the endocrinology of the pregnancy - gyllenbergs · the endocrinology of the pregnancy cornelis b....

1

The endocrinology of

the pregnancy

Cornelis B. Lambalk

VU University Medical Center

Amsterdam, The Netherlands

The XXV Signe and Ane Gyllenberg Symposium. Childbearing,

parenthood and outcomes of children-an interplay between

psychogical and biological factors, Espoo, Finland, September

21st-23rd, 2017

“Endocrinology of pregnancy”

• Endocrinology of Normal Pregnancy

• Endocrinology of Implantation

• Endocrinology of Early Pregnancy Loss

• Endocrinology of Ectopic Pregnancy

• Endocrinology of Preterm Labour

3

‘Fetal origin of development in later life’

‘The womb may be more important than the home’

Introduction

4

The reproductive endocrinology of

the (PCOS & Twin) pregnancy

Cornelis B. Lambalk

VU University Medical Center

Amsterdam, The Netherlands

The XXV Signe and Ane Gyllenberg Symposium. Childbearing,

parenthood and outcomes of children-an interplay between psychogical

and biological factors, Espoo, Finland, September 21st-23rd, 2017

5

Outline

• Introduction

• Background

• Polycystic ovarian syndrome and endocrinology of pregnancy

• Conclusions

• The endocrinology of the twin pregnancy

• Conclusions

8Cohen-Bendahan et al Neurosc Biobehav Rev 2005

0 6 10 14 18 22 26 30 34 38 42

0

17.5

15

12.5

10

7.5

5

2.5

Estrogens [ng/mL]

Estradiol

Estriol

Estrone

250

200

150

100

50

0

0 6 10 14 18 22 26 30 34 38 42

Progesterone [ ng/L]

11

Sex differences in prenatal hormone levels

Van de Beek et al Arch Sex Behav 2009

12Kuijper et al RBM Online 2013

13Kuijper et al RBM Online 2013

14Kuijper et al RBM Online 2013

15

Cord blood hormones and human development

Hollier et al Front Endocrinol 2014

16

PCOS

Polycystic ovary syndrome (PCOS)

Criteria:

• clinical and/or biochemical signs of hyperandrogenism

• polycystic ovaries on ultrasound

• oligo- or anovulation

• 5-10 % of women

• Heredity 80 %

17

Androgens in girls with PCOS mothers

Is there fetal hyperandrogenism in the PCOS pregnancy?

Does prenatal exposure to androgens cause PCOS?

Origin of fetal androgens in PCOS women?

• Maternal origin placental passage during gestation

• Fetal origin inherited trait apparent during/after

puberty

PCOS

18

PCOS

19

PCOS

Abbott et al, 1998. Trends Endocrinol Metab 9:62-67

Kent et al, 2008. J Clin Endocrinol Metab 93:1662–1669

Lummaa et al, 2007. Proc Natl Acad Sci USA 104:10915-10920

20Palomba et al Clin Endocrinol 2012

PCOS

mothers

Control mothers

P

Boys

0.87 +/- 0.21

(n = 17)

0.80 +/- 0.16

(n = 21)

n.s.

Girls

0.53 +/- 0.12

(n = 13)

0.36 +/- 0.10

(n = 12)

0.019

Free testosterone (pmol/l) in amniotic fluid

22Palomba et al Clin Endocrinol 2012

Autistic Quotient

23Kosidou et al Mol Psych 2016

Autistic Spectrum Disorder ASD

25Wu et al Hum Reprod 2017

26Homburg et al 2017, Reproductive Biology and Endocrinology

28

PCOS

However,

Medland et al, 2008. Twin Res Hum Genet 11:481-487

Kuijper et al, 2009. J Clin Endocrinol Metab, 94:1987-1990

Heritability of PCOS in a Dutch Twin-family study

Vink et al, 2006. J Clin Endocrinol Metab, 91:2100-2104

29

Aim of our study:

Compare androgen (and estrogen) levels during

gestation and in umbilical cord blood from

children born from PCOS mothers and controls

Caanen et al Eur J Endocrinol 2016

30

Subjects

- Prospective, large cohort study, 523 mothers

- Hormones throughout pregnancy

- Natural pregnancy – assisted reproduction

Methods

Caanen et al Eur J Endocrinol 2016

31

Subjects

Cases: PCOS defined by Rotterdam criteria (N=20)

Controls (N=83):

• regular cycle (<35 days)

