A prospective assessment of the predictive value of basal antral follicles in in vitro fertilization cycles

Histological assessment for investigation of dose-dependent ovarian toxicity of cyclophosphamide in the rat

Background

Cyclophosphamide (CPA) have significant effects on ovarian follicles which lead to ovarian toxicity and impair the normal female reproductive function. This study aimed to evaluate the dose-dependent effects of CPA on rat follicle numbers.

Methods

The experimental groups consisted of rats administered a single intraperitoneal injection of CPA at doses of either 50, 75,150, or 200 mg/kg followed by daily doses of 8 mg/kg for 14 days and control group given no treatment. After the treatment period, the histological evaluation was done.

Results

Primordial and primary follicles were affected by all doses of CPA, but differential follicle counts revealed that graaf and preantral follicles were most sensitive to CPA, followed by primary and primordial follicles. The greatest reduction in all type of studied follicles caused by CPA doses of 50 mg/kg.

Conclusion

Differential follicle counts revealed that CPA-induced ovarian toxicity is exhibited in structural feature of the ovary, particularly in destruction of graaf and preantral follicles in a dose-dependent manner so that the highest decrease in all type of studied follicles caused by 50 mg/kg of CPA and is suggested as the best concentration for ovotoxicity induction. These findings give insight into ovarian response to structural disruption of folliculogenesis.

Predicting Infertility: How Genetic Variants in Oocyte Spindle Genes Affect Egg Quality

Successful reproduction relies on the union of a single chromosomally normal egg and sperm. Chromosomally normal eggs develop from precursor cells, called oocytes, that have undergone accurate chromosome segregation. The process of chromosome segregation is governed by the oocyte spindle, a unique cytoskeletal machine that splits chromatin content of the meiotically dividing oocyte. The oocyte spindle develops and functions in an idiosyncratic process, which is vulnerable to genetic variation in spindle-associated proteins. Human genetic variants in several spindle-associated proteins are associated with poor clinical fertility outcomes, suggesting that heritable etiologies for oocyte dysfunction leading to infertility exist and that the spindle is a crux for female fertility. This chapter examines the mammalian oocyte spindle through the lens of human genetic variation, covering the genes TUBB8, TACC3, CEP120, AURKA, AURKC, AURKB, BUB1B, and CDC20. Specifically, it explores how patient-identified variants perturb spindle development and function, and it links these molecular changes in the oocyte to their cognate clinical consequences, such as oocyte maturation arrest, elevated egg aneuploidy, primary ovarian insufficiency, and recurrent pregnancy loss. This discussion demonstrates that small genetic errors in oocyte meiosis can result in remarkably far-ranging embryonic consequences, and thus reveals the importance of the oocyte's fine machinery in sustaining life.

Comparison of anti-Müllerian hormone and antral follicle count in the prediction of ovarian response: a systematic review and meta-analysis

BACKGROUND

Increasingly studies reported that the Anti-Müllerian hormone (AMH) seems to be a promising and reliable marker of functional ovarian follicle reserve, even better than the AFC test. Our study aimed to conduct a meta-analysis to assess the predictive value of AMH and AFC for predicting poor or high response in IVF treatment. An electronic search was conducted, and the following databases were used: PubMed, EMBASE, and the Cochrane Library (up to 7 May 2022). The bivariate regression model was used to calculate the pooled sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve. Subgroup analyses and meta-regression also were used in the presented study. Overall performance was assessed by estimating pooled ROC curves between AMH and AFC.

RESULTS

Forty-two studies were eligible for this meta-analysis. Comparison of the summary estimates for the prediction of poor or high response showed significant difference in performance for AMH compared with AFC [poor (sensitivity: 0.80 vs 0.74, P < 0.050; specificity: 0.81 vs 0.85, P < 0.001); high (sensitivity: 0.81 vs 0.87, P < 0.001)]. However, there were no significant differences between the ROC curves of AMH and AFC for predicting high (P = 0.835) or poor response (P = 0.567). The cut-off value was a significant source of heterogeneity in the present study.

CONCLUSIONS

The present meta-analysis demonstrated that both AMH and AFC have a good predictive ability to the prediction of poor or high responses in IVF treatment.

Molecular Mechanism and Prevention Strategy of Chemotherapy- and Radiotherapy-Induced Ovarian Damage

Fertility preservation is an emerging discipline, which is of substantial clinical value in the care of young patients with cancer. Chemotherapy and radiation may induce ovarian damage in prepubertal girls and young women. Although many studies have explored the mechanisms implicated in ovarian toxicity during cancer treatment, its molecular pathophysiology is not fully understood. Chemotherapy may accelerate follicular apoptosis and follicle reservoir utilization and damage the ovarian stroma via multiple molecular reactions. Oxidative stress and the radiosensitivity of oocytes are the main causes of gonadal damage after radiation treatment. Fertility preservation options can be differentiated by patient age, desire for conception, treatment regimen, socioeconomic status, and treatment duration. This review will help highlight the importance of multidisciplinary oncofertility strategies for providing high-quality care to young female cancer patients.

