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Burks HR, Peck JD, Gavrizi S, Anderson ZS, Diamond MP, Hansen KR. Effect of prematurely elevated late follicular progesterone on pregnancy outcomes following ovarian stimulation-intrauterine insemination for unexplained infertility: secondary analysis of the AMIGOS trial. Hum Reprod 2024; 39:1684-1691. [PMID: 38822675 PMCID: PMC11291944 DOI: 10.1093/humrep/deae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 03/31/2024] [Indexed: 06/03/2024] Open
Abstract
STUDY QUESTION What is the relationship between late follicular phase progesterone levels and clinic pregnancy and live birth rates in couples with unexplained infertility undergoing ovarian stimulation with IUI (OS-IUI)? SUMMARY ANSWER Late follicular progesterone levels between 1.0 and <1.5 ng/ml were associated with higher live birth and clinical pregnancy rates while the outcomes in groups with higher progesterone levels did not differ appreciably from the <1.0 ng/ml reference group. WHAT IS KNOWN ALREADY Elevated late follicular progesterone levels have been associated with lower live birth rates after fresh embryo transfer following controlled ovarian stimulation and egg retrieval, but less is known about whether an association exists with outcomes in OS-IUI cycles. Existing studies are few and have been limited to ovarian stimulation with gonadotrophins, but the use of oral agents, such as clomiphene citrate and letrozole, is common with these treatments and has not been well studied. STUDY DESIGN, SIZE, DURATION The study was a prospective cohort analysis of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial. Frozen serum was available for evaluation from 2121 cycles in 828 AMIGOS participants. The primary pregnancy outcome was live birth per cycle, and the secondary pregnancy outcome was clinical pregnancy rate per cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples with unexplained infertility in the AMIGOS trial, for whom female serum from day of trigger with hCG was available in at least one cycle of treatment, were included. Stored frozen serum samples from day of hCG trigger during treatment with OS-IUI were evaluated for serum progesterone level. Progesterone level <1.0 ng/ml was the reference group for comparison with progesterone categorized in increments of 0.5 ng/ml up to ≥3.0 ng/ml. Unadjusted and adjusted risk ratios (RR) and 95% CI were estimated using cluster-weighted generalized estimating equations to estimate modified Poisson regression models with robust standard errors. MAIN RESULTS AND THE ROLE OF CHANCE Compared to the reference group with 110/1363 live births (8.07%), live birth rates were significantly increased in cycles with progesterone 1.0 to <1.5 ng/ml (49/401 live births, 12.22%) in both the unadjusted (RR 1.56, 95% CI 1.14, 2.13) and treatment-adjusted models (RR 1.51, 95% CI 1.10, 2.06). Clinical pregnancy rates were also higher in this group (55/401 clinical pregnancies, 13.72%) compared to reference group with 130/1363 (9.54%) (unadjusted RR 1.46, 95% CI 1.10, 1.94 and adjusted RR 1.42, 95% CI 1.07, 1.89). In cycles with progesterone 1.5 ng/ml and above, there was no evidence of a difference in clinical pregnancy or live birth rates relative to the reference group. This pattern remained when stratified by ovarian stimulation treatment group but was only statistically significant in letrozole cycles. LIMITATIONS, REASONS FOR CAUTION The AMIGOS trial was not designed to answer this clinical question, and with small numbers in some progesterone categories our analyses were underpowered to detect differences between some groups. Inclusion of cycles with progesterone values above 3.0 ng/ml may have included those wherein ovulation had already occurred at the time the IUI was performed. These cycles would be expected to experience a lower success rate but pregnancy may have occurred with intercourse in the same cycle. WIDER IMPLICATIONS OF THE FINDINGS Compared to previous literature focusing primarily on OS-IUI cycles using gonadotrophins, these data include patients using oral agents and therefore may be generalizable to the wider population of infertility patients undergoing IUI treatments. Because live births were significantly higher when progesterone ranged from 1.0 to <1.5 ng/ml, further study is needed to clarify whether this progesterone range may truly represent a prognostic indicator in OS-IUI cycles. STUDY FUNDING/COMPETING INTEREST(S) Oklahoma Shared Clinical and Translational Resources (U54GM104938) National Institute of General Medical Sciences (NIGMS). AMIGOS was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U10 HD077680, U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936, and U10HD055925. Research made possible by the funding by American Recovery and Reinvestment Act. Dr Burks has disclosed that she is a member of the Board of Directors of the Pacific Coast Reproductive Society. Dr Hansen has disclosed that he is the recipient of NIH grants unrelated to the present work, and contracts with Ferring International Pharmascience Center US and with May Health unrelated to the present work, as well as consulting fees with May Health also unrelated to the present work. Dr Diamond has disclosed that he is a stockholder and a member of the Board of Directors of Advanced Reproductive Care, Inc., and that he has a patent pending for the administration of progesterone to trigger ovulation. Dr Anderson, Dr Gavrizi, and Dr Peck do not have conflicts of interest to disclose. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- H R Burks
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology and Infertility, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - J D Peck
- Department of Biostatistics and Epidemiology, OU Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - S Gavrizi
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology and Infertility, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Z S Anderson
- Department of Obstetrics and Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - M P Diamond
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology, Infertility, and Genetics, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - K R Hansen
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology and Infertility, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Minano Masip J, Kadoch E, Hemmings R, Phillips S, Bissonnette F, Kadoch IJ. A prospective proof-of-concept trial on the effect of personalized dosages of follitropin delta in intrauterine insemination. Reprod Biomed Online 2024; 48:103603. [PMID: 38359732 DOI: 10.1016/j.rbmo.2023.103603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/15/2023] [Accepted: 10/04/2023] [Indexed: 02/17/2024]
Abstract
RESEARCH QUESTION What is the efficacy and safety of individualized follitropin delta dosing for ovarian stimulation in intrauterine insemination (IUI)? DESIGN This single-centre, prospective, open-label, single-cohort study involving 106 patients established an original dosing regimen based on body weight and anti-Müllerian hormone (AMH) concentrations, with adjustments based on the ovarian response from the previous IUI cycle. Each participant was enrolled in a maximum of three IUI cycles. RESULTS Mean age was 34.5 ± 4.5 years, mean weight 69.2 ± 11.2 kg, mean AMH 15.7 ± 8.6 pmol/l, mean FSH 6.3 ± 2.6 IU/l and mean antral follicle count 16.4 ± 8.2. The percentage of patients who produced more than three mature follicles was 1.9%, 0% and 1.5%, respectively, for the three IUI cycles. The percentage of patients with two or three mature follicles was 34.0%, 36.9% and 47.1% for the three IUI cycles. The clinical pregnancy rate per IUI cycle was 17.9%, 14.3% and 17.6% for the three cycles, with a cumulative clinical pregnancy rate of 40.6%. Out of 258 cycles, 43 (16.7%) resulted in clinical pregnancy, with six of those resulting in multiple pregnancies (14.0%). Two resulted in spontaneous reduction within the first trimester and four resulted in live twin births, representing only 1.6% of the total cycles. CONCLUSIONS This study is the first to utilize follitropin delta for stimulation in IUI. It demonstrates that individualized dosing is both effective and safe, resulting in satisfactory cumulative pregnancy rates and an acceptable multiple pregnancy rate, thus achieving the primary objectives of the research.
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Affiliation(s)
- Jaume Minano Masip
- Clinique ovo, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
| | | | - Robert Hemmings
- Clinique ovo, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
| | - Simon Phillips
- Clinique ovo, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
| | - François Bissonnette
- Clinique ovo, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
| | - Isaac-Jacques Kadoch
- Clinique ovo, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada.
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Ahmad SM, Mat Jin N, Ahmad MF, Abdul Karim AK, Abu MA. Unexplained subfertility: active or conservative management? Horm Mol Biol Clin Investig 2023; 44:379-384. [PMID: 38124670 DOI: 10.1515/hmbci-2022-0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/24/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Unexplained subfertility (UEI) describes a couple whose standard subfertility workout consider acceptable but unable to conceived. METHODS This retrospective study was conducted in the Advanced Reproductive Centre, UKM Hospital, Kuala Lumpur, from January 2016 to December 2019. The data of 268 UEI couples were obtained from the clinical database. Women aged 21-45 years old was included and further divided into four groups according to the female partner's age and subfertility duration: group A (age <35 years and subfertility <2 years), group B (age <35 years and subfertility >2 years), group C (age >35 years and subfertility <2 years), and group D (age >35 years and subfertility <2 years). All statistical analyses were performed using SPSS 22.0 for Windows. RESULTS A total of 255 cases were included in this study. The mean age of the women was 32.9 ± 4.04 years, and the mean subfertility duration was 5.04 ± 2.9 years. A total of 51 (20 %) cases underwent timed sexual intercourse, 147 (57.6 %) cases had intrauterine insemination (IUI), whereas 57 (22.4 %) cases opted for in vitro fertilization (IVF). A total of 204 cases underwent active management (IUI/IVF), which showed a significant difference (p<0.05). Out of eight clinical pregnancies, half of them were from group B. CONCLUSIONS Active management in younger women with a shorter subfertility duration revealed a better pregnancy outcome. Otherwise, individualized treatment should be considered in selecting a suitable treatment plan.
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Affiliation(s)
- Siti Maisarah Ahmad
- Advanced Reproductive Centre, Faculty of Medicine (ARC), National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Reproductive Unit, Hospital Tuanku Azizah (HTA), Kuala Lumpur, Malaysia
| | - Norazilah Mat Jin
- Advanced Reproductive Centre, Faculty of Medicine (ARC), National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Teknologi MARA (UiTM), National University of Malaysia (UKM), Selangor, Malaysia
| | - Mohd Faizal Ahmad
- Advanced Reproductive Centre, Faculty of Medicine (ARC), National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Reproductive Unit, Hospital Tuanku Azizah (HTA), Kuala Lumpur, Malaysia
| | - Abdul Kadir Abdul Karim
- Advanced Reproductive Centre, Faculty of Medicine (ARC), National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Muhammad Azrai Abu
- Advanced Reproductive Centre, Faculty of Medicine (ARC), National University of Malaysia (UKM), Kuala Lumpur, Malaysia
- Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia (UKM), Kuala Lumpur, Malaysia
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Raperport C, Desai J, Qureshi D, Rustin E, Balaji A, Chronopoulou E, Homburg R, Khan KS, Bhide P. The definition of unexplained infertility: A systematic review. BJOG 2023. [PMID: 37957032 DOI: 10.1111/1471-0528.17697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/15/2023] [Indexed: 11/15/2023]
Abstract
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.
