A low number of retrieved oocytes at in vitro fertilization treatment is predictive of early menopause

BCORL1, POF1B, and USP9X copy number variation in women with idiopathic diminished ovarian reserve

PURPOSE

To analyze the copy number variation (CNV) in the X-linked genes BCORL1, POF1B, and USP9X in idiopathic diminished ovarian reserve (DOR).

METHODS

This case-control study included 47 women, 26 with DOR and 21 in the control group. Age, weight, height, BMI, and FSH level were evaluated, as well as antral follicle count (AFC), oocyte retrieval after controlled ovarian stimulation, and metaphase II (MII) oocytes. The CNVs of BCORL1, USP9X, and POF1B genes were measured by quantitative real time PCR (qPCR) using two reference genes, the HPRT1 (X-linked) and MFN2 (autosomal). Protein-protein interaction network and functional enrichment analysis were performed using the STRING database.

RESULTS

The mean age was 36.52 ± 4.75 in DOR women and 35.38 ± 4.14 in control. Anthropometric measures did not differ between the DOR and control groups. DOR women presented higher FSH (p = 0.0025) and lower AFC (p < .0001), oocyte retrieval after COS (p = 0.0004), and MII oocytes (p < .0001) when compared to the control group. BCORL1 and POF1B did not differ in copy number between DOR and control. However, DOR women had more copies of USP9X than the control group (p = 0.028).

CONCLUSION

The increase in the number of copies of the USP9X gene may lead to overexpression in idiopathic DOR and contribute to altered folliculogenesis and oocyte retrieval.

Ovarian aging in humans: potential strategies for extending reproductive lifespan

Ovarian reserve is a term used to estimate the total number of immature follicles present in the ovaries. Between birth and menopause, there is a progressive decrease in the number of ovarian follicles. Ovarian aging is a continuous physiological phenomenon, with menopause being the clinical mark of the end of ovarian function. Genetics, measured as family history for age at the onset of menopause, is the main determinant. However, physical activity, diet, and lifestyle are important factors that can influence the age of menopause. The low estrogen levels after natural or premature menopause increased the risk for several diseases, resulting in increased mortality risk. Besides that, the decreasing ovarian reserve is associated to reduced fertility. In women with infertility undergoing in vitro fertilization, reduced markers of ovarian reserve, including antral follicular count and anti-Mullerian hormone, are the main indicators of reduced chances of becoming pregnant. Therefore, it becomes clear that the ovarian reserve has a central role in women's life, affecting fertility early in life and overall health later in life. Based on this, the ideal strategy for delaying ovarian aging should have the following characteristics: (1) be initiated in the presence of good ovarian reserve; (2) maintained for a long period; (3) have an action on the dynamics of primordial follicles, controlling the rate of activation and atresia; and (4) safe use in pre-conception, pregnancy, and lactation. In this review, we therefore discuss some of these strategies and its feasibility for preventing a decline in the ovarian reserve.

New AMH cutoff values for warning of decreased ovarian response based on MCL characteristics in young women: a retrospective study using a propensity score-matching analysis

BACKGROUND

Menstrual cycle length (MCL) and ovarian response varies widely among women of childbearing age. They are provided with anti-Mu¨llerian hormone (AMH) cutoffs for "normal" and "weakened" ovarian responses, which give an early warning of the onset of decreased ovarian response.

METHODS

This was a retrospective study in women aged 21 to 35 years with MCLs of 21-35 days receiving in vitro fertilization (IVF) treatment at Center for Reproductive Medicine from October 2018 to October 2021. Intergroup variables were balanced using propensity score matching based on age and BMI, and each case patient (patients with MCLs of 21-25 days) was matched with three control patients (patients with MCLs of 26-35 days). A receiver operating characteristic curve was used to calculate the AMH cutoff values.

RESULTS

We included 135 patients with MCLs of 21-25 days and 405 matched control patients with MCLs of 26-35 days who received IVF treatment. The case group had significantly fewer retrieved oocytes, lower AMH values and higher initial and total Gonadotropin (Gn) levels during controlled ovarian hyperstimulation than the control group. The ovarian response began to decrease when AMH was < 3.5 ng/ml in the case group and < 2.7 ng/ml in the control group.

CONCLUSION

In young women with MCLs of 21-35 days, short MCL was negatively correlated with AMH values and the number of oocytes retrieved. In patients with MCLs of 21-25 days and 26-35 days, the AMH cutoff values corresponding to the onset of decreased ovarian response were 3.5 ng/ml and 2.7 ng/ml, respectively.

Self-reported menstrual cycle length during reproductive years in relation to menopausal symptoms at midlife in Project Viva

OBJECTIVE

The aim of this study was to investigate the extent to which self-reported menstrual cycle length during reproductive years is associated with menopausal symptoms and age at natural menopause at midlife.

METHODS

This analysis includes 634 women who enrolled in Project Viva during pregnancy (1999-2002) and completed the midlife visit approximately 18 years later. Women self-reported menstrual cycle length at enrollment (early pregnancy) and at midlife reported total and specific menopausal symptoms using the Menopause Rating Scale as well as age at natural menopause. We used linear and regression models to evaluate associations of cycle length with total and specific menopausal symptoms. We also applied a time-to-event Cox proportional hazards model to investigate the relationship between menstrual cycle length and onset of natural menopause. We adjusted models for age at midlife visit, prepregnancy body mass index, race/ethnicity, education, and parity.

RESULTS

At enrollment (median age, 33.3 years), 90 (14%) women reported having short (≤25 days) and 39 (6%) reported long (≥35 days) menstrual cycles. Compared with women with a normal menstrual cycle length of 26 to 34 days, women whose cycles were short had a higher total Menopause Rating Scale at midlife ( β = 2.05; 95% confidence interval [CI], 0.73-3.38). Specifically, women with short menstrual cycles during their reproductive years had higher odds of midlife sleep problems (odds ratio [OR], 1.92; 95% CI, 1.10-3.37), heart discomfort (OR, 1.68; 95% CI, 1.03-2.73), and depressive symptoms (OR, 1.85; 95% CI, 1.16-2.96). In addition, compared with women with a normal cycle length of 26 to 34 days, women reporting short cycles had an earlier onset of natural menopause (hazard ratio, 1.67; 95% CI, 1.11-2.51).

CONCLUSIONS

Compared with women with normal menstrual cycle length, those with short menstrual cycles during their reproductive years had a higher frequency of total and certain menopausal symptoms at midlife and reached menopause earlier.

Basal serum level of Δ4-androstenedione reflects the ovaries' ability to respond to stimulation in IVF cycles: setting up a new reliable index of both ovarian reserve and response

PURPOSE

Adequate androgen levels are necessary for regular follicular growth, progression beyond the pre-antral stage, and prevention of follicular atresia. The main purpose of this study was to investigate whether baseline androgen levels had a predictive value on stimulation outcomes in IVF cycles. The secondary purpose was to compare the possible predictive value of androgens with that of already known markers.

