The Copenhagen Analgesic Study
- Conditions
- Analgesic Adverse ReactionGonad Regulating Hormone Adverse Reaction
- Interventions
- Other: Observational
- Registration Number
- NCT04369222
- Lead Sponsor
- Rigshospitalet, Denmark
- Brief Summary
Fundamental aspects of reproductive function are established in fetal life and there is a present increased awareness of the potential effects of fetal exposures on reproductive health of offspring. Experimental studies strongly suggest detrimental effects of prenatal exposure to mild analgesics such as acetaminophen (e.g. paracetamol) and non-steroidal anti-inflammatory drugs, NSAIDs (e.g. ibuprofen and acetylsalicylic acid) on male as well as female gonadal development. Declining fertility has become a growing problem in developing countries, potentially resulting in severe socioeconomic challenges, and fetal exposure of mild analgesics causes part of these alarming observations.This is the first prospective human study designed primarily to assess the effect of fetal exposure of mild analgesics on male and female reproductive function.
- Detailed Description
Fetal gonadal development is essential for adult reproductive health. Experimental studies strongly suggest that maternal use of mild analgesics (e.g. paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs)) during pregnancy affect fetal gonadal development with possible severe reproductive repercussions.
In rodents, paracetamol and NSAIDs administered in therapeutic doses in early and mid-pregnancy are endocrine disruptive in the fetus causing reduced prostaglandin synthesis and delayed transition from germ cell mitosis to meiosis resulting in fetal germ cell apoptosis in both female and male gonads. Female offspring were born with reduced ovarian weight and concerning reduction (40-50%) in number of ovarian follicles. Females are born with a defined number of follicles that depletes throughout their reproductive lifespan, inevitably leading to menopause. Establishment of the primordial follicle pool during fetal life is therefore essential for female reproductive health and disruption of this process has important and lasting consequences. Although spermatogenesis is not restricted to fetal life, essential aspects of male gonadal development are tightly regulated in utero and in rodents exposure to mild analgesics causes decreased testosterone production and decreased fertility in male offspring.
In adulthood, exposed animals exhibited longer time to conceive and gave birth to fewer pubs per litter compared with controls. Furthermore, studies of rodents suggest that in both males and females, adverse reproductive effects are passed on to the next generation indicating altered genetic programming, i.e. epigenetic changes.
Analgesics are sold over the counter and up to 56% of pregnant women use mild analgesics during pregnancy. The bioavailability of acetaminophen is high (app. 90%), and the reactive metabolite passes freely over the placenta to the fetus.
Declining fertility has become a growing problem in developing countries, potentially resulting in severe socioeconomic challenges.
The anogenital distance (AGD) is defined as the distance from the anus to genital tubercle and is strongly affected by androgens in fetal life resulting in a longer AGD in males than in females.
The AGD has shown to be a sensitive marker of androgen exposure in fetal life, and remains the most sensitive parameter when evaluating prenatal exposure to endocrine disruptive environmental agents. Therefore, AGD has been identified as an endpoint in the US Environmental Protection Agency guidelines for reproductive toxicity studies.
In humans, use of mild analgesic during the first and second trimester was associated with reduced male AGD, congenital cryptorchidism and hypospadias suggestive of insufficient androgenic action. In male infants born with hypospadias, the reduction in AGD can be seen as early as in the third trimester where fetal AGD is below the fifth percentile compared to normative fetal AGD data. Thus, fetal AGD may assist in early detection of insufficient androgenic action and genital abnormalities.
In adult life, consequences can be impaired testosterone production, sub- and infertility as well as testis cancer.
Assessment of reproductive function in early life - minipuberty Minipuberty is a term used to describe the transient activation of the hypothalamic-pituitary-gonadal (HPG) axis during infancy in both boys and girls and is a window of opportunity for diagnosis of endocrine disorders as well as future reproductive function. Reproductive hormones exert effects on target tissue resulting in follicle maturation, growth of breast tissue and thickening of uterine endometrium (females) as well as testicular- and penile growth (males). The minipuberty is followed by a quiescent period during mid childhood until pubertal reactivation of the HPG axis at pubertal onset.
To date, no prospective human studies have assessed the effect of analgesic exposure on reproductive function. The few retrospective studies that are published are hampered by recall bias and/or lack of thorough reproductive evaluation, and no studies have in detail assessed human female reproductive function after the use of mild analgesics during pregnancy.
