Comparison of oocyte quality and intracytoplasmic sperm injection outcome in women with isolated polycystic ovaries or polycystic ovarian syndrome

Predictive model of IVF outcomes for polycystic ovarian morphology and polycystic ovary syndrome in GnRH antagonist protocol using AMH-MoM and ovarian sensitivity index

AIM

To evaluate the relationship between AMH and ovarian response to controlled ovarian hyperstimulation in women with PCOM and PCOS.

METHODS

A retrospective study was conducted on 559 patients who underwent the IVF-ET cycle between January 2018 and December 2022 at Gangnam Cha Hospital. Patients were divided into 3 groups matched for age and BMI: the PCOS group (n = 54), based on the new 2023 PCOS guideline; the PCOM group (n = 53); and the control group (n = 452) with normal ovaries. Serum AMH levels were converted to multiples of the median (MoM) for each corresponding age. The ovarian sensitivity index (OSI) was calculated as the number of retrieved oocytes divided by the total dose of recombinant FSH administered (per 1000 IU).

RESULTS

There were significant differences in AMH-MoM value among women with PCOS [2.7 ± 1.3 (95% CI 2.3-3.0)], those with PCOM [2.0 ± 1.0 (95% CI 1.7-2.3)], and controls [0.8 ± 0.7 (95% CI 0.8-0.9)] (p < 0.001). The abortion rates in the normoovulatory, PCOM, and PCOS groups were 18.2%, 21.1%, and 25.0%, respectively. OSI and live birth rate were positively correlated with the AMH-MoM value in normoovulatory women (r = 0.389, p < 0.05, r = 0.122, p < 0.05), while no such correlation was observed in women with PCOM and PCOS.

CONCLUSIONS

Ovarian response and live birth rate are possibly correlated with the AMH-MoM value in normoovulatory women, but not in women with PCOM and PCOS.

Polycystic ovarian syndrome and miscarriage in IVF: systematic revision of the literature and meta-analysis

PURPOSE

To evaluate the risk of miscarriage in IVF cycles in women with PCOS.

METHODS

Systematic review and meta-analysis. Systematic search of MEDLINE, EMBASE and Google Scholar. The language search was restricted to English, Spanish and French, from 2000 to 2019, with crosschecking of references from relevant articles. Inclusion criteria were: (1) IVF cycles (2) a group of patients with PCOS was considered separately, (3) the miscarriage rate was reported, (4) there was a control group, (5) definition of PCOS according the Rotterdam criteria. Exclusion criteria were been excluded from the meta-analysis: (1) publication prior to the year 2000, (2) animal studies, (3) reviews, (4) abstracts or conference papers, (5) letters, (6) case reports, (7) studies comparing different IVF techniques, (8) studies comparing groups with and without metformin or other treatments, (9) studies on induced abortions. Risk of bias was assessed by the Newcastle-Ottawa score (NOS). All the included studies had a low risk of bias (NOS scores ranging 7-8). The review protocol was registered in PROSPERO (CRD42020186713). Seventeen studies were included in the meta-analysis. There was a total of 10,472 pregnancies (2650 in PCOS and 7822 in controls) of which 1885 were miscarriages (682 in PCOS and 1203 in controls). We considered the miscarriage rate (MR), preclinical MR, early MR, and late MR.

RESULTS

In IVF pregnancies the risk of miscarriage was significantly increased when considering miscarriages in total (RR = 1.59; CI = 1.45-1.75), preclinical miscarriages (RR = 1.59; CI = 1.35-1.88), and early miscarriages (RR = 1.44; CI = 1.16-1.79). The increased miscarriage rate persisted in Chinese and Western populations when considered separately. The risk of miscarriage was increased in the subgroup of fresh transfers (RR = 1.21; CI = 1.06-1.39) as well as in the subgroup including either fresh or frozen transfers (RR = 1.95; CI = 1.72-2.22).

CONCLUSION

PCOS is linked to an increased MR in IVF pregnancies both of miscarriages in total, and to an increase in preclinical and early miscarriages.

PROSPERO NUMBER

CRD42020186713.

Serum steroid metabolome on the day of oocyte retrieval in women with polycystic ovarian syndrome and its association with pregnancy outcome of in vitro fertilization

Steroid hormone level is a crucial factor affecting the outcomes of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). The purpose of this study was to evaluate serum steroid metabolome on the day of oocyte retrieval in women with polycystic ovarian syndrome (PCOS) and explore whether specific steroids can be potential indicators to improve the prediction of pregnancy outcomes in PCOS patients undergoing IVF/ICSI. In this study, the serum levels of 21 steroids in 89 women with PCOS and 73 control women without PCOS on the day of oocyte retrieval of the first IVF/ICSI treatment cycle were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS). All patients subsequently received good-quality embryo transfer, and the correlation between their steroid profiles and pregnancy outcomes of the first embryo transfer (ET) was retrospectively analyzed. We found PCOS patients had aberrant levels of 11 out of 21 steroid hormones compared to control individuals, with androgen steroid hormones being considerably enhanced. Enzyme activity evaluation indicated that PCOS women might have abnormal activity of CYP17A1, CYP21A2, CYP11B2, CYP19A1, HSD3B, HSD11B, and HSD17B. Additionally, the level of 18-hydroxycorticosterone (p = 0.014), corticosterone (p = 0.035), and 17-hydroxypregnenolone (p = 0.005) were markedly higher in live birth group than in non- live birth group for PCOS women following frozen embryo transfer (FET). Multiple logistic regressions indicated that 18-hydrocorticosterone and 17-hydroxypregnenolone were independently associated with live birth outcomes of PCOS women following FET. Receiver operating characteristic (ROC) curve analysis revealed that 0.595ng/mL for 18-hydrocorticosterone level (AUC: 0.6936, p = 0.014).and 2.829ng/mL for 17-hydroxypregnenolone level (AUC: 0.7215, p = 0.005) were the best cutoff values to predict live birth outcomes of PCOS. In conclusion, the blood steroid metabolome was closely related to the IVF/ICSI outcomes of PCOS patients. 18-hydroxycorticosterone and 17-hydroxypregnenolone might be potential indicators to predict pregnancy outcomes of PCOS undergoing IVF/ICSI treatment. AVAILABILITY OF DATA AND MATERIALS: The data used in the current study are available from the database of Women's Hospital, School of Medicine, Zhejiang University on reasonable request.

Gonadotropins as pharmacological agents in assisted reproductive technology and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex endocrinopathy associated with subfertility/infertility and pregnancy complications. Most PCOS women opt for assisted reproductive technologies (ART) for successful conception; however, optimization of the relative doses of the gonadotropins [follicle-stimulating hormone (FSH), luteinizing hormone (LH)/human chorionic gonadotropin (hCG)] for appropriate steroidogenesis, without causing ovarian hyperstimulatory syndrome (OHSS), is challenging. Embryonic factors probably do not contribute to pregnancy loss in PCOS women, albeit hormonal imbalance impairs the metabolic microenvironment critical for oocyte maturation and endometrial receptivity. Certain clinical studies have confirmed the role of metabolic corrections in increasing the rate of pregnancy in PCOS women. This review focuses on the impact of untimely high LHCGR and/or LH levels on oocyte/embryo quality, pregnancy outcomes in ART, and exploring LHCGR as a potential drug target in PCOS women.

