Is sleep-disordered breathing associated with miscarriages? An emerging hypothesis

Effect of obstructive sleep apnea on in vitro fertilization outcomes in women with polycystic ovary syndrome

STUDY OBJECTIVES

Polycystic ovary syndrome (PCOS) confers a high risk of obstructive sleep apnea (OSA). Here we investigated the effect of OSA on first in vitro fertilization (IVF) cycle metrics and outcomes in patients with PCOS.

METHODS

This was a prospective cohort study of patients with PCOS undergoing their first IVF at a single tertiary center between October 1, 2021, and September 30, 2022. Patients were screened for OSA before IVF and grouped accordingly. Clinical and IVF cycle data were compared between groups.

RESULTS

OSA was found in 37.2% of 156 patients with PCOS, with longer infertility duration (4.3 ± 2.5 vs. 3.4 ± 2.0 years) and lower levels of anti-Müllerian and luteinizing hormones than patients without OSA (6.44 ± 2.96 vs 8.69 ± 4.03 µg/L and 6.30 ± 5.02 vs 8.46 ± 6.09 U/L). Antral follicle count was lower in patients with OSA (28.9 ± 12.4 vs 33.2 ± 12.9). During ovarian stimulation, patients with OSA required significantly higher doses of gonadotropin (2080.8 ± 1008.7 vs 1682.8 ± 619.9 U) and had lower peak estradiol level (4473.5 ± 2693.0 vs 5455.7 ± 2955.1 pmol/L) and fewer retrieved oocytes, high-quality, and available embryos (17.8 ± 7.2 vs 21.9 ± 10.5, 4.5 ± 4.4 vs 6.2 ± 4.6, 5.2 ± 4.3 vs 7.4 ± 5.0). Eleven patients were excluded for having no embryos or missing transfer. Therefore, we analyzed the outcome of the first embryo transfer in 145 patients. The biochemical and clinical pregnancy rates were lower in patients with OSA than patients without OSA (51.9% vs 66.7% and 42.3% vs 60.2%). OSA was independently associated with clinical pregnancy rate after controlling for several confounders (P = .043).

CONCLUSIONS

OSA impairs female fertility in patients with polycystic ovary syndrome, suggesting an adverse effect on in vitro fertilization cycle stimulation characteristics and clinical outcomes.

CITATION

Zhang Q, Wang Z, Ding J, et al. Effect of obstructive sleep apnea on in vitro fertilization outcomes in women with polycystic ovary syndrome. J Clin Sleep Med. 2024;20(1):31-38.

Sleep and obstructive sleep apnea in women with infertility

PURPOSE

Obstructive sleep apnea (OSA) is associated with polycystic ovarian syndrome (PCOS), a common cause of infertility. Understanding predictors and outcomes of OSA in women with infertility may guide treatment.

METHODS

A descriptive cross-sectional survey was performed to assess OSA in women presenting to an infertility clinic using validated sleep questionnaires to assess sleep and fertility outcomes. An Infertile-C group (controls with male or tubal factors) and an Infertile-S group (unknown/other infertile causes) were analyzed to assess OSA risk and other sleep disorders (e.g., restless legs syndrome (RLS) and insomnia) with fertility outcomes (time to pregnancy, PCOS, irregular menstruation, and miscarriage).

RESULTS

In 258 women, occurrences of OSA diagnosis (6%) and RLS (10%) were reported similar to women of child-bearing age in the general population. PCOS was unassociated with OSA risk. Predictors of OSA risk were BMI, insomnia symptoms, and sleep aid use. Obese women with high OSA risk were more likely to have other comorbidities (e.g., depression). In adjusted models, prior clinical OSA diagnosis was associated with miscarriage (odds ratio: 6.17 (1.24, 30.62), p = 0.026). RLS was associated with irregular menstruation (odds ratio: 3.73 (1.21, 11.53), p = 0.022).

CONCLUSIONS

Similar to other populations, women with infertility and OSA risk have more health comorbidities and higher BMI and may present with insomnia symptoms. While the data are limited, this study supports the potential associations of OSA and miscarriage. Further work is needed to evaluate OSA in female infertility.

