Women's reflections on timing of motherhood: a meta-synthesis of qualitative evidence

INTRODUCTION

Fertility declines with increasing age, especially in women. In recent decades women's age at the birth of their first child has risen markedly in many countries, and an increasing number of women do not establish a family until their late-twenties to mid-thirties. Although there can be various reasons that couples experience fertility problems, advanced maternal age is the most frequent cause for difficulties with achieving pregnancy.

OBJECTIVE

In this meta-synthesis, we investigated reflections on timing of motherhood in women who have not yet had children.

METHODS

A systematic literature search of six electronic databases and manual searches of reference lists identified eight qualitative studies published between 2011 and 2018 that focused on women's reflections on timing of motherhood. The studies were assessed with the Critical Assessment Skills Programme (CASP) quality appraisal tool. The results were synthesized using Noblit and Hare's meta-ethnographic approach as described by Malterud.

FINDINGS

An overall theme of 'Timing of motherhood' and four overlapping subthemes were identified: Making a life-changing decision, The right time, Fear of regret, and Plan B. The dilemmas associated with timing of motherhood leave women of reproductive age balancing their priorities and values against a biological deadline for having children naturally or through assisted reproductive technology.

CONCLUSIONS

Women of reproductive age are aware that they must make a life-changing decision as to if or when to have children, but they consider having children at 'the right time' to be important. Simultaneously, while some women are reluctant to have children for various reasons, they express fear that waiting too long could result in their regretting not having children later in life. Although women of reproductive age express concern about their ability to achieve pregnancy, they have limited focus on the medical risks associated with postponing motherhood. There is a need to establish preventive health initiatives to support women of reproductive age in their considerations regarding timing of motherhood.

TRIAL REGISTRATION NUMBER

PROSPERO: CRD42020175151.

The importance of the 'family clock': women's lived experience of fertility decision-making 6 years after attending the Fertility Assessment and Counselling Clinic

This study explored women's lived experience of making fertility decisions six years after attending the Fertility Assessment and Counselling (FAC) clinic in Copenhagen, Denmark, which is a personalised fertility awareness intervention. We conducted a qualitative interview study with 24 women who attended the FAC clinic 6 years earlier. Interviews were semi-structured and broadly examined the women's perceptions and experience of the intervention during follow-up. Data was analysed using a phenomenological framework and themes were identified related to women's experience of making fertility decisions after attending the FAC clinic. The overarching theme regarding the women's lived experience of making fertility decisions after attending the FAC clinic was: Fertility decisions were guided by the 'family clock'. There were four themes: (i) Deciding to 'get started' by attending the FAC clinic; (ii) Sense of making informed and empowered decisions; (iii) Influence of partner status on fertility decisions; and (iv) Decisions dictated by circumstance over preference and knowledge. At follow-up, the majority (21 women, 88%) had become parents. More than half of the women said that they had not achieved their desired family size. Consideration of women's 'family clock' is necessary in personalised fertility awareness interventions to enable women to achieve their family goals.

The Impact of Suppressing Estradiol During Ovarian Stimulation on the Unsupported Luteal Phase: A Randomized Controlled Trial

CONTEXT

Supraphysiological sex steroid levels at the follicular-luteal phase transition are implicated as the primary cause of luteal insufficiency after ovarian stimulation (OS) for in vitro fertilization.

OBJECTIVE

We aimed to determine the impact of suppressing estradiol levels during OS of multiple dominant follicles on the unsupported luteal phase and markers of endometrial maturation.

METHODS

At 2 university hospitals, 25 eligible egg donors were randomized to undergo OS using exogenous gonadotropins with or without adjuvant letrozole 5 mg/day. Final oocyte maturation was triggered with a GnRH agonist. No luteal support was provided. The primary outcome was the duration of the luteal phase. Secondary outcomes were luteal phase hormone profiles and the endometrial transcriptomic signature 5 days after oocyte pick up (OPU + 5).

RESULTS

The median (interquartile range [IQR]) luteal phase duration was 8.0 (6.8-11.5) days compared with 5.0 (5.0-6.8) days in the intervention and control group, respectively (P < 0.001). Estradiol levels were effectively suppressed in the letrozole group with a median of 0.86 (0.23-1.24) nmol/L at OPU compared to 2.82 (1.34-3.44) nmol/L in the control group. Median (IQR) progesterone levels at OPU + 5 were 67.05 (15.67-101.75) nmol/L in the letrozole group vs 2.27 (1.05-10.70) nmol/L in the control group (P < 0.001). In the letrozole group, 75% of participants revealed endometrial transcriptomic signatures interpreted as post-receptive. In the control group, 40% were post-receptive and 50% noninformative.

CONCLUSION

Suppressing estradiol levels in the follicular phase with adjuvant letrozole significantly reduces the disruption of the unsupported luteal phase after OS.

Does adjuvant letrozole reduce uterine peristalsis prior to fresh embryo transfer?

STUDY QUESTION

Does adjuvant letrozole in ovarian stimulation for in vitro fertilization (IVF) decrease the uterine peristalsis frequency (UPF) prior to fresh embryo transfer (ET)?

SUMMARY ANSWER

Adjuvant letrozole in ovarian stimulation for IVF does not reduce the UPF significantly prior to fresh ET.

WHAT IS KNOWN ALREADY

Throughout the cycle uterine peristalsis aids spermatozoa transport to the fallopian tube and may affect implantation. At fresh ET, UPF is negatively correlated with implantation and clinical pregnancy rates and is believed to be modulated by estradiol and progesterone. High levels of estradiol, from multiple follicular development, in ovarian stimulation have been reported to increase UPF, whereas progesterone is considered to be an utero-relaxant. The influence of androgens is unclear. Co-treatment with letrozole during gonadotropin ovarian stimulation limits the supra-physiological estradiol rise and may therefore reduce UPF prior to fresh ET.

STUDY DESIGN, SIZE, DURATION

This study was carried out on subjects participating in a single centre double blinded randomised controlled trial (RCT) of the impact of letrozole on follicle development and endocrine profiles, and investigated the impact of adjuvant letrozole in ovarian stimulation for IVF on UPF prior to fresh ET and the correlations of UPF with endocrine markers. Between 2016 and 2017, 39 women expected to be normal responders were randomised to co-treatment with letrozole or placebo. Of these, 33 women completed this element of the study. The study was carried out according to the Helsinki Declaration and the ICH-Good-Clinical-Practice.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible women were randomised 1:1 to adjuvant treatment with letrozole 5 mg/day or placebo in an antagonist protocol using a fixed dose of recombinant (r) FSH 150 IU/day. Final maturation was triggered with hCG 6,500 IU and luteal support with vaginal progesterone was administered from the day following oocyte aspiration. Less than one hour prior to fresh ET, six-minute duration transvaginal ultrasound recordings of the uterus in sagittal section were performed and blood samples were drawn.

