Abnormal Uterine Bleeding in Menopausal Women: Clinical and Histopathological Insights
Interviews:
Catherine Nelson-Piercy and Michelle Peate share insights on hypertensive disorders in pregnancy and onco-fertility
10 Review of the 41st Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE), 29th June–2nd July 2025
Congress Features
23 Highlights from ESHRE 2025: Advances in Endometrial Preparation Strategies for Frozen Embryo Transfer
Petya Andreeva and Ivelina Oprova
27 How AI is Revolutionising Reproductive Clinical Practice
Katie Wright
32 New Frontiers in Endometriosis: Imaging and Beyond
Ada Enesco
Abstract Reviews
38 Identifying Essential Information for a Valid Informed Consent of Egg Donors: An International Delphi Study
Jacxsens L et al.
40 Awareness, Risk Perceptions, Experiences, and Protection Strategies of Females Who Are Infertile Regarding Endocrine Disrupting Chemicals: A Qualitative Study
Akarsu GD and Akarsu RH
43 Evaluating the Role of rIVM and rICSI in Assisted Reproductive Technology: A Systematic Review and Meta-analysis of Outcomes in Low/Failed Maturation and Fertilisation Cases
Popa T et al.
45 Abstract Highlights Interviews
55 Catherine Nelson-Piercy
59 Michelle Peate Articles
63 Awareness and Utilisation of Cervical Cancer Screening Among Mothers Attending Antenatal and Postnatal Clinics at a State Hospital in Nigeria Ike EU et al.
73 Clinical, Ultrasound, and Endometrial Histopathological Features of Perimenopausal and Postmenopausal Women with Abnormal Uterine Bleeding at a Tertiary Hospital in Western Kenya Moshey IS et al.
Editorial Board
Editor-in-Chief
Dr Justin Chu
University of Birmingham, UK
Medical Director, Oxford Fertility, UK; Honorary Consultant Obstetrician and Gynaecologist Sub-specialist in Reproductive Medicine and Surgery, Birmingham Women’s and Children’s NHS Foundation Trust, UK; Honorary Senior Lecturer, Institute of Metabolism and Systems Research, University of Birmingham, UK
Prof Petya Andreeva
Shterev Hospital, Bulgaria
Dr Melihan Bechir
Columna Medical Center, Romania
Dr Arianna D'Angelo
Wales Fertility Institute, Cardiff, UK
Dr Kristo Ausmees Medita Clinic, Estonia
Dr Mátyás Benyó
University of Debrecen, Hungary
Dr Antonio Simone Laganà
University of Palermo, Italy
Dr Ioana Rugescu
Safety and Quality Specialist, Romania
Prof Eduard Ruiz-Castañé Fundació Puigvert, Spain
Dr Georgios-Sprirodon (George) Anifandis
University of Thessaly, Greece
Dr Monica Muratori
University of Florence, Italy
Dr Galia Oron
Ruth & Bruce Faculty of Medicine, Haifa, Israel
Aims and Scope
EMJ Reproductive Health is an open-access, peer-reviewed eJournal committed to helping elevate the quality of practices in reproductive health globally by informing healthcare professionals on the latest research in the field. EMJ Reproductive Health endeavours to increase knowledge, stimulate discussion, and contribute to a better understanding of current issues around reproductive health.
The journal is published annually, six weeks after the European Society of Human Reproduction and Embryology (ESHRE) Annual Meeting, and features highlights from this congress, alongside interviews with experts in the field, reviews of abstracts presented at the Annual Meeting, as well as in-depth features on Meeting sessions. Additionally, the journal covers advances within the clinical and pharmaceutical arenas by publishing sponsored content from congress symposia, which is of high educational value for healthcare professionals. This undergoes rigorous quality control checks by independent experts and the in-house editorial team.
EMJ Reproductive Health also publishes peer-reviewed research papers, review articles, and case reports relevant to the field. In addition, the journal welcomes the submission of features and opinion pieces intended to create a discussion around key topics in the field and broaden readers’ professional interests. The journal is managed by a dedicated editorial team that adheres to a rigorous double-blind peer-review process, maintains high standards of copy editing, and ensures timely publication.
EMJ Reproductive Health focuses on topics that are relevant to healthcare professionals in the field. We do not publish veterinary science papers or laboratory studies that are not linked to patient outcomes. We have a particular interest in topical studies that advance knowledge and inform of coming trends affecting clinical practice in the field.
Further details on coverage can be found here: www.emjreviews.com
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Staff members attend medical congresses as reporters when required.
This Publication
Launch Date: 2015 Frequency: Yearly
Online ISSN: ISSN 2059-450X
All information obtained by EMJ and each of the contributions from various sources is as current and accurate as possible. However, due to human or mechanical errors, EMJ and the contributors cannot guarantee the accuracy, adequacy, or completeness of any information, and cannot be held responsible for any errors or omissions. EMJ is completely independent of the review event (ESHRE 2025) and the use of the organisations does not constitute endorsement or media partnership in any form whatsoever. The cover photo is of Arc de Triomphe, Paris, France, the location of ESHRE 2025.
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Welcome
Dear Readers,
We are thrilled to welcome you to the latest issue of EMJ Reproductive Health, which covers the cutting-edge developments that were presented at the 41st European Society of Human Reproduction and Embryology (ESHRE) Annual Meeting.
Alongside breaking research updates, you can find expert insights on preparation strategies for frozen embryo transfer, and congress abstracts exploring salvage strategies for failed IVF, the impact of endocrinedisrupting chemicals on fertility, and informed consent for egg donation. Also, be sure not to miss our exclusive interviews with experts on highly important topics, including hypertensive disorders of pregnancy and onco-fertility.
Among the peer-reviewed content is a Kenyan study investigating the prevalence of endometrial hyperplasia and cancer, and the risk factors for these conditions in periand post-menopausal individuals with abnormal uterine bleeding, along with research evaluating cervical screening awareness amongst antenatal attendees in Nigeria.
We would like to take this opportunity to express our thanks to the Editorial Board, authors, peer reviewers, and interviewees who have contributed to the publication of this issue. We hope you enjoy reading this issue and find valuable insights for your clinical practice!
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Foreword
Welcome to the latest issue of EMJ Reproductive Health, where we bring you a curated collection of expert-led features, peer-reviewed articles, interviews, and abstracts presented at this year’s European Society of Human Reproduction and Embryology (ESHRE) Annual Meeting.
The 41st ESHRE Annual Meeting, held in Paris, France, served as a vibrant forum for the exchange of cutting-edge research and clinical innovation. In this issue, we spotlight some of the most compelling findings and discussions from the Annual Meeting, capturing the evolving landscape of reproductive medicine.
Among this year’s highlights is an in-depth, expert-led feature exploring duo stimulation in poor responders, a topic gaining increasing traction in assisted reproduction. We also present a range of abstracts and peer-reviewed articles addressing key issues across reproductive health and fertility, reflecting both clinical challenges and new approaches to care.
Our interviews offer further insight into the field’s current direction, featuring leading voices who share their perspectives on patient-centred care, future trends, and research priorities.
The 41st ESHRE Annual Meeting, held in Paris, France, served as a vibrant forum for the exchange of cutting-edge research and clinical innovation
Now in my second year as Editor-in-Chief, I remain grateful to our dedicated authors, reviewers, and Editorial Board for their continued contributions. Their expertise and commitment help shape each issue into a rich and reliable resource for professionals in reproductive health.
I hope you find this issue both informative and inspiring.
Justin
Chu
Medical Director, Oxford Fertility; Honorary Consultant Obstetrician and Gynaecologist Sub-specialist in Reproductive Medicine and Surgery, Birmingham Women’s and Children’s NHS Foundation Trust; Honorary Senior Lecturer, Institute of Metabolism and Systems Research, University of Birmingham, UK
ESHRE 2025 Congress Review
Review of the 41st Annual Meeting of the European Society of Human Reproduction and Embryology
Since 2015, ESHRE has published 29 clinical guidelines and best practice recommendations
THE 41st Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE) opened its doors in Paris, France, this June, marking a triumphant return to the French capital after years of postponement. From the Euro 2016 Championships to a pandemic and, most recently, the 2024 Olympics, the city’s long-awaited turn as host was finally realised, and it did not disappoint.
Held in the architecturally striking Paris Convention Centre, the ceremony welcomed a record-breaking 12,582 participants from 138 countries, alongside 2,045 exhibitors.
The ceremony began with reflections on France’s unique contributions to reproductive medicine, from the birth of the country’s first IVF baby, Amandine, in 1982, to pioneering achievements in oocyte vitrification and uterus transplantation. René Frydman, Faculty of Medicine, University Paris XI, France; Department of Gynecology and Obstetrics, Antoine Beclere Hospital, Clamart, France, a key figure in many of these milestones, was awarded honorary membership in recognition of his decades of groundbreaking work and ethical leadership in the field.
Joining him as an honorary member was Kay Elder, whose decades-long career at the Bourn Hall Clinic, Wickford, UK, home to some of the earliest developments in IVF, was celebrated for its impact on embryologist training and clinical excellence.
The ceremony continued with ESHRE Chair, Karen Sermon, taking the stage to reflect on the society’s recent achievements. Over one million assisted reproductive technology cycles were recorded across 39 European countries in 2021 alone. A newly launched EU-funded registry for cycle-by-cycle data is already being piloted in four countries, capturing data from more than 30,000 patients, with the aim of expanding across Europe. Since 2015, ESHRE has published 29 clinical guidelines and best practice recommendations, with ongoing updates to ethical frameworks in response to scientific progress. Certification programmes in embryology, reproductive surgery, and nursing continue to expand, helping to standardise clinical quality across regions.
Two research grants were awarded during the ceremony. The first focused on AI in fertility decision-making, and the second on the impact of environmental mutagens on reproductive health. Both highlight the society’s commitment to funding innovation and supporting the next generation of researchers.
ESHRE continues to play a pivotal role in shaping European legislation and public health policy. The society has been closely involved in revising EU regulations on substances of human origin, and is a founding member of the Coalition for Fertility, promoting universal access to fertility treatment across Europe. Its advocacy work extends to partnerships with organisations such as Fertility Europe and the Biomed Alliance, strengthening its voice in both clinical and political arenas.
ESHRE continues to play a pivotal role in shaping European legislation and public health policy
In true ESHRE fashion, the opening ceremony closed not just with data and debate, but with celebration, a tribute to the Late Maurice Béjart’s ‘The Rite of Spring’, performed by dancers from the Neodance Academy Mandalab, Paris, France, which echoed the theme of creation and transformation that underpins reproductive medicine itself.
As Paris welcomed the global fertility community, ESHRE 2025 began not just as an Annual Meeting but as a celebration of past triumphs, present unity, and future potential. EMJ was thrilled to be a part of this year’s Annual Meeting, and looks forward to next year’s Annual Meeting, which will be held in London, UK.
Endometriosis-Related Infertility Linked
to Higher Pregnancy Rates Than Other Infertility Causes: Landmark Population-Based Study
A MAJOR study presented at ESHRE 2025 has found that women with infertility related to endometriosis are significantly more likely to become pregnant than women with infertility from other causes.1 The findings come from the largest and longest population-based study of its kind, analysing over four million women in England over 30 years.
Led by Lucky Saraswat, University of Aberdeen, UK, and conducted in collaboration with researchers at the University of Edinburgh, UK, as part of the EU-funded FEMaLe consortium, the study linked primary care, secondary care, and maternity records for women aged 13–50 years who presented with infertility or symptoms of endometriosis between 1991–2020.
Of the 4,041,770 women included, 245,994 had a recorded diagnosis of infertility, and 111,197 had surgically confirmed endometriosis via laparoscopy or laparotomy. Among those with infertility, 14,904 (6.1%) had confirmed endometriosis, with more than half (57.4%) experiencing infertility prior to their diagnosis, highlighting ongoing diagnostic delays.
The data showed that women with infertility were over twice as likely to be diagnosed with endometriosis compared to women without infertility. Notably, among women with endometriosis-associated infertility, pregnancy rates were four times higher than among women with infertility caused by other factors such as ovulatory dysfunction, tubal factors, or unexplained infertility. Overall, 40.5% of all women with endometriosis in the study had at least one pregnancy during the study period.
These findings suggest that despite the established link between endometriosis and infertility, many women with the condition, particularly those diagnosed and managed early, may retain considerable reproductive potential. Saraswat noted that laparoscopic surgery may improve outcomes in select cases, and that increased awareness of endometriosis may prompt earlier fertility care-seeking behaviour.
The data showed that women with infertility were over twice as likely to be diagnosed with endometriosis compared to women without infertility
The results offer a valuable evidence base for fertility counselling, enabling clinicians to provide more personalised and optimistic guidance to women diagnosed with endometriosis. Anis Feki, Chair-Elect of ESHRE, called the findings reassuring and a reminder of the importance of timely diagnosis and tailored fertility management strategies.
Overall, 40.5% of all women with endometriosis in the study had at least one pregnancy during the study period
Microplastics Discovered in Human Reproductive Fluids, New Study Reveals
NEW research presented at ESHRE 2025 has confirmed that microplastics are present in human reproductive fluids, in both women and men.2
Concerns about microplastic pollution and its potential effects on human health have intensified over recent years, with research demonstrating that these plastic particles, defined as smaller than 5 mm, can accumulate in various organs and tissues. Microplastics have been linked in animal studies to inflammation, DNA damage, and cellular ageing, but data on their impact within the human reproductive system remain sparse.
Researchers analysed follicular fluid from 29 women and seminal fluid from 22 men, applying strict anti-contamination measures. Samples were collected and stored in glassware and underwent chemical treatment before being examined using laser direct infrared microscopy. Microplastics were identified in 69% of all analysed fluids, demonstrating a widespread presence. The most frequently detected polymer overall was polytetrafluoroethylene, found in 31% of the samples, followed by polypropylene (28%), polyethylene terephthalate (17%), polyamide (14%), polyethylene (10%), polyurethane (10%), and
Microplastics were identified in
69%
of all analysed fluids
polystyrene (7%). Within seminal fluid, microplastics were present in 55% of male samples and 69% of female follicular fluid samples, with polytetrafluoroethylene again the most prevalent in males (41%). Multiple types of polymer were detected in both men and women, with many samples containing more than one type of plastic particle.
While the study did not directly examine the impact of microplastics on fertility or reproductive outcomes, it confirmed the presence of a broad array of plastic polymers within human reproductive fluids. For clinicians, the results highlight the pervasive nature of microplastic exposure and the importance of discussing environmental factors with patients experiencing reproductive health concerns. Future research is needed to determine whether reducing microplastic exposure may be beneficial for reproductive health and to clarify the mechanisms by which these particles might affect human fertility.
Probiotics and Micronutrients Enhance Outcomes in Oocyte Donation
A RECENT multicentre, double-blind RCT, presented at ESHRE 2025, investigated whether micronutrients and probiotic supplementation during an oocyte donation programme could improve fertilisation rates, blastocyst development, and pregnancy outcomes.3
The study involved 130 oocyte donors and 107 recipients over 2 years, with donors randomised to receive either a supplement containing myo-inositol, D-chiro-inositol, folic acid, melatonin, coenzyme Q10, various vitamins, minerals, and Lactobacillus strains, or a placebo. The supplementation began at least 30 days prior to and continued throughout controlled ovarian hyperstimulation.
These findings suggest that while micronutrients and probiotics may not influence early embryological parameters, they could improve the competence of oocytes
These findings suggest that while micronutrients and probiotics may not influence early embryological parameters, they could improve the competence of oocytes during vitrification, thereby enhancing pregnancy success in recipients.
The study’s limitations include a relatively small sample size for subgroup analyses and a lack of long-term follow-up of pregnancies, highlighting the need for further research. Nevertheless, the results offer promising implications for optimising supplementation strategies in assisted reproductive technologies, particularly in programmes
While previous evidence suggested that micronutrient supplementation might enhance oocyte yield and quality, this study found that the supplement did not significantly affect fertilisation rates or blastocyst development. Fertilisation rates were comparable between the supplemented group and the placebo (76.7% versus 78%), as were blastulation rates (43.4% versus 45.4%). The survival rate of vitrified oocytes after thawing was also similar across groups. However, when analysing pregnancy outcomes, the study revealed a noteworthy finding: recipients using vitrified oocytes from supplemented donors had significantly higher pregnancy rates compared to the placebo group (50% versus 0%). No such difference was observed for fresh oocytes.
Fertilisation rates were comparable between the supplemented group and the placebo (76.7% versus 78%)
Hormone Therapy Does Not Affect Fertility Preservation Outcomes in Transgender Adolescents
A NEW French study, presented at ESHRE 2025 and led by Sarah HadjKaddour, Hôpital Jean Verdier, Bondy, France, has found that androgen therapy does not negatively impact fertility preservation outcomes in transgender adolescents and young adult men.4
The prospective cohort study, conducted between 2018–2023, involved 98 female-tomale individuals with an average age of 17.3 years at first consultation.
Researchers examined both the participants’ desire for parenthood and the efficacy of oocyte vitrification. While 55% of patients expressed a desire to have children, only 16% wished to carry a pregnancy, highlighting complex emotional and social considerations in transgender parenthood. Fertility preservation was completed in 18 participants, with six already undergoing testosterone therapy.
Androgen therapy does not negatively impact fertility preservation outcomes in transgender adolescents and young adult men
Crucially, results showed no significant difference in anti-Müllerian hormone levels or in the number of oocytes retrieved between those on testosterone (Group 1: n=6) and those not yet treated (Group 2: n=12). For instance, anti-Müllerian hormone levels were 4.7 (3.2–5.2) and 4.7 (2.5–7.0; non-significant) in Group 1 and Group 2, respectively. The average number of oocytes vitrified was 10.0 (8.0–19.0) and 10.0 (6.8–19.8) in Group 1 and Group 2, respectively (non-significant).
The findings are significant for transgender healthcare, indicating that fertility preservation may remain a viable option after initiating testosterone therapy, thus supporting broader reproductive autonomy for trans men. However, the researchers caution that these are preliminary results and emphasise the need for larger, multicentre studies to confirm the findings.
Mercury in Fish Linked to Infertility Risk in Portuguese Women
A STUDY presented at ESHRE 2025 highlights the reproductive health risks of methylmercury (MeHg) exposure in women of reproductive age, with fish consumption identified as a key contributor and potential link to infertility.5
Portugal’s high per capita fish consumption provides important nutrients such as omega-3 fatty acids and selenium, but also poses risks due to MeHg accumulation in seafood. This longitudinal study enrolled 150 women aged 16–45 years between 2014–2024 through prenatal and infertility clinics in Portugal. Researchers aimed to assess chronic MeHg exposure and its association with infertility, alongside other contributing factors such as diet, BMI, and geographical location. Hair samples, a biomarker for long-term mercury exposure, were analysed using atomic absorption spectrometry.
MeHg levels among participants ranged from 0.0840–5.2844 µg/kg, with a mean of 0.9632 µg/kg. Alarmingly, 38% of women (57 individuals) exceeded the US Environmental Protection Agency (EPA)’s safety threshold of 1 µg/kg. Elevated MeHg concentrations were significantly correlated with higher fish consumption (ρ=0.516; p<0.001) and a history of infertility (p=0.289; p=0.004),
suggesting that dietary exposure to mercury may impact reproductive health. Geographical disparities were also identified, with women in 11 out of 31 municipalities exceeding EPA-recommended MeHg levels. Other potential contributing variables, such as age, BMI, and location, did not show significant correlations.
These findings indicate a pressing need to balance the nutritional benefits of fish intake with the risks of mercury exposure. Public health strategies, including regional advisories on safer fish choices and environmental pollution mitigation, are critical to protect women’s reproductive health and reduce potential risks for fetal development.
MeHg levels among participants ranged from 0.0840–5.2844 µg/kg, with a mean of 0.9632 µg/kg
Alarmingly, 38% of women (57 individuals) exceeded the US Environmental Protection Agency (EPA)'s safety threshold of 1 µg/kg
Ultra-Processed Food Consumption and Semen Quality: Findings from the EARTH Study
RESEARCH presented at ESHRE 2025 investigated whether men’s consumption of ultra-processed foods (UPF) is associated with conventional semen quality parameters.6
Despite growing concerns about the health impacts of UPFs, the findings revealed no significant associations between UPF intake and semen quality among men attending a fertility clinic.
