Abstract STUDY QUESTION Are the geographic recruitment centre and dynamic sex-steroid profiles, particularly for dihydrotestosterone, associated with inter-individual differences in libido and mood-related adverse events during hormonal male contraception? SUMMARY ANSWER In this multinational analysis of the WHO testosterone undecanoate/ norethisterone (TU/NETE) enanthate trial, geographic cluster was associated with distinct androgenic profiles and clinical responses; lower dihydrotestosterone exposure emerged as a consistent predictor of decreased libido and mood-related adverse events. WHAT IS KNOWN ALREADY Combined testosterone–progestin regimens can suppress spermatogenesis effectively, but the WHO TU/NETE trial was discontinued prematurely because of mood-related adverse events despite high contraceptive efficacy. The endocrine mechanisms underlying these adverse effects remain incompletely understood. STUDY DESIGN, SIZE, DURATION This secondary analysis used serial hormone and adverse-event data from the multinational WHO/CONRAD trial, which enrolled 320 men. However, 255 participants had serum samples available for centralised steroid analysis and constituted the present analytical cohort, as the samples from Jakarta, Indonesia (65 subjects) were not sent to the Central Laboratory. PARTICIPANTS/MATERIALS, SETTING, METHODS Healthy male participants were recruited across European/Australian, South American and Asian centres and grouped into geographic clusters. Serum testosterone, calculated free testosterone, dihydrotestosterone, estradiol and norethisterone were analysed centrally by gas chromatography–mass spectrometry (GC-MS). Longitudinal mixed-effects models and time-to-event analyses were used to evaluate associations between hormone trajectories, geographic cluster, age, libido changes and mood disorders. MAIN RESULTS AND THE ROLE OF CHANCE Marked cluster-dependent heterogeneity was observed. Participants from Chile showed higher total and free testosterone and persistently higher dihydrotestosterone concentrations over time, accompanied by a higher incidence of increased libido. Participants from India showed lower dihydrotestosterone exposure and higher norethisterone concentrations and no libido and mood changes. European/Australian participants showed comparatively lower dihydrotestosterone concentrations and the highest cumulative incidence of mood disorders. Declining dihydrotestosterone concentrations were associated with decreased libido and mood-related adverse events. LIMITATIONS, REASONS FOR CAUTION The analyses are exploratory and based on secondary evaluation of a completed clinical trial. Geographic clusters may reflect genetic, environmental, dietary, cultural, behavioural and reporting-related factors, and causality cannot be inferred. WIDER IMPLICATIONS OF THE FINDINGS Comprehensive androgen profiling, particularly assessment of dihydrotestosterone, may help identify men at increased risk of neuropsychological or sexual adverse effects during hormonal male contraception and may support more individualised contraceptive regimens. FUNDING The clinical study was cosponsored and funded by United Nations Development Programme; United Nations Population Fund; United Nations International Children’s Emergency Fund; World Health Organization; World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (Human Reproduction Programme, World Health Organization, Geneva, Switzerland); and CONRAD (Eastern Virginia Medical School, Arlington, VA using funding from the Bill & Melinda Gates Foundation and U.S. Agency for International Development). DISCLOSURES R.I.M.is a Principal Research Fellow of the Australian National Health and Medical Research Council (1022327) and the Hudson Institute, which is supported by the Victorian Government’s Operational Infrastructure Scheme. The authors have no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER N/A
Abstract STUDY QUESTION Can maternal biomarkers of maternal-fetal physiologic integration predict the fetal fraction of cell-free DNA in pregnancy loss? SUMMARY ANSWER Maternal organ system biomarkers, including cardiometabolic, hepatic, renal and thyroid markers, substantially predict fetal fraction in pregnancy loss (Area Under the Receiver Operating Characteristics Curve (AUC-ROC) 0.77–0.80), indicating that fetal fraction may reflect integrated maternal-fetal physiology. WHAT IS KNOWN ALREADY Fetal fraction, which is the proportion of cell-free DNA in maternal plasma derived from the placenta, increases with gestational age and decreases with higher maternal BMI. Existing prediction models on fetal fraction rely mainly on demographics and placental hormones, and the contribution of broader maternal organ-system biomarkers remains unclear. STUDY DESIGN, SIZE, DURATION Prospective multi-center cohort study within the Copenhagen Pregnancy Loss study with development cohort (n = 992) from a tertiary university