METHODS

The study included 91 infertile patients aged 30-45 years awaiting the first IVF cycle. All women underwent the same stimulation protocol and the same starting dose of recombinant FSH. As stimulation outcomes, the number of follicles recruited, estradiol and progesterone levels on the day of trigger, the total dose of gonadotropins administered, and the number of oocytes collected were recorded. Multiple linear regression and multivariate logistic regression were used to evaluate the significant predictive value of the variables for response to controlled ovarian stimulation (COS). By studying the reliability of different markers, an attempt was made to develop a single index with the highest predictive value.

RESULTS

Pearson's correlation revealed a statistically significant inverse correlation between oocytes collected and age (r =  - 0.333, p < 0.001) and a positive correlation with AMH (anti-müllerian hormone) (r = 0.360, p < 0.001), antral follicle count (AFC) (r = 0.639, p < 0.001), and androstenedione (Δ4-A) (r = 0.359, p < 0.001). No significant correlation was reported with FSH (r =  - 0.133, p = 0.207) and total testosterone (r = 0.180, p = 0.088). In COS good responders, the G-index (= AMH ng/mL*AFC/Δ4-A ng/dL) revealed a significantly higher level (p < 0.001) than AMH, AFC, and Δ4-A alone.

CONCLUSION

Baseline serum Δ4-A, presumably crucial for ensuring a regular follicular growth, is a reliable marker of ovarian response to stimulation. Since the ovarian capacity to respond to gonadotropins does not depend exclusively on the presence of follicles, we suggest a new index, the G-index, able to contemplate both the ovarian reserve and the Δ4-A level.

Idiopathic early ovarian aging: is there a relation with premenopausal accelerated biological aging in young women with diminished response to ART?

PURPOSE

To evaluate whether young women with idiopathic early ovarian aging, as defined by producing fewer oocytes than expected for a given age over multiple in vitro fertilization (IVF) cycles, have changes in telomere length and epigenetic age indicating accelerated biological aging (i.e., increased risk of morbidity and mortality).

METHODS

A prospective cohort study was conducted at two Danish public fertility clinics. A total of 55 young women (≤ 37 years) with at least two IVF cycles with ≤ 5 harvested oocytes despite sufficient stimulation with follicle-stimulating hormone (FSH) were included in the early ovarian aging group. As controls, 52 young women (≤ 37 years) with normal ovarian function, defined by at least eight harvested oocytes, were included. Relative telomere length (rTL) and epigenetic age acceleration (AgeAccel) were measured in white blood cells as markers of premenopausal accelerated biological aging.

RESULTS

rTL was comparable with a mean of 0.46 (± SD 0.12) in the early ovarian aging group and 0.47 (0.14) in the normal ovarian aging group. The AgeAccel of the early ovarian aging group was, insignificantly, 0.5 years older, but this difference disappeared when adjusting for chronological age. Sub-analysis using Anti-Müllerian hormone (AMH) as selection criterion for the two groups did not change the results.

CONCLUSION

We did not find any indications of accelerated aging in whole blood from young women with idiopathic early ovarian aging. Further investigations in a similar cohort of premenopausal women or other tissues are needed to fully elucidate the potential relationship between premenopausal accelerated biological aging and early ovarian aging.

Association of FSHR, LH, LHR, BMP15, GDF9, AMH, and AMHR polymorphisms with poor ovarian response in patients undergoing in vitro fertilization

Objective:

This paper aimed to assess the correlation between LH, LHR, GDF9, FSHR, AMH, AMHR2, and BMP15 polymorphisms, which are related to follicular development, and decreased ovarian response in women undergoing controlled ovarian hyperstimulation (COH) for IVF.

Methods:

This age-matched case-control study included three or four controls per woman undergoing COH. Controls were women with normal ovarian response (NOR) and cases were women with poor ovarian response (POR) in oocyte retrieval (three or fewer oocytes). DNA was extracted from peripheral blood and potential associations with gene polymorphisms related to follicular development (LH, LHR, GDF9, FSHR, AMH, AMHR2, and BMP15) were analyzed.

Results:

Sixty-six patients were included, 52 in the NOR and 14 in the POR group. Two GDF9 polymorphisms were associated with follicular response after COH, one associated with POR - the presence of a mutant polymorphism in heterozygosis and homozygosis of the GDF9 398-39 (C to G) [23% NOR versus 68% POR (OR 4.01, CI 1.52-10.6, p=0.005)] - and another associated with protective response - the presence of normal homozygosis of GDF9 (C447T) [19.2% NOR versus 50% POR (OR 0.34, IC 0.14-0.84, p=0.019)]. No additional associations were found between the other analyzed polymorphisms and POR.

Conclusions:

This study found that GDF9 appears to play an important role in follicular development, whereas polymorphisms in its DNA chain may negatively affect ovarian reserve, such as 398-39 (C to G), or positively, as seen in C447T.

Does an association exist between menstrual cycle length within the normal range and ovarian reserve biomarkers during the reproductive years? A systematic review and meta-analysis

BACKGROUND

Regular menstrual cycling during the reproductive years is an indicator of spontaneous ovulation but sometimes falsely perceived as an indicator of preserved fertility. In contrast, menstrual cycle shortening, a physiologic occurrence preceding the menopausal transition, is not usually perceived as an indicator of decreased ovarian reserve in the general population.

OBJECTIVE AND RATIONALE

The individual decrease in menstrual cycle length (MCL) might represent a sensitive biomarker of diminishing ovarian reserve. The aim of this systematic review and meta-analysis is to examine the possible association between MCL in regularly cycling women (21-35 days) and ovarian reserve tests (ORT), fecundability in natural cycles and IVF outcomes.

SEARCH METHODS

An electronic database search employing PubMed, Web of Science, Trip, EBSCO, ClinicalTrials.gov and the Cochrane library was performed to identify research articles, only on human, published between January 1978 and August 2019. Search terms were pregnancy OR fertility OR fecundity OR fecundability, anti-Müllerian hormone OR AMH OR antral follicle count OR AFC OR ovarian reserve OR ovarian reserve test, in vitro fertilization OR ART OR assisted reproductive therapy OR assisted reproductive treatment OR assisted reproductive technology OR IVF OR ICSI, menstrual cycle length OR menstrual cycle characteristics. We combined these terms to complete the search. All prospective and retrospective studies exploring an association between MCL and proxies of ovarian reserve were included. The exclusions included studies of PCOS, ovarian failure, oral contraception treatment, prior chemotherapy and/or radiotherapy or ovarian surgery. The Newcastle-Ottawa scale was used to assess the quality of studies that were eligible for meta-analysis.

