The Study Of Sex Hormones And Their Metabolites And Threatened Abortion And The Correlation Between Changes In Maternal Testosterone In Early Pregnancy And Pregnancy Outcomes With Assisted Reproductive Technology

Part 1 The Study of Sex Hormone and and Their Metabolites and Threatened AbortionObjective: Threatened abortion is a common obstetric disease,and the incidence of threatened abortion has been increased in these years,which is higher in pregnancy by assisted reproduction than that of natural pregnancy.In addition to a part of fetal chromosomal abnormalities,the pathogenesis of some threatened abortion is not clear.Maternal sex hormone metabolism after pregnancy has taken important changes to maintain the growth and development of embryos(fetals).Once the balance of the maternal environment is brokened by external or internal factors,adverse pregnancy outcomes will be caused,including threatened abortion,spontaneous abortion.The purpose of this study is to evaluate changes of sex hormone metabolism in patients with threatened miscarriage,in order to understand the pathogenesis of threatened abortion,and provide the theoretic basis for clinical therapy.Material and methods: 73 women with early natural pregnancy(6-8 weeks of gestation)were recruited and divided into the following two groups based on whether they suffered from vaginal bleeding or not: group A(n=34),the threatened abortion group;and group B(n=39),the normal pregnancy group.65 women in early pregnancy by frozen and thawing embryos and transfer(F-ET)(28-40 days after embryos transfer,about 6-8 weeks of gestation)were recruited and divided into the following two groups based on whether they suffered from vaginal bleeding or not: group C(n=33),the threatened abortion group by F-ET;and group D(n=32),the normal pregnancy group by F-ET.The serum levels of human chorionic gonadotrophin(h CG),estradiol(E2),progesterone(P4)and testosterone(T)serum levels were tested and sex hormone metabolites in the urine were detected by using Gas chromatography-triple quadrupole mass spectrometry(GC-MS/MS).As the control,data of sex hormones and their metabolites were obtained in normal non-pregnant women of childbearing age(control group,n=23).T-tests and Mann-Whitney U test were used to analyze measurement data between the two groups;analysis of variance and Kruskal Wallis tests were used to analyze measurement data with among the three groups,and ?2 test was used to compare the rates.Results:(1)In natural pregnancy groups,E2 and T serum levels were lower in women with threatened miscarriage(group A)(P=0.009 and0.014,respectively).Estrone(E1),E2,estriol(E3),16?-hydroxyestron(16?-OHE1),4-methoxyestrone(4-Me OE1),2-hydroxyestradiol(2-OHE2)and 4-methoxyestradiol(4-Me OE2)levels were significantly lower in group A(P=0.001,0.003,0.009,0.001,0.012,0.032,and 0.047,respectively.).Urine levels of dehydroepiandrosterone(DHEA),androstenedione(A2)and the metabolite of(A2)were also significantly lower in group A(P=0.007,0.009,and 0.011,respectively).The ratios of 2-OHE1/E1,4-OHE1/E1,2-Me OE1/E1 and 2-Me OE2/E2 were lower in group B,whereas the ratios of 2-OHE2/E2,4-OHE2/E2,and 4-Me OE2/E2 were dramatically lower in all pregnant women(groups A and B)than that in control group.(2)In F-ET groups,there was no significance difference between group C and group D in serum sex hormones.Except testosterone(T)level in group C was lower than group D(P=0.048),there were no statistically difference between the two groups in the other sex hormones and metabolites in urine.Compared with control groups,the activity of the hydroxylation and methylation pathways for estrogen was also decreased in F-ET pregnancy groups,but there were no differences between group C and group D.Conclusions:(1)In natural pregnancy groups,deficiency in DHEA and abnormal levels of sex hormone metabolites may cause a reduction in the activity of estrogens in women with threatened abortion.The activity of the hydroxylation and methylation pathways for estrogen did not descreased timely in threatened abortion group(group A).These alterations may results in vaginal bleeding during the first trimester of natural pregnancy.