Recruitment & Eligibility
- Status
- UNKNOWN
- Sex
- All
- Target Recruitment
- 600
Not provided
Not provided
Study & Design
- Study Type
- OBSERVATIONAL
- Study Design
- Not specified
- Arm && Interventions
Group Intervention Description Exposed Observational Children born from mothers with consumption of mild analgesics 3 months before or during pregnancy
- Primary Outcome Measures
Name Time Method Testes volumen (male infants) 2.5 months old Testes volumen, measured by ultrasound
Ovarian volume (female infants) 2.5 months old Ovarian volumen, measured by abdominal ultrasound
Ovarian follicle count (female infants) 2.5 months old Ovarian follicle count, measured by abdominal ultrasound
Blood sample (female infants) 2.5 months old Serum metabolites Anti Müllarian Hormone (AMH)
Blood sample (male infants) 2.5 months old Serum metabolites testosterone, free testosterone.
- Secondary Outcome Measures
Name Time Method Scapula skinfold (male and female infants) 2.5 months old Skinfold measured below the scapula all on the left side, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Drug intake (mother) Retrieved from patient questionnaire postpartum within one year Pre- and perinatal drug intake, filled in by mother during the whole prengancy every two weeks online
Pubertal history (parents) Retrived from questionnaire within a half year Pubertal history including age at menarche, pubertal timing with regard to peers, age at menopause of the mother of the parents etc. from questionnaire
Penile measurements (male infants) 2.5 months old Penile measurements with a ruler
Epigenetic profiling (male and female infants) Single determination, 2.5 months old Epigenetic variation of loci regulating hormone signalling
Genetic profiling (male and female infants) Single determination, 2.5 months old Genotyping of different genetic loci (genetic variation of loci regulating) hormone signalling, e.g. FSHB, etc.
Partus mode Retrieved from patient files postpartum within 1 year of study completion Partus mode (vaginal delivery, cesarean section, instrumental delivery) (yes/no)
Gestational age (newborn) Retrieved from patient files postpartum within 1 year of study completion Gestational age at birth, weeks and days
Length (male and female infants) 2.5 months old Length in cm
Weight (fathers) Gestational week 12 Weight in kilograms, by digital scale with a precision of 0.1 kg (SECA delta, model 707)
Triceps skinfold (male and female infants) 2.5 months old Skinfold measured above the triceps, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Asphyxia, adverse events (newborn) Retrieved from patient files postpartum within 1 year of study completion Asphyxia (yes/no)
Birth weight (newborn) Retrieved from patient files postpartum within 1 year of study completion Birth weight, grams
Pregnancy outcome, preeclampsia (mother) Retrieved from patient files postpartum within one year Preeclampsia (yes/no)
Blood sample (mother) Gestational week 12 and 2.5 months postpartum Blood samples will be drawn from an antecubital vein and will be measured for steroid hormone metabolites and metabolites of reproductive hormones.
Testosterone, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS), Estradiol, Estrone, Progesterone, 17-hydroxyprogesterone: in-house mass-spectrometry; Turboflow (LC-MS/MS).
Luteinizing hormone (LH), follicle stimulating hormone (FSH), Sex hormone Binding Globulin (SHBG): Time-resolved immuno- flouroimmunoassay; Delfia, Turko, Finland.
Inhibin B: Specific enzyme-linked immunosorbent assay; Beckman Coulter GenII. Anti- Müllerian hormone (AMH): Specific enzyme immuno-metric assay; Immunotech Beckman Coulter.
INSL3: Time-resolved immuno- flouroimmunoassay. IGF-I and IGFBP-3 will be analyzed using an immunoassay (iSYS, iDS).Urine sample (mother) Gestational week 12 and 2.5 months postpartum The urine sample will be collected in a cup and analyzed for:
Steroid hormone metabolites using in-house mass-spectrometry; Turboflow (LC-MS/MS).
Glycoprotein hormones, specifically FSH and LH, using immunoassays.
Endocrine disrupting chemicals, specifically phthalates, phenols, perfluorinated compounds and parabens also using in-house mass-spectrometry; Turboflow (LC-MS/MS).Flank skinfold (male and female infants) 2.5 months old Skinfold measured at the flank, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Weight (male and female infants) 2.5 months old Weight in kilograms
Triceps skinfold(father) Gestational week 12 Skinfold measured above the triceps, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Scapula skinfold (father) Gestational week 12 Skinfold measured below the scapula all on the left side, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Birth length (newborn) Retrieved from patient files postpartum within 1 year of study completion Birth length, cm
Flank skinfold (father) Gestational week 12 Skinfold measured at the flank, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Biceps skinfold (father) Gestational week 12 Skinfold measured above the biceps, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Head circumference (male and female infants) 2.5 months old Head circumference measured with a measurement tape, mm.
Abdominal circumference (male and female infants) 2.5 months old Abdonimal circumference measured with a measurement tape, mm.
