News from ACOG 2018: Unexplained infertility may be an indicator of decreased ovarian reserve even in young women

Despite advances in diagnostic modalities in the infertile couples, the cause of infertility remains largely unexplained in 25% to 30% of couples. The treatment in these couples remains largely empirical.

The result of a small study presented at the ACOG 2018 by, Dr. Andrea Starostanko MD and Dr. Jonathan Ayers MD from Saint Joseph Mercy Hospital Department of Obstetrics and Gynecology, Ann Arbor, MI suggests that even in young women with unexplained infertility (UI) ovarian reserve should be evaluated as part of initial work up.

Institute for Reproductive Health

They looked at data from 343 nulligravid couples (18-34 years) who were unable to conceive after unprotected coitus for a period of 12 months. The couples underwent tubal patency test, ovulation study and anatomic status by mid-cycle TVUS, comprehensive semen analysis, and assessment of Decreased Ovarian Reserve (DOR) with serum Anti-Mullerian Hormone (AMH).

A cause of infertility was found in 142/343 (41%) couples with anovulation in 30%, anatomic abnormality in 9% and male factor in 6%.  In 201/343 (59%) of couples, no probable cause could be identified.

In these couples with UI, 118/201 women had serum AMH levels below the 95 percentile of age-appropriate value and in nearly 25% of women below the age of 35(53/201), the values were < 1.5.

The researchers concluded that: 

All women with UI should be investigated for ovarian reserve during the initial workup, irrespective of their age

Women who are diagnosed with DOR should seek consultation with a specialist for further treatment options

DOR may also be a harbinger of premature menopause and associated cardiovascular complications  

Abstract

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Sugar is as big a threat as tobacco: We need to treat it that way.

Courtesy: Fateclick 

This article is based on a speech by Dr. Aseem Malhotra, MBChB, MRCP at the UK parliamentary “Sugar Summit.” [1]The sugar summit was convened by a distressed mother Rend Platings, after learning that today’s generation of parents will be the first to bury their children because of increasing obesity. She launched ‘Sugarwise’ an organization for increasing attention, education, awareness and giving people options on sugar in their food and drink.[2]

Keith Vaz chaired the event which included number of representatives from high-profile UK retailers as Tesco, Caffè Nero, and the Jamie Oliver Group, as well as such influential stakeholders as the UK Department of Health, Public Health England, the British Soft Drinks Association, and the Food and Drink Federation. [3]

About 2 years back the WHO and Scientific Advisory Committee on Nutrition (SACN) made a recommendation to halve the amount of sugar in our diet. But, we are still far behind in meeting that mark.  Sugar continues to play a major role as an important cause of obesity for two-thirds of the U.K. population.

The U.K government has recently made an announcement of an introduction of a 20% tax on sugar-sweetened beverages in 2017,[4] similarly WHO also announced to tax sugary drink by 20% to check the global epidemics of obesity and type 2 diabetes. [5]

Scientists, researchers and public health personal has long raised voices against the hidden sugar found in daily food items and paralleled the addiction to tobacco. Legislative measures against tobacco use and smoking is the single most driving factor behind the drop in cardiovascular mortality since 3 decades.

Health Benefits:

Dr Assem Malhotra has included the following research data in his editorial. Oxford researchers have estimated that a 15% reduction in sugar consumption through such a tax would prevent 180,000 people in the UK from becoming obese within a year and a larger number from becoming overweight.[6] But the scientific evidence reveals that the positive health benefits for the whole population of such a tax goes beyond a mere reduction in calories:

