Clinical implications of the ovarian/endometrial renin-angiotensin-aldosterone system

Infertility treatment is associated with increased risk of postpartum hospitalization due to heart disease

BACKGROUND

Cardiovascular disease is a major cause of maternal mortality, but the extent to which infertility treatment is implicated in heart disease remains unclear.

OBJECTIVE

To evaluate the association between infertility treatment and postpartum heart disease.

METHODS

We designed a retrospective cohort study of patients who delivered in the United States between 2010 and 2018. The primary outcome was hospitalization within 12-month post-delivery due to heart disease (including ischemic heart disease, atherosclerotic heart disease, cardiomyopathy, hypertensive disease, heart failure, and cardiac dysrhythmias). We estimated the rate difference (RD) of hospitalizations among patients who conceived with infertility treatment and those who conceived spontaneously. Associations were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs), derived from Cox proportional hazards regression after adjustment for potential confounders.

RESULTS

Infertility treatment was recorded in 0.9% (n = 287,813) of 31,339,991 deliveries. Rates of heart disease hospitalizations with infertility treatment and with spontaneous conception were 550 and 355 per 100,000, respectively (RD 195, 95% CI: 143-247; adjusted HR 1.99, 95% CI: 1.80-2.20). The most important increase in risk was observed for hypertensive disease (adjusted HR 2.16, 95% CI: 1.92-2.42). This increased risk was apparent as early as 30-day post-delivery (HR 1.61, 95% CI: 1.39-1.86), with progressively increasing risk up to a year.

CONCLUSIONS

Although the absolute risk of postpartum heart disease hospitalization is low, infertility treatment is associated with an increased risk, especially for hypertensive disease. These findings highlight the importance of timely postpartum follow-ups in patients who received infertility treatment.

Genome wide identification and characterization of fertility associated novel CircRNAs as ceRNA reveal their regulatory roles in sheep fecundity

Reproductive traits play a vital role in determining the production efficiency of sheep. Maximizing the production is of paramount importance for breeders worldwide due to the growing population. Circular RNAs (circRNAs) act as miRNA sponges by absorbing miRNA activity through miRNA response elements (MREs) and participate in ceRNA regulatory networks (ceRNETs) to regulate mRNA expression. Despite of extensive research on role of circRNAs as miRNA sponges in various species, their specific regulatory roles and mechanism in sheep ovarian tissue are still not well understood. In this study, we performed whole genome sequencing of circRNAs, miRNA and mRNA employing bioinformatic techniques on ovine tissues of two contrasting sheep breeds "Small tail Han (X_LC) and Dolang sheep (D_LC)", which results into identification of 9,878 circRNAs with a total length of 23,522,667 nt and an average length of 2,381.32 nt. Among them, 44 differentially expressed circRNAs (DECs) were identified. Moreover, correlation between miRNA-mRNA and lncRNA-miRNA provided us with to prediction of miRNA binding sites on nine differentially expressed circRNAs and 165 differentially expressed mRNAs using miRanda. miRNA-mRNA and lncRNA-miRNA pairs with negative correlation were selected to determine the ceRNA score along with positively correlated pairs from lncRNA and mRNA network. Integration of ceRNA score and positively correlated pairs exhibit a significant ternary relationship among circRNAs-miRNA-mRNA demonestrated by ceRNA, comprising of 50 regulatory pairs sharring common nodes and predicted potential differentially expressed circRNAs-miRNAs-mRNAs regulatory axis. Based on functional enrichment analysis shortlisted key ceRNA regulatory pairs associated with reproduction including circRNA_3257-novel579_mature-EPHA3, circRNA_8396-novel130_mature-LOC101102473, circRNA_4140- novel34_mature > novel661_mature-KCNK9, and circRNA_8312-novel339_mature-LOC101110545. Furthermore, expression profiling, functional enrichments and qRT-PCR analysis of key target genes infer their implication in reproduction and metabolism. ceRNA target mRNAs evolutionary trajectories, expression profiling, functional enrichments, subcellular localizations following genomic organizations will provide new insights underlying molecular mechanisms of reproduction, and establish a solid foundation for future research. Graphical abstract summarizing the scheme of study.

