RUOLO DI VITAMINE E MICRONUTRIENTI NELLA DIAGNOSI E CURA DELL¿INFERTILITÀ DI COPPIA

Introduction Maternal nutritional status is considered by many Authors to be closely related to the reproductive success. The human reproductive process, from a probabilistic point of view, is ineffective and, in spite of the scientific research progressively adding elements to the understanding of reproductive failure, the mechanisms underlying the failure to conceive, the embryonic arrest and the occurrence of neonatal malformations remain largely unknown. In this area, nutrition and micronutrient status represent an important research target for two main aspects: 1) nutrition as a cause of reproductive failures 2) nutritional status as a key variable influencing the chance of success in assisted reproduction procedures. Aim This PhD project has been focused on the study of specific analytes in infertile couples, with particular reference to the probability of success in terms of pregnancy given particular conditions of deficiency / insufficiency. Methods and results The project was conducted at the \u201cInfertility Unit\u201d of the Fondazione IRCCS Ca 'Granda Ospedale Maggiore Policlinico of Milan in collaboration with the Department of Clinical Sciences and Community at the University of Milan, in order to assess the baseline status of specific micronutrients and place it in relation to the chances of getting pregnant using assisted reproductive technologies. Evaluated analytes (vitamin D, folate, homocysteine, vitamin B12, vitamin E, vitamin E, iron and ferritin) were selected based on their involvement in the reproductive process. Subjects were recruited from couples treated for infertility; in the study of serum levels in infertile compared to subfertile women, recruitment was performed among pregnant women during the first trimester prenatal screening (U.O. Obstetrics and Gynecology). Several outcomes were evaluated using case series disjointed or partially overlapping. In particular, the PhD work was divided into 5 main studies, the characteristics of which are summarized in the following scheme: Study: 1 Analyte: Vitamin D Main Outcome: Pregnancy Rate in in vitro fertilization cycles Design: Prospective cross-sectional Subjects: 480 women in infertile couples Main results: Women with 25 (OH) D 65 20 ng / ml are more likely to have a pregnancy compared to those with 25 (OH) D insufficiency. Adjusted OR = 2.15 (95% CI: 1.23-3.77) (p = 0 .007). Study: 2 Analyte: Vitamin D Main Outcome: Concordance of serum levels between partners Design: Prospective cross-sectional Subjects: 103 infertile couples Main results: 71% of infertile couples showed concordance between a condition of sufficiency or insufficiency between partners. This frequency is higher than expected in case of random assortment between partners(p = 0.007). Study: 3 Analyte: Vitamin D Main outcome: Serum levels in fertile versus subfertile women Design: Prospective case-control Subjects: 73 cases and 73 controls Main results: Vitamin D status does not affect the natural fertility. OR for subfertility (time to pregnancy> 12 months) in women with low vitamin D = 0.85 (95% CI: 0.44-1.62) Study: 4 Analytes: Folate, Homocystein, Vitamin B12, Vitamin A, Vitamin E, Iron, Ferritin Main outcome: Rate of insufficiency Design: Prospective cross-sectional Subjects: 269 women in infertile couples Main results: Only a minority of women attending an Infertility Unit show pre-gestational values of \u200b\u200bintraerythrocytic folate (12%) and vitamin B12 (44%) Study: 5 Analytes: Folate, Homocystein, Vitamin B12 Main outcome: Pregnancy Rate in in-vitro fertilization cycles Design: Prospective cross-sectional Subjects: 209 women in infertile couples Main results: Women with serum and intraerythrocytic folate in the third tertile of concentration are more likely to obtain a clinical pregnancy in in-vitro fertilization cycles. OR = 2.8 (1.5-5.3) and 2.1 (1.1-4.0), respectively. Conclusion Infertile couples, and women in particular, have a high incidence of vitamin D, folate and vitamin B12 insufficiency. This condition, with specific regards to vitamin D and folate, while represents a risk factor for complications of a possible pregnancy, is strongly associated with a lower success rate of in-vitro fertilization. Further studies are needed to identify possible causal relationships between insufficiency of specific analytes and reproductive failure. The demonstration of a benefit in terms of pregnancies per in-vitro fertilization cycle through the use of supplementation of micronutrients would be a result of huge interest because it would represent the rationale for an effective, economic and easy intervention, to be implemented in an area where progress is slow and mostly dependent on expensive technologies

