Assessment of risk factors for low bone mineral density in Brazilian postmenopausal women

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Seasonal variability in the fertilization rate of women undergoing assisted reproduction treatments

The objective of this study was to evaluate whether seasonality affects human-assisted reproduction treatment outcomes. For this, 1932 patients undergoing intracytoplasmic sperm injection (ICSI) were assigned to a season group according to the day of oocyte retrieval: winter (n = 435), spring (n = 444), summer (n = 469) or autumn (n = 584). Analysis of variance was used to compare the ICSI outcomes. The fertilization rate was increased during the spring (winter: 67.9%, spring: 73.5%, summer: 68.7% and autumn: 69.0%; p < 0.01). In fact, a nearly 50% increase in the fertilization rate during the spring was observed (odds ratio 1.45, confidence interval 1.20-1.75; p < 0.01). The oestradiol concentration per number of oocytes was significantly higher during the spring (winter: 235.8 pg/mL, spring: 282.1 pg/mL, summer: 226.1 pg/mL and autumn: 228.7 pg/mL; p = 0.030). This study demonstrates a seasonal variability in fertilization after ICSI, where fertilization is higher during the spring than at any other time.

Effect of hormone therapy on postural balance in postmenopausal women

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Metabolic syndrome and its associated risk factors in Brazilian postmenopausal women

Objective To evaluate the prevalence of metabolic syndrome (MetS) and its associated risk factors in Brazilian postmenopausal women.Methods In this cross-sectional study, a total of 368 postmenopausal women, aged 40-75 years, seeking health care at a public outpatient center in Southeastern Brazil, were included. According to the US National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, MetS was diagnosed in subjects with three or more of the following: waist circumference >= 88 cm, blood pressure >= 130/85 mHg, triglycerides >= 150 mg/dl, high density lipoprotein cholesterol <50 mg/dl and glucose >= 110 mg/dl. Data on past medical history, tobacco use, anthropometric indicators, and values of C-reactive protein (CRP) were collected. Multivariate analysis, using a logistic regression model (odds ratio, OR) was used to evaluate the influence of various simultaneous MetS risk factors.Results The prevalence of having at least three, four and five MetS diagnostic criteria were met in 39.6%, 16.8% and 3.8% of the cases, respectively. The most prevalent risk factor was abdominal obesity, affecting 62.5% of women. The risk of MetS increased with a personal history of diabetes (OR 5.95, 95% confidence interval (CI) 2.82-12.54), hypertension (OR 4.52, 95% CI 2.89-7.08), cardiovascular disease (OR 2.16, 95% CI 1.18-3.94) and high CRP (>1 mg/dl) (OR 3.35, 95% CI 1.65-6.79). Plasma CRP levels increased with the number of MetS components present. Age, time since menopause and smoking had no influence, while hormone therapy reduced MetS risk (OR 0.64, 95% CI 0.42-0.97).Conclusion Metabolic syndrome was highly prevalent among Brazilian postmenopausal women seeking gynecologic health care. Abdominal obesity, diabetes, hypertension and high CRP were strong MetS predictors and hormone therapy appeared to play a protective role for this condition.

Relationship between visualization of meiotic spindle in human oocytes and ICSI outcomes: a meta-analysis

The objective of this meta-analysis was to investigate the influence of meiotic spindle visualization in human oocytes on intracytoplasmic sperm injection (ICSI) outcomes. Search strategies included on-line Surveys of databases (MEDLINE, em BASE, Science Citation Index, Cochrane Controlled Trials Register and Ovid). The fixed effect was used for odds ratio. Ten trials fulfilled the inclusion criteria comparing in-vitro and clinical ICSI outcomes with or without visualization of meiotic spindle in fresh and in-vivo matured oocytes. According to the meta-analysis, the results showed statistically significant higher fertilization rate (P < 0.0001) when the meiotic spindle was viewed than when it was not. Moreover, the percentage of pro-nuclear-stage embyros with good morphology (P = 0.003), cleavage rate (P < 0.0001), percentage of day-3 top-quality embryos (P = 0.003) and percentage of embryos that reached the blastocyst stage (P < 0.0001) were statistically significantly better among, embryos derived from oocytes in which meiotic spindle was viewed compared with those in which meiotic spindle was not observed. However, these differences were not observed in the clinical pregnancy or implantation rates. This observation has clinical relevance mainly in countries where there is a legal limit on the number of oocytes to be fertilized. However, additional controlled trials are needed to further confirm these results.

