Human Reproduction

Male reproductive disorders affect millions of men worldwide, yet their genetic basis remains poorly understood. Conditions such as infertility, erectile dysfunction, prostate disorders and hormonal abnormalities are common, interconnected and often diagnosed late, underscoring the need for broader biological insight. Using genetic data from over 530,000 men across the Estonian Biobank, FinnGen, and UK Biobank, we analysed 64 male reproductive phenotypes. We identified 143 lead variants associated with these conditions, including 47 not previously linked to male reproductive traits, and detected the first genome-wide signals for 3 understudied disorders. Twelve lead variants showed at least 1.5-fold enrichment in the Finnish and Estonian populations, indicating population-specific effects and utility of isolated cohorts for variant discovery. We also highlighted 328 candidate genes and mapped shared biological pathways across prostate, testicular, penile and hormonal traits. These findings expand knowledge of male reproductive biology and offer entry points for improved diagnosis and risk prediction.

ObjectivesGiven the widespread use of period-tracking applications and evidence that some users rely on fertile-window predictions for pregnancy prevention, we aimed to quantify pregnancy risk arising from misclassification of biologically fertile days by period-tracking applications, and to compare this risk across calendar-based and basal body temperature (BBT)-supported period tracking and a digital contraceptive regulated as a medical device. MethodsWe conducted an observational analysis of cycles of mobile fertility application users who logged urinary luteinizing hormone (LH) tests. Biologically fertile days were defined using an LH-based reference fertile window (days -5 to 0 relative to ovulation). Three approaches were evaluated: a calendar-based period tracking application, a BBT-supported period tracking application, and a FDA-cleared digital contraceptive. Outcomes included day-specific frequency of fertile days misclassified as safe, cycle-level misclassification, and predicted pregnancy risk per cycle. Analyses were repeated in a subgroup of irregular cycles. Results543,167 menstrual cycles with a clear LH surge signature were included in the analysis. Calendar-based period tracking frequently misclassified fertile days as safe, with 67% of cycles containing at least one at-risk day and 25% containing at least one high-risk day. The mean predicted pregnancy risk per cycle was 22%, increasing to 65% in irregular cycles. BBT-supported period tracking reduced misclassification but remained associated with substantial risk (41% of cycles with at least one at-risk day; mean predicted pregnancy risk 9%). In contrast, the digital contraceptive showed consistently low misclassification (3% of cycles with any at-risk day and a mean predicted pregnancy risk of 0.5%). ConclusionsBoth calendar-based and BBT-supported period-tracking applications not intended for contraception frequently misclassify biologically fertile days and should not be considered reliable tools for pregnancy prevention. Regulated digital contraceptives demonstrate substantially lower pregnancy risk. Short condensationPeriod-tracking apps frequently misclassify fertile days as safe, including days with high pregnancy risk. In a large real-world analysis, both calendar- and BBT-supported trackers showed substantial risk, unlike digital contraception methods regulated as a medical device.

The use of semaglutide (SE), a glucagon-like peptide-1 receptor agonist (GLP-1RA) with glucose-lowering and weight-loss effects, has risen rapidly, particularly among women of reproductive age. While preclinical studies suggest benefits for ovarian function via the hypothalamic-pituitary-ovarian axis, its impact on the endometrial-embryo interface remains unclear. Here, we show that GLP-1R is dynamically expressed in fertile human endometrium, restricted to epithelial cells and markedly upregulated during the mid-secretory phase of the menstrual cycle. In a preclinical model of endometrial epithelial organoids, SE at physiological concentrations activates intracellular cAMP signaling, enhances epithelial metabolism, and upregulates receptivity markers without steroid hormone priming, whereas higher concentrations modestly reduce expression of a key receptivity marker PAEP/glycodelin and shift metabolism towards oxidative phosphorylation. By contrast, in stromal cells lacking detectable GLP-1R, SE disrupts decidualization, induces endoplasmic reticulum stress and suppresses cell-cycle at G2/M phase. Human embryo models, blastoids, expressed GLP-1R and underwent concordant SE-mediated transcriptional remodeling in epiblast and trophectoderm lineages, encompassing changes in metabolism and epigenetic regulation, but without shifts in lineage proportions. Notably, SE increased blastoid attachment to the endometrial epithelium in the absence of exogenous steroid hormones, suggesting enhanced epithelial-embryo interaction. Together, these findings reveal a compartment-specific mismatch, as SE augments epithelial and embryonic metabolic activity but compromises stromal support for implantation, with potential consequences for implantation due to stromal dysfunction.

