Diagnosis and treatment of diminished ovarian reserve in assisted reproductive technology cycles of women up to age 40 years: the role of insurance mandates

MicroRNA profiling reveals effects of Erzhi Tiangui granules on kidney deficiency diminished ovarian reserve: A randomized trial

BACKGROUND

Diminished ovarian reserve (DOR) is a danger signal of reduced fertility. The clinical incidence is increasing yearly, exhibiting a gradual low-age trend. Traditional Chinese medicine theory suggests that kidney deficiency is the basic pathogenesis. Erzhi Tiangui granules (ETG), a kidney-tonifying prescription, have been clinically shown to improve ovarian reserve function. The purpose of this study was to investigate the microRNA (miRNA) markers of kidney deficiency DOR and the potential mechanism of ETG on in vitro fertilization outcomes in DOR patients.

METHODS

Experiment 1: Granulosa cells from 5 normal ovarian reserves and 5 kidney deficiency DOR patients were subjected to miRNA sequencing. Experiment 2: Eighty DOR patients were randomly divided into treatment and control groups (40 subjects each), then treated with ETG and placebo, respectively. granulosa cells were collected and subjected to quantitative polymerase chain reaction for analyzing the expression of specific miRNA found in experiment 1. We also compared fertilization rates, high-quality embryos, and clinical pregnancy rates between the 2 groups.

RESULTS

miRNA sequencing revealed differential expression of 81 miRNAs, of which 39 were downregulated, specially miR-214-3p and miR-193a-5p, whereas 42 were upregulated, specially let-7e-5p and miR-140-3p. In the second experiment, we found that miR-214-3p was significantly upregulated whereas let-7e-5p and miR-140-3p were significantly downregulated in the treatment group, relative to the control group (P < .05). Patients in the ETG treatment group exhibited a significantly higher fertilization rate than those in the control group (P < .05).

CONCLUSION

ETG significantly increased fertilization rates in DOR patients with kidney deficiency syndrome and affected the expression of miR-214-3p, let-7e-5p, and miR-140-3p, the potential biomarkers.

Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States

BACKGROUND

Previous studies have demonstrated that state mandated coverage of in vitro fertilization may be associated with increased utilization, fewer embryos per transfer, and lower multiple birth rates, but also lower overall live birth rates. Given new legislation and the delay between enactment and effect, a revisit of this analysis is warranted.

OBJECTIVE

This study aimed to characterize the current impact of comprehensive state in vitro fertilization insurance mandates on in vitro fertilization utilization, live birth rates, multiple birth rates, and embryo transfer practices.

STUDY DESIGN

We conducted a retrospective cohort study of in vitro fertilization cycles reported by the 2018 Centers for Disease Control and Prevention Assisted Reproductive Technology Fertility Clinic Success Rates Report in the United States. In vitro fertilization cycles were stratified according to state mandate as follows: comprehensive (providing coverage for in vitro fertilization with minimal restrictions) and noncomprehensive. The United States census estimates for 2018 were used to calculate the number of reproductive-aged women in each state. Outcomes of interest (stratified by state mandate status) included utilization rate of in vitro fertilization per 1000 women aged 25 to 44 years, live birth rate, multiple birth rate, number of embryo transfer procedures (overall and subdivided by fresh vs frozen cycles), and percentage of transfers performed with frozen embryos. Additional subanalyzes were performed with stratification of outcomes by patient age group.

RESULTS

In 2018, 134,997 in vitro fertilization cycles from 456 clinics were reported. Six states had comprehensive mandates; 32,029 and 102,968 cycles were performed in states with and without comprehensive in vitro fertilization mandates, respectively. In vitro fertilization utilization in states with comprehensive mandates was 132% higher than in noncomprehensive states after age adjustment; increased utilization was observed regardless of age stratification. Live birth rate per cycle was significantly higher in states with comprehensive mandates (35.4% vs 33.4%; P<.001), especially among older age groups. Multiple birth rate as a percentage of all births was significantly lower in states with comprehensive mandates (10.2% vs 13.8%; P<.001), especially among younger patients. Mean number of embryos per transfer was significantly lower in states with comprehensive mandates (1.30 vs 1.36; P<.001). Significantly fewer frozen transfers were performed as a percentage of all embryo transfers in states with comprehensive mandates (66.1% vs 76.3%; P<.001). Among fresh embryo transfers, significantly fewer embryos were transferred in comprehensive states among all patients (1.55 vs 1.67; P<.001).