Single-embryo transfer reduces clinical pregnancy rates and live births in fresh IVF and Intracytoplasmic Sperm Injection (ICSI) cycles: a meta-analysis

Background: It has become an accepted procedure to transfer more than one embryo to the patient to achieve acceptable ongoing pregnancy rates. However, transfers of more than a single embryo increase the probability of establishing a multiple gestation. Single-embryo transfer can minimize twin pregnancies but may also lower live birth rates. This meta-analysis aimed to compare current data on single-embryo versus double-embryo transfer in fresh IVF/ICSI cycles with respect to implantation, ongoing pregnancy and live birth rates.Methods: Search strategies included on-line surveys of databases from 1995 to 2008. Data management and analysis were conducted using the Stats Direct statistical software. The fixed-effect model was used for odds ratio (OR). Fixed-effect effectiveness was evaluated by the Mantel Haenszel method. Seven trials fulfilled the inclusion criteria.Results: When pooling results under the fixed-effect model, the implantation rate was not significantly different between double-embryo transfer (34.5%) and single-embryo transfer group (34.7%) (P = 0.96; OR = 0.99, 95% CI 0.78, 1.25). on the other hand, double-embryo transfer produced a statistically significantly higher ongoing clinical pregnancy rate (44.5%) than single-embryo transfer (28.3%) (P < 0.0001; OR: 2.06, 95% CI = 1.64,2.60). At the same time, pooling results presented a significantly higher live birth rate when double-embryo transfer (42.5%) (P < 0.001; OR: 1.87, 95% CI = 1.44,2.42) was compared with single-embryo transfer (28.4%).Conclusion: Meta-analysis with 95% confidence showed that, despite similar implantation rates, fresh double-embryo transfer had a 1.64 to 2.60 times greater ongoing pregnancy rate and 1.44 to 2.42 times greater live birth rate than single-embryo transfer in a population suitable for ART treatment.

Administration of single-dose GnRH agonist in the luteal phase in ICSI cycles: a meta-analysis

Background: The effects of gonadotrophin-releasing hormone agonist (GnRH-a) administered in the luteal phase remains controversial. This meta-analysis aimed to evaluate the effect of the administration of a single-dose of GnRH-a in the luteal phase on ICSI clinical outcomes.Methods: The research strategy included the online search of databases. Only randomized studies were included. The outcomes analyzed were implantation rate, clinical pregnancy rate (CPR) per transfer and ongoing pregnancy rate. The fixed effects model was used for odds ratio. In all trials, a single dose of GnRH-a was administered at day 5/6 after ICSI procedures.Results: All cycles presented statistically significantly higher rates of implantation (P < 0.0001), CPR per transfer (P = 0.006) and ongoing pregnancy (P = 0.02) in the group that received luteal-phase GnRH-a administration than in the control group (without luteal-phase-GnRH-a administration). When meta-analysis was carried out only in trials that had used long GnRH-a ovarian stimulation protocol, CPR per transfer (P = 0.06) and ongoing pregnancy (P = 0.23) rates were not significantly different between the groups, but implantation rate was significant higher (P = 0.02) in the group that received luteal-phase-GnRH-a administration. on the other hand, the results from trials that had used GnRH antagonist multi-dose ovarian stimulation protocol showed statistically significantly higher implantation (P = 0.0002), CPR per transfer (P = 0.04) and ongoing pregnancy rate (P = 0.04) in the luteal-phaseGnRH- a administration group. The majority of the results presented heterogeneity.Conclusions: These findings demonstrate that the luteal-phase single-dose GnRH-a administration can increase implantation rate in all cycles and CPR per transfer and ongoing pregnancy rate in cycles with GnRH antagonist ovarian stimulation protocol. Nevertheless, by considering the heterogeneity between the trials, it seems premature to recommend the use of GnRH-a in the luteal phase. Additional randomized controlled trials are necessary before evidence-based recommendations can be provided.

