Ovarian reserve testing: a user's guide

Addressing Chronic Gynecological Diseases in the SARS-CoV-2 Pandemic

Introduction: the COVID-19 pandemic has had a considerable impact on healthcare systems worldwide. Since the actual influence of the pandemic on gynecological care is still unclear, we aim to evaluate the effect of the SARS-CoV-2 pandemic on gynecological procedures compared to the pre-pandemic period in Romania. Materials and Methods: this is a single-center retrospective observational study, involving patients hospitalized in the year before the SARS-CoV-2 pandemic (PP), in the first year of the pandemic (P1), and in the second year of the pandemic until February 2022 (P2). The percentages of interventions were analyzed globally but also according to the type of surgery applied on the female genital organs. Results: during pandemic, the number of gynecological surgeries dropped considerably, by more than 50% in some cases, or even decreased by up to 100%, having a major impact on women's health, especially in the first year of the pandemic (P1), before slightly increasing in the post-vaccination period (PV). Surgically treated cancer cases dropped by over 80% during the pandemic, and the consequences of this will be seen in the future. Conclusions: the COVID-19 pandemic played an important part in gynecological care management in the Romanian public health care system, and the effect will have to be investigated in the future.

Cancer Treatment-Related Ovarian Dysfunction in Women of Childbearing Potential: Management and Fertility Preservation Options

PURPOSE

To review the complex concerns of oncofertility created through increased cancer survivorship and the long-term effects of cancer treatment in young adults.

DESIGN

Review chemotherapy-induced ovarian dysfunction, outline how fertility may be addressed before treatment initiation, and discuss barriers to oncofertility treatment and guidelines for oncologists to provide this care to their patients.

CONCLUSION

In women of childbearing potential, ovarian dysfunction resulting from cancer therapy has profound short- and long-term implications. Ovarian dysfunction can manifest as menstrual abnormalities, hot flashes, night sweats, impaired fertility, and in the long term, increased cardiovascular risk, bone mineral density loss, and cognitive deficits. The risk of ovarian dysfunction varies between drug classes, number of received lines of therapy, chemotherapy dosage, patient age, and baseline fertility status. Currently, there is no standard clinical practice to evaluate patients for their risk of developing ovarian dysfunction with systemic therapy or means to address hormonal fluctuations during treatment. This review provides a clinical guide to obtain a baseline fertility assessment and facilitate fertility preservation discussions.

Evaluation of the relationship between ovarian reserve with congenital anomalies and intramural uterine leiomyoma among infertile women: a cross-sectional study

BACKGROUND

Ovarian reserve is a crucial indicator of a woman's fertility potential, which is determined by the quality and quantity of antral follicles and oocytes. However, certain factors such as endometriosis, pelvic inflammatory disease, myoma, and the natural process of aging can lead to a poor ovarian response to stimulation, reducing a woman's chances of conceiving.

OBJECTIVE

To evaluate the effect of uterus congenital anomalies and uterine leiomyoma are associated on ovarian reserve.

METHODS

The present cross-sectional study was performed on 321 infertile women in three groups consisted of 97 infertile women with intramural uterine leiomyoma and 81 infertile women with uterine anomalies and 143 infertile women without uterine anomalies and uterine leiomyoma during 2017-2019 in Royan Center. Sampling method was continuous and available. Data collection tool in this study was a questionnaire which was in two parts of individual variables and the second part was related to ultrasound results (number of antral follicles and ovarian volume) and laboratory tests (Anti-Mullerian Hormone (AMH) and Follicle-stimulating Hormone (FSH)). Ovarian reserve parameters were measured in three groups on the third day of the cycle in both groups. Data analysis was performed using SPSS software version 21. Quantitative variables were analyzed using t-test, qualitative variables were analyzed using chi-square test.

RESULTS

The results of in laboratory parameters showed that there was no statistically significant difference between the three groups in FSH (2.35 ± 1.55, 2.07 ± 1.81, 2.31 ± 1.93) and AMH (6.84 ± 2.75,7.52 ± 3.14,6.93 ± 3.04), respectively (P > 0.05). The results of sonographic variables also showed that the variables include number of antral follicles in right ovarian, number of antral follicles in left ovarian have statistically significant between the three groups (5.73 ± 2.69,4.84 ± 3.14,6.66 ± 3.13), respectively (P < 0.05).

CONCLUSION

The results of the present study showed that uterine abnormalities and uterine leiomyoma with different mechanisms such as reduce of antral follicle numbers and the effect on uterine and ovarian blood flow lead to a decrease in ovarian reserve and infertility. Therefore, treatment and surgery can reduce these effects and improve the fertility of the affected women.

AMH predicts miscarriage in non-PCOS but not in PCOS related infertility ART cycles

BACKGROUND

To study whether AMH levels were associated with miscarriage rates in index ART cycles undergoing fresh autologous transfers in PCOS and non-PCOS related infertility.

METHODS

In the SART CORS database 66,793 index cycles underwent fresh autologous embryo transfers with AMH values reported within the last 1-year between 2014 and 2016. Cycles that resulted in ectopic or heterotopic pregnancies, or were performed for embryo/oocyte banking were excluded. Data were analyzed using Graphpad Prism-9. Odds ratios (OR) were calculated with 95% confidence intervals (CI) along with multivariate regression analysis adjusting for age, body mass index (BMI), and number of embryos transferred. Miscarriage rates were calculated as miscarriage per clinical pregnancies.

RESULTS

Of the total 66,793 cycles, the mean AMH was 3.2 ng/ml and were not associated with increased miscarriage rates for AMH < 1 ng/ml (OR 1.1, CI 0.9-1.4, p = 0.3). Of the 8,490 PCOS patients, the mean AMH was 6.1 ng/ml and were not associated with increased miscarriage rates for AMH < 1 ng/ml (OR 0.8, CI 0.5-1.1, p = 0.2). Of the 58,303 non-PCOS patients, the mean AMH was 2.8 ng/ml and there was a significant difference in miscarriage rates for AMH < 1 ng/ml (OR 1.2, CI 1.1-1.3, p < 0.01). All findings were independent of age, BMI and number of embryos transferred. This statistical significance did not persist at higher thresholds of AMH. The overall miscarriage rate for all cycles, and cycles with and without PCOS were each 16%.

DISCUSSION

The clinical utility of AMH continues to increase as more studies investigate its predictive abilities regarding reproductive outcomes. This study adds clarity to the mixed findings of prior studies that have examined the relationship between AMH and miscarriage in ART cycles. AMH values of the PCOS population are higher than the non-PCOS. The elevated AMH associated with PCOS decreases its utility in predicting miscarriages in IVF cycles as it may be representing the number of developing follicles rather than oocyte quality in the PCOS patient population. The elevated AMH associated with PCOS may have skewed the data; removing this sub-population may have unmasked significance within the non-PCOS associated infertility.

CONCLUSIONS

AMH < 1 ng/mL is an independent predictor of increased miscarriage rate in patients with non-PCOS infertility.

Factors Associated with Poor Ovarian Reserve in Young Infertile Women: A Hospital-based Cohort Study

Background

In practice, we encounter many young infertile women with poor ovarian reserve though ovarian reserve starts to decline after 35 years of age. One of the established risk factors for poor ovarian reserve in young women is endometriosis. There are other conditions that are reported to be associated which require further research.

Aims

We aimed to study the prevalence of poor ovarian reserve and to find out the associated factors in women who are <35 years of age.

Settings and Design

This was a prospective observational cohort study conducted in a tertiary care setting.

Materials and Methods

Women aged more than 21 years and <35 years without Polycystic Ovarian Syndrome (PCOS) or ovarian dysgenesis with normal male factor were included after ethical approval. The sample size was 166 and serum anti-Mullerian hormone (AMH) was estimated by immunoenzymatic assay and expressed in ng/ml. AMH ≤0.99 ng/ml was considered poor ovarian reserve. Apart from established risk factors, the proposed risk factors studied were age 31-35 years, presence of medical disorders, gynaecological pathology and history of repeated ovulation induction (OI).

Statistical Analysis Used

Data were analysed by SPSS version 25. Chi-square test and Fisher's exact test were used to compare the variables between normal ovarian reserve and poor ovarian reserve. Risk estimation was done by logistic regression and was expressed in odds ratio (OR).

Results

Poor ovarian reserve was diagnosed in 40% of this cohort, and 62% were between 31 and 35 years. After adjusting for age >30 years, women with endometrioma, hypothyroidism and prior history of ≥3 cycles of OI were found to be having poor ovarian reserve (OR was 5.7, 2.5 and 2.3, respectively).

Conclusion

Poor ovarian reserve was present in 40% of young women, and significantly associated factors were hypothyroidism and history of repeated multiple OI. This could be a confounder for other underlying mechanisms driving early exhaustion of ovarian reserve in certain young women. Hence, along with established risk factors, these women should undergo AMH testing irrespective of age.

Factors Influencing Follicular Output Rate and Follicle-to-Oocyte Index in POSEIDON-Defined Low-Prognosis Women in Vietnam: A Cross-Sectional Study

Objective

This study aimed to identify the factors that influence follicular output rate (FORT) and follicle-to-oocyte index (FOI) among infertile Vietnamese women, as described by the Poseidon classification of poor responders.

