Prenatal expectations in transition to parenthood: former infertility and family dynamic considerations

Prenatal expectations are important for the future parent-child relationship. The authors examined how maternal and paternal prenatal expectations of the relationship with the child predicted 1st-year parenting stress and whether these expectations were violated over the transition to parenthood. They further examined how former infertility affected these associations. The participants were 745 Finnish couples, 367 having undergone a successful assisted reproductive treatment and 378 conceiving spontaneously. Couples completed a questionnaire of family representations during pregnancy and when the child was 2 and 12 months old and Abidin's Parenting Stress Index at 2 and 12 months postpartum. The hypothesis of moderately high expectations predicting the lowest level of parenting stress was substantiated only concerning paternal expectations of own autonomy with the child. Generally, however, negative expectations of own and spouse's relationship with the child were linearly associated with higher parenting stress. Postnatal representations were more positive or equal to expectations, except for negative violation occurring in maternal expectation of the father-child relationship, especially among normative mothers. The results are discussed in relation to family dynamic considerations and special features of formerly infertile couples.

Analyses of polymorphisms in the inflammasome-associated NLRP3 and miRNA-146A genes in the susceptibility to and tubal pathology of Chlamydia trachomatis infection

Susceptibility to Chlamydia trachomatis infections is 40% host based. microRNA-146a is a negative regulator of Tolllike receptor (TLR) signaling and possesses functional polymorphisms which decrease the production of premiR-146a and mature miR-146a. Single nucleotide polymorphisms (SNPs) in NLRP3 are associated with decreased NLRP3 expression and hypoproduction of interleukin (IL)-1beta. We investigated whether the SNPs miR-146a G>C (rs2910164), NLRP3 C>T (rs4925663) and G>A (rs12065526) are associated with the susceptibility to and severity of C. trachomatis infection. The genotypes of three SNPs were tested in two cohorts: cohort 1 consists of Dutch women (n = 318) attending a sexually transmitted disease (STD) clinic and cohort 2 (n = 277) consists of subfertile (n = 184) and healthy Finnish women (n=93). While in cohort 1 the analyzed SNPs were not associated with the susceptibility to C. trachomatis infections (C. trachomatis-positive vs. C. trachomatis-negative), we showed in C. trachomatis-positive women that the NLRP3 mutant AG and AA genotypes were a risk factor for the development of symptoms (P = 0.047, OR = 2.9) and more specifically for having lower abdominal pain (genotype AA: P = 0.022, OR = 31.3). In the Finnish tubal pathology group versus the control group no statistical significant differences in the incidences of the SNPs studied were found, nor for the degree of tubal pathology. In conclusion, the mutant NLRP3 A allele is a risk factor for the development of symptoms, specifically lower abdominal pain, after a C. trachomatis infection in women attending an STD clinic.

A systematic evaluation of factors associated with nocturia--the population-based FINNO study

In a case-control study with prevalence sampling, the authors explored the correlates for nocturia and their population-level impact. In 2003–2004, questionnaires were mailed to 6,000 subjects (aged 18–79 years) randomly identified from the Finnish Population Register (62.4% participated; 53.7% were female). Questionnaires contained items on medical conditions, medications, lifestyle, sociodemographic and reproductive factors, urinary symptoms, and snoring. Nocturia was defined as ≥2 voids/night. In age-adjusted analyses, factors associated with nocturia were entered into a multivariate model. Backward elimination was used to select variables for the final model, with adjustment for confounding. Although numerous correlates were identified, none affected ≥50% of nocturia cases of both sexes. The factors with the greatest impact at the population level were (urinary) urgency (attributable number/1,000 subjects (AN) = 24), benign prostatic hyperplasia (AN = 19), and snoring (AN = 16) for men and overweight and obesity (AN = 40), urgency (AN = 24), and snoring (AN = 17) for women. Moreover, correlates included prostate cancer and antidepressant use for men, coronary artery disease and diabetes for women, and restless legs syndrome and obesity for both sexes. Although several correlates were identified, none accounted for a substantial proportion of the population burden, highlighting the multifactorial etiology of nocturia.