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Affiliation(s)
- Claudia Raperport
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Desai
- Queen Mary University of London Medical School, London, UK
| | | | | | - Aparna Balaji
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | | | - Roy Homburg
- Hewitt Fertility Centre, Liverpool Women's Hospital, Liverpool, UK
| | - Khalid Saeed Khan
- Department of Preventative Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
- CIBER Epidemiology and Public Health, Madrid, Spain
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Fineman DC, Keller RL, Maltepe E, Rinaudo PF, Steurer MA. Fertility treatment increases the risk of preterm birth independent of multiple gestations. F S Rep 2023; 4:313-320. [PMID: 37719103 PMCID: PMC10504569 DOI: 10.1016/j.xfre.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 09/19/2023] Open
Abstract
Objective To investigate the complex interplay between fertility treatment, multiple gestations, and prematurity. Design Retrospective cohort study linking the national Center for Disease Control and Prevention infant birth and death data from 2014 to 2018. Setting National database from Center of Disease Control and Prevention. Patients In total, 19,454,155 live-born infants with gestational ages 22-44 weeks, 114,645 infants born using non IVF fertility treatment (NIFT), and 179,960 via assisted reproductive technology (ART). Intervention Noninvasive fertility treatment or ART vs. spontaneously conceived pregnancies. Main Outcome Measures The main outcome assessed was prematurity. Formal mediation analysis was conducted to calculate the percentage mediated by multiple gestations. Results Newborns born using NIFT or ART compared with those with no fertility treatment had a higher incidence of multiple gestation (no fertility treatment = 3.0%; NIFT = 24.7%; ART = 32.7%; P<.001) and prematurity (no fertility treatment = 11.2%; NIFT = 23.4%; ART = 28.4%; P<.001). Mediation analysis demonstrates that 76.8% (95% confidence interval [CI], 75.2%-78.1%) of the effect of NIFT on prematurity was mediated through multiple gestations. Similarly, 71.2% (95% CI, 70.8%-72.7%) of the effect of ART on prematurity is mediated through multiple gestation. However, the direct effect of NIFT on prematurity is 20.4% (95% CI, 19.0%-22.0%). The direct effect of ART was 24.7% (95% CI, 23.7%-25.6%). Conclusion A significant proportion of prematurity associated with fertility treatment is mediated by the treatment itself, independent of multiple gestations.
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Affiliation(s)
- David C. Fineman
- Case Western Reserve University PRIME Program, School of Medicine and College of Arts and Sciences, Cleveland, Ohio
| | - Roberta L. Keller
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Emin Maltepe
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Paolo F. Rinaudo
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco
| | - Martina A. Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
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Gavrizi SZ, Hosseinzadeh P, Brush RS, Tytanic M, Eckart E, Peck JD, Craig LB, Diamond MP, Agbaga MP, Hansen KR. Sperm very long-chain polyunsaturated fatty acids: relation to semen parameters and live birth outcome in a multicenter trial. Fertil Steril 2023; 119:753-760. [PMID: 36681262 PMCID: PMC10176595 DOI: 10.1016/j.fertnstert.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/23/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine whether the levels of sperm very long-chain polyunsaturated fatty acids (VLC-PUFAs) are correlated with sperm parameters and the outcome of live birth after conventional therapy for unexplained infertility. DESIGN Cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation randomized controlled trial. SETTING Multicenter randomized controlled trial. PATIENTS Male partners from 185 couples with unexplained infertility who provided baseline semen samples for analysis. INTERVENTION We determined the levels of VLC-PUFAs in total lipid isolated from sperm membranes using liquid chromatography-mass spectrometry/mass spectrometry analyses. MAIN OUTCOME MEASURES Sperm concentration, motility, morphology, total motile count (TMC), and live birth after standard treatment for unexplained infertility. RESULTS Total VLC-PUFA percentage was positively correlated with sperm concentration (Spearman's rank correlation (rs) 0.56, P<.0001), TMC (rs = 0.40, P<.0001), and morphology (rs = 0.26, P=.0005). After adjustment for male body mass index, age, and race, a one-standard-deviation increase in the percentage of total VLC-PUFA was associated with a 62% increase in the geometric mean (GM) of sperm concentration (GM Ratio: 1.62 [95% confidence intervals {CI}: 1.45, 1.82]) and a 43% increase in the geometric mean of TMC (GM Ratio: 1.43 [95% CI; 1.24, 1.63]). Although no evidence of association was observed for sperm motility, a positive relationship was also observed between the percentage of total VLC-PUFA and sperm morphology [adjusted incidence rate ratio (IRR) for one-standard-deviation increase in total VLC-PUFA: 1.18 (95% CI; 1.02, 1.36)]. After adjustment for female age and treatment group, the probability of a live birth outcome was 72% more likely among those in the third tertile of hydroxylated VLC-PUFA percentage than in the first tertile (RR 1.72 [95% CI; 1.01, 2.94]). CONCLUSIONS The positive correlation between sperm VLC-PUFAs percentage and sperm parameters, as well as the significant association between hydroxylated VLC-PUFA percentage and the outcome of live birth, strongly suggest that this class of fatty liquid chromatography-mass spectrometry/mass spectrometry acids is essential for normal sperm structure and function.
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Affiliation(s)
- Sarah Z Gavrizi
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Pardis Hosseinzadeh
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma.
| | - Richard Steven Brush
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Dean A. McGee Eye Institute, Oklahoma City, Oklahoma
| | - Madison Tytanic
- Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Dean A. McGee Eye Institute, Oklahoma City, Oklahoma
| | - Erin Eckart
- Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, Oklahoma
| | - Jennifer D Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma; Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, Oklahoma
| | - LaTasha B Craig
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Michael P Diamond
- Department of Obstetrics and Gynaecology, Augusta University, Augusta, Georgia
| | - Martin-Paul Agbaga
- Department of Cell Biology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma; Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Dean A. McGee Eye Institute, Oklahoma City, Oklahoma
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Vitek W, Oh J, Mbowe O, Thurston SW, Christianson MS, Styer AK, Polotsky AJ, Diamond MP, Cedars MI. Preconception ovarian reserve and placenta-mediated pregnancy complications among infertile women. Pregnancy Hypertens 2022; 27:193-196. [PMID: 35131729 PMCID: PMC8922433 DOI: 10.1016/j.preghy.2022.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/25/2022]
Abstract
RESEARCH QUESTION Are preconception ovarian reserve markers, such as Anti-Mullerian hormone and antral follicle count, associated with preeclampsia and placenta mediated pregnancy complications among women with unexplained infertility who conceive with superovulation? DESIGN This is a secondary analysis of women with unexplained infertility who had a singleton live birth after enrollment in the Analysis of Multiple Intrauterine Gestations after Ovarian Stimulation (AMIGOS) trial that randomized couples to superovulation with letrozole, clomiphene, or gonadotropins with insemination for up to 4 cycles. RESULTS Compared to controls (N = 156), women who developed preeclampsia (N = 17) had lower Anti-Mullerian hormone levels (2.24 ± 1.20 vs. 2.89 ± 2.32, p = 0.07) and lower antral follicle count (18 ± 7.67 vs. 21 ± 11.43, p = 0.16); though these differences were not statistically significant. There was no relationship between Anti-Mullerian hormone (OR: 1.00, 95% CI: 0.76-1.25) or antral follicle count (OR: 0.98, 95% CI 0.93-1.04) with preeclampsia and between Anti-Mullerian hormone (OR: 1.00, 95% CI: 0.83-1.17) and antral follicle count (OR: 1.00, 95% CI: 0.97-1.04) with placenta medicated pregnancy complications after adjusting for age, BMI and race. CONCLUSIONS Preconception ovarian reserve markers are not associated with preeclampsia and placenta mediated pregnancy complications among women with unexplained infertility who conceive with superovulation with insemination.
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Affiliation(s)
- Wendy Vitek
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Jinhee Oh
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Omar Mbowe
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sally W. Thurston
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | | | | | | | - Marcelle I. Cedars
- University of California San Francisco Medical Center, San Francisco, CA
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Gavrizi SZ, Arya S, Peck JD, Knudtson JF, Diamond MP, Wild RA, Hansen KR. High-sensitivity C-reactive protein levels and pregnancy outcomes in women with unexplained infertility after ovarian stimulation with intrauterine insemination in a multicenter trial. F S Rep 2022; 3:57-62. [PMID: 35386508 PMCID: PMC8978106 DOI: 10.1016/j.xfre.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/04/2022] Open
Abstract
Objective To determine if chronic inflammation, assessed by basal high-sensitivity C-reactive protein (hs-CRP) levels, is associated with pregnancy outcomes in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Design Prospective cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial. Setting Multicenter university-based randomized controlled trial. Patients A total of 781 couples with unexplained infertility. Interventions Secondary analysis. Main Outcome Measures Adjusted risk ratios of live birth, clinical pregnancy, and pregnancy loss rates by hs-CRP levels. Results Associations between hs-CRP levels and clinical pregnancy rates were not observed after adjustment for baseline body mass index. There were fewer live births among women with higher hs-CRP levels, although confidence intervals crossed 1.0. The risk of pregnancy loss was greater in women with increased hs-CRP levels (1-3 mg/L: risk ratio [RR], 1.67; 95% confidence interval [CI], 1.00-2.79; >3-10 mg/L: RR, 1.84; 95% CI, 1.06-3.20; and >10 mg/L: RR, 2.14; 95% CI, 1.05-4.36 compared to women with hs-CRP <1 mg/L). Conclusions This investigation suggests that chronic inflammation may increase the risk of pregnancy loss but not impact the clinical pregnancy rate in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Associations between inflammation and pregnancy outcomes in women with infertility merit further investigation. Clinical Trial Registration Number clinicaltrials.gov NCT01044862.
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Affiliation(s)
- Sarah Z. Gavrizi
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Sushila Arya
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jennifer D. Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer F. Knudtson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Robert A. Wild
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Zhang H. Teaming for excellence: challenges and collaboration in the world of reproductive clinical and translational research. Fertil Steril 2022; 117:33-37. [PMID: 34686371 PMCID: PMC8714684 DOI: 10.1016/j.fertnstert.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023]
Abstract
To succeed in the conduct of clinical trials in reproductive medicine, teams must be trained and cultivated to collaborate and achieve a common goal. Here I share my personal experiences and lessons learned in teaming in the research setting by covering topics in time management, resource allocation, collaboration, publishing, and communication.
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Eisenberg E, Legro RS, Diamond MP, Huang H, O’Brien LM, Smith YR, Coutifaris C, Hansen KR, Santoro N, Zhang H. Sleep Habits of Women With Infertility. J Clin Endocrinol Metab 2021; 106:e4414-e4426. [PMID: 34180998 PMCID: PMC8530742 DOI: 10.1210/clinem/dgab474] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Indexed: 01/30/2023]
Abstract
CONTEXT Sleep plays important roles in metabolic and reproductive function, and polycystic ovary syndrome (PCOS) is associated with sleep disturbances, including increased prevalence of obstructive sleep apnea. OBJECTIVE We sought to evaluate sleep parameters in infertile women with PCOS compared with women with unexplained infertility (UI) and identify risk factors for disturbed sleep. METHODS At private and academic ambulatory gynecology and infertility practices, we evaluated a prospective cohort of women diagnosed with PCOS or UI from 2 randomized clinical trials. We included 1603 infertile women enrolled in 2 concurrent randomized clinical trials. The main outcome measures were self-reported sleep measures. RESULTS Sleep duration <6 hours (6.1% vs 2.7%; P < .001), habitual snoring (37.8% vs 19.0%; P < .001), and clinical sleepiness (12.0% vs 8.6%; P < .026) were more common in women with PCOS than those with UI. After adjusting for covariates, PCOS and elevated fasting insulin were associated (P = .010) with clinical symptoms of obstructive sleep apnea (OSA) diagnosis, whereas PCOS, elevated insulin (P = .003), WC >88 cm (P = .003), and current smoking (P = .012) were associated with habitual snoring. Clinical depression score (P < .001) and PCOS diagnosis (P = .002) were associated with perceived daytime sleepiness. Short sleep duration and clinical symptoms of OSA were not associated with conception and live birth rates. CONCLUSION Infertile women with PCOS more commonly report sleep disturbances than those with UI. Markers of insulin resistance are associated with previous diagnosis of OSA, habitual snoring, and short sleep duration. The presence of clinical symptoms of OSA or short sleep duration does not affect fertility treatment response.
