Subfertility and Gastrointestinal Disease: ???Unexplained??? Is Often Undiagnosed

Genetic Regulation of Transcription in the Endometrium in Health and Disease

The endometrium is a complex and dynamic tissue essential for fertility and implicated in many reproductive disorders. The tissue consists of glandular epithelium and vascularised stroma and is unique because it is constantly shed and regrown with each menstrual cycle, generating up to 10 mm of new mucosa. Consequently, there are marked changes in cell composition and gene expression across the menstrual cycle. Recent evidence shows expression of many genes is influenced by genetic variation between individuals. We and others have reported evidence for genetic effects on hundreds of genes in endometrium. The genetic factors influencing endometrial gene expression are highly correlated with the genetic effects on expression in other reproductive (e.g., in uterus and ovary) and digestive tissues (e.g., salivary gland and stomach), supporting a shared genetic regulation of gene expression in biologically similar tissues. There is also increasing evidence for cell specific genetic effects for some genes. Sample size for studies in endometrium are modest and results from the larger studies of gene expression in blood report genetic effects for a much higher proportion of genes than currently reported for endometrium. There is also emerging evidence for the importance of genetic variation on RNA splicing. Gene mapping studies for common disease, including diseases associated with endometrium, show most variation maps to intergenic regulatory regions. It is likely that genetic risk factors for disease function through modifying the program of cell specific gene expression. The emerging evidence from our gene mapping studies coupled with tissue specific studies, and the GTEx, eQTLGen and EpiMap projects, show we need to expand our understanding of the complex regulation of gene expression. These data also help to link disease genetic risk factors to specific target genes. Combining our data on genetic regulation of gene expression in endometrium, and cell types within the endometrium with gene mapping data for endometriosis and related diseases is beginning to uncover the specific genes and pathways responsible for increased risk of these diseases.

Potential biomarkers of infertility associated with microbiome imbalances

PROBLEM

The aim of this study was to investigate the possible relationship between vaginal/rectal microbiome disbalances and miRNA expression with infertility.

METHOD OF STUDY

Observational, exploratory, preliminary study. A total of 287 multiple IVF failure infertile patients were recruited. Twenty fertile women, not IVF failure, were recruited as the control group. Swab samples were collected from the vagina and rectum. Microbial composition by NGS and miRNA expression by real-time PCR of vaginal and rectal samples was measured. Immunometabolic markers from blood (insulin, vitamin D, LDL-cholesterol, ANA, TPO, Tg, and ASCA antibodies) and saliva (sIgA) were analyzed.

RESULT(S)

Infertile patients showed a lower bacterial richness and increased Firmicutes/Bacteroidetes ratio at rectal level and an increased Lactobacillus brevis/Lactobacillus iners ratio in vaginal samples regarding the fertile group. In the same rectal swab samples, we found that miR-21-5p, which is associated with tight junction disruption and yeast overgrowth, is upregulated and that miR-155-5p, which is associated with inflammation, is overexpressed in the unexplained infertile group (*p < .05). These deregulated miRNAs were also upregulated in the vaginal samples from the same patients (*p < .05).

CONCLUSION

miRNAs could be potential biomarkers of the inflammatory impact of microbiome disbalances in unexplained infertile women.

Pregnancy in a woman with a Fontan circulation: A review

More women with congenital heart disease survive to childbearing ages, due to improvements in surgical practice and postoperative care. This review discusses pregnancy in women with a single ventricle, describing maternal obstetric and cardiovascular complications and the increased risks of prematurity and adverse neonatal outcomes. Recommendations are made based on current understanding, guidelines and published literature, with recognition that there is much knowledge yet to be gained.

Do the causes of infertility play a direct role in the aetiology of preterm birth?

BACKGROUND

It is well established that singletons born of assisted reproductive technology are at higher risk of preterm birth and other adverse outcomes. What remains unclear is whether the increased risk is attributable to the effects of the treatment alone or whether the underlying causes of infertility also play a role. The aim of this study was to examine whether any of the six categories of causes of infertility were associated with a direct effect on preterm birth using causal mediation analysis.

