Female reproductive aging--ovarian and uterine factors

The rationale, design of the Assisted reproductive technology cohort nested in a pre-pregnancy family cohort (APP-Cohort)

INTRODUCTION

Infertility has become a major global issue due to the trend of delaying marriage and advanced maternal age. Family/Birth cohort studies are essential for exploring ways to enhance health outcomes at both the individual and societal levels. However, there is a shortage of cohorts that include families who have utilized assisted reproductive technology (ART), particularly initiated at the early stages before pregnancy. The Assisted Reproductive Technology Cohort (APP-Cohort) is a prospective study aiming to investigate the epidemiology and risk factors of adverse gestational outcomes and other health issues in couples who have conceived through ART or naturally.

METHODS

The cohort study's baseline survey commenced in January 2022 at several locations in Beijing, and enrollment is currently in progress. Both spouses filled out a questionnaire covering demographic, socio-economic, and various modifiable risk factors to gather information on their lifestyle. Physical examinations and biochemical tests were carried out, alongside regular yearly health check-ups throughout pregnancy and childhood. The survey data will be connected to electronic medical records to compile health information on the couples, newborns, and children.

DISCUSSION

The APP-Cohort study collected data from both wives and husbands before conception, allowing for early assessment of environmental risk factors for maternal and offspring health. With a focus on various types of risk factors such as genetic, environmental, and shared familial traits, the ongoing follow-up of this study will enable researchers to evaluate and distinguish the impacts of these factors on pregnancy outcomes, perinatal health, and children's health for individuals conceived naturally versus those conceived through ART. By utilizing practical experience and advanced mathematical analysis of the extensive data, the APP-Cohort study will provide valuable insights to promote the administration and success rate of ART in China.

Comparative analysis of superovulated versus uterine-embryo synchronized recipients for embryo transfer in cynomolgus monkeys (Macaca fascicularis)

Introduction

Assisted reproductive technologies (ARTs), such as intracytoplasmic sperm injection and embryo transfer, are essential for generating genetically edited monkeys. Despite their importance, ARTs face challenges in recipient selection in terms of time and the number of animals required. The potential of superovulated monkeys, commonly used as oocyte donors, to serve as surrogate mothers, remains underexplored. The study aimed to compare the efficacy of superovulated and uterine-embryo synchronized recipients of embryo transfer in cynomolgus monkeys (Macaca fascicularis).

Methods

This study involved 23 cynomolgus monkeys divided into two groups-12 superovulated recipients and 11 synchronized recipients. The evaluation criteria included measuring endometrial thickness on the day of embryo transfer and calculating pregnancy and implantation rates to compare outcomes between groups.

Results

The study found no statistically significant differences in endometrial thickness (superovulated: 4.48 ± 1.36 mm, synchronized: 5.15 ± 1.58 mm), pregnancy rates (superovulated: 30.8%, synchronized: 41.7%), and implantation rates (superovulated: 14.3%, synchronized: 21.9%) between the groups (p > 0.05).

Conclusion

The observations indicate that superovulated recipients are as effective as synchronized recipients for embryo transfer in cynomolgus monkeys. This suggests that superovulated recipients can serve as viable options, offering an efficient and practical approach to facilitate the generation of gene-edited models in this species.

Uterine Aging and Reproduction: Dealing with a Puzzle Biologic Topic

Uterine aging is the process of the senescence of uterine tissue, observed in all middle-aged mammals. Since the aging-related changes in the uterus are associated with infertility and poor pregnancy outcomes, with a lack of studies discussing uterine aging, authors reviewed uterine aging and its consequences on reproduction. MEDLINE, Scopus, and PubMed searches during the years 1990-2023 were performed using a combination of keywords and terms on such topics. According to the author's evaluation, articles were identified, selected, and included in this narrative review. The aging process has an unfavorable impact on the uterus of mammals. There are different and selected molecular pathways related to uterine aging in humans and animals. Uterine aging impairs the function of the uterine myometrium, neurofibers of the human uterus, and human endometrium. These biological pathways modulate oxidative stress, anti-inflammatory response, inflammation, mitochondrial function, DNA damage repair, etc. All these dysregulations have a role in poorer reproductive performance and pregnancy outcomes in older mammals. The most recent data suggest that uterine aging is accompanied by genetic, epigenetic, metabolic, and immunological changes. Uterine aging has a negative impact on the reproductive performance in mammalian species, but it could be potentially modulated by pharmacological agents, such as quercetin and dasatinib.

