Diabetes, medical comorbidities and couple fecundity

Effects of diabetes mellitus on sperm quality and fertility outcomes: Clinical evidence

BACKGROUND

Diabetes mellitus is a global epidemic characterized by high morbidity and mortality. Diabetes mellitus can lead to acute and chronic systemic complications. Among them, a negative effect of diabetes mellitus on sperm quality and male/couple fertility has been suggested. However, available studies in diabetes mellitus men evaluated relatively small cohorts with discordant results.

OBJECTIVES

To evaluate the clinical evidences of the effects of diabetes mellitus on sperm quality and fertility outcomes.

METHODS

An extensive Medline search was performed identifying studies in the English language.

RESULTS

The prevalence of diabetes mellitus in infertile men ranges from 0.7% to 1.4%, while the prevalence of infertility in diabetes mellitus men, evaluated in a few studies, ranges from 35% to 51%. Male diabetes mellitus seems to play a negative effect on couple fecundity, while being childless or subfertile men might increase the risk of diabetes mellitus. Available cross-sectional studies investigating semen parameters and male sexual hormones in men with diabetes mellitus are heterogeneous, assessed relatively small cohorts, show often discordant results and frequently are not directly comparable to derive robust conclusions. Two meta-analyses support a negative effect of diabetes mellitus on sperm normal morphology and no effect on sperm total count, with contradictory results regarding other semen parameters. Considering only studies on type 1 diabetes mellitus men, meta-analyses support a negative effect of diabetes mellitus on sperm motility and no effect on sperm total count, with contradictory results regarding other semen parameters. The rate of children observed among type 1 diabetes mellitus men was lower than controls, especially in subjects with a longer diabetes mellitus duration. Couples with a diabetes mellitus male partner undergoing assisted reproduction techniques showed lower pregnancy rates than controls. No study evaluated the impact of diabetes mellitus treatment on semen quality and male fertility.

CONCLUSIONS

Overall, available data show that diabetes mellitus might impair male reproductive health and couple fertility. However, further larger and full of details studies are needed.

Gut-Testis Axis: Microbiota Prime Metabolome To Increase Sperm Quality in Young Type 2 Diabetes

Young type 2 diabetes (T2D) affects 15% of the population, with a noted increase in cases, and T2D-related male infertility has become a serious issue in recent years. The current study aimed to explore the improvements of alginate oligosaccharide (AOS)-modified gut microbiota on semen quality in T2D. The T2D was established in young mice of 5 weeks of age with a blood glucose level of 21.2 ± 2.2 mmol/L, while blood glucose was 8.7 ± 1.1 mM in control animals. We discovered that fecal microbiota transplantation (FMT) of AOS-improved microbiota (A10-FMT) significantly decreased blood glucose, while FMT of gut microbiota from control animals (Con-FMT) did not. Sperm concentration and motility were decreased in T2D to 10% to 20% of those in the control group, while A10-FMT brought about a recovery of around 5- to 10-fold. A10-FMT significantly increased small intestinal Allobaculum, while it elevated small intestinal and cecal Lactobacillus in some extent, blood butyric acid and derivatives and eicosapentaenoic acid (EPA), and testicular docosahexaenoic acid (DHA), EPA, and testosterone and its derivatives. Furthermore, A10-FMT improved liver functions and systemic antioxidant environments. Most importantly, A10-FMT promoted spermatogenesis through the improvement in the expression of proteins important for spermatogenesis to increase sperm concentration and motility. The underlying mechanisms may be that A10-FMT increased gut-beneficial microbes Lactobacillus and Allobaculum to elevate blood and/or testicular butyric acid, DHA, EPA, and testosterone to promote spermatogenesis and thus to ameliorate sperm concentration and motility. AOS-improved gut microbes could emerge as attractive candidates to treat T2D-diminished semen quality. IMPORTANCE A10-FMT benefits gut microbiota, liver function, and systemic environment via improvement in blood metabolome, consequently to favor the testicular microenvironment to improve spermatogenesis process and to boost T2D-diminished semen quality. We established that AOS-improved gut microbiota may be used to boost T2D-decreased semen quality and metabolic disease-related male subfertility.

The current situation and future directions for the study on time-to-pregnancy: a scoping review

Introduction

As problems associated with infertility and population aging increase, there is a growing interest in the factors that cause a decline in human fertility. Time-to-pregnancy (TTP) is a good indicator with which to reflect human fecundability. Here, we present a comprehensive overview of this topic.

Methods

Relevant qualitative and quantitative studies were identified by searching the Web of science and PubMed electronic databases. We included all literature, written in English, from inception to the 10th April 2021 providing the focus was on TTP. We conducted a narrative synthesis using thematic analysis.

Results

Traditional TTP-related study protocols include prospective and retrospective cohorts that provide a wealth of data to reveal potential influences on TTP. Thus far, a variety of factors have been shown to be associated with TTP in couples preparing for pregnancy, including basic demographic characteristics, menstrual status, chronic disease status, environmental endocrine disruptor exposure, and lifestyles. However, there are inevitable epidemiological bias in the existing studies, including recall bias, selection bias and measurement bias. Some methodological advances have brought new opportunities to TTP research, which make it possible to develop precision interventions for population fertility. Future TTP studies should take advantage of artificial intelligence, machine learning, and high-throughput sequencing technologies, and apply medical big data to fully consider and avoid possible bias in the design.