METHODS

We assembled a hospital-based cohort of births delivered at a large tertiary care hospital in Montreal, Canada between 2001 and 2007. Causes of infertility were ascertained through a clinical database and medical chart abstraction. We employed marginal structural models (MSM) to estimate the controlled direct effect of each cause of infertility on preterm birth compared with couples without the cause under examination.

RESULTS

The final study cohort comprised 18,598 singleton and twin pregnancies, including 1689 in couples with ascertained infertility. MSM results suggested no significant direct effect for any of the six categories of causes. However, power was limited in smaller subgroup analyses, and a possible direct effect for uterine abnormalities (e.g. fibroids and malformations) could not be ruled out.

CONCLUSION

In this cohort, most of the increased risk of preterm birth appeared to be explained by maternal characteristics (such as age, body mass index, and education) and by assisted reproduction. If these findings are corroborated, physicians should consider these risks when counselling patients.

Screening for unrecognized coeliac disease in subfertile couples

OBJECTIVE

Subfertility has been reported as a long-term complication of unrecognized and/or untreated coeliac disease (CD); however, the results from studies on this topic are ambiguous. We aimed to determine the prevalence of unrecognized CD in subfertile male-female couples visiting a fertility clinic compared with the general population.

METHODS

Subjects included 1038 male-female couples (n = 2076) who visited the fertility clinic of the Leiden University Medical Center in the Netherlands between 2003 and 2009. All consecutive patients were routinely, serologically screened, and those with positive test results for antibodies against IgA anti-tissue transglutaminase type 2 and IgA endomysial antibodies were considered to have unrecognized CD. Clinical data on gender, age, height, weight, diagnosis of subfertility, and previously diagnosed CD were collected from the clinical files. Subsequently, after serological screening, all patients were anonymized. The prevalence of unrecognized CD was compared with the one in the general adult population in the Netherlands (0.35%).

RESULTS

The prevalence of unrecognized CD in subfertile male-female couples was 0.48% (10/2076; 6 females and 4 males) and was not significantly more frequent compared with the general population. Compared with the control group, similar CD prevalences were found within the different subfertility categories separately: unexplained subfertility, anovulation, tubal pathology, and male factor (p = NS).

CONCLUSION

In our large study cohort of subfertile male-female couples, the prevalence of unrecognized CD is comparable to the general population in the Netherlands. No association was observed between CD and subfertility in the different subfertility categories and genders.

Nonmalignant diseases and treatments associated with primary ovarian failure: an expanded role for fertility preservation

Cancer treatments can be detrimental to fertility; recent literature has focused on the efforts of fertility preservation for this patient population. It should be recognized, however, that several nonmalignant medical conditions and therapeutic interventions could be similarly hazardous to fertility. Some of these nonmalignant diseases and their treatments that can adversely impact the reproductive axis are gastrointestinal diseases, rheumatologic disorders, nonmalignant hematologic conditions, neurologic disorders, renal disorders, gynecologic conditions, and metabolic diseases. Their negative effects on reproductive function are only now being appreciated and include impaired ovarian function, endocrine function, or sexual function and inability to carry a pregnancy to term. Complications and comorbidities associated with certain diseases may limit the success of established fertility preservation options. Recent advances in fertility preservation techniques may provide these patients with new options for childbearing. Here, we review several fertility-threatening conditions and treatments, describe current established and experimental fertility preservation options, and present three initiatives that may help minimize the adverse reproductive effects of these medical conditions and treatments by raising awareness of the issues and options: (1) increase awareness among practitioners about the reproductive consequences of specific diseases and treatments, (2) facilitate referral of patients to fertility-sparing or restorative programs, and (3) provide patient education about the risk of infertility at the time of diagnosis before initiation of treatment.

Prevalence of celiac disease in a cohort of women with unexplained infertility

Several European studies have suggested a higher prevalence of celiac disease (CD) among infertile women (4% to 8%) compared with the general population (<1%). We screened a cohort of women with unexplained infertility in Northern California for the serum markers of CD, tissue transglutaminase and endomysium antibodies (EMA). Given that only one woman out of 121 (0.8%) screened positive for CD, it appears that CD is about as prevalent in this cohort of infertile women as in the general U.S. population (<1%).

