimed to include 1200 male adults aged 18-50 years, part of a couple that is diagnosed with infertility. The couple will either start or has already been started with fertility treatment, that is, expectative management (duration of 6 months), intrauterine insemination (IUI) with or without mild ovarian stimulation or ovulation induction, either in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Male participants will be randomised in either the Impryl or the placebo group, with identical appearance of the tablets to be distributed (doses: one tablet each day), for a total duration of maximal 6 months. Patients can start directly with fertility treatment and/or natural conception. The primary outcome is the number of ongoing pregnancies confirmed by ultrasound at ≥10 to 12 weeks, and conceived in the time window between randomisation up to and including month 6 of intervention use. Secondary outcomes are change in semen parameters between baseline and after 3 months of intervention in the IUI/IVF/ICSI group, based on (prewash) total motile sperm count. Furthermore the number of pregnancies conceived in the optimal intervention time window (after full spermatogenesis of 72 days), overall number of pregnancies, time to pregnancy, embryo fertilisation rate in IVF/ICSI, embryo-utilisation rate in IVF/ICSI, number of miscarriages, live birth rate and adverse events are documented within the study period of 15 months. ETHICS AND DISSEMINATION The protocol is approved by the local medical ethical review committee at the Radboud University Medical Centre and by the national Central Committee on Research Involving Human Subjects. Findings will be shared with the academic and medical community, funding and patient organisations in order to contribute to optimisation of medical care and quality of life for patients with infertility. TRIAL REGISTRATION NUMBERS NCT03337360 and NTR6551.
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Affiliation(s)
- Roos Smits
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | | | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Didi Braat
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
- MVZ VivaNeo Kinderwunschzentrum, Dusseldorf, Germany
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Schleedoorn M, van der Velden J, Braat D, Beerendonk I, van Golde R, Peek R, Fleischer K. TurnerFertility trial: PROTOCOL for an observational cohort study to describe the efficacy of ovarian tissue cryopreservation for fertility preservation in females with Turner syndrome. BMJ Open 2019; 9:e030855. [PMID: 31831533 PMCID: PMC6924773 DOI: 10.1136/bmjopen-2019-030855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To investigate the occurrence of live birth in women with Turner syndrome (TS) after ovarian tissue cryopreservation in childhood followed by auto transplantation in adulthood and to find reliable prognostic markers for estimating the ovarian reserve in girls with TS in the future. SETTING An observational cohort study with long-term follow-up in a tertiary fertility clinic in the Netherlands. Patients recruitment between January 2018 and December 2021. PARTICIPANTS 100 females aged 2 through 18 years with classical Turner (ie, 45,X0) or Turner variants (ie, 45,X mosaicism or structural anomalies). Girls with Y chromosomal content, minor X deletions with marginal impact on fertility, active HIV, hepatitis B or hepatitis C infection, and/or an absolute contra indication for surgery, anaesthesia or future pregnancy will be excluded. INTERVENTIONS Ovarian cortical tissue will be harvested by performing a unilateral oophorectomy via laparoscopic approach. Ovarian cortex fragments will be prepared and cryopreserved. One fragment per patient will be used to determine follicular density by conventional histology, and to perform fluorescence in situ hybridisation analysis of ovarian cells. Routine chromosome analysis will be performed on both lymphocytes and buccal cells. A blood sample will be taken for hormonal analysis and all subjects will undergo a transabdominal ultrasound to determine the uterine and ovarian size. Patient characteristics, pregnancy rates and pregnancy outcomes will be collected from the patient's medical record. ETHICS AND DISSEMINATION The study protocol has been approved by the Central Committee on Research Involving Human Subjects in November 2017 (CCMO NL57738.000.16). TRIAL REGISTRATION NUMBER NCT03381300.
