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Xie H, Cheng T, Yuan F, Zhang C, He Q. Effect of anti-Müllerian hormone on early pregnancy loss in hormone replacement therapy-frozen-thawed embryo transfer cycles: An analysis including 6597 pregnant patients undergoing their first in vitro fertilization/intracytoplasmic sperm injection cycle. Int J Gynaecol Obstet 2024. [PMID: 38563796 DOI: 10.1002/ijgo.15520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 02/23/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To investigate the relationship between anti-Müllerian hormone (AMH) level and early pregnancy loss in patients who underwent their first embryo transfer by hormone replacement therapy-frozen-thawed embryo transfer (HRT-FET) and analyze the threshold effect. METHODS A retrospective cohort analysis was performed on pregnant women undergoing HRT-FET at the Reproductive Medical Center of Henan Provincial People's Hospital from January 2016 to December 2021. The patients were divided into four groups based on AMH concentration according to the Poseidon criteria: group A (≤1 μg/L), group B (1-≤2 μg/L), group C (2-≤6 μg/L), and group D (>6 μg/L). Univariate analysis, multivariate logistic regression analysis, smooth curve fitting, and threshold effect analysis were applied to investigate the influence of AMH on the outcome of early pregnancy loss in in vitro fertilization/intracytoplasmic sperm injection and HRT-FET cycles. RESULTS Of the 6597 pregnant women, early pregnancy loss occurred in 893, giving an early pregnancy loss rate of 13.54%. Univariate regression analysis demonstrated that age, female body mass index, AMH, antral follicle count, endometrial thickness at endometrial transformation day, total retrieved oocyte number, number of pregnancies, duration of infertility, type of infertility, and the number of embryos transferred were all factors influencing the early pregnancy loss rate (P < 0.050). Multivariate logistic regression analysis, after adjusting for confounders, further stratified the analysis of patients of different ages. With group A as the control group, the results showed that when age was younger than 35 years, the pregnancy loss rates in groups B, C, and D were lower than that in group A, with statistical significance (P < 0.050); when age was 35 years or older, there was no statistically significant difference in outcome indicators between the groups (P > 0.050). A threshold effect analysis revealed that the AMH threshold was 2.83 μg/L. When the AMH concentration was less than 2.83 μg/L, the early pregnancy loss rate decreased significantly with increasing AMH concentration; the early pregnancy loss rate decreased by 21% for each unit increase in AMH (odds ratio 0.79; 95% confidence interval 0.71-0.88; P < 0.001); when the AMH concentration was 2.83 μg/L or more, there was no statistical difference in the change in early pregnancy loss rate (odds ratio 1.01; 95% confidence interval 0.99-1.03; P = 0.383). CONCLUSION For pregnant women after their first embryo transfer, there is a curvilinear relationship between the influences of AMH levels on early pregnancy loss rates in patients younger than 35 years. When the AMH level was less than 2.83 μg/L, the early pregnancy loss rate declined significantly with increasing AMH levels.
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Affiliation(s)
- Huanhuan Xie
- Henan Provincial People's Hospital, Zhengzhou, China
| | | | - Fang Yuan
- Henan Provincial People's Hospital, Zhengzhou, China
| | - Cuilian Zhang
- Henan Provincial People's Hospital, Zhengzhou, China
| | - Qiaohua He
- Henan Provincial People's Hospital, Zhengzhou, China
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Iwase A, Asada Y, Sugishita Y, Osuka S, Kitajima M, Kawamura K. Anti-Müllerian hormone for screening, diagnosis, evaluation, and prediction: A systematic review and expert opinions. J Obstet Gynaecol Res 2024; 50:15-39. [PMID: 37964401 DOI: 10.1111/jog.15818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/12/2023] [Indexed: 11/16/2023]
Abstract
AIM To present evidence-based recommendations for anti-Müllerian hormone (AMH) measurement as an ovarian reserve test. METHODS A systematic literature search for the clinical utility of AMH was conducted in PubMed from its inception to August 2022 to identify studies, including meta-analyses, reviews, randomized controlled trials, and clinical trials, followed by an additional systematic search using keywords. Based on this evidence, an expert panel developed clinical questions (CQs). RESULTS A total of 1895 studies were identified and 95 articles were included to establish expert opinions subdivided into general population, infertility treatment, primary ovarian insufficiency, polycystic ovary syndrome, surgery, and oncofertility. We developed 13 CQs and 1 future research question with levels of evidence and recommendations. CONCLUSION The findings of the current systematic review covered the clinical utility of AMH including its screening, diagnosis, evaluation, and prediction. Although some clinical implications of AMH remain debatable, these expert opinions may help promote a better understanding of AMH and establish its clinical significance.