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Affiliation(s)
- Esther Eisenberg
- Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20817, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA 16802, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA 30912, USA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
| | - Louise M O’Brien
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Yolanda R Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
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Hansen KR, Peck JD, Coward RM, Wild RA, Trussell JC, Krawetz SA, Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Santoro N, Zhang H. Intrauterine insemination performance characteristics and post-processing total motile sperm count in relation to live birth for couples with unexplained infertility in a randomised, multicentre clinical trial. Hum Reprod 2021; 35:1296-1305. [PMID: 32432326 DOI: 10.1093/humrep/deaa027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/28/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Are intrauterine insemination (IUI) performance characteristics and post-processing total motile sperm count (TMC) related to live birth rate in couples with unexplained infertility? SUMMARY ANSWER Patient discomfort with IUI and lower inseminate TMC were associated with a reduced live birth rate, while time from hCG injection to IUI, sperm preparation method and ultrasound guidance for IUI were not associated with live birth success. WHAT IS ALREADY KNOWN We previously determined that some baseline characteristics of couples with unexplained infertility, including female age, duration of infertility, history of prior loss and income, were related to live birth rate across a course of ovarian stimulation and IUI treatment. However, the relationship between treatment outcomes and per-cycle characteristics, including ultrasound guidance for IUI, timing of IUI relative to hCG injection, difficult or painful IUI and inseminate TMC, are controversial, and most prior investigations have not evaluated live birth outcome. STUDY DESIGN, SIZE, DURATION This was a secondary analyses of 2462 cycles from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. This prospective, randomised, multicentre clinical trial determined live birth rates following IUI after ovarian stimulation with clomiphene citrate, letrozole or gonadotropins in 854 couples with unexplained infertility. It was conducted between 2011 and 2014, and couples could undergo up to four consecutive treatment cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS AMIGOS was an NIH-sponsored Reproductive Medicine Network trial conducted at 12 clinical sites. Participants were women with unexplained infertility who were between 18 and 40 years of age. Cluster-weighted generalised estimating equations (GEE), which account for informative clustering of multiple IUI treatment cycles within the same patient, were used to determine associations between IUI performance characteristics, including inseminate TMC, and live birth rate. Efficiency curves were also generated to examine the relationship between inseminate TMC and live birth rate. MAIN RESULTS AND THE ROLE OF CHANCE After adjustment for treatment group and baseline factors previously associated with live birth across a course of OS-IUI treatment, patient discomfort during the IUI procedure was associated with a reduction in live birth rate (aRR 0.40 (0.16-0.96)). Time from hCG trigger injection to IUI was not significantly associated with outcome. Higher TMC was associated with greater live birth rate (TMC 15.1-20.0 million (14.8%) compared to ≤5 million (5.5%)) (aRR 2.09 (1.31-3.33)). However, live births did occur with TMC ≤ 1 million (5.1%). LIMITATIONS, REASONS FOR CAUTION This investigation is a secondary analysis, and AMIGOS was not designed to address the present question. Since timed intercourse was allowed as part of the AMIGOS trial, we cannot rule out the possibility that any given pregnancy resulted from intercourse rather than IUI. WIDER IMPLICATIONS OF THE FINDINGS Most factors associated with the performance of IUI were not significantly related to obtaining live birth. Our findings suggest that higher TMC inseminated leads to an increase in live birth rate up to TMC ~20 million. However, there may be no reasonable threshold below which live birth is not possible with IUI. STUDY FUNDING/COMPETING INTEREST(S) Funding was received through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD077680, U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10 HD055925. This research was made possible by funding by the American Recovery and Reinvestment Act. Dr Hansen reports grants from NIH/NICHD and Yale University during the conduct of the study, grants from Roche Diagnostics and grants from Ferring International Pharmascience Center US outside the submitted work. Dr Peck reports support from Ferring Pharmaceuticals outside the submitted work. Dr Coward has nothing to disclose. Dr Wild reports grants from NICHD during the conduct of the study. Dr Trussell has nothing to disclose. Dr Krawetz reports grants from NICHD during the conduct of the study, grants from Merck and support from Taylor and Frances and from Springer, outside the submitted work. Dr Diamond reports grants from NIH/NICHD, Yale University, during the conduct of the study and support from Advanced Reproductive Care AbbVie, Bayer and ObsEva, outside the submitted work. Dr Legro reports support from Bayer, Kindex, Odega, Millendo and AbbVie and grants and support from Ferring, outside the submitted work. Dr Coutifaris reports grants from NICHD/NIH and personal fees from American Society for Reproductive Medicine, outside the submitted work. Dr Alvero has nothing to disclose. Dr Robinson reports grants from NIH during the conduct of the study. Dr Casson has nothing to disclose. Dr Christman reports grants from NICHD during the conduct of the study. Dr Santoro reports grants from NIH during the conduct of the study. Dr Zhang reports grants from NIH during the conduct of the study and support from Shangdong University outside the submitted work. TRIAL REGISTRATION NUMBER n/a.
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Affiliation(s)
- Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA
| | - Jennifer D Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA.,Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, OK 73104, USA
| | - R Matthew Coward
- Department of Urology, UNC School of Medicine, 2113 Physicians Office Building CB#7235, Chapel Hill, NC 27599-7235, USA.,UNC Fertility, 7920 ACC Blvd #300, Raleigh, NC 27617, USA
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA.,Department of Biostatistics and Epidemiology, University of Oklahoma College of Public Health, Oklahoma City, OK 73104, USA
| | - J C Trussell
- Department of Urology, Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA.,Department of Obstetrics and Gynecology, Augusta University, Augusta, GA 30912, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA 17033, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO 80045, USA.,Department of Obstetrics and Gynecology, Stanford University, Sunnyvale, CA 94087, USA
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, TX 78229, USA
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, VT 05446, USA.,Northeastern Reproductive Medicine, 105 W View Rd, #302, Colchester, VT 05446, USA
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Obstetrics and Gynecology, University of Florida College of Medicine, PO Box 100294, Gainesville, FL 32610, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
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12
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Palomba S, Piltonen TT, Giudice LC. Endometrial function in women with polycystic ovary syndrome: a comprehensive review. Hum Reprod Update 2020; 27:584-618. [PMID: 33302299 DOI: 10.1093/humupd/dmaa051] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/29/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. An endometrial component has been suggested to contribute to subfertility and poor reproductive outcomes in affected women. OBJECTIVE AND RATIONALE The aim of this review was to determine whether there is sufficient evidence to support that endometrial function is altered in women with PCOS, whether clinical features of PCOS affect the endometrium, and whether there are evidence-based interventions to improve endometrial dysfunction in PCOS women. SEARCH METHODS An extensive literature search was performed from 1970 up to July 2020 using PubMed and Web of Science without language restriction. The search included all titles and abstracts assessing a relationship between PCOS and endometrial function, the role played by clinical and biochemical/hormonal factors related to PCOS and endometrial function, and the potential interventions aimed to improve endometrial function in women with PCOS. All published papers were included if considered relevant. Studies having a specific topic/hypothesis regarding endometrial cancer/hyperplasia in women with PCOS were excluded from the analysis. OUTCOMES Experimental and clinical data suggest that the endometrium differs in women with PCOS when compared to healthy controls. Clinical characteristics related to the syndrome, alone and/or in combination, may contribute to dysregulation of endometrial expression of sex hormone receptors and co-receptors, increase endometrial insulin-resistance with impaired glucose transport and utilization, and result in chronic low-grade inflammation, immune dysfunction, altered uterine vascularity, abnormal endometrial gene expression and cellular abnormalities in women with PCOS. Among several interventions to improve endometrial function in women with PCOS, to date, only lifestyle modification, metformin and bariatric surgery have the highest scientific evidence for clinical benefit. WIDER IMPLICATIONS Endometrial dysfunction and abnormal trophoblast invasion and placentation in PCOS women can predispose to miscarriage and pregnancy complications. Thus, patients and their health care providers should advise about these risks. Although currently no intervention can be universally recommended to reverse endometrial dysfunction in PCOS women, lifestyle modifications and metformin may improve underlying endometrial dysfunction and pregnancy outcomes in obese and/or insulin resistant patients. Bariatric surgery has shown its efficacy in severely obese PCOS patients, but a careful evaluation of the benefit/risk ratio is warranted. Large scale randomized controlled clinical trials should address these possibilities.
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Affiliation(s)
- Stefano Palomba
- Unit of Obstetrics and Gynecology, Grande Ospedale Metropolitano of Reggio Calabria, Reggio Calabria, Italy
| | - Terhi T Piltonen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Linda C Giudice
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
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13
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Legro RS, Diamond MP, Coutifaris C, Schlaff WD, Alvero R, Casson P, Christman GM, Rosen RM, Cedars MI, Hansen KR, Robinson R, Baker V, Usadi R, Dodson WC, Estes SJ, Kunselman A, Stetter C, Barnhart KT, Coward RM, Trussell JC, Krawetz SA, Santoro N, Huang H, Zhang H, Eisenberg E. Pregnancy registry: three-year follow-up of children conceived from letrozole, clomiphene, or gonadotropins. Fertil Steril 2020; 113:1005-1013. [PMID: 32386612 DOI: 10.1016/j.fertnstert.2019.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the development of children conceived from non-IVF infertility treatments consisting of gonadotropins, clomiphene, or letrozole. DESIGN Prospective cohort study. SETTING U.S. academic health centers. PATIENT(S) Children of women with polycystic ovary syndrome who conceived with letrozole (LTZ) or clomiphene (CC) in the PPCOS II study or women with unexplained infertility (AMIGOS study) who conceived with LTZ, CC, or gonadotropin (GN). INTERVENTION(S) Longitudinal annual follow-up from birth to age 3. MAIN OUTCOME MEASURE(S) Scores from Ages and Stages Developmental Questionnaire (ASQ), MacArthur-Bates Communicative Development Inventory (MCDI), and annual growth. RESULT(S) One hundred eighty-five children from 160 families participated in at least one follow-up evaluation from the two infertility trials. Most multiple gestations in the follow-up study resulted from GN treatment (n = 14) followed by CC (n = 6) and LTZ (n = 3). There were no significant differences among the three groups at any time point with respect to abnormal scores on the ASQ. On the MCDI Words and Gestures, the LTZ group scored significantly higher than the GN group for most items (phrases, early gestures, later gestures, and total gestures). Children in the CC group scored significantly higher than the GN group for the later gestures and total gestures items. CONCLUSION(S) Differences in growth and cognitive developmental rates among children conceived with first-line infertility therapies, including LTZ, are relatively minor and likely due to differences in multiple pregnancy rates.