Among high responders, is oocyte development potential different in Rotterdam consensus PCOS vs non-PCOS patients undergoing IVF?

PURPOSE

To evaluate the oocyte potential to develop to blastocyst in Rotterdam consensus PCOS in women with hyper-responses requiring freeze-all embryos.

METHODS

Retrospective, single-academic center, cohort study of 205 patients who underwent freeze-all antagonist IVF cycles for OHSS risk between 2013 and 2019. Women in the PCOS group (n = 88) were diagnosed per the 2003 Rotterdam criteria. Control patients (n = 122) had no evidence of hyperandrogenism or menstrual disturbance. Data was compared by t-tests, chi-squared tests, or multivariate logistic regression (SPSS). Frozen blastocysts were Gardner's grade BB or better.

RESULTS

There was no difference in terms of number of oocytes collected (PCOS vs non-PCOS 27.7 ± 9.4 vs 25.9 ± 8.2, p = 0.157), number of MII (20.7 ± 8.0 vs 19.1 ± 6.6, p = 0.130), number of 2PN fertilized (15.6 ± 7.4 vs 14.4 ± 5.9, p = 0.220), and number of frozen blastocysts (7.8 ± 4.9 vs 7.1 ± 3.8, p = 0.272). In addition, fertilization rates (74 ± 17% vs 75 ± 17%, p = 0.730), blastulation rates per 2PN (51 ± 25% vs 51 ± 25%, p = 0.869), and blastulation rates per mature oocytes (37 ± 18% vs 37 ± 15%, p = 0.984) were all comparable between PCOS and controls, respectively. Moreover, there was no difference when comparing PCOS and controls in pregnancy rates (45/81 vs 77/122, p = 0.28) and clinical pregnancy rates (34/81 vs 54/122, p = 0.75), respectively. Multivariate logistic regression controlling for confounders failed to alter these results.

CONCLUSION

PCOS subjects do not seem to have altered oocyte potential as measured by number of MII oocytes collected, fertilization, and blastulation rates when compared to high-responder controls, with similar magnitude of stimulation.

IVF outcome with a high level of AMH: a focus on PCOS versus non-PCOS

BACKGROUND

The purpose of this research was to investigate whether high AMH levels in PCOS patients resulted in different IVF outcomes compared to those in non-PCOS patients.

METHODS

A retrospective cohort study was conducted involving 238 women undergoing IVF who had AMH levels > 4 ng/ml. Participants were divided into two groups: PCOS and non-PCOS.

RESULTS

The median AMH level was significantly higher in the PCOS group (7.59 ± 4.61 ng/ml vs. 5.91 ± 2.22 ng/ml, p < 0.001). The PCOS group required less gonadotropin but yielded more oocytes after stimulation. Significantly more participants from the PCOS group (41.5% [n = 39]) developed a hyperresponse to ovarian stimulation compared to the non-PCOS group (26.4% [n = 38]) (OR = 1.978, 95% CI 1.138-3.488; p = 0.015).

CONCLUSION

There were significant differences in terms of total doses of gonadotropin and the number of oocytes retrieved in the PCOS and non-PCOS groups. Women with PCOS and high AMH levels have a higher risk of hyperresponse after ovarian stimulation than women without PCOS.

Polycystic ovary syndrome phenotype does not have impact on oocyte morphology

PURPOSE

The primary objective of the present study of women participating in an ICSI program was to determine whether the morphologic quality of oocytes was related to the polycystic ovary syndrome (PCOS) phenotype.

METHODS

We performed a retrospective cohort study in the IVF unit at the Lille University Medical Center (Lille, France) between 2006 and 2015. Oocyte morphology (fragmented first polar body, abnormal zona pellucida, large perivitelline space, material in perivitelline space, abnormal shape of oocyte, granular cytoplasm and intracytoplasmic vacuoles) was evaluated in PCOS women and according to different subgroup (depending on the presence or absence of the cardinal features polycystic ovarian morphology (PCOM), hyperandrogenism (HA), and oligo-anovulation (OA)).

RESULTS

A total of 1496 metaphase II oocytes (n = 602 for phenotype A combining PCOM + HA + OA, n = 462 oocytes for phenotype C: PCOM + HA, and n = 432 for phenotype D: PCOM + OA) were assessed. The phenotypes A, C and D did not differ significantly with regard to the proportion of normal oocytes (adjusted percentages (95%CI): 35.2% (31.5 to 39.1%), 25.8% (21.9 to 29.9%) and 34.0% (29.7 to 38.6%), respectively: adjusted p = 0.13). Likewise, there were no significant intergroup differences in oocyte morphology. The ICSI outcome was not significantly associated with the PCOS phenotype.

CONCLUSION

The present study is the first to show that the PCOS phenotype (notably the presence vs. absence of OA and/or HA) is not significantly associated with the morphological quality of oocytes.

Molecular Features of Polycystic Ovary Syndrome Revealed by Transcriptome Analysis of Oocytes and Cumulus Cells

Polycystic ovary syndrome (PCOS) is typically characterized by a polycystic ovarian morphology, hyperandrogenism, ovulatory dysfunction, and infertility. Furthermore, PCOS patients undergoing ovarian stimulation have more oocytes; however, the poor quality of oocytes leads to lower fertilization and implantation rates, decreased pregnancy rates, and increased miscarriage rates. The complex molecular mechanisms underlying PCOS and the poor quality of oocytes remain to be elucidated. We obtained matched oocytes and cumulus cells (CCs) from PCOS patients, compared them with age-matched controls, and performed RNA sequencing analysis to explore the transcriptional characteristics of their oocytes and CCs. Moreover, we validated our newly confirmed candidate genes for PCOS by immunofluorescence. Unsupervised clustering analysis showed that the overall global gene expression patterns and transposable element (TE) expression profiles of PCOS patients tightly clustered together, clearly distinct from those of controls. Abnormalities in functionally important pathways are found in PCOS oocytes. Notably, genes involved in microtubule processes, TUBB8 and TUBA1C, are overexpressed in PCOS oocytes. The metabolic and oxidative phosphorylation pathways are also dysregulated in both oocytes and CCs from PCOS patients. Moreover, in oocytes, differentially expressed TEs are not uniformly dispersed in human chromosomes. Endogenous retrovirus 1 (ERV1) elements located on chromosomes 2, 3, 4, and 5 are rather highly upregulated. Interestingly, these correlate with the most highly expressed protein-coding genes, including tubulin-associated genes TUBA1C, TUBB8P8, and TUBB8, linking the ERV1 elements to the occurrence of PCOS. Our comprehensive analysis of gene expression in oocytes and CCs, including TE expression, revealed the specific molecular features of PCOS. The aberrantly elevated expression of TUBB8 and TUBA1C and ERV1 provides additional markers for PCOS and may contribute to the compromised oocyte developmental competence in PCOS patients. Our findings may also have implications for treatment strategies to improve oocyte maturation and the pregnancy outcomes for women with PCOS.

Evaluation of oocyte quality in Polycystic ovary syndrome patients undergoing ART cycles

BACKGROUND

To evaluate factors affecting oocyte/embryo quality in PolyCystic Ovary Syndrome (PCOS) patients undergoing Assisted Reproductive Technology (ART) cycles.

