Unexplained infertility: Is it over-diagnosed and over-treated?

Assessment of the Pelvic Pain Experienced by Infertile Women is of Prime Importance for Diagnosing Endometriosis

OBJECTIVE

To provide evidence regarding the significance of painful symptoms among women suffering from infertility.

DESIGN

An observational retrospective cross-sectional study.

SETTINGS

University hospital-based research center.

PATIENTS

Infertile patients aged between 18 and 42 years surgically explored for benign gynecological conditions between 01-2004 and 12-2020.

INTERVENTIONS

For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon in the month preceding the surgery. Preoperative assessment the pain symptoms was recorded. Pain intensity was assessed with a 10cm visual analog scale (VAS). The pain was considered to be severe when the VAS score was ≥ 7.

MEASUREMENTS AND MAIN RESULTS

Surgery was performed in 839 infertile women. 451 women had severe pelvic pain. Infertile patients with severe pain significantly more often had endometriosis (67.4% versus 30.7% respectively; p <.001) than infertile women without severe pelvic pain, and especially deep infiltrating lesions (43.2% versus 8.5% respectively; p <.001). Moreover, these women more often had intestinal endometriosis lesions (28.4% vs 1.8%; p <.001). After multivariable regression analysis, the presence of endometriosis, irrespective of the phenotype (superficial lesions (OR1.84 [1.19-2.86] and/or ovarian endometrioma OR 2.79 [1.70-4.59] and/or deep infiltrating endometriosis OR 4.49 [2.69-7.51]), and the presence of at least one intestine endometriosis lesion (OR6.49 [2.69-7.51] were significantly associated with severe pelvic pain.

CONCLUSION

Severe pelvic pain is significantly associated with endometriosis and especially deep infiltrating lesions in a population of infertile women. These results demonstrate the importance of thorough questioning regarding pelvic pain symptoms during the initial management of infertile patients.

Identification of a Single Nucleotide Polymorphism of Vitamin D Receptor (VDR) and Vitamin D Binding Protein (VDBP) Gene and Its Dysregulated Pathway Through VDR-VDBP Interaction Network Analysis in Vitamin D-Deficient Infertile Females

INTRODUCTION

The prevalence of female infertility in Pakistan is currently estimated at 22%, and emerging research suggests that vitamin D (VD) deficiency (VDD) may play a significant role in influencing female fertility. The focus of this study was to investigate the single nucleotide polymorphism (SNP) patterns within the VD binding protein (VDBP). The study aimed to explore dysregulated pathways and gene enrichment through an interaction network analysis, specifically focusing on the interplay between the VD receptor (VDR) and VDBP in females experiencing unexplained infertility (UI) coupled with VDD.

METHODS

A cross-sectional study was conducted on VD-deficient, fertile, and UI female subjects. VDBP and VDR were assessed by enzyme-linked immunoassay and genotyping performed. FunRich (version 3.1.3; http://funrich.org/index.html) was employed for analysis of the identified proteins: VDR and VDBP and with their mapped gene datasets, gene enrichment, and protein-protein interaction (PPI) network.

RESULTS

The mean VD and VDR values of infertile females were significantly lower than those of fertile females. VDBP in infertile females (median (IQR)): 296.05 (232.58-420.23)) was lower than that of fertile females (469.9 (269.57-875.55), (p=0.01)). On sequence analysis, a mutation rs 4588 SNP (Thr 436 Lys) was found in exon 11 of the VDBP gene of UI females, but no mutation in exons 8 and 9 of the VDR gene, with some insignificant intronic variants, was observed. The proteins such as plasma membrane estrogen receptor signaling pathway (p < 0.001), VDR, SMAD3, NCOR1, CREBBP, NCOA1, STAT1, GRB2, PPP2CA, TP53, and NCOA2 were enriched after biological pathway grouping when VDR was made the focused gene and directly interacting with VDBP.

CONCLUSION

The females with UI exhibited significantly low VD, VDBP, and VDR. The plasma membrane estrogen receptor signaling pathway was enriched in VDD infertile females.

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Prevalence of Chromosomal Abnormalities in Iranian Patients with Infertility

BACKGROUND

The numerical and structural abnormalities of chromosomes are the most common cause of infertility. Here, we evaluated the prevalence and types of chromosomal abnormalities in Iranian infertile patients.

METHODS

We enrolled 1750 couples of reproductive age with infertility, who referred to infertility clinics in Tehran during 2014- 2019, in order to perform chromosomal analysis. Peripheral blood samples were obtained from all couples and chromosomal abnormalities were evaluated by G-banded metaphase karyotyping. In some cases, the detected abnormalities were confirmed using fluorescence in-situ hybridization (FISH).

