Dunlevie Maternal-Fetal Medicine Center

Implantation of a human embryo into the endometrium is a crucial event in gestation, as it marks the initiation of a pregnancy and is prone to high failure rates. We have limited understanding of these stages because of the inaccessibility of implanting embryos and the lack of suitable model systems. Here, we establish an in vitro model that recapitulates the luminal, glandular, and stromal compartments of the superficial layer of receptive human endometrium. Human embryos and blastoids implant into the endometrial model, achieving post-implantation hallmarks including advanced trophoblast structures that underlie early events in placental development. Single-cell RNA sequencing of the embryo-endometrial interface at day 14 uncovers predicted molecular interactions between conceptus and endometrium. Disrupting signaling interactions between extravillous trophoblast and endometrial stromal cells caused defects in trophoblast outgrowth, demonstrating the importance of crosstalk processes to sustain embryogenesis. This platform opens the opportunity to investigate early stages of human embryo implantation.

Objectives. To examine the associations of self-reported disability status with health care access barriers for sexual and gender minority (SGM) people. Methods. The Population Research in Identity and Disparities for Equality (PRIDE) Study participants lived in the United States or its territories, completed the 2019 annual questionnaire (n = 4961), and self-reported their disability and health care access experiences, including whether they had a primary care provider, were uninsured, delayed care, and were unable to obtain care. We classified disabilities as physical, mental, intellectual, and other; compared participants to those without disabilities; and performed logistic regression to determine the associations of disability status and health care access barriers. Results. SGM people with disabilities were less likely to have a usual place to seek health care (69.0% vs 75.3%; P ≤ .001) and more often reported being mistreated or disrespected as reasons to delay care (29.0% vs 10.2%; P ≤ .001). SGM people with disabilities were more likely to delay care (adjusted odds ratio [AOR] = 3.28; 95% confidence interval [CI] = 2.83, 3.81) and be unable to obtain care (AOR = 3.10; 95% CI = 2.59, 3.71). Conclusions. Future work should address culturally competent health care to ameliorate disparities for the SGM disability community. (Am J Public Health. 2023;113(9):1009–1018. https://doi.org/10.2105/AJPH.2023.307333 )

ObjectiveTo investigate associations between reproductive endocrinology and infertility (REI) providers’ prior training and current knowledge, skills, attitudes, and behaviors regarding fertility preservation and family building for transgender and gender-diverse (T/GD) patients.DesignThe survey was distributed to members of the Society for Reproductive Endocrinology and Infertility, the REI-physician-focused professional body within the American Society for Reproductive Medicine, with additional participants recruited through snowball sampling.ResultsParticipants (n = 206) reported on training in T/GD care; 51% endorsed prior training. Most participants (93%) believed T/GD individuals were as fit for parenthood as cisgender individuals. Prior training was associated with an increased likelihood of offering T/GD health resources and more frequent consultations with specialist colleagues.Common barriers to providing care indicated by respondents included cost, delays in gender-affirming care, and lack of knowledge of the potential impact of hormonal interventions. Common facilitators included education and training, prior experience, and affordability of services.ConclusionsMost REI providers believed T/GD individuals are fit for parenthood and agreed that prior training facilitates care for T/GD patients. The lack of provider knowledge emerged as a barrier to care. Although training helped facilitate some components of care, systemic barriers such as the cost and variability of patient population characteristics/experiences are important considerations when serving T/GD individuals. To investigate associations between reproductive endocrinology and infertility (REI) providers’ prior training and current knowledge, skills, attitudes, and behaviors regarding fertility preservation and family building for transgender and gender-diverse (T/GD) patients. The survey was distributed to members of the Society for Reproductive Endocrinology and Infertility, the REI-physician-focused professional body within the American Society for Reproductive Medicine, with additional participants recruited through snowball sampling. Participants (n = 206) reported on training in T/GD care; 51% endorsed prior training. Most participants (93%) believed T/GD individuals were as fit for parenthood as cisgender individuals. Prior training was associated with an increased likelihood of offering T/GD health resources and more frequent consultations with specialist colleagues. Common barriers to providing care indicated by respondents included cost, delays in gender-affirming care, and lack of knowledge of the potential impact of hormonal interventions. Common facilitators included education and training, prior experience, and affordability of services. Most REI providers believed T/GD individuals are fit for parenthood and agreed that prior training facilitates care for T/GD patients. The lack of provider knowledge emerged as a barrier to care. Although training helped facilitate some components of care, systemic barriers such as the cost and variability of patient population characteristics/experiences are important considerations when serving T/GD individuals.

