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Feferkorn I, Santos-Ribeiro S, Ubaldi FM, Velasco JG, Ata B, Blockeel C, Conforti A, Esteves SC, Fatemi HM, Gianaroli L, Grynberg M, Humaidan P, Lainas GT, La Marca A, Craig LB, Lathi R, Norman RJ, Orvieto R, Paulson R, Pellicer A, Polyzos NP, Roque M, Sunkara SK, Tan SL, Urman B, Venetis C, Weissman A, Yarali H, Dahan MH. Correction to: The HERA (Hyper‑response Risk Assessment) Delphi consensus for the management of hyper‑responders in in vitro fertilization. J Assist Reprod Genet 2024; 41:519-520. [PMID: 38079078 PMCID: PMC10894774 DOI: 10.1007/s10815-023-03003-7] [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] [Indexed: 02/27/2024] Open
Affiliation(s)
- I Feferkorn
- Sackler Faculty of Medicine, IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
| | | | - F M Ubaldi
- GeneraLife Centers for Reproductive Medicine, Rome, Italy
| | | | - B Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
- ART Fertility Clinics, Dubai, United Arab Emirates
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - A Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - S C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Av. Dr. Heitor Penteado 1464, Campinas, SP, 13075‑460, Brazil
- Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, SP, Brazil
- Faculty of Health, Aarhus University, 8000, Aarhus C, Denmark
| | - H M Fatemi
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - L Gianaroli
- Società Italiana Studi di Medicina della RiproduzioneS.I.S.Me.R. Reproductive Medicine Institute, Emilia‑Romagna, Bologna, Italy
| | - M Grynberg
- Department of Reproductive Medicine, Hôpital Antoine‑Béclère, University Paris-Sud (Paris XI), Le Kremlin‑Bicêtre, Clamart, France
| | - P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Resenvej 25, 7800, Skive, Denmark
| | | | - A La Marca
- Obstetrics, Gynecology and Reproductive Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41124, Modena, Italy
| | - L B Craig
- Section of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - R Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
| | - R J Norman
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- FertilitySA, Adelaide, South Australia, Australia
- Monash Centre for Health Research and Implementation MCHRI, Monash University, Melbourne, Australia
- NHMRC Centre of Research Excellence in Women's Health in Reproductive Life (CRE-WHiRL), Melbourne, Australia
| | - R Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tarnesby‑Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - R Paulson
- University of Southern California, Los Angeles, CA, 90033, USA
| | - A Pellicer
- Department of Pediatrics, Obstetrics and Gynecology, School of Medicine, University of Valencia, Valencia, Spain
- IVI Roma Parioli, IVI-RMA Global, Rome, Italy
| | - N P Polyzos
- Department of Reproductive Medicine, Dexeus Mujer, Hospital Universitario Dexeus, Barcelona, Spain
| | - M Roque
- Department of Reproductive Medicine, ORIGEN-Center for Reproductive Medicine, Rio de Janeiro, RJ, Brazil
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - S K Sunkara
- Department of Women and Children's Health, King's College London, London, UK
| | - S L Tan
- OriginElle Fertility Clinic, 2110 Boul. Decarie, Montreal, QC, Canada
| | - B Urman
- Department of Obstetrics and Gynecology and Assisted Reproduction, American Hospital, Istanbul, Koc University School of Medicine, Istanbul, Turkey
| | - C Venetis
- Unit for Human Reproduction, 1st Dept of OB/Gyn, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Centre for Big Data Research in Health, Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- Virtus Health, Sydney, Australia
| | - A Weissman
- In Vitro Fertilization Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Yarali
- Division of Reproductive Endocrinology and Infertility, Dept. of Obstetrics and Gynecology, Hacettepe University, School of Medicine, Anatolia IVF and Women's Health Center, Ankara, Turkey
| | - M H Dahan
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, 888 Boul. de Maisonneuve E #200, Montreal, QC, H2L 4S8, Canada
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Feferkorn I, Santos-Ribeiro S, Ubaldi FM, Velasco JG, Ata B, Blockeel C, Conforti A, Esteves SC, Fatemi HM, Gianaroli L, Grynberg M, Humaidan P, Lainas GT, La Marca A, LaTasha C, Lathi R, Norman RJ, Orvieto R, Paulson R, Pellicer A, Polyzos NP, Roque M, Sunkara SK, Tan SL, Urman B, Venetis C, Weissman A, Yarali H, Dahan MH. The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization. J Assist Reprod Genet 2023; 40:2681-2695. [PMID: 37713144 PMCID: PMC10643792 DOI: 10.1007/s10815-023-02918-5] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/15/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other. RESULTS A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus). CONCLUSION These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.
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Affiliation(s)
- I Feferkorn
- IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - F M Ubaldi
- GeneraLife Centers for Reproductive Medicine, Rome, Italy
| | | | - B Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
- ART Fertility Clinics, Dubai, United Arab Emirates
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - A Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - S C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Av. Dr. Heitor Penteado 1464, Campinas, SP, 13075-460, Brazil
- Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, SP, Brazil
- Faculty of Health, Aarhus University, C, 8000, Aarhus, Denmark
| | - H M Fatemi
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - L Gianaroli
- Società Italiana Studi di Medicina della Riproduzione, S.I.S.Me.R. Reproductive Medicine Institute, Bologna, Emilia-Romagna, Italy
| | - M Grynberg
- Department of Reproductive Medicine, Hôpital Antoine-Béclère, University Paris-Sud (Paris XI), Le Kremlin-Bicêtre, Clamart, France
| | - P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Resenvej 25, 7800, Skive, Denmark
| | | | - A La Marca
- Obstetrics, Gynecology and Reproductive Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41124, Modena, Italy
| | - C LaTasha
- Section of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - R Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
| | - R J Norman
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- FertilitySA, Adelaide, South Australia, Australia
- Monash Centre for Health Research and Implementation MCHRI, Monash University, Melbourne, Australia
- NHMRC Centre of Research Excellence in Women's Health in Reproductive Life (CRE-WHiRL), Melbourne, Australia
| | - R Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - R Paulson
- University of Southern California, Los Angeles, CA, 90033, USA
| | - A Pellicer
- Department of Pediatrics, Obstetrics and Gynecology, School of Medicine, University of Valencia, Valencia, Spain
- IVI Roma Parioli, IVI-RMA Global, Rome, Italy
| | - N P Polyzos
- Department of Reproductive Medicine, Dexeus Mujer, Hospital Universitario Dexeus, Barcelona, Spain
| | - M Roque
- Department of Reproductive Medicine, ORIGEN-Center for Reproductive Medicine, Rio de Janeiro, RJ, Brazil
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - S K Sunkara
- Department of Women and Children's Health, King's College London, London, UK
| | - S L Tan
- OriginElle Fertility Clinic 2110 Boul. Decarie, Montreal, QC, Canada
| | - B Urman
- Department of Obstetrics and Gynecology and Assisted Reproduction, American Hospital, Istanbul, Koc University School of Medicine, Istanbul, Turkey
| | - C Venetis
- Unit for Human Reproduction, 1st Dept of OB/Gyn, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Centre for Big Data Research in Health, Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- Virtus Health, Sydney, Australia
| | - A Weissman
- In Vitro Fertilization Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Yarali
- Division of Reproductive Endocrinology and Infertility, Dept. of Obstetrics and Gynecology, Hacettepe University, School of Medicine, Anatolia IVF and Women's Health Center, Ankara, Turkey
| | - M H Dahan
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, 888 Boul. de Maisonneuve E #200, Montreal, QC, H2L 4S8, Canada
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Romualdi D, Ata B, Bhattacharya S, Bosch E, Costello M, Gersak K, Homburg R, Mincheva M, Norman RJ, Piltonen T, Dos Santos-Ribeiro S, Scicluna D, Somers S, Sunkara SK, Verhoeve HR, Le Clef N. Evidence-based guideline: unexplained infertility†. Hum Reprod 2023; 38:1881-1890. [PMID: 37599566 PMCID: PMC10546081 DOI: 10.1093/humrep/dead150] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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: 06/19/2023] [Indexed: 08/22/2023] Open
Abstract
STUDY QUESTION What is the recommended management for couples presenting with unexplained infertility (UI), based on the best available evidence in the literature? SUMMARY ANSWER The evidence-based guideline on UI makes 52 recommendations on the definition, diagnosis, and treatment of UI. WHAT IS KNOWN ALREADY UI is diagnosed in the absence of any abnormalities of the female and male reproductive systems after 'standard' investigations. However, a consensual standardization of the diagnostic work-up is still lacking. The management of UI is traditionally empirical. The efficacy, safety, costs, and risks of treatment options have not been subjected to robust evaluation. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for ESHRE guidelines. Following formulation of key questions by a group of experts, literature searches, and assessments were undertaken. Papers written in English and published up to 24 October 2022 were evaluated. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the available evidence, recommendations were formulated and discussed until consensus was reached within the guideline development group (GDG). Following stakeholder review of an initial draft, the final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians provide the best care for couples with UI. As UI is a diagnosis of exclusion, the guideline outlined the basic diagnostic procedures that couples should/could undergo during an infertility work-up, and explored the need for additional tests. The first-line treatment for couples with UI was deemed to be IUI in combination with ovarian stimulation. The place of additional and alternative options for treatment of UI was also evaluated. The GDG made 52 recommendations on diagnosis and treatment for couples with UI. The GDG formulated 40 evidence-based recommendations-of which 29 were formulated as strong recommendations and 11 as weak-10 good practice points and two research only recommendations. Of the evidence-based recommendations, none were supported by high-quality evidence, one by moderate-quality evidence, nine by low-quality evidence, and 31 by very low-quality evidence. To support future research in UI, a list of research recommendations was provided. LIMITATIONS, REASONS FOR CAUTION Most additional diagnostic tests and interventions in couples with UI have not been subjected to robust evaluation. For a large proportion of these tests and treatments, evidence was very limited and of very low quality. More evidence is required, and the results of future studies may result in the current recommendations being revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in the care of couples with UI, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in the field. The full guideline and a patient leaflet are available in www.eshre.eu/guideline/UI. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed by ESHRE, who funded the guideline meetings, literature searches, and dissemination of the guideline in collaboration with the Monash University led Australian NHMRC Centre of Research Excellence in Women's Health in Reproductive Life (CREWHIRL). The guideline group members did not receive any financial incentives; all work was provided voluntarily. D.R. reports honoraria from IBSA and Novo Nordisk. B.A. reports speakers' fees from Merck, Gedeon Richter, Organon and Intas Pharma; is part of the advisory board for Organon Turkey and president of the Turkish Society of Reproductive Medicine. S.B. reports speakers' fees from Merck, Organon, Ferring, the Ostetric and Gynaecological Society of Singapore and the Taiwanese Society for Reproductive Medicine; editor and contributing author, Reproductive Medicine for the MRCOG, Cambridge University Press; is part of the METAFOR and CAPE trials data monitoring committee. E.B. reports research grants from Roche diagnostics, Gedeon Richter and IBSA; speaker's fees from Merck, Ferring, MSD, Roche Diagnostics, Gedeon Richter, IBSA; E.B. is also a part of an Advisory Board of Ferring Pharmaceuticals, MSD, Roche Diagnostics, IBSA, Merck, Abbott and Gedeon Richter. M.M. reports consulting fees from Mojo Fertility Ltd. R.J.N. reports research grant from Australian National Health and Medical Research Council (NHMRC); consulting fees from Flinders Fertility Adelaide, VinMec Hospital Hanoi Vietnam; speaker's fees from Merck Australia, Cadilla Pharma India, Ferring Australia; chair clinical advisory committee Westmead Fertility and research institute MyDuc Hospital Vietnam. T.P. is a part of the Research Council of Finland and reports research grants from Roche Diagnostics, Novo Nordics and Sigrid Juselius foundation; consulting fees from Roche Diagnostics and organon; speaker's fees from Gedeon Richter, Roche, Exeltis, Organon, Ferring and Korento patient organization; is a part of NFOG, AE-PCOS society and several Finnish associations. S.S.R. reports research grants from Roche Diagnostics, Organon, Theramex; consulting fees from Ferring Pharmaceuticals, MSD and Organon; speaker's fees from Ferring Pharmaceuticals, MSD/Organon, Besins, Theramex, Gedeon Richter; travel support from Gedeon Richter; S.S.R. is part of the Data Safety Monitoring Board of TTRANSPORT and deputy of the ESHRE Special Interest Group on Safety and Quality in ART; stock or stock options from IVI Lisboa, Clínica de Reprodução assistida Lda; equipment/medical writing/gifts from Roche Diagnostics and Ferring Pharmaceuticals. S.K.S. reports speakers' fees from Merck, Ferring, MSD, Pharmasure. HRV reports consulting and travel fees from Ferring Pharmaceuticals. The other authors have nothing to disclose. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.).
