Paternal exposure and counselling: Experience of a Teratology Information Service

Family planning considerations in people with multiple sclerosis

Multiple sclerosis is often diagnosed in patients who are planning on having children. Although multiple sclerosis does not negatively influence most pregnancy outcomes, less is known regarding the effects of fetal exposure to novel disease-modifying therapies (DMTs). The withdrawal of some DMTs during pregnancy can modify the natural history of multiple sclerosis, resulting in a substantial risk of pregnancy-related relapse and disability. Drug labels are typically restrictive and favour fetal safety over maternal safety. Emerging data reporting outcomes in neonates exposed to DMTs in utero and through breastfeeding will allow for more careful and individualised treatment decisions. This emerging research is particularly important to guide decision making in women with high disease activity or who are treated with DMTs associated with risk of discontinuation rebound. As increasing data are generated in this field, periodic updates will be required to provide the most up to date guidance on how best to achieve multiple sclerosis stability during pregnancy and post partum, balanced with fetal and newborn safety.

The effects of sacubitril/valsartan and ramipril on the male fertility in hypertensive rats

OBJECTIVE:

Renin angiotensinogen system (RAS) inhibitors, ramipril and sacubitril/valsartan are frequently used in the treatment of cardiovascular diseases. Although they are known as contraindicated during pregnancy in hypertensive women, there is not any outcome of their safety in male fertility after exposure to ramipril or sacubitril/valsartan. In this study, we aimed to evaluate the effects of ramipril and sacubitril/valsartan to highlight their safety in the male fertility in normotensive and hypertensive rats.

METHODS:

Adult male normotensive and dexamethasone-induced hypertensive rats were treated with sacubitril/valsartan, ramipril and saline for 18 days. Arterial blood pressures were verified using carotid artery cannulation. Male fertility parameters, including the testis weights, histopathologic scoring of the testis, sperm count, sperm motility, morphology, and serum testosterone levels, were analyzed in treated and nontreated normotensive/hypertensive rats.

RESULTS:

Sacubitril/valsartan or ramipril treatments did not reveal a significant difference in sperm production, testicular morphology, and radioimmunoassay of serum testosterone levels compared to the control group. However, sperm motility was significantly reduced in rats under RAS inhibition.

CONCLUSION:

This finding was likely mediated by the identification of Ang receptors in the tails of rat sperm given that Ang receptors may play a role in the modulation of sperm motility. Identification of RAS-related proteins involved in sperm motility may help to explain their roles in motility. Our data provide general safety evidence for the male fertilization ability after paternal sacubitril/valsartan and ramipril exposure.

Association of paternal smoking with the risk of neural tube defects in offspring: A systematic review and meta-analysis of observational studies

PURPOSE

The present study aimed at providing some epidemiological evidences to assess the association of paternal smoking with the risk of neural tube defects (NTDs) and its specific subtypes in offspring, and explore the possible dose-response relationship between paternal smoking and risk of NTDs.

METHODS

English and Chinese databases were systematically searched from 1984 to May 2020. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. We also examined the dose-response relationship between parental smoking and risk of NTDs in offspring. Subgroup analyses and sensitivity analyses were conducted to explore possible sources of heterogeneity.

RESULTS

A total of 10 case-control studies involving 2,593 cases of NTDs and 45,100 controls were included for analysis. Findings from our study showed that paternal smoking was significantly associated with risk of total NTDs (odds ratio [OR] = 1.68; 95% confidence interval (CI): 1.48-1.92) and two subtypes including anencephaly (OR = 1.41; 95% CI: 1.06-1.86) and encephaloceles (OR = 2.90; 95% CI: 1.00-8.41). Additionally, a linear dose-response relationship between paternal smoking and risk of NTDs was observed, which indicated that the risk of NTDs in offspring was significantly increased by 45% (OR = 1.45, 95% CI: 1.14-1.84) for each increment of half a pack of cigarettes per day. Sensitivity analyses yielded consistent results. No evidence of publication bias was found.

CONCLUSIONS

Paternal smoking is significantly associated with the risk of NTDs in offspring. Therefore, it should be recommended that fathers quit smoking before pregnancy to prevent NTDs in offspring.