IVF/ICSI outcomes after culture of human embryos at low oxygen tension: a meta-analysis

Background: Improved pregnancy, implantation, and birth rates have been reported after the use of reduced O2 concentration during embryo culture, mainly due to a reduction of the cumulative detrimental effects of reactive oxygen species. However, some studies have failed to report any positive effects. The objective of this meta-analysis was to evaluate the effect of a low-O2 environment on IVF/intracytoplasmic sperm injection (ICSI) outcomes.Methods: All available published and ongoing randomised trials that compared the effects of low (similar to 5%; OC similar to 5) and atmospheric (similar to 20%; OC similar to 20) oxygen concentrations on IVF/ICSI outcomes were included. Search strategies included online surveys of databases from 1980 to 2011. The outcomes measured were fertilisation rate, implantation rate and ongoing pregnancy rates. The fixed effects model was used to calculate the odds ratio.Results: Seven studies were included in this analysis. The pooled fertilisation rate did not differ significantly (P = 0.54) between the group of oocytes cultured at low O2 tension and the group at atmospheric O2 tension. Concerning all cycles, the implantation (P = 0.06) and ongoing pregnancy (P = 0.051) rates were not significantly different between the group receiving transferred sets containing only OC similar to 5 embryos and the group receiving transferred sets with only OC similar to 20 embryos. In a meta-analysis performed for only those trials in which embryos were transferred on day 2/3, implantation (P = 0.63) and ongoing pregnancy (P = 0.19) rates were not significantly different between the groups. In contrast, when a meta-analysis was performed using only trials in which embryos were transferred on days 5 and 6 (at the blastocyst stage), the group with transferred sets of only OC similar to 5 embryos showed a statistically significantly higher implantation rate (P = 0.006) than the group receiving transferred sets with only OC similar to 20 embryos, although the ongoing pregnancy (P = 0.19) rates were not significantly different between the groups.Conclusions: Despite some promising results, it seems too early to conclude that low O2 culture has an effect on IVF outcome. Additional randomised controlled trials are necessary before evidence-based recommendations can be provided. It should be emphasised that the present meta-analysis does not provide any evidence that low oxygen concentration is unnecessary.

Evaluation of postural balance in postmenopausal women and its relationship with bone mineral density- a cross sectional study

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

A new ovarian response prediction index (ORPI): implications for individualised controlled ovarian stimulation

Background: The objective was to present a new ovarian response prediction index (ORPI), which was based on anti-Mullerian hormone (AMH) levels, antral follicle count (AFC) and age, and to verify whether it could be a reliable predictor of the ovarian stimulation response.Methods: A total of 101 patients enrolled in the ICSI programme were included. The ORPI values were calculated by multiplying the AMH level (ng/ml) by the number of antral follicles (2-9 mm), and the result was divided by the age (years) of the patient (ORPI=(AMH x AFC)/Patient age).Results: The regression analysis demonstrated significant (P<0.0001) positive correlations between the ORPI and the total number of oocytes and of MII oocytes collected. The logistic regression revealed that the ORPI values were significantly associated with the likelihood of pregnancy (odds ratio (OR): 1.86; P=0.006) and collecting greater than or equal to 4 oocytes (OR: 49.25; P<0.0001), greater than or equal to 4 MII oocytes (OR: 6.26; P<0.0001) and greater than or equal to 15 oocytes (OR: 6.10; P<0.0001). Regarding the probability of collecting greater than or equal to 4 oocytes according to the ORPI value, the ROC curve showed an area under the curve (AUC) of 0.91 and an efficacy of 88% at a cut-off of 0.2. In relation to the probability of collecting greater than or equal to 4 MII oocytes according to the ORPI value, the ROC curve had an AUC of 0.84 and an efficacy of 81% at a cut-off of 0.3. The ROC curve for the probability of collecting greater than or equal to 15 oocytes resulted in an AUC of 0.89 and an efficacy of 82% at a cut-off of 0.9. Finally, regarding the probability of pregnancy occurrence according to the ORPI value, the ROC curve showed an AUC of 0.74 and an efficacy of 62% at a cut-off of 0.3.Conclusions: The ORPI exhibited an excellent ability to predict a low ovarian response and a good ability to predict a collection of greater than or equal to 4 MII oocytes, an excessive ovarian response and the occurrence of pregnancy in infertile women. The ORPI might be used to improve the cost-benefit ratio of ovarian stimulation regimens by guiding the selection of medications and by modulating the doses and regimens according to the actual needs of the patients.

