Infertility Cohort Research Articles

P-720 Biallelic variants in IQCN cause sperm flagella assembly defects and male infertility

Abstract Study question What is the effect of defects in the manchette protein IQ motif-containing N (IQCN) on sperm flagellar assembly? Summary answer Deficiency in IQCN is responsible for sperm flagella assembly defects and abnormal computer-assisted sperm analysis (CASA) parameters, which result in male infertility. What is known already Manchette is a transient structure that is involved in the shaping of the spermatid nucleus and protein transport of flagella. Most recently, our group reported that the manchette protein IQCN is essential for fertilization. Variants in IQCN led to total fertilization failure (TFF) and defective acrosome structure phenotypes. However, the related function of IQCN in sperm flagella assembly is still unknown. Study design, size, duration Fifty infertile males were recruited from the Reproductive and Genetic Hospital of China International Trust Investment Corporation (CITIC)-Xiangya from January 2014 to October 2022. Participants/materials, setting, methods Genomic DNA was extracted from the peripheral blood samples of the affected individuals for whole-exome sequencing. The ultrastructure of the flagella was detected by transmission electron microscopy (TEM). CASA was used to test the parameters of sperm motility. An Iqcn knockout (Iqcn-/-) mouse model was generated by CRISPER-Cas9 technology. Immunoprecipitation (IP) followed by liquid chromatography‒mass spectrometry was used to select the differentially expressed IQCN-binding proteins. Immunofluorescence was used to validate the localization of IQCN-binding proteins. Main results and the role of chance Biallelic variants in IQCN (c.3913A>T and c.3040A>G; c.2453_2454del) were identified in our infertile cohort. The sperm from the affected individuals showed irregular “9 + 2” structure of sperm flagella, which resulted in abnormal CASA parameters. Similar phenotypes were observed in Iqcn-/- male mice. The CASA parameters in the sperm of Iqcn-/- male mice were significantly lower than those in Iqcn+/+ male mice. The partial of peripheral doublet microtubules (DMTs) and outer dense fibers (ODFs) were absent, or the chaotic arrangement of DMTs were observed in the principal piece and end piece of sperm flagella. The hyperactivation ability of sperm from Iqcn-/- male mice was decreased than sperm from Iqcn+/+ male mice. The CDC42 and IFT protein families are hub proteins that interact with IQCN and regulate flagella assembly during spermiogenesis. Deficiency in IQCN causes the loss of binding with CDC42 and IFT74, which leads to the absence or abnormal localization of CDC42 and IFT74 in mouse and human spermatozoa. Limitations, reasons for caution More cases are needed to demonstrate the relationship between the IQCN variations and the phenotypes. Wider implications of the findings Our findings expand the genetic and phenotypic spectrum of IQCN variants in causing male infertility, thus providing a genetic marker for sperm motility deficiency and male infertility. Trial registration number N.A.

O-152 Benign epithelial ovarian tumors following use of fertility drugs: a register-based cohort study from Denmark

Abstract Study question Is use of fertility drugs associated with an increased risk of benign epithelial ovarian tumors among women with infertility? Summary answer Among women with infertility, use of fertility drugs is not associated with an increased risk of benign epithelial ovarian tumors. What is known already Benign epithelial ovarian tumors are the most common neoplasms in the ovaries. These benign tumors share some of the same risk factors, which are associated with ovarian cancer. The general understanding of the pathogenesis and etiology of ovarian cancer is sparse; therefore, knowledge on factors influencing development of benign epithelial ovarian tumors—and hence likely ovarian cancer—is warranted. Previous studies on the association between fertility treatment and ovarian cancer are conflicting, whereas no previous study has examined the association between use of fertility drugs and benign epithelial ovarian tumors. Study design, size, duration Retrospective register-based cohort study of nearly 145,000 women included in the Danish Infertility Cohort during 1995–2017 at age 20–45 years. Women were followed from one year after infertility diagnosis until first benign epithelial ovarian tumor or one of the censoring criteria: borderline ovarian tumor, ovarian cancer, oophorectomy, emigration, death or end of follow-up (December 31, 2018). Participants/materials, setting, methods Using the Aalen-Johansen estimator, we determined 10-year cumulative risks of benign epithelial ovarian tumors among approximately 25,000 women who used fertility drugs (defined within one year after infertility diagnosis: clomiphene citrate, gonadotropins, human chorionic gonadotropin, gonadotropin-releasing hormone [GnRH] receptor modulators, and progesterone) compared with women diagnosed with infertility and no drug use. Additionally, we used Cox proportional hazards regression models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Main results and the role of chance Our results showed that the crude 10-year cumulative risk of benign epithelial ovarian tumors were 0.32% (95% CI: 0.29%–0.36%) for women who used any fertility drug compared with 0.49% (95% CI: 0.40%–0.60%) in women with no use of fertility drugs (risk difference: -0.17% [95% CI: -0.28–(-0.07)]). When adjusted for age, calendar period of infertility diagnosis, educational level, parity, obesity, polycystic ovary syndrome, and origin of infertility information, the HR for use of any fertility drug was 0.73 (95% CI 0.55–0.96). In general, the 10-year risk differences as well as the HRs for each drug evaluated separately were similar to the results for use of any drug. Lastly, we tested the robustness of our results by various pre-defined secondary analyses, and this did not change our results. Limitations, reasons for caution We did not include information on number of cycles and treatment regimens as these are only partly available in the registers. Wider implications of the findings Among women with infertility, we observe a lower relative risk of benign epithelial ovarian tumors for women treated with fertility drugs compared with women who did not use fertility drugs. However, this finding translates into a small decrease in absolute risk, which does not appear to have any clinical relevance. Trial registration number Not applicable

