Racial and ethnic differences in reproductive potential across the life cycle

Development and validation of a prediction model for suboptimal ovarian response in polycystic ovary syndrome (PCOS) patients undergoing GnRH-antagonist protocol in IVF/ICSI cycles

BACKGROUND

PCOS patients with unexpectedly low oocyte yield following conventional ovarian stimulation are referred to as suboptimal responders. However, identifying suboptimal responders presents a significant challenge within reproductive medicine and limited research exists on the occurrence of suboptimal response. This analysis aimed to develop a predictive model of suboptimal response during in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments in PCOS patients.

METHODS

This retrospective study involved a cohort of 313 PCOS patients undergoing their first IVF/ICSI cycle from 2019 to 2022. Univariate logistic regression analyses, least absolute shrinkage, selection operator regression analysis, and recursive feature elimination were employed to identify relevant characteristics and construct predictive models. Moreover, a nomogram was constructed based on the best model. Receiver operating characteristic curves, decision curve analysis (DCA), and calibration curves were used to evaluate the model.

RESULTS

The predictors included in the model were age, Anti-Mullerian hormone, antral follicle count, and basal follicle-stimulating hormone. The area under the receiver operating characteristic curve (AUC) was 0.7702 (95% confidence interval 0.7157-0.8191). The AUC, along with the DCA curve and calibration curve, demonstrated a satisfactory level of congruence and discrimination ability.

CONCLUSION

The nomogram effectively predicted the probability of suboptimal response in PCOS patients undergoing gonadotropin-releasing hormone antagonist protocol during IVF/ICSI treatment.

Analysis of the potential regulatory mechanisms of female and latent genital tuberculosis affecting ovarian reserve function using untargeted metabolomics

Female and latent genital tuberculosis (FGTB and LGTB) in young women may lead to infertility by damaging ovarian reserve function, but the regulatory mechanisms remain unclear. In this study, we investigated the effects of FGTB and LGTB on ovarian reserve function and potential regulatory mechanisms by untargeted metabolomics of follicular fluid, aiming to provide insights for the clinical management and treatment approaches for afflicted women. We recruited 19 patients with FGTB, 16 patients with LGTB, and 16 healthy women as a control group. Clinical data analysis revealed that both the FGTB and LGTB groups had significantly lower ovarian reserve marker levels compared to the control group, including lower anti-Müllerian hormone levels (FGTB: 0.82 [0.6, 1.1] μg/L; LGTB: 1.57 [1.3, 1.8] μg/L vs. control: 3.29 [2.9, 3.5] μg/L), reduced antral follicular counts (FGTB: 6 [5.5, 9.5]; LGTB: 10.5 [7, 12.3] vs. control: 17 [14.5, 18]), and fewer retrieved oocytes (FGTB: 3 [2, 5]; LGTB: 8 [4, 8.3] vs. control: 14.5 [11.5, 15.3]). Conversely, these groups exhibited higher ovarian response marker levels, such as longer gonadotropin treatment days (FGTB: 12 [10.5, 12.5]; LGTB: 11 [10.8, 11.3] vs. control: 10 [8.8, 10]) and increased gonadotropin dosage requirements (FGTB: 3300 [3075, 3637.5] U; LGTB: 3037.5 [2700, 3225] U vs. control: 2531.25 [2337.5, 2943.8] U). All comparisons were statistically significant at P < 0.05. The results suggested that FGTB and LGTB have adverse effects on ovarian reserve and response. Untargeted metabolomic analysis identified 92 and 80 differential metabolites in the control vs. FGTB and control vs. LGTB groups, respectively. Pathway enrichment analysis revealed significant alterations in metabolic pathways in the FGTB and LGTB groups compared to the control group (P < 0.05), with specific changes noted in galactose metabolism, biotin metabolism, steroid hormone biosynthesis, and nicotinate and nicotinamide metabolism in the FGTB group, and caffeine metabolism, primary bile acid biosynthesis, steroid hormone biosynthesis, and glycerophospholipid metabolism in the LGTB group. The analysis of metabolic levels has revealed the potential mechanisms by which FGTB and LGTB affect ovarian reserve function, namely through alterations in metabolic pathways. The study emphasizes the importance of comprehending the metabolic alterations associated with FGTB and LGTB, which is of considerable relevance for the clinical management and therapeutic approaches in afflicted women.

A Systematic Review of Genetics and Reproductive Health Outcomes: Asian Perspective

In the last four decades, advances in assisted reproductive technology (ART) have offered hope to individuals with fertility problems to conceive. However, a closer examination of the clinical outcomes of ART shows a stark contrast in Asian women compared to Caucasians, with majority of studies reporting lower reproductive success among Asian women. We performed a systematic review to elucidate the genes associated with ART clinical outcomes, with a focus on Asian ethnicities. We completed a database search to identify all studies associated with reproductive outcomes in women of different ethnic backgrounds. Following PRISMA, 128 studies were analyzed. Pathway analysis of gene sets was done using Cytoscapev3.4.0. We observed that age at menarche (AAM) was correlated with the timing of the first pregnancy, with Hawaiians having the lowest age (22.2 years) and Japanese the highest age (25.0 years). LIN28 mutations were associated with AAM and prevalent in both Chinese and American populations. FMR1 was most associated with ovarian reserve. Network analysis highlighted a close association between FMR1, FSHR, ESR1, BMP15, and INHA, through biological functions affecting menstrual cycle and hypothalamic-pituitary axis and therefore ovarian follicle development. Leveraging these findings, we propose the development of a personalized, ethnic-specific biomarker panel which would enhance patient stratification to address every woman's unique reproductive potential.

Ovarian response determines the luteinizing hormone suppression threshold for patients following the gonadotrophin releasing hormone antagonist protocol: A retrospective cohort study

Background

Ovarian reactivity to gonadotrophin stimulation varies, and individual adjustments to the timing and dose of gonadotrophin-releasing hormone (GnRH) antagonist administration are necessary to prevent excessive increases and decreases in luteinizing hormone (LH) levels in patients with different ovarian response following the GnRH antagonist (GnRH-A) protocol. The present study aims to investigate optimal LH suppression thresholds for patients with normal ovarian response (NOR), high ovarian response (HOR), and poor ovarian response (POR) following the GnRH-A protocol respectively.

Methods

A total of 865 in vitro fertilization (IVF) cycles using a flexible or fixed GnRH-A protocol were included. Patients were categorized into the HOR, NOR, or POR group according to their anti-Müllerian hormone (AMH) levels. Then, patients in each group were stratified into one of four subgroups according to the quartile (Q1-Q4) of the basal LH level to LH on triggering day ratio (bLH/hLH). The primary outcomes were the clinical pregnancy and live birth rates, and the secondary outcomes were the number of oocytes retrieved, MII oocytes, two pronucleus (2PN) embryos, and good-quality embryos.

Results

There were 526 patients with NOR, 180 with HOR, and 159 with POR. Basal LH level, LH on triggering day and bLH/hLH were identified as independent predictors of clinical pregnancy rate and live birth rate by logistics regression analysis. Compared to those with NOR, patients with POR had the lowest embryo implantation rate (22.6% vs. 32.8%, P < 0.05), clinical pregnancy rate (32.3% vs. 47.3%, P < 0.05) and live birth rate (22.6 vs. 37.8%, P < 0.05) of fresh embryo transfer (ET). The embryo implantation, clinical pregnancy and live birth rates of frozen embryo transfer (FET) were not significantly different among the three groups. In the subgroup analysis, patients with HOR had the highest embryo implantation rate (51.6%, P < 0.05), clinical pregnancy rate (68.4%, P < 0.05) and live birth rate (52.6%, P < 0.05) of ET in Q3, with a bLH/hLH ratio of 2.40-3.69. In the NOR group, the embryo implantation rate (41.9%, P < 0.05), clinical pregnancy rate (61.5%, P < 0.05) and live birth rate (50.8%, P < 0.05) of ET and live birth rate (53.1%, P < 0.05) of FET were highest in Q2, with a bLH/hLH ratio of 1.29-2.05. Patients with POR had the highest clinical pregnancy rate (57.1%, P < 0.05) and live birth rate (42.9%, P < 0.05) of ET in Q2, with a bLH/hLH ratio of 0.86-1.35.

Conclusions

In the present study, the bLH/hLH ratio represented the LH suppression threshold. The subgroup analysis of HOR, NOR and POR showed that, the LH suppression threshold varies according to ovarian response. We recommend LH suppression thresholds of 2.40-3.69 for HOR, 1.29-2.05 for NOR, and 0.86-1.35 for POR to obtain the highest clinical pregnancy rate and live birth rate. This study provides comprehensive and precise references for clinicians to monitor LH levels individually during controlled ovarian stimulation (COS) according to the patient's ovarian response following the GnRH-A protocol.