Endometrial receptivity in women of advanced age: an underrated factor in infertility

BACKGROUND

Modern lifestyle has led to an increase in the age at conception. Advanced age is one of the critical risk factors for female-related infertility. It is well known that maternal age positively correlates with the deterioration of oocyte quality and chromosomal abnormalities in oocytes and embryos. The effect of age on endometrial function may be an equally important factor influencing implantation rate, pregnancy rate, and overall female fertility. However, there are only a few published studies on this topic, suggesting that this area has been under-explored. Improving our knowledge of endometrial aging from the biological (cellular, molecular, histological) and clinical perspectives would broaden our understanding of the risks of age-related female infertility.

OBJECTIVE AND RATIONALE

The objective of this narrative review is to critically evaluate the existing literature on endometrial aging with a focus on synthesizing the evidence for the impact of endometrial aging on conception and pregnancy success. This would provide insights into existing gaps in the clinical application of research findings and promote the development of treatment options in this field.

SEARCH METHODS

The review was prepared using PubMed (Medline) until February 2023 with the keywords such as 'endometrial aging', 'receptivity', 'decidualization', 'hormone', 'senescence', 'cellular', 'molecular', 'methylation', 'biological age', 'epigenetic', 'oocyte recipient', 'oocyte donation', 'embryo transfer', and 'pregnancy rate'. Articles in a language other than English were excluded.

OUTCOMES

In the aging endometrium, alterations occur at the molecular, cellular, and histological levels suggesting that aging has a negative effect on endometrial biology and may impair endometrial receptivity. Additionally, advanced age influences cellular senescence, which plays an important role during the initial phase of implantation and is a major obstacle in the development of suitable senolytic agents for endometrial aging. Aging is also accountable for chronic conditions associated with inflammaging, which eventually can lead to increased pro-inflammation and tissue fibrosis. Furthermore, advanced age influences epigenetic regulation in the endometrium, thus altering the relation between its epigenetic and chronological age. The studies in oocyte donation cycles to determine the effect of age on endometrial receptivity with respect to the rates of implantation, clinical pregnancy, miscarriage, and live birth have revealed contradictory inferences indicating the need for future research on the mechanisms and corresponding causal effects of women's age on endometrial receptivity.

WIDER IMPLICATIONS

Increasing age can be accountable for female infertility and IVF failures. Based on the complied observations and synthesized conclusions in this review, advanced age has been shown to have a negative impact on endometrial functioning. This information can provide recommendations for future research focusing on molecular mechanisms of age-related cellular senescence, cellular composition, and transcriptomic changes in relation to endometrial aging. Additionally, further prospective research is needed to explore newly emerging therapeutic options, such as the senolytic agents that can target endometrial aging without affecting decidualization. Moreover, clinical trial protocols, focusing on oocyte donation cycles, would be beneficial in understanding the direct clinical implications of endometrial aging on pregnancy outcomes.