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Affiliation(s)
- Myra Schleedoorn
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | | | - Didi Braat
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Ina Beerendonk
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
| | - Ron van Golde
- Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ron Peek
- Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands
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40
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Tournié A, Fleischer K, Bukreeva I, Palermo F, Perino M, Cedola A, Andraud C, Ranocchia G. Ancient Greek text concealed on the back of unrolled papyrus revealed through shortwave-infrared hyperspectral imaging. Sci Adv 2019; 5:eaav8936. [PMID: 31620553 PMCID: PMC6777967 DOI: 10.1126/sciadv.aav8936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/13/2019] [Indexed: 05/17/2023]
Abstract
Only a few Herculaneum rolls exhibit writing on their reverse side. Since unrolled papyri are permanently glued to paperboard, so far, this fact was known to us only from 18th-century drawings. The application of shortwave-infrared (SWIR; 1000-2500 nm) hyperspectral imaging (HSI) to one of them (PHerc. 1691/1021) has revealed portions of Greek text hidden on the back more than 220 years after their first discovery, making it possible to recover this primary source for the ongoing new edition of this precious book. SWIR HSI has produced better contrast and legibility even on the extensive text preserved on the front compared to former imaging of Herculaneum papyri at 950 nm (improperly called multispectral imaging), with a substantial impact on the text reconstruction. These promising results confirm the importance of advanced techniques applied to ancient carbonized papyri and open the way to a better investigation of hundreds of other such papyri.
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Affiliation(s)
- A. Tournié
- Centre de Recherche sur la Conservation (CRC, USR 3224), Muséum National d’Histoire Naturelle, Ministère de la Culture, CNRS; CP21, 36 rue Geoffroy-Saint-Hilaire, F-75005 Paris, France
| | - K. Fleischer
- Institut für Klassische Philologie, Julius-Maximilians-Universität Würzburg, Residenzplatz 2, D-97070 Würzburg, Germany
| | - I. Bukreeva
- Consiglio Nazionale delle Ricerche, Istituto di Nanotecnologia (NANOTEC), Rome Unit, Piazzale A. Moro, 5, I-00185 Rome, Italy
- P.N. Lebedev Physical Institute, Russian Academy of Sciences, Leninskii pr., 53, 119991 Moscow, Russia
| | - F. Palermo
- Consiglio Nazionale delle Ricerche, Istituto di Nanotecnologia (NANOTEC), Rome Unit, Piazzale A. Moro, 5, I-00185 Rome, Italy
| | - M. Perino
- Dipartimento di Scienze di Base e Applicate per l’Ingegneria, Sapienza University of Rome, Via A. Scarpa 14/16, I-00161 Rome, Italy
| | - A. Cedola
- Consiglio Nazionale delle Ricerche, Istituto di Nanotecnologia (NANOTEC), Rome Unit, Piazzale A. Moro, 5, I-00185 Rome, Italy
| | - C. Andraud
- Centre de Recherche sur la Conservation (CRC, USR 3224), Muséum National d’Histoire Naturelle, Ministère de la Culture, CNRS; CP21, 36 rue Geoffroy-Saint-Hilaire, F-75005 Paris, France
| | - G. Ranocchia
- Consiglio Nazionale delle Ricerche, Istituto per il Lessico Intellettuale Europeo e Storia delle Idee (ILIESI), Via C. Fea, 2, I-00161 Rome, Italy
- Corresponding author.