Correlation between the number of oocytes and the increase of polyspermy rate in IVF cycles

Aims: To investigate the association between the number of oocytes and the polyspermy rate following in vitro fertilization (IVF) treatment. Materials and methods: 376 IVF cycles with gonadotropin-releasing hormone (GnRH) antagonist protocol in the reproductive center of our hospital were retrospectively included in the analysis, which were divided into five groups according to the number of oocytes retrieved. Group A (78 cases):1-5 oocytes, group B (118 cases): 6-10 oocytes, group C (94 cases): 11-15 oocytes, group D (55 cases): 16-20 oocytes, group E (31 cases): ≥21 oocytes. According to polyspermy rate, 376 IVF cycles were then divided into two groups. Normal level polyspermy group (170 cases): polyspermy rate<6%, and high level polyspermy group (206 cases): polyspermy rate ≥ 6%. The variables with p < .10 in univariate analysis were incorporated into the multiple logistic regression model to control the confounding, and the effect of the number of oocytes on the increase of polyspermy rate was analyzed. Results: Multiple logistic regression analysis showed that after adjustment for confounding factor, the increase risk of polyspermy rate in group B, C, D and E was 1.763, 3.804, 2.021 and 3.208 times of that in group A respectively (OR = 1.763, p = .085; OR = 3.804, p = .001; OR = 2.021, p = .158; OR = 3.208, p = .068, respectively). Conclusion: This result demonstrated that when the oocyte number is 15 or less, the more the oocyte number, the greater the increase risk of polyspermy rate. While, there appears to be little increase risk of polyspermy rate when the oocyte number is more than 15.

Systematic exclusion at study commencement masks earlier menopause for Black women in the Study of Women's Health Across the Nation (SWAN)

BACKGROUND

Shorter average lifespans for minoritized populations are hypothesized to stem from 'weathering' or accelerated health declines among minoritized individuals due to systemic marginalization. However, evidence is mixed on whether racial/ethnic differences exist in reproductive ageing, potentially due to selection biases in cohort studies that may systematically exclude 'weathered' participants. This study examines racial/ethnic disparities in the age of menopause after accounting for differential selection 'into' (left truncation) and 'out of' (right censoring) a cohort of midlife women.

METHODS

Using data from the Study of Women's Health Across the Nation (SWAN) cross-sectional screener (N = 15 695) and accompanying ∼20-year longitudinal cohort (N = 3302) (1995-2016), we adjusted for potential selection bias using inverse probability weighting (left truncation) to account for socio-demographic/health differences between the screening and cohort study, and multiple imputation (right censoring) to estimate racial/ethnic differences in age at menopause (natural and surgical).

RESULTS

Unadjusted for selection, no Black/White differences in menopausal timing [hazard ratio (HR)=0.98 (0.86, 1.11)] were observed. After adjustment, Black women had an earlier natural [HR = 1.13 (1.00, 1.26)] and surgical [HR= 3.21 (2.80, 3.62)] menopause than White women with natural menopause-corresponding to a 1.2-year Black/White difference in menopause timing overall.

CONCLUSIONS

Failure to account for multiple forms of selection bias masked racial/ethnic disparities in the timing of menopause in SWAN. Results suggest that there may be racial differences in age at menopause and that selection particularly affected the estimated menopausal age for women who experienced earlier menopause. Cohorts should consider incorporating methods to account for all selection biases, including left truncation, as they impact our understanding of health in 'weathered' populations.

[Impact of geographical origin on IVF results: A monocentric observational French cohort study comparing 3 populations: Europe, Maghreb and Sub-Saharan Africa]

OBJECTIVE

Many studies in the literature have found an association between geographic origin and poorer IVF outcomes in African American and Asian minority populations compared with Caucasian populations. The limitations of these studies are multiple (inconsistencies in the characterization of ethnic groups, mostly multicenter studies with large variability in success rates between centers, minorities having more limited and delayed access to care). Thus, socioeconomic status may have been an important bias in judging environmental or "genetic" factors. The objective of our study is to determine whether geographic origin would influence IVF response and outcomes in a French university hospital center with equal access to care.

MATERIAL AND METHODS

This was a retrospective single-center observational study from January 2013 to January 2020 comparing IVF response in 3 populations of similar size at our Medically Assisted Reproduction center, with all charges covered by Medicare. The primary objective was ovarian response to IVF, and the secondary objectives were clinical pregnancy rate and live birth rate per cycle started.

RESULTS

We analyzed 1669 cycles of first IVF attempt in women from Europe (525), Sub-Saharan Africa (649) and Maghreb (495). The SSA and Maghrebi women had a higher BMI. SSA women were more often affected by tubal or uterine infertility, HIV or HBV infection, and were less often nulliparous. The indication of male infertility was more frequent in Maghrebi women with a higher ICSI rate. There was no significant difference in the duration of stimulation, endometrial thickness at induction, number of oocytes collected, fertilization rate, number of embryos transferred and frozen. Nevertheless, the cancellation rate was higher in SSA and Maghrebi women and the total dose of gonadotropins was higher in SSA. No significant difference was found between Maghrebi and European women on IVF outcomes except for a lower number of total embryos in Maghrebi women (3.33 vs. 4.13 on average, P<0.001). The SSA had a lower rate of mature oocytes per puncture (66 % vs. 73 %, P<0.001), a lower number of total embryos per puncture (3.56 vs. 4.13 on average, P<0.016), a lower rate of clinical pregnancies per cycle (11.7% vs. 20.4%, P<0.001), a lower rate of live births per cycle (6.9% vs. 15.2%, P<0.001).

CONCLUSION

There was no significant difference between European and Maghrebi women at the end of IVF, but the results were lower for those from SSA.

Sexual health and intimacy after cancer treatment in women of color: A systematic review

OBJECTIVE

Cancer diagnosis and treatment can significantly affect women's sexual health and intimacy, leading to diminished quality of life in survivorship. The perspectives and experiences of women of color (WOC) with cancer are critical to inform comprehensive, inclusive sexual wellbeing care in survivorship. The purpose of this systematic review is to summarize contemporary literature describing sexual wellbeing experiences of WOC treated for cancer.

METHODS

A comprehensive search of CINAHL, PubMed, Embase and PsycInfo and Scopus identified studies that addressed sex and intimacy of U.S. WOC treated for cancer published in the last 15 years. The authors identified emergent themes from the literature through thematic content analysis.

RESULTS

Eighteen studies (10 qualitative, 8 quantitative) met the inclusion criteria, all with breast or gynecologic cancer samples. Studies include African American (13), Asian American (3), and Latina (10) women, as well as Non-Hispanic Whites and 'other' race/ethnicity women. Overarching themes identified were: 1) impacts of treatment on sexual health and body image, 2) process of accepting and overcoming, 3) value of an engaged and supportive partner, and 4) current clinical practice and barriers to sexual health care.

CONCLUSIONS

WOC experience changes in sex and intimacy after cancer treatment, and experiences of sexual function, sexual communication, and sexual healthcare are often shaped by sociocultural experiences. An understanding of WOC's sexual health and intimacy after cancer treatment can inform inclusive, culturally responsive sexual health interventions.

The Disparities in ART (DART) Hypothesis of Racial and Ethnic Disparities in Access and Outcomes of IVF Treatment in the USA

We propose the Disparities in ART (DART) hypothesis which identifies underlining causes that contribute to racial disparities in access and outcomes of ART treatment in the USA. Reasons for disparities in access and outcomes of ART treatment for infertility are derived from some relative contribution of four identified causes. They are simply stated as delays in obtaining treatment, higher dropout during and following unsuccessful ART treatment, provider factors, and differences in patient biological factors. Each of these causes has a subset of 4-6 factors that contribute to each of the 4 broad categorical causes that are discussed. This hypothesis may serve as a platform for better understanding the scope of the challenges and potential research inquiries that may lead to narrowing of racial/ethnic disparities in access and outcomes in ART.

Women's Health in Multiple Sclerosis: A Scoping Review

Background

Women with multiple sclerosis (MS) may face challenges related to managing reproduction, pregnancy, and menopause while simultaneously managing their disease. The purpose of this scoping review was to map the literature broadly related to topics relevant to women's health in MS to inform the clinical and research communities about the existing types and sources of evidence and knowledge gaps. Apart from coverage of topics within the field of women's health, we were interested in potential gaps related to geographic and racial and ethnic diversity. We also aimed to understand the degree of inclusion of women with progressive MS in this research.

Methods

We searched the EMBASE and Ovid Medline databases from 1980 until November 23, 2020. We included case-control and cohort studies, clinical trials and case series published in any language, conducted in women with MS, clinically isolated syndrome, or radiologically isolated syndrome, that addressed women's health. Two reviewers independently screened abstracts and full-text reports for study inclusion, and completed data extraction.

Results

Of 112,106 citations screened, 1,041 underwent full-text review and 353 met the inclusion criteria. The number of studies regarding women's health has increased exponentially over time. Almost half of the studies were conducted (at least in part) in Europe, while 21.7% were conducted in North America; only one study was conducted in Africa. Most studies did not report the race or ethnicity of their participants (n = 308, 87.2%). Among the 353 studies, 509 topics were reported as some studies addressed more than one topic. Over one-third of these focused on pregnancy (n = 201, 37.2%), followed by fetal/neonatal outcomes (14.4%) and sexual dysfunction (10%). Among the 201 studies that focused on pregnancy, only 51 (25.4%) included participants with progressive MS.