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Affiliation(s)
- Akira Iwase
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Yodo Sugishita
- Department of Frontier Medicine, Institute of Medical Science, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Satoko Osuka
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michio Kitajima
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Kawamura
- Department of Obstetrics and Gynaecology, Juntendo University Faculty of Medicine, Tokyo, Japan
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Yi Y, Fu J, Xie S, Zhang Q, Xu B, Wang Y, Wang Y, Li B, Zhao G, Li J, Li Y, Zhao J. Association between ovarian reserve and spontaneous miscarriage and their shared genetic architecture. Hum Reprod 2023; 38:2247-2258. [PMID: 37713654 DOI: 10.1093/humrep/dead180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Indexed: 09/17/2023] Open
Abstract
STUDY QUESTION Can potential mechanisms involved in the likely concurrence of diminished ovarian reserve (DOR) and miscarriage be identified using genetic data? SUMMARY ANSWER Concurrence between ovarian reserve and spontaneous miscarriage was observed, and may be attributed to shared genetic risk loci enriched in antigen processing and presentation and autoimmune disease pathways. WHAT IS KNOWN ALREADY Previous studies have shown that lower serum anti-Müllerian hormone (AMH) levels are associated with increased risk of embryo aneuploidy and spontaneous miscarriage, although findings have not been consistent across all studies. A recent meta-analysis suggested that the association between DOR and miscarriage may not be causal, but rather a result of shared underlying causes such as clinical conditions or past exposure. Motivated by this hypothesis, we conducted the present analysis to explore the concurrence between DOR and miscarriage, and to investigate potential mechanisms using genetic data. STUDY DESIGN, SIZE, DURATION Three data sources were used in the study: the clinical IVF data were retrospectively collected from an academically affiliated Reproductive Medicine Center (17 786 cycles included); the epidemiological data from the UK Biobank (UKB), which is a large-scale, population-based, prospective cohort study (35 316 white women included), were analyzed; and individual-level genotype data from the UKB were extracted for further analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS There were three modules of analysis. First, clinical IVF data were used to test the association between ovarian reserve biomarkers and the subsequent early spontaneous miscarriage risk. Second, the UKB data were used to test the association of spontaneous miscarriage history and early menopause. Third, individual-level genotype data from the UKB were analyzed to identify specific pleiotropic genes which affect the development of miscarriage and menopause. MAIN RESULTS AND THE ROLE OF CHANCE In the analysis of clinical IVF data, the risk of early spontaneous miscarriage was 1.57 times higher in the group with AMH < 1.1 ng/ml group (P < 0.001), 1.62 times for antral follicular count <5 (P < 0.001), and 1.39 times for FSH ≥10 mIU/ml (P < 0.001) in comparison with normal ovarian reserve groups. In the analysis of UKB data, participants with a history of three or more miscarriages had a one-third higher risk of experiencing early menopause (odds ratio: 1.30, 95% CI 1.13-1.49, P < 0.001), compared with participants without spontaneous miscarriage history. We identified 158 shared genetic risk loci that affect both miscarriage and menopause, which enrichment analysis showed were involved in antigen processing and presentation and autoimmune disease pathways. LIMITATIONS, REASONS FOR CAUTION The analyses of the UKB data were restricted to participants of European ancestry, as 94.6% of the cohort were of white ethnicity. Further studies are needed in non-white populations. Additionally, maternal age at the time of spontaneous miscarriage was not available in the UKB cohort, therefore we adjusted for age at baseline assessment in the models instead. It is known that miscarriage rate in IVF is higher compared to natural conception, highlighting a need for caution when generalizing our findings from the IVF cohort to the general population. WIDER IMPLICATIONS OF THE FINDINGS Our findings have implications for IVF clinicians in terms of patient counseling on the prognosis of IVF treatment, as well as for genetic counseling regarding miscarriage. Our results highlight the importance of further research on the shared genetic architecture and common pathophysiological basis of DOR and miscarriage, which may lead to new therapeutic opportunities. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Hunan Youth Science and Technology Innovation Talent Project (2020RC3060), the International Postdoctoral Exchange Fellowship Program (Talent-Introduction Program, YJ20220220), the fellowship of China Postdoctoral Science Foundation (2022M723564), and the Natural Science Foundation of Hunan Province, China (2023JJ41016). This work has been accepted for poster presentation at the 39th Annual Meeting of ESHRE, Copenhagen, Denmark, 25-28 June 2023 (Poster number: P-477). The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Yan Yi
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Jing Fu
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Shi Xie