RESULTS

We detected various chromosomal abnormalities in 114/3500 (3.257%) patients with infertility. The prevalence of chromosomal abnormalities was 44/114 (38.596%) among infertile females and 70/114 (61.403%) among infertile males. Structural chromosomal abnormalities were found in 27/1750 infertile females and 35/1750 infertile males. Numerical chromosomal abnormalities were found in 17/1750 of females and 35/1750 of males. The 45, XY, rob (13;14) (p10q10) translocation and Klinefelter syndrome (47, XXY) were the most common structural and numerical chromosomal abnormalities in the Iranian infertile patients, respectively.

CONCLUSION

In general, we found a high prevalence of chromosomal abnormalities in Iranian patients with reproductive problems. Our study highlights the importance of cytogenetic studies in infertile patients before starting infertility treatments approaches.

Serum leptin level in Sudanese women with unexplained infertility and its relationship with some reproductive hormones

BACKGROUND

The excessive concentration of leptin has negative effects on all aspects of female reproduction. Despite this established relationship, the exact role of leptin in women’s fertility is not clear enough and needs more clarification.

AIM

To evaluate the serum leptin levels in Sudanese women and to ascertain the relationship between serum leptin levels and unexplained infertility (UI).

METHODS

A matched (age and body mass index) case-control study was conducted from March 2021 to February 2022. The study samples were 210 women with UI and 190 fertile women of reproductive age who were attending the maternity hospitals and fertility clinics in Khartoum state Sudan. The serum concentration of leptin and other serum biomarkers were determined using enzyme-linked immunosorbent assays.

RESULTS

The results showed that there was a highly statistically significant difference between the two groups (P < 0.001) for all examined eight biomarkers. Whereby, leptin, luteinizing hormone (LH)/follicular stimulating hormone (FSH) ratio, prolactin hormone (PRL) and testosterone (T) were significantly higher in the UI group compared with the control group. In contrast, FSH and estradiol (E2)/T ratio were significantly lower in the UI group than in the control group and the effect size test for the difference between the two groups was very large (effect size > 0.80), for leptin level, LH/FSH ratio, PRL level, and E2/T ratio, and large (effect size 0.50- ≤ 0.80) for FSH and T.

CONCLUSION

This study reveals that leptin could be a potential biomarker for UI in Sudanese women and it may be useful for identifying women with a high risk of infertility.

Should we adopt a prognosis-based approach to unexplained infertility?

The treatment of unexplained infertility is a contentious topic that continues to attract a great deal of interest amongst clinicians, patients and policy makers. The inability to identify an underlying pathology makes it difficult to devise effective treatments for this condition. Couples with unexplained infertility can conceive on their own and any proposed intervention needs to offer a better chance of having a baby. Over the years, several prognostic and prediction models based on routinely collected clinical data have been developed, but these are not widely used by clinicians and patients. In this opinion paper, we propose a prognosis-based approach such that a decision to access treatment is based on the estimated chances of natural and treatment-related conception, which, in the same couple, can change over time. This approach avoids treating all couples as a homogeneous group and minimizes unnecessary treatment whilst ensuring access to those who need it early.

The association between the pre-pregnancy vaginal microbiome and time-to-pregnancy: a Chinese pregnancy-planning cohort study

BACKGROUND

Although sexually transmitted infections are regarded as the main cause of tubal infertility, the association between the common vaginal microbiome and female fecundability has yet to be determined. The objective of this study was to find convincing evidence relating to the impact of the vaginal bacterial structure on the fecundability of women planning pregnancy.

METHODS

We recruited women who took part in the Free Pre-pregnancy Health Examination Project from 13 June 2018 to 31 October 2018 (n = 89, phase I) and from 1 November 2018 to 30 May 2020 (n = 389, phase II). We collected pre-pregnancy vaginal swabs from each subject; then, we followed up each subject to acquire the pregnancy-planning outcome in 1 year. In phase I, 16S rRNA gene sequencing was performed to investigate the vaginal bacterial content between the pregnancy and non-pregnancy groups. These findings were verified in phase II by applying a quantitative real-time polymerase chain reaction for the measurement of the absolute abundance of specific species. Cox models were used to estimate fecundability ratios (FR) for each vaginal microbiome type.