Conclusions

This review identifies important knowledge gaps related to women's health in MS and particularly the need for future studies to include participants with a broader range of races and ethnicities, with progressive MS, and living in Asia-Pacific and African regions.

Analysis of relative factors and prediction model for optimal ovarian response with gonadotropin-releasing hormone antagonist protocol

OBJECTIVE

To explore the relative factors for best ovarian response in patients undergoing assisted reproductive technology with the gonadotropin-releasing hormone antagonist protocol and to establish a nomogram prediction model of ovarian response.

METHODS

A retrospective cohort analysis of the clinical data of 1,944 patients who received assisted reproductive treatment in the Center for Reproductive Medicine of Fujian Maternity and Child Health Hospital from April 1, 2018, to June 30, 2020. According to the number of oocytes obtained, there were 659 cases in the low ovarian response group (no more than five oocytes were retrieved), 920 cases in the normal ovarian response group (the number of retrieved oocytes was >5 but ≤18), and 365 cases in the high ovarian response group (>18 oocytes retrieved). Independent factors affecting ovarian responsiveness were screened by logistic regression, which were the model entry variables, and a nomogram prediction model was established based on the regression coefficients.

RESULTS

There were statistically significant differences in age, anti-Mullerian hormone, antral follicle count, the diagnosis of endometriosis, decreased ovarian reserve, polycystic ovary syndrome, basal follicle-stimulating hormone and basal luteinizing hormone among the three groups (P < 0.001). Multifactorial stepwise regression analysis showed that female age (0.95 [0.92-0.97], P = 0.000), decreased ovarian reserve (0.27 [0.19-0.38]), P = 0.000), endometriosis (0.81 [0.56-0.86], P = 0.000), antral follicle count (1.09 [1.06-1.12], P = 0.000), basal follicle-stimulating hormone (0.90 [0.85-0.96], P = 0.001), Anti-Mullerian hormone (1.19 [1.13-1.26], P= 0.000) and luteinizing hormone on trigger day (0.73 [0.66-0.80], P= 0.000), were independent factors for the occurrence of different ovarian responses during ovarian hyperstimulation. The predictive model of ovarian responsiveness was constructed based on the above factors, and the model was verified with 589 patients' data from July 1, 2020, to December 31, 2020, at this center. The predicted ovarian response (number of eggs obtained) of a total of 450 patients was consistent with the actual results, with a coincidence degree of 76.4%, and the consistency index of the model is 0.77.

CONCLUSION

The nomogram model was successfully developed to effectively, intuitively, and visually predict the ovary reactivity in the gonadotropin-releasing hormone antagonist protocol and provide guidance for clinical practice.

Sexual Orientation Identity Development Milestones Among Lesbian, Gay, Bisexual, and Queer People: A Systematic Review and Meta-Analysis

This paper is a systematic review and meta-analysis on sexual orientation identity development milestones among people who are lesbian, gay, bisexual, or another sexual minority identity (LGB+). Common milestones measured in the 30 studies reviewed were becoming aware of queer attractions, questioning one's sexual orientation, self-identifying as LGB+, coming out to others, engaging in sexual activity, and initiating a romantic relationship. Milestones occurred in different sequences, although attraction was almost always first, often followed by self-identification and/or sexual activity; coming out and initiating a romantic relationship often followed these milestones. Meta-analysis results showed that the mean effect sizes and 95% confidence intervals varied by milestone: attraction [M _age=12.7 (10.1, 15.3)], questioning one's orientation [M _age=13.2 [12.8, 13.6]), self-identifying [M _age=17.8 (11.6, 24.0)], sexual activity [M _age=18.1 (17.6, 18.6)], coming out [M _age=19.6 (17.2, 22.0)], and romantic relationship [M _age=20.9 (13.2, 28.6)]. Nonetheless, results also showed substantial heterogeneity in the mean effect sizes. Additional meta-analyses showed that milestone timing varied by sex, sexual orientation, race/ethnicity, and birth cohort. Although patterns were found in LGB+ identity development, there was considerable diversity in milestone trajectories.

Racial disparities in frozen embryo transfer success

PURPOSE

To compare pregnancy and birth outcomes after frozen embryo transfers (FETs) among White, Black, and Asian women and evaluate the effect of patient, protocol, and cycle characteristics on success.

METHODS

A retrospective chart review identified women who underwent an autologous FET at an academic fertility center between January 2013 and March 2020.

RESULTS

White, Black, and Asian women completed 1,181 (71.7%), 230 (14.0%), and 235 (14.3%) cycles, respectively. Black women were significantly less likely to achieve a positive hCG level (AOR 0.66, 95% CI 0.49-0.90), clinical pregnancy (AOR 0.71, 95% CI 0.53-0.97), and live birth (AOR 0.65, 95% CI 0.47-0.89) compared to White women after adjusting for possible confounders. There were no differences in the aforementioned outcomes when looking at cycles completed by Asian versus White women. When comparing outcomes by endometrial preparation protocol, significant differences were seen amongst the three groups for live birth rates following natural cycle FETs (52.36%, 25.81%, and 44.19% for White, Black, and Asian women, respectively, p = 0.02), a difference not appreciated after programmed FETs.

CONCLUSION

Black race is associated with significantly worse pregnancy and live birth rates following FET when compared to White race. Additionally, significant differences in live birth rates among White, Black, and Asian women exist following natural cycle FET versus programmed FET. These disparities in success are not only important for patient counseling, but also when determining management strategies to improve fertility rates among minority women.

Health disparities of African Americans in reproductive medicine

The first paper describing an association between African American race, infertility prevalence, and outcomes of fertility treatments was published more than 20 years ago, calling initial attention to differences in how infertility is experienced, diagnosed, and managed in African Americans. Since that initial publication, multiple other studies have explored African American race and its association with elements of the fertility spectrum-disparities that have been durable over time. The goal of this review is to provide an overview of the evolution of aspects of this research focusing on the outcomes of infertility treatments and barriers to access. A consideration of the system-based practice issues that interface with timely fertility evaluation and treatment in ways that challenge reproductive health equity will be presented.

A Lifecourse Perspective on Female Sex-Specific Risk Factors for Later Life Cognition

PURPOSE OF REVIEW

The prevalence of Alzheimer's disease and related dementias is greater in women compared to men. We provide a review of female sex-specific risk factors across the lifecourse for cognition in older adulthood, highlighting areas that need further study.

RECENT FINDINGS

Pregnancy may affect late-life cognition, with adverse pregnancy outcomes associated with an increased risk of cognitive decline but parity providing a protective effect. Cumulative estrogen exposure, influenced by age of menarche, menopause, and exogenous estrogen use, may modify a woman's risk for dementia. Menopause transition-associated symptoms may impact cognitive health at the time of the symptoms, but long-term effects remain unknown. As compared to natural menopause, surgical menopause seems to increase the risk for cognitive impairment. Studies that have assessed the association between women's reproductive health and cognition have produced conflicting results. Future studies that address these inconsistencies among diverse populations are needed to better care for women throughout their lives.

Racial/Ethnic Disparities in Pregnancy and Prenatal Exposure to Endocrine-Disrupting Chemicals Commonly Used in Personal Care Products

PURPOSE OF REVIEW

Endocrine-disrupting chemical (EDC) exposure during pregnancy is linked to adverse maternal and child health outcomes that are racially/ethnically disparate. Personal care products (PCP) are one source of EDCs where differences in racial/ethnic patterns of use exist. We assessed the literature for racial/ethnic disparities in pregnancy and prenatal PCP chemical exposures.

RECENT FINDINGS

Only 3 studies explicitly examined racial/ethnic disparities in pregnancy and prenatal exposure to PCP-associated EDCs. Fifty-three articles from 12 cohorts presented EDC concentrations stratified by race/ethnicity or among homogenous US minority populations. Studies reported on phthalates and phenols. Higher phthalate metabolites and paraben concentrations were observed for pregnant non-Hispanic Black and Hispanic women. Higher concentrations of benzophenone-3 were observed in non-Hispanic White women; results were inconsistent for triclosan. This review highlights need for future research examining pregnancy and prenatal PCP-associated EDCs disparities to understand and reduce racial/ethnic disparities in maternal and child health.

Maternal age affects the relationship of basal FSH and anti-Müllerian hormone concentrations with post-ICSI/IVF live birth

RESEARCH QUESTION

Does the association of basal FSH and anti-Müllerian hormone (AMH) concentrations with post-IVF/intracytoplasmic sperm injection (ICSI) live birth change with maternal age?

DESIGN

A total of 2003 IVF/ICSI patients were stratified according to basal FSH/AMH in concordant favourable (CF; AMH >1 ng/ml and FSH ≤10 IU/l), concordant unfavourable (CU; AMH ≤1 ng/ml and FSH >10 IU/l), discordant with favourable AMH (DFA) and discordant with favourable FSH (DFF) groups, as well as according to age in pre-advanced maternal age (pre-AMA; <35), AMA-1 (≥35, ≤37), AMA-2 (>37, ≤40) and AMA-3 (>40). IVF/ICSI outcomes were compared among CF, CU, DFA and DFF groups, and the association of basal FSH and AMH concentrations with live birth was tested by univariate and multivariate analysis in total, pre-AMA and AMA groups, separately.