Infertility and teratogenicity after paternal exposure to systemic dermatologic medications: A systematic review

BACKGROUND

This systematic review assesses effects of paternal exposure to dermatologic medications by using the former US Food and Drug Administration (FDA) pregnancy categories as a benchmark.

OBJECTIVE

To assess whether systemic dermatologic medications can cause infertility and teratogenicity when taken by men.

METHODS

Categories D and X dermatologic medications were identified; a systematic review of the literature and reviews of the FDA Adverse Events Reporting System and prescribing information were performed to identify the effects of these medications on male fertility and teratogenicity. A secondary search was performed to assess for other systemic dermatologic medications causing teratogenicity or infertility following paternal exposure.

RESULTS

A total of 13 medications met the inclusion criteria. Of 1,032 studies identified, 19 were included after a systematic review of the literature. Studies evaluating medication effects with paternal exposure were identified for 10 of the 13 evaluated medications, and evidence of a negative effect was identified for 6 medications.

LIMITATIONS

We did not encounter any studies for 3 medications that met the inclusion criteria. Information submitted to the FDA Adverse Events Reporting System may not reflect the incidence of side effects.

CONCLUSIONS

Many former pregnancy category D and X systemic dermatologic medications also have effects on male fertility. More research and better-quality studies are required in this area, particularly studies assessing potential teratogenicity.

Birth Anomalies in Monozygotic and Dizygotic Twins: Results From the California Twin Registry

Background

Inherited factors and maternal behaviors are thought to play an important role in the etiology of several congenital malformations. Twin studies can offer additional evidence regarding the contribution of genetic and lifestyle factors to common birth anomalies, but few large-scale studies have been reported.

Methods

We included data from twins (20,803 pairs) from the population-based California Twin Program. We compared concordance in monozygotic (MZ) to dizygotic (DZ) twins for the following birth anomalies: clubfoot, oral cleft, spina bifida, muscular dystrophy, deafness, cerebral palsy, strabismus, and congenital heart defects. Each birth anomaly was also examined for the associations with birth characteristics (birthweight and birth order) and parental exposures (age, smoking, and parental education).

Results

The overall prevalence of any selected birth anomaly in California twins was 38 per 1,000 persons, with a slightly decreasing trend from 1957–1982. For pairwise concordance in 6,752 MZ and 7,326 like-sex DZ twin pairs, high MZ:DZ concordance ratios were observed for clubfoot (CR 5.91; P = 0.043) and strabismus (CR 2.52; P = 0.001). Among the total 20,803 pairs, parental smoking was significantly associated with risk of spina bifida (OR 3.48; 95% CI, 1.48–8.18) and strabismus (OR 1.61; 95% CI, 1.28–2.03). A significant quadratic trend of increasing risk for clubfoot, spina bifida, and strabismus was found when examining whether father smoked, mother smoked, or both parents smoked relative to non-smoking parents (P = 0.029, 0.026, and 0.0005, respectively).

Conclusions

Our results provide evidence for a multifactorial etiology underlying selected birth anomalies. Further research is needed to understand the biological mechanisms.

The diagnosis of male infertility: an analysis of the evidence to support the development of global WHO guidance-challenges and future research opportunities

BACKGROUND

Herein, we describe the consensus guideline methodology, summarize the evidence-based recommendations we provided to the World Health Organization (WHO) for their consideration in the development of global guidance and present a narrative review of the diagnosis of male infertility as related to the eight prioritized (problem or population (P), intervention (I), comparison (C) and outcome(s) (O) (PICO)) questions. Additionally, we discuss the challenges and research gaps identified during the synthesis of this evidence.

OBJECTIVE AND RATIONALE

The aim of this paper is to present an evidence-based approach for the diagnosis of male infertility as related to the eight prioritized PICO questions.

SEARCH METHODS

Collating the evidence to support providing recommendations involved a collaborative process as developed by WHO, namely: identification of priority questions and critical outcomes; retrieval of up-to-date evidence and existing guidelines; assessment and synthesis of the evidence; and the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation the quality of the supporting evidence was then graded and assessed for consideration during a WHO consensus.

