Comparison of follicular vascularization in normal versus polycystic ovaries during in vitro fertilization as measured using 3-dimensional power Doppler ultrasonography

ICSI and PGT-A in PCOS phenotype-D patients: a matched case-control study versus idiopathic infertile women

PURPOSE

To assess oocyte competence and embryo chromosomal constitution in phenotype-D PCOS women undergoing ICSI for PGT-A at the blastocyst stage.

METHODS

Retrospective study at a private IVF center. In the period 2013-2021, 58 naïve phenotype-D PCOS women (i.e., oligomenorrhea, ovarian PCO-morphology, and absence of hyperandrogenism) underwent ICSI with ejaculated sperm for PGT-A. These cases were matched to 58 controls selected from 2211 naïve women with idiopathic infertility planned for the same treatment in the same period. The matching variables were age (≈ 36 years), BMI (≈ 22), cumulus oocyte complexes (COCs) retrieved (≈ 21-23), and sperm quality (≈ 43-45% men with all sperm parameters > 5th percentile). The primary outcome was euploid blastocyst rate (EBR) per cohort of inseminated oocytes.

RESULTS

Maturation rates per COCs and euploidy per biopsied blastocysts were similar. PCOS patients with phenotype-D showed higher fertilization per inseminated oocytes and higher blastulation per zygotes. This resulted into a higher EBR per inseminated oocytes and more euploid blastocysts available for transfer, although these differences adjusted for confounders were not significant. The live birth rate per first euploid transfers was comparable, so were all other outcomes considered.

CONCLUSIONS

Oocyte competence was not compromised in phenotype-D PCOS women, while good prognosis idiopathic infertile women might have unknown oocyte issues. In case of repeated failures after intrauterine insemination, a timely referral to IVF might represent an efficient strategy, in line with the "one-and-done" approach fulfilling a family planning perspective. Indeed, 22% of the phenotype-D PCOS women had 2 singleton LBs and 76% had surplus oocytes/euploid blastocysts after achieving ≥ 1 live birth.

Integrated lipid metabolomics and proteomics analysis reveal the pathogenesis of polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is an endocrinological and metabolic disorder that can lead to female infertility. Lipid metabolomics and proteomics are the new disciplines in systems biology aimed to discover metabolic pathway changes in diseases and diagnosis of biomarkers. This study aims to reveal the features of PCOS to explore its pathogenesis at the protein and metabolic level.

METHODS

We collected follicular fluid samples and granulosa cells of women with PCOS and normal women who underwent in vitro fertilization(IVF) and embryo transfer were recruited. The samples were for the lipidomic study and the proteomic study based on the latest metabolomics and proteomics research platform.

RESULTS

Lipid metabolomic analysis revealed abnormal metabolism of glycerides, glycerophospholipids, and sphingomyelin in the FF of PCOS. Differential lipids were strongly linked with the rate of high-quality embryos. In total, 144 differentially expressed proteins were screened in ovarian granulosa cells in women with PCOS compared to controls. Go functional enrichment analysis showed that differential proteins were associated with blood coagulation and lead to follicular development disorders.

CONCLUSION

The results showed that the differential lipid metabolites and proteins in PCOS were closely related to follicle quality,which can be potential biomarkers for oocyte maturation and ART outcomes.

The role of estrogen metabolites in human ovarian function

Estrogens produced by the ovary play diverse roles in controlling physiological changes in the function of the female reproductive system. Although estradiol acts through classical nuclear receptors, its metabolites (EMs) act by alternative pathways. It has been postulated that EMs act through paracrine-autocrine pathways to regulate key processes involved in normal follicular growth, corpus luteum (CL) development, function, and regression. The present review describes recent advances in understanding the role of EMs in human ovarian physiology during the menstrual cycle, including their role in anovulatory disorders and their action in other target tissues.

Understanding the Ovarian Interrelationship with Low Antral Follicle Counts (AFC) in the In Vivo Bos indicus Cow Model: Unilateral and Bilateral Main AFC as Possible Biomarkers of Ovarian Response to Hormonal Synchronisation