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Affiliation(s)
| | - D Romualdi
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - B Ata
- Department of Obstetrics and Gynaecology, Koc University, Istanbul, Turkey
- ART Fertility Clinics, Dubai, United Arab Emirates
| | - S Bhattacharya
- School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - E Bosch
- IVI-RMA Valencia, Valencia, Spain
| | - M Costello
- University of New South Wales, Sydney, Australia
- NHMRC Centre of Research Excellence Women’s Health in Reproductive Life (WHiRL), Monash University, Melbourne, Australia
| | - K Gersak
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - R Homburg
- Liverpool Womens’ Hospital, Hewitt Fertility Centre, Liverpool, UK
| | - M Mincheva
- Centre for Tumour Microenvironment, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - R J Norman
- NHMRC Centre of Research Excellence Women’s Health in Reproductive Life (WHiRL), Monash University, Melbourne, Australia
- The Robinson Research Institute The University of Adelaide, Adelaide, Australia
| | - T Piltonen
- Department of Obstetrics and Gynaecology, Reproductive Endocrinology and IVF Unit, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, University of Oulu, Oulu, Finland
| | | | | | - S Somers
- Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - H R Verhoeve
- Department of Gynaecology, OLVG, Amsterdam, The Netherlands
| | - N Le Clef
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
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Feferkorn I, Ata B, Esteves SC, La Marca A, Paulson R, Blockeel C, Conforti A, Fatemi HM, Humaidan P, Lainas GT, Mol BW, Norman RJ, Orvieto R, Polyzos NP, Santos-Ribeiro S, Sunkara SK, Tan SL, Ubaldi FM, Urman B, Velasco JG, Weissman A, Yarali H, Dahan MH. The HERA (Hyper-response Risk Assessment) Delphi consensus definition of hyper-responders for in-vitro fertilization. J Assist Reprod Genet 2023; 40:1071-1081. [PMID: 36933094 PMCID: PMC10239403 DOI: 10.1007/s10815-023-02757-4] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/19/2023] [Indexed: 03/19/2023] Open
Abstract
PURPOSE To provide an agreed upon definition of hyper-response for women undergoing ovarian stimulation (OS)? METHODS A literature search was performed regarding hyper-response to ovarian stimulation for assisted reproductive technology. A scientific committee consisting of 5 experts discussed, amended, and selected the final statements in the questionnaire for the first round of the Delphi consensus. The questionnaire was distributed to 31 experts, 22 of whom responded (with representation selected for global coverage), each anonymous to the others. A priori, it was decided that consensus would be reached when ≥ 66% of the participants agreed and ≤ 3 rounds would be used to obtain this consensus. RESULTS 17/18 statements reached consensus. The most relevant are summarized here. (I) Definition of a hyper-response: Collection of ≥ 15 oocytes is characterized as a hyper-response (72.7% agreement). OHSS is not relevant for the definition of hyper-response if the number of collected oocytes is above a threshold (≥ 15) (77.3% agreement). The most important factor in defining a hyper-response during stimulation is the number of follicles ≥ 10 mm in mean diameter (86.4% agreement). (II) Risk factors for hyper-response: AMH values (95.5% agreement), AFC (95.5% agreement), patient's age (77.3% agreement) but not ovarian volume (72.7% agreement). In a patient without previous ovarian stimulation, the most important risk factor for a hyper-response is the antral follicular count (AFC) (68.2% agreement). In a patient without previous ovarian stimulation, when AMH and AFC are discordant, one suggesting a hyper-response and the other not, AFC is the more reliable marker (68.2% agreement). The lowest serum AMH value that would place one at risk for a hyper-response is ≥ 2 ng/ml (14.3 pmol/L) (72.7% agreement). The lowest AFC that would place one at risk for a hyper-response is ≥ 18 (81.8% agreement). Women with polycystic ovarian syndrome (PCOS) as per Rotterdam criteria are at a higher risk of hyper-response than women without PCOS with equivalent follicle counts and gonadotropin doses during ovarian stimulation for IVF (86.4% agreement). No consensus was reached regarding the number of growing follicles ≥ 10 mm that would define a hyper-response. CONCLUSION The definition of hyper-response and its risk factors can be useful for harmonizing research, improving understanding of the subject, and tailoring patient care.
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Affiliation(s)
- Ido Feferkorn
- IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - B Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
- ART Fertility Clinics, Dubai, United Arab Emirates
| | - S C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Av. Dr. Heitor Penteado 1464, Campinas, SP, 13075-460, Brazil
- Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, SP, Brazil
- Faculty of Health, Aarhus University, 8000, Aarhus C, Denmark
| | - A La Marca
- Obstetrics, Gynecology and Reproductive Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41124, Modena, Italy
| | - R Paulson
- University of Southern California, Los Angeles, CA, 90033, USA
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - A Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - H M Fatemi
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Resenvej 25, 7800, Skive, Denmark
| | | | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - R J Norman
- School of Medicine, Robinson Research Institute, University of Adelaide, Adelaide, South Australia
- FertilitySA, Adelaide, South Australia
- Monash Centre for Health Research and Implementation MCHRI, Monash University, Clayton, Australia
- NHMRC Centre of Research Excellence in Women's Health in Reproductive Life (CRE-WHiRL), Clayton, Australia
| | - R Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - N P Polyzos
- Department of Reproductive Medicine, Dexeus Mujer, Hospital Universitario Dexeus, Barcelona, Spain
| | | | - S K Sunkara
- Department of Women and Children's Health, King's College London, London, UK
| | - S L Tan
- IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- OriginElle Fertility Clinic, 2110 Boul. Decarie, Montreal, QC, Canada
| | - F M Ubaldi
- Scientific Executive Committee - GeneraLife Centers for Reproductive Medicine, Rome, Italy
| | - B Urman
- Department of Obstetrics and Gynecology and Assisted Reproduction, American Hospital, Istanbul, Koc University School of Medicine, Istanbul, Turkey
| | | | - A Weissman
- In Vitro Fertilization Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Yarali
- School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Hacettepe University, Ankara, Turkey
- Anatolia IVF and Women's Health Center, Ankara, Turkey
| | - M H Dahan
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, 888 Boul. de Maisonneuve E #200, Montréal, QC, H2L 4S8, Canada
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Norman RJ, Morman R, Teede HJ. Reply of the Authors: Adolescent PCOS: a Postpubertal Central Obesity Syndrome. Fertil Steril 2023:S0015-0282(23)00314-X. [PMID: 37105455 DOI: 10.1016/j.fertnstert.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
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Hart RJ, Doherty DA, Mori TA, Adams LA, Huang RC, Minaee N, Handelsman DJ, McLachlan R, Norman RJ, Dickinson JE, Olynyk JK, Beilin LJ. Features of the metabolic syndrome in late adolescence are associated with impaired testicular function at 20 years of age. Hum Reprod 2020; 34:389-402. [PMID: 30576537 DOI: 10.1093/humrep/dey371] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 05/26/2018] [Revised: 11/16/2018] [Accepted: 11/28/2018] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION Are early signs of metabolic disorder in late adolescence associated with features of impaired testicular function many years before the majority seek parenthood? SUMMARY ANSWER Adolescents with features of metabolic disorder at 17 years, or insulin resistance (IR) at 20 years of age, show impaired testicular function and altered hormone levels compared to those without metabolic disorder. WHAT IS KNOWN ALREADY Controversial evidence suggests a recent decline in sperm production potentially linked to environmental influences, but its cause remains unclear. Concomitant increases in obesity and diabetes suggest that lifestyle factors may contribute to this decline in testicular function. Although obesity has been associated with adverse testicular function in some studies, it remains unclear whether poor testicular function merely reflects, or causes, poor metabolic health. If metabolic disorder were present in adolescence, prior to the onset of obesity, this may suggest that metabolic disorder maybe a precursor of impaired testicular function. STUDY DESIGN, SIZE, DURATION The Western Australian Pregnancy Cohort (Raine) Study is a longitudinal study of children born in 1989-1991 who have undergone detailed physical assessments since birth (1454 male infants born). At 17 years of age, 490 boys underwent a hepatic ultrasound examination, serum cytokine assessment (n = 520) and a metabolic assessment (n = 544). A further metabolic assessment was performed at 20 years (n = 608). Testicular assessment was performed at 20 years; 609 had reproductive hormones measured, 404 underwent a testicular ultrasound and 365 produced a semen sample. PARTICIPANTS/MATERIALS, SETTING, METHODS Testicular volume was estimated by ultrasonography, and semen analysis was performed according to World Health Organization guidelines. Concentrations of LH, FSH and inhibin B (inhB) in serum were measured by immunoassay and total testosterone by liquid chromatography-mass spectrometry.At 17 years of age, a liver ultrasound examination was performed to determine the presence of non-alcoholic fatty liver disease (NAFLD), and serum analysed for the cytokines interleukin-18 and soluble tumour necrosis factor receptor 1 and 2 (sTNFR1, sTNFR2).At 17 and 20 years of age, fasting blood samples were analysed for serum liver enzymes, insulin, glucose, triglycerides (TG), total cholesterol, high density lipoprotein and low density lipoprotein cholesterol, high sensitivity C-reactive protein and uric acid. The homoeostatic model assessment (HOMA) was calculated and approximated IR was defined by a HOMA >4. Anthropometric data was collected and dual energy X-ray absorptiometry measurement performed for lean and total fat mass. As at this young age the prevalence of metabolic syndrome was expected to be low, a two-step cluster analysis was used using waist circumference, TGs, insulin, and systolic blood pressure to derive a distinct high-risk group with features consistent with the metabolic syndrome and increased cardiometabolic risk. MAIN RESULTS AND THE ROLE OF CHANCE Men at age 17 years with increased cardiometabolic risk had lower concentrations of serum testosterone (medians: 4.0 versus 4.9 ng/mL) and inhB (193.2 versus 221.9 pg/mL) (P < 0.001 for both) compared to those within the low risk metabolic cluster. Men with ultrasound evidence of NAFLD (n = 45, 9.8%) had reduced total sperm output (medians: 68.0 versus 126.00 million, P = 0.044), testosterone (4.0 versus 4.7 ng/mL, P = 0.005) and inhB (209.1 versus 218.4 pg/mL, P = 0.032) compared to men without NAFLD.Men with higher concentrations of sTNFR1 at 17 years of age had a lower sperm output and serum concentration of inhB, with an increase in LH and FSH (all P < 0.05 after adjustment for age, BMI, abstinence and a history of cryptorchidism, varicocele, cigarette smoking, alcohol and drug use), compared to those without an elevated sTNFR1. Multivariable regression analysis, adjusting for confounders, demonstrated that men in the high-risk metabolic cluster at 20 years had a lower serum testosterone and inhB (P = 0.003 and P = 0.001, respectively). A HOMA-IR > 4 was associated with a lower serum testosterone (P = <0.001) and inhB (P = 0.010) and an increase in serum FSH (P = 0.015). LIMITATIONS, REASONS FOR CAUTION This study is limited by the sample size and multiple comparisons, and causality cannot be proven from an observational study. Due to a 3-year interval between some metabolic assessments and assessment of testicular function, we cannot exclude the introduction of a bias into the study, as some of the participants and their testicular function will not have been fully mature at the 17-year assessment. WIDER IMPLICATIONS OF THE FINDINGS Irrespective of a proven causation, our study findings are important in that a significant minority of the men, prior to seeking parenthood, presented co-existent features of metabolic disorder and signs of testicular impairment. Of particular note is that the presence of NAFLD at 17 years of age, although only present in a minority of men, was associated with an almost 50% reduction in sperm output at 20 years of age, and that the presence of IR at 20 years was associated with a 20% reduction in testicular volume. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by Australian NHMRC (Grant Numbers 634457, 35351417 and 403981) and received support from the Raine Medical Research Foundation, The Telethon Kids Institute, University of Western Australia, Women and Infants Research Foundation, Curtin University and Edith Cowan University. D.A.D., J.E.D., N.M., L.A.A., R.-C.H., T.A.M., J.K.O., L.J.B. have nothing to declare. R.J.H. is Medical Director of Fertility Specialists of Western Australia, has equity interests in Western IVF, and has received grant support from MSD, Merck-Serono and Ferring Pharmaceuticals. RMcL has equity interests in the Monash IVF Group. R.J.N. has equity interests in FertilitySA, and has received grant support from Merck Serono and Ferring Pharmaceuticals. D.J.H. has received institutional grant funding (but no personal income) for investigator-initiated testosterone pharmacology studies from Lawley and Besins Healthcare and has provided expert testimony to anti-doping tribunals and for testosterone litigation.This abstract was awarded the Fertility Society of Australia clinical exchange award for the oral presentation at ESHRE, Barcelona, in 2018.