OUTCOMES

Evidence was synthesized and recommendations were drafted to address the diagnosis of male infertility specifically encompassing the following: What is the prevalence of male infertility and what proportion of infertility is attributable to the male? Is it necessary for all infertile men to undergo a thorough evaluation? What is the clinical (ART/non ART) value of traditional semen parameters? What key male lifestyle factors impact on fertility (focusing on obesity, heat and tobacco smoking)? Do supplementary oral antioxidants or herbal therapies significantly influence fertility outcomes for infertile men? What are the evidence-based criteria for genetic screening of infertile men? How does a history of neoplasia and related treatments in the male impact on (his and his partner's) reproductive health and fertility options? And lastly, what is the impact of varicocele on male fertility and does correction of varicocele improve semen parameters and/or fertility?

WIDER IMPLICATIONS

This evidence synthesis analysis has been conducted in a manner to be considered for global applicability for the diagnosis of male infertility.

Counselling regarding paternal exposures: Can we do better?

BACKGROUND

MotherSafe is a free telephone-based counselling service for the general public and healthcare providers concerned about exposures during pregnancy and breastfeeding. Calls relating to paternal exposures are less common, but can cause distress to the person concerned. This review seeks to identify the key concerns and what information is available to address these concerns.

AIMS

To review calls made to MotherSafe about paternal exposures to teratogens during the 16 year period, 2000-2015, and to document any patterns or changes in calls over the period.

MATERIALS AND METHODS

A retrospective descriptive assessment of a prospectively collected database (2000-2015) was undertaken. Telephone counselling records identified the drugs of concern regarding paternal exposures. The information about paternal exposures provided in consumer and production information was also reviewed.

RESULTS

Of a total of 253 103 calls received at MotherSafe between 2000 and 2015, 1072 calls (0.4%) were regarding paternal exposures. The majority of these calls related to immunomodifiers (19%), hair loss products (11%) and antidepressant medications.

CONCLUSIONS

Paternal exposures represent a small proportion of all the counselling calls made to MotherSafe. The study highlighted the deficient and often misleading information about paternal exposures found in most consumer and product information sheets or via the internet. The study indicates the important role of Teratogen Information Services like Mothersafe in providing evidence-based information to both consumers and healthcare providers.

The toxicity of methotrexate in male fertility and paternal teratogenicity

INTRODUCTION

There is a high prevalence of methotrexate (MTX) use in males of reproductive age. The scope of this paper reviews what is known regarding risks to fertility and partners' pregnancy outcomes with regard to MTX use in men. Areas covered: This paper reviews the evidence for current recommendations for MTX use and male fertility and aims to educate professionals regarding MTX use in reproducing males so that patients may be counseled appropriately. A literature search included peer-reviewed sources from PubMed searches and the literature referenced within. Expert opinion: There is a lack of evidence regarding effects of MTX on male fertility. The recommendation to stop MTX three months prior to conception is safe, but is not evidenced by an understanding of the impact of MTX on spermatogenesis or paternal-mediated teratogenicity but rather the timeframe of spermatogenesis. Given the unclear evidence, patients treated with MTX must be counseled on the likelihood of adverse effects of MTX and role of sperm cryopreservation. Future studies are needed to help elucidate the unclear evidence of MTX effects on male fertility and pregnancy outcomes.

Investigating paternal preconception risk factors for adverse pregnancy outcomes in a population of internet users

BACKGROUND

Paternal preconception risk factors such as smoking, exposure to environmental substances, medication use, overweight and advanced age correlate with the occurrence of malformations and birth defects in the offspring. Nonetheless, the prevalence of risk factors for adverse pregnancy outcomes in the male population has been scarcely investigated and no report on preconception interventions targeting prospective fathers is available. We conducted a web-based survey to measure the prevalence of paternal preconception risk factors for adverse pregnancy outcomes in an Italian population of Internet users.

METHODS

Prospective or expectant fathers were enrolled during a four-week period through two of the main Italian web-sites dedicated to preconception, pregnancy, childhood and family care. Participants filled in a web questionnaire regarding preconception risk factors for adverse pregnancy outcomes. Logistic regression analysis was used to explore the predictors of paternal preconception risk factors.