UPFs currently make up more than half of all caloric intake in the USA, rising from 51% in 2003 to 54% in 2018. While several studies have linked UPFs to chronic diseases such as obesity, diabetes, and cardiovascular disease, their effects on reproductive health have not been extensively studied.
This analysis was conducted as part of the EARTH study, which recruited couples seeking fertility care at an academic medical centre in Boston, Massachusetts, USA, between 2007–2019. A total of 343 men provided 896 semen samples, with an average of just over two samples per participant. Dietary intake was assessed using a 131-item food frequency questionnaire, and UPF consumption was classified using the NOVA classification system. The primary outcomes were semen volume, total sperm count, sperm concentration, total motility, progressive motility, and normal morphology.
Multivariable generalised linear mixed models were used to evaluate the association between UPF intake, categorised into quartiles and semen quality parameters. The models were adjusted for age, BMI, education level, ethnicity, smoking status, physical activity, duration of sexual abstinence, and intake of other NOVA food groups, including unprocessed or minimally processed foods, processed culinary ingredients, and processed foods.
Participants had a median age of 36.0 years and a median BMI of 27.0 kg/m². Median UPF consumption was 5.7 servings per day. The analysis showed no statistically
significant associations between higher UPF intake and any of the semen parameters. Specifically, the adjusted mean differences between men in the highest quartile of UPF intake compared to those in the lowest were –0.23 mL for ejaculate volume, 0.25 million for total sperm count, 0.34 million per millilitre for sperm concentration, 1.54% for total motility, 1.66% for progressive motility, and 0.28% for normal morphology, with CIs crossing zero in all cases.
The analysis showed no statistically significant associations between higher UPF intake and any of the semen parameters
The authors acknowledged several limitations, including the observational nature of the study, the single dietary assessment, and the specific population of men seeking fertility care, which may limit the generalisability of the findings. Nevertheless, this research provides some reassurance that UPF intake does not appear to impact semen quality in this group.
Given the increasing global consumption of UPFs and the diversity of UPF products and diets worldwide, further research is needed to examine potential effects on reproductive health in broader and more diverse populations.
Male Infertility Linked to Higher Cardiometabolic Disease Risk, Large Population Study Confirms
MEN who are infertile have been found to have a modestly increased risk of developing heart disease, hypertension, and diabetes compared with men who are fertile, according to new research presented at ESHRE 2025.7
Male infertility has increasingly been linked to adverse long-term health outcomes, particularly concerning cardiovascular and metabolic health. Existing studies have produced mixed findings, but several suggest that men with a history of infertility may be more susceptible to cardiometabolic diseases later in life. The interplay between shared risk factors, such as age, lifestyle, chronic medical conditions, and environmental exposures, complicates interpretation of this association. Therefore, researchers sought to clarify the relationship between male infertility and cardiometabolic disease in this large population-based cohort study.
In New South Wales, Australia, 446,100 men who fathered a child between January 2009–September 2016 were recruited into this study. Men were excluded if they had a previous infertility diagnosis before 2009, were under 14 years of age at conception, or had pre-existing diagnoses of the outcomes of interest within the previous 6.5 years. Male infertility was identified using medical records, fertility procedures, or the use of gonadotropin medications.
446,100 men who fathered a child between January 2009–September 2016 were recruited into this study
Outcomes tracked over a median 5-year follow-up included hypertension, ischaemic and non-ischaemic heart disease, diabetes, and cerebrovascular disease. Appropriate statistical adjustments were made for confounding using inverse probability weighting and robust Poisson regression. Crude incidence rates (per 1,000) were notably higher in infertile men for hypertension (64.42 versus 39.47), all heart disease (56.12 versus 35.21), ischaemic heart disease (44.69 versus 28.45), nonischaemic heart disease (19.26 versus 11.57), and cerebrovascular disease (1.66 versus 1.15). After adjustment, infertile men still showed significantly higher risk for hypertension (adjusted marginal risk ratio [aRR]: 1.22), all heart disease (aRR: 1.21), non-ischaemic (aRR: 1.24) and ischaemic heart disease (aRR: 1.16), and diabetes (aRR: 1.26). No statistically significant difference was observed for cerebrovascular disease (aRR: 1.01).
Men with a history of infertility may be more susceptible to cardiometabolic diseases later in life
These findings reinforce the importance of recognising male infertility as a possible indicator of heightened cardiometabolic risk, offering clinicians an opportunity for proactive screening and early intervention among this group. However, some important confounders may not have been fully accounted for, and the selection of men who successfully fathered a child may limit the wider applicability. Future studies should focus on including men who do not achieve fatherhood and seek to further untangle the underlying mechanisms linking infertility and later-life disease.
Regenerative Treatments Enhance Pregnancy Rates in Chronic Endometritis I
A RECENT prospective, randomised clinical trial investigated whether intrauterine irrigations with peripheral blood mononuclear cells (PBMC) secretome, granulocyte-colony stimulating factor (G-CSF), and stem cells improve reproductive outcomes in women suffering from chronic endometritis (CE).8
CE is a persistent inflammation of the uterine lining associated with recurrent implantation failure and reduced pregnancy rates, often resistant to conventional antibiotic treatments.
The study included 54 women with CErelated infertility, who were divided into two groups. One received standard antibiotic therapy plus intrauterine PBMC treatment, while the control group received antibiotics alone. Additional assessments evaluated G-CSF and stem cell therapies in similar patient populations.
The results showed a significant improvement in clinical pregnancy rates among patients treated with PBMC in addition to antibiotics compared to antibiotics alone. The clinical pregnancy rate per transfer in the PBMC group was 72%, nearly double the 39% observed in controls.
Overall, pregnancy rates were similarly increased. Analysis of immune markers revealed improved modulation, with elevated IL-18 levels and a reduced IL-10/IL-18 ratio post-treatment, indicating a more favourable immune environment for implantation.
G-CSF treatment also significantly improved pregnancy rates and live birth outcomes, and was shown to promote endometrial regeneration in cases of Asherman’s syndrome. Stem cell therapy demonstrated promising results as well, with a 23% clinical pregnancy rate and shorter time to conception, although without significant changes in endometrial thickness.
Despite the encouraging findings, the study was limited by a relatively small sample size and variability in CE diagnosis, necessitating further large-scale trials to validate these results. Long-term safety and optimal treatment protocols for these regenerative therapies remain to be established. Nonetheless, the study highlights
Thin Endometrium Linked to Increased Risk of Implantation Timing Issues
NEW RESEARCH presented at ESHRE 2025 has shown that patients with a thin endometrium face a significantly higher risk of embryo implantation failure due to displacement in the ‘window of implantation’ (WOI).9
The study, involving 45,780 patients with infertility, found that individuals with an endometrial thickness <6 mm exhibited a 45.19% rate (174/385) of WOI displacement, markedly higher than those with normal (6–12 mm; 256/770=33.25%) or hypertrophic (>12 mm, 250/770=32.47%) endometrial thickness (p<0.001). The WOI refers to the critical time during which the endometrium is receptive to embryo implantation.
Researchers used a transcriptomics-based endometrial receptivity analysis on biopsies collected after 5 days of progesterone treatment. Additionally, patients with atrophic endometrium also displayed a significantly higher frequency of post-receptive (16/385=4.16%) and 2 days pre-receptive (15/385=3.9%) results, compared to patients with normal (19/770=2.47% and 8/770=1.04%, respectively) and hypertrophic (11/770=1.43% and 8/770=1.04%, respectively) endometrium
(p<0.001). Finally, the researchers analysed the total sample size before applying the propensity score strategy, and found that even patients with normal endometrial thickness had a notable 33.12% (13,834/41,764) rate of WOI displacement, underscoring the need for molecular-level receptivity assessments beyond ultrasound measurements.
While the retrospective nature of the study limits conclusions about pregnancy outcomes, the findings highlight the potential value of personalised embryo transfer timing in improving IVF.
Even patients with normal endometrial thickness had a notable 33.12% (13,834/41,764) rate of WOI displacement
Combined Genetic Screening Improves IVF Success Per Embryo Transfer
COMBINING ploidy screening with monogenic disease testing in IVF embryos significantly improves live birth rates and reduces miscarriage risk per single embryo transfer, according to a study presented at ESHRE 2025.10
Embryos with chromosomal abnormalities are a major cause of implantation failure and miscarriage. Preimplantation genetic testing for monogenic conditions (PGT-M) is commonly used to avoid transmission of single-gene disorders, while preimplantation genetic testing for aneuploidy (PGT-A) screens for chromosomal abnormalities. Since July 2021, a single European fertility centre has implemented a combined approach (coPGT-M), which simultaneously screens for both types of genetic anomalies, enabling transfer of only euploid, unaffected embryos. This retrospective cohort study compared first-rank IVF cycles between December 2019–October 2022, analysing outcomes for 126 PGT-M cycles and 131 coPGT-M cycles. Follow-up continued through December 2024.
The odds of achieving a live birth or ongoing pregnancy were 86% higher in the coPGT-M group
Both groups showed comparable baseline characteristics, including age (30.4 versus 30.3 years) and ovarian reserve. The average number of biopsied blastocysts and embryos eligible for transfer did not differ significantly between groups. While cumulative live birth or ongoing pregnancy rates per cycle were not statistically different (42.1% PGT-M versus 51.9% coPGT-M; p=0.114), outcomes per single embryo transfer were significantly improved with coPGT-M. The odds of achieving a live birth or ongoing pregnancy were 86% higher in the coPGT-M group (odds ratio: 1.86; 95% CI: 1.21–2.87; p=0.005). Moreover, the odds of pregnancy loss were reduced by 50% with coPGT-M (odds ratio: 0.5; 95% CI: 0.27–0.93;
p=0.028). The number of transfers required per patient was similar between groups.
These findings suggest that, while overall success rates per cycle remain comparable, adding ploidy screening to PGT-M offers meaningful clinical advantages in pertransfer outcomes. Incorporating this approach may help reduce emotional and physical burden by shortening the time to a successful pregnancy and minimising pregnancy loss.
This retrospective cohort study compared firstrank IVF cycles between December 2019–October 2022, analysing outcomes for 126 PGT-M cycles and 131 coPGT-M cycles
References
1. Saraswat L et al. Infertility and endometriosis: a 30-yearlong national population-based study of prevalence, association and pregnancy outcomes. Abstract O-250. ESHRE Annual Meeting, 29 June-2 July, 2025.
2. Gomez-Sanchez E et al. Unveiling the hidden danger: detection and characterisation of microplastics in human follicular and seminal fluids. Abstract O-280. ESHRE Annual Meeting, 29 June-2 July, 2025.
3. Maggi S et al. OvoVid phase 2: role of micronutrients and probiotics supplementation on reproductive outcomes in an oocyte donation program: multicentric, double-blind, randomized, controlled trial. Abstract O-009. ESHRE Annual Meeting, 29 June-2 July, 2025.
4. Hadj-Kaddour S et al. Fertility preservation in adolescent and young adult transgender men. Abstract O-032. ESHRE Annual Meeting, 29 June-2 July, 2025.
5. Cabral MM et al. Mercury exposure and reproductive health: insights from 150 women of childbearing age. Abstract O-033. ESHRE Annual Meeting, 29 June-2 July, 2025.
6. Chavarro J et al. Ultra-processed foods consumption and semen quality parameters among men attending a fertility clinic. Abstract O-193. ESHRE Annual Meeting, 29 June-2 July, 2025.
7. Marozzi J et al. Male infertility and risk of cardiometabolic conditions: a population-based cohort study. Abstract O-194. ESHRE Annual Meeting, 29 June-2 July, 2025.
8. Khalenko V et al. New approaches to the treatment of chronic endometritis: evaluating the effectiveness of intrauterine irrigations with PBMC, G-CSF, stem cells. Abstract O-196. ESHRE Annual Meeting, 29 June-2 July, 2025.
9. Perilla DV et al. Thin endometrium patients suffer from a higher risk of window of implantation displacement - a propensity score matching study. Abstract O-198. ESHRE Annual Meeting, 29 June-2 July, 2025.
10. Vanden Meerschaut F et al. Improved live birth rates and reduced miscarriage rates per single embryo transfer through aneuploidy screening in young patients undergoing PGT-M. Abstract O-203. ESHRE Annual Meeting, 29 June-2 July, 2025.
Highlights from ESHRE 2025: Advances in Endometrial Preparation Strategies for Frozen Embryo Transfer
Authors: *Petya Andreeva,1,2 Ivelina Oprova1,2
1. Shterev Hospital, Sofia, Bulgaria
2. South-West University, Blagoevgrad, Bulgaria
*Correspondence to andreivp@yahoo.com
Disclosure: The authors have declared no conflicts of interest.
Frozen embryo transfer (FET) protocols play a pivotal role in assisted reproduction, with ongoing research focused on optimising outcomes through precise hormonal management and endometrial preparation. Progesterone monitoring during the luteal phase remains a critical yet debated factor influencing implantation success and pregnancy maintenance. In parallel, novel adjunct therapies, including intrauterine platelet-rich plasma (PRP) infusion, are under investigation for their potential to enhance endometrial receptivity, especially in patients with recurrent implantation failure (RIF). These areas of study highlight the evolving complexity of FET management and the ongoing pursuit of personalised treatment strategies to improve reproductive outcomes.
NATURAL VERSUS PROGRAMMED FROZEN EMBRYO TRANSFER IN OVULATING WOMEN: OUTCOMES AND RISKS
With FET cycles rising worldwide, this year’s European Society of Human Reproduction and Embryology (ESHRE) Annual Meeting spotlighted endometrial preparation in ovulatory women as a key factor for success.1,2 A dedicated session, titled ‘Paris on Ice: Innovations in FET Cycles’, showcased emerging data comparing natural and programmed regimens, highlighting the shift towards safer, more individualised approaches.
A pivotal multicentre RCT compared natural ovulation and programmed endometrial preparation in 4,376 women who were ovulating (aged 20–40 years) undergoing
single frozen blastocyst transfer.3 Participants were randomised to either a natural regimen (n=2,185), involving ultrasound-monitored follicular development, or a programmed regimen (n=2,191), using exogenous oestrogen and progesterone (P4) once endometrial criteria were met.
The results showed that both methods produced comparable live birth rates: 51.2% in the natural ovulation group and 50.1% in the programmed group. Similarly, healthy live birth rates were almost the same, at 41.7% and 40.9%, respectively. However, notable differences were observed in maternal safety. The natural ovulation group experienced significantly lower risks of clinical pregnancy loss (14.0% versus 17.0%), hypertensive pregnancy disorders (6.1% versus 8.8%), and postpartum haemorrhage (2.0% versus 6.1%). These differences
were both statistically significant and clinically important, representing relative risk (RR) reductions between 18% and 68% for these complications.
This trial stands out from previous smaller studies, which were primarily focused on pregnancy and live birth rates, and lacked the statistical power to detect differences in obstetric complications. In contrast, this study was specifically designed to assess maternal health outcomes, offering new evidence to guide practice. While some variability existed in luteal support protocols, and both true and modified natural cycles were included, the results highlight a clear trend: natural ovulation regimens may offer a safer approach to endometrial preparation without compromising effectiveness.
This study contributes valuable data to the growing discussion about tailoring FET protocols based on both reproductive and obstetric outcomes. For women who
ovulate regularly, natural cycle FET may now be considered the preferred approach, offering a favourable balance between efficacy and improved maternal safety.
MONITORING SERUM PROGESTERONE IN ARTIFICIAL FROZEN EMBRYO TRANSFER: STILL CONTROVERSIAL
The optimal management of luteal phase support in FET cycles with artificial endometrial preparation remains under debate, particularly in cases of low serum P4 levels on the day of embryo transfer. Two recent prospective studies offer differing insights into whether individualised P4 supplementation improves clinical outcomes in this population.
The first study, a single-centre RCT conducted between May 2021–September 2024, included 824 patients with P4 levels <10 ng/mL undergoing artificial FET with micronised vaginal progesterone (MVP).4 Patients were randomised to receive either standard MVP 800 mg daily or the same regimen plus 50 mg intramuscular (IM) P4. The IM P4 group had significantly higher clinical pregnancy (39.3% versus 32.0%; p=0.029) and ongoing pregnancy (35.2% versus 28.6%; p=0.044) rates, with RRs of 1.23 and 1.22, respectively. These results support the benefit of monitoring serum P4 and using IM supplementation for patients with suboptimal P4 levels.
A single-centre RCT conducted between May 2021–September 2024, included
824 patients
with P4 levels <10 ng/mL undergoing artificial FET with micronised vaginal progesterone (MVP)
Conversely, a second prospective study conducted at a tertiary fertility centre from April 2021–December 2024 included 270 patients undergoing single blastocyst FET in artificially prepared cycles. In this trial, 87 patients with P4 <10 ng/mL were randomised to either continue MVP 400 mg twice daily or increase to 400 mg three times daily.5 No significant differences in ongoing pregnancy rates were observed between patients with P4 ≥10 ng/mL (31.1%) and those with P4 <10 ng/mL (27.3%), nor between the rescue and non-rescue low P4 subgroups. Adjusted odds ratios for ongoing pregnancy rates were not statistically significant, and no alternative serum P4 cutoff point emerged. These results suggest that moderate increases in vaginal P4 alone may not substantially improve outcomes in patients with low P4 levels.
Taken together, these studies highlight a critical gap in consensus on optimal luteal phase support strategies in artificial FET cycles. While the first trial supports the benefit of IM P4 supplementation for patients with low P4, the second study casts doubt on the reliability of serum P4 thresholds and the efficacy of adjusting vaginal P4 alone.
Future multicentre randomised trials are essential to elucidate whether the route, dosage, or formulation of progesterone beyond serum concentration alone plays a critical role in optimising FET outcomes. In the absence of definitive guidelines, individualised strategies based on progesterone monitoring and customised supplementation may yield the most favourable outcomes for select patient populations.
INTRAUTERINE PLATELET-RICH PLASMA IMPROVES PREGNANCY OUTCOMES AND LIVE BIRTH RATES IN RECURRENT IMPLANTATION FAILURE: A META-ANALYSIS
Successful embryo implantation depends not only on the quality of the embryo but also on sufficient endometrial receptivity. This critical determinant of reproductive outcomes was a primary focus of the session titled 'Using Big Data to Investigate Implantation and Early Pregnancy', with particular emphasis on RIF. RIF is characterised by the inability to achieve pregnancy following multiple transfers of high-quality embryos and affects around 10% of patients undergoing embryo transfer. It remains a significant clinical challenge, largely due to the scarcity of effective treatments addressing endometrial dysfunction.
Among the proposed therapies, intrauterine infusion of PRP has been investigated for its potential to enhance endometrial growth, vascularisation, and embryo–endometrial interaction.6 While initial studies reported encouraging outcomes, subsequent trials produced inconsistent results, leading the ESHRE RIF Working Group to advise against routine clinical use. However, this recommendation was based on outdated meta-analyses with limited sample sizes and substantial methodological heterogeneity.
To provide updated evidence, a comprehensive meta-analysis was conducted, including 31 controlled trials (n=3,813), of which 21 were RCTs. PRP infusion was associated with significantly improved outcomes. Biochemical pregnancy rates increased (RR: 1.56), particularly in RCTs (RR: 1.80), and clinical pregnancy rates were also higher (RR: 1.67; RCTs: 1.93 versus 1.40).
PRP significantly reduced miscarriage rates, both biochemical (RR: 0.51) and clinical (RR: 0.44), and more than doubled the likelihood of live birth or ongoing pregnancy (RR: 2.36).
Despite underlying heterogeneity, this analysis provides the most robust evidence supporting the use of PRP as a promising adjunct in endometrial preparation for FET in patients with RIF to date.
CONCLUSION
Compelling evidence supports natural ovulation protocols over programmed regimens in FET for women who are ovulating, demonstrating comparable efficacy with improved maternal safety. Nevertheless, the optimal approach to luteal phase support in artificial cycles remains unresolved, as current studies present conflicting findings regarding the clinical relevance of serum progesterone monitoring and tailored supplementation. Intrauterine PRP infusion shows promising results in patients with RIF, but further randomised trials are required to substantiate its utility and guide personalised FET strategies.
Successful embryo implantation depends not only on the quality of the embryo but also on sufficient endometrial receptivity
References
1. Mei J et al. Endometrial preparation methods prior to frozen embryo transfer: a retrospective cohort study comparing true natural cycle, ovulation induction, hormone replacement treatment and GnRHa pretreatment. BMC Pregnancy Childbirth. 2025; DOI: 10.1186/s12884-025-07211-0.
