RESUMEN

Ovarian tissue cryopreservation (OTC) is a method of fertility preservation in girls and young women prior to gonadotoxic treatment. It is a safe and promising method to restore fertility. The initial recovery of endocrine function is high, but the longevity of the grafted tissue varies. In this single-center, combined retro- and prospective cohort study, we report the reproductive outcome and hormonal recovery following ovarian tissue transplantation (OTT) and evaluate possible predictors of the chance of pregnancy. The study includes 40 women from eastern Denmark undergoing 53 OTTs between 2003 and 2021. Permission to obtain retrospective data was given by the Danish Patient Safety Authorities and prospective data-collection by informed consent. Initial recovery of endocrine function was seen in 18/19 women with POI, and ongoing function of the grafted tissue in 7/14 two years from OTT. Live birth rate (LBR) was 41%, with 20 children to 39 women trying to conceive. Women who conceived had higher AFC at the time of OTC than women who did not (p ± 0.04). Repeated transplantations were not successful in terms of delivery. Half of all pregnancies were achieved by ART, but PRs were lower after ART than by spontaneous conception. LBRs after OTT are encouraging. Chance of pregnancy after OTT is correlated to ovarian reserve at OTC. Repeated transplantations were not successful in terms of unfulfilled pregnancy wish.

RESUMEN

INTRODUCTION: Tonsillectomy is one of the most common procedures in the field of ear, nose and throat procedures. In 2012, the annual incidence in Denmark was 129.4 per 100,000 inhabitants. A common complication is post-tonsillectomy haemorrhaging (PTH). The overall PTH rates vary widely among studies ranging from 0.5% to 33%. METHODS: This was a nationwide open-population, retrospective and registry-based cohort study in Danes who underwent tonsillectomy complicated by PTH in hospitals and private otorhinolaryngology (ORL) offices in the period from 1991 to 2012. RESULTS: In the 1991-2012 period, a total of 177,211 tonsillectomies were performed among which 9,221 had a registered PTH (rPTH) (5.2%). The annual incidence rate of rPTH increased from 3% in 1991 to 13% in 2012 (p less-than 0.05). Males aged 20-40 years had a significantly higher risk of rPTH with the highest increase in rPTH incidence rates from 9.0% in 1998 to 16.4% in 2012 (p less-than 0.05). Approx. 12% had a primary rPTH within the first 24 hours; the maximum incidence of rPTH was on day six (14%). CONCLUSIONS: The rate of rPTH increased from 1991 to 2012 in hospitals and in private ORL office settings alike. There was a significantly higher rate of rPTH in the age group of 20-40 years and a significant geographical difference in rPTH. The highest risk of rPTH was observed on the day of surgery and on day six. TRIAL REGISTRATION: The Danish Data Protection Agency (record number 2012-41-0158) approved this study. FUNDING: The Olga Bryde Nielsen Foundation and H. Skouby & E. Skouby's Foundation supported this study financially.

Asunto(s)

Endometriosis/terapia , Fertilización In Vitro/métodos , Hormona Liberadora de Gonadotropina/agonistas , Procedimientos Quirúrgicos Ginecológicos/métodos , Infertilidad Femenina/terapia , Adulto , Tasa de Natalidad , Terapia Combinada , Dinamarca/epidemiología , Regulación hacia Abajo , Endometriosis/complicaciones , Femenino , Humanos , Infertilidad Femenina/etiología , Laparoscopía , Nacimiento Vivo , Embarazo , Estudios Retrospectivos , Resultado del Tratamiento , Adulto Joven

