Good practice recommendations on add-ons in reproductive medicine†

STUDY QUESTION

Which add-ons are safe and effective to be used in ART treatment?

SUMMARY ANSWER

Forty-two recommendations were formulated on the use of add-ons in the diagnosis of fertility problems, the IVF laboratory and clinical management of IVF treatment.

WHAT IS KNOWN ALREADY

The innovative nature of ART combined with the extremely high motivation of the patients has opened the door to the wide application of what has become known as 'add-ons' in reproductive medicine. These supplementary options are available to patients in addition to standard fertility procedures, typically incurring an additional cost. A diverse array of supplementary options is made available, encompassing tests, drugs, equipment, complementary or alternative therapies, laboratory procedures, and surgical interventions. These options share the common aim of stating to enhance pregnancy or live birth rates, mitigate the risk of miscarriage, or expedite the time to achieving pregnancy.

STUDY DESIGN, SIZE, DURATION

ESHRE aimed to develop clinically relevant and evidence-based recommendations focusing on the safety and efficacy of add-ons currently used in fertility procedures in order to improve the quality of care for patients with infertility.

PARTICIPANTS/MATERIALS, SETTING, METHODS

ESHRE appointed a European multidisciplinary working group consisting of practising clinicians, embryologists, and researchers who have demonstrated leadership and expertise in the care and research of infertility. Patient representatives were included in the working group. To ensure that the guidelines are evidence-based, the literature identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, recommendations were based on the professional experience and consensus of the working group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 46 independent international reviewers. A total of 272 comments were received and incorporated where relevant.

MAIN RESULTS AND THE ROLE OF CHANCE

The multidisciplinary working group formulated 42 recommendations in three sections; diagnosis and diagnostic tests, laboratory tests and interventions, and clinical management.

LIMITATIONS, REASONS FOR CAUTION

Of the 42 recommendations, none could be based on high-quality evidence and only four could be based on moderate-quality evidence, implicating that 95% of the recommendations are supported only by low-quality randomized controlled trials, observational data, professional experience, or consensus of the development group.

WIDER IMPLICATIONS OF THE FINDINGS

These guidelines offer valuable direction for healthcare professionals who are responsible for the care of patients undergoing ART treatment for infertility. Their purpose is to promote safe and effective ART treatment, enabling patients to make informed decisions based on realistic expectations. The guidelines aim to ensure that patients are fully informed about the various treatment options available to them and the likelihood of any additional treatment or test to improve the chance of achieving a live birth.

STUDY FUNDING/COMPETING INTEREST(S)

All costs relating to the development process were covered from ESHRE funds. There was no external funding of the development process or manuscript production. K.L. reports speakers fees from Merck and was part of a research study by Vitrolife (unpaid). T.E. reports consulting fees from Gynemed, speakers fees from Gynemed and is part of the scientific advisory board of Hamilton Thorne. N.P.P. reports grants from Merck Serono, Ferring Pharmaceutical, Theramex, Gedeon Richter, Organon, Roche, IBSA and Besins Healthcare, speakers fees from Merck Serono, Ferring Pharmaceutical, Theramex, Gedeon Richter, Organon, Roche, IBSA and Besins Healthcare. S.R.H. declares being managing director of Fertility Europe, a not-for-profit organization receiving financial support from ESHRE. I.S. is a scientific advisor for and has stock options from Alife Health, is co-founder of IVFvision LTD (unpaid) and received speakers' fee from the 2023 ART Young Leader Prestige workshop in China. A.P. reports grants from Gedeon Richter, Ferring Pharmaceuticals and Merck A/S, consulting fees from Preglem, Novo Nordisk, Ferring Pharmaceuticals, Gedeon Richter, Cryos and Merck A/S, speakers fees from Gedeon Richter, Ferring Pharmaceuticals, Merck A/S, Theramex and Organon, travel fees from Gedeon Richter. The other authors disclosed no conflicts of interest.

DISCLAIMER

This Good Practice Recommendations (GPRs) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation.ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or bedeemedinclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results.Theydo not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type.Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

Review: Improving pig survival with a focus on birthweight: a practical breeding perspective

Survival of growing pigs through to slaughter age is not only a key driver of profitability but also has implications for animal welfare. Changing preweaning mortality by over 3% gives a similar change in profit per pig as changing postweaning mortality by 1%. There is significant scope to improve both traits through management and breeding to improve survival. The aim of this literature review was to explore the relationship between litter size and piglet birthweight and the detrimental impact this negative association has had on pig survival, along with genetic strategies that have been implemented in breeding programmes. It is suggested that the primary effect of litter size on mortality was indirect, through the effects of litter size on individual piglet birthweights. The circumstances affecting the litter a piglet was born into were the most important for determining the birthweight of individual piglets, rather than the genetic make-up of the individual piglet itself. Therefore, breeding programmes should include the average piglet birthweight of a litter (i.e., a sow trait) rather than individual piglet birthweight to maintain the weight of piglets at birth. The relative weighting of litter size and average piglet birthweight should be done in a manner that avoids selecting heavy pigs from small litters. Additional genetic strategies to improve survival include survival at the litter level, or survival of individual piglets or enhanced through the use of genomic information. At the litter level, litter size at day 5 and weaning can be considered as sow traits, but the use of these traits depends on the recording environment. At the individual piglet level, pre- and postweaning survival can be recorded as 0/1 traits and analysed directly. Although heritabilities are low for all these traits, genetic improvements can be made. For preweaning survival, the genes of the nurse sow are more important than the genes of the individual piglet. The nurse sow model captures both the lactation and gestation effects, and the information obtained when piglets born from different litters are reared together. However, once a piglet is weaned, its own genes became more important for the expression of postweaning mortality outcomes. Finally, for a successful selection programme, combining the average piglet birthweight at the litter level and mortality data based on individual piglet records (not solely birthweight) might yield the best response in piglet survival.