Pregnancy outcome of patients with known celiac disease

OBJECTIVE

Celiac disease is a permanent intolerance to gluten, probably induced by an autoimmune mechanism. Controversy exists regarding the association between celiac disease and infertility, abortions, intra-uterine growth restriction (IUGR) and stillbirths. The present study was designed to investigate pregnancy outcome of patients with celiac disease.

METHODS

A retrospective comparison between all pregnancies of women with and without known celiac disease, delivered during the years 1988-2002, was conducted.

RESULTS

During the study period there were 48 deliveries of patients with celiac disease and 143,663 pregnancies of patients without known celiac disease. No statistically significant differences were noted between the groups regarding maternal or perinatal outcomes, including fertility treatments (0% among patients with known celiac versus 2.5% among patients without known celiac sprue; p=0.267), recurrent abortions (0 versus 5.2%; p=0.103), perinatal mortality (2.1 versus 1.4%; p=0.668). However, higher rates of labor induction (29.2 versus 11.9%; p<0.001) and IUGR (6.3 versus 2.1%; p=0.042) were found among patients with celiac disease as compared to patients without known celiac disease.

CONCLUSION

The course of pregnancy of patients with celiac disease including perinatal outcomes is favorable. Since we found higher rates of IUGR, careful surveillance should be performed for early detection of IUGR. Further, prospective studies should focus on screening for celiac disease among patients presenting with IUGR of an unknown etiology.

Analysis of the hemochromatosis mutations C282Y and H63D in infertile men

The aim of this study was to find out whether C282Y and H63D mutations in the hemochromatosis (HFE) gene are associated with male infertility and whether the prevalence of the HFE mutations is higher in a group of 262 infertile men in comparison to 200 fertile men. Because the C282Y and H63D HFE gene distributions in infertile men were not significantly different from fertile controls, our data suggest that the C282Y and H63D HFE gene mutations are not risk factors for male infertility and are not associated with clinical manifestations of male infertility.

Diagnosis of celiac disease in a patient with fecal incontinence

BACKGROUND

A 69-year-old white woman presented to our gastroenterology department with loose stools, daily fecal incontinence and weight loss. She had a 3-year history of fecal incontinence, which had increased in frequency and severity in the year before her most recent presentation. Prior diagnostic workup included anorectal manometry, revealing global sphincter dysfunction, which improved slightly with biofeedback therapy, and colonoscopy, which proved unremarkable. At the time of referral, the patient was taking loperamide 2mg once daily.

INVESTIGATIONS

Physical examination, fecal fat stain, abdominal CT scan, therapeutic trial of pancreatic enzymes, celiac disease serologic tests, and upper endoscopy with small-bowel biopsy.

DIAGNOSIS

Celiac disease.

MANAGEMENT

Gluten-free diet.

In vitro fertilization in Sweden: maternal characteristics

BACKGROUND

Deliveries among women who had an in vitro fertilization (IVF) are characterized by increased risks for both the mother and the infant/child. Part of these effects may be due to maternal characteristics.

METHODS

Using reports from all clinics performing IVF in Sweden, 12 186 women who gave birth after such procedures were identified (13 261 deliveries, 16 280 infants born). Various social and medical characteristics of the women were studied and compared with all women giving birth. Information was retrieved by interviews in early pregnancy or by linkage with various registers.

RESULTS

Women who had IVF were older than other women who gave birth and were older after standard IVF than after intracytoplasmatic sperm injection (ICSI). They were more often of first parity and smoked less than other delivered women. There were more women with high body mass index: they worked outside home less often and were more often of Swedish nationality. Women who had standard IVF had more previous miscarriages than expected, but this was not true for women who had ICSI. Their pattern of drug usage differed from that of other women who had given birth.

CONCLUSIONS

Women who underwent IVF and gave birth showed marked deviations from other women who gave birth. Some of these characteristics may help to explain the increased risks associated with these procedures. Women who had ICSI were less deviating than women who had standard IVF.