RESUMEN

INTRODUCTION: The effect of testosterone depends on the exposure of and the sensitivity of the androgen receptor (AR). It has been shown that a cytosine-adenine-guanine (CAG) trinucleotide repeat polymorphism in the AR gene has an impact on AR functional capacity in men. However, large studies are lacking on the impact of this polymorphism on female sexual function. AIM: To determine whether the CAG repeat length was associated with different aspects of women's sexual function and dysfunction, including desire, arousal, lubrication, orgasm, satisfaction, sexual pain, and sexually related personal distress. METHODS: This cross-sectional study included 529 healthy women, aged 19-65 years. Participants completed a questionnaire to provide demographic and sexual data. The CAG repeat length was analyzed in a blood sample. The correlations between CAG repeat lengths and different aspects of sexual function were calculated. Independent Student t-tests were performed to evaluate differences in the mean number of CAG repeats in the short and long allele and of the biallelic mean length determined by simple calculation and X-inactivation analysis, respectively, between women with sexual problems and women without sexual problems. P values <.05 were considered statistically significant. MAIN OUTCOME MEASURE: We used the Female Sexual Function Index, with 6 subdomains, to distinguish between women without and women with impaired sexual function; low sexual desire; impaired arousal, lubrication, or orgasm; diminished satisfaction; or pain during sex. The Female Sexual Distress Scale was used to measure sexually related personal distress. RESULTS: Overall, we found that increasing numbers of CAG repeats were correlated to increased sexual function. We found that women with problems achieving orgasm had a significantly lower number of CAG repeats than women that reported no problems reaching orgasm. We found no associations between CAG repeat lengths and other aspects of female sexual dysfunction, including hypoactive sexual desire disorder. CLINICAL IMPLICATIONS: The results could indicate an impact of the AR on women's sexual function, including the ability to reach orgasm. STRENGTH & LIMITATIONS: This is a large study using validated sexual questionnaires. A limitation is the cross-sectional design. Owing to the study design, this study is explorative and hypothesis generating. CONCLUSION: In this large cross-sectional study, we demonstrated that CAG repeat length is positively correlated to sexual function and that women with a reduced ability to reach orgasm had smaller numbers of CAG repeats in the AR gene than women with no orgasmic problems. These findings indicated that androgens and ARs might play a role in women's sexual function. Wåhlin-Jacobsen S, Flanagan JN, Pedersen AT, Kristensen E, Arver S, Giraldi A. Androgen Receptor Polymorphism and Female Sexual Function and Desire. J Sex Med 2018;15:1537-1546.

Asunto(s)

Receptores Androgénicos/genética , Disfunciones Sexuales Psicológicas/genética , Adulto , Anciano , Estudios Transversales , Dinamarca , Femenino , Humanos , Libido/fisiología , Persona de Mediana Edad , Polimorfismo Genético , Receptores Androgénicos/sangre , Disfunciones Sexuales Psicológicas/sangre , Encuestas y Cuestionarios , Repeticiones de Trinucleótidos , Población Blanca , Salud de la Mujer , Adulto Joven

RESUMEN

CONTEXT: The majority of Turner syndrome (TS) patients suffer from accelerated loss of primordial follicles. Low circulating levels of anti-Müllerian hormone (AMH) may predict the lack of spontaneous puberty in prepubertal girls and imminent premature ovarian insufficiency (POI) in TS women with preserved ovarian function. OBJECTIVES: To evaluate the association between circulating AMH and ovarian status in TS patients. DESIGN: Longitudinal observational cohort study. SETTING: Tertiary referral center for pediatric and gynecologic endocrinology. PARTICIPANTS: A total of 120 TS patients, aged 0 to 48 years. MAIN OUTCOME MEASURES: Longitudinal measurements of AMH, FSH, LH, estradiol, and inhibin B according to age, karyotype (45,X; 45,X/46,XX mosaicism; miscellaneous karyotypes), and ovarian status (group 0, prepubertal; group 1, never ovarian function; group 2, ongoing ovarian function; and group 3, loss of ovarian function). RESULTS: Ovarian status was highly associated with the TS karyotype: spontaneous puberty­45,X (three of 44 patients), 45,X/46,XX (15 of 17), miscellaneous (17 of 42); and POI­45,X (three of three), 45,X/46,XX (one of 15), and miscellaneous (eight of 17). AMH was associated with ovarian status (eg, group 1, <2 pmol/L; vs group 2, 19 pmol/L; P < .001). AMH < 4 pmol/L (corresponding to <-2 SD) predicted absent puberty in prepubertal girls and POI in adolescent and adult patients. CONCLUSION: The majority of women with mosaic karyotype 45,X/46,XX had ongoing ovarian function in early adulthood. AMH < -2 SD predicted failure to enter puberty in young TS girls and imminent POI in adolescent and adult TS patients.