An Explorative Study to Assess the Suicidal Risk Amongst Infertile Patients

IntroductionThis given study was designed to qualitatively and quantitatively examine the Psychosocial – emotional consequences of infertility on female infertile patients . Suicidal risk amongst infertile patients was a incidental yet significant finding with 25 percent of the study population reporting a positive result by the MINI scale. There are very few studies conducted in the Indian context that analyses the psychosocial aspects of infertility and the impact of ART treatment on the quality of life.The finding in our study indicates that both infertility and stress associated with ART treatment contributes to psychological turmoil namely depression , anxiety, psychopathology and quality of life impairment in addition to suicidal ideation and suicidal risk.ObjectivesAimsTo assess the psychosocial impact of infertility amongst female infertile patients including suicidal risk/ suicidal ideation in the given study population.MethodsA total of 300 women attending the Obstetrics and Gynecology out patients department of a tertiary hospital in Kolkata, India were selected by simple random sampling. 100 fertile women attending the routine ante natal clinic were selected as cases and 100 infertile women seeking fertility treatment were selected as controls. 100 women didn’t follow up with the study. The following questionnaires were administered to both case and control group- BAI, BDI, SCL-90-R, SF-36, MINI and socio demographic proforma ; by trained clinic psychologist . The raw scores & adjusted scores were analysed statistically by SPSS using the following tests, independent t test, chi square test and Z test.ResultsThe results of the MINI scale indicate that up to 25% of the infertile cohort suffer from suicidal risk/ suicidal ideation which is statistically significant in comparison to the control group.The other psychosocial parameters are also statistically significant in the case in comparison to the control population.Conclusions Although the psychosocial impact of infertility has been well researched and documented. Few studies have been conducted globally which assess suicidal risk amongst infertile patients. Our results corroborate earlier studies such as the Danish administrative population-based registry study by Trille Kristina Kjaer et al which found a causative link between infertility and suicidal risk.Further research is needed in this directionDisclosure of InterestNone Declared

Population-based genetic analysis in infertile men reveals novel mutations of ADAD family members in patients with impaired spermatogenesis.

The testis-specific adenosine deaminase domain-containing (ADAD) protein family, including ADAD1 and ADAD2, has been confirmed to be essential in mouse male fertility. However, the roles of ADAD1 and ADAD2 in human reproductive biology are unclear. Herein, whole-exome sequencing was conducted for 337 infertile patients to detect pathogenic variants in ADAD1 and ADAD2. Importantly, a novel deleterious biallelic variant of NM_001159285.2:c.1408G > T (p.V470F) and NM_001159285.2:c.1418A > G (p.E473G) in ADAD1 and a pathogenic homozygous missense variant of NM_001145400.2:c.1381C > T (p.R461W) in ADAD2 were identified in this infertile cohort with frequencies of 0.29 (1/337) and 0.59% (2/337), respectively. Electron microscopy revealed an abnormal morphology and severely disorganized ultrastructure of sperm from the patients. Immunofluorescence and western blotting showed a sharp decrease in ADAD1 and ADAD2 expression in sperm from the patients. Mechanistically, bioinformatics analysis suggested that ADAD2 interacts with DNAH17. Furthermore, we demonstrated that the expression of DNAH17 was markedly downregulated in the sperm of patients harboring ADAD2 variants. In addition, the expression of several autophagy regulators was significantly disrupted in the sperm of patients harboring ADAD2 variants. In conclusion, we identified novel ADAD1 and ADAD2 variants in three infertile patients from a large infertile cohort, first providing evidence that ADAD1 and ADAD2 variants might be a candidate genetic cause of human male infertility. Moreover, an important new dimension to our understanding of the genotype-phenotype correlations between the ADAD gene family and male infertility in humans has been uncovered, providing valuable information for the genetic diagnosis of male infertility.

Antimüllerian hormone is not associated with embryo ploidy in patients with and without infertility undergoing in vitro fertilization with preimplantation genetic testing

To assess the association between antimüllerian hormone (AMH) and embryo ploidy rates in 2 cohorts of patients undergoing invitro fertilization (IVF) with trophectoderm biopsy for preimplantation genetic testing for aneuploidy (PGT-A): the general population of women pursuing IVF with PGT-A (Infertile cohort) and women pursuing IVF with preimplantation genetic testing for monogenic disorders (PGT-M) owing to the risk of hereditary monogenic diseases (Non-infertile cohort). Retrospective cohort study. Academic center. Patients undergoing their first cycle of IVF with trophectoderm biopsy and PGT-A or PGT-A and PGT-M in our center between March 2012 and June 2020. Patients of advanced maternal age according to the Bologna criteria (age ≥40 years) and patients who underwent fresh embryo transfers were excluded. None. Proportion of euploid, mosaic, and aneuploid embryos per cycle. "Infertile" (n = 926) and "Non-infertile" (n = 214) patients were stratified on the basis of AMH levels, with low-AMH defined as <1.1 ng/mL in accordance with the Bologna criteria. Age-adjusted regression models showed no relationship between AMH classification and proportion of euploid, mosaic, and aneuploid embryos in the Infertile or Non-infertile cohorts. In the Infertile cohort, no association between AMH classification and embryo ploidy rates was identified in a subgroup analysis of patients aged <35 years, 35-37 years, and 38-39 years. These findings persisted in a sensitivity analysis of infertile patients stratified into AMH (ng/mL) quartile categories. No association was found between AMH and the proportion of euploid, mosaic, or aneuploid embryos in 2 large cohorts of patients undergoing IVF with PGT-A (Infertile patients) or PGT-A and PGT-M (Non-infertile patients), suggesting that a quantitative depletion of ovarian reserve does not predict the ploidy status of the embryo cohort.

