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Stavreus-Evers, Anneli
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Publications (10 of 52) Show all publications
Murto, T., Yngve, A., Skoog Svanberg, A., Altmäe, S., Salumets, A., Wånggren, K. & Stavreus-Evers, A. (2017). Compliance to the recommended use of folic acid supplements for women in Sweden is higher among those under treatment for infertility than among fertile controls and is also related to socioeconomic status and lifestyle. Food & Nutrition Research, 61, Article ID 1334483.
Open this publication in new window or tab >>Compliance to the recommended use of folic acid supplements for women in Sweden is higher among those under treatment for infertility than among fertile controls and is also related to socioeconomic status and lifestyle
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2017 (English)In: Food & Nutrition Research, ISSN 1654-6628, E-ISSN 1654-661X, Vol. 61, 1334483Article in journal (Refereed) Published
Abstract [en]

Background: Folate has been discussed in relation to fertility among women, but studies on women under treatment for infertility are lacking.

Objective: The objective of this study was to investigate folic acid supplement use and folate status among women under treatment for infertility (hereafter infertile) and fertile women also in regard to socioeconomic and lifestyle factors.

Design: Lifestyle and dietary habits, and use of dietary supplements were assessed using a questionnaire. Blood samples were obtained for analysis of folate status. 24-hour recall interviews were also performed.

Results: Highly educated, employed and infertile women were most prone to using folic acid supplements. The infertile women had a significantly better folate status than the fertile women. Folate status did not correlate with socioeconomic or lifestyle factors. The infertile women were physically more active, smoked less and were employed. Our questionnaire data had only fair agreement with the data from 24-hour recalls, but the folate status data was clearly correlated to our questionnaire results.

Conclusions: Infertile women were most prone to using folic acid supplements and had better folate status than the controls. High educational and employment status were found to be key factors for high compliance to the recommended use folic acid supplements.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2017
Keyword
Folic acid, folate, infertility, socioeconomic status, lifestyle
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-328286 (URN)10.1080/16546628.2017.1334483 (DOI)000403010200001 ()
Available from: 2017-08-22 Created: 2017-08-22 Last updated: 2017-08-22Bibliographically approved
Wickström, K., Stavreus-Evers, A., Vercauteren, O., Olovsson, M. & Edelstam, G. (2017). Effect of Lignocaine on IL-6, IL-8, and MCP-1 in Peritoneal Macrophages and Endometriotic Stromal Cells. Reproductive Sciences, 24(3), 382-392.
Open this publication in new window or tab >>Effect of Lignocaine on IL-6, IL-8, and MCP-1 in Peritoneal Macrophages and Endometriotic Stromal Cells
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2017 (English)In: Reproductive Sciences, ISSN 1933-7191, E-ISSN 1933-7205, Vol. 24, no 3, 382-392 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The objective was to evaluate the effect of lignocaine on cytokine expression and secretion in vitro in peritoneal fluid macrophages and endometriotic stromal cells. Design: Experimental in vitro study on human cells. Population and Sample: Peritoneal fluid (n = 10) and samples from endometriotic cysts (n = 7) were collected from 13 women (women with endometriosis n = 8, and healthy controls n = 5) during surgery for clinical reasons. Methods: Macrophages from the peritoneal fluid and cells from the inside of the endometriotic cysts capsules were isolated and cultivated for 24 to 48 hours in medium with and without the supplement of lignocaine 0.1 or 1.0 mg/mL. Relative gene expression of monocyte chemotactic protein 1 (MCP-1), interleukin 6 (IL-6), and IL-8 was evaluated with quantitative polymerase chain reaction and compared between treated and untreated cells with Wilcoxon matched pairs. The concentrations of MCP-1, IL-6, and IL-8 were measured using enzyme-linked immunosorbent assay and were compared between treated and untreated cells with Wilcoxon matched pairs. Results: The gene expression and protein secretion of IL-8 in endometriotic stromal cells after incubation with lignocaine 0.1 mg/mL were significantly decreased after 24 hours compared to the controls (P =.028 and P =.018). Macrophages from healthy controls had a significant lower gene expression of all tested cytokines (P =.043) after treatment with lignocaine, but there were no significant differences in protein level. Macrophages from women with endometriosis showed diverging results since 3 of 5 samples showed increased gene expression of 1 (n = 2) or 2 cytokines (n = 1) after lignocaine treatment. Conclusion: Lignocaine can affect the gene expression and secretion of some proinflammatory cytokines in vitro.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS INC, 2017
Keyword
cytokine, endometriosis, gene expression, lignocaine, protein
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-321997 (URN)10.1177/1933719116657188 (DOI)000399044500007 ()27444775 (PubMedID)
Available from: 2017-05-15 Created: 2017-05-15 Last updated: 2017-05-15Bibliographically approved
Altmae, S., Tamm-Rosenstein, K., Esteban, F. J., Simm, J., Kolberg, L., Peterson, H., . . . Stavreus-Evers, A. (2016). Endometrial transcriptome analysis indicates superiority of natural over artificial cycles in recurrent implantation failure patients undergoing frozen embryo transfer. Reproductive Biomedicine Online, 32(6), 597-613.
Open this publication in new window or tab >>Endometrial transcriptome analysis indicates superiority of natural over artificial cycles in recurrent implantation failure patients undergoing frozen embryo transfer
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2016 (English)In: Reproductive Biomedicine Online, ISSN 1472-6483, E-ISSN 1472-6491, Vol. 32, no 6, 597-613 p.Article in journal (Refereed) Published
Abstract [en]