MAIN RESULTS AND THE ROLE OF CHANGE

A total of 33 women completed the study (letrozole n = 17; placebo n = 16). Age, BMI and ovarian reserve markers were similar between the groups. On day of ET, serum estradiol levels were significantly suppressed in the letrozole group to a mean of 867 ± 827 pmol/L compared to 3,110 ± 1,528 pmol/L in the placebo group (P &lt; 0.001). Mean UPF prior to fresh ET did not differ between the intervention and placebo group (3.3 ± 0.36 versus 3.5 ± 0.51 per minute respectively, P = 0.108). UPF was assessed and agreed by two observers who were blinded to adjuvant treatment. Two patients were excluded due to poor quality of the ultrasound recordings. Supra-physiological serum estradiol in the placebo group were negatively correlated with UPF (P = 0.014; R = -0.62), but the more physiological serum estradiol levels in the letrozole group showed no correlation with UPF (P = 0.567; R = 0.15). Serum progesterone levels were similar in both groups and did not show any significant correlation with UPF. Testosterone levels were significantly higher in the letrozole group (P = 0.005) and showed a non-significant trend that negatively correlated with UPF in the placebo group (P-value=0.071, R= -0.48).

LIMITATIONS, REASONS FOR CAUTION

Limitations of the study included the limited sample size and the lack of a power calculation specifically determined for this endpoint.

WIDER IMPLICATIONS OF THE FINDINGS

The supra-physiological levels of estradiol generated during ovarian stimulation were significantly suppressed in the intervention group. However, UPF prior to fresh ET was similar in both groups. Modulating the luteal phase sex steroids with adjuvant letrozole had little measured impact on UPF. Any beneficial effect of adjuvant letrozole during ovarian stimulation is unlikely to be due to significant modulation of UPF.

STUDY FUNDING/COMPETING INTEREST(S)

MDH's salary was funded by an unrestricted research grant from Gedeon Richter. The expenses of the study was funded by a scientific collaboration: ReproUnion, co-financed by the European Union, Interreg Öresund-Kattegat-Skagerrak and Ferring Pharmaceuticals. The assays for the analyses were funded by Roche Diagnostics and an unrestricted research grant from Merck Life Science AS, Denmark. The authors have no competing interests to declare regarding this study.

TRIAL REGISTRATION NUMBER

Clinicatrials.gov: NCT02939898, EudraCT no.: 2015-005683-41.

Probiotic treatment with specific lactobacilli does not improve an unfavorable vaginal microbiota prior to fertility treatment-A randomized, double-blinded, placebo-controlled trial

OBJECTIVE

To investigate whether treatment with proprietary lactobacilli-loaded vaginal capsules improves an unfavorable vaginal microbiome diagnosed using a commercially available test and algorithm.

DESIGN

A randomized, double-blinded, placebo-controlled study was conducted in 74 women prior to undergoing fertility treatment at a single university fertility clinic between April 2019 and February 2021. The women were randomly assigned in a 1:1 ratio to receive one vaginal capsule per day for 10 days containing either a culture of more than 10⁸ CFU of Lactobacillus gasseri and more than 10⁸ CFU Lactobacillus rhamnosus (lactobacilli group) or no active ingredient (placebo group). Vaginal swabs for microbiota analysis were taken at enrollment, after treatment and in the cycle following treatment.

PARTICIPANTS AND METHODS

Women aged 18-40 years who prior to fertility treatment were diagnosed with an unfavorable vaginal microbiota, characterized by either a low relative load of Lactobacillus or a high proportion of disrupting bacteria using the criteria of the IS-pro™ diagnostic system (ARTPred, Amsterdam, the Netherlands), were enrolled in the study. The primary outcome measure was the proportion of women with improvement of the vaginal microbiota after intervention.

RESULTS

The vaginal microbiota improved after intervention in 34.2% of all participants (lactobacilli group 28.9%, placebo group 40.0%), with no significant difference in the improvement rate between the lactobacilli and placebo groups, RR = 0.72 (95% CI 0.38-1.38).

CONCLUSION

This study indicates that administering vaginal probiotics may not be an effective means of modulating the vaginal microbiome for clinical purposes in an infertile population. However, a spontaneous improvement rate of 34.2% over a period of one to three months, confirming the dynamic nature of the vaginal microbiota, indicates that a strategy of postponing further IVF treatment to await microbiota improvement may be relevant in some patients, but further research is needed.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT03843112.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Two waves of transcriptomic changes in periovulatory human granulosa cells

STUDY QUESTION

How does the human granulosa cell (GC) transcriptome change during ovulation?

SUMMARY ANSWER

Two transcriptional peaks were observed at 12 h and at 36 h after induction of ovulation, both dominated by genes and pathways known from the inflammatory system.

WHAT IS KNOWN ALREADY

The crosstalk between GCs and the oocyte, which is essential for ovulation and oocyte maturation, can be assessed through transcriptomic profiling of GCs. Detailed transcriptional changes during ovulation have not previously been assessed in humans.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study comprised 50 women undergoing fertility treatment in a standard antagonist protocol at a university hospital-affiliated fertility clinic in 2016-2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From each woman, one sample of GCs was collected by transvaginal ultrasound-guided follicle aspiration either before or 12 h, 17 h or 32 h after ovulation induction (OI). A second sample was collected at oocyte retrieval, 36 h after OI. Total RNA was isolated from GCs and analyzed by microarray. Gene expression differences between the five time points were assessed by ANOVA with a random factor accounting for the pairing of samples, and seven clusters of protein-coding genes representing distinct expression profiles were identified. These were used as input for subsequent bioinformatic analyses to identify enriched pathways and suggest upstream regulators. Subsets of genes were assessed to explore specific ovulatory functions.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified 13 345 differentially expressed transcripts across the five time points (false discovery rate, <0.01) of which 58% were protein-coding genes. Two clusters of mainly downregulated genes represented cell cycle pathways and DNA repair. Upregulated genes showed one peak at 12 h that resembled the initiation of an inflammatory response, and one peak at 36 h that resembled the effector functions of inflammation such as vasodilation, angiogenesis, coagulation, chemotaxis and tissue remodelling. Genes involved in cell-matrix interactions as a part of cytoskeletal rearrangement and cell motility were also upregulated at 36 h. Predicted activated upstream regulators of ovulation included FSH, LH, transforming growth factor B1, tumour necrosis factor, nuclear factor kappa-light-chain-enhancer of activated B cells, coagulation factor 2, fibroblast growth factor 2, interleukin 1 and cortisol, among others. The results confirmed early regulation of several previously described factors in a cascade inducing meiotic resumption and suggested new factors involved in cumulus expansion and follicle rupture through co-regulation with previously described factors.

