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TO THE EDITOR: Wensink and colleagues' article (1) describes an excess of birth defects in neonates fathered by men who received metformin during the 3-month period of spermatogenesis before conception (known as sperm development). This is an important contribution. Nevertheless, we would place its findings into a broader clinical context. Hyperglycemia, older age, and obesity are known risk factors for fetal malformations or other outcomes (2–4).
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