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Qiong Zhang
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Bin Xu
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Yonggang Wang
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Yijing Wang
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Bin Li
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Centre for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Guihu Zhao
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Centre for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Jinchen Li
- Department of Geriatrics, Bioinformatics Center, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Centre for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Yanping Li
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Jing Zhao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
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Association of the Cumulative Live Birth Rate with the Factors in Assisted Reproductive Technology: A Retrospective Study of 16,583 Women. J Clin Med 2023; 12:jcm12020493. [PMID: 36675422 PMCID: PMC9862593 DOI: 10.3390/jcm12020493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/01/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
The cumulative live birth rate (CLBR) can better reflect the overall treatment effect by successive treatments, and continuous rather than categorical variables as exposure variables can increase the statistical power in detecting the potential correlation. Therefore, the dose-response relationships might find an optimal dose for the better CLBR, offering evidence-based references for clinicians. To determine the dose-response relationships of the factors and the optimal ranges of the factors in assisted reproductive technology (ART) associated with a higher CLBR, this study retrospectively analyzed 16,583 patients undergoing the first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) from January 2017 to January 2019. Our study demonstrated the optimal ranges of age with a higher CLBR were under 32.10 years. We estimated the CLBR tends to increase with increased levels of AMH at AMH levels below 1.482 ng/mL, and the CLBR reaches a slightly high level at AMH levels in the range from 2.58-4.18 ng/mL. The optimal ranges of basal FSH with a higher CLBR were less than 9.13 IU. When the number of cryopreserved embryos was above 1.055 and the number of total transferred embryos was 2, the CLBR was significantly higher. In conclusion, there is a non-linear dose-response relationship between the CLBR with age, AMH, basal FSH, and the number of cryopreserved embryos and total transferred embryos. We proposed the optimal ranges of the five factors that were correlated with a higher CLBR in the first oocyte retrieval cycle, which may help consultation at IVF clinics.
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Liu X, Han Y, Wang X, Zhang Y, Du A, Yao R, Lv J, Luo H. Serum anti-Müllerian hormone levels are associated with early miscarriage in the IVF/ICSI fresh cycle. BMC Pregnancy Childbirth 2022; 22:279. [PMID: 35366830 PMCID: PMC8976292 DOI: 10.1186/s12884-022-04591-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/18/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Anti-Müllerian hormone (AMH) is used as a biomarker to estimate ovarian reserve. The relationship between AMH and early miscarriage of in vitro fertilization (IVF) is still inconclusive. This study aimed to explore whether serum AMH levels are associated with early miscarriage rates after in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) with fresh embryo transfer (ET).
Methods
This retrospective cohort study included 2246 patients undergoing their first oocyte retrievals for IVF/ICSI with fresh embryos transferred to Tianjin Central Hospital of Gynecology Obstetrics between May 2018 and March 2020. The serum AMH levels of the patients were measured within 12 months before the IVF/ICSI cycles. All women were divided into a low-AMH group, medium-AMH group and high-AMH group. Binary logistic regression was applied to confirm whether the serum AMH level was associated with the risk of early miscarriage independent of potential confounders, such as age, body mass index (BMI), duration of infertility, main diagnosis, history of internal medicine diseases, number of oocytes retrieved and high-quality embryo rate.
Results
The early miscarriage rate was significantly lower in the medium-AMH group than in either the low-AMH or high-AMH group among young (< 35 years) women (P = 0.015). In women above 35 years of age, the early miscarriage rates in the three AMH groups were not significantly different. Young women with high serum AMH levels had a significantly higher risk of early miscarriage regardless of age or other potential confounders (adjusted odds ratio (OR) 2.382, 95% confidence interval (CI) 1.246 to 4.553, P = 0.009). The results remained similar after restricting the analysis to women without polycystic ovary syndrome (PCOS).
Conclusions
With a high AMH level, young women had a higher risk of early miscarriage than women with a medium AMH level in their first IVF/ICSI treatment. In young women, serum AMH levels were independently associated with the risk of early miscarriage after IVF-ET treatment. Serum AMH levels might be a valuable marker to estimate the risk of early miscarriage. It is worth noting to the clinical value of AMH.