LARGE SCALE DATA

The microarray data were deposited to the Gene Expression Omnibus (www.ncbi.nlm.nih.gov/gds/, accession number: GSE133868).

LIMITATIONS, REASONS FOR CAUTION

The study included women undergoing ovarian stimulation and the findings may therefore differ from a natural cycle. However, the results confirm significant regulation of many well-established ovulatory genes from a series of previous studies such as amphiregulin, epiregulin, tumour necrosis factor alfa induced protein 6, tissue inhibitor of metallopeptidases 1 and plasminogen activator inhibitor 1, which support the relevance of the results.

WIDER IMPLICATIONS OF THE FINDINGS

The study increases our understanding of human ovarian function during ovulation, and the publicly available dataset is a valuable resource for future investigations. Suggested upstream regulators and highly differentially expressed genes may be potential pharmaceutical targets in fertility treatment and gynaecology.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by EU Interreg ÔKS V through ReproUnion (www.reprounion.eu) and by a grant from the Region Zealand Research Foundation. None of the authors have any conflicts of interest to declare.

Ovarian reserve markers and endocrine profile during oral contraception: Is there a link between the degree of ovarian suppression and AMH?

The ovarian reserve markers anti-Müllerian hormone (AMH) and antral follicle count (AFC) are suppressed in varying degree during the use of combined oral contraceptives (COC). Further, long-term use of COC can mask a condition of premature ovarian insufficiency. A desirable clinical tool that could distinguish true low ovarian reserve markers from COC-induced low levels during use of COC is warranted. The aim of this multicenter study including 235 COC users was to assess whether low age-adjusted AMH levels during COC use were linked to concomitant low levels of LH, FSH, estradiol and androgens - as a potential future tool to differentiate between 'false', COC-induced low AMH levels vs. true low AMH. Study population and methods: In total, 235 COC users from the general population aged 19-40 years were included. AMH, AFC and a reproductive hormonal profile were measured during COC intake. Age-adjusted AMH levels (Z-scores) were calculated from a comparison group of 983 non-users of COC. Differences in hormonal profile were tested between women with low versus high age-adjusted AMH-quartiles based on non-parametric Wilcoxon rank sum tests. The outcomes of interest were levels of gonadotropins, estradiol and androgens according to the four the age-adjusted AMH quartiles to find out if women with low age-adjusted AMH levels had a stronger gonadotropin suppression compared with women with higher age-adjusted AMH levels. Mean age of COC users was 30.2 years (SD 3.8), median AMH 14 pmol/l (inter-quartile range (IQR) 8.7-23)), median AFC 16 (IQR 11-25). We found no significant differences across the age-adjusted AMH quartiles in either the levels of gonadotropins, estrogens or androgens, respectively. Thus, the degree of suppression of FSH, LH, androgens and estradiol are unlikely to be a useful tool to differentiate between false low and true low ovarian reserve markers during COC use. Presently, there seems to be no alternative to withdrawal of the COC and to re-test the ovarian reserve after 2-3 months. Trial registration Trial no. NCT02785809 (www.clinicaltrials.gov).

Are different markers of endometrial receptivity telling us different things about endometrial function?

PROBLEM

To what extent do endocrine, immunological, gene expression and histological markers of endometrial receptivity correlate?

METHOD OF STUDY

Between November 2017 and September 2019, 121 women referred to a University Hospitals Fertility Clinic consented to inclusion in this cohort study. The women underwent timed endometrial biopsy followed by blood samples in a hormone-substituted cycle. Of these, 37 women had just started IVF treatment, and the remaining 84 had experienced recurrent implantation failure following IVF/ICSI. The hormone-substituted cycle consisted of initiation with oral oestradiol followed by addition of vaginal progesterone treatment for five full days. Endometrial biopsies were subject to histological examination, immune cell markers by immunohistochemistry (CD56⁺ , CD16⁺ , CD163⁺ , FoxP3) and gene expression microarray analyses with the endometrial receptivity array (ERA^® ) test (Igenomix). Plasma progesterone and oestradiol were measured on the day of biopsy.

RESULTS

CD56⁺ uterine natural killer (uNK) cell counts correlate with transcriptional markers of endometrial receptivity assessed by the ERA test. Endometrial maturation, receptivity and immunological markers were not correlated with mid-luteal blood plasma progesterone level. Mid-luteal serum oestradiol level correlated with markers of endometrial maturation and receptivity. The tests were carried out during a standard hormone substitution cycle, and the findings may not apply in the natural cycle.

CONCLUSION

CD56⁺ uNK cell counts and endometrial receptivity assessed by the ERA test appear to be linked. Mid-luteal progesterone levels were not correlated to the tested markers of endometrial receptivity. In contrast, mid-luteal oestradiol level was inversely related to markers of endometrial receptivity and maturation.

Assessing endometrial receptivity after recurrent implantation failure: a prospective controlled cohort study

RESEARCH QUESTION

What is the prevalence of disrupted markers of endometrial function among women experiencing recurrent implantation failure (RIF), and does the prevalence differ from a control cohort?

DESIGN

Prospective controlled cohort study. In total, 86 women with a history of RIF and 37 women starting their first fertility treatment were recruited for this study. Endometrial and blood profiling were carried out in a hormone-substituted cycle using oestradiol and progesterone. Endometrial biopsies were analysed by histology, immune cell profiling, and the endometrial receptivity array (ERA®) test (Igenomix, Valencia, Spain). The vaginal microbiome was analysed using a NGS-based technology (ArtPRED, Amsterdam, the Netherlands). Blood tests included oestradiol, progesterone, prolactin, thyroid-stimulating hormone, vitamin D and anti-phospholipid antibody levels.

RESULTS

Patients who had experienced RIF produced a range of test abnormalities. Compared with controls, women with RIF had a higher prevalence of chronic endometritis (24% versus 6%), a lower vitamin D level and a borderline lower progesterone level. Women who had experienced RIF had a more favourable vaginal microbiome compared with controls. Although the RIF cohort was older than the controls (mean age 33.8 years versus 30.2 years), no differences between the groups were observed in immune cell profiling and the ERA test.