Methods

This cross-sectional analysis includes women who received IVF/ICSI treatment at Hue University Hospital, Vietnam, between January 2017 and December 2019. The study population was divided into four groups: Group 1 (age < 35, AFC ≥ 5 and AMH ≥ 1.2 ng/mL, number of oocytes retrieved in the previous cycle ≤ 9), group 2 (age ≥ 35; AFC ≥ 5 and AMH ≥ 1.2 ng/mL, number of oocytes retrieved in the previous cycle ≤ 9), group 3 (age < 35; AFC < 5 and/or AMH < 1.2 ng/mL) and group 4 (age ≥ 35; AFC < 5 and/or AMH < 1.2 ng/mL). All of the patients underwent controlled ovarian stimulation utilizing GnRH antagonist.

Results

A total of 243 cases were recruited into groups 1 (n = 44), 2 (n = 33), 3 (n = 54), and 4 (n = 112). There were statistically significant differences between the four groups in terms of age, infertility type, menstrual cycle, body mass index (BMI) and waist-hip ratio (WHR), endocrine tests, and total retrieved oocytes (p 0.05). The average number of oocytes per participant was 7.27, with the highest number occurring in group 1 (10.77) and the lowest occurring in group 4 (5.59). There was a relationship between FORT and BMI (ß: -0.146, p=0.039), FSH starting dose (ß: 0.146, p=0.030), and AMH (ß:0.166, p=0.015). No statistically significant correlation was detected between FOI and other variables.

Conclusion

The starting dose of FSH for ovarian stimulation and AMH concentration were positively associated with FORT in individuals with a poor prognosis, whereas BMI was negatively correlated with FORT; No other parameters were found to correlate with FOI.

Aging-Related Ovarian Failure and Infertility: Melatonin to the Rescue

Aging has a major detrimental effect on the optimal function of the ovary with changes in this organ preceding the age-related deterioration in other tissues, with the middle-aged shutdown leading to infertility. Reduced fertility and consequent inability to conceive by women in present-day societies who choose to have children later in life leads to increased frustration. Melatonin is known to have anti-aging properties related to its antioxidant and anti-inflammatory actions. Its higher follicular fluid levels relative to blood concentrations and its likely synthesis in the oocyte, granulosa, and luteal cells suggest that it is optimally positioned to interfere with age-associated deterioration of the ovary. Additionally, the end of the female reproductive span coincides with a significant reduction in endogenous melatonin levels. Thus, the aims are to review the literature indicating melatonin production in mitochondria of oocytes, granulosa cells, and luteal cells, identify the multiple processes underlying changes in the ovary, especially late in the cessation of the reproductive life span, summarize the physiological and molecular actions of melatonin in the maintenance of normal ovaries and in the aging ovaries, and integrate the acquired information into an explanation for considering melatonin in the treatment of age-related infertility. Use of supplemental melatonin may help preserve fertility later in life and alleviate frustration in women delaying childbearing age, reduce the necessity of in vitro fertilization–embryo transfer (IVF-ET) procedures, and help solve the progressively increasing problem of non-aging-related infertility in women throughout their reproductive life span. While additional research is needed to fully understand the effects of melatonin supplementation on potentially enhancing fertility, studies published to date suggest it may be a promising option for those struggling with infertility.

Direct-to-consumer fertility testing: utilization and perceived utility among fertility patients and reproductive endocrinologists

RESEARCH QUESTION

What is the utilization of direct-to-consumer fertility tests (DTCFT) among fertility patients? How does the perceived utility of DTCFT differ between patients and reproductive endocrinologists (REI)?

DESIGN

Infertility patients visiting the Duke Fertility Center between December 2020 and December 2021 were sent an electronic invitation to participate in a patient survey. Members of the Society of Reproductive Endocrinology and Infertility were also sent e-mail invitations to participate in the REI survey. DTCFT were defined as tests not ordered by a physician or performed at a physician's office, including calendar methods of ovulation prediction, urinary ovulation prediction kits, basal body temperature (BBT) monitoring, hormone analysis, ovarian reserve testing and semen analysis. Patients and REI were asked how likely they were to recommend a given DTCFT, on a 0-10 Likert scale.

RESULTS

In total, 425 patients (response rate 50.5%) and 178 REI (response rate 21.4%) completed the surveys. Patients reported the utilization of calendar methods of ovulation prediction (83.8%), urinary ovulation prediction (78.8%), BBT monitoring (30.8%), hormone analysis (15.3%), semen analysis (10.1%) and ovarian reserve testing (9.2%). REI rated the utility of all DTCFT significantly lower than patients did (average discordance -4.2, P < 0.001), except for urinary ovulation prediction, which REI gave a significantly higher score (discordance +1.0, P < 0.001). Prior pregnancy was significantly associated with home ovulation prediction utilization among patients (adjusted odds ratio 3.21, 95% confidence interval 1.2-9.83).

CONCLUSIONS

Methods of ovulation prediction are commonly used by fertility patients. Significant discordance exists in the perceived utility of DTCFT between patients and REI. Patient education and guidelines are needed to better inform individuals considering DTCFT.

Identification of royal jelly as a potential new drug to protect the ovarian reserve and uterus against cyclophosphamide in rats

OBJECTIVE

The aim of this study was to investigate the effect of royal jelly (RJ), a powerful natural antioxidant, on cyclophosphamide-induced ovarian damage.

METHODS

Thirty-two Wistar albino rats were divided into four groups. Oral treatment was administered to all rats for 16 days after a single intraperitoneal injection. The control group received intraperitoneal and oral saline; the RJ group received intraperitoneal saline and 100 mg/kg/day oral RJ; the cyclophosphamide group received intraperitoneal 100 mg/kg cyclophosphamide and oral saline; and the treatment group received intraperitoneal 100 mg/kg cyclophosphamide and 100 mg/kg/day oral RJ. The groups were compared in terms of ovarian reserve tests and histopathological changes in the ovary and uterus.

RESULTS

All follicle counts were higher in the treatment group than in the cyclophosphamide group. The increase in the number of preantral follicles (p=0.001) and the decrease in the number of atretic follicles (p=0.004) were statistically significant. RJ treatment significantly improved follicular degeneration and cortical fibrosis in the ovary and epithelial and gland degeneration in the uterus due to cyclophosphamide toxicity.

CONCLUSION

According to these results, RJ reduces cyclophosphamide-related ovarian and endometrial damage in rats. For this reason, it should be further investigated to determine its effects on reproductive function.

Markers of ovarian reserve in women living with HIV: A systematic review

BACKGROUND

Anti-Mullerian hormone (AMH) levels indicate ovarian reserve and are predictive of reproductive aging. Studies evaluating AMH levels in women with HIV have produced conflicting results, and reasons for inter-study differences have not been assessed. To understand reproductive aging in HIV, we conducted a systematic review of ovarian reserve among women with HIV.

METHODS

We searched Ovid MEDLINE, Ovid EMBASE, and CAB Direct for studies including AMH in reproductive-aged women with HIV. Two reviewers used the Newcastle-Ottawa scale to assess the quality of extracted data.

RESULTS

Of the 315 reports screened, ten met the inclusion criteria. Studies were conducted across seven countries and included 3673 women with HIV and 2342 HIV-negative women in the comparison group. Ethnic distribution, combination antiretroviral therapy coverage, and viral load suppression varied considerably across studies. Nine of the ten reviewed studies reported lower unadjusted AMH levels in women with HIV than in those without HIV; however, in studies that adjusted for confounders (n = 4), only two showed an association between HIV and AMH. Low CD4 count and high viral load correlated with low AMH in the two largest studies. Other studies found that opioid use and elevated inflammatory markers were associated with low AMH. Study quality varied considerably, and many were of low quality (n = 6).

CONCLUSION

Current evidence is inconclusive about the relationship between HIV and AMH, although studies suggest a trend toward lower AMH among women with HIV. Future studies that adjust for HIV-related factors, inflammatory markers, and substance use are needed in the era of contemporary HIV care to confirm the association between HIV and reduced ovarian reserve and establish its underlying cause.

Influence of Seminal Metals on Assisted Reproduction Outcome

Increased levels of metal ions in human seminal fluid have a significant correlation with male fertility. Few publications explain the effect of metals in semen and their influence on assisted reproductive treatments. Semen parameters and the levels of twenty-two metals were measured in the seminal fluid of 102 men attended in a Reproductive Unit. Metals were determined by optical emission spectrophotometry. A statistical relationship was found between spermiogram and iron, which was lower than expected in pathological spermiograms (p = 0.032); zinc (p = 0.066), calcium (p = 0.047), and magnesium (p = 0.048) mean levels were higher in normozoospermics. More days of sexual abstinence correlates with higher seminal zinc (p = 0.001) and magnesium levels (p = 0.002). Lower vanadium values were found to be associated with higher fertilization rates (p = 0.039). Higher values of lead (p = 0.052) and vanadium (p = 0.032) were obtained in patients who did not reach 100% embryo cleavage rate. Aluminium (p = 0.042) and sodium (p = 0.002) were found in lower amounts associated with better blastocyst rates. The implantation rate shows an inverse association with women's age and iron and calcium content, compared to magnesium and sodium which presented a significant direct association with this percentage. A significant direct relationship was found between the positive evolution of pregnancy and the values of zinc (p = 0.004), calcium (p = 0.013), potassium (p = 0.002), and magnesium (p = 0.009). The study confirms that zinc, iron, calcium, sodium, aluminium, magnesium, vanadium, and lead have positive-negative effects on reproduction and support the analysis of metals in semen as a new line of study on male fertility with implications for reproductive outcomes.

