A low number of retrieved oocytes at in vitro fertilization treatment is predictive of early menopause

Diminished ovarian reserve in a woman with a balanced 13;21 translocation

OBJECTIVE

To present the a case of decreased ovarian reserve in a patient with a balanced 13;21 translocation.

DESIGN

Case report.

SETTING

Reproductive endocrinology and infertility practice in a university teaching hospital.

PATIENT(S)

A 33-year-old caucasian woman with primary infertility.

INTERVENTION(S)

Laboratory evaluation, hysterosalpingogram, karyotype analysis, semen analysis.

MAIN OUTCOME MEASURE(S)

Endocrinologic evaluation and genetic analysis.

RESULT(S)

A diagnosis of decreased ovarian reserve based upon laboratory evaluation with concomitant findings of a balanced translocation between the long arms of chromosomes 13 and 21.

CONCLUSION(S)

A diagnosis of primary infertility secondary to decreased ovarian reserve of unknown etiology, but with karyotype evidence of a balanced autosomal translocation and a familial history of early menopause, suggested possible roles of autosomal genes in mechanisms of ovarian follicular attrition.

Biomarkers of Ovarian Reserve

The primary function of the female ovary is the production of a mature and viable oocyte capable of fertilization and subsequent embryo development and implantation. At birth, the ovary contains a finite number of oocytes available for folliculogenesis. This finite number of available oocytes is termed "the ovarian reserve". The determination of ovarian reserve is important in the assessment and treatment of infertility. As the ovary ages, the ovarian reserve will decline. Infertility affects approximately 15%-20% of reproductive aged couples. The most commonly used biomarker assay to assess ovarian reserve is the measurement of follicle stimulating hormone (FSH) on day 3 of the menstrual cycle. However, anti-müllerian hormone and inhibin-B are other biomarkers of ovarian reserve that are gaining in popularity since they provide direct determination of ovarian status, whereas day 3 FSH is an indirect measurement. This review examines the physical tools and the hormone biomarkers used to evaluate ovarian reserve.

A high oocyte yield for intracytoplasmic sperm injection treatment is associated with an increased chromosome error rate

OBJECTIVE

To compare the chromosome error rate among oocytes from stimulated ovaries after retrieval of 1-5 oocytes, 6-10 oocytes, and >10 oocytes.

DESIGN

Retrospective cohort study.

SETTING

A university-based human genetic institute in collaboration with a private fertility center.

PATIENT(S)

Nine hundred thirty-three women undergoing intracytoplasmic sperm injection (ICSI) with a poor prognosis.

INTERVENTION(S)

Oocyte collection with ovarian stimulation. Polar body testing of ICSI oocytes for common chromosome errors.

MAIN OUTCOME MEASURE(S)

Chromosome error rate in oocytes, as determined by five-color fluorescence in situ hybridization.

RESULT(S)

In women less than 35 years and women between 35 and 40 years undergoing the first ICSI cycle, oocytes from the high-yield group had an increased likelihood for detectable chromosome errors (50.9% and 54.6%, respectively), compared to the intermediate-yield group (34.9% and 43.8%) and the low-yield group (23.3% and 41.2%). The overall high rate (>or=50%) of chromosomally abnormal oocytes in women more than 40 years appeared to be mainly due to the maternal age effect and increased only slightly with oocyte yield.

CONCLUSION(S)

Oocyte yield may be considered as an indicator of ovarian response to hormone stimulation. In women up to 40 years a high yield of oocytes after superovulation is associated with an increased chromosome error rate.