Cytokine polymorphisms and severity of tubal damage in women with Chlamydia-associated infertility

Chronic inflammation induced by Chlamydia trachomatis can lead to tubal factor infertility (TFI). To investigate the genetic basis of chlamydial TFI and various manifestations of tubal damage, we studied functional polymorphisms in selected cytokine genes (IL-10 -1082 A/G, -819 T/C, and -592 A/C; IFN-gamma +874 T/A; TNF-alpha -308 G/A; TGF-beta1 codons 10 T/C and 25 G/C; and IL-6 -174 G/C) in 114 women with laparoscopically verified TFI (hereafter known as "cases") and in 176 controls. Evidence of past infection with C. trachomatis was demonstrated in 96 cases by use of a combined test for humoral and cell-mediated immune responses to chlamydial elementary bodies (EBs) and chlamydial heat-shock protein 60 antigens. We found that the IL-10 -1082 AA genotype and the TNF-alpha -308 A allele increased the risk of severe tubal damage in women with infertility associated with C. trachomatis (odds ratio [OR], 7.3 [95% confidence interval {CI}, 1.3-42] and 4.0 [95% CI, 1.0-16], respectively), suggesting that differences in these genes contribute to the wide spectrum of disease manifestations.

Single embryo transfer in clinical practice

The high incidence of multiple pregnancies is the main reason for adverse treatment outcome in assisted reproduction. A good strategy to avoid multiple pregnancies is elective single embryo transfer and cryopreservation of spare embryos. Important factors in an elective single embryo transfer programme are good counselling of the patients and the selection of embryos with high implantation potential. In the infertility clinic at Helsinki University Central Hospital the elective single embryo transfer programme was started in 1997 and in 2000 the transfer policy turned to single embryo transfer as primary option. In 2003 60% of fresh transfers were elective single embryo transfers and 66% of frozen transfers were single embryo transfers. It has been shown that an elective single embryo transfer programme can be adopted in daily practice and that it decreases the multiple pregnancy rate, in our programme to around 7% with acceptable overall pregnancy and delivery rates. In Finland the increased use of single embryo transfer has reduced the proportion of multiple births. Finally, a good cryopreservation programme is essential to achieve a good cumulative delivery rate without multiple pregnancies.

The menopause and oral health

OBJECTIVES

To review the literature about oral symptoms and signs at the menopause with an emphasis on hormone replacement therapy (HRT). To give practical guidelines for women and their physicians in menopause-related oral health problems.

METHODS

The PubMed and Cochrane databases was searched until mid January 2009 with key words such as "menopause", "menopausal complaints", "postmenopausal complaints" and "oral diseases", "oral discomfort", "dental health", "dental diseases", "saliva", "burning mouth syndrome", "dry mouth", "xerostomia". Because of a scarcity of controlled studies no systematic review could be conducted.

RESULTS

Oral discomfort is found in many menopausal women in addition to more general climacteric complaints. The principal peri- and postmenopausal symptoms are dry mouth and burning mouth (glossodynia) which, in turn, may increase the occurrence of oral mucosal and dental diseases, such as candidiasis. The mechanisms of hormone-related oral symptoms and signs are not known although oestrogen receptors, for example, have been detected in the oral mucosa and salivary glands. In principle, the histology of oral and vaginal mucosa is very similar and thus their symptoms might share a common cause. Yet, hormone replacement therapy use does not necessarily prevent or help women with oral symptoms.

CONCLUSION

Properly controlled long-term randomized studies are needed to assess the effect of HRT on oral discomfort. Future gene profiling could identify women who may or may not benefit from HRT with regard to oral symptoms.

[Menopause in a diabetic]

With the growing incidence of both type 1 and type 2 diabetes, the number of diabetic women of menopause age is on the rise in our country. The risk of osteoporosis seems to be significant especially in type 1 diabetic patients. Similarly to other women, a diabetic woman can receive palliative treatment for her menopausal symptoms. Transdermally administered estrogen is favourable in the therapy. The possible contraindications of hormone therapy must, however, be accurately surveyed along with an assessment and treatment of risk factors for cardiovascular diseases prior to initiation of hormone therapy.

Does single embryo transfer improve the obstetric and neonatal outcome of singleton pregnancy?