Stimulating fertility awareness: the importance of getting the language right

While education about fertility is not intrinsically controversial, finding the right language to communicate the topic can be challenging, as there are several risks of unintended negative effects such as dissonance, anxiety, culpability, and stigma due to social norming. In this article, we share some of our learnings from promoting fertility awareness in the hope that they will inspire further debate and research on this topic. Starting from the ethical principles of respect for reproductive autonomy, avoiding harm (in terms of stigma or anxiety) and inclusivity, we have formulated five recommendations: (i) frame fertility awareness messages with (reproductive) autonomy in mind and aim to be inclusive of those who do not represent the traditional nuclear family; (ii) be empathetic and steer clear of blame; (iii) avoid scaremongering and offer a positive angle; (iv) give due consideration to both women and men in fertility health messaging; and (v) tailor the messages to particular contexts and audiences and develop resources in close collaboration with the target groups.

P-069 Men’s fertility knowledge and attitudes to starting a family in Greece, Nepal and the UK

Study question

What are the views of men from Greece, Nepal, and the UK on having children and what is their knowledge of fertility?

Summary answer

Between countries, there were similarities and differences in men’s views to having children. Men showed limited fertility knowledge, and access to fertility information varied.

What is known already

The global total fertility rate (TFR) has dropped to below 2.5 compared to 5 in 1950, currently being 1.61 in the EU. Internationally, the age at which people are having children has increased and is over 30 in many countries. Delaying parenthood is leaving many with smaller family sizes than desired or involuntary childlessness due to age-related infertility.

Although many men are keen to be fathers, existing studies relating to fertility knowledge and having children focus heavily on women. Compared to women, men’s fertility knowledge is limited as fertility education is rarely taught or tailored for men.

Study design, size, duration

Two anonymous surveys were conducted. The UK survey (live from 25 April – 1 December 2021) was launched via social media. Men internationally could complete the survey, and high numbers of men from Nepal participated.

The Greek survey (live from 11 – 26 May 2021) was launched in Greece through a market research company. The end sample size was n = 244 for Greece, n = 205 for Nepal and n = 128 for the UK.

Participants/materials, setting, methods

Men aged 25 to 45 years old, who wanted children but were currently childless, were included. There were four parts to the survey: basic demographics; their attitude to having a family; their fertility concerns; and their fertility knowledge. For the UK survey, since one of the authors had a link with Nepal, particular effort was made to recruit from Nepal as well as from the UK.

Main results and the role of chance

When asked how many children men wanted, most Greek (59%), Nepalese (66%) and UK (58%) men wanted two children, but higher levels of Greek (24%) and UK (25%) men wanted three children compared to Nepalese men (9%)(p < 0.001).

The ideal age men wanted to have had/have their first child was 35 years in Greece (23%), but it was 30 years in Nepal (24%) and in the UK (30%). The COVID-19 pandemic had not affected most men’s decision to have children: Greece’s (64%), Nepal (48%), UK (70%). But it had affected 21% Greek, 27% Nepalese and 16% UK men who are now intending to delay having children.

Greek (46%), Nepalese (48%) and UK (47%) men felt moderately informed on female fertility. Greek (45%), Nepalese (50%) and UK (45%) men felt more informed about male than female fertility. When questioned on when they think a woman is fertile in her menstrual cycle, 50% Greek, 38% Nepalese, and 42% UK men answered incorrectly.

The internet was the most common source men accessed fertility information from: Greece (67%), Nepal (30%) and the UK (26%). The second most common source for Greece (18%) was doctors, but for Nepalese (18%) and UK (18%) men, it was school.

Limitations, reasons for caution

The study had a relatively small sample size (n = 577). It is well documented that men typically do not show high engagement with surveys. It was only promoted on social media. Respondents were typically highly educated, active on social media and knew English or Greek to an adequate level.

Wider implications of the findings

The International Fertility Education Initiative is developing resources to deliver tailored fertility education across different populations. This survey shows that there are cultural differences that need to be considered when designing such resources.

Trial registration number

Not applicable

O-111 The International Fertility Education Initiative

Trial registration number

P-494 A survey of women’s experiences, behaviours and attitudes of using period tracker applications (apps)

Study question

What are women’s experiences, behaviours and attitudes to ovulation and period prediction when using a period tracker app?

Summary answer

Some women altered their behaviour in response to ovulation prediction and some felt stressed in response to their period arriving earlier or later than predicted.

What is known already

Period tracker apps are designed to help women track and predict menstrual cycle dates and symptoms. The majority of period tracker apps predict the date a woman is ovulating and the date of her period. Several studies have shown that ovulation cannot be accurately predicted using menstrual cycle dates, and many apps assume that women ovulate on day 14 of their cycle whereas recent large studies have shown this to be closer to days 16/17. With regards to the prediction of the first day of the period, reports have shown that period tracker apps do not always correctly predict this.

Study design, size, duration

We conducted an anonymous, online survey using multiple choice and open-ended questions on Qualtrics software. The survey was live for 19 days, from 30th June – 20th July 2021 and was promoted using the social media of authors 1 and 3 (Twitter, Instagram, Facebook and Linkedin). The qualitative data was analysed thematically.