Superovulatory response in a bovine model of reproductive aging

Two experiments were done to test the hypotheses that aging in cattle is associated with a reduced number of follicles recruited into an ovarian follicular wave, and a reduction in the ovarian response to gonadotropin treatment. Older cows (13-16 years of age) and their daughters (3-6 years of age) were treated with FSH for ovarian superstimulation four times over two consecutive years (31 and 33 superstimulations in old and young cows, respectively, experiments and years combined). In Experiment 1, ovulation was induced using LH. In Experiment 2, cumulus-oocyte complexes were collected by ultrasonographic-guided follicle aspirations before expected ovulations. The ovarian follicular and ovulatory responses were monitored daily by ultrasonography. Fewer 2-5mm follicles (P<0.01) were detected at the expected time of follicular wave emergence in older cows than in their daughters. After superstimulation, older cows had fewer follicles >or=6mm (P<0.01), and tended (P=0.1) to have fewer ovulations than their daughters (32+/-4 versus 40+/-3, respectively). There was a positive correlation in the response of individual cows to successive superstimulatory treatments (r>0.8; P<0.0001) and the number of detected ovulations from one year to the next (r=0.6; P=0.04). In conclusion, aging was associated with fewer 2-5mm follicles at follicular wave emergence and a lesser follicular and ovulatory response after superstimulatory treatment. The follicular and ovulatory response after superstimulation was repeatable within individuals, regardless of age.

Different ovarian stimulation protocols for women with diminished ovarian reserve

PURPOSE

To review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols.

METHODS

Literature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews.

RESULTS

A lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients.

CONCLUSIONS

The ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.

Age-specific levels for basal follicle-stimulating hormone assessment of ovarian function

OBJECTIVE

Traditionally, the most important measurement in the assessment of ovarian function has been age-independent baseline follicle-stimulating hormone (FSH) levels. The objective of this study was to characterize the continuum of ovarian function based on age-specific categories of baseline FSH.

METHODS

In a cross-sectional historical cohort study we evaluated records of 434 patients with baseline FSH levels of less than 12 milli international units/mL that underwent ovulation induction for in vitro fertilization (IVF) with long gonadotropin-releasing hormone (GnRH) antagonist or GnRH agonist suppression and modal gonadotropin stimulation of 300 units of gonadotropins per day. In these patients with apparent normal ovarian function by current baseline FSH criteria and with routine ovarian stimulation, we assessed IVF cycle outcomes, including oocyte yields, based on age-specific baseline FSH levels, defined as levels less than or equal to the 95% confidence interval for each age group.

RESULTS

Age-specific baseline FSH levels predicted the retrieval of fewer than or equal to four oocytes, with a positive predictive value of 19.5% and a negative predictive value of 88%. The Mantel-Haenszel common odds ratio for fewer than or equal to 4 oocyte production in the presence of premature ovarian aging was 2.8 (95% confidence interval 1.52-5.17; P<.001).

CONCLUSION

These results suggest that, within generally accepted normal baseline FSH values, women with baseline FSH above the 95% confidence limits for age produce fewer oocytes in response to normal ovulation induction protocols compared with other women their age.

Simple tools for assessment of ovarian reserve (OR): individual ovarian dimensions are reliable predictors of OR

OBJECTIVE

To determine the association between individual ovarian dimensions, advancing age, and declining ovarian reserve (OR) in an infertile population.

DESIGN

An ongoing prospective observational study.

SETTING

Academic infertility practice.

PATIENT(S)

Sixty-nine premenopausal women presenting for the evaluation and management of infertility.

INTERVENTION(S)

Transvaginal ultrasound assessment of the ovarian dimensions (length, width, and overall diameter in cm) and evaluation of the OR status by measuring serum levels of FSH and E(2) in the early follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Relationship of the individual ovarian dimensions to age (years) and OR (reflected by historical maximal FSH levels).

RESULT(S)

A statistically significant decrease in three ovarian size parameters accompanied advancing age (ovarian width, r = -0.30; ovarian length, r = -0.24; and the mean overall ovarian diameter, r = -0.30). Levels of FSH demonstrated a significant and linear correlation with age (r = 0.39). Increasing levels of FSH (and hence declining OR) were associated with statistically significant declines in the mean ovarian width (r = -0.39), length (r = -0.38), and overall mean ovarian diameter (r = -.42), Patients with a known diagnosis of diminished OR demonstrated significantly reduced ovarian dimensions compared with patients with other infertility etiologies. Multivariate linear regression analysis confirmed individual ovarian measurements (width, length, and overall diameter) as independent predictors of OR (FSH levels) after adjusting for parameters that are known to influence ovarian size, i.e., age, smoking status, body mass index, and anovulation history. Ovarian width emerged as the strongest predictor of OR (largest beta coefficient and hence the strongest association with OR status), compared with ovarian length and the mean ovarian diameter.

