The lack of evidence behind over-the-counter antioxidant supplements for male fertility patients: a scoping review

STUDY QUESTION

What is the evidence for over-the-counter antioxidant supplements for male infertility?

SUMMARY ANSWER

Less than half of over-the-counter antioxidant supplements for male fertility patients have been tested in a clinical trial, and the available clinical trials are generally of poor quality.

WHAT IS KNOWN ALREADY

The prevalence of male infertility is rising and, with this, the market for supplements claiming to improve male fertility is expanding. Up to now, there is limited data on the evidence for these over-the-counter supplements.

STUDY DESIGN SIZE DURATION

Amazon, Google Shopping and other relevant shopping websites were searched on 24 June 2022 with the following terms: 'supplements', 'antioxidants', 'vitamins', AND 'male fertility', 'male infertility', 'male subfertility', 'fertility men', 'fertility man'. All supplements with a description of ingredients in English, Dutch, French, Spanish, or German were included. Subsequently, Pubmed and Google Scholar were searched for studies that included the supplements.

PARTICIPANTS/MATERIALS SETTING METHODS

Inclusion criteria were supplements with antioxidant properties, of which the main purpose was to improve male fertility. Included supplements must be available without a doctor's prescription. Supplements containing plant extracts were excluded, as well as supplements of which the content or dosage was not clear. The ingredients, dosage, price and health claims of the supplements were recorded. We assessed whether substances in the supplements exceeded the recommended dietary allowance (RDA) or tolerable upper intake level (UL). All clinical trials and animal studies investigating included supplements were selected for this review. Clinical trials were assessed for risk of bias with a risk of bias tool appropriate for the study design.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 34 eligible antioxidant supplements found, containing 48 different active substances. The average price per 30 days was 53.10 US dollars. Most of the supplements (27/34, 79%) contained substances in a dosage exceeding the recommended daily allowance (RDA). All manufacturers of the supplements made health claims related to the improvement of sperm quality or male fertility. For 13 of the 34 supplements (38%), published clinical trials were available, and for one supplement, only an animal study was found. The overall quality of the included studies was poor. Only two supplements were tested in a good quality clinical trial.

LIMITATIONS REASONS FOR CAUTION

As a consequence of searching shopping websites, a comprehensive search strategy could not be formulated. Most supplements were excluded because they contained plant extracts or because supplement information was not available (in an appropriate language).

WIDER IMPLICATIONS OF THE FINDINGS

This is the first review that gives an insight into the market of male fertility supplements as available to infertility patients and other men seeking to improve their fertility. Earlier reviews have focused only on supplements with published clinical trials. However, we show that more than half of the supplements have not been tested in a clinical trial. To our knowledge, this review is the first to assess the dosage of supplements in relation to the RDA. In agreement with the literature, we found that the evidence on male fertility supplements is generally of poor quality. This review should urge pharmaceutical companies to evaluate their products in randomized controlled trials in order to provide people with substantiated information.

STUDY FUNDING/COMPETING INTERESTS

The research position of W.R.d.L. is funded by an unrestricted grant from Goodlife Pharma. W.R.d.L., K.F., and J.P.d.B. are in the research team of a clinical trial on Impryl^®, one of the supplements included in this review.

REGISTRATION NUMBER

N/A.

O-202 Online fertility workup with video consultation for infertile patients; a randomized controlled trial

Study question

Is an online consultation for fertility work-up as effective as regular consultation in terms of patient centeredness and shared decision making?

Summary answer

This study shows no significant differences in level of patient-centeredness and shared decision making for an online fertility work-up compared to a regular appointment.

What is known already

Couples who suffer from involuntarily childlessness can experience a high psychological burden and treatment for their infertility has a high impact on their daily life. Most optimally, patients receive personalized information and undergo diagnostic testing for fertility work-up, with as little as possible interference in their personal life. Two recent studies already evaluated the use of video-consulting to further modernize current fertility care, with positive results. However, more well-designed research is needed to expand and carefully evaluate the idea of an online fertility work-up for patients with an unfulfilled child wish.

Study design, size, duration

This is a single-center non-blinded randomized controlled trial of 84 heterosexual patient couples. Patients were followed up from the start of the fertility work-up until three months after completion of the work-up.

After the work-up, a questionnaire was send through an online research program consisting of a modified version of the Patient-Centered Questionnaire-Infertility (PCQ-I) to measure patient-centeredness and the CollaboRATE questionnaire to evaluate the level of shared decision making.

Participants/materials, setting, methods

The study population consisted of infertile couples, who were referred to a fertility clinic for the first time. Couples were randomized between a regular fertility work-up, consisting of two face-to-face appointments of in total 45 minutes, and an online fertility work-up. The latter consisted of online recommendations and diagnostic tests, based on patient specific characteristics from an anamnesis questionnaire, followed by a 30 minute video consultation with a fertilitydoctor to discuss results and treatment advice.