Facilitation of Ovarian Response by Mechanical Force-Latest Insight on Fertility Improvement in Women with Poor Ovarian Response or Primary Ovarian Insufficiency

The decline in fertility in aging women, especially those with poor ovarian response (POR) or primary ovarian insufficiency (POI), is a major concern for modern IVF centers. Fertility treatments have traditionally relied on gonadotropin- and steroid-hormone-based IVF practices, but these methods have limitations, especially for women with aging ovaries. Researchers have been motivated to explore alternative approaches. Ovarian aging is a complicated process, and the deterioration of oocytes, follicular cells, the extracellular matrix (ECM), and the stromal compartment can all contribute to declining fertility. Adjunct interventions that involve the use of hormones, steroids, and cofactors and gamete engineering are two major research areas aimed to improve fertility in aging women. Additionally, mechanical procedures including the In Vitro Activation (IVA) procedure, which combines pharmacological activators and fragmentation of ovarian strips, and the Whole Ovary Laparoscopic Incision (WOLI) procedure that solely relies on mechanical manipulation in vivo have shown promising results in improving follicle growth and fertility in women with POR and POI. Advances in the use of mechanical procedures have brought exciting opportunities to improve fertility outcomes in aging women with POR or POI. While the lack of a comprehensive understanding of the molecular mechanisms that lead to fertility decline in aging women remains a major challenge for further improvement of mechanical-manipulation-based approaches, recent progress has provided a better view of how these procedures promote folliculogenesis in the fibrotic and avascular aging ovaries. In this review, we first provide a brief overview of the potential mechanisms that contribute to ovarian aging in POI and POR patients, followed by a discussion of measures that aim to improve ovarian folliculogenesis in aging women. At last, we discuss the likely mechanisms that contribute to the outcomes of IVA and WOLI procedures and potential future directions.

Rescuing fertility during COVID-19 infection: exploring potential pharmacological and natural therapeutic approaches for comorbidity, by focusing on NLRP3 inflammasome mechanism

The respiratory system was primarily considered the only organ affected by Coronavirus disease 2019 (COVID-19). As the pandemic continues, there is an increasing concern from the scientific community about the future effects of the virus on male and female reproductive organs, infertility, and, most significantly, its impact on the future generation. The general presumption is that if the primary clinical symptoms of COVID-19 are not controlled, we will face several challenges, including compromised infertility, infection-exposed cryopreserved germ cells or embryos, and health complications in future generations, likely connected to the COVID-19 infections of parents and ancestors. In this review article, we dedicatedly studied severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) virology, its receptors, and the effect of the virus to induce the activation of inflammasome as the main arm of the innate immune response. Among inflammasomes, nucleotide oligomerization domain-like receptor protein, pyrin domain containing 3 (NLRP3) inflammasome pathway activation is partly responsible for the inflicted damages in both COVID-19 infection and some reproductive disorders, so the main focus of the discussion is on NLRP3 inflammasome in the pathogenesis of COVID-19 infection alongside in the reproductive biology. In addition, the potential effects of the virus on male and female gonad functions were discussed, and we further explored the potential natural and pharmacological therapeutic approaches for comorbidity via NLRP3 inflammasome neutralization to develop a hypothesis for averting the long-term repercussions of COVID-19. Since activation of the NLRP3 inflammasome pathway contributes to the damage caused by COVID-19 infection and some reproductive disorders, NLRP3 inflammasome inhibitors have a great potential to be considered candidates for alleviating the pathological effects of the COVID-19 infection on the germ cells and reproductive tissues. This would impede the subsequent massive wave of infertility that may threaten the patients.

Impairment of steroidogenesis and follicle development after bisphenol A exposure during pregnancy and lactation in the ovaries of Mongolian gerbils aged females

