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Gawron LM, Kaiser JE, Gero A, Sanders JN, Johnstone EB, Turok DK. Pharmacodynamic evaluation of the etonogestrel contraceptive implant initiated midcycle with and without ulipristal acetate: An exploratory study. Contraception 2024; 132:110370. [PMID: 38232940 PMCID: PMC10922844 DOI: 10.1016/j.contraception.2024.110370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To estimate the incidence of ovulation suppression within five days of etonogestrel 68 mg implant insertion in the presence of a dominant follicle with and without same-day ulipristal acetate. STUDY DESIGN This single site non-masked, exploratory randomized trial recruited people age 18-35 years with regular menstrual cycles, no pregnancy risk, and confirmed ovulatory function. We initiated transvaginal ultrasound examinations on menstrual day 7-9 and randomized participants 1:1 to etonogestrel implant alone or with concomitant ulipristal acetate 30 mg oral when a dominant follicle reached ≥14 mm in diameter. We completed daily sonography and serum hormone levels for up to seven days or transitioned to labs alone if sonographic follicular rupture occurred. We defined ovulation as follicular rupture followed by progesterone >3 ng/mL. We calculated point estimates, risk ratios and 95% confidence intervals for ovulation for each group. Ovulation suppression of ≥44% in either group (the follicular rupture suppression rate with oral levonorgestrel emergency contraception), would prompt future method testing. RESULTS From October 2020 to October 2022, we enrolled 40 people and 39 completed primary outcome assessments: 20 with etonogestrel implant alone (mean follicular size at randomization: 15.2 mm ± 0.9 mm) and 19 with etonogestrel implant + ulipristal acetate (mean follicular size at randomization: 15.4 mm ± 1.2 mm, p = 0.6). Ovulation suppression occurred in 13 (65%) of etonogestrel implant-alone participants (Risk ratio 0.6 (95% CI: 0.3, 1.1), p = 0.08) and seven (37%) of implant + ulipristal acetate participants. CONCLUSIONS Ovulation suppression of the etonogestrel implant alone exceeds threshold testing for future research while the implant + ulipristal acetate does not. IMPLICATIONS Data are lacking on midcycle ovulation suppression for the etonogestrel implant with and without oral ulipristal acetate. In this exploratory study, ovulation suppression occurred in 65% of implant participants and 37% of implant + ulipristal acetate participants. Ovulation suppression of the implant alone exceeds threshold testing for future emergency contraception research.
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Affiliation(s)
- Lori M Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.
| | - Jennifer E Kaiser
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Alexandra Gero
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Jessica N Sanders
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Erica B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - David K Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
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Verrilli LE, Allen-Brady K, Johnstone EB, Alvord MA, Welt CK. Family size for women with primary ovarian insufficiency and their relatives. Hum Reprod 2023; 38:1991-1997. [PMID: 37632248 PMCID: PMC10546072 DOI: 10.1093/humrep/dead168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
STUDY QUESTION How does the number of children in women with primary ovarian insufficiency (POI) compare to the number for control women across their reproductive lifespans? SUMMARY ANSWER Approximately 14% fewer women with POI will have children, but for those able to have children the median number is 1 less than for age-matched controls. WHAT IS KNOWN ALREADY Women with POI are often identified when presenting for fertility treatment, but some women with POI already have children and there remains a low chance for pregnancy after the diagnosis. Further, POI is heritable, but it is not known whether relatives of women with POI have a smaller family size than relatives of controls. STUDY DESIGN, SIZE, DURATION The study was a retrospective case-control study of women with POI diagnosed from 1995 to 2021 (n = 393) and age-matched controls (n = 393). PARTICIPANTS/MATERIALS, SETTING, METHODS Women with POI were identified using ICD9 and 10 codes in electronic medical records (1995-2021) from two major healthcare systems in Utah and reviewed for accuracy. Cases were linked to genealogy information in the Utah Population Database. All POI cases (n = 393) were required to have genealogy information available for at least three generations of ancestors. Two sets of female controls were identified: one matched for birthplace (Utah or elsewhere) and 5-year birth cohort, and a second also matched for fertility status (children present). The number of children born and maternal age at each birth were ascertained by birth certificates (available from 1915 to 2020) for probands, controls, and their relatives. The Mann-Whitney U test was used for comparisons. A subset analysis was performed on women with POI and controls who delivered at least one child and on women who reached 45 years to capture reproductive lifespan. MAIN RESULTS AND THE ROLE OF CHANCE Of the 393 women with POI and controls, 211 women with POI (53.7%), and 266 controls (67.7%) had at least one child. There were fewer children born to women with POI versus controls (median (interquartile range) 1 (0-2) versus 2 (0-3); P = 3.33 × 10-6). There were no children born to women with POI and primary amenorrhea or those <25 years old before their diagnosis. When analyzing women with at least one child, women with POI had fewer children compared to controls overall (2 (1-3) versus 2 (2-4); P = 0.017) and when analyzing women who reached 45 years old (2 (1-3) versus 3 (2-4); P = 0.0073). Excluding known donor oocyte pregnancies, 7.1% of women with POI had children born after their diagnosis. There were no differences in the number of children born to relatives of women with POI, including those with familial POI. LIMITATIONS, REASONS FOR CAUTION The data are limited based on inability to determine whether women were trying for pregnancy throughout their reproductive lifespan or were using contraception. Unassisted births after the diagnosis of POI may be slightly over-estimated based on incomplete data regarding use of donor oocytes. The results may not be generalizable to countries or states with late first births or lower birth rates. WIDER IMPLICATIONS OF THE FINDINGS Approximately half of women with POI will bear children before diagnosis. Although women with POI had fewer children than age matched controls, the difference in number of children is one child per woman. The data suggest that fertility may not be compromised leading up to the diagnosis of POI for women diagnosed at 25 years or later and with secondary amenorrhea. However, the rate of pregnancy after the diagnosis is low and we confirm a birth rate of <10%. The smaller number of children did not extend to relatives when examined as a group, suggesting that it may be difficult to predict POI based on family history. STUDY FUNDING/COMPETING INTEREST(S) The work in this publication was supported by R56HD090159 and R01HD099487 (C.K.W.). We also acknowledge partial support for the Utah Population Database through grant P30 CA2014 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- L E Verrilli
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Intermountain Healthcare, Murray, UT, USA
| | - K Allen-Brady
- Division of Epidemiology, Department of Internal Medicine, Salt Lake City, UT, USA
| | - E B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - M A Alvord
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - C K Welt