Anti-Müllerian hormone and antral follicle count differ in their ability to predict cumulative treatment outcomes of the first complete ovarian stimulation cycle in patients from POSEIDON groups 3 and 4

AIM

To explore the ability of anti-Müllerian hormone and antral follicle count to predict cumulative live birth and clinical pregnancy in the first complete ovarian stimulation cycle among patients from POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) groups 3-4.

METHODS

A single-center retrospective study was conducted on 260 patients in POSEIDON groups 3-4 (antral follicle count <5 and/or anti-Müllerian hormone <1.2 ng/mL) who first underwent complete in vitro fertilization/intracytoplasmic sperm injection cycles between January 2016 and June 2018. The main outcomes were cumulative live birth rate and cumulative clinical pregnancy rate.

RESULTS

Of 260 patients, 113 (43.5%) achieved clinical pregnancy and 82 (31.5%) achieved live birth in their first complete ovarian stimulation cycles. With multivariate regression analysis, age and antral follicle count were significantly correlated with cumulative clinical pregnancy, whereas age and anti-Müllerian hormone were significantly associated with cumulative live birth. Receiver operating characteristic curve analysis demonstrated that age had the highest accuracy for the prediction of cumulative treatment outcomes. The optimal cut-off value of age was 40.5 and that of antral follicle count was 2.5 for predicting cumulative clinical pregnancy. The optimal cut-off value of age was 36.5 and that of anti-Müllerian hormone was 0.725 for predicting cumulative live birth.

CONCLUSION

Our findings indicate that anti-Müllerian hormone is a better predictor of cumulative live birth than antral follicle count, independent of age, in the first complete ovarian stimulation cycle of in vitro fertilization/intracytoplasmic sperm injection among patients in POSEIDON groups 3-4.

How to personalize ovarian stimulation in clinical practice

Controlled ovarian stimulation (COS) in in vitro fertilization (IVF) cycles is the starting point from which couple’s prognosis depends. Individualization in follicle-stimulating hormone (FSH) starting dose and protocol used is based on ovarian response prediction, which depends on ovarian reserve. Anti-Müllerian hormone levels and the antral follicle count are considered the most accurate and reliable markers of ovarian reserve. A literature search was performed for studies that addressed the ability of ovarian reserve markers to predict poor and high ovarian response in assisted reproductive technology cycles. According to the predicted response to ovarian stimulation (poor- normal- or high- response), it is possible to counsel couples before treatment about the prognosis, and also to individualize ovarian stimulation protocols, choosing among GnRH-agonists or antagonists for endogenous FSH suppression, and the FSH starting dose in order to decrease the risk of cycle cancellation and ovarian hyperstimulation syndrome. In this review we discuss how to choose the best COS therapy, based on ovarian reserve markers, in order to enhance chances in IVF.

Inter-cycle and inter-observer variability of the antral follicle count in routine clinical practice

Antral follicle count (AFC) is a reliable predictor of ovarian response to stimulation and its inter-cycle and inter-observer variability has been extensively studied on in vitro fertilization (IVF), mostly in highly selected populations within studies not originally designed for this purpose. In this retrospective cohort study, we assess the inter-cycle variation of AFC in a setting similar to that of the daily practice. We included only patients undergoing mild stimulation for intrauterine insemination (IUI). One hundred and forty-eight patients had two (62 patients, group A), three (49 patients, group B) or four (37 patients, group C) IUI cycles and AFC was measured on early follicular phase of each cycle by one of the members of the medical team within daily practice. Intra-class correlation coefficients were used to estimate variability. Inter-cycle variability rendered ICCs above 0.70 in all groups improving along with the number of cycles [Group A ICC 0.78 (95%CI 0.66-0.86), Group B ICC 0.87 (95%CI 0.80-0.92) and Group C ICC 0.91 (95%CI 0.85-0.95)]. Inter-observer variability showed a high degree of concordance with ICCs above 0.95. We provide the closest approximation to real inter-cycle and inter-observer AFC variability expected in routine clinical practice.

Clinical application of a nomogram based on age, serum FSH and AMH to select the FSH starting dose in IVF/ICSI cycles: a retrospective two-centres study

OBJECTIVE

To externally validate a nomogram based on ovarian reserve markers as a tool to optimize the FSH starting dose in IVF/ICSI cycles.

STUDY DESIGN

A two-centres retrospective study including 398 infertile women undergoing their first IVF/ICSI cycle (June 2013-June 2014). IVF data were retrieved from two independent IVF centres in Italy (San Raffaele Hospital, Centre 1; Verona Hospital, Centre 2). A central lab for the routine measurement of AMH and FSH was used for both centres. All women were treated based on physical and hormonal characteristics according to locally adopted protocols. The nomogram was then retrospectively applied to the patients comparing the calculated starting dose to the one actually given.

RESULTS

In Centre 1, 64/131 women (48.8%) had an ovarian response below the target. While 45 of these patients were treated with a maximal FSH starting dose (≥225 IU), n=19/131 (14.5%) were treated with a submaximal dose. The vast majority of them (n=17/19) would have received a higher FSH starting dose by using the nomogram. Seventeen patients (n=17/131) had hyper response and about half of them would have been treated with a reduced FSH starting dose according to the nomogram. In Centre 2, 142/267 patients (53.2%) had an ovarian response below the target. While 136 of these were treated with a maximal FSH starting dose (≥225 IU), n=6/267 were treated with a submaximal dose. The majority of them (n=5/6) would have received a higher FSH starting dose. Thirty-two (n=32/267) patients had hyper response and more than half of them would have been treated with a reduced FSH dose.

