Correlation between thrombophilia and recurrent pregnancy loss in patients with polycystic ovary syndrome: a comparative study

Advances in the study of the correlation between insulin resistance and infertility

This is a narrative review of the progress of research on the correlation between insulin resistance and infertility. Insulin resistance (IR) is not only involved in the development of various metabolic diseases, but also affects female reproductive function, and to some extent is closely related to female infertility. IR may increase the risk of female infertility by activating oxidative stress, interfering with energy metabolism, affecting oocyte development, embryo quality and endometrial tolerance, affecting hormone secretion and embryo implantation, as well as affecting assisted conception outcomes in infertile populations and reducing the success rate of assisted reproductive technology treatment in infertile populations. In addition, IR is closely associated with spontaneous abortion, gestational diabetes and other adverse pregnancies, and if not corrected in time, may increase the risk of obesity and metabolic diseases in the offspring in the long term. This article provides a review of the relationship between IR and infertility to provide new ideas for the treatment of infertility.

Polycystic ovary syndrome and recurrent pregnancy loss, a review of literature

Objective

PCOS is a syndrome of ovarian dysfunction associated with recurrent pregnancy loss. Several correlating factors have been investigated that influence the risk of pregnancy loss in PCOS. However, uncertainty remains about their contribution to pregnancy loss and prognosis. This review of literature aims to identify what is known and what requires further investigation on the relationship between PCOS and recurrent pregnancy loss, to guide future research and optimize medical guidance throughout pregnancy.

Study design

a review of literature was performed on several search engines using the following terms; polycystic ovarian syndrome, PCOS, recurrent pregnancy loss, recurrent miscarriage, RPL, aborted fetus, abortus provocatus, miscarriage and habitual abortion.

Results

37 articles were included; 3 systematic reviews, 1 meta-analysis, 2 randomized controlled trials, 6 prospective cohort studies, 22 case-control studies and 3 case series. The main objectives investigated by studies were pregnancy complications, pregnancy loss and live birth in the PCOS population.

Conclusion

Studies that investigated the relationship between PCOS and recurrent pregnancy loss are few and inconsistent and warrant further research. Factors apt for further investigation include the extent to which PCOS phenotypes, BMI, obesity, insulin resistance, hyperandrogenemia, SHBG, hs-CRP, CTRP6, adiponectin, plasma leptin, homocysteine, AMH and thrombophilia contribute to further risk of miscarriage. Other factors requiring further exploration in relation to risk for miscarriage in PCOS patient with RPL include sOB-R, PAI-Fx and the Factor-V-Leiden mutations.

Thrombophilic gene polymorphisms and recurrent pregnancy loss: a systematic review and meta-analysis

PURPOSE

Recurrent pregnancy loss (RPL) is affecting 1-4% of women who conceive approximately, and no cause could be found in more than 50% of women suffering from RPL. Inherited thrombophilias have got increasing attention in women with unexplained RPL, so we aim to explore the relationship among these most common thrombophilic polymorphisms and RPL through a literature review and meta-analysis.

METHODS

Observational studies from PubMed, Embase, Cochrane, and Web of Science from 1997 to 7 April 2022 were searched. For each genetic variant, a fixed or random-effect model was used according to the heterogeneity test to calculate pooled ORs and 95% CIs for both dominant and recessive genetic models. Egger's line regression test was used to assess publication bias. The quality of the included articles was assessed by the Newcastle Ottawa scale.

RESULTS

A total of 124 articles comprising 17,278 RPL patients and 16,021 controls were included. Results showed that hyperhomocysteinemia (MTHFR) C677T (dominant model: OR, 1.43; 95% CI, 1.25-1.64; recessive model: OR, 1.60; 95% CI, 1.36-1.87), MTHFR A1298C (dominant model: OR, 1.66; 95% CI, 1.26-2.18; recessive model: OR, 1.79; 95% CI, 1.42-2.26), PAI-1 4G/5G (dominant model: OR, 1.67; 95% CI, 1.36-2.06; recessive model: OR, 1.80; 95% CI, 1.39-2.32), angiotensin-converting enzyme I/D (OR, 1.23; 95% CI, 1.00-1.53), Factor XIII V34L (OR, 1.38; 95% CI, 1.02-1.87), and β-fibrinogen-455G/A (OR, 1.60; 95% CI, 1.02-2.51) were significantly associated with RPL.

CONCLUSION

This study provides potentially useful clinical markers to evaluate the risk of RPL or to help unexplained RPL patients identify possible causes, which may allow for targeted treatment.

Clinical Research into Treating Unexplained Recurrent Spontaneous Abortion during Early Pregnancy with the Qing Yi Tiao Mian Formula

OBJECTIVE

The present study aims to analyze the clinical effect of the Qing Yi Tiao Mian (QYTM) formula on unexplained recurrent spontaneous abortion (URSA) during early pregnancy and the immune balance of T lymphocytes.

METHODS

With their consent, 45 patients with URSA in weeks 4-9 of pregnancy were separated into three groups, i.e., the conventional fetal protection (n = 15), prednisone treatment (n = 10), and QYTM formula treatment (n = 20) groups. These patients received treatment once they had been diagnosed with an intrauterine pregnancy. The conventional fetal protection group was given progesterone (20 ∼ 40 mg daily injection) for four weeks. The prednisone treatment group was given progesterone (20 ∼ 40 mg daily injection) + prednisone (5 mg/d) for four weeks. The QYTM formula treatment group was given progesterone (20 ∼ 40 mg daily injection) + QYTM formula (one dose per day) for four weeks. In addition, women who had previously had a normal pregnancy were enrolled as a control group (n = 18). The success rate of the pregnancy in the first trimester was observed in each group, and the proportion of T lymphocytes in the peripheral blood before and after treatment was recorded.