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Affiliation(s)
- Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William D Schlaff
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - R Mitchell Rosen
- Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, California
| | - Karl R Hansen
- Department of Obstetrics and Gynecology University of Oklahoma, Oklahoma City, Oklahoma
| | - Randal Robinson
- Department of Obstetrics and Gynecology, University of Texas at San Antonio, San Antonio, Texas
| | - Valerie Baker
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina
| | - William C Dodson
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Stephanie J Estes
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Christina Stetter
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - R Matthew Coward
- Department of Urology, University of North Carolina, Raleigh, North Carolina; UNC Fertility LLC, Raleigh, North Carolina
| | - J C Trussell
- Department of Urology, SUNY Upstate University Hospital, Syracuse, New York
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Esther Eisenberg
- Fertility and Infertility Branch, National Institute of Child Health and Human Development, Rockville, Maryland
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14
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Wang ET, Diamond MP, Alvero R, Casson P, Christman GM, Coutifaris C, Hansen KR, Sun F, Legro RS, Robinson RD, Usadi RS, Pisarska MD, Santoro NF, Zhang H. Androgenicity and fertility treatment in women with unexplained infertility. Fertil Steril 2020; 113:636-641. [PMID: 32192596 PMCID: PMC7088440 DOI: 10.1016/j.fertnstert.2019.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/11/2019] [Accepted: 10/25/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether biochemical or clinical markers of androgenic activity predict live birth rate with ovarian stimulation in the unexplained infertility population. DESIGN Secondary analysis of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. SETTING Multicenter university-based clinical practices. PATIENT(S) Nine hundred couples with unexplained infertility were included. Women were 18-40 years old with regular menses, a normal uterine cavity, at least one patent fallopian tube, and a male partner with ≥5 million motile sperm. Women were randomized to receive gonadotropin, clomiphene, or letrozole with IUI for four or fewer four treatment cycles. Women were evaluated for biochemical (total testosterone, DHEAS, and free androgen index) and clinical markers of androgenic activity (sebum, acne, and hirsutism). Multivariable logistic regression models adjusting for treatment group, maternal age, and body mass index were performed. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The primary outcome was live birth. Secondary outcomes included conception, clinical pregnancy, and pregnancy loss. RESULT(S) When comparing 900 women in the AMIGOS trial based on quartiles of serum TT, women were of younger age, higher body mass index, and higher waist circumference with increasing TT. Increasing quartiles of TT also showed increasing DHEAS and free androgen index values. Serum androgens were not associated with outcomes of live birth, conception, clinical pregnancy, or pregnancy loss. Clinical androgen markers were not associated with pregnancy outcomes. CONCLUSION(S) In a randomized cohort of women with unexplained infertility, biochemical and clinical measures of androgens did not predict live birth rate after ovarian stimulation treatment. CLINICAL TRIAL REGISTRATION NUMBER NCT 01044862.
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Affiliation(s)
- Erica T Wang
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Fangbai Sun
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Rebecca S Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina
| | - Margareta D Pisarska
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nanette F Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
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15
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Swanson GM, Estill M, Diamond MP, Legro RS, Coutifaris C, Barnhart KT, Huang H, Hansen KR, Trussell JC, Coward RM, Zhang H, Goodrich R, Krawetz SA. Human chromatin remodeler cofactor, RNA interactor, eraser and writer sperm RNAs responding to obesity. Epigenetics 2020; 15:32-46. [PMID: 31354029 PMCID: PMC6961666 DOI: 10.1080/15592294.2019.1644880] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 12/23/2022] Open
Abstract
In the United States almost 33% of adults are considered obese (BMI > 30 kg/m2). Both animal models and to a lesser extent human studies, have associated BMI, a measure of obesity, with alterations in sperm DNA methylation and RNAs. Sperm RNAs from the Assessment of Multiple Gestations from Ovarian Stimulation trial, were isolated and sequenced. A Generalized Linear Model identified 487 BMI associated human sperm RNA elements (short exon-sized sequences). They partitioned into four patterns; a continual increase with BMI, increase once obese (BMI>30 kg/m2); a steady decrease with BMI; and decrease once overweight (BMI 25 - 30 kg/m2). Gene Ontology revealed a unique relationship between BMI and transcripts associated with chromosome organization, adipogenesis, cellular stress and obesity-related inflammation. Coregulatory networks linked by Chromatin remodeler cofactors, RNA interactors, Erasers and Writers (CREWs) were uncovered to reveal a hierarchical epigenetic response pathway.
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Affiliation(s)
- Grace M. Swanson
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, USA
| | - Molly Estill
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, USA
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, USA
| | - Richard S. Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Kurt T. Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, USA
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, USA
| | - J. C. Trussell
- Urology Department, Upstate Medical University, Syracuse, USA
| | - R. Matthew Coward
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, USA
| | - Robert Goodrich
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, USA
| | - Stephen A. Krawetz
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, USA
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16
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Rios JS, Greenwood EA, Pavone MEG, Cedars MI, Legro RS, Diamond MP, Santoro N, Sun F, Robinson RD, Christman G, Zhang H, Huddleston HG. Associations Between Anti-Mullerian Hormone and Cardiometabolic Health in Reproductive Age Women Are Explained by Body Mass Index. J Clin Endocrinol Metab 2020; 105:5581647. [PMID: 31586179 PMCID: PMC7024739 DOI: 10.1210/clinem/dgz012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/20/2019] [Indexed: 12/24/2022]
Abstract
CONTEXT The relationship between reproductive and cardiometabolic aging is unclear. It is unknown if the relationship differs across different clinical populations. OBJECTIVE To determine whether markers of ovarian reserve are associated with cardiometabolic risk in reproductive aged women with unexplained infertility (UI), polycystic ovary syndrome (PCOS), and regularly cycling women (OVA). DESIGN AND SETTING Cross-sectional data from 8 US-based academic centers. PARTICIPANTS Women aged 25-40 from 3 clinical populations: 870 with UI, 640 with PCOS, and 921 community-based OVA. MAIN OUTCOME MEASURES Multivariable linear regression models were used to relate anti-mullerian hormone (AMH) and antral follicle count with cardiometabolic parameters including body mass index (BMI), waist circumference (WC), fasting glucose and insulin, homeostasis model assessment-insulin resistance (HOMA-IR), lipids, and C-reactive protein. RESULTS In age and study site-adjusted models, AMH inversely related to BMI in the UI and OVA groups (P = 0.02 and P < 0.001). Among women with PCOS, AMH inversely related to BMI (P < 0.001), and also to WC (P < 0.001), fasting insulin (P < 0.01), HOMA-IR (P < 0.01), triglycerides (P = 0.04), and C-reactive protein (P < 0.001) and directly related to higher total (P = 0.02), low-density lipoprotein (P < 0.01), and high-density lipoprotein cholesterol (P < 0.01). In OVA, AMH also varied inversely with WC (P < 0.001), fasting insulin (P = 0.02), and HOMA-IR (P = 0.02). Adjustment for BMI eliminated associations in the OVA group but in PCOS, the relationship of AMH to total (P = 0.03) and low-density lipoprotein cholesterol (P = 0.003) remained. CONCLUSION Associations observed between AMH and cardiometabolic indices are largely explained by BMI in women with and without PCOS. (J Clin Endocrinol Metab XX: 0-0, 2019).
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Affiliation(s)
- Julie S Rios
- Department of Obstetrics & Gynecology, University of Cincinnati, Cincinnati, Ohio
- Correspondence: Julie S. Rios, MD, Department of Obstetrics & Gynecology, University of Cincinnati, Cincinnati, OhioDepartment of Obstetrics & Gynecology, University of Cincinnati, Cincinnati, Ohio. E-mail:
| | - Eleni A Greenwood
- Department of Obstetrics & Gynecology, University of California San Francisco, San Francisco, California
| | - Mary Ellen G Pavone
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, Illinois
| | - Marcelle I Cedars
- Department of Obstetrics & Gynecology, University of California San Francisco, San Francisco, California
| | - Richard S Legro
- Department of Obstetrics & Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, Georgia
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Fangbai Sun
- Collaborative Center for Statistics in Science, Yale School of Public Health, New Haven, Connecticut
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Gregory Christman
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida
| | - Heping Zhang
- Collaborative Center for Statistics in Science, Yale School of Public Health, New Haven, Connecticut
| | - Heather G Huddleston
- Department of Obstetrics & Gynecology, University of California San Francisco, San Francisco, California
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Coward RM, Stetter C, Kunselman A, Trussell JC, Lindgren MC, Alvero RR, Casson P, Christman GM, Coutifaris C, Diamond MP, Hansen KR, Krawetz SA, Legro RS, Robinson RD, Smith JF, Steiner AZ, Wild RA, Zhang H, Santoro N. Fertility Related Quality of Life, Gonadal Function and Erectile Dysfunction in Male Partners of Couples with Unexplained Infertility. J Urol 2019; 202:379-384. [PMID: 30835629 PMCID: PMC6686175 DOI: 10.1097/ju.0000000000000205] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE We sought to determine whether lower fertility related quality of life or depression in men of couples with unexplained infertility is associated with low total testosterone levels, abnormal semen quality or erectile dysfunction. MATERIALS AND METHODS This study is a secondary analysis of a large, multicenter, randomized controlled trial in couples with unexplained infertility. Male partners underwent baseline semen analysis with measurement of fasting total testosterone and gonadotropin. They also completed surveys, including the FertiQOL (Fertility Quality of Life), the PHQ-9 (Patient Health Questionnaire-9) and the IIEF (International Index of Erectile Function). The primary study outcomes were total testosterone with low total testosterone defined as less than 264 ng/dl, semen parameters and the IIEF score. We performed multivariable logistic regression analyses adjusted for patient age, race, body mass index, education, smoking, alcohol use, infertility duration and comorbidity. RESULTS A total of 708 men with a mean ± SD age of 34.2 ± 5.6 were included in study. Of the men 59 (8.3%) had a PHQ-9 score of 5 or greater, which was consistent with depression, 99 (14.0%) had low total testosterone and 63 (9.0%) had mild or worse erectile dysfunction. Neither the FertiQOL score nor depression was associated with total testosterone or any semen parameter. The FertiQOL score was inversely associated with erectile dysfunction (for every 5-point score decline AOR 1.30, 95% CI 1.16-1.46). Depressed men were significantly more likely to have erectile dysfunction than nondepressed men (AOR 6.31, 95% CI 3.12-12.77). CONCLUSIONS In men in couples with unexplained infertility lower fertility related quality of life and depression are strongly associated with erectile dysfunction. However, neither is associated with spermatogenesis or testosterone levels. Erectile dysfunction in infertile men merits longitudinal investigation in future studies.
