Are we choosing the correct FSH starting dose during controlled ovarian stimulation for intrauterine insemination cycles? Potential application of a nomogram based on woman's age and markers of ovarian reserve

Low Estradiol Level and Endometrial Thickness on the Day of Endometrial Transformation Influence Clinical Pregnancy After Intrauterine Insemination

Background

The causes of pregnancy failure after intrauterine insemination (IUI) are controversial. The purpose of this study was to investigate the influencing factors on clinical pregnancy after IUI.

Methods

This study retrospectively analyzed 1464 cycles of IUI performed at the Meizhou People's Hospital between March 2014 and June 2023. The χ2 test and logistic regression analysis was applied to assess the associations between the some factors (maternal age, paternal age, cycle type (natural cycle or ovulation induction cycle), hormone level on the day of endometrial transformation (estradiol (E2), luteinizing hormone (LH), and progesterone (P)), endometrial thickness on the day of endometrial transformation, and forward motile sperm concentration after treatment) and pregnancy failure.

Results

Among the 1464 IUI cycles in this study, 268 cycles of assisted reproduction resulted in clinical pregnancy, with a clinical pregnancy rate of 18.3%. During the cycles with clinical pregnancy, there were 25 (12.9%) preterm births and 169 (87.1%) full-term births. The E2 level on the day of endometrial transformation in clinical pregnancy group was higher than that in the pregnancy failure group (658.79±656.02 vs 561.21±558.83 pg/mL)(P=0.025). The clinical pregnancy group had a higher percentage of endometrial thickness between 8 and 13mm on the day of endometrial transformation than the pregnancy failure group (83.2% vs 75.0%)(P=0.002). The results of regressions analysis showed that low E2 level on the day of endometrial transformation (<238.3 pg/mL vs ≥238.3 pg/mL: OR 1.493, 95% CI: 1.086-2.052, P=0.014), and endometrial thickness <8mm on the day of endometrial transformation (<8mm vs 8-13mm: OR 1.886, 95% CI: 1.284-2.771, P=0.001) may increase risk of pregnancy failure performed IUI.

Conclusion

Low estradiol level, and endometrial thickness on the day of endometrial transformation may increase risk of pregnancy failure performed intrauterine insemination.

The relationship between duration of infertility and clinical outcomes of intrauterine insemination for younger women: a retrospective clinical study

BACKGROUND

The objective of this research was to elucidate the association between the length of infertility and the outcomes of intrauterine insemination (IUI) in women of varying ages - a topic that has been the subject of investigation for numerous years, yet lacks a definitive consensus.

METHODS

A retrospective cohort investigation involving 5268 IUI cycles was undertaken at the Reproductive Medicine Center of Nanjing Drum Tower Hospital from 2016 to 2022. Utilizing the smooth fitting curve along with threshold and saturation effect analysis, the correlation between infertility duration and IUI clinical pregnancy rates was discerned. Moreover, patients were bifurcated into two cohorts based on their respective infertility durations. A secondary examination was also performed employing propensity-score matching to mitigate the impact of confounding variables. Subsequent threshold and saturation effect analysis was carried out across various subgroups, segmented on the basis of age differentiation.

RESULTS

When the duration of infertility was more than 5 years, the clinical pregnancy rate decreased with the increase of infertility duration (aOR: 0.894, 95%CI: 0.817-0.991, p = 0.043). The multivariate regression analysis suggested that longer duration of infertility (≥ 5 years) was significantly correlated with the lower clinical pregnancy rate (aOR: 0.782, 95% CI: 0.643-0.950, p = 0.01). After the propensity-score matching, the clinical pregnancy rate of women with longer infertility duration were also higher. When the duration of infertility was more than 5 years, the clinical pregnancy rate of women younger than 35 years old decreased with the increase of infertility duration (aOR: 0.906, 95%CI: 0.800-0.998, p = 0.043).

CONCLUSIONS

The clinical pregnancy rate and live birth rate of IUI in young women (< 35 years old) who have been infertile for more than 5 years significantly decrease with the prolongation of infertility time. Therefore, for young women who have been infertile for more than 5 years, IUI may not be the best choice.

Can AMH levels predict the need to step up FSH dose for controlled ovarian stimulation following a long GnRH agonist protocol in PCOS women?

BACKGROUND

To explore the role of anti-Mullerian hormone (AMH) in predicting the need to step up recombinant FSH (rFSH) dose following long GnRH agonist protocol in IVF/ICSI cycles of polycystic ovarian syndrome (PCOS) women.

METHODS

This is a retrospective cohort study of 825 PCOS women undergoing long GnRH agonist protocol enrolled from Jan 2019 to Dec 2021. The daily rFSH dose at which the first response to rFSH were recorded. The dose at which the first response to rFSH was based on folliculometry during follow up in which two or more follicles reached ≥ 11 mm. A receiver operating characteristic (ROC) curve analysis was done to investigate the ability of AMH to predict the need to step up initial rFSH dose.

RESULTS

PCOS women who needed to step up initial rFSH dose had a significantly higher AMH compared with those didn't step up initial rFSH dose (11.37 ± 3.25ng/ml vs. 8.69 ± 3.16ng/ml, p < 0.001). In multivariate logistic regression analysis, increased AMH level was an independent factor for the need to step up initial rFSH dose in PCOS patients after adjusted for confounding factors. ROC curve analysis showed AMH could predict the need to step up initial rFSH dose (AUC = 0.738, 95%CI: 0.704-0.773), having 75.4% specificity and 63% sensitivity when the threshold AMH concentration was 9.30ng/ml. 58.8% PCOS women with AMH > 9.30 ng/ml required increased rFSH dose compared to 18.8% of women with AMH ≤ 9.30ng/ml (p < 0.001). Although the clinical pregnancy rate and live birth rate were not significantly different, there was a higher incidence of OHSS among women with AMH > 9.30 ng/ml vs. AMH ≤ 9.30ng/ml (20.8% vs. 15.3%, p = 0.043).

CONCLUSION

PCOS women with AMH > 9.30 ng/ml were resistant to rFSH stimulation and require increased dose for the cycle recruitment of ovarian follicles.

Effects of different progesterone levels on reproductive outcomes in assisted reproductive technologies: from molecular basis to treatment strategies

PURPOSE

The aim of this narrative review is to offer an overview about the role of progesterone levels on pregnancy outcome in patients undergoing assisted reproductive technologies (ARTs).

METHODS

A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science) to determine the importance of elevated progesterone levels at different stages of the cycle for pregnancy rates in the in vitro fertilization (IVF) cycle. Our review also provides information on the differences between elevated progesterone levels and their interpretation in normal and in poorly responding women.

RESULTS

After careful evaluation, our search strategy yielded a total of 15 included articles, showing the possible factors that may have had an impact on the increased progesterone level before human chorionic gonadotropin (HCG) injection and the different thresholds above which the pregnancy rate was lower. Furthermore, increased progesterone on cycle day 2 or 3 could serve as a marker for increased progesterone in the late follicular phase, which is associated with a lower pregnancy rate.

CONCLUSION

Despite the literature data that support the negative effect of elevated progesterone on fresh cycles, due to lack of randomized controlled trials, the value of measuring progesterone in daily practice is questionable. Available evidence supports the detrimental effect of elevated progesterone in different subgroups of women, although there is still the need for defining different thresholds and durations of high progesterone exposure. The need for various thresholds for different cohorts of women, the inter-assay variability is making this decision harder.

Impact of Indication for Oocyte and Embryo Reception on Reproductive and Obstetric Outcomes

OBJECTIVES

This study aimed to assess if the indication for oocyte reception (OR) or embryo reception (ER) impacts the reproductive and obstetric outcomes by evaluating our experience at a tertiary fertility centre and by performing a literature review on this subject. Several previous studies have reported that, in contrast to other types of fertility treatment, the indication for OR/ER seems to have little impact on the outcomes. However, the compared indication groups vary considerably between these studies, and some data indicates worse outcomes in patients who developed premature ovarian insufficiency (POI) due to Turner syndrome or treatment with chemotherapy/radiotherapy.

DESIGN

A retrospective analysis of all cases of OR/ER at a tertiary fertility centre from 2001 until 2020 was conducted. We analysed 584 cycles from 194 individual patients. A literature review on the impact of indication on reproductive or obstetric outcomes of OR/ER was performed using the following databases: PubMed/MEDLINE, Embase, and the Cochrane Library. A total of 27 studies were included and analysed.

PARTICIPANTS, SETTING, METHODS

For the retrospective analysis, patients were divided into three major indication groups: failure of autologous assisted reproductive technology, POI, and genetic disease carrier. To assess reproductive outcomes, we determined pregnancy rate, implantation rate, miscarriage rate, and live birth rate. For comparing obstetric outcomes, we reviewed the term of birth, mode of delivery, and birthweight. Outcomes were compared using Fisher's exact test, χ2 test, and one-way ANOVA utilizing the GraphPad tool.

RESULTS

There were no significant differences in reproductive and obstetric outcomes between the three major indication groups in our population, in line with the findings reported by existing literature. Data on impaired reproductive outcomes in patients with POI after chemotherapy/radiotherapy are conflicting. Obstetrically, these patients are at higher risk of preterm birth and possibly also low birthweight, especially after abdomino-pelvic or total body irradiation. For patients with POI due to Turner syndrome, most data suggest similar pregnancy rates but a higher rate of pregnancy loss, and obstetrically an increased risk of hypertensive disorders and caesarean section.

