Thor Haahr

Abnormal vaginal microbiota may be associated with poor reproductive outcomes: a prospective study in IVF patients

STUDY QUESTION What is the diagnostic performance of qPCR assays compared with Nugent scoring for abnormal vaginal microbiota and for predicting the success rate of IVF treatment? SUMMARY ANSWER The vaginal microbiota of IVF patients can be characterized with qPCR tests which may be promising tools for diagnosing abnormal vaginal microbiota and for prediction of clinical pregnancy in IVF treatment. WHAT IS KNOWN ALREADY Bacterial vaginosis (BV) is a common genital disorder with a prevalence of approximately 19% in the infertile population. BV is often sub-clinical with a change of the vaginal microbiota from being Lactobacillus spp. dominated to a more heterogeneous environment with anaerobic bacteria, such as Gardnerella vaginalis and Atopobium vaginae. Few studies have been conducted in infertile women, and some have suggested a negative impact on fecundity in the presence of BV. STUDY DESIGN, SIZE, DURATION A cohort of 130 infertile patients, 90% Caucasians, attending two Danish fertility clinics for in vitro fertilization (IVF) treatment from April 2014-December 2014 were prospectively enrolled in the trial. PARTICIPANTS/MATERIALS, SETTING AND METHODS Vaginal swabs from IVF patients were obtained from the posterior fornix. Gram stained slides were assessed according to Nugents criteria. PCR primers were specific for four common Lactobacillus spp., G. vaginalis and A. vaginae. Threshold levels were established using ROC curve analysis. MAIN RESULTS AND THE ROLE OF CHANCE The prevalence of BV defined by Nugent score was 21% (27/130), whereas the prevalence of an abnormal vaginal microbiota was 28% (36/130) defined by qPCR with high concentrations of Gardnerella vaginalis and/or Atopobium vaginae. The qPCR diagnostic approach had a sensitivity and specificity of respectively 93% and 93% for Nugent-defined BV. Furthermore, qPCR enabled the stratification of Nugent intermediate flora. Eighty-four patients completed IVF treatment. The overall clinical pregnancy rate was 35% (29/84). Interestingly, only 9% (2/22) with qPCR defined abnormal vaginal microbiota obtained a clinical pregnancy (P = 0.004). LIMITATIONS, REASONS FOR CAUTION Although a total of 130 IVF patients were included in the study, a larger sample size is needed to draw firm conclusions regarding the possible adverse effect of an abnormal vaginal microbiota in relation to the clinical pregnancy rate and other reproductive outcomes. WIDER IMPLICATIONS OF THE FINDINGS Abnormal vaginal microbiota may negatively affect the clinical pregnancy rate in IVF patients. If a negative correlation between abnormal vaginal microbiota and the clinical pregnancy rate is corroborated, patients could be screened and subsequently treated for abnormal vaginal microbiota prior to fertility treatment. STUDY FUNDING/COMPETING INTERESTS This study was funded by The AP Møller Maersk Foundation for the advancement of Medical Science and Hospital of Central Jutland Research Fund, Denmark. No competing interests. TRIAL REGISTRATION NUMBER The project was registered at clinicaltrials.gov (file number NCT02042352).

Treatment of bacterial vaginosis in pregnancy in order to reduce the risk of spontaneous preterm delivery: a clinical recommendation

Bacterial vaginosis (BV) is characterized by a dysbiosis of the vaginal microbiota with a depletion of Lactobacillus spp. In pregnancy, prevalences between 7 and 30% have been reported depending on the study population and the definition. BV may be associated with an increased risk of spontaneous preterm delivery (sPTD). However, it is controversial whether or not BV‐positive pregnant women will benefit from treatment to reduce the risk of sPTD. We could not identify any good‐quality guideline addressing this issue. Consequently we aimed to produce this clinical recommendation based on GRADE.

Gonadotropin-releasing hormone agonist (GnRHa) trigger – State of the art

GnRH agonist (GnRHa) trigger for final oocyte maturation in GnRH antagonist co-treated IVF/ICSI cycles significantly reduces the risk of ovarian hyperstimulation syndrome (OHSS). GnRHa trigger followed by modifications of the standard luteal phase support (modified luteal phase support) secures fresh transfer in the majority of patients with excellent reproductive outcomes. In freeze all cycles (segmented cycles) GnRHa trigger allows oocyte retrieval with a minimal risk of early onset OHSS and good reproductive outcomes in subsequent frozen thaw cycles. Overall, two different luteal phase support strategies have been proposed when a fresh transfer is performed after GnRHa trigger. These involve either boosting the endogenous steroid production or adding exogenous steroids. The present review discusses the advancement of GnRHa trigger in fresh and segmented cycles and how a modified luteal phase support policy in fresh transfer cycles results in good reproductive outcomes as well as a high safety in terms of OHSS reduction. Finally, the new concept of an individualized luteal phase support policy taking the number of pre-ovulatory follicles into account when planning a fresh transfer in GnRHa triggered IVF/ICSI cycle is discussed.