Profiling the male germline genome to unravel its reproductive potential

To identify specific germline mutations related to sperm reproductive competence, in couples with unexplained infertility. In this retrospective study, couples were divided according to whether they had successful intracytoplasmic sperm injection outcomes (fertile) or not (infertile). Ancillary sperm function tests were performed on ejaculates, and whole exome sequencing was performed on spermatozoal DNA. Sperm aneuploidy and gene mutation profiles were compared between the 2 cohorts as well as according to the specific reasons for reproductive failure. Center for reproductive medicine at a major academic medical center. Thirty-one couples with negative infertility workups and normal semen parameters. Couples with mutations on fertilization- or embryo development-related genes were subsequently treated by assisted gamete treatment or microfluidics, respectively. Intracytoplasmic sperm injection cycle outcomes including fertilization, clinical pregnancy, and delivery rates. Sperm aneuploidy was lower in the fertile group (4.0% vs. 8.4%). Spermatozoa from both cohorts displayed mutations associated with sperm-egg fusion (ADAM3A) and acrosomal development (SPACA1), regardless of reproductive outcome. The infertile cohort was then categorized according to the reasons for reproductive failure: absent fertilization, poor early embryo development, implantation failure, or pregnancy loss. Spermatozoa from the fertilization failure subgroup (n = 4) had negligible PLCζ presence (10% ± 9%) and gene mutations (PLCZ1, PIWIL1, ADAM15) indicating a sperm-related oocyte-activating deficiency. These couples were successfully treated by assisted gamete treatment in their subsequent cycles. Spermatozoa from the poor early embryo development subgroup (n = 5) had abnormal centrosomes (45.9% ± 5%), and displayed mutations impacting centrosome integrity (HAUS1) and spindle/microtubular stabilization (KIF4A, XRN1). Microfluidic sperm processing subsequently yielded a term pregnancy. Spermatozoa from the implantation failure subgroup (n = 7) also had abnormal centrosomes (53.1% ± 13%) and carried mutations affecting embryonic implantation (IL9R) and microtubule and centrosomal integrity (MAP1S, SUPT5H, PLK4), whereas those from the pregnancy loss subgroup (n = 5) displayed mutations on genes involved in trophoblast development (NLRP7), cell cycle regulation (MARK4, TRIP13, DAB2IP, KIF1C), and recurrent miscarriage (TP53). By assessing the sperm genome, we identified specific germline mutations related to various reproductive processes. This information may clarify elusive factors underlying reproductive competence and enhance treatment for couples with unexplained infertility.

Apparent Homozygosity for a gr/gr AZFc Deletion in A 47,XYY Man with Oligozoospermia and Secondary Infertility.

Approximately 1 in 1000 men have a 47,XYY karyotype. Previous publications have presented cases of infertile XYY men and have suggested that the additional Y chromosome may cause disrupted meiosis leading to sperm apoptosis. The purpose of the current study was to determine whether XYY men are over-represented in infertility cohorts. In this paper, an ongoing infertility cohort was evaluated for Y chromosome microdeletions using the MLPA technique and the data from the first 2000 referrals were recorded. Moreover, the MLPA technique detected 47,XYY karyotypes. Four XYY individuals were identified within the cohort. One of the four XYY men was shown to have an apparent gr/gr partial AZFc deletion on both Y chromosomes while Sertoli cell only syndrome was detected in another case. The other two cases (out of 2000) might, therefore, represent an incidental finding. The gr/gr deletion is not detectable by the multiplex PCR method; therefore, there might be additional explanations for the fertility problems of infertile XYY men reported in previously published articles. It seems that among other cases, their XYY karyotype may be coincidental, rather than causative of their fertility issues.

Risk of colorectal cancer after use of fertility drugs—results from a large Danish population-based cohort of women with infertility

To study the association between use of fertility drugs and colorectal cancer among women with infertility. Population-based cohort study. Not applicable. The study cohort was obtained from the Danish Infertility Cohort and consisted of all women with infertility aged 20-45 years living in Denmark during 1995-2017. Information on the use of specific types of fertility drugs, colorectal cancer diagnoses, covariates, and vital status were obtained from the Danish Infertility Cohort and Danish national registers. Cox proportional hazard models adjusted for potential confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for colorectal cancer overall and rectal and colon cancer separately. Among 148,036 women in the final study cohort, 205 women were diagnosed with colorectal cancer. Ever use of clomiphene citrate (CC) was associated with a lower rate of colorectal cancer (unadjusted HR, 0.67; 95% CI, 0.51-0.89; adjusted HR, 0.68; 95% CI, 0.50-0.93). However, the lower rate was only seen among women who first used CC >8 years ago (unadjusted HR, 0.56; 95% CI, 0.41-0.76; adjusted HR, 0.52; 95% CI, 0.36-0.75). No marked associations were found between the use of any of other types of fertility drugs and colorectal cancer. The results for colon and rectal cancer analyzed separately were similar, except for a suggestion of a decreased risk of rectal cancer associated with the use of gonadotropins (adjusted HR, 0.46; 95% CI, 0.20-1.08). Among women with infertility, the use of most types of fertility drugs was not associated with colorectal cancer. However, CC may decrease the risk of colorectal cancer and gonadotropins might decrease the risk of rectal cancer, but we cannot rule out that these findings may be more related to the underlying conditions in these women or are chance findings. Consequently, the results from this study should be investigated further in large epidemiological studies.