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Şahin B, Cura Şahin G, Tinelli A. Anti-Mullerian hormone levels in spontaneous pregnancies with hyperemesis gravidarum. J OBSTET GYNAECOL 2022; 42:2255-2259. [PMID: 35264073 DOI: 10.1080/01443615.2022.2036973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We investigated the serum anti-Mullerian hormone (AMH), oestrogen and progesterone levels in spontaneously conceiving pregnant women, diagnosed for hyperemesis gravidarum (HG), in the first trimester. Pregnant women admitted at Hospital between 5 and 12 gestational weeks and treated for HG were compared, in this prospective case-control study, to a control group. The serum AMH, oestradiol, and progesterone values of both groups were evaluated and compared, and potential correlations were calculated. The serum AMH values were significantly higher in the HG group than the control group (3.15 ± 1.51 ng/mL vs. 2.27 ± 1.20 ng/mL; p = 0.012). No significant difference in the two groups was about serum oestradiol and progesterone values (p = 0.264, p = 0.235). In the HG group, there was no significant correlation between AMH and oestradiol (p = 0.570). However, a significant positive correlation was determined between AMH and progesterone (p = 0.050). The area under the ROC curve (AUC) was 0.669 and the cut-off value was 2.65 ng/ml with sensitivity of 58.3% and specificity of 66.7% for AMH in pregnant women with HG. A correlation between AMH high values and unexplained HG was detected in spontaneous pregnancies in the first trimester. High AMH levels may play a role in HG etiopathogenesis, especially in pregnant women with low progesterone levels.Impact statementWhat is already known on this subject? Aetiological causes of Hyperemesis gravidarum (HG) include hormonal, immunological, genetic, and psychological issues. However, no conclusive etiopathogenesis to explain the pathophysiological mechanism of HG has been stated.What do the results of this study add? Authors focussed on investigation a possible correlation between pregnant hormones and the HG pathogenesis, prevalent in the first trimester, when hormones are produced by either the placenta or corpus luteum. High anti-Mullerian hormone (AMH) levels may play a role in HG etiopathogenesis, especially in pregnant women with low progesterone levels.What are the implications of these findings for clinical practice and/or further research? A serum AMH level of ≥2.65 mg/mL could be predictive for the development of HG in the first trimester of a spontaneous pregnancy. Basing on these findings, more selective pharmacological treatments could be administrated to these patients.
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Affiliation(s)
- Banuhan Şahin
- Gynecology and Obstetrics Department, Amasya University Sabuncuoglu Serefeddin Training and Research Hospital, Amasya, Turkey
| | - Gizem Cura Şahin
- Obstetrics and Gynecology Department, Tokat State Hospital, Tokat, Turkey
| | - Andrea Tinelli
- Obstetrics and Gynecology Department, Veris delli Ponti Hospital, Scorrano, Lecce, Italy.,Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, Italy
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Busnelli A, Somigliana E, Cirillo F, Levi-Setti PE. Is diminished ovarian reserve a risk factor for miscarriage? Results of a systematic review and meta-analysis. Hum Reprod Update 2021; 27:973-988. [PMID: 34254138 DOI: 10.1093/humupd/dmab018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/01/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anti-Müllerian hormone (AMH) serum concentration and antral follicle count (AFC), as measured by transvaginal ultrasonography, accurately reflect the antral follicle pool. However, AMH and AFC association with fertility surrogates (i.e. age at menopause, probability of conceiving naturally and ART success rate) is questioned. Miscarriage is often considered an alternative measure of reproductive capacity. Nonetheless, the impact of diminished ovarian reserve (DOR) on miscarriage incidence remains an understudied and unresolved issue. OBJECTIVE AND RATIONALE The aim of this systematic review and meta-analysis was to elucidate associations between DOR and miscarriage risk, both in women who conceived naturally and in those who achieved pregnancy through ART. SEARCH METHODS Relevant studies were identified by a systematic search in PubMed, MEDLINE, Embase and Scopus, from database inception to 1 March 2021. Studies were included only if all the following conditions were met: DOR was defined using serum AMH concentration or AFC; miscarriage rate was reported separately for different groups of women categorized according to the AMH and/or AFC level; authors reported either the rate of intrauterine pregnancy loss before 22 weeks of gestation or enough data were available to calculate it. OUTCOMES From a total of 347 publications initially identified, 16 studies were included. Pooled results from 13 retrospective studies focusing on ART pregnancies showed a significantly higher rate of miscarriage in women with a low AMH, as compared to women with a medium or high serum AMH concentration (12 042 women, random effects model, odds ratio (OR) 1.35; 95% CI, 1.10-1.66; P = 0.004; I2=50%). The only prospective study on ART pregnancies failed to show any association (61 women, risk ratio (RR) 2.95; 95% CI, 0.66-3.18; P = 0.16). Data from two prospective studies, which included naturally conceived pregnancies, showed a significantly increased miscarriage risk for women with low serum AMH. However, these data could not undergo meta-analysis owing to differing study designs. Using three retrospective studies, we observed an association between low AFC and miscarriage incidence (three retrospective studies on ART pregnancies, random effects model, OR 1.81; 95% CI, 1.02-3.21; P = 0.04; I2=64%). WIDER IMPLICATIONS Our meta-analysis findings suggest that within the DOR patient subgroup, serum AMH and AFC biomarker levels may correlate with both the quantitative and qualitative aspects of ovarian reserve. However, owing to study limitations, the aetiology of this effect remains unclear and we are unable to define a causal relationship between DOR and increased miscarriage or to provide clinical recommendations based on this information. However, if confirmed by future well-designed studies, these findings would be profoundly informative for guiding women in family planning decisions.
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Affiliation(s)
- Andrea Busnelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Cirillo
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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