Little consensus has been reached on the best protocol for endometrial preparation for frozen embryo transfer (FET). It is not known how, and to what extent, hormone supplementation in artificial cycles influences endometrial preparation for embryo implantation at a molecular level, especially in patients who have experienced recurrent implantation failure. Transcriptome analysis of 15 endometrial biopsy samples at the time of embryo implantation was used to compare two different endometrial preparation protocols, natural versus artificial cycles, for FET in women who have experienced recurrent implantation failure compared with fertile women. IPA and DAVID were used for functional analyses of differentially expressed genes. The TRANSFAC database was used to identify oestrogen and progesterone response elements upstream of differentially expressed genes. Cluster analysis demonstrated that natural cycles are associated with a better endometrial receptivity transcriptome than artificial cycles. Artificial cycles seemed to have a stronger negative effect on expression of genes and pathways crucial for endometrial receptivity, including ESR2, FSHR, LEP, and several interleukins and matrix metalloproteinases. Significant overrepresentation of oestrogen response elements among the genes with deteriorated expression in artificial cycles (P < 0.001) was found; progesterone response elements predominated in genes with amended expression with artificial cycles (P = 0.0052).

Keyword
artificial cycle, endometrial receptivity, frozen embryo transfer, hormone response elements, recurrent implantation failure, unexplained female infertility
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-299501 (URN)10.1016/j.rbmo.2016.03.004 (DOI)000377393600006 ()27090967 (PubMedID)
Funder
EU, European Research Council, 329812EU, FP7, Seventh Framework Programme, EU41564;EU324509
Available from: 2016-07-22 Created: 2016-07-22 Last updated: 2017-11-28Bibliographically approved
Murto, T., Kunovac Kallak, T., Hoas, A., Altmäe, S., Salumets, A., Nilsson, T. K., . . . Stavreus-Evers, A. (2015). Folic acid supplementation and methylenetetrahydrofolate reductase (MTHFR)gene variations in relation to IVF pregnancy outcome. Acta Obstetricia et Gynecologica Scandinavica, 94(1), 65-71.
Open this publication in new window or tab >>Folic acid supplementation and methylenetetrahydrofolate reductase (MTHFR)gene variations in relation to IVF pregnancy outcome
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2015 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 94, no 1, 65-71 p.Article in journal (Refereed) Published
Abstract [en]

Objective:

To study folic acid intake, folate status and pregnancy outcome afterinfertility treatment in women with different infertility diagnoses in relation tomethylenetetrahydrofolate reductase (MTHFR) 677C>T, 1298A>C and 1793G>A genevariations. Also the use of folic acid supplements, folate status and the frequency ofdifferent gene variations were studied in women undergoing infertility treatment andfertile women.

