Practice Committee of the American Society for Reproductive Medicine. Optimal evaluation of the infertile female

Is There Still a Place for Reconstructive Surgery in Distal Tubal Disease?

Tubal diseases account for 25–40% of female factor infertility. Mainly, they involve the distal part of the fallopian tube, and hydrosalpinx is the most severe manifestation. Usually, the management decision is made between reconstructive surgery and ART, depending on the severity of the tubal damage, patient age, ovarian reserve, and seminogram, as well as financial, religious, ethical, and psychological factors. Estimated live-birth rates after corrective surgery range from 9% to 69%. The success rate of IVF is about 30% live-birth rate per cycle initiated in women across all ages with tubal factor infertility. Surgery offers a long-term cure and patients may attempt conception many times but are burdened with perioperative adverse events. IVF bypasses potential complications of operative treatment; however, this has its own unique risks. The effectiveness of reconstructive surgery versus ART has not been adequately evaluated. The success of fertility management depends on a thorough interpretation of existing data and careful patient selection. The presented review provides updates on the most recent progress in this area.

Assisted Reproductive Technology Treatment, the Catalyst to Amplify the Effect of Maternal Infertility on Preterm Birth

OBJECTIVE

To identify the influence of different infertility causes and assisted reproductive technology (ART) treatment on perinatal outcomes and clarify the relationship between the maternal pathophysiological changes and artificial interventions.

METHODS

A total of 1,629 fertile women and 27,112 infertile women with sole infertility causes were prospectively recruited from July 2014 to December 2017, and 9,894 singletons were finally enrolled into the study. Pregnancies with more than one cause of infertility and/or multiple births were excluded. According to the causes of infertility and the exposure of ART treatment, the participants were divided into four groups, namely, fertile naturally conceived (NC) group, infertile NC group, female factor ART group, and male factor ART group. Perinatal outcomes, including gestational age of delivery (GA), birth weight (BW), preterm birth (PTB), low birth weight (LBW), small for gestational age (SGA), and large for gestational age (LGA), were compared among groups. Logistic regression was performed for the adjustment of several covariates.

RESULTS

The birth outcomes of the infertile NC group and fertile NC group, female factor ART group, and infertile NC group were comparable. Compared to the fertile NC group, the female factor ART group had a shorter GA (39.0 ± 1.6 vs. 39.3 ± 1.5 weeks, BW: P < 0.05). An interaction test showed that ART treatment had an interaction on the effect of female infertility on GA (P = 0.023). The female factor ART group also had a higher risk of PTB (OR 1.56, 95% CI 1.18-2.07) and LGA (OR 1.27, 95% CI 1.10-1.47) compared to the fertile NC group. The risk of PTB was increased for tubal factor ART (OR 1.49, 95% CI 1.12-2.00), ovulatory dysfunction ART (OR 1.87, 95% CI 1.29-2.72), and unexplained infertility ART (OR 1.88, 95% CI 1.11-3.17). The risk of LGA was increased for tubal factor ART (OR 1.28, 95% CI 1.11-1.48) and ovulatory dysfunction ART (OR 1.27, 95% CI 1.03-1.57).

CONCLUSIONS

Our findings indicated that ART treatment could amplify the adverse effect of female infertility on neonates. Women with tubal factor infertility, ovulatory dysfunction, and unexplained infertility have a higher risk of PTB after ART treatment. Thus, clinicians should be vigilant in such patients and provide corresponding prevention strategies before and during pregnancy.

Effect of BMI on blood value of patients on HCG day with IUI treatment

BACKGROUND

This study aims to analyze the effect of the body mass index (BMI) on E₂, P and LH values in females who received intrauterine insemination (IUI) treatment on human chorionic gonadotropin (HCG) day.

METHODS

A total of 2319 cycles of IUI-assisted pregnancy treatment were selected in our hospital. Based on the BMI, female infertility patients are divided into three groups: normal weight group, overweight and obese group.

RESULTS

For patients with natural cycles and ≤ 35 years old, there were 440, 178 and 197 cases in the three groups, respectively. For patients with natural cycles and > 35 years old, there were 90, 83 and 81 cycles in the three groups, respectively. For patients with induced ovulation cycle and ≤ 35 years old, there were 425, 203 and 516 cases in the three groups, respectively. For patients with induced ovulation cycle and > 35 years old, there were 26, 26 and 54 cases in the three groups, respectively.