Participants/materials, setting, methods

The inclusion criteria was that participants had to be using or had previously used a period tracker app, be able to read English and have access to the online survey.

Main results and the role of chance

From 375 total responses, 330 complete responses were analysed, giving a completion rate of 88.0%. Respondents were aged between 14-54, with a mean age of 26.0 (±7.81). When asked what was the best thing about using the app, 29.7% (98/330) respondents selected ‘To know when I’m ovulating’. The majority of respondents sexual activity was not influenced by their app’s predicted dates (65.5%, 216/330). However, a total of 17.0% (56/330) of respondents stated that it was, with 10.9% (36/330) stating they avoided having sex on fertile days predicted by the app. Respondents were asked if their period ever started earlier than the app predicted; 54.9% (189/330) said it had and 72.1% (238/330) said it had started later than predicted. When asked how they felt if their period arrived earlier or later than expected, thematic analysis of responses when periods started earlier revealed 4 themes: feeling unaffected, being frustrated/unprepared, feeling anxious/stressed, and feeling confused/intrigued. Thematic analysis when their period arrived later than expected revealed 6 themes: anxious/concerned about pregnancy, disappointed about pregnancy, seeking advice/informing healthcare professionals, thoughts about the menopause, feeling unaffected and being better prepared.

Limitations, reasons for caution

All surveys have a selection bias. The survey was only promoted on social media of two of the authors. As the survey was in English, the women who answered the survey were mainly UK residents who were highly educated.

Wider implications of the findings

Period tracker apps need to be clearer of their intended use and reliability, especially for period and ovulation prediction. Inaccurate predictions can affect the users’ health and behaviour. This study calls for period tracker app companies to update their apps to provide transparency about their intended use and capabilities.

Trial registration number

NA

P-493 Sex and fertility education in the UK: an analysis of biology curricula and students’ experiences

Study question

What is currently being taught in United Kingdom (UK) secondary schools relating to sex and fertility and what are students’ experiences of this education?

Summary answer

There are large gaps in the UK’s biology curriculum relating to sex and fertility education with important topics being neglected.

What is known already

Sex and fertility education is essential to enable people to make informed choices about family building. This is especially important as maternal and paternal age is increasing globally. School is an important source of this education but sex and fertility education is often minimal. In order to optimise people’s contraceptive behaviour and fertility planning, an understanding of the reproductive cycle, basic physiology of fertility and preconception health is required. Fertility education interventions have been shown to improve fertility knowledge and decrease planned ages of childbearing among young adults but only if repeated.

Study design, size, duration

This study aimed to evaluate the current biology curricula relating to sex and fertility education at GCSE (General Certificate of Secondary Education) and A level (Advanced Level) in the UK and to determine 16-17-year-old students’ experiences of their sex and fertility education. This year group was chosen as we are interested in what students have learnt by the end of their mandatory education (years 1 to 11), and their experiences of this education.

Participants/materials, setting, methods

The analysis of the curricula was conducted using the most recently published specifications for science and biology at GCSE and biology at A level for the Awarding Bodies that dominate the GCSE and A-level market in the UK. The school survey included a 47-item online survey distributed to year 12 students in four secondary schools across England. In total, 244 students participated in the survey.

Main results and the role of chance

There are six Awarding Bodies in the UK that set the examinations for GCSE and A-level students. At GCSE level, the hormonal control of the menstrual cycle, contraception and ART are taught within the human reproduction section of the biology curriculum. STIs are used as examples of communicable diseases, but pregnancy does not feature other than as a consequence of contraceptive failure. At A level, there is generally less teaching of relationships, sexuality and fertility-related topics than at GCSE. The results of the school survey showed that some topics, notably puberty, the menstrual cycle, contraception and STIs, were more likely to be learnt in school. However, topics such as endometriosis, menopause, miscarriage and polycystic ovarian syndrome were more likely to be learnt outside school. Abortion was the most common topic learnt outside school, followed by puberty. The most popular sources of sex education outside school were the internet and social media. In the students’ responses to how they think sex and fertility education can be improved, six themes became apparent: LGBTQ + (lesbian, gay, bisexual, transgender, queer and others) inclusivity; topic variety; logistical improvements; attitudes towards sex; gender equality; and applicability to real life.

Limitations, reasons for caution

The COVID-19 pandemic significantly disrupted schools during the 2020/2021 academic year. Consequently, we were unable to distribute the survey to as many schools as planned. We hope to continue this study in the 2021/2022 academic year to allow further comparison between the experiences of different groups of students.

Wider implications of the findings

Ideally, school sex and fertility education would involve a comprehensive and holistic programme and would provide young people with full, accurate information to prepare them for later life. We hope that the results of our study can be used to improve sex and fertility education for young people.

Trial registration number

NA

A novel treatment for supraglottic stenosis secondary to immunoglobulin G4-related disease

Although immunoglobulin G4-related disease (IgG4-RD) has a predilection for the head and neck region, laryngeal pathology is rare. We report a case of supraglottic stenosis due to IgG4-RD together with a novel treatment strategy of employing a laryngeal stent. A 69-year-old man was referred with longstanding dyspnoea and worsening inspiratory stridor. Despite two supraglottic dilations over a 12-month period, his stenosis recurred and symptoms persisted. Serum investigations revealed elevated IgG4 levels (2.390g/l), with IgG4 infiltrate in laryngeal biopsies. The patient underwent endoscopic balloon dilation, intralesional Depo-Medrone® injection, CO₂ laser therapy and insertion of a laryngeal stent to prevent re-stenosis. Rituximab and prednisolone were commenced postoperatively and the stent was removed at 6weeks. No stenosis recurrence was visualised over a further 12-month follow-up period. Sixteen cases of laryngeal lesions with confirmed IgG4 infiltrate in biopsies have been reported in the worldwide literature to date. Based on a literature review and our experience, we recommend that similar laryngeal pathologies undergo early IgG4 serological testing and biopsy immunohistochemistry. Prompt diagnostic confirmation may prevent unnecessary surgical interventions and optimise immunosuppression. Furthermore, the use of a laryngeal stent following laryngeal surgery may help reduce stenotic recurrence and promote healing.