BackgroundPlacenta accreta spectrum (PAS) is characterized by abnormal trophoblastic invasion into the uterine myometrium and is a cause of postpartum hemorrhage and maternal death. Protease-activated receptor-1 (PAR-1) promotes various cellular actions, including invasion. Here, we analyzed the expression of PAR-1, platelet antigen, and fibrin in PAS. MethodsWe analyzed 49 PAS cases (placenta accreta vera [accreta vera], 31 cases; placenta increta [increta], 8 cases; placenta percreta [percreta], 10 cases, classified by the degree of placental villous invasion) and 33 control cases. We immunohistochemically examined the expression of PAR-1, platelet glycoprotein (GP) IIb/IIIa, and fibrin. ResultsThe frequency of previous cesarean section was higher in the increta and percreta groups than in the control and accreta vera groups. PAR-1 expression in placental villi was weak and limited in extent in control cases, whereas immunoreactivity and staining density increased in increta and percreta. Immunofluorescence revealed PAR-1 expression in cytotrophoblasts of placental villi and in aggregated platelets. PAR-1 expression scores in cytotrophoblasts increased significantly with the degree of villous invasion (accreta vera, increta, percreta) compared with controls. The immunopositive areas for GPIIb/IIIa and fibrin were significantly larger in PAS groups than in controls. Furthermore, the immunopositive areas for platelets and fibrin were positively correlated with the PAR-1 expression score. ConclusionThese results indicate that PAR-1 may play a role in placental villous invasion and that a thrombogenic placental environment may influence PAR-1 activation.

STUDY QUESTIONAre pathogenic variants in Homeodomain-interacting protein kinase (HIPK4) associated with sperm head abnormalities causing male infertility? SUMMARY ANSWERHIPK4 is a novel candidate gene associated with sperm head defects and human male infertility. WHAT IS KNOWN ALREADYNumerous genes causing male infertility due to Multiple Morphological Abnormalities of the sperm flagella (MMAF) have been described but the genetic basis of sperm head defects is less well understood. STUDY DESIGN, SIZE, DURATIONFour infertile brothers displaying varying degrees of quantitatively and/or qualitatively impaired spermatogenesis, their parents, and their fertile brother were included in the study. Further, the Male Reproductive Genomics (MERGE) cohort comprising exome/genome sequencing data of >3,300 men was queried. PARTICIPANTS/MATERIALS, SETTING, METHODSWe performed exome sequencing in all five brothers and their parents. To characterise the sperm phenotype, standard semen analysis, immunofluorescence staining, and transmission-electron microscopy (TEM) were carried out. Further, we evaluated the impact of the HIPK4 variant in cell culture experiments using HEK293T cells. MAIN RESULTS AND THE ROLE OF CHANCEAnalysing the exome data, we could not identify a common genetic cause in all four affected brothers. However, one of the affected brothers was compound heterozygous for two loss-of-function variants in DNAH17 (c.1076_1077dup p.(Lys360*) and c.7752+2T>A p.?) associated with markedly reduced sperm motility and MMAF. The variants pathogenicity was further validated by TEM of flagellar cross-sections revealing an outer dynein arm defect and axonemal disruption. On the contrary, his three infertile brothers were homozygous for the start-loss variant c.1A>G in HIPK4. This gene is expressed during spermiogenesis and is reportedly involved in sperm head shaping in mice. Heterologous expression of (partial) HIPK4 variant cDNA elucidated the alternative use of an in frame start codon located 35 amino acids downstream, resulting in an N-terminally truncated protein p.(Met1_Glu35del). The truncated HIPK4 protein lacks parts of its kinase domain and shows reduced protein stability. In line with published mouse models, all three brothers displayed 100% abnormal sperm head morphology with variable defects. Importantly, one brother affected by HIPK4 variants fathered a child after successful intracytoplasmic sperm injection demonstrating that it is a treatment option for HIPK4-related teratozoospermia. No further men from the MERGE cohort were affected by biallelic HIPK4 variants. Taken together, HIPK4 is an autosomal-recessive candidate gene associated with sperm head defects and male infertility. LARGE SCALE DATAThe reported variants in DNAH17 and HIPK4 were submitted to ClinVar. LIMITATIONS, REASONS FOR CAUTIONIndependent replication is required to assess the phenotypic spectrum and the reproductive outcome associated with biallelic HIPK4 variants and to formally establish the gene-disease relationship for male infertility. WIDER IMPLICATIONS OF THE FINDINGSThis study raises awareness of the significant genetic heterogeneity of male infertility. The described family highlights that distinct genetic causes may underlie a seemingly similar phenotype. Exome sequencing of families is helpful to efficiently disentangle individual causes among affected family members. STUDY FUNDING/COMPETING INTEREST(S)N.N., J.R., H.O., S.L., C.F., and F.T. were supported by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) within the Clinical Research Unit Male Germ Cells (CRU326, project number 329621271). R.T.W., N.N., J.R., H.O., and F.T. were supported by the Federal Ministry of Research, Technology and Space (BMFTR) as part of the project ReproTrack.MS (grant 01GR2303). S.A.K. was supported by the DFG Clinician Scientist programme CareerS Munster (project number 493624047). A.S.G. was supported by the Medical Faculty Munster via an Innovative Medical Research (IMF) grant (GA-122104).