CONCLUSION

When a patient is ≤35 years old, the BMI affects the E₂, LH and P values on the day of artificial insemination. However, the BMI is negatively correlated with E₂, LH and P in IUI on HCG day. After controlling for age and assisted pregnancy, the correlation analysis revealed that the BMI is negatively correlated with hormone E₂ and LH. The higher the BMI was, the lower the levels of hormones E₂, LH and P became. However, in the present study, the BMI did not significantly improve the clinical pregnancy rate of patients who received IUI.

Physical endometrial manipulation and its impact on success rate and live birth rate in ICSI in patients with unexplained infertility after recurrent ICSI failure, a double blinded randomized controlled trial

Background: Unexplained infertility is a rising problem and endometrial manipulation could be one of the solutions for enhancing the pregnancy rate and live birth rate in such circumstances.Aims: To evaluate the influence of local endometrial physical manipulation with specializd method for endometrial and tubal hydration (Elgazzar and Alalfy technique) on ICSI outcome and in increasing chemical, clinical, and live birth rate in ICSI after previous recurrent ICSI failure in patients with unexplained infertility.Results: When comparing group 1 (hydrotubation group) and group 2 (the control group with no intervention) with regards to the biochemical, clinical, and live birth rate, the hydrotubation group revealed higher rates and a better ICSI outcome.Conclusion: Hydrotubation is useful in increasing biochemical, clinical, and live birth rates after recurrent failed ICSI trials with a specialized method for hydration of endometrium and tubes (Elgazzar and Alalfy technique).

Insurance coverage of male infertility: what should the standard be?

Infertility is a disease, and the male partner plays a role in approximately 50% of infertility cases. For most patients, infertility care does not receive insurance coverage like other diseases, leaving them to pay out of pocket for their treatments. Because of the lack of insurance coverage, evaluations and treatments are expensive for patients, with costs often approaching the median annual US income. These increased costs reduce access to care and limit the ability to diagnose the cause of infertility, treat the underlying causes, and downgrade the intensity of the intervention needed to achieve the pregnancy. This leaves much of the burden for infertility care on the female partner. In an ideal health care system, evaluations and interventions for male infertility would receive the same insurance coverage as evaluations and interventions for other diseases.

Lower FOXO3 mRNA expression in granulosa cells is involved in unexplained infertility

AIM

The aim of this study was to investigate whether FOXO1 and FOXO3 mRNA expression in granulosa cells is the cause of unexplained infertility.

METHODS

Thirty-one patients aged <40 years (13 with unexplained infertility and 18 with male partner infertility as a control group) whose serum anti-Müllerian hormone level was >0.5 ng/μL were enrolled in the study. All patients underwent oocyte retrieval under a short protocol from June 2012 to October 2013. Real-time PCR was carried out using mRNA extracted from granulosa cells retrieved from mature follicles. We compared FOXO1 and FOXO3 mRNA expression ratios in granulosa cells between the unexplained infertility group and the male infertility group. The relation between FOXO1 and FOXO3 mRNA expression ratios in granulosa cells and assisted reproduction technology clinical outcome was also examined.

RESULTS

FOXO3 mRNA expression ratio was significantly lower in the unexplained infertility group than in the male infertility group. Moreover, FOXO3 mRNA expression ratio showed a positive correlation with both the number of retrieved oocytes and serum anti-Müllerian hormone level. A positive correlation was also identified between FOXO1 mRNA expression and total dose of hMG. As well, the number of retrieved oocytes in the unexplained infertility group was statistically lower than that in the male infertility group.

CONCLUSION

A lower FOXO3 mRNA expression in granulosa cells leads to poor oocyte development in patients with unexplained infertility undergoing controlled ovarian stimulation for in vitro fertilization-embryo transfer.