Main results and the role of chance

Of the 84 included patients, 75 questionnaires were returned for this abstract (89%). The mean score on the total PCQ-I was 2.66 (SD 0.20), on a scale of 0-3, for the online fertility work-up versus 2.57 (SD 0.29) for the control group. This was not statistically significant (p = 0.147). Also the different subscales of the PCQ-I did not show statistically differences between the two groups, but there was a positive trend for the online fertility work-up on the subscale ‘Information and Communication’ (2.85 (SD 0.21) vs 2.72 (SD 0.31); p = 0.055).

On the CollaboRATE questionnaire, no significant differences in experienced level of shared decision making were found between the two groups (means between 7.52 – 7.91 on a ten point Likert scale).

During seven video consultations (17%) some technical difficulties were experienced, for example the video worked but there was no sound. For 62% of the couples in the intervention group the time for preparation for the online fertility workup was less than five minutes, while the majority of the patients in the control group (52%) spend at least 60-90 minutes on their appointment in the fertility clinic.

Limitations, reasons for caution

This study was performed during the COVID-19 pandemic, when patients were more used to online meetings. The preferences of patient post pandemic might be different. At this point we have not yet evaluated whether online fertility consultation leads to different conclusions and treatment advices than regular fertility care.

Wider implications of the findings

In our study online fertility work-up with video consultation is perceived as good as a regular work-up, therefore future patients should be offered a choice between the two methods.  Considering the rapid development of online technology, online fertilitycare may develop further. It is important that developments undergo thorough scientific evaluation.

Trial registration number

NL8554

Molecular Processes in Stress Urinary Incontinence: A Systematic Review of Human and Animal Studies

Stress urinary incontinence (SUI) is a common and burdensome condition. Because of the large knowledge gap around the molecular processes involved in its pathophysiology, the aim of this review was to provide a systematic overview of genetic variants, gene and protein expression changes related to SUI in human and animal studies. On 5 January 2021, a systematic search was performed in Pubmed, Embase, Web of Science, and the Cochrane library. The screening process and quality assessment were performed in duplicate, using predefined inclusion criteria and different quality assessment tools for human and animal studies respectively. The extracted data were grouped in themes per outcome measure, according to their functions in cellular processes, and synthesized in a narrative review. Finally, 107 studies were included, of which 35 used animal models (rats and mice). Resulting from the most examined processes, the evidence suggests that SUI is associated with altered extracellular matrix metabolism, estrogen receptors, oxidative stress, apoptosis, inflammation, neurodegenerative processes, and muscle cell differentiation and contractility. Due to heterogeneity in the studies (e.g., in examined tissues), the precise contribution of the associated genes and proteins in relation to SUI pathophysiology remained unclear. Future research should focus on possible contributors to these alterations.

OUP accepted manuscript

STUDY QUESTION

What is the methodological validity and usefulness of randomized controlled trials (RCTs) on pain relief during oocyte retrieval for IVF and ICSI?

SUMMARY ANSWER

Key methodological characteristics such as randomization, allocation concealment, primary outcome measure and sample size calculation were inadequately reported in 33–43% of the included RCTs, and a broad heterogeneity is revealed in the studied outcome measures.

WHAT IS KNOWN ALREADY

A Cochrane review on conscious sedation and analgesia for women undergoing oocyte retrieval concluded that the overall quality of evidence was low or very low, mainly owing to poor reporting. This, and heterogeneity of studied outcome measures, limits generalizability and eligibility of results for meta-analysis.

STUDY DESIGN, SIZE, DURATION

For this review, a systematic search for RCTs on pain relief during oocyte retrieval was performed on 20 July 2020 in CENTRAL CRSO, MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, WHO ICTRP, Web of Science, Portal Regional da BVS and Open Grey.

PARTICIPANTS/MATERIALS, SETTING, METHODS

RCTs with pain or patient satisfaction as an outcome were included and analysed on a set of methodological and clinical characteristics, to determine their validity and usefulness.

MAIN RESULTS AND THE ROLE OF CHANCE

Screening of 2531 articles led to an inclusion of 51 RCTs. Randomization was described inadequately in 33% of the RCTs. A low-risk method of allocation concealment was reported in 55% of the RCTs. Forty-nine percent of the RCTs reported blinding of participants, 33% of blinding personnel and 43% of blinding the outcome assessor. In 63% of the RCTs, the primary outcome was stated, but a sample size calculation was described in only 57%. Data were analysed according to the intention-to-treat principle in 73%. Treatment groups were not treated identically other than the intervention of interest in 10% of the RCTs. The primary outcome was intraoperative pain in 28%, and postoperative pain in 2%. The visual analogue scale (VAS) was the most used pain scale, in 69% of the RCTs in which pain was measured. Overall, nine other scales were used. Patient satisfaction was measured in 49% of the RCTs, for which 12 different methods were used. Occurrence of side-effects and complications were assessed in 77% and 49% of the RCTs: a definition for these was lacking in 13% and 20% of the RCTs, respectively. Pregnancy rate was reported in 55% of the RCTs and, of these, 75% did not adequately define pregnancy. To improve the quality of future research, we provide recommendations for the design of future trials. These include use of the VAS for pain measurement, use of validated questionnaires for measurement of patient satisfaction and the minimal clinically relevant difference to use for sample size calculations.