Conclusion

There are many opportunities and future challenges for TTP related studies which would provide a scientific basis for the “precise health management” of the population preparing for pregnancy.

As the problems of infertility and population aging increase, there is a growing interest in the factors that cause a decline in human fertility. Time-to-pregnancy (TTP) is a good indicator with which to reflect human fecundability, and a longer TTP is known to reflect a reduction in fertility. Many original studies, with different designs, have used TTP to explore the factors that might influence fertility, including basic demographic characteristics, chronic disease status, environmental endocrine disruptor exposure, and lifestyles. However, much of the existing evidence is inconsistent and limited by various types of bias. This review provides a synopsis of recent TTP studies, and highlights new opportunities and future challenges.

Preconception Antidiabetic Drugs in Men and Birth Defects in Offspring : A Nationwide Cohort Study

BACKGROUND

Diabetes reduces semen quality and increasingly occurs during reproductive years. Diabetes medications, such as metformin, have glucose-independent effects on the male reproductive system. Associations with birth defects in offspring are unknown.

OBJECTIVE

To evaluate whether the risk for birth defects in offspring varies with preconceptional pharmacologic treatment of fathers with diabetes.

DESIGN

Nationwide prospective registry-based cohort study.

SETTING

Denmark from 1997 to 2016.

PARTICIPANTS

All liveborn singletons from mothers without histories of diabetes or essential hypertension.

MEASUREMENTS

Offspring were considered exposed if their father filled 1 or more prescriptions for a diabetes drug during the development of fertilizing sperm. Sex and frequencies of major birth defects were compared across drugs, times of exposure, and siblings.

RESULTS

Of 1 116 779 offspring included, 3.3% had 1 or more major birth defects (reference). Insulin-exposed offspring (n = 5298) had the reference birth defect frequency (adjusted odds ratio [aOR], 0.98 [95% CI, 0.85 to 1.14]). Metformin-exposed offspring (n = 1451) had an elevated birth defect frequency (aOR, 1.40 [CI, 1.08 to 1.82]). For sulfonylurea-exposed offspring (n = 647), the aOR was 1.34 (CI, 0.94 to 1.92). Offspring whose fathers filled a metformin prescription in the year before (n = 1751) or after (n = 2484) sperm development had reference birth defect frequencies (aORs, 0.88 [CI, 0.59 to 1.31] and 0.92 [CI, 0.68 to 1.26], respectively), as did unexposed siblings of exposed offspring (3.2%; exposed vs. unexposed OR, 1.54 [CI, 0.94 to 2.53]). Among metformin-exposed offspring, genital birth defects, all in boys, were more common (aOR, 3.39 [CI, 1.82 to 6.30]), while the proportion of male offspring was lower (49.4% vs. 51.4%, P = 0.073).

LIMITATION

Information on underlying disease status was limited.

CONCLUSION

Preconception paternal metformin treatment is associated with major birth defects, particularly genital birth defects in boys. Further research should replicate these findings and clarify the causation.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Impact of governmental support to the IVF clinical pregnancy rates: differences between public and private clinical settings in Kazakhstan-a prospective cohort study

OBJECTIVES

Infertility rates have been increasing in low-income and middle-income countries, including Kazakhstan. The need for accessible and affordable assisted reproductive technologies has become essential for many subfertile women. We aimed to explore whether the public funding and clinical settings are independently associated with in vitro fertilisation (IVF) clinical pregnancy and to determine whether the relationship between IVF clinical pregnancy and clinical settings is modified by payment type.

DESIGN

A prospective cohort study.

SETTING

Three private and two public IVF clinics located in major cities.

PARTICIPANTS

Women aged ≥18 seeking first or repeated IVF treatment and agreed to complete a survey were included in the study. Demographical and previous medical history data were collected from a survey, while clinical data from medical records. The total response rate was 14%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical pregnancy was defined as a live intrauterine pregnancy identified by ultrasound scan at 8 gestational weeks. The outcome data were missing for 22% of women.

RESULTS

Out of 446 women in the study, 68.2% attended private clinics. Two-thirds of women attending public clinics and 13% of women attending private clinics were publicly funded. Private clinics retrieved, on average, a higher number of oocytes (11.5±8.4 vs 8.1±7.2, p<0.001) and transferred more embryos (2.2±2.5 vs 1.4±1.1, p<0.001) and had a statistically significantly higher pregnancy rate compared with public clinics (79.0% vs 29.7%, p<0.001). Publicly funded women had on average a higher number of oocytes retrieved and a statistically significantly higher probability of clinical pregnancy (RR=1.23, 95% CI 1.02 to 1.47) than self-paid women, after adjusting for covariates. There was no statistically significant interaction between clinical setting and payment type.

