Hormonal regulation of postnatal growth in children born small for gestational age

Children born small for gestational age (SGA) are at high risk of permanent short stature, with approximately 10% continuing to have stature below the third centile throughout childhood and adolescence and into adulthood. The mechanisms involved in catch-up growth, and those that prevent catch-up growth, are still unknown. To date, no reliable anthropometric or endocrine parameter predictive of postnatal catch-up growth has been identified. However, subtle abnormalities in the growth hormone-insulin-like growth factor axis, the hypothalamic-pituitary-adrenal axis and thyroid function have been described, and a mechanism involving intrauterine programming of hypothalamic-pituitary function has been proposed.     

Determinants of intrauterine growth retardation: evidence against maternal depletion

This analysis examines the relationship between length of preceding birth interval and risk of intrauterine growth retardation using data on Swedish infants from the 1973 World Health Organization study of perinatal mortality. Results of a multivariate logit analysis demonstrate that the lower than average mean birth weight of infants born after short birth intervals cannot be completely attributed to their shorter mean gestation length. Infants born after birth intervals of 12 months or less are 30% more likely to be small for gestational age (SGA) than infants born 18-59 months after the previous birth, even when the effects of maternal age and parity are controlled. The results obtained here do not support maternal depletion as an explanation for the association between short birth intervals and elevated risk of SGA, since there is no evidence of an attenuation of the risk of SGA with increasing length of interval in the under 18 month birth interval range.     

Puberty after prenatal growth restraint

There is increasing evidence for a link between prenatal growth and pubertal development. Here we highlight a selection of pubertal characteristics in children who were born small for gestational age (SGA). Boys born SGA are at risk of high levels of follicle-stimulating hormone (FSH) and low levels of inhibin B and a small testicular volume during adolescence. In girls born SGA, the age at pubertal onset and the age at menarche are advanced by about 5-10 months; prenatal growth restraint may also be associated with higher FSH levels and smaller internal genitalia in adolescence. The ovulation rate was found to be reduced in adolescent girls born SGA, and an insulin-sensitizing therapy was capable of raising this low ovulation rate. Menarche is definitely advanced in girls born SGA with precocious pubarche and in those with an early-normal onset of puberty. Current evidence suggests that insulin resistance is a key mechanism linking a post-SGA state to early menarche; hence, insulin sensitization may become a valid approach to prevent early menarche and early growth arrest in girls born SGA.     

Intrauterine growth restriction in rats is associated with hypertension and renal dysfunction in adulthood

Epidemiological studies have produced evidence that unfavorable intrauterine environments during fetal life may lead to adverse outcomes in adulthood. We have previously shown that a low-sodium diet, given to pregnant rats over the last week of gestation, results in intrauterine growth restriction (IUGR). We hypothesize that pups born with IUGR are more susceptible to the development of hypertension in adulthood. IUGR fetuses and rats aged 1 wk were characterized for organ growth and renal morphogenesis. The adults (12 wk) were evaluated for weight, systolic blood pressure, activity of the renin-angiotensin-aldosterone system (RAAS), and renal function; hearts and kidneys underwent a histological examination. Brain and cardiac ventricle-to-body ratios were increased in IUGR fetuses compared with age-matched controls, whereas the kidney-to-body ratio was unchanged. Systolic blood pressure was elevated in both IUGR male and female adults. Plasma aldosterone levels were not correlated with increased plasma renin activity. Moreover, urinary sodium was decreased, whereas plasma urea was elevated in both males and females, and creatinine levels were augmented only in females, suggesting a glomerular filtration impairment in IUGR. In our model of IUGR induced by a low-sodium diet given to pregnant rats, high blood pressure, alteration of the RAAS, and renal dysfunction are observed in adult life. Differences observed between male and female adults suggest the importance of gender in outcomes in adulthood after IUGR.     

Pathogenesis of cryptorchidism.

Cryptorchidism was induced experimentally by treating pregnant mice on the 14th day of pregnancy with 5 mg estrogen. Testes from cryptorchid and control newborn and adult mice were investigated with radioimmunoassay and electron microscopy. It was concluded that a normal Leydig cell function plays a decisive role in testicular descent. In cryptorchidism, Leydig cells at birth are atrophic. Testicular testosterone content is diminished as compared to controls. Ultrastructural alterations of Leydig cells observed in our experiments closely resemble those found in biopsies of cryptorchid patients. In male mouse offspring, prenatal estrogen injection induced not only a cryptorchidism but also Leydig cell atrophy and a permanently impaired function. Testosterone content is still significantly diminished after puberty. It is proposed therefore that an insufficiency of endocrine gonadal function of hypothalamo-pituitary origin occurring during intrauterine development is one of the main causes of cryptorchidism. An appropriate long-term therapy could diminish the high sterility rate.     