The antral follicle count (AFC) is a test in which the number of oocyte-containing follicles that are developing in both ovaries are visually counted. The count of these follicles strongly relates to the population of the growing follicle reserve on the ovaries. However, the importance of the main number of antral follicle populations (mAFC) in mono-ovulatory animal species has yet to be completely elucidated. Moreover, the investigation of the ovarian interrelationship with unilateral mAFC (main number of antral follicle populations appearing on only one side of the ovary) and bilateral mAFC (main number of antral follicle populations appearing in equivalent numbers on both sides of the ovary) and how understanding this interrelationship can offer possible indicators of ovarian response to hormonal induction have not yet been investigated in mono-ovulatory Bos indicus beef cows. The aim of this study is to investigate the different ovarian interrelationships of mAFC (unilateral and bilateral mAFC) at the time of exogenous hormonal stimulation on the total number of AFC (left and right ovaries) at the beginning of the hormonal protocol for ovarian stimulation and ovarian response at the completion of exogenous hormonal stimulation as well as their usefulness as possible biomarkers of successful hormonal stimulation in Bos indicus beef cattle. Beef cows (n = 104) with low total numbers of AFC (4.7 ± 2.4 follicles) were stimulated with a gonadotropin-releasing hormone-progesterone-prostaglandin F2α-based protocol. At the beginning of the hormonal protocol, ovarian ultrasound scans were performed to evaluate AFC from both ovaries of cows. Beef cows were divided into two groups, unilateral (n = 74) and bilateral mAFC (n = 30), according to the ovarian interrelationship. At the completion of the hormonal stimulation, ovarian ultrasound scans were performed to evaluate the dominant follicle (DF) and cows with DF > 8.5 mm in diameter emerging on their ovaries were defined as having experienced a response to hormonal stimuli. There was a difference of 19.1% between Bos indicus cows bearing unilateral mAFC that produced an increase in ovarian response (odds ratio = 2.717, p < 0.05) compared to the responsive rate of cows displaying bilateral mAFC (82.4% vs. 63.3%). In unilateral mAFC, cows bearing mAFC ipsilateral to the ovary of dominant follicle (DF) had a higher responsive rate than cows bearing mAFC contralateral to the DF ovary (50.0% vs. 32.4%, p < 0.05). In mAFC ipsilateral to the DF ovary, pregnancy rates were greatest in cows bearing mAFC and DF on the right ovary compared with cows bearing mAFC and DF on the left ovary (25.0% vs. 9.1%, p < 0.05). In primiparous and multiparous cows, unilateral mAFC occurs with a greater (p < 0.05) frequency than bilateral mAFC (69.0% and 72.0% vs. 31.0% and 28.0%, respectively). In unilateral mAFC, primiparous cows bearing mAFC ipsilateral to the DF ovary had a greater responsive rate than primiparous cows bearing mAFC contralateral to the DF ovary (55.0% vs. 20.0%, p < 0.05). In mAFC ipsilateral to the DF ovary, responsive and pregnancy rates were greatest (p < 0.05) in multiparous cows bearing mAFC and DF on the right ovary compared with multiparous cows bearing mAFC and DF on the left ovary (58.1% and 22.6% vs. 25.8% and 3.2%, respectively). Furthermore, there was a positive correlation between the mean diameter of AFC at the time of the exogenous hormonal trigger and the mean diameter of DF at the completion of hormonal synchronisation (p < 0.05). Our findings emphasise that the ovarian interrelationship with unilateral mAFC at the time of the hormonal trigger might be a promising biomarker for predicting success in ovarian response to hormonal stimulation of mono-ovulatory Bos indicus beef cows with low AFCs.

Oocyte Competence in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age and affects fertility and pregnancy in cases of oligoanovulation. Ovulation induction is often used to treat anovulatory patients with PCOS, but many of these women fail to conceive and resort to assisted reproductive technologies. Alterations in oocyte competence (OC) are considered potential causative factors for subfertility in women with PCOS. In this review we present and critically assess all recent clinical and experimental data regarding OC in women with PCOS. Our analysis demonstrates that the contribution of OC to reproductive potential in women with PCOS varies and largely depends on the PCOS phenotype and comorbidities associated with PCOS.

Ovarian parameters and ovarian blood flow of women living in the area of environmental crisis

BACKGROUND AND OBJECTIVES

Exposure to environmental hazards will destroy a number of ovarian primordial follicles, reduce ovarian reserve and subsequent reproductive ability. This study designed to evaluate ovarian parameters and ovarian blood flow of women living in the area of environmental crisis Shalkar city (Kazakhstan) compared to women living in Aktobe city (Kazakhstan).

PATIENTS AND METHODS

220 women in their reproductive age studied and classified into two groups; study (Shalkar) group and control (Aktobe) group. Blood sample taken from studied women during follicular phase (day 3) for hormonal level evaluation including; follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH). Studied women evaluated using trans-vaginal ultrasound (TVS) to detect antral follicle count (AFC) during follicular scan and ovarian volume (OV), ovarian blood flow (OBF) using pulsatility index (PI) during follicular scan and luteal scan.

