Predictors of ovarian response: progress towards individualized treatment in ovulation induction and ovarian stimulation

Developmental origin of reproductive and metabolic dysfunctions: androgenic versus estrogenic reprogramming

Polycystic ovary syndrome (PCOS) is one of the most common fertility disorders, affecting several million women worldwide. Women with PCOS manifest neuroendocrine, ovarian, and metabolic defects. A large number of animal models have evolved to understand the etiology of PCOS. These models provide support for the contributing role of excess steroids during development in programming the PCOS phenotype. However, considerable phenotypic variability is evident across animal models, depending on the quality of the steroid administered and the perinatal time of treatment relative to the developmental trajectory of the fetus/offspring. This review focuses on the reproductive and metabolic phenotypes of the various PCOS animal models that have evolved in the last decade to delineate the relative roles of androgens and estrogens in relation to the timing of exposure in programming the various dysfunctions that are part and parcel of the PCOS phenotype. Furthermore, the review addresses the contributory role of the postnatal metabolic environment in exaggerating the severity of the phenotype, the translational relevance of the various animal models to PCOS, and areas for future research.

Use of metformin in the treatment of polycystic ovary syndrome

Metformin is quite an old drug, but it is optimal for the control of glycemia in Type 2 diabetes. It was reported, 15 years ago, that insulin resistance was abnormally high in most polycystic ovary syndrome (PCOS) patients. Starting from that moment, increasing numbers of studies were performed to demonstrate the efficacy of metformin in controlling and/or modulating several aspects of PCOS, which is the most common cause of menstrual irregularity, inesthetisms and infertility. Metformin induces higher glucose uptake, thus inducing a lower synthesis/secretion of insulin. Such an effect permits the possible restoration of the normal biological functions that are severely affected by the compensatory hyperinsulinemia reactive to the increased peripheral insulin resistance. These are the basis of the many positive effects of this drug, such as the restoration of menstrual cyclicity, ovulatory cycles and fertility, because abnormal insulin levels affect the hypothalamus-pituitary-ovarian function, as well as the use of glucose in peripheral tissues. Metformin improves the impairments typically observed in hyperinsulinemic PCOS patients, reducing the possible evolution towards metabolic syndrome and Type 2 diabetes; and when pregnancy occurs, it consistently reduces the risk of gestational diabetes, eclampsia and hypertension. PCOS seems to be the perfect physiopathological condition that might have higher benefits from metformin administration, obviously after Type 2 diabetes. This review focuses on the many aspects of PCOS and on the possible issues of this disease for which metformin might be a putative optimal treatment.

Polymorphisms of the bovine luteinizing hormone/choriogonadotropin receptor (LHCGR) gene and its association with superovulation traits

The major limitation to the development of embryo transfer technique in cattle is the highly variable between individuals in ovulatory response to FSH-induced superovulation. The objective of this study was to identify a predictor to forecast superovulation response on the basis of associations between superovulation performance and gene polymorphism, variation in the bovine luteinizing hormone/choriogonadotropin receptor (LHCGR) gene was investigated using PCR-single-strand conformational (PCR-SSCP) and DNA sequencing. Four single nucleotide polymorphisms (SNPs) of G51656T, A51703G, A51726G and G51737A were identified at the intron 9 of the LHCGR gene in 171 Chinese Holstein cows treated for superovulation, and evaluated its associations with superovulatory response. Association analysis showed that these four SNPs had significant effects on the total number of ova (TNO) (P < 0.05). Moreover, the A51703G and A51726G polymorphisms significantly associated with the number of transferable embryos (NTE) (P < 0.05). In addition, significant additive effect on TNO was detected in polymorphisms of G51656T (P < 0.05) and A51703G (P < 0.01), and the A51703G polymorphism also had significant additive effects on NTE (P < 0.01). These results indicate that LHCGR gene is a potential marker for superovulation response and can be used to predict the most appropriate dose of FSH for superovulation in Chinese Holstein cows.

Investigating the association between polymorphism of follicle-stimulating hormone receptor gene and ovarian response in controlled ovarian hyperstimulation

AIM

The aim of the study was to investigate the association between follicle-stimulating hormone receptor (FSHR) gene polymorphism at Position 680 and the outcomes of controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer (IVF-ET) in infertile women.

MATERIALS AND METHODS

One hundred and eight patients under 35 years of age who underwent IVF-ET procedures were included in this study. The hormonal profile and treatment of all patients were analyzed and FSHR polymorphism was examined by polymerase chain reaction-restriction fragment length polymorphism. Women from all groups were classified based on polymorphisms at Position 680, occupied either by asparagines (Asn) or serine (Ser) as Asn/Asn, Asn/Ser, and Ser/Ser genotype.