Singleton pregnancies following in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are associated with increased risks of abnormal placentation, pre-eclampsia and preterm birth. These risks might partly be a consequence of the number of transferred embryos. In this commentary we summarize the results of three observational studies and one randomized study with 1052 pregnancies following single embryo transfer (SET). An increased age- and parity-adjusted risk of gestational hypertension and placenta previa in the SET pregnancies as compared to the spontaneously conceiving controls was reported in one of the studies. Preterm births occurred in 6-12% of SET pregnancies and 4-6% of the newborns were of low birth weight (LBW). The frequency of preterm birth and LBW after SET were considered either lower than or similar to those after double embryo transfer (DET) but higher than after spontaneous conception. Comparison of SET and DET pregnancies thus shows heterogeneous results. Still, it seems that not even a transfer of one good-quality embryo at a time diminishes all the previously identified increased risks of certain obstetric complications and preterm births in singleton pregnancies following IVF or ICSI.

Is serum-soluble vascular endothelial growth factor receptor-1 of importance in unexplained infertility?

OBJECTIVE

To analyze the role of vascular endothelial growth factor (VEGF) and its naturally occurring circulating antagonist, soluble VEGF receptor-1 (sVEGFR-1), in infertility. VEGF is a key angiogenic factor in the endometrial and ovarian cyclic processes that are crucial for fertility and sVEGFR-1 impairs its function and fertility in animals - less is known as regards human fertility.

DESIGN

Case-control study.

SETTING

University Central Hospital, a tertiary referral center.

POPULATION

Women with unexplained infertility (n=15) and fertile controls (n=10) had serial blood samples collected during their natural cycles, and the infertile women during a subsequent in vitro fertilization (IVF) cycle.

METHODS

Enzyme-linked immunosorbent assay was used for this study.

MAIN OUTCOME MEASURES

Concentrations of VEGF and sVEGFR-1 in the natural cycles and of sVEGFR-1 during a subsequent IVF cycle.

RESULTS

Plasma VEGF concentrations showed no cyclicity in fertile women, but were higher in the infertile group at the midluteal phase. Serum sVEGFR-1 concentrations were similar between the groups and between natural and IVF cycles. However, in infertile women, concentrations of sVEGFR-1 increased from the follicular phase to the luteal phase. In the follicular phase infertile women had a high ratio of VEGF/sVEGFR-1, which was decreased in the luteal phase. Both findings were associated with failure to achieve pregnancy in subsequent IVF cycles.

CONCLUSIONS

One cause of unexplained infertility may be unbalanced secretion of sVEGFR-1 with concomitant changes in free VEGF during the transition from the follicular to the luteal phase. This aberration may be related to impaired implantation.

The role of Chlamydia trachomatis infection in male infertility

To study the association between plasma antibodies to Chlamydia trachomatis and male infertility, 90 men from infertile couples attending a University Hospital IVF clinic for IVF/intracytoplasmic sperm injection, and 190 healthy blood donors as control subjects were studied for IgG and IgA antibodies to C. trachomatis, and for the men from infertile couples seminal fluid analysis was performed according to the World Health Organization criteria. The prevalence of plasma IgG antibodies to C. trachomatis was higher among men from infertile couples than control men, and men with chlamydial antibodies had lower sperm counts than those without.

Oral health in perimenopausal and early postmenopausal women from baseline to 2 years of follow-up with reference to hormone replacement therapy

Female sex hormones also affect the mouth but there are little data on oral health of menopause age women. This 2-year follow-up study investigated oral health of perimenopausal and early postmenopausal women. Because hormone replacement therapy (HRT) users have been reported to be more health conscious than nonusers, we expected differences between women using and women not using HRT. Of 3,173 women, a random sample of 400 (200 using and 200 not using HRT) was examined. Of them, 161 case-control pairs of women using/not using HRT were reexamined 2 years later. Dental and periodontal status was recorded according to the WHO criteria and resting and stimulated saliva flow was measured. Panoramic tomography of the jaws was taken at baseline and at follow-up. The patients also filled in a structured questionnaire on their systemic health, medication, and health habits. The results were analyzed statistically between and within the groups. No difference was observed in any dental parameters or salivary flow rates between the groups. However, during the follow-up, women in HRT group had received more dental restorations (p<0.05) and they also reported more often recent dental appointments (p<0.05). Although no difference in oral health status or salivary flow rates between women using or not using HRT was found, the observation on dental restorations may indicate a more health conscious attitude in the HRT group.