Asunto(s)

Hormona Antimülleriana/sangre , Insuficiencia Ovárica Primaria/sangre , Insuficiencia Ovárica Primaria/diagnóstico , Síndrome de Turner/sangre , Síndrome de Turner/diagnóstico , Adolescente , Adulto , Biomarcadores/sangre , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Estudios Longitudinales , Persona de Mediana Edad , Insuficiencia Ovárica Primaria/epidemiología , Pronóstico , Síndrome de Turner/epidemiología , Adulto Joven

RESUMEN

Menopause is associated with an increased incidence of insulin resistance and metabolic diseases. In a chronic palmitate treatment model, we investigated the role of skeletal muscle fatty acid exposure in relation to the metabolic deterioration observed with menopause. Human skeletal muscle satellite cells were isolated from premenopausal (n = 6) and postmenopausal (n = 5) women. In an in vitro model, the myotubes were treated with palmitate (300 µM) for one-, two- or three days during differentiation. Effects on lipid accumulation, inflammation and insulin signaling were studied. Palmitate treatment led to a 108% (CI 95%: 50%; 267%) increase in intramyocellular ceramide in the myotubes from the postmenopausal women (post-myotubes) compared with a 26% (CI 95%: -57%; 96%) increase in myotubes from the premenopausal women (pre-myotubes), (p<0.05). Furthermore, post-myotubes had a 22% (CI 95%: 4%; 34%) increase in pJNK (p = 0.04) and a 114% (CI 95%: 50%; 177%) increase in Hsp70 protein expression (p = 0.03) after three days of palmitate treatment, compared with pre-myotubes, in which no increase in either pJNK (-12% (CI 95: -26%; 2%)) or Hsp70 (7% (CI 95: -78%; 91%)) was detected. Furthermore, post-myotubes showed a blunted insulin stimulated phosphorylation of AS160 in response to chronic palmitate treatment compared with pre-myotubes (p = 0.02). The increased intramyocellular ceramide content in the post-myotubes was associated with a significantly higher mRNA expression of Serine Palmitoyltransferase1 (SPT1) after one day of palmitate treatment (p = 0.03) in post-myotubes compared with pre-myotubes. Our findings indicate that post-myotubes are more prone to develop lipid accumulation and defective insulin signaling following chronic saturated fatty acid exposure as compared to pre-myotubes.

Asunto(s)

Ceramidas/metabolismo , Insulina/metabolismo , Fibras Musculares Esqueléticas/citología , Fibras Musculares Esqueléticas/metabolismo , Palmitatos/farmacología , Posmenopausia/metabolismo , Transducción de Señal/efectos de los fármacos , Tejido Adiposo/efectos de los fármacos , Tejido Adiposo/metabolismo , Femenino , Proteínas HSP70 de Choque Térmico/metabolismo , Humanos , Resistencia a la Insulina , Proteínas Quinasas JNK Activadas por Mitógenos/metabolismo , Metabolismo de los Lípidos/efectos de los fármacos , Persona de Mediana Edad , Fibras Musculares Esqueléticas/efectos de los fármacos , Estrés Oxidativo/efectos de los fármacos , Fosfoproteínas/metabolismo , Posmenopausia/efectos de los fármacos

RESUMEN

Puberty is characterized by a series a hormonal events leading to the attainment of adult reproductive capacity. Clinical manifestations of the pubertal processes include breast development, pubic hair development, menarche and regular menstrual bleedings. Abnormal pubertal development includes a spectrum of disorders such as premature thelarche, premature adrenarche, central and peripheral precocious puberty, adolescent polycystic ovarian syndrome, functional ovarian hyperandrogenism, late-onset congenital adrenal hyperplasia, primary and secondary amenorrhea, and premature ovarian insufficiency. Diagnosis of these reproductive disorders includes biochemical as well as clinical evaluation. The biochemical evaluation of reproductive function includes measurement of basal reproductive hormone levels and dynamic pituitary or adrenal hormone testing. Correct interpretation of such test results requires detailed knowledge on the normal maturational changes in the hypothalamic-pituitary-ovarian and hypothalamic-pituitary-adrenal axes. Changes in basal reproductive hormone levels in infancy, childhood and adolescence as well as the GnRH and ACTH test procedures in girls and adolescents are described in this chapter.