CONCLUSION

Comprehensive state mandated insurance coverage for in vitro fertilization services is associated with greater utilization of these services, fewer embryos per transfer, fewer frozen embryo transfers, lower multiple birth rates, and higher live birth rates. These findings have important public health implications for reproductive-aged individuals in the United States and present notable opportunities for research on access to fertility care.

Effect of acupuncture for diminished ovarian reserve: study protocol for a randomized controlled trial

Background

Diminished ovarian reserve (DOR) is a condition in which the ovary loses its normal reproductive potential, compromising fertility. Although the prevalence and incidence of DOR is increasing, there are currently no effective treatments for this condition. Acupuncture has been reported as an alternative therapy for female infertility. The purpose of this study is to investigate the effect of acupuncture for women with DOR.

Methods/design

In this randomized controlled trial, a total of 120 women with DOR will be randomly assigned to receive either acupuncture or sham acupuncture for 12 weeks. The primary outcome will be determined by the mean change from baseline in the antral follicle count (AFC) at week 12. Secondary outcomes include serum levels of FSH, LH, E2, and AMH, the length of menstrual cycle, and the score of Self-Rating Anxiety Scale (SAS).

Discussion

This study is expected to investigate the effectiveness of acupuncture versus sham acupuncture in improving ovarian reserve for women with DOR.

Trial registration

Acupuncture-Moxibustion Clinical Trial Registry ChiCTR1800014988. Registered on 6 February 2018

Searching for female reproductive aging and longevity biomarkers

Female reproductive aging is, in a way, a biological phenomenon that develops along canonical molecular pathways; however, it has particular features. Recent studies revealed complexity of the interconnections between reproductive aging and aging of other systems, and even suggested a cause-effect uncertainty between them. It was also shown that reproductive aging can impact aging processes in an organism at the level of cells, tissues, organs, and systems. Women at the end of their reproductive lives are characterized by the accelerated incidence of age-related diseases. Timing of the onset of menarche and menopause and variability in the duration of reproductive life carry a latent social risk: not having enough information about the reproductive potential, women keep on postponing childbirth. Identification and use of the most accurate and sensitive aging biomarkers enable the prediction of menopause timing and quantification of the true biological and reproductive ages of an organism. We discuss current views on reproductive aging and peculiarities of using available biomarkers of aging. We also consider latest advances in the search for potential genetic markers of reproductive aging. Finally, we posit the importance of determining the female biological age and highlight potential research directions in this area.

Maternal serum concentration of anti-Müllerian hormone is a better predictor than basal follicle stimulating hormone of successful blastocysts development during IVF treatment

Background

The conditions of diminished ovarian reserve and primary ovarian insufficiency, characterized by poor fertility outcomes, currently comprise a major challenge in reproductive medicine, particularly in vitro fertilization. Currently in the IVF industry, blastocyst developmental success rate per treatment is routinely overlooked when a live birth results from treatment. Limited data are available on this significant and actionable variable of blastocyst development optimization, which contributes to improvement of treatment success Women with elevated basal FSH concentration are reported to still achieve reasonable pregnancy rates, although only a few studies report correlations with blastocysts development. Diagnostic values of AMH/basal FSH concentrations can be useful for determining the optimal stimulation protocol as well as identification of individuals who will not benefit from IVF due to poor prognosis. The objective of this study is to identify actionable clinical and culture characteristics of IVF treatment that influence blastocyst developmental rate, with the goal of acquiring optimal success.