Development, promotion, and application of online OvAge calculator based on the WeChat applet: Clinical prediction model research

Ovarian age assessment is an important indicator to evaluate the ovarian reserve function and reproductive potential of women. At present, the application of ovarian age prediction model in China needs further improvement and optimization to make it more suitable for the actual situation of women in China. In this study, we collected subjects and their data in three ways: firstly, we collected clinical data from a number of women go to local hospital, including healthy women and women with DOR or PCOS; secondly, we obtained data by recruited healthy women through CRO companies for a fee; thirdly, we collected data from a number of healthy women using WeChat applet. Using the data collected by CRO company and WeChat applet, we applied the generalized linear model to optimize the ovarian age prediction model. The optimized formula is: OvAge = exp (3.5254-0.0001*PRL-0.0231*AMH), where P = 0.8195 for PRL and P = 0.0003 for AMH. Applying the formula to the hospital population data set for testing, it showed that the predicted ovarian age in the healthy women was comparable to their actual age, with a root mean squared error (RMSE) = 5.6324. The prediction accuracy was high. These data suggest that our modification of the ovarian age prediction model is feasible and that the formula is currently a more appropriate model for ovarian age assessment in healthy Chinese women. This study explored a new way to collect clinical data, namely, an online ovarian age calculator developed based on a WeChat applet, which can collect data from a large number of subjects in a short period of time and is more economical, efficient, and convenient. In addition, this study introduced real data to optimize the model, which could provide insights for model localization and improvement.

Serum levels of anti-Müllerian hormone influence pregnancy outcomes associated with gonadotropin-releasing hormone antagonist treatment: a retrospective cohort study

As a specific predictor of ovarian reserve, serum anti-Müllerian hormone (AMH) has become an area of intense research interest in the field of assisted reproductive technology. We assessed the relationship between AMH levels and pregnancy outcomes in Chinese patients and investigate the influencing factors of cumulative live birth in patients with high AMH levels. A total of 1379 patients starting their IVF/ICSI cycle were divided into normal (Group A, 1.1-4.0 ng/ml, n = 639) and high (Group B, > 4.0 ng/ml, n = 740) groups by serum AMH levels. Live birth rate (LBR), cumulative live birth rate (CLBR) and cumulative clinical pregnancy rate (CCPR) were also investigated. Compared with Group A, Group B had a significantly higher CLBR (65.80% vs. 43.95%) and CCPR (76.77% vs. 57.14%), respectively. Binomial logistic regression analysis showed that age over 40 years, LH/FSH > 2.5, total Gn dose and Gn duration, and greater than 4000 ng/ml serum E2 levels on HCG day were significantly associated with CLBR in Group B. The AUC value of CLBR averaged 0.664 (ranging from 0.621 to 0.706) (p < 0.001). The patients with high AMH levels had higher CPR, higher LBR, and lower MR with no statistically significant differences, although there were significant improvements in CLBR. Advanced age (> 40 years) still impacted CLBR, even in women with good ovarian reserves. Consequently, it is still recommended that patients over 40 years old with high AMH levels actively receive IVF treatment if they seek to become pregnant. PCOS diagnoses did not influence the CLBR. In summary, this study showed that serum AMH levels could positively predict patient ovarian responses and further affect pregnancy outcomes.

AMH independently predicts aneuploidy but not live birth per transfer in IVF PGT-A cycles

BACKGROUND

While anti-Müllerian hormone (AMH) predicts quantitative IVF outcomes such as oocyte yield, it is not certain whether AMH predicts markers of oocyte quality such as aneuploidy.

METHODS

Retrospective case-control analysis of the SART-CORS database, 2014-2016, to determine whether anti-Müllerian hormone (AMH) predicts aneuploidy and live birth in IVF cycles utilizing preimplantation genetic testing for aneuploidy (PGT-A).

RESULTS

Of 51,273 cycles utilizing PGT-A for all embryos, 10,878 cycles were included in the final analysis; of these, 2,100 cycles resulted in canceled transfer due to lack of normal embryos and 8,778 cycles resulted in primary FET. AMH levels of cycles with ≥ 1 euploid embryo were greater than those of cycles with no normal embryos, stratifying by number of embryos biopsied (1-2, 3-4, 5-6, and ≥ 7), P < 0.017 for each stratum. Adjusting for age and number of embryos biopsied, AMH was a significant independent predictor of ≥ 1 euploid embryo for all age groups: < 35 yrs (aOR 1.074; 95%CI 1.005-1.163), 35-37 years (aOR 1.085; 95%CI 1.018-1.165) and ≥ 38 years (aOR 1.055; 95%CI 1.020-1.093). In comparative model analysis, AMH was superior to age as a predictor of  ≥ 1 euploid embryo for age groups < 35 years and 35-37 years, but not  ≥ 38 years. Across all cycles, age (aOR 0.945, 95% CI 0.935-0.956) and number of embryos (aOR 1.144, 95%CI 1.127-1.162) were associated with live birth per transfer, but AMH was not (aOR 0.995, 95%CI 0.983-1.008). In the subset of cycles resulting in ≥ 1 euploid embryo for transfer, neither age nor AMH were associated with live birth.

CONCLUSIONS

Adjusting for age and number of embryos biopsied, AMH independently predicted likelihood of obtaining ≥ 1 euploid embryo for transfer in IVF PGT-A cycles. However, neither age nor AMH were predictive of live birth once a euploid embryo was identified by PGT-A for transfer. This analysis suggests a predictive role of AMH for oocyte quality (aneuploidy risk), but not live birth per transfer once a euploid embryo is identified following PGT-A.

Protocatechuic Acid Delays Postovulatory Oocyte Ageing in Mouse

SCOPE

Tea is a popular beverage worldwide and has many health functions. Protocatechuic acid (PCA) is an important bioactive component of tea and has benefit to health. In some cases, oocytes after ovulation may miss the optimal fertilization time and enter a postovulatory ageing process. Therefore, to investigate the role of PCA in delaying oocyte ageing is aimed.

METHODS AND RESULTS

Metaphase II (MII) oocytes aged in vitro are randomly divided into three groups: control, aged, and aged + PCA. PCA treatment (30 µM) reduces the fragmentation rate and the incidence of abnormal spindle morphology and chromosome misalignment of oocytes aged 24 h in vitro. The mitochondrial dysfunction of aged oocytes, such as decreased mitochondrial membrane potential and excessive accumulation of reactive oxygen (ROS), is also alleviated by PCA. PCA also delays apoptosis of aged oocytes, and improves the sperm binding capacity. Otherwise, aged oocytes treated with PCA have a higher fertilization rate and blastocyst rate compared with untreated aged oocytes in vitro.

CONCLUSION

PCA is an important bioactive ingredient of tea that improves aged oocyte quality, suggesting that PCA is available to improve the quality of aged oocytes in vitro.

ROS-CCL5 axis recruits CD8+ T lymphocytes promoting the apoptosis of granulosa cells in diminished ovary reserve

Follicular atresia was initiated with the apoptosis of granulosa cells (GCs) mostly mediated by oxidative stress (OS). Our previous studies found that the number of CD8⁺ T cells and proportion of CD8⁺/CD4⁺ T cells increased in the follicles of diminished ovary reserve (DOR). However, the mechanism was still poorly explored. Herein, our results showed that the level of H₂O₂ in follicular fluid (FF) and reactive oxygen species (ROS) in GCs were increased, while the expression of SOD1, SOD2 and GPX1 was down-regulated in GCs with DOR. In addition, we found that OS within a certain range promoted the expression of CCL5 in GCs, which facilitated the infiltration of CD8⁺ T cells to the follicles. In vitro co-culture experiment showed that CD8⁺ T cells inhibited GCs proliferation and promoted their apoptosis through intrinsic apoptosis pathway. Maraviroc, the CCR5 antagonist, alleviated CCL5-induced immune attack of CD8⁺ T cells. Our results indicated that ROS-CCL5 axis recruited CD8⁺ T cells into FF resulting in the apoptosis of GCs in DOR. This has further implications for the understanding of the pathology of DOR and searching for the therapeutic management of this disease.

Quality of clinical prediction models in in vitro fertilisation: Which covariates are really important to predict cumulative live birth and which models are best?