P–485 A systematic analysis of acupuncture for IVF treatment: how should the HFEA traffic light scale for add-ons rate it?

Study question

How should acupuncture be rated on the Human Fertilisation and Embryology Authority traffic light scheme for IVF add-ons?

Summary answer

Randomised controlled trials examining the possible effects of acupuncture on IVF success rates are conflicting, and acupuncture should be rated amber.

What is known already

The use of complementary therapies in assisted reproduction and IVF has become increasingly more commonplace in recent years. Patients seeking to maximise their chances of conception are often interested in purchasing additional treatments (termed ‘add-ons’) to augment their treatment cycle, often at a high price even in the absence of robust underlying evidence. The use of acupuncture is popular due to putative holistic benefits including stress reduction, and the perceived lack of side-effects and minimal invasiveness. The HFEA traffic light system has not yet rated any complementary therapies, even though these are promoted by fertility clinics.

Study design, size, duration

A systematic review of randomised controlled trials (RCTs) of acupuncture during IVF treatment was conducted. A literature search for acupuncture studies was conducted on the PubMed database and the University College London (UCL) library database. Search terms used were “acupuncture” paired with “IVF”, “in vitro fertilisation”, “assisted reproduction” and “RCT”. Study quality and variance in treatment protocols were assessed, to understand both any evidence and its quality. Statistical analysis was performed using STATA.

Participants/materials, setting, methods

The UCL library database yielded 403 individual search results and PubMed database yielded 47. Papers were screened and sorted according to the inclusion and exclusion criteria. Inclusion: publication in English, in an English-language journal; RCT; intervention administered during IVF; either pregnancy rate (PR), ongoing/clinical PR or live birth rate (LBR) reported. Exclusion: reviews; not in English; not RCT; above outcomes not reported.

Main results and the role of chance

After final screening, a total of 34 acupuncture RCTs were included in the review and meta-analysis. The sample sizes of the studies analysed ranged from 44 to 809 (median 162). Only a minority of studies (18%, 6/34) involved blinding of both assessor and participant, while foregoing incorporation of blinding into study design was most common (44%, 15/34 studies). There was little consistency regarding the timing of acupuncture treatment during the IVF protocol across RCTs. A total of 21/34 studies (62%) had a protocol involving acupuncture administration before and after the embryo transfer procedure on the day of transfer. The number of needle insertions during the treatment protocols ranged from 5–13 (mean 8.7). Manual acupuncture only was performed in 8/34 (24%) of studies and 26/34 (76%) utilised electrical stimulation of at least some of the acupuncture needles. Out of 34 RCTs, only 10/34 studies (29%) reported LBR. The meta-analysis included all identified RCTs. The most clinically relevant outcome measure reported in each study found a slight benefit of acupuncture for overall IVF success (OR 1.37, 95% CI 1.13–1.65) however the effect was diluted when only comparing studies reporting LBR (OR 1.14 ,95% CI 0.81–1.61).

Limitations, reasons for caution

Methodological heterogeneity of acupuncture RCTs in IVF (needling location, stimulation, retention time, repetition and timing) complicates data pooling. Underlying neurophysiological mechanisms of action are still being clarified and may help delineate optimal regimens, potentially tailored to individual causes of infertility. Treatment safety and potential for worse outcomes must be considered.

Wider implications of the findings: Complementary therapies are a popular add-on for IVF treatment but assessing them from a robust biomedical perspective is challenging due to issues with study design (including controls), study quality and general attitudes. For acupuncture, future research should arguably focus on biomedical perspectives and shift away from Traditional Chinese Medicine philosophies.

Trial registration number

Not applicable

P-469 Period Tracker Applications – are they giving women accurate menstrual cycle information?

Study question

Are period trackers giving women accurate information about their periods and ovulation?

Summary answer

The top 10 period trackers gave conflicting information on period dates, ovulation day and the fertile window.

What is known already

Period tracking applications allow women to track their menstrual cycles and receive a prediction for their periods. The majority of applications also provide predictions of day of ovulation and the fertile window. Previous research indicates applications are basing predictions on assuming women undergo a textbook 28-day cycle with ovulation occurring on day 14 and a fertile window between days 10 and 17.

Study design, size, duration

An audit of menstrual cycle apps was conducted on the Apple app store using menstrual cycle tracker/period tracker as the search terms. The top ten apps that followed the inclusion and exclusion criteria were analysed and used for this study. All apps had the ability to allow retrospective data entry giving future cycle predictions and fertile window, and nine of the apps predicted a day of ovulation.

Participants/materials, setting, methods

Five women’s profiles for 6 menstrual cycles were created and entered into each app. Cycle length (CL) and ovulation day (OD) for the 6th cycle were; Woman 1 – Constant 28 day CL, 0D 16, Woman 2 – Average 23 day CL, OD 13, Woman 3 – Average 28 day CL, OD 17, Woman 4 – Average 33 day CL, OD 20 and Woman 5 – Irregular, average 31 day CL, OD 14.