Study question: How is glycodelin, a glycoprotein secreted by reproductive tissues, causally related to reproductive diseases and traits? Summary answer: We present evidence for a causal role of sex hormones in determining glycodelin levels, but limited evidence that glycodelin subsequently causally impacts reproductive traits. What is known already: Glycodelin is expressed in female and male reproductive tissues and has four glycoforms (-A, -C, -F and -S), with the glycosylation pattern determining its function. Differences in the levels of glycodelin are associated with reproductive traits, including fertility, endometriosis, preeclampsia, and female-specific malignancies. Study design, size, duration: We used cross-sectional data from the UK Biobank to investigate relationships between glycodelin and reproductive-related traits in men and women by performing genome-wide association studies (GWAS) and Mendelian randomization (MR) analyses. Participants/materials, setting, methods: We included individuals of European genetic ancestry aged 40-69 in 2006-2010, with genetic data in the UK Biobank v3 release. We performed GWAS of glycodelin levels in 46,468 people, stratified by sex (21,368 men and 25,100 women) and menopause status (6,409 pre- and 18,691 post-menopausal women). We tested bidirectional casual associations between glycodelin levels and 19 reproductive-related traits using one- and two-sample MR analyses. Main results and the role of chance: Nine genetic signals reached genome-wide significance (P<5x10-8) across the glycodelin phenotypes. A known genetic signal (rs9409964) near the PAEP gene, which encodes glycodelin, was most strongly associated (P<3x10-80 across all phenotypes), and had heterogeneous effects (effect (SD) per A allele of 1.31 in men vs 0.60 in women, and 0.4 in pre- vs 0.9 in post-menopausal women). Higher serum concentrations of bioavailable testosterone raised glycodelin in men (effect = 0.14 SD, IVW P=4.1x10-13), while effects in women depended on menopause status (pre-menopausal effect = -0.16 SD, IVW P=3.6x10-3; post-menopausal effect = 0.10 SD, IVW P=5.9x10-4). There was no strong evidence that differences in glycodelin levels were caused by, or were the cause of, other reproductive-related traits. Limitations, reasons for caution: Proteomic measurements of glycodelin did not differentiate between glycoforms and were derived from blood and might not reflect levels in reproductive tissues. The sample size for the pre-menopausal GWAS was modest, reducing our power to detect relationships with reproductive conditions. Genetic instruments are assumed to be proxies for average lifelong exposure, which does not reflect variation in hormones and biomarkers over lifetime. Wider implications of the findings: We suggest that reported associations of glycodelin with reproductive conditions are likely to result from the effects of sex hormones rather than being directly causal. These findings may help reconcile previously conflicting associations between glycodelin and reproductive traits.

This small pilot feasibility study shows that reverse phase protein array (RPPA) technology is a useful tool for targeted proteomics analysis in human ovarian follicular fluid. RPPA supplements mass spectrometry approaches that are currently used by providing functional signal transduction data that drive cellular biology. Herein, we present the first report of using RPPA in follicular fluid to elucidate protein signaling pathways. The results show potential associations between follicular fluid proteins measured with RPPA and reproductive outcomes from in vitro fertilization, including oocyte maturity, oocyte fertilization, embryo quality, and pregnancy. This study provides evidence that RPPA is a feasible approach to be used in clinical studies of reproductive endpoints. However, a larger study of RPPA to identify diagnostic and prognostic follicular fluid protein biomarkers of infertility is needed.

BackgroundUterine atony ([~]70%), lacerations ([~]20%) and placenta-related problems ([~]10%) are assumed main reasons for postpartum hemorrhage genesis. Coagulation components predictive for postpartum blood loss can be identified prepartum and before traditionally assumed main reasons are observed. ObjectivesTo better understand postpartum hemorrhage genesis, we prospectively researched prepartum clinical information, presence of assumed main reasons and peripartum coagulation changes in parturient women. Study designIn 676 women with vaginal deliveries, age, BMI, parity, gestation age, duration of second stage of labor and presence and type of assumed main reasons (uterine atony, lacerations and placenta-related problems) were recorded. Measured blood loss within 24h postpartum defined no, non-severe or severe PPH (<500ml, [&ge;]500ml to <1000ml, [&ge;]1000ml). Hemoglobin, platelet count, fibrinogen, factor II and factor XIII activity were measured at admission and 24-48h postpartum. ResultsOf 191 women developing postpartum hemorrhage, 53.9% did not show assumed main reasons (expected <5%, p<.001). Of 45 women with severe postpartum hemorrhage, 15.5% were without assumed main reasons (<5%, p<.001). Sole atony occurred less frequently than expected (8.2% in non-severe and 35.5% in severe PPH, p<.001). FXIII showed the largest decrease of coagulation factors by far, from no (-12%) to non-severe (-20%) and severe postpartum hemorrhage (-32%, p<.001). Duration of the second stage of labor was longer in women developing postpartum hemorrhage later on (71 vs. 46 minutes, p=.004), but was not different between women with or without assumed main reasons. ConclusionUterine atony frequency is low in non-severe postpartum hemorrhage, but progresses from non-severe to severe postpartum hemorrhage. It can thus not be the frequent reason for postpartum hemorrhage it is assumed to be, as all postpartum hemorrhages start as non-severe. A prolonged second stage of labor together with an ongoing (likely self-reinforcing) consumptive coagulopathy helps to explain postpartum hemorrhage genesis. FXIII is a prepartum predictor of postpartum blood loss and shows the most pronounced peripartum coagulation factor loss in any setting. This might allow to identify new treatment pathways.