The improvement in IVF cryopreservation techniques over the last 20 years has led to an increase in elective single embryo transfer, thus reducing multiple pregnancy rates. This strategy of successive transfers of fresh followed by frozen embryos has resulted in the acceptance of using cumulative live birth over complete cycles of IVF as a critical measure of success. Clinical prediction models are a useful way of estimating the cumulative chances of success for couples tailored to their individual clinical factors, which help them prepare for and plan future treatment. In this review, we describe several models that predict cumulative live birth and recommend which should be used by couples and/or their clinicians and when they should be used. We also discuss the most relevant predictors to consider when either developing new IVF prediction models or updating existing models.

Risk factors for clinical pregnancy loss after IVF in women with PCOS

RESEARCH QUESTION

Which factors are associated with the risk of clinical pregnancy loss in women with polycystic ovary syndrome (PCOS) undergoing IVF?

DESIGN

Case-control study nested in a multicentre randomized trial comparing live birth rates between fresh and frozen embryo transfer in women with PCOS. Women with the outcome of clinical pregnancy loss were selected as the case group, those with live birth as the control group. Parameters before IVF treatment and variables during ovarian stimulation and embryo transfer were compared.

RESULTS

Women with clinical pregnancy loss had higher maternal body mass index (BMI, P = 0.010), anti-Müllerian hormone (AMH, P = 0.032), 2-h glucose concentration after 75 g oral glucose tolerance test (OGTT, P = 0.025), and a higher proportion of fresh embryo transfers (P = 0.001). There were significant interactions between the types of transfer and antral follicle count (AFC, P = 0.013), 2-h glucose concentration after OGTT (P = 0.024) on clinical pregnancy loss in PCOS, indicating that these factors may have different effects on pregnancy loss after fresh versus frozen embryo transfer. When the multivariable logistic regression analysis was stratified by the fresh or frozen embryo transfer, AFC (adjusted odds ratio [aOR] 1.03, 95% confidence interval [CI] 1.01-1.05) was a risk factor for clinical pregnancy loss after fresh embryo transfer, while 2-hour glucose concentration after OGTT (aOR 1.13, 95% CI 1.01-1.25) was associated with clinical pregnancy loss in frozen embryo transfer (FET) cycles.

CONCLUSIONS

In women with PCOS, fresh embryo transfer, higher BMI, AFC and 2-h glucose concentration after OGTT were risk factors for clinical pregnancy loss. FET may be a better choice to decrease the risk of clinical pregnancy loss, especially for those with higher AFC. During FET, 2-h glucose after OGTT appears to be associated with clinical pregnancy loss and warrants close monitoring.

Age-related changes in serum anti-Müllerian hormone in women of reproductive age in Kenya

Background. Anti-Müllerian hormone (AMH) is produced by the granulosa cells of ovarian antral follicles and plays a role in therecruitment of dominant follicles during folliculogenesis. The serum level of AMH is proportional to the number of developing folliclesin the ovaries and reflects ovarian reserve. Nomograms of AMH variation with age exist from Caucasian populations, but there are none drawn from local African data.Objectives. To establish age-specific median serum AMH levels in an unselected East African population of women of reproductive age.Methods. We retrospectively analysed data on 1 718 women who underwent AMH testing using the Beckman Coulter AMH Gen IIenzyme-linked immunosorbent assay during the period 2015 - 2019 at Aga Khan University Hospital, Nairobi, Kenya. Age-specific median AMH levels were derived and presented in 5-year age bands. AMH levels were then log-transformed and, using linear regression in a natural spline function, presented on a scatter plot to demonstrate variation across reproductive age.Results. The median (interquartile range (IQR)) age of women who were tested for AMH was 38 (19 - 49) years. For the study population, the median (IQR) serum AMH level was 0.87 (0.01 - 17.10) ng/mL. The AMH concentration was inversely related to age, with a progressive decline whereby an increase of 1 year resulted in a corresponding decrease in AMH of 0.18 ng/mL. The proportion of women with decreased ovarian reserve increased exponentially with age from 14.9% in those aged 20 - 24 years to 48.7% at 35 - 39 years.Conclusion. From a large dataset of mainly black African women, this study confirms that serum AMH declines with advancing age,as reported elsewhere in Caucasian populations. There was, however, a higher than expected number of women with diminished ovarian reserve for age. Future studies prospectively exploring ovarian reserve in the general population could unravel underlying biological, reproductive and environmental factors that may influence AMH levels and reproductive capacity in this indigenous population.

Association between cigarette smoking and ovarian reserve among women seeking fertility care

INTRODUCTION

This study examined the association of smoking with ovarian reserve in a cross-sectional study of 207 women enrolled in the Louisville Tobacco Smoke Exposure, Genetic Susceptibility, and Infertility (LOUSSI) Study and assessed effect modification by NAT2 acetylator phenotype.

METHODS

Information on current smoking status was collected using a structured questionnaire and confirmed by cotinine assay. Serum anti-Müllerian hormone (AMH) levels were used to assess ovarian reserve. Diminished ovarian reserve (DOR) was defined as AMH <1ng/mL. Single nucleotide polymorphisms in the NAT2 gene, which metabolizes toxins found in cigarette smoke, were analyzed to determine NAT2 acetylator status. Linear and logistic regression were used to determine the effects of smoking on ovarian reserve and evaluate effect modification by NAT2. Regression analyses were stratified by polycystic ovary syndrome (PCOS) status and adjusted for age.

RESULTS

Current smoking status, either passive or active as measured by urinary cotinine assay, was not significantly associated with DOR. For dose-response assessed using self-report, the odds of DOR increased significantly for every additional cigarette currently smoked (Odds ratio, OR:1.08; 95% confidence interval, 95%CI:1.01-1.15); additionally, every 1 pack-year increase in lifetime exposure was associated with an increased odds of DOR among women without PCOS (OR: 1.08 95%CI: 0.99-1.18). These trends appear to be driven by the heavy or long-term smokers. Effect modification by NAT2 genotype was not established.

CONCLUSION

A history of heavy smoking may indicate increased risk of diminished ovarian reserve.

Age-specific random day serum antimüllerian hormone reference values for women of reproductive age in the general population: a large Chinese nationwide population-based survey

BACKGROUND

Antimüllerian hormone, the most reliable biomarker of ovarian reserve, is widely used in various clinical situations. Antimüllerian hormone levels consistently decrease with age. However, there is no standard, age-specific reference values for antimüllerian hormone in women of reproductive age, which limits its application.

OBJECTIVE

This study aimed to establish age-specific antimüllerian hormone percentile reference values for women of reproductive age.

STUDY DESIGN

A nationwide, population-based cross-sectional survey was conducted between May 2019 and April 2021 in 15 provinces and municipalities in mainland China. A total of 10,053 eligible women aged 20 to 49 years were selected using a multistage stratified sampling procedure. Women who were pregnant, had undergone ovarian surgery, took hormone drugs in the past 3 months, or had an antimüllerian hormone outlier value were excluded from establishing antimüllerian hormone percentile reference values. Serum antimüllerian hormone concentrations were measured using ultrasensitive, 2-site enzyme-linked immunosorbent assays (Ansh Lab, Webster, TX) in the Reproductive Endocrinology Laboratory of Peking University Third Hospital. Generalized additive models for location scale and shape with the Box-Cox t original distribution were used to estimate the fitted antimüllerian hormone percentile reference values.

RESULTS

A total of 9112 eligible women aged 21 to 49 years were included in the fitting model. The fitted 50th (2.5th-97.5th) percentiles of antimüllerian hormone values for women aged 21, 25, 30, 35, 40, 45, and 49 years were 4.83 (0.79-18.41), 4.47 (0.72-16.58), 3.67 (0.50-13.82), 2.59 (0.24-10.35), 1.35 (0.05-6.68), 0.33 (<0.01 to 3.40), and 0.04 (<0.01 to 1.77) ng/mL, respectively. The population-based decline rate of antimüllerian hormone accelerated with increasing age, especially age >35 years. The magnitude of the decline of the 25th antimüllerian hormone percentile curve was greater than that of the 75th percentile curve.

CONCLUSION

This study established age-specific antimüllerian hormone percentile reference values for women of reproductive age based on a large representative sample of the general population and described antimüllerian hormone changes. These findings may facilitate antimüllerian hormone application in clinical practices.

POSEIDON groups and their distinct reproductive outcomes: Effectiveness and cost-effectiveness insights from real-world data research

The Patient-Oriented Strategies Encompassing IndividualizeDOocyte Number (POSEIDON) criteria identify and classify the so-called 'low-prognosis' patients undergoing assisted reproductive technology (ART). Recent large-scale studies using real-world data (RWD) have shown that patients classified under this system have distinct reproductive outcomes. Moreover, these studies also confirm that POSEIDON patients are commonly found in fertility centers. RWD has substantiated the validity of the POSEIDON biomarkers' thresholds (antral follicle count [AFC] and/or anti-Müllerian hormone [AMH]) for patient classification. Lastly, a predictive model has been developed and validated to estimate the POSEIDON metric of success (i.e., number of oocytes needed to achieve at least one euploid blastocyst). Although more evidence is needed in this area, current insights from RWD research indicate that infertility patients can be counseled and managed more effectively under the POSEIDON scope, with potential gains for all parties involved.