2. Liu X et al. Natural cycle versus hormone replacement therapy as endometrial preparation in ovulatory women undergoing frozen-thawed embryo transfer: the compete openlabel randomized controlled trial. PLoS Med. 2025;22(6):e1004630.
3. Wang Z et al. Natural ovulation regimen versus programmed regimen for endometrial preparation before frozen embryo transfer (FET) in ovulatory women: a randomized clinical trial. Abstract O-185. ESHRE Annual Meeting, 29 June-2 July, 2025.
4. Stoop D et al. Serum progesterone on day of frozen embryo transfer (FET), including non-rescued patients with low progesterone, does not impact outcome: a prospective analysis and randomized trial. Abstract O-188. ESHRE Annual Meeting, 29 June-2 July, 2025.
5. Le TMC et al. Individualized luteal phase support with intramuscular progesterone in patients with low serum progesterone on the day of frozen-thawed embryo transfer: a randomized clinical trial. Abstract O-187. ESHRE Annual Meeting, 29 June-2 July, 2025.
6. Chow E et al. Intrauterine platelet-rich plasma infusion increases biochemical/ clinical pregnancy whilst decreasing miscarriage, resulting in increased live birth/ongoing pregnancy in patients suffering from recurrent implantation failure: A meta-analysis. Abstract O-152. ESHRE Annual Meeting, 29 June-2 July, 2025.
How AI is Revolutionising Reproductive Clinical Practice
THIS YEAR marked the 41st Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE), held from 29th June–2nd July, in Paris, France. It brought together leading experts and clinicians from around the world to discuss groundbreaking developments in human reproduction and embryology. One key interdisciplinary focused session, titled ‘Incorporating Artificial Intelligence in Clinical Practice – Are We There Yet?’,1 featured presentations from Ariel Hourvitz, Assaf-Harofeh Medical Center, Be'er Ya'akov, Israel; and Eduardo Hariton, University of California San Francisco (UCSF), USA. They discussed the implementation of AI in assisted reproductive technology and its role in streamlining the workflow of fertility treatments, as well as how AI can be leveraged to enhance ovarian stimulation.
INTRODUCTION
In his talk, ‘Implementation of Artificial Intelligence (AI) in ART and Streamlining the Workflow of Fertility Treatments using AI’, Hourvitz outlined how AI technologies are already beginning to optimise the complex processes involved in fertility treatment, particularly in procedures such as IVF. By enabling the analysis of large and complex datasets, AI has the potential to support more precise, standardised, and costeffective clinical decision-making; however, Hourvitz also highlighted a number of challenges that must be addressed for AI to be implemented responsibly. These include difficulties with data acquisition, the limited standardisation of electronic medical records, concerns around data privacy and security, and the absence of clear regulatory frameworks in many contexts.
There is also an ongoing risk that excessive dependence on AI could undermine clinicians’ decision-making skills and reduce the essential human element of patient care. Nevertheless, AI applications are already being employed across almost every stage of fertility treatment, from diagnosis and prognostic modelling to treatment planning and workload allocation. Although this is the case, Hourvitz emphasised that AI should be viewed as an adjunct to clinical expertise, enhancing evidence-based practice while preserving the empathy and professional judgement that remain central to high-quality reproductive care.
OPTIMISING TRIGGER TIMING AND NATURAL CYCLE MANAGEMENT USING AI IN IVF
AI applications are already being employed across almost every stage of fertility treatment
Determining the optimal timing for ovulation trigger during controlled ovarian stimulation remains one of the most subjective and debated aspects of IVF treatment, with significant variation observed between clinicians and practices globally. Differences in clinical approaches, notably between Europe and the USA, reflect this ongoing
uncertainty. For example, European clinics often wait for larger follicle sizes before triggering ovulation, whereas clinics in the USA may proceed at smaller sizes. Given the crucial impact of trigger timing on treatment outcomes, this area has attracted considerable research interest, with numerous studies aiming to define the ideal day for ovulation induction.
AI-SUPPORTED DECISION-MAKING IN TRIGGER TIMING
Hourvitz and colleagues recently demonstrated how AI can be utilised to support trigger timing decisions.2 Their team developed a machine learning model based on the XGBoost algorithm, trained on a large dataset of approximately 10,000 antagonist IVF cycles from a single centre.2 The model incorporated clinical and laboratory parameters, including patient age, BMI, stimulation protocol, cycle day, hormonal profiles, and ultrasound follicular measurements. Notably, follicle count, serum oestradiol levels, and mid-size follicles measuring 14–16 mm emerged as the most influential predictive factors.2,3
PREDICTIVE ACCURACY AND CLINICAL IMPACT
The model showed strong predictive performance, with R2 values of 0.81, 0.73, and 0.69 for trigger decisions on the same day, the following day, and after 2 days, respectively.2 However, Hourvitz emphasised that accuracy metrics alone are insufficient; the clinical relevance is determined by whether AI-driven recommendations translate into improved patient outcomes.
To evaluate this, cycles where the clinician’s trigger decision aligned with the algorithm’s recommendation (‘concordant’ group) were compared against cycles with discordant decisions. The concordant group yielded a significantly higher mean oocyte retrieval (12.3 versus 8.7), equating to an additional 3.6 oocytes and nearly one more blastocyst per cycle.2 This finding reinforces the tangible benefits of AI-informed trigger timing in maximising IVF success.
Further validation was performed in a multi-centre setting involving IVF units across Europe, Asia, and the USA, with the model expanded to cover all stimulation
protocols beyond antagonists.4 These efforts confirmed consistent performance across diverse populations and treatment regimens, supporting the algorithm’s generalisability.4
AI IN NATURAL CYCLE OVULATION PREDICTION
Extending beyond stimulated cycles, Hourvitz’s team developed an AI-driven ovulation prediction tool for managing natural cycles.5 This model aids in timing frozen embryo transfers, intrauterine insemination, and timed intercourse. Applications are particularly valuable for general obstetricians and gynaecologists less familiar with fertility protocols.
The model was trained on 500 natural cycles featuring detailed hormonal and ultrasound monitoring. Validation was performed using two datasets: one based on ovulation dates determined by consensus among fertility experts, and another based on objective criteria, including a luteinising hormone surge followed by documented follicular collapse. The XGBoost model achieved 93% accuracy in predicting ovulation timing in both datasets.5
Clinical outcome analysis again revealed that concordance between clinical decisions and AI predictions corresponded with superior results, affirming the algorithm’s utility in natural cycle management.
FUTURE PERSPECTIVES AND CLINICAL INTEGRATION
Hourvitz’s presentation illustrated the promising role of AI in enhancing clinical decision-making in fertility treatment. Despite challenges such as data quality, interpretability, and integration into clinical workflows, machine learning offers precise, evidence-based guidance that can improve treatment outcomes.
Ongoing prospective RCTs are underway to validate the safety and effectiveness of AI-driven protocols. Ultimately, the vision is a fully integrated AI-managed IVF cycle encompassing both clinical and laboratory processes. Hourvitz concluded with a quote originally stated by Antonio Di Leva, University of Turin, Italy: “Machines will not replace physicians, but physicians using AI will soon replace those not using it.” This signals a paradigm shift in reproductive medicine.
INTEGRATING AI FOR ENHANCED IVF OUTCOMES
Following Hourvitz’s discussion, Hariton took the stage to explore the transformative potential of AI, shifting focus to its practical applications in optimising ovarian stimulation and streamlining clinical workflow. Hariton highlighted the urgent need for AI-driven solutions given the rapidly changing fertility landscape, marked by increasing patient demand, a shortage of trained fertility specialists, and lengthy wait times globally. He noted how AI in reproductive medicine, though still an early field, is crucial for improving outcomes and operational efficiency within increasingly consolidated clinic networks.
PERSONALISED OUTCOME PREDICTION FOR PATIENT COUNSELLING
Hariton spotlighted the critical role of AI in outcome prediction and patient prognostication. He noted that physicians often carry inherent biases, such as availability bias, which can subjectively influence their treatment decisions. Patients, however, seek highly personalised expectations, not just general statistics, to prepare emotionally and financially for treatment.
To address this, Hariton showcased the AI Pathway to Parenthood™ tool (US Fertility LLC, Rockville, Maryland, USA), a model that harnessed 8 years of data, encompassing millions of patient data points and over 100,000 cycles, to provide precise, personalised predictions for IVF, intrauterine insemination, and egg freezing. The tool integrates clinical parameters like age, diagnosis, ovarian reserve, and BMI to identify similar patients and predict individual success rates. This expectationsetting proved invaluable for patients and was hypothesised to reduce dropout rates, as even those with insurance coverage often disengage due to emotional distress rather than financial constraints.
Hariton highlighted the urgent need for AI-driven solutions given the rapidly changing fertility landscape
OPTIMISING OVARIAN STIMULATION DOSING
Addressing the significant subjectivity in gonadotropin dosing, which varies widely across continents and even within clinics, Hariton presented how AI can standardise this crucial step. He referenced a study by Fanton et al.6 that developed a patientspecific, interpretable model to optimise the starting dose of follicle-stimulating hormone (FSH). This model, trained on nearly 20,000 cycles, identified patients as either doseresponsive (where oocyte yield changes with dose; approximately 30%) or flatresponsive (where yield is consistent across a range of doses; about 64%).
For dose-responsive individuals, optimal AI-guided dosing resulted in more mature oocytes and blastocysts with a slightly lower total FSH dose. For those who were flat-responsive, AI allowed for significantly lower medication doses (e.g., 1,375 units less per cycle) with similar outcomes, leading to substantial cost savings without compromising success.6
ENHANCING FOLLICULAR MONITORING AND TRIGGER OPTIMISATION
Hariton briefly touched upon advancements in follicular monitoring, highlighting AI’s ability to automate 3D ovarian sweeps and accurately measure follicles. This technology promises to improve geographic access by enabling remote ultrasounds and even patient self-administered home scans, as demonstrated by a study that showed equivalent accuracy and higher patient satisfaction.7 This also allows for faster monitoring by less trained personnel and standardises accuracy, which is crucial for feeding precise data into AI models.
Revisiting trigger optimisation, Hariton detailed his own thesis project, an early AI study that used causal inference models to predict the optimal trigger time. By analysing over a decade of patient data, his model predicted an average gain of 1.4 more fertilised eggs (eggs with two pronuclei) and approximately 0.5 more blastocysts per cycle when clinicians followed AI recommendations. He noted that, while doctors often made the right decision, there was a significant “purple zone” where AI could improve outcomes. Subsequent real-world studies, like one involving two senior reproductive endocrinologists using a tool called Stim Assist™ (Alife Health Inc., San Francisco, California, USA), further confirmed AI’s acceptability and integration into practice, showing maintained oocyte counts with reduced FSH doses and no increased risk of ovarian hyperstimulation.8
References
1. Hourvitz A, Hariton E. Incorporating artificial intelligence in clinical practice – are we there yet? Session 34. ESHRE Annual Meeting, 29 June-2 July, 2025.
2. Reuvenny S et al. An artificial intelligence-based approach for selecting the optimal day for triggering in antagonist protocol cycles. Reprod Biomed Online. 2024;48(1):103423.
3. Hanassab S et al. Explainable artificial intelligence to identify follicles that optimize clinical outcomes during assisted conception. Nat Commun. 2025;16(1):296.
STREAMLINING WORKFLOW AND FUTURE OUTLOOK
Hariton echoed Hourvitz’s findings on workload balancing, emphasising that AI can help labs manage not just the number of retrievals, but the actual anticipated workload in terms of oocytes and blastocysts. Building on this, he noted that such insights allow clinics to smooth out busy days, reducing instances of operating over capacity from, for example, 32 times a year to just nine.
In his concluding remarks, Hariton stressed the need to separate AI excitement from reality. He called for continued investment in peer-reviewed validation (both internal and external) and a clear business case for AI, focusing on how these tools can drive operational efficiency, improve patient outcomes, and potentially reduce costs for the entire healthcare system rather than simply adding expenses. Ultimately, AI holds immense potential to transform the IVF clinic and embryology lab, enhancing decision support and refining reproductive medicine practices.
4. Hourvitz A et al. Machine-learning predictive modeling for mature oocyte retrieval: a transcontinental study with various treatment protocols. Poster 4142071. ASRM Scientific Congress & Expo, 19-23 October, 2024.
5. Luz A et al. Improved clinical pregnancy rates in natural frozenthawed embryo transfer cycles with machine learning ovulation prediction: insights from a retrospective cohort study. Sci Rep. 2024;14(1):29451.
6. Fanton M et al. An interpretable machine learning model for individualized gonadotrophin starting
dose selection during ovarian stimulation. Reprod Biomed Online. 2022;45(6):1152-9.
7. Chung EH et al. Virtual compared with in-clinic transvaginal ultrasonography for ovarian reserve assessment. Obstet Gynecol. 2022;139(4):561-70.
8. Berga SL et al. Should menopause care be part of the skill set of a reproductive endocrinology and infertility specialist? Fertil Steril. 2024;121(2):213-8.
New Frontiers in Endometriosis: Imaging and Beyond
A DEDICATED session on endometriosis at the 41ˢᵗ Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE) highlighted the significant progress being made in both imaging technologies and emerging diagnostic biomarkers. Experts explored how clinical tools are evolving to support earlier, more accurate, and more patient-friendly diagnosis, redefining the way endometriosis is detected and managed.
FROM INVASIVE PROCEDURES TO IMAGING FIRST
The session opened with Mee Kristine, Oslo University Hospital, Norway, who traced the diagnostic evolution from invasive laparoscopy to the current use of non-invasive imaging. Today, transvaginal sonography (TVS) and MRI are at the heart of diagnosis and disease mapping, helping to identify the three main phenotypes of endometriosis: superficial peritoneal, ovarian (endometriomas), and deep infiltrating endometriosis.
TVS remains the first-line imaging modality. It is widely available, cost-effective, and environmentally friendly, with excellent test performance. As a dynamic tool, TVS allows real-time interaction with the patient, enabling the clinician to assess site-specific tenderness and gain immediate insight. However, TVS has limitations, particularly in detecting peritoneal lesions and disease in the lateral pelvic compartments.
MRI serves as a valuable second-line tool when TVS is inconclusive or negative in patients who are symptomatic. It is also used preoperatively and postoperatively if symptoms persist. Its strengths include the ability to generate multiplanar images and better visualisation of lateral and
extra-pelvic disease, which are crucial for identifying issues such as ureteral involvement. However, MRI lacks dynamic interaction with the patient and, like TVS, has limited ability to detect superficial peritoneal lesions.
IMAGING AT THE CENTRE OF DIAGNOSIS AND MANAGEMENT
The 2022 ESHRE guideline1 formally placed imaging at the forefront of the endometriosis diagnostic pathway, recommending it alongside clinical examination as the first-line assessment for suspected endometriosis. Importantly, a negative ultrasound does not rule out the condition. In cases where empirical medical therapy is ineffective or inappropriate, particularly in infertility, diagnostic laparoscopy may still be necessary, especially to assess peritoneal involvement.
Imaging now plays a critical role beyond diagnosis, guiding treatment decisions, surgical planning, and longterm management. It provides essential information about lesion location, size, and complexity, which informs surgical strategy, risk evaluation, and the required level of surgical expertise.
Both TVS and MRI have limited sensitivity for detecting gastrointestinal, diaphragmatic, and superficial peritoneal disease
FERTILITY AND IMAGING
Endometriosis often affects fertility, being linked to reduced ovarian reserve and elevated oxidative stress in the pelvic environment. Here, imaging is essential: it supports fertility preservation, guides egg retrieval in assisted reproductive technology (ART), and helps tailor treatment protocols based on uterine and ovarian accessibility.
A recent Australian study showed the importance of early endometriosis diagnosis.2 Women diagnosed with endometriosis after their first ART cycle required more treatment cycles, had higher rates of intrauterine insemination, and reported lower live birth rates than women without endometriosis. In contrast, women diagnosed prior to initiating ART had outcomes similar to those without endometriosis. This highlights how timely imaging and diagnosis can improve fertility success rates.
DIAGNOSTIC GAPS AND THE NEED FOR EXPERTISE
Despite its advantages, imaging still faces challenges. Both TVS and MRI have limited sensitivity for detecting gastrointestinal, diaphragmatic, and superficial peritoneal disease. Operator expertise is also a major factor, though standardised protocols and key signs (such as the ‘negative sliding sign’ or ovarian immobility) can assist in detection in less specialised settings.
Surgical treatment continues to play an important role, particularly for women with severe symptoms, anatomical distortion, or fertility concerns. The goals of surgery include symptom relief, anatomical restoration, function preservation (such as bowel and ureteral integrity), and recurrence prevention.
The latest ESHRE Guidelines support surgery for endometriosis-related infertility in cases of minimal-to-mild disease and ovarian endometriosis, where evidence suggests improved spontaneous pregnancy rates postoperatively.1 However, surgery before ART is not recommended for superficial or ovarian endometriosis. In deep disease, decisions should be individualised based on pain severity and patient preference.
Surgical technique is also evolving. For superficial peritoneal disease, the standard approach is shifting from ablation, which destroys the lesion with heat, to excision, which involves removing the lesion along with the affected peritoneum. This method is more complex and demands advanced surgical planning, once again highlighting the indispensable role of accurate imaging.
IMAGING INNOVATIONS
Future directions in imaging aim to overcome current limitations. 3D TVS offers better spatial visualisation and could improve the detection of deep or even superficial lesions. Though difficult to identify on current imaging, superficial lesions may be visible if there is some fluid in the posterior cul-de-sac. New methods are under investigation to enhance the detection of these subtle findings.
In 2024, the International Deep Endometriosis Analysis (IDEA) group consensus expanded its guidelines to include routine evaluation of the parametrium, helping to improve identification of lateral compartment disease.3 Another exciting development is pelveoneurosonography, which enables
visualisation of the sacral nerve roots and plexus, structures often involved in chronic pelvic pain but difficult to assess with traditional imaging.
Additionally, molecular imaging is showing promise. The University of Oxford’s DETECT study4 is evaluating 99mTc-maraciclatide, a radiolabelled tracer that binds to the αvβ3 integrin, a protein expressed on the surface of endometriotic lesions. This novel agent may allow non-invasive detection of earlystage endometriosis, a major breakthrough if successfully validated. The tracer offers the potential for functional imaging of active lesions and could complement conventional anatomical imaging modalities.
AI: SUPPORTING DIAGNOSIS AND ACCESS
AI is also making its way into endometriosis diagnostics, offering opportunities to improve early detection and overcome workforce shortages. AI could be used for triage, helping to identify patients who need further imaging, as well as to accelerate diagnosis in adolescents or those experiencing infertility.
3D TVS offers better spatial visualisation and could improve the detection of deep or even superficial lesions
However, challenges remain. MRI data are complex, requiring substantial computational power. TVS images, by contrast, are highly operator-dependent and variable. AI model development is also limited by small and non-representative datasets, a lack of validation, and inconsistent data quality.5
Despite these hurdles, AI holds long-term promise. It could support less experienced clinicians, reduce diagnostic delays, and streamline patient access to expert care, particularly in underserved regions.
BEYOND IMAGING: THE RISE OF BIOMARKERS
In the second part of the session, Arne Vanhie, Leuven University Fertility Centre and University Hospital Leuven, Belgium, addressed the growing interest in noninvasive biomarkers as a complement, or potential alternative, to imaging.
He began by distinguishing between biomarkers and diagnostic tests. While biomarkers may correlate with the presence of disease, true diagnostic tests must demonstrate measurable performance using metrics such as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Vanhie also highlighted the crucial role of prevalence in determining a test’s utility, as lower prevalence dramatically reduces PPV, meaning tests are more reliable in specialist settings than in general practice.
To meet the diverse needs in endometriosis diagnosis, he identified three types of diagnostic tests, each with a different aim, population, and expected outcome. A referral test aims to triage patients who are symptomatic more effectively for imaging,
and must prioritise high sensitivity to avoid missed cases. A replacement test could eventually obviate the need for laparoscopy in patients with negative imaging, requiring a high NPV or PPV, and should reduce healthcare costs. A ‘red flag’ test would identify patients likely to have deep disease and ensure they are referred to expert centres. This type of test must offer a high PPV and contribute to increased detection of deep endometriosis.