CONCLUSION

In both Centres, applying the nomogram would have resulted in more appropriate FSH starting doses compared to the the ones actually given based on clinicians choices. The use of an objective algorithm based on patient's age, serum FSH and AMH levels may thus be an effective advice on the selection of the tailored FSH starting dose. Hence, the use of this easily available nomogram could increase the proportion of patients achieving the optimal ovarian response.

Chemotherapy-induced damage to ovary: mechanisms and clinical impact

Cancer is a major public health problem around the world. Currently, about 5% of women diagnosed with cancer are of reproductive age. These young survivors may face compromised fertility. The effects of chemotherapeutic agents on ovarian reserve and its clinical consequences are generally inferred from a variety of surrogate markers of ovarian reserve, all aiming to provide prognostic information on fertility or the likelihood of success of infertility treatment. Until recently, the mechanisms that are responsible for chemotherapy-induced ovarian damage were not fully elucidated. The understanding of these mechanisms may lead to targeted treatments to preserve fertility. In this manuscript, we will review the current knowledge on the mechanism of ovarian damage and clinical impact of chemotherapy agents on fertility.

Nomogram to predict the number of oocytes retrieved in controlled ovarian stimulation

OBJECTIVE

Ovarian reserve tests are commonly used to predict ovarian response in infertile patients undergoing ovarian stimulation. Although serum markers such as basal follicle-stimulating hormone (FSH) or random anti-Müllerian hormone (AMH) level and ultrasonographic markers (antral follicle count, AFC) are good predictors, no single test has proven to be the best predictor. In this study, we developed appropriate equations and novel nomograms to predict the number of oocytes that will be retrieved using patients' age, serum levels of basal FSH and AMH, and AFC.

METHODS

We analyzed a database containing clinical and laboratory information of 141 stimulated in vitro fertilization (IVF) cycles performed at a university-based hospital between September 2009 and December 2013. We used generalized linear models for prediction of the number of oocytes.

RESULTS

Age, basal serum FSH level, serum AMH level, and AFC were significantly related to the number of oocytes retrieved according to the univariate and multivariate analyses. The equations that predicted the number of oocytes retrieved (log scale) were as follows: model (1) 3.21-0.036×(age)+0.089×(AMH), model (2) 3.422-0.03×(age)-0.049×(FSH)+0.08×(AMH), model (3) 2.32-0.017×(age)+0.039×(AMH)+0. 03×(AFC), model (4) 2.584-0.015×(age)-0.035×(FSH)+0.038×(AMH)+0.026×(AFC). model 4 showed the best performance. On the basis of these variables, we developed nomograms to predict the number of oocytes that can be retrieved.

CONCLUSION

Our nomograms helped predict the number of oocytes retrieved in stimulated IVF cycles.

Cryopreservation of in vitro matured oocytes after ex vivo oocyte retrieval from gynecologic cancer patients undergoing radical surgery

Objective

The aim of this study was to report a case series of in vitro matured (IVM) oocyte freezing in gynecologic cancer patients undergoing radical surgery under time constraints as an option for fertility preservation (FP).

Methods

Case series report. University-based in vitro fertilization center. Six gynecologic cancer patients who were scheduled to undergo radical surgery the next day were referred for FP. The patients had endometrial (n=2), ovarian (n=3), and double primary endometrial and ovarian (n=1) cancer. Ex vivo retrieval of immature oocytes from macroscopically normal ovarian tissue was followed by mature oocyte freezing after IVM or embryo freezing with intracytoplasmic sperm injection.

Results

A total of 53 oocytes were retrieved from five patients, with a mean of 10.6 oocytes per patient. After IVM, a total of 36 mature oocytes were obtained, demonstrating a 67.9% maturation rate. With regard to the ovarian cancer patients, seven IVM oocytes were frozen from patient 3, who had stage IC cancer, whereas one IVM oocyte was frozen from patient 4, who had stage IV cancer despite being of a similar age. With regard to the endometrial cancer patients, 15 IVM oocytes from patient 1 were frozen. Five embryos were frozen after the fertilization of IVM oocytes from patient 6.

Conclusion

Immature oocytes can be successfully retrieved ex vivo from macroscopically normal ovarian tissue before radical surgery. IVM oocyte freezing provides a possible FP option in patients with advanced-stage endometrial or ovarian cancer without the risk of cancer cell spillage or time delays.

A double-blind randomised controlled trial on the effect of dehydroepiandrosterone on ovarian reserve markers, ovarian response and number of oocytes in anticipated normal ovarian responders

OBJECTIVE

To assess the effect of dehydroepiandrosterone (DHEA) on antral follicle count (AFC), ovarian response to a standard low dose of gonadotrophin stimulation and number of oocytes in anticipated normal responders undergoing in vitro fertilisation (IVF).

DESIGN

Randomised, double-blind, placebo-controlled study.

SETTING

Tertiary reproductive unit.

POPULATION

Seventy-two subfertile women with AFC of 5-15 scheduled for IVF.