OUTCOMES

Eleven studies were eligible for meta-analysis, including 12 031 women. The included studies had a low risk of bias. Short MCL (21-27 days) was associated with lower ORT values as compared to normal (28-31 days), long (32-35 days) and all other (28-35 days) MCL sets. The estimated weighted mean difference (WMD) of AMH level was -1.3 ng/mL (95% CI: -1.75 to -0.86, P < 0.001) between the short and normal MCL sets. The estimated WMD of AFC values was -5.17 (95% CI: -5.96 to -4.37, P < 0.001) between the short and normal MCL sets. The weighted overall odds ratio (OR) of fecundability in natural cycles between women with short versus normal MCL sets was statistically significant (overall OR 0.81; 95% CI 0.72-0.91, P < 0.001). In the IVF setting, fewer oocytes were retrieved in short MCL in comparison to normal, long and all other MCL sets, with an estimated WMD of -1.8 oocytes (95% CI: -2.5 to -1.1, P < 0.001) in the short versus normal MCL sets. The weighted overall OR of clinical pregnancy rate between women with short versus all other MCL sets was statistically significant (overall OR 0.76; 95% CI: 0.60 to 0.96, P = 0.02). Low levels of heterogeneity were found in most meta-analyses of MCL and qualitative ovarian reserve biomarkers, while heterogeneity was high in meta-analyses performed for quantitative measures.

WIDER IMPLICATIONS

MCL in regularly cycling women is closely related to ovarian reserve biomarkers during the reproductive years. A short MCL, as compared to normal, is significantly associated with lower ORT values, reduced fecundability and inferior IVF outcomes, independent of age. The results imply that short MCL may be a sign of ovarian aging, combining the quantitative and qualitative facets of ovarian reserve. Educational efforts ought to be designed to guide women with short MCL at a young age, who desire children in the future, to seek professional counselling.

Acupuncture for Poor Ovarian Response: A Randomized Controlled Trial

Acupuncture is believed to improve ovarian reserve and reproductive outcomes in women undergoing in vitro fertilization (IVF). This study was conducted to evaluate the effect of network-optimized acupuncture followed by IVF on the oocyte yield in women showing a poor ovarian response. This study was an exploratory randomized controlled trial conducted from June 2017 to January 2020 at the Pusan National University Hospital. Women diagnosed with poor ovarian response were enrolled and randomly divided into two groups: IVF alone and Ac + IVF groups (16 acupuncture sessions before IVF treatment). Eight acupoints with high degree centrality and betweenness centrality were selected using network analysis. Among the participants, compared with the IVF treatment alone, the acupuncture + IVF treatment significantly increased the number of retrieved mature oocytes in women aged more than 37 years and in those undergoing more than one controlled ovarian hyperstimulation cycle. The negative correlation between the number of retrieved mature oocytes and consecutive controlled ovarian hyperstimulation cycles was not observed in the Ac + IVF group irrespective of the maternal age. These findings suggest that physicians can consider acupuncture for the treatment of women with poor ovarian response and aged > 37 years or undergoing multiple IVF cycles.

A comparison of the efficacy and safety of traditional Chinese medicine in preconditioning patients with diminished ovarian reserve that would undergo In Vitro fertilization: A network meta-analysis protocol

BACKGROUND

Diminished Ovarian Reserve (DOR) is a common disease in reproductive-age women in the diagnosis and treatment of infertility. The incidence of DOR increased quickly in recent years and had became one of the most important factors that made the quality of women life decline. Gynecology and reproductive medicine professors have made great efforts to explore good treatment methods all over the world. Traditional Chinese Medicine has made some achievement in treating DOR as a kind of complementary and alternative therapy In Vitro Fertilization (IVF) in recent years, it is indispensable to propose a network meta-analysis (NMA) protocol to discuss the efficacy and safety of TCM in IVF.

METHODS

A literature search will be conducted in 8 electronic databases.

RESULTS

The efficacy and safety of traditional Chinese medicine in preconditioning patients with diminished ovarian reserve that would undergo In Vitro Fertilization will be evaluated.

RESULTS

The systematic review will evaluate the efficacy and safety of TCM in IVF.

CONCLUSION

The result of this study will provide reliable evidence of the use of TCM in IVF.

INPLASY REGISTRATION NUMBER

INPLASY2020110062.

ETHICS AND DISSEMINATION

This review does not require ethical approval.

Cutting the ovarian surface improves the responsiveness to exogenous hormonal treatment in aged mice

Purpose

Ovarian vascular abnormality and ovarian fibrosis are observed in the low responder patients and aging mice. Vascularization and fibrosis are regulated by injury‐repair system, such as wound. Thus, in this study, the authors tried to investigate the effect of the surgical treatment to ovarian surface with cutting on the functions of ovary in aging mouse model, gcNrg1KO.

Method

The ovarian surface of gcNrg1KO was surgically cut, and then the ovary was returned inside of bursa ovarica. To assess the effect of cutting on fertility, mating test, smear analysis, and exogenous hormonal treatment were done. Additionally, the histological analysis was used for observing the remodeling of ovarian stroma after the surgical approach.

Result

Ovarian fibrosis disappeared at 7 days after surgery. With the abrogation of fibrosis, the blood vessels were fluently observed around the follicles, and the follicular development was re‐started. The responses against exogenous hormone were recovered at 21 days after the surgery, and estrous cycle and delivery were also recovered by the surgery and the fertility was maintained for 3 months.

Conclusion

This cutting method of ovarian surface becomes a good option against low responder patients.

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.

Altered microRNA and Piwi-interacting RNA profiles in cumulus cells from patients with diminished ovarian reserve

Diminished ovarian reserve (DOR) is defined as decreased number or quality of follicles and oocytes in a woman at childbearing age. It is estimated that up to 10% of women in the general population may suffer from DOR. This study aims to comprehensively characterize microRNA (miRNA) and Piwi-interacting RNA (piRNA) expression profiles in cumulus cells of DOR patients. Cumulus cells were collected from 20 women of similar chronological age who received assisted reproductive technology treatment: 10 with DOR and 10 with normal ovarian reserve (NOR). The small RNAs were extracted from each sample and reverse transcribed. Deep sequencing and bioinformatic analysis were performed to identify the small noncoding RNA profiles. The rRNAs were the most abundant small RNA class in cumulus cells derived from human MII oocytes, following were miRNAs and tRNAs. Twenty-six piRNAs, 79 annotated miRNAs, and 5 novel miRNAs were identified differentially expressed. In DOR group, the chromosomal strand bias patterns of piRNAs on chromosome 1, 3, 5, and X were distinct from its counterpart in NOR group. The involved biological pathways from the putative target genes of differentially expressed miRNAs were enriched by using GO analysis and KEGG pathway annotations, and mTOR pathway and meiosis-associated biological processes were enriched. This study provided additional information on the dysfunctions of cumulus cells in patients with diminished ovarian reserve. Future investigations will involve the characterization of specific functional roles of noncoding small RNA in ovarian reserve regulation.

Influence of follicular fluid and cumulus cells on oocyte quality: clinical implications

An equilibrium needs to be established by the cellular and acellular components of the ovarian follicle if developmental competence is to be acquired by the oocyte. Both cumulus cells (CCs) and follicular fluid (FF) are critical determinants for oocyte quality. Understanding how CCs and FF influence oocyte quality in the presence of deleterious systemic or pelvic conditions may impact clinical decisions in the course of managing infertility. Given that the functional integrities of FF and CCs are susceptible to concurrent pathological conditions, it is important to understand how pathophysiological factors influence natural fertility and the outcomes of pregnancy arising from the use of assisted reproduction technologies (ARTs). Accordingly, this review discusses the roles of CCs and FF in ensuring oocyte competence and present new insights on pathological conditions that may interfere with oocyte quality by altering the intrafollicular environment.