CONCLUSION

These data demonstrate that a single test or treatment for the endometrial factor in RIF is unlikely to be clinically effective. Diagnosing the endometrium in women with RIF permits targeted rather than blind interventions. Relative vitamin D deficiency, lower mid-luteal progesterone and chronic endometritis are ready targets for treatment. Understanding the role and treatment of an unfavourable vaginal microbiome in RIF needs further investigation.

[Recommended therapy for psychosocial consequences of infertility and fertility treatment]

Infertility and fertility treatment are both major stressors, which can cause prolonged psychological distress and vulnerability as summarised in this review. There are well-founded initiatives such as screening, patient-centred care and, in a Nordic context, psychosocial interventions with training sessions in e.g. coping in order to improve the well-being of these patients. However, in Denmark, psychosocial care in public fertility clinics is limited, and no mental health professionals are represented at the public clinics. Consequently, a gap remains between the recommendations in this area and the clinical practice.

Biological and Clinical Rationale for Androgen Priming in Ovarian Stimulation

Androgen receptors are expressed by all stages of growing follicles, and follicular fluid androgen levels are positively correlated to granulosa cell androgen receptor and follicle-stimulating hormone (FSH) receptor expression. Thus, androgens may promote follicular growth, accumulation and/or responsiveness to gonadotropins. This is explored therapeutically in the concept of androgen priming, to improve the ovarian response to stimulation in assisted reproduction. Androgen effects may be achieved in two different ways, either directly by providing exogenous androgen or by providing luteinizing hormone (LH) activity [i.e., LH or human chorionic gonadotropin (hCG)] to stimulate local ovarian production of androgen. The androgen concentrations in follicular fluid by far exceed the levels in female circulation and it has recently been shown that there was no correlation between serum testosterone levels and follicular fluid androgen levels. There is some evidence that administration of exogenous dehydroepiandrosterone or testosterone increases live birth rates, but an optimal protocol has not been established and such adjuvant treatment should be considered experimental. Furthermore, studies exploring long-term administration of LH activity, achieving LH levels comparable to those seen in women with polycystic ovary syndrome, are awaited. The aim of the present review is to discuss critically the most suitable approach for androgen priming from a biological and clinical standpoint, and to evaluate current approaches and results obtained in clinical trials.

Ovarian reserve markers in women using various hormonal contraceptives

Objectives: The aim of the study was to assess whether the ovarian reserve markers anti-Müllerian hormone (AMH) and antral follicle count (AFC) were lower among women using the progestin-only pill (POP) or levonorgestrel-releasing intrauterine system (LNG-IUS) and similar to the decrease observed in combined oral contraceptive (COC) pill users.Methods: This retrospective study comprised 565 hormonal contraceptive users (COC, POP, LNG-IUS or contraceptive vaginal ring) and 983 non-hormonal contraceptive users, who were seen in two Danish fertility assessment and counselling clinics between 2015 and 2019. Adjusted multiple regression analysis was used to examine the differences in AMH and AFC between hormonal and non-hormonal contraceptive users.Results: Compared with non-hormonal contraceptive users, AMH was 31.1% lower among COC users [95% confidence interval (CI) -39.6%, -25.9%; p < 0.001], 35.6% lower among POP users (95% CI -49.0%, -18.6%; p < 0.001) and 17.1% lower among LNG-IUS users (95% CI -31.4%, 0.002%; p = 0.052); no significant differences were seen among vaginal ring users. Compared with non-hormonal contraceptive users, AFC was 31.3% lower among COC users (95% CI -35.0%, -25.3%; p < 0.001) and 29.7% lower among POP users (-39.1%, -17.9%; p < 0.001); no significant differences were seen among LNG-IUS or vaginal ring users. Ovarian volume was more than 50% reduced among COC and vaginal ring users (p < 0.001) but was unchanged among POP and LNG-IUS users.Conclusion: Assessment of ovarian reserve markers among users of all types of hormonal contraception should be interpreted cautiously and the type of contraceptive method considered.

Preparation of the endometrium and timing of blastocyst transfer in modified natural cycle frozen-thawed embryo transfers (mNC-FET): a study protocol for a randomised controlled multicentre trial

INTRODUCTION

Despite the high number of frozen embryo transfer (FET) cycles being conducted (190 000 cycles/year) in Europe, the timing of blastocyst transfer and the use of luteal phase progesterone support in modified natural cycle FET (mNC-FET) in assisted reproductive technologies are controversial. In mNC-FET, the timing of blastocyst warming and transfer is determined according to the time of implantation in a natural cycle, aiming to reach blastocyst endometrial synchronicity. However, the optimal day of blastocyst transfer following ovulation trigger is not determined. In addition, the value of luteal phase support to maintain the endometrium remains uncertain. Thus, there is a need to identify the optimal timing of blastocyst warming and transfer and the effect of luteal phase support in a randomised controlled trial design. The aim of this randomised controlled trial is to investigate if progesterone supplementation from the early luteal phase until gestational age 8 weeks is superior to no progesterone supplementation and to assess if blastocyst warming and transfer 6 days after ovulation trigger is superior to 7 days after ovulation trigger in mNC-FET with live birth rates as the primary outcome.

METHODS AND ANALYSIS

Multicentre, randomised, controlled, single-blinded trial including 604 normo-ovulatory women aged 18-41 years undergoing mNC-FET with a high-quality blastocyst originating from their first to third in vitro fertilisation/intracytoplasmic sperm injection cycle. Participants are randomised (1:1:1:1) to either luteal phase progesterone or no luteal phase progesterone and to blastocyst warming and transfer on day 6 or 7 after human chorionic gonadotropin trigger. Only single blastocyst transfers will be performed.

ETHICS AND DISSEMINATION

The study is approved by the Danish Committee on Health Research Ethics (H-18025839), the Danish Medicines Agency (2018061319) and the Danish Data Protection Agency (VD-2018-381). The results of the study will be publicly disseminated.

TRIAL REGISTRATION NUMBER

The study is registered in EudraCT (2018-002207-34) and on ClinicalTrials.gov (NCT03795220); Pre-results.

Status one year after fertility assessment and counselling in women of reproductive age-a qualitative study

INTRODUCTION

Over the past 50 years women and men have postponed family formation in high-income societies. Fertility assessment and counselling has been suggested as a method to reduce delayed childbearing and its consequences. This study explored women's perceptions of how attending a fertility assessment intervention influenced their decisions and choices regarding family formation and childbearing.