METHODS

Eligible women were randomised into the DHEA group (n = 36), who received DHEA (GNC(®) , 25 mg three times a day), or the placebo group (n = 36), who received placebo, starting from 12 weeks before the scheduled IVF treatment according to a computer-generated randomisation list. Monthly assessment of AFC, serum anti-Mullerian hormone (AMH) and follicle-stimulating hormone (FSH) levels, ovarian response to a standard dose of gonadotrophin stimulation at week 8 and the number of oocytes obtained were compared.

MAIN OUTCOME MEASURES

The primary outcome was AFC after 12 weeks of DHEA or placebo.

RESULTS

DHEA for 12 weeks prior to IVF treatment in anticipated normal responders leads to significantly higher serum and follicular DHEA-S and testosterone relative to placebo. However, no significant differences in AFC, AMH and FSH, ovarian response to standard-dose ovarian stimulation and IVF cycle outcomes can be detected.

CONCLUSION

No significant differences in AFC, ovarian response to a standard low dose of gonadotrophin stimulation and number of oocytes obtained were detected in anticipated normal responders receiving 12 weeks of DHEA prior to IVF treatment relative to placebo.

TWEETABLE ABSTRACT

No difference in ovarian response markers in normal responders receiving 12 weeks of DHEA.

Outcomes of ovarian stimulation after treatment with chemotherapy

PURPOSE

Chemotherapeutic agents have a known gonadotoxic effect; however, it is difficult to predict the impact they may have on ovarian stimulation. The objective of this study was to evaluate response to ovarian stimulation in patients exposed to chemotherapy compared with patients who were chemotherapy-naïve.

METHODS

A retrospective cohort study of 130 patients with cancer or autoimmune disease was performed. Demographics, ovarian reserve, ovarian response and stimulation parameters, and oocyte data were compared between patients who were pre- and post-chemotherapy. Logistic regression modeling was performed to identify risk factors for cancellation and low oocyte yield, adjusting for confounders as appropriate.

RESULTS

Antral follicle count (AFC) was significantly lower in post-chemo patients (9 vs. 17, p < 0.001). Post-chemotherapy patients were more likely to be cancelled during stimulation (23 vs. 4 %, p = 0.003). Among those that went to retrieval, there was no difference in total number of oocytes (10 vs. 10, p = 0.31) or mature oocytes retrieved (8 vs. 8, p = 0.38), despite higher starting (300 vs. 450 IU, p < 0.001) and total gonadotropin (3075 vs. 4612.5 IU, p = 0.008) doses in post-chemotherapy patients. Low AFC (≤6) was associated with cycle cancellation (OR 7.7, 95 % CI 1.8-33.2) and low oocyte yield (<6) (OR 5.4, 95 % CI 1.6-17.7).

CONCLUSIONS

Patients post-chemotherapy have lower AFC compared with the chemotherapy-naïve and have higher cancellation rates. Among those who underwent oocyte retrieval, oocyte yield was similar in both groups. Low AFC was most strongly associated with cycle cancellation and oocyte yield. Post-chemotherapy patients had higher rates of cycle cancellation but did equally well as pre-chemotherapy patients if they reached retrieval.

Diagnostic evaluation of the infertile female: a committee opinion

Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all relevant factors with initial emphasis on the least invasive methods for detection of the most common causes of infertility. The purpose of this committee opinion is to provide a critical review of the current methods and procedures for the evaluation of the infertile female, and it replaces the document of the same name, last published in 2012 (Fertil Steril 2012;98:302–7).

The correlations of anti-mullerian hormone, follicle-stimulating hormone and antral follicle count in different age groups of infertile women

Background

The objective of our study was to identify the correlations between the tests currently used in ovarian reserve assessment: anti-Mullerian hormone (AMH), follicle stimulating hormone (FSH) and antral follicle count (AFC) and to distinguish the most reliable markers for ovarian reserve in order to select an adequate strategy for the initial stages of infertility treatment.

Materials and Methods

In this prospective study, 112 infertile women were assessed. Subjects were divided into three age groups: group I <35 years (n=39), group II 35-40 years (n=31), and group III 41-46 years (n=42). AMH, FSH and AFC were determined on days 2-3 of the patients’ menstrual cycles.

Results

There was a significantly elevated negative correlation between age and AMH level (r_s=-0.67, p<0.0001) and AFC (r_s=-0.55, p<0.0001). We observed a significantly positive correlation between age and FSH (r_s=0.38, p<0.0001). AMH negatively correlated with FSH (r_s=-0.48, p<0.0001) and positively with AFC (r=-0.71, p=0.0001). There was a moderate negative relation between FSH and AFC (r=-0.41, p=0.0001) and moderate positive relation between age and FSH (r_s=0.38, p<0.0001). The correlation analysis performed in separate groups showed that AMH and AFC showed a statistically significant positive correlation for group I (r=0.57, p<0.0001), group II (r=0.69, p<0.0001) and group III (r=0.47, p<0.002). A statistically significant correlation between FSH and AMH was detected only in groups I (r=-0.41, p<0.02) and II (r=-0.55, p<0.0001). A statistically significant correlation existed between FSH and AFC only in group III (r=-0.42, p<0.006), as well as between age and AFC only in group I (r=-0.35, p<0.03).