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41
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Koedooder R, Singer M, Schoenmakers S, Savelkoul PHM, Morré SA, de Jonge JD, Poort L, Cuypers WJSS, Beckers NGM, Broekmans FJM, Cohlen BJ, den Hartog JE, Fleischer K, Lambalk CB, Smeenk JMJS, Budding AE, Laven JSE. The Vaginal Microbiome as a Predictor for Outcome of In Vitro Fertilization With or Without Intracytoplasmic Sperm Injection: A Prospective Study. Obstet Gynecol Surv 2019. [DOI: 10.1097/01.ogx.0000584064.03901.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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42
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Koedooder R, Singer M, Schoenmakers S, Savelkoul PHM, Morré SA, de Jonge JD, Poort L, Cuypers WJSS, Beckers NGM, Broekmans FJM, Cohlen BJ, den Hartog JE, Fleischer K, Lambalk CB, Smeenk JMJS, Budding AE, Laven JSE. Corrigendum. The vaginal microbiome as a predictor for outcome of in vitro fertilization with or without intracytoplasmic sperm injection: a prospective study. Hum Reprod 2019; 34:2091-2092. [PMID: 31299066 DOI: 10.1093/humrep/dez127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/29/2019] [Accepted: 05/20/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- R Koedooder
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre (UMC), Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - M Singer
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands
| | - S Schoenmakers
- Division Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Wytemaweg 80, 3015 CN Rotterdam
| | - P H M Savelkoul
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands.,Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - S A Morré
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands.,Institute of Public Health Genomics, Department of Genetics and Cell Biology, Research Institute GROW, Faculty of Health, Medicine & Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - J D de Jonge
- ARTPred B.V., Kruisweg 647, 2131 NC Hoofddorp, The Netherlands
| | - L Poort
- IS-Diagnostics Ltd, Department of Medical Microbiology and Infection Control, Amsterdam UMC, VUmc, Science park 106, 1098 XG Amsterdam, The Netherlands
| | - W J S S Cuypers
- Dutch Division, MVZ VivaNeo Kinderwunschzentrum Düsseldorf GmbH, Völklinger Straße 4, 40219 Düsseldorf, Germany
| | - N G M Beckers
- VivaNeo Medisch Centrum Kinderwens, Simon Smitweg 16, 2353 GA Leiderdorp, The Netherlands
| | - F J M Broekmans
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - B J Cohlen
- Isala Voortplantingscentrum, Isala Kliniek, Dokter Spanjaardweg 29, 8025 BT Zwolle, The Netherlands
| | - J E den Hartog
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Maastricht Universitair Medisch Centrum+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - K Fleischer
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - C B Lambalk
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - J M J S Smeenk
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Sint Elisabeth Ziekenhuis, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - A E Budding
- Laboratory of Immunogenetics, Department of Medical Microbiology and Infection Control, Amsterdam UMC, location VUmc, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands.,IS-Diagnostics Ltd, Department of Medical Microbiology and Infection Control, Amsterdam UMC, VUmc, Science park 106, 1098 XG Amsterdam, The Netherlands
| | - J S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre (UMC), Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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Leijdekkers JA, van Tilborg TC, Torrance HL, Oudshoorn SC, Brinkhuis EA, Koks CAM, Lambalk CB, de Bruin JP, Fleischer K, Mochtar MH, Kuchenbecker WKH, Laven JSE, Mol BWJ, Broekmans FJM, Eijkemans MJC. Do female age and body weight modify the effect of individualized FSH dosing in IVF/ICSI treatment? A secondary analysis of the OPTIMIST trial. Acta Obstet Gynecol Scand 2019; 98:1332-1340. [PMID: 31127607 DOI: 10.1111/aogs.13664] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/05/2019] [Accepted: 05/21/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The OPTIMIST trial revealed that for women starting in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment, no substantial differences exist in first cycle and cumulative live birth rates between an antral follicle count (AFC)-based individualized follicle-stimulating hormone (FSH) dose and a standard dose. Female age and body weight have been suggested to cause heterogeneity in the effect of FSH dose individualization. The objective of the current study is to evaluate whether these patient characteristics modify the effect of AFC-based individualized FSH dosing in IVF/ICSI treatment. MATERIAL AND METHODS A secondary data-analysis of the OPTIMIST trial. Women initiating IVF/ICSI treatment were classified as predicted poor (AFC 0-7), suboptimal (AFC 8-10) or hyper responders (AFC >15), and randomly allocated to a standard FSH dose (150 IU/d) or an individualized FSH dose (450, 225 or 100 IU/d for predicted poor, suboptimal and hyper responders, respectively). In each predicted response category, logistic regression models with interaction terms were used to evaluate the presence of effect modification. The first cycle was analyzed, and the primary outcomes were first complete cycle live birth rate (including fresh plus frozen-thawed embryo transfers) and ovarian hyperstimulation syndrome (OHSS) risks. RESULTS No effect modification was revealed in the predicted poor (n = 234) and suboptimal (n = 277) responders. In the predicted hyper responders (n = 521), the effect of the individualized FSH dose on the first cycle live birth rate was modified by female age (P = 0.02) and the effect on OHSS risks was modified by body weight (P = 0.02). A dose reduction from 150 to 100 IU/d generally decreased the OHSS risks in predicted hyper responders, but also reduced the chance of a live birth in young women, and had no beneficial impact on OHSS risks in women with a relatively low body weight. CONCLUSIONS In women with a predicted hyper response undergoing IVF/ICSI treatment, female age and body weight seem to modify the effect of FSH dose individualization. Although a reduced FSH starting dose generally decreases the OHSS risks, it may also reduce the chance of a live birth, specifically for young women. Future studies could consider these findings when investigating the optimal approach to reduce OHSS risks while maintaining the probability of a live birth for predicted hyper responders in IVF/ICSI treatment.