CONCLUSIONS

Private clinics and public funding were independently associated with higher IVF clinical pregnancy rates. There is also a need to further investigate whether the increase in public funding will influence clinical pregnancy rates.

Inherited Metabolic Memory of High-fat Diet Impairs Testicular Fatty Acid Content and Sperm Parameters

Exposure to a high-fat diet (HFD) from early-life is associated with a testicular metabolic signature linked to abnormal sperm parameters up to two generations after exposure in mice. Hereby, we describe a testicular lipid signature associated with "inherited metabolic memory" of exposure to HFD, persisting up to two generations in mice. Diet-challenged mice (n = 36) were randomly fed after weaning with standard chow (CTRL); HFD for 200 days or transient HFD (HFD_t ) (60 days of HFD+140 days of standard chow). Subsequent generations (36 mice per generation) were fed with chow diet. Mice were euthanized 200 days post-weaning. Glucose homeostasis, serum hormones, testicular bioenergetics and antioxidant enzyme activity were evaluated. Testicular lipid-related metabolites and fatty acids were characterized by ¹ H-NMR and GC-MS. Sons of HFD display impaired choline metabolism, mitochondrial activity and antioxidant defenses, while grandsons show a shift in testicular ω3/ω6 ratio towards a pro-inflammatory environment. Grandsons of HFDt raise 3-hydroxybutyrate levels with possible implications to testicular insulin resistance. Sperm counts decrease in grandsons of HFD-exposed mice, regardless of the duration of exposure. HFD-induced "inherited metabolic memory" alters testicular fatty acid metabolism with consequences to sperm parameters up to two generations. This article is protected by copyright. All rights reserved.

Fertility outcomes in women with pre-existing type 2 diabetes-a prospective cohort study

OBJECTIVE

To study childbirth and the risk of miscarriage and infertility among women who have received a diagnosis of type 2 diabetes before the start of their reproductive journey.

DESIGN

Register-based cohort study using the Skåne Healthcare Register SETTING: All healthcare visits for the whole population of the southernmost region in Sweden over the past 20 years PATIENT(S): All women who were aged 18-45 years between January 1, 1998 and December 31, 2019 and who received a clinical diagnosis of type 2 diabetes before their first childbirth, miscarriage, or infertility diagnosis (n = 230) were compared with a healthcare-seeking population of women without any type of diabetes, matched for calendar year and age (n = 179,434).

INTERVENTION(S)

None MAIN OUTCOME MEASURE(S): Childbirth, miscarriage, and infertility diagnosis RESULT(S): The birthrate was lower among women with type 2 diabetes (62.6% vs. 83.8%), and they were less likely to give birth (crude risk ratio [RR] = 0.73, 95% confidence interval [CI]: 0.66-0.81). They had a higher risk of experiencing a miscarriage (RR = 1.88, 95% CI: 1.50-2.36). The risk of infertility was increased (RR = 3.44, 95% CI: 2.88-4.10) as was the risk of having infertility and not giving birth (RR = 4.47, 95% CI: 3.44-5.82). All results remained the same after adjustment for polycystic ovary syndrome and obesity.

CONCLUSION(S)

Women with type 2 diabetes with onset before their reproductive journey were more often childless compared with women without diabetes and had a higher risk of experiencing both miscarriage and infertility. This patient group may be in need of targeted information regarding potential fertility issues as part of their clinical treatment.

Genes Regulating Spermatogenesis and Sperm Function Associated With Rare Disorders

Spermatogenesis is a cell differentiation process that ensures the production of fertilizing sperm, which ultimately fuse with an egg to form a zygote. Normal spermatogenesis relies on Sertoli cells, which preserve cell junctions while providing nutrients for mitosis and meiosis of male germ cells. Several genes regulate normal spermatogenesis, some of which are not exclusively expressed in the testis and control multiple physiological processes in an organism. Loss-of-function mutations in some of these genes result in spermatogenesis and sperm functionality defects, potentially leading to the insurgence of rare genetic disorders. To identify genetic intersections between spermatogenesis and rare diseases, we screened public archives of human genetic conditions available on the Genetic and Rare Diseases Information Center (GARD), the Online Mendelian Inheritance in Man (OMIM), and the Clinical Variant (ClinVar), and after an extensive literature search, we identified 22 distinct genes associated with 21 rare genetic conditions and defective spermatogenesis or sperm function. These protein-coding genes regulate Sertoli cell development and function during spermatogenesis, checkpoint signaling pathways at meiosis, cellular organization and shape definition during spermiogenesis, sperm motility, and capacitation at fertilization. A number of these genes regulate folliculogenesis and oogenesis as well. For each gene, we review the genotype–phenotype association together with associative or causative polymorphisms in humans, and provide a description of the shared molecular mechanisms that regulate gametogenesis and fertilization obtained in transgenic animal models.