Conclusion

Currently, AMH should be considered as the more reliable of the ovarian reserve assessments tests compared to FSH. There is a strong positive correlation between serum AMH level and AFC. The use of AMH combined with AFC may improve ovarian reserve evaluation.

Elevated day 3 follicle-stimulating hormone in younger women: is gonadotropin stimulation/intrauterine insemination a good option?

OBJECTIVE

The objective of the study was to determine the fecundity of young women (<35 years) with an elevated day 3 follicle stimulating hormone (FSH) undergoing gonadotropin-stimulation/intrauterine insemination.

STUDY DESIGN

This was a retrospective study. The study was conducted at an academic fertility center. A total of 1396 gonadotropin stimulation/intrauterine insemination cycles from 563 women were stratified by day 3 FSH levels (<10 vs ≥10 U/L) and outcomes were compared. Gonadotropin dose, treatment duration, peak estradiol (E2), number of preovulatory follicles (total, large, and medium size), E2/follicle, endometrial thickness, spontaneous abortion, clinical and multiple pregnancy rates were measured. The statistics included a Student t test, a χ(2), regression, and a discrete survival analysis.

RESULTS

An elevated day 3 FSH was found in 10.2% of the women, despite favorable age (31.9 ± 2.5 years). Women with a day 3 FSH of 10 U/L or greater when compared with women with a normal day 3 level required significantly more medication (1058.9 ± 1106.0 vs 632.7 ± 477.5 IU, P < .0001) were triggered a day earlier (10.6 ± 2.4 vs 11.5 ± 2.9 days, P = .0006) and had E2 levels (on the day of and the day prior to human chorionic gonadotropin administration) that were significantly higher (529.5 ± 244.3 vs 450.0 ± 244.2 and 359.6 ± 141.7 vs 306.8 ± 160.9 pg/mL, respectively, P < .05). Clinical pregnancy rates were comparable among the groups (14.6 vs 14%, respectively, P > .05). Spontaneous abortion and multiple pregnancy rates were higher among women with an FSH of 10U/L or greater but not significantly so (27.8% vs 12.0%, 22.2% vs 13.8% for FSH of ≥10 vs FSH < or >10 U/L, P > .05).

CONCLUSION

Women younger than 35 years with an elevated day 3 FSH, when treated aggressively with gonadotropins have pregnancy rates comparable with those of women with a normal baseline FSH. To achieve this outcome, they need higher doses of medication to stimulate the production of a larger preovulatory follicular cohort.

Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: from theory to practice

BACKGROUND

The main objective of individualization of treatment in IVF is to offer every single woman the best treatment tailored to her own unique characteristics, thus maximizing the chances of pregnancy and eliminating the iatrogenic and avoidable risks resulting from ovarian stimulation. Personalization of treatment in IVF should be based on the prediction of ovarian response for every individual. The starting point is to identify if a woman is likely to have a normal, poor or a hyper response and choose the ideal treatment protocol tailored to this prediction. The objective of this review is to summarize the predictive ability of ovarian reserve markers, such as antral follicle count (AFC) and anti-Mullerian hormone (AMH), and the therapeutic strategies that have been proposed in IVF after this prediction.

METHODS

A systematic review of the existing literature was performed by searching Medline, EMBASE, Cochrane library and Web of Science for publications in the English language related to AFC, AMH and their incorporation into controlled ovarian stimulation (COS) protocols in IVF. Literature available to May 2013 was included.

RESULTS

The search generated 305 citations of which 41 and 25 studies, respectively, reporting the ability of AMH and AFC to predict response to COS were included in this review. The literature review demonstrated that AFC and AMH, the most sensitive markers of ovarian reserve identified to date, are ideal in planning personalized COS protocols. These sensitive markers permit prediction of the whole spectrum of ovarian response with reliable accuracy and clinicians may use either of the two markers as they can be considered interchangeable. Following the categorization of expected ovarian response to stimulation clinicians can adopt tailored therapeutic strategies for each patient. Current scientific trend suggests the elective use of the GnRH antagonist based regimen for hyper-responders, and probably also poor responders, as likely to be beneficial. The selection of the appropriate and individualized gonadotrophin dose is also of paramount importance for effective COS and subsequent IVF outcomes.

CONCLUSION

Personalized IVF offers several benefits; it enables clinicians to give women more accurate information on their prognosis thus facilitating counselling especially in cases of extremes of ovarian response. The deployment of therapeutic strategies based on selective use of GnRH analogues and the fine tuning of the gonadotrophin dose on the basis of potential ovarian response in every single woman can allow for a safer and more effective IVF practice.

Ovarian stimulation in cancer patients

The patients referred for fertility preservation owing to a malignant disease do not represent the typical population of subfertile patients treated in IVF units. Cancer may affect multiple tissues throughout the body and can result in a variety of complications during controlled ovarian stimulation. Determination of the controlled ovarian stimulation protocol and gonadotropin dose for oocyte/embryo cryopreservation requires an individualized assessment. This review highlights the new protocols that are emerging to reduce time constraints and emphasizes management considerations to decrease complications.