(2)In F-ET pregnancy groups,there were no differences between the two groups in urine sex hormone and metabolites,except T decreased in group C.There were no differences in the activity of the hydroxylation and methylation pathways for estrogen.These changes were different with natural pregnant groups,which may be caused by supplementation of exogenous estrogen and progesterone.Part 2 The Correlation between Changes in Maternal Testosterone in Early Pregnancy and Pregnancy Outcomes with Assisted Reproductive TechnologyObjective: Androgens play an important role in the female reproductive and endocrine systems.Androgens increase after pregnancy and have an irreplaceable role in maintaining normal pregnancy.Hypersecretion and hyposecretion of androgens during pregnancy will associated with adverse pregnancy outcomes.In this study,we try to investigate the changes in maternal testosterone(T)in early pregnancy after assisted reproductive technology(ART)and its effects on pregnancy outcomes.Materials and methods: A total of 872 subfertile women who conceived with ART between December 2014 and January 2016 in the Reproductive Medicine Center of the First Affiliated Hospital of Anhui Medical University were recruited in this study,which included fresh embryo transfer(IVF-ET,n=234)and frozen-thawed embryo transfer(F-ET,n=638)of IVF.Maternal serum total T level was examined for all pregnant women both in pre-pregnant and at early pregnancy(6-8 weeks of gestation).All the pregnant women were followed-up including vaginal bleeding in early pregnancy,miscarriage,complications during pregnancy,premature delivery(PTD)and delivery mode.Result(s):(1)In the F-ET cycles,except for 35 cases that were lost to follow-up after the third review and 36(5.6%)miscarried,a total of 567(88.9%)were delivered.The median multiple T increasing after pregnancy was 1.90 with IQR: 1.18-3.02.By single factor and multifactor correlation analysis,the multiple T increasing after pregnancy showed no relation to vaginal bleeding in early pregnancy(c OR 0.950,95% CI 0.892-1.102;a OR 1.018,95% CI 0.982-1.154,P>0.05),miscarriage(c OR 1.024,95% CI 0.895-1.173;a OR 1.002,95% CI 0.989-1.106;P>0.05),pregnancy complications(c OR 0.997,95% CI 0.902-1.102;a OR 0.969,95% CI 0.873-1.075;P>0.05),PTD(c OR 0.985,95% CI 0.885-1.036;a OR 1.009,95% CI 0.921-1.106;P>0.05)or cesarean delivery(c OR 1.108,95% CI 0.927-1.118,a OR 1.030,95% CI 0.926-1.144;P>0.05)?(2)In the IVF/ICSI-ET cycles,except for 2(0.8%)cases that were lost to follow-up after the third review and18(7.7%)were abortion,a total of 214(88.9%)were delivered.The median of multiple T increasing after pregnancy was 2.83 with IQR: 1.69-4.82.After single factor correlation analysis,the multiple T increasing was associated with pregnancy complications(c OR 1.078,95% CI 1.009-1.153,P<0.05).After a subsequent analysis adjusting for confounders,we found that patients with increased serum T in early pregnancy had a higher incidence of pregnancy complications(a OR 1.101,95% CI 1.006-1.204,P<0.05).By single factor and multifactor correlation analysis,the multiple T increasing after pregnancy showed no relation to vaginal bleeding in early pregnancy(c OR 1.005,95% CI 0.938-1.077;a OR 1.033,95% CI0.949-1.123;P>0.05),miscarriage(c OR 0.981,95% CI 0.860-1.118;a OR 0.974,95% CI 0.863-1.414;P>0.05),PTD(c OR 0.997,95% CI0.942-1.054;a OR 1.104,95% CI 0.886-1.159;P>0.05),or cesarean delivery(c OR,0.992,95% CI 0.914-1.076;a OR 1.040,95% CI 0.928-1.165;P>0.05).(3)Both Fresh-ET and Frozen-ET cycles,single factor correlation analysis(c OR 1.674,95% CI 1.165-2.404,P<0.01 and c OR 2.249,95% CI 1.191-4.246,P<0.05)and multifactor correlation analysis(a OR 1.900,95% CI 1.225-2.947,P<0.01 and a OR 2.423,95% CI1.157-5.074,P<0.05),all results showed that the type of infertility was associated with vaginal bleeding in early pregnancy.(4)Twin pregnancy had a significant effect on PTD(c OR 2.735,95% CI 1.997-3.746;a OR 2.887,95% CI 2.014-4.138 and c OR 3.368,95% CI 1.849-6.138;a OR 3.369,95% CI 1.725-6.579,P <0.01 respectively)and cesarean delivery(cOR3.054,95% CI 1.700-5.489;a OR 4.321,95% CI 2.190-8.525 and c OR 2.462,95% CI1.246-4.864;a OR 2.679,95% CI1.236-5.086,P <0.01 respectively).Conclusion(s): The multiple T increasing after pregnancy was significantly associated with pregnancy complications in the IVF/ICSI-ET cycles,but it had no relation to pregnant complications in the F-ET cycles.The multiple T increasing had no relation to vaginal bleeding,miscarriage,or delivery mode neither in Frozen-ET cycles nor fresh-ET cycles.Patients with secondary infertility are prone to vaginal bleeding in the early stage of pregnancy via ART pregnancy,and twin pregnancies have high statisticly risk for PTD and caesarean delivery.Further investigation is necessary to elucidate the etiology of increased maternal and neonatal morbidity among women treated with ART.