METHODS

This case-control retrospective study was performed on PCOS patients referred to the infertility department of Imam Khomeini Hospital in Ahvaz from October 2017 to September 2019. Demographic and reproductive characterizations including age, gender, abortion history and infertility type (primary and secondary infertility) were extracted from patient's records. TSH, AMH, LH, FSH, prolactin, lipid profile and blood glucose was measured. Biochemistry pregnancy was checked by determination of serum βHCG level and then, clinical pregnancy was confirmed by observing of pregnancy sac and fetal heart rate using Transvaginal USS.

RESULTS

One-hundred thirty-five patients include 45 PCOS and 90 Non-PCOS patients with mean age of 31.93 ± 5.04 and 30.8 ± 5.38 (p = 0.24) were considered as case and control groups respectively. Retrieved oocyte numbers were significantly higher in PCOS patients (p = 0.024), but there was no significant difference in number of oocyte subtypes (MI, MII and GV) between two groups. The embryo numbers and its subtypes did not differ significantly in both groups. The clinical pregnancy rate was insignificantly lower in PCOS patients (p = 0.066) and there was a significant correlation between retrieved oocyte numbers with age(r= -0.2, p= 0.022) and AMH level (r = 0.433, p < 0.0001) respectively. Cholesterol level had shown a positive significant correlation with number of MI oocytes (r = 0.421, p = 0.026) and MII oocytes significantly affected by age (r= -0.250, p = 0.004) and AMH level (r = 0.480, p < 0.0001). Using Receiver operation characteristic (ROC) curve analysis, the cut-off value of total number of oocytes was > 10.5 with area under curve of 0.619±0.054(sensitivity 55.56% and specificity 69.66%) CONCLUSIONS: The results of this study showed that although the number of oocytes in PCOS patients was significantly higher than non-PCOS patients, the quality of oocytes was not statistically different. The number and quality of embryos were not significantly different in both groups. Our results indicated a significant relationship between the level of AMH and the number of retrieved oocytes and embryos. We found there is a significant correlation between cholesterol level and number of MI oocytes.

Comparison of a progestin-primed ovarian stimulation protocol with a flexible GnRH antagonist protocol in patients with polycystic ovary syndrome who are participating in an IVF programme: study protocol for a randomised controlled trial

INTRODUCTION

Women with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization (IVF) protocols are typically characterised by an increased number of oocytes retrieved. The oocytes are often of poor quality, leading to lower pregnancy rates, higher miscarriage rates and an increased risk of developing ovarian hyperstimulation syndrome (OHSS). Since our previous preliminary study showed that a novel progestin-primed ovarian stimulation (PPOS) protocol blocked the luteinising hormone (LH) surge during IVF and achieved a higher pregnancy rate with a lower incidence of OHSS, we designed a prospective randomised controlled trial to compare the efficacy and safety of this PPOS protocol with the flexible gonadotropin-releasing hormone (GnRH) antagonist protocol in patients with PCOS who are undergoing IVF procedures.

METHODS AND ANALYSIS

Patients with PCOS will be randomised to one of two controlled ovarian stimulation regimens-GnRH antagonist or PPOS-using a computer-generated random number. A freeze-all strategy using embryo vitrification techniques and frozen embryo transfer will be performed in both groups. The primary outcome is the live-birth rate per transfer. Secondary outcomes include the incidence of premature LH surges, the duration and total dose of human menopausal gonadotropin stimulation, the number of oocytes retrieved, the incidence of moderate or severe OHSS, the number of embryos available for transfer, implantation rates, clinical pregnancy rates, pregnancy loss rates, ectopic pregnancy rates, pregnancy and neonatal complications, and congenital anomalies. The necessary sample size for this trial was estimated as 392 participants, with 196 participants in each group. Intention-to-treat analysis was used in processing our experimental data.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the hospital (2016-133-T82). The trial will be conducted according to the principles of the World Medical Association's Declaration of Helsinki and in accordance with Good Clinical Practice standards. The findings of this trial will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTRIPR16009580.

Early and late pregnancy loss in women with polycystic ovary syndrome undergoing IVF/ICSI treatment: a retrospective cohort analysis of 21 820 pregnancies

OBJECTIVE

To examine early and late pregnancy loss in women with and without polycystic ovary syndrome (PCOS) undergoing IVF/ICSI transfers.

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine centre at a tertiary hospital.

POPULATION

We studied women with a positive β-human chorionic gonadotropin (β-hCG) after in vitro fertilisation/intra-cytoplasmic sperm injection (IVF/ICSI) treatment from May 2014 to April 2019.

METHODS

Odds ratios (OR) for early (≤13 weeks) and late (>13 weeks) pregnancy loss were calculated among women with and without PCOS for plurality of the pregnancy with adjustment for confounding factors.

MAIN OUTCOME MEASURES

Early pregnancy loss (EPL) and late pregnancy loss (LPL).

RESULTS

From 21 820 women identified with a positive β-hCG, 2357 (10.8%) women had PCOS, and 19 463 (89.2%) women did not. EPL occurred in 16.6% (391) of women with PCOS versus 18.3% (3565) in women with non-PCOS (OR 0.89, 95% CI 0.79-0.99, P = 0.04). After adjustment for age and other confounders, the rate of EPL was not statistically significantly associated with PCOS status (adjusted OR [aOR] 0.91, 95% CI 0.80-1.05). Women with PCOS demonstrated a higher rate of LPL (6.4% in PCOS versus 3.6% in non-PCOS, OR 1.81, 95% CI 1.48-2.21, P < 0.001). In multivariable analysis, the potential impact of PCOS was less strong (aOR 1.38, 95% CI 0.96-1.98), with BMI and maternal comorbidities also associated with LPL (aOR 1.08, 95% CI 1.04-1.1 and aOR 2.07, 95% CI 1.43-3.00, respectively).

CONCLUSIONS

Polycystic ovary syndrome was not independently associated with EPL. There was an increased risk of LPL but this difference was not statistically significant.

TWEETABLE ABSTRACT

Polycystic ovary syndrome women are at increased risk of late pregnancy loss, partly driven by elevated BMI and maternal comorbidities.

Systematic oxidative stress is not associated with live birth rate in young non-obese patients with polycystic ovarian syndrome undergoing assisted reproduction cycles: A prospective cohort study

OBJECTIVE

Oxidative stress may be associated with polycystic ovary syndrome (PCOS) and poor outcomes after assisted reproduction treatment. It is unclear if systematic oxidative stress is correlated with live birth rate in patients with PCOS after controlled ovarian stimulation. This study aimed to investigate the serum oxidative stress markers on the day of trigger hCG and its relationship with live birth rate in young non-obese women with or without PCOS undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment.

STUDY DESIGN

In this prospective cohort study, 50 patients with PCOS and 50 patients without PCOS aged less than 35 years and undergoing IVF/ICSI between February 2017 and January 2018 were studied. The body mass index (BMI) of all participants was less than 28 kg/m². Serum malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels on the day of hCG were measured. Demographic and cycle characteristics, embryo laboratory data and pregnancy outcomes after fresh embryo transfer were analyzed. Univariate analysis and logistic regression analysis were used to analyze independent variables predicting the live birth rate.