Obstructive Sleep Apnea and Risk of Miscarriage

The purpose of this project was to evaluate whether screening positive on obstructive sleep apnea questionnaires in the first trimester of pregnancy was associated with miscarriage. This was a secondary analysis of a prospective observational cohort study of participants who were screened for sleep apnea during pregnancy with the Epworth Sleepiness Scale, Berlin Questionnaire, and novel items related to sleep and napping. This secondary analysis was IRB exempt. Our primary outcome was miscarriage in the index pregnancy. An association between responses to the sleep apnea screening questions with miscarriage of the index pregnancy was queried via Poisson regression. We found that gravidae who had elevated scores on both the Epworth Sleepiness Scale and the Berlin Questionnaire were more likely to experience miscarriage than those who had elevated scores on only one questionnaire or neither (p = 0.018). Gravidae who reported snoring (p = 0.042) or hypertension (p = 0.013) in the first trimester were more likely to experience miscarriage than gravidae who did not. Gravidae who reported napping in the first trimester were less likely to experience miscarriage (p = 0.045), even after adjusting for confounding variables (p = 0.007). In conclusion, we found that screening positive on both the Berlin Questionnaire and Epworth Sleepiness Scale was statistically significantly associated with miscarriage prior to adjustment for confounding variables, as did snoring and hypertension. After adjusting for confounding variables, only not napping was associated with miscarriage. Given the small sample size, further investigation into this topic is warranted.

A latent-class heteroskedastic hurdle trajectory model: patterns of adherence in obstructive sleep apnea patients on CPAP therapy

BACKGROUND

Sleep apnea patients on CPAP therapy exhibit differences in how they adhere to the therapy. Previous studies have demonstrated the benefit of describing adherence in terms of discernible longitudinal patterns. However, these analyses have been done on a limited number of patients, and did not properly represent the temporal characteristics and heterogeneity of adherence.

METHODS

We illustrate the potential of identifying patterns of adherence with a latent-class heteroskedastic hurdle trajectory approach using generalized additive modeling. The model represents the adherence trajectories on three aspects over time: the daily hurdle of using the therapy, the daily time spent on therapy, and the day-to-day variability. The combination of these three characteristics has not been studied before.

RESULTS

Applying the proposed model to a dataset of 10,000 patients in their first three months of therapy resulted in nine adherence groups, among which 49% of patients exhibited a change in adherence over time. The identified group trajectories revealed a non-linear association between the change in the daily hurdle of using the therapy, and the average time on therapy. The largest difference between groups was observed in the patient motivation score. The adherence patterns were also associated with different levels of high residual AHI, and day-to-day variability in leakage.

CONCLUSION

The inclusion of the hurdle model and the heteroskedastic model into the mixture model enabled the discovery of additional adherence patterns, and a more descriptive representation of patient behavior over time. Therapy adherence was mostly affected by a lack of attempts over time, suggesting that encouraging these patients to attempt therapy on a daily basis, irrespective of the number of hours used, could drive adherence. We believe the methodology is applicable to other domains of therapy or medication adherence.

Beneficial effects of estrogens in obstructive sleep apnea hypopnea syndrome

Epidemiological studies showing the higher frequency of obstructive sleep apnea hypopnea syndrome in men, polycystic ovary syndrome (PCOS), and in post-menopausal women suggest the beneficial role of estrogen. These findings are well supported by the pre-clinical studies (ten research studies described in this review) showing that estrogen and phytoestrogens attenuate the deleterious effects of chronic intermittent hypoxia (obstructive apnea in animals) on the genioglossal muscles and on other organs (co-morbidities) in ovariectomized rodents. Moreover, clinical studies (four research studies described in this review) have also shown the beneficial role of estrogen therapy on the parameters of obstructive apnea in post-menopausal women. The beneficial effects of estrogen and phytoestrogens on obstructive sleep apnea and its co morbidities have been attributed to increase in thioredoxin, Nrf-2, activation of p38 MAP kinases, inhibition of vagal C fibers, and attenuation of HIF-1α. It is possible that estrogen-mediated activation of p38 MAP kinase may inhibit HIF-1α to attenuate lung inflammation, which may inhibit the activation of vagal C fibers to attenuate bronchoconstriction and prevent obstruction during sleep. Moreover, estrogen-mediated increase in thioredoxin and Nrf-2 may also contribute in increasing antioxidant defense and attenuating inflammation.

Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level.

Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but thresholds for and effectiveness of intervention are unclear. Clinicians should use shared decision making for screening and treatment decisions.http://ow.ly/N0oN30noWnx

Obstructive sleep apnoea and polycystic ovary syndrome: A comprehensive review of clinical interactions and underlying pathophysiology

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine disorder in women of reproductive age. PCOS is associated with multiple comorbidities including, obesity, insulin resistance and type 2 diabetes, as well as mood disorders and impaired quality of life (QoL). Obstructive sleep apnoea (OSA) is also a common medical condition that is often undiagnosed, particularly in women. OSA is associated with a similar spectrum of comorbidities to that observed in PCOS, including manifestations of the metabolic syndrome and impaired QoL, whilst obesity frequently constitutes a common denominator in the pathophysiology of both OSA and PCOS. Hence, it is not surprising that OSA and PCOS may coexist in women of reproductive age, and the current clinical guidelines on the management of PCOS recommend screening for OSA symptoms in overweight/obese women with PCOS. In this review, we examine the relationship between OSA and PCOS and explore the potential underlying mechanisms that link these two conditions.

Síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) y embarazo

El embarazo es una condición temporal de la vida en la que ocurren importantes cambios en la fisiología de la mujer, los cuales se resuelven, en gran medida, después del parto. Hay cambios físicos, hormonales y psicológicos, con un aumento progresivo de peso. Estos factores pueden predisponer a un trastorno respiratorio del sueño o a exacerbar alguno ya existente. La literatura científica sugiere una mayor prevalencia de ronquido en las mujeres embarazadas. Las bases de datos demuestran que en menos del 1% de los embarazos aparece el código del diagnóstico de apnea de sueño. Se ha relacionado la presencia tanto de ronquido como de apnea durante el embarazo con algunos desenlaces adversos que se tratan en este artículo, el cual busca sensibilizar a los médicos para que consideren este diagnóstico durante el embarazo.

Obstructive sleep apnea and hormones - a novel insight

Obstructive sleep apnea (OSA), a disorder characterized by repetitive collapse of the upper respiratory tract during sleep, occurs in about 4% of middle-aged men and 2% of women. The incidence of the disorder is rising due to an increase in obesity and ageing of the population. Patients with obstructive sleep apnea are at elevated risk of some endocrinal and metabolic disorders, which may lead to serious consequences including shortening of life expectancy. The recognition and understanding of interactions between local upper airway dysfunction and its endocrinal consequences is therefore vital. In this review we will focus on the influence of OSA on bone metabolism and endocrine homeostasis.

Sleep disordered breathing in pregnancy

Key points

Educational aims

Sleep disordered breathing (SDB) is very common during pregnancy, and is most likely explained by hormonal, physiological and physical changes. Maternal obesity, one of the major risk factors for SDB, together with physiological changes in pregnancy may predispose women to develop SDB. SDB has been associated with poor maternal and fetal outcomes. Thus, early identification, diagnosis and treatment of SDB are important in pregnancy. This article reviews the pregnancy-related changes affecting the severity of SDB, the epidemiology and the risk factors of SDB in pregnancy, the association of SDB with adverse pregnancy outcomes, and screening and management options specific for this population.

Sleep disordered breathing should be sought and treated during #pregnancyhttp://ow.ly/U2UO3

Sleep Disordered Breathing and Adverse Pregnancy Outcomes

Sleep disordered breathing (SDB) occurs in 0.6% to 15% of reproductive-aged women. Because of an overlap in symptoms of SDB and normal pregnancy findings, the diagnosis of SDB in pregnancy is challenging. The repetitive arousals, sleep fragmentation, and hypoxias experienced by patients with SDB lead to an increase in oxidative stress and inflammation. In the nonpregnant population SDB is associated with an increased risk of diabetes mellitus, heart disease, and stroke. Increasing evidence identifies an association between SDB in pregnancy and gestational diabetes, preeclampsia, and fetal growth abnormalities.