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Affiliation(s)
- Jori A Leijdekkers
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Theodora C van Tilborg
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Simone C Oudshoorn
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Egbert A Brinkhuis
- Department of Obstetrics and Gynecology, Meander Medical Center, Amersfoort, The Netherlands
| | - Carolien A M Koks
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Cornelis B Lambalk
- Center for Reproductive Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique H Mochtar
- Center for Reproductive Medicine, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Danhof NA, van Wely M, Repping S, Koks C, Verhoeve HR, de Bruin JP, Verberg MFG, van Hooff MHA, Cohlen BJ, van Heteren CF, Fleischer K, Gianotten J, van Disseldorp J, Visser J, Broekmans FJM, Mol BWJ, van der Veen F, Mochtar MH. Follicle stimulating hormone versus clomiphene citrate in intrauterine insemination for unexplained subfertility: a randomized controlled trial. Hum Reprod 2019; 33:1866-1874. [PMID: 30137325 DOI: 10.1093/humrep/dey268] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/24/2018] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Is FSH or clomiphene citrate (CC) the most effective stimulation regimen in terms of ongoing pregnancies in couples with unexplained subfertility undergoing IUI with adherence to strict cancellation criteria as a measure to reduce the number of multiple pregnancies? SUMMARY ANSWER In IUI with adherence to strict cancellation criteria, ovarian stimulation with FSH is not superior to CC in terms of the cumulative ongoing pregnancy rate, and yields a similar, low multiple pregnancy rate. WHAT IS ALREADY KNOWN FSH has been shown to result in higher pregnancy rates compared to CC, but at the cost of high multiple pregnancy rates. To reduce the risk of multiple pregnancy, new ovarian stimulation regimens have been suggested, these include strict cancellation criteria to limit the number of dominant follicles per cycle i.e. withholding insemination when more than three dominant follicles develop. With such a strategy, it is unclear whether the ovarian stimulation should be done with FSH or with CC. STUDY DESIGN, SIZE, DURATION We performed an open-label multicenter randomized superiority controlled trial in the Netherlands (NTR 4057). PARTICIPANTS/MATERIALS, SETTING, METHODS We randomized couples diagnosed with unexplained subfertility and scheduled for a maximum of four cycles of IUI with ovarian stimulation with 75 IU FSH or 100 mg CC. Cycles were cancelled when more then three dominant follicles developed. The primary outcome was cumulative ongoing pregnancy rate. Multiple pregnancy was a secondary outcome. We analysed the data on intention to treat basis. We calculated relative risks and absolute risk difference with 95% CI. MAIN RESULTS AND THE ROLE OF CHANCE Between July 2013 and March 2016, we allocated 369 women to ovarian stimulation with FSH and 369 women to ovarian stimulation with CC. A total of 113 women (31%) had an ongoing pregnancy following ovarian stimulation with FSH and 97 women (26%) had an ongoing pregnancy following ovarian stimulation with CC (RR = 1.16, 95% CI: 0.93-1.47, ARD = 0.04, 95% CI: -0.02 to 0.11). Five women (1.4%) had a multiple pregnancy following ovarian stimulation with FSH and eight women (2.2%) had a multiple pregnancy following ovarian stimulation with CC (RR = 0.63, 95% CI: 0.21-1.89, ARD = -0.01, 95% CI: -0.03 to 0.01). LIMITATIONS, REASONS FOR CAUTION We were not able to blind this study due to the nature of the interventions. We consider it unlikely that this has introduced performance bias, since pregnancy outcomes are objective outcome measures. WIDER IMPLICATIONS OF THE FINDINGS We revealed that adherence to strict cancellation criteria is a successful solution to reduce the number of multiple pregnancies in IUI. To decide whether ovarian stimulation with FSH or with CC should be the regimen of choice, costs and patients' preferences should be taken into account. STUDY FUNDING/COMPETING INTEREST(S) This trial received funding from the Dutch Organization for Health Research and Development (ZonMw). Prof. Dr B.W.J. Mol is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for Merck, ObsEva and Guerbet. The other authors declare that they have no competing interests. TRIAL REGISTRATION NUMBER Nederlands Trial Register NTR4057. TRIAL REGISTRATION DATE 1 July 2013. DATE OF FIRST PATIENT’S ENROLMENT The first patient was randomized at 27 August 2013.