GnRH Agonist Trigger and LH Activity Luteal Phase Support versus hCG Trigger and Conventional Luteal Phase Support in Fresh Embryo Transfer IVF/ICSI Cycles—A Systematic PRISMA Review and Meta-analysis

Introduction The use of GnRH agonist (GnRHa) for final oocyte maturation trigger in oocyte donation and elective frozen embryo transfer cycles is well established due to lower ovarian hyperstimulation syndrome (OHSS) rates as compared to hCG trigger. A recent Cochrane meta-analysis concluded that GnRHa trigger was associated with reduced live birth rates (LBRs) in fresh autologous IVF cycles compared to hCG trigger. However, the evidence is not unequivocal, and recent trials have found encouraging reproductive outcomes among couples undergoing GnRHa trigger and individualized luteal LH activity support. Thus, the aim was to compare GnRHa trigger followed by luteal LH activity support with hCG trigger in IVF patients undergoing fresh embryo transfer. Material and methods We conducted a systematic review and meta-analysis of randomized trials published until December 14, 2016. The population was infertile patients submitted to IVF/ICSI cycles with GnRH antagonist cotreatment who underwent fresh embryo transfer. The intervention was GnRHa trigger followed by LH activity luteal phase support (LPS). The comparator was hCG trigger followed by a standard LPS. The critical outcome measures were LBR and OHSS rate. The secondary outcome measures were number of oocytes retrieved, clinical and ongoing pregnancy rates, and miscarriage rates. Results A total of five studies met the selection criteria comprising a total of 859 patients. The LBR was not significantly different between the GnRHa and hCG trigger groups (OR 0.84, 95% CI 0.62, 1.14). OHSS was reported in a total of 4/413 cases in the GnRHa group compared to 7/413 in the hCG group (OR 0.48, 95% CI 0.15, 1.60). We observed a slight, but non-significant increase in miscarriage rate in the GnRHa triggered group compared to the hCG group (OR 1.85; 95% CI 0.97, 3.54). Conclusion GnRHa trigger with LH activity LPS resulted in comparable LBRs compared to hCG trigger. The most recent trials reported LBRs close to unity indicating that individualization of the LH activity LPS improved the luteal phase deficiency reported in the first GnRHa trigger studies. However, LPS optimization is needed to further limit OHSS in the subgroup of normoresponder patients (<14 follicles ≥ 11 mm). Prospero registration number CRD42016051091

Vaginal seeding or vaginal microbial transfer from the mother to the caesarean-born neonate: a commentary regarding clinical management

Recent evidence suggests cesarean delivery (CD) to be a risk factor for inflammatory and metabolic diseases such as asthma, allergies and other chronic immune disorders in the child. One hypothetical pathogenesis of these associations has been proposed to be a disruption of the neonatal colonization (NC) after CD. To further support this hypothesis, it has been observed that the effect of CD on NC was different according to type of CD, i.e. planned or emergency, and that the risk of asthma in children born by CD was mitigated by rupture of membranes, though still increased compared to children delivered vaginally. This article is protected by copyright. All rights reserved.

Individualized controlled ovarian stimulation in expected poor-responders: an update

Controlled ovarian stimulation with subsequent multi-follicular development continues to be a keystone in ART. Evidence supports an individualized approach to ovarian stimulation, usually involving combinations of ovarian reserve tests, body mass index and age to tailor the exogenous gonadotropin dose, and potentially adjuvant treatment aiming for high safety and a shortening of time to live birth. While stimulation and trigger concepts have been developed successfully in normo- and hyperresponder patients, the poor responder patient remains difficult to manage. However, recent advances in definition and classification of the expected poor ovarian responder patient might enable a more accurate and clinically useful interpretation of new treatment concepts in a more homogenous study population. In the present review, we discuss the classification of the expected poor ovarian responder patient as well as clinically useful measurements of efficacy for controlled ovarian stimulation, and finally, we discuss the evidence for clinical management of patients with expected poor ovarian response, including adjuvant treatments such as growth hormone, androgens, and LH activity.In conclusion, the best available evidence supports that the treatment of the expected poor ovarian response patient should be individualized in all steps of ART, including the choice of GnRH analogue, the gonadotropin type and dose, ovulation trigger, and the possible use of adjuvant therapies.

Reproductive outcome of patients undergoing in vitro fertilisation treatment and diagnosed with bacterial vaginosis or abnormal vaginal microbiota: a systematic PRISMA review and meta‐analysis

Despite recent efforts, the risks associated with bacterial vaginosis (BV) or abnormal vaginal microbiota in IVF patients are not well‐established.