Risk factors for monozygotic twinning after in vitro fertilization : a systematic review and meta-analysis

Objectives: To establish the risk factors for monozygotic twin (MZT) and monochorionic twin (MCT) pregnancies after in vitro fertilization (IVF). Design: Systematic review and meta-analysis. Setting: Not applicable. Patient(s): Women who achieved MZT and non-MZT pregnancies through IVF. Intervention(s): Systematic search of Medline from January 1995 to October 2018 with cross-checking of references from relevant articles in English. Main Outcome Measure(s): Possible risk factors for MZT or MCT pregnancies after IVF, comprising extended embryo culture, insemination method (conventional IVF and intracytoplasmic sperm injection [ICSI]), embryo biopsy for preimplantation genetic testing for aneuploidies or for monogenic/single-gene defects (PGT-A or PGT-M) programs, assisted hatching (AH), oocytes donation, female age, and embryo cryopreservation. Result(s): A total of 40 studies were included. Blastocyst transfer compared with cleavage-stage embryo transfer, and female age <35 years were associated with a statistically significant increase in the MZT and MCT pregnancy rate after IVF: (23 studies, OR 2.16, 95% CI, 1.74\u20132.68, I 2 =78%; 4 studies, OR 1.29; 95% CI, 1.03\u20131.62, I 2 =62%; and 3 studies, OR 1.90, 95% CI, 1.21\u20132.98, I 2 =59%; 2 studies, OR 2.34; 95% CI, 1.69\u20133.23, I 2 =0, respectively). Conventional IVF compared with ICSI and assisted hatching were associated with a statistically significantly increased risk of MZT pregnancy (9 studies, OR 1.19, 95% CI, 1.04\u20131.35, I 2 =0; 16 studies, OR 1.17, 95% CI, 1.09\u20131.27, I 2 =29%, respectively). Embryo biopsy for PGT-A or PGT-M, embryo cryopreservation, and oocytes donation were not associated with MZT pregnancies after IVF. Conclusion(s): Blastocyst transfer is associated with an increased risk of both MZT and MCT pregnancies after IVF. Further evidence is needed to clarify the impact of female age, insemination method and AH on the investigated outcomes

Ovarian stimulation and endometriosis progression or recurrence: a systematic review

Available evidence on the impact of ovarian stimulation on the progression of endometriosis or its recurrence was systematically reviewed. Data from ovarian stimulation alone, or associated with intrauterine insemination (IUI) or IVF, were included. Sixteen studies were selected. Initial case reports (n = 11) documented some severe clinical complications. However, subsequent observational studies were more reassuring. Overall, five conclusions can be drawn: (i) IVF does not worsen endometriosis-related pain symptoms (moderate quality evidence); (ii) IVF does not increase the risk of endometriosis recurrence (moderate quality evidence); (iii) the impact of IVF on ovarian endometriomas, if present at all, is mild (low quality evidence); (iv) IUI may increase the risk of endometriosis recurrence (low quality evidence); (v) deep invasive endometriosis might progress with ovarian stimulation (very low quality evidence). In conclusion, available evidence is generally reassuring (at least for IVF) and does not justify aggressive clinical approaches such as prophylactic surgery before assisted reproductive technology treatment to prevent endometriosis progression or recurrence. However, further evidence is required before being able to reach definitive conclusions. In particular, the potential effects on deep invasive endometriosis and the possible synergistic effect of stimulation and pregnancy are two areas that need to be explored further