Hysterosalpingo-foam sonography: patient selection and perspectives

We present an overview of the common types of tubal patency tests, with a focus on hysterosalpingo-foam sonography (HyFoSy). Current evidence suggests that HyFoSy is an accurate alternative to X-ray hysterosalpingography (HSG) for outpatient tubal evaluation in women who are at low risk for tubal disease. It may be superior to saline hysterosalpingo-contrast sonography (HyCoSy) in excluding tubal occlusion. A hyperechogenic medium may enhance contrast visualization and enable clearer delineation of tubal anatomy. This may enhance confidence in the diagnosis of tubal patency, reduce false occlusion results, and improve the diagnostic yield of the test. It would be reasonable to deduce that HyFoSy would have similar performance characteristics as HyCoSy with other positive contrast agents. The available evidence supports the accuracy of HyFoSy compared to other forms of tubal investigation. We suggest a decision-making pathway based on the most current professional recommendations and available evidence. However, in this article, we do not provide a definitive exposition of the methods used for investigating tubal patency. Rather, we explore the contexts in which the various investigations are most and least suitable, and identify their strengths and limitations. Finally, we also discuss challenges encountered when performing tubal contrast sonography in clinical practice, including the problem of false occlusion results.

What is the contribution of embryo-endometrial asynchrony to implantation failure?

PURPOSE

The synchronized development of a viable embryo and a receptive endometrium is critical for successful implantation to take place. The aim of this paper is to review current thinking about the importance of embryo-endometrial synchrony in in vitro fertilization (IVF).

METHODS

Detailed review of the literature on embryo-endometrial synchrony.

RESULTS

By convention, the time when the blastocyst first attaches and starts to invade into the endometrium has been defined as the 'window of implantation'. The term window of implantation can be misleading when it is used to imply that there is a single critical window in time that determines whether implantation will be successful or not. Embryo maturation and endometrial development are two independent continuous processes. Implantation occurs when the two tissues fuse and pregnancy is established. A key concept in understanding this event is developmental 'synchrony', defined as when the early embryo and the uterus are both developing at the same rate such that they will be ready to commence and successfully continue implantation at the same time. Many different events, including controlled ovarian hyperstimulation as routinely used in IVF, can potentially disrupt embryo-endometrial synchrony. There is some evidence in humans that implantation rates are significantly reduced when embryo-endometrial development asynchrony is greater than 3 days (±1.5 days).

CONCLUSIONS

Embryo-endometrial synchrony is critical for successful implantation. There is an unmet need for improved precision in the evaluation of endometrial development to permit better synchronization of the embryo and the endometrium prior to implantation.

Endometrial BCL6 Overexpression in Eutopic Endometrium of Women With Endometriosis

The objective of this study was to examine B-cell CLL/lymphoma 6 (BCL6) expression in human eutopic endometrium across the menstrual cycle in women with and without endometriosis and to establish a cutoff for future studies. This design was a series of case-control studies in tertiary University teaching hospitals. We examined BCL6 expression by messenger RNA and immunohistochemically in prospectively collected samples in both the proliferative (P) and the secretory phases. BCL6 is minimally increased in the mid-secretory phase of the menstrual cycle compared to the P phase in normal patients. BCL6 protein expression was significantly higher in the secretory phase of patients with endometriosis (n = 29) versus fertile controls without endometriosis at laparoscopy (n = 20; P < .0001). Normal fertile controls (n = 28) recruited for endometrial biopsy also had low levels of secretory phase BCL6 expression compared to women with unexplained infertility (UI; n = 119). A receiving-operator characteristic analysis of these data revealed an area under the curve of 94% (95% confidence interval 85%-100%; P < .0001) with an HSCORE cutoff of 1.4 to differentiate cases with and without endometriosis. Using this cutoff value, BCL6 was positive in 88% of cases with UI. Laparoscopic examination of a subset of 65 patients confirmed abnormalities in 98% of cases; 61 (93.8%) were found to have endometriosis, 3 (4.6%) with hydrosalpinx, and 1 (1.5%) with a normal pelvis. These data suggest that BCL6 is a promising candidate as a single diagnostic biomarker for detection of endometriosis in women with otherwise UI and may be associated with endometrial dysfunction, including progesterone resistance.

Comparison of Uterine Receptivity between Fertile and Unexplained Infertile Women by Assessment of Endometrial and Subendometrial Perfusion Using Contrast-Enhanced Ultrasound: Which Index is Better--Peak Intensity or Area under the Curve?