RESULTS

In phase I, 59.6% (53/89) of women became pregnant within 1 year. The principal coordinate analysis showed that the pre-pregnancy vaginal microbial community structures of the pregnant and non-pregnant groups were significantly different (PERMANOVA test, R² = 0.025, P = 0.049). The abundance of the genus Lactobacillus in the pregnancy group was higher than that of the non-pregnant group (linear discriminant analysis effect size (LDA) > 4.0). The abundance of the genus Gardnerella in the non-pregnant group was higher than those in the pregnant group (LDA > 4.0). In phase II, female fecundability increased with higher absolute loads of Lactobacillus gasseri (quartile Q4 vs Q1, FR = 1.71, 95%CI 1.02-2.87) but decreased with higher absolute loads of Fannyhessea vaginae (Q4 vs Q1, FR = 0.62, 95%CI 0.38-1.00). Clustering analysis showed that the vaginal microbiome of type D (characterized by a higher abundance of Lactobacillus iners, a lower abundance of Lactobacillus crispatus and Lactobacillus gassri) was associated with a 55% reduction of fecundability (FR = 0.45, 95%CI 0.26-0.76) compared with type A (featuring three Lactobacillus species, low Gardnerella vaginalis and Fannyhessea vaginae abundance).

CONCLUSIONS

This cohort study demonstrated an association between the pre-pregnancy vaginal microbiome and female fecundability. A vaginal microbiome characterized by a higher abundance of L. iners and lower abundances of L. crispatus and L. gasseri appeared to be associated with a lower fecundability. Further research now needs to confirm whether manipulation of the vaginal microenvironment might improve human fecundability.

Human papillomavirus prevalence in unexplained infertile women with chronic endometritis

Introduction: This study investigates unexplained infertile women with or without chronic endometritis (CE) and examines the prevalence of the human papillomavirus (HPV) in this population. Material and Method: This study was done with a cross-sectional and retrospective method. The prevalence of HPV infection and related cases in the participants were examined. In this study, 15 infertile women with CE and 64 infertile women without CE were and analyzed from four perspectives: negative HPV, low-risk HPV, probable high-risk HPV, and the presence of high-risk HPV. Results: The participants have mean age of 32.89 years ±3.95. High-risk HPV infection was detected in 3 (20%) and 11 (17%) of the patients with and without CE, respectively (p>0.05). The negative HPV (2 (13%) and 17 (26%)), low-risk HPV (3 (20%) and 20 (31%)), and probable high-risk HPV (7 (46%) and 16 (25%)) in infertile women with CE and infertile women had no significantly different prevalence (p>0.05). The two studied groups had no significantly different mean age, body mass index (BMI), and Infertility duration were not in (P=0.08, P=0.932, and P=0.283, respectively). Conclusion: HPV has no significantly different prevalence in unexplained infertile women with and without CE. It is recommended that this study be repeated with more unexplained infertile women with CE.

The current situation and future directions for the study on time-to-pregnancy: a scoping review

Introduction

As problems associated with infertility and population aging increase, there is a growing interest in the factors that cause a decline in human fertility. Time-to-pregnancy (TTP) is a good indicator with which to reflect human fecundability. Here, we present a comprehensive overview of this topic.

Methods

Relevant qualitative and quantitative studies were identified by searching the Web of science and PubMed electronic databases. We included all literature, written in English, from inception to the 10th April 2021 providing the focus was on TTP. We conducted a narrative synthesis using thematic analysis.

Results

Traditional TTP-related study protocols include prospective and retrospective cohorts that provide a wealth of data to reveal potential influences on TTP. Thus far, a variety of factors have been shown to be associated with TTP in couples preparing for pregnancy, including basic demographic characteristics, menstrual status, chronic disease status, environmental endocrine disruptor exposure, and lifestyles. However, there are inevitable epidemiological bias in the existing studies, including recall bias, selection bias and measurement bias. Some methodological advances have brought new opportunities to TTP research, which make it possible to develop precision interventions for population fertility. Future TTP studies should take advantage of artificial intelligence, machine learning, and high-throughput sequencing technologies, and apply medical big data to fully consider and avoid possible bias in the design.

Conclusion

There are many opportunities and future challenges for TTP related studies which would provide a scientific basis for the “precise health management” of the population preparing for pregnancy.

As the problems of infertility and population aging increase, there is a growing interest in the factors that cause a decline in human fertility. Time-to-pregnancy (TTP) is a good indicator with which to reflect human fecundability, and a longer TTP is known to reflect a reduction in fertility. Many original studies, with different designs, have used TTP to explore the factors that might influence fertility, including basic demographic characteristics, chronic disease status, environmental endocrine disruptor exposure, and lifestyles. However, much of the existing evidence is inconsistent and limited by various types of bias. This review provides a synopsis of recent TTP studies, and highlights new opportunities and future challenges.