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Affiliation(s)
- R J Hart
- Division of Obstetrics and Gynaecology, University of Western Australia (UWA), Perth, Western Australia, Australia.,Fertility Specialists of Western Australia, Claremont, Western Australia, Australia
| | - D A Doherty
- Division of Obstetrics and Gynaecology, University of Western Australia (UWA), Perth, Western Australia, Australia.,Women and Infants Research Foundation, Perth, Western Australia, Australia
| | - T A Mori
- Medical School, UWA, Royal Perth Hospital, Western Australia, Australia
| | - L A Adams
- Medical School, UWA, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - R-C Huang
- Telethon Kids Institute, UWA, Perth, Western Australia, Australia
| | - N Minaee
- Women and Infants Research Foundation, Perth, Western Australia, Australia
| | - D J Handelsman
- ANZAC Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - R McLachlan
- Hudson Institute, Monash University, Melbourne, Australia
| | - R J Norman
- Robinson Institute, Research Institute, School of Medicine, University of Adelaide & Fertility SA, Adelaide, Australia
| | - J E Dickinson
- Division of Obstetrics and Gynaecology, University of Western Australia (UWA), Perth, Western Australia, Australia
| | - J K Olynyk
- Department of Gastroenterology, Fiona Stanley and Fremantle Hospital and School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - L J Beilin
- Medical School, UWA, Royal Perth Hospital, Western Australia, Australia
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7
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Wang R, van Welie N, van Rijswijk J, Johnson NP, Norman RJ, Dreyer K, Mijatovic V, Mol BW. Effectiveness on fertility outcome of tubal flushing with different contrast media: systematic review and network meta-analysis. Ultrasound Obstet Gynecol 2019; 54:172-181. [PMID: 30740799 DOI: 10.1002/uog.20238] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/01/2019] [Accepted: 02/06/2019] [Indexed: 05/23/2023]
Abstract
OBJECTIVES To compare, in women with infertility, the effectiveness and safety of tubal flushing using oil-based contrast medium, water-based contrast medium or their combination, and no tubal flushing, and to evaluate the effectiveness of tubal flushing on fertility outcome over time. METHODS We performed a systematic review and network meta-analysis, searching the electronic databases MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, and trial registries, up to 25 September 2018. We included randomized controlled trials (RCTs) comparing the following interventions with each other or with no intervention in women with infertility: tubal flushing using water-based contrast medium, tubal flushing using oil-based contrast medium or additional tubal flushing with oil-based medium following diagnostic tubal flushing with water-based medium. The outcomes included clinical pregnancy, live birth, ongoing pregnancy, miscarriage, ectopic pregnancy and adverse events. RESULTS Of the 283 studies identified through the search, 14 RCTs reporting on 3852 women with infertility were included. Network meta-analysis showed that tubal flushing using oil-based contrast medium was associated with higher odds of clinical pregnancy within 6 months after randomization and more subsequent live births compared with tubal flushing using water-based medium (odds ratio (OR), 1.67 (95% CI, 1.38-2.03), moderate certainty of evidence; and OR, 2.18 (95% CI, 1.30-3.65), low certainty of evidence, respectively) and compared with no intervention (OR, 2.28 (95% CI, 1.50-3.47), moderate certainty of evidence; and OR, 2.85 (95% CI, 1.41-5.74), low certainty of evidence, respectively). These results agreed with those of the pairwise meta-analysis. For clinical pregnancy within 6 months, there was insufficient evidence of a difference between tubal flushing with water-based contrast medium and no intervention (OR, 1.36 (95% CI, 0.91-2.04), low certainty of evidence). For fertility outcomes after 6 months, there was insufficient evidence of a difference in any comparison (low to very low certainty of evidence). Compared with tubal flushing using water-based contrast medium, the use of oil-based contrast medium was associated with higher odds of asymptomatic intravasation (OR, 5.06 (95% CI, 2.29-11.18), moderate certainty of evidence). CONCLUSIONS In women with infertility undergoing fertility workup, tubal flushing using oil-based contrast medium probably increases clinical pregnancy rates within 6 months after randomization and may increase subsequent live-birth rates, compared with tubal flushing using water-based contrast medium and compared with no intervention. Evidence on fertility outcomes beyond 6 months is inadequate to draw firm conclusions. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Wang
- Robinson Research Institute and Adelaide Medical School, The University of Adelaide, North Adelaide, Australia
| | - N van Welie
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J van Rijswijk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - N P Johnson
- Robinson Research Institute and Adelaide Medical School, The University of Adelaide, North Adelaide, Australia
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - R J Norman
- Robinson Research Institute and Adelaide Medical School, The University of Adelaide, North Adelaide, Australia
- Fertility SA, Adelaide, Australia
| | - K Dreyer
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - B W Mol
- Robinson Research Institute and Adelaide Medical School, The University of Adelaide, North Adelaide, Australia
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University and Monash Health, Clayton, Australia
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8
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Dang VQ, Vuong LN, Ho TM, Ha AN, Nguyen QN, Truong BT, Pham QT, Wang R, Norman RJ, Mol BW. The effectiveness of ICSI versus conventional IVF in couples with non-male factor infertility: study protocol for a randomised controlled trial. Hum Reprod Open 2019; 2019:hoz006. [PMID: 30937394 PMCID: PMC6436611 DOI: 10.1093/hropen/hoz006] [Citation(s) in RCA: 9] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/23/2019] [Accepted: 02/20/2019] [Indexed: 12/29/2022] Open
Abstract
Study questions Does ICSI result in a higher live birth rate as compared with conventional IVF in couples with non-male factor infertility? What is known already ICSI is primarily indicated for severe male factor infertility. While the use of ICSI for couples with non-male factor infertility has been increasing worldwide, this is not supported by data from randomised controlled trials. Evidence from non-randomised studies suggest no benefit from ICSI compared with conventional IVF in non-male factor infertility, if not a harm. Study design, size, duration This randomised, open-label, multi-centre trial aims to compare the effectiveness of one ICSI cycle and one conventional IVF cycle in infertile couples with non-male factor infertility. A total of 1064 couples will be randomly allocated to an ICSI group and a conventional IVF group. The estimated duration of the study is 30 months. Participants/materials, setting, methods Eligible couples are those whose husbands’ total sperm count and motility are normal, have undergone ≤2 previous IVF/ICSI attempts, use antagonist protocol for ovarian stimulation, agree to have ≤2 embryos transferred and are not participating in another IVF study at the same time. Women undergoing IVM cycles, using frozen semen or having a poor fertilisation (≤25%) in previous cycle will not be eligible. Couples will be randomised to undergo ICSI or conventional IVF (1:1) with ongoing pregnancy resulting in live birth after the first embryo transfer of the started treatment cycle as the primary endpoint. All analyses will be conducted on an intention-to-treat basis. Effect sizes will be summarised as relative risk (RR), with precision evaluated by 95% CIs. STUDY FUNDING/COMPETING INTEREST(S) All authors declare having no conflict of interests with regards to this trial. This work was supported by a grant from MSD [MISP #57508]. Trial registration number NCT03428919. Trial registration date 8 February 2018. DATE OF FIRST PATIENT’S ENROLMENT 16 March 2018.
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Affiliation(s)
- V Q Dang
- IVFMD, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam.,HOPE Research Center, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam
| | - L N Vuong
- HOPE Research Center, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam.,Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, District 5, Ho Chi Minh City, Vietnam
| | - T M Ho
- HOPE Research Center, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam.,IVFAS, An Sinh Hospital, 10 Tran Huy Lieu, Phu Nhuan District, Ho Chi Minh City, Vietnam
| | - A N Ha
- IVFMD, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam
| | - Q N Nguyen
- IVFMD, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam
| | - B T Truong
- IVFAS, An Sinh Hospital, 10 Tran Huy Lieu, Phu Nhuan District, Ho Chi Minh City, Vietnam
| | - Q T Pham
- IVFMD, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam.,HOPE Research Center, My Duc Hospital, 4 Nui Thanh, Tan Binh District, Ho Chi Minh City, Vietnam
| | - R Wang
- Discipline of Obstetrics and Gynaecology, Robinson Research Institute and Adelaide Medical School, The University of Adelaide, Ground Floor, 55 King William Road, North Adelaide SA 5006 Adelaide, Australia
| | - R J Norman
- Discipline of Obstetrics and Gynaecology, Robinson Research Institute and Adelaide Medical School, The University of Adelaide, Ground Floor, 55 King William Road, North Adelaide SA 5006 Adelaide, Australia.,Fertility SA, 431 King William Street, South Australia 5000, Adelaide, Australia
| | - B W Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, 246 Clayton Road, Clayton 3168, Victoria, Australia
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Grieger JA, Grzeskowiak LE, Smithers LG, Bianco-Miotto T, Leemaqz SY, Andraweera P, Poston L, McCowan LM, Kenny LC, Myers J, Walker JJ, Norman RJ, Dekker GA, Roberts CT. Metabolic syndrome and time to pregnancy: a retrospective study of nulliparous women. BJOG 2019; 126:852-862. [PMID: 30734474 DOI: 10.1111/1471-0528.15647] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine: (1) the association between metabolic syndrome (MetS), time to pregnancy (TTP), and infertility; (2) associations between individual and an increasing number of MetS components, TTP, and infertility; and (3) whether these relationships differ by body mass index (BMI < 30 kg/m2 versus BMI ≥ 30 kg/m2 ). DESIGN Retrospective cohort study. SETTING Multiple centres (in Australia, Ireland, New Zealand, and the UK). POPULATION Five thousand five hundred and nineteen low-risk nulliparous pregnant women. METHODS Data on retrospectively reported TTP (number of months to conceive) and a blood sample to assess metabolic health were collected between 14 and 16 weeks of gestation. MetS was defined according to the International Diabetes Federation criteria. Accelerated failure time models with log-normal distribution were conducted to estimate time ratios (TRs) and 95% CIs. Differences in MetS on infertility (TTP > 12 months) were compared using a generalised linear model (Poisson distribution) with robust variance estimates (relative risks, RRs; 95% CIs). All analyses (entire cohort and split by BMI) were controlled for a range of maternal and paternal confounding factors. MAIN OUTCOME MEASURES Time to pregnancy and infertility. RESULTS Of the 5519 women included, 12.4% (n = 684) had MetS. Compared with women without MetS, women with MetS had a longer TTP (adjusted TR 1.30; 95% CI 1.15-1.46), which was similar in women who were obese and in women who were not obese. Marginal estimates for median TTP in women with MetS versus without MetS was 3.1 months (3.0-3.3 months) versus 4.1 months (3.6-4.5 months), respectively. Women with MetS were at a 62% greater risk for infertility and were at a greater risk for infertility whether they were obese (adjusted RR 1.62; 95% CI 1.15-2.29) or not (adjusted RR 1.73; 95% CI 1.33-2.23). Reduced high-density lipoprotein cholesterol (HDL-C) and raised triglycerides (TGs) were the main individual components associated with risk for infertility. CONCLUSION Metabolic syndrome is associated with longer TTP and infertility, independent of obesity. Additional studies, before pregnancy, are required to support our findings and to determine the applicability of which combinations of metabolic abnormalities pose the greatest risk to delayed fertility, or whether individual components are amenable to modification. TWEETABLE ABSTRACT Metabolic syndrome is associated with longer time to pregnancy and infertility, independent of obesity.
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Affiliation(s)
- J A Grieger
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - L E Grzeskowiak
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - L G Smithers
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - T Bianco-Miotto
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Waite Research Institute, School of Agriculture, Food and Wine, University of Adelaide, Adelaide, South Australia, Australia
| | - S Y Leemaqz
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - P Andraweera
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - L Poston
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, Westminster Bridge, London, UK
| | - L M McCowan
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - L C Kenny
- Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK
| | - J Myers
- Maternal and Fetal Health Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - J J Walker
- Obstetrics and Gynaecology Section, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - R J Norman
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Fertility SA, Adelaide, South Australia, Australia
| | - G A Dekker
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Women and Children's Division, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - C T Roberts
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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Lim SS, Kakoly NS, Tan JWJ, Fitzgerald G, Bahri Khomami M, Joham AE, Cooray SD, Misso ML, Norman RJ, Harrison CL, Ranasinha S, Teede HJ, Moran LJ. Metabolic syndrome in polycystic ovary syndrome: a systematic review, meta-analysis and meta-regression. Obes Rev 2019; 20:339-352. [PMID: 30339316 DOI: 10.1111/obr.12762] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/25/2018] [Accepted: 03/30/2018] [Indexed: 01/08/2023]
Abstract
Women with polycystic ovary syndrome (PCOS) have increased risk of metabolic syndrome. The relative contribution of clinical, demographic or biochemical factors to metabolic syndrome in PCOS is not known. A literature search was conducted in MEDLINE, CINAHL, EMBASE and clinical trial registries. Of 4530 studies reviewed, 59 were included in the systematic review and 27 in the meta-analysis and meta-regression. In good and fair quality studies, women with PCOS had an overall increased prevalence of metabolic syndrome (odds ratio, OR 3.35, 95% confidence interval, CI 2.44, 4.59). Increased prevalence of metabolic syndrome occurred in overweight or obese women with PCOS (OR 1.88, 95% 1.16, 3.04) but not in lean women (OR 1.45, 95% CI 0.35, 6.12). In meta-regression analyses, the markers of metabolic syndrome diagnostic criteria (waist circumference, high-density lipoprotein cholesterol, triglyceride, blood pressure), BMI, glucose tolerance (2-hr oral glucose tolerance test) and surrogate markers of insulin resistance (HOMA-IR) but not markers of reproductive dysfunction (sex hormone binding globulin, testosterone, PCOS phenotypes) contributed significantly to the heterogeneity in the prevalence of metabolic syndrome. Women with PCOS have increased risk of metabolic syndrome which was associated with obesity and metabolic features but not with indices of hyperandrogenism.
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Affiliation(s)
- S S Lim
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - N S Kakoly
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - J W J Tan
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - G Fitzgerald
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - M Bahri Khomami
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - A E Joham
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - S D Cooray
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - M L Misso
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - R J Norman
- Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, South Australia, Australia
| | - C L Harrison
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - S Ranasinha
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - H J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia.,Monash Partners Academic Health Sciences Centre, Melbourne, Victoria, Australia
| | - L J Moran
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, South Australia, Australia
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11
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Kakoly NS, Khomami MB, Joham AE, Cooray SD, Misso ML, Norman RJ, Harrison CL, Ranasinha S, Teede HJ, Moran LJ. Ethnicity, obesity and the prevalence of impaired glucose tolerance and type 2 diabetes in PCOS: a systematic review and meta-regression. Hum Reprod Update 2019; 24:455-467. [PMID: 29590375 DOI: 10.1093/humupd/dmy007] [Citation(s) in RCA: 193] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/12/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Our prior meta-analyses demonstrated an increased prevalence of impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) with polycystic ovary syndrome (PCOS), but with substantial clinical heterogeneity. OBJECTIVE AND RATIONALE We aimed to update our previous review to quantify the prevalence of IGT and T2DM in PCOS with only quality studies (good and fair quality). We also aimed to examine the contribution of parameters including ethnicity, obesity and method of diagnosing T2DM in explaining the observed heterogeneity in IGT and T2DM prevalence in PCOS. SEARCH METHODS We conducted a literature search (MEDLINE, CINAHL, EMBASE, clinical trial registries and hand-searching) up to June 2016 to identify studies reporting the prevalence of dysglycemia (IGT and T2DM) in women with and without PCOS. We included studies where women with PCOS (defined according to original National Institute of Health) were compared to women without PCOS for the end-points of the prevalence of IGT or T2DM. We excluded case reports, case series, editorials, and narrative reviews. Studies where PCOS was diagnosed by self-report, or where IGT or T2DM were measured by fasting glucose, only were excluded. We assessed the methodological quality of the included studies using a priori criteria based on the Newcastle-Ottawa Scaling (NOS) for non-randomized studies. Data are presented as odds ratio (OR) (95% CI) with random-effects meta-analysis by Mantel-Haenszel methods. We assessed the contribution of demographic and clinical factors to heterogeneity using subgroup and meta-regression analysis. OUTCOMES We reviewed 4530 studies and included 40 eligible studies in the final analysis. On meta-analysis of quality studies, women with PCOS had an increased prevalence of IGT (OR = 3.26, 95% CI: 2.17-4.90) and T2DM (OR = 2.87, 95% CI: 1.44-5.72), which differed by ethnicity (for IGT, Asia: 5-fold, the Americas: 4-fold and Europe: 3-fold), was higher with obesity, and doubled among studies using self-report or administrative data for diagnosing diabetes. The ethnicity-related difference retained its significance for Asia and Europe in BMI-matched subgroups. Clear contributors to heterogeneity did not emerge in meta-regression. WIDER IMPLICATIONS Our findings underscore the importance of PCOS as a cause of dysglycemia with a higher prevalence of IGT and T2DM. They support the relevance of ethnicity and obesity and emphasize the need for accurate diagnostic methods for diabetes. PROSPERO REGISTRATION NUMBER CRD42017056524.