RESULT

Our study showed that all patients in the Asn/Asn group were normal responders and in the Asn/Ser group 64.8% were normal responders and 21.1% and 14.1% were poor and hyper responders respectively. In the Ser/Ser group we did not have normal responders and 46.7% of these patients were poor responders and 53.3% were hyper responders.

CONCLUSION

FSH receptor polymorphism is correlated with response to ovarian stimulation.

ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria

The definition presented here represents the first realistic attempt by the scientific community to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. POR to ovarian stimulation usually indicates a reduction in follicular response, resulting in a reduced number of retrieved oocytes. It has been recognized that, in order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. By definition, the term POR refers to the ovarian response, and therefore, one stimulated cycle is considered essential for the diagnosis of POR. However, patients of advanced age with an abnormal ORT may be classified as poor responders since both advanced age and an abnormal ORT may indicate reduced ovarian reserve and act as a surrogate of ovarian stimulation cycle outcome. In this case, the patients should be more properly defined as 'expected poor responder'. If this definition of POR is uniformly adapted as the 'minimal' criteria needed to select patients for future clinical trials, more homogeneous populations will be tested for any new protocols. Finally, by reducing bias caused by spurious POR definitions, it will be possible to compare results and to draw reliable conclusions.

Heterosexual couples’ uses and meanings of ovarian stimulation: Relatedness, embodiment and emotions

This article is about how ovarian stimulation is understood within the context of heterosexual couples’ relationships. The empirical research involves 15 semi-structured interviews with patients in Portugal who have undergone IVF programmes performed with eggs collected in stimulated cycles. We argue that the uses and meanings of ovarian stimulation expressed in the patients’ narratives represent situated values and knowledges conveyed by existing emotional resources within multiple gendered relations and identities. We discuss how empirical reconfigurations work in a mode of conversion of physical and emotional pain so that the application of subcutaneous injections to women’s bodies makes sense within IVF couples’ daily routine and in their conjugal relationship. The different practices of men’s involvement in the injection of hormones into women’s bodies are perceived as emotional moments, and men’s cooperation and/ or protection seems to be essential in this domain. The cultural assumptions underlying women’s duties regarding maternity reinforce a moral framework in which the pain and the complications associated with the ovarian stimulation are naturalized, normalized and accepted.

Single-nucleotide polymorphisms in the FSH receptor gene and ovarian performance: future role in IVF

The ovarian response to follicle stimulating hormone (FSH) stimulation in assisted conception cycles is variable. Although it would be beneficial to predict accurately the response of patients to FSH, to date no absolute predictors of ovarian performance have been identified. Recently, there have been a number of studies on the effect of single-nucleotide polymorphisms (SNPs) in the FSH receptor gene and its predictability in ovarian response to FSH stimulation. Several reports have shown that two very common SNPs at positions 307 and 680 in exon 10 of the FSH receptor gene are associated with ovarian response in IVF. The SNPs in exon 10 result in four discrete allelic variants characterised by the amino acid combinations Thr(307)-Asn(680), Ala(307)-Ser(680), Ala(307)-Asn(680) and Thr(307)-Ser(680). Because Thr(307) is almost always in linkage disequilibrium with Asn(680), and Ala(307) almost always with Ser(680), most studies are focussed solely on position 680. Some authors have shown predictability of ovarian response to FSH stimulation in patients with different alleles, while others have refuted this finding. In vitro models have not shown any difference in response among various alleles. Most of the available studies are retrospective, observational. Until now, there is no clear clinical benefit in the screening for SNP before IVF treatment. However, there is the prospect of devising mathematical models using a group of polymorphisms to provide an important tool for improving ovulation induction, especially in poor responders.

Risk charts to identify low and excessive responders among first-cycle IVF/ICSI standard patients

Ovarian stimulation carries a risk of either low or excessive ovarian response. The aim was to develop prognostic models for identification of standard (ovulatory and normal basal FSH) patients’ risks of low and excessive response to conventional stimulation for IVF/intracytoplasmic sperm injection. Prospectively collected data on 276 first-cycle patients treated with 150 IU recombinant FSH (rFSH)/day in a long agonist protocol were analysed. Logistic regression analysis was applied to the outcome variables:low (seven or less follicles) and excessive (20 or more follicles) response. Variables were woman’s age, menstrual cycle length, weight or body mass index, ovarian volume, antral follicle count (AFC) and basal FSH. The predictive performance of the models was evaluated from the prediction error (Brier score, %) where zero corresponds to a perfect prediction. Model stability was assessed using 1000 bootstrap cross-validation steps. The best prognostic model to predict low response included AFC and age (Brier score 7.94) and the best model to predict excessive response included AFC and cycle length (Brier score 15.82). Charts were developed to identify risks of low and excessive ovarian response. They can be used for evidence-based risk assessment before ovarian stimulation and may assist clinicians in individual dosage of their patients.