The goal of this study was to compare uterine receptivity between women with normal fertility and those with unexplained infertility during natural cycles by assessment of endometrial and subendometrial perfusion using contrast-enhanced ultrasound (CEUS). We wanted to determine the better index: peak intensity (PI) or area under the curve (AUC). Thirty women with unexplained infertility were recruited into the study group, and 30 women with normal fertility were recruited into the control group. All women underwent CEUS during the late proliferative phase, ovulation phase, and implantation window of a menstrual cycle. Endometrial PI, endometrial AUC, subendometrial PI and subendometrial AUC were analyzed. In the late proliferative phase, the control group had a significantly higher endometrial PI (p < 0.001) as well as subendometrial PI (p < 0.001) and AUC (p = 0.004) than the study group. In the ovulation phase, the control group had a significantly higher endometrial PI (p < 0.001) and AUC (p = 0.021), as well as subendometrial PI (p < 0.001) and AUC (p = 0.003). During the implantation window, there were no significant differences between the two groups. Only subendometrial PI underwent a significant periodic change during the menstrual cycle in both groups. This finding was further confirmed by evaluation of the microvessel density of endometria. In conclusion, CEUS can be used to assess endometrial and subendometrial perfusion to evaluate uterine receptivity. Subendometrial PI was the most sensitive index compared with endometrial PI, endometrial AUC and subendometrial AUC.

Exposure to bisphenol A in young adult mice does not alter ovulation but does alter the fertilization ability of oocytes

Follicle growth culminates in ovulation, which allows for the expulsion of fertilizable oocytes and the formation of corpora lutea. Bisphenol A (BPA) is present in many consumer products, and it has been suggested that BPA impairs ovulation; however, the underlying mechanisms are unknown. Therefore, this study first evaluated whether BPA alters ovulation by affecting folliculogenesis, the number of corpora lutea or eggs shed to the oviduct, ovarian gonadotropin responsiveness, hormone levels, and estrous cyclicity. Because it has been suggested (but not directly confirmed) that BPA exerts toxic effects on the fertilization ability of oocytes, a second aim was to evaluate whether BPA impacts the oocyte fertilization rate using an in vitro fertilization assay and mating. The possible effects on early zygote development were also examined. Young adult female C57BL/6J mice (39 days old) were orally dosed with corn oil (vehicle) or 50 μg/kgbw/day BPA for a period encompassing the first three reproductive cycles (12-15 days). BPA exposure did not alter any parameters related to ovulation. Moreover, BPA exposure reduced the percentage of fertilized oocytes after either in vitro fertilization or mating, but it did not alter the zygotic stages. The data indicate that exposure to the reference dose of BPA does not impact ovulation but that it does influence the oocyte quality in terms of its fertilization ability.

Paternal Urinary Concentrations of Parabens and Other Phenols in Relation to Reproductive Outcomes among Couples from a Fertility Clinic

BACKGROUND

Human exposure to phenols, including bisphenol A and parabens, is widespread. Evidence suggests that paternal exposure to environmental chemicals may adversely affect reproductive outcomes.

OBJECTIVES

We evaluated associations of paternal phenol urinary concentrations with fertilization rate, embryo quality, implantation, and live birth.

METHODS

Male-female couples who underwent in vitro fertilization (IVF) and/or intrauterine insemination (IUI) cycles in a prospective study of environmental determinants of fertility and pregnancy outcomes were included. The geometric mean of males' specific gravity-adjusted urinary phenol concentrations measured before females' cycle was quantified. Associations between male urinary phenol concentrations and fertilization rate, embryo quality, implantation, and live birth were investigated using generalized linear mixed models to account for multiple cycles per couple.

RESULTS

Couples (n = 218) underwent 195 IUI and 211 IVF cycles. Paternal phenol concentrations were not associated with fertilization or live birth following IVF. In adjusted models, compared with the lowest quartile of methyl paraben, paternal concentrations in the second quartile were associated with decreased odds of live birth following IUI (adjusted odds ratio = 0.19; 95% CI: 0.04, 0.82).

CONCLUSIONS

To our knowledge, these are some of the first data on the association of paternal urinary phenol concentrations with reproduction and pregnancy outcomes. Although these results do not preclude possible adverse effects of paternal paraben exposures on such outcomes, given the modest sample size, further understanding could result from confirmation using a larger and more diverse population.