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Affiliation(s)
- N A Danhof
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S Repping
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Koks
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbus 7777, 5500 MB, Veldhoven, The Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG oost, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - J P de Bruin
- Jeroen Bosch Hospital, Department of Obstetrics and Gynecology, Postbus 90153, 5200 ME, 's-Hertogenbosch, The Netherlands
| | - M F G Verberg
- Fertility Clinic Twente, Demmersweg 66, 7556 BN, Hengelo, The Netherlands
| | - M H A van Hooff
- Department of Obstetrics and Gynaecology, Sint Franciscus Gasthuis, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - B J Cohlen
- Department of Obstetrics and Gynecology, Isala Hospital, Postbus 10400, 8000 GK, Zwolle, The Netherlands
| | - C F van Heteren
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Postbus 9015, 6500 GS, Nijmegen, The Netherlands
| | - K Fleischer
- Centre for Reproductive Medicine, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - J Gianotten
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Postbus 417, 2000 AK, Haarlem, The Netherlands
| | - J van Disseldorp
- Department of Obstetrics and Gynaecology, St. Antonius hospital Nieuwegein, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - J Visser
- Department of Obstetrics and Gynaecology Amphia, Postbus 90157, 4800 RL, Breda, The Netherlands
| | - F J M Broekmans
- Centre for Reproductive Medicine, University Medical Centre Utrecht, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - B W J Mol
- Monash University, Monash Medical Centre, 246 Clayton Rd, Clayton VIC 3168, Australia
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M H Mochtar
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
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Schleedoorn MJ, van der Velden AAEM, Braat DDM, Peek R, Fleischer K. To Freeze or Not to Freeze? An Update on Fertility Preservation In Females with Turner Syndrome. Pediatr Endocrinol Rev 2019; 16:369-382. [PMID: 30888127 DOI: 10.17458/per.vol16.2019.svb.tofreezeornot] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Infertility is a major concern for females with Turner syndrome (TS), regardless of their age. While fertility preservation is now routinely offered to girls and young women with cancer, there are currently no recommendations on fertility preservation in girls and young women with TS who generally face an even higher risk for infertility. Despite the lack of international guidelines, preservation procedures have been performed experimentally in females with TS. Methods A systematic literature search based on the PRISMA-P methodology for systematic reviews was performed in order to collect all published data on fertility preservation options in females with TS between January 1980 and April 2018. A total number of 67 records were included in this review. The records were screened for information regarding cryopreservation of mature oocytes and ovarian tissue in females with TS. Two ongoing trials on fertility preservation in young females with TS were also included. Results Cryopreservation of oocytes or ovarian tissue has been performed experimentally in >150 girls and adolescents with TS over the last 16 years. The efficacy of fertility preservation options in females with TS is still unknown due to the lack of follow-up data. Conclusion The efficacy of fertility preservation procedures in females with TS is still unknown. Future studies with focus on efficacy, safety and long-term follow-up are desperately needed.