Design:

Observational study. Setting: University hospital. Population:Women undergoing infertility treatment and healthy, fertile, non-pregnant women.

Methods:

A questionnaire was used to assess general background data and use ofdietary supplements. Blood samples were taken to determine plasma folate andhomocysteine levels, and for genomic DNA extraction. A meta-analysis of four studieswas performed to assess pregnancy outcome in relation to MTHFR 677 TT vs. CC, and1298 CC vs. AA polymorphisms.

Main outcome measures:

Folic acid supplementintake, and plasma folate, homocysteine and genomic assays.

Results:

Women in theinfertility group used significantly more folic acid supplements and had better folatestatus than fertile women, but pregnancy outcome after fertility treatment was notdependent on folic acid intake, folate status or MTHFR gene variations. However, ameta-analysis demonstrated that MTHFR 1298AA polymorphism was related topregnancy outcome.

Conclusion:

Folic acid supplementation seems to play only a minorrole in the context of pregnancy outcome after in vitro fertilisation, and other variablesin folate metabolism are of more importance. In particular, MTHFR 1298AA genevariation appears to have a positive association with the success of fertility treatment

Keyword
Folate, folic acid, homocysteine, infertility, MTHFR, pregnancy outcome
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-220246 (URN)10.1111/aogs.12522 (DOI)000346704100012 ()25283235 (PubMedID)
Available from: 2014-03-12 Created: 2014-03-12 Last updated: 2017-12-05Bibliographically approved
Aghajanova, L., Mahadevan, S., Altmäe, S., Stavreus-Evers, A., Regan, L., Sebire, N., . . . Van den Veyver, I. B. (2015). No evidence for mutations in NLRP7, NLRP2 or KHDC3L in women with unexplained recurrent pregnancy loss or infertility. Human Reproduction, 30(1), 232-238.
Open this publication in new window or tab >>No evidence for mutations in NLRP7, NLRP2 or KHDC3L in women with unexplained recurrent pregnancy loss or infertility
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2015 (English)In: Human Reproduction, ISSN 0268-1161, E-ISSN 1460-2350, Vol. 30, no 1, 232-238 p.Article in journal (Refereed) Published
Abstract [en]

STUDY QUESTION: Are mutations in NLRP2/7 (NACHT, LRR and PYD domains-containing protein 2/7) or KHDC3L (KH Domain Containing 3 Like) associated with recurrent pregnancy loss (RPL) or infertility?

SUMMARY ANSWER: We found no evidence for mutations in NLRP2/7 or KHDC3L in unexplained RPL or infertility.

WHAT IS KNOWN ALREADY: Mutations in NLRP7 and KHDC3L are known to cause biparental hydatidiform moles (BiHMs), a rare form of pregnancy loss. NLRP2, while not associated with the BiHM pathology, is known to cause recurrent Beckwith Weidemann Syndrome (BWS).

STUDY DESIGN, SIZE, AND DURATION: Ninety-four patients with well characterized, unexplained infertility were recruited over a 9-year period from three IVF clinics in Sweden. Blood samples from 24 patients with 3 or more consecutive miscarriages of unknown etiology were provided by the Recurrent Miscarriage Clinic at St Mary's Hospital, London, UK.

PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients were recruited into both cohorts following extensive clinical studies. Genomic DNA was isolated from peripheral blood and subject to Sanger sequencing of NLRP2, NLRP7 and KHDC3L. Sequence electropherograms were analyzed by Sequencher v5.0 software and variants compared with those observed in the 1000 Genomes, single nucleotide polymorphism database (dbSNP) and HapMap databases. Functional effects of non-synonymous variants were predicted using Polyphen-2 and sorting intolerant from tolerant (SIFT).

MAIN RESULTS AND THE ROLE OF CHANCE: No disease-causing mutations were identified in NLRP2, NLRP7 and KHDC3L in our cohorts of unexplained infertility and RPL.