Main results and the role of chance

For cycle length, the apps all predicted woman 1’s cycles correctly but for women 2-5, the apps predicted 0 to 8 days shorter or longer than expected. For day of ovulation; for woman 1, no apps predicted this correctly; the apps ranged from day 13-15. For woman 2, 1 app was correct and overall the apps showed a lot of variation from day 8 to 13. For woman 3, no apps got it right, with a range of day 13-16. For woman 4, 2 apps got it right, but the apps ranged from day 13-20. For woman 5, no apps got right; the apps ranged from day 13-21. Irrespective of cycle length, 7 apps predicted a fertile window of 7 days in almost all cases; except 1 app that predicted 6 days for woman 2 and a different app which predicted 8 days for woman 4. For the remaining 3 apps, one always predicted a 10 day fertile window. One app predicted an 11 day fertile window in 4/5 women. One app predicted a 12 day fertile window in 4/5 women.

Limitations, reasons for caution

The five profiles created spanned a range of observed cycle characteristics, but many permutations are possible. A Monte Carlo type analysis could be conducted to examine these possibilities to provide more precise assessment of app performance, but as data had to be added manually into apps, this was not possible.

Wider implications of the findings

The apps do not use the same algorithm and show variation. The information given by these apps is not 100% accurate, especially for the day of ovulation and the fertile window which can only be predicted if using a marker of ovulation, such as basal body temperature or ovulation sticks.

Trial registration number

not applicable

P–539 The use of expanded carrier screening of gamete donors

Study question

What are the sperm and egg donor rejection rates after expanded carrier screening (ECS)?

Summary answer

Using an ECS panel looking at 46/47 genes, 17.6% of donors were rejected.

What is known already

The use of ECS is becoming commonplace in assisted reproductive technology, including testing of egg and sperm donors. Most national guidelines recommend rejection of donors if they are carriers of a genetic disease. If the use of ECS increases, there will be a decline in the number of donors available.

Study design, size, duration

A review of the current preconception ECS panels available to donors was carried out through an online search. The genetic testing results of donors from Cryos International were analysed to determine how many were rejected on the basis of the ECS.

Participants/materials, setting, methods

Data on gamete donors and their carrier status was provided by Cryos International, who screen donors using their own bespoke ECS panel. The ECS panels identified through the review were compared to the Cryos International panel and data.

Main results and the role of chance

A total of 16 companies and 42 associated ECS panels were reviewed. There were a total of 2673 unique disorders covered by the panels examined, with a mean of 329 disorders screened. None of these disorders were common to all panels. Cryos International screen 46 disorders in males and 47 in females. From 883 candidate donors, 17.6% (155/883) were rejected based on their ECS result. Carriers of alpha-thalassaemia represented the largest proportion of those rejected (19.4%, 30/155), then spinal muscular atrophy (15.5%, 24/155) and cystic fibrosis (14.8%, 23/155).

Limitations, reasons for caution

Panel information was found on company web sites and may not have been accurate.

Wider implications of the findings: This study highlights the need for consistent EU regulations and guidelines which allow genetic matching of gamete donors to recipients, preventing the need to reject donors who are known carriers. A larger ECS panel would be most beneficial, however, this would not be viable without matching of donors and recipients.

Trial registration number

Not applicable

P–469 Period Tracker Applications – are they giving women accurate menstrual cycle information?

Study question

Are period trackers giving women accurate information about their periods and ovulation?

Summary answer

The top 10 period trackers gave conflicting information on period dates, ovulation day and the fertile window.

What is known already

Period tracking applications allow women to track their menstrual cycles and receive a prediction for their periods. The majority of applications also provide predictions of day of ovulation and the fertile window. Previous research indicates applications are basing predictions on assuming women undergo a textbook 28-day cycle with ovulation occurring on day 14 and a fertile window between days 10 and 17.

Study design, size, duration

An audit of menstrual cycle apps was conducted on the Apple app store using menstrual cycle tracker/period tracker as the search terms. The top ten apps that followed the inclusion and exclusion criteria were analysed and used for this study. All apps had the ability to allow retrospective data entry giving future cycle predictions and fertile window, and nine of the apps predicted a day of ovulation.

Participants/materials, setting, methods

Five women’s profiles for 6 menstrual cycles were created and entered into each app. Cycle length (CL) and ovulation day (OD) for the 6th cycle were; Woman 1 – Constant 28 day CL, 0D 16, Woman 2 – Average 23 day CL, OD 13, Woman 3 – Average 28 day CL, OD 17, Woman 4 – Average 33 day CL, OD 20 and Woman 5 – Irregular, average 31 day CL, OD 14.

Main results and the role of chance

For cycle length, the apps all predicted woman 1’s cycles correctly but for women 2–5, the apps predicted 0 to 8 days shorter or longer than expected. For day of ovulation; for woman 1, no apps predicted this correctly; the apps ranged from day 13–15. For woman 2, 1 app was correct and overall the apps showed a lot of variation from day 8 to 13. For woman 3, no apps got it right, with a range of day 13–16. For woman 4, 2 apps got it right, but the apps ranged from day 13–20. For woman 5, no apps got right; the apps ranged from day 13–21. Irrespective of cycle length, 7 apps predicted a fertile window of 7 days in almost all cases; except 1 app that predicted 6 days for woman 2 and a different app which predicted 8 days for woman 4. For the remaining 3 apps, one always predicted a 10 day fertile window. One app predicted an 11 day fertile window in 4/5 women. One app predicted a 12 day fertile window in 4/5 women.