Increased risk of severe maternal morbidity in women with twin pregnancies resulting from oocyte donation

STUDY QUESTION

Is there a difference in the risk of serious maternal complications during pregnancy and the postpartum in twin pregnancies according to mode of conception: natural conception, non-IVF fertility treatment, IVF, ICSI or oocyte donation?

SUMMARY ANSWER

Women with twin pregnancies after medically assisted reproduction (MAR) had an overall risk of serious maternal complications 30% higher compared with women with natural twin pregnancies, and this association varied according to the MAR procedure; the risk was increased by 50% with IVF using autologous oocytes and by 270% with oocyte donation.

WHAT IS KNOWN ALREADY

IVF has been reported as a risk factor for serious maternal complications in several concordant studies of singleton pregnancies. For twin pregnancies, this association is less well documented with imprecise categorisation of the mode of conception, and results are contradictory.

STUDY DESIGN, SIZE, DURATION

This is a secondary analysis of the national, observational, prospective, population-based cohort study of twin pregnancies (JUmeaux Mode d'Accouchement), which took place in France from 10 February 2014 through 1 March 2015. All French maternity units performing more than 1500 annual deliveries were invited to participate, regardless of their academic, public or private status or level of care. Of the 191 eligible units, 176 (92%) participated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with a twin pregnancy who gave birth at or after 22 weeks of gestation were eligible (N = 8823 women included). We excluded women whose mode of conception was unknown (n = 75). Serious maternal complications were regrouped within the recently emerged concept of severe acute maternal morbidity (SAMM), as a binary composite outcome. The exposure of interest was the mode of conception, studied in five classes: natural conception (reference group), non-IVF fertility treatment including insemination and ovarian stimulation, IVF with autologous oocyte, ICSI with autologous oocyte and oocyte donation. To assess the association between the mode of conception and SAMM, we used multivariate logistic regression to adjust for confounders. Structural equation modelling (SEM) was used to explore the contribution to this association of potential intermediate factors, i.e. factors possibly caused by the mode of conception and responsible for SAMM: non-severe pre-eclampsia, placenta praevia and planned mode of delivery.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 8748 women of the study population, 5890 (67.3%) conceived naturally, 854 (9.8%) had non-IVF fertility treatment, 1307 (14.9%) had IVF with autologous oocytes, 368 (4.2%) had ICSI with autologous oocytes and 329 (3.8%) used oocyte donation. Overall, 538 (6.1%) developed SAMM. Women with twin pregnancy after any type of MAR had a higher risk of SAMM than those with a natural twin pregnancy, after adjustment for confounders (7.9% (227/2858) compared to 5.3% (311/5890), adjusted odds ratio (aOR) 1.3, 95% CI 1.1-1.6). This association varied according to the MAR procedure. The risk of SAMM was higher among women with IVF using either autologous oocytes (8.3%; 108/1307) or oocyte donation (14.0%; 46/329) compared with the reference group (respectively aOR 1.5, 95% CI 1.1-1.9 and aOR 2.7, 95% CI 1.8-4.1) and higher after oocyte donation compared with autologous oocytes (aOR 1.7, 95% CI 1.1-2.6). Conversely, the risk of SAMM for women with non-IVF fertility treatment (6.2%; 53/854) and with ICSI using autologous oocytes (5.4%; 20/368) did not differ from that of the reference group (5.3%; 311/5890) (respectively aOR 1.1, 95% CI 0.8-1.5 and aOR 0.9, 95% CI 0.6-1.5). The tested intermediate factors poorly explained these increased risks.

LIMITATIONS, REASONS FOR CAUTION

Beyond the confounders and intermediate factors considered in our analysis, specific causes of infertility and specific aspects of infertility treatments may explain the differences in the risk of SAMM by mode of conception. However, these data were not available.

WIDER IMPLICATIONS OF THE FINDINGS

Our study showed an increased risk of SAMM in women with twin pregnancies after MAR, notably after IVF using autologous oocytes and particularly after oocyte donation. To avoid unnecessary exposure to the high-risk combination of MAR and multiple pregnancies, transfer of a single embryo should be encouraged whenever possible. Knowledge of these differential risks may inform discussions between clinicians and women about the mode of conception and help to optimise obstetric care for women in subgroups at higher risk.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the French Ministry of Health (Programme Hospitalier de Recherche Clinique, AOM2012). There are no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Female Infertility and Cardiovascular Risk - A Hype or an Underestimated Reality?

