Elevated day 3 FSH/LH ratio: a marker to predict IVF outcome in young and older women

Assisted reproductive technology and interactions between serum basal FSH/LH and ovarian sensitivity index

Objectives

This study aimed to investigate whether the FSH (follicle-stimulating hormone)/LH (Luteinizing hormone) ratio correlates with ovarian response in a cross-sectional retrospective study of a population with normal levels of anti-Müllerian hormone (AMH).

Methods

This was a retrospective cross-sectional study with data obtained from medical records from March 2019 to December 2019 at the reproductive center in the Affiliated Hospital of Southwest Medical University. The Spearmans correlation test evaluated correlations between Ovarian sensitivity index (OSI) and other parameters. The relationship between basal FSH/LH and ovarian response was analyzed using smoothed curve fitting to find the threshold or saturation point for the population with mean AMH level (1.1<AMH<6μg/L). The enrolled cases were divided into two groups according to AMH threshold. Cycle characteristics, cycle information and cycle outcomes were compared. The Mann-Whitney U test was used to compare different parameters between two groups separated by basal FSH/LH in the AMH normal group. Univariate logistic regression analysis and multivariate logistic regression analysis were performed to find the risk factor for OSI.

Results

A total of 428 patients were included in the study. A significant negative correlation was observed between OSI and age, FSH, basal FSH/LH, Gn total dose, and Gn total days, while a positive correlation was found with AMH, AFC, retrieved oocytes, and MII egg. In patients with AMH <1.1 ug/L, OSI values decreased as basal FSH/LH levels increased, while in patients with 1.1<AMH<6 ug/L, OSI values remained stable with increasing basal FSH/LH levels. Logistic regression analysis identified age, AMH, AFC, and basal FSH/LH as significant independent risk factors for OSI.

Conclusions

We conclude that increased basal FSH/LH in the AMH normal group reduces the ovarian response to exogenous Gn. Meanwhile, basal FSH/LH of 3.5 was found to be a useful diagnostic threshold for assessing ovarian response in people with normal AMH levels. OSI can be used as an indicator of ovarian response in ART treatment.

Development and Validation of a Clinical Pregnancy Failure Prediction Model for Poor Ovarian Responders During IVF/ICSI

BACKGROUNDS

Despite the great advances in assisted reproductive technology (ART), poor ovarian response (POR) is still one of the most challenging tasks in reproductive medicine. This predictive model we developed aims to predict the individual probability of clinical pregnancy failure for poor ovarian responders (PORs) under in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).

METHODS

The nomogram was developed in 281 patients with POR according to the Bologna criteria from January 2016 to December 2019, with 179 in the training group and 102 in the validation group. Univariate and multivariate logistic regression analyses were used to identify characteristics that were associated with clinical pregnancy failure. The nomogram was constructed based on regression coefficients. Performance was evaluated using both calibration and discrimination.

RESULTS

Age >35 years, body mass index (BMI) >24 kg/m², basic follicle-stimulating hormone (FSH) >10 mIU/ml, basic E2 >60 pg/ml, type B or C of endometrium on human chorionic gonadotropin (hCG) day, and the number of high-quality embryos <2 were associated with pregnancy failure of POR patients. The area under the receiver operating characteristic curve (AUC) of the training set is 0.786 (95% confidence interval (CI): 0.710-0.861), and AUC in the validation set is 0.748 (95% CI: 0.668-0.827), showing a satisfactory goodness of fit and discrimination ability in this nomogram.

CONCLUSION

Our nomogram can predict the probability of clinical pregnancy failure in PORs before embryo transfer in IVF/ICSI procedure, to help practitioners make appropriate clinical decisions and to help infertile couples manage their expectations.

The comparison of evaluative effectiveness between antral follicle count/age ratio and ovarian response prediction index for the ovarian reserve and response functions in infertile women