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Hariton E, Alvero R, Hill MJ, Mersereau JE, Perman S, Sable D, Wang F, Adamson GD, Coutifaris C, Craig LB, Hosseinzadeh P, Imudia AN, Johnstone EB, Lathi RB, Lin PC, Marsh EE, Munch M, Richard-Davis G, Roth LW, Schutt AK, Thornton K, Verrilli L, Weinerman RS, Young SL, Devine K. Meeting the demand for fertility services: the present and future of reproductive endocrinology and infertility in the United States. Fertil Steril 2023; 120:755-766. [PMID: 37665313 DOI: 10.1016/j.fertnstert.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
The field of reproductive endocrinology and infertility (REI) is at a crossroads; there is a mismatch between demand for reproductive endocrinology, infertility and assisted reproductive technology (ART) services, and availability of care. This document's focus is to provide data justifying the critical need for increased provision of fertility services in the United States now and into the future, offer approaches to rectify the developing physician shortage problem, and suggest a framework for the discussion on how to meet that increase in demand. The Society of REI recommend the following: 1. Our field should aggressively explore and implement courses of action to increase the number of qualified, highly trained REI physicians trained annually. We recommend efforts to increase the number of REI fellowships and the size complement of existing fellowships be prioritized where possible. These courses of action include: a. Increase the number of REI fellowship training programs. b. Increase the number of fellows trained at current REI fellowship programs. c. The pros and cons of a 2-year focused clinical fellowship track for fellows interested primarily in ART practice were extensively explored. We do not recommend shortening the REI fellowship to 2 years at this time, because efforts should be focused on increasing the number of fellowship training slots (1a and b). 2. It is recommended that the field aggressively implements courses of action to increase the number of and appropriate usage of non-REI providers to increase clinical efficiency under appropriate board-certified REI physician supervision. 3. Automating processes through technologic improvements can free providers at all levels to practice at the top of their license.
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Affiliation(s)
- Eduardo Hariton
- Reproductive Science Center of the San Franisco Bay Area, San Francisco, California
| | - Ruben Alvero
- Fertility and Reproductive Health, Lucille Packard Children's Hospital, Sunnyvale, California; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California.
| | - Micah J Hill
- National Institutes of Health, National Institute for Child Health and Human Development, Program in Reproductive and Adult Endocrinology, Bethesda, Maryland
| | | | - Shana Perman
- Shady Grove Fertility, Washington, District of Columbia; Shady Grove Fertility, Columbia, Maryland
| | - David Sable
- Special Situations Life Sciences Fund and Department of Biological Sciences, Columbia University, New York, New York
| | - Fiona Wang
- Lucile Packard Children's Hospital/Stanford Children's Health and Stanford Fertility and Reproductive Health, Sunnyvale, California
| | - Geoffrey David Adamson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, ACF, Stanford University, Stanford, California
| | - Christos Coutifaris
- Division of Reproductive Endocrinology and Infertility, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - LaTasha B Craig
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Pardis Hosseinzadeh
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Johns Hopkins University, Baltimore, Maryland
| | - Anthony N Imudia
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Erica B Johnstone
- Division of Reproductive Endocrinology and Infertility, University of Utah, Salt Lake City, Utah
| | - Ruth B Lathi
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Paul C Lin
- Seattle Reproductive Medicine, Seattle, Washington; Seattle Reproductive Medicine, Bellevue, Washington
| | - Erica E Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Michele Munch
- Department of Obstetrics and Gynecology, Pennsylvania State University Health, York, Pennsylvania
| | - Gloria Richard-Davis
- Department of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, University of Arkansas, Little Rock, Arkansas
| | | | - Amy K Schutt
- Texas Fertility Center, Austin, Texas; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Kim Thornton
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston; Boston IVF, Waltham, Massachusetts
| | - Lauren Verrilli
- Division of Reproductive Endocrinology and Infertility, University of Utah, Salt Lake City, Utah
| | - Rachel S Weinerman
- Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Steven L Young
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Kate Devine
- National Institutes of Health, National Institute for Child Health and Human Development, Program in Reproductive and Adult Endocrinology, Bethesda, Maryland; Shady Grove Fertility, Washington, District of Columbia; Departments of Obstetrics and Gynecology, Georgetown University and George Washington University, Washington, DC
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Miller RH, Pollard CA, Brogaard KR, Olson AC, Barney RC, Lipshultz LI, Johnstone EB, Ibrahim YO, Hotaling JM, Schisterman EF, Mumford SL, Aston KI, Jenkins TG. Tissue-specific DNA methylation variability and its potential clinical value. Front Genet 2023; 14:1125967. [PMID: 37538359 PMCID: PMC10394514 DOI: 10.3389/fgene.2023.1125967] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/07/2023] [Indexed: 08/05/2023] Open
Abstract
Complex diseases have multifactorial etiologies making actionable diagnostic biomarkers difficult to identify. Diagnostic research must expand beyond single or a handful of genetic or epigenetic targets for complex disease and explore a broader system of biological pathways. With the objective to develop a diagnostic tool designed to analyze a comprehensive network of epigenetic profiles in complex diseases, we used publicly available DNA methylation data from over 2,400 samples representing 20 cell types and various diseases. This tool, rather than detecting differentially methylated regions at specific genes, measures the intra-individual methylation variability within gene promoters to identify global shifts away from healthy regulatory states. To assess this new approach, we explored three distinct questions: 1) Are profiles of epigenetic variability tissue-specific? 2) Do diseased tissues exhibit altered epigenetic variability compared to normal tissue? 3) Can epigenetic variability be detected in complex disease? Unsupervised clustering established that global epigenetic variability in promoter regions is tissue-specific and promoter regions that are the most epigenetically stable in a specific tissue are associated with genes known to be essential for its function. Furthermore, analysis of epigenetic variability in these most stable regions distinguishes between diseased and normal tissue in multiple complex diseases. Finally, we demonstrate the clinical utility of this new tool in the assessment of a multifactorial condition, male infertility. We show that epigenetic variability in purified sperm is correlated with live birth outcomes in couples undergoing intrauterine insemination (IUI), a common fertility procedure. Men with the least epigenetically variable promoters were almost twice as likely to father a child than men with the greatest number of epigenetically variable promoters. Interestingly, no such difference was identified in men undergoing in vitro fertilization (IVF), another common fertility procedure, suggesting this as a treatment to overcome higher levels of epigenetic variability when trying to conceive.