Infertility may be an early indicator of later-life health risk development, such as cardiovascular disease (CVD), the leading cause of death globally. Various infertility-associated factors such as female age, polycystic ovarian syndrome, endometriosis and metabolic syndrome are also risk factors for CVD. Whether there is a real association between female infertility and CVD, given that common pathways lead to both entities, or since both female infertility and CVD share a common basis, needs to be further investigated. If such an association is confirmed, infertile women might benefit from the initiation of preventive strategies aiming to control CVD risk factors. Thus, female infertility may represent an early indicator of future CVD and concomitantly a unique opportunity to identify women at increased risk for developing CVD. It is therefore imperative that large population- based studies are performed to elucidate this issue further and promote public awareness, if necessary.

Identification of female-specific risk enhancers throughout the lifespan of women to improve cardiovascular disease prevention

Cardiovascular disease (CVD) remains the leading cause of death in women in the United States and globally, with heart disease actually on the rise among middle-aged women in the United States. This disease burden can be reduced by prioritizing a preventive approach to cardiovascular health. The 2019 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Primary Prevention of CVD contains important updates for delivery of primary prevention and also highlights early menopause and pre-eclampsia as two female-specific risk factors that enhance CVD risk. Additionally other female-specific risk factors including early menarche, polycystic ovarian syndrome, multi-parity, other adverse pregnancy outcomes, and hormone therapy also influence women's CVD risk throughout their lifespan. It is vital that both women and healthcare clinicians are made aware of this information as it has lifesaving potential. This review aims to (1) Introduce the key points of the 2019 ACC/AHA Guideline (2) Highlight the evidence for the female-specific risk factors for refining CVD risk assessment and (3) Discuss the impact of the female-specific risk enhancing factors on primary prevention interventions such as statin therapy. This approach will be able to more personalize risk assessment in women, with an emphasis on the importance of shared decision making in building authentic partnerships between clinicians and women patients throughout their lifespan.

Aldosterone in Gynecology and Its Involvement on the Risk of Hypertension in Pregnancy

Aldosterone is the main mineralocorticoid hormone, responsible of the regulation of fluid and electrolyte balance and blood pressure. It acts also as a pro-inflammatory factor responsible of an increased cardiovascular risk, independent from blood pressure values. After the discovery of mineralocorticoid receptor (MR) in mononuclear leukocytes, further studies supported its role in inflammatory and even autoimmune mechanisms underlying several diseases. In particular, recent studies reported a possible involvement of aldosterone in some gynecological conditions and diseases, characterized by inflammation, hypertension and increased cardio-metabolic risk, such as use of hormonal contraceptives, preeclampsia, polycystic ovary syndrome, uterine fibroids, and endometriosis. The aim of this mini-review is to report the possible involvement of aldosterone in all these gynecological conditions, suggesting different pathogenetic mechanisms and new target treatments of MR blockers for these diseases.

Failure of fertility therapy and subsequent adverse cardiovascular events

BACKGROUND

Infertility may indicate an underlying predisposition toward premature cardiovascular disease, yet little is known about potential long-term cardiovascular events following fertility therapy. We investigated whether failure of fertility therapy is associated with subsequent adverse cardiovascular events.

METHODS

We performed a population-based cohort analysis of women who received gonadotropin-based fertility therapy between Apr. 1, 1993, and Mar. 31, 2011, distinguishing those who subsequently gave birth and those who did not. Using multivariable Poisson regression models, we estimated the relative rate ratio of adverse cardiovascular events associated with fertility therapy failure, accounting for age, year, baseline risk factors, health care history and number of fertility cycles. The primary outcome was subsequent treatment for nonfatal coronary ischemia, stroke, transient ischemic attack, heart failure or thromboembolism.

RESULTS

Of 28 442 women who received fertility therapy, 9349 (32.9%) subsequently gave birth and 19 093 (67.1%) did not. The median number of fertility treatments was 3 (interquartile range 1-5). We identified 2686 cardiovascular events over a median 8.4 years of follow-up. The annual rate of cardiovascular events was 19% higher among women who did not give birth after fertility therapy than among those who did (1.08 v. 0.91 per 100 patient-years, p < 0.001), equivalent to a 21% relative increase in the annual rate (95% confidence interval 13%-30%). We observed no association between event rates and number of treatment cycles.