Maladies inflammatoires chroniques de l’intestin et grossesse

OBJECTIVE

Obstetrical prognosis for women suffering from Crohn's disease and from ulcerative colitis, and consequences of pregnancy on inflammatory bowel diseases (IBD).

PATIENTS AND METHODS

Retrospective study, of 76 pregnancies, after the diagnosis of IBD among 77 women (33 ulcerative colitis, 44 Crohn's disease).

RESULTS

Pregnancy did not modify the evolutive profile of IBD. No particular gravity of IBD revealed during pregnancy or post-partum was noticed. The outcome of the 54 pregnancies associated with quiescent IBD was the same as in the general population. Five of ten pregnancies started during an active period of Crohn's disease or ulcerative colitis ended in fetal loss (3 spontaneous abortions, 2 medical terminations). In women with a first acute episode or IBD reactivation during pregnancy (n=12), one-third of the newborns were low weight for gestational age, one-third were born preterm and only one-third were term babies with normal weight. Vaginal delivery did not trigger development or exacerbation of perianal Crohn's disease (n=20). Cesarean section was performed in 2 with an ileal pouch-anal anastomosis (n=4) and 1 patient with an ileo-rectal anastomosis (n=3) to avoid injury to the anal sphincter. Ileostomy (n=2) did not contraindicate delivery.

CONCLUSION

Control of IBD is the main obstetrical factor for prognosis. Starting pregnancy can be advised if the disease is quiescent, with rapid and efficient management of possible flare-ups. Delivery route must be determined on a case-by-case basis, each considering pregestational anal continence and the clinical presentation of the perineum.

Uterine motor alterations and estrous cycle disturbances associated with colonic inflammation in the rat

The impact of colitis on uterine contractility and estrous cycle was investigated after intracolonic administration of 2,4,6-trinitrobenzenesulfonic acid (TNBS) in rats. Colitis severity was assessed by macroscopic damage scoring (MDS) 4 days after TNBS, and myeloperoxidase (MPO) activity was measured in both colon and uterus of control and colitic rats. Estrous cycle stages were determined by vaginal smears and histology, and uterine contractility was assessed in vitro on longitudinal and circular strips. In control rats, uterine MPO activity varied markedly during the cycle and peaked around estrus. In rats with moderate colitis [MDS < 5, 3.1 ± 0.2 (mean ± SE)], uterine MPO decreased by 61% compared with estrus control, without disruption of the cycle. Frequency of spontaneous contractions was reduced by 32% in circular muscle. Contractile responses to KCl and carbachol were not affected, whereas maximal response to oxytocin decreased by 47% in the longitudinal muscle. In rats with severe colitis (MDS > 5, 6.0 ± 0.2), uterine MPO was reduced by 96% and estrous cycle was disrupted. Spontaneous contractility was impaired in circular strips, and a 39% decrease in the contraction frequency occurred in the longitudinal strips. Circular strips did not contract to KCl or carbachol; however, longitudinal strips had maximal responses to KCl, carbachol, and oxytocin reduced by 36%, 27%, and 46%, respectively. Estrogen replacement protected the uterine responses to carbachol in colitic rats, whereas oxytocin responses remained depressed. These data indicate that colonic inflammation can influence both spontaneous and evoked uterine contractility, in relation to estrous cycle disturbances, impaired estradiol production, and functional alterations of myometrial cells.

Irritable bowel syndrome and inflammatory bowel disease in pregnancy

Irritable bowel syndrome and inflammatory bowel disease are gastrointestinal disorders affecting young adults. The peak incidence of irritable bowel syndrome and inflammatory bowel disease is in the late adolescence and early adult years, the time during which many women are planning and beginning their families. Since the potential for life-altering changes and pregnancy complications exist with these diseases, affected pregnant women present a challenge for the gastroenterologist, pregnancy provider, and nurses caring for them. This article outlines what is known about these diseases and their effect on fertility and pregnancy as well as their clinical management during pregnancy.