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Cetera GE, Tozzi AE, Chiappa V, Castiglioni I, Merli CEM, Vercellini P. Artificial Intelligence in the Management of Women with Endometriosis and Adenomyosis: Can Machines Ever Be Worse Than Humans? J Clin Med 2024; 13:2950. [PMID: 38792490 PMCID: PMC11121846 DOI: 10.3390/jcm13102950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/08/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Artificial intelligence (AI) is experiencing advances and integration in all medical specializations, and this creates excitement but also concerns. This narrative review aims to critically assess the state of the art of AI in the field of endometriosis and adenomyosis. By enabling automation, AI may speed up some routine tasks, decreasing gynecologists' risk of burnout, as well as enabling them to spend more time interacting with their patients, increasing their efficiency and patients' perception of being taken care of. Surgery may also benefit from AI, especially through its integration with robotic surgery systems. This may improve the detection of anatomical structures and enhance surgical outcomes by combining intra-operative findings with pre-operative imaging. Not only that, but AI promises to improve the quality of care by facilitating clinical research. Through the introduction of decision-support tools, it can enhance diagnostic assessment; it can also predict treatment effectiveness and side effects, as well as reproductive prognosis and cancer risk. However, concerns exist regarding the fact that good quality data used in tool development and compliance with data sharing guidelines are crucial. Also, professionals are worried AI may render certain specialists obsolete. This said, AI is more likely to become a well-liked team member rather than a usurper.
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Affiliation(s)
- Giulia Emily Cetera
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.E.C.); (C.E.M.M.)
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Alberto Eugenio Tozzi
- Predictive and Preventive Medicine Research Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Valentina Chiappa
- Gynaecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy;
| | | | - Camilla Erminia Maria Merli
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.E.C.); (C.E.M.M.)
| | - Paolo Vercellini
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.E.C.); (C.E.M.M.)
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
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Creinin MD, Cagnacci A, Spaczyński RZ, Stute P, Chabbert-Buffet N, Korver T, Simoncini T. Experts' view on the role of oestrogens in combined oral contraceptives: emphasis on oestetrol (E4). Front Glob Womens Health 2024; 5:1395863. [PMID: 38655395 PMCID: PMC11035732 DOI: 10.3389/fgwh.2024.1395863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction The evolution of contraception has been crucial for public health and reproductive well-being. Over the past 60 years, combined oral contraceptives (COCs) have remained an important part of the contraceptive landscape worldwide; continued development has worked toward maintaining efficacy and improving safety. Methods Seven global experts convened to discuss the clinical relevance of the oestrogen in COCs, focusing on the impact of the new oestrogen, oestetrol (E4). Participants then commented through an online forum on the summary content and other participants' feedback. We prepared this report to describe the experts' views, their follow-up from the open forum and the evidence supporting their views. Results Ethinylestradiol (EE) and oestradiol (E2) affect receptors similarly whereas E4 has differential effects, especially in the liver and breast. Adequate oestrogen doses in COCs ensure regular bleeding and user acceptability. EE and E4 have longer half-lives than E2; accordingly, COCs with EE and E4 offer more predictable bleeding than those with E2. Oestrogen type and progestin influence VTE risk; E2 poses a lower risk than EE; although promising, E4/DRSP VTE risk is lacking population-based data. COCs alleviate menstrual symptoms, impact mental health, cognition, libido, skin, and bone health. Conclusion Oestrogens play an important role in the contraceptive efficacy, bleeding patterns, and overall tolerability/safety of COCs. Recent studies exploring E4 combined with DRSP show promising results compared to traditional formulations, but more definitive conclusions await further research.