LIMITATIONS

The small number of patients in the retrospective analysis resulted in low statistical power when evaluating differences between smaller subgroups. There were some missing data on the occurrence of complications during pregnancy. Our analysis covers a period of 20 years, during which several technological innovations have also been made.

CONCLUSIONS

Our study shows that the important heterogeneity in couples treated with OR/ER does not significantly impact their reproductive or obstetric outcomes, except for POI due to Turner syndrome or treatment with chemotherapy/radiotherapy, where there seems to be an important uterine/endometrial component that cannot be entirely overcome by providing a healthy oocyte.

Nomogram to predict FSH starting dose in poor ovarian response women in progestin primed ovarian stimulation protocol

Prediction of individual ovarian response to exogenous gonadotropin is a cornerstone for success and safety in all controlled ovarian stimulation (COS) protocols. Providing the best FSH starting dose according to each woman's own characteristics is the key to the success of individualized treatment. The objective of this investigation was to evaluate the potential application of a novel nomogram based on antral follicle counting (AFC), anti-Müllerian hormone (AMH) and body mass index (BMI) as a tool to optimize the follicle-stimulating hormone (FSH) starting dose in women with poor ovarian response in in-vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) cycles in progestin-primed ovarian stimulation (PPOS). We performed a retrospective analysis involving 130 poor ovarian responders undergoing IVF/ICSI cycles in a PPOS protocol from June 2017 to February 2019 in our reproductive center. The individual FSH starting dose was selected according to patients' clinical history and characteristics. The influence of variables including age, BMI, AMH and AFC on the FSH starting dose was assessed through multiple regression analysis. We used the variables reaching the statistical significance for calculation for the final predictive model. In the univariate analysis, BMI, AMH and AFC were significant (P < 0.05) predictors of FSH starting dose, age was canceled. In the multivariate analysis, BMI, AMH and AFC remained significant (P < 0.05). According to the nomogram, 118 patients (90.77% of 130) would have received a higher FSH starting dose and 12 patients (9.23% of 130) a lower FSH starting dose than practice dose. The application of the nomogram based on three variables easily determined in clinical practice: BMI, AMH and AFC would lead to a more tailored FSH starting dose in women with poor ovarian response.

Relationship Between Number of Oocytes Retrieved and Embryo Euploidy Rate in Controlled Ovarian Stimulation Cycles

This cohort study is aimed to determine if higher number of oocytes retrieved affects the rate of euploidy in the embryos of women undergoing controlled ovarian stimulation (COS) for in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy (PGT-A). A negative trend between the number of oocytes retrieved and embryo euploidy rate was observed using Visual Analytics software, especially when a higher number of oocytes were retrieved. After regression analysis, patient age was the only variable found to have a statistically significant negative effect (p < 0.0001) on euploidy rate in all regression models. Number of oocytes retrieved was not found to have a statistically significant effect on euploidy rate when analyzed per number of biopsied blastocysts (p = 0.5356), per number of oocytes retrieved (p = 0.1025), and per number of fertilized oocytes (p = 0.7241). The parameter estimates in the linear regression models were negative for number of oocytes retrieved. This study shows a statistically significant effect between patient age and embryo euploidy rate, which is already known. There is some evidence to suggest that higher number of oocytes retrieved may negatively impact the number of euploid embryos per number of oocytes retrieved based on the visual analytic graphs, p value approaching significance, and the negative parameter estimates in the regression models.

The Relationship Between Insulin Resistance and Obesity and Serum Anti-Mullerian Hormone Level in Chinese Women with Polycystic Ovary Syndrome: A Retrospective, Single-Center Cohort Study

Background

Anti-Mullerian hormone (AMH) is vital in the pathophysiological process of polycystic ovary syndrome (PCOS). The exact relationship between obesity and insulin resistance (IR) with AMH levels remains unclear.

Methods

A retrospective, single-center cohort study of 220 women with PCOS who underwent physical, endocrine, and metabolic assessments were performed. Patients were grouped by age, body mass indices (BMI), Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), and different phenotypes. Pearson correlation analysis assessed the correlation between AMH and HOMA-IR, BMI, and other PCOS indicators, and multiple linear regression analysis was performed to determine factors influencing AMH.

Results

In 220 patients with PCOS, serum AMH levels decreased with age and were significantly higher in the IR group than in the non-IR group (P < 0.01). AMH increased significantly in anovulatory patients with hyperandrogenemia and/or polycystic ovary, with no significant difference between obese and non-obese individuals. AMH levels correlated positively with luteinizing hormone (LH), LH/follicular stimulating hormone (FSH), testosterone, fasting insulin (FINS), and HOMA-IR levels; negatively with age and BMI levels (P < 0.05) and weakly with fasting plasma glucose in the classical PCOS phenotype (r=0.148, P < 0.05). Regression analysis showed that age, testosterone, FINS, LH, LH/FSH, and BMI influenced AMH levels (P < 0.05).

Conclusion

Chinese women with PCOS-IR showed associations with greater AMH levels. AMH levels correlated positively with HOMA-IR levels and negatively with BMI. AMH combined with BMI and HOMA-IR levels may help determine PCOS severity.

How to dose follitropin delta for the first insemination cycle according to the ESHRE and ASRM guidelines; a retrospective cohort study

BACKGROUND

Follitropin Delta (FD) is indicated exclusively for in-vitro fertilization however, being a gonadotropin it could be used for other purposes. A dosing algorithm exists for FD and IVF but is needed for intrauterine insemination (IUI) cycles. The objective of this study is to determine dosing for FD for the first controlled ovarian hyperstimulation (COH) cycle according to current stimulation guidelines.

RESULTS

A retrospective study of 157 subjects from a single university fertility center from January 2017 to March 2020, was performed. All patients stimulated with FD for IUI were included. The number of failed, normal, or overstimulation cycles was determined based on stimulating not more than 2 mature follicles. We then stratified the group based on the AFC, AMH, and body weight. Of 157 subjects, 49% stimulated correctly, 5.6% failed and 45.4% overstimulated. An analysis of the COH IUI cycles based on stratification and over or lack of stimulation per published guidelines found that women with a bodyweight < 80 kg or AMH ≥ 1.5 ng/ml or AFC ≥ 10 initially stimulate with FD 2.0 to 3.0mcg daily. For women with an AFC of 6-9 stimulate with Follitropin Delta 3.0mcg daily. For women with an AFC < 6 or serum AMH < 1.5 ng/ml stimulate with FD 3.0-4.0mcg daily. For women with body weight > 80 kg stimulate initially with daily with 4.0-6.0mcg FD.

CONCLUSIONS

Follitropin Delta can be used safely for controlled ovarian stimulation and insemination at doses easily dispensed by the current methods of delivery, within the current published guidelines for follicle development.

Analysis of cumulative outcomes and influencing factors of patients with discrepancies between age and AMH levels in the early follicular phase prolonged protocol

OBJECTIVE

To explore the cumulative outcomes and influencing factors of patients with discrepancies between age and Anti-Müllerian hormone (AMH) levels in the early follicular phase prolonged protocol.

METHODS

A total of 1282 cycles of in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) assisted pregnancy with the early follicular phase prolonged protocol in the Reproductive Medicine Center of the Third Affiliated Hospital of Zhengzhou University from September 2015 to December 2020 were retrospectively analyzed. They were divided into the young low-AMH group (n=1076) and the older high-AMH group (n=206). The primary outcomes included cumulative clinical pregnancy rate (CCPR) and cumulative live birth rate (CLBR). Secondary outcomes included the number of oocytes retrieved, number of available embryos, clinical pregnancy rate (CPR), live birth rate (LBR), miscarriage rate (MR), pregnancy complications, and neonatal outcomes.

RESULTS

The CPR (68.7% vs. 59.4%) and the LBR (60.7% vs. 43.1%) in the young low-AMH group were higher than those in the older high-AMH group. In contrast, the number of oocytes retrieved (11 vs. 17), number of available embryos (5 vs. 8), and MR (10.6% vs. 18.3%) in the young low-AMH group were lower. There was no significant difference between the two groups in the CCPR, CLBR, pregnancy complications, and neonatal outcomes. Logistic regression analysis showed that infertility duration, basal follicle-stimulating hormone (FSH), and antral follicle count (AFC) correlated with CCPR, while maternal age, type of infertility, basal FSH, AFC, and infertility duration correlated with CLBR. The area under the receiver operating characteristic curves (ROC) curve for the combined model of infertility duration, AFC, and basal FSH to predict cumulative pregnancy was 0.629 (95%CI:0.592-0.666), while the combined model of maternal age, AFC, basal FSH, infertility duration, and type of infertility to predict cumulative live birth was 0.649 (95%CI:0.615-0.682).

CONCLUSION

Although AMH levels are low by contrast, young patients have a favorable outcome after IVF/ICSI. In patients with discrepancies between age and AMH levels in the early follicular phase prolonged protocol, maternal age correlates better with cumulative live birth. The model that combines maternal age and other factors can help predict cumulative live birth, but its value is limited.

Live birth rate and neonatal outcomes following interventional embolization of hydrosalpinx

BACKGROUND

Hydrosalpinx has a negative effect on the pregnancy outcomes of in vitro fertilization and embryo transfer (IVF-ET), and the pretreatment for hydrosalpinx play an important role in improving the outcomes of IVF-ET. This study aimed to investigate the impacts of interventional embolization of hydrosalpinx on the live birth rate and neonatal outcome after in-vitro fertilization.