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Affiliation(s)
- R. Matthew Coward
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC
- UNC Fertility, Raleigh, NC
| | - Christy Stetter
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - JC Trussell
- Department of Urology, Upstate University Hospital, Syracuse, NY
| | - Mark C. Lindgren
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Ruben R. Alvero
- Department of Obstetrics and Gynecology, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Peter Casson
- Northeastern Reproductive Medicine, Colchester, VT
| | | | - Christos Coutifaris
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Stephen A. Krawetz
- Department of Obstetrics and Gynecology, Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI
| | - Richard S. Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA
| | - Randal D. Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - James F. Smith
- Department of Urology, University of California, San Francisco, San Francisco, CA
| | - Anne Z. Steiner
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Robert A. Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
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18
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Torchen LC, Legro RS, Dunaif A. Distinctive Reproductive Phenotypes in Peripubertal Girls at Risk for Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2019; 104:3355-3361. [PMID: 30844044 PMCID: PMC6589072 DOI: 10.1210/jc.2018-02313] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/01/2019] [Indexed: 12/12/2022]
Abstract
CONTEXT Increased testosterone (T) levels are a cardinal feature of polycystic ovary syndrome (PCOS). Female relatives of affected women, including premenarchal daughters, have elevated T levels supporting a genetic susceptibility to this phenotype. Girls with obesity (OB-g) also have increased T levels throughout puberty, which may indicate risk for PCOS. OBJECTIVE We tested the hypothesis that premenarchal daughters of women affected with PCOS (PCOS-d) have distinctive phenotypic features compared with OB-g. DESIGN, SETTING, AND PARTICIPANTS Forty-eight PCOS-d, 30 OB-g, and 22 normal weight (NW-g) premenarchal girls were studied. Mothers of OB-g and NW-g had no evidence for PCOS. MAIN OUTCOME MEASURES Reproductive hormones were measured. RESULTS Body mass index differed by design, was highest in OB-g, followed by PCOS-d (P > 0.001). PCOS-d and OB-g had similar increases in free T levels compared with NW-g (PCOS-d vs NW-g, P = 0.01; OB-g vs NW-g, P = 0.0001). Sex hormone binding globulin levels were lowest in OB-g and lower in PCOS-d than in NW-g (PCOS-d vs NW-g, P = 0.005; OB-g vs NW-g, P < 0.0001; PCOS-d vs OB-g, P < 0.0001). Anti-Müllerian hormone (AMH) levels in PCOS-d were significantly increased compared with OB-g, who tended to have lower AMH levels than NW-g (PCOS-d vs OB-g, P < 0.0001; PCOS-d vs NW-g, P = 0.10). CONCLUSIONS Despite similarly elevated free T levels, PCOS-d had increased AMH levels compared with OB-g. This finding suggests that OB-g lack alterations in ovarian folliculogenesis, a key reproductive feature of PCOS. Causal mechanisms may differ in PCOS-d or OB-g, or elevated T in OB-g may not be an early marker for PCOS.
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Affiliation(s)
- Laura C Torchen
- Division of Endocrinology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Andrea Dunaif
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
- Correspondence and Reprint Requests: Andrea Dunaif, MD, Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1055, New York, New York 10029. E-mail:
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19
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The management of unexplained infertility: an evidence-based guideline from the Canadian Fertility and Andrology Society. Reprod Biomed Online 2019; 39:633-640. [PMID: 31439397 DOI: 10.1016/j.rbmo.2019.05.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 11/20/2022]
Abstract
Unexplained infertility is a common diagnosis affecting as many as 50% of couples seeking infertility care. As a diagnosis of exclusion, its treatment remains largely empirical. Historically, a step-wise progression in treatment has been initiated with the least invasive, least expensive option followed by a gradual progression to therapies using assisted reproductive technology. In recent years there have been advocates for more rapid-progression IVF. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based recommendations for the treatment of unexplained infertility, including expectant management, laparoscopy, intrauterine insemination (IUI) alone, ovarian stimulation with oral agents or gonadotropins alone, ovarian stimulation + IUI, and IVF. The quality of supporting evidence for each recommendation is evaluated using the framework outlined by the Canadian Task Force on Preventive Health Care. This guideline recognizes that the therapeutic approach should be individualized taking into account patient age and duration of infertility, and emphasizes those strategies that are most likely to result in a healthy live birth.
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20
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Barrett ES, Vitek W, Mbowe O, Thurston SW, Legro RS, Alvero R, Baker V, Bates GW, Casson P, Coutifaris C, Eisenberg E, Hansen K, Krawetz S, Robinson R, Rosen M, Usadi R, Zhang H, Santoro N, Diamond M. Allostatic load, a measure of chronic physiological stress, is associated with pregnancy outcomes, but not fertility, among women with unexplained infertility. Hum Reprod 2019; 33:1757-1766. [PMID: 30085177 DOI: 10.1093/humrep/dey261] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 07/11/2018] [Indexed: 12/27/2022] Open
Abstract
STUDY QUESTION Among infertile women undergoing ovarian stimulation, is allostatic load (AL), a measure of chronic physiological stress, associated with subsequent fertility and pregnancy outcomes? SUMMARY ANSWER AL at baseline was not associated with conception, spontaneous abortion or live birth, however, it was significantly associated with increased odds of pre-eclampsia and preterm birth among women who had a live birth in the study. WHAT IS KNOWN ALREADY Several studies have linked AL during pregnancy to adverse outcomes including preterm birth and pre-eclampsia, hypothesizing that it may contribute to well-documented disparities in pregnancy and birth outcomes. However, AL biomarkers change over the course of pregnancy, raising questions as to whether gestational AL assessment is a valid measure of cumulative physiologic stress starting long before pregnancy. To better understand how AL may impact reproductive outcomes, AL measurement in the non-pregnant state (i.e. prior to conception) is needed. STUDY DESIGN, SIZE, DURATION A secondary data analysis based on data from 836 women who participated in Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS), a multi-center, randomized clinical trial of ovarian stimulation conducted from 2011 to 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS Ovulatory women with unexplained infertility (ages 18-40) were enrolled and at baseline, biological and anthropometric measures were collected. AL scores were calculated as a composite of the following baseline variables determined a priori: BMI, waist-to-hip ratio, systolic blood pressure, diastolic blood pressure, dehydroepiandrosterone sulfate, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, C-reactive protein and HOMA score. Participants received ovarian stimulation for up to four cycles and if they conceived, were followed throughout pregnancy. We fit multi-variable logistic regression models examining AL (one-tailed and two-tailed) in relation to the following reproductive outcomes: conception, spontaneous abortion, live birth, pre-eclampsia, preterm birth and low birthweight. MAIN RESULTS AND THE ROLE OF CHANCE Adjusting for covariates, a unit increase in two-tailed AL score was associated with 62% increased odds of pre-eclampsia (OR: 1.62, 95% CI: 1.14, 2.38) 44% increased odds of preterm birth (OR: 1.44, 95% CI: 1.02, 2.08), and 39% increased odds of low birthweight (OR: 1.39, 95% CI: 0.99, 1.97). The relationship between AL and preterm birth was mediated by pre-eclampsia (P = 0.0003). In one-tailed AL analyses, associations were similar, but slightly attenuated. AL was not associated with fertility outcomes (conception, spontaneous abortion, live birth). LIMITATIONS, REASONS FOR CAUTION Results may not be generalizable to fertile women who conceive naturally or women with other types of infertility. Comparisons to previous, related work are difficult because variables included in AL composite measures vary across studies. AL may be indicative of overall poor health, rather than being specific to chronic physiological stress. WIDER IMPLICATIONS OF THE FINDINGS Our results suggest that chronic physiological stress may not impact success of ovarian stimulation, however, they confirm and extend previous work suggesting that AL is associated with adverse pregnancy outcomes. Physiological dysregulation due to chronic stress has been proposed as a possible mechanism underlying disparities in birth outcomes, which are currently poorly understood. Assessing biomarkers of physiological dysregulation pre-conception or in early pregnancy, may help to identify women at risk of adverse pregnancy outcomes, particularly pre-eclampsia. STUDY FUNDING/COMPETING INTEREST(S) Support for AMIGOS was provided by: U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10HD055925. Support for the current analysis was provided by T32ES007271, R25HD075737, P30ES001247 and P30ES005022. This research was made possible by funding by American Recovery and Reinvestment Act. The content is solely the responsibility of the authors and does not necessarily represent the official views of NICHD, NIEHS or NIH. E.B., W.V., O.M., R.A., M.R., V.B., G.W.B., C.C., E.E., S.K., R.U., P.C, H.Z., N.S. and S.T. have nothing to disclose. R.L. reported serving as a consultant to Abbvie, Bayer, Kindex, Odega, Millendo and Fractyl and serving as a site investigator and receiving grants from Ferring. K.H. reported receiving grants from Roche Diagnostics and Ferring. R.R. reported a grant from AbbVie. M.D. reported being on the Board of Directors of and a stockholder in Advanced Reproductive Care. TRIAL REGISTRATION NUMBER Clinical Trials.gov number: NCT01044862.
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Affiliation(s)
- Emily S Barrett
- Department of Epidemiology, Environmental and Occupational Health Sciences Institute, Rutgers School of Public Health, 170 Frelinghuysen Road, Piscataway, NJ, USA.,Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY, USA
| | - Wendy Vitek
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY, USA
| | - Omar Mbowe
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, 265 Crittenden Avenue, Rochester, NY, USA
| | - Sally W Thurston
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, 265 Crittenden Avenue, Rochester, NY, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State University College of Medicine, 500 University Drive, Hershey, PA, USA
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, Warren Alpert School of Medicine, Brown University, 90 Plain Street, Providence, RI, USA
| | - Valerie Baker
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, 1195 West Fremont Avenue, Sunnyvale, CA, USA
| | - G Wright Bates
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, USA
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, 111 Colchester Avenue, Burlington, VT, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3701 Market Street, Philadelphia, PA, USA
| | - Esther Eisenberg
- Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 6710B Rockledge Drive, Bethesda, MD, USA
| | - Karl Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, 825 NE 10th Street, Oklahoma City, OK, USA
| | - Stephen Krawetz
- Department of Obstetrics and Gynecology, Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, 275 E. Hancock, Detroit, MI, USA
| | - Randal Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Drive, San Antonio, TX, USA
| | - Mitchell Rosen
- Department of Reproductive Endocrinology and Infertility, University of California, 550 16th Street, San Francisco, CA, USA
| | - Rebecca Usadi
- Carolinas Health Care System, 1025 Morehead Medical Drive, Charlotte, NC, USA
| | - Heping Zhang
- Yale School of Public Health, 300 George Street, New Haven, CT, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, 12631 E 17th Avenue, Aurora, CO, USA
| | - Michael Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA, USA
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21
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Huang H, Kuang H, Sun F, Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson PR, Christman GM, Hansen KR, Santoro N, Eisenberg E, Zhang H. Lower prevalence of non-cavity-distorting uterine fibroids in patients with polycystic ovary syndrome than in those with unexplained infertility. Fertil Steril 2019; 111:1011-1019.e1. [PMID: 30926125 PMCID: PMC6487215 DOI: 10.1016/j.fertnstert.2019.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To study whether there is a difference in the prevalence of non-cavity-distorting uterine fibroids between infertile patients with polycystic ovary syndrome (PCOS) and those with unexplained infertility (UI). DESIGN A secondary analysis of data from three randomized clinical trials. SETTING Academic health centers. PATIENT(S) A total of 2,249 patients with normal uterine cavities. INTERVENTIONS(S) None. MAIN OUTCOME MEASURE(S) The presence or absence of non-cavity-distorting fibroids. RESULT(S) Compared with women with UI, those with PCOS were younger, had a higher body mass index, and were more likely to be Hispanic or African American, with a lower percentage of previous conception and live birth, a higher percentage of current smokers, a lower percentage of current alcohol users, and higher total testosterone, fasting insulin, and homeostasis-model-assessment insulin resistance. The prevalence of women with non-cavity-distorting uterine fibroids was lower in women with PCOS than in those with UI (6.7% vs. 12.4%); this result held after patients were divided into Black and non-Black or into three different body mass index groups. After adjustment for all the other variables in the final model, patients with PCOS had a significantly lower prevalence of fibroids than those with UI (odds ratio 0.54). No differences in the prevalence of non-cavity-distorting fibroids with any dimensions ≥4 cm or the volume of the largest fibroid was found between the two groups. CONCLUSION(S) A lower prevalence of non-cavity-distorting uterine fibroids was found in infertile women with PCOS than in those with UI.