• no acne or hirsutism

• natural conception

Inclusion:

• age > 18

• singleton pregnancies

Exclusion:

• multiple gestation

• delivery < 32 weeks

• assisted reproduction

Methods

Caanen et al Eur J Endocrinol 2016

32

Time points

Maternal blood samples:• 20 weeks of gestation• delivery

Neonatal blood samples:• cord blood

Hormones measured*

Estrogens:• estrone (E1)• estradiol (E2)• estriol (E3)

Androgens:• testosterone (T)• androstenedione (ADION)• dehydroepiandrosterone sulfate (DHEAS)

*using LCMS technology (Salt Lake City)

Methods

Caanen et al Eur J Endocrinol 2016

Regression analyses

Maternal serum levels (means) - 20 weeks

PCOS mothers pregnant with a girl:

significantly higher ADION and T levels

34

Girls Boys

PCOS Non-PCOS P-value PCOS Non-PCOS P-value

ADION (ng/ml) 2.13 1.08 0.034 2.60 1.24 0.084

T (ng/ml) 1.04 0.507 0.019 1.15 0.56 0.113

DHEAS (ng/ml) 3.12 2.76 0.788 4.18 2.58 0.654

E1 (pg/ml) 3889.3 4469.4 0.928 5433.3 3128.7 0.061

E2 (pg/ml) 6441.4 6942.2 0.559 7250.0 6074.4 0.300

E3 (pg/ml) 2213.6 2106.2 0.815 2345.0 1972.9 0.139

Results

Caanen et al Eur J Endocrinol 2016

Regression analyses

Maternal serum levels (means) - delivery

PCOS mothers pregnant with a girl:

significantly higher ADION and T levels

35

Girls Boys

PCOS Non-PCOS P-value PCOS Non-PCOS P-value

ADION (ng/ml) 4.22 1.62 0.009 4.48 2.04 0.537

T (ng/ml) 2.79 0.91 0.004 2.57 1.1 0.675

DHEAS (ng/ml) 9.11 6.85 0.360 5.16 6.09 0.940

E1 (pg/ml) 9786.7 8845.3 0.690 13625 7454.5 0.015

E2 (pg/ml) 8184.8 9882.3 0.979 13850 9460.0 0.208

E3 (pg/ml) 2342.3 4392.9 0.461 19922.3 7843.4 0.341

Results

Caanen et al Eur J Endocrinol 2016

Regression analyses

Cord blood (means)

Girls from PCOS mothers: no elevated androgens

36

Girls Boys

PCOS Non-PCOS P-value PCOS Non-PCOS P-value

ADION (ng/ml) 0.45 0.84 0.094 0.49 0.54 0.834

T (ng/ml) 0.12 0.15 0.959 0.178 0.20 0.676

DHEAS (ng/ml) 4.9 5.65 0.577 2.98 2.90 0.162

E1 (pg/ml) 10511.1 22025.7 0.007 14734.5 21123.9 0.718

E2 (ng/ml) 5426.1 8919.2 0.052 9601.5 9196.4 0.520

E3 (ng/ml) 57412.1 52729.2 0.836 51568 55135.1 0.378

Results

Caanen et al Eur J Endocrinol 2016

37

• There are no indications of increased fetal androgen levels of

PCOS mothers in their offspring, despite consequently maternal

elevated levels throughout the pregnancy

• Apparently placental aromatase sufficiently protects

Conclusions (1)

Caanen et al Eur J Endocrinol 2016

• There is a significant reduction of E1 levels - E2 and ADION

tend to be reduced, only in the girls

• These gender specific differences may suggest a fetal gonadal

origin of altered sex-steroidogenesis

• It remains to be determined if this altered setting is intrinsic to

the female fetus of a PCOS mother, or still of maternal origin

38

Conclusions (2)