MATERIAL AND METHODS

Follow-up data from a longitudinal semi-structured qualitative interview study including 20 women aged 35-40 years seeking individual fertility counselling at the Fertility Assessment and Counselling Clinic at Rigshospitalet, Copenhagen, Denmark. The interviews were conducted one year after their consultation. Data were analysed by qualitative content analysis.

RESULTS

The women perceived an increase in their knowledge after they had attended the counselling. The women saw the counselling as a catalyst for change-they changed their behaviour and relationship status. The women stopped thinking about the pros and cons of childbearing and acted instead. The women did not experience any regrets about acting. Some of the women felt that they were still in limbo as they were still in doubt concerning childbearing. The consultation had not given them an answer with a clear deadline in terms of delaying attempts to become pregnant, and this frustrated them.

CONCLUSIONS

Our study highlights the impact of a fertility assessment and counselling intervention which included a perceived increase in knowledge. The clinic allows for an individualized approach to fertility awareness which is necessary given the unique nature of childbearing decisions.

Anti-Müllerian hormone levels and fecundability in women with a natural conception

OBJECTIVES

To investigate the association between anti-Müllerian hormone (AMH), a well-established marker of the ovarian reserve, and time-to-pregnancy (TTP) in natural conceptions, and to assess changes in serum-AMH in early pregnancy.

STUDY DESIGN

A cross sectional study comprising 279 women aged 21-42 years with a natural conception recruited during 2012-2014. AMH was measured in gestational week 10-19. AMH z-scores (z-AMH) adjusted for gestational week at blood sampling were categorised in the 1st, 2nd-4th (reference), and 5th quintile. Data were analysed by discrete-time survival-analysis and results presented as odds ratios (OR), 95% confidence interval (CI); OR <1 indicating a longer TTP and OR >1 indicating a shorter TTP.

RESULTS

The median AMH-level was 23.0 (range:<3.0;144.0)pmol/l, and serum-AMH decreased by 7.5% (95% CI:-12.0%;-2.8%) per gestational week. Mean±SD female age was 30.9±3.6years. The median TTP was 2 (range: 1-32) months. After adjustment for possible confounders including total sperm count, TTP was unrelated to female age (aOR:1.0, 95% CI:0.9;1.0) and continuous z-AMH (aOR:0.8, 95% CI:0.7;1.0), but women in the low z-AMH group had a shorter TTP than the reference group (aOR:1.7, 95% CI:1.1;2.7). TTP was prolonged in preconception oral contraceptive (OC) users (aOR:0.7, 95% CI:0.5;1.0, p=0.04). Compared with women having used OC <2 years, TTP was significantly longer in women having used OC for 2-12 years (aOR:0.5, 95% CI:0.2;1.0, p=0.048) and >12 years (aOR:0.4, 95% CI:0.2;0.9, p=0.022) after age-adjustment.

CONCLUSIONS

TTP was unrelated with z-AMH when modelled as a continuous covariate. Unexpectedly, TTP was shorter in the low z-AMH group. Natural conception was observed in women with a wide range of AMH-levels including women with undetectable serum-AMH. A continuous decrease in serum-AMH was observed during first and second trimester. Preconception OC-use was identified as an independent predictor of a prolonged TTP, and the duration of OC-use appeared to influence the delay in conception. Although this is presently one of the largest studies investigating the association between AMH and fecundability in fertile women, the study has some limitation including a relatively low participation rate and a risk of selection bias in addition to AMH assessment in pregnancy and a retrospective collection of TTP and OC-use associated with a risk of recall bias. These limitations may explain the unexpected finding of a shorter TTP in the low z-AMH group.

Left-right differences in ovarian volume and antral follicle count in 1423 women of reproductive age

The aim of this cross-sectional study was to investigate side differences in antral follicle count (AFC) and ovarian volume in left versus right ovaries in relation to chronological and "biological" age, the latter estimated by anti-Müllerian hormone (AMH) levels. The cohort comprised 1423 women: 1014 fertile and 409 infertile. All were examined by transvaginal sonography and serum AMH. Overall the right ovary contained 8.1% more antral follicles (p = 0.002) and had 10.7% larger volume compared with the left (p < 0.001). In all AMH quartiles, the right ovarian volume was larger than the left (p ≤ 0.003). AFC was significantly higher in the right compared to the left ovary in the three upper AMH quartiles (p ≤ 0.005). The findings were similar when stratified in age quartiles. More than half (54.8%) had polycystic ovarian (PCO) morphology in at least one ovary. Of these women, 46.3% (n = 361) had PCO morphology unilateral - most frequently on the right side (27.6%) compared to the left (18.7%, p < 0.001). The consistent difference in AFC and ovarian volume found in AMH and age quartiles may be explained by presence of a larger pool of primordial follicles in the right ovary established during fetal life.

[Fertility screening is a new concept]

The Fertility Assessment and Counselling Clinic was initiated in 2011 as an analogue to the family planning clinics in the 1970s, but with a pro-fertility aim. The idea was to provide individual assessment of fertility risk factors, ovarian reserve and sperm concentration to help women and men to fulfil their reproductive life plan. Fertility screening on an individual level is a new concept, and the Fertility Assessment and Counselling Clinic is the first of its kind. The aim of the clinic is to reduce the need for fertility treatments and to prevent involuntary childlessness.