Anti-Müllerian hormone serum concentrations of women with germline BRCA1 or BRCA2 mutations

STUDY QUESTION

Do women with BRCA1 or BRCA2 mutations have reduced ovarian reserve, as measured by circulating anti-Müllerian hormone (AMH) concentration?

SUMMARY ANSWER

Women with a germline mutation in BRCA1 have reduced ovarian reserve as measured by AMH.

WHAT IS KNOWN ALREADY

The DNA repair enzymes encoded by BRCA1 and BRCA2 are implicated in reproductive aging. Circulating AMH is a biomarker of ovarian reserve and hence reproductive lifespan.

STUDY DESIGN, SIZE, DURATION

This was a cross-sectional study of AMH concentrations of 693 women at the time of enrolment into the Kathleen Cuningham Foundation Consortium for research in the Familial Breast Cancer (kConFab) cohort study (recruitment from 19 August 1997 until 18 September 2012). AMH was measured on stored plasma samples between November 2014 and January 2015 using an electrochemiluminescence immunoassay platform.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible women were from families segregating BRCA1 or BRCA2 mutations and had known mutation status. Participants were aged 25–45 years, had no personal history of cancer, retained both ovaries and were not pregnant or breastfeeding at the time of plasma storage. Circulating AMH was measured for 172 carriers and 216 non-carriers from families carrying BRCA1 mutations, and 147 carriers and 158 non-carriers from families carrying BRCA2 mutations. Associations between plasma AMH concentration and carrier status were tested by linear regression, adjusted for age at plasma storage, oral contraceptive use, body mass index and cigarette smoking.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean AMH concentration was negatively associated with age (P < 0.001). Mutation carriers were younger at blood draw than non-carriers (P ≤ 0.031). BRCA1 mutation carriers had, on average, 25% (95% CI: 5%–41%, P = 0.02) lower AMH concentrations than non-carriers and were more likely to have AMH concentrations in the lowest quartile for age (OR 1.84, 95% CI: 1.11–303, P = 0.02). There was no evidence of an association between AMH concentration and BRCA2 mutation status (P = 0.94).

LIMITATIONS, REASONS FOR CAUTION

AMH does not directly measure the primordial follicle pool. The clinical implications of the lower AMH concentrations seen in BRCA1 mutation carriers cannot be assessed by this study design.

WIDER IMPLICATIONS OF THE FINDINGS

Women with a germline mutation in BRCA1 may have reduced ovarian reserve. This is consistent with other smaller studies in the literature and has potential implications for fertility and reproductive lifespan.

STUDY FUNDING/COMPETING INTEREST(S)

kConFab is supported by a grant from the Australian National Breast Cancer Foundation, and previously by the National Health and Medical Research Council (NHMRC), the Queensland Cancer Fund, the Cancer Councils of New South Wales, Victoria, Tasmania and South Australia, and the Cancer Foundation of Western Australia. K.A.P. is an Australian National Breast Cancer Foundation Practitioner Fellow. J.L.H. is a NHMRC Senior Principal Research Fellow. M.H. is a NHMRC Practitioner Fellow. R.A.A. reports personal fees from Roche Diagnostics & Beckman Coulter outside the submitted work and C.S. reports other earnings from Melbourne IVF outside the submitted work. The remaining authors have nothing to declare and no conflicts of interest.

Is there any relationship between cardiovascular risk markers and young women with diminished ovarian reserve?

OBJECTIVE

It has been widely known that cardiovascular disease (CVD) risk is increased in menopause. The aim of the study was to evaluate whether this risk was elevated in young women with diminished ovarian reserve (DOR).

METHODS

A hundred women with DOR and 100 women with normal ovarian reserve (NOR) attending the infertility unit at Suleymaniye Maternity, Research &Training Hospital, were enrolled in the study. CVD risk markers such as insulin resistance (defined by the homeostasis model assessment ratio [HOMA-IR]), C-reactive protein (CRP), low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC), and triglyceride (TG) were assessed.

RESULTS

HOMA-IR, CRP, TG, LDL levels were higher and HDL was lower among patients with DOR compared to the controls (p < 0.05 for all). There were positive associations between DOR and HOMA-IR, CRP, TG, LDL levels and a negative correlation with HDL (p < 0.05 for all). However, multivariate logistic regression analysis showed that HOMA-IR, CRP, TG, and HDL were independent variables that were associated with DOR.

CONCLUSIONS

CVD risk markers were increased in women with DOR. Further studies with larger groups are needed to investigate the nature of the link in these patients.

Genetic associations with diminished ovarian reserve: a systematic review of the literature

PURPOSE

Diminished ovarian reserve (DOR) affects 10 % of women seeking fertility treatment. Although it is much more prevalent than premature ovarian failure, less is known about its etiology. The purpose of this article is to review the possible genetic causes of, and associations with, pathologic DOR.

METHODS

A systematic review was conducted using PubMed from 1966 through November 2013.

RESULTS

Twenty-one articles identified genes associated with DOR: one gene mutation (FMR1), three polymorphisms (GDF9, FSHR, and ESR1), and seven genes differentially expressed between women with DOR and controls (AMH, LHCGR, IGF1, IGF2, IGF1R, IGF2R and GREM1). Six candidate genes were discovered in mice, including Foxl2, Gdf9, Bmp15, Aire, Wnt4, and Gpr3. Two case reports of chromosomal translocations were also identified.

CONCLUSIONS

While the etiology of pathologic DOR is likely multifactorial, it is possible that many cases attributed to an idiopathic cause may have a genetic component. Larger studies are needed to expose the impact gene mutations, polymorphisms, and epigenetics have on pathologic DOR.

Do BRCA1 and BRCA2 mutation carriers have earlier natural menopause than their noncarrier relatives? Results from the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer

PURPOSE

Limited data suggest that germline BRCA1 mutations are associated with occult primary ovarian insufficiency and that BRCA1 and BRCA2 mutation carriers might have earlier natural menopause (NM) than their noncarrier relatives.

PATIENTS AND METHODS

Eligible women were mutation carriers and noncarriers from families segregating a BRCA1 or BRCA2 mutation. Data were self-reported using uniform questionnaires at cohort entry and every 3 years thereafter. NM was defined as the cessation of menses for 12 months without another cause. Cox proportional hazards analysis modeled time from birth to NM, adjusting for multiple potential confounders. Analysis time was censored at the earliest of the following: last follow-up, bilateral oophorectomy, hysterectomy, commencement of hormone therapy, insertion of intrauterine device, or any cancer diagnosis. Hazard ratios (HRs) were estimated as a measure of how likely mutation carriers are, relative to noncarriers, to reach NM at a given age.