hospital and external validation cohorts from two secondary university hospitals (n = 275 and n = 241). Enrollment was from November 2020 to February 2023. PARTICIPANTS/MATERIALS, SETTING, METHODS Women ≥18 years with confirmed intrauterine pregnancy loss before 22 weeks at three Danish university hospitals were included. Fetal fraction was estimated from cfDNA sequencing using SeqFF. Six clinical characteristics and 36 biochemistry measurements, selected to reflect physiological domains implicated in placentation including thyroid, renal, lipid, and inflammatory markers, were analyzed using Bayesian Hurdle lognormal regression and gradient boosting models with external validation. MAIN RESULTS AND THE ROLE OF CHANCE In adjusted hurdle models, higher total thyroid hormone levels were associated with adequate fetal fraction (e.g., total triiodothyronine (TT3) Odds Ratio (OR) 2.76 (95% CI 1.31–5.87); total thyroxine (TT4) OR 2.42 (95% CI 1.43–4.29)), while higher levels of creatinine and uric acid were inversely associated (e.g., creatinine OR 0.39 (95% CI 0.17–0.91); uric acid OR 0.47 (95% CI 0.26–0.90)). The magnitude of fetal fraction was additionally associated with HDL cholesterol/total cholesterol ratio, uric acid and creatinine. A gradient-boosting model achieved AUC-ROC 0.77 in internal cross-validation and 0.80/0.78 in external validation (two secondary university hospitals), with aspartate transaminase (AST)/alanine transaminase (ALT) ratio among the strongest predictors alongside beta subunit of human chorionic gonadotropin (βhCG) and gestational age. LIMITATIONS, REASONS FOR CAUTION The cross-sectional design and pregnancy loss focus limit inference regarding the directionality between maternal biomarkers, placental health and fetal fraction. SeqFF-based fetal fraction estimation adds measurement noise versus genotype methods, while our pre-specified biomarker panel limits scope to investigated parameters. Our findings require validation in ongoing pregnancies. WIDER IMPLICATIONS OF THE FINDINGS The findings suggest fetal fraction may reflect maternal-fetal physiologic integration rather than merely a technical quality-control parameter. The associations between fetal fraction and cardiometabolic, thyroid, hepatic and renal markers suggest that fetal fraction may offer broader insights into maternal physiology and maternal organ system adaptation during pregnancy, influencing cell-free DNA dynamics (reflecting placental shedding, maternal clearance and dilution). The model enables personalized clinical decision-making regarding cell-free fetal DNA test timing in pregnancy loss and thereby improving the efficiency and success rate of cell-free fetal DNA testing. FUNDING The preparation of our cohort was funded by the Ole Kirks Foundation, while the study itself received support from the BioInnovation Institute Foundation (BII21SG1020554, NNF20SA0066125, and NNF15OC0016662), the Novo Nordisk Foundation (NNF23OC0087269, NNF22OC0077221), the A.P. Moller Foundation, the Independent Research Fund Denmark (6215-00037B), and the Pioneer Center for Statistical and Computational Methods for Advanced Research to Transform Biomedicine (SMARTbiomed), DNRF grant number P4. DISCLOSURES HSN has received scientific grants paid to her institution from Freya Biosciences, Ferring Pharmaceuticals, BioInnovation Institute, Ministry of Education, Novo Nordisk Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, and Ole Kirks Fond. HSN has received personal payments or honoraria for lectures and presentations from Ferring Pharmaceuticals, Merck, AstraZeneca, Cook Medical, Gedeon Richter, IBSA Nordic, Novo Nordisk, and Bessins. SB declares speaker’s fees from Novo Nordisk and Extempore. All other authors declare no conflict of interests. This article is the subject of a patent (application number WO2025181337A1) filed by the Capital Region of Denmark, where TSH, DW, and HSN are named inventors. TRIAL REGISTRATION NUMBER N/A
Abstract STUDY QUESTION Is conservative management of benign-looking adnexal masses on ultrasound cost-effective compared with universal surgery, from the perspective of the Italian National Health Service (NHS)? SUMMARY ANSWER In this model-based analysis, conservative management of benign-looking adnexal masses was less costly and associated with fewer unnecessary surgical procedures than universal surgery scenario, with net savings exceeding €4.1 million per 1,919 patients over two years and consistent results across all deterministic sensitivity analyses. WHAT IS KNOWN ALREADY The International Ovarian Tumour Analysis Phase 5 (IOTA 5) prospective multicentre cohort demonstrated that conservative management of benign-looking adnexal masses on ultrasound is clinically safe, with cumulative 2-year rates of invasive malignancy, torsion and cyst rupture each below 0.5%. Spontaneous resolution occurred in 20.2% of newly diagnosed masses, suggesting that a substantial