Male Sexual Dysfunction and Infertility in Spinal Cord Injury Patients: State-of-the-Art and Future Perspectives

Spinal cord injury (SCI) is a relevant medical and social problem. According to the World Health Organization, the commonly estimated worldwide annual incidence of SCI is 40 to 80 cases per million population. After the SCI experience, most men present with sexual dysfunction (erectile dysfunction (ED) and ejaculatory dysfunction), fertility problems (such as impaired spermatogenesis, abnormalities in sperm viability, motility, and morphology), and systemic disorders such as genitourinary infection and endocrine imbalances. The best options available for managing the ejaculatory disorders in patients suffering from SCI are penile vibratory stimulation (PVS) and electroejaculation (EEJ). Furthermore, the treatment of ED in SCI patients consists of medical therapies including phosphodiesterase 5 inhibitors (PDE5i), intracavernosal injections (ICI), vacuum erection devices (VEDs), and surgical as penile prosthesis (PP). This review provides a snapshot of the current evidence for the mechanisms of sexual dysfunction and infertility in SCI patients, discusses the best management strategies for these conditions, and offers our perspective on the direction of future research.

Determination of idiopathic female infertility from infrared spectra of follicle fluid combined with gonadotrophin levels, multivariate analysis and machine learning methods

By in vitro fertilization, oocytes can be removed and the embryo can be cultured, and then trans cervically replaced when they reach cleavage or when the blastocyst stage. The characterization of the follicular fluid is important for the treatment process. Women who applied to the Academic Hospital in vitro fertilization (IVF) Center diagnosed with idiopathic female infertility (IFI) were sought in the patient group. Demographics and clinical gonadotropin measurements of the study population were recorded. Of the 116 follicular fluid samples (n=58 male-induced infertility; n=58 control) were analyzed using the FTIR system. To identify FTIR spectral characteristics of follicular fluids associated with an ovarian reserve and reproductive hormone levels from control and IFI, six machine learning methods and multivariate analysis were used. To assess the quantitative information about the total biochemical composition of a follicular fluid across various diagnoses. FTIR spectra showed a higher level of vibrations corresponding to lipids and a lower level of amide vibrations in the IFI group. Furthermore, the T square plot from Partial Last Square (PLS) analysis showed, that these vibrations can be used to distinguish IFI from the control group which was obtained by principal component analysis (PCA). Proteins and lipids play an important role in the development of IFI. The absorption dynamics of FTIR spectra showed wavenumbers with around 100% discrimination probability, which means, that the presented wavenumbers can be used as a spectroscopic marker of IFI. Also, six machine learning methods showed, that classification accuracy for the original set was from 93.75% to 100% depending on the learning algorithm used. These results can inform about IFI women's follicular fluid has biomacromolecular differentiation in their follicular fluid. By using a safe and effective tool for the characterization of changes in follicular fluid during in vitro fertilization, this study builds upon a comprehensive examination of the idiopathic female infertility remodeling process in human studies. We anticipate that this technology will be a valuable adjunct for clinical studies.

Leptin levels in women with unexplained infertility: A systematic review and meta-analysis

BACKGROUND

Unexplained infertility (UI) is usually used for any heterosexual couple who failed to have a successful clinical pregnancy without identifying clear causes after they undergo all standard fertility tests. Evidence shows that leptin is one of the most accurate biomarkers for UI. Nevertheless, conflicting results regarding leptin levels in women with UI have been reported.

AIM

To find the serum leptin levels in women with UI.

METHODS

All studies written in English and conducted before April 30, 2021 from PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar, OpenGrey, OATD, and the infertility conference abstract were included. Studies were found eligible if they provided the mean and standard deviation of leptin for the case group and control group. The quality assessment of individual studies was evaluated using the Joanna Briggs Institute Quality Assessment Tool. Data synthesis and statistical analysis were done using STATA software version 16.

RESULTS

A total of 378 studies were reviewed, and just six studies that fulfilled the eligibility criteria were included in this meta-analysis. The pooled result showed that leptin levels were significantly higher in women with UI compared to fertile women, with a standardized mean difference of 0.97 (95% confidence interval: -0.49-2.43). However, heterogeneity across studies was highly significant (P < 0.00001; I² = 98.8%).

CONCLUSION

The results of this study suggest that leptin levels are elevated in women with UI compared with fertile women; hence, leptin could be a potential biomarker for UI in women, and it may be useful for identifying women with a high risk of infertility.

Endometrial Factor in Unexplained Infertility and Recurrent Implantation Failure

Unexplained infertility (UI) and recurrent implantation failure (RIF) are diagnoses based on failed pregnancy attempts within current infertility treatment models. Both diagnoses are made when fertility is unexplained based on current diagnostic methods and has no clear cause; UI is diagnosed when testing is inconclusive, and RIF is diagnosed after three failed in vitro fertilization cycles. In both cases, interventions are often introduced without an understanding of the cause of the infertility, frequently leading to frustration for patients and caregivers. Here, we review evidence to support an influence of endometrial factor in patients given these poorly defined diagnoses and possible treatments targeting the endometrium to improve outcomes in these patients.