Depressive symptomatology, psychological stress, and ovarian reserve: a role for psychological factors in ovarian aging?

OBJECTIVE

The aim of this study was to examine psychological factors in relation to antral follicle count (AFC), a marker of ovarian reserve, in a multiethnic sample of 683 premenopausal women in the Ovarian Aging (OVA) Study.

METHODS

In cross-sectional analyses, linear regression was performed to determine whether AFC decline across women varied over levels of depression as well as depression in combination with psychological stress. The total and subscale scores of the Center for Epidemiological Studies Depression Scale were used to measure depression, and the Perceived Stress Scale was used to measure psychological stress.

RESULTS

After covariate adjustment, the two-way interaction of age × positive affect and the three-way interaction of age × positive affect × stress were related to AFC (b = 0.047, P = 0.036; b = 0.012, P = 0.099, respectively). In stratified analyses, stress was related to AFC in women with low positive affect (b = -0.070, P = 0.021) but not in women with high positive affect (b = 0.018, P = 0.54). AFC decline across women was progressively higher in women with low positive affect who reported low (-0.747 follicles/year), mid (-0.920 follicles/year), and high (-1.112 follicles/year) levels of stress. Results examining the Center for Epidemiological Studies Depression Scale total and remaining subscale scores were all nonsignificant (P values > 0.05).

CONCLUSIONS

Cross-sectional evidence suggests that (1) women with low positive affect may experience accelerated AFC decline and (2) low positive affect may be a vulnerability factor, or, alternatively, high positive affect may be a protective factor, in moderating the negative effects of psychological stress on AFC decline.

Antral follicle count determines poor ovarian response better than anti-Müllerian hormone but age is the only predictor for live birth in in vitro fertilization cycles

PURPOSE

To determine the predictive value of serum anti-müllerian hormone (AMH) concentrations and antral follicle counts (AFC), on ovarian response and live birth rates after IVF and compare with age and basal FSH.

METHODS

Basal levels of AMH, FSH and antral follicle count were measured in 192 patients prior to IVF treatment. The predictive value of these parameters were evaluated in terms of retrieved oocyte number and live birth rates.

RESULTS

Poor responders in IVF were older, had lower AFC and AMH but higher basal FSH levels. In multivariate analysis AFC was the best and only independent parameter among other parameters and AMH was better than age and basal FSH to predict poor response to ovarian stimulation. Addition of AMH, basal FSH, age and total gonadotropin dose to AFC did not improve its prognostic reliability. Area under curve (AUC) for each parameter according to ROC analysis also revealed that AFC performed better in poor response prediction compared with AMH, basal FSH and age. The cut-off point for mean AMH and AFC in discriminating the best between poor and normal ovarian response cycles was 0.94 ng/mL (with a sensitivity of 70% and a specificity of 86%) and 5.5 (with a sensitivity of 91% and a specificity of 91%), respectively. However, age was the only independent predictor of live birth in IVF as compared to hormonal and ultrasound indices of ovarian reserve.

CONCLUSION

AFC is better than AMH to predict poor ovarian response. Although AMH and AFC could be used to predict ovarian response they had limited value in live birth prediction. The only significant predictor of the probability of achieving a live birth was age.

Testing and interpreting measures of ovarian reserve: a committee opinion

Currently, there is no uniformly accepted definition of decreased ovarian reserve (DOR), as the term may refer to three related but distinctly different outcomes: oocyte quality, oocyte quantity, or reproductive potential. Available evidence concerning the performance of ovarian reserve tests is limited by small sample sizes, heterogeneity among study design, analyses and outcomes, and the lack of validated outcome measures.

Psychological stress and reproductive aging among pre-menopausal women

BACKGROUND

Life history models suggest that biological preparation for current versus longer term reproduction is favored in environments of adversity. In this context, we present a model of reproductive aging in which environmental adversity is proposed to increase the number of growing follicles at the cost of hastening the depletion of the ovarian reserve over time. We evaluated this model by examining psychological stress in relation to reproductive aging indexed by antral follicle count (AFC), a marker of total ovarian reserve. We hypothesized that stress would be related to (i) higher AFC in younger women, reflecting greater reproductive readiness as well as (ii) greater AFC loss across women, reflecting more accelerated reproductive aging.

METHODS

In a multi-ethnic, community sample of 979 participants [ages 25-45 (mean (standard deviation) = 35.2 (5.5)); 27.5% Caucasian] in the Ovarian Aging study, an investigation of the correlates of reproductive aging, the interaction of age-x-stress was assessed in relation to AFC to determine whether AFC and AFC loss varied across women experiencing differing levels of stress. Stress was assessed by the perceived stress scale and AFC was assessed by summing the total number of antral follicles visible by transvaginal ultrasound.

RESULTS

In linear regression examining AFC as the dependent variable, covariates (race/ethnicity, socio-economic status, menarcheal age, hormone-containing medication for birth control, parity, cigarette smoking, bodymass index, waist-to-hip ratio) and age were entered on step 1, stress on step 2 and the interaction term (age-x-stress) on step 3. On step 3, significant main effects showed that older age was related to lower AFC (b = -0.882, P = 0.000) and greater stress was related to higher AFC (b = 0.545, P = 0.005). Follow-up analyses showed that the main effect of stress on AFC was present in the younger women only. A significant interaction term (b = -0.036, P = 0.031) showed the relationship between age and AFC varied as function of stress. When the sample was divided into tertiles of stress, the average follicle loss was -0.781, -0.842 and -0.994 follicles/year in the low-, mid- and high-stress groups, respectively.