Individual fertility assessment and counselling in women of reproductive age

The overall aim of this thesis was to validate the new concept of the Fertility Assessment and Counselling (FAC) Clinic at Rigshospitalet. The intention was to: explore the prognostic value of fertility risk factors by a risk score and provide an estimate of female fecundity, to quantify the impact of oral contraception (OC) on ovarian reserve parameters defined as Anti Müllerian Hormone (AMH), Antral Follicle Count (AFC) and ovarian volume, and to gain knowledge of attitudes and considerations toward family formation in women of advanced age. The thesis is based on the following four manuscripts:   Manuscript I describes the predictive value of individual fertility assessment and counselling in terms of subsequent time to pregnancy within two years after the initial consultation at the FAC Clinic. The follow up study comprised 519 women, of which 352 had tried to conceive. At the time of follow-up, 259/352 had achieved a pregnancy, 74/352 were still trying and 19/352 had given up. The remaining 167 women had no attempts to conceive. The risk assessment provided a score based on the appearance of fertility risk factors: green (low), yellow (low), orange (medium) and red (high). Two-thirds of the women with only low risk scores conceived spontaneously within 12 months (65%), while this figure was only 32% for women with at least one high risk score (n=82). Accordingly, presence of at least one high risk score reduced the odds of achieving a pregnancy within 12 months by 73% (OR 0.27, 95%CI 0.13-0.57). The FAC Clinic concept seems as a usable tool for fertility experts to guide women on how to fulfil their reproductive life-plan, but longer follow-up studies are needed. Manuscript II describes the impact of OC on ovarian reserve parameters in 887 women at the FAC Clinic. Of the 887 women, 244 (27.5%) used OC.  The 244 users of OC were significantly younger than non-users with a mean age of 31.5 (SD 4.3) vs. 34.1 (SD 4.3) years (p < 0.001). Overall, there was no difference between the two groups in relation to bodyweight, BMI, smoking habits, gestational age at birth, prenatal exposure to maternal smoking or maternal age at menopause. In linear regression analyses adjusted for age, ovarian volume was 50% lower, AMH was 19% lower, and AFC was 18% lower in OC-users compared to non-users. Among the OC users there was a significant decrease in antral follicles sized 5-7 and 8-10 mm and an increase in the number of small follicles sized 2-4 mm. Physicians have to be aware of the impact of OC use on ovarian reserve parameters and possible concealment of premature ovarian insufficiency, when assessing the fertility status and estimating the reproductive lifespan in OC users. Manuscript III describes the family intentions and personal considerations on postponing childbearing in 340 childless women of advanced age. The study comprised 140 cohabiting and 200 single women aged 35-43 seeking fertility assessment and counselling at the FAC Clinic. The majority (82%) was well-educated and in employment. Despite their mean age of 37.4 years, the main reasons for attending the FAC Clinic were to gain knowledge on the possibility of postponing pregnancy (63%) and due to a concern about their fecundity (52%). Both the cohabiting and single women expressed a wish for two or more children (60%). The most important benefits were "personal development" (89%) and "to give and receive love" (86%). The main concerns about childbearing were "less time to myself" (82%) and "less time to job and career" (76%). The single women were more positive regarding the use of donor sperm (70%) compared to the cohabiting women (25%). Our results indicated a general overestimation of the women´s own reproductive capacity and an underestimation of their risk of future infertility and childlessness with continuous postponement of pregnancies. Manuscript IV describes attitudes toward family formation in ten single and ten cohabiting childless women of advanced age. The women were interviewed one week before their consultation at the FAC Clinic about their family formation intentions, considerations and concerns. The interviews were analysed and condensed into four categories: ''The biological clock'', ''The difficult choice'', ''The dream of the nuclear family'', and ''Mother without a father''. The categories were condensed into two subthemes; `Fear´ and `Expectations´ and gathered into one main theme 'The conflict of choosing', which reflected the women's attitudes toward family formation prior to individual fertility counselling. The women attended the FAC Clinic due to a concern about their fecundity and a fear for infertility. Overall, the women expressed a dream of the nuclear family and finding "Mr. Right" and many with the wish of buying more time. Both groups would consider solo motherhood due to their advanced age, although it was considered to be Plan B, as it was not "natural".

Mono-ovulation in women with polycystic ovary syndrome: a clinical review on ovulation induction

Polycystic ovary syndrome (PCOS) affects 5-10% of women of reproductive age and is the most common cause of anovulatory infertility. The treatment approaches to ovulation induction vary in efficacy, treatment duration and patient friendliness. The aim was to determine the most efficient, evidence-based method to achieve mono-ovulation in women diagnosed with PCOS. Publications in English providing information on treatment, efficacy and complication rates were included until September 2015. Systematic reviews, meta-analyses and randomized controlled trials were favoured over cohort and retrospective studies. Clomiphene citrate is recommended as primary treatment for PCOS-related infertility. It induces ovulation in three out of four patients, the risk of multiple pregnancies is modest and the treatment is simple and inexpensive. Gonadotrophins are highly efficient in a low-dose step-up regimen. Ovulation rates are improved by lifestyle interventions in overweight women. Metformin may improve the menstrual cycle within 1-3 months, but does not improve the live birth rate. Letrozole is effective for ovulation induction, but is an off-label drug in many countries. Ovulation induction in women with PCOS should be individualized with regard to weight, treatment efficacy and patient preferences with the aim of achieving mono-ovulation and subsequently the birth of a singleton baby.

Attitudes towards family formation in cohabiting and single childless women in their mid- to late thirties

This study aimed to explore attitudes towards family formation in single or cohabiting childless women of advanced age. The design comprised semi-structured qualitative interviews of 20 women aged 34-39 years attending the Fertility Assessment and Counselling Clinic, Rigshospitalet, Copenhagen. A sample of 10 single women and 10 cohabiting women was chosen with equal distribution of postgraduate education length. Data were analysed using content analysis following the method of Graneheim and Lundman and consolidated criteria for reporting qualitative research (COREQ). The general attitude towards family formation was characterized by a fear of the consequences of choosing motherhood on one hand, and a 'ticking biological clock' and a wish to establish a nuclear family on the other. The women idealized the perception of perfect mothering in terms of uncompromising expectations of child rearing and showed an increasing awareness of solo motherhood as a possible solution to advanced age, the wish of a child and single status compared to earlier studies. Our study contributes to knowledge and understanding of personal considerations related to childbearing in nullipara women in their mid- to late 30s and may be useful in a fertility assessment and counselling setting.

Cesarean scar pregnancy: a systematic review of treatment studies

OBJECTIVE

To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality.

DESIGN

Systematic review.

SETTING

Not applicable.

PATIENT(S)

A total of 2,037 women with CSP.

INTERVENTION(S)

Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments.

MAIN OUTCOME MEASURE(S)

Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000 mL, or blood transfusion.

RESULT(S)

Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy.

CONCLUSION(S)

This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Individual fertility assessment and pro-fertility counselling; should this be offered to women and men of reproductive age?