RESULTS

After conventional ovarian stimulation, the patients with PCOS had higher serum MDA and GPx concentrations (P < 0.03) and lower serum SOD levels (P < 0.03) on the hCG trigger day than the controls. Further, the serum MDA and GPx levels on the trigger day were also positively correlated with the number of good quality embryos (R = 0.26, P = 0.01; R = 0.21, P = 0.04; respectively). However, cycle characteristics, IVF/ICSI outcomes and pregnancy outcomes were comparable between the two groups. Multivariate logistic regression analysis showed that the rate of good quality embryos (OR 1.04, 95 %CI 1.01-1.06, P = 0.005) and the duration of infertility (OR 0.74, 95 %CI 0.56-0.98, P = 0.04) were predictive factors of live birth rate. The ROC curve analysis showed the AUC for the model was 0.76 (95 %CI: 0.67-0.86, P < 0.001).

CONCLUSION

The data suggest that moderate systemic oxidative stress on the hCG trigger day had no detrimental effects on live birth rate in young and non-obese patients with PCOS after IVF/ICSI treatment.

Homocysteine impairs porcine oocyte quality via deregulation of one-carbon metabolism and hypermethylation of mitochondrial DNA†

Homocysteine (Hcy) is an intermediate in the one-carbon metabolism that donates methyl groups for methylation processes involved in epigenetic gene regulation. Although poor oocyte quality in polycystic ovarian syndrome (PCOS) patients is associated with elevated Hcy concentration in serum and follicular fluid, whether Hcy directly affects oocyte quality and its mechanisms are poorly understood. Here we show that Hcy treatment impaired oocyte quality and developmental competence, indicated by significantly reduced survival rate, polar body extrusion rate, and cleavage rate. Hcy treatment resulted in mitochondrial dysfunction, with increased production of mitochondrial ROS, reduced mtDNA copy number, and the expression of 7 out of 13 mtDNA-encoded genes and 2 ribosome RNA genes, 12S rRNA and 16S rRNA. Upon Hcy treatment, the expression of one-carbon metabolic enzymes and DNMT1 was enhanced. Interestingly, DNA methyltransferase inhibitor 5'AZA rescued Hcy-induced mitochondrial dysfunction, impaired oocyte quality and developmental competence. Concurrently, expression of one-carbon metabolic enzymes and methylation status of mtDNA coding sequences were also normalized, at least partially, by 5'AZA treatment. Our findings not only extend the understanding about how Hcy induces poor oocyte quality, but also contribute to a novel angle of identifying targets for enhancing the quality of oocyte from PCOS patients.

Up-regulated FHL2 inhibits ovulation through interacting with androgen receptor and ERK1/2 in polycystic ovary syndrome

BACKGROUND

The ovulatory dysfunction mechanisms underlying polycystic ovary syndrome (PCOS) are not completely understood. There is no effective therapy for PCOS so far.

METHODS

We measured the expression of four and a half LIM domain 2 (FHL2) and other related-genes in human granulosa cells (hGCs) from patients with and without PCOS. To minimise the heterogeneity of patients with PCOS, we only included PCOS patients meeting all three criteria according to the revised Rotterdam consensus. The in vitro effects of FHL2 on ovulatory genes and the underlying mechanisms were examined in KGN cells. The role of FHL2 in ovulation was investigated in vivo by overexpressing FHL2 in rat ovaries via intrabursal lentivirus injection.

FINDINGS

Increased FHL2 and androgen receptor (AR) expression and decreased CCAAT/enhancer-binding protein β (C/EBPβ) expression were observed in hGCs from patients with PCOS. FHL2 inhibited the expression of ovulation-related genes, including phosphorylated ERK1/2, C/EBPβ, COX2 and HAS2 in KGN cells. It was partially by interacting with AR to act as its co-regulator to inhibit C/EBPβ expression and by binding to ERK1/2 to inhibit its phosphorylation. Moreover, FHL2 abundance in hGCs was positively correlated with the basal serum testosterone concentration of patients with PCOS, and dihydrotestosterone (DHT)-induced FHL2 upregulation was mediated by AR signalling in KGN cells. Additionally, lentiviral-mediated functional FHL2 overexpression in rat ovaries for 1 week contributed to an impaired superovulatory response, displaying decreased numbers of retrieved oocytes and a lower MII oocyte rate. 3-week FHL2 overexpression rat models without superovulation led to acyclicity and polycystic ovary morphology.

INTERPRETATION

Our findings provide novel insights into the mechanisms underlying the pathogenesis of PCOS, suggesting that FHL2 could be a potential treatment target for ovulatory obstacles in PCOS. FUND: National Key Research and Development Program of China, National Natural Science Foundation, National Institutes of Health project and Shanghai Commission of Science and Technology.

Factors Associated with Ovarian Hyperstimulation Syndrome (OHSS) Severity in Women With Polycystic Ovary Syndrome Undergoing IVF/ICSI

INTRODUCTION

Age, polycystic ovary syndrome (PCOS), low body mass index (BMI), high antral follicle count (AFC), increased anti-Muller hormone (AMH) levels, and elevated serum estradiol (E2) concentrations are risk factors for ovarian hyperstimulation syndrome (OHSS). However, data on the relationship between risk factors and OHSS severity in patients with PCOS are rare.

OBJECTIVE

This retrospective study examined the risk factors for OHSS and their effect on OHSS severity in patients with PCOS undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

METHOD

The records of 2,699 women were reviewed and included in this study. These women were diagnosed with PCOS during their first IVF/ICSI cycle between January 2010 and December 2017. We analyzed the association between each of the interrogated risk factors (including female age, BMI, AFC, basal serum E2, and the number of oocytes retrieved) and OHSS. The effects of each risk factor on OHSS severity were further explored. Logistic regression was performed as part of the above analysis.

RESULTS

Of the 2,699 women with PCOS who underwent assisted reproductive technology (ART), 75.2% had a normal response to controlled ovarian hyperstimulation (COH), while 24.8% developed OHSS. All OHSS patients were younger and had lower BMIs and basal serum follicle-stimulating hormone (FSH) and E2 levels but higher AFCs than those in the normal group. AFC demonstrated a strong correlation with OHSS, with a cutoff value of 24 in patients with PCOS. A total of 19.5% of the patients had mild OHSS, while 80.5% had moderate OHSS. Compared with those in the moderate OHSS group, those in the mild OHSS group were older and had higher basal serum FSH levels and lower serum E2 and T levels. However, BMI and AFC were not different between the mild and moderate OHSS groups. Basal serum E2 showed a strong correlation with OHSS severity, with a cutoff value of 37.94 pg/ml.

CONCLUSIONS

AFC is a strong marker of OHSS, and basal serum E2 is the best predictor of OHSS severity in women with PCOS undergoing IVF treatment.

[Polycystic ovary syndrome does not affect blastulation nor cumulative live birth rates]

OBJECTIVES

Polycystic ovarian syndrome (PCOS) brings complications in the management of the assisted reproductive technology (ART) because of an oocyte quality probably impaired due to modifications of intra- and extra-ovarian factors. Our study aimed to investigate the extended culture in PCOS patients and its influence on the cumulative live birth rates.

METHODS

Fifty-nine PCOS patients (as defined by the Rotterdam criteria) and 114 normo-ovulatory patients (i.e. with tubal, male or idiopathic infertility, regular cycles and AMH>2ng/mL) aged<37years old who underwent a 1st or 2nd ART attempt with extended culture to day 6 were included from October 2015 to December 2017. The blastulation and cumulative live birth rates were compared between the two groups.