CONCLUSION(S)

Single ovarian dimensions are reliable predictors of advancing age and declining OR status in premenopausal infertile women. The magnitude of this association is most robust for the ovarian width.

Female reproductive ageing: current knowledge and future trends

Over the past few decades, postponement of childbearing has led to a decrease in family size and increased rates of age-related female subfertility. Age-related decrease in ovarian follicle numbers and a decay in oocyte quality dictate the occurrence of natural loss of fecundity and, ultimately, menopause. The rate of this ovarian ageing process is highly variable among women. Identification of women who have severely decreased ovarian reserve for their age is, therefore, clinically relevant. Endocrine and imaging tests for ovarian reserve relate mainly to the quantitative aspect of ovarian reserve, but their capacity to predict the chances for pregnancy is limited. Genetic factors regulating the size of the follicle pool and the rate of its depletion might be identified in the near future and, possibly, assist the accurate prediction of a woman's reproductive lifespan.

Ovarian reserve tests for predicting fertility outcomes for assisted reproductive technology: the International Systematic Collaboration of Ovarian Reserve Evaluation protocol for a systematic review of ovarian reserve test accuracy

BACKGROUND

The presence of a wide range of tests of ovarian reserve suggests that no single test provides a sufficiently accurate result. Many tests are used without reference to an evidence base. So far, individual studies conducted on these tests are too small to give precise estimates of prognostic accuracy.

OBJECTIVES

To systematically assess the accuracy of the available tests of ovarian reserve in terms of prediction of fertility outcomes.

SEARCH STRATEGY

The search will be conducted using the name of the respective index test being studied (as listed on the MESH database), if more than 2000 citations are listed, 'ovary' and or 'ovarian', 'fertility' and or 'reserve' will be combined with the original search term as required. Studies of the accuracy of tests of ovarian reserve will be obtained without language restrictions from 1980 to 2005 using the following electronic databases and Ovid software: MEDLINE, EMBASE, PUBmed, Biological extracts, Pascal, Cochrane Library (CDSR, DARE, CCTR, HTA), Best Evidence databases, SCISEARCH, Conference Proceedings (ISI Proceedings, Healthstar, Current Contents, Science Citation Index, Cancerlit and Econlit and NHS Economic Evaluation database. The National Research Register, the Medical Research Council's Clinical Trials Register, MEDION, DARE, and the US Clinical Trials register.

SELECTION CRITERIA

Studies will be selected if accuracy of tests are compared with a reference standard and include data that can be abstracted into a two-by-two table to calculate sensitivity and specificity. The studies to be included in this review will examine one of the following index 'tests' within a study population of women undergoing assisted reproductive technology: * Clinical variables--age, history of cancelled cycles. * Basal blood tests--follicle-stimulating hormone (FSH), lutenising hormone (LH), FSH:LH ratios, estradiol (E(2)), inhibin A and B, progesterone (P(4)), P(4):E(2) ratios, antimullerian hormone, testosterone, vascular endothelial growth factor, insulin-like growth factor-1:insulin-like growth factor binding protein-1 ratios. * Dynamic tests--clomiphene citrate challenge test, gonadotropin analogue stimulating test, exogenous FSH ovarian reserve test. * Ultrasound tests-antral follicle count, ovarian volume, ovarian stromal peak systolic velocity, including waveform and pulsatility index, ovarian follicular vascularity. * Histology--ovarian biopsy. Data collection and analysis Two independent reviewers will perform quality assessment and data extraction. Prognostic accuracy will be determined by calculating positive and negative likelihood ratios for the following outcomes or reference standards: live birth, ongoing pregnancy, clinical pregnancy, biochemical pregnancy, embryos available for transfer, eggs obtained at oocyte retrieval, cycles cancelled prior to oocyte retrieval. Main results and conclusions N/A.