Clinical outcomes in relation to the daily dose of recombinant follicle-stimulating hormone for ovarian stimulation in in vitro fertilization in presumed normal responders younger than 39 years: a meta-analysis

BACKGROUND

The optimal ovarian stimulation dose to obtain the best balance between the probability of pregnancy and the risk of complications, while maximizing cost-effectiveness of in vitro fertilization (IVF) treatment, is yet to be established.

METHODS

A systematic search of the electronic databases PubMed, EMBASE and Cochrane library, from 1984 until October 2009 for randomized controlled trials comparing different doses of recombinant FSH in IVF, was performed.

RESULTS

Ten studies (totaling 1952 IVF cycles) were included in the present meta-analysis, comprising patients younger than 39 years with regular menstrual cycle, normal basal FSH levels and two normal ovaries. Comparison was made between studies using a daily dose of 100 versus 200 IU recFSH, and between 150 versus 200 IU recFSH or higher. Although oocyte yield was greater in the >200 IU/day dose group, pregnancy rates were similar compared with lower dose groups. The risk of insufficient response to ovarian stimulation was greatest in the 100 IU/day dose group. The risk of developing ovarian hyperstimulation syndrome was greater in the >200 IU/day dose group. The number of embryos available for cryopreservation was lowest in the 100 IU/day group, but similar comparing the 150 IU/day and the >200 IU/day dose groups.

CONCLUSIONS

This meta-analysis suggests that the optimal daily recFSH stimulation dose is 150 IU/day in presumed normal responders younger than 39 years undergoing IVF. Compared with higher doses, this dose is associated with a slightly lower oocyte yield, but similar pregnancy and embryo cryopreservation rates. Furthermore, the wide spread adherence to this optimal dose will allow for a considerable reduction in IVF costs and complications.

AMH and AFC as predictors of excessive response in controlled ovarian hyperstimulation: a meta-analysis

BACKGROUND

Anti-Mullerian hormone (AMH) is a marker of ovarian reserve status and represents a good predictor of ovarian response to ovarian hyperstimulation. The aim of this study was to assess the accuracy of AMH and antral follicle count (AFC) as predictors of an excessive response in IVF/ICSI treatment.

METHODS

A systematic review and meta-analysis of the existing literature was performed. Studies were included if 2 × 2 tables for the outcome excessive response in IVF patients in relation to AMH/AFC could be constructed. Using a bivariate meta-analytic model, both summary point estimates for sensitivity and specificity were calculated, as well as summary ROC curves. Clinical value was analysed by calculating post-test probabilities of excessive response at optimal cut-off levels, as well as the corresponding abnormal test rates.

RESULTS

Nine studies reporting on AMH and five reporting on AFC were found. Summary estimates of sensitivity and specificity for AMH were 82 and 76%, respectively, and 82 and 80%, respectively, for AFC. Comparison of the summary estimates and ROC curves for AMH and AFC showed no statistical difference. Abnormal test rates for AMH and AFC amounted to ∼14 and 16%, respectively, at cut-off levels where test performance is optimal [likelihood ratio for a positive result (LR + ) > 8], with a post-test probability of ± 70%.

CONCLUSIONS

Both AMH and AFC are accurate predictors of excessive response to ovarian hyperstimulation. Moreover, both tests appear to have clinical value. This opens ways to explore the potential of individualized FSH dose regimens based on ovarian reserve testing.

Prestimulation parameters predicting live birth in anovulatory WHO Group II patients undergoing ovulation induction with gonadotrophins

BACKGROUND

The objective of this study was to identify baseline predictors of live birth in anovulatory patients undergoing ovulation induction, and based on these predictors, develop nomograms for estimation of the probability of live birth in a single cycle.

METHODS

Univariate and multivariate logistic regression were used for retrospective analysis of clinical, sonographic and endocrinological parameters collected prior to the start of ovarian stimulation in a cohort of anovulatory World Health Organization (WHO) Group II patients (n = 335), who were resistant to clomiphene citrate (CC) and therefore stimulated with gonadotrophins using a low-dose step-up protocol.

RESULTS

The univariate analysis identified age [OR = 0.91 (95% CI: 0.84-0.98), P = 0.015], duration of infertility [OR = 0.71 (95% CI: 0.56-0.91), P = 0.007], serum follicle stimulating hormone (FSH) concentration at the start of stimulation [OR = 0.83 (95% CI: 0.69-0.99), P = 0.034] and menstrual cycle pattern (P = 0.022) as significant predictors of live birth. Baseline concentrations of luteinizing hormone, androgens, glucose and insulin, as well as body mass index, were not predictors of live birth. In the multivariate analysis, duration of infertility, FSH and menstrual cycle pattern were independent predictors, and nomograms were designed with these three parameters for individual prediction of the probability of live birth.