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Affiliation(s)
- M. D. Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - A. Cagnacci
- Academic Unit of Obstetrics and Gynecology, DINOGMI, IRCCS-Azienda Ospedaliera Universitaria San Martino di Genova, Genova, Italy
| | - R. Z. Spaczyński
- Collegium Medicum, University of Zielona Gora, Zielona Gora, Poland
| | - P. Stute
- Department of Obstetrics and Gynecology, Bern University Hospital, Bern, Switzerland
| | - N. Chabbert-Buffet
- Gynécologie—Obstétrique et Médecine de la Reproduction—Maternité, Hospital Tenon, Paris, France
| | - T. Korver
- Reprovision Clinical Consultancy, Oss, Netherlands
| | - T. Simoncini
- Division of Obstetrics and Gynecology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Olga M, Yuliya Z, Vitaly L, Ekaterina Z, Konstantin P, Svetlana E, Maria S, Tatyana V. Reference intervals and biological variation in parameters of the thrombin generation test in healthy individuals. Int J Lab Hematol 2024; 46:336-344. [PMID: 37985000 DOI: 10.1111/ijlh.14205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Establish the referenceintervals (RIs) and analyze biological variability (BV) to introduce the thrombin generation test (TGT) into clinical practice. METHODS To determine the RIs parameters of TGT, we analyzed platelet-poor plasma (PPP) (n = 123), rich (PRP) (n = 76), and microparticle-mediated TGT (MP-TGT) (n = 32) in healthy participants. For the BV study, we collected samples from five participants over 5 weeks. A nested analysis of variance (ANOVA) was performed to evaluate the BV results. RESULTS The between-individual variation (CVG ), within-individual variation (CVI ), analytical variation (CVA ) for TGT on PPP for all parameters were from 5.5% to 17.3%, 5.4% to 17.7%, and 2.6% to 5.3%, respectively. For PRP, the CVG , CVI , and CVA were ranged from 3.0% to 23.7%, 8.4% to 23.0%, and 4.1% to 6.9%, respectively. The index of individuality (II) ranged from 0.3 to 3.1 for PPP and from 0.3 to 4.5 for PRP. The reference change value (RCV) for PPP was from 19.8% to 50.1%, while for PRP, it was 27.2% to 66.5%. We recommend using the RIs for the parameters ETP (nM/min): 1101.6-2332.1 and Peak (nM): 163.5-381.3 for PPP and ETP (nM/min): 1088.5-2634.9; Peak (nM): 72.6-210.7 for PRP. The resulting MP-TGT are highly dependent on age require a larger sample. CONCLUSION For TGT on PPP and PRP the RIs developed on our population for Peak and ETP parameters can be used. Time parameters: Lagtime and ttPeak, min with II < 0.6, require monitoring over time with RCV calculation.
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Affiliation(s)
- Melnichnikova Olga
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Zhilenkova Yuliya
- Department of Laboratory Medicine and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Lukinov Vitaly
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Zolotova Ekaterina
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Pishchulov Konstantin
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Evgina Svetlana
- Department of Laboratory Medicine and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Simakova Maria
- Personalized Medicine Centre, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Vavilova Tatyana
- Department of Laboratory Medicine and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
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Hugon-Rodin J, Fontana P, Poncet A, Streuli I, Casini A, Blondon M. Longitudinal profile of estrogen-related thrombotic biomarkers after cessation of combined hormonal contraceptives. Blood 2024; 143:70-78. [PMID: 37939264 DOI: 10.1182/blood.2023021717] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
ABSTRACT The persistence of risk of venous thromboembolism (VTE) due to combined hormonal contraceptives (CHCs), after their cessation, is unknown but important to guide clinical practice. The objective of this prospective cohort study was to define the time until normalization of estrogen-related thrombotic biomarkers after CHC cessation. We enrolled women aged 18 to 50 years who had decided to stop their CHC, excluding those with a personal history of VTE, anticoagulation, or pregnancy. The study started before cessation of CHC, with 6 visits afterwards (at 1, 2, 4, 6, and 12 weeks after cessation). Primary outcomes were normalized sensitivity ratios to activated protein C (nAPCsr) and to thrombomodulin (nTMsr), with sex hormone-binding globulin (SHBG) as a secondary end point. We also included control women without CHC. Among 66 CHC users, from baseline until 12 weeks, average levels of nAPCsr, nTMsr, and SHBG decreased from 4.11 (standard deviation [SD], 2.06), 2.53 (SD, 1.03), and 167 nmol/L (SD, 103) to 1.27 (SD, 0.82), 1.11 (SD, 0.58), and 55.4 nmol/L (SD, 26.7), respectively. On a relative scale, 85.8%, 81.3%, and 76.2% of the decrease from baseline until 12 weeks was achieved at 2 weeks and 86.7%, 85.5%, and 87.8% at 4 weeks after CHC cessation, respectively. Levels were not meaningfully modified throughout the study period among 28 control women. In conclusion, CHC cessation is followed by a rapid decrease in estrogen-related thrombotic biomarkers. Two to 4 weeks of cessation before planned major surgery or withdrawal of anticoagulants in patients with VTE appears sufficient for the majority of women. The trial is registered at www.clinicaltrials.gov as #NCT03949985.