RESULTS

A total of 1,840 women were eligible for analysis. Overall only 19% reached NM. A lower proportion of BRCA1 and BRCA2 mutation carriers reached NM compared with noncarriers. Conversely, a higher proportion of mutation carriers were censored at cancer diagnosis or oophorectomy than noncarriers. The adjusted HR estimates for NM were 1.03 (95% CI, 0.75 to 1.40; P = .9) for 445 BRCA1 mutation carriers and 559 noncarrier relatives and 1.01 (95% CI, 0.71 to 1.42; P = .9) for 374 BRCA2 mutation carriers and 462 noncarrier relatives.

CONCLUSION

We found no evidence that BRCA1 and BRCA2 mutation carriers are at higher risk of NM at a given age than their noncarrier relatives.

Ovarian reserve and anti-Mullerian hormone (AMH) in mothers of dizygotic twins

This study aimed to explore if natural dizygotic (DZ) twinning is associated with earlier menopause and lower anti-Mullerian hormone (AMH) values. We investigated if advanced biological reproductive aging, which can be responsible for the multiple follicle growth in familial twinning, is similar to mechanisms that occur in normal ovarian aging, reflected by earlier menopause in mothers of DZ twins and lower levels of AMH. A total of 16 mothers of DZ twins enrolled with the Netherlands Twin Register (average age at first assessment: 35.9 ± 3.0 years) and 14 control mothers (35.1 ± 3 years) took part in a prospective study. Fifteen years after entry into the study, which included follicle-stimulating hormone (FSH) assessment, AMH was measured in stored serum samples and menopause status was evaluated. Average AMH levels were not significantly different between DZ twin mothers and controls (2.1 ± 2.4 μg/L vs. 1.9 ± 1.9 μg/L). Among the 16 mothers of twins, 7 had an elevated (FSH) value over 10 U/L at first assessment. Their AMH levels were lower than the nine twin mothers with normal FSH values: 0.6 ± 0.4 versus 3.4 ± 2.6 μg/L (p = .01). Of the mothers of twins, eight mothers had entered menopause at the second assessment compared with only one control mother (p = .07). Thus, slightly more DZ mothers were in menopause than the control mothers, although this difference was not significant. The subgroup of DZ twin mothers who had an increased FSH concentration 15 years ago had a limited ovarian reserve as reflected by lower AMH levels. These data indicate that advanced ovarian aging can be a feature in familial DZ twinning, particularly with elevated early follicular phase FSH.

Interpreting human follicular recruitment and antimüllerian hormone concentrations throughout life

The changes in the relationships between circulating antimüllerian hormone, the size of the primordial follicle pool, and follicular recruitment before and through the reproductive years have now been clarified, and show dynamic changes through sexual development. The constant relationship between the number of follicles and circulating antimüllerian hormone exists only after the age of 25 years, implying that the association between follicular recruitment and follicular survival to the later stages of development is not constant across the reproductive life course. This commentary assesses the factors that may underlie these relationships and their clinical implications for reproductive health.

The OPTIMIST study: optimisation of cost effectiveness through individualised FSH stimulation dosages for IVF treatment. A randomised controlled trial

Background

Costs of in vitro fertilisation (IVF) are high, which is partly due to the use of follicle stimulating hormone (FSH). FSH is usually administered in a standard dose. However, due to differences in ovarian reserve between women, ovarian response also differs with potential negative consequences on pregnancy rates. A Markov decision-analytic model showed that FSH dose individualisation according to ovarian reserve is likely to be cost-effective in women who are eligible for IVF. However, this has never been confirmed in a large randomised controlled trial (RCT). The aim of the present study is to assess whether an individualised FSH dose regime based on an ovarian reserve test (ORT) is more cost-effective than a standard dose regime.

Methods/Design

Multicentre RCT in subfertile women indicated for a first IVF or intracytoplasmic sperm injection cycle, who are aged < 44 years, have a regular menstrual cycle and no major abnormalities at transvaginal sonography. Women with polycystic ovary syndrome, endocrine or metabolic abnormalities and women undergoing IVF with oocyte donation, will not be included. Ovarian reserve will be assessed by measuring the antral follicle count. Women with a predicted poor response or hyperresponse will be randomised for a standard versus an individualised FSH regime (150 IU/day, 225-450 IU/day and 100 IU/day, respectively). Participants will undergo a maximum of three stimulation cycles during maximally 18 months. The primary study outcome is the cumulative ongoing pregnancy rate resulting in live birth achieved within 18 months after randomisation. Secondary outcomes are parameters for ovarian response, multiple pregnancies, number of cycles needed per live birth, total IU of FSH per stimulation cycle, and costs. All data will be analysed according to the intention-to-treat principle. Cost-effectiveness analysis will be performed to assess whether the health and associated economic benefits of individualised treatment of subfertile women outweigh the additional costs of an ORT.

Discussion

The results of this study will be integrated into a decision model that compares cost-effectiveness of the three dose-adjustment strategies to a standard dose strategy. The study outcomes will provide scientific foundation for national and international guidelines.

Trial registration

NTR2657

Effect of aging on follicular function may be relieved by exogenous gonadotropin treatment in a sheep model

The current study investigated hormonal and ovarian changes during physiological reproductive aging in Sarda ewes. In a first experiment, follicular and corpus luteum dynamics were compared during an induced oestrus cycle in aged (12-14 years) and young adult ewes (4-5 years). Oestrus cycle characteristics did not differ between the two experimental groups. However, follicular function during the follicular phase showed significant alterations in aged ewes, as determined by a lack of dominance effect and by lower mean values of circulating oestradiol (E(2)) and inhibin levels, compared with young adult ewes. In a second experiment, differences in follicle growth, hormonal milieu and oocyte quality in response to exogenous FSH administration were assessed in aged and adult ewes. No differences were recorded in ovarian response to FSH treatment between young adult and aged ewes, as evaluated by ultrasonographic data and circulating concentrations of LH, E(2) and inhibin-A. Although the total number of recovered oocytes was similar in the two age groups, the number of good quality oocytes selected for IVM was significantly lower in aged ewes compared with adult ones. Thereafter, no differences were recorded in cleavage rates, total blastocyst output, embryo developmental kinetic and quality between aged and adult groups. In conclusion, this study demonstrated that reproductive aging in sheep is associated with impaired follicle functionality and an increase in the proportion of oocytes showing morphological abnormalities. However interestingly, oocyte developmental competence in vitro and embryo cryotolerance were not affected by the aging process, when only good quality oocytes were chosen.

Effects of reproductive history on symptoms of menopause: a brief report

OBJECTIVE

The aim of this study was to examine the relationship between reproductive history and menopausal symptoms among urban women.

METHODS

This was a cohort study of women aged 35 to 47 years recruited in Philadelphia, PA. Two hundred ninety-one premenopausal women meeting the study eligibility criteria and contributing reproductive health history and infertility information completed the assessments of occurrence and severity of several menopausal symptoms over a 14-year period. Reproductive history included the number of pregnancies, live births, preterm deliveries, and miscarriages. Trying to get pregnant for more than 1 year was used as an assessment of infertility. The occurrence of severe hot flashes, vaginal dryness, and decreased libido was evaluated.