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Affiliation(s)
| | - Chad A. Pollard
- Department of Cell Biology and Physiology, Brigham Young University, Provo, UT, United States
| | | | | | - Ryan C. Barney
- Department of Cell Biology and Physiology, Brigham Young University, Provo, UT, United States
| | - Larry I. Lipshultz
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States
| | - Erica B. Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Yetunde O. Ibrahim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Health Science Center in San Antonio, San Antonio, TX, United States
| | - James M. Hotaling
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Enrique F. Schisterman
- Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sunni L. Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Kenneth I. Aston
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Tim G. Jenkins
- Department of Cell Biology and Physiology, Brigham Young University, Provo, UT, United States
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
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Legro RS, Hansen KR, Diamond MP, Steiner AZ, Coutifaris C, Cedars MI, Hoeger KM, Usadi R, Johnstone EB, Haisenleder DJ, Wild RA, Barnhart KT, Mersereau J, Trussell JC, Krawetz SA, Kris-Etherton PM, Sarwer DB, Santoro N, Eisenberg E, Huang H, Zhang H. Effects of preconception lifestyle intervention in infertile women with obesity: The FIT-PLESE randomized controlled trial. PLoS Med 2022; 19:e1003883. [PMID: 35041662 PMCID: PMC8765626 DOI: 10.1371/journal.pmed.1003883] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 12/03/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Women with obesity and infertility are counseled to lose weight prior to conception and infertility treatment to improve pregnancy rates and birth outcomes, although confirmatory evidence from randomized trials is lacking. We assessed whether a preconception intensive lifestyle intervention with acute weight loss is superior to a weight neutral intervention at achieving a healthy live birth. METHODS AND FINDINGS In this open-label, randomized controlled study (FIT-PLESE), 379 women with obesity (BMI ≥ 30 kg/m2) and unexplained infertility were randomly assigned in a 1:1 ratio to 2 preconception lifestyle modification groups lasting 16 weeks, between July 2015 and July 2018 (final follow-up September 2019) followed by infertility therapy. The primary outcome was the healthy live birth (term infant of normal weight without major anomalies) incidence. This was conducted at 9 academic health centers across the United States. The intensive group underwent increased physical activity and weight loss (target 7%) through meal replacements and medication (Orlistat) compared to a standard group with increased physical activity alone without weight loss. This was followed by standardized empiric infertility treatment consisting of 3 cycles of ovarian stimulation/intrauterine insemination. Outcomes of any resulting pregnancy were tracked. Among 191 women randomized to standard lifestyle group, 40 dropped out of the study before conception; among 188 women randomized to intensive lifestyle group, 31 dropped out of the study before conception. All the randomized women were included in the intent-to-treat analysis for primary outcome of a healthy live birth. There were no significant differences in the incidence of healthy live births [standard 29/191(15.2%), intensive 23/188(12.2%), rate ratio 0.81 (0.48 to 1.34), P = 0.40]. Intensive had significant weight loss compared to standard (-6.6 ± 5.4% versus -0.3 ± 3.2%, P < 0.001). There were improvements in metabolic health, including a marked decrease in incidence of the metabolic syndrome (baseline to 16 weeks: standard: 53.6% to 49.4%, intensive 52.8% to 32.2%, P = 0.003). Gastrointestinal side effects were significantly more common in intensive. There was a higher, but nonsignificant, first trimester pregnancy loss in the intensive group (33.3% versus 23.7% in standard, 95% rate ratio 1.40, 95% confidence interval [CI]: 0.79 to 2.50). The main limitations of the study are the limited power of the study to detect rare complications and the design difficulty in finding an adequate time matched control intervention, as the standard exercise intervention may have potentially been helpful or harmful. CONCLUSIONS A preconception intensive lifestyle intervention for weight loss did not improve fertility or birth outcomes compared to an exercise intervention without targeted weight loss. Improvement in metabolic health may not translate into improved female fecundity. TRIAL REGISTRATION ClinicalTrials.gov NCT02432209.
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Affiliation(s)
- Richard S. Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- * E-mail:
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia, United States of America
| | - Anne Z. Steiner
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Marcelle I. Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California, United States of America
| | - Kathleen M. Hoeger
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York, United States of America
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina, United States of America
| | - Erica B. Johnstone
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, United States of America
| | - Daniel J. Haisenleder
- Ligand Core Laboratory, University of Virginia Center for Research in Reproduction, Charlottesville, Virginia, United States of America
| | - Robert A. Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Kurt T. Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jennifer Mersereau
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - J. C. Trussell
- Department of Urology, SUNY Upstate University Hospital, Syracuse, New York, United States of America
| | - Stephen A. Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, United States of America
| | - Penny M. Kris-Etherton
- Department of Nutritional Sciences, Penn State College of Health and Human Development, Pennsylvania, United States of America
| | - David B. Sarwer
- Center for Obesity Research and Education, College of Public Health, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Esther Eisenberg
- Fertility and Infertility Branch, NICHD, Rockville, Maryland, United States of America
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut, United States of America
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut, United States of America
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Keihani S, Verrilli LE, Zhang C, Presson AP, Hanson HA, Pastuszak AW, Johnstone EB, Hotaling JM. Semen parameter thresholds and time-to-conception in subfertile couples: how high is high enough? Hum Reprod 2021; 36:2121-2133. [PMID: 34097024 DOI: 10.1093/humrep/deab133] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 04/25/2021] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION What thresholds for total sperm count, sperm concentration, progressive motility, and total progressive motile sperm count (TPMC) are associated with earlier time-to-conception in couples undergoing fertility evaluation? SUMMARY ANSWER Values well above the World Health Organization (WHO) references for total sperm count, concentration, and progressive motility, and values up to 100 million for TPMC were consistently associated with earlier time-to-conception and higher conception rates. WHAT IS KNOWN ALREADY Although individual semen parameters are generally not able to distinguish between fertile and infertile men, they can provide clinically useful information on time-to-pregnancy for counseling patients seeking fertility treatment. Compared to the conventional semen parameters, TPMC might be a better index for evaluating the severity of male infertility. STUDY