The Rapid Growth of Fibroids during Early Pregnancy

Several studies aimed to disentangle whether pregnancy influences the growth of uterine fibroids but results were inconsistent. In this study, we speculated that fibroid enlargement during pregnancy may not be linear and we hypothesized that this phenomenon may mainly occur during initial pregnancy. To test this hypothesis, we set up a prospective cohort study of women with fibroids undergoing IVF. Cases were women achieving a viable pregnancy. Controls were the subsequent women with fibroids but failing to become pregnant. Twenty-five cases and 25 controls were recruited. The total number of fibroids in the two groups was 46 and 41, respectively. The mean \ub1 SD diameter of the fibroids was 17 \ub1 10 and 20 \ub1 11 mm, respectively (p = 0.18). A statistically significant enlargement emerged exclusively in pregnant women. The median (Interquartile Range) modification of the diameter of the lesions in cases and controls was +34% (+6%/+65%) and +2% (-6%/+12%), respectively (p<0.001). The median (Interquartile Range) modification of the volume of the lesions was +140% (+23%/+357%) and 0% (-18%/+37%), respectively (p<0.001). In pregnant women, we failed to document any significant correlation between the magnitude of the growth and ovarian responsiveness to hyper-stimulation, suggesting that steroids hormones are not the unique factors involved. In conclusion, fibroids undergo a rapid and remarkable growth during initial pregnancy. Reasons behind this phenomenon remain to be clarified. The early rise in steroids hormones during early pregnancy may not be sufficient to explain the process. Other pregnancy-related hormones and proteins may play also key roles

Variables affecting long-term usage rate of sperm samples cryopreserved for fertility preservation in cancer patients

Background: Previous evidence highlighted that only a minority of men who banked their semen before cancer therapies subsequently used their frozen samples. This may question the economical validity of sperm cryopreservation programmes. However, in most contributions, the duration of follow-up was insufficient to draw robust information on the real rate of use. Objectives: To shed more light on the potential benefits of cryopreservation programmes. Materials and methods: Men who cryopreserved their semen in a public hospital for a diagnosis of cancer between 1986 and 2009 were retrospectively reviewed. The rate of use as well as the possible determinants was investigated. Results: The median time of follow-up was 12 [IQR: 7-16] years. One hundred forty-four patients out of 1,524 (9.4%, 95%CI: 8.1%-11.0%) used their frozen samples of whom 64% were azoospermic. The rate of men achieving parenthood with frozen semen was 46%. Predictive factors of use were older age at the time of storage, lower sperm count at the time of storage and a diagnosis of testicular cancer. The impact of this latter factor was also supported by the lower frequency of azoospermia after cancer treatment in these patients. Discussion: Cost-beneficial studies are warranted to assess and possibly improve the economical validity of sperm banking. Conclusion: The usage rate of frozen sperm in cancer patient is low, even extending the duration of follow-up

Vitamin D deficiency and infertility : insights from in vitro fertilization cycles

Context: Vitamin D deficiency has been proven to affect fertility in mammals, but data in human is less convincing. In particular, data on in vitro fertilization (IVF), an attractive model to draw information on this topic, are sparse and conflicting.Objective: Our objective was to investigate IVF outcome in women with deficient 25-hydroxyvitamin D [25 (OH)D] serum levels (30 ng/mL) had the highest chances of pregnancy.Conclusions: VitaminDis an emerging factor influencing female fertility and IVF outcome. Additional studies are pressingly needed to confirm a causal relationship and to investigate the potential therapeutic benefits of vitamin D supplementation

Effect of vitamin D supplementation on assisted reproduction technology (ART) outcomes and underlying biological mechanisms: protocol of a randomized clinical controlled trial. The "supplementation of vitamin D and reproductive outcome" (SUNDRO) study

Background Vitamin D plays an important role in human physiology and pathology. The receptor for vitamin D regulates 0.5-5% of the human genome. Accordingly, vitamin D insufficiency has been shown to increase the risk of several diseases. In recent years, based on growing evidence, on a role of vitamin D has been also postulated in reproductive health both in animals and humans, especially in female fertility female fertility. In vitro fertilization success was shown to be higher in women with appropriate reserves of vitamin D. However a causal relation has not been demonstrated and randomized controlled trials testing the effectiveness of vitamin D supplementation in IVF are warranted. Methods This is a multicenter randomized double blinded placebo controlled study aimed at determining the benefits of vitamin D [25(OH)D] supplementation in improving clinical pregnancy rate in women undergoing IVF. Eligible women with a serum level of 25-hydroxyvitamin D [25(OH)D] < 30 ng/ml will be randomized. Recruited women will be given the drug (either 600,000 IU of 25(OH) D or placebo in a single oral administration) at the time of randomization. Two centres will participate and the sample size (700 women) is foreseen to be equally distributed between the two. Patients will be treated according to standard IVF protocols. Discussion The primary aim of the study is the cumulative clinical pregnancy rate per oocyte retrieval. Clinical pregnancy is defined as the presence of at least one intrauterine gestational sac with viable foetus at first ultrasound assessment (3 weeks after a positive human chorionic gonadotropin [hCG] assessment). Secondary outcomes include: 1) clinical and embryological variables; 2) oocyte and endometrium quality at a molecular level. To investigate this latter aspect, samples of cumulus cells, follicular and endometrial fluids will be obtained from a subgroup of 50 age-matched good-prognosis cases and controls