Asunto(s)

Técnicas de Diagnóstico Endocrino , Reproducción/fisiología , Adolescente , Desarrollo del Adolescente/fisiología , Adulto , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Modelos Biológicos

RESUMEN

OBJECTIVE: Diagnostic factors are needed to improve the currently used serum CA125 and risk of malignancy index (RMI) in differentiating ovarian cancer (OC) from other pelvic masses, thereby achieving precise and fast referral to a tertiary center and correct selection for further diagnostics. The aim was to evaluate serum Human Epididymis protein 4 (HE4) and the risk of ovarian malignancy algorithm (ROMA) for these purposes. METHODS: Serum from 1218 patients in the prospective ongoing pelvic mass study was collected prior to diagnosis. The HE4 and CA125 data were registered and evaluated separately and combined in ROMA and compared to RMI. RESULTS: 809 benign tumors, 79 borderline ovarian tumors, 252 OC (64 early and 188 late stage), 9 non-epithelial ovarian tumors and 69 non-ovarian cancers were evaluated. Differentiating between OC and benign disease the specificity was 62.2 (CA125), 63.2 (HE4), 76.5 (ROMA) and 81.5 (RMI) at a set sensitivity of 94.4 which corresponds to RMI=200. The areas under the curve (AUC) were 0.854 (CA125), 0.864 (HE4), 0,897 (ROMA) and 0.905 (RMI) for benign vs. early stage OC. For premenopausal benign vs. OC AUC were 0.925 (CA125), 0.905 (HE4), 0.909 (ROMA) and 0.945 (RMI). CONCLUSION: HE4 and ROMA helps differentiating OC from other pelvic masses, even in early stage OC. ROMA performs equally well as the ultrasound depending RMI and might be valuable as a first line biomarker for selecting high risk patients for referral to a tertiary center and further diagnostics. Further improvements of HE4 and ROMA in differentiating pelvic masses are still needed, especially regarding premenopausal women.

Asunto(s)

Algoritmos , Biomarcadores de Tumor/sangre , Antígeno Ca-125/sangre , Técnicas de Apoyo para la Decisión , Proteínas de la Membrana/sangre , Neoplasias Glandulares y Epiteliales/diagnóstico , Neoplasias Ováricas/diagnóstico , Neoplasias Pélvicas/diagnóstico , Proteínas/metabolismo , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Epitelial de Ovario , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , Neoplasias Glandulares y Epiteliales/sangre , Neoplasias Ováricas/sangre , Neoplasias Pélvicas/sangre , Estudios Prospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Proteína 2 de Dominio del Núcleo de Cuatro Disulfuros WAP , Adulto Joven

RESUMEN

OBJECTIVE: Risk of malignancy index (RMI), based on a serum cancer antigen 125 level, ultrasound findings and menopausal status, is used to discriminate ovarian cancer from benign pelvic mass. In Denmark, patients with pelvic mass and RMI ≥200 are referred to tertiary gynecologic oncology centers according to the national guidelines for ovarian cancer treatment. The guidelines include recalculation of RMI at the tertiary center and, if indicated, positron emission tomography/computed tomography and fast-track surgery by specialists in cancer surgery. The aim of this study was to validate the use of RMI ≥200 as a tool for preoperative identification of ovarian cancer at a tertiary center. DESIGN: Prospective observational study. SETTING: A tertiary center in Copenhagen, Denmark. POPULATION: One thousand one hundred and fifty-nine women with pelvic mass. METHODS: The RMI was calculated after ultrasound examination and blood sampling for serum cancer antigen 125 analysis within two weeks before surgery. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values were calculated to evaluate the ability of RMI to distinguish between ovarian cancer and benign pelvic mass. RESULTS: There were 778 women diagnosed with benign pelvic mass, while 251 had ovarian cancer and 74 had borderline ovarian tumor. Fifty-six women were diagnosed with other forms of cancer. Sensitivity and specificity for ovarian cancer vs. benign pelvic mass for RMI ≥200 were 92 and 82%, respectively. Corresponding positive and negative predictive values were 62 and 97%. CONCLUSIONS: Risk of malignancy index ≥200 is a reliable tool for identifying patients with ovarian cancer pelvic masses at a tertiary centre to select patients for further preoperative examinations.