CONCLUSIONS

Psychological stress was related to higher AFC among younger women and greater AFC decline across women, suggesting that greater stress may enhance reproductive readiness in the short term at the cost of accelerating reproductive aging in the long term. Findings are preliminary, however, due to the cross-sectional nature of the current study.

The value of human chorionic gonadotropin stimulation test in predicting ovarian response during in-vitro fertilization

PURPOSE

To assess the predictive value of human Chorionic Gonadotropin (hCG) theca-stimulation test for ovarian reserve in women undergoing in-vitro fertilization (IVF) treatments.

METHODS

39 women were included in the study. All participants received a single hCG 10000 IU injection on cycle day 2-3. Serum levels of estradiol, testosterone, androstenedione and 17-OH progesterone were measured prior to the injection and on days 1, 3 and 7 following the injection. hCG-induced hormone levels were compared with ovarian response during the subsequent IVF cycle.

RESULTS

There were 11 good responders (>10 oocytes) and 22 low responders (<3 oocytes). Before hCG stimulation serum E2 levels were higher in low responders compared to good responders (370.3 ± 443 vs. 138.3 ± 54 pmol/ml). Following hCG stimulation, day 3 androstendione levels showed an increase in good responders compared to low responders. The ratio between day 3 androstendione and day 0 estradiol was significantly different between the two groups (p = 0.03). ROC analysis of this test revealed area = 0.837 (good prediction), which was much better than day 3 FSH (area = 0.635, poor prediction).

CONCLUSIONS

These preliminary results demonstrate the potential use of the hCG theca stimulation test in differentiating between good and poor responders. Larger series are needed for further verification of the test in routine clinical application.

Fertility and age

The changing social scenario together with economic growth and an increase in job opportunities has to a great extent reduced gender inequality and has resulted in more and more older women seeking help from infertility clinics. Fertility and aging have always been closely linked and the age of the female partner remains the single most important factor in predicting success with treatment. Although tests for the ovarian reserve are an important informative tool and are helpful in selecting treatment options, they are poor predictors of the outcome.

The correlation of the antral follicle count and Serum anti-mullerian hormone

OBJECTIVE

To compare the value of the basal serum anti-Müllerian hormone (AMH) level with most of the established ovarian reserve tests.

MATERIAL AND METHODS

A total of 141 infertile women was studied prospectively. On cycle day 3, serum levels of AMH, inhibin B, estradiol (E), FSH and LH levels were measured, and the number of early antral follicles (2-6 mm in diameter) estimated at ultrasound scanning to compare the strengths of hormonal-follicular correlations.

RESULTS

The mean age of the participants was 29.18±5.54. The mean AMH and total AFC on day 3 were 2.23±1.90 ng/ml and 8.35±2.83, respectively. Serum AMH levels were more tightly correlated (p<0.001) with number of the early antral follicle count (r=0.467, p<0.0001) than age and serum levels of FSH (r=-0.400, p<0.001; r=-0.299, p<0.001 respectively). No correlation was detected between serum levels of inhibin B, E2, and LH (r=0.154, p=0.06; p=0.31; r=-0.085 and r=0.067, p=0.42) and AFC.

CONCLUSION

Serum AMH levels showed a strong correlation with AFC, and also this correlation is stronger than the other ovarian reserve parameters.

The cohort of antral follicles measuring 2-6 mm reflects the quantitative status of ovarian reserve as assessed by serum levels of anti-Müllerian hormone and response to controlled ovarian stimulation

OBJECTIVE

To evaluate the relationship between serum anti-Müllerian hormone (AMH) and antral follicle size, and to ascertain which cohort of antral follicles is most predictive of the response to controlled ovarian stimulation during assisted reproduction treatment (ART).

DESIGN

Prospective study.

SETTING

University-based Assisted Conception Unit.

PATIENT(S)

One hundred thirteen women undergoing first cycle of ART.

INTERVENTION(S)

Transvaginal 3D-ultrasound assessment and venipuncture in the early-follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Serum AMH levels, number of mature oocytes retrieved and poor ovarian response.

RESULT(S)

The antral follicle cohorts measuring 2 to 3 mm, >3 to 4 mm, >4 to 5 mm, and >5 to 6 mm were most significantly correlated with AMH (r = .30, .27, .30, and .41, respectively) and the number of mature oocytes retrieved (r = .28, .23, .29, and .34, respectively). Although these follicle cohorts of 2-6 mm were significant predictors of the number of mature oocytes retrieved on regression analysis, their discriminative ability (area under the curve [AUC]: 0.829) for the prediction of poor ovarian response was similar to total counts made using cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm (AUCs: 0.794, 0.812, 0.852, and 0.826, respectively).

CONCLUSION(S)

The number of antral follicles measuring 2 to 6 mm is most reflective of the quantitative ovarian reserve. However, the ability of this group of antral follicles to predict poor ovarian response appears similar to that of the follicular cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm.