RESULTS

Both ovaries AFC was significantly less in study (Shalkar) group compared to and control (Aktobe) group (p=0.0001). Mean ovarian volume was significantly less in Shalkar group in both follicular phase and luteal phase (5.86±0.23 and 6.19±0.22Cm(3); respectively) compared to Aktobe group (6.85±0.19 and 6.92±0.18Cm(3); respectively). In addition, mean ovarian pulsatility index was significantly high with subsequent decrease in ovarian blood flow in Shalkar group in both follicular phase and luteal phase (3.36±0.20 and 3.45±0.19Cm/s; respectively) compared to Aktobe group (2.96±0.16 and 2.92±0.15Cm/s; respectively).

CONCLUSION

This study suggests definite environmental effect on ovarian parameters as indicated by decreased AFC, decreased both follicular and luteal OV and OBF in women living in environmental crisis Shalkar group compared to Aktobe group.

Proteomics of follicular fluid from women with polycystic ovary syndrome suggests molecular defects in follicular development

CONTEXT

Polycystic ovary syndrome (PCOS), a major cause of anovulatory infertility, is characterized by arrested follicular growth. Altered protein levels in the follicular fluid surrounding the ovum may reflect the molecular defects of folliculogenesis in these women.

OBJECTIVE

To identify differentially regulated proteins in PCOS by comparing the follicular fluid protein repertoire of PCOS with healthy women.

METHODS

The follicular fluid samples were collected from PCOS and normo-ovulatory women undergoing in vitro fertilization. Follicular fluid proteins were subjected to digestion using trypsin, and resultant peptides were labeled with isobaric tags for relative and absolute quantification reagents and analyzed by liquid chromatography tandem mass spectrometry. Differential abundance of selected proteins was confirmed by ELISA.

RESULTS

A total of 770 proteins were identified, of which 186 showed differential abundance between controls and women with PCOS. Proteins involved in various processes of follicular development including amphiregulin; heparan sulfate proteoglycan 2; tumor necrosis factor, α-induced protein 6; plasminogen; and lymphatic vessel endothelial hyaluronan receptor 1 were found to be deregulated in PCOS. We also identified a number of new proteins from follicular fluid, whose function in the ovary is not yet clearly established. These include suprabasin; S100 calcium binding protein A7; and helicase with zinc finger 2, transcriptional coactivator.

CONCLUSIONS

Proteins indispensable for follicular growth were found to be differentially expressed in follicular fluid of women with PCOS, which may in part explain the aberrant folliculogenesis observed in these women.

Ovarian stromal vessels assessed by spatiotemporal image correlation-high definition flow in women with polycystic ovary syndrome: a case-control study

OBJECTIVE

To compare spatiotemporal image correlation-high definition flow (STIC-HDF) indices from spherical samples of ovary between women with polycystic ovary syndrome (PCOS) and normal women.

METHODS

This was a prospective case-control study of premenopausal women with a diagnosis of PCOS according to the Rotterdam criteria and of healthy, regularly menstruating, premenopausal women (controls) matched for age (< 35 years) and body mass index. Women were assessed in the follicular phase of the menstrual cycle by 4D STIC-HDF transvaginal ultrasound. Based on 1-cm(3) spherical sampling, we calculated for each woman the vascularization index (VI) for the most vascularized part of the ovarian stroma in all three-dimensional volumes of the 4D STIC-HDF sequence. The maximum (VI(sys)) and minimum (VI(diast)) values were assumed to represent systole and diastole, respectively, and the mean VI for all frames from one cardiac cycle was calculated. Based on these three VI values, we calculated the following indices: volumetric systolic/diastolic ratio (vS/D), volumetric resistance index (vRI) and volumetric pulsatility index (vPI), and compared them between study and control groups.

RESULTS

The study included 32 PCOS women (mean age, 29.6 years) and 32 controls (mean age, 30.4 years). Mean VI(sys) (26.246% vs 8.136%, P < 0.0001) and mean VI(diast) (22.242% vs 5.997%, P < 0.0001) were significantly higher in PCOS women compared with controls. Median vS/D (1.15 vs 1.33, P < 0.001), mean vRI (0.17 vs 0.30, P < 0.001) and median vPI (0.14 vs 0.28, P < 0.001) were significantly lower in PCOS women compared with controls.

CONCLUSION

4D STIC-HDF indices from 1-cm(3) spherical samples of the ovaries were different between PCOS women and controls, suggesting lower impedance to flow in ovarian stromal vessels in PCOS women.

Two- and three-dimensional sonographic and color Doppler techniques for diagnosis of polycystic ovary syndrome. The stromal/ovarian volume ratio as a new diagnostic criterion

OBJECTIVES

The purpose of this work was to study the role of 2-dimensional (2D) and 3-dimensional (3D) sonographic and Doppler techniques in the diagnosis of polycystic ovary syndrome.