CONCLUSIONS

The chances of live birth in women with WHO Group II anovulatory infertility resistant to CC undergoing ovulation induction with gonadotrophins is highly influenced by the menstrual cycle pattern. Increases in duration of infertility and concentration of FSH (within the normal range) before the start of stimulation have negative influences on the likelihood of achieving a live birth.

Normal serum concentrations of anti-Müllerian hormone in women with regular menstrual cycles

Anti-Müllerian hormone (AMH) has become the 'molecule of the moment' in the field of reproductive endocrinology. Indeed, it is valuable as a means of increasing understanding of ovarian pathophysiology and for guiding clinical management across a broad range of conditions. However, no normative values have been established for circulating AMH in healthy women. In this cross-sectional study, 277 healthy females (aged 18-50 years) were included. AMH was measured by commercial enzyme-linked immunosorbent assay. Serum AMH concentrations show a progressive decline with female ageing. The age-related changes in AMH were best fitted by a polynomial function. Mean AMH concentrations were not modified by past use of oral contraceptive and were independent of parity of women. Age-specific normative values for circulating AMH concentration were established. AMH concentrations seem to be independent of the reproductive history of the patient.

Demographic characteristics and clinical profile of poor responders in IVF / ICSI: A comparative study

BACKGROUND

Ovarian response varies considerably among individuals and depends on various factors. Poor response in IVF yields lesser oocytes and is associated with poorer pregnancy perspective. Cycle cancellation due to poor response is frustrating for both clinician and the patient. Studies have shown that women conceiving after poor ovarian response have more pregnancy complications like PIH and preeclampsia than women with normal ovarian response. In addition, poor ovarian response could be a predictor of early menopause. This paper studies various demographic and clinical profiles of poor responders and tries to look at the known and unknown factors which could contribute to poor ovarian response in IVF.

MATERIALS AND METHODS

Data were collected retrospectively from 104 poor responders who had less than four oocytes at retrieval and compared with 324 good responders for factors like age, BMI, type of sub fertility, duration of sub fertility, environmental factors like stress at work, smoking, pelvic surgery, chronic medical disorder, indication of IVF, basal FSH, mean age of menopause in their mothers etc.

RESULTS

Among the poor responders, 60.57% were above 35 years of age compared to 36.41% in control group, which is statistically significant. Mean age of menopause in mother was found to be four years earlier in poor responder group. Male factor and unexplained infertility were significantly (P<0.05) higher in good responders (P<0.05). Significant proportion (31.73%) of women in study group had undergone some pelvic surgery (P<0.05).

CONCLUSION

Apart from age, prior pelvic surgery also could be used as predictors for poor ovarian response. Heredity also plays a major role in determining ovarian response.

An observational study of assisted reproductive technology outcomes in new European Union member states: an overview of protocols used for ovarian stimulation

BACKGROUND

The development of new fertility treatment options has facilitated individualized assisted reproductive technology (ART) protocols to improve outcomes. Manufacturing improvements to recombinant human follitropin alfa have allowed precise dosing based on mass (filled-by-mass; FbM) rather than bioactivity (filled-by-bioassay; FbIU). Continued monitoring and reporting of follitropin alfa treatment outcomes in routine clinical practice is essential.

OBJECTIVE

To provide an overview of the frequency of different controlled ovarian-stimulation protocols used in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles in new European Union member states, and to provide post-registration efficacy and safety data on follitropin alfa.

RESEARCH DESIGN AND METHODS

A 2-year, prospective, observational, multicentre, Phase IV study conducted at ART clinics in the Czech Republic, Estonia, Latvia, Lithuania, Poland, Slovakia and Slovenia. Women aged 18-47 years undergoing ovarian stimulation with follitropin alfa for conventional IVF or ICSI were eligible for inclusion. The main treatment outcome was cumulative clinical pregnancy rate. Data were analysed descriptively.

RESULTS

Clinical pregnancy outcomes were available for 4055 of 4085 (99.3%) patients. In total, 1897 (46.8%) patients used follitropin alfa FbIU; 2133 (52.6%) used follitropin alfa FbM. Clinical pregnancy was achieved by 39.5% (1603/4055) of patients. A greater proportion of patients with polycystic ovary syndrome achieved a clinical pregnancy than those with endometriosis (41.8% vs 37.8%, respectively). A higher cumulative pregnancy rate was observed with the use of follitropin alfa FbM than follitropin alfa FbIU (41.3% vs 37.8%, respectively; p = 0.02).