Aim of the present study was to explore the evaluative effectiveness of age, ovarian volume (OV), antral follicle count (AFC), serum follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), AFC/Age ratio, AMH/Age ratio, FSH/luteinizing hormone (LH) ratio, and ovarian response prediction index (ORPI) to determine which could more advantageously assess ovarian reserve and response.This research enrolled 319 consecutive infertile women who had undergone in vitro fertilization-ET/intracytoplasmic sperm injection (IVF-ET/ICSI) treatments. Abovementioned variables were measured and calculated. Receiver operating characteristic (ROC) curve analysis was used to analyze the predictive accuracy of variables and to calculate cut-off values and corresponding sensitivity and specificity.Our study revealed that the significant variables for evaluating a decline in ovarian reserve include age, OV, FSH, AFC/Age ratio, AMH/Age ratio, and ORPI. Moreover, the area under the curve (AUC) of AFC/Age ratio was higher than other 5 variables (AUC = 1.000), and the cut-off value of AFC/Age ratio was 0.111 (sensitivity 100.00%, specificity 100.00%). The significant variables forecasting excessive ovarian response were age, AFC, AMH, FSH, AFC/Age ratio, AMH/Age ratio, FSH/LH ratio, and ORPI, and the significant variables forecasting poor ovarian response were AMH, LH, OV, AFC/Age ratio, AMH/Age ratio, and FSH/LH ratio. When ORPI was used to predict excessive response, the cut-off value of ORPI was 0.880 (sensitivity 84.72%, specificity 67.32%) and ORPI presented better effectiveness. When used to predict poor response, the evaluative effectiveness of 6 variables was almost similar, although the AUC of AFC/Age ratio presented the largest value.Regarding the infertile women, AFC/Age ratio performed better than did the other variables in evaluating ovarian reserve, and it offered excellent effectiveness in predicting poor ovarian response, however, ORPI presented better effectiveness in predicting excessive ovarian response.

Do young women with unexplained infertility show manifestations of decreased ovarian reserve?

PURPOSE

To investigate whether unexplained infertility at a young age demonstrates manifestations of decreased ovarian reserve.

METHODS

A total of 100 women were divided into two equally sized groups. The study group comprised women aged ≤ 37 years diagnosed with unexplained infertility, and the control group included age-matched women with either mechanical factor or severe male factor infertility.

RESULTS

Both groups were comparable in their basic characteristics. Overall, women with unexplained infertility presented with inferior ovarian reserve results set against women of the control group. The number of ≥ 14-mm follicles on the day of hCG administration was significantly lower in the study compared with the control group (7.0 ± 4.5 vs. 10.4 ± 4.1 follicles, respectively, P < 0.001). Likewise, basal serum FSH was higher in the study compared with the control group (8.4 ± 5.5 vs. 6.4 ± 1.7 IU/L, respectively, P = 0.015), while antral follicle count was lower (10.9 ± 6.6 vs. 16.2 ± 6.6 follicles, respectively, P < 0.001). Furthermore, women with unexplained infertility required a higher total dose of FSH for ovarian stimulation (2,923 ± 1,701 vs. 2,196 ± 941 IU/L, respectively, P = 0.010), but exhibited a lower number of retrieved oocytes (9.3 ± 6.3 vs. 15.6 ± 7.9 oocytes, respectively, P < 0.001), alongside a lower number of achieved embryos (5.3 ± 4.0 vs. 8.0 ± 4.7 embryos, respectively, P = 0.002). Interestingly, the cumulative clinical pregnancy rate was not significantly different between the two groups (44% vs. 58%, respectively, P = 0.163).

CONCLUSIONS

Young women ≤ 37 years of age with unexplained infertility have clear manifestations of sub-optimal ovarian reserve set against controls. Our findings suggest that unexplained infertility at a young age may be a risk factor for developing poor ovarian response, specifically as a quantitative, rather than a qualitative, risk factor.

Body symmetry and reproductive hormone levels in women

Fluctuating asymmetry (FA), a morphological marker of developmental stability, may be related to an individual's biological condition, e.g., health or fertility. The aim of this study was to test if the level of a woman's FA was related to her fertility and reproductive potential as measured by reproductive hormone levels. Fifty-three healthy, non-pregnant, naturally cycling women (mean age = 23.42, SD = 1.85 years), participated in the study, conducted in Wrocław (Poland) in May 2015. Early-follicular phase serum levels of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were measured. FA was calculated based on anthropometric measures of six bilateral body traits, and the composite FA index was used in statistical analyses. No relationship was observed between FA and the levels of FSH, LH, and AMH (p > .05), controlled for potential confounders. However, the level of E2 was positively correlated with FA (p < .05). Thus, in young women, FA was not related to hormones levels related to ovarian reserve, but more symmetrical women had lower E2 levels. As FA is an index of developmental stability, environmental, and genetic stress, the results of the study confirm previous research suggesting that developmental conditions may be related to women's endogenous estrogen levels.