Authors’ reply re: Vaginal seeding or vaginal microbial transfer from the mother to the caesarean‐born neonate: a commentary regarding clinical management

A recent publication in the journal gives us another excellent evidence-based account of the implications of VS. Irrespective of growing evidence of concerns associated with it, there has been a rapid rise in the demand for VS. Emerging clinical evidence, particularly from the study by Dominguez-Bello et al., which showed the partial restoration of microbiota by VS after caesarean section, is interesting. If it is to be of any clinical benefit VS should gift neonates with a more normal colony of organisms, with the associated potential positive health benefits. These may include improvements in the incidence of obesity, autism, asthma, atopic conditions, and other non-communicable diseases. We live in an on-demand world, and expectant mothers can opt for any intervention that keeps their kids on an equal footing with their highly competitive peers. Some Australian hospitals have already developed clinical guidelines for VS for patients who request it. It may be a matter of respecting the patient’s autonomy, responding to pressure from patient advocacy groups, or supporting the expectant woman who may want the feeling that she has ‘ownership’ of the caesarean birth following VS. It seems, however, that nobody knows the answer to the million-dollar question ‘Is vaginal seeding clinically useful?’ Until we find hard evidence, pregnant women will continue making the decision to have VS performed, or not, for the best interests of their neonate. It will be interesting to see the follow-up results and academic performances of the neonates who had VS performed once they become preschoolers and commence regular schooling. This will obviously take a few more years, and until then VS will continue to take place and will continue to create puzzles among care givers, despite the numerous publications against it.& References

Treatment of Abnormal Vaginal Microbiota before Frozen Embryo Transfer: Case-Report and Minireview to Discuss the Longitudinal Treatment Efficacy of Oral Clindamycin

Abnormal vaginal microbiota (AVM) or bacterial vaginosis (BV) might negatively impact reproductive outcomes of in vitro fertilization (IVF). However, before randomized controlled trials are initiated to investigate cause and effect, it is necessary to establish the optimal treatment for AVM. Metronidazole seems ineffective to treat the biofilm in AVM; thus, clindamycin could be suggested as a relevant antibiotic agent for future intervention based studies. In the present case report, we present the first longitudinal follow-up of the vaginal microbiota with molecular methods during and after oral clindamycin treatment. Furthermore, we review the recent literature with the aim to discuss the optimal AVM treatment in a fertility setting. The patient was 40 years old suffering from unexplained secondary infertility. Prior to the present transfer cycle, she had had two failed IVF cycles. The tentative explanation of failed treatment was age-related aneuploidy. However, the patient asked for AVM diagnosis and she was subsequently diagnosed and treated successfully. Unfortunately, the patient did not achieve pregnancy after clindamycin treatment and two subsequent frozen embryo transfer cycles. Taken together, we report an excellent AVM treatment efficacy both short-term and long-term following oral clindamycin treatment. We discuss the potential impact on the vaginal microbiota of co-treatment with estrogen patches in the stimulated frozen embryo transfer cycle. Furthermore, we discuss future aspects of AVM treatment such as the potential impact of estrogen and live biotherapeutic products to positively modulate the microbiota of the reproductive tract.

Progesterone levels on pregnancy test day after hormone replacement therapy-cryopreserved embryo transfer cycles and related reproductive outcomes

RESEARCH QUESTION Do serum progesterone levels determine ongoing pregnancy rates (OPR) in hormone replacement therapy frozen-thawed embryo transfer (HRT-FET) cycles? DESIGN A cohort study of 244 HRT-FET cycles from a Danish public fertility centre. Data from patients undergoing HRT-FET from January 2016 to December 2017 were extracted from a clinical database. All patients had transfer in HRT cycles of autologous embryos frozen on day 5 or 6. Endometrial preparation was performed using 6 mg oestradiol valerate daily from the second day of the cycle followed by vaginal micronized progesterone (90 mg/8 h). All patients had serum progesterone measurement during the artificial luteal phase. RESULTS The optimal cut-off for ongoing pregnancy was 35 nmol/l based on sensitivity analysis of different progesterone levels as a factor variable and its association with ongoing pregnancy. No significant differences regarding number of embryos transferred, embryo quality, age, body mass index (BMI) or smoking were found in the two groups of progesterone < 35 nmol/l and ≥ 35 nmol/l, respectively. A total of 51% of patients had a serum progesterone < 35 nmol/l. The range of all measurements was 0.3 to 110 nmol/l. The unadjusted OPR was significantly lower in the < 35 nmol/l group compared with the ≥ 35 nmol/l group (38% versus 51%;P = 0.04). A logistic regression analysis, adjusting for smoking, age, BMI, number of embryos transferred and blastocyst age showed a significant decrease in OPR when progesterone was < 35 nmol/l of 44% (95% confidence interval [CI] 35-54%) compared with ≥ 35 nmol/l of 58% (95% CI 48-68%), risk difference of 14% (95% CI 2-26%,P = 0.02). CONCLUSIONS Serum progesterone levels < 35 nmol/l decrease the chance of OPR in HRT-FET cycles.