DESIGN, SIZE, DURATION We used data from a longitudinal cohort study on subfertile men from 2002 to 2017 and included 6061 men with initial semen analysis (SA) in the study. PARTICIPANTS/MATERIALS, SETTING, METHODS Men from subfertile couples who underwent a SA within the study period were included, and 5-year follow-up data were collected to capture conception data. Couples were further categorized into two subgroups: natural conception (n = 5126), after separating those who achieved conception using ART or IUI; natural conception without major female factor (n = 3753), after separating those with severe female factor infertility diagnoses. TPMC was calculated by multiplying the semen volume (ml) by sperm concentration (million/ml) and the percentage of progressively motile sperm (%). Cox proportional hazard models were used to report hazard ratios (HRs) with 95% CIs before and after adjusting for male age, the number of previous children before the first SA, and income. Using the regression tree method, we calculated thresholds for total sperm count, sperm concentration, progressive motility, and TPMC to best differentiate those who were more likely to conceive within 5 years after first SA from those less likely to conceive. We also plotted continuous values of semen parameters in predicting 5-year conception rates and time-to-conception. MAIN RESULTS AND THE ROLE OF CHANCE Overall, the median time to conception was 22 months (95% CI: 21-23). A total of 3957 (65%) couples were known to have achieved conception within 5 years of the first SA. These patients were younger and had higher values of sperm concentration, progressive motility, and TPMC. In the overall cohort, a TPMC of 50 million best differentiated men who were more likely to father a child within 5 years. Partners of men with TPMC ≥50 million had a 45% greater chance of conception within 5 years in the adjusted model (HR: 1.45; 95% CI: 1.34-1.58) and achieved pregnancy earlier compared to those men with TPMC < 50 million (median 19 months (95% CI: 18-20) versus 36 months (95% CI: 32-41)). Similar results were observed in the natural conception cohort. For the natural conception cohort without major female factor, the TPMC cut-off was 20 million. In the visual assessment of the graphs for the continuous semen parameter values, 5-year conception rates and time-to-conception consistently plateaued at higher values of sperm concentration, total sperm count, progressive motility, and TPMC compared to the WHO reference levels and our calculated thresholds. For TPMC, values up to 100-150 million were still associated with a better conception rate and time-to-conception in the visual assessment of the curves. LIMITATIONS, REASONS FOR CAUTION There was limited information on female partners and potential for inaccuracies in capturing less severe female infertility diagnoses. Also we lacked details on assisted pregnancies achieved outside of our healthcare network (with possible miscoding as 'natural conception' in our cohort). We only used the initial SA and sperm morphology, another potentially important parameter, was not included in the analyses. We had no information on continuity of pregnancy attempts/intention, which could affect the time-to-conception data. Finally, most couples had been attempting conception for >12 months prior to initiating fertility treatment, so it is likely that we are underestimating time to conception. Importantly, our data might lack the generalizability to other populations. WIDER IMPLICATIONS OF THE FINDINGS Our results suggest that a TPMC threshold of 50 million sperm provided the best predictive power to estimate earlier time-to-conception in couples evaluated for male factor infertility. Higher values of sperm count, concentration and progressive motility beyond the WHO references were still associated with better conception rates and time-to-conception. This provides an opportunity to optimize semen parameters in those with semen values that are low but not abnormal according to the WHO reference values. These data can be used to better inform patients regarding their chances of conception per year when SA results are used for patient counseling. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Lauren E Verrilli
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Heidi A Hanson
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Alexander W Pastuszak
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Erica B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
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Legro RS, Hansen KR, Diamond MP, Steiner A, Mersereau J, Sarwer DB, Kris-Etherton PM, Wild RA, Krawetz SA, Hoeger KM, Usadi R, Johnstone EB, Hao H, Eisenberg E, Santoro NF, Zhang H. OR11-04 Effect of Preconception Intensive vs. Standard Lifestyle Intervention on Birth Outcomes in Obese Women With Unexplained Infertility: A Multicenter Randomized Trial. J Endocr Soc 2020. [PMCID: PMC7209215 DOI: 10.1210/jendso/bvaa046.2149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
We hypothesized that weight loss with an intensive preconception lifestyle (IL) intervention of caloric restriction with meal replacements, daily orlistat and increased physical activity in women with obesity and unexplained infertility (UI) was more likely to result in Good Birth Outcome than a standard lifestyle modification (SL) with increased physical activity alone. The 16 week period of lifestyle modification was followed by an open label empiric infertility treatment regimen of 3 cycles of ovarian stimulation with clomiphene, ovulation triggering with hCG and intrauterine insemination. We randomized 379 obese women 18-40y with UI (regular menses, normal ovarian reserve, patent reproductive tract and normal male factor). A Good Birth Outcome (GBO) was the primary outcome, defined as a live birth of an infant born at ≥37wks with a birthweight between 2500-4000g and no major congenital anomaly. Key secondary outcomes were live birth, pregnancy loss and pregnancy complication rates. The study had 80% power and an alpha of 0.05 to detect an absolute 15% difference in GBO. An Intention-to-Treat analysis was used. Both groups (SL N=191, IL N =188) were well matched at baseline(e.g. weight (kg), mean ± SD, SL:107±21, IL: 108 ±23). Women in the IL arm lost significantly more weight preconception than SL (SL -0.3±3.4 vs IL -7.3±6.6 kg, P<.001) with similar decreases in associated biometric and biochemical parameters. Overall 59.4% of the IL group lost >5% weight vs 6.5% in SL group(P<.001). Despite achieving the targeted weight loss, GBO rate between groups was not significantly different (IL12.2% vs SL 15.2%, IL Rate Ratio, 95% CI: 0.8, 0.5-1.3) or in live birth (IL 20.2% vs SL 22.0%, IL RR: 0.9, 0.6-1.4). Pregnancy loss among women who conceived trended higher in the IL group (IL 38.1% vs SL 23.7%, IL RR:1.6, 0.9-2.8) but miscarriage rates (loss after visualized intrauterine pregnancy), were significantly higher in IL (IL 20.6% vs SL 3.4%, IL RR: 6.1, 1.4-25.8, P=0.005). Birthweights were similar in both groups (IL: 3199±712 vs SL: 3106±794g). Major pregnancy complications trended lower in IL: Preterm Labor (IL 3.2% vs SL 10.2%), Pre-eclampsia (IL 6.3% vs SL 11.9%), Gestational DM (IL 9.5% vs SL 16.9%). Adverse events were more common in the IL group, i.e. increased GI side effects of bloating, flatulence, diarrhea and steatorrhea, likely related to use of orlistat. Moderate weight loss prior to conception does not improve live birth or GBO rates compared to exercise alone in obese women. Of concern, early pregnancy loss is more common when conception occurs after IL intervention. However a benefit to IL modification preconception may be lower perinatal morbidity, although further larger studies are necessary to confirm this potential benefit.