The ovaries regulate fertility and hormonal control in females, and aging is a crucial factor in this process, when ovarian function is drastically impacted. Exogenous endocrine disruptors may accelerate this process, acting as the main agents in decreased female fertility and hormonal imbalance, since they impact different features related to reproduction. In the present study, we demonstrate the implications of exposure of adult mothers to the endocrine disruptor bisphenol A (BPA) during pregnancy and lactation on their ovarian function during the transition to later in life (aging). The follicle population of BPA exposed ovaries showed impairment in the development of follicles to the mature stages, with growing follicles being halted in the early stages. Atretic and early-atretic follicles were also enhanced. Expression of estrogen and androgen receptors in the follicle population demonstrated impairment in signaling function: ERβ was highly expressed in follicles from BPA exposed females, which also showed a higher incidence of early atresia of developed follicles. ERβ1 wild-type isoform was also enhanced in BPA-exposed ovaries, compared to its variant isoforms. In addition, steroidogenesis was targeted by BPA exposure: aromatase and 17-β-HSD were reduced, whereas 5-α reductase was enhanced. This modulation was reflected in serum levels of estradiol and testosterone, which decreased in BPA-exposed females. Imbalances in steroidogenesis impair the development of follicles and play an important role in follicular atresia. Our study demonstrated that BPA exposure in two windows of susceptibility - gestation and lactation - had implications during aging, enhancing perimenopausal and infertile features.

A Preliminary Study on the Correlation Between Age and Endometrial Receptivity

Background

It is well established that female fertility declines with age, primarily because of loss of ovarian function. However, few studies have clarified the relationship between increasing age and endometrial receptivity. Here, we aimed to study the impact of age on endometrial receptivity, meanwhile, we examined the expression of endometrial mesenchymal stem cell (eMSC) surface markers (CD146 and PDGF-Rβ), essential for endometrial development and re-growth, in different age groups.

Methods

Participants were enrolled in this study between October 2020 and July 2021. All 31 patients were divided into three age groups; early (30-39 years old, n=10), intermediate (40-49 years old, n=12) and advanced (≥50 years old, n=9). We assessed localization and expression of CD146 and PDGF-Rβ by immunofluorescence and further analyzed selected endometrial receptivity markers (Homeobox A10 HOXA10, leukemia inhibitory factor LIF and osteopontin) and steroid hormone receptors by immunohistochemistry.

Results

There were no significant differences in expression of HOXA10 and OPN (p>0.05) among the three groups. However, we found a significant difference in LIF expression between the early and advanced age groups, with higher expression noted in the latter group (p=0.02). Similarly, estrogen receptor (ER) and progesterone receptor (PR) expression were significantly increased (p=0.01 and p=0.01, respectively) in the advanced age group compared with the early age group. There were no significant difference in CD146 and PDGF-Rβ expression among the three groups (p>0.05).

Conclusion

These results suggest that the age of the patient does not influence their endometrial receptivity. So, this study serves to increase our understanding of the impact of age and eMSCs on endometrial receptivity and expands the etiology of age-related infertility.

Epigenetic clocks provide clues to the mystery of uterine ageing

BACKGROUND

Rising maternal ages and age-related fertility decline are a global challenge for modern reproductive medicine. Clinicians and researchers pay specific attention to ovarian ageing and hormonal insufficiency in this regard. However, uterine ageing is often left out of the picture, with the majority of reproductive clinicians being close to unanimous on the absence of age-related functional decline in the uterine tissues. Therefore, most existing techniques to treat an age-related decline in implantation rates are based primarily on hormonal supplementation and oocyte donation. Solving the issue of uterine ageing might lead to an adjustment to these methods.

OBJECTIVE AND RATIONALE

A focus on uterine ageing and the possibility of slowing it emerged with the development of the information theory of ageing, which identifies genomic instability and erosion of the epigenetic landscape as important drivers of age-related decline in the functionality of most cells and tissues. Age-related smoothing of this landscape and a decline in tissue function can be assessed by measuring the ticking of epigenetic clocks. Within this review, we explore whether the uterus experiences age-related alterations using this elegant approach. We analyse existing data on epigenetic clocks in the endometrium, highlight approaches to improve the accuracy of the clocks in this cycling tissue, speculate on the endometrial pathologies whose progression might be predicted by the altered speed of epigenetic clocks and discuss the possibilities of slowing down the ticking of these clocks.