RESULTS

Among the 20 patients with URSA in the QYTM formula treatment group, 19 remained pregnant. Thus, the success rate during early pregnancy was 95%, which was significantly higher than the conventional fetal protection (53.33%) and prednisone treatment (70%) groups. The CD8+ T and natural killer (NK) cells population in the URSA groups was higher compared with the control group (P < 0.01). The QYTM formula treatment significantly decreased the ratio of CD8+ T lymphocytes (P < 0.01) and NK cells (P < 0.01).

CONCLUSION

The QYTM formula significantly decreased the spontaneous abortion rate in patients with URSA during early pregnancy. The mechanism may be closely related to the inhibition of the killer lymphocytes' proliferation by CD8+ T lymphocytes and NK cells.

Insulin resistance in women with recurrent miscarriage: a systematic review and meta-analysis

PURPOSE

This review aimed to investigate the association of insulin resistance (IR) in women with recurrent pregnancy loss compared to women with normal pregnancy history.

METHODS

PubMed, EMBASE, the Web of Science and Google Scholar databases were accessed to collect published observational studies that compared IR of recurrent pregnancy loss women with healthy women until the 6^th of October 2022. Outcomes assessed in this review and meta-analysis included fasting blood glucose, fasting plasma insulin, homeostasis model assessment for IR, glucose to insulin ratio. Mean differences, odds ratios with 95% confidence interval were pooled using the fixed or random effect models. Sensitivity analyses were performed to validate the robustness of the results. Review Manager version 5.4.1 and Stata version 8.0 were used.

RESULTS

A total of nineteen studies involving 4453 individuals were included. Recurrent pregnancy loss patients presented significantly higher fasting blood glucose, fasting plasma insulin, homeostasis model assessment for IR, and lower glucose to insulin ratios. Additionally, recurrent pregnancy loss patients had higher rates of IR as defined by abnormal fasting plasma insulin, homeostasis model assessment for IR, and glucose to insulin ratio. Sensitivity analyses validated the robustness of the results.

CONCLUSION

In the current review, we show that recurrent pregnancy loss is associated with a higher degree of IR and highlight the importance of screening and treatment of IR.

Effect of weight loss on pregnancy outcomes, neuronal-reproductive-metabolic hormones and gene expression profiles in granulosa cells in obese infertile PCOS patients undergoing IVF-ET

OBJECTIVE

To investigate the effect of weight loss on pregnancy outcomes, PCOS related neuronal-reproductive-metabolic hormones and ovarian granulosa cell gene expression profiles in obese PCOS infertile patients undergoing in vitro fertilization-embryo transfer (IVF-ET).

METHODS

75 patients undergoing IVF-ET due to tubal factors alone collected as the control group (group A), and 352 patients with obese PCOS infertility were divided into four groups according to the amount of weight loss before IVF: 0 kg (group B), 1-5 kg (group C), 5-10 kg (group D), and >10 kg (group E). Six cases of ovarian granulosa cells were collected randomly with the random number table method in each group for detecting mRNA profiling. Pathway networks and biological functions of the differentially expressed genes were analyzed. Validation by RT-PCR was performed.

RESULTS

(1) The levels of luteinizing hormone(LH), testosterone(T) and homeostasis model assessment insulin resistance(HOMA-IR) in group E were significantly lower than those in groups B and C (P<0.05). (2) Compared with groups A and E, groups B and C showed increased total gonadotropin (Gn) and days of Gn stimulation (P<0.05), and the E₂ level on trigger day and number of oocytes obtained in group B was significantly less than that in group E (P<0.05 or 0.01). Embryo implantation rate, clinical pregnancy rate and live birth rate were increased and miscarriage rate was decreased in groups A, D and E compared with group B (P<0.05 or 0.01). (3) There were significant differences among the control group and PCOS groups in some genes that are involved in neuronal-reproductive-metabolic endocrine, transcriptional regulation, cell proliferation and differentiation, etc (P<0.05). RNA-Seq results were validated by real time PCR analysis for the expression of follicle stimulating hormone receptor (FSHR), drosophila mothers against decapentaplegic protein 7(Smad7) and glutathione peroxidase 3(GPX3) genes that are known to have an important role in follicular development. Functional alterations were confirmed by the improvement in the ovarian responsiveness to Gn and embryo quality.

CONCLUSION

Weight loss more than 5kg may regulate the neuroreproductive endocrine hormone secretion, insulin resistance and gene expression profiles of ovarian granulosa cells, so as to improve the ovarian responsiveness to Gn, the embryo quality, embryo implantation rate, clinical pregnancy rate, live birth rate, and reduce the spontaneous abortion rate in obese infertile PCOS patients undergoing IVF-ET.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier ChiCTR1800018298.

Potential environmental toxicant exposure, metabolizing gene variants and risk of PCOS-A systematic review

Exposure of environmental toxicants such as potentially toxic metals and pesticides have largely been attributed to produce adverse effects on general women's health and to be more precise on the reproductive system. In order to explore exposure of toxicants and metabolizing gene variants as risk factor for polycystic ovarian syndrome (PCOS), literature search was carried out using the databases PubMed, Central Cochrane Library, Google Scholar, Science Direct with appropriate keywords upto 6 December 2020. While most of the studies indicate higher serum Cu concentration and lower concentration of Mn as risk factor, studies also report presence of higher pesticide concentration in PCOS women. Genes such as MTHFR, CYPs participate in the metabolism of toxicants and may show different response due to underlying genetic variants. Thus, toxicant exposure are to some extent responsible for the pathogenesis of syndrome through oxidative stress and endocrine disruption, but the susceptibility may vary due to the underlying genetic polymorphism of the exposed population.