Small for gestational age and the metabolic syndrome: which mechanism is suggested by epidemiological and clinical studies?

The metabolic and cardiovascular complications associated with in-utero undernutrition have been identified during the past 10 years. Reduced fetal growth is independently associated with an increased risk of development of cardiovascular diseases, the insulin-resistance syndrome or one of its components (i.e., hypertension, dyslipidaemia, impaired glucose tolerance and type 2 diabetes). Insulin resistance appears to be a key component underlying these metabolic complications. Although the mechanism remains unclear, several pieces of evidence support an active role of adipose tissue in the emergence of insulin resistance (an abnormal growth pattern and repartition, hypersensitivity to catecholamines, regulation of leptin and adiponectin secretion and modulation of peroxisome proliferator-activated receptor gamma). Among individuals born SGA, those who are more at risk of gaining excess adiposity are those who are thin at birth following a period of fetal growth restriction. This period of undernutrition is followed by a neonatal period of catch-up growth and renutrition. This pattern induces important modifications in adipose tissue, with long-term consequences, among which is a high risk of early development of insulin resistance. Not all individuals born SGA will show such modifications in adipose tissue, meaning that not all of those born SGA are at risk of insulin resistance and diabetes. From a broader point of view, several hypotheses have been proposed over the past 10 years to explain this unexpected association between being born SGA and the later development of disease. Each of them points to a detrimental fetal environment, to a genetic susceptibility or to interactions between these two components playing a critical role in this context. Although not confirmed, the hypothesis suggesting that this association could be the consequence of genetic/environmental interactions remains the most attractive.     

Changing Male Reproductive Health: A Review of the Clinical Evidence?

Several lines of circumstantial evidence suggest that we may be seeing adverse changes in male reproductive health. A possible decline in semen quality has attracted most attention, but there are stronger indications of a rising incidence of testicular cancer, with increases observed in both Europe and the USA. There are striking geographic variations in both the incidence of testis cancer and in the observed rate of increase, and it is noteworthy that testis cancer is much more common in Denmark, where low sperm counts have been reported, than in Finland, where semen quality seems to be better. Another cause for concern is the rising incidence of congenital malformations of the male genital tract — cryptorchidism and hypospadias. In the UK, for example, rates of cryptorchidism have increased by as much as 65 to 77%. The data are harder to interpret on semen quality. In a meta-analysis, Carlsen et al. (1992) identified significant decreases over time in sperm concentration, corresponding to a fall of almost 50% between 1940 and 1990. Several groups have since examined secular trends in semen quality, with some reporting a downward trend and others no change. However, evidence has emerged of striking regional differences in semen quality, whether due to ethnic, genetic, environmental, or lifestyle factors remains to be determined.     

DNA methylation of IGF2, GNASAS,INSIGF and LEP and being born small for gestational age

Being born small for gestational age (SGA), a proxy for intrauterine growth restriction (IUGR), and prenatal famine exposure are both associated with a greater risk of metabolic disease. Both associations have been hypothesized to involve epigenetic mechanisms. We investigated whether prenatal growth restriction early in pregnancy was associated with changes in DNA methylation at loci that were previously shown to be sensitive to early gestational famine exposure. We compared 38 individuals born preterm (<32 weeks) and with a birth weight too low for their gestational age (-1SDS) and a normal postnatal growth (>-1SDS at 3 months post term; “AGA”). The SGA individuals were not only lighter at birth, but also had a smaller length (P=3.3x10^-13) and head circumference at birth (P=4.1x10^-13). The DNA methylation levels of IGF2, GNASAS, INSIGF and LEP were 48.5%, 47.5%, 79.4% and 25.7% respectively. This was not significantly different between SGA and AGA individuals. Risk factors for being born SGA, including preeclampsia and maternal smoking, were also not associated with DNA methylation at these loci. Growth restriction early in development is not associated with DNA methylation at loci shown to be affected by prenatal famine exposure. Our and previous results by others indicate that prenatal growth restriction and famine exposure may be associated with different epigenetic changes or non epigenetic mechanisms that may lead to similar later health outcomes.     