Antral follice counts (AFC) predict ovarian response and pregnancy outcomes in oocyte donation cycles

PURPOSE

Antral follicle count (AFC) is used as a marker of ovarian response. We assessed its value in predicting pregnancy outcomes in ovum donation cycles by retrospective review.

METHODS

Oocyte donors (n = 94) underwent ovarian hyperstimulation using rFSH and GnRH-antagonists. Recipients were synchronized using GnRH-agonist down-regulation followed by fixed dose of estrogen and progesterone following hCG. Outcomes measured included correlation of AFC to pregnancy outcomes and cycle characteristics in those with and without clinical and ongoing-delivered cycles.

RESULTS

AFC significantly correlated with clinical [Exp beta 1.12; 95% CI: 1.02-1.23, p < 0.05] and ongoing-delivered pregnancy [Exp beta 1.10; 95% CI: 1.01-1.20, p < 0.05]. Significantly greater AFC, total and M-2 oocytes, and cycles resulting in cryopreserved embryos were seen in clinical and ongoing-delivered cycles.

CONCLUSIONS

AFC predicts cycle stimulation responses and clinical outcomes and may serve as a guide for dosing protocols and in choosing to proceed with the most optimal cycle.

Ultrasound tests of ovarian reserve; a systematic review of accuracy in predicting fertility outcomes

We conducted a systematic review of studies evaluating the diagnostic accuracy of all the ultrasound based tests of ovarian reserve, including antral follicle count (AFC), ovarian volume and stromal blood flow in predicting fertility outcomes and, where appropriate, performed a meta-analysis to determine the predictive_value at each cut-off value described in the literature. Included in the analysis were 17 studies for AFC, six studies for ovarian volume and six studies for stromal blood flow. Meta-analyses showed that women with AFC less than four were 8.7 times more likely not to get pregnant after IVF (two studies; 95% CI, 2.4-31.7) than women with AFC four or more. The sensitivity and specificity of AFC to predict cycle cancellation was 66.7% and 94.7%, respectively. Women with an AFC of less than four were 37 times (two studies; 95% CI, 13.68-100.45) more likely to have their cycle cancelled than women with AFC of four o r more. Ovarian volume measurement, at a cut off value of 3 cm3, showed specificity for prediction of cycle cancellation and non-pregnancy of 92% (three studies, 95% CI, 89-94) and 93% (three studies, 95% CI, 87-97), respectively. The clinical value of Doppler studies for ovarian stromal blood flow was unclear.

A strict infertility diagnosis has poor agreement with the clinical diagnosis entered into the Society for Assisted Reproductive Technology registry

Based on a recent review of the medical literature, a clinical diagnosis of infertility may not agree with strict criteria. Standardized definitions of diagnostic categories are essential for accurate patient prognosis and future research.

The antral follicle count: practical recommendations for better standardization

OBJECTIVE

To provide recommendations for the standardized use of the Antral follicle count (AFC) which is used to predict ovarian response to gonadotrophin stimulation during assisted reproductive technology treatment. However, the nature of the follicles that are visualized by ultrasound and the competence of the oocytes held within are largely unknown. In addition, there is considerable variability in the clinical definitions and technical methods used to count and measure antral follicles in both published studies and clinical practice.

DESIGN AND SETTING

In December 2007, specialist reproductive medicine clinicians and scientists attended a workshop in an effort to address these issues. Literature concerning the physiology and measurement of ovarian antral follicles was reviewed, clinical and technical considerations regarding antral follicle measurement were discussed, and an operational definition of AFC was developed.

PATIENT(S)

None.

INTERVENTION(S)

None.

OUTCOME MEASURES

Simple recommendations were established for the standardization of AFC assessment in routine clinical practice. The basic clinical and technical requirements required for AFC evaluation were agreed upon, and a systematic method of measuring and counting antral follicles in routine practice was proposed.

CONCLUSION(S)

The use of a standardized approach according to the practical recommendations for antral follicle counting as presented is encouraged in future clinical trials and routine practice. The authors also advocate a systematic evaluation of these recommendations as standardized study data become available.

Approaches to improve the diagnosis and management of infertility

BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.

Prediction of high ovarian response to controlled ovarian hyperstimulation: anti-Müllerian hormone versus small antral follicle count (2-6 mm)

PURPOSE

To evaluate the predictive value of basal serum anti-müllerian hormone level and small antral follicle count for high ovarian response to controlled ovarian hyperstimulation.

METHODS

A total of 159 patients were prospectively included. Basal serum anti-müllerian hormone and small antral follicle count (2-6 mm) were measured.

RESULTS

Small antral follicle count and anti-müllerian hormone have similar predictive accuracy for high ovarian response with area under curve of 0.961 and 0.922, respectively. The sensitivity and specificity for prediction of high ovarian response were 89% and 92% for small antral follicle count and 93% and 78% for anti-müllerian hormone at the cutoff values of > or = 16 and > or = 34.5 pmol/l, respectively.

CONCLUSIONS

Small antral follicle count and anti-müllerian hormone are equally accurate predictors of high ovarian response and facilitate determination of the optimal strategy for controlled ovarian hyperstimulation.

[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.