The correlation of estrogen receptor 1 and progesterone receptor genes polymorphisms with recurrent pregnancy loss in a cohort of Egyptian women

Recurrent pregnancy loss (RPL) represents one of the pregnancy complications affecting 1-3% of women. Sex hormones, progesterone and estrogen play a critical role in the maintenance of pregnancy; they are mediated by estrogen receptor 1 (ESR1) and progesterone receptor (PR) genes respectively. Polymorphisms of (ESR1) and (PR) genes are linked to RPL. We aimed to explore the association of single nucleotide polymorphisms (SNPs) of (ESR1) gene and (PR) gene with RPL in a cohort of Egyptian population (50 infertile Egyptian women who experienced RPL and 50 healthy women), using polymerase chain reaction-restriction fragment length polymorphism analysis (PCR-RFLP) of (ESR1) gene and DNA sequencing of exons 1 and 5 of (PR) gene. Genotyping of ESR1 gene SNP's: (rs2234693) and (rs9340799) revealed higher significance in cases compared to controls of p value (p = 0.006 and p = 0.001) respectively. However, the frequencies of the two variants in (PG) gene; S344T (rs3740753) (p = 0.0001) and H770H (rs1042839) (p = 0.001) were significantly higher in women compared to the healthy control women. New polymorphism P352Q was observed in 2% of cases (p = 0.0001). There was a significant association of SNP's of ESR1 and PR genes with recurrent pregnancy loss RPL. Further demographics studies should be carried on a larger number of women at risk of recurrent implantation to elucidate this SNP's association and its role in RPL women.

Hereditary thrombophilia and recurrent pregnancy loss: a systematic review and meta-analysis

STUDY QUESTION

Is there an association between hereditary thrombophilia in pregnant women and risk of recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

Pregnant women with hereditary thrombophilia have an increased risk of RPL, especially for pregnant women with the G1691A mutation of the factor V Leiden (FVL) gene, the G20210A mutation of the prothrombin gene (PGM), and deficiency of protein S (PS).

WHAT IS KNOWN ALREADY

Prior studies have suggested that pregnant women with hereditary thrombophilia have a higher risk of RPL, however, the results are inconsistent; furthermore, a complete overview is missing. This lack of information is an obstacle to the risk assessment of RPL in pregnant women with hereditary thrombophilia. A comprehensive meta-analysis on the relation between hereditary thrombophilia and the risk of RPL is needed.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis was performed using observational studies published in English before 1 April 2020 to evaluate the relation between hereditary thrombophilia and risk of RPL.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Relevant studies were identified from PubMed, Web of Science, and EMBASE searches and complemented with perusal of bibliographies of retrieved articles. The exposure of interest was hereditary thrombophilia, including FVL mutation, PGM, deficiency of antithrombin (AT), deficiency of protein C (PC), and deficiency of PS. The overall risk estimates were pooled using random effects models. Subgroup and sensitivity analyses were carried out to explore possible sources of heterogeneity and assess the robustness of the results.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 89 studies involving 30 254 individuals were included. Results showed that women with FVL mutation (odds ratio (OR): 2.44, 95% CI: 1.96-3.03), PGM (OR: 2.08, 95% CI: 1.61-2.68), or deficiency of PS (OR: 3.45, 95% CI: 1.15-10.35) had higher risks of developing RPL. Compared with the reference group, there was no observed relation between a deficiency in AT or PC and RPL (all P > 0.05). Heterogeneity in the risk estimates of RPL was partially explained by geographic region, definitions of RPL, types of RPL, and controlled confounders. Sensitivity analyses validated the robustness of the findings.

LIMITATIONS, REASONS FOR CAUTION

Only 39 of the included studies controlled for one or more confounders, and the heterogeneity across all included studies was high. Based on the data available, we cannot determine whether this association is confounded by other potential risk factors of RPL.

WIDER IMPLICATIONS OF THE FINDINGS

This systematic review and meta-analysis show a possible association between hereditary thrombophilia and an increased risk of RPL, suggesting that testing for hereditary thrombophilia should be considered in individuals with RPL.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Hunan Provincial Key Research and Development Program (Grant number: 2018SK2062) and National Natural Science Foundation Program (Grant number: 81973137). There are no conflicts of interest.

REGISTRATION NUMBER

N/A.

The effect of metformin on homocysteine levels in patients with polycystic ovary syndrome: A systematic review and meta-analysis

PURPOSE

Metformin is widely used as an insulin sensitizer in polycystic ovary syndrome (PCOS) patients. However, previous studies have found that the effect of metformin on the level of homocysteine were not consistent in PCOS patients. The aim of this review was to analyze the effect of metformin on homocysteine levels in patients with PCOS patients.

METHODS

The Cochrane Library, Pubmed, and Web of Science were searched according to predefined search terms. There is no restriction for publication time and language.