RESULTS

The PCOS and control patients were 32.22 and 32.91years old respectively (P=0.05). The median number of oocytes retrieved was significantly higher in the PCOS group and the median oocyte maturity rate significantly lower compared with controls. The blastulation rates were similar between the PCOS and the control groups, respectively 57.8% vs. 58.6%, P=0.88. Because of the risks of hyperstimulation syndrome, a freeze all strategy was achieved for 38.9% of PCOS patients vs. 14.0% of the control patients (P<0.01). The cumulative live birth rates were not statistically different: 31.7% in the PCOS group vs. 37.2% in the control group, P=0.50.

CONCLUSIONS

PCOS was not observed to affect the extended culture nor the cumulative live birth rates in comparison to normo-ovulatory patients, supporting the blastocyst transfer strategy as a suitable option to PCOS patients.

Use of Cumulative Live Birth Rate per Total Number of Embryos to Calculate the Success of IVF in Consecutive IVF Cycles in Women Aged ≥35 Years

Objective

The use of cumulative live birth rate (CLBR) per ovarian stimulation cycle is proving to be an accurate method to calculate the success of IVF; however, the cycle outcome is closely associated with the number of embryos transferred (ET). Our aim was to report CLBR after IVF according to the number of embryos required to achieve a live birth in women aged ≥35 years, considering age, body mass index (BMI), and ethnicity.

Methods

We conducted a retrospective cohort study including 1344 patients who underwent IVF between January 2013 and June 2016 at the First Affiliated Hospital of Xinjiang Medical University. The cumulative probability of live birth for each couple was estimated using the Kaplan–Meier method, and survival curves were compared according to age, BMI, and ethnicity using the log-rank test.

Results

CLBR increased rapidly from 1 to 5 ETs, moderately from 6 to 10 ETs, and slowly thereafter. CLBR was significantly different across 4 categories based on BMI as well as across those based on age; low CLBR was significantly associated with the age of ≥42 years and obesity.

Conclusion

The association between CLBR and number of ET provides realistic and precise information regarding the success of IVF and can be applied to guide clinicians and patients.

Association of Vitamin D Metabolites With Embryo Development and Fertilization in Women With and Without PCOS Undergoing Subfertility Treatment

Objective: The relationship between fertilization rates and 1,25-dihydroxyvitamin D (1,25(OH)₂D₃), 25-hydroxyvitamin D2 (25(OH)D₂), 25-hydroxyvitamin D3 (25(OH)D₃), 24,25-dihydroxyvitamin D (24,25(OH)₂D₃), and 25-hydroxy-3epi-Vitamin D3 (3epi25(OH)D₃) concentrations in age and weight matched women with and without PCOS was studied. Methods: Fifty nine non-obese women, 29 with PCOS, and 30 non-PCOS undergoing IVF, matched for age and weight were included. Serum vitamin D metabolites were taken the menstrual cycle prior to commencing controlled ovarian hyperstimulation. Results: Vitamin D metabolites did not differ between PCOS and controls; however, 25(OH)D₃ correlated with embryo fertilization rates in PCOS patients alone (p = 0.03). For all subjects, 3epi25(OH)D₃ correlated with fertilization rate (p < 0.04) and negatively with HOMA-IR (p < 0.02); 25(OH)D₂ correlated with cleavage rate, G3D3 and blastocyst (p < 0.05; p < 0.009; p < 0.002, respectively). 24,25(OH)₂D₃ correlated with AMH, antral follicle count, eggs retrieved and top quality embryos (G3D3) (p < 0.03; p < 0.003; p < 0.009; p < 0.002, respectively), and negatively with HOMA-IR (p < 0.01). 1,25(OH)₂D₃ did not correlate with any of the metabolic or embryo parameters. In slim PCOS, 25(OH)D₃ correlated with increased fertilization rates in PCOS, but other vitamin D parameters did not differ to matched controls. Conclusion: 3epi25(OH)D₃, 25(OH)D₂, and 24,25(OH)₂D₃, but not 1,25(OH)₂D₃, were associated with embryo parameters suggesting that vitamin D metabolites other than 1,25(OH)₂D₃ are important in fertility.

The effect of serum and follicular fluid secreted frizzle-related protein-5 on in vitro fertilization outcomes in patients with polycystic ovary syndrome

In this study, we aimed to investigate serum and follicular fluid (FF) secreted frizzle-related protein-5 (Sfrp-5) levels in nonobese, nonhyperandrogenic patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization (IVF), in addition to IVF outcomes. In total, 160 patients undergoing IVF treatment were included in the study: 80 patients diagnosed with PCOS according to the Rotterdam criteria (group I, study) and 80 patients with the etiology of male factor infertility (group II, control). There were statistically significant between-group differences in serum estradiol (E₂) levels on the day of hCG administration (2377.00 ± 733.23 vs. 1931.3 ± 1,010.69), the total gonadotropin dose required (2000.63 ± 1,051.87 vs. 1.134.69 ± 286.45), and the total number of retrieved oocytes (8.60 ± 2.06 vs. 11.05 ± 4.39) (p < 0.05). There was also a statistically significant between-group difference in serum and FF Sfrp-5 levels on the day of oocyte retrieval (11.40 ± 2.88 vs. 8.87 ± 1.85, p < 0.001; 11.06 ± 2.30 vs. 9.71 ± 2.15, p = 0.008; respectively). However, there were no between-group differences in fertilization rates, clinical pregnancy rates, and live birth rates (p > 0.05). A correlation analysis showed that serum and FF Sfrp-5 levels were associated with insulin and inflammatory markers (p < 0.05). In a selected population of nonobese, nonhyperandrogenic PCOS patients, there was a significant difference in Sfrp-5 levels of the PCOS group versus those of the control group. Further studies are needed to determine the effects of Sfrp-5 in women with PCOS.

Polycystic ovary syndrome throughout a woman's life

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women and the main cause of infertility due to anovulation. However, this syndrome spans the lives of women affecting them from in-utero life until death, leading to several health risks that can impair quality of life and increase morbidity and mortality rates. Fetal programming may represent the beginning of the condition characterized by hyperandrogenism and insulin resistance which leads to a series of medical consequences in adolescence, adulthood, and old age. Menstrual and fertility problems evolve into metabolic complications as age advances. An early and precise diagnosis is important for an adequate management of PCOS, especially at the extreme ends of the reproductive lifespan. However, many different phenotypes are included under the same condition, being important to look at these different phenotypes separately, as they may require different treatments and have different consequences. In this way, PCOS exhibits a great metabolic complexity and its diagnosis needs to be revised once again and adapted to recent data obtained by new technologies. According to the current medical literature, lifestyle therapy constitutes the first step in the management, especially when excess body weight is associated. Pharmacotherapy is frequently used to treat the most predominant manifestations in each age group, such as irregular menses and hirsutism in adolescence, fertility problems in adulthood, and metabolic problems and risk of cancer in old age. Close surveillance is mandatory in each stage of life to avoid health risks which may also affect the offspring, since fetal and post-natal complications seem to be increased in PCOS women.