Successful embryo implantation requires complex interactions between the embryo and the endometrium. Improvements in embryo testing have led to increased success rates for embryo transfer following in vitro fertilization, however, even with euploid embryos under ideal conditions, failure occurs in more than 30% of cases. Methods for diagnosing and improving endometrial function are currently lacking. Here we developed a functional test ("Simbryo FX") for the ability of the endometrium to support embryo implantation. We collected endometrial biopsy samples from over 100 patients, and used these to grow endometrial organoids. We interacted these organoids with blastoids, pluripotent stem cell based models of the human blastocyst, and measured the hCG produced by the blastoids as well as the degree to which the blastoids invaded the organoids. We found that both of these measures correlated with clinical outcomes, and that combining them allowed us to predict the likelihood of failure in the next embryo transfer with high specificity. Thus, interacting patient-derived endometrial organoids with blastoids represents a promising approach to evaluating endometrial function among patients preparing for embryo transfer.

STUDY QUESTION[Do structural genomic variants, that can be identified by using optical genome mapping, contribute to male infertility?] SUMMARY ANSWER[By using optical genome mapping we can identify several types of structural variants, both known and new, that may contribute to male infertility.] WHAT IS KNOWN ALREADY[Traditional approaches such as karyotyping, CFTR and chromosome Y microdeletion testing are successful in explaining clinical findings in [~]30% of MI patients, leaving the rest without a genetic diagnosis. Recent research suggests at least 265 genes may play a role in male fertility. While the assessment of the roles of copy number variants and single nucleotide variants in monogenic forms of disease in these genes is underway, much less is known about structural variants.] STUDY DESIGN, SIZE, DURATION[We performed a longitudinal case/control study on a total of 220 individuals; 88 patients with male infertility, negative for cytogenetic abnormalities using karyotyping, and molecular testing for chrY microdeletions, and CFTR gene variants, and 132 healthy male individuals that underwent optical genomic mapping for other reasons. Exclusion criteria for the control cohort were low-sperm quality and/or inclusion in IVF procedures. The study was approved by the National Medical Ethics Committee of the Republic of Slovenia (reference number: 0120-213/2022/6). Optical genome mapping was performed from an aliquot of whole blood collected for routine testing purposes at the Clinical Institute of Genomic Medicine (CIGM), UMC Ljubljana from January 2023 to November 2024.] PARTICIPANTS/MATERIALS, SETTING, METHODS[We examined structural variants in 220 participants by using optical genome mapping, which was performed with DLE-1 SP-G2 chemistry and the Saphyr instrument. The de novo assembly and Variant Annotation Pipeline were executed on Bionano Solve3.7_20221013_25 while reporting and direct visualization of structural variants was done on Bionano Access 1.7.2. All obtained variants were filtered using the Bionano Access software and in-house generated gene/regions of interest panel bed files. The first filter was applied to include variants below a population frequency of 10%, and overlapping the regions of interest. Subsequently, all variants occurring with frequency 0% in the internal manufacturer variant dataset were manually evaluated for possible involvement of the overlapping genes or regions in biological processes involved in MI. The male infertility cohort also underwent research whole exome analyses as previously reported. All results of optical genomic mapping were confirmed by an appropriate alternative method where available.] MAIN RESULTS AND THE ROLE OF CHANCE[We show that the overall number of structural variants in MI patients does not differ from that of healthy individuals. By looking in detail at genes and regions associated with MI, we identified 21 rare variants absent from controls in 25.0 % of MI patients, of which five were likely causative, and two would be missed by using traditional approaches. These variants include inversions, duplications, amplifications, deletions (e.g. SPAG1), and insertions/expansions (e.g. DMPK), that were validated using additional methods. While the remaining SV cannot be currently classified as pathogenic according to existing criteria, they open a new avenue in genetic research of MI. LARGE SCALE DATA[Variants reported in this study were deposited into ClinVar under accession numbers SUB15650956 (https://www.ncbi.nlm.nih.gov/clinvar/)] LIMITATIONS, REASONS FOR CAUTION[Technical limitations of optical genome mapping include the lack of DLE-1 labelling of centromeric and telomeric regions, the inability to detect Robertsonian translocations, the unclear exact location of smaller structural variants located between the DLE-1 labels, and unclear boundaries in case of their location in segmentally duplicated regions (this limitation is shared with other methods). The ACGM criteria of rarity are also hard to apply, as the fertility status of the individuals in healthy population databases such as GnomAD and DGV is unknown. Similarly, gene-associated phenotype and the proposed inheritance model both need to be considered as parts of the ACMG criteria, but for many candidate genes associated with MI, no model of inheritance has yet been proposed.] WIDER IMPLICATIONS OF THE FINDINGS[Currently, with the established diagnostic approaches we are able to resolve [~]30% of male infertility cases, with [~]70% of patients remaining undiagnosed. The significance of our work is in showing that rare structural variants can be identified in MI, by using optical genome mapping, opening new avenues of research of the genetics of this important contributor to human fertility.] STUDY FUNDING/COMPETING INTEREST(S)[All authors declare having no conflict of interest in regard to this research. This work was funded by the Slovenian Research and Innovation Agency (ARIS) Programme grant P3-0326: Gynecology and Reproduction: Genomics for personalized medicine] Lay summaryMale infertility affects about 5% of adult males and has complex causes, including genetic ones, such as mutations in the CFTR gene, small deletions on chromosome Y, and balanced translocations, but currently we can only find a genetic cause in [~]30% of patients. This means [~]70% of cases remain undiagnosed but potentially, they too may have a yet unknown genetic cause. Indeed, so far research has shown at least 265 genes have been proposed to play a role in male fertility. In these genes, there has so far been limited research of single nucleotide variants and of copy number variants, but many structural variants are not visible using commonly used methods in clinical genetic testing. Therefore, apart from chromosome Y microdeletions and chromosomal numerical and structural anomalies, such as balanced translocations, the role of smaller structural variants in male infertility is unknown, but based from what we know from other diseases, they also may play a role in male infertility. Optical genome mapping is a novel method for the detection of structural variants, such as balanced and unbalanced translocations, insertions, duplications, deletions, and complex structural rearrangements in a wide range of sizes. By using optical genome mapping to test a cohort of 88 infertile men and 132 healthy controls, we aimed to provide the first insights into the range of SV that may be associated with MI. We found, by using optical genome mapping, the overall number of structural variants in MI patients not to be significantly different to the control group. However, by looking at genes and regions associated with MI, we can find rare structural variants that are absent from controls in 25.0% of MI patients. These variants include inversions, duplications, amplifications, deletions (e.g. deletion in SPAG1), and insertions/expansions (e.g. in DMPK), that were validated using additional methods. Five of these variants (5.6%) were likely causative, and two would be missed by traditional approaches. While the remaining SV cannot be currently classified as pathogenic according to existing criteria, they open a new avenue in genetic research of MI.