PROMISING BIOMARKER RESEARCH
Recent advances have yielded some exciting candidates for the diagnosis of endometriosis. One area of promise lies in salivary microRNAs. A 2022 study involving 153 patients with various disease stages used a random forest model based on 109 salivary microRNAs.6 Interim data from a multicentre validation study are highly encouraging, showing 96.2% sensitivity, 95.1% specificity, and a PPV of 95.1%.7 These results suggest real potential for clinical application, although full validation is still ongoing.
Another line of research has identified plasma protein biomarkers, including proteins involved in the coagulation cascade, complement system, and proteinlipid complexes.8 One model, trained specifically to detect Stage III–IV disease, showed excellent sensitivity and specificity and could be a promising candidate for a red flag test. Even when applied across all
Interim data from a multicentre validation study are highly encouraging, showing 96.2 sensitivity %
95.1 specificity 95.1
disease stages, the model performed well, with 87% sensitivity and 72% specificity for early-stage (Stage I) endometriosis. As with the salivary test, further independent validation is needed.
A FUTURE WITHIN REACH
The ESHRE 2025 session made it clear that the future of endometriosis diagnosis lies in integrated, non-invasive, and personalised care. Imaging has become central not just for diagnosis but also for surgical planning, fertility management, and
References
1. Becker CM et al.; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022;2022(2):hoac009.
2. Moss KM et al. Delayed diagnosis of endometriosis disadvantages women in ART: a retrospective population linked data study. Hum Reprod. 2021;36(12):3074-82.
3. Guerriero S et al. Addendum to consensus opinion from International Deep Endometriosis Analysis (IDEA)
disease monitoring. Molecular imaging and AI are adding new layers of insight, while biomarkers are approaching clinical readiness.
Though challenges remain in validation, standardisation, and access, the combination of advanced imaging, AI, and biomarkers offers a path toward earlier detection, fewer diagnostic delays, improved surgical outcomes, and better quality of life for patients. As Vanhie concluded, “Are we there yet? Not quite, but we may be closer than ever.”
group: sonographic evaluation of the parametrium. Ultrasound Obstet Gynecol. 2024;64(20):275-80.
4. University of Oxford. DETECT (Detecting Endometriosis inTEgrins Using teChneTium-99m Imaging Study). NCT05623332. https:// clinicaltrials.gov/study/NCT05623332.
5. Dungate B et al. Assessing the utility of artificial intelligence in endometriosis: promises and pitfalls. Womens Health (Lond). 2024;20:17455057241248121.
6. Bendifallah et al. Salivary microRNA signature for diagnosis of endometriosis. J Clin Med. 2022;11(3):612.
7. Validation of a salivary miRNA signature of endometriosis – interim data. NEJM Evid. 2023;2(7):EVIDoa2200282.
8. Schoeman EM et al. Identification of plasma protein biomarkers for endometriosis and the development of statistical models for disease diagnosis. Hum Reprod. 2025;40(2):270-9.
ESHRE 2025
Abstract Reviews
This issue’s abstract reviews delve into timely and thought-provoking research presented at the 41st Annual Meeting of the European Society for Human Reproduction and Embryology (ESHRE). From ethical considerations in egg donor consent to fertility challenges in the context of environmental exposures, these studies offer fresh insights and clinical reflections.
Identifying Essential Information for a Valid Informed Consent of Egg Donors: An International Delphi Study
1. Department of Philosophy and Moral Sciences, Bioethics Institute Ghent, Ghent University, Belgium
2. Department of Health Care Management and Policy, Ghent University, Belgium
3. Department of Reproductive Medicine, Ghent University Hospital, Belgium
*Correspondence to lara.jacxsens@ugent.be
Disclosure: Jacxsens has previously been employed by Bijzonder Onderzoeksfonds (BOF) through a doctoral fellowship grant (BOF. STG.2020.0009.01). The other authors have declared no conflicts of interest.
Acknowledgements: The authors would like to thank all the professionals and egg donors who participated in the Delphi study for their valuable insights.
Adequate information disclosure is essential for informed consent in medical procedures like egg donation. However, studies have indicated that egg donors are not always properly informed, and disclosure practices have been deemed inadequate.1 Scholars have therefore emphasised the importance of adequate information disclosure, often focusing on risk information;2 however, this raises the question of what information specifically should be disclosed to prospective egg donors. There is a clear need for a comprehensive guideline of essential information for prospective egg donors. To address this need, the authors conducted an international Delphi study.3
METHODS
Through a three-round iterative survey process, the authors aimed to reach consensus among professionals and egg donors on which information items are relevant and morally necessary for valid informed consent of prospective egg donors. Invitations to participate were sent in November 2023, and the final round concluded in November 2024. The survey comprised 13 information categories, which contained 134 concrete information items (CII). Participants evaluated relevance using a 4-point Likert scale, and moral necessity using a dichotomous (yes/no) format. The Content Validity Index (CVI) was used to analyse relevance, and moral necessity was determined by the percentage of agreement. A consensus threshold was set at 0.78 for both dimensions. Participants also had the opportunity to provide comments. A total of 35 participants (comprising egg donors and professionals from disciplines including medicine, psychology, law, and bioethics) were recruited from 14 countries.
RESULTS
Of the 134 CIIs evaluated, 27 failed to meet the relevance threshold, and 44 fell below the threshold for moral necessity. Four CIIs reached a CVI of 1. All experts thought it was relevant for a candidate donor to know: 1) the need to undergo ovarian stimulation; 2) a pick-up procedure; 3) her legal rights over the donated eggs after the pick-up procedure; and 4) her legal right to withdraw consent. The latter is the only CII that scored a 100% on moral necessity. In several categories, almost all CIIs reached a consensus on moral necessity among most non-medical experts, while fewer CIIs reached a consensus among medical experts. Such differences in agreement between expert groups were found in the categories “Physical side-effects and risks,” “Psychological side-effects and risks,”
“Risks and side-effects of the egg pickup,” “Practicalities affecting an egg donor's everyday life,” and “Alternative treatments.” The most notable difference was between what egg donors and medical professionals considered morally necessary to disclose.
FUTURE RESEARCH AND LIMITATIONS
Future research should further investigate the discrepancy in scoring between medical professionals and egg donors and involve a larger sample of egg donors to better understand their needs on this topic. Despite efforts, input from registered nurses and midwives was not obtained. Some participants dropped out during the iterative rounds, potentially weakening the results, though dropout rates remained within the acceptable 20–30% range.
CONCLUSION
The final results give professionals a standard of essential information to make sure that prospective egg donors are adequately informed and know what to expect when they decide to donate. They also give researchers a potential standard by which to evaluate the quality of the information provision in fertility clinics.
References
1. Tober D et al. Alignment between expectations and experiences of egg donors: what does it mean to be informed? Reprod Biomed Soc Online. 2020;12:1-13.
2. Cattapan AR. Good eggs? Evaluating consent forms for egg donation. J Med Ethics. 2016;42(7):455-9.
3. Jacxsens L et al. Identifying essential information for a valid informed consent (IC) of egg donors: an international Delphi study. Abstract 0-222. ESHRE Annual Meeting, 29 June-2 July, 2025.
Awareness, Risk Perceptions, Experiences, and Protection Strategies of Females Who Are Infertile Regarding Endocrine Disrupting Chemicals: A Qualitative Study
Authors:
*Gokhan
D. Akarsu,1 R. Höbek Akarsu2
1. Pharmacy Services, Yozgat Bozok University, Türkiye
2. Nursing, Yozgat Bozok University, Türkiye
*Correspondence to gokhan_dogukan_akarsu@hotmail.com
Disclosure: The authors have declared no conflicts of interest.
Infertility, defined as failure to conceive after 12 months of unprotected intercourse, affects an estimated 48.5 million couples globally, with environmental factors increasingly recognised as critical contributors. Genetic and behavioural factors can cause female infertility, with environmental and lifestyle factors likely to play a more significant role in increasing infertility.1 Among these, endocrine-disrupting chemicals (EDC), such as bisphenol A, phthalates, per- and polyfluoroalkyl substances, parabens, and pesticides, are particularly concerning due to their hormonally active properties and ubiquity in daily-use products.2
EDCs may affect male fertility on multiple levels, ranging from impairments in sperm production and quality, to alterations in the morphology and histology of the male reproductive system. It has been suggested that EDC exposure can lead to decreased sperm motility, concentration, volume, and normal morphology, as well as increased sperm DNA damage.3
Epidemiological evidence post-2020 links elevated bisphenol A levels in females undergoing assisted reproduction (IVF) with reduced oocyte yield and fertilisation rates, implantation failures, and increased polycystic ovary syndrome and endometriosis risk.4
EDCs, a class of exogenous chemicals, disrupt the natural hormone synthesis and metabolic processes in organisms, triggering a cascade of adverse outcomes, as well as impacting embryogenesis and fetal development. The ubiquity of human exposure to these environmental pollutants is a pressing concern, occurring through ingestion, inhalation, or dermal absorption.5,6
For all these reasons, females, especially those who are infertile, should stay away from EDCs in order to avoid more reproductive health problems. It is also important to determine females’ awareness, risk perceptions, and protective behaviours on this issue. This study provides important information to increase the awareness of females who are infertile about chemical endocrine disruptors. In addition, it is thought that the strategies suggested by females to protect themselves from endocrine disruptors will be useful in protecting reproductive health. The aim of this study is to explore the awareness, risk perceptions, experiences, and protection strategies of females with infertility problems regarding EDCs.7
MATERIALS AND METHODS
This study was designed as a qualitative and descriptive research. Data collection was conducted between 22 July 2023–27 October 2024 at a tertiary research and training hospital located in the Central Anatolia region of Türkiye. The study sample consisted of
Theme
1. Awareness and knowledge level
2. Risk perception
3. Personal experiences
4. Protection strategies
5. Expectations and suggestions
EDC: endocrine-disrupting chemical.
Sub-themes
- Sources of information about EDCs
- Information from healthcare professionals
- Influence of media and social media
- Beliefs about EDCs' effects on fertility
- Perceived personal risk
- Perception of EDCs as invisible or uncontrollable
- Awareness of past chemical exposure
- Experiences with the healthcare system
- Socioeconomic influences
- Behavioural changes in daily life
- Conscious product selection and label reading
- Use of organic/natural alternatives
- Expectations from healthcare providers
- Need for public awareness
- Demand for educational programmes
16 young females with primary infertility who had been under follow-up for at least 3 years, were between 30–35 years of age, and were not undergoing active infertility treatment at the time of data collection.
Data were collected through an in-depth interview using a demographic information form and a semi-structured interview form, as well as a descriptive information form designed by the researcher following the literature. In developing data collection tools, feedback was obtained from four additional researchers. The semi-structured interview form consisted of a series of open-ended questions prepared by researchers by reviewing the literature, to help participants explore their experiences and perceptions.
The voice recordings and notes taken during the interviews were combined and read to produce a single report. This report was subjected to content analysis according to Colaizzi’s descriptive qualitative method.8 In the first step of
the analysis, the report was read multiple times to reveal patterns. Using MAXQDA, researchers coded similar patterns containing the same keywords, metaphors, or transitions, then categorised all codes. Each of the two authors independently analysed the data and created separate codes. Subsequently, the authors combined the codes and reached a consensus. In case of disagreement, the two authors jointly revised the reports. Finally, all codes were reviewed and summarised, and themes and sub-themes were identified.
RESULTS
The participants were between the ages of 30–35 years, most of them had a Bachelor’s degree or higher, their income was medium, and their infertility period was 3–8 years. The study found five main themes and 15 sub-themes (Table 1).
Most of the participants were unaware of EDCs and had never heard of them before,
Table 1: Themes and sub-themes on females’ experiences with endocrine disrupting chemicals.
but they had some guesses. They agreed that it had the potential to be very dangerous for their reproductive health and were concerned about this situation for both their previous health problems and the new generation. They requested more information from health authorities and the Ministry of Health. Various risk reduction strategies were suggested by the participants, such as educating themselves about the issues, changing aspects of their consumerism, or completely avoiding the risks. Participants suggested that they could reduce their exposure to chemicals in plastics by using reusable shopping bags, metal straws, and cardboard. A suggestion was made to switch to organic, local products and shop at farmers' markets instead of large supermarkets.
CONCLUSION
This thematic framework highlights the complex and interrelated factors influencing how females with infertility problems perceive, experience, and respond to the risks posed by EDCs, underscoring the need for targeted education, accessible preventive strategies, and more responsive healthcare practices.
References
1. World Health Organization (WHO). Infertility prevalence estimates, 1990–2021. 2023. Available at: https://www.who.int/publications/i/ item/978920068315. Last accessed: 26 January 2025.
2. Tricotteaux-Zarqaoui S et al. Endocrine disruptor chemicals exposure and female fertility declining: from pathophysiology to epigenetic risks. Front Public Health. 2024;12:1466967.
3. Lahimer M et al. Endocrine disrupting chemicals and male fertility: from physiological to molecular effects. Front Public Health. 2023;11:1232646.
4. Wang J et al. Advances in understanding the reproductive toxicity of endocrine-disrupting chemicals in women. Front Cell Dev Biol. 2024;12:1390247.
5. Dutta S et al. Reproductive toxicity of combined effects of endocrine disruptors on human reproduction. Front Cell Dev Biol. 2023;11:1162015.
6. Yilmaz B et al. Endocrine disrupting chemicals: exposure, effects on human health, mechanism of action, models for testing and strategies for prevention. Rev Endocr Metab Disord. 2020;21(1):127-47.
7. Akarsu GD, Akarsu RH. Infertile women’s awareness, risk perceptions, experiences and protection strategies regarding endocrine disrupting chemicals: a qualitative study. Human Reproduction. 2025;DOI: 10.1093/humrep/ deaf097.036.
8. Colaizzi P, “Psychological research as a phenomenologist views it” Valle RS, King M (eds.), Existential Phenomenological Alternatives for Psychology (1978), New York: Oxford University Press, pp.6.
Evaluating the Role of rIVM and rICSI in Assisted Reproductive Technology: A Systematic Review and Meta-analysis of Outcomes in Low/Failed
Maturation and Fertilisation Cases
Authors: *Teodora Popa,1,2 Andrew Thompson,1,2 Halil Ruso,1 Daria Iliev,1 Chloe He,1 Zofia Rzeznik,1,3 Brinkley Gantt Mickel,1,2 Hannah Coffey,1 Rufus Morgan,1 Oana Paun,1 Madison Bailey,1 Muhammad Fatum,1 Jyoti Taneja,1 Ali Al Chami,1 Cristina Hickman1,4
1. Avenues Life, London, UK
2. UCL Institute for Women’s Health, London, UK
3. Imperial College London, UK
4. Department of Metabolism, Digestion, and Reproduction, King’s College London, UK
*Correspondence to teodora@avenues.life
Disclosure: Popa has received support for attending conferences from Merck, the British Fertility Society, IBSA, and Cooper Surgical; travel grants from Merck, the British Fertility Society, IBSA, and Cooper Surgical; and payment or honoraria for speakers’ events from Merck and Cooper Surgical, with personal fees of less than 1,000 GBP. Ruso has received support for attending conferences from Merck, the British Fertility Society, IBSA, and Cooper Surgical; travel grants from Merck, the British Fertility Society, IBSA, and Cooper Surgical; and payment or honoraria for speakers’ events from Merck and Cooper Surgical, with personal fees of less than 1,000 GBP. Taneja has received support for attending conferences from Merck, the British Fertility Society, IBSA, and Cooper Surgical; research and travel grants from Merck, the British Fertility Society, IBSA, and Cooper Surgical; and payment or honoraria for speakers’ events from Merck, with personal fees of less than 1,000 GBP. Al Chami has received support for attending the conference from Merck, the British Fertility Society, IBSA, and Cooper Surgical; research and travel grants from Merck, the British Fertility Society, IBSA, and Cooper Surgical; and payment or honoraria for speakers’ events from Merck, with personal fees of less than 1,000 GBP. Hickman has received payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Vitrolife, Cooper Surgical, Planer, Hamilton Thorne, Merck Serono, and Ferring, with personal fees of less than 1,000 GBP. The other authors have declared no conflicts of interest.
Approximately 80% of retrieved oocytes in IVF cycles reach maturity, with 60–80% undergoing successful fertilisation. However, 5–15% of cycles experience poor oocyte maturation or failed fertilisation, limiting treatment success. Rescue intracytoplasmic sperm injection (rICSI) and rescue in vitro maturation (rIVM) have been proposed as salvage strategies in these cases. Historically, concerns over embryo quality, aneuploidy risk, and low developmental potential have limited their routine use. Yet, the Human Fertilisation and Embryology Authority (HFEA)’s 9th Code of Practice (October 2023) formally permitted rICSI.
METHODS
To evaluate the feasibility, safety, and effectiveness of Day 0 rICSI and rIVM, the authors conducted a systematic review and meta-analysis of 38 studies published between 1992–2023, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.1 Studies examining Day 1 rICSI were excluded. The analysis included 24 studies on rIVM (7,183 cycles) and 14 on rICSI (2,475 cycles; 1,377 transfers), focusing on clinical pregnancy as the primary outcome, and secondary outcomes such as fertilisation rates, polyploidy risk, blastulation, miscarriage, and live birth rates.
RESULTS
rIVM showed oocyte maturation rates of 57% (metaphase [M] stage: MI–MII) and 68% (germinal vesicle [GV] stage: GV–MII), with blastulation rates of 21% (MI–MII) and 16% (GV–MII). Clinical pregnancy rates reached 19% for MI–MII mature oocytes, but GV–MII rIVM cycles had a high miscarriage rate (67%). Pre-vitrification maturation was 63% (24/38), which was slightly higher than 59% (19/32) post-vitrification, with higher survival rates pre-vitrification (95% versus 82%). For cycles with fewer than nine mature oocytes, rIVM significantly improved clinical pregnancy (56% versus 47%; p<0.001) and live birth rates (65% versus 48%; p<0.001).
For rICSI, pooled fertilisation rates were 68.0% (11,022/16,101), with polyploidy rates at 6.0% and malformation rates at 0.3% (2/711 embryos). The clinical pregnancy rate was 45%, the implantation rate was 30% (647/2,124), and live births reached 709 cases, with no increased risk of malformations. The estimated impact of routine rIVM and rICSI could result in an additional 1,714 live births annually in the UK.
CONCLUSION
These findings indicate that rICSI and rIVM significantly improve pregnancy and live birth outcomes in cycles with low fertilisation or oocyte maturity, without major safety concerns. Nonetheless, study heterogeneity and the suboptimal outcomes associated with GV-stage oocytes, particularly the high miscarriage rate, warrant caution. Further prospective studies are needed to assess the long-term health of resulting offspring. Overall, these interventions offer promising strategies to optimise assisted reproductive technology outcomes, minimise cycle cancellations, and improve conception chances through evidence-based and safetyconscious approaches.
Reference
1. Coffey H et al. O-183 evaluating the role of rescue IVM and rescue ICSI in ART: a systematic review and meta-analysis of outcomes in low/failed maturation and fertilisation cases. Hum Reprod. 2025;40(Suppl_1):deaf097.183.
The following highlights showcase cutting-edge research presented at the 41ˢᵗ Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE), held in Paris, France. This selection explores the latest innovations in reproductive medicine, from AI in sperm detection and the role of the endometrial microbiome, to the psychological impact of pregnancy loss and the effectiveness of pre-implantation genetic testing in reducing time to pregnancy. Together, these findings reflect the dynamic progress shaping fertility care today.
Psychological Toll of Pregnancy Loss Evident in Both Women and Men
A LARGE prospective study presented at ESHRE 2025 revealed the significant mental health impact of pregnancy loss on both women and their partners, highlighting an urgent need for improved psychosocial support in reproductive care.1
Led by Astrid Marie Kolte, Copenhagen University Hospitals, Denmark; Hvidovre Hospital, Denmark, the study followed over 2,000 women and 1,200 partners across 4 years, assessing symptoms of depression, stress, and anxiety within 2–8 weeks after pregnancy loss.
Among women, nearly half (49.4%) reported elevated stress, while 24.1% had moderateto-severe anxiety, and 12.2% met criteria for moderate-to-severe depression. Partners were also affected, with 23.6% reporting stress, 8.3% anxiety, and 3.8% depression.
Key risk factors included prior pregnancy losses and insufficient primary treatment, both strongly associated with worse mental health outcomes. Conversely, having living children was linked to lower rates of distress across all measures.