[Quality of oocytes and embryos from women with polycystic ovaries syndrome: State of the art]

The frequency of polycystic ovary syndrome (PCOS) and the consequent fertility disorders cause many difficulties in the management of the assisted reproductive technics. Some studies are focused on different additional treatments, stimulation protocols or techniques that could optimize the in vitro fertilization cycles. The quality of the oocytes and embryos of these patients is also an outstanding issue. They remain difficult to actually evaluate during management, and none of the few published studies on this subject demonstrated any inferiority, compared to control patients. However, many differences have been highlighted, studying intra- and extra-ovarian factors. The advent of new genetic techniques could allow a better understanding of the pathophysiological mechanisms of the syndrome, as well as refining the evaluation of oocytes and embryos, in order to better predict the results of in vitro fertilization attempts. Pregnancy and birth rates, however, appear to be comparable to those of the general population.

Intracytoplasmic oxidative stress reverses epigenetic modifications in polycystic ovary syndrome

In polycystic ovary syndrome (PCOS), substantial genetic and environmental alterations, along with hyperandrogenism, affect the quality of oocytes and decrease ovulation rates. To determine the mechanisms underlying these alterations caused specifically by an increase in plasma androgens, the present study was performed in experimentally-induced PCOS mice. As the study model, female B6D2F1 mice were treated with dehydroepiandrosterone (DHEA, 6 mg per 100 g bodyweight). After 20 days, oocytes at the germinal vesicle and metaphase II stages were retrieved from isolated ovaries and subsequent analyses of oocyte quality were performed for each mouse. DHEA treatment resulted in excessive abnormal morphology and decreased polar body extrusion rates in oocytes, and was associated with an increase in oxidative stress. Analysis of fluorescence intensity revealed a significant reduction of DNA methylation and dimethylation of histone H3 at lysine 9 (H3K9) in DHEA-treated oocytes, which was associated with increased acetylation of H4K12. Similarly, mRNA expression of DNA methyltransferase-1 and histone deacetylase-1 was significantly decreased in DHEA-treated mice. There was a significant correlation between excessive reactive oxygen species (ROS) production and increased histone acetylation, which is a novel finding and may provide new insights into the mechanism causing PCOS. The results of the present study indicate that epigenetic modifications of oocytes possibly affect the quality of maturation and ovulation rates in PCOS, and that the likely mechanism may be augmentation of intracytoplasmic ROS.

Avoiding OHSS: Controlled Ovarian Low-Dose Stimulation in Women with PCOS

The polycystic ovary syndrome is a common endocrine disorder which influences outcome and potential risks involved with controlled ovarian stimulation for artificial reproductive techniques (ART). Concrete practical recommendations for the dosage of gonadotropins, the preferred protocol and preventive methods to avoid ovarian hyperstimulation syndrome (OHSS) are lacking. We present retrospective data of 235 individually calculated gonadotropin low-dose stimulations for ART in a single center from 2012 to 2014. Clinical data and outcome parameter of patients diagnosed with PCOS according to Rotterdam criteria (n = 39) were compared with patients without PCOS (n = 196). The starting dose of gonadotropins was individually calculated depending on patients' age, BMI, ovarian reserve, ovarian response in previous cycles, and diagnostic criteria of PCOS. Mean age and duration of infertility did not differ between the groups, whereas mean BMI (p = 0.007) and AMH (p < 0.001) were higher in the PCOS-group. A lower mean FSH-starting and maximum dose was administered to women with PCOS (p < 0.001). The biochemical pregnancy rate of 42.4 % and the clinical pregnancy rate of 32.2 % for PCOS-patients did not differ from those of the control group (42.2 % and 34.4 % respectively). Neither mild, nor moderate or severe manifestation of OHSS occurred significantly more often in patients with PCOS. Our study supports the use of a calculated low-dose FSH-stimulation strategy in ART for patients with PCOS. Further randomized clinical trials should confirm this strategy and lead to define individual risk factors for OHSS, which can be used for recommendation of safer ART-techniques like in vitro maturation.

The impact of follicular fluid adiponectin and ghrelin levels based on BMI on IVF outcomes in PCOS

PURPOSE

This study aimed at evaluating the effects of polycystic ovary syndrome (PCOS) and body mass index (BMI) on follicular fluid (FF) adiponectin and ghrelin levels, and on in vitro fertilization outcomes in patients who underwent controlled ovarian hyperstimulation.

METHODS

This prospective cross-sectional study was performed with a total of 120 primary infertile women [group 1; non-PCOS = 60 (BMI <25 = 30, BMI ≥25 = 30) and group 2; PCOS = 60 (BMI <25 = 30, BMI ≥25 = 30)]. On the day of oocyte pickup, FF samples were collected.

RESULTS

The FF adiponectin levels were lower in the lean PCOS group than the lean non-PCOS group (p = 0.001), and these levels were lower in the overweight non-PCOS group compared to lean non-PCOS group (0.001). However, there was no difference in the FF ghrelin levels between the groups. Additionally, we could not find a relationship between clinical pregnancy and adiponectin and ghrelin levels.

CONCLUSION

The FF adiponectin and ghrelin levels have no effects on clinical pregnancy in PCOS. Therefore, further studies are needed to elucidate this issue.

Abnormally activated one-carbon metabolic pathway is associated with mtDNA hypermethylation and mitochondrial malfunction in the oocytes of polycystic gilt ovaries

Polycystic ovarian syndrome (PCOS) is associated with hyperhomocysteinemia and polycystic ovaries (PCO) usually produce oocytes of poor quality. However, the intracellular mechanism linking hyperhomocysteinemia and oocyte quality remains elusive. In this study, the quality of the oocytes isolated from healthy and polycystic gilt ovaries was evaluated in vitro in association with one-carbon metabolism, mitochondrial DNA (mtDNA) methylation, and mitochondrial function. PCO oocytes demonstrated impaired polar body extrusion, and significantly decreased cleavage and blastocyst rates. The mitochondrial distribution was disrupted in PCO oocytes, together with decreased mitochondrial membrane potential and deformed mitochondrial structure. The mtDNA copy number and the expression of mtDNA-encoded genes were significantly lower in PCO oocytes. Homocysteine concentration in follicular fluid was significantly higher in PCO group, which was associated with significantly up-regulated one-carbon metabolic enzymes betaine homocysteine methyltransferase (BHMT), glycine N-methyltransferase (GNMT) and the DNA methyltransferase DNMT1. Moreover, mtDNA sequences coding for 12S, 16S rRNA and ND4, as well as the D-loop region were significantly hypermethylated in PCO oocytes. These results indicate that an abnormal activation of one-carbon metabolism and hypermethylation of mtDNA may contribute, largely, to the mitochondrial malfunction and decreased quality of PCO-derived oocytes in gilts.

miR-483-5p and miR-486-5p are down-regulated in cumulus cells of metaphase II oocytes from women with polycystic ovary syndrome

The aim of this study was to compare the expression of microRNAs (miRNAs) in cumulus cells from polycystic ovary syndrome (PCOS) and non-PCOS women. In the present study, miRNA expression profiles of the cumulus cell samples were determined by miRNA microarrays. Quantification of selected miRNAs and predicted target genes was performed using quantitative real-time PCR (qRT-PCR). The results showed that miR-483-5p and miR-486-5p are significantly decreased in cumulus cells of PCOS patients PCOS (fold change >2, false discovery rate <0.001). qRT-PCR found that four predicted genes, SOCS3, SRF, PTEN and FOXO1, were significantly increased in PCOS cumulus cells (all P < 0.001), and IGF2 (host gene of miR-483-5p) was significantly decreased in PCOS cumulus cells (P < 0.001). These results indicated that miR-483-5p might play an important role in reducing insulin resistance, and that miR-486-5p might promote cumulus cell proliferation through activation of PI3K/Akt. The findings from this study provided new insights into the complex molecular mechanisms involved in PCOS by revealing pathways possibly regulated by miRNAs. The differences in miRNAs (miR-483-5p, miR-486-5p) and their target gene expression in cumulus cells may provide clues for future research and help to explain aberrant follicular development and subfertility in women with PCOS.