Evaluating the efficacy of ovulation stimulation with intrauterine insemination in women with diminished ovarian reserve compared to women with normal ovarian reserve.

To assess the efficacy of ovulation induction and intrauterine insemination (IUI) in couples with diminished ovarian reserve (DOR). Women aged 20-39 years and men younger than 50 years were included. Four "ovarian reserve groups" were created according to anti-Müllerian hormone (AMH) and the partner's age. Gestational sac finding on ultrasound examination was the primary outcome measure. The study was carried out on a total of 770 cycles of 362 women in an infertility cohort that consisted of 75 women with DOR treated by 153 cycles and 287 women without DOR treated by 617 cycles. The pregnancy rate was similar in the four ovarian reserve groups in terms of first, second, third plus fourth, and total attempts of IUI cycles. Moreover, the pregnancy rate, miscarriage rate, and multiple pregnancy rate were similar. We found no difference in the cumulative pregnancy rate among the groups after four IUI cycles. Multivariate logistic regression analysis of the entire cohort revealed that infertility duration, post-wash sperm count, and follicle number greater than 11 mm on the day of human chorionic gonadotropin trigger were independent predictors of pregnancy (P< 0.001). Neither age nor AMH predicted pregnancy after ovulation stimulation and IUI. Ovulation stimulation and IUI are equally effective in women with DOR and in women with normal ovarian reserve in terms of pregnancy rate, multiple pregnancy rate, and miscarriage rate per IUI cycle or cumulative pregnancy rate after four cycles of IUI.

Tumors of the central nervous system among women treated with fertility drugs: a population-based cohort study.

To investigate the association between fertility drugs and tumors of the central nervous system (CNS). This cohort study was based on The Danish Infertility Cohort and included 148,016 infertile women living in Denmark (1995-2017). The study cohort was linked to national registers to obtain information on use of specific fertility drugs, cancer diagnoses, covariates, emigration, and vital status. Cox proportional hazard regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all CNS tumors and separately for gliomas, meningiomas and diverse benign tumors of the brain and other parts of the CNS. During a median 11.3years of follow-up, 328 women were diagnosed with CNS tumors. No marked associations were observed between use of the fertility drugs clomiphene citrate, gonadotropins, gonadotropin-releasing hormone receptor modulators and progesterone and CNS tumors. However, use of human chorionic gonadotropin was associated with a decreased rate of meningiomas (HR 0.49 95% CI 0.28-0.87). No clear associations with CNS tumors were observed according to time since first use or cumulative dose for any of the fertility drugs. No associations between use of most types of fertility drugs and CNS tumors were observed. However, our findings only apply to premenopausal women and additional studies with longer follow-up time are necessary.

Ethnic discordance in serum anti-Müllerian hormone in European and Indian healthy women and Indian infertile women

Research questionDoes anti-Müllerian hormone (AMH) differ between healthy European and Indian women, and are potential ethnic differences modified by infertility diagnosis? DesignCross-sectional analysis of three prospectively recruited cohorts (n = 2758); healthy European women (n = 758), healthy community cohort from Kolhapur, India (n = 400) and infertility cohort from Kolhapur, India (n = 1600). AMH was determined by assay. Ethnicity, age and cause of infertility were modelled using additive quantile regression models. ResultsHealthy Indian women had lower AMH than their healthy European counterparts (population estimates 20.0% lower [95% CI 7.2–36.5]), with increasing discordance with increasing age; at 25 years AMH was 11.9% lower (95% CI 9.4–14.1), increasing to 40.0% lower (95% CI 0–64.6) by age 45. Comparison of healthy and infertile Indian women revealed differences that were related to cause of infertility. Women whose male partner had severe oligoasthenoteratozoospermia (n = 95) had similar AMH to controls; women with polycystic ovary syndrome (n = 220) had higher AMH, especially in those <30 years, and in women with a principal diagnosis of unexplained infertility (n = 757) AMH was lower (median difference 22.6% lower; 95% CI 9.1–37.7) than controls. ConclusionsAMH is substantially lower in healthy Indian women at all ages than their European counterparts. Infertile Indian women have variable differences in AMH from healthy Indian controls, with the extent and direction of differences primarily reflecting the underlying cause of infertility. Recognition of ethnic and cause-specific differences are critical to ensure accurate contextualizing of results and clinical outcomes for patients.