The value of transvaginal 4-dimensional hysterosalpingo-contrast sonography in predicting the necessity of assisted reproductive technology for women with tubal factor infertility

Background

More than 50 million women suffer from infertility worldwide, among whom 30% have associated fallopian tube pathology. Fortunately, the diagnostic accuracy of tubal patency has been enhanced with the consistent development of ultrasound imaging technology, especially the invention of transvaginal 4-dimensional hysterosalpingo-contrast sonography (TV 4D HyCoSy). However, detailed imaging data for evaluating the tubal condition for spontaneous conception and assessing the necessity of assisted reproductive technology (ART) have yet to be amassed.

Methods

Patients with tubal factor infertility (TFI) who received TV 4D HyCoSy were recruited for this study. They were divided into two groups according to the method of conception: the natural pregnancy group (patients who naturally conceived within 3 months after TV 4D HyCoSy) and the assisted reproduction group (patients who failed to conceive naturally within the 3 months but successfully conceived through ART). Logistic regression analysis was performed to examine the data obtained from participants' medical history and TV 4D HyCoSy investigation.

Results

Of the initial 1,433 women, 348 were excluded due to exclusion criteria or lack of follow-up. A total of 1,085 TFI patients were finally included, with individuals in the natural pregnancy group accounting for 27.74% (n=301), and those in the ART group accounting for 37.33% (n=405). The age was younger and the duration of infertility was shorter in the group of women who conceive spontaneously after TV 4D HyCoSy (P<0.05). In terms of imaging data, their endometrial thickness was thinner, right fallopian tube wall was more intact, morphology of the right fallopian tube was smoother, and their ovarian motility (bilateral), fallopian tube visualization (bilateral) and overflow condition of the contrast agent from the fimbriae of fallopian tube (bilateral) were better. In addition, the resistance of the contrast agent injection was less likely to be persistent, reflux was less likely to happen and 0/1 dispersion of the contrast agent around the ovary (bilateral) were more likely to be annular (P<0.05).

Conclusions

The imaging data gathered from TV 4D HyCoSy in TFI patients were comprehensive, which suggested that TV 4D HyCoSy could have potential to be used to assess the necessity of post-HyCoSy ART intervention in patients with TFI. This could be of benefit in reducing the incidence of overtreatment and potential complications of ART.

Morphological features of the secretory phase endometrium in women with unexplained infertility

In this study, we evaluated the structural features of the endometrial tissues, the immunohistochemical expression of MUC-1, which plays an important role in implantation, and the biochemical markers during the implantation window. Randomly chosen 18 fertile and 18 unexplained infertile women that have 27-32 days long menstrual cycle, normal hormonal values, normal USG findings of ovary and endometrium were included. Five, six, and seven days after ovulation, endometrial biopsies were taken and prepared in accordance with light and electron microscopy tissue preparation methods. Immunohistochemical methods were used to determine MUC-1 expression in the tissues. Serum hormone levels were determined. The MUC-1 immunoreactivity, as well as the serum levels of FSH, LH, TSH, estrogen, progesterone, and total testosterone did not differ significantly between the two groups; however, prolactin levels were higher in the infertile group. In the unexplained infertile samples, intraepithelial lymphocytes were frequently observed, the microvilli of the surface columnar epithelium were widespread, cells with pinopodes as well as vesiculated cells were minimal, pinopode development was insufficient, and the development of the endometrial glands was deficient. It was concluded that these structural differences observed in the surface and glandular epithelium of the endometrium in unexplained infertile patients may be due to the insufficiency of these cells in responding to steroid hormones; therefore, these changes may affect the implantation of the blastocyst in the endometrium.

The effect of plastic bottled water consumption on outcomes of ICSI cycles undertaken for unexplained infertility

RESEARCH QUESTION

Do bisphenol A (BPA) levels in maternal urine, serum and follicular fluid affect embryo quality and intracytoplasmic sperm hinjection (ICSI) cycle outcomes in women with unexplained infertility?

DESIGN

Prospective study conducted between 1 April 2019 and 30 September 2019. The study cohort consisted of 82 women aged between 23 and 33 years who underwent intracytoplasmic sperm injection owing to unexplained infertility and provided urine, blood and follicular fluid samples on the day of oocyte retrieval. Consumption of drinking water from plastic carboys or bottles at home were considered as chronic BPA exposure. Demographic features and IVF outcomes of the patients were collected.

