1. Dr Nora El-Attabi Supervised by Dr Charlsworth Dec 3 2010

2.  > 50% western women use mild analgesia in pregnancy  New evidence emerged which shows possible link with cryptorchidism  May account for subsequent marked increase in male subfertility  Decrease PG and potentially testosterone  Supported by Animal studies from the 1980s

3.  Study looked at Pregnant women and second phase of animal research using rats  Eligible women were analysed for use of medication during their pregnancy and the outcome on their male babies  Rat experiments assessed exposure to painkillers on the developing fetuses.

4.  2503 women, 1463 in Finland, 1040 in Denmark  Written questionnaire- (Have you taken any medication during this pregnancy’)  Telephone interview – (Have you taken any pain-relief medicine during this pregnancy)  In Finland –written questionnaire only (1463)  In Denmark- written questionnaire (834), telephone interview (491), or both (295)  Examination of cryptochidism developed by Scorer (1964)Scorer (1964

5. Schematic representation of the human segment of the study

6.  Paracetamol and aspirin administrated at varying doses  Effects on the masculinisation of developing fetuses investigated by: ◦ Distance between the anus and the base of the penis (Anogenital distance ) ◦ Concentration of testosterone and prostaglandin in extracted testes

8. Human study: Fisher's exact test Odds ratios (ORs, 95% CI) calculated by logistic regression, Adjusted for some confounding factors Rats study: In vivo: (ANOVA) and (Dunnett's post hoc test) Ex viva: Two-sided unpaired Student's t-test.

9.  Significant underreporting of analgesia in questionnaire (30.9% vs. 57.2%)  Mild analgesia not considered as a medication  Limited to reliable data from telephone interviews (491 Danish women)  All Finnish women excluded from conclusion

10. During whole of pregnancy

11. During first trimester

12. During second trimester

13. Finnish women results

14. Mean prevalence of congenital cryptorchidism relative to weeks of maternal use of any mild analgesics and paracetamol during the first and the second trimester.

15. Intrauterine exposure from GD13 to 21 to paracetamol in rats led to a reduction in the testosterone-dependent AGD of male offspring.

16. Mild analgesic compounds paracetamol and acetylsalicylic acid reduced PGD2 and testosterone production in ex vivo cultured GD14.5 rat testes.

17.  There was an association between the timing and the duration of mild analgesic use during pregnancy and the risk of cryptorchidism. Also if multiple mild analgesics combined  Use of analgesic medicine was in general not associated with congenital cryptorchidism in the Finnish cohort  Intrauterine exposure of rats to analgesics led to a reduction in the AGDI and reduced PG and testosterone production in rats.  This also happened at the lowest dose of 150mg/kg/day- recommendations for humans is 50mg/kg/day; further work needed to determined the no adverse effect level  The results suggest that intrauterine exposure to mild analgesics is a risk factor for development of male reproductive disorders.

18. Strengths  Borderline cases were examined by two researchers  Genetically well-defined populations-maximum residence abroad of 3 years for the mother and 10 years for the father and grandparents  Even mild forms of cryptorchidism taken into account  Some confounding factors taken into account  Two complementary rat models  AGDi calculated- AGD / cube root of body weight

19. Weaknesses  Dated on Last scan or LMP not on booking scan  Both studies used different Methods and Design  Regular bi-national workshops  Women asked in 3 rd trimester  Testes descent can take months after birth  No adjustment for some confounding factors (genetic/ mother’s alcohol intake)  Examinations were standardised but physical examination not the same as their standard = named descriptions in Scorer

20. Scorer’s MethodResearch paper’s method

21. Cont>  Eventually analyses based on quite a small group of boys (e.g. only 42 boys from 491 had cryptorchidism, 10 women took more than one compound)  Only 6 of the 17 different subgroup showed a significant association  Wide confidence intervals- lack of precision in the results  Subjective methods for measurements of AGD  Measured testosterone levels in rats but not humans  State ‘paracetamol showed statistically significant differences in AGDi’. However the human studies showed paracetamol to be a non significant player in cryptorchidism  The overall risk of cryptorchidism is relatively low (approx 1- 8% Danish population)

22.  Mild painkillers in pregnancy has a possible anti-androgenic action in the male foetus causing congenital cryptorchidism, the best described risk factor for poor semen quality  Direct association between both the timing and extent of mild analgesic consumption during pregnancy  Further supported by 2 different rat models However  Not robust(small sample size, wide confidence intervals, and other limitations as described) This study is not strong enough to prove a link between use of painkillers in pregnancy and cryptorchidism and subsequent sub fertility in males  Results of study unlikely to change recommendations- Pregnant women should continue to avoid ibuprofen and aspirin, but no evidence that occasional use of paracetamol is harmful.  However it does suggest an important avenue for more research and the researchers intend to follow up their participants as the boys are now entering puberty However

23.  1. Did the study address a clearly focused issue? Yes as pregnant women were studied to determine any harmful effects of mild analgesia in pregnancy  2.Did the authors use an appropriate method to answer their question? Yes as eligible women were identified, given questionnaires and telephone interviews on analgesia used in pregnancy and then the outcome of their male babies were analyzed. 2 complementary rat studies were also used  3.Was the cohort recruited in an acceptable way? Yes, women living in their native Denmark or Finland were studied. However of the possible 2503 women recruited, only 491 women had reliable data that was drawn upon in the conclusion due to poor questionnaires  4. Was the exposure accurately measured to minimize bias? Subjective method was used in the human study to assess for cryptorchidism and regular bi-national workshops held to minimize errors. All 491 women used the same method for data collection 

24.  5.Was the outcome accurately measured to minimize bias? Used appropriate statistical tests for both humans and rat studies.  6.Have the authors identified all important confounding factors? No, although some were included for example if the child had an older brother with cryptochidism,, many others such maternal alcohol intake, prematurity and genetic abnormalities in the newborn were not considered.  7. Was the follow up of subjects complete enough? 8. Was the follow up of subjects long enough? n/a  9. What are the results of this study? Use of mild painkillers in pregnancy has a possible anti-androgenic action in the male foetus causing congenital cryptorchidism, the best described risk factor for poor semen quality. Also a direct association between both the timing and extent of mild analgesic consumption during pregnancy. Further supported by 2 different rat models. However association not strong due to many weaknesses in the sample as above and wide confidence intervals. Majority of the results were not significant and those that were, we already knew would be RF 

25.  10. Do you believe the results? No,as the design and methods were flawed and data presented in a biased way. Too much use of the word trend and not enough significance in the human study. Rat study did show strong links but this was already known  11. Can the results be applied to the local population? Although the local population is identifiable, cannot use these results to change outcome as no significant link between using Paracetamol and Cryptochidism  12. Do the results of this study fit with other available evidence? Rat model does, human model is supposed to compliment rat model but different designs and methods used so not really comparable.

26. Any Questions?

27. Thank you