ObjectivePerimenopause is an under-recognized life stage that may be accompanied by complex and fluctuating symptoms. We aimed to quantify the prevalence of perimenopause uncertainty and explore the underlying drivers. MethodsWe conducted a mixed-methods study based on a cross-sectional survey of U.S. women aged 35 years and above (N=7,640). Closed-ended responses were analyzed to estimate the prevalence of perimenopause uncertainty with subgroup differences investigated by age and symptom severity. Content analysis of free-text responses (n=409) was conducted to identify the main uncertainty drivers. ResultsOverall, 34% of participants reported being unsure of their reproductive stage. Uncertainty peaked among those aged 40-44 (42%) and was highest among those with severe symptom burden (37%). The content analysis revealed three main uncertainty drivers. Symptom confusion and attribution was the most common (56%), reflecting difficulties interpreting bodily changes and distinguishing perimenopause from other causes. Knowledge gaps and information seeking accounted for 28% of responses, highlighting limited health literacy, assumptions about age, and active searches for evidence. Barriers to confirmation and care (16%) described dismissive healthcare encounters and reluctance to acknowledge perimenopause. Younger women (35-39 years) were more likely to cite knowledge gaps, while healthcare barriers peaked in the 40-44 age group. ConclusionPerimenopause uncertainty is a prevalent and clinically meaningful challenge. This uncertainty is conceptually distinct from illness-focused models: it is a universal transition with ambiguity and often lack of validation. Better symptom recognition and targeted communication is a crucial first step toward improving womens awareness and support during perimenopause.

ABSTRACT/SUMMARYO_ST_ABSObjectiveC_ST_ABSCannabis use during pregnancy is increasing; associations with neonatal growth may be confounded by nicotine. We evaluated prenatal cannabis exposure (PreCE) and neonatal outcomes in a prospective cohort with biochemical control for nicotine exposure. MethodsIn the Cannabis Use During Early Life and Development (CUDDEL) study, pregnant women with a lifetime history of cannabis use were classified as PreCE if they self-reported use or had urine THC-COOH positivity at any trimester (n=297) and as unexposed if they reported no use and tested negative (n=151). Linear regression and modified Poisson models estimated associations with birthweight and small for gestational age (SGA; <10th and <5th percentiles), adjusting for sociodemographic factors, gestational age, maternal age and BMI, and urinary cotinine. Analyses stratified by cannabis use frequency (>weekly vs <monthly) and cotinine status. ResultsParticipants (N=448; 18-41 years; 85.3% non-Hispanic Black) had lower birthweight with PreCE in adjusted models (Beta=-0.08; padj=0.041). High-frequency PreCE was associated with lower birthweight compared with unexposed pregnancies (Beta=-0.13; padj=0.03), whereas low-frequency PreCE was not. Cotinine-positive PreCE showed the greatest birthweight reduction versus unexposed (Beta=-0.20; padj<0.001). PreCE was also associated with higher likelihood of SGA <5th percentile; risk was highest in PreCE+Nicotine compared with both unexposed and PreCE-Nicotine groups. ConclusionsPrenatal cannabis exposure was associated with reduced birthweight and SGA in this cohort. Nicotine co-exposure intensified these associations, yet effects persisted without cotinine, supporting cannabis as an independent perinatal risk factor and emphasizing the value of cotinine assessment in populations where blunt use or secondhand exposure is common.