Persistent organic pollutants as predictors of increased FSH:LH ratio in naturally cycling, reproductive age women

Although several recent studies suggest endocrine disrupting compounds, such as polychlorinated biphenyls (PCBs), dichlorodiphenyldichloroethylene (p,p', DDE), and hexachlorobenzene (HCB), target different organs and systems in the body, their impact on female reproductive function in humans is not well characterized. We seek to determine the relationship between several known endocrine disrupting compounds and a marker of ovarian responsivity, the FSH:LH ratio (higher ratio indicates less ovarian responsivity). For this analysis, 169 naturally cycling women between 21 and 38 years of age completed interviews and had their blood drawn on day 3 of their menstrual cycle for analyses of toxicants, gonadal sex hormones (E₂ and P₄), and gonadotropins (FSH and LH). PCB congeners were classified into five groups based on their environmental persistence, distribution in human tissue, and toxicological action, reflecting the structure, mechanism, and known biological activity of individual PCB congeners. For every unit (ppb) increase in the level of the estrogenic PCB group, there was a 5-fold greater risk of a FSH:LH ratio ≥ 2, controlling for individual differences in age, percent body fat, cycle day 3 estradiol levels, parity, alcohol use and cigarette smoking in the past year (exp[ß] = 5; p = ≤0.01). PCB congeners identified as estrogenic were analyzed individually, and, of the 19 potentially estrogenic congeners, five were significantly, and positively related to an increased FSH:LH ratio. Four of these congeners are non-persistent, easily volatilize in the environment, and are easily metabolized, and hence, are indicative of very recent or current exposure. p,p'-DDE and HCB were not associated with FSH:LH ratio. We find a clinical indicator of ovarian responsivity, FSH:LH ratio, is associated with a specific group of estrogenic PCBs. These congeners may become airborne when they volatilize from dredged PCB-contaminated soil or from indoor PCB-containing window caulk and sealants in older buildings leading to inhalation exposure. PCB exposure, particularly to non-persistent, estrogenic congeners, may pose an unrecognized threat to female fecundity within the general population.

Associations Between TP53 and MDM2 Polymorphisms and the Follicle-Stimulating Hormone/Luteinizing Hormone Ratio in Infertile Women

AIMS

This is a follow-up study based on the results of our previous article, to further explore the effect of the TP53 codon 72 (rs1042522) and MDM2 SNP309 (rs2279744) polymorphisms on basal follicle-stimulating hormone (FSH)/luteinizing hormone (LH) ratios in infertility women.

MATERIALS AND METHODS

The distribution of two genetic polymorphisms (rs1042522 and rs2279744) and basal FSH/LH ratios were tested and analyzed in 1051 in vitro fertilization (IVF) patients at a university-affiliated hospital.

RESULTS

The TP53 codon 72 polymorphism had a significant association with the FSH/LH ratio (group I: FSH/LH <2.3 and group II: FSH/LH ≥2.3) (C/C vs. G/G: odds ratio [OR] = 1.69, 95% confidence interval [CI]: 1.07-2.65, p = 0.02; G/C vs. G/G: OR = 1.86, 95% CI: 1.25-2.77, p = 0.002). In a stratification analysis, C allele carriers and the C/C genotype showed a strong association with positive clinical pregnancy outcomes after IVF compared with G allele carriers and the G/G genotype in the recessive, dominant, and allelic genetic models in group I (C/C vs. G/G: OR = 1.84, 95% CI: 1.25-2.69, p = 0.01; C/C vs. G carrier: OR = 1.52, 95% CI: 1.12-2.07, p = 0.01; C carrier vs. G/G: OR = 1.46, 95% CI: 1.07-2.01, p = 0.02; C allele vs. G allele: OR = 1.34, 95% CI: 1.11-1.62, p = 0.003), no significant associations by stratification were observed for group II. No associations were found between MDM2 SNP309 and either of two groups.

CONCLUSION

The TP53 codon 72 polymorphism is associated with FSH/LH ratios, suggesting that it is a potential predictive genetic marker of IVF outcome in patients younger than 35 years of age with baseline FSH levels below 10 IU/L and who have an FSH/LH ratio <2.3.

Nanosized titanium dioxide-induced premature ovarian failure is associated with abnormalities in serum parameters in female mice

Background

Exposure to titanium dioxide nanoparticles (TiO₂ NPs) that are widely used in food, medicine, sunscreen products and cosmetics is reported to cause ovarian damage and lower fertility in animals. However, the potential effects of TiO₂ NPs application on premature ovarian failure (POF) have rarely been evaluated to date.

Methods

In this study, female mice were continuously exposed to TiO₂ NPs at doses of 2.5, 5 or 10 mg/kg via gavage instillation for 30 days, and investigated the serum hormones and autoimmunity markers associated with POF.