RESULTS

Different outcome patterns were observed in discordant AMH/FSH groups from different age categories; favourable basal FSH concentrations were associated with higher delivery rates in pre-AMA patients, but with lower delivery rates in AMA groups. Within pre-AMA patients, DFF patients presented higher delivery rates but lower oocyte yield compared with DFA patients. In the univariate analysis, favourable AMH (P < 0.02) and oocyte yield (P < 0.002) were positively associated with live birth in all AMA groups. The multivariate analysis revealed that favourable basal FSH, but not AMH or oocyte yield, is associated with live birth in pre-AMA patients independently of other variables (P = 0.012).

CONCLUSIONS

The relationship of basal FSH and AMH with IVF/ICSI success changes with maternal age; basal FSH better reflects clinical outcomes probably determined by oocyte quality in pre-AMA patients, while AMH better suits AMA patients.

National egg-freezing trends: cycle and patient characteristics with a focus on race/ethnicity

OBJECTIVE

To describe the trends and characteristics of oocyte cryopreservation (OC) cycles stratified by self-reported race/ethnicity in the United States DESIGN: Retrospective cohort analysis using the Society for Assisted Reproductive Technology Clinical Outcome Reporting System SETTING: US fertility clinics PATIENTS: All patients undergoing OC from 2012 through 2016 INTERVENTIONS: None MAIN OUTCOME MEASURES: The OC cycle trends were analyzed on the basis of race/ethnicity: non-Hispanic white, non-Hispanic black, Asian/Pacific islander, Hispanic, and other (American Indian, Alaskan native, or mixed race).

RESULTS

Between 2012 and 2016, there was a total of 29,631 OC cycles; the total number of cycles increased yearly from 2,925 in 2012 to 8,828 in 2016. When compared with the demographics of the United States, OC was underused by some minority patient groups because majority of the cycles (66.5%) were performed in white patients. The total number of OC cycles increased annually among all the ethnic groups, most notably among Asian patients. The patients of all the ethnic backgrounds were most commonly under 35 years of age and underwent 1 OC cycle, except for Asian patients, who most frequently underwent OC between the ages of 35 and 37 years and were more likely to have undergone ≥2 cycles than patients of other minority groups. After adjustment for cofounders, there were no clinically significant differences in oocyte yield and the percentage of maturation across the racial/ethnic groups.

CONCLUSIONS

Nationally, OC cycles have been increasing in number, most often in patients under the age of 35 years, with similar proportions of patients of minority groups pursuing OC over time. The oocyte yield was comparable across the ethnic groups. Future research regarding subsequent thawing outcomes is warranted.

Ethnic and Sociocultural Differences in Ovarian Reserve: Age-Specific Anti-Müllerian Hormone Values and Antral Follicle Count for Women of the Arabian Peninsula

BACKGROUND

Anti-Müllerian hormone (AMH) and antral follicle count (AFC) age-specific reference values form the basis of infertility treatments, yet they were based upon studies performed primarily on Caucasian populations. However, they may vary across different age-matched ethnic populations. This study aimed to describe age-specific serum AMH and AFC for women native to the Arabian Peninsula.

METHODS

A retrospective large-scale study was performed including 2,495 women, aged 19 to 50 years, native to the Arabian Peninsula. AMH and AFC were measured as part of their fertility assessment at tertiary-care fertility centres. Age-specific values and nomograms were calculated.

RESULTS

2,495 women were evaluated. Mean, standard deviation and median values were calculated for AMH and AFC by 1-year and 5-years intervals. Median age was 34.81 years, median AMH was 1.76ng/ml and median AFC was 11. From the total group, 40.60% presented with AMH levels below 1.3ng/mL. For women <45 years old, the decrease in AFC was between -0.6/-0.8 per year. Up to 36 years old, the decrease of AMH was 0.1ng/ml. However, from 36 to 40 years old, an accelerated decline of 0.23ng/ml yearly was noted. In keeping with local customs, 71.23% of women wore the hijab and 25.76% the niqab. AMH and AFC were significantly lower for niqab group compared with hijab group (p=0.02 and p=0.04, respectively).

CONCLUSION

This is to-date the largest data set on age-specific AMH and AFC values in women from the Arabian Peninsula aiming to increase clinical awareness of the ovarian reserve in this population.

Characterizing the Clinical and Genetic Spectrum of Polycystic Ovary Syndrome in Electronic Health Records

CONTEXT

Polycystic ovary syndrome (PCOS) is one of the leading causes of infertility, yet current diagnostic criteria are ineffective at identifying patients whose symptoms reside outside strict diagnostic criteria. As a result, PCOS is underdiagnosed and its etiology is poorly understood.

OBJECTIVE

We aim to characterize the phenotypic spectrum of PCOS clinical features within and across racial and ethnic groups.

METHODS

We developed a strictly defined PCOS algorithm (PCOSkeyword-strict) using the International Classification of Diseases, ninth and tenth revisions and keywords mined from clinical notes in electronic health records (EHRs) data. We then systematically relaxed the inclusion criteria to evaluate the change in epidemiological and genetic associations resulting in 3 subsequent algorithms (PCOScoded-broad, PCOScoded-strict, and PCOSkeyword-broad). We evaluated the performance of each phenotyping approach and characterized prominent clinical features observed in racially and ethnically diverse PCOS patients.

RESULTS

The best performance came from the PCOScoded-strict algorithm, with a positive predictive value of 98%. Individuals classified as cases by this algorithm had significantly higher body mass index (BMI), insulin levels, free testosterone values, and genetic risk scores for PCOS, compared to controls. Median BMI was higher in African American females with PCOS compared to White and Hispanic females with PCOS.

CONCLUSIONS

PCOS symptoms are observed across a severity spectrum that parallels the continuous genetic liability to PCOS in the general population. Racial and ethnic group differences exist in PCOS symptomology and metabolic health across different phenotyping strategies.

Pubertal development mediates the association between family environment and brain structure and function in childhood

Psychosocial acceleration theory suggests that pubertal maturation is accelerated in response to adversity. In addition, suboptimal caregiving accelerates development of the amygdala–medial prefrontal cortex circuit. These findings may be related. Here, we assess whether associations between family environment and measures of the amygdala–medial prefrontal cortex circuit are mediated by pubertal development in more than 2000 9- and 10-year-old children from the Adolescent Brain Cognitive Development Study (http://dx.doi.org/10.15154/1412097). Using structural equation modeling, demographic, child-reported, and parent-reported data on family dynamics were compiled into a higher level family environment latent variable. Magnetic resonance imaging preprocessing and compilations were performed by the Adolescent Brain Cognitive Development Study's data analysis core. Anterior cingulate cortex (ACC) thickness, area, white matter fractional anisotropy, amygdala volume, and cingulo-opercular network–amygdala resting-state functional connectivity were assessed. For ACC cortical thickness and ACC fractional anisotropy, significant indirect effects indicated that a stressful family environment relates to more advanced pubertal stage and more mature brain structure. For cingulo-opercular network–amygdala functional connectivity, results indicated a trend in the expected direction. For ACC area, evidence for quadratic mediation by pubertal stage was found. Sex-stratified analyses suggest stronger results for girls. Despite small effect sizes, structural measures of circuits important for emotional behavior are associated with family environment and show initial evidence of accelerated pubertal development.

Breast cancer among Asian Indian and Pakistani Americans: A surveillance, epidemiology and end results-based study

Breast cancer incidence is increasing among Asian Indian and Pakistani women living in the United States. We examined the characteristics of breast cancer in Asian Indian and Pakistani American (AIPA) and non-Hispanic white (NHW) women using data from the surveillance, epidemiology and end results (SEER) program. Breast cancer incidence rates were estimated via segmented Poisson regression using data between 1990 and 2014 from SEER 9 registries, including New Jersey and California. Disease characteristics, treatment and survival information between 2000 and 2016 for 4900 AIPA and 482 250 NHW cases diagnosed after age 18 were obtained from SEER 18 registries and compared using descriptive analyses and multivariable competing risk proportional hazards regression. Breast cancer incidence was lower in AIPA than NHW women, increased with age and the rate of increase declined after age of 46 years. AIPA women were diagnosed at significantly younger age (mean (SD) = 54.5 (13.3) years) than NHW women (mean (SD) = 62 (14) years, P < .0001) and were more likely than NHW cases (P < .0001) to have regional or distant stage, higher grade, estrogen receptor-negative, progesterone receptor-negative, triple-negative or human epidermal growth factor receptor 2-enriched tumors, subcutaneous or total mastectomy, and lower cumulative incidence of death due to breast cancer (hazard ratio = 0.79, 95% CI: 0.72-0.86, P < .0001). AIPA had shorter median follow-up (52 months) than NHW cases (77 months). Breast cancer in AIPA women has unique characteristics that need to be further studied along with a comprehensive evaluation of their follow-up patterns.