BackgroundEstimating the contribution of preeclampsia (PE) to perinatal mortality in low-resource settings remains difficult due to limited diagnostic capacity. Lack of specific histopathologic changes in stillbirth, foetuses and/or placenta often hampers assignment of PE as cause of death. While PE angiogenic biomarkers (sFlt-1, PlGF) predict adverse pregnancy outcomes, their post-mortem diagnostic utility is unclear. We evaluated the potential role of these biomarkers in identifying PE-related perinatal deaths. MethodsThis cross-sectional study was conducted among pregnant women who delivered a stillborn infant or experienced an early neonatal death at Maputo Central Hospital in Mozambique. Concentrations of sFlt-1, PlGF and their ratio (sFlt-1/PlGF) were assessed in maternal blood and post-mortem foetal/neonatal and placental blood. Causes of death were determined via minimally invasive tissue sampling (MITS) and diagnostic accuracy was assessed using ROC curves for standardized and optimal biomarker cut-offs. ResultsA total of 100 women with perinatal deaths (98 stillbirths and 2 early neonatal deaths) were included in the study between March 2021 and April 2022. Maternal sFlt-1/PlGF ratios showed the highest diagnostic accuracy for PE-related deaths (area under curve [AUC]=82%), followed by placental (AUC=75%) and foetal blood (AUC=61%). PlGF levels were significantly reduced in PE-associated deaths. sFlt-1/PlGF cutoffs of [&ge;]85 and [&ge;]110 in maternal and placental blood were reliable cut-offs for identifying PE-related foetal/neonatal deaths. Optimal ratio cut-offs were [&ge;]50 (maternal blood), [&ge;]230 (placental blood), and [&ge;]140 (foetal blood), with maternal and placental sFlt-1/PlGF ratios showing significant associations with PE-related death (OR=10.58 and 5.98 respectively). Sensitivity and specificity in maternal and placental blood were 84% and 73%, and 67% and 78%, respectively, with a positive predictive value (PPV) of 84% in both. ConclusionsMaternal and placental angiogenic biomarkers enable reliable identification of preeclampsia-related perinatal deaths and could significantly enhance cause-of-death determination in low-resource, high-burden settings. These findings underscore the potential value of biomarker measurement for both risk stratification and mortality surveillance. Research in contextO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIsFlt-1, PlGF, and their ratio, are well-established in predicting and diagnosing preeclampsia during pregnancy. C_LIO_LIHowever, their utility in identifying preeclampsia-related perinatal deaths particularly in postmortem investigations such as minimally invasive tissue sampling (MITS) samples, is underexplored. C_LI What this study addsO_LIThis study is the first to evaluate diagnostic accuracy of these biomarkers using postmortem placental and foetal/neonatal blood samples from MITS to identify preeclampsia-related perinatal deaths. C_LIO_LIWe show that maternal and placental sFlt-1/PlGF ratios can reliably identify preeclampsia-related perinatal deaths at standardized ratio cutoffs of [&ge;]85 and [&ge;]110 respectively. Whilst significantly reduced PlGF concentrations, lower placental and perinatal anthropometric measurements were hallmark features of PE-related deaths. C_LIO_LIThe study suggests optimal sFlt-1/PlGF ratio cut-offs for maternal ([&ge;]50) and placental ([&ge;]230) blood, providing robust diagnostic thresholds for use in perinatal mortality surveillance and antenatal risk stratification in high-burden settings. C_LI How this study might affect research, practice or policyO_LIThe use of preeclampsia biomarker analysis in determining causes of perinatal death offers a feasible, scalable, and objective method that may help overcome challenges in accurate cause of death attribution in LMICs. C_LIO_LIThis has important implications for mortality surveillance system monitoring and pregnancy risk assessments, where autopsy is rare and clinical records are often incomplete. C_LIO_LIIncorporating biomarker-based diagnostics into existing perinatal death investigations could significantly improve mortality data and guide targeted health interventions. C_LI

ContextPeritoneal endometriosis (PE) remains challenging to diagnose, as it cannot be detected using standard imaging modalities and no clinically validated biomarkers are available. ObjectiveTo identify novel blood-based biomarkers for PE using whole blood transcriptomics combined with machine learning approaches. Design, Setting, and PatientsThis observational study enrolled 48 women undergoing laparoscopic surgery for endometriosis-related symptoms at tertiary referral centres in Slovenia and Austria. Patients were classified as having PE (n=20), peritoneal and ovarian endometriosis (PE and OE, n=8), or no endometriosis (controls, n=20). Patients were further stratified by menstrual phase (proliferative or secretory). Whole blood samples were collected preoperatively. MethodsWhole-blood RNA sequencing was performed, and differentially expressed genes (DGEs) and transcripts (DTEs) were identified. Sequencing data were processed using a machine learning pipeline to select key features and develop support vector machine (SVM) classifiers for predicting endometriosis status. ResultsIn the proliferative group, no DGEs and only two DTEs distinguished PE from controls. In contrast, in the secretory group, 1,035 DGEs and 922 DTEs were identified, with no overlap between menstrual phases. Enrichment analysis of secretory phase DGEs indicated their involvement in angiogenesis and immune-related pathways. Feature selection identified six transcripts that achieved the best SVM classification performance in distinguishing cases from controls across both menstrual phases (AUC = 0.92, sensitivity = 75%, specificity = 100%). ConclusionThis study provides first evidence that integrating whole-blood transcriptomics with machine learning can identify potential blood-based biomarkers for PE and highlights the influence of menstrual cycle phase. These findings require validation in larger, independent cohort.