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Affiliation(s)
| | - Karl R Hansen
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Garg D, Johnstone EB, Fair DB, Carrell DT, Berga S, Letourneau JM. Oncofertility conundrum: discrepancy between anti-Mϋllerian hormone and mature oocyte yield in a peripubertal girl with Hodgkin lymphoma. J Assist Reprod Genet 2019; 36:1753-1756. [PMID: 31313012 DOI: 10.1007/s10815-019-01516-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/20/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- D Garg
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, 84108, USA.
| | - E B Johnstone
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, 84108, USA
| | - D B Fair
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, 84108, USA
| | - D T Carrell
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, 84108, USA
| | - S Berga
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, 84108, USA
| | - J M Letourneau
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, 84108, USA
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9
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Patel B, Byrne JLB, Phillips A, Hotaling JM, Johnstone EB. When standard genetic testing does not solve the mystery: a rare case of preimplantation genetic diagnosis for campomelic dysplasia in the setting of parental mosaicism. Fertil Steril 2019; 110:732-736. [PMID: 30196970 DOI: 10.1016/j.fertnstert.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To report a rare case of somatic mosaicism with a germline component of campomelic dysplasia in a woman undergoing in vitro fertilization with preimplantation genetic diagnosis (IVF-PGD). DESIGN Case report. SETTING Clinic. PATIENT(S) A 28-year old G2P0110 and her 34-year old husband had two previous pregnancies complicated by fetal campomelic dysplasia with suspected germline mosaic mutation. The couple, both phenotypically normal, underwent IVF-PGD to reduce their chances of transmission. None of the embryos could initially be determined to be disease free, because all embryos shared either a maternal or a paternal short tandem repeat haplotype with the products of conception from her last pregnancy. INTERVENTION(S) Peripheral-blood cytogenomic single-nucleotide polymorphism (SNP) microarray to identify the carrier of the mutation, and IVF-PGD to identify the disease-free embryo. MAIN OUTCOME MEASURE(S) Disease-free embryo. RESULT(S) Only one of the five euploid embryos was identified as disease free. CONCLUSION(S) A woman with suspected germline mosaicism for campomelic dysplasia was found to be a somatic mosaic with a germline component via a peripheral blood SNP microarray test. This identified her solitary disease-free embryo, which was transferred to her uterus but did not result in a viable pregnancy.
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Affiliation(s)
- Biren Patel
- Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah.
| | - Jan L B Byrne
- Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Amber Phillips
- Genetic Counseling, University of Utah, Salt Lake City, Utah
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Patel B, Meeks H, Wan Y, Johnstone EB, Glenn M, Smith KR, Hotaling JM. Transgenerational effects of chemotherapy: Both male and female children born to women exposed to chemotherapy have fewer children. Cancer Epidemiol 2018; 56:1-5. [PMID: 30005388 DOI: 10.1016/j.canep.2018.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/30/2018] [Accepted: 07/03/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is little known about the transgenerational effect of chemotherapy. For example, chemotherapy is known to decrease fecundity in women. But if women are able to have offspring after chemotherapy exposure, do these children also have decreased fecundity? METHODS This study is a retrospective cohort study utilizing the Utah Population Database (UPDB), a comprehensive resource that links birth, medical, death and cancer records for individuals in the state of Utah. The male and female children (F1 generation) of chemotherapy-exposed women (F0 generation) were identified. The number of live births (F2 generation) to this F1 generation was compared to two sets of chemotherapy-unexposed, matched controls using conditional Poisson regression models (regression coefficient, 95% confidence interval, P-value). The first unexposed was established using the general population and the second unexposed was established using first cousins to the F1 generation. RESULTS The exposed F1 individuals had 77.2% fewer children (-1.48; -2.51 to -0.70; p = 0.001) relative to the unexposed general population. F1 males had 86.9% fewer children (-2.03; -4.91 to -0.51; p = 0.005) and F1 females had 70.5% fewer children (-1.22; -2.40 to -0.36; p = 0.016). When comparing to their unexposed cousins, the F1 generation (both sexes combined) had 74.3% (-1.36; -2.82 to -0.29; p = 0.029) fewer children. CONCLUSION The sons and daughters (F1 generation) of chemotherapy-exposed women have fewer live births when compared to both matched, unexposed general population and cousin controls. Chemotherapy may have a transgenerational effect in exposed women which needs further investigation.
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Affiliation(s)
- Biren Patel
- Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, United States.
| | - Huong Meeks
- Family Consumer Studies, and Population Sciences, University of Utah, Salt Lake City, UT, United States
| | - Yuan Wan
- Family Consumer Studies, and Population Sciences, University of Utah, Salt Lake City, UT, United States
| | - Erica B Johnstone
- Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, United States
| | - Martha Glenn
- Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States
| | - Ken R Smith
- Family Consumer Studies, and Population Sciences, University of Utah, Salt Lake City, UT, United States
| | - James M Hotaling
- Urology (General Surgery), University of Utah, Salt Lake City, UT, United States
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11
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Yamamoto A, Johnstone EB, Bloom MS, Huddleston HG, Fujimoto VY. A higher prevalence of endometriosis among Asian women does not contribute to poorer IVF outcomes. J Assist Reprod Genet 2017; 34:765-774. [PMID: 28417349 PMCID: PMC5445055 DOI: 10.1007/s10815-017-0919-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/04/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The purpose of the study was to determine whether diagnosis of endometriosis or endometriosis with endometrioma influences in vitro fertilization (IVF) outcomes in an ethnically diverse population. METHODS Women undergoing a first IVF cycle (n = 717) between January 1, 2008 and December 31, 2009, at a university-affiliated infertility clinic, were retrospectively assessed for an endometriosis diagnosis. Differences in prevalence of endometriosis by ethnicity were determined, as well as differences in IVF success by ethnicity, with a focus on country of origin for Asian women. A multivariate model was generated to assess the relative contributions of country of origin and endometriosis to chance of clinical pregnancy with IVF. RESULTS Endometriosis was diagnosed in 9.5% of participants; 3.5% also received a diagnosis of endometrioma. Endometriosis prevalence in Asian women was significantly greater than in Caucasians (15.7 vs. 5.8%, p < 0.01). Women of Filipino (p < 0.01), Indian (p < 0.01), Japanese (p < 0.01), and Korean (p < 0.05) origin specifically were more likely to have endometriosis than Caucasian women, although there was no difference in endometrioma presence by race/ethnicity. Oocyte quantity, embryo quality, and fertilization rates did not relate to endometriosis. Clinical pregnancy rates were significantly lower for Asian women, specifically in Indian (p < 0.05), Japanese (p < 0.05), and Korean (p < 0.05) women, compared to Caucasian women, even after controlling for endometriosis status. CONCLUSIONS The prevalence of endometriosis appears to be higher in Filipino, Indian, Japanese, and Korean women presenting for IVF treatment than for Caucasian women; however, the discrepancy in IVF outcomes was conditionally independent of the presence of endometriosis. Future research should focus on improving pregnancy outcomes for Asian populations whether or not they are affected by endometriosis, specifically in the form of longitudinal studies where exposures can be captured prior to endometriosis diagnoses and infertility treatment.