LIMITATIONS, REASONS FOR CAUTION: Due to the limited patient size, it is difficult to conclude if the low frequency single nucleotide polymorphisms observed in the present study are causative of the phenotype. The design of the present study therefore is only capable of detecting highly penetrant mutations.

WIDER IMPLICATIONS OF THE FINDINGS: The present study supports the hypothesis that mutations in NLRP7 and KHDC3L are specific for the BiHM phenotype and do not play a role in other adverse reproductive outcomes. Furthermore, to date, mutations in NLRP2 have only been associated with the imprinting disorder BWS in offspring and there is no evidence for a role in molar pregnancies, RPL or unexplained infertility.

STUDY FUNDING/COMPETING INTERESTS: This study was funded by the following sources: Estonian Ministry of Education and Research (Grant SF0180044s09), Enterprise Estonia (Grant EU30020); Mentored Resident research project (Department of Obstetrics and Gynecology, Baylor College of Medicine); Imperial NIHR Biomedical Research Centre; Grant Number C06RR029965 from the National Center for Research Resources (NCCR; NIH). No competing interests declared.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-238225 (URN)10.1093/humrep/deu296 (DOI)000350146100028 ()25376457 (PubMedID)
Available from: 2014-12-10 Created: 2014-12-10 Last updated: 2017-12-05Bibliographically approved
Parn, T., Ruiz, R. G., Kallak, T. K., Ruiz, J. R., Davey, E., Hreinsson, J., . . . Altmae, S. (2015). Physical activity, fatness, educational level and snuff consumption as determinants of semen quality: findings of the ActiART study. Reproductive Biomedicine Online, 31(1), 108-119.
Open this publication in new window or tab >>Physical activity, fatness, educational level and snuff consumption as determinants of semen quality: findings of the ActiART study
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2015 (English)In: Reproductive Biomedicine Online, ISSN 1472-6483, E-ISSN 1472-6491, Vol. 31, no 1, 108-119 p.Article in journal (Refereed) Published
Abstract [en]

In this study, the association between physical activity and other potential determinants, objectively measured by accelerometry, was examined. Sixty-two men attending an infertility clinic participated in the study. Obese men (body mass index >= 30) and those with a waist circumference 102 cm or more had lower semen volume than the other men (P < 0.05). Higher values in sperm parameters were observed in participants who completed university studies and those who did not consume snuff, compared with the other participants (P < 0.05). Finally, men who spent an average number of 10 min-bouts of moderate-to-vigorous physical activity had significantly better semen quality than those who engaged in low or high numbers of bouts of activity (P < 0.05). No associations were found for sedentary or moderate-to-vigorous physical activity time when it was not sustained over 10 min, i.e. not in bouts. Men who have average levels of physical activity over sustained periods of 10 min are likely to have better semen quality than men who engage in low or high levels of such activity. Similarly, high levels of total and central adiposity, low educational level and snuff consumption are negatively related to semen quality.

Keyword
accelerometry, adiposity, education, physical activity, semen, snuff
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-259111 (URN)10.1016/j.rbmo.2015.03.004 (DOI)000357392300015 ()25999214 (PubMedID)
Available from: 2015-07-28 Created: 2015-07-27 Last updated: 2017-12-04Bibliographically approved
Aghajanova, L., Altmae, S., Stavreus-Evers, A. & Giudice, L. C. (2015). Stanniocalcin-1 in Human Endometrium. Paper presented at 63rd Annual Meeting of the Pacific-Coast-Reproductive-Society (PCRS) on Building Connections, Achieving Excellence, MAR 11-15, 2015, Rancho Mirage, CA. Fertility and Sterility, 103(2), E6-E7.
Open this publication in new window or tab >>Stanniocalcin-1 in Human Endometrium
2015 (English)In: Fertility and Sterility, ISSN 0015-0282, E-ISSN 1556-5653, Vol. 103, no 2, E6-E7 p.Article in journal, Meeting abstract (Other academic) Published
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-257311 (URN)000353843400007 ()
Conference
63rd Annual Meeting of the Pacific-Coast-Reproductive-Society (PCRS) on Building Connections, Achieving Excellence, MAR 11-15, 2015, Rancho Mirage, CA
Note