Being one of the few studies to include both members of the couple, the study offers new insight into the often overlooked psychological toll on partners. The results show that pregnancy loss is not only a clinical event but a deeply emotional one,
with lasting implications for both individuals. Future care models should incorporate tailored psychological support as part of comprehensive miscarriage management.
Key risk factors included prior pregnancy losses and insufficient primary treatment, both strongly associated with worse mental health outcomes
24.1 12.2
49.4 had moderate-to-severe anxiety, and reported elevated stress, while met criteria for moderateto-severe depression % % %
AI Tool Outperforms Age Stratification in Predicting IVF Pregnancy Success
A NEW machine learning model can more accurately predict the likelihood of pregnancy before IVF begins, outperforming conventional age-based methods and promising more personalised counselling for patients, according to research presented at ESHRE 2025.2
Maternal age has long been the dominant factor in assessing IVF success, but researchers argue that relying solely on age can overlook other critical influences, like ovarian reserve, sperm quality, and past IVF outcomes. This new approach uses AI to integrate these additional variables, offering couples a clearer understanding of their chances of conception.
The international, multicentre study analysed 3,852 first autologous IVF cycles performed between 2018–2023, across six fertility centres in two countries. Cases involving egg donation, fertility preservation, or genetic testing were excluded. The AI model included multiple clinical variables: maternal and paternal age, anti-Müllerian hormone levels, antral follicle count, sperm origin and type, and history of past failed cycles.
The international, multicentre study analysed
3,852 first autologous IVF cycles performed between 2018–2023
Researchers trained three separate machine learning models to predict the likelihood of a positive biochemical pregnancy after the first, second, and third embryo transfers. Each model accounted for the chance that no transfer would occur. They used repeated ten-fold cross-validation to ensure robustness and compared the AI’s performance with traditional age-based prediction models.
Relying solely on age can overlook other critical influences, like ovarian reserve, sperm quality, and past IVF outcomes
The AI model significantly outperformed age-only models in predicting biochemical pregnancy, achieving a higher area under the curve score (0.731 versus 0.695) and improved accuracy (67.5% versus 65.3%). Importantly, the model was most accurate at the extremes: it correctly predicted outcomes with over 86% accuracy for women with a <20% chance of pregnancy, and nearly 78% accuracy for those with a >80% chance. Predictive accuracy was lower in mid-range probability cases, between 40–59%.
Explainability analyses confirmed maternal age as the top predictor in first transfers, but for subsequent transfers, ovarian reserve markers, such as anti-Müllerian hormone levels and antral follicle count, became more influential. Previous cycle outcomes also helped refine predictions.
While the AI model is not intended to replace clinical decision-making, it offers a meaningful step forward in IVF counselling. By providing patients with more accurate and individualised expectations from the outset, it may help reduce anxiety and improve the quality of shared decision-making.
Gaps in Miscarriage Data and Reporting in France
A NEW French study presented by Marie-Caroline Compans, Sexual and Reproductive Health and Rights Unit, Institut national d'études démographiques (Ined), Aubervilliers, France, at ESHRE 2025, sheds light on the challenges of accurately measuring miscarriage prevalence and risk factors using diverse data sources.3 Drawing on 13,632,246 medical records for pregnancies, FECOND study survey data (2010–11), a nationally representative sample of women of reproductive age in France (N=7,196 pregnancies), and 50 in-depth interviews about miscarriage experiences, the research emphasises the need for a multi-source approach to understand early pregnancy loss in France.
Contrary to expectations, financial precarity and educational attainment were not significantly associated with miscarriage risk
Findings show a decline in hospital-managed miscarriages, from 6.9% of clinically recognised pregnancies in 2009 to 5.1% in 2023, based on the French National Health Data System. Including primary care data, these rates range from 9.9% in 2013 to 8.9% in 2023, still lower than the 14.0% miscarriage rate reported in the FECOND national survey. This discrepancy suggests that many miscarriages go unreported in medical records, particularly those managed outside of hospitals.
Both sources confirmed maternal age and previous miscarriages as major risk factors, but neither showed strong links between miscarriage and socio-economic status.
Contrary to expectations, financial precarity and educational attainment were not significantly associated with miscarriage risk.
The study’s upcoming qualitative interviews aim to uncover why miscarriages are misreported or underreported in surveys. Researchers hope to better understand how women interpret and respond to questions about pregnancy loss, which could help improve future data collection.
The findings could inform more accurate reproductive health monitoring and help address existing data limitations in both medical and survey-based systems.
Failed First Frozen Embryo Transfer Does Not Predict Second Failure
A RECENT retrospective cohort study, presented at ESHRE 2025, offers reassurance to women undergoing fertility treatment, showing that a prior failed frozen embryo transfer (FET), whether due to biochemical pregnancy loss (BPL), clinical pregnancy loss (CPL), or implantation failure (IF), does not increase the risk of another pregnancy loss in a subsequent FET.4
The study examined outcomes of 2,385 women who underwent their first two single embryo FETs between 2017–2021
2017–2021
The study examined outcomes of 2,385 women who underwent their first two single embryo FETs using either untested or genetically screened (euploid) embryos between 2017–2021 at a high-volume fertility centre.
Among women whose first FET resulted in BPL, CPL, or IF, second FET outcomes were statistically similar across all groups. Rates of subsequent BPL, CPL, and IF in the second FET were comparable, regardless of the outcome of the first transfer. Live birth rates in the second FET also showed no significant difference across groups, with results remaining consistent even after accounting for factors such as age, embryo quality, BMI, endometrial thickness, and hormonal levels.
Importantly, in both euploid and untested embryo transfers, prior loss or implantation failure did not negatively affect future FET success. These results challenge concerns that an initial failed cycle may signal an underlying reproductive issue that is likely to recur.
While the study is limited by its retrospective design, its findings provide valuable insights for clinicians and patients. In an emotionally and financially demanding treatment journey like IVF, this evidence supports a more optimistic outlook for those experiencing early setbacks. Patients can be reassured that a prior failed FET does not predict poor outcomes in a future transfer, offering renewed hope and a clearer path forward in fertility planning.
Study Compares Fertility Journey for 2S/ LGBTQIA+ and
Mixed-Gender
Couples
NEW research presented at ESHRE 2025 has demonstrated that Two-Spirit (2S)/LGBTQIA+ couples undergoing medically assisted reproduction (MAR) report higher relationship satisfaction and lower depressive symptoms than mixed-sex/gender couples, but encounter significant systemic and interpersonal barriers within fertility care.5
Previous research has shown that 20% of MAR-seeking couples identify as 2S/ LGBTQIA+, yet fertility care remains rooted in a medicalised, cisgender framework of infertility, and little is known about the psychological and relational impact on 2S/ LGBTQIA+ couples. Although some research has begun exploring the well-being of lesbian couples in this context, broader evidence for other gender and sexual minority populations has been scarce, especially regarding patient-centred care and relational dynamics.
This mixed-methods study forms part of a wider longitudinal project examining the experiences of 345 couples (80 2S/ LGBTQIA+ and 265 mixed-sex/gender), recruited from Canada and the USA between November 2019–April 2024. The 2S/LGBTQIA+ sample comprised couples with same-gender partners and those with gender-diverse identities. The authors noted that the sample lacked racial and educational diversity, and that male samesex/gender couples were underrepresented.
Couples about to begin MAR completed validated questionnaires on sociodemographics, medical history, psychological and relationship functioning, and perceptions of patient-centred care. Additionally, 2S/LGBTQIA+ participants provided qualitative data via an open-ended question about clinic experiences.
Quantitative results revealed no significant differences in anxiety symptoms or patientcentred care communication and respect domains between groups. However, mixedsex/gender couples had higher depressive symptoms (F[1, 205.347]=7.123; p=0.008;
This mixed-methods study forms part of a wider longitudinal project examining the experiences of 345 couples
2S/LGBTQIA+ and
mixed-sex/gender
d=0.34), whereas 2S/LGBTQIA+ couples reported greater relationship satisfaction (F[1, 212.442]=8.288; p=0.004; d=–0.39) and more frequent use of dyadic coping strategies (F[1, 206.457]=5.929; p=0.016; d=–0.35).
Qualitative feedback from the 2S/LGBTQIA+ cohort revealed frequent barriers such as heteronormativity, financial strain, and repeated identity disclosures, as well as microaggressions from healthcare providers and families, contributing to additional stress. Nevertheless, strong relational bonds and robust social support networks emerged as important coping resources.
The findings indicate that, although 2S/ LGBTQIA+ couples are resilient and maintain healthy relationships amid systemic challenges, mainstream fertility services often fail to address their unique needs. For clinical practice, these results underscore the importance of inclusive, affirming care: providers should address the broader spectrum of family structures and adapt communication, mental health support, and clinic systems to avoid perpetuating stigma. Continuous education on diversity, policy changes to improve access, and tailored support for minority stressors are essential for creating equitable reproductive care for all family formations.
AI Tool ‘T’easy’ Boosts Speed and Accuracy in Sperm Detection
PRESENTED at ESHRE 2025, a novel AI-driven platform known as T’easy is redefining how embryologists identify sperm in testicular tissue samples. The technology, developed by researchers at UZ Brussel, Belgium, in collaboration with Robovision AI, Ghent, Belgium, offers a faster, smarter, and more precise approach to sperm detection following testicular sperm extraction, a complex but crucial procedure in male infertility treatment.6
In cases where ejaculation is not possible or effective, sperm must be retrieved directly from testicular tissue. However, identifying viable sperm within dense, immotile cell suspensions is time-consuming and demands highly trained staff. T’easy addresses this challenge by combining AI algorithms, high-resolution imaging, and operator validation to automate the detection process.
The system was trained on 5,373 annotated images and over 13,000 labelled spermatozoa, with performance tested across multiple datasets. In the initial test set, T’easy achieved a recall of 95.0% and a precision of 94.8%. While performance slightly decreased with a larger, more diverse dataset (89.1% recall; 80.7% precision), further model training led to strong proof-of-concept results. In two clinical samples, T’easy identified over 98% of sperm cells, with fewer false positives and negatives than human operators, in less than half the time.
Each sample analysis took only 10 minutes using T’easy, compared to 24 minutes by experienced embryologists, who also detected fewer sperm overall.
While further refinements are needed to improve generalisability and image consistency, T’easy represents a major step toward automation in fertility labs, with the potential to streamline testicular sperm extraction workflows, reduce operator fatigue, and enhance outcomes in assisted reproduction.
Species-Specific Role of Lactobacilli in Endometrial Health
NEW data from a large-scale retrospective study presented at ESHRE 2025 suggests that not all Lactobacillus species offer equal protection against pathogenic bacteria in the endometrium, a finding that may help refine future diagnostics and therapeutic approaches to infertility.7
Researchers from Igenomix Vitrolife Group, Valencia, Spain, shared results from an analysis of 7,795 endometrial biopsies, investigating the presence of Lactobacillus species and their relationship to 26 potential reproductive tract pathogens.
While Lactobacillus crispatus was associated with lower pathogen prevalence (11.9%), Lactobacillus gasseri showed the opposite trend, with nearly half (45.8%) of samples testing positive for at least one pathogen. Samples containing Lactobacillus iners and Lactobacillus jensenii had intermediate pathogen rates of 28.7% and 24.2%, respectively.
The study also found that the absence of any Lactobacillus species was correlated with higher rates of pathogen detection (31.1%) compared to samples with Lactobacillus present (23.3%; p<0.001). In multivariate analysis, Lactobacillus gasseri was positively associated with pathogen presence (adjusted odds ratio: 2.3), while Lactobacillus crispatus showed a protective association (adjusted odds ratio: 0.5).
Not all Lactobacillus species offer equal protection against pathogenic bacteria in the endometrium
Though limited by its retrospective nature and lack of direct clinical outcome data, the study underscores the clinical value of microbiome profiling in reproductive medicine and suggests that Lactobacillus species should not be treated as a single, uniform category in future diagnostics and interventions.
Pre-implantation Genetic Testing for Aneuploidy Reduces
Time to Pregnancy in Women Aged ≥39 Without Affecting Per-Cycle Success Rates
A MULTICENTRE retrospective study presented at ESHRE 2025 suggests that preimplantation genetic testing for aneuploidy (PGT-A) significantly shortens the time to live birth in women aged ≥39, without compromising cumulative live birth rates per started IVF cycle.8
The study, conducted across a multinational private fertility network, analysed 4,763 patients aged ≥35 years undergoing their first IVF/intracytoplasmic sperm injection cycle. Propensity score matching was used to compare 1,440 patients who underwent PGT-A with 1,440 who did not, adjusting for key variables such as age, oocyte yield, and treatment year.
While both groups showed similar rates of available blastocysts and comparable cumulative live birth rates (30.1% with PGT-A versus 32.4% without), the live birth rate per embryo transfer was significantly higher in the PGT-A group (44.2% versus 29.1%; adjusted odds ratio: 2.15; 95% CI: 1.78–2.61).
Importantly, PGT-A conferred a significant advantage in time to pregnancy, but only
among women aged ≥39. In this subgroup, time to live birth was notably shorter (adjusted hazard ratio: 2.53; 95% CI: 1.56–4.12), a trend that remained significant even in women aged ≥40 and ≥41 years.
Although retrospective in design and limited to first-cycle analysis, the study provides valuable real-world evidence that PGT-A may enhance treatment efficiency and patient satisfaction for selected age groups, without sacrificing per-cycle outcomes.
Importantly, PGT-A conferred a significant advantage in time to pregnancy, but only among women aged ≥39
References
1. Kolte AM et al. Pregnancy loss has significant mental health consequences, a prospective cohort study of 2,085 women and 1,212 partners. Abstract O-156. ESHRE Annual Meeting, 29 June-2 July, 2025.
2. Correa Mañas N et al. AI-driven prognosis for autologous IVF: leveraging data from 3,852 cycles across multiple centers for personalized success predictions. Abstract O-151. ESHRE Annual Meeting, 29 June-2 July, 2025.
3. Compans MC et al. Miscarriage prevalence and factors: a multi-source approach in France. Abstract O-148. ESHRE Annual Meeting, 29 June-2 July, 2025.
4. Barrett F et al. Biochemical or clinical pregnancy loss following the first embryo frozen transfer does not increase the risk of pregnancy loss in the subsequent embryo transfer. Abstract O-147. ESHRE Annual Meeting, 29 June-2 July, 2025.
5. Péloquin K et al. Beyond medical infertility: a mixed-methods study of 2S/LGBTQIA+ couples undergoing medically assisted reproduction. Abstract O-157. ESHRE Annual Meeting, 29 June-2 July, 2025.
6. Wouters K et al. T’easy: redefining sperm detection after testicular sperm extraction (TESE) – a faster, smarter and more efficient approach to sperm retrieval in IVF Labs. Abstract O-228. ESHRE Annual Meeting, 29 June-2 July, 2025.
7. Castellón García JA et al. Unravelling the endometrial microbiome: relationship between pathogen prevalence and the presence of Lactobacillus species. Abstract O-252. ESHRE Annual Meeting, 29 June-2 July, 2025.
8. Neves RA et al. PGT-A decreases the time to pregnancy whilst not negatively impacting per cycle outcomes: a multicentre retrospective cohort study with propensity score matching. Abstract O-268. ESHRE Annual Meeting, 29 June-2 July, 2025.
Interviews
EMJ had the pleasure of speaking with Catherine Nelson-Piercy, Consultant Obstetric Physician at Guy’s and St Thomas’ NHS Foundation Trust, London UK; and Michelle Peate, Program Leader of the Psychosocial Health and Wellbeing Research Unit at the University of Melbourne, Australia. Together, they offered a wide-ranging perspective on reproductive health, from the clinical management of high-risk pregnancies and autoimmune conditions, to fertility preservation in patients with cancer and the emotional complexities of reproductive decision-making. Their insights highlight the importance of holistic, patient-centred care and the evolving landscape of reproductive medicine.
Featuring: Catherine Nelson-Piercy and Michelle Peate
Catherine Nelson-Piercy
Consultant Obstetric Physician, Guy’s and St. Thomas’ Hospitals Trust, London, UK
Another misconception is the idea of ‘mild’ versus ‘severe’ preeclampsia. It’s only mild until it becomes severe, and predicting who will deteriorate is very difficult
You’ve cared for women with a wide range of complex conditions during pregnancy. What drew you to obstetric medicine originally, and what continues to inspire you about the field?
I actually never wanted to be an obstetrician or gynaecologist. I always wanted to be a physician. I was training in diabetes and endocrinology and used to look after women with diabetes in pregnancy. That’s when I met my mentor, Michael de Swit, Professor Emeritus of Obstetric Medicine at Imperial College London, UK. After seeing women with diabetes, he would go into another room and look after women with cardiac disease. And I thought, this is really interesting.
What draws me to the specialty is that you are a general physician. I look after all sorts of medical problems in pregnancy. It’s like being a generalist and a specialist
at the same time. You get the breadth of general medicine and the depth of specialist pregnancy-related complications. It doesn’t matter what’s wrong with the patient, hopefully, you can help them.
Q2
You’ve worked extensively with hypertensive disorders of pregnancy. What do you think are the biggest misconceptions around managing hypertension in pregnant women?
Hypertension is becoming more common because our patients are older and more obese, so it’s now very prevalent. I think the biggest misconception is that people don’t realise how dangerous it can be. There is also a lack of awareness about the long-term health implications for the mother.
Another misconception is the idea of ‘mild’ versus ‘severe’ pre-eclampsia. It’s only mild
until it becomes severe, and predicting who will deteriorate is very difficult. Personally, I believe most women with preeclampsia should be admitted to a hospital. That’s not what’s currently happening. They are often managed as outpatients, largely because we don’t have the resources, and women don’t want to stay in the hospital.
But women die of pre-eclampsia due to a range of rare crises that, when added together, are not that rare. Combined with the complications for the baby, I think the biggest misconception is that it’s not a fatal disease, when it absolutely can be.
Q3
Autoimmune diseases pose unique challenges during pregnancy. Which conditions do you see most often in your practice, and how has management evolved over time?
We see a lot of women with autoimmune conditions because they often affect women of childbearing age. In my own practice, I mostly see rheumatological conditions like lupus, rheumatoid arthritis, and antiphospholipid syndrome. But we also see inflammatory bowel disease, autoimmune skin conditions, and even neurological conditions like myasthenia gravis.
The real game changer during my career has been biologic drugs. They have transformed how we treat autoimmune diseases and many other conditions. We now know that many of these drugs are safe in pregnancy. That means women no longer have to stop their medication to become pregnant, which keeps their disease well-controlled and helps them have safer pregnancies. It is a total game changer.
Initially, the RCOG focused on thromboprophylaxis after Caesarean section, but they soon realised women were also dying after vaginal deliveries and during pregnancy, so the scope expanded.
The last version I led was published in 2016, but it is now very out of date. I am not leading the next version, so I won’t comment on that, but the 2016 guideline led to much more widespread use of thromboprophylaxis.
Some people ask why, despite all this heparin use, pulmonary embolism rates are still the same. My view is that, without the guideline, the death rate would be even higher. Women are older, more obese, and up to 40–50% now have Caesarean births. The UK has a more aggressive
Five percent of women terminate a wanted pregnancy due to hyperemesis, and 7% report suicidal ideation
approach to thromboprophylaxis than the USA or Canada, which they think is a bit excessive. But it is hard to justify using less when embolism is now the leading cause of maternal death, having overtaken cardiac disease.
Yes, it is expensive. Yes, it is a treatment burden. And we are probably not always giving it to the right women at the right time. But I think we have prevented many deaths, and the guideline is used internationally.
Q5Can you also tell us about the hyperemesis guideline?
This was the first version of the guideline on nausea, vomiting, and hyperemesis, published in 2024. It is so important, as about 3% of pregnant women are affected, and it can be completely incapacitating. Yet many do not get access to proper treatment. Their concerns are not validated, and some even terminate wanted pregnancies because they can’t get help.
Five percent of women terminate a wanted pregnancy due to hyperemesis, and 7% report suicidal ideation. It is all the more heartbreaking because this condition is treatable. My hope is that general practitioners, gynaecologists, early pregnancy units, and emergency departments will all follow the
guideline and offer women the appropriate antiemetics. That could make a huge difference.
Q6 In your view, what are the biggest challenges clinicians face when managing high-risk pregnancies today?