IntroductionNon-obstructive azoospermia (NOA) represents the most severe form of male infertility. Current clinical tools have limited ability to predict sperm production or guide surgical sperm retrieval. Conventional B-mode ultrasound provides qualitative grayscale images and cannot characterize testicular microstructure relevant to spermatogenesis. Quantitative ultrasound (QUS) provides objective parameters from raw radiofrequency data, which quantitatively measure tissue heterogeneity. We hypothesize that men with spermatogenesis will have different QUS features compared to men without spermatogenesis (measured by total motile count, TMC, on semen analysis), with the goal of identifying imaging biomarkers for prognosis and intraoperative guidance. MethodsWe prospectively analyzed men presenting for infertility evaluation who underwent high-frequency ultrasound imaging and semen analysis. Imaging was performed using a 36-MHz transducer with fixed acquisition parameters. Ninety-two QUS features were extracted from manually annotated testicular regions of interest, including Nakagami distribution parameters (m, {omega}, k), envelope statistics, and texture features. Univariate associations between each QUS feature and TMC were assessed using Spearman correlation with Bonferroni correction. Top-performing features were evaluated using logistic regression and receiver operating characteristic (ROC) analysis to discriminate sperm presence or absence (TMC>0 vs TMC=0). ResultsThirty-seven men (18 azoospermic, 19 with sperm present in the ejaculate) contributed 135 regions of interest. Seventeen of 92 QUS features significantly correlated with TMC after correction. The coefficient of variation of the Nakagami k-factor within the superficial testicular parenchyma (K_Zone1_Cv) demonstrated the strongest correlation ({rho}=0.51, corrected p<0.001), suggesting that greater spatial heterogeneity in the superficial parenchyma was associated with higher sperm counts. K_Zone1_Cv discriminated sperm presence with an AUC of 0.77 (95% CI 0.60-0.92), sensitivity 73.7%, and specificity 83.3%. QUS features with the highest univariate association were highly intercorrelated, suggesting a shared biological signal. ConclusionQuantitative ultrasound-derived measures of testicular microstructure heterogeneity correlate with sperm production and demonstrate moderate discrimination of sperm presence. These findings suggest QUS may provide a non-invasive imaging biomarker of spermatogenesis. Study findings warrant further assessment and validation in male infertility for sperm retrieval prognosis and the potential for intra-operative surgical guidance.

Genitourinary infections (GUIs) during pregnancy are a significant clinical concern linked to maternal morbidity. While Streptococcus is a common gut commensal and a known urogenital pathobiont, whether gut-resident Streptococcus plays a causal role in the etiology of pregnancy-related infections remains unclear due to confounding in observational studies. To investigate the potential causal effect of gut Streptococcus abundance on the risk of maternal genitourinary infection during pregnancy using Mendelian randomization (MR). We performed a two-sample MR analysis using publicly available genome-wide association study (GWAS) summary statistics. Genetic instruments for gut Streptococcus abundance were obtained from the MiBioGen consortium (N=18,340). Outcome data for maternal genitourinary infection (ICD-10 O23.x) were sourced from the FinnGen consortium (N=111,731). The inverse-variance weighted (IVW) method was used as the primary analysis, supplemented by sensitivity analyses (MR-Egger, weighted median, MR-PRESSO). We further assessed potential mediation via systemic inflammation (C-reactive protein, interleukin-6) and associations with eleven major adverse pregnancy outcomes (APOs). Genetically predicted higher gut Streptococcus abundance was associated with a reduced risk of maternal genitourinary infection (IVW odds ratio [OR] = 0.63, 95% confidence interval [CI]: 0.43-0.93, p = 0.020). Sensitivity analyses supported this protective association, with no evidence of horizontal pleiotropy (MR-Egger intercept p = 0.942) or significant heterogeneity. No causal effects were observed on systemic inflammatory markers (CRP, IL-6, all p > 0.05) or on major APOs, including postpartum haemorrhage, placental abruption, etc. This MR study provides genetic evidence supporting a causal, protective role of gut Streptococcus against the risk of clinically diagnosed genitourinary infection during pregnancy. This effect appears specific and is not mediated through the systemic inflammatory pathways examined, suggesting a localized mechanism within the genitourinary tract.

Medical management of pregnancy loss and termination has evolved considerably over the past decade, with misoprostol-based protocols emerging as a cornerstone of care in many settings. Standardized regimens, such as the FIGO 2017 recommendations, aim to improve outcomes by ensuring effectiveness, safety, and reproducibility across diverse clinical contexts. Evaluating their real-world performance is essential, particularly in resource-constrained environments where protocol adherence can directly influence patient care. ObjectiveTo evaluate the effectiveness, safety, and clinical applicability of the FIGO 2017 misoprostol protocol for medical management of first{square}trimester missed abortions, second{square}trimester intrauterine fetal demise (IUFD), and medical termination of pregnancy (MTP) in a Tunisian tertiary center. MethodsA retrospective descriptive and analytical study was conducted in the Gynecology Department A of Charles Nicole Hospital between January 2022 and December 2023. All patients admitted for first{square}trimester missed miscarriage, IUFD, or MTP and managed with misoprostol were included. ResultsA total of 190 patients were included: 65.8% with first{square}trimester missed abortion, 14.4% with IUFD, and 19.8% with MTP. The global success rate was 89.7%. Median induction{square}to{square}expulsion time was 32 h for first{square}trimester pregnancy loss, 19 h for IUFD, and 21 h for MTP. Multigravida women experienced significantly shorter expulsion intervals. Complications occurred in 8.8% of cases, with no uterine rupture. ConclusionThe FIGO 2017 misoprostol protocol is highly effective and safe in the Tunisian context, offering high success rates, shorter hospitalization, and minimal complications. Findings support its continued implementation and highlight the need for further research in women with uterine scars.