Milder ovarian stimulation for in-vitro fertilization reduces aneuploidy in the human preimplantation embryo: a randomized controlled trial

BACKGROUND

To test whether ovarian stimulation for in-vitro fertilization (IVF) affects oocyte quality and thus chromosome segregation behaviour during meiosis and early embryo development, preimplantation genetic screening of embryos was employed in a prospective, randomized controlled trial, comparing two ovarian stimulation regimens.

METHODS

Infertile patients under 38 years of age were randomly assigned to undergo a mild stimulation regimen using gonadotrophin-releasing hormone (GnRH) antagonist co-treatment (67 patients), which does not disrupt secondary follicle recruitment, or a conventional high-dose exogenous gonadotrophin regimen and GnRH agonist co-treatment (44 patients). Following IVF, embryos were biopsied at the eight-cell stage and the copy number of 10 chromosomes was analysed in 1 or 2 blastomeres.

RESULTS

The study was terminated prematurely, after an unplanned interim analysis (which included 61% of the planned number of patients) found a lower embryo aneuploidy rate following mild stimulation. Compared with conventional stimulation, significantly fewer oocytes and embryos were obtained following mild stimulation (P < 0.01 and < 0.05, respectively). Consequently, both regimens generated on average a similar number (1.8) of chromosomally normal embryos. Differences in rates of mosaic embryos suggest an effect of ovarian stimulation on mitotic segregation errors.

CONCLUSIONS

Future ovarian stimulation strategies should avoid maximizing oocyte yield, but aim at generating a sufficient number of chromosomally normal embryos by reduced interference with ovarian physiology.

A systematic review of tests predicting ovarian reserve and IVF outcome

The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.

Unexplained infertility: does it really exist?

Recent medical literature has quite extensively addressed the use of various terminologies within the field of reproductive medicine. This discussion has, however, so far overlooked the fact that one of the most frequently made diagnosis, so-called unexplained infertility (UI), not only didactically but, even more importantly, clinically, appears unsustainable as an independent diagnosis. The arguments in support of such a contention are manifold. The diagnosis of UI is highly subjective. It is dependent on which diagnostic tests have been performed (or have been omitted) and at what level of quality. Paradoxically, a diagnosis of UI will, therefore, be more often reached if the diagnostic workup is incomplete or of poor quality. Supported by evidence from the literature, the argument is made that the conditions, most frequently misdiagnosed as UI, are endometriosis, tubal infertility (especially distal and peritubal disease), premature ovarian ageing and immunological infertility. Because of the obvious unreliability of a diagnosis of UI and the widely reported unevenness in diagnostic criteria, we recommend the abandonment of UI as a formal infertility diagnosis. Better efforts to reach infertility diagnoses more accurately should improve the diagnostic accuracy of hitherto frequently missed diagnoses, which often falsely have led to a diagnosis of UI.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

Ovarian response to stimulation of HIV-positive patients during IVF treatment: a matched, controlled study

BACKGROUND

Our aim was to compare the ovarian response of HIV-positive and -negative patients during IVF.

METHODS

Setting - HIV and IVF reference university hospital. Twenty-seven HIV-infected patients who had undergone IVF between March 2000 and March 2005 were matched with 77 HIV-negative patients for age, aetiology of infertility, whether it was primary or secondary infertility, duration of infertility, history of pelvic surgery and type of pituitary inhibition. Outcome - poor responders were defined using one of the following criteria: a cancelled cycle (for insufficient ovarian response), less than four mature follicles (> or = 16 mm), peak serum levels of E2 lower than 1000 pg/ml.

RESULTS

There were no differences between the two groups of patients for the matched criteria. The proportion of African women and of women with a history of pelvic inflammatory disease was significantly higher among HIV patients than among the control group. With the exception of a lower number of transferred embryos among HIV-positive patients versus HIV-negative ones (1.3 versus 1.9; P = 0.035), there was no significant difference between the two groups of patients regarding ovarian response parameters.

CONCLUSION

HIV-infected patients who are in good general condition and who are matched to a control group present a similar ovarian response to stimulation, suggesting the existence of a similar ovarian reserve.

Pilot study investigating the age-related decline in ovarian function of regularly menstruating normal women

OBJECTIVE

To use a pilot study to investigate markers of the age-related decline in ovarian function of regularly menstruating normal women.