• An econometric analysis of 175 countries (considered the highest quality of study with the exception of randomized controlled trials) revealed that for every additional 150 sugar calories available for consumption, there was an 11-fold increase in the prevalence of type 2 diabetes in the population. This is compared with 150 calories from another source such as fat or protein and independent of body mass index (BMI) and physical activity levels.
• The prevalence of type 2 diabetes in the US population between 1988 and 2012 increased by 25% in both obese and normal-weight populations, which goes to show that type 2 diabetes is not a condition related purely to obesity.
• A high-quality prospective cohort study revealed a trebling in cardiovascular mortality among US adults who consumed more than 25% of calories from added sugar versus those who consumed less than 10%, with consistent findings across physical activity levels and BMI.
• The positive health effects of reducing sugar intake appear to be quite rapid. In a study of 43 Latino and African-American children with metabolic syndrome, keeping total calories and calories from carbohydrate identical, a reduction from a mean of 28% of calories from added sugar to 10% significantly reduced triglycerides, LDL cholesterol, blood pressure, and fasting insulin within just 10 days.

Here is a video of Dr. Aseem Malhotra’s lecture at Cape Town Sugar Free Breakfast” Sugar is public enemy number one.”

 How much sugar is safe?

No amount of added sugar is needed by our body, as it does not have any nutritional value. Just a very little amount of free sugar, which includes sugar in fruit juices, honey and syrup has a very deleterious impact on most common global disease of tooth decay. It is the single most important cause of chronic pain and hospital admission in young children.

WHO recently recommended that no more than 3% of our daily calorie intake should come from sugar which amounts to three teaspoons. The average US and UK citizen consumes nearly 4-7 times the recommended amount. This is also because of much of the sugar is consumed unknowingly because it comes from foods that are normally not considered to have much added sugar like Tomato ketchup, salad dressings, and bread. The rest comes from sugary drinks and junk foods like cookies, ice-cream and chocolates.

He also further added that in US, there is no reference range of sugar printed on the food labels. In Europe and UK, food labels carry the range but does not differentiate between children and adults. A can of regular cola contains 9 teaspoons of added sugar which is triple the amount of daily recommendation made in 2009. The public lacks knowledge because of confusing food labels and nearly 80% of processed food contains sugar.[7]

It took nearly 50 years of research and lobbying before a link was established between tobacco and lung cancer. Dr. Cristin Kearns, University of California, San Francisco reveals in her recent paper published in JAMA internal medicine how sugar industry paid scientist and researcher to downplay its role in causation of coronary artery disease. [8]

Sugar Research Foundation paid two scientists, Mark Hegsted and his colleague Dr. Robert McGandy to write a review that countered the link between sucrose and   coronary artery disease. Both of them, overlooked the studies that implicated sugar as a culprit, instead  made only one recommendation of  changing fat and cholesterol intake to prevent coronary heart disease.[9] Similarly, Coca-Cola and candy makers have both tried to influence research practice in favor of their products.  

The message is very clear. There is nothing wrong in an occasional treat, but sugar cannot be a part of “healthy balanced diet”.

Dr. Aseem Malhotra's other articles can be read at his blog: http://doctoraseem.com/

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[1] http://www.thesugarreductionsummit.co.uk/

[2] http://sugarwise.org/

[3]http://blog.euromonitor.com/2016/10/sugar-summit-sugarwise-takeaways.html

[4] https://petition.parliament.uk/petitions/106651

[5] http://www.who.int/mediacentre/news/releases/2016/curtail-sugary-drinks/en/

[6] Briggs ADM, Mytton OT, Kehlbacher A, et al. Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ. 2013;347:f6189.

[7] Aseem M. The dietary advice on added sugar needs emergency surgery. BMJ. 2013;346:f3199.

[8] http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2548255

[9] https://www.statnews.com/2016/09/12/sugar-industry-harvard-research/

Breast arterial calcification during screening mammography identifies women at high risk for CVD.

Routine Mammography widely recommended as screening tool for breast cancer may also help predicts the woman risk for Coronary Disease, which could lead to a potential early intervention.