O-310 Browsing the Male Genome to Unravel Its Reproductive Potential

Abstract Study question Can whole genome profiling of sperm DNA be used to identify aspects of ART failure and predict embryo developmental competence? Summary answer Whole genome profiling of sperm DNA identifies germline gene mutations associated with reproductive failure and helps characterize subtle male factor infertility. What is known already A routine semen analysis provides limited information on the characteristics of the male gamete and is unable to predict spermatozoa performance in ART. Therefore, ancillary tests may be used to further assess the male gamete’s reproductive potential. Whole exome sequencing (WES) of the male genome carried out on somatic cells has proven to be a powerful technique capable of identifying the genetic roots of infertility. Here, we aim to preferentially detect germline mutations by exclusively sequencing spermatozoal DNA to identify genes related to the different underlying etiologies of reproductive failure. Study design, size, duration Over a 6-year period, 31 consenting couples with negative female infertility workups and normal semen parameters were included in this study. These couples were divided according to whether they reported a successful pregnancy with ART (fertile; n = 10) or not (infertile; n = 21). Sperm aneuploidy assessment by copy number variant (CNV) analysis with WES were carried out on ejaculated spermatozoa. Gene mutation profiles were enlisted and compared between the two patient cohorts to identify genes involved. Participants/materials, setting, methods DNA was extracted and amplified from at least 500 spermatozoa (DNA concentration, 760±486 ng/ul; quality, 1.7±0.1 nm) for CNV analyses by WES. Mutations corresponding to the CNV were then annotated and assessed using the CLC Genomic Server 9.0. Genes were considered duplicated or deleted when their read depth was &amp;gt;1.5 or &amp;lt; 0.5 times the median read depth in the control, respectively. Main results and the role of chance All couples (n = 31) (maternal age, 37.6±3yrs; paternal age, 39.7±5yrs) had adequate semen parameters (concentration, 59.2±30x106/mL, 44.8±18% motility, normal morphology) and normal peripheral karyotypes. The fertile cohort (n = 10) underwent 12 ICSI cycles, achieving an 82.6% (57/69) fertilization rate with 10/12 (83.3%) cycles resulting in live births. The infertile cohort (n = 21) underwent 25 ICSI cycles, achieving a 68.4% (91/133) fertilization rate and 6/14 (42.9%) clinical pregnancies, all resulting in pregnancy loss. CNV analysis indicated lower sperm aneuploidy in the fertile (4.0% vs. 8.4%) cohort (P &amp;lt; 0.00001). In both cohorts, mutations associated with sperm–egg fusion (ADAM3A) and acrosomal development (SPACA1, SPATA16) were identified, justifying ICSI utilization. The infertile cohort included complete fertilization failure, poor early embryo development, implantation failure, or pregnancy loss. Couples with complete fertilization failure (n = 4) had gene deletions (PLCZ1, PIWIL1, ADAM15) indicating sperm-related oocyte-activating deficiency. Those with poor early embryo development (n = 5) had mutations essential for centrosome integrity (HAUS1) and spindle/microtubular stabilization (KIF4A, XRN1). Couples who failed to achieve pregnancy (n = 7) had mutations commonly implicated in embryonic implantation (IL9R) and microtubule/centrosomal integrity (MAP1S). Those with pregnancy losses (n = 5) displayed mutations related to trophoblast development (NLRP7), cell cycle regulation (MARK4, TRIP13, DAB2IP, KIF1C), and a gene linked to recurrent miscarriage (TP53). Limitations, reasons for caution Using WES, we were able to identify germline mutations that appear to be involved in various aspects of human reproduction. These findings are new and should be validated in a larger study population. Moreover, although we attempted to control for maternal age, we still cannot exclude confounding female factors. Wider implications of the findings Evaluating the sperm genome can help identify elusive genetic factors associated with reproductive competence and help guide treatment options for couples unable to conceive who undergo ART. Therefore, screening spermatozoal DNA may serve as an additional tool in precision medicine to identify and treat subtle male factor infertility. Trial registration number N/A

P-783 Fertility treatment and risk of ovarian cancer in a large nationwide cohort of 151,821 infertile Danish women

Abstract Study question Do use of fertility drugs increase the risk of ovarian cancer among infertile women Summary answer Use certain types of fertility drugs may modify the risk of ovarian cancer among infertile women, primarily for serous ovarian tumors and among parous women. What is known already Even though most previous studies on the association between fertility treatment and ovarian cancer have not been able to show a convincing association, some studies have found an increased risk of this malignancy among women undergoing fertility treatment. However, many of the previous studies have had methodological limitations including selection bias and potential confounding due to missing information of important factors, such as parity status and hormonal contraceptive use, small sample size as well as short- and incomplete follow-up time. Furthermore, only few studies have assessed the association between fertility treatment and ovarian cancer according to histological type. Study design, size, duration This retrospective register-based cohort study included virtually all 20-45 year old infertile women in Denmark between 1971 and 2017 as identified in the Danish Infertility Cohort. All women were followed from entry in the cohort (i.e. the date of first infertility diagnosis) to occurrence of ovarian cancer, any other cancer (except non-melanoma skin cancer), death, emigration, bilateral oophorectomy or end of follow-up (December 31, 2017), whichever occurred first. The median follow-up length was 10.3 years Participants/materials, setting, methods In total, 332 women were diagnosed with ovarian cancer during the follow-up period. Information on the use of specific fertility drugs (clomiphene citrate, gonadotropins, hCGs, GnRH receptor modulators and progesterone), ovarian cancer, covariates and vital status was obtained from the Danish Infertility Cohort and various Danish national registers. Cox proportional hazard regression models were used to calculate hazard ratios (HRs) and 95% CIs for ovarian cancer overall and for serous ovarian tumors. Main results and the role of chance After adjustment for attained age (as the underlying time scale), calendar year of study entry, highest obtained level of education, maternal age at first childbirth, number of childbirths, hormonal contraceptive use as well as mutual adjustment for treatment with any other specific fertility drugs, ever use of hCG (HR 0.62, 95% CI 0.44-0.89) and GnRH receptor modulators (HR 0.63, 95% CI 0.40-1.00) were associated with a decreased risk of overall ovarian cancer. In contrast, ever use of gonadotropins (HR 1.43; 95% CI 0.91-2.24) and especially progesterone (HR 1.81; 95% CI 1.18-2.78) increased the risk of overall ovarian cancer. No marked association was observed for clomiphene citrate (HR 1.07, 95% CI 0.80-1.44)). The rates for serous ovarian cancer generally resembled those observed for overall ovarian cancer; however only the association for progesterone reached statistical significance (HR 2.89; 95% CI 1.67-4.99). The observed associations existed mainly among parous women and did not vary with time since first use of the fertility drug in question and no statistically significant associations were observed with cumulative dose of the specific fertility drugs. Limitations, reasons for caution The median age at the end of follow-up was only 42.5 years, which is markedly lower than the usual peak age for ovarian cancer in Denmark (mid 60s). Hence, we were not able to capture the true, potential long-term association between use of fertility drugs and ovarian cancer. Wider implications of the findings Use of certain specific types of fertility drugs in fertility treatment may modify the risk of ovarian cancer among subgroups of women. However, although this study is by far the largest to date, additional large epidemiological studies with longer follow-up time are needed to further clarify the observed associations. Trial registration number Not applicable.