Results

Exposure to TiO₂ NPs resulted in POF, reductions in the levels of estradiol, progesterone and inhibin B and increases in luteinizing hormone, follicle-stimulating hormone, follicle-stimulating hormone/luteinizing hormone ratio, anti-Müllerian hormone, thyroid-stimulating hormone, free triiodothyronine, free tetraiodothyronine, anti-nuclear antibody and anti-thyroid peroxidase antibody levels in serum.

Conclusion

Exposure to TiO₂ NPs induced POF triggered by alterations in hormones and autoimmunity markers. Our findings highlight the necessity for significant caution in handling and usage of TiO₂ NPs by female consumers.

Do FSH/LH ratio and gonadal hormone levels predict clinical improvement in postmenopausal schizophrenia women?

Menopause is a process characterized by a decline in estrogen levels and is therefore a period of biological vulnerability for psychotic relapse in women with schizophrenia. Our goal was to correlate not only gonadal hormone levels but also follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels with improvement in specific clinical symptoms. Thirty-seven acutely ill postmenopausal schizophrenia women with a newly initiated, clinically determined change in antipsychotic medication participated in a 12-week prospective observational outcome study. Scales used were the PANSS scale for psychotic symptoms, the PSP for functioning, and CGI for global clinical impression. Circulating FSH, LH, estradiol, progesterone, and testosterone serum levels were determined by chemiluminescent immunoassay. Partial correlational analyses were performed along with a Bonferroni significance correction (p < 0.0007). After adjustment for confounding factors, the FSH/LH ratio correlated positively with mean changes in PANSS positive scores, and there was a correlation with worsening of CGI total and cognitive scores. Testosterone was also positively associated with improvement in PANSS positive scores. However, after correction for multiple testing, the initial correlations were no longer statistically significant. In summary, while the hormone assays we did in this small sample did not prove to be significantly linked to clinical improvement in any of the schizophrenia symptom domains, we recommend further investigation of pituitary, adrenal, and gonadal hormone ratios as potential markers of clinical improvement in this population.

Correlation between the serum luteinizing hormone to folliclestimulating hormone ratio and the anti-Müllerian hormone levels in normo-ovulatory women

Serum anti-Müllerian hormone (AMH) levels are regarded as an age-specific marker for predicting the ovarian reserve in women of reproductive age. Some studies have shown that the luteinizing hormone (LH)/follicle stimulating hormone (FSH) ratio can be used as a predictor of ovarian reserve. The purpose of this study was to assess the variation of LH/FSH ratio with aging and to evaluate the correlation between serum LH/FSH ratio and AMH levels as a predictor of the ovarian reserve in normo-ovulatory women. We retrospectively analyzed the day 3 serum hormone levels in 1,251 patients (age range: 20-50 yr) between January 2010 and January 2011. We divided the patients into 6 groups according to their age. Relation between serum AMH level and LH/FSH ratio was analyzed statistically. The serum AMH level was inversely correlated with age (r = -0.400, P < 0.001). A significant negative correlation was found between serum LH/FSH ratio and age (r = -0.213, P < 0.001). There was a significant partial correlation between serum LH/FSH ratio and AMH level when adjusted by age (r = 0.348, P < 0.001). The LH/FSH ratio could be considered as a useful marker for the ovarian reserve and could be applied to the clinical evaluation with AMH.

Follicle-stimulating hormone/luteinizing hormone ratio as an independent predictor of response to controlled ovarian stimulation

AIM

To determine whether a follicle-stimulating hormone (FSH)/luteinizing hormone (LH) ratio over 3 in the setting of a normal FSH (<12 IU/l) is associated with a higher rate of failed controlled ovarian stimulation cycles.

DESIGN

Retrospective cohort.

MATERIALS & METHODS

A total of 676 patients were identified; 198 patients had a FSH/LH ratio >3 and 477 patients had a FSH/LH ratio <3. Exclusion criteria included: age >40 years; estradiol (E2) prime protocols; E2 at start >70 pg/ml; and FSH at start >12 IU/l. The main outcome measure was cycle cancellation.

RESULTS

An elevated FSH/LH ratio >3 was more likely to result in the individual's cycle cancelled (15 vs 5.24%; p = 0.0001). The total gonadotropin dosage was greater in the higher ratio versus lower ratio group (2636 vs 2242 IU; significant). Peak E2 was significantly lower in the FSH/LH >3 group (peak E2: 1635 vs 1942 pg/ml).

CONCLUSION

The value of the FSH/LH ratio in patients with normal FSH levels, may have a role in determining the appropriate stimulation protocol and predict cycle cancellations.