Body mass index growth trajectories, early pubertal maturation, and short stature

BACKGROUND

Childhood body mass index (BMI) trajectory classes are rarely linked to early puberty risk, particularly among Chinese children. We estimated early puberty risk across BMI trajectory classes, investigated factors contributing to pubertal development, and examined differences in final adult height between children exhibiting early and nonearly pubertal maturation across the classes.

METHODS

The Taiwan Children Health Study recruited 10-year-old children in 2010 from 14 Taiwanese communities and resurveyed them at age 11, 12, and 18 years. The study comprised 3109 children (50.4% boys) with available data for BMI (age 6-11 years) and pubertal stages (age 11, 12, and 18 years).

RESULTS

Classes 1-4 were persistently healthy weight, rapid BMI growth, chronically overweight/obese, and early transient overweight/obese. Children in class 3 exhibited the highest risk of early pubertal maturation. Puberty genetic score, low sleep quality, and high fat-free mass collectively explained 15% of the variance in Tanner stages among class 3 children. Early pubertal maturation was considered to cause short and tall stature in boys and girls, respectively.

CONCLUSIONS

Modifying sleep quality and fat-free mass may reduce early puberty risk in children with chronic overweight/obesity. Vigorous physical activity may reduce adiposity and increase the final adult height in the children.

Is menopause still evolving? Evidence from a longitudinal study of multiethnic populations and its relevance to women's health

Background

To reflect on the impact of changing patterns of delayed marriage and reproduction and to seek evidence as to whether menopause is still evolving, characteristics of the menopause transition were investigated within and between ethnic populations in this study.

Methods

A cross-sectional analysis was conducted using data on 747 middle-aged women obtained from the Study of Women’s Health Across the Nation (SWAN) from 1996 to 2008. The ethnic groups included: Afro-American, Chinese, Japanese, Caucasian, and Hispanic. Perimenopause age and duration, menopause age, and hormonal indicators of menopause were examined across five ethnicities.

Results

We found a similar window of menopause age within populations, but no significant difference in perimenopause and menopause age between populations. The rate of increase of follicle-stimulating hormone and testosterone differed significantly in Hispanics and African-Americans during the menopause transition period.

Conclusions

The broad window of variation in age at menopause within the population and the absence of significant differences between populations, in combination with population variation in menopause symptoms, suggest that menopause is a relatively recently evolved and still evolving trait. Under the mate choice theory of menopause, menopause is the result of the accumulation of infertility mutations in older women due to men’s preference for younger mates. We propose a shifting mate choice-shifting menopause model which posits that, as the age of mate choice/marriage shifts to older ages, so will the age at menopause, and that menopause is a transient phase of female fertility; it can de-evolve, be delayed, if not disappear completely. Integrated longitudinal menopausal studies linked with genomics and hormonal studies on diverse ethnic populations can provide valuable information bearing on women’s health and personalized medicine.

Age at menopause and mortality in Taiwan: A cohort analysis

OBJECTIVE

Previous research suggested age at menopause may predict risk of all-cause, cardiovascular disease (CVD), cancer and diabetes mortality; however, findings were inconsistent across populations. We aimed to investigate this association in Taiwanese postmenopausal women.

STUDY DESIGN

We used data from the MJ Health Database in Taiwan and included 36,931 postmenopausal women who entered health check-up programs during 1999-2016. Information on age at menopause and covariates were collected from health surveys and medical examinations at baseline. Age at menopause was categorized into <40-44, 45-49, 50-54 (reference) and 55-60 years. We used Cox proportional hazards regression for analysis.

MAIN OUTCOME MEASURES

Causes of death (obtained from the National Register of Death as of July 2018).

RESULTS

Mean age (SD) at menopause was 50.2 (4.0) years and there were 5316 deaths over an average follow-up time of 14.6 years. After adjustment for birth cohort, education, smoking, BMI and comorbidities, results showed women aged <40-44 years at menopause compared with the reference category had higher diabetes mortality (hazard ratio [HR] = 1.44; 95 % CI: 1.03, 2.02). Women aged 45-49 years at menopause had higher all-cause mortality (HR = 1.07, 1.01, 1.14), and these women were also associated with increased CVD mortality (HR = 1.22; 1.07, 1.40).

CONCLUSIONS

In Taiwanese women, early age (<40-44) at menopause is associated with higher diabetes mortality, and earlier age (45-49) at menopause is associated with higher all-cause and CVD mortality. Age at menopause could be deemed an important cardio-metabolic disease marker for women at midlife that indicates future longevity.

Embryos derived from donor or patient oocytes are not different for in vitro fertilization outcomes when PGT allows euploid embryo selection: a retrospective study

BACKGROUND

At our facilities, patients that received embryos using donor oocyte during in vitro fertilization (IVF), usually have had at least one failed attempt to produce at least one euploid embryo with their own oocytes; however, the current debate between using donor over patient oocytes remains inconclusive. We examined the aneuploidy rate and IVF clinical outcomes from embryos derived from either donor or patient oocytes.

METHODS

Retrospectively, 973 cycles were examined of patients who underwent a standard IVF protocol. Chromosomal content was determined using Pre-implantation Genetic Testing (PGT) by either microarray-comparative genomic hybridization or Next-generation sequencing from either Day 3 (blastocysts) or Day 5 (trophectoderm) embryo biopsies, respectively. Embryo implantation was confirmed by serum β-hCG (> 10 m IU/mL/Day 14), whereas clinical pregnancy by a fetal heartbeat (Week 6.5-8).

RESULTS

Embryos derived from donor oocytes presented with more monosomies than embryos derived from patient oocytes (41.2% vs. 25.4%, p < 0.05, respectively); however, only Trisomy 7 (0.4% vs. 2.3%, p < 0.05) and Trisomy in X (0.7% vs. 2.3%, p < 0.05) were significantly less present when compared to patient oocyte derived embryos. Interestingly, rates for embryo implantation (46.7% vs. 50.8%, p = 0.35), clinical pregnancy (38.5% vs. 43.1%, p = 0.30), and live birth (30.5% vs. 30.5%, p = 0.99) were similar for embryos derived from donor and patient oocytes. These results did not change when adjusted for the number of embryos implanted.

CONCLUSION

Here, we show no significant differences in achieving pregnancy when using donor oocytes. Taking into consideration that aneuploidy rates are > 30% in embryos, independent of the oocyte origin, PGT should be recommended with donor oocytes as well.

Pubertal development mediates the association between family environment and brain structure and function in childhood

Psychosocial acceleration theory suggests that pubertal maturation is accelerated in response to adversity. In addition, suboptimal caregiving accelerates development of the amygdala-medial prefrontal cortex circuit. These findings may be related. Here, we assess whether associations between family environment and measures of the amygdala-medial prefrontal cortex circuit are mediated by pubertal development in more than 2000 9- and 10-year-old children from the Adolescent Brain Cognitive Development Study (http://dx.doi.org/10.15154/1412097). Using structural equation modeling, demographic, child-reported, and parent-reported data on family dynamics were compiled into a higher level family environment latent variable. Magnetic resonance imaging preprocessing and compilations were performed by the Adolescent Brain Cognitive Development Study's data analysis core. Anterior cingulate cortex (ACC) thickness, area, white matter fractional anisotropy, amygdala volume, and cingulo-opercular network-amygdala resting-state functional connectivity were assessed. For ACC cortical thickness and ACC fractional anisotropy, significant indirect effects indicated that a stressful family environment relates to more advanced pubertal stage and more mature brain structure. For cingulo-opercular network-amygdala functional connectivity, results indicated a trend in the expected direction. For ACC area, evidence for quadratic mediation by pubertal stage was found. Sex-stratified analyses suggest stronger results for girls. Despite small effect sizes, structural measures of circuits important for emotional behavior are associated with family environment and show initial evidence of accelerated pubertal development.

New insights into the genetics of spermatogenic failure: a review of the literature

Genetic anomalies are known to affect about 15% of infertile patients with azoospermia or severe oligozoospermia. Despite a throughout diagnostic work-up, in up to the 72% of the male partners of infertile couples, no etiological factor can be found; hence, the cause of infertility remains unclear. Recently, several novel genetic causes of spermatogenic failure (SPGF) have been described. The aim of this review was to collect all the available evidence of SPGF genetics, matching data from in-vitro and animal models with those in human beings to provide a comprehensive and updated overview of the genes capable of affecting spermatogenesis. By reviewing the literature, we provided a list of 60 candidate genes for SPGF. Their investigation by Next Generation Sequencing in large cohorts of patients with apparently idiopathic infertility would provide new interesting data about their racial- and ethnic-related prevalence in infertile patients, likely raising the diagnostic yields. We propose a phenotype-based approach to identify the genes to look for.