DESIGN

Prospective.

SETTING

Tertiary research center.

PATIENT(S)

Healthy volunteers (n = 42) aged 18 to 50 years who had regular ovulatory menstrual cycles and a prior pregnancy.

INTERVENTION(S)

A single 300-IU dose of human recombinant FSH on day 3 of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Antral follicle count by transvaginal ultrasound and basal and FSH-stimulated serum markers.

RESULT(S)

Age correlated most strongly with FSH-stimulated inhibin B (r = -0.660), followed by antral follicle count (r = -0.578), basal FSH (r = 0.509), basal Müllerian inhibiting substance (MIS; r = -0.468), and basal inhibin B (r = -0.358). Total antral follicle count correlated most strongly with basal MIS level (r = 0.642).

CONCLUSION(S)

Of the parameters tested, FSH-stimulated serum inhibin B level had the strongest correlation with age. Basal serum MIS level had the strongest correlation with total antral follicle count. We confirm a previous report that in normal women, the antral follicle count as determined by transvaginal ultrasound examination correlates better with age than do basal FSH and basal inhibin B levels.

Use of ovarian reserve tests for the prediction of ongoing pregnancy in couples with unexplained or mild male infertility

The chance of infertile patients conceiving is related to factors like female age and duration of infertility. This prospective observational study evaluated whether the results of ovarian reserve tests, including the novel marker serum anti-Mullerian hormone (AMH), were of additional value in predicting ongoing pregnancy. Two hundred and twenty-two patients diagnosed with unexplained infertility or mild male factor (total motile count>10x10(6)) on the basis of the infertility work-up were prospectively included. Antral follicle count, AMH, inhibin B, FSH and oestradiol concentrations were determined during the early follicular phase. Outcome measures were treatment-dependent and treatment-independent ongoing pregnancy and time to ongoing pregnancy. There were 159 ongoing pregnancies, 52 of which occurred spontaneously. Pregnant patients were significantly younger than those who did not become pregnant (median age 32.4 versus 34.9 years, P<0.001) and FSH concentrations were higher in non-pregnant patients (median 6.8 versus 7.6 IU/l, P=0.04). Only age (hazard ratio 0.93, 95% CI 0.90-0.97) and whether or not the patient was undergoing treatment (hazard ratio 8.10, 95% CI 5.66-11.61) were significantly associated with time to ongoing pregnancy. Ovarian reserve tests, other than chronological age, seem of limited value in predicting (time to) ongoing pregnancy in patients with unexplained and mild male infertility.

Are cause of subfertility and in vitro fertilization treatment risk factors for an earlier start of menopause?

OBJECTIVE

To study whether women diagnosed with unexplained subfertility reach the menopause transition and natural menopause earlier than women with tubal subfertility, in an in vitro fertilization (IVF)-treated population, and to examine the influence of the number of IVF cycles on the occurrence of an early menopause transition and natural menopause.

DESIGN

This retrospective cohort study included 12 IVF clinics in the Netherlands. A nationwide retrospective cohort study was conducted among women whose first IVF cycle was stimulated with gonadotrophins in the Netherlands between 1983 and 1995 (n = 7,842). Most of the women were in their late 30s at the end of the follow-up period (range 24-55 y). The main outcome measures were the relative risk (RR) of having reached natural menopause and the risks (RR) of having entered the menopause transition or natural menopause according to the cause of subfertility and the number of IVF cycles.

RESULTS

Women with unexplained subfertility did not have an increased risk of entering the menopause transition or natural menopause (adjusted RR = 0.5; 95% CI, 0.2-1.5; and RR = 0.8; 95% CI, 0.6-1.1). After a 5-year follow-up period, we found no increased risk for entering the menopause transition or natural menopause among women who had undergone six or more IVF cycles when compared with women who had undergone only one IVF cycle (adjusted RR = 0.4; 95% CI, 0.1-1.7; and RR = 0.9; 95% CI, 0.6-1.6).

CONCLUSIONS

Underlying causes of unexplained subfertility do not predispose women to an early start of menopause. Although the number of IVF cycles was not associated with early menopause, longer follow-up is needed.