Unaltered timing of embryo development in women with polycystic ovarian syndrome (PCOS): a time-lapse study

PURPOSE

Polycystic ovarian syndrome (PCOS) is a common cause of female infertility. Factors other than anovulation, such as low embryo quality have been suggested to contribute to the infertility in these women. This 2-year retrospective study used timelapse technology to investigate the PCOS-influence on timing of development in the pre-implantation embryo (primary endpoint). The secondary outcome measure was live birth rates after elective single-embryo transfer.

METHODS

In total, 313 embryos from 43 PCOS women, and 1075 embryos from 174 non-PCOS women undergoing assisted reproduction were included. All embryos were monitored until day 6. Differences in embryo kinetics were tested in a covariance regression model to account for potential confounding variables: female age, BMI, fertilization method and male infertility.

RESULTS

Time to initiate compaction and reach the morula stage as well as the duration of the 4th cleavage division was significantly shorter in PCOS embryos compared with non-PCOS embryos. No other kinetic differences were found at any time-points annotated. The proportion of multi-nucleated cells at the 2-cell stage was significantly higher in PCOS embryos compared with non-PCOS embryos. The live birth rates were comparable between the two groups.

CONCLUSION

The findings suggest that the causative factor for subfertility in PCOS is not related to timing of development in the pre-implantation embryo.

Metabolic heterogeneity of follicular amino acids in polycystic ovary syndrome is affected by obesity and related to pregnancy outcome

Background

Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder frequently accompanied by obesity and by insulin resistance, and patients with this syndrome suffer from infertility and poor pregnancy outcome. Disturbances in plasma amino acid (AA) metabolism have been implicated in women with PCOS. However, direct evidence on follicular AA metabolic profiles in PCOS patients and their relationship with pregnancy outcome is sparse.

Methods

We conducted a prospective study in 63 PCOS patients and 48 controls in the Division of Reproductive Center, Peking University Third Hospital. Follicular AA levels were measured by the liquid chromatography-tandem mass spectrometric method, and the results were analyzed based on different grouping criteria.

Results

The levels of aromatic amino acid (AAA) increased in PCOS patients independent of obesity (P < 0.05), whereas the levels of branched-chain amino acid (BCAA), glutamic acid, phenylalanine, alanine, and arginine increased with body mass index irrespective of the PCOS status (all P < 0.05). In addition, compared with non insulin resistant-PCOS patients and controls, insulin resistant-PCOS group had higher levels of leucine, valine and glutamic acid (all P < 0.05). In PCOS group, aspartic acid and serine levels were elevated in pregnant patients compared with the non-pregnant subjects (both P < 0.05). Moreover, the levels of BCAA and valine were higher in the non-pregnant group than in the pregnant group (both P < 0.05). The pregnancy rate (45.00%) of subjects with elevated BCAA level was significantly lower than that (66.67%) in control subjects (P = 0.036) at a BCAA cutoff value of 239.10 μM, while the abortion rate was much higher (33.33% versus 2.78%, P = 0.004).

Conclusions

Both PCOS and obesity were accompanied by follicular AA metabolic disturbances, with obesity exerting a more pronounced effect on AA metabolic profiles. The disruptions in specific AAs in the follicular fluid might account for the inferior pregnancy outcome in obese patients and increased risk of abortion in PCOS patients.

First intention IVF protocol for polycystic ovaries: does oral contraceptive pill pretreatment influence COH outcome?

BACKGROUND

Morphological aspect of polycystic ovaries (PCO) is a very common finding in an IVF center population: this includes PCOS patients identified in 18-25% of the couples presenting with infertility and so called "sonographic PCO only" the prevalence of which has been estimated as high as 33% in asymptomatic patients. Finding the optimal first intention IVF protocol for polycystic ovaries patients is still challenging in order to improve the controlled ovarian hyperstimulation (COH) outcome while avoiding ovarian hyperstimulation syndrome (OHSS). It has been suggested that women with PCO would benefit from a longer period of pituitary down-regulation. The purpose of this study was to compare an extended duration of OCP pretreatment with a classic GnRH agonist protocol.

METHODS

A single center prospective non-randomized study was performed from January 2009 to December 2010 in the Lille University Hospital including 113 women diagnosed with PCO(S) according to the Rotterdam ultrasonographic criteria and undergoing their first IVF attempt. Comprehensive hormonal and ultra-sonographic assessments were collected during COH in these patients. LH and androgen suppression and dynamics of follicular growth were compared between the two protocols as well as the COH outcome in terms of oocyte/embryo number and quality, implantation and pregnancy rates.

RESULTS

No significant difference was observed between the two groups concerning dynamics of follicular growth and hormonal values. Clinical and ongoing pregnancy rates were significantly lower in the OCP group despite same oocyte and embryo quality. Nevertheless, the cumulative pregnancy rate did not differ between the two groups. The incidence of OHSS was not statistically significant.

CONCLUSIONS

Extended duration of OCP pretreatment, as a first intention IVF protocol for PCO patients, does not improve the pattern of follicular growth nor the oocyte and embryo quality.

[Impact of polycystic ovary syndrome on oocyte and embryo quality]

This review analyzes the literature concerning oocyte and embryo quality, in case of in vitro fertilization (IVF) for women with polycystic ovary syndrome (PCOS). Alterations in oocyte quality, and consequently in embryo quality, may be due to endocrine and intra-ovarian paracrine changes. However, most of publications find similar biological and clinical results after IVF, with or without microinjection, for women with PCOS compared to those obtained in control populations. Subgroups of more pejorative outcome probably exist within PCOS population. Finally, obesity, which is frequent in PCOS, is clearly deleterious, and multidisciplinary care, including lifestyle modifications, is then needed.

Polycystic ovaries at ultrasound: normal variant or silent polycystic ovary syndrome?

OBJECTIVE

It is not known whether polycystic ovaries (PCO) are an ovarian appearance without pathological meaning or whether they share with polycystic ovary syndrome (PCOS) the same ovarian follicle abnormality. There are few studies including strictly selected women with PCO but without other criteria of PCOS. In order to address these issues, we compared hormonal, metabolic and ultrasound parameters obtained from patients with PCO only, patients with PCOS and controls.

METHODS

This was a comparative analysis including three age-matched groups of 95 patients, who were included consecutively in a database: controls, patients with sonographic PCO but no symptoms (PCO group) and patients with PCOS. A clinical examination, fasting serum sampling and pelvic ultrasound examination were performed between cycle days 2 and 5 and results were compared between groups.

RESULTS

The median serum anti-Mullerian hormone (AMH) level in the PCO group was intermediate between that in controls and that in the PCOS group (33.6 pmol/L, 19.8 pmol/L and 63.3 pmol/L, respectively), the differences being significant after adjustment for follicle number (P < 0.05), while the mean androgen serum level in the PCO group was similar to that in the control group and significantly lower than that in the PCOS group (P < 0.05) (median serum testosterone levels: 0.90 nmol/L, 0.79 nmol/L and 1.39 nmol/L; median androstenedione levels: 5.25 nmol/L, 4.37 nmol/L and 6.09 nmol/L, respectively). Body mass index, waist circumference and insulin levels had no effect on these differences.