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Affiliation(s)
- Ayae Yamamoto
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Health, University of California, San Francisco, 499 Illinois Street, 6th floor, San Francisco, CA, 94158, USA.
- Department of Health Policy and Management, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Erica B Johnstone
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Health, University of California, San Francisco, 499 Illinois Street, 6th floor, San Francisco, CA, 94158, USA
- Division of Reproductive Endocrinology and Infertility, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Michael S Bloom
- Department of Environmental Health Sciences, University at Albany, State University of New York, Rensselaer, NY, USA
- Department of Epidemiology and Biostatistics, University at Albany, State University of New York, Rensselaer, NY, USA
| | - Heather G Huddleston
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Health, University of California, San Francisco, 499 Illinois Street, 6th floor, San Francisco, CA, 94158, USA
| | - Victor Y Fujimoto
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Health, University of California, San Francisco, 499 Illinois Street, 6th floor, San Francisco, CA, 94158, USA
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12
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Schliep KC, Mumford SL, Johnstone EB, Peterson CM, Sharp HT, Stanford JB, Chen Z, Backonja U, Wallace ME, Buck Louis GM. Sexual and physical abuse and gynecologic disorders. Hum Reprod 2016; 31:1904-12. [PMID: 27334336 DOI: 10.1093/humrep/dew153] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/31/2016] [Indexed: 01/03/2023] Open
Abstract
STUDY QUESTION Is sexual and/or physical abuse history associated with incident endometriosis diagnosis or other gynecologic disorders among premenopausal women undergoing diagnostic and/or therapeutic laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER No association was observed between either a history of sexual or physical abuse and risk of endometriosis, ovarian cysts or fibroids; however, a history of physical abuse was associated with a higher likelihood of adhesions after taking into account important confounding and mediating factors. WHAT IS KNOWN ALREADY Sexual and physical abuse may alter neuroendocrine-immune processes leading to a higher risk for endometriosis and other noninfectious gynecologic disorders, but few studies have assessed abuse history prior to diagnosis. STUDY DESIGN, SIZE, DURATION The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of the 14 surgical centers located in Salt Lake City, UT, USA or San Francisco, CA, USA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS Prior to surgery, women completed standardized abuse questionnaires. Relative risk (RR) of incident endometriosis, uterine fibroids, adhesions or ovarian cysts by abuse history were estimated, adjusting for age, race/ethnicity, education, marital status, smoking, gravidity and recruitment site. We assessed whether a history of chronic pelvic pain, depression, or STIs explained any relationships via mediation analyses. MAIN RESULTS AND ROLE OF CHANCE 43 and 39% of women reported experiencing sexual and physical abuse. No association was observed between either a history of sexual or physical abuse, versus no history, and risk of endometriosis (aRR: 1.00 [95% confidence interval (CI): 0.80-1.25]); aRR: 0.83 [95% CI: 0.65-1.06]), ovarian cysts (aRR: 0.67 [95% CI: 0.39-1.15]); aRR: 0.60 [95% CI: 0.34-1.09]) or fibroids (aRR: 1.25 [95% CI: 0.85-1.83]); aRR: 1.36 [95% CI: 0.92-2.01]). Conversely, a history of physical abuse, versus no history, was associated with higher risk of adhesions (aRR: 2.39 [95% CI: 1.18-4.85]). We found no indication that the effect of abuse on women's adhesion risk could be explained by a history of chronic pelvic pain, depression or STIs. LIMITATIONS, REASONS FOR CAUTION Limitations to our study include inquiries on childhood physical but not sexual abuse. Additionally, we did not inquire about childhood or adulthood emotional support systems, found to buffer the negative impact of stress on gynecologic health. WIDER IMPLICATIONS OF THE FINDINGS Abuse may be associated with some but not all gynecologic disorders with neuroendocrine-inflammatory origin. High prevalence of abuse reporting supports the need for care providers to screen for abuse and initiate appropriate follow-up. STUDY FUNDING/COMPETING INTERESTS Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.
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Affiliation(s)
- K C Schliep
- Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Rockville, MD, USA
| | - Sunni L Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Rockville, MD, USA
| | - Erica B Johnstone
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - C Matthew Peterson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Howard T Sharp
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph B Stanford
- Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Zhen Chen
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Rockville, MD, USA
| | - Uba Backonja
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, WA, USA
| | - Maeve E Wallace
- Mary Amelia Women's Center, Tulane University, New Orleans, LA, USA
| | - Germaine M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Rockville, MD, USA
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13
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Johnstone EB, Hotaling JM. Conservation of ovarian reserve across ethnicities: evidence of the evolutionary importance of maintenance of ovarian reserve. Fertil Steril 2016; 106:272. [PMID: 27179786 DOI: 10.1016/j.fertnstert.2016.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/20/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Erica B Johnstone
- Department of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, Utah Center for Reproductive Medicine, University of Utah, Salt Lake City, Utah
| | - James M Hotaling
- Division of Andrology/Urology, Department of Surgery (Urology), Center for Reconstructive Urology and Mens Health, University of Utah, Salt Lake City, Utah
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Schliep KC, Mumford SL, Peterson CM, Chen Z, Johnstone EB, Sharp HT, Stanford JB, Hammoud AO, Sun L, Buck Louis GM. Pain typology and incident endometriosis. Hum Reprod 2015; 30:2427-38. [PMID: 26269529 DOI: 10.1093/humrep/dev147] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 06/01/2015] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis. WHAT IS KNOWN ALREADY Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management. STUDY DESIGN, SIZE, DURATION The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months. MAIN RESULTS AND THE ROLE OF CHANCE There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location. LIMITATIONS, REASONS FOR CAUTION Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons. WIDER IMPLICATIONS OF THE FINDINGS Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed. STUDY FUNDING/COMPETING INTERESTS Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.