Laparoscopic surgeries for uterine fibroids and ovarian cysts reduce ovarian reserve via age- and surgical type-manner

Aim: Diminished ovarian reserve can be characterized by poor response to ovulation and low number of eggs. The risk factors include endometriosis, receiving cancer treatment, luteal phase deficiency and gynecologic surgery. Uterine fibroids and ovarian cysts are the most common benign gynecological diseases in women globally. This prospective study evaluated the influence of laparoscopic surgery treating benign gynecological diseases on ovarian reserve. Methods: A total of 121 patients with uterine fibroids or benign ovarian cysts who received laparoscopic surgeries (41 with hysterectomy, 36 with myomectomy, 18 with adnexectomy, and 26 with ovarian cystectomy) were included. The ovarian reserve status defined as serum anti-Mullerian hormone concentration was assessed at 1 month before and after surgery, respectively. Results: The anti-Mullerian hormone reduction level was 22.34% in cystectomy, 44.1% in adnexectomy, 24.92% in myomectomy, and 47.61% in hysterectomy (p < 0.001). Multivariate analysis showed that adnexectomy had significantly high risk of high serum anti-Mullerian hormone reduction level (adjusted odds ratio (aOR): 14.90, 95% confidence interval (CI): 2.56-86.93, p = 0.003). Conclusions: These 4 laparoscopic surgeries all reduced the AMH levels 1 month after the procedure. Further prospective studies with longer follow-up are necessary to know the real impact on the ovarian reserve. Adnexectomy was an independent factor of reduced ovarian reserve in 1 month after surgery.

hsa-miR-320a-3p and hsa-miR-483-5p levels in human granulosa cells: promising bio-markers of live birth after IVF/ICSI

BACKGROUND

MicroRNAs (miRNAs) are considered potential biomarkers for various diseases. This study investigated whether hsa-miR-320a-3p and hsa-miR-483-5p levels in human ovarian granulosa cells derived from follicular fluids are associated with embryo developmental competence.

METHODS

We collected 195 granulosa cells samples and analyzed the treatment outcomes in patients undergoing in vitro fertilization (n = 147) or intracytoplasmic sperm injection (n = 48) cycles. The hsa-miR-320a-3p and hsa-miR-483-5p levels in granulosa cells were measured using quantitative reverse transcription-polymerase chain reaction.

RESULTS

Patients were subdivided into four groups according to the granulosa cells hsa-miR-320a-3p and hsa-miR-483-5p levels quartiles (Q1-Q4). Embryo developmental competence was compared using the chi-square test. Patients in Q3 were less likely to achieve a normal fertilization rate for in vitro fertilization and blastocyst formation than those in Q1 as they expressed high levels of hsa-miR-320a-3p and hsa-miR-483-5p (P < 0.05). Patients in Q3 and Q4 were less likely to achieve a good-quality embryo as they expressed high levels of hsa-miR-483-5p and hsa-miR-320a-3p (P < 0.05). The hsa-miR-320a-3p and hsa-miR-483-5p levels were not associated with clinical pregnancy. However, multiple regression analysis indicated that in Q3 and Q4 intervals had experienced a decreased chance of live birth due to high expression levels of hsa-miR-320a-3p and hsa-miR-483-5p levels. The relative hsa-miR-320a-3p expression levels in granulosa cells were weakly and positively correlated with the patient age (P = 0.0033). Moreover, both the basal follicle stimulating hormone (P = 0.0003) and ovarian stimulation protocols (P = 0.006 and P = 0.004) significantly and positively affected hsa-miR-320a-3p levels. The days of stimulation was negatively correlated with the relative hsa-miR-320a-3p expression level (P = 0.047).

CONCLUSIONS

The hsa-miR-320a-3p and hsa-miR-483-5p levels in human granulosa cells negatively correlated with the good-quality embryo rate and live birth, indicating that hsa-miR-320a-3p and hsa-miR-483-5p can be used as potential negative indicators to predict good-quality embryos and live births.

Age-related changes in Folliculogenesis and potential modifiers to improve fertility outcomes - A narrative review

Reproductive aging is characterized by a decline in oocyte quantity and quality, which is directly associated with a decline in reproductive potential, as well as poorer reproductive success and obstetrical outcomes. As women delay childbearing, understanding the mechanisms of ovarian aging and follicular depletion have become increasingly more relevant. Age-related meiotic errors in oocytes are well established. In addition, it is also important to understand how intraovarian regulators change with aging and how certain treatments can mitigate the impact of aging. Individual studies have demonstrated that reproductive pathways involving antimullerian hormone (AMH), vascular endothelial growth factor (VEGF), neurotropins, insulin-like growth factor 1 (IGF1), and mitochondrial function are pivotal for healthy oocyte and cumulus cell development and are altered with increasing age. We provide a comprehensive review of these individual studies and explain how these factors change in oocytes, cumulus cells, and follicular fluid. We also summarize how modifiers of folliculogenesis, such as vitamin D, coenzyme Q, and dehydroepiandrosterone (DHEA) may be used to potentially overcome age-related changes and enhance fertility outcomes of aged follicles, as evidenced by human and rodent studies.

Age Group-specific Reference Intervals for the Elecsys Anti-Müllerian Hormone Assay in Healthy Korean Women: a Nationwide Population-based Study

Background

Anti-Müllerian hormone (AMH) is one of the most reliable markers of ovarian reserve. Automated AMH assays are widely used in clinical laboratories, but reference intervals for the Elecsys AMH assay for Asian populations have not yet been determined. We aimed to determine reference intervals in healthy Korean women.

Methods

The study included 1,450 women aged 19 to 54 years who participated in the Korea National Health and Nutrition Examination Survey between 2013 and 2016. The study participants were divided into seven 5-year age groups. AMH and progesterone concentrations were measured using Roche Elecsys assays, and bone morphogenetic protein-15 (BMP15) was genotyped for the detection of major variants. Age group-specific reference intervals for AMH were established as recommended by the CLSI EP28-A3c guidelines.

Results

The mean age was 37.4 years. AMH concentrations decreased with increasing age, especially after 40 years, with the median AMH decreasing from 30.9 pmol/L in participants of 19-24 years to 0.071 pmol/L in participants of 50-54 years. The mid-95 percentile AMH reference intervals decreased from 7.93-81.21 pmol/L in participants of 19-24 years to 0.07-3.86 pmol/L in participants of 50-54 years. Disease-associated BMP15 variants were not detected.

Conclusions

We determined Elecsys AMH assay reference intervals in healthy Korean women. The results may provide basic information for the interpretation of AMH concentrations and assessment of ovarian reserve in Korean women.

Fertility With Early Reduction of Ovarian Reserve

Female infertility is defined as the failure to conceive after a year of frequent, unprotected sexual activity. Infertility affects 8-10% of females worldwide. There are many causes of infertility. One of them is diminished ovarian reserve (DOR). In this condition, the ovary loses its reproductive potential, which affects fertility. This condition may be caused due to injury, but it usually results from aging. DOR is one of the main reasons for infertility in women worldwide. A woman with DOR has fewer eggs in her ovaries than usual. The quality of the remaining eggs may not be bad. This condition impairs the development of existing eggs. Patients with DOR may be able to get pregnant if they are properly treated according to their profile. Their treatments are individually tailored according to their needs. These patients should be recommended a robust approach toward treatment and increasing fertility. The chances of pregnancy increase if the treatment is started early.

Comparison of efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of cesarean scar pregnancy

To compare the efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of caesarean scar pregnancy (CSP). 60 patients with CSP admitted to our hospital were selected as the study subjects, and divided into observation group (n = 35) and control group (n = 25) in accordance with the therapeutic options. The observation group was treated with ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, while the control group was treated with hysteroscopic electro-resection after methotrexate chemotherapy. The observation group was superior to the control group in the amount of intraoperative haemorrhage, in-hospital costs, and postoperative time to control vaginal haemorrhage, time to return to a normal serum human chorionic gonadotropin (HCG) level. The observation group had a lower incidence rate of adverse reactions (5.71% vs. 28.00%, p < .05) and a higher first-attempt success rate for treatment (85.71% vs. 84.00%, p > .05) compared with the control group. Ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP. IMPACT STATEMENTWhat is already known on this subject? Caesarean scar pregnancy (CSP), a rare form of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section (CS), is a long-term complication of CS that may be life-threatening for parturients. Some therapies have been used to treat CSP, such as uterine artery embolisation and uterine artery embolisation chemotherapy combined with curettage, but the potential adverse effects may affect the ovarian reserve and even affecting the fertility of patients.What do the results of this study add? This study showed that ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP.What are the implications of these findings for clinical practice and/or further research? The findings of this study may provide some references for the clinical practitioners and further research and may contribute to the treatment of CSP.

The role of FSH to AMH ratio in poor prognosis patients undergoing ICSI cycle

Objective:

The objective of this study was to estimate the number of oocyte retrieval and cycle cancellation using follicle stimulating hormone (FSH) to anti-Mullerian hormone (AMH) ratio in poor prognosis patients undergoing intracytoplasmic sperm injection treatment.