RESULTS

Among the 82 women with unexplained infertility, clinical pregnancy was achieved in 22 (26.8%) patients after the IVF and embryo transfer cycle. The patients who consumed tap water had statistically significantly lower BPA values in three body fluids compared with patients who consumed plastic bottled water (all P < 0.001). Women who had grade 1 embryos transferred had lower serum BPA values than women who had grade 2 embryos transferred (10.8 ± 5.2 versus 26.9 ± 22 ng/ml, P = 0.003). Serum and follicular fluid BPA levels were statistically significantly higher in women who failed to achieve clinical pregnancy (P < 0.001, P = 0.006, respectively) and obtain a live birth (both P = 0.007).

CONCLUSIONS

A negative relationship was found between serum and follicular fluid BPA levels and embryo quality, clinical pregnancy and live birth in these women. In addition, the BPA levels of women who consume tap water at home were lower than those who use plastic bottled water.

Iodine and fertility: do we know enough?

Iodine is a vital micronutrient and its importance in thyroid function is well established. However, abnormalities in iodine intake may also have other effects. In particular, iodine is taken up avidly by the ovary and endometrium. Iodine deficiency is associated with reduced fertility. The use of high iodine concentration contrast media has recently been shown to improve conception rates in couples with unexplained infertility (UI). We hypothesize that this improvement could be related to the iodine excess and mechanisms independent of its action on thyroid. In this article, the metabolism of iodine and its potential role in fertility will be discussed, including the impact of both iodine deficiency and excess states and the importance of iodine in normal fetal development. This will include insights from animal studies on the effect of iodine in the uterine and ovarian structural environment, hormonal milieu and immunological factors affecting implantation. We speculate that iodine may well have a role as a potential therapy for UI.

Pregnancy predictors in unexplained infertility after intrauterine insemination

BACKGROUND

Intrauterine insemination (IUI) is a first-line treatment for unexplained infertility (UI). There was a compelling need for the improvement of pregnancy rate in females with UI.

OBJECTIVE

To explore the pregnancy predictors in cases of UI undergoing IUI.

METHOD

A total of 212 couples who underwent 446 IUI cycles were involved the study. Different factors were grouped to explore the influencing factors of IUI for UI.

RESULT

Female age and somking affected pregnancy outcomes. As the number of treatment cycles increased, the pregnancy rate increased. The BMI, treatment regimens, type of infertility, endometrium, and timing insemination have no significant prognostic value.

CONCLUSION

Apart from the number of treatment cycles, somking, and female age, no other factors had prognostic value. More studies and samples are necessary to evaluate whether other factors affect conception.

Dysfunction of Shh signaling activates autophagy to inhibit trophoblast motility in recurrent miscarriage

In early pregnancy, the placenta anchors the conceptus and supports embryonic development and survival. This study aimed to investigate the underlying functions of Shh signaling in recurrent miscarriage (RM), a serious disorder of pregnancy. In the present study, Shh and Gli2 were mainly observed in cytotrophoblasts (CTBs), Ptch was mainly observed in syncytiotrophoblasts (STBs), and Smo and Gli3 were expressed in both CTBs and STBs. Shh signaling was significantly impaired in human placenta tissue from recurrent miscarriage patients compared to that of gestational age-matched normal controls. VEGF-A and CD31 protein levels were also significantly decreased in recurrent miscarriage patients. Furthermore, inhibition of Shh signaling impaired the motility of JAR cells by regulating the expression of Gli2 and Gli3. Intriguingly, inhibition of Shh signaling also triggered autophagy and autolysosome accumulation. Additionally, knockdown of BECN1 reversed Gant61-induced motility inhibition. In conclusion, our results showed that dysfunction of Shh signaling activated autophagy to inhibit trophoblast motility, which suggests the Shh pathway and autophagy as potential targets for RM therapy.

The Livebirth Rate Per In Vitro Fertilization Cycle Is Higher Than The Cumulative Live Birth Rates of Intrauterine Insemination for Patients of Poseidon Group 3 With Unexplained Infertility

BACKGROUND

No studies have been done to examine the efficacy of IVF and intrauterine insemination (IUI) for the treatment of young patients with unexplained infertility and low ovarian reserve, although it is becoming an increasingly significant indication for in-vitro fertilization (IVF). The goal of this research was to compare the efficacy of IVF with IUI on Poseidon group 3 patients with unexplained infertility (PG3&UI).

METHODS

This was a retrospective analysis of PG3&UI patients who had IVF/intracytoplasmic sperm injection (ICSI) or IUI at the Third Affiliated Hospital of Guangzhou Medical University between January 1, 2015, and March 31, 2021. To equalize the baseline characteristics of the IVF/ICSI and IUI groups, propensity score matching (PSM) was utilized. Intention-to-treat (ITT) and per-protocol (PP) analyses were used to compare the differences in live births. To discover variations in time to biochemical pregnancy leading to live birth, Kaplan-Meier curves were produced. To evaluate the expenses per live birth between two procedures, a cost-effective analysis was done.