Limitations, reasons for caution

The five profiles created spanned a range of observed cycle characteristics, but many permutations are possible. A Monte Carlo type analysis could be conducted to examine these possibilities to provide more precise assessment of app performance, but as data had to be added manually into apps, this was not possible.

Wider implications of the findings: The apps do not use the same algorithm and show variation. The information given by these apps is not 100% accurate, especially for the day of ovulation and the fertile window which can only be predicted if using a marker of ovulation, such as basal body temperature or ovulation sticks.

Trial registration number

Not applicable

P–476 Women’s attitudes to having children: A mixed-methods study using an online questionnaire of women aged 25–45 years old

Study question

What are women’s attitudes to having children including their ideal age to have children, factors affecting their decision and their understanding of female fertility?

Summary answer

The average age women wanted to have children was age 30, with most still developing their career. They showed a good knowledge of fertility awareness.

What is known already

Women globally are delaying the birth of their first child, with the average age of first birth approaching age 32 in some countries. The fertility rate stands at 1.3 in several European Union countries. Some people are not having the desired family size or are childless by circumstance. We need to ensure we provide fertility education from school-age onwards.

Study design, size, duration

We conducted an anonymous, online survey of multiple choice and open-ended questions using Qualtrics software. The survey was live for 32 days from May 15th, 2020 to June 16th, 2020 and was promoted using social media. A mixed-method approach was used to analyse quantitative and qualitative data.

Participants/materials, setting, methods

A total of 922 women from 44 countries participated in the survey. After filtering out women who did not consent and those who did not want to have children, a total of 834 responses remained. Elimination of blank surveys or insufficient data resulted in a final number of 667 responses.

Main results and the role of chance

The mean age of the respondents was 31.3 (±4.76). The majority were white British (347/667, 52%) and heterosexual (614/667, 92.0%). A high proportion had a university education (195/667, 29%) or postgraduate education (392/667, 59%). The majority were married/in a civil partnership (223/667, 33%) or cohabitating (215/667, 32%). 135/667 (20%) were single and never married.

When asked ‘In an ideal world, at what age approximately would you like to have had or have children? a normal distribution was observed with a mean age of 30.2 (±3.2). When asked ‘What factors have led you to decide on that particular age?’ the most frequent choice was “I am developing my career”, followed by “I am not financially ready.” Women were asked how informed they felt about fertility. The majority of women said they felt moderately informed (60%, 400/667), very informed (28%, 190/667), or they were not informed at all (12%, 77 /667). Most women thought female fertility decline starts at age 35 (32.8%, 219/667). To the question “What is the oldest age at which women can get pregnant?” almost 70% of women (465/667) believed the oldest age to be between 40–49 and 24%, (160/667) said over 50.

Limitations, reasons for caution

All surveys have a selection bias. The survey was only promoted on social media. As the survey was in English, the women who answered the survey were mainly UK residents who were highly educated.

Wider implications of the findings: In a group of highly educated women, age 30 was the most common age for wanting a child but career development and finances are the main reasons affecting their decision. These women had some understanding of female fertility. Global fertility education is essential to ensure people make informed reproductive choices.

Trial registration number

NA

544 Vasculitic Subglottic Stenosis: A Question of Immunosuppression?

Introduction

Subglottic stenosis (SGS) is the commonest manifestation of tracheobronchial disease in granulomatosis with polyangiitis (GPA) and carries a high degree of morbidity.

Management of SGS-GPA is a double-edged sword. Delayed treatment may cause respiratory compromise and infectious complications. However, aggressive surgical management may initiate a systemic inflammatory response, reactivating the vasculitic cascade and potentially lead to long-term complications including renal vasculitis and consequential end-stage renal failure.

There is currently no internationally agreed management strategy for this disease.

Method

This retrospective review was undertaken to analyse our unique combination of surgical dilatations and immunosuppressive-focused adjuvant management strategy between years 2011-2020.

Results

Sixteen of our one hundred and nine GPA patients (14.7%) had SGS and were included in our analysis. Whilst three patients (18.8%) improved solely on medical treatment, thirteen (81.3%) required combined surgery and immunosuppression (consisting of cyclophosphamide or Rituximab regimens). Thirty-nine surgical dilatations and two tracheostomies were performed over a mean 53-month follow-up period, with a calculated mean procedure rate of one every 24.8 months (2.7 - 89 months).

Conclusions

Our current management strategy affords a lower procedure rate at every 24.8 months compared to other published studies with combined procedure rate at every 14.9 months.

Integrating a newly developed BAC-based physical mapping resource for Lolium perenne with a genome-wide association study across a L. perenne European ecotype collection identifies genomic contexts associated with agriculturally important traits

BACKGROUND AND AIMS

Lolium perenne (perennial ryegrass) is the most widely cultivated forage and amenity grass species in temperate areas worldwide and there is a need to understand the genetic architectures of key agricultural traits and crop characteristics that deliver wider environmental services. Our aim was to identify genomic regions associated with agriculturally important traits by integrating a bacterial artificial chromosome (BAC)-based physical map with a genome-wide association study (GWAS).

METHODS

BAC-based physical maps for L. perenne were constructed from ~212 000 high-information-content fingerprints using Fingerprint Contig and Linear Topology Contig software. BAC clones were associated with both BAC-end sequences and a partial minimum tiling path sequence. A panel of 716 L. perenne diploid genotypes from 90 European accessions was assessed in the field over 2 years, and genotyped using a Lolium Infinium SNP array. The GWAS was carried out using a linear mixed model implemented in TASSEL, and extended genomic regions associated with significant markers were identified through integration with the physical map.