Racial/Ethnic Differences in the Utilization of Infertility Services: A Focus on American Indian/Alaska Natives

Objectives Previous studies have identified racial/ethnic disparities in infertility care, but patterns among American Indian/Alaska Natives (AI/AN) have not been reported. Our objective was to evaluate infertility services use in the US by race/ethnicity using data from the National Survey of Family Growth (NSFG). Methods We analyzed female respondent data from the pooled NSFG cycles 2002, 2006-2010 and 2011-2013. Respondents reported use of infertility services and types of services. We calculated weighted crude and adjusted prevalence proportion ratios (PPR) and 95% confidence intervals (95% CI) using modified Poisson regression with robust error variances accounting for the complex survey design to compare infertility services use across race/ethnicities. Results Overall, 8.7% of women reported using medical services to get pregnant. The prevalence of using any medical service to help get pregnant was lower for American Indian/Alaska Native (AI/AN) (PPR: 0.60, 95% CI 0.43-0.83) and black (PPR: 0.53, 95% CI 0.44-0.63) compared to white women and in Hispanic compared to non-Hispanic women (PPR: 0.57, 95% CI 0.48-0.67). The prevalence of accessing treatment, testing, and advice also differed by race and ethnicity. Conclusions for Practice We observed disparities in accessing services to get pregnant among AI/AN and black women and reduced use of advice among Asian/Pacific Islanders compared to whites. We also observed reduced service utilization for Hispanic compared to non-Hispanic women. Differential utilization of specific services suggests barriers to infertility care may contribute to reproductive health disparities among underserved populations.

Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back

Diminished fertility and poor ovarian response pose a conundrum to the experts in the field of reproductive medicine. There is limited knowledge about the risk factors of diminished ovarian reserve other than the iatrogenic ones. One of the leading causes of infertility in women today is diminished ovarian reserve (DOR). DOR is characterized by a low number of eggs in a woman's ovaries and/or with poor quality of the remaining eggs, which boils down to impaired development of the existing eggs, even with assisted reproductive techniques. A good number of such women with low ovarian reserve may conceive with their own eggs, if they are given individualized treatment that is tailored for their profile. Such patients should be counseled appropriately for an aggressive approach towards achieving fertility. The sooner the treatment is started, the better the chances of pregnancy.

Don't Give Up! A Cyber-ethnography and Discourse Analysis of an Online Infertility Patient Forum

Infertility affects women across the socioeconomic spectrum; however, it is by no means egalitarian in its distribution, nor uniform in its lived experience. Evidence shows striking disparities by income, race, and education in infertility prevalence, access to infertility services, and success rates after receiving infertility treatments. However, few studies so far have investigated disparities in patients' access to psychological support during the infertility journey. This paper undertakes a cyber-ethnography of the online patient forum, "Finding a Resolution for Infertility," hosted by RESOLVE: The National Infertility Association. It also draws from interviews with 54 infertility patients recruited from the forum. Our aim was to examine how social support operates within this virtual realm, by examining how the forum's language, norms, and values create and enforce categories of deserving and belonging among site users. We find that the forum's discourse privileges an infertility narrative we term the "persistent patient," in which a patient exhaustively researches treatment options, undergoes multiple cycles of treatment despite repeated failures, and ultimately achieves success (a healthy baby). Meanwhile, there is little to no discursive space for discussion of the financial and social resources necessary to act in accordance with this script. Thus, women without such resources can be alienated, silenced, and denied mental health support by this online community.

Ovarian reserve testing: a user's guide

Ovarian reserve is a complex clinical phenomenon influenced by age, genetics, and environmental variables. Although it is challenging to predict the rate of an individual's ovarian reserve decline, clinicians are often asked for advice about fertility potential and/or recommendations regarding the pursuit of fertility treatment options. The purpose of this review is to summarize the state-of-the-art of ovarian reserve testing, providing a guide for the obstetrician/gynecologist generalist and reproductive endocrinologist. The ideal ovarian reserve test should be convenient, be reproducible, display little if any intracycle and intercycle variability, and demonstrate high specificity to minimize the risk of wrongly diagnosing women as having diminished ovarian reserve and accurately identify those at greatest risk of developing ovarian hyperstimulation prior to fertility treatment. Evaluation of ovarian reserve can help to identify patients who will have poor response or hyperresponse to ovarian stimulation for assisted reproductive technology. Ovarian reserve testing should allow individualization of treatment protocols to achieve optimal response while minimizing safety risks. Ovarian reserve testing may inform patients regarding their reproductive lifespan and menopausal timing as well as aid in the counselling and selection of treatment for female cancer patients of reproductive age who receive gonadotoxic therapy. In addition, it may aid in establishing the diagnosis of polycystic ovary syndrome and provide insight into its severity. While there is currently no perfect ovarian reserve test, both antral follicular count and antimüllerian hormone have good predictive value and are superior to day-3 follicle-stimulating hormone. The convenience of untimed sampling, age-specific values, availability of an automated platform, and potential standardization of antimüllerian hormone assay make this test the preferred biomarker for the evaluation of ovarian reserve in women.

Effect of race and ethnicity on utilization and outcomes of assisted reproductive technology in the USA

BACKGROUND

The purpose of this study was to determine the utilization and live birth rates of assisted reproductive technology (ART) modalities among various racial and ethnic groups in recent years.

METHODS

We reviewed ART data reported to the Society for Assisted Reproductive Technologies Clinic Outcome Reporting System (SART CORS) for autologous ART and third-party ART (3ART) cycles which involved donor oocytes, sperm, embryos and gestational carrier, performed in the U.S. between 2004 and 2013. To gauge demand by various racial/ethnic groups for ART services, we examined fertility rates and demographics of the entire U.S. birth cohort over the same time interval.

RESULTS

Of 1,132,844 autologous ART cycles 335,462 resulted in a live birth (29.6%). An additional, 217,030 3ART cycles resulted in 86,063 live births (39.7%). Hispanic and Black women demonstrated high fertility and lower utilization rates of autologous ART and 3ART. Caucasian and Asian women exhibited lower fertility rates and higher autologous ART and 3ART utilization. Autologous ART resulted in higher live birth rates among Caucasian and Hispanic women and lower rates among Asian and especially Black women. 3ART improved live birth rates in all races/ethnicities, though Black women experienced lower live birth rates with most modalities. Spontaneous abortion rates were higher among Black women following autologous ART and some 3ART modalities than those among Caucasian women.

CONCLUSION

Utilization of ART is inversely related to fertility rates. Autologous ART produces lower live birth rates among Asian and Black women. 3ART results in relatively low live birth rates among Black women.

TRIAL REGISTRATION

SART CORS #57 , Registered 5/14/2015.

Age-Based Reproductive Healthcare Stereotype Threat (HCST) as a Stressor Affecting Prenatal Mental Health in Pregnant Women of Advanced Maternal Age: Measurement, Process, Outcomes, and Interactions with Ethnicity/Race, SES, and Other Social Identities

PURPOSE OF REVIEW

Reproductive health, and pregnancy more specifically, is the first critical link between generations. Beginning with this first critical link, pregnancy acts as a domino, affecting the expression of genes and determining the lifespan mental and physical health and reproductive potential of offspring and, likely, of subsequent generations. Given the powerful intergenerational domino that is pregnancy, the development of innovative models to enhance reproductive health and outcomes is an invaluable public health investment.

RECENT FINDINGS

While U.S. pregnancy and birth outcomes have improved dramatically since the 1960s- including substantial progress within the past 15 years, largely catalyzed by the Healthy People initiative-group-based disparities remain. What's more, social change and medical advancements have led to an evolving window of female reproductive age. Despite becoming more common, being an older expectant mother remains a stigmatized social identity. The concept of healthcare stereotype threat (HCST) is introduced in relation to reproductive health. Stereotype threat is a situational predicament in which an individual who possesses a stigmatized social identity fears confirming negative group-based stereotypes. HCST is a healthcare-specific form of stereotype threat, arising out of stereotypes that are salient in healthcare settings. It is hypothesized that the experience of age-based reproductive HCST is an overlooked stressor affecting prenatal mental and physical health among women of advanced maternal age.

SUMMARY

The hypothesized process of age-based reproductive HCST is described; outcomes and consequences are discussed; interactions with ethnicity/race, SES, and other aspects of social identity are considered; and strategies for prevention and intervention are explored, including active and passive shifts in three areas: (1) internally, in both providers and patients; (2) in the external environment, or the physical healthcare setting itself; and (3) within interpersonal interactions that occur within healthcare settings, particularly between physicians and patients. Implications for gynecological, infertility, and obstetric care and improving the reproductive outcomes of older women are discussed.

Does elevated progesterone on day of oocyte maturation play a role in the racial disparities in IVF outcomes?