METHODS

A total of 112 young adult lean women with polycystic ovary syndrome and 52 healthy volunteers with regular ovulatory cycles, matched for age and body mass index, underwent a detailed history, medical examination, hormonal assay, and 2D and 3D sonographic and Doppler flow ovarian evaluation during the early follicular phase.

RESULTS

The Ferriman-Gallwey score, circulating androgen levels, ovarian volume, and mean number of small subcapsular follicles on 2D and 3D sonography were significantly higher in the patients with polycystic ovary syndrome than the controls (P < .001). A stromal score of 1 or 2 was found in all of the patients but none of the controls. The ovarian stromal/total area ratio was 0.32 or higher in 104 of 112 of the patients (93%), which was significantly higher than in the controls (P < .001). On Doppler analysis, the lowest ovarian stromal resistance levels were found in the patients. On 3D sonography, the total ovarian stromal volume, ovarian stroma/total ovarian volume ratio, and stromal mean grayness were significantly higher in the patients than the controls. With 3D power Doppler imaging, ovarian vascularization measurements were significantly lower in the controls than the patients. The ovarian stroma/total ovarian volume ratio was the most accurate predictor of both hyperandrogenemia (area under the curve, 0.915; P < .0001) and hirsutism (area under the curve, 0.891; P < .0001).

CONCLUSIONS

Our data strongly support the use of 3D sonography with analysis of stromal volume and vascularization in the diagnosis of polycystic ovary syndrome.

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

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

Systemic inflammation, cellular influx and up-regulation of ovarian VCAM-1 expression in a mouse model of polycystic ovary syndrome (PCOS)

PCOS, a major cause of anovulatory sterility, is associated with obesity, insulin resistance and chronic inflammation. New evidence suggests that the immune system aggravates the clinical features of PCOS. Our aim was to study the immune, metabolic and endocrine features of a mouse model of PCOS elicited by androgenisation using dehydroepiandrosterone (DHEA). We observed a significant weight gain and insulin resistance in DHEA-androgenised mice, coupled with the formation of ovarian follicular cysts. DHEA up-regulated the expression of vascular cell adhesion molecule (VCAM)-1 and intercellular adhesion molecule (ICAM)-1 in the granulosa cell layer of the majority of cysts, and VCAM-1 expression in the theca cell layer of all follicles and cysts. The expression of these markers was low in control tissue. Peritoneal cells from PCOS-mice showed enhanced production of inflammatory cytokines, suggesting an association between chronic inflammation and PCOS. In addition, DHEA-androgenisation induced the activation of CD4(+) cells both in vivo and in vitro, and their expression of the respective ligands for VCAM-1 and ICAM-1, VLA-4 and LFA-1, as assessed in vitro. CD4(+) cells were present in androgenised ovaries, especially in the granulosa cell layer of cysts with high VCAM-1 expression. Herein, we present novel evidence that the immune system is activated systemically and locally in a mouse model for PCOS. We propose that VCAM-1 is involved in aggravating PCOS symptoms by promoting leukocyte recruitment to the ovaries and perpetuating local inflammation. These findings offer novel therapeutic opportunities for PCOS, such as blockage of VCAM-1 expression.

Assessment of ovarian vascularization in the polycystic ovary by three-dimensional power Doppler ultrasonography

OBJECTIVE

To assess whether there are differences in ovarian echogenicity and vascularization as assessed by three-dimensional power Doppler angiography (3D-PDA) between women with polycystic ovaries (PCO) and women with normal ovaries (NO).

METHODS

Eighty-three women were classified into two groups according to the 2003 Rotterdam consensus criteria. The NO group comprised women (n = 45) with regular menstrual cycles and proven fertility, whereas the PCO group comprised women (n = 38) with oligo-anovulation, clinical and/or biochemical features of hyperandrogenism, and polycystic ovary morphology at two-dimensional ultrasound. All women were evaluated by means of 3D-PDA. The parameters studied in both groups were follicle number per ovary (FNPO), ovarian volume (OV), mean gray value (MG) and three vascular indices: vascularization index (VI), flow index (FI) and vascularization flow index (VFI).

RESULTS

The PCO group showed a higher mean OV as well as FNPO. No differences in MG, VI, FI and VFI were found between the groups.

CONCLUSIONS

3D-PDA indices are not useful for discriminating between normal and polycystic ovaries.