High and low BMI increase the risk of miscarriage after IVF/ICSI and FET

BACKGROUND

The extremes of BMI are associated with an increased risk of miscarriage both in spontaneously conceived pregnancies and after fertility treatment. The aim of the present study was to study the effect of BMI on miscarriage rate (MR) in fresh IVF/ICSI, and in spontaneous and hormonally substituted frozen-thawed embryo (FET) cycles.

METHODS

Analysis was carried out on 3330 first pregnancy cycles, performed during the years 1999-2004, of which 2198 were fresh, 666 were spontaneous and 466 were hormonally substituted FET cycles. A categorical, a linear and a quadratic models of the effect of BMI on miscarriage were studied by logistic regression. Factors related to patient characteristics, protocol and embryo parameters were also examined.

RESULTS

MR was higher in hormonally substituted FET (23.0%), compared with the fresh cycles (13.8%) and spontaneous FET (11.4%, P < 0.0001). Multivariate logistic regression revealed that the relationship between BMI and the risk of miscarriage is not linear but quadratic (U-shaped) (P = 0.01), indicating a higher risk of miscarriage in underweight and obese women. Hormonal substitution for FET was also associated with a 1.7-fold higher MR, compared with the fresh cycles (P = 0.002, 95% confidence interval 1.2-2.3).

CONCLUSIONS

Obese and underweight women have an increased risk of miscarriage, and hormonally substituted FET is associated with an even higher MR.

Estradiol fatty acid esters in adipose tissue and serum of pregnant and pre- and postmenopausal women

CONTEXT

The 17beta-estradiol fatty acid esters are hormone derivatives with long-lasting estrogenic effect. They are transported in serum lipoproteins and thought to be sequestered in adipose tissue.

OBJECTIVE

Our objective was to determine the 17beta-estradiol fatty acid ester concentrations in serum and adipose tissue in women of various hormonal states.

DESIGN

After several chromatographic steps separating esterified from free estradiol, time-resolved fluoroimmunoassay was used as a quantifying tool.

PARTICIPANTS

Samples were obtained from pregnant women undergoing cesarean section (n = 13), or premenopausal (n = 8) and postmenopausal women (n = 6) during gynecological surgery.

MAIN OUTCOME MEASURES

17beta-Estradiol and 17beta-estradiol fatty acid ester concentrations in serum, and visceral and sc adipose tissue were examined.

RESULTS

The ratio of esterified to free estradiol in plasma increased with decreasing estradiol level from 0.5% in pregnant, to 15% in premenopausal and 110% in postmenopausal women. Estradiol esters constituted about 10% of the free estradiol present in adipose tissue in pregnancy. In nonpregnant women, most of the adipose tissue estradiol was in esterified form, the median ester to free ratio being elevated to 150-490%. After menopause, the overwhelming majority of estradiol in both free and esterified form was present in adipose tissue.

CONCLUSIONS

The overall higher ester to free estradiol ratio in adipose tissue than in serum indicates active esterification capacity in adipose tissue. The predominance of esterified and free estradiol in postmenopausal adipose tissue compared with serum suggests in situ production and storage. Whether the estradiol esters have an independent physiological role in adipose tissue remains to be clarified.

Insufficient growth hormone secretion is associated with metabolic syndrome after allogeneic stem cell transplantation in childhood

The aim was to evaluate whether the metabolic syndrome associates with other endocrinopathies observed after allogeneic stem cell transplantation (SCT) in childhood. Thirty-one SCT long-term survivors, transplanted for leukemia (n=26) or nonmalignant hematologic diseases (n=5) were evaluated by oral glucose tolerance test and assessment of serum lipids at a median age of 15 (range 7 to 34) years. Hyperinsulinemia, hypertriglyceridemia, and abdominal obesity were required for the diagnosis of metabolic syndrome. Growth hormone (GH) secretion was evaluated either with GH releasing hormone and arginine (n=14), clonidine (n=15), or insulin-tolerance (n=2) test. A GH peak level of <20 mU/L was considered insufficient. The thyroid and gonadal functions were assessed. Twelve patients (39%) had metabolic syndrome. Nine out of 12 (75%) patients with metabolic syndrome had insufficient GH response in provocative testing as opposed to 6/19 (31%) of those without it (P=0.02). No difference was observed in thyroid or gonadal function between patients with versus without metabolic syndrome. In conclusion, metabolic syndrome is frequently associated with insufficient GH secretion in the SCT long-term survivors. This should implicate a close follow-up of the metabolic parameters in SCT patients with either frank GH insufficiency or signs of inadequate GH response in provocative testing.

Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

The aim of this study was to calculate the probability of becoming pregnant after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, and to evaluate complications during pregnancy and childbirth.

METHODS

A questionnaire was posted to 160 women with an IPAA and to 160 controls. The probability of becoming pregnant after IPAA was calculated by the Kaplan-Meier method.

RESULTS

Of 54 women who had undergone IPAA surgery, 36 (67 per cent) succeeded in becoming pregnant naturally, compared with 49 (82 per cent) of 60 controls. The probability of pregnancy after 2 years of trying was 56 per cent in the IPAA group and 91 per cent in the control group (P < 0.001). Women in the IPAA group needed infertility investigations more often (24 versus 10 per cent; P = 0.044). In all, 39 (72 per cent) women in the IPAA group and 53 (88 per cent) in the control group bore a child. Twenty-one of 39 women in the IPAA group and 13 of 53 in the control group had a caesarean section (P = 0.005). Anal incontinence after delivery occurred more often in the control group.

CONCLUSION

Women with an IPAA mostly suffer a reduction in the probability of conception rather than complete infertility. Because complications during pregnancy and delivery were rare, caesarean section should be based mainly on obstetric indications.

Effect of hysterectomy or LNG-IUS on serum inhibin B levels and ovarian blood flow

OBJECTIVES

Nearly one third of women complain of heavy menstrual bleeding during their reproductive years. Hysterectomy and levonorgestrel-releasing intrauterine system (LNG-IUS) are effective treatment options for menorrhagia. However, the influence of these two treatment modalities on ovarian function remains unclear. The aim of the study was to evaluate the effect of hysterectomy or LNG-IUS on ovarian function.

METHODS

Of 107 women, aged 35-49 years, referred for menorrhagia to the University of Helsinki, Finland, 54 were randomised to hysterectomy group and 53 to LNG-IUS group. Serum concentrations of inhibin B were measured at baseline, at 6-month, and at 12-month follow-up visits. The pulsatility indeces (PI) of ovarian and intraovarian arteries were measured by transvaginal ultrasound on the same visits. Changes in outcome measures between the groups were tested by Student's t-test for independent samples and within the group by Wilcoxon signed rank test. To test association between outcome variables and explaining factors a multiple linear regression model was used.

RESULTS

Serum inhibin B concentrations decreased after the first 6 months in both groups (P<0.05). No change was observed in PI of the ovarian arteries in either group. PI of the intraovarian arteries decreased at 6 and 12 months (P<0.05) in the hysterectomy group, which was not seen among LNG-IUS users. Change in PIs between the treatment arms was also significant (P<0.05). In multiple linear regression model treatment modality explained the change in serum inhibin B concentration and the change in PI of intraovarian artery (P<0.05).

CONCLUSIONS

Hysterectomy but not LNG-IUS alters intraovarian blood flow and may impair ovarian function.

Infertility treatment and marital relationships: a 1-year prospective study among successfully treated ART couples and their controls

BACKGROUND

Evidence about the effects of infertility and assisted reproduction technique (ART) on marital relationships is discrepant. Here, we examined the impact of ART on marital relationships. The roles of life stressors, infertility and treatment characteristics in predicting marital relations were also evaluated.

METHODS

SUBJECTS

367 couples with singleton IVF/ICSI pregnancies.

CONTROLS

379 couples with spontaneous singleton pregnancies. Women and men were assessed when the child was 2 months (T2) and 12 months old (T3). They further reported stressful life events at T2 and depression in pregnancy.

RESULTS

No between-group differences were found in marital satisfaction and dyadic cohesion. Dyadic consensus deteriorated from T2 to T3 only among control women. Sexual affection was low among control men at T2 and stressful life events decreased it further. Depression during pregnancy predicted deteriorated marital relations only in control couples. Several unsuccessful treatment attempts were associated with good dyadic consensus and cohesion among ART women. Spontaneous abortions and multiple parity predicted poor marital satisfaction in ART women, whereas long duration of infertility and multiple parity predicted poor marital relations in ART men.

