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Mutsaerts MAQ, van Oers AM, Groen H, Burggraaff JM, Kuchenbecker WKH, Perquin DAM, Koks CAM, van Golde R, Kaaijk EM, Schierbeek JM, Oosterhuis GJE, Broekmans FJ, Bemelmans WJE, Lambalk CB, Verberg MFG, van der Veen F, Klijn NF, Mercelina PEAM, van Kasteren YM, Nap AW, Brinkhuis EA, Vogel NEA, Mulder RJAB, Gondrie ETCM, de Bruin JP, Sikkema JM, de Greef MHG, ter Bogt NCW, Land JA, Mol BWJ, Hoek A. Randomized Trial of a Lifestyle Program in Obese Infertile Women. N Engl J Med 2016; 374:1942-53. [PMID: 27192672 DOI: 10.1056/nejmoa1505297] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Small lifestyle-intervention studies suggest that modest weight loss increases the chance of conception and may improve perinatal outcomes, but large randomized, controlled trials are lacking. METHODS We randomly assigned infertile women with a body-mass index (the weight in kilograms divided by the square of the height in meters) of 29 or higher to a 6-month lifestyle intervention preceding treatment for infertility or to prompt treatment for infertility. The primary outcome was the vaginal birth of a healthy singleton at term within 24 months after randomization. RESULTS We assigned women who did not conceive naturally to one of two treatment strategies: 290 women were assigned to a 6-month lifestyle-intervention program preceding 18 months of infertility treatment (intervention group) and 287 were assigned to prompt infertility treatment for 24 months (control group). A total of 3 women withdrew consent, so 289 women in the intervention group and 285 women in the control group were included in the analysis. The discontinuation rate in the intervention group was 21.8%. In intention-to-treat analyses, the mean weight loss was 4.4 kg in the intervention group and 1.1 kg in the control group (P<0.001). The primary outcome occurred in 27.1% of the women in the intervention group and 35.2% of those in the control group (rate ratio in the intervention group, 0.77; 95% confidence interval, 0.60 to 0.99). CONCLUSIONS In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization. (Funded by the Netherlands Organization for Health Research and Development; Netherlands Trial Register number, NTR1530.).
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Affiliation(s)
- Meike A Q Mutsaerts
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Anne M van Oers
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Henk Groen
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Jan M Burggraaff
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Walter K H Kuchenbecker
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Denise A M Perquin
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Carolien A M Koks
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Ron van Golde
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Eugenie M Kaaijk
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Jaap M Schierbeek
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Gerrit J E Oosterhuis
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Frank J Broekmans
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Wanda J E Bemelmans
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Cornelis B Lambalk
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Marieke F G Verberg
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Fulco van der Veen
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Nicole F Klijn
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Patricia E A M Mercelina
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Yvonne M van Kasteren
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Annemiek W Nap
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Egbert A Brinkhuis
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Niels E A Vogel
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Robert J A B Mulder
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Ed T C M Gondrie
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Jan P de Bruin
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - J Marko Sikkema
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Mathieu H G de Greef
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Nancy C W ter Bogt
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Jolande A Land
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Ben W J Mol
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
| | - Annemieke Hoek
- From the Departments of Obstetrics and Gynecology (M.A.Q.M., A.M.O., J.A.L., A.H.), General Practice (M.A.Q.M.), and Epidemiology (H.G.), and the Institute of Human Movement Sciences (M.H.G.G.), University Medical Center Groningen, University of Groningen, the Department of Obstetrics and Gynecology, Martini Hospital (N.E.A.V.), and the Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences (M.H.G.G.), Groningen, the Department of Obstetrics and Gynecology, Scheper Hospital, Emmen (J.M.B.), the Department of Obstetrics and Gynecology, Isala Clinics, Zwolle (W.K.H.K.), the Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden (D.A.M.P.), the Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven (C.A.M.K.), the Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht University, Maastricht (R.G.), the Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis (E.M.K.), the Department of Obstetrics and Gynecology, VU University Medical Center (C.B.L.), and the Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam (F.V.), Amsterdam, the Department of Obstetrics and Gynecology, Deventer Hospital, Deventer (J.M. Schierbeek), the Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein (G.J.E.O.), the Department of Reproductive Medicine, Division Female and Baby, University Medical Center Utrecht, Utrecht University, Utrecht (F.J.B.), the Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven (W.J.E.B.), the Department of Obstetrics and Gynecology, Medical Spectrum Twente, Enschede (M.F.G.V.), the Department of Gynecology and Reproductive Medicine, Leiden University Medical Center, University of Leiden, Leiden (N.F.K.), the Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen (P.E.A.M.M.), the Department of Obstetrics a
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Conway G, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Franks S, Gambineri A, Kelestimur F, Macut D, Micic D, Pasquali R, Pfeifer M, Pignatelli D, Pugeat M, Yildiz BO. The polycystic ovary syndrome: a position statement from the European Society of Endocrinology. Eur J Endocrinol 2014; 171:P1-29. [PMID: 24849517 DOI: 10.1530/eje-14-0253] [Citation(s) in RCA: 364] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most common ovarian disorder associated with androgen excess in women, which justifies the growing interest of endocrinologists. Great efforts have been made in the last 2 decades to define the syndrome. The presence of three different definitions for the diagnosis of PCOS reflects the phenotypic heterogeneity of the syndrome. Major criteria are required for the diagnosis, which in turn identifies different phenotypes according to the combination of different criteria. In addition, the relevant impact of metabolic issues, specifically insulin resistance and obesity, on the pathogenesis of PCOS, and the susceptibility to develop earlier than expected glucose intolerance states, including type 2 diabetes, has supported the notion that these aspects should be considered when defining the PCOS phenotype and planning potential therapeutic strategies in an affected subject. This paper offers a critical endocrine and European perspective on the debate on the definition of PCOS and summarises all major aspects related to aetiological factors, including early life events, potentially involved in the development of the disorder. Diagnostic tools of PCOS are also discussed, with emphasis on the laboratory evaluation of androgens and other potential biomarkers of ovarian and metabolic dysfunctions. We have also paid specific attention to the role of obesity, sleep disorders and neuropsychological aspects of PCOS and on the relevant pathogenetic aspects of cardiovascular risk factors. In addition, we have discussed how to target treatment choices based according to the phenotype and individual patient's needs. Finally, we have suggested potential areas of translational and clinical research for the future with specific emphasis on hormonal and metabolic aspects of PCOS.
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Affiliation(s)
- Gerard Conway
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Didier Dewailly
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Evanthia Diamanti-Kandarakis
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Héctor F Escobar-Morreale
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Stephen Franks
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Alessandra Gambineri
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Fahrettin Kelestimur
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Djuro Macut
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Dragan Micic
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Renato Pasquali
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Marija Pfeifer
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Duarte Pignatelli
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Michel Pugeat
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Bulent O Yildiz
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
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