The role of oxygen in ruminant preimplantation embryo development and metabolism

The long-term effects of in vitro embryo culture on animal health are presently unknown, however, current knowledge directs investigations toward understanding the mechanisms involved in regulating embryo development. In vitro culture is known to have short-term effects, particularly on gene expression and metabolism at the blastocyst stage, while large offspring syndrome is commonly observed following transfer of in vitro produced bovine embryos. Indeed, it is likely that the environment surrounding the early embryo, prior to implantation, may program later development. Regulation of gene expression and metabolism, through gene activation, is mediated by transcription factors, which are themselves controlled by internal and external factors. Alterations in the surrounding environment during preimplantation embryo development, such as that which occurs with inadequate developmental 'support' during in vitro culture, may modify the activation, or inactivation, of several transcription factors, and may therefore have long-term consequences for the developing offspring. In vitro culture deviates from in vivo conditions in many respects, but one of the critical factors that is generally not considered is the oxygen tension under which embryos are cultured. Numerous studies have demonstrated that atmospheric oxygen conditions during culture have detrimental effects on embryo development. While it is generally believed that this arises from the production of reactive oxygen species, this presents an over-simplistic view of the role of oxygen during development. The hypoxia-inducible factor transcription factor family is involved in the responses of cells to alterations in external oxygen concentrations, regulating the expression of numerous genes. Alterations in expression of some of these genes have been highlighted by recent studies in the bovine embryo, implicating oxygen as a regulator of several cellular and metabolic pathways. While it is clear that oxygen plays a role during embryo development, further work to investigate interactions between oxygen and other signaling pathways such as pH and Ca(2+), mitochondria and metabolism is required, as well as exposure of embryos at different time points, to determine the mechanisms that control preimplantation development, the interactions of a range of stimuli and to establish culture procedures that support optimal development and minimize risks to health. This review focuses largely on work undertaken in ruminant models, with brief references to other species.

Assessment of the ovarian volume, number and volume of follicles and ovarian vascularity by three-dimensional ultrasonography and power Doppler angiography on the HCG day to predict the outcome in IVF/ICSI cycles

OBJECTIVE

The aim of this prospective study was to investigate whether ovarian blood flow is related to embryological parameters and whether it could be a predictor of outcomes of IVF/ICSI.

METHODS

Eighty infertile women underwent ovarian stimulation with gonadotrophins after a long protocol with GnRH agonists. The ovarian volume (OV), number of follicles (NF) and follicular volume (FV) of all follicles >10 mm and vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) were obtained by three-dimensional (3D) ultrasonography and power Doppler angiography (PDA) on the day of HCG administration. These parameters were tested for their relation with IVF laboratory parameters.

RESULTS

The OV, FV, VI, FI and VFI were significantly greater in the pregnant group. The NF and FV were the only independent predictors of the number of oocytes retrieved, mature and fertilized, and the number of embryos developed and their cumulative embryo score. Nevertheless, the number of grade 1 embryos depends on the NF and the VI. The ovarian FI and the number of transferred grade 1 embryos can predict gestation in 76% of IVF patients. A low FI and non-grade 1 embryo transferred are also associated with an increased pregnancy loss.

CONCLUSION

3D ultrasonography and PDA allow for an easier ovarian assessment in IVF cycles. The predictive value of IVF outcome suggests a high clinical usefulness of this new technique.

Therapeutic strategies for ovulation induction in infertile women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by hirsutism, obesity, hyperandrogenism and insulin resistance. The syndrome is often accompanied by infertility because of anovulation. Many approaches have been proposed to solve this problem, with the most commonly used therapies being ovarian drilling and pharmacological ovulation induction. Ovarian drilling is a procedure in which a laser fiber or electro-surgical needle punctures the ovary four to ten times. Side-effects are rare and often related to surgery itself. Pharmacological strategies include administration of metformin and insulin-sensitizing agents, clomiphene citrate (CC), gonadotropins and aromatase inhibitors. Metformin appears valuable in increasing ovulation rate, menstrual cyclicity and pregnancy rate. CC is an oral estrogen antagonist that raises circulating concentrations of follicle-stimulating hormone (FSH) and induces follicular growth in most women with PCOS and anovulation. Failure to respond is associated with high body mass index and high androgen levels. Aromatase inhibitors mimic the central reduction of negative feedback through which CC works. Ovulation induction with recombinant FSH has proved successful, but treatment requires skill and experience to avoid multiple pregnancies and ovarian hyperstimulation syndrome. The hypothetical deleterious effects of the high luteinizing hormone concentrations observed in PCOS patients seem to be related to the concomitant hyperinsulinemia (and/or insulin resistance). A thorough understanding of the syndrome and a careful assessment of each patient are the mainstays for choosing an appropriate treatment regimen.