During the 1970s new contraceptive options developed and legal abortions became accessible. Family planning clinics targeting young women and men provided advice and assistance on contraception. Today, delayed childbearing, low total fertility rates and increasing use of social oocyte freezing create a need for pro-fertility initiatives. Three years ago we established a new separate unit: The Fertility Assessment and Counselling (FAC) clinic. The FAC clinic offers free individual counselling based on a clinical assessment including measurement of serum anti-Müllerian hormone and ovarian and pelvic sonography in women, sperm analysis in men, and a review of reproductive risk factors in both sexes. The FAC clinic includes a research programme with the goal to improve prediction and protection of fertility. Our first proposition is that clinics for individual assessment and counselling need to be established, as there is a strong unmet demand among women and men to obtain: (i) knowledge of fertility status, (ii) knowledge of reproductive lifespan (women) and (iii) pro-fertility advice. Addressing these issues is often more challenging than treating infertile patients. Therefore, we propose that fertility assessment and counselling should be developed by specialists in reproductive medicine. There are two main areas of concern: As our current knowledge on reproductive risk factors is primarily based on data from infertile patients, the first concern is how precisely we are able to forecast future reproductive problems. Predictive parameters from infertile couples, such as duration of infertility, are not applicable, diagnostic factors like tubal patency are unavailable and other parameters may be unsuitable when applied to the general population. Therefore, strict validation of reproductive forecasting in women and men from the general population is crucial. The second main concern is that we may turn clients into patients. Screening including reproductive forecasting may induce unnecessary anxiety through false positive predictions and may even result in overtreatment in contrast to the intended preventive concept. False negative findings may create false reassurance and result in postponement of conceptions.

Increasing prevalence of group B streptococcal infection among pregnant women

INTRODUCTION

Group B streptococci (GBS) can cause preterm delivery for women and sepsis and meningitis in infants younger than 90 days of age. The present retrospective cohort study determines the trend over time in the rates of GBS and in demographic risk factors for GBS among pregnant women delivering at Rigshospitalet (RH).

MATERIAL AND METHODS

In the period from 2002 to 2010, a total of 33,616 women gave birth at the RH. Our cohort was defined as 16,587 (49%) women examined by 24,724 cultures. All microbiological requisitions from the Department of Obstetrics at RH were extracted from the Clinical Microbiology Database. Maternal data were obtained from a local database at the RH.

RESULTS

In our cohort, a total of 638 (3.8%) women were diagnosed with GBS, 517 (81%) from urine, 92 (14%) from vaginal swabs and 29 (5%) from both. The overall rate of women colonised with GBS rose from 3.3% in 2002 to 5.1% in 2010 (p < 0.0001). A total of 48 infants had early-onset group B streptococcus (EOGBS), 1.4 per 1,000 neonates in the general population and 7.8 per 1,000 among women with GBS (p < 0.0001).

CONCLUSION

We found a low GBS colonisation rate in our pregnant cohort, but the rate followed an increasing trend over the study period. GBS during pregnancy was associated with a low birth weight and preterm delivery. More research on preventive measures is needed, but updated guidelines, screening and intrapartum antibiotic prophylaxis continue to be the cornerstones of EOGBS disease prevention.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study

OBJECTIVE

To examine the association between intended mode of delivery and severe postpartum haemorrhage.

DESIGN

A retrospective cohort study.

SETTING

Material from a nationwide study in Denmark.

POPULATION

Danish women giving birth in 2001-08.

METHODS

We compared use of red blood cell transfusion by intended mode of delivery in the total population (n = 382 266), in low-risk nulliparous women (n = 147 132) and in women with a previous caesarean delivery (n = 25 156).

MAIN OUTCOME MEASURE

Red blood cell transfusion within 7 days of delivery.

RESULTS

In the total population the crude transfusion rates for women with planned caesarean delivery and intended vaginal delivery were 2.24 and 1.75%. After adjustment for maternal age, body mass index, birthweight, smoking, parity, number of infants and previous caesarean delivery, the risk of red blood cell transfusion was significantly lower in women with planned caesarean delivery compared with intended vaginal delivery (odds ratio 0.82; 95% CI 0.73-0.92; P < 0.01). In low-risk nulliparous women and in women with a previous caesarean delivery the transfusion rates were lower for planned caesarean delivery compared with intended vaginal delivery before and after adjustment.

CONCLUSION

Compared with intended vaginal delivery, planned caesarean delivery was associated with a reduced risk of severe postpartum haemorrhage indicated by use of red blood cell transfusion.

[Pneumomediastinum and subcutaneous emphysema complicating active labour]

Subcutaneous emphysema and pneumomediastinum were first described by Hamman in 1945. Spontaneous pneumomediastinum is an uncommon, self-limiting condition caused by alveolar rupture and usually results from bronchial hyper-reactivity or barotraumas. We report a case describing a 25 year old patient in her first pregnancy, who during active labour developed subcutaneous emphysema and pneumomediastinum. Pneumomediastinum in labour is a rare complication to Valsalva maneuver, and it is diagnosed with a computed tomography. The most common symptoms are chest pain, dyspnea, neck pain and odynophagia.

[Treatment of placenta percreta requires a multidisciplinary approach]

Placenta percreta is a rare life-threatening obstetrical condition, often resulting in severe haemorrhage and hysterectomy. The incidence seems to be increasing, probably secondary to the increase in caesarean section rates. We present a protocol for an elective multidisciplinary approach with proactive management to reduce haemorrhage and allow appropriate surgery, which imply a low maternal and fetal morbidity as well as maintained fertility.

[Pregnancy within the uterine scar of a prior Caesarean section]

Rarely, but with increasing frequency, we detect pregnancies within the uterine scar of a prior Caesarean section. These ectopic pregnancies entail a risk of severe bleeding and uterine rupture, and thus constitute a threat to the pregnant woman's life, underlining the necessity of awareness about these complications. Vaginal bleeding and/or mild to moderate lower abdominal pain are symptoms seen in half of the women. The diagnosis is made by sonography and criteria for these are listed. We here present the most recent studies on treatment strategies, follow-up and future fertility.

Preparation of bioconjugates by solid-phase conjugation to ion exchange matrix-adsorbed carrier proteins

A solid-phase conjugation method utilizing carrier protein bound to an ion exchange matrix was developed. Ovalbumin was adsorbed to an anion exchange matrix using a batch procedure, and the immobilized protein was then derivatized with iodoacetic acid N-hydroxysuccinimid ester. The activated protein was conjugated with glutathione, the conjugation ratio determined by acid hydrolysis, and amino acid analysis performed with quantification of carboxymethyl cysteine. Elution of conjugates from the resin by a salt gradient revealed considerable heterogeneity in the degree of derivatization, and immunization experiments with the eluted conjugates showed that the more substituted conjugates gave rise to the highest titers of glutathione antibodies. Direct immunization with the conjugates adsorbed to the ion exchange matrix was possible and gave rise to high titers of glutathione antibodies. Conjugates of ovalbumin and various peptides were prepared in a similar manner and used for production of peptide antisera by direct immunization with the conjugates bound to the ion exchanger. Advantages of the method are its solid-phase nature, allowing fast and efficient reactions and intermediate washings, and the ability to release conjugates from the solid phase under mild conditions.