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Affiliation(s)
- N S Kakoly
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - M B Khomami
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - A E Joham
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - S D Cooray
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - M L Misso
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - R J Norman
- The Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide and Fertility, Adelaide SA, Australia
| | - C L Harrison
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - S Ranasinha
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - H J Teede
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia.,Monash Partners Academic Health Sciences Centre, PO Box 315, Prahran, Melbourne, Victoria, Australia
| | - L J Moran
- The Department of Epidemiology and Preventive Medicine, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,The Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide and Fertility, Adelaide SA, Australia
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Costello MF, Misso ML, Balen A, Boyle J, Devoto L, Garad RM, Hart R, Johnson L, Jordan C, Legro RS, Norman RJ, Mocanu E, Qiao J, Rodgers RJ, Rombauts L, Tassone EC, Thangaratinam S, Vanky E, Teede HJ. Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: assessment and treatment of infertility. Hum Reprod Open 2019; 2019:hoy021. [PMID: 31486807 PMCID: PMC6396642 DOI: 10.1093/hropen/hoy021] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/13/2018] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION What is the recommended assessment and management of infertile women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertize and consumer preference? SUMMARY ANSWER International evidence-based guidelines, including 44 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of infertile women with PCOS. WHAT IS KNOWN ALREADY Previous guidelines on PCOS lacked rigorous evidence-based processes, failed to engage consumer and multidisciplinary perspectives or were outdated. The assessment and management of infertile women with PCOS are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. PARTICIPANTS/MATERIALS, SETTING, METHODS Governance included a six continent international advisory and a project board, a multidisciplinary international guideline development group (GDG), consumer and translation committees. Extensive health professional and consumer engagement informed the guideline scope and priorities. The engaged international society-nominated panel included endocrinology, gynaecology, reproductive endocrinology, obstetrics, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Extensive online communication and two face-to-face meetings over 15 months addressed 19 prioritized clinical questions involving nine evidence-based reviews and 10 narrative reviews. Evidence-based recommendations (EBRs) were formulated prior to consensus voting within the guideline panel. STUDY DESIGN, SIZE, DURATION International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. A (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation and ultimately recommendation strength. The guideline was peer-reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE II criteria and underwent methodological review. This guideline was approved by all members of the GDG and has been approved by the NHMRC. MAIN RESULTS AND THE ROLE OF CHANCE The quality of evidence (QOE) for the EBRs in the assessment and management of infertility in PCOS included very low (n = 1), low (n = 9) and moderate (n = 4) quality with no EBRs based on high-quality evidence. The guideline provides 14 EBRs, 10 clinical consensus recommendations (CCRs) and 20 clinical practice points on the assessment and management of infertility in PCOS. Key changes in this guideline include emphasizing evidence-based fertility therapy, including cheaper and safer fertility management. LIMITATIONS, REASONS FOR CAUTION Overall evidence is generally of low to moderate quality, requiring significantly greater research in this neglected, yet common condition. Regional health systems vary and a process for adaptation of this guideline is provided. WIDER IMPLICATIONS OF THE FINDINGS The international guideline for the assessment and management of infertility in PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program. STUDY FUNDING/COMPETING INTEREST(S) The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine (ASRM). GDG members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Norman has declared a minor shareholder interest in the IVF unit Fertility SA, travel support from Merck and grants from Ferring. Prof. Norman also has scientific advisory board duties for Ferring. The remaining authors have no conflicts of interest to declare. This article was not externally peer-reviewed by Human Reproduction Open.
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Affiliation(s)
- M F Costello
- School of Women's and Children's Health, University of New South Wales, High St, Kensington, Sydney, New South Wales, Australia
| | - M L Misso
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - A Balen
- Reproductive Medicine and Surgery, Leeds Centre for Reproductive Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - J Boyle
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - L Devoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Chile, Santiago, Chile
| | - R M Garad
- Monash Health, Clayton, Melbourne, Australia.,National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - R Hart
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia
| | - L Johnson
- Victorian Assisted Reproductive Treatment Authority, Victoria, Australia
| | - C Jordan
- Victorian Assisted Reproductive Treatment Authority, Victoria, Australia.,Genea Hollywood Fertility, 190 Cambridge St, Wembley WA, Australia
| | - R S Legro
- Department of Obstetrics and Gynecology, Penn State University College of Medicine, USA
| | - R J Norman
- National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash University, Melbourne, Victoria, Australia.,Adelaide University, Adelaide, South Australia, Australia
| | - E Mocanu
- Royal College of Surgeons, Rotunda Hospital, 123 St Stephen's Green, Dublin, Ireland
| | - J Qiao
- Peking University Third Hospital, Haidian Qu, Beijing Shi, China
| | - R J Rodgers
- Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, South Australia, Australia
| | - L Rombauts
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Melbourne, Victoria 3168, Australia
| | - E C Tassone
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - S Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - E Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - H J Teede
- Monash Health, Clayton, Melbourne, Australia.,National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Victoria, Australia
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13
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Gadalla MA, Huang S, Wang R, Norman RJ, Abdullah SA, El Saman AM, Ismail AM, van Wely M, Mol BWJ. Effect of clomiphene citrate on endometrial thickness, ovulation, pregnancy and live birth in anovulatory women: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51:64-76. [PMID: 29055102 DOI: 10.1002/uog.18933] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/08/2017] [Accepted: 10/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare the impact of clomiphene citrate (CC) vs other drug regimens on mid-cycle endometrial thickness (EMT), ovulation, pregnancy and live birth rates in women with World Health Organization (WHO) group II ovulatory disorders. METHODS We searched MEDLINE, EMBASE, Scopus, Web of Science, The Cochrane Central Register of Clinical Trials (CENTRAL) and the non-MEDLINE subset of PubMed from inception to December 2016 and cross-checked references of relevant articles. We included only randomized controlled trials (RCTs) comparing CC used alone vs other drug regimens for ovulation induction in women with WHO group II anovulation. Outcomes were mid-cycle EMT, ovulation, pregnancy and live birth rates. We pooled weighted mean differences (WMD) with 95% confidence intervals (CI) for continuous variables (EMT) and risk ratios (RR) with 95% CI for binary variables (ovulation, pregnancy and live birth rates). RESULTS We retrieved 1718 articles of which 33 RCTs (4349 women, 7210 ovulation induction cycles) were included. In 15 RCTs that compared CC with letrozole, EMT was lower in the CC group (1957 women, 3892 cycles; WMD, -1.39; 95% CI, -2.27 to -0.51; I2 = 100%), ovulation rates after CC and letrozole were comparable (1710 women, 3217 cycles; RR, 0.97; 95% CI, 0.90-1.04; I2 = 47%), while CC led to a lower pregnancy rate (1957 women, 3892 cycles; RR, 0.78; 95% CI, 0.63-0.95; I2 = 43%) and a lower live birth rate (RR, 0.70; 95% CI, 0.49-0.98; I2 = 35%). In two RCTs that compared CC with CC plus metformin, EMT, ovulation and pregnancy rates were comparable (101 women, 140 cycles; WMD, -0.23; 95% CI, -0.92 to 0.45; I2 = 78%; RR, 0.84; 95% CI, 0.67-1.06; I2 = 0%; and RR, 0.79; 95% CI, 0.33-1.87; I2 = 0%). In three studies that compared CC with CC plus N-acetyl cysteine (NAC), EMT was lower in the CC group (340 women, 300 cycles; WMD, -1.51; 95% CI, -1.98 to -1.04; I2 = 45%). In two studies that compared CC with CC + nitric oxide (NO) donor, EMT was lower in the CC group (120 women, 304 cycles; WMD, -1.75; 95% CI, -2.08 to -1.41; I2 = 0%). Compared with CC plus NO donor or NAC, CC showed statistically significant lower ovulation and pregnancy rates. Compared with tamoxifen in three studies, CC showed a tendency towards lower EMT (571 women, 844 cycles; WMD, -1.34; 95% CI, -2.70 to 0.01; I2 = 96%) with comparable ovulation and pregnancy rates. CONCLUSIONS In women with WHO group II ovulatory disorders, ovulation induction with CC might result in lower EMT than other ovulation induction regimens. Whether the lower EMT caused the lower pregnancy and live birth rates remains to be elucidated. Letrozole seems to be beneficial for these women. However, our findings should be interpreted with caution as the quality of evidence was very low. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M A Gadalla
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - S Huang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Reproductive Medicine Centre, Peking University Third Hospital, Beijing, China
| | - R Wang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - R J Norman
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - S A Abdullah
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - A M El Saman
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - A M Ismail
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - M van Wely
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - B W J Mol
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
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14
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Braakhekke M, Kamphuis EI, Mol F, Norman RJ, Bhattacharya S, van der Veen F, Mol BWJ. Effectiveness and safety as outcome measures in reproductive medicine. Hum Reprod 2016; 30:2249-51. [PMID: 26384402 DOI: 10.1093/humrep/dev201] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of reproductive medicine is to help couples with an unfulfilled child wish to have a child by offering them the best treatment option. The choice of treatment reflects effectiveness and safety. While effectiveness refers to the extent to which a treatment increases the chance of a couple in having a baby, safety relates to adverse effects associated with such a treatment. In an attempt to integrate effectiveness and safety, healthy singleton live birth (at term) has been suggested as the ideal outcome measure for evaluative research in reproductive medicine. Although intuitively desirable, this proposal overlooks the fact that assessment of effectiveness and safety in this context cannot be measured as a single outcome. In this paper, we explain why effectiveness and safety outcomes in reproductive medicine should be assessed independently, and later synthesized to inform clinical decision-making.
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Affiliation(s)
- M Braakhekke
- Centre for Reproductive Medicine, Room Q3-119, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - E I Kamphuis
- Centre for Reproductive Medicine, Room Q3-119, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - F Mol
- Centre for Reproductive Medicine, Room Q3-119, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - R J Norman
- Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
| | - S Bhattacharya
- Reproductive Medicine, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - F van der Veen
- Centre for Reproductive Medicine, Room Q3-119, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - B W J Mol
- Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
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15
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Moran LJ, Thomson RL, Buckley JD, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. Erratum to: Steroidal contraceptive use is associated with lower bone mineral density in polycystic ovary syndrome. Endocrine 2016; 52:404. [PMID: 26924153 DOI: 10.1007/s12020-016-0907-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Lisa J Moran
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 55 King William Road, North Adelaide, SA, 5006, Australia.
| | - R L Thomson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - J D Buckley
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - M Noakes
- Fertility SA, Adelaide, SA, Australia
| | - P M Clifton
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - R J Norman
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 55 King William Road, North Adelaide, SA, 5006, Australia
- Fertility SA, Adelaide, SA, Australia
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16
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Boyle JA, Cunningham J, Norman RJ, Dunbar T, O'Dea K. Polycystic ovary syndrome and metabolic syndrome in Indigenous Australian women. Intern Med J 2015; 45:1247-54. [DOI: 10.1111/imj.12910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/07/2015] [Accepted: 09/09/2015] [Indexed: 12/01/2022]
Affiliation(s)
- J. A. Boyle
- Monash Centre for Health Research Implementation, School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Obstetrics and Gynaecology; Monash Health; Melbourne Victoria Australia
| | - J. Cunningham
- Menzies School of Health Research; Darwin Northern Territory Australia
| | - R. J. Norman
- The Robinson Institute; University of Adelaide; Adelaide South Australia Australia
| | - T. Dunbar
- Charles Darwin University; Darwin Northern Territory Australia
| | - K. O'Dea
- The Sansom Institute; University of South Australia; Adelaide South Australia Australia
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17
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Moran LJ, Thomson RL, Buckley JD, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. Steroidal contraceptive use is associated with lower bone mineral density in polycystic ovary syndrome. Endocrine 2015; 50:811-5. [PMID: 25957668 DOI: 10.1007/s12020-015-0625-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 05/04/2015] [Indexed: 11/29/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a common condition affecting reproductive-aged women with features including hyperandrogenism and menstrual irregularity frequently treated with hormonal steroidal contraceptives. Women with PCOS appear to have lower bone mineral density (BMD). While steroidal contraceptives may positively affect bone health, their effect on BMD in PCOS is not known. The aim of this study was to assess BMD in women with PCOS according to recent contraceptive use. A cross-sectional analysis of 95 pre-menopausal overweight or obese sedentary women with PCOS [age 29.4 ± 6.4 years, body mass index (BMI) 36.1 ± 5.3 kg/m(2)] who either recently took steroidal contraceptives (ceased 3 months prior) or were not taking steroidal contraceptives was conducted. Clinical outcomes included BMD, anthropometry, insulin, glucose, reproductive hormones, dietary intake and vitamin use. BMD was significantly lower for women who used contraceptives compared to those who did not (mean difference 0.06 g/cm(2) 95 % confidence interval -0.11, -0.02, p = 0.005). In regression models, lower BMD was independently associated with contraceptive use (β = -0.05, 95 % CI -0.094, -0.002, p = 0.042), higher testosterone (β = -0.03, 95 % CI -0.05, -0.0008, p = 0.043) and lower BMI (β = 0.006, 95 % CI 0.002, 0.01, p = 0.007) (r (2) = 0.22, p = 0.001 for entire model). We report for the first time that overweight and obese women with PCOS with recent steroidal contraceptive use had lower BMD in comparison to non-users independent of factors known to contribute to BMD. Whether this observation is directly related to steroidal contraceptive use or other factors requires further investigation.