KEY RESULTS

Between ~3600 and 7500 physical map contigs were derived, depending on the software and probability thresholds used, and integrated with ~35 k sequenced BAC clones to develop a resource predicted to span the majority of the L. perenne genome. From the GWAS, eight different loci were significantly associated with heading date, plant width, plant biomass and water-soluble carbohydrate accumulation, seven of which could be associated with physical map contigs. This allowed the identification of a number of candidate genes.

CONCLUSIONS

Combining the physical mapping resource with the GWAS has allowed us to extend the search for candidate genes across larger regions of the L. perenne genome and identified a number of interesting gene model annotations. These physical maps will aid in validating future sequence-based assemblies of the L. perenne genome.

Differential expression of secreted factors SOSTDC1 and ADAMTS8 cause profibrotic changes in linear morphoea fibroblasts

BACKGROUND

Linear morphoea (LM) is a rare connective tissue disorder characterized by a line of thickened skin and subcutaneous tissue and can also affect the underlying muscle and bone. Little is known about the disease aetiology, with treatment currently limited to immune suppression, and disease recurrence post-treatment is common.

OBJECTIVES

In order to uncover new therapeutic avenues, the cell-intrinsic changes in LM fibroblasts compared with site-matched controls were characterized.

METHODS

We grew fibroblasts from site-matched affected and unaffected regions from five patients with LM, we subjected them to gene expression analysis and investigation of SMAD signalling.

RESULTS

Fibroblasts from LM lesions showed increased migration, proliferation, altered collagen processing, and abnormally high basal levels of phosphorylated SMAD2, thereby rendering them less responsive to transforming growth factor (TGF)-β1 and reducing the degree of myofibroblast differentiation, which is a key component of the wound-healing and scarring process in normal skin. Conditioned media from normal fibroblasts could reverse LM-affected fibroblast migration and proliferation, suggesting that the LM phenotype is driven by an altered secretome. Gene array analysis and RNA-Seq indicated upregulation of ADAMTS8 and downregulation of FRAS1 and SOSTDC1. SOSTDC1 knock-down recapitulated the reduced TGF-β1 responsiveness and LM fibroblast migration, while overexpression of ADAMTS8 induced myofibroblast markers.

CONCLUSIONS

We demonstrate that cell-intrinsic changes in the LM fibroblast secretome lead to changes observed in the disease, and that secretome modulation could be a viable therapeutic approach in the treatment of LM.

Use of an alternative method to evaluate erythema severity in a clinical trial: difference in vehicle response with evaluation of baseline and postdose photographs for effect of oxymetazoline cream 1·0% for persistent erythema of rosacea in a phase IV study

Background

Once‐daily topical oxymetazoline cream 1·0% significantly reduced persistent facial erythema of rosacea in trials requiring live, static patient assessments.

Objectives

To evaluate critically the methodology of clinical trials that require live, static patient assessments by determining whether assessment of erythema is different when reference to the baseline photograph is allowed.

Methods

In two identically designed, randomized, phase III trials, adults with persistent facial erythema of rosacea applied oxymetazoline or vehicle once daily. This phase IV study evaluated standardized digital facial photographs from the phase III trials to record ≥ 1‐grade Clinician Erythema Assessment (CEA) improvement at 1, 3, 6, 9 and 12 h postdose.

Results

Among 835 patients (oxymetazoline n = 415, vehicle n = 420), significantly greater proportions of patients treated with oxymetazoline vs. vehicle achieved ≥ 1‐grade CEA improvement. For the comparison between phase IV study results and the original phase III analysis, when reference to baseline photographs was allowed while evaluating post‐treatment photographs, the results for oxymetazoline were similar to results of the phase III trials (up to 85.7%), but a significantly lower proportion of vehicle recipients achieved ≥ 1‐grade CEA improvement (up to 29.7% [phase 4] vs. 52.3% [phase 3]; P<0.001). In the phase IV study, up to 80·2% of patients treated with oxymetazoline achieved at least moderate erythema improvement vs. up to 22·9% of patients treated with vehicle. The association between patients’ satisfaction with facial skin redness and percentage of erythema improvement was statistically significant.

Conclusions

Assessment of study photographs, with comparison to baseline, confirmed significant erythema reduction with oxymetazoline on the first day of application. Compared with the phase III trial results, significantly fewer vehicle recipients attained ≥ 1‐grade CEA improvement, suggesting a mitigated vehicle effect. This methodology may improve the accuracy of clinical trials evaluating erythema severity.

What's already known about this topic?

Phase III studies that evaluate the effects of medications on persistent facial erythema associated with rosacea require investigator assessments without allowing comparison with baseline images.

What does this study add?

Grading of facial erythema of rosacea that utilized baseline photographs compared with post‐treatment photographs enhanced the accuracy of persistent facial erythema assessments.

Furthermore, this method more accurately differentiated active treatment with oxymetazoline cream 1·0% from vehicle compared with live, static assessments.

Methodology that allows for comparison to baseline photographs may improve the accuracy of clinical trials that evaluate erythema severity.

Linked Comment: https://doi.org/10.1111/bjd.17725.

https://www.bjdonline.com/article/

Survey and genetic characterization of Vibrio cholerae in Apalachicola Bay, Florida (2012-2014)

AIMS

A small outbreak of gastroenteritis in 2011 in Apalachicola Bay, FL was attributed to consumption of raw oysters carrying Vibrio cholerae serotype O75. To better understand possible health risks, V. cholerae was surveyed in oysters, fish and seawater, and results were compared to data for Vibrio vulnificus and Vibrio parahaemolyticus.