Anything New about Paternal Contribution to Reproductive Outcomes? A Review of the Evidence

Paternal health and behavioral lifestyles affect reproductive and neonatal outcomes and yet the magnitude of these effects remain underestimated. Even though these impacts have been formally recognized as a central aspect of reproductive health, health care services in Europe often neglect the involvement of fathers in their reproductive programs. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews, a literature search was carried out to assess the possible impact of paternal health on reproductive outcomes. The comprehensive strategy included cohort studies and meta-analysis available on PubMed, Web of Science, CINAHL, and Google scholar. Cross-referencing of bibliographies of the selected papers ensured wider study capture. Paternal factors were grouped into two categories respectively identified with the terms "Biological Paternal Factors" and "Lifestyle Paternal Factors". Advanced age may impair male fertility and affect early pregnancy stages. Increased body mass index, smoking, alcohol and recreational drugs, all alter seminal fluid parameters. Hazardous alcohol use correlates with low birthweight in pregnancy and harmful behavioral lifestyles have been linked to congenital heart defects, metabolic and neurodevelopmental disorders in the offspring. Measures targeting paternal health and lifestyle within the first 1,000 days' timeframe need to be implemented in couples undergoing reproductive decisions. Health professionals, as well as future fathers, must be aware of the benefits for the offspring associated with correct paternal behaviors. More research is needed to build guidelines and to implement specific programs aiming at reproductive health promotion.

Metabolic diseases affect male reproduction and induce signatures in gametes that may compromise the offspring health

The most prevalent diseases worldwide are non-communicable such as obesity and type 2 diabetes. Noteworthy, the prevalence of obesity and type 2 diabetes is expected to steadily increase in the next decades, mostly fueled by bad feeding habits, stress, and sedentarism. The reproductive function of individuals is severely affected by abnormal metabolic environments, both at mechanical and biochemical levels. Along with mechanical dysfunctions, and decreased sperm quality (promoted both directly and indirectly by metabolic abnormalities), several studies have already reported the potentially harmful effects of metabolic disorders in the genetic and epigenetic cargo of spermatozoa, and the epigenetic inheritance of molecular signatures induced by metabolic profile (paternal diet, obesity, and diabetes). The inheritance of epigenetic factors towards the development of metabolic abnormalities means that more people in reproductive age can potentially suffer from these disorders and for longer periods. In its turn, these individuals can also transmit this (epi)genetic information to future generations, creating a vicious cycle. In this review, we collect the reported harmful effects related to acquired metabolic disorders and diet in sperm parameters and male reproductive potential. Besides, we will discuss the novel findings regarding paternal epigenetic inheritance, particularly the ones induced by paternal diet rich in fats, obesity, and type 2 diabetes. We analyze the data attained with in vitro and animal models as well as in long-term transgenerational population studies. Although the findings on this topic are very recent, epigenetic inheritance of metabolic disease has a huge societal impact, which may be crucial to tackle the 'fat epidemic' efficiently.

Diet during early life defines testicular lipid content and sperm quality in adulthood

Childhood obesity is a serious concern associated with ill health later in life. Emerging data suggest that obesity has long-term adverse effects upon male sexual and reproductive health, but few studies have addressed this issue. We hypothesized that exposure to high-fat diet during early life alters testicular lipid content and metabolism, leading to permanent damage to sperm parameters. After weaning (day 21 after birth), 36 male mice were randomly divided into three groups and fed with a different diet regimen for 200 days: a standard chow diet (CTRL), a high-fat diet (HFD) (carbohydrate: 35.7%, protein: 20.5%, and fat: 36.0%), and a high-fat diet for 60 days, then replaced by standard chow (HFD_t). Biometric and metabolic data were monitored. Animals were then euthanized, and tissues were collected. Epididymal sperm parameters and endocrine parameters were evaluated. Testicular metabolites were extracted and characterized by 1H-NMR and GC-MS. Testicular mitochondrial and antioxidant activity were evaluated. Our results show that mice fed with a high-fat diet, even if only until early adulthood, had lower sperm viability and motility, and higher incidence of head and tail defects. Although diet reversion with weight loss during adulthood prevents the progression of metabolic syndrome, testicular content in fatty acids is irreversibly affected. Excessive fat intake promoted an overaccumulation of proinflammatory n-6 polyunsaturated fatty acids in the testis, which is strongly correlated with negative effects upon sperm quality. Therefore, the adoption of high-fat diets during early life correlates with irreversible changes in testicular lipid content and metabolism, which are related to permanent damage to sperm quality later in life.

Sub-fecundity and associated factors among mothers with natural planned conception attending antenatal care service in Arba Minch Health Facilities

Background

Fecundity is a physiological ability to have children. The inability to get the desired child which was commonly caused by the prolonged time to conceive due to unwanted non-conception period increased from time to time. As a result, many couples are developing psychological, social, and economic problems and unstable life. However, information on fecundity status is limited in Ethiopia context. Therefore, this study aimed to assess the proportion of sub-fecundity and associated factors in Ethiopia context.