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Affiliation(s)
- Lisa J Moran
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 55 King William Road, North Adelaide, SA, 5006, Australia.
| | - R L Thomson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - J D Buckley
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - M Noakes
- Fertility SA, Adelaide, SA, Australia
| | - P M Clifton
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - R J Norman
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 55 King William Road, North Adelaide, SA, 5006, Australia
- Fertility SA, Adelaide, SA, Australia
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18
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Ranasinha S, Joham AE, Norman RJ, Shaw JE, Zoungas S, Boyle J, Moran L, Teede HJ. The association between Polycystic Ovary Syndrome (PCOS) and metabolic syndrome: a statistical modelling approach. Clin Endocrinol (Oxf) 2015; 83:879-87. [PMID: 26052744 DOI: 10.1111/cen.12830] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [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] [Received: 03/24/2015] [Revised: 04/14/2015] [Accepted: 06/01/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) affects 12-21% of women. Women with PCOS exhibit clustering of metabolic features. We applied rigorous statistical methods to further understand the interplay between PCOS and metabolic features including insulin resistance, obesity and androgen status. DESIGN Retrospective cross-sectional analysis. PATIENTS Women with PCOS attending reproductive endocrine clinics in South Australia for the treatment of PCOS (n = 172). Women without PCOS (controls) in the same Australian region (n = 335) from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab), a national population-based study (age- and BMI-matched within one standard deviation of the PCOS cohort). MEASUREMENTS The factor structure for metabolic syndrome for women with PCOS and control groups was examined, specifically, the contribution of individual factors to metabolic syndrome and the association of hyperandrogenism with other metabolic factors. RESULTS Women with PCOS demonstrated clustering of metabolic features that was not observed in the control group. Metabolic syndrome in the PCOS cohort was strongly represented by obesity (standardized factor loading = 0·95, P < 0·001) and insulin resistance factors (loading = 0·92, P < 0·001) and moderately by blood pressure (loading = 0·62, P < 0·001) and lipid factors (loading = 0·67, P = 0·002). On further analysis, the insulin resistance factor strongly correlated with the obesity (r = 0·70, P < 0·001) and lipid factors (r = 0·68, P < 0·001) and moderately with the blood pressure factor (loading = 0·43, P = 0·002). The hyperandrogenism factor was moderately correlated with the insulin resistance factor (r = 0·38, P < 0·003), but did not correlate with any other metabolic factors. CONCLUSIONS PCOS women are more likely to display metabolic clustering in comparison with age- and BMI-matched control women. Obesity and insulin resistance, but not androgens, are independently and most strongly associated with metabolic syndrome in PCOS.
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Affiliation(s)
- S Ranasinha
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
| | - A E Joham
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Vic, Australia
| | - R J Norman
- Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, North Adelaide, SA, Australia
| | - J E Shaw
- Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - S Zoungas
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Vic, Australia
| | - J Boyle
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
| | - L Moran
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, North Adelaide, SA, Australia
| | - H J Teede
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Vic, Australia
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Hart RJ, Doherty DA, McLachlan RI, Walls ML, Keelan JA, Dickinson JE, Skakkebaek NE, Norman RJ, Handelsman DJ. Testicular function in a birth cohort of young men. Hum Reprod 2015; 30:2713-24. [PMID: 26409015 DOI: 10.1093/humrep/dev244] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [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: 06/11/2015] [Accepted: 09/08/2015] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION By investigating a birth cohort with a high ongoing participation rate to derive an unbiased population, what are the parameters and influences upon testicular function for a population not selected with regard to fertility? SUMMARY ANSWER While varicocele, cryptorchidism and obesity may impact on human testicular function, most common drug exposures and the presence of epididymal cysts appear to have no or minimal adverse impact. WHAT IS KNOWN ALREADY The majority of previous attempts to develop valid reference populations for spermatogenesis have relied on potentially biased sources such as recruits from infertility clinics, self-selected volunteer sperm donors for research or artificial insemination or once-fertile men seeking vasectomy. It is well known that studies requiring semen analysis have low recruitment rates which consequently question their validity. However, there has been some concern that a surprisingly high proportion of young men may have semen variables that do not meet all the WHO reference range criteria for fertile men, with some studies reporting that up to one half of participants have not meet the reference range for fertile men. Reported median sperm concentrations have ranged from 40 to 60 million sperm/ml. STUDY DESIGN, SIZE AND DURATION The Western Australian Pregnancy Cohort (Raine) was established in 1989. At 20-22 years of age, members of the cohort were contacted to attend for a general follow-up, with 753 participating out of the 913 contactable men. Of these, 423 men (56% of participants in the 20-22 years cohort study, 46% of contactable men) participated in a testicular function study. Of the 423 men, 404 had a testicular ultrasound, 365 provided at least one semen sample, 287 provided a second semen sample and 384 provided a blood sample. PARTICIPANTS/MATERIALS, SETTING, METHODS Testicular ultrasound examinations were performed at King Edward Memorial Hospital, Subiaco, Perth, for testicular volume and presence of epididymal cysts and varicoceles. Semen samples were provided and analysed by standard semen assessment and a sperm chromatin structural assay (SCSA) at Fertility Specialists of Western Australia, Claremont, Perth. Serum blood samples were provided at the University of Western Australia, Crawley, Perth and were analysed for serum luteinizing hormone (LH), follicular stimulating hormone (FSH), inhibin B, testosterone, dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), estradiol, estrone and the primary metabolites of DHT: 5α-androstane-3α,17β-diol (3α-diol) and 5-α androstane-3-β-17-beta-diol (3β-diol). Serum steroids were measured by liquid chromatography, mass spectrometry and LH, FSH and inhibin B were measured by ELISA assays. MAIN RESULTS AND THE ROLE OF CHANCE Cryptorchidism was associated with a significant reduction in testicular (P = 0.047) and semen (P = 0.027) volume, sperm concentration (P = 0.007) and sperm output (P = 0.003). Varicocele was associated with smaller testis volume (P < 0.001), lower sperm concentration (P = 0.012) and total sperm output (P = 0.030) and lower serum inhibin B levels (P = 0.046). Smoking, alcohol intake, herniorrhaphy, an epididymal cyst, medication and illicit drugs were not associated with any significant semen variables, testicular volume or circulating reproductive hormones. BMI had a significantly negative correlation with semen volume (r = -0.12, P = 0.048), sperm output (r = -0.13, P = 0.02), serum LH (r = -0.16, P = 0.002), inhibin B (r = -0.16, P < 0.001), testosterone (r = -0.23, P < 0.001) and DHT (r = -0.22, P < 0.001) and a positive correlation with 3αD (r = 0.13, P = 0.041) and DHEA (r = 0.11, P = 0.03). Second semen samples compared with the first semen samples in the 287 participants who provided two samples, with no significant bias by Bland-Altman analysis. Testis volume was significantly correlated positively with sperm concentration (r = 0.25, P < 0.001) and sperm output (r = 0.29, P < 0.001) and inhibin B (r = 0.42, P < 0.001), and negatively correlated with serum LH (r = -0.24, P < 0.001) and FSH (r = -0.32, P < 0.001). SCSA was inversely correlated with sperm motility (r = -0.20, P < 0.001) and morphology (r = -0.16, P = 0.005). WHO semen reference criteria were all met by only 52 men (14.4%). Some criteria were not met at first analysis in 15-20% of men, including semen volume (<1.5 ml, 14.8%), total sperm output (<39 million, 18.9%), sperm concentration (<15 million/ml, 17.5%), progressive motility (<32%, 14.4%) and morphologically normal sperm (<4%, 26.4%), while all five WHO criteria were not met in four participants (1.1%). LIMITATIONS AND REASONS FOR CAUTION This was a large cohort study; however, potential for recruitment bias still exists. Men who did not participate in the testicular evaluation study (n = 282) did not differ from those who did (n = 423) with regard to age, weight, BMI, smoking or circulating reproductive hormones (LH, FSH, inhibin B, T, DHT, E2, E1, DHEA, 3α-diol, 3β-diol), but were significantly shorter (178 versus 180 cm, P = 0.008) and had lower alcohol consumption (P = 0.019) than those who did participate. WIDER IMPLICATIONS OF THE FINDINGS This study demonstrated the feasibility of establishing a birth cohort to provide a relatively unbiased insight into population-representative sperm output and function and of investigating its determinants from common exposures. While varicocele, cryptorchidism and obesity may impact on human testicular function, most common drug exposures and the presence of epididymal cysts appear to have little adverse impact, and this study suggests that discrepancies from the WHO reference ranges are expected, due to its derivation from non-population-representative fertile populations.
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Affiliation(s)
- R J Hart
- School of Women's and Infants' Health, University of Western Australia, Perth, WA 6008, Australia Fertility Specialists of Western Australia, Bethesda Hospital, 25 Queenslea Drive, Claremont, WA 6010, Australia
| | - D A Doherty
- School of Women's and Infants' Health, University of Western Australia, Perth, WA 6008, Australia Women and Infants Research Foundation, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA, Australia
| | - R I McLachlan
- Hudson Institute of Medical Research, Monash Medical Centre, Melbourne, Australia
| | - M L Walls
- School of Women's and Infants' Health, University of Western Australia, Perth, WA 6008, Australia Fertility Specialists of Western Australia, Bethesda Hospital, 25 Queenslea Drive, Claremont, WA 6010, Australia
| | - J A Keelan
- School of Women's and Infants' Health, University of Western Australia, Perth, WA 6008, Australia Women and Infants Research Foundation, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA, Australia
| | - J E Dickinson
- School of Women's and Infants' Health, University of Western Australia, Perth, WA 6008, Australia Women and Infants Research Foundation, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA, Australia
| | - N E Skakkebaek
- Department of Growth and Reproduction, University Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
| | - R J Norman
- Robinson Institute, University of Adelaide, FertilitySA, Adelaide, Australia
| | - D J Handelsman
- ANZAC Research Institute, University of Sydney, Concord Hospital, Sydney, Australia
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Dewailly D, Lujan ME, Carmina E, Cedars MI, Laven J, Norman RJ, Escobar-Morreale HF. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update 2013; 20:334-52. [DOI: 10.1093/humupd/dmt061] [Citation(s) in RCA: 309] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Moran LJ, Teede HJ, Noakes M, Clifton PM, Norman RJ, Wittert GA. Sex hormone binding globulin, but not testosterone, is associated with the metabolic syndrome in overweight and obese women with polycystic ovary syndrome. J Endocrinol Invest 2013; 36:1004-10. [PMID: 23812344 DOI: 10.3275/9023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism and an increased risk of Type 2 diabetes and cardiovascular disease. Decreased SHBG and elevated testosterone are associated with metabolic syndrome and glucose intolerance in women. AIM The aim of this study was to assess the relationship between SHBG and testosterone and metabolic syndrome and glucose intolerance in PCOS. MATERIAL/SUBJECTS AND METHODS Cross-sectional study in overweight and obese premenopausal non-diabetic women with PCOS (no.=178: no.=55 metabolic syndrome, no.=16 glucose intolerance). Data were analyzed by multiple regression with metabolic syndrome, oral glucose tolerance test (OGTT) glucose or SHBG as dependent variables and reproductive hormones, insulin resistance, glucose tolerance, lipids or C-reactive protein as independent variables. RESULTS Metabolic syndrome was independently associated with body mass index [odds ratio (OR) 1.084 95% confidence interval (CI) 1.034-1.170, p=0.015] and SHBG (OR 0.961 95% CI 0.932-0.995, p=0.018). Glucose tolerance was independently associated with OGTT insulin (β=0.418, p<0.001), age (β=0.154, p=0.033) and PRL (β=-0.210, p=0.002). SHBG was independently associated with OGTT insulin (β=-0.216, p=0.014) and PCOS diagnostic criteria (β=0.197, p=0.010). CONCLUSIONS SHBG, but not testosterone, is independently associated with metabolic syndrome in overweight women with PCOS and is associated with insulin resistance and PCOS diagnostic criteria.
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Affiliation(s)
- L J Moran
- The Robinson Institute, University of Adelaide, North Adelaide, Australia.