Recently two studies were presented linking the amount of calcium in breast arteries to calcium build up in coronary arteries. The first study was presented in March 24, 2016 at the American College of Cardiology’s 65^th Annual Scientific Session. The study was simultaneously published online in JACC: Cardiovascular Imaging.[i]

Recently, another study was also presented at the North American Menopause Society (NAMS) 2016 Annual Meeting.[2]

Coronary artery calcification(CAC) is considered very early sign of cardiovascular disease. Several noninvasive imaging techniques have been devised to evaluate the risk of CVD of an individual namely USG, MRI and CT scan.   While MRI and sonography pick up the abnormalities in arterial anatomy caused due to atherosclerosis, CT scan rely on calcium present in the coronary artery. Although CT scan is a good screening tool to predict the calcium deposition, it requires specific types of equipment, and/or specially trained personnel in addition to the high cost incurred by patients.

Interestingly, Earlier studies have shown that Breast Artery Calcifications (BAC) is associated with increased risks of CVD similar to CAC.  Studies have also associated the presence of BAC to increased risk of metabolic syndrome. [3]

In the study published in the JACC: Cardiovascular Imaging 292 women who had digital mammography and CT scan within 1 year were included in the study. Of these, 124, or 42.5 percent, were found to have evidence of breast arterial calcification. The overall accuracy of breast arterial calcification for the presence of CAC was 70 percent, and 63 percent of those with CAC also had breast arterial calcification.[4]

The other risk assessment tools that are used to calculate risk for heart disease are from Framingham Heart Study [5] which requires you to put in your age, sex, total and HDL cholesterol levels, smoking status, systolic blood pressure, and use of any blood pressure-lowering medications to calculate risk. 

The other, the ASCVD risk estimator, uses the same information while also considering a person’s race and whether they have diabetes.[6] BAC appeared to be as strong predictor of risk for CVD, if not better than Framingham and ASCVD risk calculator.

About 70% of women who had BAC on mammogram were also shown to have CAC by CT scan of the chest. The prevalence of BAC picked up at routine screening mammography is 3%-29%.

 In the paper presented at the annual meeting of North American Menopause Society (NAMS) the lead author Dr. Schnatz presented a 10 year follow up of women in whom BAC was detected at. routine mammography from June to August 2004. Data regarding risk factors for CVD and CVD events that happened was collected at baseline and also at every follow-up.

Out of 1029 subjects recruited for the study, 112 patients had baseline BAC. Those women who had calcification at baseline were 2.3 times more likely have an CVD event as compared to those who did not have calcifications. (P = .034). They were also 3.2 times more likely to have experienced stroke in 10 years. (P = .018).

Dr. Schnatz wants to call upon the researchers to add the BAC to other risk calculation tools to improve the composite outcome.

Presently there is still no consensus on using BAC as screening test for CVD risk stratification. A large study of 40,000 subjects is still ongoing in Netherlands.

The clinical implications of this research finding:

• Radiologists and primary care physicians must be educated on the link between BAC and CAC.
• About 37 million mammograms are performed in USA annually, so they serve as double screening for cancer and heart disease too, with no extra money, time or radiation.
• Each year approximately 4 million women will be diagnosed with BAC while undergoing routine mammography in USA.  About 2-3 million of these women will have atherosclerotic disease. So the diagnosis of BAC can be used for risk stratification and preventive care treatment.
• The finding of BAC during a screening mammogram should trigger an investigation of the women’s risk for CVD and implementing aggressive strategies to modify the risk.
• The reverse is not true, that women with risk factors should be referred for mammography.

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[1]http://imaging.onlinejacc.org/article.aspx?articleID=2503388

[2] https://www.menopause.org/annual-meetings/2016-meeting/scientific-program

[3] http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322014001200841

[4] https://www.acc.org/about-acc/press-releases/2016/03/25/09/26/mammograms-another-way-to-screen-for-heart-disease?w_nav=S

[5] http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/risk-assessment/

[6] http://tools.acc.org/ASCVD-Risk-Estimator/