Height (fathers) Gestational week 12 Height in cm, by stadiometer (Holtain Ltd, Crymych, UK) with a precision of 0.1 cm
Biceps skinfold (male and female infants) 2.5 months old Skinfold measured above the biceps, measured in mm (Harpenden skinfold Caliper, British Indicators Ltd, London, UK)
Meconium, adverse events (newborn) Retrieved from patient files postpartum within 1 year of study completion Meconium in amionic fluids (yes/no)
Pregnancy outcome, gestational hypertension (mother) Retrieved from patient files postpartum within one year Gestational hypertension (yes/no)
Medical history and exposure (parents) Retrived from questionnaire within a half year General- and reproductive health, the pregnancy, own birth weight, lifestyle, drinking and smoking habits from questionnaire
Blood sample (father) Gestational week 12 Blood samples will be drawn from an antecubital vein and will be measured for steroid hormone metabolites and metabolites of reproductive hormones:
Testosterone, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS), Estradiol, Estrone, Progesterone, 17-hydroxyprogesterone: in-house mass-spectrometry; Turboflow (LC-MS/MS).
Luteinizing hormone (LH), follicle stimulating hormone (FSH), Sex hormone Binding Globulin (SHBG): Time-resolved immuno- flouroimmunoassay; Delfia, Turko, Finland.
Inhibin B: Specific enzyme-linked immunosorbent assay; Beckman Coulter GenII. Anti- Müllerian hormone (AMH): Specific enzyme immuno-metric assay; Immunotech Beckman Coulter.
INSL3: Time-resolved immuno- flouroimmunoassay. IGF-I and IGFBP-3 will be analyzed using an immunoassay (iSYS, iDS).Anogenital distance (AGD) (male and female infants) App. gestational age 30 weeks Distance from anus to genital tubercle, third trimester ultrasound
Blood sample (female infants) 2.5 months old (estradiol and inhibin B, luteinizing hormone (LH)/follicular stimulating hormone (FSH) ratio)
Pubertal staging (male and female infants) 2.5 months old Pubertal staging using Tanners classification (including testicular size in boys assessed by Prader's orchidometer)
Pregnancy outcome, induction of labor (mother) Retrieved from patient files postpartum within one year In duction of labor (yes/no)
Urine sample (father) Gestational week 12 The urine sample will be collected in a cup and analyzed for:
Steroid hormone metabolites using in-house mass-spectrometry; Turboflow (LC-MS/MS).
Glycoprotein hormones, specifically FSH and LH, using immunoassays.
Endocrine disrupting chemicals, specifically phthalates, phenols, perfluorinated compounds and parabens also using in-house mass-spectrometry; Turboflow (LC-MS/MS).Classification of external genitalia with an external masculinization score (EMS) (male and female infants). EMS provides an objective aggregate score of the extent of masculinization of the external genitalia. 2.5 months old It is an individual score with a maximum of 12 points. The following is assessed:
Classification of genital tubercle, measured length with a ruler (mm) \>30mm = 3 points, 21-30mm = 2 points, 11-20mm = 1 point,\< 10mm = 0 points) Location of gonads, (objectively assessed): labioscrotal = 1,5 points, inguino-scrotal = 1, inguinal = 0,5 points, impalpable = 0 points Site of the urinary meatus (objectively assessed): typical male = 3 points, coronal/glandular = 2,5 points, penile = 2 points, peno-scrotal = 1,5 points, perineal = 0,5 points, typical female = 0 points.
Labia/scrotal fusion (objectively assessed): fused = 3 points, posterior fusion = 1,5 points, unfused = 0 points.Uterine volume (female infants) 2.5 months old Uterine volume, measured by abdominal ultrasound
Blood sample (male infants) 2.5 months old Serum metabolites of reproductive hormones (AMH, inhibin B levels, ratios of inhibin B/FSH and LH/FSH)
Urine sample (10 mL) (male and female infants) 2.5 months old Steroid hormone metabolites using in-house mass-spectrometry; Turboflow (LC-MS/MS).
Glycoprotein hormones, specifically FSH and LH, using immunoassays.
Endocrine disrupting chemicals, specifically phthalates, phenols, perfluorinated compounds and parabens also using in-house mass-spectrometry; Turboflow (LC-MS/MS).Endometrial thickness (female infants) 2.5 months old Endometrial thickness, measured by abdominal ultrasound
Medical report (mother) Every 2 weeks from enrollment in early pregnancy to birth Specific medical report on medicine consumption incl. analgesics
Trial Locations
- Locations (2)
Department of Obstetrics and Section of fetal medicine, Rigshospitalet
🇩🇰Copenhagen, Denmark
Department of Growth and Reproduction, Rigshospitalet
🇩🇰Copenhagen, Denmark