Meeting Abstract: O-6

Available from: 2015-07-02 Created: 2015-07-01 Last updated: 2017-12-04Bibliographically approved
Kunovac Kallak, T., Baumgart, J., Nilsson, K., Åkerud, H., Sundström Poromaa, I. & Staverus-Evers, A. (2015). Vaginal gene expression during treatment with aromatase inhibitors. Clinical Breast Cancer, 15(6), 527-535.
Open this publication in new window or tab >>Vaginal gene expression during treatment with aromatase inhibitors
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2015 (English)In: Clinical Breast Cancer, ISSN 1526-8209, E-ISSN 1938-0666, Vol. 15, no 6, 527-535 p.Article in journal (Refereed) Published
Abstract [en]

Vaginal gene expression in aromatase inhibitor-treated women was compared with postmenopausal control women treated with vaginal estrogen therapy. Vaginal tissue from aromatase inhibitor-treated women had low expression of genes involved in cell differentiation, proliferation, and cell adhesion, and associated with vaginal discomfort. The presence of vaginal aromatase suggests that this is the result of local and systemic aromatase inhibition. Background: Aromatase inhibitor (AI) treatment suppresses estrogen biosynthesis and causes genitourinary symptoms of menopause such as vaginal symptoms, ultimately affecting the quality of life for many postmenopausal women with breast cancer. Thus, the aim of this study was to examine vaginal gene expression in women during treatment with AIs compared with estrogen-treated women. The secondary aim was to study the presence and localization of vaginal aromatase. Patients and Methods: Vaginal biopsies were collected from postmenopausal women treated with AIs and from age-matched control women treated with vaginal estrogen therapy. Differential gene expression was studied with the Affymetrix Gene Chip Gene 1.0 ST Array (Affymetrix Inc, Santa Clara, CA) system, Ingenuity pathway analysis, quantitative real-time polymerase chain reaction, and immunohistochemistry. Results: The expression of 279 genes differed between the 2 groups; AI-treated women had low expression of genes involved in cell differentiation, proliferation, and cell adhesion. Some differentially expressed genes were found to interact indirectly with the estrogen receptor alpha. In addition, aromatase protein staining was evident in the basal and the intermediate vaginal epithelium layers, and also in stromal cells with a slightly stronger staining intensity found in AI-treated women. Conclusion: In this study, we demonstrated that genes involved in cell differentiation, proliferation, and cell adhesion are differentially expressed in AI-treated women. The expression of vaginal aromatase suggests that this could be the result of local and systemic inhibition of aromatase. Our results emphasize the role of estrogen for vaginal cell differentiation and proliferation and future drug candidates should be aimed at improving cell differentiation and proliferation. (C) 2015 Elsevier Inc. All rights reserved.

Keyword
Estrogen; Genitourinary symptom of menopause; Microarray; Vagina; Vaginal atrophy
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-245413 (URN)10.1016/j.clbc.2015.06.012 (DOI)000365190800018 ()26283501 (PubMedID)
Funder
Swedish Cancer Society, CAN 2012/603
Available from: 2015-02-26 Created: 2015-02-26 Last updated: 2017-12-04Bibliographically approved
Baumgart, J., Nilsson, K., Stavreus Evers, A., Kallak, T. K., Kushnir, M. M., Bergquist, J. & Sundström Poromaa, I. (2014). Androgen levels during adjuvant endocrine therapy in postmenopausal breast cancer patients. Climacteric, 17(1), 48-54.
Open this publication in new window or tab >>Androgen levels during adjuvant endocrine therapy in postmenopausal breast cancer patients
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2014 (English)In: Climacteric, ISSN 1369-7137, E-ISSN 1473-0804, Vol. 17, no 1, 48-54 p.Article in journal (Refereed) Published
Abstract [en]

Objective

To investigate plasma steroid hormone levels in postmenopausal breast cancer patients with and without adjuvant endocrine therapy and in healthy postmenopausal women.