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Affiliation(s)
- Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Hongying Kuang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, People's Republic of China
| | - Fangbai Sun
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Peter R Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Karl R Hansen
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Esther Eisenberg
- Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut.
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22
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Trussell JC, Coward RM, Santoro N, Stetter C, Kunselman A, Diamond MP, Hansen KR, Krawetz SA, Legro RS, Heisenleder D, Smith J, Steiner A, Wild R, Casson P, Coutifaris C, Alvero RR, Robinson RB, Christman G, Patrizio P, Zhang H, Lindgren MC. Association between testosterone, semen parameters, and live birth in men with unexplained infertility in an intrauterine insemination population. Fertil Steril 2019; 111:1129-1134. [PMID: 30982604 DOI: 10.1016/j.fertnstert.2019.01.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/14/2019] [Accepted: 01/24/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine whether men with unexplained infertility and low total T (TT) have abnormal spermatogenesis and lower fecundity. DESIGN Secondary analysis of the prospective, randomized, multicenter clinical trial, Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS). SETTING Infertility clinics. PATIENT(S) Nine hundred couples with unexplained infertility enrolled in AMIGOS. Semen analysis with an ejaculate of at least 5 million total motile sperm was required for enrollment. For inclusion in this secondary analysis, a fasting TT was required. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Logistic regression, adjusted for age and body mass index, assessed the association between low TT (defined as <264 ng/dL), semen parameters, and pregnancy outcome. RESULT(S) Seven hundred eighty-one men (mean age, 34.2 ± 5.7 years) with a median (interquartile range) TT of 411 (318-520) ng/dL were included. Men with TT <264 ng/dL were less likely to have normal (≥4% strict Kruger) morphology (unadjusted odds ratio [OR], 0.56; 95% confidence interval [CI], 0.34, 0.92; adjusted OR, 0.59; 95% CI, 0.35, 0.99). There was no association between low TT and semen volume < 1.5 mL, sperm concentration < 15 × 106/mL, or motility < 40%. Among couples whose male partner had low TT, 21 (18.8%) had a live birth, compared with 184 (27.5%) live births in couples with a male partner having TT > 264 ng/dL. The odds of live birth decreased by 40% in couples whose male partner had low TT (unadjusted OR, 0.60; 95% CI, 0.36, 1.00; adjusted OR, 0.65; 95% CI, 0.38, 1.12). CONCLUSION(S) In couples with unexplained infertility, low TT in the male partner was associated with abnormal sperm morphology and lower live birth rates. CLINICAL TRIAL REGISTRATION NUMBER NCT01044862.
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Affiliation(s)
- J C Trussell
- Department of Urology, Upstate University Hospital, Syracuse, New York.
| | - R Matthew Coward
- Department of Urology, UNC School of Medicine, Chapel Hill, North Carolina; UNC Fertility, Raleigh, North Carolina
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christy Stetter
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Allen Kunselman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Georgia Regents University, Augusta, Georgia
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, Michigan
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Dan Heisenleder
- Ligand Assay and Analysis Core, University of Virginia, Charlottesville, Virginia
| | - James Smith
- Department of Urology, University of California, San Francisco, San Francisco, California
| | - Anne Steiner
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Robert Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Peter Casson
- Partner of Northeastern Reproductive Medicine, Colchester, Vermont
| | - Cristos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Phildelphia, Pennsylvania
| | - Reuben R Alvero
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, Rhode Island
| | - R B Robinson
- University of Texas Health Science Center, San Antonio, San Antonio, Texas
| | - Greg Christman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida
| | | | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Mark C Lindgren
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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23
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Kent J, Dodson WC, Kunselman A, Pauli J, Stone A, Diamond MP, Coutifaris C, Schlaff WD, Alvero R, Casson P, Christman GM, Rosen RM, Hansen KR, Robinson RD, Baker V, Usadi R, Santoro N, Zhang H, Eisenberg E, Legro RS. Gestational Weight Gain in Women With Polycystic Ovary Syndrome: A Controlled Study. J Clin Endocrinol Metab 2018; 103:4315-4323. [PMID: 30085187 PMCID: PMC6194806 DOI: 10.1210/jc.2017-02764] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/27/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Women with polycystic ovary syndrome (PCOS) have increased risk for pregnancy complications, possibly related to pre-existing obesity and excessive gestational weight gain (GWG). OBJECTIVES To assess the contributions of diagnosis and preconception weight on GWG and perinatal outcomes. RESEARCH DESIGN AND METHODS Prospective cohort study of singleton pregnancies in PCOS (n = 164) and ovulatory controls (n = 176) from infertility treatment. MAIN OUTCOME MEASURES GWG, birthweight, pregnancy complications. RESULTS From preconception baseline, normal-weight women with PCOS gained 2.3 pounds more during the first trimester (95% CI, 0.3 to 4.3; P = 0.02), and by the end of the second trimester, 4.2 pounds more than controls (95% CI, 0.7 to 7.7; P = 0.02). Women who were overweight with PCOS gained significantly more weight than did controls by the end of the second trimester (5.2 pounds; 95% CI, 0.2 to 10.2; P = 0.04), whereas women with obesity and PCOS and control women had similar weight gain throughout pregnancy. Within normal-weight, overweight, and obese groups, prevalence of pre-eclampsia and gestational diabetes did not differ between the PCOS and control groups, nor was there a difference in birthweight. Preconception body mass index (BMI) was significantly associated with GWG; for every 1-kg/m2 increase in preconception BMI, GWG decreased by 0.62 pounds (95% CI, -0.85 to -0.40; P < 0.001). CONCLUSIONS Women with PCOS who are of normal weight or are overweight before conception experience more GWG than do ovulatory controls. Within normal-weight, overweight, and obese groups, rates of perinatal complications do not significantly differ between women with PCOS and controls. Preconception BMI is the strongest predictor of GWG.
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Affiliation(s)
- James Kent
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - William C Dodson
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jaimey Pauli
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Alicia Stone
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William D Schlaff
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - R Mitchell Rosen
- Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, California
| | - Karl R Hansen
- Department of Obstetrics and Gynecology University of Oklahoma, Oklahoma City, Oklahoma
| | - Randall D Robinson
- Department of Obstetrics and Gynecology, University of Texas at San Antonio, San Antonio, Texas
| | - Valerie Baker
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Esther Eisenberg
- Infertility and Fertility Branch, National Institute of Child Health and Human Development, Rockville, Maryland
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
- Correspondence and Reprint Requests: Richard S. Legro, MD, Department of Obstetrics and Gynecology, Penn State College of Medicine, M.S. Hershey Medical Center, 500 University Drive, H103, Hershey, Pennsylvania 17033. E-mail:
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Hansen KR, Eisenberg E, Baker V, Hill MJ, Chen S, Talken S, Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Santoro N, Zhang H, Wild RA. Midluteal Progesterone: A Marker of Treatment Outcomes in Couples With Unexplained Infertility. J Clin Endocrinol Metab 2018; 103:2743-2751. [PMID: 29767754 PMCID: PMC6276712 DOI: 10.1210/jc.2018-00642] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Adequate luteal phase progesterone exposure is necessary to induce endometrial changes required for a successful pregnancy outcome. The relationship between low midluteal progesterone concentration and the outcome of live birth in ovarian stimulation with intrauterine insemination (OS-IUI) treatments is not defined. OBJECTIVE To determine the level of midluteal progesterone portending a low chance of live birth after OS-IUI in couples with unexplained infertility. DESIGN AND SETTING Secondary analyses of data from a prospective, randomized, multicenter clinical trial that determined pregnancy outcomes following OS-IUI with clomiphene citrate, letrozole, or gonadotropins for couples with unexplained infertility. PARTICIPANTS Couples (n = 900) underwent 2376 OS-IUI cycles during the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation clinical trial. MAIN OUTCOME MEASURES Live birth as it relates to midluteal progesterone level and thresholds below which no live births occur by treatment group. RESULTS Thresholds for non-live birth cycles were similar for clomiphene (14.4 ng/mL) and letrozole (13.1 ng/mL) yet were lower for gonadotropin (4.3 ng/mL) treatments. A midluteal progesterone level >10th percentile specific for each treatment group independently was associated with greater odds for a live birth in all OS-IUI cycles (adjusted OR: 2.17; 95% CI: 1.05, 4.48). CONCLUSIONS During OS-IUI, a low midluteal progesterone level was associated with a low probability of live birth. Thresholds differed by medication, with the lowest threshold for gonadotropin. Several pathophysiologic mechanisms may account for low progesterone levels. Refinement of the predictive range associated with particular ovarian stimulation medications during treatment of unexplained infertility may improve accuracy.
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Affiliation(s)
- Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Correspondence and Reprint Requests: Karl R. Hansen, MD, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Boulevard, AAT 2444, Oklahoma City, Oklahoma 73104. E-mail:
| | - Esther Eisenberg
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Valerie Baker
- Department of Obstetrics and Gynecology, Stanford University, Sunnyvale, California
| | - Micah J Hill
- Reproductive Endocrinology and Infertility Fellowship, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Sara Talken
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Greenwood EA, Cedars MI, Santoro N, Eisenberg E, Kao CN, Haisenleder DJ, Diamond MP, Huddleston HG. Antimüllerian hormone levels and antral follicle counts are not reduced compared with community controls in patients with rigorously defined unexplained infertility. Fertil Steril 2017; 108:1070-1077. [PMID: 29202959 DOI: 10.1016/j.fertnstert.2017.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 08/11/2017] [Accepted: 09/13/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To test the hypothesis that women with unexplained infertility demonstrate evidence of diminished ovarian reserve when compared with a population of community controls. DESIGN Cross-sectional study. SETTING Multicenter university-based clinical practices. PATIENT(S) Study participants included 277 healthy, normo-ovulatory female partners with rigorously defined unexplained infertility randomly selected from a multicenter trial (Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation). Controls included 226 healthy, normo-ovulatory women not seeking treatment for fertility from a community-based cohort (Ovarian Aging study). INTERVENTION(S) Serum antimüllerian hormone (AMH) assay at a central laboratory, FSH, fasting serum metabolic testing, transvaginal ultrasonography for antral follicle counts (AFCs), anthropometric measurements. MAIN OUTCOME MEASURE(S) Average AMH, AFC, and AMH/AFC were compared between infertile and control women by age. Analyses of covariance compared these outcomes while controlling for confounders, including age, race, body mass index, smoking history, and study site. RESULT(S) In our models, AMH, AFC, and AMH/AFC ovarian reserve indices did not differ between infertile women and community-based controls, after controlling for age, race, body mass index, smoking history, and study site. CONCLUSION(S) Currently utilized predictors of ovarian reserve do not discriminate women with rigorously defined unexplained infertility from healthy community-based women of similar demographic characteristics. Contrary to our hypothesis, among women with FSH in the normal range (≤12 IU/L), women with unexplained infertility did not show evidence of decreased ovarian reserve as measured by AMH and AFC. Ovarian reserve markers in isolation may not serve as predictors of future fertility.