METHODS AND RESULTS

Enrichment protocols were used to compare prevalence of V. cholerae (0, 48, 50%), V. vulnificus (89, 97, 100%) and V. parahaemolyticus (83, 83, 100%) in fish, seawater and oysters respectively. Compared to other species, Most probable number results indicated significantly (P < 0·001) lower abundance of V. cholerae, which was also detected more frequently at lower salinity, near-shore sites; other species were more widely distributed throughout the bay. Genes for expression (ctxA, ctxB) and acquisition (tcpA) of cholera toxin were absent in all strains by PCR, which was confirmed by whole genome sequencing; however, other putative virulence genes (toxR, rtxA, hlyA, opmU) were common. Multi-locus sequence typing revealed 78% of isolates were genetically closer to V. cholerae O75 lineage or other non-O1 serogroups than to O1 or O139 serogroups. Resistance to amoxicillin, kanamycin, streptomycin, amikacin, tetracycline and cephalothin, as well as multidrug resistance, was noted.

CONCLUSIONS

Results indicated minimal human health risk posed by V. cholerae, as all isolates recovered from Apalachicola Bay did not have the genetic capacity to produce cholera toxin. Vibrio cholerae was less prevalent and abundant relative to other pathogenic Vibrio species.

SIGNIFICANCE AND IMPACT OF THE STUDY

These studies provide important baseline observations for V. cholerae virulence potential regarding: (i) genetic relatedness to V. cholerae O75, (ii) antibiotic resistance and (iii) prevalence of multiple virulence genes. These data will serve as a biomonitoring tool to better understand ecosystem status and management if bacterial densities and virulence potential are altered by environmental and climatic changes over time.

Improving the magnetoelectric performance of Metglas/PZT laminates by annealing in a magnetic field

A comprehensive investigation of magnetostriction optimization in Metglas 2605SA1 ribbons is performed to enhance magnetoelectric performance. We explore a range of annealing conditions to relieve remnant stress and align the magnetic domains in the Metglas, while minimizing unwanted crystallization. The magnetostriction coefficient, magnetoelectric coefficient, and magnetic domain alignment are correlated to optimize magnetoelectric performance. We report on direct magnetostriction observed by in-plane Doppler vibrometer and domain imagining using scanning electron microscopy with polarization analysis for a range of annealing conditions. We find that annealing in an oxygen-free environment at 400 °C for 30 min yields an optimal magnetoelectric coefficient, magnetostriction and magnetostriction coefficient. The optimized ribbons had a magnetostriction of 50.6 ± 0.2 μm m-1 and magnetoelectric coefficient of 79.3 ± 1.5 μm m-1 mT-1. The optimized Metglas 2605SA1 ribbons and PZT-5A (d31 mode) sensor achieves a magnetic noise floor of approximately 600 pT Hz-1/2 at 100 Hz and a magnetoelectric coefficient of 6.1 ± 0.03 MV m-1 T-1.

Highly Pathogenic Avian Influenza (H5N1) Virus in Feathers

H5N1 highly pathogenic avian influenza (HPAI) virus causes high mortality of infected birds, with infection in multiple organs, including in feathers. Feathers have been proposed as samples for diagnosis of HPAI infection in birds, and this study is part of a broader investigation validating the use of feathers for diagnostic purposes. To understand and characterize the morphological basis for feather infection, sections from 7 different skin tracts of ducks and chickens infected with 3 different clades of H5N1 HPAI virus from Indonesia and Vietnam were examined histologically. Results showed that in ducks, lesions and viral antigen were mainly detected in the epidermis of feathers and follicles, whereas in chickens, they were mostly found in the dermis of these structures. Abundant viral antigen was found in nearly all the feathers examined from chickens, and there was no apparent difference between virus isolates or skin tracts in the proportion of feathers that were antigen positive. By immunohistochemistry, the majority of feathers from most skin tracts from ducks infected with a Vietnamese H5N1 HPAI virus contained abundant levels of viral antigen, while few feathers were antigen positive from ducks infected with 2 Indonesian viruses. These results support and inform the use of feathers for diagnostic detection of H5N1 HPAI virus in birds.

Propranolol and prednisolone combination for the treatment of segmental haemangioma in PHACES syndrome

Posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe syndrome (also known as PHACES syndrome) is a rare neurocutaneous disorder. Children presenting with these manifestations need careful ophthalmological, cardiac and neurological assessment. They may have one or more of these extracutaneous manifestations, the most common being cerebral and cardiovascular anomalies. There is controversy about treating these children with propranolol especially if they have cerebrovascular involvement with narrow, dysplastic or absent blood vessels. The concern with propranolol is that hypotension may lead to reduced cerebral blood flow and neurological consequences. Prior to propranolol the systemic treatment for haemangiomas was prednisolone and then the concern was the opposite, namely hypertension. Our proposal was whether a combination of these two drugs would provide a safer and faster recovery. We report three retrospective cases of PHACES syndrome, each of whom received treatment with a combination of propranolol and prednisolone: two children were started on prednisolone and propranolol was added because the haemangiomas failed to respond adequately; the third child was started on propranolol and developed peripheral ischaemia and ulceration necessitating a reduction in dose addition of a low dose of prednisolone. All three patients, who failed on the one treatment, responded well to combination therapy without any significant complications. These outcomes suggest that for some patients with PHACES syndrome the use of combination treatment with propranolol and prednisolone could be advantageous, potentially allowing for the introduction of low doses of each with an enhanced combined effect. The doses can be increased gradually depending on the magnetic resonance imaging findings.