O-083 Tumors of the central nervous system among women treated with fertility drugs: a population-based cohort study

Abstract Study question Is the use of fertility drugs among infertile women associated with tumors of the central nervous system (CNS)? Summary answer The use of most specific types of fertility drugs is not associated with an increased risk of CNS tumors overall. What is known already Few previous studies have investigated the association between fertility drugs and CNS tumors. Studies have reported inconsistent results regarding the risk of CNS tumors associated with assisted reproductive technologies such as in vitro fertilization (IVF). No studies have reported the risk associated with various specific fertility drugs. Study design, size, duration Retrospective population-based cohort study of all women included in the Danish Infertility Cohort. The study cohort consisted of 148 016 infertile women after exclusion of women who emigrated, died, were diagnosed with cancer before infertility diagnosis, and women for whom information on level of education was missing. The cohort was linked to various national health- and civil registers to study all 20- to 45-year old infertile women in Denmark during 1995-2017. Participants/materials, setting, methods The study cohort was linked to various national health and population registers to obtain information on fertility drugs (clomiphene citrate, gonadotropins, human chorionic gonadotropin, gonadotropin-releasing hormone receptor modulators and progesterone), CNS tumors, relevant covariates and vital and emigration status. Cox proportional hazard regression models were used to calculate hazard ratios and 95% confidence intervals for CNS tumors overall and for gliomas, meningiomas and diverse benign tumors of the brain and other parts of the CNS. Main results and the role of chance During a median 11.3 years of follow-up, 328 women were diagnosed with a CNS tumor. No marked associations were observed between use of most types of fertility drugs (clomiphene citrate, gonadotropins, gonadotropin releasing hormone receptor modulators and progesterone) and CNS tumors. However, ever use of human chorionic gonadotropin was associated with an increased rate of gliomas (HR 2.13 95% CI 0.90-5.01) but a decreased rate of meningiomas (HR 0.49 95% CI 0.28-0.87). No clear associations with CNS tumors were observed according to time since first use or cumulative dose for any specific fertility drugs. Additional studies with longer follow-up are necessary to support these findings. Limitations, reasons for caution The median age at end of follow-up (43.5 years) was lower than the median age for CNS tumors diagnosis (60 years). Information on estrogen use, treatment regimens and number of cycles is only partly available in the registers and these were not included in this study. Wider implications of the findings This study presents reassuring results regarding the risk of tumors of the CNS among women treated with fertility drugs. Our study is only generalizable to premenopausal women, and the risk for postmenopausal women remains to be assessed. Trial registration number not applicable

The role of sperm DNA integrity in couples with recurrent implantation failure following IVF treatment.

There is increasing evidence from the literature that indicates the association between impaired sperm DNA integrity and male infertility. However, the data is insufficient regarding recurrent implantation failure (RIF) and sperm DNA damage. This study aimed to investigate the association between sperm DNA fragmentation and RIF cases. Basic semen parameters and sperm DNA fragmentation index (DFI) of men whose partner was suffering from RIF were compared with men whose partner was diagnosed with unexplained infertility (UEI) but had clinical pregnancies following IVF treatment. A retrospective analysis from a large-volume IVF center has been performed, and a total of 197 couples underwent analysis. Two groups were formed, couples with RIF and couples diagnosed with UEI but had clinical pregnancies (controls) following IVF cycles. The mean number of cycles showed significant differences between the groups. However, no statistical difference was observed between RIF and the control group regarding patient characteristics, semen parameters, and sperm DNA fragmentation index (DFI). Also, no statistically significant correlation was found between sperm DFI and clinical pregnancies in the unexplained infertility cohort. Our results show that sperm DNA fragmentation may not be an important contributing factor to RIF cases.