Validity of self-reported causes of subfertility

The authors assessed the accuracy of cause(s) of subfertility as reported by women in a self-administered questionnaire in comparison with medical record information, in a nationwide cohort study of women receiving in vitro fertilization treatment in the Netherlands (n = 9,164) between 1983 and 1995. Validity was expressed as sensitivity and specificity, and reliability was expressed by the kappa statistic and overall agreement between self-reports and medical records for various subfertility categories. The sensitivity for subfertility attributed to tubal, male, hormonal, cervical, uterine, and idiopathic factors and for endometriosis was 84%, 78%, 65%, 40%, 46%, 59%, and 83%, respectively. The corresponding kappas were 0.79, 0.71, 0.38, 0.34, 0.13, 0.50, and 0.52, respectively. For 54% of all women who reported two or more causes of subfertility, the medical record revealed only one major factor. Conversely, for 43% of all women whose subfertility was attributed to two or more major factors in the record, only one factor was reported by the women. Older age at the time of filling out the questionnaire, low educational level, long duration of subfertility, and pre-in vitro fertilization treatment were associated with less accurate reporting. The results indicate that the validity of self-reports for tubal and male subfertility is satisfactory. For unexplained subfertility, the validity is moderate; for other causes of subfertility and when two causes of subfertility play a role, the validity is low.

Antral follicle counts are related to age at natural fertility loss and age at menopause

OBJECTIVE

The variability in ultrasound-based antral follicle counts sized 2-10 mm after allowing for age-related decline is considerable. This may represent differences in actual reproductive age among women. This hypothesis was tested by cohort comparison for distribution of age at occurrence of reproductive events.

DESIGN

A model with a nonlinear mean decline with age was fitted to antral follicle counts (AFC) obtained in 163 regularly cycling fertile volunteers. Ages at last child birth and menopause were predicted from the individual AFC by using thresholds to represent these events and the model for decline with age. Distributions of the observed ages at last childbirth (proxy variable for loss of natural fertility) and ages at menopause were obtained from the BALSAC demographic database and the Prospect-EPIC study, respectively. The observed distributions were compared with the predicted distributions by using visual comparison and quantile-quantile plots. Predictions of age at last child and age at menopause were done using percentiles of the modeled AFC distribution for given age, and corresponding percentiles of the predicted distributions of age at these reproductive events, with predictions following from the position of a woman's AFC relative to these percentiles.

RESULTS

The predicted distributions of age at last child and age at menopause showed good agreement with the observed distributions in the BALSAC and EPIC cohort. Compared with age alone, antral follicle counts gave some additional information for individual prediction of age at last child and menopause.

CONCLUSIONS

The link between declining antral follicle counts and reproductively significant events like loss of natural fertility and menopause is strengthened by the high degree of similarity among the predicted and observed age distributions. Predictive usefulness of this relationship in a clinical setting may be more marginal, except in the case of women who have low AFCs for their age.

Early ovarian ageing: are women with polycystic ovaries protected?

Screening asymptomatic women in the general population for 'early ovarian ageing' will be more effective in high-risk groups. Recent findings support the hypothesis that women with polycystic ovaries (PCO) may have actually been born with a larger pool of resting follicles. The mechanism is almost certainly genetic and occurs in fetal life. If, as is widely accepted, the rate of depletion of the ovarian reserve depends primarily on the size of the remaining pool of small follicles, women with PCO will be unlikely to undergo an accelerated depletion of their follicle pool, normally seen in the late thirties, significantly earlier. In terms of asymptomatic screening for early ovarian ageing in the general population, women with PCO constitute a low-risk group and should therefore be excluded.

Female age in ART: when to stop?

With increasing age the probability of ongoing pregnancy established by the use of assisted reproduction technology (ART) decreases. As a result the question arises whether age limits for the application of ART should be established. From a literature review and ongoing research data it appears that the costs per child born greatly increase after the age of 40 for both intrauterine insemination with mild ovarian stimulation and in vitro fertilisation treatment, while in cases of 44 and over, prognosis is flat zero. The willingness to pay for extra costs will greatly determine whether and at what age strict limits should be applied. Fortunately, predictive factors for success, like the antral follicle count, may enable the identification of women over 40 and under 44 that still have favourable prospects, thereby decreasing the necessary costs per childbirth and allowing couples into ART programs that are often denied based solely on female age.