RESULTS

Eleven studies were included and the data were extracted. The homocysteine level in PCOS patients was significantly increased after taking metformin (mean difference [MD] -1.33; 95% confidence interval [CI] -2.16 to -0.49, p = 0.002). Subgroup analysis showed that the level of homocysteine was generally increased in PCOS patients with body mass index (BMI) ≥25 after taking metformin alone (MD -1.82; 95% CI -2.56 to -1.07, p < 0.00001). There was no significant change in homocysteine level in PCOS patients with BMI <25 (MD 0.69; 95% CI -0.41 to 1.79, p = 0.22). Subgroup analysis showed that there was no significant difference when taking metformin >3 months or taking metformin ≤3 months (p = 0.84). Taking metformin ≥1700 mg/days significantly increased homocysteine levels in PCOS patients (MD -2.05; 95% CI -2.40 to -1.70, p < 0.00001). When taking metformin <1700 mg/days, there was no significant difference in homocysteine level in PCOS patients (MD 0.15; 95% CI -1.06 to 1.37, p = 0.80). The difference between the two subgroups was significant (p = 0.0006). There was no significant difference in vitamin B12 level before and after metformin treatment (MD 24.70; 95% CI -22.54 to 71.93, p = 0.31). There was a decrease in serum folic acid level after metformin administration (MD 1.03; 95% CI 0.80 to 1.26, p < 0.00001).

CONCLUSION

Taking metformin alone increased homocysteine levels and decreased folic acid levels in nonpregnant PCOS patients. And, it was suggested that the dosage of metformin should be less than 1700 mg/days. The supplement of folic acid and B vitamins during metformin administration may be essential in nonpregnant PCOS patients. We should pay much attention to the potential effect of metformin in PCOS patients.

Introduction of Female Reproductive Processes and Reproductive Diseases

The female reproductive process is very complicated, including multiple processes. Each process is different and plays a vital role in reproduction. If some reproductive diseases occur, these processes will be abnormal, causing infertility problem. In this Chapter, we will describe the female reproductive process and their corresponding reproductive diseases.

Polycystic Ovary Syndrome: A Brain Disorder Characterized by Eating Problems Originating during Puberty and Adolescence

Polycystic ovary syndrome (PCOS) is an endocrine condition associated with reproductive and psychiatric disorders, and with obesity. Eating disorders, such as bulimia and recurrent dieting, are also linked to PCOS. They can lead to the epigenetic dysregulation of the hypothalamic-pituitary-gonadal (HPG) axis, thereby impacting on ovarian folliculogenesis. We postulate that PCOS is induced by psychological distress and episodes of overeating and/or dieting during puberty and adolescence, when body dissatisfaction and emotional distress are often present. We propose that upregulated activation of the central HPG axis during this period can be epigenetically altered by psychological stressors and by bulimia/recurrent dieting, which are common during adolescence and which can lead to PCOS. This hypothesis is based on events that occur during a largely neglected stage of female reproductive development. To date, most research into the origins of PCOS has focused on the prenatal induction of this disorder, particularly in utero androgenization and the role of anti-Müllerian hormone. Establishing causality in our peripubertal model requires prospective cohort studies from infancy. Mechanistic studies should consider the role of the gut microbiota in addition to the epigenetic regulation of (neuro) hormones. Finally, clinicians should consider the importance of underlying chronic psychological distress and eating disorders in PCOS.

The Prevalence and Impact of Polycystic Ovary Syndrome in Recurrent Miscarriage: A Retrospective Cohort Study and Meta-Analysis

Background: The use of different definitions and diagnostic approaches of polycystic ovary syndrome (PCOS) and recurrent miscarriage (RM) has led to a wide range of prevalence rates in the literature. Despite the persistent controversy about the factual prevalence of PCOS in RM, a vast number of studies have revealed evidence about their association with each other. The goals of this study were to evaluate the prevalence of polycystic ovarian morphology and PCOS within the RM population, performing meta-analyses with the obtained data from this study, together with previous reports on this topic and evaluating reproductive outcome in women with RM and PCOS. Methods: A retrospective cohort study with 452 women with RM and a meta-analysis were conducted. The main outcome parameter was the prevalence of PCOS in RM patients. Results: In the retrospective study, the prevalence of PCOS in RM was 9.5%. Negative results for the selected risk factors for RM were present in 283 patients (62.6%). From all evaluated possible underlying causes for RM, only the presence of thrombophilic disorders was significantly associated with PCOS (PCOS: 20.9% versus no PCOS: 7.8%, p = 0.010). In the meta-analysis of three studies on PCOS in RM patients, which used the revised Rotterdam criteria for defining PCOS, an estimated pooled prevalence of 14.3% (95% CI: 6.2–24.9) was found. In the retrospective data set, women in the PCOS group revealed significantly higher luteinizing hormone (LH), testosterone, and Anti-Mullerian hormone (AMH) levels than age- and body mass index (BMI)-matched controls with RM negative for the selected risk facotrs (p < 0.05). The rate of further miscarriages was significantly higher in PCOS women than in controls (71.4% versus 53.6%, respectively; p = 0.031). Conclusions: The prevalence of PCOS seems slightly increased in women with RM. Women with PCOS suffering from RM showed a significantly higher risk for further miscarriage and decreased chances of having a life birth of about 18% which did not reach statistical significance. Therefore, we assume that PCOS plays a moderate role in RM.

Factor V Leiden 1691G > A mutation and the risk of recurrent pregnancy loss (RPL): systematic review and meta-analysis

Background

Although numerous replication case-control studies have attempted to determine the association between Factor V Leiden (FVL) 1691G > A mutation and susceptibility to Recurrent pregnancy loss (RPL), there have been confliction among the results of various ethnic groups. To address this limitation, here we implemented first meta-analysis to provide with consistent conclusion of the association between FVL 1691G > A mutation and RPL risk.