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Affiliation(s)
- M J Schleedoorn
- Radboud University Medical Center, Department of Obstetrics and Gynaecology (route 791) O.Box 9101, 500 HB Nijmegen, The Netherlands, E-mail:
| | - A A E M van der Velden
- The Netherlands, Department of Paediatric Endocrinology, Radboud university medical center, Amalia Children's Hospital, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - R Peek
- Department of Obstetrics and Gynaecology, Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - K Fleischer
- Department of Obstetrics and Gynaecology, Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Duijnhouwer AL, Bons LR, Timmers HJLM, van Kimmenade RRL, Snoeren M, Timmermans J, van den Hoven AT, Kempers M, van Dijk APJ, Fleischer K, Roos-Hesselink JW. Aortic dilatation and outcome in women with Turner syndrome. Heart 2018; 105:693-700. [PMID: 30368486 DOI: 10.1136/heartjnl-2018-313716] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/13/2018] [Accepted: 09/27/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Women with Turner syndrome (TS) are at increased risk of aortic dissection, which is related to ascending aortic diameter. However, the relation between aortic diameter and outcome is not well determined. This study evaluates the prevalence of aortic dilatation, the growth rate of the aorta and the risk of aortic complications in adults with TS. METHODS Single centre, retrospective study of all women with TS followed with a strict protocol in an outpatient TS clinic. Aortic diameters were analysed using advanced imaging. The primary outcome was a combined endpoint of aortic-related mortality, aortic dissection and preventive aortic surgery. The secondary endpoint was aortic growth and prevalence of aortic dilatation, defined as an aortic size index >20 mm/m2 at baseline. RESULTS At least one cardiac MR/CT was available in 268 women with TS, having median age of 28.7 (IQR: 21.3-39.7) years. Aortic dilatation was present in 22%. Linear regression identified independent factors associated with larger aortic diameters: age (coefficient=0.23; p<0.001), hypertension (coefficient=2.7; p<0.001), bicuspid aortic valve (coefficient=3.3; p<0.001), 45XO karyotype (coefficient=1.7; p=0.002), weight (coefficient=0.075; p<0.001) and growth hormone treatment (coefficient=1.4; p=0.044). During follow-up (6.8±3.2 years), five women (2%) reached the primary endpoint (two dissections, three aortic surgery). Women withmore than one scan (n=171; 1015 patient-years follow-up), the median aortic growth was 0.20 (IQR: 0.00-0.44) mm/year. In multivariate analysis, aortic growth was not associated with baseline aortic diameter or other variables. CONCLUSIONS Aortic dilatation is common and known associations were confirmed in large adult TS cohort However, aortic dissection, related mortality and preventive aortic surgery are rare. Growth hormone treatment in childhood was associated with aortic dimensions.