Endocrine disrupters and testicular dysgenesis syndrome

Over the last couple of generations, we have been exposed to an increasing number of endocrine disrupters in our environment, including dichlorodiphenyltrichloroethane (DDT), PCB, certain pesticides, the phthalate DBP, synthetic steroids in meat and many other agents (table 1), which act as agonists or antagonists of sex steroids. Although biologists working with wildlife have been concerned about the possible effects of these chemical agents on animal reproduction, it appears that clinicians have been less concerned about possible health effects in humans. However, the increasing incidence of hormone-dependent cancers, including cancer of the breast, prostate and testis, and signs of an increasing incidence of male reproductive health problems should alert us to the possible association between exposure to endocrine disrupters and the current high frequency of reproductive problems. In Denmark, for example, 5% of all children are now born after assisted reproduction (intracytoplasmic sperm injection, in vitro fertilization, donor insemination and intrauterine insemination) and 1% of all (mostly young) men develop testicular cancer. Evidence exists to support the concept that hypospadias, undescended testis, poor semen quality and testicular cancer are symptoms of an underlying testicular dysgenesis syndrome, which may be becoming increasingly common due to adverse environmental effects. Experimental and epidemiological evidence suggests that testicular dysgenesis syndrome is a result of disruption of foetal programming and gonadal development during foetal life.     

Toll-like receptors in the gonads and reproductive tract: emerging roles in reproductive physiology and pathology

Interactions between the immune system and reproductive system have important consequences for fertility and reproductive health in general. There is increasing evidence that many of the interactions between the immune and reproductive systems involve the Toll-like receptors (TLRs). While there is no doubt that TLRs are important in providing protection against infection in the reproductive tract, there is increasing evidence for the involvement of TLRs in more basic pathology and physiology of reproduction. In the female, TLRs have been implicated in critical aspects of ovarian, endometrial and placental function, as well as in ovarian cancer, pelvic inflammatory disease, intrauterine growth restriction, pre-eclampsia and preterm birth. In the male, TLRs appear to play a role in the control of testicular steroidogenesis and spermatogenesis in disease and, potentially, during normal function, as well. Recent studies also have begun to highlight the role of various TLRs in the aetiology of prostatitis and prostatic cancer. Given the nascent state of knowledge concerning this important area, it is clear that more studies are needed, which should provide valuable new insights into the biology of the TLRs and reproductive function in general.     

US experience in evaluation and diagnosis of GH therapy of intrauterine growth retardation/small-for-gestational-age children

The potential role of exogenous GH in treating short children born small for gestational age (SGA) has been discussed since the early 1960s. Pivotal studies in Europe during the last 10 years have shown that GH treatment of short children born SGA during childhood and early puberty (1) normalizes stature, (2) increases final height above predicted height and (3) allows children to reach their target height. A study now under way in the USA will provide additional much needed data about efficacy and safety of GH treatment in intrauterine growth retardation/SGA.     

Testicular dysgenesis syndrome

In the Western world fertility rates are low and infertility is a major health problem. Unofficial statistics from Denmark reveal that about 6% of all Danish children are now born after assisted reproduction techniques, including in vitro fertilization, intracytoplasmic sperm injection, donor insemination or homologous insemination. However, there are no retrospective data on trends in fecundity (ability to conceive). We, and others, have focused on some aspects of adverse trends in male reproductive health such as the rising incidence of testicular cancer, low and probably declining semen quality, high and possibly increasing frequencies of undescended testes and hypospadias. Due to medical specialization and the different ages at presentation of symptoms, reproductive problems used to be analysed separately by various professional groups, for instance paediatric endocrinologists, urologists, andrologists or oncologists. There is evidence that poor semen quality, testicular cancer, undescended testes and hypospadias are symptoms of one underlying entity, testicular dysgenesis syndrome (TDS), which may be increasingly common due to adverse environmental influences. Experimental and epidemiological studies suggest that TDS is the result of disruption of embryonal programming and gonadal development during fetal life. An endocrine disrupter hypothesis to explain the adverse trends has been proposed. It is recommended that future epidemiological studies on trends in male reproductive health should not focus on one symptom alone, but be more comprehensive and take all aspects of TDS into account.     

Aspects cliniques, biologiques et thérapeutiques de la cryptorchidie diagnostiquée à l’âge adulte: analyse d’une série de 69 cas

Objective

To report the clinical, biological and therapeutic features of adult cryptorchidism and to determine whether orchidopexy at adulthood may improve male fertility.

Material and methods

We retrospectively studied the clinical pattern, biological and therapeutic features of 69 men aged of more than 18 years admitted for cryptorchidism at the urological department of Aristide-Le-Dantec teaching hospital between January 1999 and December 2007.