METHOD

In the present retrospective study, 3351 women receiving the first frozen embryo transfer (FET) after freeze-all policy were reviewed. Patients who received interventional embolization of hydrosalpinx (n = 1268) were included in the study group and those with hydrosalpinx-free bilateral fallopian tube obstruction (n = 2083) in the control group. The primary outcome was live birth (LB) rate; the secondary endpoints included rates of implantation, clinical pregnancy (CP), multiple pregnancy, and pregnancy loss.

RESULTS

The LB rate was similar between embolization group (39.91%) and control group (43.21%) (P > 0.05). The rate of implantation (35.81% vs. 32.24%), CP (50.84% vs. 47%) and multiple pregnancy rate (28.71% vs. 24.16%) in the control group were significantly higher than in the embolization group (P < 0.05). The miscarriage rate (39.91%, vs 43.21%, P > 0.05), ectopic gestation rate (2.35% vs 2.83%, P > 0.05), and ongoing pregnancy rate (41.56% vs 44.89%, P > 0.05) were comparable between two groups. After adjustment for confounding factors, interventional embolization of hydrosalpinx was found to have no influence on the LB rate. The thicker endometrium, more embryos transferred, and transfer of blastocyst stage embryos significantly increased the LB rate and CP rate.

CONCLUSION

The interventional embolization of hydrosalpinx can achieve the LB rate similar to that of hydrosalpinx-free obstruction patients with less risk, less pain and reduced medical cost. Thus, embolization of hydrosalpinx is one of the preferable clinical treatments for patients with hydrosalpinx.

Impact of Follicle Stimulating Hormone Receptor (FSHR) Polymorphism on the Efficiency of Co-Treatment with Growth Hormone in a Group of Infertile Women from Romania

“Poor responders” (PR) are an important category of infertile women who experience a modest response to controlled ovarian stimulation. In this study, we evaluated response to growth hormone (GH) administration among PR patient subtypes stratified by follicle stimulation hormone receptor (FSHR) polymorphism (c.2039A > G p.Asn680Ser). We conducted a cohort study of 125 women with poor ovarian response, 58 of whom received GH in addition to the standard treatment, and 67 of whom received the standard treatment only. The Ala307Thr polymorphism genotypes were analyzed using a polymerase chain reaction-restriction fragment length polymorphism method, and the FSHR gene polymorphism was analyzed using a predesigned TaqMan SNP Genotyping Assay (rs6166). A comparative analysis detected statistically significant differences in mean mature follicles (p = 0.0002), metaphase-II oocytes (p = 0.0005), progesterone levels (p = 0.0036), and IGF levels (follicle IGF1, p = 0.0004) between GH-treated and non-GH-treated participants with the FSHR (Ser/Ser) polymorphism. However, the differences were modest among participants with the other two FSHR polymorphisms (Ser/Asn and Asn/Asn). The subcategory of patients with the FSHR Asn680Ser (Ser/Ser) polymorphism showed a stronger response when GH was added to the IVF protocol.

Variation in Anti-Mullerian Hormone Levels with Age in Women Accessing In Vitro Fertilization Services in Ghana

Background: The emergence of AMH as a reliable biomarker for assessing ovarian reserve and optimization of assisted reproductive technology (ART) remains a promising tool for the evaluation and prediction of controlled ovarian stimulation (COS) outcomes. This study assessed the association between serum AMH levels and maternal age in females receiving in vitro fertilization (IVF) treatment in Ghana. Methods: We conducted a prospective cohort study at a specialized fertility center in Ghana. Descriptive analysis was performed, and the differences between maternal age and AMH categories were assessed by the Kruskal–Wallis test. Results: We included 426 women with mean (±SD) age and AMH levels of 35.25 ± 6.33 years and 2.80 ± 2.60 ng/mL, respectively. Women with very-low AMH levels (0.94 ± 73 ng/mL) were older (>40 years), whereas the younger (20–25 years) group had higher levels (4.85 ± 3.34 ng/mL). There was a significant negative correlation between women’s age and serum AMH levels (R = −0.46; p < 0.001). None of the younger women had AMH levels <0.30 ng/mL, while 70% of women who had AMH levels of <0.30 ng/mL were older women (>40years). In addition, none of the older women had AMH levels >4 ng/mL with only 5% having AMH levels between 2.20 and 4.0 ng/mL. Conclusions: AMH levels ≤0.3 ng/mL are archetypal of 70% of Ghanaian women >40 years old receiving fertility treatment. A combined assessment of AMH levels and age supports clinical decisions in predicting ovarian response to controlled ovarian stimulation (COS) and may be valuable in predicting of IVF success. Further research to evaluate the combined use of age, AMH, and other ovarian reserve markers in assessing ovarian response to COS is recommended.

Patient-tailored reproductive health care

Patient-tailored reproductive health care represents an important challenge for the current practice of infertility prevention, diagnosis and treatment. This approach is based on the concept of precision medicine, taking into account genetic, epigenetic, metabolic and lifestyle characteristics of each individual patient. Even though this goal is still far from being wholly achieved, some aspects can already be put into practice nowadays. Personalization can be based on a comprehensive analysis and synthesis of the patients' personal and familial history, taking into account outcomes of previous assisted reproduction technique (ART) attempts, if available, and confronting these data with the past and the latest clinical and laboratory examination outcomes. As to the male fertility status, there is an urgent need for the inclusion of an accurate diagnostic workup of infertile men leading to the choice of the most adequate follow-up for each particular pathological condition. The follow-up of women who have become pregnant as a result of the ART attempt has also to be personalized. This should be done taking into account both the basic data extracted from the patient's file and those derived from the experience gathered during the latest attempt. Last but not least, the individual condition of each couple has to be taken into account when counseling the patients as to the urgency of the actions to be taken to resolve their fertility problem.

Falsely elevated serum estradiol in woman of reproductive age led to unnecessary intervention and delayed fertility opportunity: a case report and literature review

BACKGROUND

The optimal management of patients in reproductive endocrinology relies on the accuracy and validity of sex hormone assays. Endogenous or exogenous substances can compete with the analyte. This competition can result in interfering errors and falsely indicate elevated serum levels. Obvious interference in estradiol assays appears to occur rarely. Consequently, clinicians who are not familiar with the potential of interference could be misled. In addition to unnecessary investigations and interventions and severe mental stress, falsely elevated estradiol results can result in missed or delayed fertility opportunities.

CASE

A 28-year-old female with pregnancy demand was diagnosed with polycystic ovary syndrome, Hashimoto's thyroiditis and subclinical hypothyroidism. She was found to have persistently elevated levels of serum estradiol in the early follicular phase (between 527 and 642 pg/mL). Screening workup was performed for nearly 11 months to find the causes. Serum tumor biomarkers were normal. Abdominal and pelvic computed tomography were negative for adrenal or adnexal masses. A left mesosalpinx cyst and benign pathological results were achieved by laparoscopic surgery. Hormonal substances and dietary supplements were absent, as determined by dietary records. Ultrasound confirmed follicles could grow slowly and eventually ovulate. Falsely elevated estradiol levels were suspected due to the discrepancy among high estradiol levels, follicle growth and normal gonadotropin levels. Immunological interference by heterophile antibody was finally verified by two competitive chemiluminescent immunoassay platforms (estradiol levels in the early follicle phase: 619 pg/mL, Siemens ADVIA CENTAUR and 60 pg/mL, Beckman, DxI 800). Successful clinical pregnancy was eventually achieved by combining induced ovulation, ultrasound monitoring and intercourse guidance.

CONCLUSIONS

Analytical interference and laboratory error should be suspicious at first when the clinical characteristics contradict the laboratory results of serum hormones. Measuring serum estradiol with another immunoassay platform is an easy and non-time-consuming method to exclude the heterophile interfering.

Serum anti-Müllerian hormone as a predictor of polycystic ovarian syndrome among women of reproductive age

BACKGROUND

Polycystic ovarian syndrome (PCOS) affects up to one-fifth of women of reproductive age and causes anovulatory subfertility. Some studies have recommended that an anti-Müllerian hormone (AMH) level greater than 3.8-5 ng/mL can be used for diagnosing PCOS. This study aims to analyse serum AMH levels among PCOS women of reproductive age to use AMH as a biomarker predictor along with other Rotterdam criteria.

METHODS

In this cross-sectional study, a total of 98 women visiting the fertility center of a private hospital in Lahore, Pakistan, were screened. Data were obtained from 51 PCOS newly diagnosed women aged 28.24 years (SD ± 4.84 years) meeting at least two of the Rotterdam criteria and specific inclusion criteria. Baseline variables, menstrual cycle length, ovarian morphology on ultrasound, hirsutism, sex hormones, gonadotropin, and serum AMH levels were analysed during the follicular phase (1-5 days) of the menstrual cycle. Serum AMH was measured by an enzyme-linked immunosorbent assay.

RESULTS

A high serum AMH level (7.23 ± 4.67 ng/ml) was recorded with normal sex hormone levels. Women with oligo-/amenorrhea had a significant mean difference for luteinizing hormone (p = 0.02) and AMH levels (p = 0.03) when compared with women of normal menstrual cycle length. PCOS women with high AMH levels (≥ 3.9 ng/ml) showed a significant difference in ovarian morphology (p < 0.05) when compared with the normal AMH group.

CONCLUSIONS

An elevated serum AMH level can be used as a strong predictor to reflect the certainty of PCOS diagnosis among women of reproductive age when study concurrently with the other Rotterdam criteria.

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.

Association between hospital treatment volume and major complications in ovarian hyperstimulation syndrome

OBJECTIVE

An inverse relationship between hospital volume and adverse patient outcomes has been established for many conditions, but has not yet been examined in ovarian hyperstimulation syndrome (OHSS). Given the rarity of severe OHSS, but potential for high morbidity, this study aimed to elucidate the effect of hospital volume on inpatient OHSS-related complications.