Ovarian reserve and reproductive age may be determined from measurement of ovarian volume by transvaginal sonography

BACKGROUND

The human ovary contains a fixed number of primordial follicles that decreases bi-exponentially with age, culminating in the menopause at an average age of 50-51 years. There currently is no reliable test of ovarian reserve for individual women that will accurately predict their remaining reproductive lifespan.

METHODS AND RESULTS

We use the Faddy-Gosden model of human primordial follicle population decline to describe the natural decay of the ovarian follicle pool. Assuming that the wide distribution for age at menopause is due to the wide variation in number of primordial follicles at birth, we describe follicle population decline for early and late menopausal women. Using published data on age-related ovarian volume as measured by transvaginal sonography, we have obtained a highly significant correlation between primordial follicle population and ovarian volume. We show that ovarian volume in women aged 25-51 years accurately reflects the number of primordial follicles remaining, and describe how measurement of ovarian volume by transvaginal sonography may determine ovarian reserve and reproductive age.

CONCLUSIONS

The accurate assessment of ovarian reserve will revolutionize the management of women requesting assisted conception, those who have had treatment for childhood cancer and those who are considering delaying a family for personal or professional reasons.

Assessment of ovarian reserve

PURPOSE OF REVIEW

Various methods have been proposed and are currently used in the assessment of ovarian reserve in order to predict the outcome in assisted reproduction. This review focuses on the current information regarding the ovarian reserve markers and tests, an active area of research.

RECENT FINDINGS

Female age alone is a rough parameter for assessing ovarian reserve. The basal follicle stimulating hormone level is not adequately sensitive to predict poor outcome and the same is true for other basal parameters, including basal estradiol, the follicle stimulating hormone/luteinizing hormone ratio, and inhibin-B levels. The clomiphene citrate challenge test has a low sensitivity but this sensitivity is greater than that of basal follicle stimulating hormone. The value of other hormonal dynamic tests remains to be determined. Among the ultrasound markers the total antral follicle count seems to be promising. Ovarian biopsy in this assessment is controversial. History of poor response to ovarian stimulation is a strong indicator for declining ovarian function.

SUMMARY

There is currently no clinically useful predictive test sufficiently accurate and distinct in time from controlled ovarian stimulation to assess ovarian reserve accurately. Further research is warranted to validate the ovarian reserve tests in the general population and in populations with different causes of infertility.

Early ovarian ageing

Observations from reproductive biology, epidemiology, and clinical assisted reproduction support the hypothesis that the time interval between the onset of accelerated decline of the ovarian reserve and the menopause is more or less fixed. Thus, it is estimated that women who become menopausal by the age of 45 may have experienced an accelerated decline of their fertility before the age of 32. Up to 10% of women in the general population may fall into this category, which has been described as "early ovarian ageing". Because of the long latent phase and predictable natural history, this condition is suitable for screening. High-risk groups include, women with a family history of early menopause. IVF has provided a model for the development of ovarian reserve tests, some of which appear promising as potential screening tools for the detection of early ovarian ageing in asymptomatic women in the general population.

[Inhibins, activins and anti-Müllerian hormone: structure, signalling pathways, roles and predictive value in reproductive medicine]

Anti-Müllerian hormone (AMH), inhibins and activins are members of the transforming growth factor (TGFbeta) superfamily and are known to have a variety of actions concerning reproduction, hormonogenesis, development processes and differentiation. Inhibins and activins are dimeric glycoproteins that are defined by their actions on the pituitary gonadotroph cells. AMH, inhibins and activins have a vast array of actions usually exerted through paracrine and endocrine mechanisms. The recent availability of specific inhibin assays has demonstrated that inhibin B is the relevant circulating inhibin form in the human male. Inhibin B seems to be a useful marker of spermatogenesis, but serum and seminal inhibin B levels are not predictive parameters for the selection of azoospermic men as candidates for testicular sperm extraction (TESE). AMH in seminal plasma may be important for sperm production, and is a good marker for sertoli cell development. It might be the only one seminal marker of spermatogenesis in non-obstructive azoospermia. Nevertheless, many of these studies were carried out with small patient numbers, and consequently must be interpreted with caution. In women ongoing assisted reproductive therapy (ART), day 3 inhibin B and AMH levels predict the number of oocytes retrieved, but cannot predict likelihood of pregnancy. Further studies are needed to determine if AMH and inhibin predict ART outcomes better than classical parameters (age, FSH levels and follicular ultrasonography). AMH and inhibin are also specific markers of Sertoli- and granulosa-cell origin in gonadal tumors.