RESULTS

Women scoring positive on the infertility index were significantly more likely to report severe decreased libido (odds ratio [OR], 1.86; 95% CI, 1.05-3.31) and were more than twice as likely to report severe vaginal dryness (OR, 2.79; 95% CI, 1.19-6.94) in multivariable models. None of the other reproductive health indices were related to the report of severe hot flashes, vaginal dryness, or decreased libido. The race-specific models continued to find a significant increased risk of severe vaginal dryness (OR, 2.79; 95% CI, 1.22-6.36) and decreased libido (OR, 1.87; 95% CI, 1.04-3.34) among white women scoring positive on the infertility index; however, the relationship did not remain significant among African American women.

CONCLUSIONS

Severe vaginal dryness and decreased libido are common and important considerations of the menopausal transition, and the experience of infertility problems may influence the report of severe vaginal dryness and decreased libido particularly among white women.

Enhanced hypothalamic-pituitary sensitivity to estrogen in premenopausal women with diminished ovarian reserve compared with older perimenopausal controls

OBJECTIVE

We have previously characterized the reproductive hormone profile in infertile women with diminished ovarian reserve (DOR) as being distinct from that seen in age-comparable healthy controls. Hypothesizing that DOR reflects accelerated reproductive aging, we herein compare urinary reproductive hormone dynamics between young women with DOR and a population of chronologically older perimenopausal controls.

METHODS

In this prospective observational study, urinary levels of pituitary gonadotropins (follicle-stimulating hormone and luteinizing hormone) and metabolites of estrogen (estrone conjugate) and progesterone were assessed in daily morning urine samples collected in a spontaneous menstrual cycle in 8 infertile premenopausal women with DOR and in 11 perimenopausal controls. Areas under the curves were calculated for the respective measured hormones, and comparisons were made using the Mann-Whitney U test.

RESULTS

Urinary estrone conjugate levels were significantly attenuated in premenopausal women with DOR compared with the older perimenopausal cohort. Despite the relatively lower estrogen, a significantly more pronounced luteinizing hormone surge was evident in the younger population. Early follicle-stimulating hormone was lower in women with DOR, but luteal urinary progesterone excretion was comparable in the two groups.

CONCLUSIONS

Our data suggest distinctions in functioning of the central (hypothalamic-pituitary) and peripheral (ovarian) components of the hypothalamic-pituitary-ovarian axis in premenopausal women with DOR compared with chronologically older perimenopausal controls. Increased hypothalamic-pituitary sensitivity to estrogen positive feedback is suggested in premenopausal women with DOR. Our observations identify DOR as a distinct entity in the paradigm of reproductive senescence.

The effect of recombinant LH on embryo quality: a randomized controlled trial in women with poor ovarian reserve

BACKGROUND

Poor ovarian response is a common clinical problem, affecting up to 26% of IVF cycles. For these women, addition of recombinant luteinizing hormone (rLH) to ovarian hyperstimulation with recombinant FSH has a beneficial effect on ongoing pregnancy rates, but its effect on the yield of top-quality embryos is unknown.

METHODS

We conducted a randomized controlled trial in women expected to respond poorly under ovarian hyperstimulation during their first IVF cycle [all women aged 35-41 and women with FSH > 12 IU/ml and antral follicle count (AFC) ≤ 5]. Women were randomly allocated to rFSH and rLH (2:1 ratio) or rFSH alone (control group) after down-regulation with a GnRH agonist. The primary outcome was the proportion of top-quality embryos per woman on the day of transfer. Secondary outcomes were the number of stimulation days, the number of follicles ≥17 mm, the number of oocytes, the fertilization rate, the number of embryos, the number of women with ≥1 top-quality embryo, the biochemical, clinical and ongoing pregnancy rates and the miscarriage rate.

RESULTS

There were 116 women allocated to the rLH group and 128 allocated to the control group. The proportion of top-quality embryos per woman was 17% in the rLH group and 11% in the control group [mean difference 0.06; 95% confidence interval (CI) -0.01-0.14]. In the rLH and control groups respectively, 47 (41%) and 41 (32%) women had at least one top-quality embryo on the day of transfer (relative risk: 1.3, 95% CI 0.91-1.77). The ongoing pregnancy rate was 13 versus 12% (relative risk: 1.1; 95% CI 0.57-2.16) for the rLH group compared with the control group.

CONCLUSIONS

This study found no significant difference in embryo quality after the addition of rLH to rFSH for ovarian stimulation in women with poor ovarian reserve.

CLINICAL TRIALS IDENTIFIER

NTR1457.

Long-term complications of assisted reproductive technologies

Since the birth of the first baby through in vitro fertilisation over 30 years ago, there has been a rapid increase in the number of women using assisted reproductive technologies. New techniques are constantly being introduced and are evolving rapidly. Understanding the long-term impact of these treatments, which have been linked with several potential complications affecting the mother and the child, poses a constant challenge for the scientific community. The main complications discussed in this review include the rare but serious risk of thromboembolic disease particularly in the upper half of the body and a higher risk of pregnancy complications including abnormal placentation, miscarriage, gestational diabetes and hypertensive disorders. A link between assisted conception and a number of genital cancers particularly of the breast, ovary and endometrium has also been suggested, but the evidence is currently inconclusive. A number of foetal and neonatal complications including imprinting disorders, low birth weight, congenital malformations and growth disorders are also discussed.

Increasing age influences uterine integrity, but not ovarian function or oocyte quality, in the cheetah (Acinonyx jubatus)

Although the cheetah (Acinonyx jubatus) routinely lives for more than 12 yr in ex situ collections, females older than 8 yr reproduce infrequently. We tested the hypothesis that reproduction is compromised in older female cheetahs due to a combination of disrupted gonadal, oocyte, and uterine function/integrity. Specifically, we assessed 1) ovarian response to gonadotropins; 2) oocyte meiotic, fertilization, and developmental competence; and 3) uterine morphology in three age classes of cheetahs (young, 2-5 yr, n = 17; prime, 6-8 yr, n = 8; older, 9-15 yr, n = 9). Ovarian activity was stimulated with a combination of equine chorionic gonadotropin and human chorionic gonadotropin (hCG), and fecal samples were collected for 45 days before gonadotropin treatment and for 30 days after oocyte recovery by laparoscopy. Twenty-six to thirty hours post-hCG, uterine morphology was examined by ultrasound, ovarian follicular size determined by laparoscopy, and aspirated oocytes assessed for nuclear status or inseminated in vitro. Although no influence of age on fecal hormone concentrations or gross uterine morphology was found (P > 0.05), older females produced fewer (P < 0.05) total antral follicles and oocytes compared to younger counterparts. Regardless of donor age, oocytes had equivalent (P > 0.05) nuclear status and ability to reach metaphase II and fertilize in vitro. A histological assessment of voucher specimens revealed an age-related influence on uterine tissue integrity, with more than 87% and more than 56% of older females experiencing endometrial hyperplasia and severe pathologies, respectively. Our collective findings reveal that lower reproductive success in older cheetahs appears to be minimally influenced by ovarian and gamete aging and subsequent dysfunction. Rather, ovaries from older females are responsive to gonadotropins, produce normative estradiol/progestogen concentrations, and develop follicles containing oocytes with the capacity to mature and be fertilized. A more likely cause of reduced fertility may be the high prevalence of uterine endometrial hyperplasia and related pathologies. The discovery that a significant proportion of oocytes from older females have developmental capacity in vitro suggests that in vitro fertilization and embryo transfer may be useful for "rescuing" the genome of older, nonreproductive cheetahs.

ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria

The definition presented here represents the first realistic attempt by the scientific community to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. POR to ovarian stimulation usually indicates a reduction in follicular response, resulting in a reduced number of retrieved oocytes. It has been recognized that, in order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. By definition, the term POR refers to the ovarian response, and therefore, one stimulated cycle is considered essential for the diagnosis of POR. However, patients of advanced age with an abnormal ORT may be classified as poor responders since both advanced age and an abnormal ORT may indicate reduced ovarian reserve and act as a surrogate of ovarian stimulation cycle outcome. In this case, the patients should be more properly defined as 'expected poor responder'. If this definition of POR is uniformly adapted as the 'minimal' criteria needed to select patients for future clinical trials, more homogeneous populations will be tested for any new protocols. Finally, by reducing bias caused by spurious POR definitions, it will be possible to compare results and to draw reliable conclusions.

What is the role of assisted reproduction technology in the management of age-related infertility?

Although in the UK the upper age limit for National Health Service (NHS) provision of in vitro fertilisation (IVF) is 39 years of age there has been an increase in number of women having fertility treatment in their 40s. However, the success rates of IVF and intra-uterine insemination (IUI) in this group remain low. Human Fertilisation and Embryology Authority (HFEA) data from 2006 showed that the live-birth rate from IVF in the UK was 11% in the age group 40-42, 4.6% in the age group 43-44 and less than 4% in women over 44. We performed a literature search for studies using terms and combinations of terms in online databases and published meta-analyses reporting the outcome of interventions in older women. This review showed that assisted reproduction technologies (ARTs) continue to have low live-birth rates in women over 40. Trials showed that assisted hatching may increase the chance of pregnancy in women with poor history. Blastocyst transfer is associated with better outcome, whereas application of pre-implantation genetic screening (PGS) in older women has not increased the success rates. It appears that, with the exception of egg-donation, ART has no answer yet to age-related decline of female fertility.

Nomogram for the decline in serum antimüllerian hormone: a population study of 9,601 infertility patients

OBJECTIVE

To define an optimal model for the decline in circulating antimüllerian hormone (AMH) with age and develop a validated age-related nomogram.

DESIGN

Cohort study with validation of linear, biphasic linear, differential, power, and quadratic equations undertaken in two additional cohorts.

SETTING

United Kingdom infertility clinics.

PATIENT(S)

Training cohort of 4,590 infertile women. Two separate validation cohorts; 4,588 infertile women, and 423 women with confirmed ovulation and normal pelvic ultrasound who have a male partner with severe oligospermia.

INTERVENTION(S)

Serum AMH measurement.

MAIN OUTCOME MEASURE(S)

Optimal fit and age-related AMH nomogram.

RESULT(S)

The linear model had the largest sum of absolute and squared residuals and provided a less adequate fit than the four nonlinear models. Of these, the R(2) ranged from 19.45% to 19.48% in the training dataset, from 21.30% to 21.36% in the validation dataset, and from 13.29% to 13.75% in the partners of oligospermic males. The parameters of the differential model were difficult to estimate, and the goodness-of-fit of the power model was slightly inferior to the quadratic model.

CONCLUSION(S)

Circulating AMH concentrations decline with increasing reproductive age in a manner optimally described by a quadratic equation. This validated age-related AMH nomogram will enable counseling of infertility patients regarding reproductive performance.

A changing perspective: improving access to fertility preservation

Approximately 120,000 young women are diagnosed with cancer every year in the USA. Many will have treatment that can reduce their fertility, although few will learn this fact before their treatment commences. This presents a tremendous quality of life issue post-treatment, as evidenced in this Perspectives by a personal account from a 23-year-old woman diagnosed with breast cancer. Clinicians must increase awareness about patients' desires for motherhood and awareness about their individual reproductive potential. We demonstrate novel evidence about the wide variability in ovarian reserve in women of similar age, using assessment by antral follicle count. We show how a unified approach between oncology and fertility teams can help patients better understand their risk of treatment-related infertility, as well as how to take effective measures to mitigate it. Finally, we present options for fertility preservation, based on the time point at which consultation occurs.

Is antral follicle count a genetic trait?

OBJECTIVE

The aim of this study was to determine the relationship between maternal age of menopause and antral follicle count.

METHODS

This was a cross-sectional study of 124 women aged 25 to 48 years presenting with infertility. Women reported their mother's age of menopause and underwent transvaginal ultrasound to assess antral follicle count. Participant age, age greater than 37 years, and maternal age of menopause, as well as interactions among these, were incorporated into a multiple linear regression model to predict antral follicle count. Three different ages of maternal menopause were inputted into this model to illustrate the relationship between maternal age of menopause and rate of decline in antral follicle count.

RESULTS

Women with a lower maternal age of menopause have lower antral follicle counts but also a slower decline until the age of 37 years.

CONCLUSIONS

Maternal age of menopause predicts antral follicle count and its decline, indicating a genetic component to this trait.

Correlation of telomere length and telomerase activity with occult ovarian insufficiency

BACKGROUND

Occult ovarian insufficiency is associated with infertility, impaired response to ovarian stimulation, and reduced live birth rates in women treated with assisted reproductive technologies. Although a decline in ovarian follicle number is expected with age, the proximate causes of occult ovarian insufficiency in young women remain poorly understood. Abnormalities in telomere length and telomerase activity in human granulosa cells may serve as molecular markers for this condition.

METHODS

A cross-sectional study was performed. Subjects (37 yr old or less) undergoing in vitro fertilization were classified as cases of occult ovarian insufficiency or controls with mechanical infertility (male or tubal factor). Granulosa cells were acquired at the time of oocyte retrieval to quantify telomere length and telomerase activity.

RESULTS

Fifty-four women were enrolled. Human granulosa cell telomerase activity was demonstrated, and lack of granulosa cell telomerase activity was associated with occult ovarian insufficiency (odds ratio, 11.0; 95% confidence interval, 1.3-495.6; P = 0.02). Telomeres were shorter in women with occult ovarian insufficiency than in controls (relative telomere/single copy gene ratio, 1.88 vs. 3.15; P = 0.039).

CONCLUSIONS

Aberrant telomere homeostasis is associated with occult ovarian insufficiency in young women. This finding is consistent with the presence of telomeric attenuation that has been shown in multiple age-related conditions.