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Affiliation(s)
- Justine Hugon-Rodin
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
- Gynecology Department, Gynecological Endocrinology Unit, Hospital Saint Joseph, INSERM Unité Mixte de Recherche 1153, Équipe de Recherche en Épidémiologie Obstétricale Périnatale et Pédiatrique, Paris, France
| | - Pierre Fontana
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Antoine Poncet
- Center for Clinical Research, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Isabelle Streuli
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Douxfils J, Morimont L, Creinin MD, Gaspard U, Foidart JM. Hormonal therapies and venous thrombosis: considerations for prevention and management-a reappraisal. Res Pract Thromb Haemost 2023; 7:100155. [PMID: 37255853 PMCID: PMC10225911 DOI: 10.1016/j.rpth.2023.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Jonathan Douxfils
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, University of Namur, Namur Research Institute for Life Sciences, Clinical Pharmacology Research Group, Namur, Belgium
| | - Laure Morimont
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, University of Namur, Namur Research Institute for Life Sciences, Clinical Pharmacology Research Group, Namur, Belgium
| | - Mitchell D. Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California, USA
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Belgium
| | - Jean-Michel Foidart
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
- University of Liège, Liège, Belgium
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Kangasniemi MH, Arffman RK, Haverinen A, Luiro K, Hustad S, Heikinheimo O, Tapanainen JS, Piltonen TT. Effects of estradiol- and ethinylestradiol-based contraceptives on adrenal steroids: A randomized trial. Contraception 2022; 116:59-65. [PMID: 36084710 DOI: 10.1016/j.contraception.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Ethinylestradiol (EE)-based combined oral contraceptives (COC) affect adrenal function by altering steroid and corticosteroid-binding globulin (CBG) synthesis that may contribute to adverse effects related to these drugs. The effects of COCs containing natural estrogens remain unclear. We compared the effects of COCs containing estradiol valerate (EV) and EE on cortisol and other adrenal steroid hormones. STUDY DESIGN A spin-off study of a randomized, open-label trial. Fifty-nine healthy women were allocated to groups that engaged in the continuous use of EV+dienogest (DNG), EE+DNG, or DNG only for 9 weeks. We measured changes in adrenal steroids, CBG, and the free cortisol index (FCI). RESULTS Treatment with EE+DNG increased total cortisol (mean increment 668 nmol/L, p < 0.001) and cortisone (10 nmol/L, p= 0.001) levels, whereas the change from the baseline was insignificant for the EV+DNG and DNG-only groups. Dehydroepiandrosterone sulfate decreased by 24% in the EE+DNG group but remained unchanged in the EV+DNG and DNG-only groups. Aldosterone and 17-hydroxyprogesterone levels did not differ between the groups. All preparations increased CBG, but the increase in the EE+DNG group (median increment 42 µg/mL, p < 0.001) was 9- and 49-fold higher than that in the EV+DNG and DNG-only groups, respectively. The FCI remained unchanged in all study groups, indicating that cortisol and CBG mainly increased in parallel, although some individuals demonstrated larger alterations in the cortisol-CBG balance. CONCLUSION In COCs, EV had a milder effect on circulating CBG and adrenal steroid levels than EE; however, further research is necessary to determine the long-term effects. TRIAL REGISTRATION ClinicalTrials.gov NCT02352090 IMPLICATIONS: EV-based COC had reduced effects on circulating CBG and adrenal steroids compared to EE, probably due to a lower hepatic impact. Whether the sensitization of the adrenals to ACTH varies according to COC contents and whether it relates to experienced side effects needs to be investigated. These results encourage further research and development of contraceptives containing natural estrogens.
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Affiliation(s)
- Marika H Kangasniemi
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, Oulu, Finland.