Material and Methods:

This retrospective study including fresh cycles was conducted in Zekai Tahir Burak Women’s Health Training and Research Hospital, between January 2015 and October 2018. Women aged between 24 and 44 years were recruited and the baseline serum hormone levels, FSH/AMH ratio, and the antral follicle count were recorded. Number of retrieved oocytes, metaphase-II oocytes, fertilised oocytes, and the number and grade of the embryos were also recorded.

Results:

A total of 108 cycles, corresponding to 92 women with poor prognosis were eligible for analysis. The use of FSH/AMH ratio performed well in predicting retrieved oocyte count <5 with an area under the curve (AUC) of 0.82 [95% confidence interval (CI): 0.71-0.92]. A FSH/AMH ratio cut-off of 11.36 was set for the retrieval of <5 oocyte at oocyte pick-up (OPU) with 80% sensitivity and 87% specificity. The FSH/AMH cut-off value was 14.22 to differentiate cycle cancellation and no oocyte retrieval at OPU, with a sensitivity of 91% and a specificity of 44% (AUC of 0.71; 95% CI: 0.59-0.83). There was no correlation between FSH/AMH ratio and clinical pregnancy.

Conclusion:

The assessment of this simple ratio at the beginning of the cycle may help clinicians better anticipate gonadotropin stimulation treatment and better counsel patients about cycle cancellation and the expected oocyte yield.

Evaluation of anti-Müllerian hormone in pre-menopausal women stratified according to thyroid function, autoimmunity and age

Background

AMH is a reliable index of ovarian reserve. It is not clear whether, or how much, thyroid function and/or thyroid autoimmunity can impair ovarian function and AMH secretion in the long term.

Aim

This retrospective cross-sectional study compared AMH levels in pre-menopausal women with/without positive thyroid autoimmunity or hypofunction.

Methods

From January 2019 to May 2022, AMH was evaluated in 250 pre-menopausal women not undergoing assisted fertility procedures who were referred to a secondary endocrine centre. Thyroid function and autoimmunity, sonographically measured thyroid volume, FSH and E2 in the early follicular phase, and PRL and progesterone in the luteal phase were also evaluated. Exclusion criteria were: age < 18 years, genetic hypogonadism, pregnancy and previous treatments that have potentially damaging effects on gonads.

Results

We evaluated 171 women (mean age ± SD: 31.5 ± 9.0 years) off L-T4 treatment and 79 women on L-T4 treatment (39.7 ± 9.5 years; P < 0.001). AMH (median, IQR, CI) was 16.1 pmol/l (7.1 – 35.7 pmol/l, 21.4 – 29.9 pmol/l) and 7.6 pmol/l (1.4 – 17.8 pmol/l, 8.6 – 14.7 pmol/l; P < 0.001), respectively. When the women were stratified according to age (18-25, 26-30, 31-35, 36-40, 41-45, > 46 years) no significant difference emerged between those on/off L-T4 treatment in groups of the same age-range. In women on- or off-L-T4 treatment, AMH was negatively related with age on univariate and multivariate analyses (P < 0.0001). In both groups, AMH was negatively related to FSH (P < 0.0001). On multivariate analysis, AMH was positively related to the age of the mother on spontaneous menopause (P = 0.006) and negatively to thyroid volume (P = 0.02) in women on L-T4. AMH levels were significantly (P = 0.03) higher in TPOAb-negative than in TPOAb-positive women, but age was significantly (P = 0.001) lower in TPOAb-negative than in TPOAb-positive women.

Conclusions

In our cohort of women, age proved to be a better predictor of AMH levels than any of the other factors linked to thyroid function and autoimmunity. Our data do not support the hypothesis that subclinical hypothyroidism and/or autoimmunity are associated with decreased ovarian reserve. However, a larger number of cases is needed in order to obtain conclusive data.

Are antral follicle count and serum anti-Mullerian hormone level, as reliable markers of ovarian reserve, affected by UV radiation?

ObjectiveWe aimed to assess whether ovarian reserve test including serum follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), anti-Mullerian hormone (AMH) levels, and antral follicle count (AFC) which are ovarian reserve markers are affected by ultraviolet (UV) radiation or not.MethodsWomen between the ages of 25 and 40 who served as flight crew constituted the study population in this prospective case-control study. Age-matched women having no risk factor for low ovarian reserve were selected as control group. Participants were compared according to age, duration in profession, and ovarian reserve markers.ResultsA total of 134 patients were included: 66 participants in study group and 68 participants in control group. Serum AMH levels and AFC were found to be significantly lower while serum FSH and E2 levels were significantly higher in the study group. This difference was found to be more significant, especially in the advanced age group. When the participants were classified according to their working time, lower ovarian reserve was observed in women with longer working time.DiscussionWorking for a while in the air and being closer to the sun have negative effects on ovarian functions. Preventive measures may be taken earlier in flight crew than those in the normal population to prevent the decline of ovarian functions and possible conceiving problems.

Assessment of ovarian reserve in patients with type 1 diabetes: a systematic review and meta-analysis

PURPOSE

Current knowledge about the ovarian reserve in patients with type 1 diabetes is inconsistent and based on studies with small sample size. This meta-analysis aimed to produce a comprehensive evaluation on the ovarian reserve of type 1 diabetes female patients and to analyze the associated factors with the ovarian reserve.

METHODS

Systematic searches were conducted for studies published from the inception to December 2021. Original human observational studies either with case-control, cross-sectional, or longitudinal design evaluating ovarian reserve markers between type 1 diabetes patients and healthy controls were included. Levels of anti-müllerian hormone (AMH), follicle-stimulating hormone (FSH), and estradiol (E2) were extracted.

RESULTS

It was indicated that women with type 1 diabetes were associated with decreased levels of AMH compared with healthy controls (weighted mean difference [WMD] -0.70 ng/ml, 95% confidence intervals [CI] -1.05 to -0.34 ng/ml, P = 0.0001). Subgroup analyses stratified by age showed that adult patients with type 1 diabetes were associated with decreased levels of AMH (WMD -0.70 ng/ml, 95% CI -1.06 to -0.34 ng/ml, P = 0.0001) and FSH (WMD -1.07 IU/L, 95% CI -1.75 to -0.39 IU/L, P = 0.002) compared with healthy controls. Meta-regression analysis showed no significant correlation between AMH, FSH, and clinical factors, while level of E2 was negatively correlated with daily insulin doses and glycosylated hemoglobin A1c (HbA1c) values.

CONCLUSION

According to this meta-analysis, type 1 diabetes might be associated with decreased AMH levels. Further studies using different markers and fertility outcomes focus on the ovarian reserve of women with type 1 diabetes are urgently needed.

Endocrine disrupting chemicals impact on ovarian aging: Evidence from epidemiological and experimental evidence

Endocrine-disrupting chemicals (EDCs) are ubiquitous in daily life, but their harmful effects on the human body have not been fully explored. Recent studies have shown that EDCs exposure could lead to infertility, menstrual disorder and menopause, resulting in subsequent effects on female health. Therefore, it is of great significance to clarify and summarize the impacts of EDCs on ovarian aging for explaining the etiology of ovarian aging and maintaining female reproductive health. Here in this review, we focused on the impacts of ten typical environmental contaminants on the progression of ovarian aging during adult exposure, including epidemiological data in humans and experimental models in rodents, with their clinical phenotypes and underlying mechanisms. We found that both persistent (polychlorinated biphenyls, perfluoroalkyl and polyfluoroalkyl substances) and non-persistent (phthalates) EDCs exposure could increase an overall risk of ovarian aging, leading to the diminish of ovarian reserve, decline of fertility or fecundity, irregularity of the menstrual cycle and an earlier age at menopause, and/or premature ovarian insufficiency/failure in epidemiological studies. Among these, the loss of follicles can also be validated in experimental studies of some EDCs, such as BPA, phthalates, parabens and PCBs. The underlying mechanisms may involve the impaired ovarian follicular development by altering receptor-mediated pro-apoptotic pathways, inducing signal transduction and cell cycle arrest and epigenetic modification. However, there were inconsistent results in the impacts on fertility/fecundity, menstrual/estrous cycle and hormone changes response to different EDCs, and differences between human and animal studies. Our review summarizes the current state of knowledge on ovarian disrupters, highlights their risks to ovarian aging and identifies knowledge gaps in humans and animals. We therefore propose that females adopt healthy lifestyle changes to minimize their exposure to both persistent and non-persistent chemicals, that have the potential damage to their reproductive function.

Seasonal dynamic of cholecalciferol (D3) and anti-Muellerian hormone (AMH) with impact on ovarian response and IVF/ICSI

OBJECTIVE

Recent studies revealed intriguing associations between cholecalciferol (D3) and reproductive functions. Seasonal changes of D3 concentrations are well known; however, they are not always considered in the context of reproductive functions. In this study, we analyzed D3 serum concentration in IVF/ICSI patients with respect to seasonal 3-month quartiles and anti-Muellerian hormone (AMH) referring to the impact on Assisted Reproductive Technologies (ART) outcome.