Repeated implantation failure at the crossroad between statistics, clinics and over-diagnosis

The most common definition of repeated implantation failure (RIF) is the failure to obtain a clinical pregnancy after three completed IVF cycles. This definition, however, may lead to misuse of the diagnosis. To disentangle this, we set up a mathematical model based on the following main assumptions: rate of success of IVF constant and set at 30%; and RIF postulated to be a dichotomous condition (yes or no) with a prevalence of 10%. On this basis, the expected cumulative chance of pregnancy after three and six cycles was 59% and 79%, respectively. Consequently, the false\u2013positive rate of a diagnosis of RIF is 75% and 51%, respectively. Increasing the rate of success of IVF or the prevalence of RIF lowers but does not make unremarkable the rate of false\u2013 positive diagnoses. Overall, this model shows that the commonly used definition of RIF based on three failed attempts in a standard population with good prognosis leads to over-diagnosis and, potentially, to over-treatments

The long pentraxin 3 is a soluble and cell-associated component of the human semen

The long pentraxin 3 (PTX3) is a multifunctional soluble pattern recognition receptor, involved in several processes ranging from innate resistance and inflammation to clearance of apoptotic cells and organization of hyaluronic acid-rich extracellular matrices. PTX3 is also a novel marker in several pathological conditions of infectious, inflammatory, or autoimmune origin. This study was designed to assess whether PTX3 is expressed in the male reproductive tract and whether PTX3 interacts with human spermatozoa influencing their function. Here we show for the first time by immunohistochemistry that PTX3 is expressed in the male genital tract in perivascular connective tissue, in endothelial cells, in the interstitium, and in the cytoplasm of prostatic epithelial glandular cells; PTX3 was detectable in seminal plasma in variable levels, which correlated with the percentage of normal spermatozoa. Moreover, PTX3 binds to spermatozoa, in particular with immotile cells, localizing in the neck and in the subacrosomial region. Finally, recombinant PTX3 did not interfere with sperm motility

High prevalence of vitamin D deficiency in infertile women referring for assisted reproduction

A comprehensive analysis of the vitamin D status of infertile women is the first step in understanding hypovitaminosis impact on reproductive potential. We sought to determine vitamin D profiles of women attending an infertility center and to investigate non-dietary determinants of vitamin D status in this population. In this cross-sectional analysis, a cohort of 1072 women (mean age \ub1 standard deviation 36.3 \ub1 4.4 years) attending an academic infertility center was used to examine serum 25-hydroxy-vitamin D (25(OH)D) levels in relation to demographic characteristics, seasons and general health risk factors. Both unadjusted and adjusted levels of serum 25(OH)D were examined. Median 25(OH)D concentration was below 30 ng/mL for 89% of the entire year. Over the whole year, 6.5% of patients had 25(OH)D levels 6410 ng/mL, 40.1% 6420 ng/mL, and 77.4% 6430 ng/mL. Global solar radiation was weakly correlated with 25(OH)D levels. At multivariable analysis, 25(OH)D levels were inversely associated with BMI; conversely, 25(OH)D levels were positively associated with height and endometriosis history. Serum 25(OH)D levels are highly deficient in women seeking medical help for couple\u2019s infertility. Levels are significantly associated with body composition, seasonal modifications and causes of infertility. Importantly, this deficiency status may last during pregnancy with more severe consequences