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Pedros DCC, Oliveira JBA, Petersen CG, Mauri AL, Nascimento AM, Vagnini LD, Nicoletti A, Massaro FC, Cavagna M, Martins AMVC, Baruffi RLR, Franco JG, Hart R, Doherty DA, Handelsman DJ, McLachlan R, Skakkebaek NE, Keelan JA, Norman RJ, Dokuzeylul N, Onal M, Acet M, Basar M, Kahraman S, Garolla A, Pizzol D, Ghezzi M, Selice R, Bertoldo A, Menegazzo M, Foresta C, Jordan C, Broderick P. Session 18: Lifestyle dangers for men's fertility. Hum Reprod 2013. [DOI: 10.1093/humrep/det145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Saad H, Khalil E, Bora SA, Parikh J, Abdalla H, Thum MY, Bina V, Roopa P, Shyamala S, Anupama A, Tournaye H, Polyzos NP, Guzman L, Nelson SM, Lourenco B, Sousa AP, Almeida-Santos T, Ramalho-Santos J, Okhowat J, Wirleitner B, Neyer T, Bach M, Murtinger M, Zech NH, Polyzos NP, Nwoye M, Corona R, Blockeel C, Stoop D, Camus M, Tournaye H, Rajikin MH, Kamsani YS, Chatterjee A, Nor-Ashikin MNK, Nuraliza AS, Scaravelli G, D'Aloja P, Bolli S, De Luca R, Spoletini R, Fiaccavento S, Speziale L, Vigiliano V, Farquhar C, Brown J, Arroll N, Gupta D, Boothroyd C, Al Bassam M, Moir J, Johnson N, Pantasri T, Robker RL, Wu LL, Norman RJ, Buzaglo K, Velez M, Shaulov T, Sylvestre C, Kadoch IJ, Krog M, Prior M, Carlsen E, Loft A, Pinborg A, Andersen AN, Dolleman M, Verschuren WMM, Eijkemans MJC, Dolle MET, Jansen EHJM, Broekmans FJM, Van der Schouw YT, Fainaru O, Pencovich N, Hantisteanu S, Barzilay I, Ellenbogen A, Hallak M, Cavagna M, Baruffi RLR, Petersen CG, Mauri AL, Massaro FC, Ricci J, Nascimento AM, Vagnini LD, Pontes A, Oliveira JBA, Franco JG, Canas MCT, Vagnini LD, Nascimento AM, Petersen CG, Mauri AL, Massaro FC, Nicoletti A, Martins AMVC, Cavagna M, Oliveira JBA, Baruffi RLR, Franco JG, Lichtblau I, Olivennes F, Aubriot FA, Junca AM, Belloc S, Cohen-Bacrie M, Cohen-Bacrie P, de Mouzon J, Nandy T, Caragia A, Balestrini S, Zosmer A, Sabatini L, Al-Shawaf T, Seshadri S, Khalaf Y, Sunkara SK, Joy J, Lambe M, Lutton D, Nicopoullos J, Bora SA, Parikh J, Faris R, Abdalla H, Thum MY, Behre HM, Howles CM, Longobardi S, Chimote N, Mehta B, Nath N, Chimote NM, Mehta B, Nath N, Chimote N, Chimote NM, Mine K, Yoshida A, Yonezawa M, Ono S, Abe T, Ichikawa T, Tomiyama R, Nishi Y, Kuwabara Y, Akira S, Takeshita T, Shin H, Song HS, Lim HJ, Hauzman E, Kohls G, Barrio A, Martinez-Salazar J, Iglesias C, Velasco JAG, Tejada MI, Maortua H, Mendoza R, Prieto B, Martinez-Bouzas C, Diez-Zapirain M, Martinez-Zilloniz N, Matorras R, Amaro A, Bianco B, Christofolini J, Mafra FA, Barbosa CP, Christofolini DM, Pesce R, Gogorza S, Ochoa C, Gil S, Saavedra A, Ciarmatori S, Perman G, Pagliardini L, Papaleo E, Corti L, Vanni VS, Ottolina J, de Michele F, Marca AL, Vigano P, Candiani M, Li L, Yin Q, Huang L, Huang J, He Z, Yang D, Parikh J, Bora SA, Abdalla H, Thum MY, Tiplady S, Ledger W, Godbert S, Hart S, Johnson S, Wong AWY, Kong GWS, Haines CJ, Franik S, Nelen W, Kremer J, Farquhar C, Gillett WR, Lamont JM, Peek JC, Herbison GP, Sung NY, Hwang YI, Choi MH, Song IO, Kang IS, Koong MK, Lee JS, Yang KM, Celtemen MB, Telli P, Karakaya C, Bozkurt N, Gursoy RH, Younis JS, Ben-Ami M, Pundir J, Pundir V, Omanwa K, Khalaf Y, El-Toukhy T. Female (in)fertility. Hum Reprod 2013. [DOI: 10.1093/humrep/det213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev 2013; 14:95-109. [PMID: 23114091 DOI: 10.1111/j.1467-789x.2012.01053.x] [Citation(s) in RCA: 296] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/02/2012] [Accepted: 09/13/2012] [Indexed: 12/14/2022]
Abstract
While many women with polycystic ovary syndrome (PCOS) are overweight, obese or centrally obese, the effect of excess weight on the outcomes of PCOS is inconsistent. The review aimed to assess the effects of overweight, obesity and central obesity on the reproductive, metabolic and psychological features of PCOS. MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting outcomes according to body mass index categories or body fat distribution. Data were presented as mean difference or risk ratio (95% confidence interval). This review included 30 eligible studies. Overweight or obese women with PCOS had decreased sex hormone-binding globulin (SHBG), increased total testosterone, free androgen index, hirsutism, fasting glucose, fasting insulin, homeostatic model assessment-insulin resistance index and worsened lipid profile. Obesity significantly worsened all metabolic and reproductive outcomes measured except for hirsutism when compared to normal weight women with PCOS. Overweight women had no differences in total testosterone, hirsutism, total-cholesterol and low-density lipoprotein-cholesterol compared to normal weight women and no differences in SHBG and total testosterone compared to obese women. Central obesity was associated with higher fasting insulin levels. These results suggest that prevention and treatment of obesity is important for the management of PCOS.
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Affiliation(s)
- S S Lim
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia
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Lim SS, Davies MJ, Norman RJ, Moran LJ. Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2012; 18:618-37. [PMID: 22767467 DOI: 10.1093/humupd/dms030] [Citation(s) in RCA: 463] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is closely associated with obesity but the prevalence of obesity varies between published studies. The objective of this research was to describe the prevalence of overweight, obesity and central obesity in women with and without PCOS and to assess the confounding effect of ethnicity, geographic regions and the diagnostic criteria of PCOS on the prevalence. METHODS MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting the prevalence of overweight, obesity or central obesity in women with and without PCOS. Data were presented as prevalence (%) and risk ratio (RR) [95% confidence interval (CI)]. Random-effect models were used to calculate pooled RR. RESULTS This systematic review included 106 studies while the meta-analysis included 35 studies (15129 women). Women with PCOS had increased prevalence of overweight [RR (95% CI): 1.95 (1.52, 2.50)], obesity [2.77 (1.88, 4.10)] and central obesity [1.73 (1.31, 2.30)] compared with women without PCOS. The Caucasian women with PCOS had a greater increase in obesity prevalence than the Asian women with PCOS compared with women without PCOS [10.79 (5.36, 21.70) versus 2.31 (1.33, 4.00), P < 0.001 between subgroups). CONCLUSIONS Women with PCOS had a greater risk of overweight, obesity and central obesity. Although our findings support a positive association between obesity and PCOS, our conclusions are limited by the significant heterogeneity between studies and further studies are now required to determine the source of this heterogeneity. Clinical management of PCOS should include the prevention and management of overweight and obesity.
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Affiliation(s)
- S S Lim
- The Robinson Institute, University of Adelaide, Adelaide, Australia
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Homan G, Litt J, Norman RJ. The FAST study: Fertility ASsessment and advice Targeting lifestyle choices and behaviours: a pilot study. Hum Reprod 2012; 27:2396-404. [DOI: 10.1093/humrep/des176] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Thomson RL, Brinkworth GD, Noakes M, Clifton PM, Norman RJ, Buckley JD. The effect of diet and exercise on markers of endothelial function in overweight and obese women with polycystic ovary syndrome. Hum Reprod 2012; 27:2169-76. [PMID: 22552687 DOI: 10.1093/humrep/des138] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Women with polycystic ovary syndrome (PCOS) present with vascular abnormalities, including elevated markers of endothelial dysfunction. There is limited evidence for the effect of lifestyle modification and weight loss on these markers. The aim of this study was to determine if 20 weeks of a high-protein energy-restricted diet with or without exercise in women with PCOS could improve endothelial function. METHODS This is a secondary analysis of a subset of 50 overweight/obese women with PCOS (age: 30.3 ± 6.3 years; BMI: 36.5 ± 5.7 kg/m(2)) from a previous study. Participants were randomly assigned by computer generation to one of three 20-week interventions: diet only (DO; n = 14, ≈ 6000 kJ/day), diet and aerobic exercise (DA; n = 16, ≈ 6000 kJ/day and five walking sessions/week) and diet and combined aerobic-resistance exercise (DC; n = 20, ≈ 6000 kJ/day, three walking and two strength sessions/week). At Weeks 0 and 20, weight, markers of endothelial function [vascular cell adhesion molecule-1 (sVCAM-1), inter-cellular adhesion molecule-1 (sICAM-1), plasminogen activator inhibitor-1 (PAI-1) and asymmetric dimethylarginine (ADMA)], insulin resistance and hormonal profile were assessed. RESULTS All three treatments resulted in significant weight loss (DO 7.9 ± 1.2%, DA 11.0 ± 1.6%, DC 8.8 ± 1.1; P < 0.001 for time; P = 0.6 time × treatment). sVCAM-1, sICAM-1 and PAI-1 levels decreased with weight loss (P≤ 0.01), with no differences between treatments (P ≥ 0.4). ADMA levels did not change significantly (P = 0.06). Testosterone, sex hormone-binding globulin and the free androgen index (FAI) and insulin resistance also improved (P < 0.001) with no differences between treatments (P ≥ 0.2). Reductions in sVCAM-1 were correlated to reductions in testosterone (r = 0.32, P = 0.03) and FAI (r = 0.33, P = 0.02) as well as weight loss (r= 0.44, P = 0.002). Weight loss was also associated with reductions in sICAM-1 (r= 0.37, P = 0.008). CONCLUSIONS Exercise training provided no additional benefit to following a high-protein, hypocaloric diet on markers of endothelial function in overweight/obese women with PCOS.
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Affiliation(s)
- R L Thomson
- Nutritional Physiology Research Centre, Sansom Institute for Health Research, University of South Australia, Adelaide 5001, Australia.
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Fauser BCJM, Tarlatzis BC, Rebar RW, Legro RS, Balen AH, Lobo R, Carmina H, Chang RJ, Yildiz BO, Laven JSE, Boivin J, Petraglia F, Wijeyeratne CN, Norman RJ, Dunaif A, Franks S, Wild RA, Dumesic D, Barnhart K. Consensus on women's health aspects of polycystic ovary syndrome (PCOS). Hum Reprod 2012; 27:14-24. [PMID: 22147920 DOI: 10.1093/humrep/der396] [Citation(s) in RCA: 224] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in females with a high prevalence. The etiology of this heterogeneous condition remains obscure and its phenotype expression varies. Two, widely cited, previous ESHRE/ASRM-sponsored PCOS consensus workshops focused on diagnosis (published in 2004) and infertility management (published in 2008). The present third PCOS consensus paper summarizes current knowledge and identifies knowledge gaps regarding various women's health aspects of PCOS. Relevant topics addressed-all dealt with in a systematic fashion-include adolescence, hirsutism and acne, contraception, menstrual cycle abnormalities, quality of life, ethnicity, pregnancy complications, long-term metabolic and cardiovascular health and finally cancer risk. Additional, comprehensive background information is provided separately in an extended online publication.
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Escobar-Morreale HF, Carmina E, Dewailly D, Gambineri A, Kelestimur F, Moghetti P, Pugeat M, Qiao J, Wijeyaratne CN, Witchel SF, Norman RJ. Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update 2011; 18:146-70. [PMID: 22064667 DOI: 10.1093/humupd/dmr042] [Citation(s) in RCA: 229] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hirsutism, defined by the presence of excessive terminal hair in androgen-sensitive areas of the female body, is one of the most common disorders in women during reproductive age. METHODS We conducted a systematic review and critical assessment of the available evidence pertaining to the epidemiology, pathophysiology, diagnosis and management of hirsutism. RESULTS The prevalence of hirsutism is ~10% in most populations, with the important exception of Far-East Asian women who present hirsutism less frequently. Although usually caused by relatively benign functional conditions, with the polycystic ovary syndrome leading the list of the most frequent etiologies, hirsutism may be the presenting symptom of a life-threatening tumor requiring immediate intervention. CONCLUSIONS Following evidence-based diagnostic and treatment strategies that address not only the amelioration of hirsutism but also the treatment of the underlying etiology is essential for the proper management of affected women, especially considering that hirsutism is, in most cases, a chronic disorder needing long-term follow-up. Accordingly, we provide evidence-based guidelines for the etiological diagnosis and for the management of this frequent medical complaint.
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Affiliation(s)
- H F Escobar-Morreale
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramon y Cajal & Universidad de Alcalá & Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS & CIBER Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM, 28034 Madrid, Spain.
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Dunning KR, Akison LK, Russell DL, Norman RJ, Robker RL. Increased Beta-Oxidation and Improved Oocyte Developmental Competence in Response to L-Carnitine During Ovarian In Vitro Follicle Development in Mice. Biol Reprod 2011; 85:548-55. [DOI: 10.1095/biolreprod.110.090415] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hickey M, Doherty DA, Atkinson H, Sloboda DM, Franks S, Norman RJ, Hart R. Clinical, ultrasound and biochemical features of polycystic ovary syndrome in adolescents: implications for diagnosis. Hum Reprod 2011; 26:1469-77. [DOI: 10.1093/humrep/der102] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lim SS, Norman RJ, Clifton PM, Noakes M. The effect of comprehensive lifestyle intervention or metformin on obesity in young women. Nutr Metab Cardiovasc Dis 2011; 21:261-268. [PMID: 20163941 DOI: 10.1016/j.numecd.2009.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [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] [Received: 07/13/2009] [Revised: 10/08/2009] [Accepted: 10/14/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Young women are at high risk of weight gain but few weight management interventions have been investigated in this group. This study aimed to determine the effect of metformin on body weight, body composition, metabolic risk factors and reproductive hormone levels in overweight or obese young women compared to placebo and comprehensive lifestyle intervention. METHODS AND RESULTS 203 overweight or obese young women (BMI 33.2+/-0.3 kg/m², age 28+/-0.3 years) were randomised to 1500 mg/day metformin (M) plus general lifestyle advice, placebo (P) plus general lifestyle advice or comprehensive lifestyle intervention including structured diet, exercise and behavioural therapy (L) for 12-weeks. At 12-weeks, linear mixed models found that L group had greater weight loss (-4.2+/-0.4 kg) compared to M (-1.0+/-0.4 kg) and P groups (-0.2+/-0.3 kg) (P < 0.0001). Weight loss between M and P groups were not significantly different. Attrition rate was 48% for L, 34% for M and 29% for P (P = 0.08). Intention-to-treat analysis showed that 10% (8/79) of the subjects in P group had gained weight (>3%), compared to 3% (2/65) from M group and none (0/59) from L group (P < 0.001). The L group had the greatest decrease in waist circumference (-5.2+/-0.7 cm) and fat mass (-5.4+/-0.7 kg) compared to the other groups (P < 0.05). No significant time-by-group effects were seen in plasma lipids, SHBG, testosterone, blood pressure, serum folate, serum ferritin and serum vitamin B12. CONCLUSION Lifestyle intervention was more effective in reducing body weight and improving body composition compared to metformin among healthy overweight or obese young women.