The biggest issue is that highrisk pregnancies are not rare anymore; they are common, but it is not reflected in the training. High-risk pregnancy is not part of the curriculum for most midwives, so the workforce is not equipped for the sheer volume of complex cases.
Staffing is also a huge challenge. When I started, there were just two obstetric physicians in England. Now we have 36, but we need one in every maternity unit. Women with pre-existing medical conditions need access to specialist advice. Yes, we have maternal medicine networks, but they only cover England, not the devolved nations. Not every hospital has a physician who understands pregnancy. So, we need better staffing and much more training at all levels.
Q7 Is there anything in the field of hypertensive care in pregnancy, perhaps a trial, a new treatment, or a new approach, that you find particularly promising right now?
I am involved in the Giant PANDA study, a randomised controlled trial comparing nifedipine and labetalol. It has finished recruiting, but the results are not published yet. That will help us understand which treatment is more effective.
Beyond treatment, I think there now is a lot of interest
One-size-fits-all care pathways do not work. We need a joined-up, woman-centred approach, delivered by midwives and clinicians
in postnatal care. Women with pre-eclampsia and hypertensive disorders are at risk of later problems, like high blood pressure, stroke, kidney disease, and heart disease. We know this, but nothing is being done nationally. There is no funding for postnatal care.
We also need better prepregnancy counselling. Many women enter pregnancy with high blood pressure and don’t know the risks or how to optimise their health. The idea of “getting fit for pregnancy” is still quite new, but it is so important.
Q8 If you could change just one thing about how the healthcare system approaches high-risk pregnancies, what would it be and why?
That’s a really difficult question, and I don’t think there’s a single answer. But if you had asked me, “What’s the one skill I’d teach all clinicians that could reduce maternal mortality overnight?” I know exactly what I would say, I would teach every midwife and obstetrician how to diagnose pulmonary oedema. That alone would save lives by preventing deaths from cardiac disease.
But in terms of the broader healthcare system, I think what we need is better holistic care. High-risk pregnancy encompasses more than a single condition; it involves more than just cardiac disease or hypertension. In the real world, these pregnancies are shaped by social deprivation, mental health challenges, comorbidities, and vulnerability. One-size-fits-all care pathways do not work. We need a joined-up, woman-centred approach, delivered by midwives and clinicians trained in managing complexity and multimorbidity. Without that shift, we will not be able to change outcomes for the women who need us most.
Michelle Peate
Principal Research Fellow, Department of Obstetrics, Gynaecology and Newborn Health; Program Leader, Psychosocial Health and Wellbeing Research (emPoWeR) Unit, Department of Obstetrics and Gynaecology, University of Melbourne, Australia
Your research has had a major impact on fertility preservation for patients with cancer. What initially drew you to this area of reproductive health?
That’s an interesting question. I came to this work in a somewhat roundabout way. During my undergraduate studies, I majored in genetics, and while I started off interested in that field, I became more drawn to reproductive health in general, specifically around questions of inheritance and how people make reproductive decisions: do you want a baby? Do you not? What drives those decisions?
That’s when I was invited by my then supervisor to explore this area for my PhD. From there, I became deeply involved in fertility preservation, not just for patients with cancer, but in a broader context. The goal was simple: raise awareness that cancer treatment can affect fertility, and ensure that people know what their options are.
The goal was simple: raise awareness that cancer treatment can affect fertility, and ensure that people know what their options are
Although my background was very science-based, it wasn’t until I started working in a psychosocial research group that I became really interested in the decision-making aspect. One of my colleagues was doing a PhD focused on women with breast cancer, and asked them about their priorities during treatment, at diagnosis, and afterwards. One thing stood out: many women said that no one had told them that their cancer treatment could affect their fertility. They only discovered this later, when they were recovering and trying to return to life as normal.
That had a big impact on me. I was in my 20s at the time and thought, ‘what if that happened to me?’ I always imagined I’d become a mother. So, I felt a lot of empathy, and I realised this wasn’t just about biology. This was about people’s futures, their relationships, and their identities. I thought, ‘we should be able to do something about this’.
I’ll never forget meeting a woman early on in my work who told me that her oncologist dismissed her fertility concerns because she already had two children, even though she was with a new partner, and they had a vision for their future family. She told me, “Yes, I’m worried about surviving, but I’m also thinking about life after cancer.”
At the end of the day, if just one patient tells me that something we did helped them, then it’s all worth it.
Q2Is it common for patients to be unaware that cancer treatments can impact their fertility?
Yes, and why should you know about it unless you’ve gone through it? At diagnosis, people are overwhelmed. They’re scared. They’re thinking about survival, not fertility. If clinicians don’t bring it up, then patients won’t know to ask.
That’s part of the problem. People don’t know what they don’t know, and that means that patients rely heavily on their clinical teams to guide them. However, what gets raised often depends on the clinician’s own biases or assumptions. Our goal has always
been to build something into the system so that everyone has the opportunity to be informed.
Some patients don’t care about fertility, and that’s completely valid, but they should at least be offered the chance to talk about it. There’s often only a small window; ideally, fertility preservation happens before chemotherapy starts, and no one wants to delay treatment.
Interestingly, we had hope at one point that cancer treatments were becoming less toxic, but now we’re seeing more immunotherapy, and we don’t yet know its longterm effects on fertility. Therefore, this work remains critical.
Q3 Can you tell us more about your work on developing decision aids for patients? How do these tools change the conversation between patients and clinicians?
Absolutely. Decision aids are tools specifically designed to help people make complex
health decisions. These aren’t just general leaflets; they’re developed using international standards, and they’re grounded in decision science.
They’re especially useful in situations where there’s no clear ‘right’ or ‘wrong’ choice, like fertility preservation. Whether to preserve fertility or not is a values-based decision. It depends on your personal circumstances, beliefs, financial situation, health, and so many other things.
What decision aids do is walk people through their options in a structured way. They outline the pros and cons, and they include something called ‘values clarification’ exercises. These help people weigh up what’s important to them, including whether they value the chance of a biological child highly and if it’s worth the emotional or financial investment.
Crucially, decision aids are not meant to replace clinicians, but instead are there to enhance those conversations. We want
patients to feel more confident, more informed, and more empowered to ask questions. It also supports clinicians, especially in oncology, where they may not feel equipped to talk about fertility, and vice versa for fertility specialists discussing cancer treatment. The aid acts as a bridge between these two worlds.
As everything is standardised and evidence-based, patients get consistent, comprehensive information; no one’s relying on memory or assumptions. That improves the experience for both the patient and the clinician.
Q4 How can healthcare systems better integrate fertility preservation into routine cancer care?
There have been some great developments in the past 10–15 years. Most oncology guidelines now recommend discussing fertility with patients, but we need to go further and embed that into actual practice. This means training clinicians, embedding
prompts into electronic health records, and creating clear referral pathways.
At the Royal Children’s Hospital in Melbourne, Australia, one of my colleagues built a prompt into the electronic system. It literally asks, “Have you discussed fertility preservation?” This links directly to relevant guidelines. She also secured funding for an oncofertility care coordinator, someone whose job is to have those conversations. That’s been a game changer.
However, we also need organisational buy-in and, frankly, funding. In Australia, most fertility preservation is private, and that’s a huge barrier. We need equity, not just in financial terms, but also geographic access. People in rural or remote areas still miss out. That really highlights the systemic barriers. We want care to be patient-centred, not dependent on who you happen to see.
One colleague I work with runs a mobile service that brings fertility preservation to different locations, but ideally, we’d have an integrated system that works for everyone.
Q5You’ve done extensive work on patient decision-making in oncofertility. What are some of the biggest misconceptions patients or clinicians may have?
From patients, the biggest one is, ‘this isn’t important enough to ask about’. Some don’t want to bother their specialist, or they assume that it’s not worth mentioning, but if it’s important to you, then it’s important, full stop.
Another misconception is that fertility preservation guarantees success. That’s not true.
Creating space for thoughtful decision making is essential
Especially in oncology, patients usually only have time for one cycle before treatment. Fertility preservation can improve chances, but it doesn’t guarantee a baby.
From clinicians, the traditional belief was that survival is what matters. While that’s true, we’ve now seen through research, including from the Dana-Farber Cancer Institute, Boston, Massachusetts, USA, and our own work in Australia, that many women would even consider less effective treatment if it meant preserving fertility. That shows how important this is to people.
There’s also sometimes an assumption that patients will make the ‘wrong’ decision, but as one of my gynaecology colleagues says: “Maybe we didn’t give them the right tools or information to make the right decision for them.” I strongly believe in patient autonomy. It’s our job to support them so that they can make the right decision for themselves, whatever that may be.
Q6 You’ve led large studies on reproductive decision-making and support tools. What lessons have emerged about how individuals make decisions about their reproductive futures?
One key lesson is that reproductive decisions are emotional and deeply value driven. You can have all the knowledge and still choose something that defies logic because of fear, hope, or pressure from family or society.
Traditional measures of ‘informed choice’ focus on knowledge, attitude, and alignment with action, but I think we’re missing the emotional dimension. You can have excellent knowledge and even a negative attitude towards fertility preservation, but still choose it because the emotional weight is so strong.
Another thing I’ve learned is that patients make better decisions when they feel validated and supported, not rushed or
dismissed. That’s especially true in cancer, where timelines are tight. Creating space for thoughtful decision making is essential.
Transparency also matters. In our decision aids, we always include a section on ‘what we know and what we don’t know’. Patients appreciate that. If we’re honest about uncertainty, it helps them feel more in control.
Q7 What do you see as the next big frontier in reproductive health research?
I think there are several. Menopause and perimenopause are finally getting attention, socially and clinically. I’ve been working more in that space, particularly around decision-making for treatments like menopausal hormone therapy.
I’m also fascinated by the role of AI. People are already using tools like ChatGPT (OpenAI, San Francisco, California, USA) as informal counsellors, asking whether they should freeze their eggs or start treatment. That raises big questions about trust, accuracy, and the intersection of behavioural science and digital health.
Another emerging area is reproductive decision-making in chronic illness. I’m starting a project on fertility and kidney disease. For example, some people with kidney disease are told not to conceive until after a transplant, but they don’t know when that will happen. It creates this awkward time lag that affects family planning.
We are also seeing more interest in patient-centred care and unmet needs work across conditions like endometriosis and autoimmune disease. That is something oncology has led, and I think it’s time that other fields caught up.
Q8
Lastly, if you could change one thing in how reproductive health support is delivered, whether in fertility preservation, decision-making, or broader patient care, what would it be?
Equity. Every person, regardless of background or health condition, should have timely, person-centred information to support reproductive decision making. That means embedding care into the system, not relying on people to know the right
Every person, regardless of background or health condition, should have timely, person-centred information to support reproductive decision making
questions to ask. When someone faces a situation that may affect fertility, they should be offered clear, relevant, values-based support before the moment passes.
We also need to shift from just treating symptoms to improving overall wellbeing. I come from a psycho-oncology background, and one of its pioneers, the late Doctor Jimmie Holland, used to say: “We may not be able to fix everything physically, but we can improve the patient’s experience.”
That ethos still guides everything I do. Even if we can’t change the outcome, we can help make it easier to bear.
Awareness and Utilisation of Cervical Cancer Screening Among Mothers
Background: Cervical cancer is preventable when detected early by screening for the presence of abnormal cells on the uterine cervix. This study assessed awareness and utilisation of cervical cancer screening services among mothers attending antenatal and postnatal clinics at State Hospital, Ijebu-Ode, Nigeria.
Methods: In this descriptive cross-sectional study, the authors used a simple random sampling technique to select 330 respondents. Two hundred and twenty-one and 109 respondents from antenatal and postnatal clinics, respectively, were selected randomly. Participants were required to complete a self-structured questionnaire at both clinics, and the collected data was analysed using a statistical package for social sciences (SPSS).
Results: The mean age of the respondents was 27±1.29 years, with the majority being married. While 59.8% of the women were aware of cervical cancer screening, the utilisation of cervical cancer screening services was low, with the majority (63.9%) never having undergone the screening. Factors like young age, insufficient knowledge, and lack of awareness of cervical cancer screening services affected its utilisation.
Conclusion: Results indicate an urgent need for the promotion of healthcare-seeking behaviours by relevant stakeholders. Avenues for promoting this could be awareness programmes about the availability of screening services and their benefits, through media, places of worship, women's groups, and during routine medical checks. This will improve cervical cancer screening utilisation services among women, thereby reducing morbidity and mortality from cervical cancer in Sub-Saharan Africa.
Key Points
1. This is a descriptive cross-sectional survey investigating awareness of cervical cancer screening and its utilisation among mothers attending antenatal and postnatal clinics at a State Hospital in Nigeria.
2. While awareness of cervical cancer screening among mothers was high, utilisation of screening services was low.
3. Poor uptake of cervical cancer screening services among women of reproductive age will have a detrimental effect on morbidity and mortality in cervical cancer. Significant interventions are urgently needed to encourage women to seek healthcare.
INTRODUCTION
Cervical cancer begins in the epithelial cells of the cervix following an ongoing period of infection with high-risk types of human papillomavirus (HPV). Cancerous cells begin to develop and invade the cervix and surrounding tissues over time if they are not quickly eliminated.1 In 2022, there were 660,000 new cases of cervical cancer worldwide, ranking it as the 4th most frequent cancer amongst females.2 Furthermore, out of the 660,000 women who received cervical cancer diagnoses, more than half of them passed away from the disease.2
Over 90% of cervical cancer diagnoses and deaths occur in low- and middleincome countries in sub-Saharan Africa, Central America, and Southeast Asia.2,3 Furthermore, cervical cancer is the main cause of cancer-related mortality for women in low-resource nations, particularly in Africa.2 In Nigeria, cervical cancer is the 2nd most common malignancy among females aged 15–44 years.4
According to current statistics, every year 12,075 women are diagnosed with cervical cancer, and amongst them, 7,968 die as a result of the disease.4 Cervical HPV 16 or 18 infections are thought to affect 3.5% of women in the general population at any point in time.4 These infections account for 66.9% of invasive cervical cancer cases.4 Elevated cervical cancer risk is associated with increased HPV serotype 16 and 18 infection, which are implicated in 70–75% of cervical cancer cases globally.5
Additional risk factors include socioeconomic and cultural variables like gender bias, obesity, poverty, poor diet, inactivity, excessive alcohol intake, exposure to ionising radiation, environmental contaminants, and infections (such as Helicobacter pylori, hepatitis B and C, Epstein–Barr virus, and HIV).2,6 Geographic disparities in the incidence of cervical cancer are associated with unequal access to services for immunisation, screening, and treatment.2
The established efficiency of intervention measures like immunisation against the most oncogenic HPV subtypes and screening, especially with HPV-based methods, makes cervical cancer a largely preventable disease.7 If substantial action is not taken, it is predicted that by 2030, there will be approximately 700,000 cases worldwide and 400,000 mortalities from cervical cancer, a rise of 21% and 27%, respectively.5
A medical examination of the cervix and its cells is known as cervical cancer screening. Its goal is to find precancerous cervical cell changes before symptoms arise. Treatment can prevent cervical cancer from developing at this point because, by the time a person is symptomatic, the disease may have spread and become more difficult to treat.1
A study on awareness, knowledge, and screening for cervical cancer among women of a faith-based organisation in Nigeria documented that awareness of cervical cancer screening was high (68.1%) among the respondents.8 A similar study conducted among female undergraduates
in Ogun State found that the majority of respondents (68.4%) were aware of the procedure.9 However, a descriptive crosssectional study using a convenience sample technique among 289 women of childbearing age, in the same community, in Ogun State, on knowledge of cervical cancer and awareness of its screening, discovered that 39% of the women were aware of cervical cancer screening.10 Furthermore, research in Ibadan, Nigeria, revealed that cervical screening uptake was very low amongst the respondents.11 Similarly, a research from Ethiopia documented that the level of utilisation was low, with only 14.2% of participants had ever undergone the procedure.12 Another study among women in the Gwafan community, NorthCentral Nigeria, found that mothers’ participation in cervical cancer screening was low.13 Additionally, a study carried out among healthcare practitioners in lowresource settings found that only 20.6% of respondents had ever undergone cervical cancer screening.14 Moreover, a systematic review on cervical cancer screening uptake among women of reproductive age in SubSaharan Africa found that the uptake of pap smear tests was low, at 12.87%.15
There are three types of factors that may affect mothers’ uptake of cervical cancer screening: psychosocial, organisational, and demographic, such as age, income, education, marital status, beliefs, knowledge, and fear of discomfort and embarrassment.16
In a study by Abugu et al.,8 respondents gave a variety of reasons for not taking part in the cervical screening programme, including not knowing the significance of getting screened (40.9%), not feeling susceptible to cervical cancer (18.2%), and not knowing about cervical cancer screening (69.7%). Another study on obstacles to the uptake of cervical cancer screening and treatment identified poor awareness of screening services, personal factors, painful procedures, and financial constraints as individual-related barriers to screening.16 The impediments at the institutional level were misdiagnosis, perceived lack of privacy, and the attitude of health workers. The socio-cultural aspects of the respondents’ belief systems
or religion, such as the conviction that infidelity is the cause of the illness or that it is a divine punishment, their belief in traditional medicine, church or spiritual healing centres for divine intervention, and influence of their husbands and in-laws in decision-making that are typically prevalent in rural communities.16 The respondents cited policy-level impediments to the uptake of cervical cancer screening as being low education/campaigns on the disease and insufficient screening facilities.16 In addition, an analysis of the variables influencing cervical cancer screening among Asian women identified obstacles to its use, such as knowledge, attitudes and beliefs, perceived risk, psychological variables, self-efficacy, past experiences, time, home, culture, fatalism, social support, access, cost, safety, insurance, and variables connected to the health system.17
Furthermore, an investigation into the factors that motivate women to undergo cervical cancer screening in Ibadan revealed personal obstacles to screening uptake, including anxiety about unfavourable test results, discomfort associated with the process, and cultural and religious constraints, including being attended to by male medical personnel.11 A small percentage of women believed they were not at risk for cervical cancer, and others were scared of being classified as promiscuous.11 Previous studies documented that improved cervical cancer screening rates among women can be achieved through care-seeking behaviour interventions, which include screening services without financial implication, female midwives collecting samples, providing printed materials, oral invitations, and encouragement by peers, women leaders, and other influential figures, as well as clients’ reminders and brochures.18-20 In a related study, a strategic trial on tactics to boost uptake among young women invited for their first cervical screening, it was found that encouraging women to get screened for cervical cancer could not be achieved by offering a nurse navigator, giving them the option of timed appointments, or by providing a self-sample kit upon request.21
RESEARCH OBJECTIVE
Cervical cancer continues to be the leading cause of cancer-related deaths among women in resource-limited settings, even though it is avoidable if detected and treated early.2,3 Without significant interventions, there is a greater possibility of an upsurge in the number of cervical cancer diagnosis and mortality globally.2,5 Therefore, significant interventions such as effective cervical cancer screening programmes for HPV infection serotypes 16 or 18, which is the causative agent among women at risk; early treatment of this infection or any abnormal cervical changes if present; as well as positive healthcareseeking behaviour of women at risk of this infection, will drastically decrease the prevalence and burden of cervical cancer cases.2
MAIN OBJECTIVE
The study's main objective was to assess the awareness and utilisation of cervical cancer screening services among mothers attending the antenatal and postnatal clinic at State Hospital, Ijebu-Ode, Nigeria.
Specific Objectives
1. To determine the level of awareness of cervical cancer among mothers attending antenatal and postnatal clinics at State Hospital, Ijebu-Ode.
2. To evaluate the level of utilisation of cervical cancer screening services among mothers attending antenatal and postnatal clinics at State Hospital, Ijebu-Ode.
3. To identify factors influencing the utilisation of cervical cancer screening services among mothers attending antenatal and postnatal clinics at State Hospital, Ijebu-Ode
4. To highlight ways of overcoming barriers associated with the utilisation of cervical cancer screening services among mothers attending antenatal and postnatal clinics at State Hospital, Ijebu-Ode.
METHODS
Research Area
The research was carried out at State Hospital, Ijebu-Ode, within the Ijebu-Ode Local Government Area of Ogun State. IjebuOde has a population of about 154,032 and occupies an area of 192 km2 22
Study Design
A quantitative descriptive cross-sectional survey was utilised.
Population and Sampling
The target population consisted of women within the age group of 18–50 years attending prenatal and postnatal clinics at State Hospital, Ijebu-Ode. The population was taken from clinic attendance registers of both clinics comprising 1,200 women, 800 from antenatal and 400 from postnatal clinics.