Serum estradiol level change after human chorionic gonadotropin administration had no correlation with live birth rate in IVF cycles

OBJECTIVE

To investigate the correlation between the estradiol (E2) level change after hCG administration and the live birth rate in GnRH agonist long or short protocols, and to explore the possible factors related to E2 dynamics after hCG administration during controlled ovarian hyperstimulation (COH).

STUDY DESIGN

A retrospective analysis was performed on 2868 patients who received IVF/intracytoplasmic sperm injection (ICSI) treatment with GnRH agonist long or short protocol. The patients were divided into three groups according to their serum E2 changes after hCG administration, and the live birth rates were compared among groups. The area under the receiver operating characteristic (ROC) curve was calculated to assess the predictive value of E2 change for the probability of live birth. Logistic regression analysis was also applied to exclude interference from various confounding factors. Finally, multivariate regression analysis was conducted to assess factors related to the E2 change after hCG administration.

RESULTS

No significant difference was observed in live birth rates (4.26%, 36.38% or 30.81% in long protocol (P=0.697); 25.81%, 26.71% or 30.81% in short protocol (P=0.697)) among patients with increasing, plateauing or decreasing E2 responses after hCG administration. The area under the ROC curve for the E2 change in prediction of live birth rate was 0.506 in long protocol, or 0.524 in short protocol. Logistic regression analysis showed that the serum E2 change after hCG administration had no correlation with live birth rate. Multivariate regression analysis showed that the percentage of mature follicles (larger than 14mm) and the duration of stimulation negatively correlated with the E2 change after hCG administration.

CONCLUSIONS

In GnRH agonist cycles, the serum E2 change after hCG administration had no correlation with live birth rate in fresh embryo transfer cycles, and this change negatively correlated with the percentage of mature follicles on the day of hCG administration.

Predictive value of hormonal parameters for live birth in women with unexplained infertility and male infertility

BACKGROUND

Infertile women might get pregnant sometime after fertility treatment, but today, there is no prediction model on who will eventually have children. The objective of the present study was to characterize hormone levels in an arbitrary menstrual cycle in women with unexplained infertility and male infertility, and to determine the predictive value for long-term possibility of live birth.

METHODS

In this cross-sectional study, with 71 infertile women with diagnosis unexplained infertility and male infertility, blood samples were obtained during the proliferative and secretory phases of an arbitrary menstrual cycle. Serum concentrations of FSH, LH, AMH, inhibin B, estradiol, progesterone, PRL and TSH were determined. The predictive value of ovulation and hormonal analysis was determined by identifying the proportion of women with at least one live birth. Mann Whitney U test, chi2 test and Spearman's correlation were used for statistical analysis. A value of p < 0.05 was considered statistically significant.

RESULTS

There were no differences in hormone values and live birth rates between women with unexplained infertility and male infertility. The best sole predictors of live birth were age of the women, followed by ovulatory cycle, defined as serum progesterone concentration of greater than or equal to 32 nmol/L, and a serum TSH concentration of less than or equal to 2.5 mIU/L. Combining the age with the ovulatory cycle and serum TSH less than or equal to 2.5 mIU/L or serum AMH greater than or equal to 10 pmol/L the predictive value was close to 90%.

CONCLUSIONS

Age in combination with the presence of an ovulatory cycle and serum TSH or serum AMH is predictive for long-term live birth. The advantage of serum AMH compared with serum TSH is the very little variation throughout the menstrual cycle, which makes it a useful tool in infertility diagnosis.

The root of reduced fertility in aged women and possible therapentic options: current status and future perspects

It is well known that maternal ageing not only causes increased spontaneous abortion and reduced fertility, but it is also a high genetic disease risk. Although assisted reproductive technologies (ARTs) have been widely used to treat infertility, the overall success is still low. The main reasons for age-related changes include reduced follicle number, compromised oocyte quality especially aneuploidy, altered reproductive endocrinology, and increased reproductive tract defect. Various approaches for improving or treating infertility in aged women including controlled ovarian hyperstimulation with intrauterine insemination (IUI), IVF/ICSI-ET, ovarian reserve testing, preimplantation genetic diagnosis and screening (PGD/PGS), oocyte selection and donation, oocyte and ovary tissue cryopreservation before ageing, miscarriage prevention, and caloric restriction are summarized in this review. Future potential reproductive techniques for infertile older women including oocyte and zygote micromanipulations, derivation of oocytes from germ stem cells, ES cells, and iPS cells, as well as through bone marrow transplantation are discussed.