proportion of women managed surgically under a universal-surgery strategy would undergo unnecessary intervention. Despite this evidence, the economic implications of systematically adopting conservative management have not been formally evaluated: no cost-effectiveness analysis applying incremental cost-effectiveness ratio (ICER) methodology has been conducted for this clinical scenario. STUDY DESIGN, SIZE, DURATION Cost-effectiveness analysis from the Italian NHS payer perspective, based on published aggregate 2-year outcome data from the IOTA5 prospective cohort (1,919 patients with a newly diagnosed adnexal mass classified as benign on subjective ultrasound assessment). Two management strategies were compared over a 2-year time horizon: Scenario A (universal surgery) and Scenario B (IOTA5 conservative model: surgery in 16.1% of cases plus three post-baseline ultrasound examinations for the remaining 83.9%) using surgeries avoided as the intermediate effectiveness outcome. PARTICIPANTS/MATERIALS, SETTINGS, METHODS Clinical outcome data were derived from the published IOTA5 2-year interim analysis. Cost inputs were based on Italian NHS DRG (Diagnosis-Related Group) national tariffs (DRG 358/359 for adnexal surgery) and the NHS outpatient ultrasound tariff (code 88.78.2: €41.20). A weighted mean surgery cost of €2,700 was applied (85% DRG 359 at €2,550; 15% DRG 358 at €3,551). Three post-baseline ultrasound examinations were modelled for conservatively managed patients, consistent with the IOTA5 follow-up protocol (scans at 3, 6, and 12 months from recruitment; Froyman et al., 2019). Surgical complication costs were included as a supplementary analysis, applying published complication rates (overall 13.3%; major 0.6%) from the IOTA5 surgical cohort (Froyman et al., 2019). Event rates and tariffs were taken from published aggregate data and official tariff schedules, whereas the DRG case-mix, the unit costs of complications and the number of follow-up scans were assumptions made by the authors and were not derived from patient-level resource-use data. The ICER was calculated as net cost difference per surgery avoided. Uncertainty was explored using deterministic one-way and multi-way sensitivity analyses; probabilistic sensitivity analysis was not possible because individual patient data were not available. MAIN RESULTS AND THE ROLE OF CHANCE Scenario A (universal surgery) incurred total costs of €5,260,363 versus €1,112,359 for Scenario B, yielding net savings of €4,148,004 (79% cost reduction) over two years. Including surgical complication costs increased savings to €4,286,004. The base-case ICER was −€2,576 per surgery avoided, placing conservative management in the dominant south-east quadrant of the cost-effectiveness plane (less costly and more appropriate). One-way sensitivity analysis confirmed dominance across all parameter ranges tested (ICER range: −€2,512 to −€3,513 per surgery avoided). The break-even surgery rate, at which the conservative strategy would cease to dominate, was approximately 95%, far above the 16.1% observed in IOTA5. LIMITATIONS, REASONS FOR CAUTION This analysis was based on published aggregate rather than individual patient data; consequently, only deterministic sensitivity analyses could be performed. These assess robustness across the tested parameter ranges but do not replace formal probabilistic sensitivity analysis. The effectiveness outcome was intermediate rather than final, so the ICER cannot be compared with conventional cost-per-QALY thresholds. In addition, the DRG case mix and complication unit costs were based on author-defined assumptions rather than observed data. The downstream costs and health consequences of delayed cancer diagnosis were not incorporated into the primary model; therefore, the finding of economic dominance should be interpreted within the assumptions of the model. Finally, because cost estimates were derived from Italian NHS tariffs, their generalisability to other healthcare systems may be limited. WIDER IMPLICATIONS OF THE FINDINGS Conservative management of adnexal masses classified as benign on ultrasound appears to be both clinically safe and substantially less costly than universal surgery, with projected savings exceeding €4.1 million per 1919 patients over 2 years in the Italian NHS setting. Standardisation of gynaecological ultrasound training, a prerequisite for safe implementation, represents a modest investment relative to the potential clinical and economic benefits. Confirmation in a cost-utility framework, using prospectively collected quality-of-life data and patient-level resource use, is required before these findings can be regarded as definitive. FUNDING No external funding was received for this study. DISCLOSURES The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A. This is a secondary analysis of published aggregate data from the IOTA5 study (ClinicalTrials.gov, NCT01698632).