RESULTS

According to ITT analysis, the live birth rate for the IVF/ICSI group was substantially higher than the cumulative live birth rate (CLBR) for the IUI group (22.6% (38/168) vs. 11.3% (19/168), RR 2.00, 95% CI 1.20-3.32, P = 0.006). In the PP analysis, the live birth rate was 23.0% (38/165) in the IVF/ICSI group and 11.7% (19/162) in the IUI group (RR = 1.96, 95% CI 1.18-3.26, P = 0.007). When censored at 365 days, the Kaplan-Meier analysis revealed that the IVF/ICSI group had a higher live birth rate than the IUI group (log-rank test χ²= 6.025; P = 0.014). However, when the two groups were censored at 180 days, the live birth rates were not substantially different (log-rank test χ²= 3.847; P = 0.05). The number of hospital visits per live birth in the IUI group was higher than in the IVF/ICSI group (85 vs. 48). The overall cost of a live birth was comparable across the two groups (¥132242 vs. ¥131611), while the medical expenses for a live delivery from IVF/ICSI were higher than those from IUI (¥118955 vs. ¥108279).

CONCLUSIONS

The livebirth rate per IVF/ICSI cycle with at most one embryo transfer is higher than the CLBR of IUI, with fewer hospital visits and similar expenses.

How and Why to Define Unexplained Infertility?

Unexplained infertility represents up to 30% of all cases of infertility. It is a diagnosis of exclusion, where no cause for infertility may be identified in the investigation of the couple, be it anovulation, fallopian tube blockage, or severe male factor. Unexplained infertility therefore cannot be considered a diagnosis to which a specific treatment is directed, rather that it indicates a failure to reach a diagnosis of the true cause of infertility. In this review, we explore the evidence base and potential limitations of the current routine infertility assessment. We also aim to highlight the importance of considering the prognosis of each individual couple through the process of assessment and propose a reconsidered approach to treatment, targeted to the prognosis rather than the diagnosis. Ultimately, a better understanding of the mechanisms of infertility will reduce the number of couples diagnosed with "unexplained" infertility.

Impairment of Uterine Contractility Is Associated with Unexplained Infertility

The uterine junctional zone represents the juncture between endometrium and myometrium. The junctional zone is hormonally dependent and displays continuous peristaltic activity throughout the menstrual cycle in the nonpregnant state which is concerned with sperm transport and embryo implantation. Peristalsis may be observed using various invasive and noninvasive modalities, of which ultrasound is the most readily applied in the clinical setting. Women with pelvic pathology display alterations in uterine peristalsis which may contribute to infertility. Characterization of peristalsis in infertility subgroups, the development of a subjective peristalsis tool, and the application of potential therapeutics to an assisted reproductive treatment setting are the subject of ongoing investigation. Meta-analysis indicates a potential role for oxytocin antagonist in the improvement of fertility treatments.

The association between vaginal microbiota and female infertility: a systematic review and meta-analysis

PURPOSE

This study aimed to explore the association between vaginal microbiota and infertility.

METHODS

We searched a range of electronic databases for appropriate articles, including PubMed, Web of Science, Embase, Chinese National Knowledge Infrastructure (CNKI), and Wanfang, from inception to 8th September 2019. Identified articles were then screened using strict inclusion and exclusion criteria. By referring to Tamarelle's method, we divided vaginal microbiota into two categories: low-Lactobacillus vaginal microbiota (LL-VMB) and high-Lactobacillus vaginal microbiota (HL-VMB). Patients were defined as HL-VMB if they had a Nugent score of 0-3, a negative Amesel/Spiegel's test, or if the vaginal community status was dominated by either L. crispatus, L. iners, L. gasseri and L. jensenii via 16S rRNA sequencing. Otherwise, cases were regarded as LL-VMB. Statistical analyses were performed with STATA 13.0 statistical software. Effect estimates are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Fifteen articles were included in our final analysis. The HL-VMB was negatively related to infertility; a fixed model showed that the pooled OR was 0.83 (95% CI 0.77-0.90). There was no significant publication bias, as determined by Begg's test (P = 0.488) and Egger's test (P = 0.652). Using a random effect model, the pooled OR for intermediate bacterial vaginitis (BV) and infertility was 1.39 (95% CI 1.10-1.76) and the pooled OR for positive BV was 1.72 (95% CI 1.10-2.69). Subgroup and sensitivity analyses further demonstrated that the associations identified were stable. However, the acquired evidence was not sufficient to make inferences with regards to the mechanisms underlying these relationships.