Dietary factors associated with metabolic syndrome in Brazilian adults

Background: Metabolic Syndrome (MS) is defined as the association of numerous factors that increase cardiovascular risk and diet is one of the main factors related to increase the MS in the population. This study aimed to evaluate the association of diet on the presence of MS in an adult population sample.Methodology: 305 adults were clinically screened to participate in a lifestyle modification program. Anthropometric assessments included waist circumference (WC), body fat and calculated BMI (kg/m(2)) and muscle-mass index (MMI kg/m(2)). Dietary intake was estimated by 24 h dietary recall. Fasting blood was used for biochemical analysis. MS was diagnosed using NCEP-ATPIII (2001) criteria with adaptation for glucose (>= 100 mg/dL). Logistic regression (Odds ratio) was performed in order to determine the odds ratio for developing MS according to dietary intake.Results: An adequate intake of fruits, OR = 0.52 (CI:0.28-0.98), and an intake of more than 8 different items in the diet (variety), OR = 0.31 (CI: 0.12-0.79) showed to be a protective factor against a diagnosis of MS. Saturated fat intake greater than 10% of total caloric value represented a risk for MS diagnosis, OR = 2.0 (1.04-3.84).Conclusion: Regarding the dietary aspect, a risk factor for MS was higher intake of saturated fat, and protective factors were high diet variety and adequate fruit intake.

Perinatal factors associated with early deaths of preterm infants born in Brazilian Network on Neonatal Research centers

Objective: To evaluate perinatal factors associated with early neonatal death in preterm infants with birth weights (BW) of 400-1,500 g.Methods: A multicenter prospective cohort study of all infants with BW of 400-1,500 g and 23-33 weeks of gestational age (GA), without malformations, who were born alive at eight public university tertiary hospitals in Brazil between June of 2004 and May of 2005. Infants who died within their first 6 days of life were compared with those who did not regarding maternal and neonatal characteristics and morbidity during the first 72 hours of life. Variables associated with the early deaths were identified by stepwise logistic regression.Results: A total of 579 live births met the inclusion criteria. Early deaths occurred in 92 (16%) cases, varying between centers from 5 to 31%, and these differences persisted after controlling for newborn illness severity and mortality risk score (SNAPPE-II). According to the multivariate analysis, the following factors were associated with early intrahospital neonatal deaths: gestational age of 23-27 weeks (odds ratio - OR = 5.0; 95%CI 2.7-9.4), absence of maternal hypertension (OR = 1.9; 95%CI 1.0-3.7), 5th minute Apgar 0-6 (OR = 2.8; 95%CI 1.4-5.4), presence of respiratory distress syndrome (OR = 3.1; 95%CI 1.4-6.6), and network center of birth.Conclusion: Important perinatal factors that are associated with early neonatal deaths in very low birth weight preterm infants can be modified by interventions such as improving fetal vitality at birth and reducing the incidence and severity of respiratory distress syndrome. The heterogeneity of early neonatal rates across the different centers studied indicates that best clinical practices should be identified and disseminated throughout the country.