The aim of this study was to evaluate if premature progesterone elevation on the last day of assisted reproduction technique stimulation contributes to racial disparities in IVF outcome. A total of 3289 assisted reproduction technique cycles were evaluated in Latino, Asian, African American, and white women. Live birth was more likely in white women (42.6%) compared with Asian (34.8%) and African American women (36.3%), but was similar to Latino women (40.7%). In all racial groups, progesterone was negatively associated with live birth and the negative effect of progesterone persisted when adjusting for confounders. Although the effect of elevated progesterone was similar in all racial groups, the prevalence of elevated progesterone differed. Progesterone > 1.5 ng/ml occurred in only 10.6% of cycles in white women compared with 18.0% in Latino and 20.2% in Asian women. Progesterone > 2 ng/ml occurred in only 2.3% of cycles in white women compared with 6.3% in Latino, 5.9% in Asian and 4.4% in African American women. The increased prevalence of premature elevated progesterone persisted when controlling for IVF stimulation parameters. In conclusion, premature progesterone elevation had a negative effect on live birth in all racial groups studied. The prevalence of elevated progesterone was higher in racial minorities.

Influence of race and ethnicity on in vitro fertilization outcomes: systematic review

OBJECTIVE

We conducted a systematic review to evaluate the influence of race and ethnicity on clinical pregnancy and live birth outcomes after in vitro fertilization (IVF).

STUDY

We searched PubMed, EMBASE, Web of Science, CINAHL, POPLINE, and Cochrane Central, and hand-searched relevant articles published through July 22, 2015.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers independently evaluated abstracts to identify studies that compared clinical pregnancy rates and live birth rates for ≥2 racial and/or ethnic groups after nondonor IVF cycles.

RESULTS

Twenty-four studies were included. All 5 US registry-based studies showed that black, Hispanic, and Asian women had lower clinical pregnancy rates and/or live birth rates after IVF, compared with white women. Similarly, most clinic-specific studies reported significant disparities in these primary outcomes, potentially attributable to differences in infertility diagnosis, spontaneous abortion, and obesity. Studies varied with respect to definitions of race/ethnicity, inclusion of first cycles vs multiple cycles for individual women, and collected covariates. Most studies were limited by sample size, inadequate adjustment for confounding, selection bias, and extensive missing data.

CONCLUSIONS

Although current evidence points to race and ethnicity, especially black race, as strong predictors of poorer outcomes after IVF, the utility of results is constrained by the limitations described.

Ethnicity or environment: effects of migration on ovarian reserve among Bangladeshi women in the United Kingdom

OBJECTIVE

To assess whether the quality of early childhood environments among different groups of Bangladeshi women, including migrants to the United Kingdom (UK), contributes to variation in ovarian reserve and the rate of reproductive aging in later life.

DESIGN

Cross-sectional study.

SETTING

Not applicable.

PATIENT(S)

A total of 179 healthy women volunteers aged 35-59 years were divided into four groups: [1] 36 Bangladeshis living in Sylhet, Bangladesh; [2] 53 Bangladeshis who migrated to the UK as adults; [3] 40 Bangladeshis who migrated to the UK as children aged 0-16 years; and [4] a reference group of 50 women of European origin living in London.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of serum antimüllerian hormone, inhibin B, FSH, and E2, and anthropometrics derived from biomarkers; reproductive, demographic, and health variables from structured questionnaires.

RESULT(S)

Bangladeshi migrants who moved to the UK as children and European women had a highly significantly larger, age-related ovarian reserve compared with migrant Bangladeshis who had moved to the UK as adults or Bangladeshi women still living in Bangladesh. There were no other significant covariates in the model aside from age and menopausal status.

CONCLUSION(S)

The study points to the importance of childhood development in considering variation in ovarian reserve across different ethnic groups. Clinical studies and research in assisted reproductive technology have emphasized the role of genes or race in determining inter-population variation in ovarian reserve. Early life developmental factors should be given due consideration when evaluating inter-group differences in response to assisted reproductive technology.

Lights and Shadows about the Effectiveness of IVF in HIV Infected Women: A Systematic Review

Background. HIV infected women have higher rates of infertility. Objective. The purpose of this literature review is to evaluate the effectiveness of fresh IVF/ICSI cycles in HIV infected women. Materials and Methods. A search of the PubMed database was performed to identify studies assessing fresh nondonor oocyte IVF/ICSI cycle outcomes of serodiscordant couples with an HIV infected female partner. Results and Discussion. Ten studies met the inclusion criteria. Whenever a comparison with a control group was available, with the exception of one case, ovarian stimulation cancelation rate was higher and pregnancy rate (PR) was lower in HIV infected women. However, statistically significant differences in both rates were only seen in one and two studies, respectively. A number of noncontrolled sources of bias for IVF outcome were identified. This fact, added to the small size of samples studied and heterogeneity in study design and methodology, still hampers the performance of a meta-analysis on the issue. Conclusion. Prospective matched case-control studies are necessary for the understanding of the specific effects of HIV infection on ovarian response and ART outcome.

Obesity adversely affects serum anti-müllerian hormone (AMH) levels in Caucasian women

OBJECTIVE

Previous studies regarding the effect of obesity on serum anti-müllerian hormone (AMH) levels have been conflicting. Our aim was to determine the effect of obesity on serum AMH levels among women from different racial backgrounds.

METHODS

The medical records of 350 women (159 Caucasian, 99 African-American, 58 Hispanic, 34 Asian with ages 16-46) evaluated for infertility at an academic-affiliated center and who had AMH levels measured as part of their evaluation were reviewed. Age, AMH, body mass index (BMI), self-reported race, etiology of infertility, smoking history, maximum serum early follicular follicle-stimulating hormone (FSH) levels, antral follicle count (AFC), and history of ovarian surgery, chemotherapy, or radiotherapy were recorded.

RESULTS

Age correlated negatively with AMH and antral follicle count across all races (p < 0.05). After adjusting for age, polycystic ovary syndrome diagnosis, and smoking, elevated BMI had a negative correlation with AMH in Caucasian women (β = 0.17, p = 0.01) but not in African-American, Hispanic, or Asian women.

CONCLUSION

Elevated BMI correlates negatively with AMH in Caucasian women but not in African-American, Hispanic, or Asian women. Additional studies are needed to elucidate further the effect of race on the interaction between obesity and ovarian reserve.

Cigarettes, genetic background, and menopausal timing: the presence of single nucleotide polymorphisms in cytochrome P450 genes is associated with increased risk of natural menopause in European-American smokers

OBJECTIVE

This study aims to evaluate associations between variations in genes involved in the metabolism of environmental chemicals and steroid hormones and risk of menopause in smokers.

METHODS

Survival analysis was performed on 410 eligible participants from the Penn Ovarian Aging study (ongoing for 14 years), a cohort study of late-reproductive-age women. Single nucleotide polymorphisms at the following loci were studied: COMT Val158Met, CYP1B1*4 Asn452Ser, CYP1B1*3 Leu432Val, and CYP3A4*1B.

RESULTS

Significant interactions between smoking and single nucleotide polymorphisms were observed in European-American carriers of CYP3A4*1B and CYP1B1*3, supporting a greater risk of menopause entry compared with those not carrying these alleles. Among CYP1B1*3 carriers, smokers had a greater risk of menopause entry than nonsmokers (adjusted hazard ratio [HR], 2.26; 95% CI, 1.4-3.67; median time to menopause, 10.42 and 11.07 y, respectively). No association between smoking and menopause was identified in CYP1B1 wild types. Among CYP3A4*1B carriers, smokers were at greater risk for menopause entry than nonsmokers (adjusted HR, 15.1; 95% CI, 3.31-69.2; median time to menopause, 11.36 and 13.91 y, respectively). Risk of menopause entry in CYP3A4 wild types who smoked was far lower (adjusted HR, 1.59; 95% CI, 1.03-2.44). Heavily smoking CYP1B1*3 carriers (adjusted HR, 3.0; 95% CI, 1.54-5.84; median time to menopause, 10.41 y) and heavily smoking CYP3A4*1B carriers (adjusted HR, 17.79; 95% CI, 3.21-98.65; median time to menopause, 5.09 y) had the greatest risk of menopause entry.

CONCLUSIONS

Our finding that the risk of menopause entry in European-American smokers varies depending on genetic background represents a novel gene-environment interaction in reproductive aging.

Does accelerated reproductive aging underlie premenopausal risk for cardiovascular disease?

OBJECTIVE

The menopausal transition is associated with an increase in risk for cardiovascular disease; however, whether variability in reproductive aging relates to cardiovascular risk factors in the premenopausal period has not been studied.

METHODS

In a multiethnic sample of 951 healthy, regularly cycling women aged 25 to 45 years (mean [SD] age, 35.2 [5.5] y), we examined antimüllerian hormone (AMH), a validated marker of ovarian reserve, in relation to the overall number of cardiometabolic risk factors, calculated as the sum of the five components of metabolic syndrome (triglycerides ≥150 mg/dL; high-density lipoprotein <50 mg/dL; homeostasis model assessment of insulin resistance ≥2.6; waist circumference equal to or higher than race-specific cutoff; and hypertensive [vs normotensive] status), and in relation to each of these risk factors individually.