RESULTS

We enrolled 131 prospective and 205 expectant fathers. More than half of the total participants used medications during the preconception period, 35% were smokers and 8% were obese. Exposure to environmental substances was declared by almost 20% of the participants, with the group including pesticides/herbicides/professional paints being the most prevalent. More than a half of the study sample included men aged over 35 years. According to the multivariate analysis, smoking and exposure to environmental toxics were less frequent among individuals with a university degree (respectively: OR = 0.52; 95% CI 0.32-0.84; OR = 0.52; 95% CI 0.29-0.93). Paternal obesity and medication use in the preconception period were not associated with any of the independent variables.

CONCLUSIONS

The prevalence of preconception risk factors among male population should not be neglected when planning preconception interventions, confirming that preconception health must be focused on the couple, rather than on women only.

Contraceptive Provision to Adolescent Females Prescribed Teratogenic Medications

BACKGROUND AND OBJECTIVES

Rates of adult women receiving contraceptive provision when simultaneously prescribed a known teratogen are alarmingly low. The prevalence of this behavior among pediatric providers and their adolescent patients is unknown. The objective of this study was to describe pediatric provider behaviors for prescribing teratogens concurrently with counseling, referral, and/or prescribing of contraception (collectively called contraceptive provision) in the adolescent population.

METHODS

A retrospective review was conducted examining visits in 2008-2012 by adolescents aged 14 to 25 years in which a known teratogen (US Food and Drug Administration pregnancy risk category D or X) was prescribed. The electronic medical records were queried for demographic information, evidence of contraceptive provision, and menstrual and sexual histories. The data were analyzed using standard statistical methods.

RESULTS

Within 4172 clinic visits, 1694 females received 4506 prescriptions for teratogenic medications. The most commonly prescribed teratogens were topiramate, methotrexate, diazepam, isotretinoin, and enalapril. The subspecialties prescribing teratogens most frequently were neurology, hematology-oncology, and dermatology. Overall, contraceptive provision was documented in 28.6% of the visits. Whites versus nonwhites and older versus younger girls were more likely to receive contraceptive provision. The presence of a federal risk mitigation system for the teratogen also increased the likelihood of contraceptive provision.

CONCLUSIONS

Our data demonstrate female adolescents prescribed teratogens receive inadequate contraception provision, which could increase their risk for negative pregnancy outcomes. Although the presence of a federal risk mitigation system appears to improve contraceptive provision, these systems are costly and, in some instances, difficult to implement. Efforts to improve provider practices are needed.

Paternal therapy with disease modifying drugs in multiple sclerosis and pregnancy outcomes: a prospective observational multicentric study

Background

Most of Multiple Sclerosis (MS) patients undergo disease modifying drug (DMD) therapy at childbearing age. The objective of this prospective, collaborative study, was to assess outcomes of pregnancies fathered by MS patients undergoing DMD.

Methods

Structured interviews on pregnancies fathered by MS patients gathered in the Italian Pregnancy Dataset were collected; pregnancies were divided according to father exposure or unexposure to DMD at time of procreation. Treatment were compared with multivariable logistic and linear models.

Results

Seventy-eight pregnancies fathered by MS patients were tracked. Forty-five patients were taking DMD at time of conception (39 beta-interferons, 6 glatiramer acetate), while 33 pregnancies were unexposed to DMD. Seventy-five pregnancies ended in live-births, 44 in the exposed and 31 in the unexposed group. No significant differences between the two groups were found in the risk of spontaneous abortion or malformations (p > 0.454), mean gestational age (p = 0.513), frequency of cesarean delivery (p = 0.644), birth weight (p = 0.821) and birth length (p = 0.649). In comparison with data of the Italian general population, the proportion of spontaneous abortion and caesarean delivery in exposed pregnancies fell within the estimates, while the proportion of pre-term delivery in the exposed group was higher than expected.

Conclusions

Our data indicate no association between paternal DMD exposure at time of conception and risk of spontaneous abortion, adverse fetal outcomes and congenital malformations. Further studies clarifying the role of DMD fathers intake prior and during pregnancy are desirable, to supply guidelines for clinical practice.