MATERIALS AND RESEARCH METHODS

We studied 469 female patients, presenting between 2012 and 2018 for ART treatment in our fertility center. D3 as well as the AMH serum concentrations were measured at the beginning of the follicle stimulation (days 3-5 of menstrual cycles). Results were evaluated with respect to seasonal quartiles and outcome of the ART cycles.

RESULTS

D3 concentrations showed significant fluctuations within annual quartiles with a pronounced peak in August-October and a minimum in February-April (26.0 vs. 20.5 mg/dl; p < 0.0001). Similar seasonal dynamics were found for AMH (2.98 vs. 1.78 ng/ml; p = 0.010) and these were associated with significantly shorter stimulation periods during August-October (11.29 vs. 12.12 days; p = 0.042), higher number of fertilized oocytes between August and October (6.23 vs. 4.97; p = 0.05) along with a trend towards higher numbers of cumulus-oocyte complexes. However, no such differences were found for the numbers of MII oocytes or pregnancy rates.

CONCLUSION

Our data indicate seasonal 3-month quartile variations of AMH concentrations and characteristics of ART, such as days of ovarian stimulation and number of fertilized oocytes. Highest AMH concentrations were found between August and October and this quartile was associated with highest D3 concentrations.

Assessment of Ovarian Reserve in Patients with Migraine

Objective The aim of our study is to investigate the relationship between migraine and ovarian reserve. Methods The study group consists of women between the ages of 25-51, including 44 patients diagnosed with migraine and 43 controls. Ovarian reserves were performed by antral follicle count and measured anti-Müllerian hormone level. The cohort was divided into four subgroups according to age as follows: 30 years and below, 31-35 years, 36-40 years, and 41 years of age and above. Results Of the 87 individuals included in this study, 44 were migraine patients, and 43 were healthy controls. The mean ages of the study and control groups were 34.3 (minimum: 25, maximum: 51) and 36.5 (minimum: 27, maximum: 51) years, respectively. There was no statistically significant difference between the two groups regarding age (p=0.48). In the study and control groups, respectively; mean AMH levels were 2.67 ± 2.46 ng/mL and 2.55 ± 2.38 ng/mL (p=0.819), mean basal FSH levels were 7.92 ± 2.52 U/L and 9.11 ± 3.19 U/L (p=0.066), mean basal LH levels were 6.35 ± 3.59 U/L and 6.06 ± 2.86U/L (p=0.681), mean basal estradiol levels were 65.02 ± 69.54 ng/L and 49.47 ± 27.08 ng/L (p=0.244), and mean AFC were 10.9 ± 3.9 and 10.2 ± 3.7 (p=0.435). Between subgroups aged ≤30 years, serum anti-Müllerian hormone levels were found to be significantly different (p=0.036). There was no statistically significant difference between any age subgroups in terms of antral follicle count. Conclusion In conclusion, detecting possible reduction of ovarian reserves in reproductive-age (especially younger than 30 years) migraine patients by utilizing anti-Müllerian hormone and ultrasonographic markers would allow these women to make cognizant decisions regarding marriage and family planning, as well as inform them whether they are in early menopause risk

Anti-Müllerian hormone, an ovarian reserve marker in hypogonadotropic hypogonadism

OBJECTIVE

To determine the usefulness of Anti-Müllerian Hormone (AMH) and antral follicle count (AFC) as an ovarian reserve marker in hypogonadotropic hypogonadism (HH) patients and to find a limit value for the gonadotropin levels in the diagnosis of HH patients.

STUDY DESIGN

It is a retrospective cross-sectional single-center study. One hundred ninety-nine women with HH and 171 healthy controls with no cycle disorders were included into this study. Continuous variables were expressed as mean ± standard deviation. Statistical comparisons were carried out according to the intention to treat by Student's t-test, Mann-Whitney U test, where appropriate. Receiver operating characteristic curve-ROC was used to represent the sensitivity and specificity pair corresponding to decision threshold of FSH and LH levels in HH diagnosis. P < 0.05 was accepted to be statistically significant.

RESULTS

There was not any statistically significant difference between HH and control group regarding the age (23.94 ± 6.56 vs. 23.92 ± 3.01, respectively; p = 0.09). Serum AMH levels didn't show statistically significant difference between HH and control group (3.26 ± 2.61 ng/mL vs. 3.15 ± 1.46 ng/mL, respectively; p = 0.11). The difference of AFC between HH and control group was statistically significant (6.67 ± 6.33 vs. 10.91 ± 2.92, respectively; p < 0.001). Follicle-stimulating hormone (FSH), Luteinizing-hormone (LH) and Estradiol (E₂) levels between the groups were found to be significantly different. Area under the receiver operating characteristic curve-ROC for FSH was 0.98 and for LH was 0.96. For the diagnosis of HH, FSH levels lower than 3.05 IU/L (with a sensitivity of 92% and specificity of 94%) and LH levels lower than 1.55 IU/L (with a sensitivity of 91% and specificity of 92%) can be used.

CONCLUSION

In conclusion, serum AMH levels reflect the follicle cohort in HH cases validly with negligible underestimation of ovarian reserve. FSH < 3.05 IU/L and LH < 1.55 IU/L could be used with high sensitivity and specificity for the diagnosis of HH.

Effect of salpingectomy on ovarian reserve: A systematic review and meta-analysis

AIM

To determine the effect of salpingectomy on ovarian reserve.

METHODS

PubMed, EMBASE, Web of Science, Dynamed plus, and Cochrane Controlled Trials Register databases were searched from their inception to December 2020 to identify relevant studies, including cross-sectional studies, retrospective studies, and randomized controlled trials. Studies that compared anti-Müllerian hormone (AMH) levels and/or antral follicle count (AFC) between the control and salpingectomy groups or before and after surgery were included.

RESULTS

Twenty-one articles were included in the systematic review. Meta-analyses were performed on 16 studies in which data were presented as mean ± SD values. A meta-analysis comparing AMH levels before and after surgery in the same patients showed no significant decrease in all cases, irrespective of whether it was unilateral or bilateral salpingectomy. There was no significant decrease in the AFC in the meta-analysis comparing levels before and after bilateral salpingectomy, either. In contrast, in the case-controlled study the salpingectomy group had significantly lower levels of AMH in all meta-analyses of unilateral and bilateral surgery (mean difference: -0.31, 95% confidence interval [CI]: -0.55, -0.07), only unilateral cases (mean difference: -0.28, 95% CI: -0.50, -0.06), and only bilateral cases (mean difference: -0.71, 95% CI: -1.19, -0.23). The salpingectomy group that included unilateral and bilateral cases had significantly lower AFC compared with no-surgery controls (mean difference: -1.31, 95% CI: -2.13, -0.48).

CONCLUSION

Although not conclusive, it does appear that patients who underwent salpingectomy (either unilateral or bilateral) have a decreased ovarian reserve.

Ovarian failure risk in post-pubertal patients with cancer: a prognostic model

Aim: To develop a predictive model for ovarian failure (OF) after chemotherapy in young post-pubertal women with cancer. Methods: Retrospective, monocentric cohort study including 348 patients referring to the Oncofertility Unit of San Raffaele Hospital (Milan, Italy) from August 2011 to January 2020. A predictive model was constructed by multivariate logistic regression and receiver operating characteristic analysis. Results: Data about menstrual function resumption were available for 184 patients. The best predictive model for OF was identified by the combination of age; number of chemotherapy lines; vincristine, adriamycin, ifosphamide/adriamycin, ifosphamide; capecitabine; adriamycin, bleomycine, vinblastine, doxorubicin (area under the curve= 0.906, CI 95% 0.858-0.954, p = 0.0001). Conclusions: The model predicts the probability of loss of ovarian function at cancer diagnosis and with every change of treatment.

Can nanomaterials support the diagnosis and treatment of human infertility? A preliminary review

Human infertilities are disorders that afflict many people all over the world. Both male and female reproductive systems must work together in a precise and coordinated manner and infertility has a wide range of problems for this system. Recent advances in nanomedicine immensely helped design the diagnostic and therapeutic approaches to alleviate human infertility in both sexes. Nanoscience has recently been used by researchers to increase the detection limit of infertility-related biomarkers via fabricating sensitive nanobiosensors for detecting follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-müllerian hormone (AMH), pregnancy-associated plasma protein-A (PAPP-A), progesterone, and testosterone. At the same time, a variety of nanostructures, including magnetic nanoparticles (i.e., zinc nanoparticles, cerium nanoparticles, gold nanoparticles, silver nanoparticles), nano-vitamins, extracellular vesicles, and spermbots, have shown promising outcomes in the treatment of human infertilities. Despite recent advancements, some nanostructures might have toxic effects on cells, especially germ cells, and must be optimized with the right ingredients, such as antioxidants, nutrients, and vitamins, to obtain the right strategy to treat and detect human infertilities. This review presents recent developments in nanotechnology regarding impairments still faced by human infertility. New perspectives for further use of nanotechnology in reproductive medicine studies are also discussed. In conclusion, nanotechnology, as a tool for reproductive medicine, has been considered to help overcome current impairments.