CONCLUSIONS

This study represents the most comprehensive audit of individualized ART in clinical practice in Central and Eastern Europe. Overall, clinical pregnancy was achieved by 39.5% of patients after stimulation with follitropin alfa. The use of follitropin alfa FbM resulted in a higher cumulative pregnancy rate than did the FbIU formulation. However, limitations of the study include the observational and non-comparative study design, and descriptive nature of statistical analyses; furthermore, the study was not designed to make direct comparisons between the success rates of different ovarian-stimulation protocols.

A randomised controlled trial of 300 versus 225 IU recombinant FSH for ovarian stimulation in predicted normal responders by antral follicle count

OBJECTIVE

To test the hypothesis that among women predicted to have a normal ovarian response, ovarian stimulation using 300 IU follicle-stimulating hormone (FSH) results in the retrieval of more mature oocytes than 225 IU during in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) treatment.

DESIGN

Prospective randomised controlled study.

SETTING

University-based assisted conception unit.

POPULATION

A cohort of 131 women predicted to have a normal ovarian response to gonadotrophin stimulation, based on antral follicle count.

METHODS

Subjects undergoing their first cycle of IVF/ICSI were randomised to receive a fixed daily dose of 300 (experimental arm) or 225 IU (control arm) of recombinant FSH (Gonal-F).

MAIN OUTCOME MEASURES

Number of mature oocytes retrieved and live birth rates.

RESULTS

The number (mean +/- standard deviation) of mature oocytes retrieved (8.2 +/- 5.0 versus 9.0 +/- 4.8, for 300 and 225 IU, respectively; P = 0.34) was similar in each group. There were no differences between the 300- and 225 IU arms in live birth rates (31 versus 41%, respectively; P = 0.25), cycle cancellations resulting from insufficient ovarian response (0 versus 6.1%, respectively; P = 0.12), and prevalence of moderate (3.1 versus 3.0, respectively; P = 1.0) and severe (0 versus 1.5%, respectively; P = 1.0) ovarian hyperstimulation syndrome.

CONCLUSIONS

The use of a higher daily dose of 300 IU of recombinant FSH for ovarian stimulation does not improve the number of mature oocytes retrieved, or live birth rates, among women with a predicted normal response during conventional IVF/ICSI.

Evaluating the performance of serum antimullerian hormone concentration in predicting the live birth rate of controlled ovarian stimulation and intrauterine insemination

OBJECTIVE

To evaluate the role of serum antimullerian hormone (AMH) concentration in predicting live birth outcome in controlled ovarian stimulation and intrauterine insemination (IUI).

DESIGN

Retrospective analysis.

SETTING

Tertiary assisted reproduction unit.

PATIENTS

243 patients undergoing IUI treatment.

INTERVENTION(S)

Archived early follicular phase serum samples taken at the start of the first treatment cycle before ovarian stimulation were retrieved from patients undergoing IUI treatment.

MAIN OUTCOME MEASURE(S)

First-cycle and cumulative live birth rates.

RESULT(S)

Patients attaining a successful live birth, either in the first cycle or cumulatively after three cycles, had significantly higher serum AMH concentrations than those failing treatment. Serum AMH concentration correlated positively with antral follicle count (AFC) and duration of stimulation and inversely with maternal age, serum FSH concentration, and total dose of gonadotropin used. After controlling for age, body mass index, AFC, and FSH, AMH remained the only significant predictor of cumulative live birth. The area under the receiver operating characteristic curve was 0.668 in predicting cumulative live birth. Serum AMH concentration was significantly higher in overresponders.

CONCLUSION(S)

Serum AMH concentration was significantly higher in subjects with a live birth from the first cycle or after three cycles of stimulated IUI treatment compared with those failing treatment. Serum AMH concentration has a modest predictive value on ovarian overresponse.

Polymorphisms in the 5' upstream region of the FSH receptor gene, and their association with superovulation traits in Chinese Holstein cows

To identify a predictor to forecast superovulation response on the basis of associations between superovulation performance and gene polymorphism, variation in the bovine follicle stimulating hormone receptor (FSHR) gene was investigated using PCR-single-strand conformational (PCR-SSCP) and DNA sequencing. One single nucleotide polymorphism (SNP) of G-278A located in the 5' upstream region of bovine FSHR gene was found in 118 Chinese Holstein cows treated for superovulation. Two SNPs of G-278A (GU253337) and A-320T (rs43676359) were analyzed. In polymorphic locus -278, all cows without superovulation response were mutations with genotypes of CD and DD. Cows with CC genotype had a significant increase in the total number of ova (TNO) (P<0.01), and produced more transferable embryos (NTE) than those of the CD and DD genotypes (P<0.01). At this locus, the additive effects seemed to be highly significant (P<0.01) and allele C was associated with an increase in the TNO and NTE. These results indicated that the FSHR is a potential marker for superovulation response and can be used as a predictor for superovulation in Chinese Holstein cows.