Results

The mean age of our patients was 31.04 ± 8.4 years. In the majority of cases, cryptorchidism was diagnosed in a context of infertility (38 cases), scrotum vacancy (21 cases) and testicular cancer (six cases). Cryptorchidism was unilateral in 69.5% and bilateral in 30.4% of cases. Semen analyses were done for 60 patients and showed azoospermia in 46.6%, oligozoospermia in 38.3% and a normal sperm count in 15% of cases. In all bilateral cryptorchidism cases, semen analyses showed azoospermia. At surgery, the undescended testis was found in 66 cases (95.6%) and orchidopexy was the most done surgical procedure. Seven patients (without testicular cancer) underwent unilateral orchiectomy and histology of specimens showed sertoli-cell-only syndrome with no spermatogenesis in all cases. The histological type of testicular cancer was seminoma (three cases) and embryonic carcinoma (three cases). In azoospermic men (28 cases) no induction of spermatogenesis was achieved after orchidopexy. In infertile patients, the improvement of sperm count was seen in three patients with unilateral cryptorchidism. Three patients with unilateral crytorchidism achieved pregnancy (pregnancy rate of 7.8%).

Conclusion

Orchidopexy for adult cryptorcidism had little impact in male fertility. Because of the risk of testicular cancer, orchidectomy was recommended as treatment of unilateral cryptorchidism. But with the recent development of TESE, orchidopexy appears as a reasonable treatment of adult cryptorchidism.     

Early influences on the tempo of puberty

Fetal growth retardation appears to be associated with an increased risk of premature adrenarche, early puberty, polycystic ovary syndrome and associated fertility problems. In a rat model of intrauterine growth retardation, based on ligation of the uterine arteries, the onset of puberty was delayed in female pups, with anovulation during the first cycle. The ovaries showed a lower number of follicles. The onset of puberty was also delayed in male pups. Testosterone production was lower in these growth-retarded rats compared with controls. The relationship between birth weight and the onset of puberty and pubertal progression in different cohorts of healthy children has been examined. In girls, no differences were observed in timing and progression of puberty, including age of menarche, between groups of different birth weights. In boys, a relatively delayed onset of puberty was observed in those with low birth weight, with a normally timed progression. In children with low birth weight, particularly boys, higher dehydroepiandrosterone levels were found compared with children with a normal birth weight, indicating an overactive adrenal gland in children with low birth weight. These data indicate that impaired fetal growth may have long-lasting effects on pubertal development. The fact that results of human studies on the relationship between fetal growth and the onset of puberty are often controversial may be explained by the heterogeneity of children born small for gestational age with respect to the intrauterine insult that they experience. From rat studies, it is clear that a serious intrauterine insult associated with growth failure can lead to dysregulation of puberty and gonadal function.     

Is fetal testis in danger?

Estrogens are classically known to play a major role in female reproduction, but there is now compelling evidence that they may also be involved in the regulation of male reproductive function. In humans, a decrease in sperm count and an increase in the incidences of testicular cancer, cryptorchidism and hypospadia have been observed in many countries over the last 50 years. Male reproductive alterations were also observed in wildlife. Such male reproductive disorders have been attributed to the increase in concentration of xenobiotics, and of xenoestrogens in particular, in the environment and in food. Epidemiological, clinical and experimental studies have suggested that excessive exposure to estrogens during fetal/neonatal life can lead to reproductive disorders in adulthood. Using an in vitro model, we showed that estrogens directly affected the development of the fetal testis. Lastly, we clearly demonstrated that the fetal and neonatal testis is very sensitive to estrogens since the invalidation of estrogen receptor alpha leads to an increase of steroidogenesis and the invalidation of estrogen receptor beta enhances the development of the germ cell lineage in the male.     

DNA methylation of IGF2, GNASAS,INSIGF and LEP and being born small for gestational age