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Affiliation(s)
- K C Schliep
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - S L Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
| | - C M Peterson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - Z Chen
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
| | - E B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - H T Sharp
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - J B Stanford
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - A O Hammoud
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - L Sun
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
| | - G M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20852, USA
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Patel DP, Brant WO, Myers JB, Zhang C, Presson AP, Johnstone EB, Dorais JA, Aston KI, Carrell DT, Hotaling JM. Sperm Concentration Is Poorly Associated With Hypoandrogenism in Infertile Men. Urology 2015; 85:1062-1067. [DOI: 10.1016/j.urology.2015.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/22/2014] [Accepted: 01/13/2015] [Indexed: 11/24/2022]
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Johnstone EB, Louis GMB, Parsons PJ, Steuerwald AJ, Palmer CD, Chen Z, Sun L, Hammoud AO, Dorais J, Peterson CM. Increased urinary cobalt and whole blood concentrations of cadmium and lead in women with uterine leiomyomata: Findings from the ENDO Study. Reprod Toxicol 2014; 49:27-32. [PMID: 24994689 DOI: 10.1016/j.reprotox.2014.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 05/06/2014] [Accepted: 06/13/2014] [Indexed: 11/26/2022]
Abstract
Multiple trace elements have estrogen receptor activity, but the association of these elements with uterine leiomyoma has not been defined. A cohort of 473 women aged 18-44 undergoing surgery for benign gynecologic indications provided whole blood and urine specimens for trace element analysis, which was performed by inductively coupled plasma mass spectrometry. Twenty elements were analyzed in blood and 3 in urine. The surgeon documented whether fibroids were present. Geometric mean concentrations were compared between women with and without fibroids, and logistic regression models were generated to assess the impact of the concentration of each trace element on the odds of fibroids. In multivariate regressions, odds of a fibroid diagnosis were higher with increased whole blood cadmium (AOR 1.44, 95% CI 1.02, 2.04) and lead (AOR 1.31 95% CI 1.02, 1.69), and urine cobalt (AOR 1.31, 95% CI 1.02, 1.70). Urinary cadmium and lead were not related to fibroid diagnosis. Increased exposure to trace elements may contribute to fibroid growth, and fibroids may serve as a reservoir for these elements. Differences between urinary and whole blood findings merit further investigation, as urinary cadmium has been considered a superior marker of exposure.
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Affiliation(s)
- Erica B Johnstone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, 50 North 1900 East, Ste. 2B200, Salt Lake City, UT 84108, United States.
| | - Germaine M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Health, 6100 Executive Boulevard, Rockville, MD 20852, United States
| | - Patrick J Parsons
- Laboratory of Inorganic and Nuclear Chemistry, Wadsworth Center, New York State Department of Health, and the Department of Environmental Health Sciences, The University at Albany, New York 12201, United States
| | - Amy J Steuerwald
- Laboratory of Inorganic and Nuclear Chemistry, Wadsworth Center, New York State Department of Health, and the Department of Environmental Health Sciences, The University at Albany, New York 12201, United States
| | - Christopher D Palmer
- Laboratory of Inorganic and Nuclear Chemistry, Wadsworth Center, New York State Department of Health, and the Department of Environmental Health Sciences, The University at Albany, New York 12201, United States
| | - Zhen Chen
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Health, 6100 Executive Boulevard, Rockville, MD 20852, United States
| | - Liping Sun
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Health, 6100 Executive Boulevard, Rockville, MD 20852, United States
| | - Ahmad O Hammoud
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, 50 North 1900 East, Ste. 2B200, Salt Lake City, UT 84108, United States
| | - Jessie Dorais
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, 50 North 1900 East, Ste. 2B200, Salt Lake City, UT 84108, United States
| | - C Matthew Peterson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, 50 North 1900 East, Ste. 2B200, Salt Lake City, UT 84108, United States
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Peterson CM, Johnstone EB, Hammoud AO, Stanford JB, Varner MW, Kennedy A, Chen Z, Sun L, Fujimoto VY, Hediger ML, Buck Louis GM. Risk factors associated with endometriosis: importance of study population for characterizing disease in the ENDO Study. Am J Obstet Gynecol 2013; 208:451.e1-11. [PMID: 23454253 DOI: 10.1016/j.ajog.2013.02.040] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 01/05/2013] [Accepted: 02/25/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We sought to identify risk factors for endometriosis and their consistency across study populations in the Endometriosis: Natural History, Diagnosis, and Outcomes (ENDO) Study. STUDY DESIGN In this prospective matched, exposure cohort design, 495 women aged 18-44 years undergoing pelvic surgery (exposed to surgery, operative cohort) were compared to an age- and residence-matched population cohort of 131 women (unexposed to surgery, population cohort). Endometriosis was diagnosed visually at laparoscopy/laparotomy or by pelvic magnetic resonance imaging in the operative and population cohorts, respectively. Logistic regression estimated the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for each cohort. RESULTS The incidence of visualized endometriosis was 40% in the operative cohort (11.8% stage 3-4 by revised criteria from the American Society for Reproductive Medicine), and 11% stage 3-4 in the population cohort by magnetic resonance imaging. An infertility history increased the odds of an endometriosis diagnosis in both the operative (AOR, 2.43; 95% CI, 1.57-3.76) and population (AOR, 7.91; 95% CI, 1.69-37.2) cohorts. In the operative cohort only, dysmenorrhea (AOR, 2.46; 95% CI, 1.28-4.72) and pelvic pain (AOR, 3.67; 95% CI, 2.44-5.50) increased the odds of diagnosis, while gravidity (AOR, 0.49; 95% CI, 0.32-0.75), parity (AOR, 0.42; 95% CI, 0.28-0.64), and body mass index (AOR, 0.95; 95% CI, 0.93-0.98) decreased the odds of diagnosis. In all sensitivity analyses for different diagnostic subgroups, infertility history remained a strong risk factor. CONCLUSION An infertility history was a consistent risk factor for endometriosis in both the operative and population cohorts of the ENDO Study. Additionally, identified risk factors for endometriosis vary based upon cohort selection and diagnostic accuracy. Finally, endometriosis in the population may be more common than recognized.