Identification and in vitro characterization of follicle stimulating hormone (FSH) receptor variants associated with abnormal ovarian response to FSH

CONTEXT

FSH mediates cyclic follicle growth and development and is widely used for controlled ovarian stimulation in women undergoing infertility treatment. The ovarian response of women to FSH is variable, ranging from poor response to ovarian hyperstimulation.

OBJECTIVE

We investigated whether genetic alterations of the FSH receptor (FSHR) contribute to this variability.

DESIGN AND PATIENTS

Our approach was to study women undergoing treatment with in vitro fertilization falling into the edges of the normal distribution of ovarian response to FSH, with respect to age.

SETTING

We conducted the study at the Yale Fertility Clinic.

METHODS

We extracted RNA from cumulus cells surrounding the oocytes of women undergoing in vitro fertilization and analyzed the FSHR mRNA by RT-PCR and sequencing.

RESULTS

We identified four abnormal FSHR splicing products (three exon deletions and one intron insertion) in the FSHR mRNA in 37% (13 of 35) of women tested. All alterations affected the extracellular ligand-binding portion of the receptor without causing a frameshift. When transfected in HEK293T cells, all four splicing variants showed markedly decreased cAMP activation compared to controls. Untransfected cells showed no response to FSH, whereas all the cell lines showed normal cAMP activation when treated with forskolin, a nonreceptor-mediated cAMP stimulant. None of the normal or mutant forms showed any response to LH or TSH.

CONCLUSIONS

Our findings strongly indicate FSHR variants as being an intrinsic genetic cause of some forms of infertility and identify a need for functional characterization of these variants and the investigation of more individualized ovarian stimulation protocols.

Approaches to improve the diagnosis and management of infertility

BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.

Clomiphene citrate resistance in relation to follicle-stimulating hormone receptor Ser680Ser-polymorphism in polycystic ovary syndrome

BACKGROUND

Clomiphene citrate (CC) response in anovulatory women is difficult to predict and patient-tailored treatment would benefit patient care and time-management. The objective of this study was to evaluate the role of the follicle-stimulating hormone receptor (FSHR) Ser680Ser-polymorphism as a predictor for CC response.

METHODS

In this retrospective study, 193 patients, diagnosed with polycystic ovary syndrome (PCOS) according to Rotterdam criteria and treated with ovulation induction, were included over a 5-year period in a university hospital in the Netherlands. Data on demographics, BMI, menstrual cycle, laboratory screening (including FSHR genotyping), transvaginal ultrasonography of ovaries and ovulation parameters were collected. Main outcome measures were response to CC and FSHR genotype.

RESULTS

The frequency distribution of the 680-polymorphism was 26% (Asn/Asn), 50% (Asn/Ser) and 24% (Ser/Ser). No significant differences in basal characteristics were found. Significantly more patients with Ser/Ser-polymorphism were resistant to CC (28%) compared with Asn/Ser (14%) and Asn/Asn group (15%), with an odds ratio for ovulation of 0.44 (95% CI, 0.21-0.97). Patients with higher FSH levels, higher age and lower BMI were significantly more likely to ovulate in univariate analysis. In a multivariate logistic regression model, corrected for age, BMI, mean ovarian, volume, hyperandrogenism, and amenorrhoea, only FSHR and basal FSH levels were predictive for ovulation.

CONCLUSIONS

Chance of resistance to CC is almost double in women with PCOS harbouring the Ser/Ser genotype.

Developmental programming: contribution of prenatal androgen and estrogen to estradiol feedback systems and periovulatory hormonal dynamics in sheep

Prenatal testosterone excess leads to neuroendocrine and periovulatory disruptions in the offspring culminating in progressive loss of cyclicity. It is unknown whether the mediary of these disruptions is androgen or estrogen, because testosterone can be aromatized to estrogen. Taking a reproductive life span approach of studying control, prenatal testosterone, and dihydrotestosterone-treated offspring, this study tested the hypothesis that disruptions in estradiol-negative but not -positive feedback effects are programmed by androgenic actions of testosterone and that these disruptions in turn will have an impact on the periovulatory hormonal dynamics. The approach was to test estradiol-negative and -positive feedback responses of all three groups of ovary-intact females during prepubertal age and then compare the periovulatory dynamics of luteinizing hormone, follicle-stimulating hormone, estradiol, and progesterone during the first breeding season. The findings show that estradiol-negative but not estradiol-positive feedback disruptions in prenatal testosterone-treated females are programmed by androgenic actions of prenatal testosterone excess and that follicular phase estradiol and gonadotropins surge disruptions during reproductive life are consistent with estrogenic programming. Additional studies carried out testing estradiol-positive feedback response over time found progressive deterioration of estradiol-positive feedback in prenatal testosterone-treated sheep until the time of puberty. Together, these findings provide insight into the mechanisms by which prenatal testosterone disrupts the reproductive axis. The findings may be of translational relevance since daughters of mothers with hyperandrogenism are at risk of increased exposure to androgens.