Methods and findings

A retrospective observational study was performed, based on 106 women undergoing IVF, regardless of prognosis, over a six-month period from January 1, 2015 to June 31, 2015. Rate of high-quality blastocyst production, which can be used for embryo transfer or vitrification, per normally fertilized oocyte, was evaluated. Treatment was determined successful when outcome was ≥ 40% high-quality blastocysts. The data were initially evaluated with the Evtree algorithm, a statistical computational analysis which is inspired by natural Darwinian evolution incorporating concepts such as mutation and natural selection (see Supplementary Material). The analysis processes all variables simultaneously against the outcome, aiming to maximize discrimination of each variable to then create a “branch” of the tree which can be used as a decision in treatment. The final model results in only those variables which are significant to outcomes. Generalized linear model (GLM) employing logistic regression and survival analysis with R software was used and the final fitting of the model was determined through the use of random forest and evolutionary tree algorithms. Individuals presenting with an [AMH] of >3.15 ng/ml and a good prognosis had a lower success per treatment (n = 11, 0% success) when total gonadotropin doses were greater than 3325 IU. Individuals that presented with an [AMH] of <1.78 ng/ml and a poor prognosis exhibited a greater success per treatment (n = 11, 80% success). AMH emerged as a superior indicator of blastocyst development compared to basal FSH. The accuracy of the prediction model, our statistical analysis using decision tree, evtree methodology is 86.5% in correctly predicting outcome based on the significant variables. The likelihood that the outcome with be incorrect of the model, or the error rate is 13.5%.

Conclusions

[AMH] is a superior indicator of ovarian stimulation response and an actionable variable for stimulation dose management for optimizing blastocyst development in culture. Women whose [AMH] is ≥3.2 mg/ml, having a good prognosis, and developing >12 mature follicles result in <40% blastocysts when gonadotropin doses exceed 3325 IU per treatment. IVF treatments for poor responders that present with infertility due to diminished ovarian reserve, if managed appropriately, can produce more usable blastocyst per IVF treatment, thus increasing rate of blastocyst developmental success and ultimately increasing live birth rates. Future studies are needed to investigate the intra-follicular and the intra-cellular mechanisms that lead to the inverse relationship of blastocysts development and total gonadotropin doses in good responders in contrast to poor responders.

Limitations and barriers in access to care for male factor infertility

The primary challenge to identifying and addressing barriers in access to care for male factor infertility is accurate measurement of the prevalence of male infertility. Current estimates are based on couples pursuing assisted reproduction, and likely underestimate the problem. These estimates also fail to account for the number of patients facing infertility due to cancer or cancer treatment. Lack of health insurance coverage for the diagnosis and treatment of infertility presents a major barrier for couples struggling with infertility. However, it is not the only barrier. Education level, household income, cultural norms, religious beliefs, geographic location, and the availability of specialty-trained reproductive urologists are all important factors in determining the ease with which patients access and obtain infertility care. Addressing each of these obstacles directly is imperative to improving reproductive care and outcomes for infertile couples in the United States.

The Bologna criteria for poor ovarian response: a contemporary critical appraisal

Postponement of child bearing and maternal age at first pregnancy are on the rise, contributing considerably to an increase in age-related infertility and the demand for assisted reproductive technologies (ART) treatment. This brings to the infertility clinics many women with low ovarian reserve and poor ovarian response (POR) to conventional stimulation. The Bologna criteria were released to standardize the definition of POR and pave the way for the formulation of evidence-based, efficient modalities of treatment for women undergoing IVF-ET. More than four years have passed since the introduction of these criteria and the debate is still ongoing whether a revision is due. Women with POR comprise several sub-groups with diverse baseline distinctiveness, a major issue that has fueled the discussion. Although antral follicle count (AFC) and anti-Müllerian hormone (AMH), are considered good predictors of ovarian reserve, their threshold values are still not universally standardized. Different definitions for sonographic AFC and diverse assays for AMH are held responsible for this delay in standardization. Adding established risk factors to the criteria will lead to more reliable and reproducible definition of a POR, especially in young women. The original criteria did not address the issue of oocyte quality, and the addition of risk factors may yield specific associations with quality vs. quantity. Patient’s age is the best available criterion, although limited, to predict live-birth and presumably oocyte quality. High scale studies to validate these criteria are still missing while recent evidence raises concern regarding over diagnosis.

Diminished ovarian reserve in the United States assisted reproductive technology population: diagnostic trends among 181,536 cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System

OBJECTIVE

To evaluate trends in diminished ovarian reserve (DOR) assignment in the Society for Assisted Reproductive Technology (SART) Clinic Outcomes Reporting System database and to evaluate its accuracy in predicting poor ovarian response (POR) as defined in European Society of Human Reproduction and Embryology's Bologna criteria (2011).