INTERPRETATION

Fertility therapy failure was associated with an increased risk of long-term adverse cardiovascular events. These women merit surveillance for subsequent cardiovascular events.

A comparative study of reproductive and metabolic responses to administration of exogenous melatonin and aldosterone in xeric and mesic spiny mice populations

A comparative study of reproduction revealed differences between desert-adapted Acomys russatus and Mediterranean Acomys cahirinus populations with respect to the environmental cues used for reproductive activity. Long day (LD) conditions were noted as initial reproductive cue for both populations. This research is a follow-up affects comparative endocrine and metabolic study in regards to reproduction where LD-acclimated mice were treated with, exogenous aldosterone (ALDO) and melatonin (MLT). Only the reproductive system of A. russatus females was significantly affected by both hormones. In A. cahirinus females, MLT decreased leptin levels, while in A. russatus, a treatment with both hormones increased leptin levels. In A. russatus males, MLT affects both reproductive and metabolic functions. However, in A. cahirinus males, ALDO and MLT treatments caused an increase in leptin levels, and a decrease in free fatty acid (FFA) levels, respectively. Correlations between leptin and FFA in general were affected by both MLT and ALDO treatments in A. russatus males and A. cahirinus females. Our results support the general idea, that although the reproductive system of A. russatus responded to an osmotic stress, in our case expressed by ALDO treatment, which can be considered as an ultimate signal, where, photoperiod changes are an initial signal.

Is there a role of the local tissue RAS in the regulation of physiologic and pathophysiologic conditions in the reproductive tract?

The renin-angiotensin system is well known as a systemic endocrine pathway that regulates blood pressure and salt-water metabolism. In addition to the systemic renin-angiotensin system there is evidence in different species for the presence of a local tissue renin-angiotensin system, which allows local production of the bioactive peptides angiotensin II and angiotensin (1-7). The local renin-angiotensin system has been found in a variety of tissues including tissue of the human reproductive tract. Thus, it was suspected that it may have important functions in the local hormonal microenvironment. Here, a systematic literature search was undertaken to review whether there is evidence for regulatory functions of the local tissue renin-angiotensin system in the human reproductive tract under physiological and pathological conditions.

Changes in global gene expression during in vitro decidualization of rat endometrial stromal cells

During the preimplantation phase of pregnancy the endometrial stroma differentiates into decidua, a process that implies numerous morphological changes and is an example of physiological transdifferentiation. Here we show that UIII rat endometrial stromal cells cultured in the presence of calf serum acquired morphological features of decidual cells and expressed decidual markers. To identify genes involved in decidualization we compared gene expression patterns of control and decidualized UIII cells using cDNA microarray. We found 322 annotated genes exhibiting significant differences in expression (>3-fold, fold discovery rate (FDR) >0.005), of which 312 have not been previously related to decidualization. Analysis of overrepresented functions revealed that protein synthesis, gene expression, and chromatin architecture and remodeling are the most relevant modified functions during decidualization. Relevant genes are also found in the functional terms differentiation, cell proliferation, signal transduction, and matrix/structural proteins. Several of these new genes involved in decidualization (Csdc2, Trim27, Eef1a1, Bmp1, Wt1, Aes, Gna12, and Men1) are shown to be also regulated in uterine decidua during normal pregnancy. Thus, the UIII cell culture model will allow future mechanistic studies to define the transcriptional network regulating reprogramming of stromal cells into decidual cells.

Novel mechanisms responsible for postmenopausal hypertension

Blood pressure increases in many women after menopause. Hypertension is one of the major risk factors for cardiovascular disease. However, the mechanisms responsible for the postmenopausal increase in blood pressure are yet to be elucidated. Various humoral systems have been proposed to play a role in postmenopausal hypertension, such as changes in estrogen/androgen ratios, increases in endothelin and oxidative stress, and activation of the renin-angiotensin system (RAS). In addition, obesity, type II diabetes, and activation of the sympathetic nervous system are common in postmenopausal women and may also play important roles. However, progress in elucidating the mechanisms responsible for postmenopausal hypertension has been hampered by the lack of a suitable animal model. The aging female spontaneously hypertensive rat (SHR) exhibits many of the characteristics found in postmenopausal women. In this review, some of the possible mechanisms that could play a role in postmenopausal hypertension are discussed, as well as the characteristics of the aged female SHR as a model to study.