Methods

A health institution based cross-sectional study was conducted in Arba Minch health facilities from March 25 to April 25, 2020. By using a systematic sampling method, 539 mothers were selected for the study. Structured questionnaire was used for data collection. A binary logistic regression model was used to identify factors associated with the sub-fecundity. Variables with p-value <0.25 in the bi-variable logistic regression analysis were interred and checked for association in a multivariable logistic regression model. The level of statistical significance was declared at p-value <0.05.

Result

The proportion of sub-fecundity was 17.8% with 95%CI (14.8%-21.3%). Mothers’ age ≥ 30 (AOR = 2.54, 95%CI; 1.18–5.48), partners’ age ≥ 35 (AOR = 2.20, 95%CI; 1.01–4.75), coffee consumption of ≥ 4 cups/day (AOR = 2.93, 95%CI; 1.14–7.53), menses irregularity (AOR = 3.79 95%CI; 2.01–7.14) and coital frequency of 1day/week (AOR = 3.65, 95%CI; 1.47–9.05) were significantly associated with the sub-fecundity.

Conclusion

This study found that a substantial proportion of mothers were sub-fecund. Factors that contributed to the sub-fecundity were pre-pregnancy; mothers’ age, partners’ age, coffee drinking of ≥ 4 cups/day, coital frequency of 1day/week, and menses irregularity. Thus, efforts to prevent sub-fecundity should focus on awareness creation as to plan to conceive at early age, reducing coffee consumption, increasing days of coital frequency per week, and investigating and treating mothers with irregular menses.

Plasma glycemic measures and fecundability in a Singapore preconception cohort study

OBJECTIVE

To examine the association between plasma glycemia in women attempting to conceive and fecundability, as measured by time to pregnancy.

DESIGN

Prospective preconception population-based study.

SETTING

Hospital.

PATIENT(S)

Asian preconception women, 18-45 years old, attempting conception for ≤12 cycles at study entry.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

We ascertained time to pregnancy within a year of glycemic assessment in menstrual cycles. We estimated fecundability ratios (FRs) and 95% confidence intervals using discrete-time proportional hazards models, adjusting for age, ethnicity, education, body mass index, and cycle regularity and accounting for left truncation and right censoring.

RESULT(S)

We studied a population sample of 766 women from the Singapore Preconception Study of Long-Term Maternal and Child Outcomes prospective cohort. Compared with women with normoglycemia, women with dysglycemia (prediabetes and diabetes, defined by the American Diabetes Association) had a lower FR (0.56). Compared with the respective lowest quintiles, women in the highest quintile of fasting glucose (≥5.1 mmol/L) had an FR of 0.60, while women in the highest 2-hour postload glucose quintile (≥6.9 mmol/L) had an FR of 0.66. Overall, the FRs decreased generally across the range of fasting and 2-hour plasma glucose. Glycated hemoglobin was not associated with fecundability.

CONCLUSION(S)

Increasing preconception plasma glucose is associated with reduced fecundability, even within the normal range of glucose concentrations.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03531658.

Pre-pregnancy maternal fasting plasma glucose levels in relation to time to pregnancy among the couples attempting first pregnancy

STUDY QUESTION

What is the relationship between pre-pregnancy maternal glucose levels and fecundability in Chinese couples?

SUMMARY ANSWER

Elevated pre-pregnancy maternal glucose levels were associated with fecundability, as reflected by prolonged time to pregnancy (TTP) among the couples with no prior gravidity.

STUDY DESIGN, SIZE, DURATION

Based on the National Free Pre-conception Check-up Projects supported by the Chinese government, 2 226 048 eligible couples attempting first pregnancy and participating in the project from 2015 to 2016 were included. They were followed-up for 1 year or until they reported pregnancy.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

The Kaplan–Meier method was used to estimate the cumulative pregnancy rate in each menstrual cycle, and the discrete-time analogue of the Cox models was used to estimate the fecundability odds ratios (FORs) and 95% CIs by different pre-pregnancy maternal glucose levels (impaired fasting glucose (IFG) or diabetes as compared to normal).

MAIN RESULTS AND THE ROLE OF CHANCE

The cumulative pregnancy rate for 12 cycles of the normal fasting plasma glucose (FPG) level group was 42.29%, significantly higher than that of the IFG (35.52%) and diabetes groups (31.52%). After adjusting for confounding factors, the FORs were 0.82 (95% CI: 0.81–0.83) and 0.74 (95% CI: 0.72–0.76) for the IFG and diabetes groups, respectively, as compared to the normal group. The association between pre-pregnancy maternal FPG levels and the FORs was non-linear, and the optimal FPG level for greatest fecundability (shortest TTP) was 3.90–4.89 mmol/L.

LIMITATIONS, REASONS FOR CAUTION

The findings from this register-based cohort study require cautious interpretation given that information bias would be inevitable for single FPG measurements and for TTP calculations that were based on telephone follow-up information. Additionally, because couples who achieved pregnancy during their first menstrual cycle in the study were excluded, the pregnancy rates reported were low and possibly biased.