An Explorative Study to Assess the Suicidal Risk Amongst Infertile Patients

AimsTo assess the psychosocial impact of infertility amongst female infertile patients including suicidal risk/ suicidal ideation in the given study population.MethodsA total of 300 women attending the Obstetrics and Gynecology out patients department of a tertiary hospital in Kolkata, India were selected by simple random sampling. 100 fertile women attending the routine ante natal clinic were selected as cases and 100 infertile women seeking fertility treatment were selected as controls. 100 women didn't follow up with the study. The following questionnaires were administered to both case and control group- BAI, BDI, SCL-90-R, SF-36, MINI and socio demographic proforma ; by trained clinic psychologist .The raw scores &amp; adjusted scores were analysed statistically by SPSS using the following tests, independent t test, chi square test and Z test.ResultsThe results of the MINI scale indicate that up to 25% of the infertile cohort suffer from suicidal risk/ suicidal ideation which is statistically significant in comparison to the control group.The other psychosocial parameters are also statistically significant in the case in comparison to the control population.ConclusionAlthough the psychosocial impact of infertility has been well researched and documented. Few studies have been conducted globally which assess suicidal risk amongst infertile patients.Our results corroborate earlier studies such as the Danish administrative population-based registry study by Trille Kristina Kjaer et al which found a causative link between infertility and suicidal risk.Further research is needed in this direction.

Distinct gut and vaginal microbiota profile in women with recurrent implantation failure and unexplained infertility

BackgroundFemale reproductive tract dysbiosis impacts implantation. However, whether gut dysbiosis influences implantation failure and whether it accompanies reproductive tract dysbiosis remains scantly explored. Herein, we examined the gut-vaginal microbiota axis in infertile women.MethodsWe recruited 11 fertile women as the controls, and a cohort of 20 infertile women, 10 of whom had recurrent implantation failure (RIF), and another 10 had unexplained infertility (UE). Using amplicon sequencing, which employs PCR to create sequences of DNA called amplicon, we compared the diversity, structure, and composition of faecal and vaginal bacteria of the controls with that of the infertile cohort. Of note, we could only sequence 8 vaginal samples in each group (n = 24/31).ResultCompared with the controls, α-diversity and β-diversity of the gut bacteria among the infertile groups differed significantly (p < 0.05). Taxa analysis revealed enrichment of Gram-positive bacteria in the RIF group, whereas Gram-negative bacteria were relatively abundant in the UE group. Strikingly, mucus-producing genera declined in the infertile cohort (p < 0.05). Hungatella, associated with trimethylamine N-oxide (TMAO) production, were enriched in the infertile cohort (p < 0.05). Vaginal microbiota was dominated by the genus Lactobacillus, with Lactobacillus iners AB-1 being the most abundant species across the groups. Compared with the infertile cohort, overgrowth of anaerobic bacteria, associated with vaginal dysbiosis, such as Leptotrichia and Snethia, occurred in the controls.ConclusionThe gut microbiota had little influence on the vaginal microbiota. Gut dysbiosis and vaginal eubiosis occurred in the infertile women, whereas the opposite trend occurred in the controls.

Women with female infertility seeking medically assisted reproduction are not at increased risk of developing multiple sclerosis.

Is female infertility among women seeking medically assisted reproduction (MAR) associated with prevalent as well as incident multiple sclerosis (MS)? Women with a record of female infertility did not have an increased risk of developing MS compared with apparent fertile women; however, the prevalence of MS was slightly higher among women undergoing MAR compared with women who had a child without MAR, but this was not related to origin of infertility (i.e. male versus female factor infertility). Women with MS have fewer children compared with women without MS. Persons with MS more often have other coexisting autoimmune disorders including hypothyroidism compared with the general population. Thyroid dysfunction is associated with ovarian cause of infertility, miscarriage and ovarian failure. Conversely, women with endometriosis, that is highly associated with infertility, also more often have other coexisting autoimmune diseases including MS and hypothyroidism compared with the general population. However, whether the low fertility rate among women with MS is due to a genetically predisposition to other autoimmune and endocrine disorders that leads to reduced fertility, or an active choice of the woman, disease-related pathology or treatment-specific effect on endocrine and/or ovarian function, is not completely understood. A register-based cohort study of a total of 310 357 women from 1996 to 2018. A cross-sectional design was used for analysing prevalence of MS, whereas a cohort design with up to 24 years of follow-up was used for analysing incidence of MS. Three cohorts were included in the study (i) 55 404 women with a female infertility diagnosis registered in the Danish IVF register; (ii) 25 096 women with only male factor infertility recorded in the IVF register and thus no female infertility diagnosis and (iii) 229 857 age- and calendar-matched women with a record of first child birth in the Danish Medical Birth Register (DMBR) and no record ever in the IVF register. The prevalence and incidence of MS in the female infertility cohort were compared with the two control cohorts of apparent fertile women using log-binomial regression and Cox proportional hazard regression, respectively. The crude prevalence of having MS per 1000 persons was 3.2 for women who had undergone MAR treatment regardless of origin of infertility (i.e. male versus female factor infertility) and 2.3 for fertile DMBR controls. The age, calendar and educational level adjusted prevalence ratio of having a diagnosis of MS at the first MAR treatment was 1.27 (95% CI 1.07-1.52) for infertile women compared with fertile DMBR controls, and 1.00 (95% CI 0.77-1.31) for comparison to women with a male partner with infertility who had also undergone MAR treatment. We found no association between incident MS and female infertility compared with either of the control groups of fertile women. The cohort of infertile women is highly selected on the basis of their choice of having fertility treatment and thus does not include women with unestablished infertility or women who, for some reason, have chosen not to have MAR treatment. Additionally, due to the nature of the observational study design, we cannot exclude the possibility of unmeasured and/or residual confounding. Our results suggest that women with MS may undergo MAR treatment more often than women without MS due to more awareness about the possibility of MAR treatments, sexual dysfunction related to MS disease, but also need for timing of the pregnancy to avoid an unnecessary long time period without disease modifying therapy-especially of high efficacy-and hence a wish to conceive quickly. These findings are important for clinicians dealing with women with MS of childbearing age. The authors received no financial support for the study. T.I.K. has served on a scientific advisory board for Novartis and has received support for congress participation from Biogen. M.M. has served on scientific advisory boards for Biogen, Sanofi, Roche, Novartis, Merck, Abbvie and Alexion. She has received honoraria for lecturing from Biogen, Merck, Novartis, Sanofi and Genzyme and has received research support and support for congress participation from Biogen, Genzyme, Roche, Merck and Novartis. The remaining authors declare no conflict of interest. N/A.