CONCLUSIONS

Successful ART does not constitute a risk for marital adjustment. The shared stress of infertility may even stabilize marital relationships.

The effect of hormone therapy on the health-related quality of life in elderly women

OBJECTIVES

The purpose of this study was to compare the health-related quality of life (HRQoL) of elderly users and non-users of hormone therapy (HT).

SUBJECTS AND METHODS

Subjects were participants in an ongoing intervention study, which is aimed at elucidating the effectiveness of an educational program in the prevention of osteoporosis. A random sample (n=4200) of the female population in Southern Finland within the age group of 60-70 years was drawn from the population register and invited to take part in the trial; 2181 (52%) accepted the invitation and were randomized either to the educational program or to a control group. In 2002 all 2181 participants were asked by a postal survey about HRQoL (generic15D), education, profession, climacteric symptoms, use of HT, chronic diseases and medication. Of the 1663 respondents (76% of the participants; 40% of the original cohort) 585 (mean age 67.5 years) were HT users and 1078 (mean age 68.9 years) non-users.

RESULTS

After standardizing for age, education, number of continuous medication and ongoing diseases HRQoL of HT users was significantly better on the dimensions of usual activities, vitality and sexual activity. The effect of HT on overall HRQoL on a 0-1 scale was positive, but neither statistically significant nor clinically important. The number of medication and diseases had a statistically significant negative effect, but higher education a positive, but statistically non-significant effect on HRQoL overall.

CONCLUSIONS

Among elderly women HT use has a statistically significant positive effect on some dimensions of HRQoL, but not on HRQoL overall. To improve HRQoL is not an indication for elderly postmenopausal women to use HT.

Obstetric and neonatal outcome after single embryo transfer

BACKGROUND

Single embryo transfer (SET) pregnancies practically lack vanishing twins and may be associated with improved neonatal outcome. Our objective was to compare the obstetric and neonatal outcome of SET singletons with the outcome of singletons following double embryo transfer (DET) and spontaneous conception.

METHODS

A 7-year (1997-2003) cohort of fresh SET (n = 269) and DET (n = 230, including 25 vanishing twins) cycles resulting in singleton birth at Helsinki University Central Hospital, Finland, was linked to the Finnish Medical Birth Register and the obstetric and neonatal outcome data compared with that from 15 037 spontaneously conceived singleton pregnancies.

RESULTS

The obstetric and neonatal outcome of the SET group was comparable to that in the DET group. Compared with the comparison cohort, gestational hypertension (P = 0.005), placenta praevia (P < 0.001), preterm contractions (P = 0.01) and maternal hospitalization (P < 0.001) was more typical of women in the SET group. After adjusting for age, parity and socio-economic status the SET pregnancies showed increased risks of Caesarean section [odds ratio (OR) 1.54 with 95% confidence interval (CI) 1.18-2.00], preterm birth (OR 2.85; 95% CI 1.96-4.16) and low birthweight (OR 2.01; 95% CI 1.19-3.99) compared with the comparison cohort.

CONCLUSIONS

Our results indicate that subject- and infertility-related mechanisms other than the number of transferred embryos influence the neonatal outcome of singleton IVF pregnancies.

Ante- and perinatal factors and child characteristics predicting parenting experience among formerly infertile couples during the child's first year: a controlled study

In this prospective controlled study, the authors examined (a) parenting experiences among couples with successful assisted reproduction treatment (ART; n = 367) and fertile spontaneously conceiving controls (n = 371) and (b) the impact of ante- and perinatal factors and child characteristics on parenting experiences. The results show that positive mothering experiences increased more during the 1st year of parenting and were generally higher among ART mothers than control mothers. No differences were found between ART fathers and controls in their fathering experience. Unpleasant birth experiences, low birth weight, and difficulty soothing the child were associated with high levels of parental stress in the control group, but this was not so among the ART parents. Psychosocial interventions in maternal care should take into account the various meanings that couples give to the history of infertility and conception and ante- and perinatal experiences.