WIDER IMPLICATIONS OF THE FINDINGS

The current report suggests that elevated pre-pregnancy maternal glucose levels were associated with prolonged TTP. Early evaluation and preventive treatment for female partners with IFG or diabetes in a pre-pregnancy examination are necessary.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by the National Key Research and Development Program of China (grants No. 2016YFC1000300 and 2016YFC1000307), the National Natural Science Foundation of China (grant No. 81872634), the CAMS Innovation Fund for Medical Sciences (grant No. 2018-I2M-1-004), the National Human Genetic Resources Sharing Service Platform (grant No. 2005DKA21300) and the National Population and Reproductive Health Science Data Center (grant No. 2005DKA32408), People’s Republic of China. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A

[Andrological diagnostics prior to treatment by assisted reproduction]

Infertility is defined as the inability of a couple to succeed in achieving a spontaneous pregnancy after 1 year. Male and female factors contribute to infertility with approximately 40% each. In the remaining cases factors that affect fertility can be found in both partners. The andrological work-up should be started simultaneously with the gynecological diagnostic procedure in order to identify and treat andrological factors related to infertility. Since the majority of intracytoplasmic sperm injection procedures are performed due to andrological infertility, andrological diagnostics can prevent a delay in assisted reproductive technology. The andrological work-up can be necessary before 12 months of unsuccessful conception if the female partner is older than 35 years or andrological factors are present that could impair male fertility.

Underutilization of primary medical care among men presenting for fertility evaluation

Objective

To determine the proportion of men presenting for fertility evaluation who reported having an established primary care physician (PCP).

Design

Retrospective, observational study.

Setting

Academic health center.

Patient(s)

All men presenting for initial male factor infertility consultation with a single reproductive urologist between 2002 and 2018.

Intervention(s)

Men were asked to provide the name of their PCP at the time of initial visit.

Main Outcome Measure(s)

Descriptive statistics characterized the proportion of men with a PCP at the time of evaluation and associations between PCP status and clinical characteristics.

Result(s)

Among 4,127 men presenting for initial fertility consultation, 844 (20.5%) reported having an established PCP, 480 (11.6%) reported no PCP, and 2,803 (67.9%) did not have data available. Among 1,302 men who had a prior primary care visit within our healthcare system, 414 (31.8%) had been seen within 1 year before their fertility evaluation. Men with an established PCP were slightly older than those without a PCP, with higher body mass index, and lower systolic blood pressure. Hormonal profiles were similar across groups, but men with an established PCP had a significantly higher total motile sperm count than those without a PCP, median 53 (interquartile range, 11–109) versus 35 (interquartile range, 8–98).

Conclusion(s)

More than one third of men presenting for fertility evaluation did not have an established PCP. Reproductive urologists are uniquely positioned to facilitate the critical relationship between young men and PCPs, which should be a key component of the male fertility treatment paradigm.

Optimal Endocrine Evaluation and Treatment of Male Infertility

This article aims to define the optimal endocrine workup of male factor infertility, including evaluation and treatment of men who have previously been on exogenous testosterone or anabolic steroids. Future directions include the expansion of genetic testing for infertility to include endocrine gene products.

Preconception blood pressure and time to pregnancy among couples attempting to conceive their first pregnancy

BACKGROUND

The association of abnormal blood pressure levels (including hypertension and prehypertension) with reduced fecundability among young childbearing-age couples is not yet elucidated completely.

OBJECTIVE

The purpose of this study was to investigate the association between abnormal preconception blood pressure level and time to pregnancy among couples who are attempting to conceive their first pregnancy.

STUDY DESIGN

A total of 2,234,350 eligible couples (with no previous gravidity and whose female partners were 20-49 years old) participated in the National Free Preconception Check-up Projects from January 1, 2015, to December 31, 2016. Each couples' preconception blood pressure levels were measured, and time to pregnancy was recorded. Cox models for discrete survival time were used to estimate fecundability odds ratios and their corresponding 95% confidence intervals after adjustment for age, ethnicity, educational level, occupation, household registration, region, tobacco exposure, alcohol intake, body mass index, duration of marriage of the couples, and fasting plasma glucose levels of the female partner.

RESULTS

Compared with normotensive women, those women with hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) had a 21% lower pregnancy rate (fecundability odds ratio, 0.79; 95% confidence interval, 0.78-0.81). A similar finding was found among men (fecundability odds ratio, 0.89; 95% confidence interval, 0.88-0.90). Prehypertension (systolic blood pressure between 120 and 139 mm Hg, and/or a diastolic blood pressure between 80 and 89 mm Hg) in both male and female partners was associated slightly with reduced fecundability odds ratios. Compared with couples in which both partners were normotensive, the pregnancy rate was reduced by 27% (fecundability odds ratio, 0.73; 95% confidence interval, 0.69-0.77) among couples in which both partners had hypertension.

CONCLUSION

Abnormal preconception blood pressure levels were associated with prolonged time to pregnancy among couples who were attempting to conceive their first pregnancy; the mechanism is worth further investigation.

In vitro fertilization, interpregnancy interval, and risk of adverse perinatal outcomes

OBJECTIVE

To compare associations between interpregnancy intervals (IPIs) and adverse perinatal outcomes in deliveries following IVF with deliveries following spontaneous conception or other (non-IVF) fertility treatments.