Asunto(s)

Técnicas de Apoyo para la Decisión , Neoplasias Ováricas/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Antígeno Ca-125/sangre , Diagnóstico Diferencial , Femenino , Enfermedades de los Genitales Femeninos/diagnóstico , Humanos , Menopausia , Persona de Mediana Edad , Neoplasias Ováricas/sangre , Neoplasias Ováricas/diagnóstico por imagen , Neoplasias Ováricas/cirugía , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Medición de Riesgo , Sensibilidad y Especificidad , Ultrasonografía

RESUMEN

BACKGROUND: Previous reports have shown that the proteomic markers apolipoprotein A1, hepcidin, transferrin, inter-alpha trypsin IV internal fragment, transthyretin, connective-tissue activating protein 3 and beta-2 microglobulin may discriminate between a benign pelvic mass and ovarian cancer (OC). The aim was to determine if these serum proteomic biomarkers alone as well as in combination with age and serum CA125, could be helpful in triage of women with a pelvic mass. METHODS: We included prospectively 144 patients diagnosed with (OC), 40 with a borderline tumor and 469 with a benign tumor. Surface-enhanced laser desorption/ionization time of flight-mass spectrometry was used for analyses. The Danish Index (DK-Index) based on the proteomic data, age and CA125 was developed using logistic regression models. RESULTS: Multivariate logistic regression analysis demonstrated that the selected proteomic markers, CA125 and age were independent predictors of OC and the combination of these is proposed as the DK-index. A sensitivity (SN) of 99% had a specificity (SP) of 57% for DK-index and 49% for CA125. At a SN of 95%, the SP increased to 81% for DK-index compared to 68% for CA125 alone. For stage I+II the SP was 58% for DK-index and 49% for CA125. For stage III+IV the corresponding values were 94% and 86% respectively. CONCLUSIONS: The DK-index warrants further evaluation in independent cohorts.

Asunto(s)

Biomarcadores de Tumor/sangre , Proteínas de Neoplasias/sangre , Neoplasias Ováricas/diagnóstico , Proteómica , Adulto , Anciano , Anciano de 80 o más Años , Antígeno Ca-125/sangre , Femenino , Humanos , Modelos Logísticos , Persona de Mediana Edad , Oportunidad Relativa , Neoplasias Ováricas/sangre , Sensibilidad y Especificidad

RESUMEN

CONTEXT: In adult women, anti-Müllerian hormone (AMH) is related to the ovarian follicle pool. Little is known about AMH in girls. OBJECTIVE: The objective of the study was to provide a reference range for AMH in girls and adolescents and to evaluate AMH as a marker of ovarian function. SETTING: The study was conducted at a tertiary referral center for pediatric endocrinology. MAIN OUTCOME MEASURES: We measured AMH in 926 healthy females (longitudinal values during infancy) as well as in 172 Turner syndrome (TS) patients according to age, karyotype (A: 45,X; B: miscellaneous karyotypes; C: 45,X/46,XX), and ovarian function (1: absent puberty; 2: cessation of ovarian function; 3: ongoing ovarian function). RESULTS: AMH was undetectable in 54% (38 of 71) of cord blood samples (<2; <2-15 pmol/liter) (median; 2.5th to 97.5th percentile) and increased in all (37 of 37) infants from birth to 3 months (15; 4.5-29.5 pmol/liter). From 8 to 25 yr, AMH levels were stable (19.9; 4.7-60.1 pmol/liter), with the lower level of the reference range clearly above the detection limit. AMH levels were associated with TS-karyotype groups (median A vs. B: <2 vs. 3 pmol/liter, P = 0.044; B vs. C: 3 vs. 16 pmol/liter, P < 0.001) as well as with ovarian function (absent puberty vs. cessation of ovarian function: <2 vs. 6 pmol/liter, P = 0.004; cessation of ovarian function vs. ongoing ovarian function: 6 vs. 14 pmol/liter, P = 0.001). As a screening test of premature ovarian failure in TS, the sensitivity and specificity of AMH less than 8 pmol/liter was 96 and 86%, respectively. CONCLUSION: AMH seems to be a promising marker of ovarian function in healthy girls and TS patients.