Methods

After a systematic literature search, pooled odds ratio (OR) and their corresponding 95% confidence interval (CI) were used to evaluate the strength of the association. Additionally, meta-regression analyses were performed to find potential source of heterogeneity.

Results

In this meta-analysis, 62 studies, containing 10,410 cases and 9406 controls, were included in quantitative analysis. Overall population analysis revealed a significant positive association in the dominant (OR = 2.15, 95% CI = 1.84-2.50, P < 0.001), over-dominant (OR = 1.88, 95% CI = 1.61-2.19, P < 0.001), allelic (OR = 2.05, 95% CI = 1.79-2.35, P < 0.001), and heterozygote (OR = 1.97, 95% CI = 1.68-2.30, P < 0.001) models. Moreover, a significant association of dominant (OR = 3.04, 95% CI = 2.04-4.54, P < 0.001), over-dominant (OR = 2.65, 95% CI = 1.74-4.05, P < 0.001), and heterozygote (OR = 2.67, 95% CI = 1.81-4.22, P < 0.001) models was found in the Iranian population. The subgroup analysis indicated strong significant association in Asian, European, Africa population, and case-control studies but not in South Americans and cohort studies.

Conclusion

The FVL 1691G > A mutation and the risk of RPL confers a genetic contributing factor in increasing the risk of RPL, particularly in Iranians, except for South Americans.

Factors associated with spontaneous abortion: a systematic review

Abstract Objectives: to compile studies produced regardinggenetic and non-genetic risks factors associated with occurrence of spontaneous abortion. Methods: it talks about a systematic review article, with studies between January of 2008 to November of 2018 according to SciELO, PubMed, Lilacs and BVS. Results: in total, 567 articles were found. After applying the definedeligibility criteria, 44 articles made part of the review, being the majority published on Asia between 2008 and 2011, and 10 articles published on Brazil. Not genetic causes like sociodemographic factors and healthy state were among the most associated conditions of spontaneous abortion. Asiatic continent had predominance about the correlation of spontaneous abortion with factors related to life style like obesity, smoking and labor activities, on the other hand, in the Americas, causes related to sociodemographics factors like low pay and low studies are high-lighted. Conclusions: the risk factors change about the occurrence region, being important to make local studies capable of subsidize the implantation of public politics and to reduce abortions.

Association between factor V Leiden mutation and recurrent pregnancy loss in the middle east countries: a Newcastle-Ottawa meta-analysis

PURPOSE

Heritable thrombophilia is a category of genetic disorders of the coagulation cascade with the increasing risk of thrombus formation and recurrent pregnancy loss (RPL). Factor V Leiden (FVL) (R506Q) mutation is the most common genetic cause of deep venous thrombosis, but its association with RPL has been inconsistent in studies arising from non-Western countries. The present metanalysis was aimed to determine whether an association exists between FVL and RPL in the Middle East.

METHODS

We searched PubMed, MEDLINE Web of Science, Scopus, and Embase, evaluating the association between the FVL and RPL. The Middle East countries (Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, The State  of Palestine, Syria, Turkey, The United Arab Emirates, and Yemen) were evaluated in succession. Raw data were extracted, and 19 case-control studies were included in our final analysis.

RESULTS

Overall, 2513 cases and 1836 controls in the Middle East showed a prevalence of FVL mutation as 12.6% and 4.9% in patients and controls, respectively. To evaluate the relationship between FVL mutation and RPL, we used Forest plot (random effect model) with the overall random OR of 2.37 (CI 95%: 1.50-3.75). FVL mutation was associated with a higher risk of RPL. In Iran, the OR was 1.90 (95% CI 1.04-3.45), and in Turkey, the OR was 3.01 (95% CI 1.10-8.23).

CONCLUSION

The results of our study support an association between FVL mutation status and RPL in women of the Middle East countries. It is recommended that specific policies include comprehensive testing for FVL mutation as a standard of care in women of the Middle East region with unexplained RPL.

Significant association between methylenetetrahydrofolate reductase gene C677T polymorphism with polycystic ovary syndrome risk: A meta-analysis update

The methylenetetrahydrofolate reductase (MTHFR) may play a pathological role in polycystic ovary syndrome (PCOS). However, the conclusions of published reports on the relationship between the MTHFR C677T polymorphism and PCOS risk remain controversial.To derive a more precise estimation we performed a metaanalysis based on 22 studies that together included 2405 cases and 2419 controls. PubMed, EMBASE, WanFang and the Chinese National Knowledge Infrastructure databases were used to retrieve articles up to up to October 28, 2019. The crude odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated to evaluate the association.Metaanalysis results showed a significant association between the MTHFR C677T polymorphism and PCOS risk in 3 genetic models (allele model: OR = 1.40, 95% CI = 1.27-1.53; dominant model: OR = 1.47, 95% CI = 1.17-1.85); homozygous model: OR = 1.90, 95% CI = 1.55-2.32). Moreover, significant associations were observed when stratified by ethnicity, source of controls, etiology, and genotype methods.This metaanalysis suggests that the T-allele of the MTHFR C677T polymorphism is associated with an increased risk of PCOS, especially in Asians further studies with larger population sizes are needed to confirm these results.