LIMITATIONS, REASONS FOR CAUTION

Consensus has not been reached on some methodological characteristics, for which we formulated recommendations. To prevent further heterogeneity in research on this topic, recommendations were formulated based on expert opinion, or on the most used method thus far. Future research may provide evidence to base new recommendations on.

WIDER IMPLICATIONS OF THE FINDINGS

Use of the recommendations given for design of trials on this topic can increase the generalizability of future research, increasing eligibility for meta-analyses and preventing wastefulness.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was obtained for this study. S.B. reports being the editor-in-chief of Human Reproduction Open. For this manuscript, he was not involved with the handling process within Human Reproduction Open, or with the final decision. Furthermore, S.B. reports personal fees from Remuneration from Oxford University Press as editor-in-chief of Human Reproduction Open, personal fees from Editor and contributing author, Reproductive Medicine for the MRCOG, Cambridge University Press. The remaining authors declare no conflict of interest in relation to the work presented.

TRIAL REGISTRATION NUMBER

Not applicable.

A fertility workup with video consultation: a pilot study with patient experiences in times of the COVID-19 pandemic

Background

Due to the COVID-19 pandemic, major parts of elective health care in the Netherlands, such as reproductive medicine, were paused. When health care was resumed, video consultation was used as a new solution to continue consultations with the new governmental rules of social distancing. Prior to this COVID-19 situation, video consultation was not used extensively in the Netherlands; therefore, physicians and patients are not familiar with this way of consultation.

Objective

The purpose of this study was to measure the level of patient centeredness and shared decision making in infertile couples who have undergone fertility workup through video consultation.

Methods

This is a questionnaire study with an additional qualitative part for a more in depth understanding. Infertile couples (ie, male and female partners with an unfulfilled wish for a child after 1 year of unprotected intercourse) were referred to a fertility center and underwent fertility workup through video consultation. The fertility workup consisted of 2 separate video consultations, with diagnostic tests according to a protocol. After the last video consultation couples received a digital questionnaire, which consisted of a modified version of the Patient-Centered Questionnaire-Infertility (PCQ-I) and CollaboRATE questionnaire. Fifty-three eligible infertile couples were approached, and of these, 22 participated. Four women were approached for a semistructured interview.

Results

The median score on the modified PCQ-I (scale of 0 to 3) was 2.64. The highest rating was for the subscale communication and information, and the lowest rating was for the subscale organization of care. The median score on the CollaboRATE questionnaire (scale of 1 to 9) was 8 for all 3 subquestions. Patients mentioned privacy, less travel time, and easy use of the program as possible benefits of video consultation. However, patients preferred the first consultation with their physician to be face-to-face consultation as video consultation was considered less personal.

Conclusions

The high levels of patient centeredness and shared decision making show that video consultation is a promising way of providing care remotely, although attention has to be payed to mitigate the more impersonal setting of video consultation when compared with face-to-face consultation.

Genetic variants and expression changes in urgency urinary incontinence: A systematic review

Aim

To perform a systematic review summarizing the knowledge of genetic variants, gene, and protein expression changes in humans and animals associated with urgency urinary incontinence (UUI) and to provide an overview of the known molecular mechanisms related to UUI.

Methods

A systematic search was performed on March 2, 2020, in PubMed, Embase, Web of Science, and the Cochrane library. Retrieved studies were screened for eligibility. The risk of bias was assessed using the ROBINS‐I (human) and SYRCLE (animal) tool. Data were presented in a structured manner and in the case of greater than five studies on a homogeneous outcome, a meta‐analysis was performed.

Results

Altogether, a total of 10,785 records were screened of which 37 studies met the inclusion criteria. Notably, 24/37 studies scored medium‐high to high on risk of bias, affecting the value of the included studies. The analysis of 70 unique genes and proteins and three genome‐wide association studies showed that specific signal transduction pathways and inflammation are associated with UUI. A meta‐analysis on the predictive value of urinary nerve growth factor (NGF) levels showed that increased urinary NGF levels correlate with UUI.

Conclusion

The collective evidence showed the involvement of two molecular mechanisms (signal transduction and inflammation) and NGF in UUI, enhancing our understanding of the pathophysiology of UUI. Unfortunately, the risk of bias was medium‐high to high for most studies and the value of many observations remains unclear. Future studies should focus on elucidating how deficits in the two identified molecular mechanisms contribute to UUI and should avoid bias.