Methods

Steroid hormone levels in postmenopausal breast cancer patients treated with aromatase inhibitors (n = 32) were compared with breast cancer patients treated with tamoxifen (n = 34), breast cancer patients without adjuvant endocrine therapy (n = 15), and healthy postmenopausal women (n = 56). Pregnenolone, 17-hydroxypregnenolone, 17-hydroxyprogesterone, 11-deoxycortisol, cortisol, cortisone, dehydroepiandrosterone (DHEA), androstenedione, total testosterone, dihydrotestosterone, estrone and estradiol were measured using liquid chromatography-tandem mass spectrometry. Sex hormone binding globulin was measured by solid-phase chemiluminescent immunometric assays, and the free androgen index was calculated.

Results

Aromatase inhibitor users did not differ in dihydrotestosterone, total testosterone, androstenedione, DHEA, or free androgen index levels from healthy controls or untreated breast cancer patients. The highest total testosterone levels were found in tamoxifen-treated women, who had significantly higher plasma concentrations than both women treated with aromatase inhibitors and breast cancer patients without adjuvant treatment. Concentrations of cortisol and cortisone were significantly greater in aromatase inhibitor users as well as tamoxifen users, in comparison with healthy controls and untreated breast cancer patients. Aromatase inhibitor users had lower estrone and estradiol plasma concentrations than all other groups.

Conclusion

Adjuvant treatment with aromatase inhibitors or tamoxifen was associated with increased cortisol and cortisone plasma concentrations as well as decreased estradiol concentrations. Androgen levels were elevated in tamoxifen-treated women but not in aromatase inhibitor users.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-214588 (URN)10.3109/13697137.2013.800039 (DOI)000329847900007 ()23647561 (PubMedID)
Available from: 2014-01-08 Created: 2014-01-08 Last updated: 2017-12-06Bibliographically approved
Haroun, S., Altmäe, S., Karypidis, H., Kuningas, M., Landgren, B.-M., Åkerud, H., . . . Stavreus-Evers, A. (2014). Association between trefoil factor 3 gene variants and idiopathic recurrent spontaneous abortion. Reproductive Biomedicine Online, 29(6), 737-44.
Open this publication in new window or tab >>Association between trefoil factor 3 gene variants and idiopathic recurrent spontaneous abortion
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2014 (English)In: Reproductive Biomedicine Online, ISSN 1472-6483, E-ISSN 1472-6491, Vol. 29, no 6, 737-44 p.Article in journal (Refereed) Published
Abstract [en]

Trefoil factor 3 (TFF3) gene is an inflammatory mediator expressed in human endometrium during the window of implantation. The aim of this study was to evaluate the possible genetic association of TFF3 variants in recurrent spontaneous abortion. Women with a history of recurrent spontaneous abortion (n = 164) and healthy pregnant women (n = 143) were genotyped for five TFF3 polymorphisms (rs225439 G/A, rs533093 C/T, rs225361 A/G, rs11701143 T/C and rs77436142 G/C). In addition, haplotypes formed within the gene were analysed. Within the recurrent spontaneous abortion group, women who at some point had given birth and childless women had 4.19 ± 1.75 and 5.34 ± 3.42 consecutive spontaneous abortions, respectively. Women who had experience recurrent spontaneous abortions had a lower allele frequency of the rs11701143 promoter region minor C allele compared with fertile women (0.02 versus 0.05, P = 0.015). Patients with rs225361 AG genotype had significantly more successful pregnancies before spontaneous abortion than those with homozygous AA and GG genotypes (P = 0.014). No significant differences in haplotype frequencies between patients and controls were detected. Possible genetic risk factors identified that might contribute to the pathogenesis of idiopathic recurrent spontaneous abortion were TFF3 gene variants.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-238226 (URN)10.1016/j.rbmo.2014.08.007 (DOI)000345759300012 ()25444508 (PubMedID)
Available from: 2014-12-10 Created: 2014-12-10 Last updated: 2017-12-05Bibliographically approved
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