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 181,536 fresh, autologous ART cycles reported to SART by U.S. clinics in 2004 and 2011 (earliest and most recent available reporting years).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

DOR assignment was the primary exposure. POR, defined as cycle cancellation for poor response or less than 4 oocytes retrieved after conventional gonadotropin stimulation (>149 IU FSH daily), was the primary outcome. Secondary outcomes were live birth and number of oocytes retrieved. DOR prevalence, power of DOR and FSH (</≥12 mIU/mL) to predict POR, and live birth in POR cycles were also calculated.

RESULT(S)

DOR prevalence increased from 19% to 26% from 2004 to 2011. Among cycles clinically assigned as DOR, incidence of POR decreased from 32% to 30%, and live birth improved from 15% to 17%. Comparing basal FSH ≥12 versus clinical assignment of DOR, basal FSH had a higher specificity (92.2% vs. 81.6%) and positive predictive value (38.3% vs. 30.9%) for predicting POR. Live birth among POR cycles was 4%.

CONCLUSION(S)

DOR diagnosis is increasing, and accuracy remains poor, despite the availability of additional diagnostic parameters such as antral follicle count and antimüllerian hormone. POR entailed poor outcomes, but the majority of patients clinically assigned as DOR did not experience POR. Development and use of more accurate predictors of POR are needed to minimize patient distress resulting from overdiagnosis.

Assisted hatching and intracytoplasmic sperm injection are not associated with improved outcomes in assisted reproduction cycles for diminished ovarian reserve: an analysis of cycles in the United States from 2004 to 2011

OBJECTIVE

To investigate the impact of intracytoplasmic sperm injection (ICSI) and assisted hatching (AH) on assisted reproductive technology (ART) outcomes in initial cycles with diminished ovarian reserve (DOR) as the primary diagnosis.

DESIGN

Retrospective cohort study of cycles from the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System database.

SETTING

Not applicable.

PATIENT(S)

A total of 422,949 fresh, nondonor, initial ART cycles of which 8,597 were diagnosed with only elevated FSH and 38,926 were diagnosed with only DOR according to the SART DOR categorization.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth and clinical pregnancy rates.

RESULT(S)

ICSI and AH were associated with diminished odds of live birth in SART DOR-only cycles (adjusted odds ratio [AOR] 0.88, 95% confidence interval [CI] 0.81-0.96 for ICSI; AOR 0.77, 95% CI 0.71-0.84 for AH). No association between odds of live birth and either ICSI or AH in elevated FSH-only cycles was observed. The combination of ICSI and AH was associated with significantly lower odds of live birth in SART DOR-only cycles but not in elevated FSH-only cycles.

CONCLUSION(S)

In initial ART cycles for which the only indication relates to a diagnosis of DOR, AH and ICSI are not associated with improved live birth rates.

Systematic evaluation of the quality of clinical practice guidelines on the use of assisted reproductive techniques

OBJECTIVE

To conduct a systematic evaluation of clinical practice guidelines (CPGs) on the use of assisted reproductive technologies.

METHODS

We searched Medline, the Turning Research into Practice database, and guidelines-specific databases from December 2006 to November 2011. Three reviewers independently assessed each Guideline using the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument. A standardized score was calculated separately for each of the six domains.

RESULTS

Fourteen Guidelines were included. Overall, the quality of these was suboptimal. The scores for each AGREE II domain ranged between 37% and 80%. Three (22%) were deemed "Recommended"; nine (64%),"Recommended with modifications"; and two (14%), "Not recommended". Agreement among reviewers was very good (Intraclass Correlation Coefficient: 0.915 [95% CI 0.807-0.970]).

CONCLUSIONS

The overall quality of the CPGs on Assisted Reproduction Techniques published during the last 5 years is suboptimal. Most Guidelines present significant shortcomings in important domains such as "stakeholder involvement", "rigor of development", and "applicability". Instruments such as the AGREE II and "the Grading of Recommendation Assessment Development and Evaluation" system could prove useful to improve CPGs in this field. Guideline users could benefit from the present results when choosing which guidelines to implement.