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Affiliation(s)
| | - Lidia R Bons
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Henri J L M Timmers
- Department of Endocrinology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Miranda Snoeren
- Department of Radiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Janneke Timmermans
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Marlies Kempers
- Department of Medical Genetics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Kathrin Fleischer
- Department of Gynaecology, Radboud University Medical Centre, Nijmegen, Netherlands
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Smits RM, Mackenzie-Proctor R, Fleischer K, Showell MG. Antioxidants in fertility: impact on male and female reproductive outcomes. Fertil Steril 2018; 110:578-580. [DOI: 10.1016/j.fertnstert.2018.05.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/23/2018] [Indexed: 12/15/2022]
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Cornelisse S, Fleischer K, Repping S, Mastenbroek S. An informed decision between cleavage-stage and blastocyst-stage transfer in IVF requires data on the transfers of frozen–thawed embryos. Hum Reprod 2018; 33:1370. [DOI: 10.1093/humrep/dey112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Simone Cornelisse
- Center for Reproductive Medicine, Radboudumc, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - Kathrin Fleischer
- Center for Reproductive Medicine, Radboudumc, Geert Grooteplein Zuid 10, GA Nijmegen, The Netherlands
| | - Sjoerd Repping
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, AZ, Amsterdam, The Netherlands
| | - Sebastiaan Mastenbroek
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, AZ, Amsterdam, The Netherlands
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Franik S, Smeets D, van de Zande G, Gomes I, D'Hauwers K, Braat DDM, Fleischer K, Ramos L. Klinefelter syndrome and fertility-Impact of X-chromosomal inheritance on spermatogenesis. Andrologia 2018; 50:e13004. [PMID: 29512178 DOI: 10.1111/and.13004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2018] [Indexed: 11/26/2022] Open
Abstract
With the use of testicular sperm extraction (TESE), spermatozoa can be retrieved in about 30%-50% of men with Klinefelter syndrome (KS). The reason for the absence or presence of spermatozoa in half of the men with KS remains unknown. Therefore, the search for an objective marker for a positive prediction in finding spermatozoa is of significant clinical value to avoid unnecessary testicular biopsies in males with (mostly) low testicular volume and impaired testosterone. The objective of this study was to determine whether paternal or maternal inheritance of the additional X-chromosome can predict the absence or presence of spermatogenesis in men with KS. Men with KS who have had a testicular biopsy for diagnostic fertility workup TESE were eligible for inclusion. Buccal swabs from nine KS patients and parents (trios) were taken to compare X-chromosomal inheritance to determine the parental origin of both X-chromosomes in the males with KS. Spermatozoa were found in TESE biopsies 8 of 35 (23%) patients after performing a unilateral or bilateral TESE. Different levels of spermatogenesis (from the only presence of spermatogonia, up to maturation arrest or hypospermatogenesis) appeared to be present in 19 of 35 (54%) men, meaning that the presence of spermatogenesis not always yields mature spermatozoa. From the nine KS-trios that were genetically analysed for X-chromosomal inheritance origin, no evidence of a correlation between the maternal or paternal origin of the additional X-chromosome and the presence of spermatogenesis was found. In conclusion, the maternal or paternal origin of the additional X-chromosome in men with KS does not predict the presence or absence of spermatogenesis.
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Affiliation(s)
- S Franik
- Department of Obstetrics and Gynaecology, Radboudumc Nijmegen, Nijmegen, The Netherlands.,Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
| | - D Smeets
- Department of Human Genetics, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - G van de Zande
- Department of Human Genetics, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - I Gomes
- Department of Human Genetics, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - K D'Hauwers
- Department of Urology, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - K Fleischer
- Department of Obstetrics and Gynaecology, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - L Ramos
- Department of Obstetrics and Gynaecology, Radboudumc Nijmegen, Nijmegen, The Netherlands
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50