OBJECTIVE: The goal of this study was to investigate the risk of preterm birth subtypes and hypertensive disorders of pregnancy in patients with systemic vasculitis using large, statewide databases. METHODS: Births to nulliparous patients with prevalent systemic vasculitides (Takayasu arteritis [TAK], Behçet disease [BD], antineutrophil cytoplasmic antibody-associated vasculitis [AAV], and Kawasaki disease [KD]) were identified using International Classification of Diseases, Ninth Revision codes in linked administrative data and birth records from the California Department of Health Care Access and Information and California Vital Statistics from 1991 to 2012. Hypertensive disorders of pregnancy and preterm delivery (PTD) subtypes were identified. Multivariable-adjusted Poisson models estimated risk ratios (RRs) of these outcomes compared with the general birthing population without history of rheumatic disease. RESULTS: A total of 96 births to nulliparous patients with systemic vasculitis were identified (TAK, 14; AAV, 31; BD, 26; KD, 15) and compared with 4,191,900 births of the nulliparous general population. Adjusted RRs for all PTD types were elevated in patients with vasculitis (RR 3.21, 95% confidence interval [CI] 2.15-4.79), as were the RRs of all PTD subtypes including preterm premature rupture of membranes (RR 4.30, 95% CI 2.05-9.01) and spontaneous PTD (RR 4.99, 95% CI 3.01-8.28). Of the spontaneous PTDs among patients with vasculitis, 16.7% were early PTDs (20-31 weeks), with the remaining 83.3% occurring between 32 to 36 weeks. Patients with vasculitis also had an elevated risk of hypertensive disorders of pregnancy (RR 2.96, 95% CI 1.72-5.10). CONCLUSION: Among first-time births, we found that patients with systemic vasculitis have an elevated risk of PTD subtypes as well as hypertensive disorders of pregnancy.

OBJECTIVE: Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. STUDY DESIGN: = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. RESULTS: SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. CONCLUSION: Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention. KEY POINTS: · By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..

Purpose: Binding, packing, using stand-to-pee (STP) devices, and tucking are nonhormonal, nonsurgical gender-affirming body modifications (GABMs) that are used to affirm gender expression. This study sought to describe the sociodemographic characteristics of and side effects experienced by those using GABMs. Methods: We conducted a cross-sectional study of The Population Research in Identity and Disparities for Equality Study participants who completed the 2023 Annual Questionnaire. Data on sociodemographics and self-reported side effects were collected and analyzed using descriptive statistics. Results: Of 6296 participants, 1694 reported GABMs including binding ( n = 995), packing ( n = 590), using an STP device ( n = 351), and tucking ( n = 265). Each GABM had a distinct side effect profile. Pain (2.0%–48.2% past-year prevalence) and dermatologic concerns (0.5%–23.2% past-year prevalence) were reported across GABMs. Conclusion: While GABMs promote mental health and patient safety, they carry a risk of adverse physical health effects. Providers play a vital role in managing GABM-associated side effects to ensure patients can continue to affirm their gender identities.