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Kuzbari O, Peterson CM, Franklin MR, Hathaway LB, Johnstone EB, Hammoud AO, Lamb JG. Comparative analysis of human CYP3A4 and rat CYP3A1 induction and relevant gene expression by bisphenol A and diethylstilbestrol: implications for toxicity testing paradigms. Reprod Toxicol 2013; 37:24-30. [PMID: 23384967 DOI: 10.1016/j.reprotox.2013.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/07/2013] [Accepted: 01/26/2013] [Indexed: 11/19/2022]
Abstract
Bisphenol A (BPA) and diethylstilbestrol (DES) are endocrine-disrupting chemicals that interact with the human pregnane X receptor (PXR). CYP3A4 enzyme is essential in the hydroxylation of steroid hormones and is regulated by PXR. In the present study, human and rat hepatoma cell lines were exposed to BPA and DES. Both BPA and DES (10-50μM) caused a significant activation of the CYP3A4 promoter via the PXR in the DPX2 human hepatoma cell line. No activation of rat PXR was seen. BPA and DES treated DPX2 cells demonstrated increased expression of CYP3A4 mRNA, and increased enzyme activity. In summary, BPA, in concentrations relevant to current safety levels of human exposure, activates the human PXR and demonstrates an increase in CYP3A4 mRNA expression and enzyme activity. BPA actions in this model system occur to a greater extent than DES. This study raises concerns regarding our current toxicity testing paradigms and species utilization.
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Affiliation(s)
- Oumar Kuzbari
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Suite 2B200, Salt Lake City, UT 84112, United States.
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Johnstone EB, Davis G, Zane LT, Cedars MI, Huddleston HG. Age-related differences in the reproductive and metabolic implications of polycystic ovarian syndrome: findings in an obese, United States population. Gynecol Endocrinol 2012; 28:819-22. [PMID: 22475130 DOI: 10.3109/09513590.2012.671389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The objective of this study was to explore age-related differences in the reproductive and metabolic manifestations of polycystic ovarian syndrome (PCOS). Using a prospective cross-sectional design, we compared metabolic and reproductive findings in women attending a multidisciplinary clinic for PCOS, stratified across the following age groups: 18-25 (n = 71), 26-35 (n = 129), and 36-45 (n = 29). The study included primarily overweight and obese women, with a mean BMI of 31.1 in the entire study group. Older women had a decreased prevalence of biochemical hyperandrogenemia (p-trend: 0.0005). Of women meeting diagnostic criteria for PCOS, older women (n = 15) had larger median waist circumference and higher median diastolic blood pressure, total cholesterol, LDL cholesterol and fasting glucose compared to younger women (p-trend: 0.03, 0.01, 0.01, 0.01 and 0.06, respectively). The odds of metabolic syndrome for women ages 36-45 are increased four-fold relative to the younger groups (OR: 4.01; 95% CI: 1.04-15.4; p = 0.04). We conclude that there are significant age-related differences in both the clinical presentation and metabolic manifestations of PCOS.
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Affiliation(s)
- Erica B Johnstone
- Department of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility Division, University of Utah, Salt Lake City, UT, USA
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Lamb JD, Johnstone EB, Rousseau JA, Jones CL, Pasch LA, Cedars MI, Huddleston HG. Physical activity in women with polycystic ovary syndrome: prevalence, predictors, and positive health associations. Am J Obstet Gynecol 2011; 204:352.e1-6. [PMID: 21288501 DOI: 10.1016/j.ajog.2010.12.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 09/30/2010] [Accepted: 12/02/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the prevalence and predictors of physical activity in women with polycystic ovary syndrome (PCOS) and to explore the potential health benefits that are associated with physical activity in this population. STUDY DESIGN This was a cross-sectional assessment of 150 women with PCOS. Active women (those who met Department of Health and Human Services [DHHS] guidelines for exercise) were compared with inactive women with regards to demographic and psychosocial variables and health characteristics. RESULTS Fifty-nine percent (88/150 women) met the DHHS guidelines for physical activity. Active women were more likely than inactive women to be nulliparous (64.1% vs 40.0%; P = .04) and white (71.6% vs 42.6%; P = .0004). Inactive women were more likely to have mild depression (adjusted odds ratio, 2.2; 95% confidence interval, 1.01-4.79; P = .048). CONCLUSION Women with PCOS who met the DHHS guidelines for physical activity were more likely to enjoy a variety of health benefits. Our findings identify several groups that are at risk for inadequate physical activity.
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Johnstone EB, Rosen MP, Neril R, Trevithick D, Sternfeld B, Murphy R, Addauan-Andersen C, McConnell D, Pera RR, Cedars MI. The polycystic ovary post-rotterdam: a common, age-dependent finding in ovulatory women without metabolic significance. J Clin Endocrinol Metab 2010; 95:4965-72. [PMID: 20719841 PMCID: PMC2968725 DOI: 10.1210/jc.2010-0202] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The age-specific prevalence of polycystic ovaries (PCO), as defined by the Rotterdam criteria, among normal ovulatory women, has not yet been reported. It is also uncertain whether these women differ from their peers in the hormonal or metabolic profile. METHODS A total of 262 ovulatory Caucasian women aged 25-45 yr, enrolled in a community-based ovarian aging study (OVA), underwent transvaginal ultrasound assessment of ovarian volume and antral follicle count (AFC) in the early follicular phase and were categorized as to whether they met the Rotterdam definition of PCO by AFC (≥12 in one ovary) and/or by volume (>10 cm(3) for one ovary). The effect of age on prevalence of PCO was assessed. Serum hormones and metabolic measures were compared between women meeting each element of the Rotterdam criterion and those without PCO using age-adjusted linear regressions. RESULTS The prevalence of PCO by AFC was 32% and decreased with age. Those with PCO by AFC had lower FSH; higher anti-Müllerian hormone, estrone, dehydroepiandrostenedione sulfate, and free androgen index; and slightly higher total testosterone than those without PCO. However, slightly higher body mass index and waist circumference were the only metabolic differences. Women with PCO by volume had higher anti-Müllerian hormone and free androgen index but did not differ in any other hormonal or metabolic parameter. DISCUSSION PCO is a common, age-dependent finding among ovulatory women. These women lack the metabolic abnormalities seen in PCO syndrome. Isolated PCO in an ovulatory woman is not an indication for metabolic evaluation.
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Affiliation(s)
- Erica B Johnstone
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California 94115, USA
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