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Affiliation(s)
- Eleni A Greenwood
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California.
| | - Marcelle I Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado
| | - Esther Eisenberg
- Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
| | - Chia-Ning Kao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Daniel J Haisenleder
- Ligand Core Laboratory, University of Virginia Center for Research in Reproduction, Charlottesville, Virginia
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, Georgia
| | - Heather G Huddleston
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California
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Arya S, Kupesic-Plavsic S, Mulla ZD, Dwivedi AK, Crisp Z, Jose J, Noble LS. Ovulation induction and controlled ovarian stimulation using letrozole gonadotropin combination: A single center retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 218:123-128. [PMID: 28985546 DOI: 10.1016/j.ejogrb.2017.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/12/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the effect of letrozole in combination with low dose gonadotropins for ovulation induction in anovulatory infertility from polycystic ovary syndrome (PCOS) and controlled ovarian stimulation for endometriosis, and unexplained infertility patients. STUDY DESIGN Retrospective cohort study in a setting of private Reproductive Endocrinology and Infertility Clinic affiliated with the University. Three hundred couples (650 cycles) requiring OI/COS for PCOS (92 patients, 195 cycles), endometriosis (89 patients, 217 cycles), and unexplained infertility (119 patients, 238 cycles). Patients received 2.5mg or 5mg letrozole for 5days (D3-D7) and recombinant follicle-stimulating hormone on alternating D3-D7 and human menopausal gonadotropin-highly purified alternating D5-D10 until growth of ideally 2 mature follicles. Ovulation was triggered with 10,000 IU of HCG. Maximum number of cycles per patient was four. RESULTS Main outcome measures were clinical pregnancy rates, multiple order pregnancy rates, miscarriage rates, number of follicles and endometrial thickness on the day of HCG administration. The cumulative incidence of pregnancy was estimated as 35% (95%CI: 29%-41%) overall and was highest in patients with PCOS (36.6%), followed by unexplained infertility (34.6%) and endometriosis (32.5%). The pregnancy rates per cycle in PCOS, endometriosis and unexplained infertility patients were 17%, 13.2% and 17.2% respectively, no statistically significant difference between the groups. There were three twin pregnancies in PCOS, and one in unexplained infertility group. Monofolliculogenesis was noted in 48% of patients. CONCLUSION(S) Letrozole-low dose gonadotropins combination appears to be effective across different causes of infertility for superovulation. The letrozole-low dose gonadotropin combination resulted in high rate of monofolliculogenesis, low occurrence of multiple gestations and no case of OHSS or cycle cancellation.
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Affiliation(s)
- Sushila Arya
- Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4801 Alberta Ave, El Paso, TX, 79905, USA.
| | - Sanja Kupesic-Plavsic
- Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA.
| | - Zuber D Mulla
- Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA.
| | - Alok K Dwivedi
- Department of Biomedical Sciences, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA.
| | - Zeni Crisp
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA
| | - Jisha Jose
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX, 79905, USA
| | - Luis S Noble
- Reproductive Endocrinology and Infertility, Southwest Center for Reproductive Health, 700 S Mesa Hills Dr., El Paso, TX, 79912, USA.
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Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson PA, Christman GM, Huang H, Hansen KR, Baker V, Usadi R, Seungdamrong A, Bates GW, Rosen RM, Schlaff W, Haisenleder D, Krawetz SA, Barnhart K, Trussell J, Santoro N, Eisenberg E, Zhang H. Sexual function in infertile women with polycystic ovary syndrome and unexplained infertility. Am J Obstet Gynecol 2017; 217:191.e1-191.e19. [PMID: 28455078 DOI: 10.1016/j.ajog.2017.04.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/16/2017] [Accepted: 04/17/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed. OBJECTIVE The objective of the study was to determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility. STUDY DESIGN A secondary data analysis was performed on 2 of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials: Pregnancy in Polycystic Ovary Syndrome Study II and Assessment of Multiple Intrauterine Gestations From Ovarian Stimulation. Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale. RESULTS Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each P < .001), greater phenotypic (Ferriman-Gallwey hirsutism score, sebum score, and acne score; each P < .001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each P < .001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory, were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility. CONCLUSION Reproductive-age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function.
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Styer AK, Jin S, Liu D, Wang B, Polotsky AJ, Christianson MS, Vitek W, Engmann L, Hansen K, Wild R, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Christy A, Diamond MP, Eisenberg E, Zhang H, Santoro N. Association of uterine fibroids and pregnancy outcomes after ovarian stimulation-intrauterine insemination for unexplained infertility. Fertil Steril 2017; 107:756-762.e3. [PMID: 28089575 PMCID: PMC5472203 DOI: 10.1016/j.fertnstert.2016.12.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/04/2016] [Accepted: 12/12/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the association of non-cavity-distorting uterine fibroids and pregnancy outcomes after ovarian stimulation-intrauterine insemination (OS-IUI) in couples with unexplained infertility. DESIGN Secondary analysis from a prospective, randomized, multicenter clinical trial investigating fertility outcomes after OS-IUI. SETTING Reproductive Medicine Network clinical sites. PATIENT(S) Nine hundred couples with unexplained infertility who participated in the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. INTERVENTION(S) Participants were randomized to one of three arms (clomiphene citrate, letrozole, or gonadotropins), and treatment was continued for up to four cycles or until pregnancy was achieved. MAIN OUTCOMES MEASURE(S) Conception (serum hCG increase), clinical pregnancy (fetal cardiac activity), and live birth rates. RESULT(S) A total of 102/900 participants (11.3%) had at least one documented fibroid and a normal uterine cavity. Women with fibroids were older, more likely to be African American, had a greater uterine volume, lower serum antimüllerian hormone levels, and fewer antral follicles than women without fibroids. In conception cycles, clinical pregnancy rates were significantly lower in participants with fibroids than in those without uterine fibroids. Pregnancy loss before 12 weeks was more likely in African American women with fibroids compared with non-African American women with fibroids. There was no difference in conception and live birth rates in subjects with and without fibroids. CONCLUSION(S) No differences were observed in conception and live birth rates in women with non-cavity-distorting fibroids and those without fibroids. These findings provide reassurance that pregnancy success is not impacted in couples with non-cavity-distorting fibroids undergoing OS-IUI for unexplained infertility. CLINICAL TRIAL REGISTRATION NUMBER NCT01044862.
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Affiliation(s)
- Aaron K Styer
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.
| | - Susan Jin
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Dan Liu
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Baisong Wang
- Shanghai, Jiao Tong University, Shanghai, People's Republic of China
| | - Alex J Polotsky
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
| | - Mindy S Christianson
- Department of Obstetrics and Gynecology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wendy Vitek
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, New York
| | - Lawrence Engmann
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut
| | - Karl Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Robert Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, Shands Hospital, University of Florida, Gainesville, Florida
| | - Alicia Christy
- Division of Women's Reproductive Health, US Department of Veteran's Affairs, Washington, DC
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Esther Eisenberg
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
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Jo J, Kim TH, Hyun MK, Kim H, Kim DI. Traditional Korean medicine for female infertility: A review of results from infertility support programs in Korea. Eur J Integr Med 2016. [DOI: 10.1016/j.eujim.2016.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Santoro N, Eisenberg E, Trussell JC, Craig LB, Gracia C, Huang H, Alvero R, Casson P, Christman G, Coutifaris C, Diamond M, Jin S, Legro RS, Robinson RD, Schlaff WD, Zhang H. Fertility-related quality of life from two RCT cohorts with infertility: unexplained infertility and polycystic ovary syndrome. Hum Reprod 2016; 31:2268-79. [PMID: 27402910 PMCID: PMC5027926 DOI: 10.1093/humrep/dew175] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 06/16/2016] [Indexed: 01/05/2023] Open
Abstract
STUDY QUESTION Does fertility-related quality of life (FertiQOL) differ by infertility diagnosis between women with polycystic ovary syndrome (PCOS) and their partners, compared with couples with unexplained infertility (UI)? SUMMARY ANSWER Women with PCOS report lower QOL than those with UI, whereas males with UI report lower QOL than males with PCOS partners. WHAT IS KNOWN ALREADY The fertility-specific QOL survey, FertiQOL, has been used to examine fertility-related QOL in a number of worldwide cohorts. Few data have addressed fertility-related QOL as a function of infertility diagnosis. Overall, men report better QOL than women with infertility, and there is variation in FertiQOL scores across different samples from different countries. STUDY DESIGN, SIZE, DURATION This was a prospective, cohort study derived from two concurrent, randomized clinical trials, and designed to examine QOL in infertile females with PCOS and UI at the time of enrollment compared with each other and their male partners; to compare concordance FertiQOL scores in this study across other worldwide cohorts; and to determine if baseline FertiQOL was associated with pregnancy outcome. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with PCOS and their partners (n = 733 and n = 641, respectively), and couples with UI (n = 865 women and 849 men) completed a validated fertility-specific QOL survey (FertiQOL) at the time of the study screening visit. PCOS women were randomized to either clomiphene citrate or letrozole treatment; couples with UI were randomized to clomiphene citrate, letrozole or gonadotrophin plus IUI. FertiQOL results were compiled by diagnosis (PCOS or UI) and compared by diagnosis and sex using Wilcoxon Rank-Sum testing. Relationships between baseline FertiQOL and pregnancy outcomes were examined using logistic regression. Multivariable models were performed to assess the association between FertiQOL scores and key participant characteristics. MAIN RESULTS AND THE ROLE OF CHANCE Women with PCOS had lower total FertiQOL scores (72.3 ± 14.8) than those with UI (77.1 ± 12.8; P < 0.001); this was true for each domain (except Relational). These differences were largely explained by variation in BMI, hirsutism, household income and age. Women had lower overall FertiQOL scores than their male partners. Males with PCOS partners had higher scores than males with UI (84.9 ± 10.2 versus 83.3 ± 10.8; P = 0.003). Scores were not consistently associated with conception or pregnancy outcome. LIMITATIONS, REASONS FOR CAUTION The use of multiple tests of association may have resulted in spurious statistically significant findings. Inherent sociodemographic differences between women with PCOS and those with UI largely account for the lower QOL in women with PCOS. Our study was unable to assess if changes in QOL affected pregnancy outcome as FertiQOL data were collected prior to treatment. Finally, the participants for both studies represent their local communities, but are not a population-based sample and thus firm conclusions about how representative these couples are to the general population must be made with caution. WIDER IMPLICATIONS OF THE FINDINGS Women with PCOS with elevated BMI and hirsutism scores and with lower socioeconomic status may require more, targeted psychosocial support than those with other diagnoses. Possible attribution of infertility to the male partner appears to result in a lower QOL. There appears to be substantial national variation in FertiQOL scores, with US-based cohorts reporting overall higher QOL. STUDY FUNDING/COMPETING INTERESTS This work was supported by National Institutes of Health (NIH)/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Grants U10 HD39005 (to M.D.), U10 HD38992 (to R.S.L.), (to C.C.), U10 HD38998 (to R.A.), U10 HD055942 (to R.D.R.), HD055944 (to P.C.), U10 HD055936 (to G.C.), U10HD055925 (to H.Z.); and U10 U54-HD29834 (to the University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core of the Specialized Cooperative Centers Program in Reproduction and Infertility Research). Most importantly, this research was made possible by the funding by American Recovery and Reinvestment Act. N.S., E.E., J.C.T., C.G., H.H., R.A., P.C., G.C., C.C., M.D., S.J., W.D.S. and H.Z. report no conflicts of interests/disclosures. L.B.C. reports research support from Ferring Pharmaceuticals and Roche Diagnostics; R.S.L. reports receipt of consulting fees from AstraZeneca, Euroscreen, Sprout Pharmaceuticals, Taken, Kindex, Clarus and Bayer, Inc., and research support from AstraZeneca and Ferring Pharmaceuticals. R.D.R. reports research support from AbbVie. TRIAL REGISTRATION NUMBER Pregnancy in Polycystic Ovary Syndrome II (PPCOS II), NCT00719186; Assessment of Multiple Intrauterine Gestations in Ovulation Stimulation (AMIGOS) NCT01044862, clinicaltrials.gov. TRIAL REGISTRATION DATE PPCOS II 17 July 2008; AMIGOS 7 January 2010. DATE OF FIRST PATIENT'S ENROLMENT PPCOS II 19 February 2009; AMIGOS 2 August 2010.