Fatores associados à recorrência da infecção do trato urinário em crianças

OBJETIVOS: verificar a freqüência de infecção urinária recorrente (ITU) e avaliar os fatores associados à recorrência da ITU em crianças. MÉTODOS: estudo retrospectivo de 95 pacientes com seguimento de um ano (68 meninas e 27 meninos, mediana de idade três anos). As variáveis estudadas foram: sexo, idade, febre, constipação, tipo de bactéria, refluxo vésico-ureteral (RVU), anormalidades na cintilografia renal com ácido dimercaptosuccínico (DMSA). RESULTADOS: infecção urinária recorrente ocorreu em 49,5% crianças (19 com trato urinário normal, 19 com RVU e 9 com estenose da junção pielocalicial). Comparando o grupo com ITU recorrente com o grupo sem ITU recorrente não se encontrou diferença significativa entre sexos, presença de febre, constipação e anormalidades na cintilografia renal com DMSA. A ITU recorrente foi significativamente maior nas crianças com um ano ou menos, naquelas menores de dois anos com RVU, nas com bactéria diferente da Escherichia coli e sem profilaxia antibacteriana. Os fatores de risco significativos para a recorrência ITU foram idade < 2 anos (OR = 3,83) e refluxo vésico-ureteral (OR = 4,95). CONCLUSÕES: por causa da elevada freqüência de ITU recorrente é importante o seguimento regular de grupo de crianças com fatores de risco para ITU recorrente.

Cicatrizes renais em crianças com refluxo vesicoureteral primário

OBJETIVO: verificar a incidência de cicatrizes renais em crianças com refluxo vesicoureteral primário, comparando com sexo, idade no diagnóstico, infecção febril, grau do refluxo e tipo de bactéria. MÉTODOS: estudo retrospectivo de 58 crianças, com idade entre dois meses a 11 anos, apresentando refluxo vesicoureteral primário, detectado pela uretrocistografia miccional, após episódio documentado de infecção urinária. Diagnóstico de cicatriz renal foi obtido pela cintilografia com DMSA cinco meses, no mínimo, após o tratamento da infecção urinária; em 40 crianças, o exame foi repetido após período de seis meses a seis anos. RESULTADOS: 45 crianças (77,6%) eram meninas e 13 (22,4%) eram meninos, 51,7% com idade menor ou igual a 2 anos. A incidência de cicatriz renal foi de 55,2%. Houve maior proporção significativa de cicatrizes renais no sexo feminino, na presença do sintoma febre e no refluxo dilatado (III, IV e V). Presença de febre e sexo feminino foram fatores de risco significativos na ocorrência de cicatriz renal (febre - OR= 6,19, e sexo feminino - OR= 4,12). Houve tendência da presença de cicatriz renal em maiores de 2 anos. O intervalo entre início dos sintomas e a primeira consulta foi maior nas crianças com cicatrizes renais. Novas cicatrizes renais foram observadas em 12,5%. CONCLUSÃO: a presença de febre e sexo feminino foram fatores de risco para presença de cicatrizes renais, principalmente no refluxo vesicoureteral dilatado. A alta incidência de cicatrizes renais neste estudo pode estar relacionada ao retardo do diagnóstico do refluxo vesicoureteral.

Fatores de risco associados à mortalidade de recém-nascidos de muito baixo peso na cidade de Botucatu, São Paulo, no período 1995-2000

OBJETIVOS: avaliar as práticas assistenciais, a ocorrência de doenças, a mortalidade durante a hospitalização e os fatores associados em recém-nascidos prematuros de muito baixo peso (PT-MBP). MÉTODOS: estudo transversal comparando dois períodos: 1995-1997 e 1998-2000 e envolvendo todos os PT-MBP nascidos vivos (n= 451), em um centro perinatal, em Botucatu, São Paulo, Brasil. Os fatores de risco pré-natal e pós-natal foram submetidos a análise multivariada. RESULTADOS: a mortalidade diminuiu de 36,2% para 29,5%. A sobrevida melhorou e foi superior a 50% a partir de 28 semanas e de 750 g de peso. O uso de corticosteróide antenatal aumentou de 25% para 42%, o surfactante exógeno de 14% para 28%, com redução na incidência e gravidade da síndrome do desconforto respiratório. A regressão logística mostrou que a síndrome do desconforto respiratório grave, Odds ratio=18, e a sepse precoce, Odds ratio=2,8, foram importantes fatores de risco para morte em 1995-1997. No período de 1998-2000, a sepse precoce e tardia, Odds ratio=10,5 e 12, respectivamente, aumentaram o risco de morte. CONCLUSÕES: a melhora na assistência perinatal diminuiu a mortalidade do PT-MBP. O aumento na exposição antenatal ao corticosteróide diminuiu a gravidade da síndrome do desconforto respiratório. em 1998-2000, a sepse foi o único fator de risco para morte.