Application of fluorescence in situ hybridization techniques in clinical genetics: use of two alphoid repeat probes detecting the centromeres of chromosomes 13 and 21 or chromosomes 14 and 22, respectively

Two cloned DNA fragments, one derived from an alpha satellite subfamily common to chromosomes 13 and 21, and the other derived from a similar subfamily common to chromosomes 14 and 22, have been used as biotinylated probes in in situ hybridization studies. Under high stringency conditions, chromosome specific centromeric labelling can be obtained. The applications of this technique in clinical situations are illustrated on metaphases from a fetus with trisomy 21, a fetus with trisomy 13, and a child with clinical features of cat-eye syndrome.

Prenatal diagnosis of alpha-1-antitrypsin deficiency using polymerase chain reaction (PCR). Comparison of conventional RFLP methods with PCR used in combination with allele specific oligonucleotides or RFLP analysis

Prenatal diagnosis of alpha 1-antitrypsin (AAT) deficiency can be performed in the 1st trimester of pregnancy. These diagnoses have been based on DNA technology using either RFLP analysis or hybridization with allele specific oligonucleotides. Several RFLPs within and flanking the AAT gene have been found to render most families informative. The polymerase chain reaction allows specific DNA sequences to be amplified up to ten million fold. Both sequences containing a specific mutation or an RFLP can be amplified by this method. We have compared conventional RFLP methods with PCR used in combination with allele specific oligonucleotides or RFLP analysis, in a case of prenatal diagnosis of AAT deficiency of the ZZ type.

Oligonucleotide-priming methods for the chromosome-specific labelling of alpha satellite DNA in situ

It is demonstrated that either general staining of the centromeric regions of all primate chromosomes, or selective staining of the centromeric region of specific chromosomes, may be obtained in preparations of metaphase chromosomes by probing specifically for different regions within the alpha satellite DNA monomer. In order to exploit observed patterns of sequence variation within the monomer for this purpose, we have developed two new DNA analysis methods. In PRimed IN Situ labelling (PRINS), synthetic oligonucleotides derived from subsections of the monomer are hybridized to the chromosomes. The oligonucleotides then serve as primers for the in situ incorporation of biotin-labelled nucleotides catalysed by Klenow polymerase. Incorporated biotin is visualized with fluorescein isothiocyanate-labelled avidin (FITC-avidin). In Primed Amplification Labelling (PAL), biotin-labelled hybridization probes are produced in a polymerase chain reaction (PCR, Saiki et al. 1985), in which two synthetic oligonucleotide primers anneal within the same monomer. With the right choice of primers libraries of labelled probes derived from most monomers present as templates are produced. If DNA from a specific chromosome is used as template, then the resulting probe mixture gives stronger and more chromosome-specific signals in in situ hybridization experiments than does a cloned alpha satellite DNA probe derived from the same chromosome. The results obtained indicate that the alpha-repeat monomer is composed of regions with different degrees of chromosome specificity.

Detection of point mutations in amplified single copy genes by biotin-labelled oligonucleotides: diagnosis of variants of alpha-1-antitrypsin

Specific analysis for point mutations in genomic DNA has until recently been a difficult and time-consuming task, using large amounts of unstable, hazardous and expensive 32P. By enzymatically amplifying the mutation-bearing sequence of the DNA the sensitivity of the analysis is increased several 100-fold, making the detection possible with stable, non-radioactive and inexpensive biotinylated oligonucleotides. We have applied this method (polymerase chain reaction (PCR] to the detection of the Z-mutation in the alpha-1-antitrypsin gene. After amplification, dot-blots of amplified DNA were subjected to hybridization with allele specific biotinylated oligonucleotide probes and washed at temperatures giving allele specificity. The bound biotin was visualized with avidin conjugated alkaline phosphatase using 5-bromo-4-chloro-3-indolylphosphate and nitro blue tetrazolium as colour reagents. The detection can be performed on less than 1 microgram genomic DNA, and is therefore applicable on small amounts of blood, fibroblasts and chorionic villus biopsies.

Treatment of genomic DNA with T4 DNA ligase improves Southern blot analysis

Images

Detection of alpha 1-antitrypsin genotypes by analysis of amplified DNA sequences

Images

Improved methods for the detection of unique sequences in Southern blots of mammalian DNA by non-radioactive biotinylated DNA hybridization probes

Biotinylated DNA hybridization probes offers a stable, cheap and non-radioactive alternative to probes labelled with 32P. Insufficient sensitivity has, however, up till now, been prohibitive for the use of such probes in detecting unique sequences in Southern blots of human DNA. By optimizing the steps in the procedure we have improved the sensitivity enough for such use. We have showed (1) that long probes (greater than 500 nucleotides) perform unproportionally better than short probes; (2) that a simple affinity labelling with avidin alkaline phosphatase conjugate performs better than laborious immunochemical systems; (3) that use of 3% BSA as blocking agent at 37 degrees C and the presence of 0.5 mol/l NaCl together with 1% BSA during the affinity labelling nearly eliminate background staining; (4) that a dramatic gain in sensitivity is gained by affinity labelling at pH 9.0 instead of 7.5; (5) that biotin-labelling can be highly reproducibly performed on a preparative scale with cheap and easily synthesized bio-11-dUTP in a two step nick-translation and (6) that biotinylated probes and hybridization mixtures can be stored for months and reused. The study has resulted in the presentation of a fast procedure, which is generally applicable to routine DNA diagnostic work, also in parts of the world where it is difficult to get a regular supply of 32P.

A hotel fire

A hotel fire in Copenhagen claimed 35 victims of eight different nationalities. An account is given of some major aspects of the dental identification work, including a few case reports. This disaster became professionally important because the dental expert team was allowed a completely free hand. Eight dental experts cooperated closely in recording, photographing and radiographing dental conditions in the victims and thereby became able to establish that, with adequate facilities at hand, complete dental registration of a single victim required an average of three man-hours. Three of the experts subsequently cooperated in establishing comparable antemortem data on the known missing persons, in comparing the ante- and postmortem data sets, and in completing the necessary paper work. Here, it could be shown that a further two man-hours were required per victim. In a final report to the police it was proposed that---in any future case---such number of dentists should be assigned which, allowing three man-hours per victim, would enable the dental team to finish the oral autopsy of the given number of victims within five full working days, i.e. a minimum of two dentists per 30 victims. Two dentists will accomplish complete recording in less than half the time it will take any dentist working single-handed to finish it, so that the question of cost can hardly become an obstacle. It remains for the profession to make sure that an adequate number of knowledgeable dental experts are always available.