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Affiliation(s)
- Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, 12631 E 17th Avenue AO1 Room 4010, Aurora, CO 80045, USA
| | - Esther Eisenberg
- Fertility & Infertility Branch, NICHD, NIH, Bethesda, MD 20892, USA
| | - J C Trussell
- Department of Urology, State University of New York Upstate Medical University, 750 E Adams St, Syracuse, NY 13210, USA
| | - LaTasha B Craig
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, PO Box 26901, WP 2410 Oklahoma City, OK 73126, USA
| | - Clarisa Gracia
- Department of Obstetrics and Gynecology, University of Pennsylvania Penn Fertility Center, 3701 Market Street, Philadelphia, PA 19104, USA
| | - Hao Huang
- Collaborative Center for Statistics in Science, Yale School of Public Health, 60 College Street, New Haven, CT 06520-8034, USA
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, 12631 E 17th Avenue AO1 Room 4010, Aurora, CO 80045, USA Present address: Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - Peter Casson
- Present address: Northeastern Reproductive Medicine, 105 West View Rd. Suite 305, Colchester, VT 05446, USA
| | - Gregory Christman
- Present address: Department of Obstetrics and Gynecology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32611-0294, USA
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania Penn Fertility Center, 3701 Market Street, Philadelphia, PA 19104, USA
| | - Michael Diamond
- Present address: Georgia Regents University/Medical College of Georgia, 1120 15th Street, BA-7300, Augusta, GA 30912-3300, USA
| | - Susan Jin
- Collaborative Center for Statistics in Science, Yale School of Public Health, 60 College Street, New Haven, CT 06520-8034, USA
| | - Richard S Legro
- Penn State College of Medicine, 500 University Drive, Hersey, PA 17033, USA
| | - Randal D Robinson
- University of Texas at San Antonio Health Sciences Center, 8300 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - William D Schlaff
- Present address: Department of Obstetrics and Gynecology, Thomas Jefferson University, 834 Chestnut Street, Suite 400, Philadelphia, PA 19107, USA
| | - Heping Zhang
- Collaborative Center for Statistics in Science, Yale School of Public Health, 60 College Street, New Haven, CT 06520-8034, USA
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Hansen KR, He ALW, Styer AK, Wild RA, Butts S, Engmann L, Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Huang H, Santoro N, Eisenberg E, Zhang H. Predictors of pregnancy and live-birth in couples with unexplained infertility after ovarian stimulation-intrauterine insemination. Fertil Steril 2016; 105:1575-1583.e2. [PMID: 26949110 DOI: 10.1016/j.fertnstert.2016.02.020] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 02/11/2016] [Accepted: 02/11/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify baseline characteristics of couples that are likely to predict conception, clinical pregnancy, and live birth after up to four cycles of ovarian stimulation with IUI in couples with unexplained infertility. DESIGN Secondary analyses of data from a prospective, randomized, multicenter clinical trial investigating pregnancy, live birth, and multiple pregnancy rates after ovarian stimulation-IUI with clomiphene citrate, letrozole, or gonadotropins. SETTING Outpatient clinical units. PATIENT(S) Nine-hundred couples with unexplained infertility who participated in the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation clinical trial. INTERVENTION(S) As part of the clinical trial, treatment was randomized equally to one of three arms and continued for up to four cycles or until pregnancy was achieved. MAIN OUTCOME MEASURE(S) Conception, clinical pregnancy, and live-birth rates. RESULT(S) In a multivariable logistic regression analysis, after adjustment for other covariates, age, waist circumference, income level, duration of infertility, and a history of prior pregnancy loss were significantly associated with at least one pregnancy outcome. Other baseline demographic and lifestyle characteristics including smoking, alcohol use, and serum levels of antimüllerian hormone were not significantly associated with pregnancy outcomes. CONCLUSION(S) While age and duration of infertility were significant predictors of all pregnancy outcomes, many other baseline characteristics were not. The identification of level of income as a significant predictor of outcomes independent of race and education may reflect differences in the underlying etiologies of unexplained infertility or could reveal disparities in access to fertility and/or obstetrical care. CLINICAL TRIAL REGISTRATION NCT01044862.
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Affiliation(s)
- Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Amy Linnea W He
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Aaron K Styer
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Samantha Butts
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lawrence Engmann
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Georgia Regents University, Augusta, Georgia
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, Shands Hospital, University of Florida, Gainesville, Florida
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
| | - Esther Eisenberg
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
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Gunn DD, Bates GW. Evidence-based approach to unexplained infertility: a systematic review. Fertil Steril 2016; 105:1566-1574.e1. [PMID: 26902860 DOI: 10.1016/j.fertnstert.2016.02.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To summarize the available evidence for the efficacy of various treatments for unexplained infertility. DESIGN Systematic review. SETTING Not applicable. PATIENT(S) Patients aged 18-40 years with unexplained infertility. INTERVENTION(S) Clomiphene citrate, letrozole, timed intercourse, IUI, gonadotropins, IVF, and IVF-intracytoplasmic sperm injection. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate, ongoing pregnancy rate, and live birth rate. RESULT(S) Thirteen studies with a total of 3,081 patients were identified by systematic search and met inclusion criteria. The available literature demonstrates that expectant management may be comparable to treatment with clomiphene and timed intercourse or IUI. Clomiphene may be more effective than letrozole, and treatment with gonadotropins seems more effective, albeit with significantly higher risk of multiple gestations than either oral agent. On the basis of current data, IVF, with or without intracytoplasmic sperm injection, is no more effective than gonadotropins with IUI for unexplained infertility. CONCLUSION(S) Adequately powered, randomized controlled trials that compare all of the available treatments for unexplained infertility are needed. Until such data are available, clinicians should individualize the management of unexplained infertility with appropriate counseling regarding the empiric nature of current treatment options including IVF.
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Affiliation(s)
- Deidre D Gunn
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Alabama-Birmingham, Birmingham, Alabama.
| | - G Wright Bates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Alabama-Birmingham, Birmingham, Alabama
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Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Ager J, Huang H, Hansen KR, Baker V, Usadi R, Seungdamrong A, Bates GW, Rosen RM, Haisenleder D, Krawetz SA, Barnhart K, Trussell JC, Ohl D, Jin Y, Santoro N, Eisenberg E, Zhang H. Letrozole, Gonadotropin, or Clomiphene for Unexplained Infertility. N Engl J Med 2015; 373:1230-40. [PMID: 26398071 PMCID: PMC4739644 DOI: 10.1056/nejmoa1414827] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The standard therapy for women with unexplained infertility is gonadotropin or clomiphene citrate. Ovarian stimulation with letrozole has been proposed to reduce multiple gestations while maintaining live birth rates. METHODS We enrolled couples with unexplained infertility in a multicenter, randomized trial. Ovulatory women 18 to 40 years of age with at least one patent fallopian tube were randomly assigned to ovarian stimulation (up to four cycles) with gonadotropin (301 women), clomiphene (300), or letrozole (299). The primary outcome was the rate of multiple gestations among women with clinical pregnancies. RESULTS After treatment with gonadotropin, clomiphene, or letrozole, clinical pregnancies occurred in 35.5%, 28.3%, and 22.4% of cycles, and live birth in 32.2%, 23.3%, and 18.7%, respectively; pregnancy rates with letrozole were significantly lower than the rates with standard therapy (gonadotropin or clomiphene) (P=0.003) or gonadotropin alone (P<0.001) but not with clomiphene alone (P=0.10). Among ongoing pregnancies with fetal heart activity, the multiple gestation rate with letrozole (9 of 67 pregnancies, 13%) did not differ significantly from the rate with gonadotropin or clomiphene (42 of 192, 22%; P=0.15) or clomiphene alone (8 of 85, 9%; P=0.44) but was lower than the rate with gonadotropin alone (34 of 107, 32%; P=0.006). All multiple gestations in the clomiphene and letrozole groups were twins, whereas gonadotropin treatment resulted in 24 twin and 10 triplet gestations. There were no significant differences among groups in the frequencies of congenital anomalies or major fetal and neonatal complications. CONCLUSIONS In women with unexplained infertility, ovarian stimulation with letrozole resulted in a significantly lower frequency of multiple gestation but also a lower frequency of live birth, as compared with gonadotropin but not as compared with clomiphene. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01044862.).
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Affiliation(s)
- Michael P Diamond
- From the Department of Obstetrics and Gynecology, Georgia Regents University, Augusta (M.P.D.); Department of Obstetrics and Gynecology, Wayne State University, Detroit (M.P.D., J.A., S.A.K.); Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey (R.S.L.); Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia (C.C., K.B.); Department of Obstetrics and Gynecology, University of Colorado, Denver (R.A., N.S.); Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio (R.D.R.); Department of Obstetrics and Gynecology, University of Vermont, Burlington (P.C.); Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor (G.M.C., D.O.); Department of Biostatistics, Yale University School of Public Health, New Haven, CT (H.H., Y.J., H.Z.); Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City (K.R.H.); Stanford University Medical Center, Stanford, CA (V.B.); Carolinas Medical Center, Charlotte, NC (R.U.); University of Medicine and Dentistry of New Jersey, Newark (A.S.); University of Alabama at Birmingham, Birmingham (G.W.B.); Department of Reproductive Endocrinology and Infertility, University of California, San Francisco, San Francisco (R.M.R.); Ligand Core Laboratory, University of Virginia Center for Research in Reproduction, Charlottesville (D.H.); Upstate University Hospital, Syracuse, NY (J.C.T.); and Fertility and Infertility Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD (E.E.)
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Legro RS. In defense of publishing baseline data from clinical trials. Fertil Steril 2015; 103:902-3. [PMID: 25712574 DOI: 10.1016/j.fertnstert.2015.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 01/26/2015] [Indexed: 10/24/2022]
Affiliation(s)
- Richard S Legro
- Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
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