The effect of micronutrient supplementation on serum anti-Mullerian hormone levels: a retrospective pilot study

BACKGROUND

The anti-Müllerian-hormone (AMH) is secreted by the granulosa cells of the oocytes and can be used as a marker of the ovarian reserve; helpful to estimate female fertility or the menopause onset. Although various factors may influence AMH levels, the correlation with nutritional factors needs more research.

OBJECTIVE

To evaluate the effect of a micronutrient supplementation on female AMH levels.

METHODS

This retrospective analysis includes a total of 244 women, who attended the Karl Landsteiner Institute, Korneuburg, Austria from January 2013 to June 2019 due to an unfulfilled desire for a child. All women were treated with an oral micronutrient preparation consisting the dosage of one soft capsule and one tablet per day for 3 months. The soft capsule contains omega-3 fatty acids and the tablet is a standardized combination of coenzyme Q₁₀, vitamin E, folic acid, selenium, catechins from green tea extract, and glycyrrhizin from licorice extract. Serum AMH levels before and after 3 months were compared. In addition, available clinical data such as ovulation frequency, endometrium thickness, and luteal phase duration were analyzed.

RESULTS

The mean age of the women was 37.3 ± 1.8 years, the mean body mass index of 24.3 ± 4.6 k/m². The mean serum AMH levels and endometrial thickness values were significantly higher after micronutrient supplementation as compared to baseline (1.42 ± 0.86 versus 1.86 ± 0.82 ng/mL and 6.10 ± 1.76 versus 7.29 ± 1.65 mm, respectively). In addition, ovulation frequency and luteal phase duration significantly improved in more than 60%.

CONCLUSION

Proposed micronutrient supplementation had a positive effect on serum AMH levels, endometrial thickness, ovulation frequency, and luteal phase duration. It could be a simple, risk-free therapeutic option to improve female fertility. More research is warranted to prove this effect.

Virtual Compared With In-Clinic Transvaginal Ultrasonography for Ovarian Reserve Assessment

OBJECTIVE

To evaluate noninferiority of virtual transvaginal ultrasonography compared with in-clinic ultrasonography for ovarian reserve assessment.

METHODS

We conducted a single-site, head-to-head crossover trial. Participants performed self-administered virtual transvaginal ultrasonography at home, guided by a remote-certified ultrasound technologist, then underwent transvaginal ultrasonography in-clinic with another ultrasound technologist. Participants were women in the greater Boston area interested in evaluating ovarian reserve and recruited through social media, health care referrals, and professional networks. The uterus and ovaries were captured in sagittal and transverse views. These randomized recordings were reviewed by two or three independent, blinded reproductive endocrinologists. The primary outcome was noninferiority of the rate of clinical quality imaging produced at home compared with in clinic. Sample size was selected for greater than 90% power, given the 18% noninferiority margin. Secondary outcomes included antral follicle count equivalency and net promoter score superiority.

RESULTS

Fifty-six women were enrolled from December 2020 to May 2021. Participants varied in age (19-35 years), BMI (19.5-33.9), and occupation. Ninety-six percent of virtual and 98% of in-clinic images met "clinical quality." The difference of -2.4% (97.5% CI lower bound -5.5%) was within the noninferiority margin (18%). Antral follicle counts were equivalent across settings, with a difference in follicles (0.23, 95% CI -0.36 to 0.82) within the equivalence margin (2.65). Virtual examinations had superior net promoter scores (58.1 points, 97.5% CI of difference 37.3-79.0, P<.01), indicating greater satisfaction with the virtual experience.

CONCLUSION

Virtual transvaginal ultrasonography remotely guided by an ultrasonography technologist is noninferior to in-clinic transvaginal ultrasonography for producing clinical quality images and is equivalent for estimating antral follicle count. Virtual transvaginal ultrasonography had superior patient satisfaction and has potential to significantly expand patient access to fertility care.

FUNDING SOURCE

This study was sponsored by Turtle Health.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04687189.

Altered T lymphocyte subtypes and cytokine profiles in follicular fluid associated with diminished ovary reserve

PROBLEM

Diminished ovarian reserve (DOR) is a daunting obstacle in in vitro fertilization (IVF) or intra cytoplasmic sperm injection (ICSI), leading to poor reproductive outcomes. We aim to characterize the T cell and cytokine profiles in follicular fluid (FF) and elucidate its contribution to the development of DOR.

METHOD OF STUDY

A total of 92 infertile women were enrolled in the study. We assessed the ultrastructure, proliferation, and apoptosis of granulosa cells (GCs). The levels of CCL5 and cytokines in FF was measured. Additionally, we classified the T cells and analyzed cytokines production in T cell. We further verified whether CCL5 can recruit specific T cell subcytes to the follicles.

RESULTS

Cytoplasmic vacuolization, nucleolar dissociation, partial shortening, swelling, and fusion of mitochondrial cristae were obvious in GCs with DOR. The proliferation of GCs decreased and the proportion of apoptosis increased in DOR. The down-regulation of Bcl-2 and up-regulation of caspase3 were seen in GCs with DOR. The number of CD8⁺ T cells and proportion of CD8⁺ /CD4⁺ T cells in DOR exceeded the control. Higher positive percentage of CD69, CCR5, and IFN-γ in CD8⁺ T cells, lower positive percentage of IL-10 in CD4⁺ T cells and PD-1 in CD8⁺ T cells were detected in DOR. CCL5 accumulated promoting the recruitment of CD8⁺ T cells to the follicles on interaction with CCR5.

CONCLUSION

The abnormal proportion of CD8⁺ T cells and elevated CCL5 and IFN-γ may change the immune balance in FF and impair the growth of GCs, which in turn fuel the progression of DOR.

Radioactive iodine and female fertility

Radioactive iodine (I¹³¹) is used after surgery in the treatment of Differentiated Thyroid Carcinoma (DTC). There is no solid evidence about the potential deleterious effect of I¹³¹ on women fertility. The objective of this study is to assess the impact that I¹³¹ may have on fertility in women. All women followed by DTC in our department have been analyzed and women younger than 45 years old at the time of diagnosis and initial treatment were included. There were 40 women exposed to I¹³¹ (study group) and 11 women who were only treated with thyroidectomy (control group). Of the women exposed to I¹³¹, 40% went through early menopause, while no cases were reported among their controls. Furthermore, 29.2% of women exposed to I¹³¹ had decreased Antimüllerian Hormone (AMH), compared to the only 11% of unexposed women (not significant). Regarding the fertility impairment "perceived" by patients, in the group of women exposed to iodine, 17.9% described being unable to complete their genesic desire whereas, none was registered in the control group. We conclude that radioactive iodine can affect a woman's fertility and shorten her reproductive life, so this is an aspect that should be taken into consideration.

COVID-19 disease does not cause ovarian injury in women of reproductive period: An observational before-and-after COVID-19 study

Research question

Design

Results

Conclusion

Dietary patterns are associated with improved ovarian reserve in overweight and obese women: a cross-sectional study of the Lifestyle and Ovarian Reserve (LORe) cohort

BACKGROUND

Growing evidence suggests that adherence to certain dietary patterns is associated with improved fecundity and reproductive outcomes in the general population and infertile couples assisted reproductive treatments. The objective of this study was to assess if dietary patterns are associated with ovarian reserve in reproductive age women without a history of infertility.

METHODS

This was a cross-sectional study of 185 women in the Lifestyle and Ovarian Reserve (LORe) cohort. Women aged 18-44 without a history of infertility were recruited from the local community at an academic medical center. Subjects completed validated food frequency and physical activity questionnaires to assess patterns over the year prior to presentation. Dietary patterns including a Western (including meat, refined carbohydrates, high-calorie drinks), prudent (including fruits, vegetables, olive oil and nuts), fertility (lower intake of trans fat with higher intake of monounsaturated fatty acids, increased intake of plant based protein, high-fat dairy, lower glycemic load carbohydrates and supplemental iron) and profertility diet (PFD) (characterize by whole grains, soy and seafood, low pesticide residue produce, supplemental folic acid, B12 and vitamin D) were identified through principal component analysis. Main outcome measures were serum antimullerian hormone concentration (AMH) (ng/mL) and antral follicle count (AFC) obtained by transvaginal ultrasound.

RESULTS

After stratifying by BMI, adjusting for age, smoking and physical activity, dietary patterns were not associated with ovarian reserve in normal weight women. Increased adherence to a profertility diet in overweight and obese women (BMI ≥ 25 kg/m²) was associated with a significantly higher AMH. Women in the third and fourth quartiles of PFD adherence had a mean AMH concentration of 1.45 ng/mL (95%CI 0.33-2.56, p = 0.01) and 1.67 ng/mL (95%CI 0.60-2.74, p = 0.003) higher than women in the lowest quartile respectively. The highest adherence to PFD was also associated with a higher AFC in women with a BMI ≥ 25 kg/m² (β = 7.8, 95%CI 0.003-15.34, p < 0.05). Other common dietary patterns were not significantly associated with ovarian reserve.

CONCLUSIONS

Increased adherence to a profertility diet is associated with improved markers of ovarian reserve in overweight and obese women. These findings provide novel insight on potential modifiable lifestyle factors associated with ovarian reserve.