No evidence for an increased risk of adverse pregnancy outcome after paternal low-dose methotrexate: an observational cohort study

OBJECTIVE

There is increasing awareness of the potential impact of paternal exposures on pregnancy outcome. In particular this applies to MTX, which is used in low doses for the treatment of RA and other inflammatory diseases. MTX is associated with a specific pattern of malformations in fetuses of exposed women, but there is uncertainty concerning the risk of paternal low-dose MTX. The aim of this study was to investigate whether paternal low-dose MTX therapy around conception has an unfavourable effect on pregnancy outcome.

METHODS

We performed a prospective observational cohort study involving pregnancies fathered by men who were treated with low-dose MTX around conception. Pregnancies were identified through our Teratology Information Service. Pregnancy outcomes were compared with a cohort neither exposed to MTX nor to other teratogens. Outcomes evaluated were major birth defects, spontaneous abortion (SAB), elective termination of pregnancy, gestational age at delivery, and birth weight.

RESULTS

A total of 113 pregnancies with paternal low-dose MTX treatment were compared with 412 non-exposed pregnancies. Neither the rate of major birth defects [odds ratio (OR) 1.02, 95% CI 0.05, 7.0) nor the risk of SAB (hazard ratio 1.19, 95% CI 0.65, 2.17) was increased. Gestational age at delivery and birth weights did not differ significantly between groups. The rate of electively terminated pregnancies was increased in the MTX-exposed patients compared with controls.

CONCLUSION

Our study does not confirm an increased risk of adverse pregnancy outcome after paternal low-dose MTX therapy. The reassuring findings do not support the necessity of a 3-month MTX-free interval until conception. In the case of unavoidable paternal MTX therapy, it seems reasonable not to postpone family planning.

Effects of preconceptional paternal drug exposure on birth outcomes: cohort study of 340 000 pregnancies using Norwegian population-based databases

AIMS

We aimed to explore associations between drugs dispensed to the father prior to conception and pregnancy outcomes, such as pre-term birth, perinatal mortality, foetal growth retardation and birth defects.

METHODS

In this cohort study, two population-based registries, the Medical Birth Registry of Norway and the Norwegian Prescription Database, were linked. The study cohort consisted of 340 000 pregnancies in 2004-10. The association between specific drugs dispensed to the fathers during the last 3 months prior to conception and pregnancy outcomes was explored by estimating odds ratios (ORs) using multivariate logistic regression.

RESULTS

About one quarter (26%) of the fathers were dispensed at least one drug during the last 3 months prior to conception and 1.3% were dispensed at least one drug requiring special attention. Overall, the odds of different adverse pregnancy outcomes were not increased when the father had been dispensed drugs, i.e. the OR and 95% confidence intervals (CIs) for any birth defect when the fathers had been dispensed any drug were 0.99 (0.94, 1.0). When the fathers had been dispensed diazepam we found increased risk of perinatal mortality and growth retardation, with OR and 95% CIs of 2.2 (1.2, 3.9) and 1.4 (1.2, 1.6), respectively.

CONCLUSIONS

Large studies are necessary to reveal increased risk of rare outcomes as specific birth defects. Our study did not indicate that paternal drug exposure is an important risk factor for adverse pregnancy outcomes.

Paternal drug use: before and during pregnancy

OBJECTIVE

Exploratory investigation on drug use by fathers before and during pregnancy with regard to the number of pregnancies.

RESEARCH DESIGN AND METHODS

Data of Dutch community pharmacies were used in which fathers were linked to children. The prevalence of the 15 most prescribed drug groups were calculated per trimester for one trimester preconception and three trimesters during pregnancy. Drugs with possible harmful effect on the semen and/or embryo based on recent safety issues were analyzed for two trimesters before conception. Descriptive statistics was used.

RESULTS

During the four trimesters, fathers had used one or more drugs in 73% of the pregnancies. Per trimester, drug use ranged from 35 to 39%, with the highest prevalence in the third trimester, statistically significant for the use of one or two drugs. Drugs used most frequently belong to 'anti-inflammatory and antirheumatic products'. Drugs such as SSRIs with possible harmful effect on the semen and/or embryo are used in 1.4% by fathers before conception.

CONCLUSION

A proportion of 73% of fathers used drugs before and during pregnancy, increasing toward the third trimester. To increase the knowledge on possible effects, organizations like EUROCAT and (EN)(O)TIS might be encouraged to also collect paternal drug use.