Chinese herbal medicine for infertility with anovulation: a systematic review

The aim of this systematic review is to assess the effectiveness and safety of Chinese herbal medicine (CHM) in treatment of anovulation and infertility in women. Eight (8) databases were extensively retrieved. The Chinese electronic databases included VIP Information, CMCC, and CNKI. The English electronic databases included AMED, CINAHL, Cochrane Library, Embase, and MEDLINE(®). Randomized controlled trials using CHM as intervention were included in the study selection. The quality of studies was assessed by the Jadad scale and the criteria referred to Cochrane reviewers' handbook. The efficacy of CHM treatment for infertility with anovulation was evaluated by meta-analysis. There were 692 articles retrieved according to the search strategy, and 1659 participants were involved in the 15 studies that satisfied the selection criteria. All the included trials were done in China. Meta-analysis indicated that CHM significantly increased the pregnancy rate (odds ratio [OR] 3.12, 95% confidence interval [CI] 2.50-3.88) and reduced the miscarriage rate (OR 0.2, 95% CI 0.10-0.41) compared to clomiphene. In addition, CHM also increased the ovulation rate (OR 1.55, 95% CI 1.06-2.25) and improved the cervical mucus score (OR 3.82, 95% CI 1.78-8.21) compared to clomiphene, while there were no significant difference between CHM and clomiphene combined with other medicine. CHM is effective in treating infertility with anovulation. Also, no significant adverse effects were identified for the use of CHM from the studies included in this review. However, owing to the low quality of the studies investigated, more randomized controlled trials are needed before evidence-based recommendation regarding the effectiveness and safety of CHM in the management of infertility with anovulation can be provided.

Unexplained infertility: association with inherited thrombophilia

INTRODUCTION

Unexplained infertility represents one of the most common diagnoses in fertility care. Attention is being paid to the association between inherited thrombophilia and infertility causes. In this study we investigated the prevalence of inherited thrombophilia according to infertility causes.

MATERIALS AND METHODS

We studied Prothrombin gene G20210A mutation, Factor V Leiden, deficiencies in protein S and C and antithrombin in 930 Caucasian infertile women referred to Fertility Center of the Department of Sciences for Woman and Child's Health, University of Florence, of whom 230 with unexplained, 195 female and 283 male infertility, and in 240 women who have conceived naturally without hormonal stimulation therapy.

RESULTS

A significant relationship between inherited thrombophilia [OR 95%CI 1.97 (1.05-3.68), p = 0.03] and unexplained infertility was observed, whereas no association between thrombophilia and female and male infertility was found. Significantly higher prevalence of prothrombin gene mutation in unexplained infertile women in comparison to that observed in fertile women was observed (5.7% vs 2.1% p = 0.04); the prevalence of the other thrombophilia determinants was higher, even if not significantly, in the unexplained infertile group.

CONCLUSIONS

This study demonstrates the relationship between inherited thrombophilia and unexplained infertility, thus suggesting the contribution of genetic components in modulating unexplained infertility, behind anovulation, male and tubal factor.

Role of laparohysteroscopy in women with normal pelvic imaging and failed ovulation stimulation with intrauterine insemination

CONTEXT:

Women with primary infertility and no obvious pelvic pathology on clinical evaluation and imaging are either treated empirically or further investigated by laparoscopy.

AIMS:

The role of diagnostic laparoscopy in women who fail to conceive after empirical treatment with ovulation induction and intrauterine insemination was evaluated.

SETTINGS AND DESIGN:

Retrospective study at a private infertility center.

MATERIALS AND METHODS:

A study of patients who underwent diagnostic laparoscopy between 1^st January 2001 and 31^st December 2008 was performed. Those patients who had no detectable pathology based on history, physical examination, and ultrasound and had treatment for three or more cycles in the form of ovulation induction and IUI were included in the study. Moderate and severe male factor infertility and history of any previous surgery were exclusion criteria.

STATISTICAL ANALYSIS USED:

Data were statistically analyzed using Statistics Package for Social Sciences (ver. 16.0; SPSS Inc., Chicago).

RESULTS:

Of the 127 women who underwent diagnostic laparoscopy and hysteroscopy, 87.4% (n = 111) of patients had positive findings. Significant pelvic pathology (moderate endometriosis, pelvic inflammatory disease, and tubal pathology) was seen in 26.8% of cases.

CONCLUSION:

One in four women had significant pelvic pathology where treatment could possibly improve future fertility. Diagnostic laparoscopy has a role in infertile women with no obvious abnormality before they proceed to more aggressive treatments.