| | - Riikka K Arffman
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, Oulu, Finland
| | - Annina Haverinen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kaisu Luiro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Steinar Hustad
- Department of Clinical Science and Core Facility for Metabolomics, University of Bergen, Norway
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha S Tapanainen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Terhi T Piltonen
- Department of Obstetrics and Gynecology, University of Oulu, Oulu University Hospital and Medical Research Centre PEDEGO Research Unit, Oulu, Finland
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Kangasniemi MH, Arffman RK, Joenväärä S, Haverinen A, Luiro K, Tohmola T, Renkonen R, Heikinheimo O, Tapanainen JS, Piltonen TT. Ethinylestradiol in combined hormonal contraceptive has a broader effect on serum proteome compared with estradiol valerate: a randomized controlled trial. Hum Reprod 2022; 38:89-102. [PMID: 36416543 PMCID: PMC9825269 DOI: 10.1093/humrep/deac250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/19/2022] [Indexed: 11/24/2022] Open
Abstract
STUDY QUESTION Does an estradiol-based combined oral contraceptive (COC) have a milder effect on the serum proteome than an ethinylestradiol (EE)-based COC or dienogest (DNG) only? SUMMARY ANSWER The changes in serum proteome were multifold after the use of a synthetic EE-based COC compared to natural estrogen COC or progestin-only preparation. WHAT IS KNOWN ALREADY EE-based COCs widely affect metabolism, inflammation, hepatic protein synthesis and blood coagulation. Studies comparing serum proteomes after the use of COCs containing EE and natural estrogens are lacking. STUDY DESIGN, SIZE, DURATION This was a spin-off from a randomized, controlled, two-center clinical trial. Women (n = 59) were randomized to use either EE + DNG, estradiol valerate (EV) + DNG or DNG only continuously for 9 weeks. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were healthy, young, white volunteer women. Serum samples were collected before and after 9 weeks of hormonal exposure. Samples from 44 women were available for analysis (EE + DNG n = 14, EV + DNG n = 16 and DNG only n = 14). Serum proteins were analyzed by quantitative, discovery-type label-free proteomics. MAIN RESULTS AND THE ROLE OF CHANCE Altogether, 446 proteins/protein families with two or more unique peptides were detected and quantified. The number of proteins/families that altered over the 9-week period within the study groups was 121 for EE + DNG and 5 for EV + DNG, while no changes were detected for DNG only. When alterations were compared between the groups, significant differences were detected for 63 proteins/protein families, of which 58 were between the EE + DNG and EV + DNG groups. The most affected functions during the use of EE + DNG were the complement system, acute phase response signaling, metabolism and the coagulation system. The results were validated by fetuin-B and cortisol-binding globulin ELISA and sex hormone-binding globulin immunoassay. LARGE SCALE DATA Data are available via ProteomeXchange with identifiers PXD033617 (low abundance fraction) and PXD033618 (high abundance fraction). LIMITATIONS, REASONS FOR CAUTION The power analysis of the trial was not based on the proteomic analysis of this spin-off study. In the future, targeted proteomic analysis with samples from another trial should be carried out in order to confirm the results. WIDER IMPLICATIONS OF THE FINDINGS The EE-based COC exerted a broader effect on the serum proteome than the EV-based COC or the DNG-only preparation. These results demonstrate that the effects of EE in COCs go far beyond the established endpoint markers of estrogen action, while the EV combination is closer to the progestin-only preparation. The study indicates that EV could provide a preferable option to EE in COCs in the future and signals a need for further studies comparing the clinical health outcomes of COCs containing EE and natural estrogens. STUDY FUNDING/COMPETING INTEREST(S) Funding for this researcher-initiated study was obtained from the Helsinki University Hospital research funds, the Hospital District of Helsinki and Uusimaa, the Sigrid Juselius Foundation, the Academy of Finland, the Finnish Medical Association, the University of Oulu Graduate School, the Emil Aaltonen Foundation, the Swedish Cultural Foundation in Finland, the Novo Nordisk Foundation, Orion Research Foundation and the Northern Ostrobothnia Regional Fund. The funders had no role in study design, data collection and analysis, publishing decisions or manuscript preparation. T.P. has received honoraria for lectures, consultations and research grants from Exeltis, Gedeon Richter, MSD, Merck, Pfizer, Roche, Stragen and Mithra Pharmaceuticals. O.H. occasionally serves on advisory boards for Bayer AG and Gedeon Richter and has designed and lectured at educational events for these companies. The other authors have nothing to disclose. O.H. occasionally serves on advisory boards for Bayer AG and Gedeon Richter and has designed and lectured at educational events for these companies. The other authors have nothing to disclose. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT02352090. TRIAL REGISTRATION DATE 27 January 2015. DATE OF FIRST PATIENT’S ENROLMENT 1 April 2015.
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Affiliation(s)
- M H Kangasniemi
- Correspondence address. Department of Obstetrics and Gynecology, Clinical Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, 90014 Oulu, Finland. E-mail:
| | - R K Arffman
- Department of Obstetrics and Gynecology, Clinical Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - S Joenväärä
- Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland,HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - A Haverinen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - K Luiro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T Tohmola
- Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland,HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - R Renkonen
- Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland,HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - O Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J S Tapanainen
- Department of Obstetrics and Gynecology, Clinical Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland,Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T T Piltonen
- Department of Obstetrics and Gynecology, Clinical Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
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