Biological versus chronological ovarian age: implications for assisted reproductive technology

BACKGROUND

Women have been able to delay childbearing since effective contraception became available in the 1960s. However, fertility decreases with increasing maternal age. A slow but steady decrease in fertility is observed in women aged between 30 and 35 years, which is followed by an accelerated decline among women aged over 35 years. A combination of delayed childbearing and reduced fecundity with increasing age has resulted in an increased number and proportion of women of greater than or equal to 35 years of age seeking assisted reproductive technology (ART) treatment.

METHODS

Literature searches supplemented with the authors' knowledge.

RESULTS

Despite major advances in medical technology, there is currently no ART treatment strategy that can fully compensate for the natural decline in fertility with increasing female age. Although chronological age is the most important predictor of ovarian response to follicle-stimulating hormone, the rate of reproductive ageing and ovarian sensitivity to gonadotrophins varies considerably among individuals. Both environmental and genetic factors contribute to depletion of the ovarian oocyte pool and reduction in oocyte quality. Thus, biological and chronological ovarian age are not always equivalent. Furthermore, biological age is more important than chronological age in predicting the outcome of ART. As older patients present increasingly for ART treatment, it will become more important to critically assess prognosis, counsel appropriately and optimize treatment strategies. Several genetic markers and biomarkers (such as anti-Müllerian hormone and the antral follicle count) are emerging that can identify women with accelerated biological ovarian ageing. Potential strategies for improving ovarian response include the use of luteinizing hormone (LH) and growth hormone (GH). When endogenous LH levels are heavily suppressed by gonadotrophin-releasing hormone analogues, LH supplementation may help to optimize treatment outcomes for women with biologically older ovaries. Exogenous GH may improve oocyte development and counteract the age-related decline of oocyte quality. The effects of GH may be mediated by insulin-like growth factor-I, which works synergistically with follicle-stimulating hormone on granulosa and theca cells.

CONCLUSION

Patients with biologically older ovaries may benefit from a tailored approach based on individual patient characteristics. Among the most promising adjuvant therapies for improving ART outcomes in women of advanced reproductive age are the administration of exogenous LH or GH.

Ovarian aging: mechanisms and clinical consequences

Menopause is the final step in the process referred to as ovarian ageing. The age related decrease in follicle numbers dictates the onset of cycle irregularity and the final cessation of menses. The parallel decay in oocyte quality contributes to the gradual decline in fertility and the final occurrence of natural sterility. Endocrine changes mainly relate to the decline in the negative feedback from ovarian factors at the hypothalamo-pituitary unit. The declining cohort of antral follicles with age first results in gradually elevated FSH levels, followed by subsequent stages of overt cycle irregularity. The gradual decline in the size of the antral follicle cohort is best represented by decreasing levels of anti-Mullerian hormone. The variability of ovarian ageing among women is evident from the large variation in age at menopause. The identification of women who have severely decreased ovarian reserve for their age is clinically relevant. Ovarian reserve tests have appeared to be fairly accurate in predicting response to ovarian stimulation in the assisted reproductive technology (ART) setting. The capacity to predict the chances for spontaneous pregnancy or pregnancy after ART appears very limited. As menopause and the preceding decline in oocyte quality seem to have a fixed time interval, tests that predict the age at menopause may be useful to assess individual reproductive lifespan. Especially genetic studies, both addressing candidate gene and genome wide association, have identified several interesting loci of small genetic variation that may determine fetal follicle pool development and subsequent wastage of his pool over time. Improved knowledge of the ovarian ageing mechanisms may ultimately provide tools for prediction of menopause and manipulation of the early steps of folliculogenesis for the purpose of contraception and fertility lifespan extension.

Clinical implications of ovarian reserve testing

Serum and urinary markers of ovarian reserve, follicular phase inhibin B, follicle stimulating hormone, and antimullerian hormone levels, are physiologically associated with ovarian aging, decline with chronologic age, and appear to predict later stages of reproductive aging including the menopause transition and menopause. In infertile women, they can be used to predict low oocyte yield and treatment failure in women undergoing in vitro fertilization. These markers seem to be affected by common ovarian toxicants, such as smoking, which advance the age at menopause. Although available for commercial use, home test kits have not been shown to predict fertility or infertility in the general population. Clinical use of these markers is limited by the variety of assays, lack of definitive thresholds, and their intercycle variability in older women. Results should be conveyed with caution when highly discrepant with age, in the obese, and in women with irregular menstrual cycles. Further research is needed to assess their predictive value for determining fertility in the general population.

[The role of ultrasound examination to evaluate ovarian reserve of infertile patients]

The accurate assessment of ovarian reserve is an essential step before the treatment of infertile couples. Ovarian reserve could either be evaluated through clinical or biological parameters, but ultrasound plays a remarkable role, since it permits the direct visualization and count of ovarian antral follicles. Nevertheless, the available literature data are conflicting about the real sensibility and specificity of this method to predict the exact number of retrieved oocytes or the occurrence of pregnancy after a procedure for medical assisted reproduction. New technologies have been developed, as the 3D-ultrasound, who does not ameliorate ultrasound accuracy, but permits the reduction of the time necessary for patient's examination and virtually eliminates inter- and intra-observer bias. The place of the ovarian artery flow evaluation by Doppler remains unclear and need more studies.

Implications of diminished ovarian reserve (DOR) extend well beyond reproductive concerns

OBJECTIVES

To investigate whether a diagnosis of diminished ovarian reserve (DOR) in premenopausal years has adverse implications for skeletal health and quality of life.

DESIGN

This was a cross-sectional study of infertile, albeit healthy, mid-reproductive-age women (younger than 42 y) attending an academic infertility practice.

RESULTS

Eighty-nine women with varying causes of infertility were prospectively enrolled. Serum (cycle d 1-3) was collected for markers of ovarian reserve, bone metabolism, testosterone, and free androgen index. Bone mineral density (BMD) was assessed and categorized as low if the Z score was less than -1.0). Infertile women with DOR (n = 28) demonstrated significantly higher serum follicle-stimulating hormone levels (P < 0.001), lower müllerian-inhibiting substance (MIS) levels (P < 0.001), smaller ovarian dimensions (P < 0.05), lower testosterone levels (P = 0.035), lower free androgen index (P = 0.019), and enhanced bone metabolism (P = 0.003); although the prevalence of low BMD was higher in women with DOR who were younger than 41, this relationship was not of statistical significance (P = 0.106). Women younger than 41 years of age with DOR were significantly more likely to manifest disturbed sleep (P = 0.049) and acknowledge dissatisfaction with sexual intimacy (P = 0.004) compared with those with infertility and normal ovarian reserve. After adjustment for potential confounders, a diagnosis of DOR was significantly associated with low BMD, increased bone turnover, sexual dissatisfaction, and disturbed sleep.

CONCLUSIONS

Our data suggest that DOR unmasked in the context of infertility evaluation has adverse implications for a woman's well-being that extend well beyond the thus far appreciated reproductive concerns. A decline in ovarian hormones, specifically estrogen and testosterone, concomitant with DOR may be hypothesized as a mechanism that can explain the observed multisystem ramifications of DOR including increased bone turnover, low BMD, sexual distress, and disturbed sleep.