METHODS

This is a retrospective observational study querying the National Inpatient Sample, 1/2001-12/2011. Study population was 11,878 patients with OHSS treated at 735 hospitals. Annualized hospital OHSS treatment volume was grouped as: low-volume (1 case/year), mid-volume (>1 but < 3.5 cases/year), and high-volume (≥3.5 cases/year). Main outcome measure was major complication rates stratified by hospital treatment volume, assessed by multinomial regression and binary logistic regression models.

RESULTS

A total of 2,415 (20.3%) patients were treated at low-volume centers, 5,023 (42.3%) at mid-volume centers, and 4,440 (37.4%) at high-volume centers. Patients treated at high-volume centers were more likely to be older and less comorbid with higher incomes and lower body mass index (P < 0.05). High-volume hospitals were more likely to be urban-teaching centers with large bed capacity (P < 0.001). Overall, 1,624 (13.7%) patients experienced a major complication during hospitalization. Patients treated at high-volume hospitals had lower rates of major complications (high: 11.0%, mid: 15.2%, low: 15.6%, P < 0.001). On multivariable analysis, treatment at high-volume hospitals was independently associated with a nearly 20% lower rate of major complications (odds ratio 0.82, 95% confidence interval 0.70-0.97, P = 0.021).

CONCLUSION

Our study suggests that higher hospital treatment volume for OHSS may be associated with improved outcomes.

Ovarian Response, Pregnancy Outcomes, and Complications Between Salpingectomy and Proximal Tubal Occlusion in Hydrosalpinx Patients Before in vitro Fertilization: A Meta-Analysis

Objectives

Contradictory findings exist in studies comparing salpingectomy and proximal tubal occlusion (PTO) in treating hydrosalpinx patients before in vitro fertilization (IVF). Therefore, this meta-analysis aimed to comprehensively compare ovarian response, pregnancy outcomes, and complications between salpingectomy and PTO in treating these patients.

Methods

Embase, PubMed, and Web of Science were searched to identify relevant articles published from 1980 to August 31, 2020. Eight studies that involve 716 hydrosalpinx patients before IVF were included, among whom 408 patients received salpingectomy and 308 patients received PTO. The data were pooled; the standardized mean difference (SMD) or odds ratio (OR) was calculated.

Results

Proximal tubal occlusion-treated patients had higher fertilization rate (SMD = 0.35, 95% CI: 0.11–0.59), while similar days of controlled ovarian hyperstimulation (COH) (SMD: 0.15, 95% CI: −0.36–0.67) and number of retrieved oocytes (SMD = −0.22, 95% CI: −0.54–0.10) compared with salpingectomy-treated patients. Furthermore, no difference of implantation rate (OR = 1.17, 95% CI: 0.62–2.20), clinical pregnancy rate (OR = 0.82, 95% CI: 0.59–1.15), ongoing pregnancy rate (OR = 0.64, 95% CI: 0.36–1.13), or live birth rate (OR = 0.67, 95% CI: 0.16–2.72) was shown between salpingectomy-treated patients and PTO-treated patients. Additionally, ectopic pregnancy rate (OR = 1.13, 95% CI: 0.21–5.92) and miscarriage rate (OR = 0.88, 95% CI: 0.31–2.48) were similar between salpingectomy-treated patients and PTO-treated patients.

Conclusion

Proximal tubal occlusion exhibits a higher fertilization rate but no obvious benefits on days of COH, number of retrieved oocytes, pregnancy outcomes, and complications over salpingectomy in hydrosalpinx patients before IVF.

Activation of AKT/mammalian target of rapamycin signaling in the peripheral blood of women with premature ovarian insufficiency and its correlation with FMR1 expression

BACKGROUND

The protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signaling pathway regulates early follicular activation and follicular pool maintenance in female germline cells. Fragile X mental retardation 1 (FMR1) regulates folliculogenesis and it is variably expressed in patients with Premature Ovary Insufficiency. FMR1 expression is supposed to be linked to AKT/mTOR signaling in an ovarian response dependent manner as demonstrated in recent in vitro and in vivo studies in the female germline in vitro and in vivo.

METHODS

We evaluated changes in the expression of AKT/mTOR signaling pathway genes by real time PCR in the peripheral blood of 74 patients with Premature Ovarian Insufficiency and 56 fertile controls and correlated their expression with FMR1 expression.

RESULTS

Expression of the genes AKT1, TSC2, mTOR, and S6K was significantly more abundant in patients with POI than in the controls. For AKT1, TSC2 and mTOR, gene expression was not affected by FMR1-CGG repeat number in the 5´-untranslated region. FMR1 and S6K expression levels, however, were significantly upregulated in patients with POI and an FMR1 premutation. Independent of a premutation, expression of mTOR, S6K, and TSC2 was significantly correlated with that of FMR1 in all patients. Furthermore, when grouped according to ovarian reserve, this effect remained significant only for mTOR and S6K, with higher significance note in patients with Premature Ovarian Insufficiency than in the controls.

CONCLUSIONS

In Premature ovarian insufficiency patients, activation of AKT/mTOR signaling pathway is remarkable and putatively pathognomonic. Additionally, it seems to be triggered by an FMR1/mTOR/S6K linkage mechanism, most relevant in premutation carriers.

Machine Learning-Based Modeling of Ovarian Response and the Quantitative Evaluation of Comprehensive Impact Features

Appropriate ovarian responses to the controlled ovarian stimulation strategy is the premise for a good outcome of the in vitro fertilization cycle. With the booming of artificial intelligence, machine learning is becoming a popular and promising approach for tailoring a controlled ovarian stimulation strategy. Nowadays, most machine learning-based tailoring strategies aim to generally classify the controlled ovarian stimulation outcome, lacking the capacity to precisely predict the outcome and evaluate the impact features. Based on a clinical cohort composed of 1365 women and two machine learning methods of artificial neural network and supporting vector regression, a regression prediction model of the number of oocytes retrieved is trained, validated, and selected. Given the proposed model, an index called the normalized mean impact value is defined and calculated to reflect the importance of each impact feature. The proposed models can estimate the number of oocytes retrieved with high precision, with the regression coefficient being 0.882% and 89.84% of the instances having the prediction number ≤ 5. Among the impact features, the antral follicle count has the highest importance, followed by the E2 level on the human chorionic gonadotropin day, the age, and the Anti-Müllerian hormone, with their normalized mean impact value > 0.3. Based on the proposed model, the prognostic results for ovarian response can be predicted, which enables scientific clinical decision support for the customized controlled ovarian stimulation strategies for women, and eventually helps yield better in vitro fertilization outcomes.

Is it necessary to monitor the serum luteinizing hormone (LH) concentration on the human chorionic gonadotropin (HCG) day among young women during the follicular-phase long protocol? A retrospective cohort study

BACKGROUND

The normal physiological function of LH requires a certain concentration range, but because of pituitary desensitization, even on the day of HCG, endogenous levels of LH are low in the follicular-phase long protocol. Therefore, our study aimed to determine whether it is necessary to monitor serum LH concentrations on the day of HCG (LH_HCG) and to determine whether there is an optimal LH_HCG range to achieve the desired clinical outcome.

METHODS

A retrospective cohort study included 4502 cycles of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) from January 1, 2016, to June 30, 2019, in a single department. The main outcome measures included retrieved eggs, available embryos, and live birth rate.

RESULTS

The LH_HCG was divided into five groups: Group A (LH ≤ 0.5), Group B (0.5 IU/L < LH ≤ 1.2 IU/L), Group C (1.2 IU/L < LH ≤ 2.0 IU/L), Group D (2.0 IU/L < LH ≤ 5.0 IU/L), Group E (LH > 5 IU/L). In terms of the numbers of retrieved eggs (15.22 ± 5.66 vs. 13.54 ± 5.23 vs. 12.90 ± 5.05 vs. 12.30 ± 4.88 vs. 9.6 ± 4.09), diploid fertilized oocytes (9.85 ± 4.70 vs. 8.69 ± 4.41 vs. 8.39 ± 4.33 vs. 7.78 ± 3.96 vs. 5.92 ± 2.78), embryos (7.90 ± 4.48 vs. 6.83 ± 4.03 vs. 6.44 ± 3.88 vs. 6.22 ± 3.62 vs. 4.40 ± 2.55), and high-quality embryos (4.32 ± 3.71 vs. 3.97 ± 3.42 vs. 3.76 ± 3.19 vs. 3.71 ± 3.04 vs. 2.52 ± 2.27), an increase in the LH_HCG level showed a trend of a gradual decrease. However, there was no significant difference in clinical outcomes among the groups (66.67% vs. 64.33% vs. 63.21% vs. 64.48% vs. 63.33%). By adjusting for confounding factors, with an increase in LH_HCG, the number of retrieved eggs decreased (OR: -0.351 95%CI - 0.453-[- 0.249]).

CONCLUSION

In the follicular-phase long protocol among young women, monitoring LH_HCG is recommended in the clinical guidelines to obtain the ideal number of eggs.

Effect of Hyperinsulinemia and Insulin Resistance on Endocrine, Metabolic, and Reproductive Outcomes in Non-PCOS Women Undergoing Assisted Reproduction: A Retrospective Cohort Study

Objective: To evaluate the effect of hyperinsulinemia (HI) and insulin resistance (IR) on endocrine, metabolic, and reproductive outcomes in women without polycystic ovary syndrome (PCOS) undergoing assisted reproduction.