DESIGN

Cohort using linked birth certificate and assisted reproductive technology surveillance data from Massachusetts and Michigan.

SETTING

Not applicable.

PATIENT(S)

1,225,718 deliveries.

INTERVENTION(S)

None.

MAIN OUTCOMES MEASURE(S)

We assessed associations between IPI and preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA) according to live birth or nonlive pregnancy outcome in the previous pregnancy.

RESULT(S)

In IVF deliveries following previous live birth, risk of PTB was 22.2% for IPI 12 to <24 months (reference); risk of PTB was higher for IPI <12 months (adjusted relative risk [aRR] 1.24, 95% confidence interval [CI] 1.09-1.41) and IPI ≥60 months (aRR 1.12, 95% CI 1.00-1.26). In non-IVF deliveries following live birth, risk of PTB was 6.4% for IPI 12 to <24 months (reference); risk of PTB was higher for IPI <12 and ≥60 months (aRR 1.19, 95% CI 1.16-1.21, for both). In both populations, U-shaped or approximately U-shaped associations were observed for SGA and LBW, although the association of IPI <12 months and SGA was not significant in IVF deliveries. In IVF and non-IVF deliveries following nonlive pregnancy outcome, IPI <12 months was not associated with increased risk of PTB, LBW, or SGA, but IPI ≥60 months was associated with significant increased risk of those outcomes in non-IVF deliveries.

CONCLUSION(S)

Following live births, IPIs <12 or ≥60 months were associated with higher risks of most adverse perinatal outcomes in both IVF and non-IVF deliveries.

High Blood Pressure Is a Highly Prevalent but Unrecognised Condition in Primary Infertile Men: Results of a Cross-sectional Study

BACKGROUND

Although most of the components related to metabolic syndrome were shown to have a detrimental effect on male fertility, the effects of high blood pressure (HBP) have been partially analysed.

OBJECTIVE

To investigate the prevalence and impact of hypertension on clinical and semen parameters in a cohort of white European men presenting for couple's infertility at a single tertiary referral academic centre.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was performed including analysis of data from 2185 primary infertile men. Comorbidities were scored with Charlson Comorbidity Index (CCI; categorised 0 vs ≥1). HBP was defined as blood pressure ≥140/90mmHg. Semen analyses followed the 2010 World Health Organization reference criteria.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Descriptive statistics and logistic regression analyses tested the association among semen parameters, clinical characteristics, and HBP.

RESULTS AND LIMITATIONS

Overall, HBP was found in 6.8% of infertile patients and in 3.6% of age-comparable men without known fertility problems. Of 148 patients, 85 (58%) were either unaware of their HBP or not adequately medically-controlled. +HBP men were older (median age [interquartile range], 37 [33-40] vs 39 [36-44] yr; p<0.001), had higher CCI scores (X₂=25.6; p<0.001), higher BMI (25.1 [23.3-27.3] vs 26.8 [24.9-29.4]; p<0.001), and a waist circumference >102cm in a greater proportion of individuals (41% vs 23%; X₂=4.68 p<0.05) than -HBP men. Hypertensive and normotensive men did not differ in terms of hormonal milieu and semen parameters. Patients did not differ in terms of HPB rates according to oligozoospermia, asthenozoospermia, and teratozoospermia status. The lack of a real control group represents the main limitation of the study.

CONCLUSIONS

Hypertension and unrecognised or not adequately controlled HBP are highly prevalent among white European primary infertile men. Hypertension per se did not have an impact on hormonal and semen parameters.

PATIENT SUMMARY

Because of its effects in terms of overall prospective men's health, high blood pressure must be comprehensively considered over the basic work-up of every infertile man in the outpatient clinic setting.

Parental health status and infant outcomes: Upstate KIDS Study

OBJECTIVE

To assess parental health status inclusive of infertility and infant outcomes.

DESIGN

Birth cohort with cross-sectional analysis of parental health status and infant outcomes.

SETTING

Not applicable.

PATIENT(S)

Parents (n = 4,886) and infants (n = 5,845) participating in the Upstate KIDS birth cohort.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Infertility was defined as [1] sexually active without contraception for 1+ years without pregnancy, [2] ever requiring ≥12 months to become pregnant, and [3] requiring ≥12 months for index pregnancy. Multivariable linear regression with generalized estimating equations estimated the change (β coefficient and 95% confidence interval [CI]) in infant outcomes (gestation, birthweight, length, head circumference, ponderal index) and relative to each disease, including infertility after adjusting for age, body mass index, and infertility treatment.

RESULT(S)

Prevalence of parental chronic diseases ranged from <1% to 19%, and 21% to 54% for infertility. Maternal hypertension was negatively associated with gestation (β, -0.64; 95% CI, -1.03, -0.25) and birthweight (-151.98; -262.30, -41.67) as was asthma and birthweight (-75.01; -130.40, -19.62). Maternal kidney disease was associated with smaller head circumference (-1.09; -2.17, -0.01), whereas paternal autoimmune disease was associated with larger head circumference (0.87; 0.15, 1.60). Infertility was negatively associated with birthweight (-62.18; -103.78, -20.58), length (-0.33; -0.60, -0.06), and head circumference (-0.35; -0.67, -0.03).