SEARCH METHODS

Data for this review were identified by searches of Medline, PubMed and Google Scholar. References from relevant articles using the search terms 'ageing', 'maternal age', 'female reproduction', 'uterus', 'endometrium', 'implantation', 'decidualization', 'epigenetic clock', 'biological age', 'DNA methylation', 'fertility' and 'infertility' were selected. A total of 95 articles published in English between 1985 and 2022 were included, six of which describe the use of the epigenetic clock to evaluate uterine/endometrium ageing.

OUTCOMES

Application of the Horvath and DNAm PhenoAge epigenetic clocks demonstrated a poor correlation with chronological age in the endometrium. Several approaches were suggested to enhance the predictive power of epigenetic clocks for the endometrium. The first was to increase the number of samples in the training dataset, as for the Zang clock, or to use more sophisticated clock-building algorithms, as for the AltumAge clock. The second method is to adjust the clocks according to the dynamic nature of the endometrium. Using either approach revealed a strong correlation with chronological age in the endometrium, providing solid evidence for age-related functional decline in this tissue. Furthermore, age acceleration/deceleration, as estimated by epigenetic clocks, might be a promising tool to predict or to gain insights into the origin of various endometrial pathologies, including recurrent implantation failure, cancer and endometriosis. Finally, there are several strategies to slow down or even reverse epigenetic clocks that might be applied to reduce the risk of age-related uterine impairments.

WIDER IMPLICATIONS

The uterine factor should be considered, along with ovarian issues, to correct for the decline in female fertility with age. Epigenetic clocks can be tested to gain a deeper understanding of various endometrial disorders.

Which assisted reproductive technology (ART) treatment strategy is the most clinically and cost-effective for women of advanced maternal age: a Markov model

Objective

To evaluate the clinical and cost-effectiveness of preimplantation genetic testing for aneuploidy, social freezing, donor and autologous assisted reproductive technology (ART) treatment strategies for women aged 35–45 following 6–12 months of infertility.

Methods

Four Markov decision-analytic models comprising: (i) Preimplantation genetic testing for aneuploidy (PGT-A); (ii) autologous ART from age 40 using oocytes cryopreserved at age 32 (social freezing); (iii) ART using donated oocytes (donor ART); (iv) standard autologous ART treatment (standard care) were developed for a hypothetical cohort of 35 to 45 years old ART naïve women with 6–12 months of infertility. Input probabilities for key parameters including live birth rates were obtained from the available literature. Deterministic and probabilistic sensitivity analyses were conducted to address uncertainty in estimating the parameters and around the model’s assumptions. Cost effectiveness was assessed from both societal and patient perspectives .

Result(s)

For infertile women at age 40 and above, social freezing is the most cost-saving strategy with the highest chance of a cumulative live birth at a lowest cost from a societal perspective. PGT-A and donor ART were associated with higher treatment costs and cumulative live-birth rates compared with the autologous ART. Among the four ART strategies, standard autologous ART has the lowest cumulative live birth rate of 45% at age 35 and decreasing to 1.6% by age 45 years. At a willingness-to-pay threshold of Australian dollars (A$)50,000, our model shows all alternative treatment strategies –PGT-A, social freezing and donor ART have a higher probability of being cost-effective compared to the standard autologous ART treatment. However, higher out-of-pocket expenditure may impede their access to these alternate strategies.

Conclusion

Given current evidence, all alternate strategies have a higher probability of being cost-effective compared to the standard autologous ART treatment. Whether this represents value for money depends on societal and individual’s willingness-to-pay for children conceived with ART treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08485-2.

Reproductive aging and telomeres: Are women and men equally affected?