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Weiss NS, Nahuis MJ, Bordewijk E, Oosterhuis JE, Smeenk JM, Hoek A, Broekmans FJ, Fleischer K, de Bruin JP, Kaaijk EM, Laven JS, Hendriks DJ, Gerards MH, van Rooij IA, Bourdrez P, Gianotten J, Koks C, Lambalk CB, Hompes PG, van der Veen F, Mol BWJ, van Wely M. Gonadotrophins versus clomifene citrate with or without intrauterine insemination in women with normogonadotropic anovulation and clomifene failure (M-OVIN): a randomised, two-by-two factorial trial. Lancet 2018; 391:758-765. [PMID: 29273245 DOI: 10.1016/s0140-6736(17)33308-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND In many countries, clomifene citrate is the treatment of first choice in women with normogonadotropic anovulation (ie, absent or irregular ovulation). If these women ovulate but do not conceive after several cycles with clomifene citrate, medication is usually switched to gonadotrophins, with or without intrauterine insemination. We aimed to assess whether switching to gonadotrophins is more effective than continuing clomifene citrate, and whether intrauterine insemination is more effective than intercourse. METHODS In this two-by-two factorial multicentre randomised clinical trial, we recruited women aged 18 years and older with normogonadotropic anovulation not pregnant after six ovulatory cycles of clomifene citrate (maximum of 150 mg daily for 5 days) from 48 Dutch hospitals. Women were randomly assigned using a central password-protected internet-based randomisation programme to receive six cycles with gonadotrophins plus intrauterine insemination, six cycles with gonadotrophins plus intercourse, six cycles with clomifene citrate plus intrauterine insemination, or six cycles with clomifene citrate plus intercourse. Clomifene citrate dosages varied from 50 to 150 mg daily orally and gonadotrophin starting dose was 50 or 75 IU daily subcutaneously. The primary outcome was conception leading to livebirth within 8 months after randomisation defined as any baby born alive after a gestational age beyond 24 weeks. Primary analysis was by intention to treat. We made two comparisons, one in which gonadotrophins were compared with clomifene citrate and one in which intrauterine insemination was compared with intercourse. This completed study is registered with the Netherlands Trial Register, number NTR1449. FINDINGS Between Dec 8, 2008, and Dec 16, 2015, we randomly assigned 666 women to gonadotrophins and intrauterine insemination (n=166), gonadotrophins and intercourse (n=165), clomifene citrate and intrauterine insemination (n=163), or clomifene citrate and intercourse (n=172). Women allocated to gonadotrophins had more livebirths than those allocated to clomifene citrate (167 [52%] of 327 women vs 138 [41%] of 334 women, relative risk [RR] 1·24 [95% CI 1·05-1·46]; p=0·0124). Addition of intrauterine insemination did not increase livebirths compared with intercourse (161 [49%] vs 144 [43%], RR 1·14 [95% CI 0·97-1·35]; p=0·1152). Multiple pregnancy rates for the two comparisons were low and not different. There were three adverse events: one child with congenital abnormalities and one stillbirth in two women treated with clomifene citrate, and one immature delivery due to cervical insufficiency in a woman treated with gonadotrophins. INTERPRETATION In women with normogonadotropic anovulation and clomifene citrate failure, a switch of treatment to gonadotrophins increased the chance of livebirth over treatment with clomifene citrate; there was no evidence that addition of intrauterine insemination does so. FUNDING The Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Nienke S Weiss
- Center for Reproductive Medicine, Academic Medical Center, Amsterdam, Netherlands; Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Marleen J Nahuis
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Esmee Bordewijk
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Jurjen E Oosterhuis
- Department of Obstetrics and Gynecology, St Antonius Ziekenhuis, Utrecht, Netherlands
| | - Jesper Mj Smeenk
- Department of Obstetrics and Gynecology, Elisabeth Ziekenhuis, Tilburg, Netherlands
| | - Annemieke Hoek
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Frank Jm Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University, Nijmegen, Netherlands
| | - Jan Peter de Bruin
- Jeroen Bosch Hospital, Department of Obstetrics and Gynecology, 's Hertogenbosch, Netherlands
| | - Eugenie M Kaaijk
- Department of Obstetrics and Gynecology, OLVG Amsterdam-Oost, Netherlands
| | - Joop Se Laven
- Department of Obstetrics and Gynecology, Erasmus MC Rotterdam, Rotterdam, Netherlands
| | - Dave J Hendriks
- Department of Obstetrics and Gynecology, Amphia Ziekenhuis Breda, Breda, Netherlands
| | - Marie H Gerards
- Department of Obstetrics and Gynecology, Martini Hospital Groningen, Groningen, Netherlands
| | - Ilse Aj van Rooij
- Department of Obstetrics and Gynecology, Elisabeth-Tweesteden Hospital, Tweesteden, Netherlands
| | - Petra Bourdrez
- Department of Obstetrics and Gynecology, VieCuri Medical Center, Venlo, Netherlands
| | - Judith Gianotten
- Department of Obstetrics and Gynecology, Spaarne Gasthuis, Haarlem, Netherlands
| | - Carolien Koks
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands
| | - Cornelis B Lambalk
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Peter G Hompes
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Fulco van der Veen
- Center for Reproductive Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia; Academic Medical Center, Amsterdam, Netherlands
| | - Madelon van Wely
- Center for Reproductive Medicine, Academic Medical Center, Amsterdam, Netherlands.
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