Hypertensive pregnancy complications in poor and normal responders after in vitro fertilization

OBJECTIVE

To investigate whether women pregnant after a poor response in IVF have pregnancy-induced hypertension and preeclampsia more frequently than women with pregnancies after a normal response in IVF. Poor response to ovarian stimulation for IVF reflects advanced ovarian aging, which may be associated with early vascular aging. This may become apparent in an increased incidence of hypertensive pregnancy complications in pregnancies achieved after poor response in IVF.

DESIGN

Patient-control study.

SETTING

Tertiary Fertility Center.

PATIENT(S)

One hundred fifty poor (three oocytes or fewer) and 150 normal responders (8-12 oocytes) pregnant after IVF-intracytoplasmic sperm injection (ICSI), matched for age, type of infertility, dose of recombinant FSH, singleton or twin pregnancy, and IVF or ICSI treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary end points were birth weight of the neonate and the incidence of pregnancy-related hypertensive disorders. Secondary end points were duration of pregnancy, type of delivery, and live birth of the neonate.

RESULT(S)

Poor and normal responders did not have significantly different incidences in pregnancy-related hypertensive disorders, nor did their neonates differ significantly in birth weight. Moreover, duration of pregnancy, type of delivery, and live birth ratios were similar in both poor and normal responders.

CONCLUSION(S)

From this matched control study we were unable to confirm our hypothesis, that women pregnant after a poor response in IVF have pregnancy-induced hypertension and preeclampsia more frequently than women with pregnancies after a normal response in IVF. These results do not support a vascular etiology of poor response.

Mild ovarian stimulation for IVF

BACKGROUND

Mild ovarian stimulation for in vitro fertilization (IVF) aims to achieve cost-effective, patient-friendly regimens which optimize the balance between outcomes and risks of treatment.

METHODS

Pubmed and Medline were searched up to end of January 2008 for papers on ovarian stimulation protocols for IVF. Additionally, references to related studies were selected wherever possible.

RESULTS

Studies show that mild interference with the decrease in follicle-stimulating hormone levels in the mid-follicular phase was sufficient to override the selection of a single dominant follicle. Gonadotrophin-releasing hormone antagonists compared with agonists reduce length and dosage of gonadotrophin treatment without a significant reduction in the probability of live birth (OR 0.86, 95% CI 0.72-1.02). Mild ovarian stimulation may be achieved with limited gonadotrophins or with alternatives such as anti-estrogens or aromatase inhibitors. Another option is luteinizing hormone or human chorionic gonadotrophin administration during the late follicular phase. Studies regarding these approaches are discussed individually; small sample size of single studies along with heterogeneity in patient inclusion criteria as well as outcomes analysed does not allow a meta-analysis to be performed. Additionally, the implications of mild ovarian stimulation for embryo quality, endometrial receptivity, cost and the psychological impact of IVF treatment are discussed.

CONCLUSIONS

Evidence in favour of mild ovarian stimulation for IVF is accumulating in recent literature. However, further, sufficiently powered prospective studies applying novel mild treatment regimens are required and structured reporting of the incidence and severity of complications, the number of treatment days, medication used, cost, patient discomfort and number of patient drop-outs in studies on IVF is encouraged.

Graded response to short photoperiod during development and early adulthood in Siberian hamsters and the effects on reproduction as females age

Short day (SD) lengths delay puberty, suppress ovulation, inhibit sexual behavior, and decelerate reproductive aging in female Siberian hamsters (Phodopus sungorus). To date, the modulation of the age-associated decline in reproductive outcomes has only been demonstrated in female hamsters experiencing different day lengths during development. To determine if developmental delay is necessary for photo-inhibition to decelerate reproductive aging, hamsters raised in LD were transferred to SD as young adults and remained there for 6 months. Females that demonstrated the most immediate and sustained photo-inhibition were found to have greater numbers of ovarian primordial follicles at advanced ages (9 and 12 months) than did females held in LD, nonresponders to SD, and females with a marginal SD-response. Similarly, for females raised in SD from conception to 6 months of age, prolonged developmental delay was associated with greater numbers of primordial follicles at later ages as compared to hamsters that became refractory to SD. A robust response to SD in juvenile and adult hamsters is associated with decelerated reproductive aging, which may result in greater reproductive success in older females as compared to age-matched individuals demonstrating a more modest response to SD.