Successful reproduction is very important for individuals and for society. Currently, the human health span and lifespan are the object of intense and productive investigation with great achievements, compared to the last century. However, reproduction span does not progress concomitantly with lifespan. Reproductive organs age, decreasing the levels of sexual hormones, which are protectors of health through their action on several organs of the body. Thus, this is the starting point of the organismal decay and infertility. This starting point is easily detected in women. In men, it goes under the surface, undetected, but it goes, nevertheless. Regarding fertility, aging alters the hormonal equilibrium, decreases the potential of reproductive organs, diminishes the quality of the gametes and worsen the reproductive outcomes. All these events happen at a different pace and affecting different organs in women and men. The question is what molecular pathways are involved in reproductive aging and if there is a possible halting or even reversion of the aging events. Answers to all these points will be explained in the present review.

Investigating the rate of different ovarian response in in vitro fertilization cycles based on estrogen receptor beta +1730 polymorphism: A cross-sectional study

Background

The response to ovarian stimulation is different among women referring for assisted reproductive techniques. This difference could be due to different genotypes in genes related to reproduction such as estrogen receptor beta (ERβ or ESR2) gene.

Objective

In the present study, we explored the rate of ESR2 gene polymorphism in infertile women undergoing IVF treatment with different ovarian response to ovulation induction.

Materials and Methods

A cross-sectional study was performed among 91 infertile women. The relationship between genotype distribution of the +1730 G/A polymorphism in the ESR2 gene (rs4986938) and the mean number of follicles and oocytes, their mean ratio, mean number of embryos, mean size of the follicles and pregnancy rates were measured. The ESR2 gene +1730 G/A polymorphism were identified by the amplification-refractory mutation system-polymerase chain reaction.

Results

Genotypes GG, GA, and AA of the ESR2 gene presented frequencies of 27.5%, 67%, and 5.5%, respectively, in the infertile women. The results of the study showed that the mean number of follicles and oocytes, their mean ratio, mean number of embryos, mean size of the follicles, and pregnancy rates are not related to different genotypes.

Conclusion

According to the endocrine and paracrine factors which are involved in the ovulation induction and maturation of oocytes, more studies with higher number of participants are required to confirm the results of the present study; in addition, further studies are required to find out other gene polymorphisms affecting estrogen receptor efficacy in the infertile women.

Predictive factors for successful pregnancy in an egg-sharing donation program

Objective

To investigate the predictive factors for successful pregnancy in oocyte recipient ICSI cycles in an egg-sharing donation program.

Methods

Analysed data were obtained via chart review of 1505 vitrified oocytes donated from 268 patients to 225 oocyte recipients, undergoing 307 ICSI cycles. Patients were participating in an egg-sharing donation program between January 2015 and May 2017. Adjusted generalised linear models were used to investigate the impact of oocyte donor and recipient characteristics on recipients’ pregnancy achievement.

Results

Implantation rate in the oocyte donor was highly correlated with pregnancy achievement in the oocyte recipient’s cycles (ExpB: 1.181, CI: 1.138-1.226, p<0.001). The ROC curve analysis demonstrated that the implantation rate in the oocyte donor has a strong predictive value for pregnancy success in the oocyte recipient (area under the curve: 0.98, CI: 0.95-0.99, p<0.001). Pregnancy in oocyte donors and recipients were highly associated (ExpB: 54.6, CI: 28.1-105.8, p<0.001), regardless of the oocyte recipient’s age. In oocyte recipients, the high-quality embryos rates on days 2 (ExpB: 3.397, CI: 1.635-7.054, p=0.001) and 3 (ExpB: 6.629, CI: 1.185-37.092, p=0.031), and blastocyst development rates (ExpB: 2.331, CI: 1.086-5.001, p=0.030) were positively associated with pregnancy outcome.

Conclusion

The strong association in pregnancy success between donors and recipients, and the lack of correlation between donor characteristics and cycles’ outcomes, demonstrate the power of oocyte quality on the success of ICSI treatment.

Impact of advanced paternal age on the intracytoplasmic sperm injection (ICSI) outcomes in donor egg cycles

Background

The purpose of this study is to assess the impact of paternal age on the oocyte-donation outcomes in intracytoplasmic sperm injection (ICSI) cycles.