The sample size was calculated using Taro Yamane’s formula which was developed in 1967 and is stated below:
n=N/1+ [N (e2)]
Where n is sample size, N is number of the study population (1,200), and e is the level of precision or relative error of estimation: 0.05
n=1,200/1+[1,200x(0.05)2] n=300
An expected 10% non-response was added, which gave a final sample size of 330.
Population proportional distribution
Antenatal population size: 800/1200 x 100=67%
Postnatal population size: 400/1200 x 100=33%
Questionnaire distribution
Women attending the antenatal clinic: 67/100 x 330=221 respondents
Women attending the postnatal clinic: 33/100 x 330=109 respondents
A convenient sampling technique was used to choose the respondents.
Instrument for Data Collection
Information was obtained from respondents with a self-developed questionnaire called the Awareness and Utilization of Cervical Cancer Screening Questionnaire (AUCSQ). It has five sections: ‘A’, ‘B’, ‘C’, ‘D’, and ‘E’. Section A obtained data on the demographic characteristics of the respondents. Section B focused on the level of awareness of the women about cervical cancer screening in an adapted option 'Yes' or 'No'. Section C contained items with four-point Likert scale options (4 being ‘frequently’, 3 being ‘occasionally’, 2 being ‘rarely’, and 1 being ‘I don’t do it’) to collect information on the use of cervical screening services. Section D focused on the variables influencing the use of cervical cancer screening services by mothers attending antenatal and postnatal clinics with 'Yes' or 'No' options. Section E contained items to identify ways of improving cervical screening among mothers attending antenatal and postnatal clinics. It was prepared to select either 'Agree' or 'Disagree' preferences. The tool was written in English and interpreted for illiterate respondents in Yoruba and Ijebu local dialect.
Validation of survey tool
The questionnaire was reviewed by experts in maternity nursing and oncology before its final administration to respondents.
Reliability of survey tool
The test-retest approach was used to decide how reliable the instrument was. A pilot study was conducted with twenty women who were not included in the sample. They were selected from GRA, Ijebu-Ode, Oke Oyinbo Health Centre.
Method of Data Collection
Prior to the distribution of the study questionnaire, permission for conducting the study was obtained from clinic coordinators by the researchers. Rapport was established with the respondents by the researchers, the objectives of the study were explained to them, and their permission was sought before any
questionnaires were distributed. The respondents were given assurance of the confidentiality of their responses, as they were for research purposes only. The questionnaires were administered to 330 respondents between 10 am and 12 pm throughout the clinic days of a week by the researcher to target women in prenatal and postnatal clinics. The researchers solicited the help of the nursing staff working in the clinics for the distribution and collection of questionnaires.
Method of Data Analysis
Using the Statistical Package for Social Science (SPSS; International Business Machines Corporation, New York, USA) software version 21, data collected were coded into a computer system. Descriptive statistics of frequency, percentages, means, and standard deviations were used to analyse the research objectives.
Ethical Considerations
The research was authorised by the Babcock University Health Research and Ethics Committee (BUHREC516/18), and an administrative permit was obtained from the appropriate hospital authorities. Respondents’ informed consent was obtained after they were informed of the objectives of the study through the language they understood. The anonymity and confidentiality of respondents were ensured by transcribing all data using codes.
RESULTS
Three hundred questionnaires were administered, but 296 questionnaires (99% response rate) were retrieved for analysis.
Socio-Demographic Data of Respondents
Most of the respondents (36.5%) were found to be between the ages of 25–29 years, while the least (4.1%) were between the ages of 45–49 years. Of respondants, 76% were married, and 56.1% practice Islam as their religion. The majority (52%) were graduates of tertiary institutions, while 44.3% were self-employed. Many (44.3%)
1
2 Source of information:
3 Aware that cervical screening aims at secondary
4
5 Cervical screening may not be done for women under 20
6 Early age at first sexual intercourse, multiple sexual partners, and previous history of sexually transmitted diseases are predisposing factors to cervical cancer
respondents commenced sexual activities at the age of 19–21 years, with an average of 20±0.86 years. Most (80.1%) had no experience of sexually transmitted infection.
Awareness of Cervical Cancer Among Mothers attending Antenatal and Postnatal Clinics
The study found that awareness of cervical cancer screening was high among respondents, as the majority (59.8%) of women attending antenatal and postnatal clinics were aware of cervical cancer screening. Most of them (64.2%) learnt about it through nurses. Furthermore, over half of the respondents (63.9%) were unsure if women under the age of 20 years could get screened for cervical cancer (Table 1).
Utilisation of Cervical Cancer Screening Services Among Respondents
Findings depicted that a high proportion (72.6%) of respondents agreed that
there is no provision for a screening centre in their area. Most (84.5%) of the respondents had not performed the screening due to screening cost. Meanwhile, out of 15.5% of respondents who had performed the screening, only 11.5% of them performed it once (Table 3). Overall, the level of use of cervical cancer testing was low amongst the women, as the majority (63.9%) of them had never undergone the screening before (Table 2).
Factors Influencing Respondents’ Use of Cervical Cancer Screening Services
According to the results of this survey, the majority, 40.2% and 55.4% of respondents claimed that income level and educational level, respectively, do not affect the use of cervical cancer screening services. However, the majority, 59.8%, 80.1%, 60.1%, and 72.3% of respondents agreed that age, inadequate understanding of the procedure, cost of the test, and ignorance of the indications and benefits of the screening,
Table 1: Awareness of cervical cancer among respondents.
Table 2: Utilisation of cervical cancer screening services among respondents.
1
2
3 If no, why?
4 If yes, how many times:
Table 3: Factors influencing utilisation of cervical cancer screening services among respondents.
10
12
SD: standard deviation.
respectively, are possible reasons that could have an impact on women’s utilisation of cervical cancer testing services. Furthermore, 56.1% of the respondents were in agreement that the lack of female screeners in healthcare facilities affected the utilisation of cervical cancer assessment services. While fewer (44.3%) respondents concurred that lack of convenient clinic time will not affect the use of cervical cancer assessment services amongst women (Table 3).
Ways of Overcoming Barriers Related to Cervical Cancer Screening Services Amongst Mothers
Findings revealed that almost 95.9%, 83.8%, and 80.1% of the respondents concurred that more public awareness programmes such as sharing of posters
and flyers, public enlightenment on social media, and health talks at marketplaces as done for HIV/AIDS, respectively, will be useful tools for overcoming hurdles of cervical cancer screening services amongst women. Additionally, most women (95.9%) suggested that cervical cancer screening should be made known to both educated and uneducated people. The majority (76%) also agreed that cervical cancer screening should be part of the topics discussed during antenatal clinics.
DISCUSSION
The average age of participants was 27±1.29 years. The majority were married (76%) and graduates of tertiary institutions (52%). Furthermore, 44.3% were self-employed and 35.8% were
unemployed. The current research found that most women attending prenatal and postnatal clinics (59.8%) were aware of cervical cancer screening. The results are consistent with the findings of past studies, in which respondents had a high level of awareness regarding cervical cancer screening.8,9 However, the finding varies from similar studies that documented respondents’ inadequate knowledge of cervical cancer screening.10,11 This could mean that environmental factors, such as home or work locations, could have led to exposure to health-related information that improved their awareness of cervical cancer screening services. For instance, awareness of cervical cancer screening was high in a previous study conducted among women in an advanced learning environment such as a university.9 However, in similar studies carried out among women in the community, awareness was low,10 despite the alarmingly high incidence and mortality rate of cervical cancer in low- and middleincome countries.
Furthermore, the use of cervical cancer screening was low among mothers attending antenatal and postnatal clinics, as the majority (63.9%) had never undergone the screening before. This finding corroborates similar studies that documented a low percentage of cervical cancer screening use among respondents.12-15 This is concerning, as respondents' high level of awareness of the significance of cervical cancer screening for early diagnosis, prompt treatment, and prevention of mortality does not correspond to their use of the procedure. In contrast, a meta-analysis of seven studies conducted in Sub-Saharan Africa found that knowledge about cervical cancer increased screening uptake by nearly five-fold.15 Low utilisation of screening services amongst respondents in the current study and in similar studies is likely a key factor contributing to the high cervical cancer prevalence and mortality in Sub-Saharan Africa.2,3
The author's study found that the age of women, lack of awareness regarding cervical cancer screening, financial constraints, ignorance of the benefits of the screening, lack of female screeners in the healthcare
facilities, and lack of healthcare funding, including infrastructures such as screening centres, could influence the use of cervical cancer screening services by mothers who visit prenatal and postnatal clinics at State Hospital, Ijebu-Ode. This result aligns with the conclusions of related research.8,11,16,17 However, in a qualitative study conducted in the Ecuadorian Province of Azuay, women and healthcare professionals, perceived different barriers to cervical cancer screening. Healthcare professionals believed that the main barriers were at the policy level (no structured screening plan; no health promotion) and at the individual level (no risk perception; personal beliefs). On the other hand, the women primarily noted organisational-level obstacles, such as lengthy wait times, restricted access to health facilities, and poor communication between patients and doctors.18
Results from participants in the current study suggested that additional public awareness campaigns should be intensified in locations where women congregate, such as in prenatal clinics, postnatal clinics, and marketplaces, as well as social media, in order to address the issue of awareness of cervical cancer screening. This finding is corroborated in similar studies, which also documented that improved healthcareseeking behaviour interventions, such as screening services without financial implication, female midwives collecting samples, providing printed materials, oral invitations, clients’ reminders, individualised self-sample kit upon request, the option of timed appointments, and support from peers and women leaders, among others, are capable of promoting participation of women in cervical cancer screening services.19-22 Furthermore, research has shown that political will is also required to enhance cervical cancer preventive initiatives.15
LIMITATIONS OF STUDY
Problem with Data Collection from Respondents
The method of gathering data from respondents involves questionnaires; nevertheless, some respondents did
not provide the requested information when completing the surveys.
Problem of Generalisation of Results
Given the study was only conducted across two health clinics, the findings might not be generalisable beyond these two clinics.
CONCLUSION
According to the findings of this study, mothers who attended antenatal and postnatal clinics at State Hospital, Ijebu-Ode, were highly aware of
References
1. National Cancer Institute (NCI). What is cervical cancer? Available at: https:// www.cancer.gov/types/cervical. Last accessed: 27 November 2023.
2. World Health Organization (WHO). Cervical cancer. 2023. Available at: https://www.who.int/news-room/factsheets/detail/cervical-cancer. Last accessed 27 November 2023.
3. Brisson M et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lowermiddle-income countries. Lancet. 2020;395(10224):575-90.
4. ICO/IARC HPV Information Centre. Institut Català d’Oncologia Avda. Gran Via de l’Hospitalet, 199-203, 08908 L’Hospitalet de Llobregat (Barcelona, Spain). Available at: www.hpvcentre. net. Last accessed: 27 November 2023.
5. World Health Organization. WHO releases new estimates of the global burden of cervical cancer associated with HIV. 2020. Available at: https:// www.who.int/news/item/16-11-2020who-releases-new-estimates-of-theglobal-burden-of-cervical-cancerassociated-with-hiv. Last accessed: 27 November 2023.
6. World Health Organization. Cervical cancer. 2018. Available at: https:// www.who.int/health-topics/cervicalcancer#tab=tab_1. Last accessed: 22 November 2023.
7. Bouvard V et al. The IARC perspective on cervical cancer screening. N Engl J Med. 2021;385: 1908-18.
the screening services available for cervical cancer, but they did not make use of available resources. Significant interventions, such as education campaigns and free screenings, are urgently needed by the right parties to encourage women to seek healthcare. This would increase the number of women using cervical cancer services, reducing morbidity and mortality from cervical cancer in Sub-Saharan Africa.
8. Abugu LI, Nwagu EN. Awareness, knowledge and screening for cervical cancer among women of a faith-based organization in Nigeria. Pan Afr Med J. 2021;39(1):200.
9. Maitanmi JO et al. Knowledge and acceptability of cervical cancer screening among female undergraduates in babcock university Ilishan-Remo, Ogun State, Nigeria. Ecancermedicalscience. 2023;(17):1502.
10. Philip ZD et al. Knowledge of cervical cancer and awareness of it’s screening among women of childbearing age in Ilishan-Remo community, Ogun State. Amer J Pediatr Med Health Sci. 2023;1(1):36-47.
11. Ilevbare OE et al. Drivers of cervical cancer screening uptake in Ibadan, Nigeria. Heliyon. 2020;6(3):e03505.
12. Belay AS et al. Cervical cancer screening utilization and its predictors among women in bench Sheko Zone, Southwest Ethiopia: using health belief model. BMC Cancer. 2023;(23):472.
13. Ari ES et al. Improving the care seeking behaviour toward cervical cancer screening participation among Gwafan community women, northcentral, Nigeria. BMC Women's Health. 2023;23:356.
14. Ifemelumma CC et al. cervical cancer screening: assessment of perception and utilization of services among health workers in low resource setting. Int J Reprod Med. 2019;2019:6505482.
15. Yimer N.B. et al. Cervical cancer screening uptake in sub-Saharan Africa: a systematic review and meta-analysis. Public Health. 2021;195:105-11.
16. Binka C et al. Barriers to the uptake of cervical cancer screening and treatment among rural women in Ghana. Biomed Res Int. 2019;2019:6320938.
17. Salehiniya H et al. Factors related to cervical cancer screening among Asian women. Eur Rev Med Pharmacol Sci. 2021;25(19):6109-22.
18. Crespo BV et al. Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health. 2022;22:2144.
19. Khalil S et al. Addressing breast cancer screening disparities among uninsured and insured patients: a student-run free clinic initiative. J Community Health. 2020;45(3):501-5.
20. Antinyan A et al. Cervical cancer screening invitations in low and middle income countries: evidence from Armenia. Soc Sci Med. 2021;273:113739.
21. Kurt G, Akyuz A. Evaluating the effectiveness of interventions on increasing participation in cervical cancer screening. J Nurs Res. 2019;27(5):1-11.
22. Kitchener H et al. A cluster randomized trial of strategies to increase uptake amongst young women invited for their first cervical screen: the strategic trial. J Med Screen. 2018;25(2):88-98.
Clinical, Ultrasound, and Endometrial Histopathological Features of Perimenopausal
and Postmenopausal
Women with Abnormal Uterine Bleeding at a Tertiary Hospital in Western Kenya
Authors: *Issa S. Moshey,1 Benjamin O. Elly,2 Peter Itsura,1 Anisa Mburu,3 Afrin Shaffi,1 Kibor Kibet,4 Erick Chesori,4 Philliph Tonui1
1. Department of Reproductive Health, Moi University School of Medicine, Eldoret, Kenya
2. Department of Obstetrics & Gynecology, Kenyatta University School of Medicine, Nairobi, Kenya
3. Department of Obstetrics & Gynecology, The Aga Khan Hospital, Mombasa, Kenya
4. Department of Pathology, Moi Teaching and Referral Hospital, Eldoret, Kenya
*Correspondence to mosheyissa@yahoo.com
Disclosure:
All the authors of this study have declared receiving grants from the Academic Model Providing Access to Healthcare (AMPATH) Oncology & Hematology Institute at Moi Teaching and Referral Hospital for the histopathological evaluation of collected biopsy samples; and nonfinancial support in the form of Pipelle® samplers and printing of consent forms and questionnaires from the Academic Model Providing Access to Healthcare (AMPATH) Oncology & Hematology Institute at Moi Teaching and Referral Hospital.
Background: Abnormal uterine bleeding (AUB) affects 3–30% of perimenopausal women and 5–10% of those who are postmenopausal. While the aetiology of the condition in these women is mostly benign, it could also be a symptom of endometrial hyperplasia (EH) and endometrial cancer (EC). Conditions linked to EH and EC, such as obesity, diabetes, and hypertension, are on the rise in Kenya. Despite studies in various populations reporting differences in endometrial histopathology and the prevalence of EH and EC, data from sub-Saharan Africa remain scarce.
Objectives: To describe the clinical, ultrasound, and endometrial histopathological features; determine the prevalence of EH and EC; and identify factors associated with the diagnosis of the two conditions in peri- and postmenopausal women with AUB at the Moi Teaching & Referral Hospital (MTRH), a tertiary hospital in Eldoret, Kenya.
Methods: This was a cross-sectional study of women aged ≥40 years with AUB, conducted between June 2019–May 2020 at MTRH. A total of 64 perimenopausal women and 36
postmenopausal women were enrolled. Endometrial biopsies were performed using a Pipelle® (Cooper Surgical Inc., Trumbull, Connecticut, USA) endometrial suction curette, followed by histopathological evaluation by two pathologists. Data on sociodemographic, clinical and reproductive characteristics (BMI, chronic illness, bleeding patterns, parity, contraception use), and ultrasound findings (presence of uterine mass, endometrial thickness) were recorded. Associations between these characteristics and the diagnosis of EH/EC were tested using χ² or Fisher’s exact test, and significance was accepted at a p value ≤0.05.
Results: Of 64 perimenopausal women, 42 (65.6%) were either overweight or obese, and 11 (17.2%) had at least one chronic illness linked to EC. Of the 36 postmenopausal women, 31 (86.1%) were either overweight or obese, and 20 (55.5%) had at least one chronic illness linked to EC. From the perimenopausal group, 40 (62.5%) had cyclical or benign patterns, 23 (35.9%) had EH with or without atypia, and one (1.6%) had EC. EH without atypia was the most frequently seen individual pattern in this group (32.8%). Among the 36 postmenopausal women, 15 (41.7%) had cyclical or benign patterns, 14 (38.9%) had EH with or without atypia, and seven (19.4%) had EC. EH without atypia was also the most frequently seen individual pattern in this group (25.0%). None of the clinical and reproductive characteristics were significantly associated with the diagnosis of EH/EC. A thickened endometrium on ultrasound was the only feature associated with the diagnosis of EH/EC (p=0.004) on multivariate analysis.
Conclusion: The most frequently observed histopathological features in perimenopausal women with AUB and in women with postmenopausal bleeding at MTRH were normal cyclical patterns (secretory or proliferative) in the perimenopausal group, benign pathologies (chronic endometritis in perimenopausal and atrophic endometrium in postmenopausal), and EH without atypia in both groups of women. Only a small proportion of perimenopausal women were diagnosed with EH with atypia (3.1%) and EC (1.5%), the two pathologies of greatest clinical concern. Based on these findings, the authors do not recommend the routine performance of endometrial biopsies for perimenopausal women with AUB unless symptoms persist despite medical therapy and risk factor modification. Conversely, in women with postmenopausal bleeding, the authors strongly recommend histological evaluation of the endometrium, particularly in those with an endometrial thickness >4 mm on ultrasound, given the relatively high prevalence of EH with atypia (13.8%) and EC (19.4%) observed in this study.
Key Points
1. Endometrial histopathological patterns observed in perimenopausal women with abnormal uterine bleeding (AUB) in this study were predominantly normal cyclical patterns (39%), endometrial hyperplasia (EH) without atypia (32.9%), and benign endometrial pathologies, such as chronic endometritis (7.8%).
2. Endometrial histopathological patterns observed in women with postmenopausal bleeding in this study were predominantly pathological: EH without atypia (25%), atrophic endometrium (19.4%), and endometrial cancer (19.4%).
3. While the overall prevalence of EH in perimenopausal women with AUB in this study was significantly high (35.9%), hyperplasia with atypia constituted <10% of these cases. Endometrial cancer in this group of women was seen even less frequently (1.6%). Due to the low prevalence of these two conditions, which are of greatest clinical concern, the authors do not recommend routine endometrial histological evaluation in this group of women unless AUB persists despite risk factor modification and medical therapy.