RESULTS

In age-adjusted models, results showed that the number of cardiometabolic risk factors was 52.1% higher among women with low versus high AMH levels and 46.0% higher among women with mid versus high AMH levels. In addition, results showed that low and mid levels of AMH (vs high) were associated with an increase in risk with respect to high-density lipoprotein (odds ratio [OR], 1.814; 95% CI, 1.211-2.718 and OR, 1.568; 95% CI, 1.083-2.269, respectively), waist circumference (OR, 2.012; 95% CI, 1.380-2.934 and OR, 1.881; 95% CI, 1.333-2.654, respectively), and hypertensive status (OR, 2.373; 95% CI, 1.095-5.143 and OR, 2.052; 95% CI, 0.976-4.314, respectively) outcomes. Associations, however, attenuated when body mass index was covaried (Ps > 0.05).

CONCLUSIONS

Cross-sectional evidence suggests that having a greater ovarian reserve is associated with having a healthier cardiometabolic risk factor profile. Future longitudinal studies are needed to determine whether this association may be mediated by body mass index.

Ethnicity as a determinant of ovarian reserve: differences in ovarian aging between Spanish and Indian women

OBJECTIVE

To investigate differences in ovarian reserve markers (antimüllerian hormone [AMH] and antral follicle count [AFC]) in Indian and Spanish women.

DESIGN

Cross-sectional study.

SETTING

In vitro fertilization (IVF) clinics.

PATIENT(S)

Infertile Spanish (n=229) and Indian (n=236) women who underwent controlled ovarian stimulation for IVF from January to October 2012.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Data on ovarian reserve markers and results after ovarian stimulation were collected.

RESULT(S)

The mean age of women undergoing their first or second IVF cycle was significantly higher in Spanish than in Indian women (37.5±3.3 years vs. 31.5±3.8 years). Despite this 6-year age gap, AFCs were similar (9.5±4.7 vs. 9.9±4.6), as were day 3 FSH levels (7.5±4.5 IU/L vs. 6.9±2.3 IU/L). AMH levels were slightly lower in Spanish women (1.6±1.7 ng/mL vs. 2.5±1.6 ng/mL). Multivariate regression analysis showed that being Indian decreased AFC by 2.3, such that AFC in Indian women was similar to that in Spanish women 6.3 years older (95% confidence interval 3.39-1.10).

CONCLUSION(S)

Similar ovarian reserve markers and ovarian response were observed in women with a 6-year age difference in favor of the Spanish, suggesting ethnic differences in ovarian aging. Further research is needed to understand whether these differences are genetically induced or are caused by other variables, such as nutrition. Our results may help clinicians to counsel infertile women when discussing assisted reproductive technology outcomes according to age and ethnic background.

Ecology drives intragenomic conflict over menopause

Menopause is the transition from reproductive to non-reproductive life well before natural death. Rather than involving a smooth, rapid change, it is normally preceded by a long period of erratic hormonal fluctuation that is accompanied by a plethora of unpleasant symptoms. Here, we (1) suggest that this turbulent period owes to conflict, between a woman's maternally inherited (MI) and paternally inherited (PI) genes, over the trade-off between reproduction and communal care; (2) perform a theoretical analysis to show that this conflict is resolved either through silencing or fluctuating expression of one of the genes; (3) highlight which of the symptoms preceding menopause may result from antagonistic co-evolution of MI and PI genes; (4) argue that ecological differences between ancestral human populations may explain the variability in menopause among different ethnic groups; (5) discuss how these insights may be used to inform family planning and cancer risk assessment based on a woman's ancestral background.

Effect of ethnicity on live birth rates after in vitro fertilisation or intracytoplasmic sperm injection treatment

OBJECTIVE

To assess the relationship between the ethnicity of women and the clinical success of in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment.

DESIGN

Observational cohort study.

SETTING

Nottingham University Research and Treatment Unit in Reproduction (NURTURE), UK.

SAMPLE

A total of 1517 women, of which 1291 were white Europeans and 226 belonged to an ethnic minority group. All the women were undergoing their first cycle of assisted reproductive technology (ART) between 2006 and 2011.

METHODS

All of the women underwent their first cycle of ART between 2006 and 2011.

MAIN OUTCOME MEASURES

Live birth rates following IVF or ICSI treatment.

RESULTS

Although pre-treatment ovarian reserve variables [mean age, basal follicle stimulating hormone (FSH), and total antral follicle count] were significantly favourable in the ethnic group, the live birth rates were significantly lower in this group (35%) compared with the white European group (43.8%) (relative risk 0.8; 95% CI 0.66-0.97). On logistic regression analysis, ethnicity was an independent predictor of live birth rate (OR 0.688; 95% CI 0.513-0.924). After controlling for the other independent variables (age and FSH), the significant association between ethnicity and live birth rate remained strong (OR 0.591; 95% CI 0.425-0.822) on multivariate logistic regression analysis.

CONCLUSIONS

Live birth rates following IVF or ICSI treatment were significantly lower in the ethnic minority group compared with white European women, which suggests that ethnicity is a major determinant of live birth following IVF treatment.

Racial/ethnic differences in clinical and biochemical type 2 diabetes mellitus risk factors in children

OBJECTIVE

To examine whether periadolescent children demonstrate the significant racial/ethnic differences in body fatness relative to BMI and in the prevalence and relationship of body composition to risk factors for type 2 diabetes (T2DM) as in adults.

DESIGN AND METHODS

Family history of obesity and T2DM, anthropometry, insulin sensitivity and secretory capacity, lipids, and cytokines (IL-6, CRP, TNF-α, and adiponectin) were examined in a cohort of 994 middle school students (47% male, 53%, female; 12% African American, 14% East Asian, 13% South Asian, 9% Caucasian, 44% Hispanic, and 8% other).

RESULTS

Fractional body fat content was significantly greater at any BMI among South Asians. There were racial/ethnic specific differences in lipid profiles, insulin secretory capacity, insulin sensitivity, and inflammatory markers corrected for body fatness that are similar to those seen in adults. Family history of T2DM was associated with lower insulin secretory capacity while family history of obesity was more associated with insulin resistance.

CONCLUSIONS

Children show some of the same racial/ethnic differences in risk factors for adiposity-related comorbidities as adults. BMI and waist circumference cutoffs to identify children at-risk for adiposity-related comorbidities should be adjusted by racial/ethnic group as well as other variables such as birthweight and family history.

Body size and time-to-pregnancy in black women

STUDY QUESTION

Are overall and central obesity associated with reduced fecundability in US black women?

SUMMARY ANSWER

Overall and central obesity--based on self-reported measures of body mass index (BMI, kg/m(2)), waist circumference and waist-to-hip ratio--were independent risk factors for subfertility in our cohort.

WHAT IS KNOWN ALREADY

Overall obesity (BMI ≥ 30 kg/m(2)) has been associated with infertility in several studies. The role of central obesity is less clear. There are no previous studies of time-to-pregnancy (TTP) in black women.

STUDY DESIGN, SIZE, DURATION

Data were derived from the Black Women's Health Study, a prospective cohort study. During 1995-2011, there were 2239 planned pregnancy attempts reported by 1697 women, resulting in 2022 births. Cohort retention was greater than 80%.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible women were aged 21-40 years and reported at least one planned pregnancy attempt during 1995-2011. Height and weight were reported in 1995, with weight updated every two years; waist and hip circumferences were reported in 1995 and updated in 2003. A validation study within the cohort showed high correlations between self-reported and technician-measured weight (r = 0.97), height (r = 0.93), waist circumference (r = 0.75) and hip circumference (r = 0.74). In 2011, TTP was reported in months. Proportional probabilities regression models were used to estimate fecundability ratios (FRs) and 95% confidence intervals (CI), adjusting for covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

High BMI was associated with delayed conception: relative to BMI 18.5-24.9, FRs for BMI categories of <18.5, 25.0-29.9, 30.0-34.9 and ≥ 35.0 were 0.92 (CI: 0.64-1.32), 0.93 (CI: 0.84-1.03), 0.92 (CI: 0.79-1.06) and 0.73 (CI: 0.61-0.87), respectively. Associations were stronger among nulliparous women (P-interaction = 0.003). After controlling for BMI, reduced fecundability was observed among women with large waist circumferences (≥ 33 versus <26 inches: FR = 0.73, CI: 0.60-0.88) and large waist-to-hip ratios (≥ 0.85 versus <0.71: FR = 0.83, CI: 0.71-0.97).

LIMITATIONS, REASONS FOR CAUTION

TTP was reported retrospectively and error in recall is likely, particularly as time since the pregnancy increases. However, results were similar when based on the most recent versus first pregnancies. Confounding may have been introduced by the lack of control for important determinants of TTP. Nevertheless, control for maternal age and education, which are highly correlated with TTP determinants such as paternal age and persistence in trying, should reduce the extent of confounding. The analysis was confined to planned pregnancies. If pregnancy intention was related both to body size and fecundability, our results could be biased. Bias is likely to be small because we found little difference in body size and other measured characteristics between pregnancy planners and non-planners.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings add to the growing body of literature showing that excess BMI is associated with reduced fecundability and further suggest that central obesity is an important independent risk factor for infertility. The relation of obesity to infertility is especially relevant to US black women because they have higher rates of obesity and infertility. Reductions in overall and central obesity may offer the potential to improve fertility outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by National Cancer Institute grant CA58420. We have no competing interests to report.