Marijuana Is Associated With a Hormonal Imbalance Among Several Habits Related to Male Infertility: A Retrospective Study.

Marijuana is one of the most consumed drugs worldwide. There is increasing evidence of an association between marijuana and male infertility. This study intends to assess the repercussion of marijuana smoking and other habits (sedentary lifestyle, alcohol, and tobacco use) in the testicular function of infertile men seeking andrological evaluation. A retrospective study was performed using medical records data of men aged 18–59 years from 2009 to 2017. Complete semen analyses, sperm functional tests, SHBG, and hormonal levels, testosterone-to-estradiol ratio (T/E2), and testis volume were evaluated. Exclusion criteria included cryptorchidism, infertility caused by genetic or infectious diseases, and cancer. A multiple linear regression analysis was performed to investigate which habit could predict certain parameters using the software SPSS 23.0 (P < 0.05). In a sample of 153 men, semen parameters, testosterone levels, and testis volume were not significantly influenced. Marijuana use had the broader hormonal changes since it influences estradiol (P = 0.000; B = −11.616), prolactin (P = 0.000; B = 3.211), SHBG levels (P = 0.017; B = 7.489), and T/E2 (P = 0.004; B = 14.030). Sedentary lifestyle (P = 0.028; B = 1.279) and tobacco smoking (P = 0.031; B = −2.401) influenced the prolactin levels. Marijuana is associated with hormonal imbalance in this infertile cohort by lowering estradiol levels and inhibiting aromatase function.

Fertility drugs and incidence of thyroid cancer in a Danish nationwide cohort of 146 024 infertile women.

Do fertility drugs increase the risk of thyroid cancer among infertile women? The use of most types of fertility drugs was not associated with an increased risk of thyroid cancer. The incidence of thyroid cancer is higher for women than men, especially during reproductive years, indicating that reproductive hormones may be involved in the development of thyroid cancer. Only a few previous studies have examined the association between the use of fertility drugs and incidence of thyroid cancer and the results are inconclusive. A retrospective, population-based cohort study including all 146 024 infertile women aged 20-45 years and living in Denmark in the period 1995-2017. The women were followed from the date of entry in the cohort (i.e. date of first infertility diagnosis) until the occurrence of thyroid cancer or any other cancer (except non-melanoma skin cancer), death, emigration, total thyroidectomy or the end of follow-up (31 December 2018), whichever occurred first. The median length of follow-up was 11.3 years. In total, 167 women were diagnosed with thyroid cancer during the follow-up period. Information on the use of specific fertility drugs (clomiphene citrate, gonadotropins, hCGs, GnRH receptor modulators and progesterone), thyroid cancer, covariates and vital status was obtained from the Danish Infertility Cohort and various Danish national registers. Cox proportional hazard regression models were used to calculate hazard ratios (HRs) and 95% CIs for thyroid cancer overall and for papillary thyroid cancer. After adjustment for the calendar year of infertility diagnosis, the highest obtained level of education, parity status, obesity or thyroid disease and mutual adjustment for other registered fertility drugs, no marked associations were observed between the use of clomiphene citrate, hCG, gonadotropins or GnRH receptor modulators and risk of overall or papillary thyroid cancer. However, ever use of progesterone was associated with an increased rate of both overall (HR 1.63; 95% CI 1.07-2.48) and papillary (HR 1.66, 95% CI 1.04-2.65) thyroid cancer after mutual adjustment for other specific fertility drugs. For most specific fertility drugs, we observed a tendency toward higher associations with thyroid cancer within the first 5 years after the start of drug use than after 5 years from the start of use. No marked associations were detected according to the cumulative dose for any of the specific fertility drugs. Despite a large study population, the statistical precision in some subgroup analyses may be affected due to the low number of thyroid cancer cases. Although we were able to adjust for a number of potential confounders, residual and unmeasured confounding may potentially have affected the observed associations, as we could not adjust for some factors that may influence the association between fertility drugs and thyroid cancer, including age at menarche and BMI. Although this study, which is the largest to date, provides reassuring evidence that there is no strong link between the use of fertility drugs and thyroid cancer incidence, we observed a modest increased thyroid cancer incidence after the use of progesterone. However, we cannot rule out that this is a chance finding and the potential association between the use of progesterone and thyroid cancer should therefore be investigated further in large epidemiological studies. The results of the present study provide valuable knowledge for clinicians and other health care personnel involved in the diagnosis and treatment of infertility. The study was supported by research grants from the Jascha Foundation and the Aase and Ejner Danielsens Foundation. B.N. received honoraria and/or non-financial support by Gedeon Richter Nordics AB, IBSA Nordic APS and Merck KGAA. The remaining authors have no competing interests. N/A.