Anti-Helicobacter pylori antibodies in cervical mucus: a new cause of infertility

OBJECTIVE

The aims of our study were to determine on the one hand a correlation between the presence of anti-Helicobacter pylori (anti-H. pylori) IgG antibodies in serum and cervical mucus of women with idiopathic infertility, and on the other hand the effect of these antibodies on cervical mucus quality, in particular related to the ability of spermatozoa to penetrate it.

STUDY DESIGN

We analysed anti-H. pylori IgG antibodies in the serum and cervical mucus of 67 patients diagnosed with idiopathic infertility using the Quanta Lite H. pylori IgG test. The penetration of normal sperm, in 15 cervical mucus samples positive for anti-H. pylori antibodies and in 15 negative samples, was assessed using the simplified slide test.

RESULTS

A significant positive correlation emerged between anti-H. pylori IgG antibody concentrations in the serum and in the cervical mucus (r=0.9275; p<0.00001). In the 15 anti-H. pylori IgG mucus-positive samples the slide test showed abnormal penetration by the spermatozoa.

CONCLUSIONS

Our study demonstrated that the presence of anti-H. pylori antibody in the cervical mucus can be involved in female infertility, interfering with sperm progression. Considering the close correlation found between serum and cervical mucus anti-H. pylori antibody titres, measuring serum antibodies could become an additional test, in particular in couples with unexplained infertility.

Association study of AMH and AMHRII polymorphisms with unexplained infertility

OBJECTIVE

To investigate the association of AMH and AMHRII polymorphisms with reproductive abilities in a sample of women with idiopathic infertility.

DESIGN

Case-control study.

SETTING

University Department of Obstetrics and Gynecology, and University Unit of Clinical Genetics.

PATIENT(S)

76 women with idiopathic sterility and 100 fertile women as controls.

INTERVENTION(S)

Genotyping was performed by high-resolution melt analysis.

MAIN OUTCOME MEASURE(S)

Genotype distribution and allele frequency of AMH and AMHRII polymorphisms. Reconstruction of haplotype alleles to evaluate the linkage disequilibrium between single nucleotide polymorphisms.

RESULT(S)

Allele frequencies of -482 A>G, IVS 5-6 C>T, IVS 10+77 A>G, 146T>G polymorphisms are statistically significantly different in infertile patients compared with controls.

CONCLUSION(S)

Genetic variants of AMH and AMHRII genes seem to be associated with infertility, suggesting a role in the pathophysiology of normo-estrogenic and normo-ovulatory infertility. A clearer understanding of their function in ovarian physiology may help clinicians to find a role for antimüllerian hormone measurement in the field of reproductive medicine.

Endometrial claudin-4 and leukemia inhibitory factor are associated with assisted reproduction outcome

BACKGROUND

Claudin-4 (CLDN4) is one of several proteins that act as molecular mediators of embryo implantation. Recently, we examined immunolabeling of leukemia inhibitory factor (LIF) in the endometrial tissue of 52 IVF patients, and found that LIF staining intensity was strongly correlated with successful pregnancy initiation. In the same set of patients, we have now examined endometrial CLDN4 expression, to see how expression intensity may vary with LIF. We examined CLDN4 in the luteal phase of the menstrual cycle, immediately preceding IVF treatment. Our aim was to compare expression of LIF and CLDN4 in the luteal phase, and document these patterns as putative biomarkers for pregnancy.

METHODS

Endometrial tissue was collected from women undergoing IVF. Endometrial biopsies were obtained during the luteal phase preceding IVF, and were then used for tissue microarray (TMA) immunolabeling of CLDN4. Previously published LIF expression data were then combined with CLDN4 expression data, to determine CLDN4/LIF expression patterns. Associations between successful pregnancy after IVF and combined CLDN4/LIF expression patterns were evaluated.

RESULTS

Four patterns of immunolabeling were observed in the endometrial samples: 16% showed weak CLDN4 and strong LIF (CLDN4-/LIF+); 20% showed strong CLDN4 and strong LIF (LIF+/CLDN4+); 28% showed strong CLDN4 and weak LIF (CLDN4+/LIF-); and 36% showed weak CLDN4 and weak LIF (CLDN4-/LIF-). Successful implantation after IVF was associated with CLDN4-/LIF+(p = 0.003). Patients showing this endometrial CLDN4-/LIF+ immunolabeling were also 6 times more likely to achieve pregnancy than patients with endometrial CLDN4+/LIF- immunolabeling (p = 0.007).