Materials and Methods: The study included 1,104 non-PCOS women undergoing in vitro fertilization/intracytoplasmic sperm injection-fresh embryo transfer. HI was evaluated by serum fasting insulin (FIN), and IR was evaluated by homeostatic model assessment of insulin resistance index (HOMA-IR). In addition, biometric, sex hormone, and metabolic parameters were measured. Independent t-test, linear, and logistic regression examined associations between HI, IR, and endocrine, metabolic, ovarian stimulation characteristics, and reproductive outcomes.

Results: Women with HI and IR had lower levels of progesterone, luteinizing hormone, follicle-stimulating hormone, estradiol, high-density lipoproteins, and increased levels of triglycerides low-density lipoproteins. For ovarian stimulation characteristics, those with HI and IR had a longer duration of stimulation, a higher total gonadotropin dose, and a lower peak estradiol level. Linear regression confirmed these associations. For reproductive outcomes, HI and IR were not associated with clinical pregnancy, live birth, and miscarriage.

Conclusions: HI and IR did not impair reproductive outcomes in non-PCOS women undergoing assisted reproduction.

Reproductive Outcome After GnRH Agonist Triggering With Co-Administration of 1500 IU hCG on the Day of Oocyte Retrieval in High Responders: A Long-Term Retrospective Cohort Study

While triggering oocyte maturation with GnRH agonist (GnRHa) seems to be safe and effective in terms of the risk of developing OHSS and the number of metaphase II oocytes, it nevertheless results in luteal phase deficiency. To date, strategies have been developed in order to rescue defective luteal phase of GnRHa triggered cycles. Our study aimed to assess the reproductive outcome of GnRHa triggered cycles combined with modified luteal support (1500 IU hCG at the day of oocyte retrieval) in women with high ovarian response and to compare the outcome with hCG triggered cycles in GnRH antagonist IVF-ICSI procedures. A retrospective cohort database review of the results of GnRH antagonist IVF-ICSI cycles was conducted at a tertiary-care IVF center in Ljubljana, Slovenia. A total of 6126 cycles, performed from January 1, 2014, to December 31, 2020, were included in the final analysis. Final oocyte maturation was performed with either 5000, 6500, or 10,000 IU hCG (women with normal ovarian response) or 0.6 mg GnRHa (buserelin), supplemented with 1500 IU hCG on the day of oocyte retrieval (in women with high ovarian response). In cases of excessive ovarian response and/or high risk of OHSS luteal support was not introduced and all good quality blastocysts were frozen. According to significant differences in patients' age and the number of oocytes in the two groups, matching by age and number of oocytes was performed. No significant differences were observed regarding pregnancy rate per embryo transfer, rate of early pregnancy loss, and livebirth rate per pregnancy between the GnRHa and hCG trigger groups, respectively. A significant difference in the number of developed embryos and blastocysts, as well as the number of frozen blastocysts, was seen in favor of the GnRHa trigger. However, the birth weight in the GnRHa trigger group was significantly lower.

CONCLUSION

The results of our study support the use of GnRHa for final oocyte maturation in GnRH antagonist IVF cycles in women with high ovarian response. Luteal phase rescue was performed by co-administration of 1500 IU hCG on the day of oocyte retrieval and estradiol and progesterone supplementation. In our experience, such an approach results in a comparable reproductive outcome with hCG trigger group.

The Predictive Levels of Serum Anti-Müllerian Hormone and the Combined Index of the Number of Retrieved Oocytes and Good-Quality Embryos in Advanced-Age Infertile Women

The primary objective of the study was to assess the values of serum anti-Müllerian hormone (AMH) levels and the combined index for the prediction of number of oocytes retrieved (NOR) and number of good-quality embryos (GQE) in infertile women undergoing IVF/ICSI treatment. A group of 521 infertile women aged 21-46 years were recruited as subject in this study. Serum AMH, hormones, and antral follicle count (AFC) were measured. The infertile women were categorized into three groups: 21-34 years (reproductive age), 35-39 years (reproductive age), and 40-46 years (advanced-age infertile). The predictive accuracy of variables was analyzed by the receiver operating characteristic (ROC) curve. AFC, AFC/age ratio, AMH/age ratio, and ovarian response prediction index (ORPI) decreased gradually, while AMH decreased significantly with increase in age. Moreover, NOR and GQE were positively correlated with AFC, AMH, AFC/age ratio, AMH/age ratio, and ORPI (P < 0.001). A statistical significance was observed in predicted oocyte retrieval including AMH, AMH/age ratio, and ORPI between 21-34 years and 35-46 years; especially in the 35-46 years group, these variables reached a "high" grade in the diagnostic accuracy because area under curve (AUC) ranged from 0.982 to 0.988 significantly. No statistical significance was observed for FSH, AMH, AFC, and related combined index predicting GQE. The predictive value of AFC and AFC/age ratio was limited regarding oocyte retrieval; however, AMH, AMH/age ratio, and ORPI concurrently had an excellent value for predicting NOR in reproductive-age women, especially in advanced-age infertile women.

Anti-Mullerian Hormone (AMH) and adenomyosis: Mini-review of literature of the last 5 years

INTRODUCTION

Adenomyosis is a form of endometriosis characterized by the presence of endometrial tissue in the myometrium. The correlation between anti-Mullerian hormone (AMH) expression and adenomyosis is unclear. Few studies investigated this possible correlation with promising results. The aim of this mini-review is to illustrate the potential prognostic and therapeutic role of AMH in adenomyosis.

MATERIALS AND METHODS

A study protocol was completed conforming to the Preferred Reporting Items for Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. We performed an electronic databases search from each database's inception from August 2017 to August 2022 for full-text articles and published abstracts. For database searches, the following main keywords were the following text words: "adenomyosis" or "uterine endometriosis" [Mesh] AND "AMH" or "anti-mullerian hormone".

RESULTS

From the literature search, 8 abstracts of studies were retrieved and independently screened for inclusion by three authors. It was found that the most common therapeutic strategies (such as adenomyomectomy and high-intensity focused ultrasound (HIFU) do not alter AMH levels. Moreover, a higher expression of the AMH receptor II was observed in adenomyotic tissue, hence a possible therapeutic use of AMH was hypothesized.

CONCLUSION

The available evidence shows an unclear relationship between adenomyosis and AMH. Probably, women with adenomyosis have lower levels of AMH and the surgical treatment (adenomyomectomy, HIFU) does not alter this characteristic, therefore in all of them, ovarian function is not influenced.

Long-term GnRH agonist pretreatment before frozen embryo transfer improves pregnancy outcomes in women with adenomyosis

RESEARCH QUESTION

Do frozen embryo transfer (FET) cycles following long-term gonadotrophin-releasing hormone agonist (GnRHa) pretreatment have better pregnancy outcomes than fresh embryo transfer cycles with long or ultra-long GnRHa protocol in these patients?

DESIGN

This study included 537 women with adenomyosis divided into three groups: (Group A) FET cycles following long-term GnRHa pretreatment (192 patients); (Group B) fresh embryo transfer cycles with the ultra-long GnRHa protocol (241 patients); (Group C) fresh embryo transfer cycles with the long GnRHa protocol (104 patients).

RESULTS

The total gonadotrophin dose and stimulation duration were significantly lower in Group A than in Groups B and C. The implantation and live birth rates were significantly higher in Group A than in Groups B and C. In the long-term GnRHa pretreatment and FET treatment of Group A, implantation (odds ratio [OR] 1.729, 95% confidence interval [CI] 1.073-2.788, P = 0.025), clinical pregnancy (OR 1.665, 95% CI 1.032-2.686, P = 0.037) and live birth rates (OR 1.694, 95% CI 1.045-2.746, P = 0.033) increased and miscarriage rate (OR 0.203, 95% CI 0.078-0.530, P = 0.001) decreased when compared with Group C. Comparison of Groups A and B showed that with the long-term GnRHa pretreatment, FET was a protective factor for live birth rate (OR 1.350, 95% CI 1.017-1.792, P = 0.038).

CONCLUSION

FET following long-term GnRHa pretreatment has a better IVF/intracytoplasmic sperm injection outcome, and a potential benefit in terms of a lower gonadotrophin dose, and a shorter stimulation duration than fresh embryo transfer combined with a long or ultra-long GnRHa protocol.

Sequential cleavage and blastocyst embryo transfer and IVF outcomes: a systematic review

BACKGROUND

Sequential embryo transfer has been proposed as a way to improve embryo implantation in women for in vitro fertilization (IVF), but the effect on pregnancy outcomes remains ambiguous. This systematic review was conducted to investigate the efficacy of sequential embryo transfer on IVF outcomes.

METHODS

A literature search was performed in the PubMed, Web of Science, Cochrane Library, ScienceDirect and Wanfang databases. Data were pooled using a random- or fixed-effects model according to study heterogeneity. The results are expressed as relative risks (RRs) with 95% confidence intervals (CIs). Heterogeneity was evaluated by the I² statistic. The study protocol was registered prospectively on INPLASY, ID: INPLASY202180019.

RESULTS

Ten eligible studies with 2658 participants compared sequential embryo transfer and cleavage transfer, while four studies with 513 participants compared sequential embryo transfer and blastocyst transfer. The synthesis results showed that the clinical pregnancy rate was higher in the sequential embryo transfer group than in the cleavage embryo transfer group (RR 1.42, 95% CI 1.26-1.60, P< 0.01) for both women who did experience repeated implantation failure (RIF) (RR 1.58, 95% CI 1.17-2.13, P< 0.01) and did not experience RIF (Non-RIF) (RR 1.44, 95% CI 1.20-1.66, P< 0.01). However, sequential embryo transfer showed no significant benefit over blastocyst embryo transfer.