CONCLUSION

PCO is an abnormal condition, affected women showing no evidence of hyperandrogenism but having higher AMH serum levels compared with controls, suggesting a granulosa cell abnormality in PCO similar to that observed in PCOS. The absence of hyperandrogenism in PCO does not seem linked to the metabolic status.

Comparison of Endocrine Profile and In Vitro Fertilization Outcome in Patients with PCOS, Ovulatory PCO, or Normal Ovaries

Aim. To compare the basic endocrine profile and outcomes of in vitro fertilization (IVF) in women with polycystic ovary syndrome (PCOS), ovulatory polycystic ovaries (PCO), or normal ovaries (NO). Methods. The basic clinical features and in vitro fertilization and embryo transfer outcome in patients receiving IVF or intracytoplasmic sperm injection (ICSI) were retrospectively analyzed. Results. The body mass index, basal luteinizing hormone, and testosterone levels were significantly lower in patients with ovulatory PCO compared to those in patients with PCOS. The PCOS patients exhibited the shortest duration of ovarian stimulation and lowest dose of gonadotropin, followed by the ovulatory PCO and NO patients. The ovulatory PCO and PCOS patients showed similar levels of E2 on the human chorionic gonadotropin treatment day and numbers of oocytes, which were both significantly higher than those of the NO patients. The fertilization rate of the PCOS patients was significantly lower than the other two groups. Compared to NO patients, the cleavage rate was lower in both PCOS and ovulatory PCO patients, however, the number of available embryos was significantly more in these two groups. The incidence of the moderate to severe ovarian hyperstimulation syndrome (OHSS) was markedly higher in the PCOS and ovulatory PCO patients. Conclusion. Ovulatory PCO patients do not express similar endocrine abnormalities as PCOS patients. Although the fertilization rate and cleavage rate were relatively low in PCOS patients, ultimately, all the three groups showed similar transferred embryo numbers, clinical pregnancy rates, and implantation rates. Since the incidence of OHSS was much higher in the PCOS and ovulatory PCO patients, we should take more care of these patients and try to prevent severe OHSS.

The role of androgens in follicle maturation and ovulation induction: friend or foe of infertility treatment?

BACKGROUND

Effects of androgens on follicle maturation have been controversial for some time. Here, we review the potential of their applications in improving human ovulation induction, based on human and animal data, reported in the literature.

METHODS

We reviewed the published literature for the years 2005-2011, using relevant key words, in PubMed, Medline and Cochrane reviews, and then performed secondary reviews of referenced articles, which previously had not been known or preceded the searched time period. A total of 217 publications were reviewed.

RESULTS

Contrary to widely held opinion, recent data, mostly developed in the mouse, convincingly demonstrate essential contribution of androgens to normal follicle maturation and, therefore, female fertility. Androgens appear most engaged at preantral and antral stages, primarily affect granulosa cells, and exert effects via androgen receptors (AR) through transcriptional regulation but also in non-genomic ways, with ligand-activated AR modulating follicle stimulating hormone (FSH) activity in granulosa cells. While some androgens, like testosterone (T) and dehydroepiandrosterone (DHEA), appear effective in improving functional ovarian reserve (FOR) in women with diminished ovarian reserve (DOR), others may even exert opposite effects. Such differences in androgens may, at least partially, reflect different levels of agonism to AR.

DISCUSSION

Selective androgens appear capable of improving early stages of folliculogenesis. They, therefore, may represent forerunners of a completely new class of ovulation-inducing medications, which, in contrast to gonadotropins, affect follicle maturation at much earlier stages.

Extra- and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte maturation and embryo developmental competence

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common metabolic dysfunction and heterogeneous endocrine disorder in women of reproductive age. Although patients with PCOS are typically characterized by increased numbers of oocytes retrieved during IVF, they are often of poor quality, leading to lower fertilization, cleavage and implantation rates, and a higher miscarriage rate.

METHODS

For this review, we searched the database MEDLINE (1950 to January 2010) and Google for all full texts and/or abstract articles published in English with content related to oocyte maturation and embryo developmental competence.

RESULTS

The search showed that alteration of many factors may directly or indirectly impair the competence of maturating oocytes through endocrine and local paracrine/autocrine actions, resulting in a lower pregnancy rate in patients with PCOS. The extra-ovarian factors identified included gonadotrophins, hyperandrogenemia and hyperinsulinemia, although intra-ovarian factors included members of the epidermal, fibroblast, insulin-like and neurotrophin families of growth factors, as well as the cytokines.

CONCLUSIONS

Any abnormality in the extra- and/or intra-ovarian factors may negatively affect the granulosa cell-oocyte interaction, oocyte maturation and potential embryonic developmental competence, contributing to unsuccessful outcomes for patients with PCOS who are undergoing assisted reproduction.

Exposing cultured mouse ovarian follicles under increased gonadotropin tonus to aromatizable androgens influences the steroid balance and reduces oocyte meiotic capacity

Acquisition of oocyte developmental competence relies on the well-controlled events accompanying antral follicular development. Elevated basal androgen levels, as in PCOS, potentially affect oocyte quality. Current experiments in an in vitro follicle bioassay studied dose-effects of androstenedione and testosterone on FSH and hCG stimulated antral follicle growth and meiotic maturation. The addition of either androgens altered follicle's endogenous production of androstenedione, testosterone, estradiol, and progesterone and affected the oocyte's capacity to resume meiosis. Exposure to 200 nM androstenedione induced an increased production of testosterone and estradiol. Exposure to a concentration of ≥200 nM testosterone induced elevated levels of estradiol and progesterone. Significant dose-dependent negative effects on polar body extrusion were seen at concentrations of ≥200 nM of either androgen. In addition, chromosome displacement on the metaphase plate was observed in oocytes obtained from androstenedione-treated follicles. Follicles exposed to a combination of 25 mIU/ml FSH and 3 mIU/ml hCG and elevated aromatizable androgens altered the steroid production profile, affected the follicular development and impaired oocyte meiotic competence.

Spindle and chromosome configurations of in vitro-matured oocytes from polycystic ovary syndrome and ovulatory infertile women: a pilot study

PURPOSE

To evaluate the meiotic spindle and chromosomal distribution of in vitro-matured oocytes from infertile nonobese women with PCOS and male or tubal causes of infertility (controls), and to compare in vitro maturation (IVM) rates between groups.

METHODS

Seventy four patients (26 with PCOS and 48 controls) undergoing stimulated cycles of oocyte retrieval for ICSI were selected prospectively. Thirteen PCOS patients and 27 controls had immature oocytes retrieved submitted to IVM. After IVM, oocytes showing extrusion of the first polar body were fixed and processed for evaluation of the meiotic spindle and chromosome distribution by immunofluorescence microscopy.

RESULTS

There were no differences between PCOS and control groups with respect to IVM rates (50.0% and 42.9%, respectively) nor the percentage of meiotic abnormalities in metaphase II oocytes (35.3% and 25%, respectively).

CONCLUSIONS

In vitro-matured oocytes obtained from stimulated cycles of nonobese PCOS did not have an increased ratio of meiotic abnormalities.

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.