Reduced ovarian function in long-term survivors of radiation- and chemotherapy-treated childhood cancer

Seventy percent of children with cancer survive. Radiation and chemotherapy may, however, impair ovarian function. The aim of this population-based study was to achieve a comprehensive knowledge of the degree of ovarian damage. Ovarian function was evaluated in 100 childhood cancer survivors and 21 controls of similar age. Menstrual cycle pattern was recorded, and strictly timed ovarian sonography and hormonal assessment were performed. The median age of the survivors was 5.4 yr (range, 0.1-15.3) at the time of diagnosis and 25.7 yr (18.5-44.4) at study entry. Seventeen survivors with premature ovarian failure had follicle-depleted or nondetectable ovaries, elevated FSH and LH, and immeasurable inhibin B. Thirteen survivors used oral contraception. Survivors with spontaneous menstrual cycles (n = 70) had smaller ovarian volume per ovary than controls (median, 4.8 vs. 6.8 cm(3); P < 0.001) and a lower number of antral follicles per ovary (median, 7.5 vs. 11; P < 0.001). Further, they had lower inhibin B levels than controls (median, 94 vs. 111 pg/ml; P = 0.03) and higher estradiol levels (median, 0.12 vs. 0.08 pM; P = 0.04). Multiple linear regression analysis was performed to predict the total antral follicle number per ovary, and it showed a reduced number with ovarian irradiation (beta = -0.40, P < 0.001), alkylating chemotherapy (beta = -0.25, P = 0.01), older age at diagnosis (beta = -0.25, P = 0.01), and longer time period off treatment (beta = -0.19, P = 0.044). One in every six female survivors may develop premature ovarian failure. In survivors with spontaneous menstrual cycles, the results indicate a diminished ovarian reserve. Consequently, cessation of fertility may occur much earlier than anticipated. Adult survivors with spontaneous cycles should be informed hereof to plan childbearing.

Women with regular menstrual cycles and a poor response to ovarian hyperstimulation for in vitro fertilization exhibit follicular phase characteristics suggestive of ovarian aging

OBJECTIVE

To investigate whether follicular phase characteristics associated with ovarian aging can be observed in women of normal reproductive age, who had previously shown a poor response to ovarian hyperstimulation for IVF.

DESIGN

Observational, prospective study.

SETTING

Tertiary fertility center.

PATIENT(S)

Eleven regularly cycling, ovulatory women, aged 29-40 years who previously presented with fewer than four dominant follicles after ovarian hyperstimulation for IVF.

INTERVENTION(S)

Frequent serum hormone assessments and transvaginal ultrasound during the follicular phase of a spontaneous, unstimulated cycle.

MAIN OUTCOME MEASURE(S)

Duration of the follicular phase; serum LH, FSH, E(2), P, inhibin A, and inhibin B levels; and number of antral follicles observed by ultrasound. Results were compared with the cycle characteristics of a reference population of 38 healthy normo-ovulatory women aged 20-36 years (as published elsewhere).

RESULT(S)

Poor responders had significantly fewer antral follicles than controls. Median FSH concentrations were significantly higher compared with controls, but the majority had FSH levels within the normal range. Follicular phase P levels were significantly higher in poor responders. Duration of the follicular phase, E(2), and inhibin A and inhibin B serum levels did not differ between poor responders and controls.

CONCLUSION(S)

Normo-ovulatory regularly cycling women with a previous poor response to ovarian hyperstimulation for IVF show follicular phase characteristics suggestive of ovarian aging.