CONCLUSION

The current systematic review demonstrates that sequential cleavage and blastocyst embryo transfer improve the clinical pregnancy rate over conventional cleavage embryo transfer. For women with adequate embryos, sequential transfer could be attempted following careful consideration. More high-grade evidence from prospective randomized studies is warranted.

Immediate versus delayed frozen embryo transfer in women following a failed IVF-ET attempt: a multicenter randomized controlled trial

BACKGROUND

The optimal time at which to perform a frozen-thawed embryo transfer (FET) following a failed in-vitro fertilization-embryo transfer (IVF-ET) attempt remains elusive to most reproductive experts. Physicians often delay the introduction of FET due to concerns related to potential residual effects of ovarian hyperstimulation which may interfere with the regular menstrual cycle. Moreover, given that most of the published studies on the topic are retrospective and have inconsistent findings, it is crucial to develop evidence-based randomized control guides for clinical practice. Therefore, this well-designed randomized controlled trial (RCT) was conducted to determine whether it is necessary to delay FET for at least one menstrual cycle after the failure of fresh embryo transfer.

METHODS

Infertile women eligible for IVF-ET were invited to participate in this multicenter, randomized, non-inferiority, parallel-group, unblinded, controlled trial at the academic fertility centers of four public hospitals in Chinese Mainland. Infertile women scheduled to receive their first FET cycle after a failed IVF-ET attempt were randomly assigned to either (a) the immediate FET group in which FET was performed in the first menstrual cycle following the failed IVF-ET cycle (n = 366) or (b) the delayed FET group in which FET was performed in the second or subsequent menstrual cycle following the failed IVF-ET cycle (n = 366). All FET cycles were performed during hormone replacement cycles for endometrial preparation. The primary outcome was the ongoing pregnancy, defined as a detectable fetal heart beat beyond twelve weeks of gestation. Secondary outcomes were other pregnancy-related outcomes, maternal and neonatal complications. Analysis was performed by both intention-to-treat and per-protocol principles.

RESULTS

A total of 646 FETs were completed. The frequency of moderate to severe depression and high stress level prior to FET in delayed FET group were significantly higher than that in immediate FET group (10.6% vs 6.1%, p = 0.039; 30.3% vs 22.4%, p = 0.022, respectively). Immediate FET resulted in a higher frequency of clinical pregnancy than did delayed FET (41.7% vs 34.1%), for a relative risk (RR) of 1.23 (95% confidence interval [CI], 1.00-1.50; p = 0.045). Women who underwent immediate FET also had a lower frequency of biochemical pregnancy loss (11.7% vs. 30.6%), with a RR of 0.28 (95% CI 0.23-0.63, p < 0.001), and a higher frequency of embryo implantation (25.2% vs. 20.2%), with a RR of 1.25 (95% CI 1.01-1.53; p = 0.038). Although the ongoing pregnancy and live birth rates did not differ significantly between the immediate FET and delayed FET groups (37.1% vs 30.3%, RR 1.22, 95% CI 0.99-1.52, p = 0.067; 36.5% vs 30.0%, RR 1.22, 95% CI 0.98-1.52, p = 0.079, respectively), a multivariate logistic regression analysis adjusted for potential confounders such as depression and stress levels revealed that the immediate FET group had a significantly higher ongoing pregnancy and live birth rates than the delayed FET group (odds ratio 0.68, 95% CI 0.47-0.99, p = 0.041; odds ratio 0.67, 95% CI 0.46-0.96, p = 0.031). The risks of maternal and neonatal complications were comparable between the two groups.

CONCLUSIONS

In women with a previous failed IVF-ET attempt, immediate FET resulted in higher ongoing pregnancy and live birth rates than delayed FET. These findings warrant caution in the indiscriminate application of a delayed FET strategy when apparent risk of high stress level is perceived.

TRIAL REGISTRATION

ChiCTR2000033313 .

The Clinical Efficacy of Three Different Follicle-Stimulating Hormones for Follicle Growth and Development in Long-Protocol Controlled Ovarian Hyperstimulation Treatment

Objective

To compare the use and clinical efficacy of three different follicle-stimulating hormones (FSHs) for follicle growth and development in long-protocol controlled ovarian hyperstimulation (COH).

Methods

A total of 540 gonadotropin-releasing hormone (GnRH) agonists’ long protocol treatment cycles at our hospital between January 2015 and May 2020 and met the inclusion criteria were retrospectively analyzed. The cycles were divided into three groups based on their indexes (groups A, B, and C). Each of the groups received a different type of FSH during treatment. A cross-group comparison was then undertaken to evaluate the growth and development of the three largest follicles and the patients’ pregnancy-related indexes between the normal-response and high-response populations.

Results

In the normal-response populations, the number of high-quality embryos obtained in groups A and B was significantly higher than in group C, and the FSH dosage was significantly lower than in group C (P < 0.05). There were more follicles with a diameter of 16–18 mm found in group A than in group C on the day of hCG injection (hCG day) (P < 0.05), but there were no significant differences in the groups in other indicators. In the high-response populations, the number of oocytes retrieved and high-quality embryos obtained in group A were significantly higher than in group C (P < 0.05), and the total dosage and duration of FSH stimulation in group C were significantly higher than groups A and B (P < 0.05).

Conclusion

Three different types of FSH led to comparable growth rates of the three largest follicles and clinical pregnancy rates per fresh cycle in long-protocol COH treatment.

Genetic determination of the ovarian reserve: a literature review

The ovarian reserve is one of the most important indicators of female fertility. It allows for the evaluation of the number of viable oocytes. This parameter is actively used in pregnancy planning and in assisted reproductive technology application, as it determines chances of successful fertilization and healthy pregnancy. Due to increased attention towards diagnostic tests evaluating the ovarian reserve, there has been a growing interest in factors that influence the state of the ovarian reserve. True reasons for pathological changes in the ovarian reserve and volume have not yet been explored in depth, and current diagnostic screening methods often fall short in efficacy. In the following review we analyze existing data relating to the study of the ovarian reserve through genetic testing, determining specific characteristics of the ovarian reserve through genetic profiling. We explore existing studies dedicated to finding specific genetic targets influencing the state of the ovarian reserve.

Research progress of melatonin (MT) in improving ovarian function: a review of the current status

Melatonin (MT) is an endogenous hormone mainly synthesized by pineal cells, which has strong endogenous effects of eliminating free radicals and resisting oxidative damages. Melatonin (MT) can not only regulate the body’s seasonal and circadian rhythms; but also delay ovarian senescence, regulate ovarian biological rhythm, promote follicles formation, and improve oocyte quality and fertilization rate. This review aimd to provide evidence concerning the synthesis and distribution, ovarian function, and role of MT in development of follicles and oocytes. Moreover, the role of MT as antioxidative, participating in biological rhythm regulation, was also reviewed. Furthermore, the effects of MT on various ovarian related diseases were analyzed, particularly for the ovarian aging and polycystic ovary syndrome (PCOS).

CHRONIC ENDOMETRITIS IN PATIENTS WITH REPEATED IMPLANTATION FAILURES:EPIDEMIOLOGY, ETIOLOGY, PATHOGENESIS AND OVERCOMING INFERTILITY

Recent evidence indicates that the endometrium plays a much more important role in successful implantation and clinical pregnancy than many other recognized factors. Chronic endometritis (CE) is associated with negative reproductive outcomes, including repeated implantation failures. Streptococcus spp., Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae, Staphylococcus spp., Corynebacterium and Mycoplasma / Ureaplasmaspp are currently considered the main pathogens of CE. This disease disrupts the architectonics of the endometrium at different levels: first of all, CE promotes changes in the population of immunocompetent cells and, therefore, contributes to the disruption of the local immune response in the endometrium at the time of implantation. Antibiotic treatment for CE improves implantation rates and decreases abortion rates, although there are no well-designed prospective studies to support this conclusion. Considering the insufficient effectiveness of antibiotic therapy for CE, especially in cases of resistance of pathogens, or in the case of viral chronic endometritis, it is necessary to develop schemes with additional use of drugs that affect other etiopathogenetic pathways of development and maintenance of CE. An example of such a treatment can be cytokine therapy, which requires further study regarding the efficacy and safety in CE therapy.

Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain

Multiple gestations have become an increasing phenomenon that has impacted public health globally, largely due to the application of assisted reproductive technologies. The objective of this work was to find out the discourse that the health professionals involved in its follow-up have in our context. For this, a qualitative methodology was chosen, with semi-structured interviews recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for this purpose, with the following analysis categories: the current trend of multiple gestations, impact, and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of the professionals interviewed. Professionals stated that the current socioeconomic and legal context hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the importance of the psychic impact of such gestations on the couple, on the mother in particular, as well as the economic effect on families, health, and society in general. They expressed the need to create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Work on specific models is needed to adequately size the impact of multiple gestations, as well as to generate social health policies that lead to co-responsible reconciliation measures that favour women having one pregnancy at a time.