Aging of the human ovary and testis

Aging is associated with structural and functional alterations in all organs of the human body. The aging of gonads represents in this respect a special case, because these organs are not functional for the whole lifespan of an individual and their normal function is not indispensable for functions of the rest of the body. Ovarian function lasts for the reproductive life of a woman, i.e., from menarche until menopause. The testicular endocrine function, in contrast, begins already in utero, is interrupted between neonatal life and puberty, and continues thereafter along with spermatogenesis, with only slight decline, until old age. The aging processes of the ovary and testis are therefore very different. We describe in this review the structural and functional alterations in the human ovary and testis upon aging. Special emphasis will be given to clinically significant alterations, which in women concern the causes and consequences of the individual variability of fertility during the latter part of the reproductive age. The clinically important aspect of testicular aging entails the decline of androgen production in aging men.

Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review

Metformin is an insulin sensitizer widely used for the treatment of patients affected by type 2 diabetes mellitus. Because many women with polycystic ovary syndrome (PCOS) are insulin resistant, metformin was introduced in clinical practice to treat these patients also. Moreover, metformin's effect has other targets beside its insulin-sensitizing action. The present review was aimed at describing all evidence-based and potential uses of metformin in PCOS patients. In particular, we will analyze the uses of metformin not only for the treatment of all PCOS-related disturbances such as menstrual disorders, anovulatory infertility, increased abortion, or complicated pregnancy risk, hyperandrogenism, endometrial, metabolic and cardiovascular abnormalities, but also for the prevention of the syndrome.

Impact of GnRH ovarian stimulation protocols on intracytoplasmic sperm injection outcomes

BACKGROUND

Although a large number of studies have been conducted in relation to ovarian response and pregnancy after GnRH agonist and GnRH antagonist controlled ovarian hyperstimulation protocols, most of them used single or combinations of a few predictive factors, and none included the stimulation protocol in the multivariable analysis. The present study was thus primarily designed to investigate the predictive value of the stimulation protocol and to analyze the possible relationships between stimulation protocols and treatment outcomes after adjusting for a large set of variables that potentially affect reproductive outcomes. Factors related to pregnancy achievement and predictive of the number of oocytes retrieved and high quality of the embryos obtained were also analyzed.

METHODS

To analyze the impact of GnRH ovarian stimulation protocols on the independent predictors of ovarian response, high quality embryos and clinical pregnancy, two groups out of 278 ICSI treatment cycles were compared prospectively, 123 with a GnRH agonist and 155 with a GnRH antagonist, with multivariable analysis assessing outcomes after adjusting for a large set of variables.

RESULTS

Antagonists were significantly associated with lower length and total dose of GnRH, lower length of rFSH, and higher numbers of oocytes and high quality embryos, whereas the agonist presented a higher fertilization rate and probability of pregnancy. Significant predictors of retrieved oocytes and high quality embryos were the antagonist protocol, lower female age, lower serum levels of basal FSH and higher total number of antral follicles. Significant predictors of clinical pregnancy were the agonist protocol, reduced number of attempts, increased endometrial thickness and lower female age. The probability of pregnancy increased until 30 years-old, with a decline after that age and with a sharp decline after 40 years-old.

CONCLUSION

The models found suggest that not only the protocol but also factors as female age, basal FSH, antral follicles, number of attempts and endometrial thickness should be analyzed for counselling patients undergoing an ICSI treatment.

Functional genetic polymorphisms and female reproductive disorders: Part I: Polycystic ovary syndrome and ovarian response

BACKGROUND

The identification of polymorphisms associated with a disease can help to elucidate its pathogenesis, and this knowledge can be used to improve prognosis for women with a particular disorder, such as polycystic ovary syndrome (PCOS). Since an altered response to ovarian stimulation is also a characteristic of the disease, further knowledge about its aetiology could help in defining the parameters that determine the response of an individual to ovarian stimulation.

METHODS

PubMed and EMBASE databases were systematically searched for gene association studies published until the end of August 2007, using search criteria relevant to PCOS and ovarian response to stimulation. Data from additional papers identified through hand searches were also included; 139 publications were reviewed.

RESULTS

Several genes involved in ovarian function and metabolism are associated with increased susceptibility to PCOS, but none is strong enough to correlate alone with susceptibility to the disease, or response to therapy. A single-nucleotide polymorphism in exon 10 of the FSH receptor (FSHR) gene, FSHR p.N680S, was consistently identified as having a significant association with ovarian response to FSH.

CONCLUSIONS

No consistent association between gene polymorphism and PCOS could be identified. The FSHR gene may play a significant role in the success of ovarian stimulation, and can be used as a marker to predict differences in FSHR function and ovarian response to FSH. Genotyping the FSHR p.N680S polymorphism may provide a means of identifying a population of poor responders before in vitro fertilization procedures are initiated.