Asunto(s)

Hormona Antimülleriana/sangre , Ovario/fisiología , Síndrome de Turner/sangre , Adolescente , Adulto , Factores de Edad , Anciano , Biomarcadores/sangre , Niño , Femenino , Humanos , Lactante , Recién Nacido , Inhibinas/sangre , Persona de Mediana Edad , Curva ROC , Valores de Referencia , Estadísticas no Paramétricas , Síndrome de Turner/fisiopatología

RESUMEN

OBJECTIVE: The key enzyme in the biosynthesis of estradiol, aromatase, has been demonstrated within endometriosis. Combined administration of aromatase inhibitor and GnRH-agonist may efficiently suppress estrogen biosynthesis through a combined pituitary, ovarian, peripheral and "in situ" action. The aim of this study was to test the concept of combined down-regulation prior to IVF in patients with endometriomas. STUDY DESIGN: Prospective pilot study in a university-based tertiary fertility clinic including 20 infertile patients with endometriomas undergoing IVF/ICSI. The patients received goserelin 3.6mg sc on treatment Days 1, 28 and 56, and one daily tablet of anastrozole 1mg from Day 1 to Day 69. Controlled ovarian stimulation was initiated from Day 70. Outcome measures were change in endometriomal volume and serum CA125 during down-regulation, standard IVF parameters including pregnancy and delivery rate, and endocrine response. The paired T test and Wilcoxon Signed Rank test were used to analyse paired differences. RESULTS: During the combined down-regulation, the endometriomal volume and the serum CA125 level decreased by 29% (3-39%) and 61% (21-74%), respectively (median (95%CI), P=0.007 and P=0.001). In the IVF/ICSI cycle, the number of oocytes retrieved was 7.5 (6.0-10.0) and the fertilization rate was 0.78 (0.38-1.0). Nine patients (45%) conceived, five (25%) had a clinical pregnancy, and three (15%) delivered healthy children (two singletons and one twin). CONCLUSIONS: Prolonged combined anastrozole and goserelin down-regulation significantly reduces endometriomal volume and serum CA125, and is compatible with IVF pregnancy and delivery. However, a high pregnancy loss was noted.

Asunto(s)

Inhibidores de la Aromatasa/uso terapéutico , Endometriosis/tratamiento farmacológico , Estrógenos/metabolismo , Fertilización In Vitro , Hormona Liberadora de Gonadotropina/agonistas , Goserelina/uso terapéutico , Nitrilos/uso terapéutico , Triazoles/uso terapéutico , Enfermedades Uterinas/tratamiento farmacológico , Adulto , Anastrozol , Inhibidores de la Aromatasa/efectos adversos , Inhibidores de la Aromatasa/farmacología , Antígeno Ca-125/sangre , Regulación hacia Abajo/efectos de los fármacos , Quimioterapia Combinada , Endometriosis/sangre , Endometriosis/patología , Femenino , Goserelina/farmacología , Humanos , Nitrilos/efectos adversos , Nitrilos/farmacología , Proyectos Piloto , Embarazo , Resultado del Embarazo , Estudios Prospectivos , Triazoles/efectos adversos , Triazoles/farmacología , Enfermedades Uterinas/sangre , Enfermedades Uterinas/patología

RESUMEN

With respect to recurrent pregnancy loss (RPL), unfortunately there is very little consensus about which investigations are useful for identifying causes and evaluating the prognosis, and also about which treatments are effective. In this review, arguments are given for the claim that this lack of consensus may mainly be because studies in the field of RPL have yielded very heterogeneous results. This heterogeneity, in the authors' belief, is caused by the scientists' lack of appreciation, when they do research, of important epidemiological knowledge about RPL (e.g., about the multifactorial background for most of the RPL cases and the importance of matching/adjusting for a series of prognostic variables when groups are mutually compared). Furthermore, many studies in RPL contain methodological flaws that are sometimes severe. A series of important epidemiological features of RPL is highlighted in the review and the most important methodological pitfalls, many of them specific for RPL research, are discussed. Advice is given about to how to avoid the pitfalls in order that the validity of the studies can improve for the benefit of the patients.

Asunto(s)

Aborto Habitual , Proyectos de Investigación , Femenino , Humanos , Embarazo