INTRODUCTION
Abnormal uterine bleeding (AUB) is defined as uterine bleeding that doesn’t correspond with the regularity, frequency, duration, or amount of blood flow of normal menstrual bleeding.1 Its prevalence among women of reproductive age varies widely, reported between 3–30%, with adolescents and perimenopausal women being the most affected. Postmenopausal bleeding is a subset of AUB, occurring in approximately 10% of postmenopausal women.2 Overall, a third of women will experience AUB at some point in their life, with as many as 70% of gynaecologic consultations in the perimenopausal and postmenopausal periods attributed to the condition.3
The aetiology of AUB in perimenopausal and postmenopausal women often includes ovulatory dysfunction or benign pathologies such as endometrial polyps, uterine leiomyomas, or endometrial atrophy. However, AUB could also be the first and principal symptom of more serious underlying conditions, such as endometrial hyperplasia (EH) and endometrial cancer (EC), particularly in higher-risk groups like perimenopausal or postmenopausal women. Endometrial biopsy is recommended in these higher-risk women to exclude precancerous or malignant changes, with the primary goal of detecting these changes early to facilitate timely interventions.4
EC is the leading gynaecologic malignancy in most developed countries, and the second most common malignancy after cervical cancer in developing countries.5,6 It predominantly affects women who are postmenopausal and perimenopausal, with only 2–5% of cases detected in women aged <40 years.7 Notably, AUB is the most frequently reported symptom in women with EC, and up to 90% of cases reported to have this symptom.8
While cervical cancer is the leading gynaecologic malignancy in Kenya, the true prevalence of EC remains less clearly defined. It is estimated that for every 30 cases of cervical cancer in the country, there is one case of EC. This highlights a significant yet under-recognised disease
burden in our population.9 The rising prevalence of risk factors for EH and EC in Kenya, such as obesity, diabetes, and chronic hypertension, further reiterates the importance of understanding the regional epidemiology of the two conditions. Despite studies in various populations reporting differences in endometrial histopathology and the prevalence of EH and EC, data from sub-Saharan Africa remain scarce. This study aims to address these gaps by providing regional data on the sociodemographic, clinical, reproductive, ultrasound, and histopathological features of women with AUB in Western Kenya. The findings are intended to inform local clinical protocols for the investigation and management of AUB, with an emphasis on early detection of EH and EC.
METHODS
Study Design
This is a cross-sectional study that employed a census method for participant recruitment. Sampling was not applied as the estimated number of eligible patients was relatively low (an average of 110 patients per year, based on past records).
Study Setting
The study was conducted at the Gynecology Unit of Moi Teaching & Referral Hospital, Eldoret, Kenya, between the months of June 2019–May 2020. This tertiary hospital is the second largest national referral hospital in Kenya, serving a catchment population of approximately 20 million people. The Gynecology Unit comprises the Gynecology OutPatient Clinic, Gynecology Ward, and the Gynecologic Oncology Ward.
Participants
All women aged ≥40 years, presenting with AUB (including women with postmenopausal bleeding), who met the eligibility criteria and consented, were recruited over a period of 12 months. There was no strict classification of perimenopause. The average age of entry into menopause in the Western Kenya region
is 48 years, with most women taking around 2–8 years to transition into menopause. The authors thus categorised women aged ≥40 years who were presenting with AUB as perimenopausal (mean age: ~46 years), while those who were ≥40 years and were presenting with bleeding (postmenopausal bleeding) following at least 12 consecutive months of non-iatrogenic amenorrhoea were classified as postmenopausal (mean age: ~62 years)
• Inclusion criteria: women aged ≥40 years presenting with AUB.
• Exclusion criteria: women with positive pregnancy tests, overt vulvar/vaginal/ cervical lesions, known bleeding disorders, or inability to undergo biopsy due to an obstructing intrauterine pathology or positioning issues.
Study Procedure
All women aged ≥40 years presenting with vaginal bleeding not characteristic of normal menses, or with postmenopausal bleeding, at the Gynecology Unit were approached and assessed for eligibility. A detailed history, physical examination, and routine investigations for AUB, including thyroid function tests (TFT), were ordered as indicated. Many participants had prior workups from lower-level facilities, including TFT. This was particularly true for the perimenopausal group. Due to resource limitations, the authors did not subject these participants to repeat testing for the sake of the study, except for those who were being seen for the first time. Needless to say, none of the participants who had thyroid function assessment had abnormal TFT results.
Pelvic ultrasound imaging was performed on all participants, followed by endometrial biopsy using a Pipelle® (Cooper Surgical Inc., Trumbull, Connecticut, USA) endometrial suction curette. Subsequent interviews were conducted using a prevalidated structured questionnaire after investigations, ultrasound imaging, and a successful endometrial biopsy procedure. This was done because part of the information being filled in the questionnaire comprised the ultrasound findings.
Furthermore, since one of the exclusion criteria was the inability to undergo the biopsy procedure due to obstructing intrauterine pathology or positioning issues, the authors administered the questionnaire only to those who had a successful biopsy procedure.
Biopsy samples were promptly sent to the pathology department, where two expert pathologists independently conducted histological evaluations of each sample. Discrepant histopathological diagnoses were resolved through a joint review to reach consensus.
Data Collection and Variables
Data were collected using a pre-tested, interviewer-administered, structured questionnaire (Supplementary Figure 1), which captured the following data:
• Socio-demographic data: age, marital status, level of education, employment status, and medical insurance.
• Clinical characteristics: BMI, chronic illness (diabetes or chronic hypertension), cigarette smoking, and family history of cancer (breast, colon, ovarian or uterine cancer).
• Reproductive characteristics: menstrual status, age at menarche and menopause, current bleeding pattern (heavy, irregular, heavy and irregular, continuous, spotting), duration of AUB, hormonal contraceptive use (previous and/or current), and obstetric history (parity, age at first pregnancy).
• Pelvic ultrasound findings: uterine size, endometrial thickness (ET), and presence of uterine or endometrial mass.
The questionnaire was pre-validated during the first week of the study through an internal pre-test/pilot study. Connelly LM10 cites that “a pilot study sample can be 10% of the sample projected for the larger parent study.” Using this, the authors calculated the sample size for the pilot study from an estimated mean of 110 patients aged ≥40 years with AUB, arriving at 11 participants. The questionnaire was administered to 11 women with characteristics similar to the authors’ intended study population.
Responses obtained from the 11 participants confirmed the clarity and suitability of the questionnaire for data collection, with the data obtained being adequate to answer the study’s primary objectives.
Consent acquisition, biopsy collection, and questionnaire administration were all carried out by this study’s principal investigator (Issa S. Moshey). Pelvic ultrasounds were done by the on-duty sonographer.
Statistical Data Analysis and Presentation
Descriptive statistics, such as the mean and the corresponding SD, were used to describe continuous variables such as age if Gaussian assumptions were met. Otherwise, the median and the corresponding interquartile range (IQR) were used. Gaussian assumptions were assessed using the Shapiro-Wilk test for normality. Non-continuous variables were described using frequencies and proportions. Associations between clinical, reproductive characteristics, and ultrasound findings, and the diagnosis of EH/EC were tested using the χ² or Fisher’s exact test, depending on cell counts. Significance was accepted at p value ≤0.05. Logistic regression was modelled using factors that were associated with EH/EC diagnosis in the bivariate analysis. Data were analysed using Stata 16, and results were presented using text and tables.
RESULTS
Between June 2019–May 2020, a total of 107 women aged ≥40 years who presented with either vaginal bleeding that was not characteristic of normal menses or postmenopausal bleeding were approached and assessed for eligibility. The participant recruitment process resulted in the recruitment of a total of 100 participants (64 perimenopausal and 36 postmenopausal). All 64 of the perimenopausal and 34 of the postmenopausal participants had adequate biopsy samples. The postmenopausal participants with inadequate samples each had repeat biopsies, which eventually yielded adequate specimens.
Sociodemographic Characteristics
The mean ages of the perimenopausal and postmenopausal groups were 46.05 years (SD: ±3.73) and 62.11 years (SD: ±7.96), respectively. The majority of the perimenopausal (65.6%) and postmenopausal (66.6%) women were married. Half of the perimenopausal and 47.0% of the postmenopausal participants had primary education as the highest level of education. The majority of the perimenopausal participants (67.2%) were employed, compared with only 44.4% of the postmenopausal group.
Clinical Characteristics
Out of the 64 perimenopausal women, 42 (65.62%) were either overweight or obese, and 11 (17.18%) had at least one chronic illness linked to EC (chronic hypertension, diabetes). Among the 36 postmenopausal women, 31 (86.11%) were either overweight or obese, and 20 (55.56%) had a history of at least one chronic illness linked to EC. Only one participant in the perimenopausal group (1.56%) and six in the postmenopausal group (16.67%) had a family history of a cancer linked to EC (breast, colorectal, ovarian, or uterine cancer). None of the participants reported cigarette smoking (active or passive).
Reproductive Characteristics
The mean menarcheal ages of the 64 perimenopausal and 36 postmenopausal women were 14.86 years (SD: ±1.53) and 14.78 years (SD: ±1.12), respectively. The mean age at menopause among the 36 postmenopausal women was 49.31 years (SD: ±5.0). The median parity was 4 (IQR: 3) for the perimenopausal group and 7 (IQR: 4) for the postmenopausal group.
In terms of bleeding patterns, 40 (62.50%) of the perimenopausal participants had heavy and irregular menses, 12 (18.75%) had heavy menstrual bleeding, and seven (10.94%) had non-stop bleeding as the most common bleeding patterns. In the postmenopausal group, 21 (58.34%) had spotting, nine (25.0%) had spotting alternating with heavy bleeding, and six (16.67%) had heavy bleeding alone.
The median durations of AUB in the perimenopausal and postmenopausal groups were 21 months (IQR: 82) and 3 months (IQR: 11), respectively. Hormonal contraceptive use (current or past) was reported in 47 (73.44%) of the perimenopausal and 21 (58.33%) of the postmenopausal women.
Ultrasound Features
Out of the 100 perimenopausal and postmenopausal women, 92 (92%) underwent transabdominal ultrasound, while eight (8.0%) had transvaginal ultrasound. Among the 64 perimenopausal women, bulky uterus was reported in 33 (51.56%), hypoechoic uterine masses in 23 (35.93%), and endometrial thickening in 17 (26.56%). In the postmenopausal group, 15 participants (41.67%) were reported to have a bulky uterus, eight (22.22%) had a hypoechoic uterine mass, and 18 (50.0%) had endometrial thickening. ET thresholds considered abnormal were >16 mm in perimenopausal and >4 mm in postmenopausal women. In the postmenopausal group, only two out of seven (28.5%) women diagnosed with EC, all five (100%) diagnosed with EH with atypia, and eight out of nine (88.8%) diagnosed with EH without atypia had thickened endometrium. From the perimenopausal group, one patient diagnosed with EC, and only eight out of the 21 (38%) diagnosed with EH without atypia, had a thickened endometrium. Neither of the two women diagnosed with EH with atypia in this group had thickened endometrium.
Endometrial Histopathological Patterns of Perimenopausal and Postmenopausal Participants
Histological results in both groups of women were classified into three main categories: (1) normal cyclical patterns and benign pathologies group (N/B group); (2) EH with or without atypia group (EH group); and (3) malignancy group (M group).
(62.5%) had normal/cyclical patterns or benign endometrial pathologies (N/B group), 23 (35.94%) had EH (EH group), and only one (1.56%) had EC (M Group). These data are presented in Table 1
Histopathological Patterns of Postmenopausal Participants
Out of the 36 postmenopausal participants, 15 (41.66%) had N/B group patterns, 14 (38.89%) had EH group patterns, and seven (19.44%) had M group patterns (Table 2).
Clinical, Reproductive and Ultrasound Features Associated with Diagnosis of Endometrial Hyperplasia and Cancer
Out of the 100 biopsies done, 55 (55%) were N/B patterns, while 45 (45%) were EH and malignant (EC) pathologies. Data on factors linked to EH and EC, including clinical characteristics (BMI, chronic illness, family history of cancer, reproductive characteristics, and ultrasound features), of the 100 participants were stratified into the N/B and EH/EC groups to test for associations between these factors and a diagnosis of EH and cancer (EH/EC).
None of the clinical or reproductive characteristics were associated with a diagnosis of EH/EC on bivariate analysis (all p values >0.05).
When it comes to ultrasound features, endometrial thickening (p=0.001) and presence of hyperechoic complex mass/ masses (p=0.014) were significantly associated with the diagnosis of EH and EC on bivariate analysis. Upon subjecting these two variables to a multivariate model, only endometrial thickening was established to be associated with the diagnosis of EH/EC (p=0.004; adjusted odds ratio: 4.17).
DISCUSSION
Histopathological Patterns of Perimenopausal Participants
Out of 64 perimenopausal participants, 40
A number of studies globally have examined endometrial histopathological patterns in women with AUB. Many of these have focused on perimenopausal or postmenopausal women, while others have focused on all women, including
Table 1: Histopathological patterns of perimenopausal participants.
Table 2: Histopathological patterns of postmenopausal participants.
those of reproductive age, <40 years. The authors’ study uniquely concentrates solely on perimenopausal and postmenopausal women, two groups of women with the highest incidence of EH and EC. Regional data on the subject remain limited, with most existing studies on the topic being from Northern and Western Africa.
The majority (65.63% of the perimenopausal and 86.11% of the postmenopausal participants) were either overweight or obese, which is comparable to findings by Elkholi et al.11 from Egypt, where all participants were either overweight or obese. In contrast, Meena et al.12 in India, reported that only 4% of their participants were overweight or obese. This difference could possibly be due to differences in age distribution, as their participants were relatively younger. Furthermore, the high rates of overweight and obesity among the authors’ participants reflect the country’s trend, as evidenced in a multiregional study by Mkuu et al.,13 which reported that one in three women (33%) in Kenya were either overweight or obese.13
Regarding chronic illnesses linked to EC, 26% of the participants in the authors' study had chronic hypertension and 5% had diabetes. These findings are consistent with Elkholi et al.11 who reported a 20.6% prevalence of chronic hypertension in their participants. Comparable findings were also reported in India by Meena et al.,12 where 21% of the participants had chronic hypertension. In contrast, Piróg et al.14 from Poland reported a higher prevalence of hypertension and diabetes (50.9% and 17.5%, respectively).14 This difference reflects the higher burden of lifestylerelated non-communicable diseases in developed countries compared to developing countries.
The predominant bleeding pattern in the postmenopausal group in the authors’ study was spotting (55.56%), followed by heavy bleeding alternating with spotting (25%) and heavy bleeding alone (16.67%). This contrasts with the findings of Elkholi et al.11 from Egypt, who reported light menseslike bleeding as the most common pattern in women with postmenopausal bleeding
(61.15%), followed by spotting (29.89%).11 The contrast could be due to the fact that they exclusively studied women who had an ET ≤4 mm, while in the authors’ study, all women with postmenopausal bleeding were included, regardless of their ET.
Cyclical endometrial patterns were a common feature in the authors' perimenopausal participants. Interestingly, three postmenopausal women also exhibited cyclical patterns, despite these findings being uncommon after menopause due to the cessation of ovarian activity. The authors postulated that peripheral oestrogen sources (especially in women who are obese) or exogenous progestins could induce such proliferative or secretory changes in this group.
The authors acknowledge that EH with and without atypia are two different conditions with differing management strategies, with EH without atypia having a lower risk of progression (<5%) to EC compared to EH with atypia (8–29% risk), according to studies done in Western populations.15 However, the authors’ primary objective was to look at the prevalence of EH in general, and not just EH with atypia. The authors’ decision to do so aligns with the International Federation of Gynecology and Obstetrics (FIGO) classification system (PALM-COEIN) of AUB, where EH (both with and without atypia) falls under the M category that denotes ‘malignancy or EH’.
The prevalence of EH and EC in perimenopausal women in the authors’ study was 35.94% and 1.56%, respectively, comparable to findings by Abdelazim et al.16 from Egypt, who reported a prevalence of 35.70% of EH. However, the prevalence of EC in their study was higher compared to the authors’ study (6.40% versus 1.56%), which could be attributed to an older population in their study. Belcaro et al.17 from Italy reported a prevalence of 26.64% of EH in their study, somewhat comparable to the authors’ findings. However, the prevalence of EC in their study was remarkably lower than in this study (0.48% versus 1.56%).17 While the prevalence of EC in perimenopausal women in this study is comparable to that reported in similar
Table 3: Prevalence (%) of endometrial hyperplasia and cancer in perimenopausal and postmenopausal women with abnormal uterine bleeding reported in different studies.
*Both hyperplasia without atypia and with atypia combined. AUB: abnormal uterine bleeding; EC: endometrial cancer; EH: endometrial hyperplasia.
studies from other regions, that of EH was relatively higher (Table 3).
The prevalence of EH and EC in postmenopausal women in this study was 38.89% and 19.44%, respectively, both markedly higher compared to the prevalences reported in other populations. Piróg et al.14 from Poland reported a prevalence of 40.40% of EH, which is comparable to the authors’ finding.
However, the prevalence of EC in their study was much lower compared to the authors’ study (3.50% versus 19.44%), possibly due to their exclusion of women with ET >4 mm.14 Nemer et al.20 from Saudi Arabia, on the other hand, reported a lower prevalence of EH compared to the authors’ study (15.80% versus 38.89%) and a prevalence of EC that was comparable to the authors’ study (15.80% versus 19.44%).20 Overall, European studies showed lower EC
rates in women with postmenopausal bleeding compared to studies from Asia and Africa (Table 3).
None of the clinical characteristics (BMI, diabetes, chronic hypertension, family history of significant malignancy, and reproductive characteristics) were associated with the diagnosis of EH/EC. This compares to findings by Piróg et al.14 from Poland, who reported that neither BMI, diabetes, nor chronic hypertension was associated with the diagnosis of EH/EC in women with postmenopausal bleeding.14 However, numerous systematic reviews have established an association between BMI, diabetes, chronic hypertension, and the diagnosis of EH/EC.25-27 This discrepancy may stem from the authors’ limited sample size and statistical power to test for associations.
In this study, ET cut-offs of 16 mm for perimenopausal and 4 mm for postmenopausal women were used to define a thickened endometrium. In premenopausal women, ET normally fluctuates throughout the menstrual cycle, ranging from 1–16 mm (1–4 mm immediately after menstruation, 5–7 mm in the early proliferative phase, 8–11 mm in the late proliferative phase, and 7–16 mm in the secretory phase). Given this variability, the use of a fixed ET threshold in premenopausal women can be challenging due to a significant overlap between normal and abnormal values. To address this, the authors classified any ET measurement exceeding 16 mm (the uppermost limit observed during any phase of the menstrual cycle) as abnormal or thickened. This approach was particularly appropriate for the authors’ perimenopausal participants, many of whom had irregular or erratic cycles, making it difficult to determine the specific phase of the menstrual cycle they were in at the time of ultrasound evaluation.
From the ultrasound findings, ET was the only factor significantly associated with the diagnosis of EH/EC in both bivariate and multivariate analyses in this study. This compares to findings by Piróg et al.,14 who reported that EH/EC were unlikely to be present in women with postmenopausal bleeding who had an ET
<4 mm. ET measurement is also applied in predictive tools for the assessment of EC risk in women with AUB, particularly postmenopausal women, e.g., the risk of EC scoring model.28
CONCLUSION
This study revealed a relatively higher prevalence of EH in perimenopausal women, and both EH and cancer in postmenopausal women with AUB, compared to most studies from other populations. Nevertheless, the most frequently observed histopathological features were normal cyclical patterns (secretory or proliferative) in the perimenopausal, benign pathologies (chronic endometritis in perimenopausal, and atrophic endometrium in postmenopausal), and EH without atypia in both groups. Only a small proportion of perimenopausal women were diagnosed with EH with atypia (3.1%) and EC (1.5%), the two pathologies that are of greatest clinical concern. Based on these findings, the authors do not recommend the routine performance of endometrial biopsies for perimenopausal women with AUB, unless their symptoms persist despite medical therapy and risk factor modification. Conversely, in women with postmenopausal bleeding, the authors strongly recommend the performance of endometrial histological evaluation, particularly in those with an ET >4 mm on ultrasound, given the relatively high prevalence of EH with atypia (13.8%) and EC (19.4%) observed in this study.
Study Strengths
To the best of the authors’ knowledge, this study was the first of its kind in subSaharan Africa at the time it was conducted, providing insights into an important subject that could be used by others from the region to explore more areas of the topic.
All endometrial biopsies were taken by one qualified person, with an overall sample adequacy rate of 100%.
Histological evaluation of all biopsies was done by two expert consultant pathologists to minimise inter-observer variability.
Study Limitations
There is a relatively lower accuracy of the Pipelle endometrial suction curette in detecting focal pathologies such as endometrial polyps and fibroids compared to hysteroscopically guided biopsies.
The pelvic ultrasounds performed in this study were mostly transabdominal and not transvaginal, which has a higher accuracy in the detection of pelvic pathologies and
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