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Affiliation(s)
- S S Lim
- Discipline of Physiology, School of Molecular and Biomedical Science, Adelaide University, SA 5000, Australia.
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Norman RJ, Robker R, Xing Y, Wu L, Lane M, Vitthala S, Edwards C, Sabatini L, Tozer A, Al-Shawaf T, Boeckxstaens A, Blockeel C, Polyzos NP, Devroey P, Ellis JE, Johnson SJ, Shaw R, Godbert S. SELECTED ORAL COMMUNICATION SESSION, SESSION 50: ENDOCRINOLOGY, Tuesday 5 July 2011 17:00 - 18:00. Hum Reprod 2011. [DOI: 10.1093/humrep/26.s1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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McLernon DJ, Harrild K, Bergh C, Davies MJ, de Neubourg D, Dumoulin JCM, Gerris J, Kremer JAM, Martikainen H, Mol BW, Norman RJ, Thurin-Kjellberg A, Tiitinen A, van Montfoort APA, van Peperstraten AM, Van Royen E, Bhattacharya S. Clinical effectiveness of elective single versus double embryo transfer: meta-analysis of individual patient data from randomised trials. BMJ 2010; 341:c6945. [PMID: 21177530 PMCID: PMC3006495 DOI: 10.1136/bmj.c6945] [Citation(s) in RCA: 228] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2010] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the effectiveness of elective single embryo transfer versus double embryo transfer on the outcomes of live birth, multiple live birth, miscarriage, preterm birth, term singleton birth, and low birth weight after fresh embryo transfer, and on the outcomes of cumulative live birth and multiple live birth after fresh and frozen embryo transfers. DESIGN One stage meta-analysis of individual patient data. DATA SOURCES A systematic review of English and non-English articles from Medline, Embase, and the Cochrane Central Register of Controlled Trials (up to 2008). Additional studies were identified by contact with clinical experts and searches of bibliographies of all relevant primary articles. Search terms included embryo transfer, randomised controlled trial, controlled clinical trial, single embryo transfer, and double embryo transfer. Review methods Comparisons of the clinical effectiveness of cleavage stage (day 2 or 3) elective single versus double embryo transfer after fresh or frozen in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatments were included. Trials were included if the intervention differed only in terms of the intended number of embryos to be transferred. Trials that involved only blastocyst (day five) transfers were excluded. RESULTS Individual patient data were received for every patient recruited to all eight eligible trials (n=1367). A total of 683 and 684 women randomised to the single and double embryo transfer arms, respectively, were included in the analysis. Baseline characteristics in the two groups were comparable. The overall live birth rate in a fresh IVF cycle was lower after single (181/683, 27%) than double embryo transfer (285/683, 42%) (adjusted odds ratio 0.50, 95% confidence interval 0.39 to 0.63), as was the multiple birth rate (3/181 (2%) v 84/285 (29%)) (0.04, 0.01 to 0.12). An additional frozen single embryo transfer, however, resulted in a cumulative live birth rate not significantly lower than the rate after one fresh double embryo transfer (132/350 (38%) v 149/353 (42%) (0.85, 0.62 to 1.15), with a minimal cumulative risk of multiple birth (1/132 (1%) v 47/149 (32%)). The odds of a term singleton birth (that is, over 37 weeks) after elective single embryo transfer was almost five times higher than the odds after double embryo transfer (4.93, 2.98 to 8.18). CONCLUSIONS Elective single embryo transfer results in a higher chance of delivering a term singleton live birth compared with double embryo transfer. Although this strategy yields a lower pregnancy rate than a double embryo transfer in a fresh IVF cycle, this difference is almost completely overcome by an additional frozen single embryo transfer cycle. The multiple pregnancy rate after elective single embryo transfer is comparable with that observed in spontaneous pregnancies.
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Affiliation(s)
- D J McLernon
- Medical Statistics Team, Section of Population Health, University of Aberdeen, Aberdeen AB25 2ZD, UK.
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Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2010. [DOI: 10.1093/humupd/dmq051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Norman RJ, Thomas A. James Boyer Brown, 1919-2009. Hum Reprod Update 2010; 17:139-40. [PMID: 20923875 DOI: 10.1093/humupd/dmq047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hickey M, Doherty DA, Hart R, Norman RJ, Mattes E, Atkinson HC, Sloboda DM. Maternal and umbilical cord androgen concentrations do not predict digit ratio (2D:4D) in girls: a prospective cohort study. Psychoneuroendocrinology 2010; 35:1235-44. [PMID: 20299156 DOI: 10.1016/j.psyneuen.2010.02.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 02/15/2010] [Accepted: 02/21/2010] [Indexed: 10/19/2022]
Abstract
Digit ratio (2D:4D) is widely used as a marker of prenatal androgen exposure. However, there are no published prospective studies where prenatal androgen exposure has been measured and correlated with digit ratio in adult life. We aimed to establish the prospective relationship between prenatal androgen exposure in the second and third trimesters of pregnancy (as measured by maternal circulating androgen concentrations and umbilical cord androgen concentrations) and digit ratio in adolescent girls. Androgen concentrations (testosterone, free androgen index, androstenedione, DHEAS) and sex hormone binding globulin (SHBG) were measured in stored plasma samples from pregnant mothers at 18 (n=118) and 34/36 (n=114) weeks of gestation and in cord blood (n=82) from the Western Australian Pregnancy (Raine) Cohort Study (www.rainestudy.org.au). Digit ratio was measured in 244 female offspring from this cohort at age 14-16 years. Only one borderline statistically significant correlation between maternal circulating androstenedione levels at 18 weeks of gestation and left hand digit ratio was seen. No other statistically significant relationship between maternal androgen concentrations or umbilical cord androgen concentrations and digit ratio in adolescence were observed. These findings suggest that variation in 2D:4D in girls is not established as a result of testosterone concentrations in the second and third trimesters. We conclude that prenatal androgen exposure as measured by maternal circulating androgen concentrations at 18 and 34/36 weeks of gestation or in the umbilical cord at birth may not predict digit ratio in girls.
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Affiliation(s)
- M Hickey
- School of Women's and Infants' Health, University of Western Australia, Perth, Australia.
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Hickey M, Sloboda DM, Atkinson HC, Doherty DA, Franks S, Norman RJ, Newnham JP, Hart R. The relationship between maternal and umbilical cord androgen levels and polycystic ovary syndrome in adolescence: a prospective cohort study. J Clin Endocrinol Metab 2009; 94:3714-20. [PMID: 19567524 DOI: 10.1210/jc.2009-0544] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [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: 11/19/2022]
Abstract
CONTEXT The prenatal antecedents of polycystic ovary syndrome (PCOS) are not known, but prenatal androgen exposure is thought to contribute. This has not previously been investigated in large prospective studies of normal human pregnancy. OBJECTIVE The aim of the study was to establish the prospective relationship between early life androgen exposure and PCOS in adolescence. DESIGN AND SETTING A prospective cohort study was conducted in the general community. PATIENTS OR OTHER PARTICIPANTS A total of 2900 pregnant women were recruited at 18 wk gestation. Prenatal androgen exposure was measured from maternal blood samples (at 18 and 34-36 wk) and umbilical cord blood. Timed (d 2-5 menstrual cycle) blood samples were collected, clinical hyperandrogenism was assessed, and transabdominal ultrasound examination of ovarian morphology was performed in 244 unselected girls from the Raine cohort aged 14-17 yr. MAIN OUTCOME MEASURE(S) We examined the relationship between early life androgen exposure and PCOS in adolescence. RESULTS We did not observe a statistically significant relationship between early life androgen exposure and PCOS in adolescence. CONCLUSIONS This is the first prospective study to evaluate the relationship between prenatal androgen exposure and PCOS in adolescence in normal pregnancy. Our findings do not support the hypothesis that maternal androgens, within the normal range for pregnancy, directly program PCOS in the offspring.
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Affiliation(s)
- M Hickey
- School of Women's and Infants' Health, University of Western Australia, Crawley WA 6009 Perth, Australia.
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Norman RJ, Menabawey M, Lowings C, Chard T, Gard T. Free subunits of human chorionic gonadotropin do not respond to intravenous injection of thyrotropin releasing hormone. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443618609112299] [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] [Indexed: 11/13/2022]
Affiliation(s)
- R. J. Norman
- Department of Obstetrics, Gynaecology, and Reproductive Physiology, St Bartholomew's Hospital Medical College and the London Hospital Medical College, London
| | - M. Menabawey
- Department of Obstetrics, Gynaecology, and Reproductive Physiology, St Bartholomew's Hospital Medical College and the London Hospital Medical College, London
| | - C. Lowings
- Department of Obstetrics, Gynaecology, and Reproductive Physiology, St Bartholomew's Hospital Medical College and the London Hospital Medical College, London
| | - T. Chard
- Department of Obstetrics, Gynaecology, and Reproductive Physiology, St Bartholomew's Hospital Medical College and the London Hospital Medical College, London
| | - T. Gard
- Department of Clinical Biochemistry, Addenbrookes Hospital, Cambridge
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Thomson RL, Buckley JD, Moran LJ, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. Comparison of aerobic exercise capacity and muscle strength in overweight women with and without polycystic ovary syndrome. BJOG 2009; 116:1242-50. [PMID: 19438498 DOI: 10.1111/j.1471-0528.2009.02177.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess maximal aerobic capacity (VO2max) and muscle strength in overweight and obese women with polycystic ovary syndrome (PCOS) and determine their relationship with metabolic and hormonal factors. DESIGN Cross-sectional study. SETTING Clinical Research Unit. POPULATION Overweight and obese women with PCOS (n = 10) and age-and weight-matched healthy controls (n = 16). METHODS VO2max was measured during an incremental treadmill test and maximal isometric (ImS) and isokinetic knee extensor strength (IkS) (120 degrees/second) were assessed by isokinetic dynamometry. MAIN OUTCOME MEASURES VO2max, ImS, IkS, waist circumference, blood lipids, glucose, insulin, insulin resistance (homeostatic model assessment [HOMA2]), C-reactive protein (CRP), hormonal profile. RESULTS PCOS women had higher levels of testosterone and free testosterone (P < or = 0.05), but there were no significant differences in any cardiovascular disease (CVD) risk markers between the groups. VO2max was similar in women with PCOS and healthy controls (PCOS 26.0 +/- 4.1 ml/kg/minute, controls 25.7 +/- 3.8 ml/kg/minute; P = 0.90), as was ImS (PCOS 1.50 +/- 0.54 Nm/kg, controls 1.50 +/- 0.47 Nm/kg; P = 0.96) and IkS (PCOS 1.04 +/- 0.32 Nm/kg, controls 1.16 +/- 0.23 Nm/kg; P = 0.32). VO2max was inversely related to waist circumference, insulin, HOMA2 and CRP. Waist circumference was inversely associated with ImS and IkS. No significant associations between exercise parameters and hormonal variables were identified. CONCLUSIONS Compared to age- and weight-matched healthy overweight and obese women with similar insulin resistance and CVD risk profiles, women with PCOS had similar aerobic capacity and muscle strength. This suggests PCOS, at least in the absence of an adverse metabolic profile is unlikely to limit physical function. Larger studies examining the effects of PCOS on exercise tolerance in a diverse range of PCOS phenotypes is required.
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Affiliation(s)
- R L Thomson
- Australian Technology Network Centre for Metabolic Fitness, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
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Thomson RL, Buckley JD, Moran LJ, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. Comparison of aerobic exercise capacity and muscle strength in overweight women with and without polycystic ovary syndrome. BJOG 2009. [PMID: 19438498 DOI: 10.1111/j.1471.0528.2009.02177.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess maximal aerobic capacity (VO2max) and muscle strength in overweight and obese women with polycystic ovary syndrome (PCOS) and determine their relationship with metabolic and hormonal factors. DESIGN Cross-sectional study. SETTING Clinical Research Unit. POPULATION Overweight and obese women with PCOS (n = 10) and age-and weight-matched healthy controls (n = 16). METHODS VO2max was measured during an incremental treadmill test and maximal isometric (ImS) and isokinetic knee extensor strength (IkS) (120 degrees/second) were assessed by isokinetic dynamometry. MAIN OUTCOME MEASURES VO2max, ImS, IkS, waist circumference, blood lipids, glucose, insulin, insulin resistance (homeostatic model assessment [HOMA2]), C-reactive protein (CRP), hormonal profile. RESULTS PCOS women had higher levels of testosterone and free testosterone (P < or = 0.05), but there were no significant differences in any cardiovascular disease (CVD) risk markers between the groups. VO2max was similar in women with PCOS and healthy controls (PCOS 26.0 +/- 4.1 ml/kg/minute, controls 25.7 +/- 3.8 ml/kg/minute; P = 0.90), as was ImS (PCOS 1.50 +/- 0.54 Nm/kg, controls 1.50 +/- 0.47 Nm/kg; P = 0.96) and IkS (PCOS 1.04 +/- 0.32 Nm/kg, controls 1.16 +/- 0.23 Nm/kg; P = 0.32). VO2max was inversely related to waist circumference, insulin, HOMA2 and CRP. Waist circumference was inversely associated with ImS and IkS. No significant associations between exercise parameters and hormonal variables were identified. CONCLUSIONS Compared to age- and weight-matched healthy overweight and obese women with similar insulin resistance and CVD risk profiles, women with PCOS had similar aerobic capacity and muscle strength. This suggests PCOS, at least in the absence of an adverse metabolic profile is unlikely to limit physical function. Larger studies examining the effects of PCOS on exercise tolerance in a diverse range of PCOS phenotypes is required.