CONCLUSION

The combined immunolabeling expression of CLDN4-/LIF+ in endometrial tissue is a potential biomarker for predicting successful pregnancy in IVF candidates.

Decreased sperm motility is associated with air pollution in Salt Lake City

OBJECTIVE

To study the correlation between indices of air pollution and sperm parameters.

DESIGN

Ecological study.

SETTING

Contained geographic area.

PATIENT(S)

Resident men presenting for semen analysis or artificial insemination.

INTERVENTION(S)

Analysis of levels of particulate air pollution (particulate matter [PM] 2.5) over a five-year period in relation to sperm parameters obtained from semen analyses and separately in relation to sequences of sperm parameters at the time of semen preparations for artificial insemination. To account for the duration of spermatogenesis (72 days), "corrected" variables were created by shifting backward 1, 2, 3 and 4 months each of the semen parameters. The final analysis corrected for season of the year and current temperature.

MAIN OUTCOME MEASURE(S)

Sperm concentration, sperm motility and sperm morphology.

RESULT(S)

The study included 1,699 semen analyses and 877 inseminations. PM 2.5 levels were highest in the winter months, when the ambient temperature was the lowest. Semen analysis data showed that values of PM 2.5 were negatively correlated to sperm motility two months and three months following the recording of the PM 2.5 values. Artificial insemination data also showed that sperm motility correlated negatively with PM 2.5 values recorded three months previously.

CONCLUSION(S)

Both semen analysis and sperm parameters data obtained from men presenting for multiple inseminations over time showed that air pollution is associated with reduced sperm motility two to three month after exposure.

Diagnostic criteria for polycystic ovary syndrome: pitfalls and controversies

It is estimated that as many as 1.4 million Canadian women may be afflicted with polycystic ovary syndrome (PCOS). Although PCOS is heralded as one of the most common endocrine disorders occurring in women, its diagnosis, management, and associated long-term health risks remain controversial. Historically, the combination of androgen excess and anovulation has been considered the hallmark of PCOS. To date, while these symptoms remain the most prevalent among PCOS patients, neither is considered an absolute requisite for the syndrome. Inclusion of ultrasonographic evidence of polycystic ovaries as a diagnostic marker has substantially broadened the phenotypic spectrum of PCOS, yet much debate surrounds the validity of these newly identified milder variants of the syndrome. Difficulty in resolving the spectrum of PCOS stems from the continued use of inconsistent and inaccurate methods of evaluating androgen excess, anovulation, and polycystic ovaries on ultrasound. At present, there is no clear-cut definition of biochemical hyperandrogenemia, particularly since we depend on poor laboratory standards for measuring androgens in women. Clinical signs of hyperandrogenism are ill-defined in women with PCOS, and the diagnosis of both hirsutism and polycystic ovarian morphology remains alarmingly subjective. Lastly, there is an inappropriate tendency to assign ovulatory status solely on the basis of menstrual cycle history or poorly timed endocrine measurements. In this review, we elaborate on these limitations and propose possible resolutions for clinical and research settings. By stimulating awareness of these limitations, we hope to generate a dialogue aimed at solidifying the evaluation of PCOS in Canadian women.

Correlation of antimüllerian hormone and baseline follicle-stimulating hormone levels

OBJECTIVE

To compare how a given level of antimüllerian hormone (AMH) might be used to predict the level of FSH.

DESIGN

Retrospective cohort study.

SETTING

Academically affiliated private fertility center.

PATIENT(S)

Eighty-one women in preparation for an IVF cycle.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of FSH and AMH before start of ovulation induction.

RESULT(S)

Serum AMH and log-converted FSH levels were negatively correlated (R(2) = 0.42). The linear regression model for FSH, based on random AMH, was as follows: LnFSH = 2.3 + -0.25 x lnAMH; 95% confidence limits of the coefficient 0.-32 to 0.-18, suggesting that an AMH level of 0.5 ng/mL is predictive of a baseline FSH level of 12.1 mIU/mL (95% confidence interval 11.4-12.7 mIU/mL).

CONCLUSION(S)

These data demonstrate a statistical association between FSH and AMH in assessing ovarian reserve. Using FSH and AMH in combination may improve the evaluation of ovarian reserve. However, it remains to be determined which of these two ovarian function parameters is superior in assessing ovarian reserve with a single test and which test, or combination of tests, will in the future be used in routine infertility evaluations.