Fundamental role of folliculo-luteal function in recurrent miscarriage

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis

Background

Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I²: 74.33%).

Conclusion

We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness.

Trial registration number

This review was prospectively registered with PROSPERO (CRD42020220915).

Successful pregnancy with restorative reproductive medicine after 16 years of infertility, three recurrent miscarriages, and eight unsuccessful embryo transfers with in vitro fertilization/intracytoplasmic sperm injection: a case report

BACKGROUND

Restorative reproductive medicine represents a comprehensive approach to subfertility (infertility and miscarriage) with investigations, diagnoses, and treatments combined with fertility charting to restore optimal reproductive function. Restorative reproductive medicine assumes that multiple factors need to be identified and treated (cycle optimization) for up to 12 cycles to achieve a successful pregnancy. Conception can occur during normal intercourse without intrauterine insemination or in vitro fertilization.

CASE PRESENTATION

A 35-year-old Croatian female presented for fertility treatment in May 2019 with a previous diagnosis of polycystic ovaries, infertility of 16 years duration, and 8 unsuccessful embryo transfers with in vitro fertilization and intracytoplasmic sperm injection. She was gravida 3 para 0, with 2 miscarriages after spontaneous conception at 5-6 weeks gestation in 2002 and 2004, followed by a miscarriage after in vitro fertilization at 12 weeks gestation in 2011. We initially found poor follicle function and suboptimal progesterone levels. Restorative reproductive medicine treatment resulted in conception after two cycles of treatment. This pregnancy ended in miscarriage at 7 weeks 4 days. Additional investigations found a balanced Robertsonian translocation (13, 14) and a uterine septum. We achieved repeat fertilization with restorative reproductive medicine after three cycles of treatment following resection of the uterine septum and ovulation induction with letrozole and human chorionic gonadotrophin. She had a full-term healthy pregnancy and live birth in 2021.

CONCLUSION

We propose that a full evaluation of underlying factors, and up to 12 cycles of cycle optimization, should be offered to subfertile patients before considering in vitro fertilization treatment.

Towards the Clinical Evaluation of the Luteal Phase in Fertile Women: A Preliminary Study of Normative Urinary Hormone Profiles

Objective: To describe and evaluate urinary hormone profiles in the luteal phase.

Setting and Patients: Twenty-five healthy fertile women, with regular ovulatory pattern cycles as assessed by temperature and cervical mucus, at a university based center.

Methods: Daily urinary hormonal assessment of luteinizing hormone, estrone glucuronide, and pregnanediol glucuronide. This was done during 3 or more cycles, with 78 completed cycles. Samples were analyzed by both crude levels and levels adjusted for the hormone excretion rate. Correlation between measured parameters (LH surge, vulvar mucus) was assessed with regard to their ability to detect presumed ovulation.

Results: An upper, middle, and lower tercile range for the main urinary reproductive hormones was determined and a classification system of zones proposed, considering profiles over or under the 10th percentile. Adjustment for the urine excretion rate proved useful for interpreting individual samples; this was less necessary with multiple samples over time where trends could be determined. This serial evaluation, in at least two cycles, lowered the possibility of finding an isolated luteal phase defect and helped identify the recurrence of such. Vulvar mucus findings performed well in determining the timing of ovulation. Despite the proven fertility of the study population, lower luteal phase hormones were detected in both an isolated and, in some situations, recurrent manner.

Conclusion: A feasible method is proposed to accurately, thoroughly and reproducibly study the luteal phase in order to evaluate and treat identified abnormalities in a properly timed, restorative manner. This preliminary study provides the basis for future research, correlating urinary hormones with clinical findings, particularly those of luteal phase defects.