BackgroundLipedema is a chronic condition characterized by disproportionate adipose tissue accumulation, pain, and sensitivity, often influenced by hormonal fluctuations. Despite its prevalence, the specific impact of exogenous hormones on the disease course remains understudied. ObjectiveTo investigate the association between hormonal contraceptive use and the presence and severity of lipedema in Brazilian women. MethodsA cross-sectional study was conducted at Amato - Instituto de Medicina Avancada using a structured online questionnaire administered between August and November 2025. Brazilian women aged 18 years or older with suspected or diagnosed lipedema were included. The questionnaire assessed demographic and clinical characteristics, history of contraceptive use, lipedema symptoms, and impact on quality of life. Symptom scores (0-8 points) and quality of life impact scores (0-15 points) were calculated. Statistical analyses included Chi-square and Kruskal-Wallis tests, Spearman correlations, and logistic and linear regressions. ResultsA total of 637 women participated, with a mean age of 41.8 {+/-} 8.7 years and a mean BMI of 28.9 {+/-} 6.4 kg/m{superscript 2}. Of the participants, 491 (77.1%) had a confirmed diagnosis of lipedema. It was observed that 58.8% of users reported symptom worsening after contraceptive use (p<0.001). Free-text analysis revealed that 15.1% of participants experienced the onset of lipedema symptoms concurrently with the start of contraceptive use. Weight gain as a side effect was strongly associated with worsening. In multivariate logistic regression, symptom score (OR=1.562, p<0.001) and age at menarche (OR=0.746, p=0.0135) were significant predictors of worsening. Regarding impact on quality of life, BMI (beta=0.364) and pain (beta=0.641) were independent predictors. Conclusions: This study demonstrates a significant association between hormonal contraceptive use and self-reported worsening of lipedema symptoms. These results have potential implications for individualized contraceptive counseling for women with lipedema and reinforce the need for prospective investigations to confirm the nature and direction of this association.

BackgroundPrescribing pharmaceutical agents during pregnancy requires a balance between maternal therapeutic needs and foetal risks. Quetiapine, an atypical antipsychotic, is prescribed in psychiatric disorders and increasingly used off-label in low-dosages (<200mg daily) for insomnia during pregnancy. This study aimed to investigate the possible relationship between using quetiapine in a low dosage during pregnancy and the neonatal outcome within the first three days after birth. MethodsA retrospective cohort study was conducted at the Radboud University Medical Centre (RadboudUMC), Nijmegen, The Netherlands. Liveborn neonates admitted to the RadboudUMC during the years 2017-2024 whose mothers used at least one dose of quetiapine ([&le;] 200mg daily) during pregnancy were included. Maternal characteristics and neonatal outcomes were analysed using SPSS, dose-dependent outcomes were also assessed. Results30 neonates were included. Of these, 7 (23.3%) were born preterm, 7 (23.3%) were small for gestational age (SGA), 6 (20.0%) were admitted to the neonatal intensive care unit (NICU) and 2 (6.3%) exhibited withdrawal symptoms. Most neonates were admitted to the hospital for 3 days. ConclusionThis study is the first to evaluate neonatal outcome after maternal low dose quetiapine in pregnancy in the Netherlands. We found relatively high rates of preterm birth, SGA and NICU admissions. As this was a single-centre study without a control group and with a small sample size in an academic population, results should be interpreted with caution. We recommend further prospective and multicentre studies including control groups.

Preterm premature rupture of membranes (PPROM) is a major obstetric complication, particularly at early gestational ages. This retrospective, bicentric study (2019-2023) analyzed the short-term outcomes of pregnancies complicated by PPROM between 22 and 32 weeks of gestation under expectant management. Patients were divided into two groups: G1 (22-26 weeks) and G2 (26-32 weeks). The mean maternal age was 32 years, with a history of PPROM and preterm birth in 26% and 29% of cases, respectively. Antenatal corticosteroids were administered to all patients in G2 and to 28% of those in G1 (p<0.001). Chorioamnionitis was observed in 48% of patients in G1 and 37% in G2 (p=0.183). The mean gestational age at delivery was 28.03 weeks, with an overall neonatal survival rate of 26% in G1 and 88% in G2 (p<0.001), with survival starting from 25 weeks. Hyaline membrane disease was more frequent in G1 (83% vs. 43%, p<0.001), as was intraventricular hemorrhage without ventricular dilation (70% vs. 27%, p=0.003). Free hyperbilirubinemia was more common in G2 (70% vs. 47%, p=0.002). The analysis of factors influencing neonatal prognosis highlighted the gestational age at rupture, gestational age at delivery, birth weight, Apgar score, and the amount of amniotic fluid as key determinants. In conclusion, these factors play a critical role in neonatal prognosis in cases of PPROM.