Being born small for gestational age (SGA), a proxy for intrauterine growth restriction (IUGR) and prenatal famine exposure are both associated with a greater risk of metabolic disease. Both associations have been hypothesized to involve epigenetic mechanisms. We investigated whether prenatal growth restriction early in pregnancy was associated with changes in DNA methylation at loci that were previously shown to be sensitive to early gestational famine exposure. We compared 38 individuals born preterm (<32 weeks) and with a birth weight too low for their gestational age (less than −1SDS; SGA) with 75 individuals born preterm but with a birth weight appropriate for their gestational age (greater than −1SDS) and a normal postnatal growth (greater than −1SDS at three months post term; AGA). The SGA individuals were not only lighter at birth, but also had a smaller length (p = 3.3 × 10⁻¹³) and head circumference at birth (p = 4.1 × 10⁻¹³). The DNA methylation levels of IGF2, GNASAS, INSIGF and LEP were 48.5, 47.5, 79.4 and 25.7% respectively. This was not significantly different between SGA and AGA individuals. Risk factors for being born SGA, including preeclampsia and maternal smoking, were also not associated with DNA methylation at these loci. Growth restriction early in development is not associated with DNA methylation at loci shown to be affected by prenatal famine exposure. Our and previous results by others indicate that prenatal growth restriction and famine exposure may be associated with different epigenetic changes or non-epigenetic mechanisms that may lead to similar later health outcomes.Key words: SGA, DOHAD, IUGR, DNA methylation, famine, IGF2, LEP, INS, GNASAS     

Environmental oestrogens disrupt testicular descent and damage male reproductive health: Mechanistic insight

Environmental oestrogens (EEs) as environmental pollutants have been paid much attention due to their impact on congenital malformation of male genitourinary system. Exposure to EEs for prolonged time could hinder testicular descent and cause testicular dysgenesis syndrome. Therefore, it is urgent to understand the mechanisms by which EEs exposure disrupt testicular descent. In this review, we summarize recent advances in our understanding of the process of testicular descent, which is regulated by intricate cellular and molecular networks. Increasing numbers of the components of these networks such as CSL and INSL3 are being identified, highlighting that testicular descent is a highly orchestrated process that is essential to human reproduction and survival. The exposure to EEs would lead to the imbalanced regulation of the networks and cause testicular dysgenesis syndrome such as cryptorchidism, hypospadias, hypogonadism, poor semen quality and testicular cancer. Fortunately, the identification of the components of these networks provides us the opportunity to prevent and treat EEs induced male reproductive dysfunction. The pathways that play an important role in the regulation of testicular descent are promising targets for the treatment of testicular dysgenesis syndrome.     

Effect of prenatal or perinatal nicotine exposure on neonatal thyroid status and offspring growth in rats

Smoking during pregnancy causes intrauterine growth retardation and low birth weight of the offspring. However, it is unclear whether nicotine, rather than other compounds from a cigarette, would mediate long-term growth retardation. There is a body of evidence suggesting that optimal thyroid status is important for the normal development of the fetus. Therefore, these studies examined whether developmental nicotine exposure would interfere with the growth of the offspring and alter the thyroid status of neonates. Pregnant Sprague-Dawley rats were given 0, 15 or 25 mg nicotine pellets throughout pregnancy. Some offspring continued to receive 1 or 2 mg/kg/day nicotine during early postnatal period. The remaining offspring received no further treatment after birth. The body weight of all offspring was monitored until adulthood. Additionally, the neonatal thyroid status from all treatment groups was assessed from the serum of 10-day-old pups. Regardless of the timing of nicotine exposure, the nicotine treatment significantly increased the body weight in female offspring starting on postnatal day (PD) 35 and such an increase persisted into adulthood (PD 91). However, this nicotine exposure paradigm led to a transient increase in male offspring body weight on PD 35. Furthermore, current nicotine exposure regimens did not alter the total T4 level, T3 uptake and the calculated Free T4 index. The present findings are in agreement with some clinical studies reporting a higher body weight among children born to mothers who smoked during pregnancy. Furthermore, the data on thyroid status suggest that cigarette smoking-induced alterations in thyroid status might be mediated through compounds in cigarettes other than nicotine.     

Intrauterine undernutrition and programming as a new risk of cardiovascular disease in later life

It is believed that atherogenesis is a multifactorial process, which could already start in utero. Development of atherosclerosis progresses over decades and leads to the cardiovascular morbidity and mortality in adulthood. At present, we have no exact explanation for all the risk factors acting in the pathogenesis of atherosclerosis. This review should provide an overview about the possible role of intrauterine undernutrition in the development of risk factors for cardiovascular disease. Intrauterine undernutrition leads to changes in fetal growth and metabolism and programs later development of some of these risk factors. A number of experimental and human studies indicates that hypertension as well as impaired cholesterol and glucose metabolism are affected by intrauterine growth. Intrauterine undernutrition plays an important role and acts synergistically with numerous genetic and environmental factors in the development of atherosclerosis. There is evidence that undernutrition of the fetus has permanent effects on the health status of human individuals.