Coagulation Biomarkers in Women with Recurrent Miscarriage and Polycystic Ovarian Syndrome: Systematic Review and Meta-Analysis

Introduction Pregnant women with polycystic ovarian syndrome (PCOS) have high risk of pregnancy loss. Pathophysiological mechanisms appear to be associated with obesity, hormonal factors, or blood clotting disorders. Our aim is to perform a systematic review and meta-analysis on the relationship between coagulation disorders and risk of recurrent miscarriage (RM) in patients with PCOS and to identify coagulation biomarkers for this condition. Material and Methods PubMed and MEDLINE databases were searched for publications in English language. The search terms used included "RM", "polycystic ovary syndrome", "coagulation disorders", and "thrombophilia". Odds ratios (ORs) and 95% confidence intervals (CIs) for miscarriage in different RM groups (with and without PCOS). Results A total of 575 publications including the search terms were identified. Six studies were included for qualitative analysis, and five were included for quantitative analysis (meta-analysis). We found no association between RM and inherited thrombophilias in patients with PCOS: (1) Factor V Leiden (OR, 0.74; 95% CI, 0.38 - 1.45; p = 0.38); (2) C677T methylenetetrahydrofolate reductase polymorphism (MTHFR) (OR, 1.01; 95% CI, 0.64 - 1.59; p = 0.97); and (3) A1297C MTHFR polymorphism (OR, 1.08; 95% CI, 0.62 - 1.89; p = 0.77). Other potential biomarkers were identified, with emphasis on plasminogen activator inhibitor type 1. Conclusion Data available in the current literature revealed that there was no association between RM and inherited thrombophilias in patients with PCOS. RM patients with PCOS have a high risk of thromboembolic events.

Coagulation parameters predictive of polycystic ovary syndrome

OBJECTIVE

To explore coagulation parameters in association with polycystic ovarian syndrome (PCOS) and establish a model for predicting the risk of PCOS.

STUDY DESIGN

This study included 181 outpatients with PCOS. A total of 301 women who attempted to seek pre-pregnancy consultation at the Department of Gynecology of our hospital were included in the control group, and six coagulation parameters were measured for all included subjects. A logistic regression model was built based on the training dataset using the purposeful selection method to select important predictors. The performance of the established model was validated on the test dataset.

RESULTS

There were statistically significant differences found among all coagulation parameters except D-Dimer (DD, P = 0.080). The purposeful selection method selected age (odds ratio [OR] = 0.89; p = 0.008), prothrombin time (PT, OR = 0.68, p < 0.0001), thrombin time (TT, OR = 3.30; p = 0.0005), and fibrin degradation products (FDP, OR = 0.24; p = 0.0002) as important predictors of PCOS risk. The receiver operating characteristic (ROC) curve analysis indicated that the area under the ROC curve (AUC) of the model was 0.81 for the training dataset with an optimal cut-off point of the predicted probability of 0.45, leading to a sensitivity of 0.71 and a specificity of 0.82. The AUC was 0.79 for the test data.

CONCLUSIONS

It was found that the coagulation parameters, including PT, TT, and FDP, are predictive of PCOS. These results highlight the potential of anti-coagulation therapies to lower the risk of adverse outcomes in women with PCOS.

Review of current guidelines for recurrent pregnancy loss: new strategies for optimal evaluation of women who may be superfertile

The current evidence-based guidelines for the evaluation of recurrent pregnancy loss recommended by the American Society for Reproductive Medicine and by the European Society of Human Reproduction and Embryology are compared and contrasted in this review. The clinical use of either of these guidelines will result in a probable diagnosis for only half of the affected patients. New strategies for a full evaluation of recurrent pregnancy loss incorporating 24- chromosome microarary on the products of conception offer more explanations for patients and caregivers. This new algorithm should decrease the use of empiric, unproven treatments. Combining the results of genetic testing on the miscarriage tissue with the conventional diagnostic tests has made it possible to explain the etiology of pregnancy loss in more than 90% of the cases. This cost-saving strategy can decrease the emotional distress and frustration for both couples and physicians when it comes to management of recurrent pregnancy loss.

Endocrine causes of recurrent pregnancy loss

OBJECTIVE

To review the available data on endocrine disorders and recurrent pregnancy loss.

FINDINGS

Our group found that most endocrine disorders do not seem to be correlated with a diagnosis of recurrent pregnancy loss (RPL). The exception to this is testing for thyroid stimulating hormone and thyroid antibodies, which is recommended due to a strong correlation with recurrent pregnancy loss and positive anti-thyroid peroxidase antibodies.

CONCLUSION

The available literature supports testing thyroid function and antibodies in women with RPL. Testing for other endocrine disorders is only warranted if otherwise clinically indicated, independent from a history of recurrent pregnancy loss.

Are there differences in basal thrombophilias and C-reactive protein between women with or without PCOS?

RESEARCH QUESTION

Polycystic ovary syndrome (PCOS) women have increased cardiovascular risks, although it is unclear whether the haemostatic system and coagulation contribute to that increased risk.

DESIGN

Women attending the Gynecology Unit of the 'Virgen de la Arrixaca' University Hospital (Murcia, Spain) for routine gynaecological examinations between September 2014 and May 2016 were assessed for PCOS using the Rotterdam criteria (hyperandrogenism [H], oligo/amenorrhoea [O] and polycystic ovarian morphology [POM]) and were classified into four phenotypic. In total, 126 cases were identified and 159 control women were selected. All women underwent physical and gynaecological examinations, and blood tests between the second and fifth day of the menstrual cycle. Differences in hormonal, basal thrombophilia and metabolic parameters, and C-reactive protein (CRP) between PCOS and controls were analysed.