CONCLUSION

This systematic review and meta-analysis identified a negative correlation between HL-VMB and female infertility. However, due to a variety of limitations, the evidence acquired does not allow us to identify the specific mechanisms underlying this association. Further high-quality studies are needed to verify the causal relationship and explore the molecular mechanisms involved.

Association between serum homocysteine level and unexplained infertility in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI): A retrospective, hospital-based, case-control study

Background

Lower serum homocysteine (Hcy) levels are found to correlate with a better chance of clinical pregnancy and better embryo grades in assisted reproductive technology (ART). However, there is little knowledge on the association between Hcy level and unexplained infertility until now.

Methods

A total of 388 infertile women undergoing IVF/ICSI treatments were recruited, including 129 women with unexplained causes (case group) and 259 women with known causes (control group), and the case group was further divided into subgroups A (≤8 μmol/L), B (>8 and <15 μmol/L), and C (≥15 μmol/L) based on the serum Hcy level. The associations between serum Hcy level and IVF/ICSI pregnancy outcomes were examined in infertile women with unknown causes.

Results

A significantly higher serum Hcy level was measured in the case group than in the control group (P = .008). Subgroup analysis revealed a significant difference in the total number of oocytes retrieved among subgroups A, B, and C (P = .031), and no significant difference was seen among these three groups in terms of age, BMI, E₂ level on the hCG day, number of M‐II oocytes, number of fertilized oocytes, or total number of high‐quality embryos (P > .05). Spearman correlation analysis revealed a negative correlation between serum Hcy level and total number of oocytes retrieved (r = −.406, P = .019). Univariate and multivariate linear regression analyses revealed that serum Hcy level had no correlations with any IVF/ICSI outcomes.

Conclusion

Serum Hcy level has no associations with IVF/ICSI pregnancy outcomes.

Recent advances and future opportunities to diagnose male infertility

PURPOSE OF REVIEW

Infertility affects 10-15% of couples, making it one of the most frequent health disorders for individuals of reproductive age. The state of childlessness and efforts to restore fertility cause substantial emotional, social, and financial stress on couples. Male factors contribute to about half of all infertility cases, and yet are understudied relative to female factors. The result is that the majority of men with infertility lack specific causal diagnoses, which serves as a missed opportunity to inform therapies for these couples.

RECENT FINDINGS

In this review, we describe current standards for diagnosing male infertility and the various interventions offered to men in response to differential diagnoses. We then discuss recent advances in the field of genetics to identify novel etiologies for formerly unexplained infertility.

SUMMARY

With a specific genetic diagnosis, male factors can be addressed with appropriate reproductive counseling and with potential access to assisted reproductive technologies to improve chances of a healthy pregnancy.

Towards a more pragmatic and wiser approach to infertility care

Infertility represents a very peculiar area of medicine. Contrary to other areas, where signs and symptoms lead to a diagnosis, which in turn leads to a specific treatment, in reproduction the lack of signs and symptoms for more than 12 months suggests the diagnosis of ‘unexplained subfertility’, and if this condition has lasted for some years, couples qualify for IVF. Diagnosis and treatments can extend over long periods of time (even years) and the accuracy of the diagnostic armamentarium is not optimal. Uncertainty about diagnosis and the need for significant perseverance is demanding on both couples and physicians, and actually constitute a very favourable situation for overdiagnosis (‘unexplained subfertility’) and overtreatment (IVF) on one hand, and, on the other, it may also affect compliance with treatments. To improve our capacity to properly handle this challenging situation, increased attention should be given to the duration of pregnancy seeking. Initiating treatments earlier in older women is unwise because this population has a lower fecundity and, therefore, duration of pregnancy seeking is even more important to achieve a reliable diagnosis of infertility. Moreover, if the infertility work-up is unremarkable, duration of pregnancy seeking should be extended up to more than 2 years prior to making a diagnosis of unexplained infertility regardless of age. An adequate period of pregnancy seeking is also required for couples who are diagnosed with conditions that can interfere with fertility to avoid overdiagnosis and overtreatment. Indeed, most causes of infertility will reduce but not impair natural conception. Within this sometimes long-term management, physicians should also pay attention to detrimental life habits in order to optimize the chances of both natural and assisted reproduction technology -mediated pregnancy. Even if interventional studies are not conclusive, it is advisable to address the problems of obesity and smoking. Focussing on frequency of sexual intercourse may be also beneficial for natural conception. Finally, there is the need for improving our capacity to handle compliance. Providing information on the importance of persevering at the start of treatment, promoting shared decision-making and tackling patient, clinic and treatment causes of drop-out can all improve the overall chances of parenthood. Thus, we plead for a wiser and more pragmatic approach to infertility, paying more attention to these neglected, but in our opinion essential, aspects of infertility care.