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Affiliation(s)
- R L Thomson
- Australian Technology Network Centre for Metabolic Fitness, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
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Thomson RL, Buckley JD, Moran LJ, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. The effect of weight loss on anti-Müllerian hormone levels in overweight and obese women with polycystic ovary syndrome and reproductive impairment. Hum Reprod 2009; 24:1976-81. [PMID: 19380385 DOI: 10.1093/humrep/dep101] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anti-Müllerian hormone (AMH) has been proposed as a clinical predictor of improvements in reproductive function following weight loss in overweight and obese women with polycystic ovary syndrome (PCOS). This study aimed to assess whether baseline and/or change in AMH levels with weight loss predict improvements in reproductive function in overweight and obese women with PCOS. METHODS Fifty-two overweight and obese women with PCOS and reproductive impairment (age 29.8 +/- 0.8 years, BMI 36.5 +/- 0.7 kg/m(2)) followed a 20-week weight loss programme. AMH, weight, menstrual cyclicity and ovulatory function were assessed at baseline and post-intervention. RESULTS Participants who responded with improvements in reproductive function (n = 26) had lower baseline AMH levels (23.5 +/- 3.7 versus 32.5 +/- 2.9 pmol/l; P = 0.03) and experienced greater weight loss (-11.7 +/- 1.2 versus -6.4 +/- 0.9 kg; P = 0.001) compared with those who did not respond (n = 26). Logistic regression analysis showed that weight loss and baseline AMH were independently related to improvements in reproductive function (P = 0.002 and P = 0.013, respectively). AMH levels did not change with weight loss in both responders and non-responders. CONCLUSIONS In overweight and obese women with PCOS and reproductive dysfunction, a 20-week weight loss intervention resulted in improvements in reproductive function but no change in AMH levels. CLINICAL TRIALS REGISTRATION NUMBER ACTRN12606000198527.
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Affiliation(s)
- R L Thomson
- Australian Technology Network Centre for Metabolic Fitness and Nutritional Physiology Research Centre, Sansom Institute for Health Research, University of South Australia, Adelaide 5001, Australia
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Yang X, Dunning KR, Hickey TE, Norman RJ, Liang X, Robker RL. 511. THE EFFECTS OF HIGH FAT DIET ON LIPID LOCALISATION IN THE PERI-OVULATORY CUMULUS OOCYTE COMPLEX. Reprod Fertil Dev 2009. [DOI: 10.1071/srb09abs511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Intracellular neutral lipids are stored in discrete droplets that are surrounded by lipid associated proteins, such as adipophilin and perilipin, which control cellular lipid metabolism by regulating the access of lipases. The role of lipids in oocyte maturation is unclear, although they have a potential role as an energy source for the oocyte and early embryo. To elucidate potential mechanisms controlling lipid utilisation in the peri-ovulatory cumulus-oocyte-complex (COC) we 1) localised lipid droplets by immunohistochemistry for adipophilin and perilipin and direct staining of neutral lipids with BODIPY and 2) investigated whether a high fat diet can alter oocyte lipid quantity or localisation. Ovaries were isolated from 21 day old mice before and 10h after the ovulation stimulus hCG. Adipophilin and perilipin were both detected by immunohistochemistry in peri-ovulatory follicles with similar localisation before and after hCG. In separate experiments, adult mice were fed a high fat or control diet for 4 weeks and COCs were isolated from preovulatory follicles prior to hCG or from the oviduct 13h after hCG stimulation followed by BODIPY staining and quantification with confocal microscopy. BODIPY staining showed that COCs possess low levels of lipids evenly distributed in the oocyte before hCG but increased lipid assembled as droplets in the oocyte after ovulation. In mice fed a high fat diet, intracellular lipids were markedly increased in both the cumulus cells and oocytes from preovulatory and ovulated COCs. The ubiquitous expression of lipid droplet proteins in the peri-ovulatory follicle together with the changes in neutral lipid storage concurrent with ovulation suggests that lipid metabolism play an important role in oocyte release, transport and/or developmental competence. Furthermore, the dramatic effect of dietary fat on COC lipid content may contribute to the impaired oocyte quality we have observed in obese mice as well as reduced fertility in obese women
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Lan VTN, Norman RJ, Nhu GH, Tuan PH, Tuong HM. Ovulation induction using low-dose step-up rFSH in Vietnamese women with polycystic ovary syndrome. Reprod Biomed Online 2009; 18:516-21. [DOI: 10.1016/s1472-6483(10)60128-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wu LLY, Yang X, Dunning KR, Norman RJ, Robker RL. 151. LIPOTOXICITY MEDIATED ENDOPLASMIC RETICULUM STRESS, MITOCHONDRIAL DYSFUNCTION AND APOPTOSIS CONTRIBUTE IMPAIRED OOCYTE QUALITY IN RESPONSE TO OBESITY. Reprod Fertil Dev 2009. [DOI: 10.1071/srb09abs151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In obesity, accumulation of lipid in non-adipose tissues, a process termed lipotoxicity, is associated with endoplasmic reticulum (ER) stress, mitochondrial dysfunction and ultimately apoptosis . We have previously shown that diet-induced obesity in mice causes impaired oocyte developmental competence, but whether this is due to activation of lipotoxicity pathways in the ovary is not known. The present study examined the hypothesis that diet-induced lipid accumulation in the cumulus oocyte complex (COC) disrupts ER homeostasis and mitochondrial membrane potential which leads to apoptosis. COCs and mural granulosa cells were collected from ovaries of adult mice fed a high fat (HFD) or control diet for 4 weeks. ER homeostasis was assessed by measuring expression of known ER stress marker genes, GRP78, ATF4 and CHOP. COCs from mice fed HFD showed significantly increased expression of GRP78 and ATF4. There was a similar trend towards increased expression in granulosa cells. Mitochondrial function was assessed by measuring membrane potential using the dual emission probe JC-1. In COCs from mice fed HFD there were reduced numbers of active mitochondria but instead large aggregated clusters of inactive mitochondria. Apoptosis in granulosa cells was determined by DNA laddering assay which showed significantly increased DNA fragmentation in cells from mice fed HFD. Apoptosis was also assessed by TUNEL staining of paraffin embedded ovaries from identical treatment groups. Ovaries from HFD mice appeared to have increased TUNEL positivity in both granulosa and cumulus cells. Our results demonstrate that the ER stress, mitochondrial dysfunction and apoptosis are markedly increased in granulosa cells and COCs from mice fed HFD, suggesting that lipotoxicity contributes to the impaired oocyte quality and reduced fertility observed in response to obesity.
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Nieuwenhuis-Ruifrok AE, Kuchenbecker WKH, Hoek A, Middleton P, Norman RJ. Insulin sensitizing drugs for weight loss in women of reproductive age who are overweight or obese: systematic review and meta-analysis. Hum Reprod Update 2008; 15:57-68. [PMID: 18927072 DOI: 10.1093/humupd/dmn043] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Women of reproductive age, who are overweight or obese, are prone to infertility. Weight loss in these women leads to increased fecundity, higher chances of conception after infertility treatment and improved pregnancy outcome. In spite of the advantages, most patients have difficulty in losing weight and often regain lost weight over time. This review assesses whether treatment with insulin sensitizing drugs contributes to weight loss, compared with diet or a lifestyle modification programme. METHODS After a systematic search of the literature, only randomized controlled trials (RCTs), investigating the effect of insulin sensitizing drugs on weight loss compared with placebo and diet and/or a lifestyle modification programme, were included. Subjects were restricted to women of reproductive age. The main outcome measure was change in body mass index (BMI). RESULTS Only 14 trials, unintentionally all but two on women with polycystic ovary syndrome (PCOS) only, were included in the analysis. Treatment with metformin showed a statistically significant decrease in BMI compared with placebo (weighted mean difference, -0.68; 95% CI -1.13 to -0.24). There was some indication of greater effect with high-dose metformin (>1500 mg/day) and longer duration of therapy (>8 weeks). Limitations were power, low use of intention-to-treat analysis and heterogeneity of the studies. CONCLUSION A structured lifestyle modification programme to achieve weight loss should still be the first line treatment in obese women with or without PCOS. Adequately powered RCTs are required to confirm the findings of this review and to assess whether the addition of high-dose metformin therapy to a structured lifestyle modification programme might contribute to more weight loss.
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Affiliation(s)
- A E Nieuwenhuis-Ruifrok
- University Medical Centre Groningen, Section Reproductive Medicine, Groningen, The Netherlands
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de Lacey S, Davies M, Homan G, Briggs N, Norman RJ. Factors and perceptions that influence women's decisions to have a single embryo transferred. Reprod Biomed Online 2008; 15:526-31. [PMID: 18028744 DOI: 10.1016/s1472-6483(10)60384-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to identify factors that inhibit or promote the adoption of single embryo transfer (SET). A cohort of 163 women patients receiving IVF/intracytoplasmic sperm injection treatment, comprising 87 women choosing SET and 63 women choosing double embryo transfer (DET), were interviewed using a structured questionnaire. The data were compared using logistic regression analysis. Confidence in the chance of pregnancy with SET, younger age and first treatment were predictive of a decision for SET. Preference for a healthy and singleton pregnancy was predictive but perceptions of the incidence or risk of multiple gestation were not. Factors such as a sense of time urgency and past experience of treatment were significant and predictive of diminished choice of SET. The clinic doctor was an important influencing factor. The results of this study confirm that improved pregnancy rates in SET coupled with an official clinic policy to promote SET in younger, first cycle patients influenced many women to choose SET. However, repeated treatment, advancing age and urgency to become pregnant are factors that moderate a woman's choice for SET.
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Affiliation(s)
- S de Lacey
- Discipline of Obstetrics and Gynaecology, Research Centre for Reproductive Health, School of Paediatrics and Reproductive Health, University of Adelaide, South Australia.
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Dunning KR, Akison LK, Russell DL, Norman RJ, Robker RL. 428. Normal follicle growth and maturation in a three-dimensional in vitro culture system: follicular environment manipulation and assessment of oocyte outcomes. Reprod Fertil Dev 2008. [DOI: 10.1071/srb08abs428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In vivo, the oocyte matures in a niche environment surrounded by somatic cells, and later in ovarian follicular development, by follicular fluid. Maternal diet influences the environment in which an oocyte matures but the mechanisms by which an altered metabolic profile, such as hyperinsulinemia, affects oocyte quality are not known. We investigated the use of a three dimensional follicle culture system allowing direct manipulation of the follicular environment thus circumventing systemic hormonal and metabolic effects. Secondary follicles (113.4 ± 1.02µm, n = 54) were isolated from mice at d12, encapsulated individually in 2µl of alginate matrix, and cultured in aMEM/5%FCS/10 mIU/mL LH/100 mIU FSH at 37°C/5%CO2, with media sampling and replacement every second day. Following 12 days of culture there was a significant 3-fold increase in follicle diameter (320 ± 10.1µm, n = 51). Histological analysis showed normal follicular morphology and antrum formation. Analysis of oestradiol (15.0ng/mL), androstenedione (7.8ng/mL) and progesterone (23.7ng/mL) in the media at d12 confirmed normal steroidogenesis and differentiation. Treatment of follicles with an ovulatory stimulus (1.5IU/mL hCG/5ng/mL Egf), resulted in cumulus expansion and hyaluronan localising to the cumulus oocyte complex (COC) and follicular basement membrane. These analyses were consistent with follicle growth and induction of ovulation in vivo. Further, COCs isolated from follicles and matured in vitro (IVM) in the presence of Egf and FSH, underwent cumulus expansion (CEI 2.8 ± 0.2) and were capable of fertilisation and blastocyst development. LH did not induce IVM COC expansion (CEI 1.36 ± 0.2), reflecting the normal in vivo differentiation process. However, culturing follicles in high insulin (5ug/mL) led to a significant increase in the degree of IVM cumulus expansion in response to LH (CEI 2.1 ± 0.3) indicating inappropriate cumulus cell differentiation, which may lead to poorer oocyte quality. These results demonstrate that this technique recapitulates normal in vivo folliculogenesis and is useful for manipulation of the follicular environment and assessment of oocyte outcomes.
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Abstract
As assisted reproductive technology (ART) expanded globally, several countries introduced prescribed requirements for treatment and monitoring of outcomes, as well as a licensing or accreditation requirement. While it is common for ART laboratories to be required to have an effective quality control system, the remainder of the clinic is often under less stringent regulation. Furthermore, when treatment conditions are prescribed, the standards tend to be conservative and clinics may choose to establish their own standards. Total quality management systems are now being used by an increasing number of ART clinics. In Australia and New Zealand, it is now a requirement to have a quality management system in order to be accredited and to help meet customer demand for improved delivery of ART services in these two countries.
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Affiliation(s)
- G M Warnes
- Repromed, 180 Fullarton Road, Dulwich, South Australia 5065, Australia
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