Resistin and chemerin levels in follicular fluid of infertile women with endometriosis undergoing ICSI

Chemerin and resistin are two adipocytokines involved in inflammatory processes that may paly a role in the development of endometriosis. The purpose of the current study was to examine the levels of chemerin and resistin in the follicular fluid (FF) of endometriosis patients and additionally, assess the association of FF chemerin and resistin with the severity of endometriosis and the number of mature oocyte and embryos. A total of 80 reproductive-aged women who underwent intracytoplasmic sperm injection and embryo transfer were evaluated in this study. FF samples were obtained from subjects with (n = 40) and without endometriosis (n = 40). The concentrations of chemerin and resistin were examined using ELISA. The Resistin FF level was significantly (p-value=.03) higher in women with endometriosis than women without endometriosis, while the effect size was medium (d = 0.47). There was no significant difference in Chemerin concentration between the two groups of this study. Results also showed a tendency towards the increase of FF values of resistin and chemerin in endometriosis patients with stage III-IV than stage I-II; however, this difference was not significant. No significant correlations were found between FF levels of resistin and chemerin with the number of mature oocyte and embryos. Thus, elevated FF resistin levels may be associated with endometriosis.IMPACT STATEMENTWhat is already known on this subject? To our knowledge, no studies have investigated chemerin levels in follicular fluid of infertile women with endometriosis undergoing ICSI. Although follicular fluid levels of resistin have been previously studied in endometriosis, it has not been studied yet whether its level is associated with the number of oocyte and embryos.What do the results of this study add? Our results indicate that significantly increased resistin levels in follicular fluid may be associated with the presence of endometriosis.What are the implications of these findings for clinical practice and/or further research? The findings are promising in that significantly increased resistin levels may add to the knowledge of the pathophysiology of endometriosis.

Response to ovulation induction treatments in women with polycystic ovary syndrome as a function of serum anti-Müllerian hormone levels

PURPOSE

To assess whether anti-Müllerian hormone (AMH) can predict response to ovulation induction (OI) with clomiphene citrate (CC), letrozole (LET), or follicle-stimulating hormone (FSH) in women with polycystic ovary syndrome (PCOS) undergoing OI/intrauterine inseminations (IUI).

METHODS

A total of 738 OI/IUI cycles from 242 patients at an academic center were stratified in three groups by medication: CC (n = 295), LET (n = 180), and FSH (n = 263), in a retrospective fashion. Ovarian response to treatment (RT, development of at least one dominant follicle) was assessed using mixed effects logistic regression models.

RESULTS

Overall, RT cycles had lower AMH levels compared to no-RT cycles (p < 0.001). This finding persisted when analysis was limited to oral agents but attenuated in FSH cycles. For CC and LET cycles, the predicted probability (PProb) for RT decreased as AMH levels increased (PProb (95%CI): 97% (93-100), 79% (70-88), and 75% (61-89); 85% (78-93), 75% (67-83), and 73% (63-86) for AMH pct.: ≤ 25th, ≥ 50th, and ≥ 75th, for CC and LET, respectively)). However, RT was noted in 98.5% of FSH/IUI cycles regardless of AMH. For CC cycles, those with AMH ≥ 75th pct. had lower odds for RT over cycles with AMH < 75th pct. (OR 0.2, 95%CI 0.04-0.8, p = 0.02). Similarly, lower odds for RT were observed in LET cycles with AMH ≥ 75th pct. (0.6, 0.3-1.4, p = 0.25).

CONCLUSION

In PCOS, increasing serum AMH levels are associated with lower probability of RT to oral agents. Our findings constitute a valuable tool for the clinician when counseling PCOS patients and designing a personalized ovulation induction treatment strategy.

Minimal ovarian stimulation is an alternative to conventional protocols for older women according to Poseidon's stratification: a retrospective multicenter cohort study

OBJECTIVE

To investigate whether minimal ovarian stimulation (mOS) is as effective as conventional ovarian stimulation (cOS) for older women belonging to different groups according to the Poseidon criteria.

MATERIAL AND METHODS

Observational retrospective multicentre cohort including women from Poseidon's groups 2 and 4 that underwent in vitro fertilization (IVF). We performed a mixed-effects logistic regression model, adding as a random effect the patients and the stimulation cycle considering the dependence of data. Survival curves were employed as a measure of the cumulative live birth rate (CLBR). The primary outcomes were live birth rate per embryo transfer and CLBR per consecutive embryo transfer and oocyte consumed until a live birth was achieved.

RESULTS

A total of 2002 patients underwent 3056 embryo transfers (mOS = 497 and cOS = 2559). The live birth rates per embryo transfer in mOS and cOS showed no significant difference in both Poseidon's groups. Likewise, the logistic regression showed similar live birth rates between the two protocols in Poseidon's groups 2 (OR 1.165, 95% CI 0.77-1.77; p = 0.710) and 4 (OR 1.264 95% CI 0.59-2.70; p = 0.387). However, the survival curves showed higher CLBR per oocyte in women that received mOS (Poseidon group 2: p < 0.001 and Poseidon group 4: p = 0.039).

CONCLUSIONS

Minimal ovarian stimulation is a good alternative to COS as a first-line treatment for patients belonging to Poseidon's groups 2 and 4. The number of oocytes needed to achieve a live birth seems inferior in mOS strategy than cOS.

There is a cycle to cycle variation in ovarian response and pre-hCG serum progesterone level: an analysis of 244 consecutive IVF cycles

We aimed to answer one key question, that was not previously addressed as to whether serum progesterone (P_4-hCG day) and its co-variates (estradiol (E_{2-hCG day}) and the number of retrieved oocytes) of a given cycle can be predictive of the subsequent cycle when both cycles are consecutive and comparable for the stimulation protocol, gonadotropin dose and duration of stimulation. We analyzed such 244 consecutive (< 6 months) IVF cycles in 122 patients with GnRH agonist long protocol and found that P₄, E₂ and the number of retrieved oocytes significantly vary between the two cycles. Although P₄ increased (ranging from 4.7 to 266.7%) in the 2nd cycle in 61 patients, E₂ and the number of retrieved oocytes, which are normally positively correlated with P₄ paradoxically decreased in the 41% and 37.7% respectively, of these same 61 patients. When a similar analysis was done in the 54 out of 122 patients (44.3%) in whom serum P₄ was decreased in the 2nd cycle, the mean decrease in P₄ was − 34.1 ± 23.3% ranging from − 5.26 to − 90.1%. E₂ and the number of retrieved oocytes paradoxically increased in the 42.3% and 40.7% of these 54 patients respectively. P₄ remained the same only in the 7 (5.7%) of these 122 patients. These findings indicate that late follicular phase serum P₄ may change unpredictably in the subsequent IVF cycle. The changes are not always necessarily proportional with ovarian response of previous cycle suggesting that growth characteristics and steroidogenic activities of antral cohorts may exhibit considerable cycle to cycle variations.

Psychosocial and professional burden of Medically Assisted Reproduction (MAR): Results from a French survey

OBJECTIVE

To evaluate the impact of infertility and Medically Assisted Reproduction (MAR) throughout all aspects of life among infertile women and men.

MATERIALS AND METHODS

An online survey included 1 045 French patients (355 men, 690 women) who were living or had lived the experience of infertility and MAR. The questionnaire included 56 questions on several domains: global feelings, treatment burden, rapport with medical staff, psychosocial impact, sexual life and professional consequences.

RESULTS

Respondents had experienced an average of 3.6 (95% CI: 3.3-3.9) MAR cycles: 5% (n = 46) were pregnant, 4% (n = 47) were waiting to start MAR, 50% (n = 522) succeeded in having a live birth following MAR, 19% (n = 199) were currently undergoing ART, and 21% (n = 221) dropped out of the MAR process without a live birth. Satisfaction rates regarding the received medical care were above 80%, but 42% of patients pointed out the lack of information about non-medical support. An important impact on sexual life was reported, with 21% of patients admitted having not had intercourse for several weeks or even several months. Concerning the impact on professional life, 63% of active workers currently in an MAR program (n = 185) considered that MAR had strong repercussions on the organization of their working life with 49% of them reporting a negative impact on the quality of their work, and 46% of them reporting the necessity to lie about missing work during their treatment.

CONCLUSION

Despite a high overall level of satisfaction regarding medical care, the burden of infertility and MAR on quality of life is strong, especially on sexuality and professional organization. Clinical staff should be encouraged to develop non-medical support for all patients at any stage of infertility treatment. Enterprises should be warned about the professional impact of infertility and MAR to help their employees reconcile personal and professional life.

Prevalence of oligomenorrhea among women of childbearing age in China: A large community-based study

OBJECTIVE

To investigate the prevalence and the related characteristics of oligomenorrhea among women within childbearing age in China.

STUDY DESIGN

A large-scale community-based investigation was conducted from 2013 to 2015. A total of 12,964 women aged 18-49 years from 9 provinces/municipalities in China were recruited for healthcare screening in local community health centers. Outcome measures include clinical history, ultrasonographic exam, and hormonal and metabolic parameters.

RESULTS

Among women within childbearing age in China, the prevalence of oligomenorrhea was 12.2% (1,579/12,964). Both sociodemographic factors and medical history were significantly associated with oligomenorrhea (P < 0.05). In such women, the prevalence of obesity, acne, seborrhea, acanthosis, larger ovarian size, and polycystic ovarian morphology was higher when compared with normal women; the prevalence of anti-Mullerian hormone, total testosterone, and androstenedione (P < 0.05) was higher as well. The infertility rates of all women were higher in the oligomenorrhea group (17.2%, 272⁄1,579) than in the non-oligomenorrhea group (9.0%, 1,024⁄11,385), and among women without contraception, for the oligomenorrhea group, the infertility rate was 32.5% (128⁄394), and for the non-oligomenorrhea group, 17.9% (400⁄2,240). In the oligomenorrhea group, 57.4% (156/272) of the women underwent treatments for infertility, which was higher than the non-oligomenorrhea group 36.1% (370/1,024).