Abstract Study question Can proteins released by embryos into culture medium between 7- and 14-days post-fertilization (d.p.f.) potentially function as biomarkers indicating the ploidy status of the embryos? Summary answer Combined secreted levels of calreticulin (CALR), human Placental Lactogen (hPL), Placental Growth Factor (PlGF) and human Pappalysin-1 (PAPP-A) differentiate euploid from chromosome 21-aneuploid embryos. What is known already Exploring post-implantation embryo development is vital due to potential errors impacting early pregnancy or postnatal health during this period. Trisomy 21 (T21) is a common aneuploidy that can lead to live births but with postnatal health concerns, while chromosome 21 monosomy (M21) often results in embryo developmental arrest. Understanding post-implantation development and secreted products into human post-implantation niche is crucial for unraveling embryo-maternal interactions. Building on prior studies indicating ploidy-related gene and metabolite expression in pre-implantation embryos (DOI:10.1016/j.fertnstert.2019.01.023), this study aims to assess variations in the secretome of embryos with different ploidy during post-implantation development. Study design, size, duration Comparative study involving 48 science-donated human 6 d.p.f. blastocysts initiating hatching coming from in-vitro fertilization cycles. Preimplantation genetic testing identified Euploid (n = 20), pure T21 (n = 14), and pure M21 (n = 14) embryos. Two extended in-vitro culture protocols were compared: co-culturing of human embryos in a 3D system with endometrial cells or in a culture medium designed for post-implantation development but lacking maternal cells. Participants/materials, setting, methods Euploid, T21 and M21 blastocysts were thawed and cultured in-vitro until 14 d.p.f. in both culture systems described above. Levels of CALR, hPL, PlGF and PAPP-A in conditioned embryo media were quantified by ELISA immunoassays at 7, 10, 12 and 14 d.p.f. Absolute secreted protein concentrations (ng/mL) in each case were compared by two-way ANOVA followed by Tukey’s test for multiple comparisons. P < 0.05 was consider as statistically significant. Main results and the role of chance In both culture systems tested, at 7 d.p.f. secreted CALR, hPL and PlGF by M21 embryos were diminished when compared to euploid embryos (p < 0.01). At 10 d.p.f., euploid embryos displayed a significant increase in secreted PAPP-A, surpassing levels in T21 (p < 0.05) and M21 embryos (p < 0.01). Embryo co-culture in 3D endometrial systems led to progressive increase in secreted PAPP-A and PlGF by euploid embryos at 14 d.p.f. compared to earlier timepoints (7 d.p.f.,p<0.01; 10d.p.f.,p<0.05). PAPP-A secretion did not increase in T21 embryos during extended culture. T21 embryos demonstrated decreased PAPP-A secretion at 10, 12, and 14 d.p.f. compared to euploid embryos (p < 0.01 in all cases). Secreted PlGF in T21 embryos rose significantly at 12 (p < 0.05) and 14 d.p.f. (p < 0.05), despite consistently lower levels than euploid embryos (p < 0.01). All studied proteins showed significantly diminished secretions during post-implantation development in M21 embryos compared to euploid ones. Comparing culture systems, the absence of maternal cells led to a significant decrease in secreted protein levels and viability impairment beyond 11 d.p.f. Consequently, only two timepoints (7- 10d.p.f.) were considered for analysis in this culture system. The findings underscore the potential of these secreted biomarkers for distinguishing embryo ploidy, with maternal co-culture supporting enhanced developmental outcomes. Limitations, reasons for caution This is an in-vitro pilot study that should be validated in larger cohorts. Wider implications of the findings Secretions of CALR, hPL, and PlGF at 7 d.p.f. effectively distinguish M21 embryos, while PAPP-A and PlGF secretions at 10-12 d.p.f. are indicative of embryo ploidy. Additionally, co-culturing with maternal cells notably promotes proper embryo development, particularly enhancing trophoblast differentiation and secretion of trophoblast-related proteins. Funding: ISCII(PI20/00405;PI23/00860;FI18/00009;MV21/00086); GVA (CIAICO/2022/203;CIAPOT/2022/18) and IDI-20210916 Trial registration number Not Applicable

Abstract Fanconi Anemia (FA) is an inherited DNA-repair deficiency caused by mutations in diverse Fanc genes that leads to bone marrow failure and malignancies. FA disease begins at early embryonic stages, and while FA prenatal testing has long been available, no fetal therapies for FA currently exist. Postnatally, FA hematologic disease can be cured through allogeneic hematopoietic stem cell transplantation (HSCT); however, this requires chemotherapy and/or irradiation-based conditioning which amongst various side-effects also increases likelihood of malignancies later in life in these fragile patients. Given fetal immune tolerance and the competitive advantage of healthy hematopoietic stem and progenitor cells (HSPCs) over failing FA HSPCs, in utero HSCT without conditioning may be an alternative approach to stabilization of the hematopoietic system without conventional toxicities. We performed in utero HSCT using HSPCs from wildtype (WT) donors into two FA mouse models ( Fancd2 −/− , Fanca −/− ) and observed robust multi-lineage hematopoietic donor engraftment in homozygous FA mice compared to both heterozygous FA and WT littermates. Upon serial assessments, we also observed increasing donor chimerism up to 94.1%, showcasing the competitive advantage of WT donor HSPCs over FA HSPCs. Given that 1% donor chimerism is predicted to stabilize FA BM, in utero HSCT may be a safe and curative prenatal treatment for all subtypes of FA.