RESULTS

After adjusting by BMI and age, PCOS women had higher LH (P < 0.001), testosterone (P < 0.001), free testosterone (P = 0.01) and anti-Müllerian hormone (P < 0.001) and lower FSH (P = 0.03) compared with controls, whereas sex hormone-binding globulin was no different. Cases showed significantly higher protein S, glucose, insulin and insulin resistance (HOMA-IR) compared with controls (P < 0.05). There were no differences in protein C levels, antithrombin III, prothrombin time, homocysteine, D-dimer, factor V Leyden, prothrombin G20210A polymorphism or CRP. The H+O phenotype showed the poorest results for insulin and HOMA-IR (P = 0.04 and 0.05).

CONCLUSIONS

The results suggest that there are no differences in the basal thrombophilias between women with and without PCOS. However, PCOS with H+O shows the poorest metabolic profile.

ESHRE guideline: recurrent pregnancy loss

STUDY QUESTION

What is the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature?

SUMMARY ANSWER

The guideline development group formulated 77 recommendations answering 18 key questions on investigations and treatments for RPL, and on how care should be organized.

WHAT IS KNOWN ALREADY

A previous guideline for the investigation and medical treatment of recurrent miscarriage was published in 2006 and is in need of an update.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 31 March 2017 and written in English were included. Cumulative live birth rate, live birth rate and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 38 recommendations on risk factors, prevention and investigations in couples with RPL, and 39 recommendations on treatments. These include 60 evidence-based recommendations – of which 31 were formulated as strong recommendations and 29 as conditional – and 17 good practice points. The evidence supporting investigations and treatment of couples with RPL is limited and of moderate quality. Of the evidence-based recommendations, only 10 (16.3%) were supported by moderate quality evidence. The remaining recommendations were supported by low (35 recommendations: 57.4%), or very low quality evidence (16 recommendations: 26.2%). There were no recommendations based on high quality evidence. Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions investigations and treatments that should not be used for couples with RPL.

LIMITATIONS, REASONS FOR CAUTION

Several investigations and treatments are offered to couples with RPL, but most of them are not well studied. For most of these investigations and treatments, a recommendation against the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in RPL, based on the best evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. One of the most important consequences of the limited evidence is the absence of evidence for a definition of RPL.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. J.E. reports position funding from CARE Fertility. S.L. reports position funding from SpermComet Ltd. S.M. reports research grants, consulting and speaker’s fees from GSK, BMS/Pfizer, Sanquin, Aspen, Bayer and Daiichi Sankyo. S.Q. reports speaker’s fees from Ferring. The other authors report no conflicts of interest.

ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.

Association between Thrombophilic Genes Polymorphisms and Recurrent Pregnancy Loss Susceptibility in the Iranian Population: a Systematic Review and Meta-Analysis

Studies have indicated that thrombophilic genes polymorphisms are associated with recurrent pregnancy loss (RPL) in the Iranian population. We aimed to evaluate the precise association between thrombophilic genes polymorphisms (MTHFR C677T, MTHFR A1298C, Prothrombin G20210A, FVLG1691A, and PAI-1 4G/5G) and RPL risk in the Iranian population. PubMed, Web of Science, Google Scholar, and ISC were searched for eligible articles published up to April 1, 2017. In total, 37 case-control studies in 18 relevant publications were selected: 1,199, 1,194, 630, 830, and 955 RPL cases and 1,079, 1079, 594, 794, and 499 controls for MTHFR C677T, MTHFR A1298C,Prothrombin G20210A, FVL G1691A, and PAI-1 4G/5G, respectively. The results indicated a significant increased risk of RPL in all genetic models in the population. Also, Prothrombin G20210A and FVL G1691A as well as PAI-1 4G/5G polymorphisms were associated with RPL risk in the Iranian population. Hence, thrombophilic genes polymorphisms are associated with an increased RPL risk in the Iranian population.

Plasminogen Activator Inhibitor-1 4G/5G Polymorphism is Associated with Reproductive Failure: Metabolic, Hormonal, and Immune Profiles

PROBLEM

Association between PAI-1 4G/5G polymorphism and reproductive failures has been postulated. We aimed to investigate its impact on metabolic, hormonal, and immune profiles of women with reproductive failures.

METHOD OF STUDY

A retrospective study was carried out in 208 women with a history of reproductive failure. Study patients were divided into three groups: women with repeated implantation failure (RIF, n = 40), recurrent pregnancy loss (RPL, n = 113), and both RIF and RPL (n = 55). Fertile controls were 92.

RESULTS

PAI-1 4G/4G was prevalent in RPL, RIF, and RIF/RPL groups when compared with controls (P = 0.003) and associated with increased risks of RIF, RPL, and RIF with RPL (OR = 4.5, 2.2 and 2.7). Women with PAI-1 4G/4G have significantly higher BMI, glucose, and PAI-1 levels and lower NK cytotoxicity when compared with women without PAI-1 4G/4G.

CONCLUSION

PAI-1 4G/5G polymorphism plays a major role in the pathogenesis of RPL and RIF by altering metabolic and immunological profiles.

54G/C polymorphism of SREBF-1 gene is associated with polycystic ovary syndrome

OBJECTIVE

A sterol regulatory element-binding protein (SREBF-1) transcription factor is a major regulator of lipid metabolism, carbohydrate, and plays a key role in energy homeostasis. The 54(G/C) polymorphism of SREBF-1 gene was reported that it is related with metabolic diseases including obesity, type 2 diabetes, and dyslipidemia. Among these, polycystic ovary syndrome (PCOS) is known as a common metabolic-endocrine disorder of women in reproductive ages.