CONCLUSIONS

Obesity, acne, seborrhea, acanthosis, larger ovarian size, and polycystic ovarian morphology were significantly associated with oligomenorrhea. The increase of anti-Mullerian hormone, total testosterone, and androstenedione level was also demonstrated in the oligomenorrhea group. Higher prevalence of infertility and medical treatment rate was observed in women with oligomenorrhea.

Rescue In Vitro Maturation in Polycystic Ovarian Syndrome Patients Undergoing In Vitro Fertilization Treatment who Overrespond or Underrespond to Ovarian Stimulation: Is It A Viable Option? A Case Series Study

Background

This study intends to present the role of rescue in vitro maturation (IVM) in polycystic ovarian syn- drome (PCOS) patients undergoing in vitro fertilization (IVF) treatment who have inappropriate responses to ovarian stimulation.

Materials and Methods

This was a retrospective case series study of five PCOS patients undergoing IVF treatment considered for cycle cancellation due to increased risk of ovarian hyperstimulation syndrome (OHSS) as group A or poor response to ovarian stimulation as group B. Patients in group A had high oestradiol levels and recruitment of high numbers of small/intermediate sized follicles that did not meet the criteria for human chorionic gonadotropin (hCG) triggering. Patients in group B responded inadequately to hormonal stimulation despite high gonadotropin dosage. Treatment was changed to rescue IVM cycles after the patients provided consent.

Results

In group A, three IVF patients deemed to have high chances of developing OHSS as evidenced by high oestradiol levels were converted to IVM. A total of the 58/68 oocytes retrieved were mature or matured in vitro. There were 26 cleaving embryos obtained. Two patients had live births and one patient suffered a miscarriage. In group B, rescue IVM was implemented in two patients due to poor ovarian response (POR). A total of 22/26 oocytes retrieved were mature or matured in vitro. There were 13 cleaving embryos obtained. One patient had a live birth, whilst the other suffered a miscarriage.

Conclusion

Rescue IVM could be a viable option in PCOS patients undergoing IVF treatment who are unable to safely meet the criteria for hCG triggering due to overresponse to ovarian stimulation or ovarian resistance to high doses of stimulation. Conversion to IVM can still result in reasonable oocyte retrieval and lead to clinical pregnancy and live births without the risks of OHSS.

Severe early-onset ovarian hyperstimulation syndrome with liver dysfunction in an IVF segmentation cycle

Severe early-onset ovarian hyperstimulation syndrome (OHSS) with deranged liver function tests is an entity that cannot be eliminated wholly even after gonadotropin-releasing hormone (GnRH) agonist trigger without any luteal human chorionic gonadotropin (hCG) rescue in a GnRH antagonist protocol with the freeze-all approach. We describe a case of young polycystic ovary syndrome patient with prior history of severe early-onset OHSS in her last in vitro fertilisation cycle in which she received antagonist protocol followed by blastocyst transfer. Given her history, she was planned for agonist trigger and freeze all approach during the present cycle. Despite segmentation of the cycle without any luteal rescue hCG, she developed early-onset severe OHSS with markedly deranged liver function tests for which she underwent ascitic tapping and remained hospitalised for 8 days. Her symptoms improved with conservative management, and she was discharged satisfactorily. She underwent letrozole based frozen-thawed embryo transfer cycle after 4 months. One good quality blastocyst was transferred, and she conceived in the same cycle.

Clinical Application of AMH Measurement in Assisted Reproduction

Anti-Müllerian hormone reflects the continuum of the functional ovarian reserve, and as such can predict ovarian response to gonadotropin stimulation and be used to individualize treatment pathways to improve efficacy and safety. However, consistent with other biomarkers and age-based prediction models it has limited ability to predict live birth and should not be used to refuse treatment, but rather to inform counselling and shared decision making. The use of absolute clinical thresholds to stratify patient phenotypes, assess discordance and individualize treatment protocols in non-validated algorithms combined with the lack of standardization of assays may result in inappropriate classification and sub-optimal clinical decision making. We propose that holistic baseline phenotyping, incorporating antral follicle count and other patient characteristics is critical. Treatment decisions driven by validated algorithms that use ovarian reserve biomarkers as continuous measures, reducing the risk of misclassification, are likely to improve overall outcomes for our patients.

Progestin-Primed Ovarian Stimulation with Dydrogesterone versus Medroxyprogesterone Acetate in Women with Polycystic Ovarian Syndrome for in vitro Fertilization: A Retrospective Cohort Study

Purpose

Dydrogesterone (DYG) is an alternative progestin in progestin-primed ovarian stimulation (PPOS) protocol with weaker pituitary suppression than medroxyprogesterone acetate (MPA) in normal ovulatory women. However, the endocrinological characteristics, oocyte retrieval and pregnancy outcomes of DYG application in polycystic ovarian syndrome (PCOS) patients undergoing in vitro fertilization (IVF) remain unclear.

Patients and methods

This retrospective cohort study included 420 PCOS patients who underwent controlled ovarian stimulation with human menopausal gonadotropin (hMG) and DYG (n=105) or MPA (n=315) from January 2014 to December 2017. Baseline characteristics of the two groups were balanced with propensity score matching using the nearest-neighbor random matching algorithm in a ratio of 1:3. The primary outcome measure was the number of oocytes retrieved. Other main outcome measures included the number of viable embryos, incidence of premature luteinizing hormone (LH) surge and live birth rate per frozen-thawed embryo transfer (FET) cycle.

Results

A similar number of oocytes was retrieved in the two protocols (16.1±6.5 vs 15.1±10.0, P=0.342). Patients in both groups achieved consistent LH suppression with no premature LH surge detected. In the DYG + hMG group, the mean LH levels were significantly higher than the MPA + hMG group on cycle day 9–11 and trigger day (all P<0.001), and the dose of hMG was significantly lower (1710.7±431.6 vs 1891.3±402.2 IU, P<0.001). No significant between-group differences were found in the number of viable embryos (5.3±3.1 vs 5.0±4.1, P=0.139) and live birth rate per FET cycle (43.5% vs 47.7%, P=0.383). None of the participants experienced moderate-to-severe ovarian hyperstimulation syndrome in either group.

Conclusion

Our results showed that the application of DYG in PPOS protocol could achieve comparable oocyte retrieval and pregnancy outcomes to MPA, but significantly reduce the consumption of gonadotropins in PCOS women for IVF treatment.

Personalized medicine for in vitro fertilization procedure using modeling and optimal control

In vitro fertilization (IVF) is the most common technique in assisted reproductive technology and in most cases the last resort for infertility treatment. It has four basic stages: superovulation, egg retrieval, fertilization, and embryo transfer. Superovulation is a drug-induced method to enable multiple ovulation per menstrual cycle and key component towards a successful IVF cycle. Although there are the general guidelines for dosage, the dose is not optimized for each patient, and complications, such as overstimulation, can occur. To overcome the shortcomings of this general system, a mathematical procedure is developed which can provide a customized model of this stage regarding the size distribution of eggs (follicles/ oocytes) obtained per cycle as a function of the chemical interactions of the drugs used and the conditions imposed on the patient during the cycle, which provide a basis for predicting the possible outcome. Uncertainty and risk are modeled and included in optimal drug dosage decisions. This paper describes the theory, model, and the optimal control procedure for improving outcomes of IVF treatment for one of the four protocols used in real practice. The validation of the procedure is performed using clinical data from the patients previously undergone IVF cycles. Customized patient-specific model parameters are obtained by using initial two-day data for each patient. Subsequently, this model is used to predict the FSD for the remaining days of the cycle. This procedure was conducted for 49 patients. The results of the customized models are found to be closely matching with the observed FSD. These results thus validate the modeling approach and consequently its use for predicting the customized optimal drug dosage for each patient. Using the customized model and the optimized dosage, the FSD at the end of the cycle was determined. A small double-blind clinical trial was also conducted in India. The results from the trial show that the dosage predicted by using the model is 40% less than the suggestion made by the IVF clinicians. The testing and monitoring requirements for patients using optimized drug dosage is reduced by 72%. Work on the other three protocols and for patients in the USA is started and is showing promising results.

Comparison of the umbilical cord Blood's anti-Mullerian hormone level in the newborns of mothers with polycystic ovary syndrome (PCOS) and healthy mothers

Background

Polycystic ovary syndrome (PCOS) is one of the most common endocrine diseases. At present, the cause of the disease is not fully understood, but many studies have shown that PCOS is associated with genetic and environmental factors. The present study aimed to assess the umbilical cord blood’s Anti-mullerian hormone (AMH) level in the newborns of mothers suffering from PCOS comparing to healthy mothers.

Methods

This prospective cohort study was conducted on 120 pregnant women with PCOS, who were selected through Rotterdam criteria, and 60 healthy pregnant women as the control group. The subjects in each group were divided into obese and non-obese mothers according to their body mass index (BMI) before pregnancy. The cord blood samples were collected from the offsprings on the time of childbirth. Finally, the circulating concentrations of AMH in both sexes of the newborns were determined by specific assays.

Results

The research results showed that the blood level of AMH was higher in the neonates of obese mothers with PCOS comparing to the controls (P < 0.001). Mean AMH level was higher in male neonates born from non-obese PCOS mothers than in the controls (P < 0.001); however, there was not a significant difference in the level of AMH in female neonates between these two groups (P = 0.264). Also the level of the above biomarker was higher in both sexes of the neonates belonging to obese PCOS mothers compared with the neonates born from non-obese PCOS mothers (P < 0.001).

Conclusion(s)

It can be said that the cord blood AMH level of neonates from obese women with PCOS is higher than that in the newborns of non-obese PCOS mothers. Further longitudinal studies are needed to confirm the clinical findings of the present research.