CONCLUSION(S)

Infertility was significantly associated with reduced infant size even after accounting for infertility treatment, although the magnitude of reduction varied by definition of infertility. Absence of pregnancy within a year of being at risk may be informative about health.

Personalized Therapy Against Preeclampsia by Replenishing Placental Protein 13 (PP13) Targeted to Patients With Impaired PP13 Molecule or Function

Hypertensive disorders affect about one third of all people aged 20 and above, and are treated with anti-hypertensive drugs. Preeclampsia (PE) is one form of such disorders that only develops during pregnancy. It affects ten million pregnant women globally and additionally causes fetal loss and major newborn disabilities. The syndrome's origin is multifactorial, and anti-hypertensive drugs are ineffective in treating it. Biomarkers are helpful for predict its development. Generic drugs, such as low dose aspirin, were proven effective in preventing preterm PE. However, it does not cure the majority of cases and many studies are underway for fighting PE with extended use of additional generic drugs, or through new drug development programs. This review focuses on placental protein 13 (PP13). This protein is only expressed in the placenta. Impaired PP13 DNA structure and/or its reduced mRNA expression leads to lower blood PP13 level that predict a higher risk of developing PE. Two polymorphic PP13 variants have been identified: (1) The promoter PP13 variant with an "A/A" genotype in the -98 position (versus "A/C" or "C/C"). Having the "A/A" genotype is coupled to lower PP13 expression, mainly during placental syncytiotrophoblast differentiation and, if associated with obesity and history of previous preeclampsia, it accurately predicts higher risk for developing the disorder. (2) A thymidine deletion at position 221 causes a frame shift in the open reading frame, and the formation of an early stop codon resulting in the formation of DelT221, a truncated variant of PP13. In pregnant rodents, both short- and long- term replenishment of PP13 causes reversible hypotension and vasodilation of uterine vessels. Long-term exposure is also accompanied by the development of larger placentas and newborns. Also, only w/t PP13 is capable of inducing leukocyte apoptosis, providing maternal immune tolerance to pregnancy. Based on published data, we propose a targeted PP13 therapy to fight PE, and consider the design and conduct of animal studies to explore this hypothesis. Accordingly, a new targeted therapy can be implemented in humans combining prediction and prevention.

The sixth vital sign: what reproduction tells us about overall health. Proceedings from a NICHD/CDC workshop

STUDY QUESTION

Does the fertility status of an individual act as a biomarker for their future health?

SUMMARY ANSWER

Data support an association between reproductive health and overall health for men and women.

WHAT IS ALREADY KNOWN

Various chronic conditions, such as diabetes, obesity and cancer, can compromise fertility, but there are limited data for the converse situation, in which fertility status can influence or act as a marker for future health. Data reveal an association between infertility and incident cardiovascular disease and cancer in both men and women.

STUDY DESIGN SIZE AND DURATION

A National Institute of Child Health and Human Development-Centers for Disease Control and Prevention workshop in April 2016 was convened that brought together experts in both somatic diseases and conditions, and reproductive health. Goals of the workshop included obtaining information about the current state of the science linking fertility status and overall health, identifying potential gaps and barriers limiting progress in the field, and outlining the highest priorities to move the field forward.

PARTICIPANTS/MATERIALS SETTING AND METHODS

Approximately 40 experts participated in the workshop.

MAIN RESULTS AND THE ROLE OF CHANCE

While the etiology remains uncertain for infertility, there is evidence for an association between male and female infertility and later health. The current body of evidence suggests four main categories for considering biological explanations: genetic factors, hormonal factors, in utero factors, and lifestyle/health factors. These categories would be key to include in future studies to develop a comprehensive and possibly standardized look at fertility status and overall health. Several themes emerged from the group discussion including strategies for maximizing use of existing resources and databases, the need for additional epidemiologic studies and public health surveillance, development of strategies to frame research so results could ultimately influence clinical practice, and the identification of short and long-term goals and the best means to achieve them.

LIMITATIONS REASONS FOR CAUTION

Further research may not indicate an association between fertility status and overall health.

WIDER IMPLICATIONS OF THE FINDINGS

Currently medical care is compartmentalized. Reproductive medicine physicians treat patients for a short period of time before they transition to others for future care. Going forward, it is critical to take an interdisciplinary patient care approach that would involve experts in a broad range of medical specialties in order to more fully understand the complex interrelationships between fertility and overall health. If infertility is confirmed as an early marker of chronic disease then screening practices could be adjusted, as they are for patients with a family history of malignancy.

STUDY FUNDING/COMPETING INTERESTS

Funding for the workshop was provided by the Fertility and Infertility Branch, National Institute of Child Health and Human Development, National Institutes of Health and the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. There are no conflicts of interest to declare. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Institutes of Health.

TRIAL REGISTRATION NUMBER

Not applicable.