STUDY DESIGN

Here, we performed a comparative study of 54(G/C) polymorphism of SREBF-1 gene with PCOS. The 54(G/C) polymorphism of SREBF-1 gene was analyzed by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) of total 286 PCOS patients and 149 matched controls of healthy women. Statistical analysis was performed using HapAnalyzer. A p-value under 0.05 was considered statistically significant.

RESULTS

There was a strong association between the 54(G/C) polymorphism of SREBF-1 gene and PCOS (OR: 0.65, 95% CI: 0.46-0.90, p: 0.0129). The genotype and allelic frequencies were in Hardy-Weinberg equilibrium (HWE).

CONCLUSION

This is the first study on the genetic variation of SREBF-1 gene and PCOS. We concluded that 54(G/C) polymorphism of SREBF-1 gene is associated with PCOS. Therefore, our results suggest that SREBF-1 gene may play a role in genetic predisposition to PCOS, which is helpful in understanding the etiology of PCOS.

Association between plasminogen activator inhibitor-1 gene polymorphisms and recurrent pregnancy loss: a systematic review and meta-analysis

Human plasminogen activator inhibitor-1 (PAI-1) is closely related to embryonic development and pregnancy success. The association between PAI-1 gene polymorphisms (PAI-1-844G/A and PAI-1-675G/A) and the risk of recurrent pregnancy loss (RPL) is controversial. Therefore, we perform this review to clarify the association between PAI-1 gene polymorphisms and RPL risk. We performed a systematic search for studies that described the effect of PAI-1 polymorphisms on RPL risk. The odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were considered under recessive genetic models. Furthermore, we conducted a subgroup analysis based on the studies' geographic regions of origin. Data were analyzed using Stata 11.2 software. Eighteen studies were included, and a high degree of statistical heterogeneity existed among the studies. In this study, we found a significant association between the PAI-1-675G/A polymorphism and the risk of RPL under the recessive model (OR = 1.70, 95% CI = 1.21-2.38). However, no significant association between the PAI-1-844G/A polymorphism and RPL was noted. PAI-1-675G/A (4G/5G) polymorphisms play a potential role in RPL. The screening of PAI-1 (4G/5G) gene mutations should be included during an RPL diagnostic workup, and patients should be treated using anticoagulant therapy during pregnancy if necessary.

A retrospective study of the pregnancy, delivery and neonatal outcome in overweight versus normal weight women with polycystic ovary syndrome

STUDY QUESTION

Do overweight women with polycystic ovary syndrome (PCOS) have a higher risk of perinatal complications than normal weight women with PCOS?

SUMMARY ANSWER

Overweight women with PCOS with an ongoing singleton pregnancy have an increased risk of preterm birth as well as an increased risk of giving birth to a baby with a higher birthweight than normal weight women with PCOS.

WHAT IS KNOWN ALREADY

There is evidence that overweight (BMI > 25 kg/m²) has a negative influence on the prevalence of gestational diabetes mellitus and fetal macrosomia in women with PCOS.

STUDY DESIGN, SIZE, DURATION

We set up a retrospective comparative cohort study of 93 overweight (BMI ≥ 25 kg/m²) and 107 normal weight (BMI < 25 kg/m²) women with PCOS who were scheduled for fertility treatment between January 2000 and December 2009 and achieved a pregnancy as a result of a treatment cycle, or spontaneously before or between treatment cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All data (patient characteristics, medical information, pregnancy, delivery and neonatal outcome) were retrieved from patient medical files. All pregnancy, delivery and neonatal outcome parameters were adjusted for age and pre-pregnancy smoking behaviour. The neonatal outcome parameters were additionally adjusted for gestational age.

MAIN RESULTS AND THE ROLE OF CHANCE

The median BMI in the overweight and normal weight women was, respectively, 30.8 kg/m² [interquartile quartile range (IQR) 5.8] and 20.9 kg/m² (IQR 2.3) (P < 0.001). Baseline characteristics did not differ between groups, except for free testosterone and fasting insulin levels, which were higher, and sex hormone-binding globulin, which was lower, in overweight versus normal weight women (all P < 0.001). The time-to-pregnancy was significantly higher in the overweight group (P = 0.01). Multivariate analyses of the ongoing singleton pregnancies showed significantly more preterm births in overweight (10/61) versus normal weight (2/71) women [adjusted odds ratio 0.1, 95% confidence interval (CI) 0-0.6, P = 0.01]. The mean birthweight of newborns was significantly higher in overweight (3386 ± 663 g) than in normal weight (3251 ± 528 g) women (adjusted mean difference 259.4, 95% CI 83.4-435.4, P = 0.004).

LIMITATIONS, REASON FOR CAUTION

Our results only represent the pregnancy, delivery and neonatal outcome of ongoing singleton pregnancies. The rather small sample size and observational nature of the study are further limitations.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest the importance of pre-pregnancy weight loss in overweight women with PCOS in order to reduce the risk of adverse perinatal outcomes.

STUDY FUNDING/COMPETING INTERESTS

Veerle De Frène is holder of a Special PhD Fellowship by the Flemish Foundation for Scientific Research (FWO-Vlaanderen). Petra De Sutter is holder of a fundamental clinical research mandate by the Flemish Foundation for Scientific Research (FWO-Vlaanderen). There are no competing interests.