Caanen et al Eur J Endocrinol 2016

Alterations in cord blood parameters of female

offspring of women with polycystyc ovary

syndrome: a systematic review

Schouten et al RBM Online submitted 39

Systematic review 2017

41Schouten et al

Methods

42

Study Type of study Inclusion period Place

Cord

blood

Hormone

analyzing

method

Definition

PCOS

PCOS

n =

Control

n =

Anderson

2010

Prospective case-

control study

Not reported Chicago, USA Mixed LC-MS NIH 17 14

Barry

2010

Case-control Not reported University College

Hospital and Royal Free

Hospital, London

Venous IA (ECI) Rotterdam 10 20

Caanen

2016

Prospective

cohort study

2004-2009 Multicentre,

the Netherlands

Mixed LC-MS/MS Rotterdam 20 83

Daan

2016

Cross-sectional

case-control

study

PCOS: 2008-2010

Control: 2011-2014

Multicentre,

the Netherlands

Mixed LC-MS/MS Rotterdam 61 82

Maliqueo

2013

Case-control Not reported Santiago, Chile Mixed IA (RIA) Rotterdam* 20 30

Vanky

2012

Substudy of

PREGMET study

(prospective,

randomized,

double-blind

multicenter trial)

Not reported Trondheim, Norway Arterial

Venous

IA (ELISA) Rotterdam 68 -

Schouten et al RBM Online submitted

Results

43Schouten et al

Results

44Schouten et al RBM Online submitted

Results: overview

46

Results: overview

47

Conclusions (3)

• No clear indication of elevated androgen levels

• Different concentrations of steroids, E1 and E 2 lower

• Different reproductive endocrinology in female PCOS offspring

at time of birth

• Focus on placental enzyme activity

• IPD meta-analysis is on its way

48Schouten et al RBM Online submitted

49

Outline

• Introduction

• Background

• Polycystic ovarian syndrome and endocrinology of pregnancy

• Conclusions

• The endocrinology of the twin pregnancy

• Conclusions

50

51

Estrogens

Fetal

Maternal

DZ MZ Singleton

Endocrine assumptions in twins

Kuijper et al Fertil Steril 2015

52

Androgens

DZ ♀♀ ♀♂

Maternal

Fetal

Endocrine assumptions; opposite sex twin girls

Kuijper et al Fertil Steril 2015

53

Singleton mothers mid-gestation

N=248

Singleton mothers at delivery

N=178

Neonatal samples at delivery

N=178

♀N=89 ♂N=88

NC

N=54

Included after GA 20 weeks: 3

Blood sample not taken at delivery: 73

ART

N=35

NC

N=48

ART

N=40Kuijper et al Fertil Steril 2015

54

Twin mothers mid-gestation N=204

Twin mothers at delivery N=174

Neonatal samples of the twins at delivery

N=156 (sample from both children) and N=12 (sample

from only one child)*

NC N=14

ART N=1

NC N=12

ART N=16

? N=2

MZ pairs N=14

N=1*

MZ pairsN=15

N=1*

DZ pairs N=29

N=1*

DZ pairsN=33

N=4*

♂♀♂♂♀♀

DZ pairs N=65

N=5*

NC N=11

ART N=2

? N=3

NC N=10

ART N=24

? N=3

NC N=25

ART N= 41

? N= 4

Included after GA 20 weeks: 24

Blood sample not taken at delivery: 54

Kuijper et al Fertil Steril 2015

57

0

1

2

3

4

31 33 35 37 39 41 43

gestational age (weeks)

MZ

DZ

Singleton

Kuijper et al Fertil Steril 2015

58

Twin vs singleton Estrogen & Progesterone

Kuijper et al Fertil Steril 2015

59

Twin vs Singleton Androgens

Kuijper et al Fertil Steril 2015

60

MZ versus DZ

• Overall no differences

• No differences between MZ boys and DZ boys

• DZ girls versus MZ girls• Higher Estriol • Lower FSH

Kuijper et al Fertil Steril 2015

61

Same sex twin boys vs opposite sex twin boys

Kuijper et al Fertil Steril 2015

62

No indications for androgen over exposure

Same sex twin girls vs opposite sex twin girls

Androgens

DZ ♀♀ ♀♂

Maternal

Fetal

Kuijper et al Fertil Steril 2015

63

Endocrine facts in twins

Estrogens

Fetal

Maternal

DZ MZ Singleton

Kuijper et al Fertil Steril 2015

64

• Estrogen and progesterone concentrations are higher in mothers of

twins compared to singletons

• In contrast to what is generally assumed opposite-sex twin babies

are in utero not overexposed to sex steroid hormones at time of

birth

• In opposite-sex twins we found no distinct androgenic effects of

boys on their female co-twin

• DZ girls experience a higher estrogenic milieu compared to MZ

girls

• The hypothalamic-pituitary-gonadal axis in male newborns with a

female co-twin is partially suppressed since these boys have lower

LH and inhibin B levels compared to same sex dizygotic twin boys

Conclusions (4)