Methods

Two hundred and seventy-eight infertile couples were retrospectively involved. Inclusion criteria were: infertility from almost 1 year, normal or sub-fertile seminal parameters, overall oocyte survival rate greater than 85%. Baseline characteristics included male age, recipient age, male body mass index (BMI), smoking, drinking status. Main outcome measures: fertilization rate (FR), cleavage rate (CR), pregnancy rate (PR).

Results

Patients were categorized in group 1 ≤45, group 2 >45 years. A total of 1,724 frozen oocytes were included. After warming, 1,642 oocytes survived. Median overall oocyte survival rate was 100% [interquartile range (IQR), 85-100%]. Median male age was 44±5.60 years (IQR, 31-70 years). Median recipients age was 42±3.62 years (IQR, 29-50 years). Group 1 included 166 men, group 2 112 men. Two hundred and seventy-eight fresh ICSI cycle were performed. "Two-pronuclear" (2PN) FR was 72.6%±0.20%, CR 93.0%±0.16%, PR 39.6%. Miscarriage rate was 25.5%. Live birth rate per cycles was 29.5%. Comparison between group 1, group 2 and ICSI outcomes confirmed an association with FR, resulting 80.0% (IQR, 67.0-83.0%) and 67.0% (IQR, 50.0-80.0%), respectively (P<0.01). There were no significant differences between the two groups with respect to seminal parameters.

Conclusions

It would be recommended more emphasis on the advancing male age when counselling older couples who undergo egg donation program.

Effects of maternal age on embryo quality and pregnancy outcomes using testicular sperm with intracytoplasmic sperm injection

Objective

The aim of this study was to evaluate the influence of maternal age on fertilization, embryo quality, and clinical pregnancy in patients undergoing intracytoplasmic sperm injection (ICSI) using testicular sperm from partners with azoospermia.

Methods

A total of 416 ICSI cycles using testicular spermatozoa from partners with obstructive azoospermia (OA, n=301) and non-obstructive azoospermia (NOA, n=115) were analyzed. Female patients were divided into the following age groups: 27 to 31 years, 32 to 36 years, and 37 to 41 years. The rates of fertilization, high-quality embryos, clinical pregnancy, and delivery were compared across maternal age groups between the OA and NOA groups.

Results

The rates of fertilization and high-quality embryos were not significantly different among the maternal age groups. Similarly, the clinical pregnancy and delivery rates were not significantly different. The fertilization rate was significantly higher in the OA group than in the NOA group (p<0.05). Age-group analysis revealed that the fertilization and high-quality embryo rates were significantly different between the OA and NOA groups in patients aged 27 to 31 years old, but not for the other age groups. Although the clinical pregnancy and delivery rates differed between the OA and NOA groups across all age groups, significant differences were not observed.

Conclusion

In couples using testicular sperm from male partners with azoospermia, pregnancy and delivery outcomes were not affected by maternal age. However, women older than 37 years using testicular sperm from partners with azoospermia should be advised of the increased incidence of pregnancy failure.

The Effect of Preimplantation Genetic Screening on Implantation Rate in Women over 35 Years of Age

OBJECTIVE

Advanced maternal age (AMA) is an important factor in decreasing success of assisted reproductive technology by having a negative effect on the success rate of intra-cytoplasmic sperm injection (ICSI), particularly by increasing the rate of embryo aneuploidy. It has been suggested that the transfer of euploid embryos increases the implantation and pregnancy rates, and decreases the abortion rate. Preimplantation genetic screening (PGS) is a method for selection of euploid embryos. Past studies, however, have reported different results on the success of pregnancy after PGS in AMA. Investigating the pregnancy rate of ICSI with and without PGS in female partners over 35 years of age referred to infertility centers in Tehran.

MATERIALS AND METHODS

In this randomized controlled trial, 150 couples with the female partner over age of 35 were included. Fifty couples underwent PGS and the remaining were used as the control group. PGS was carried out using fluorescent in situ hybridization (FISH) for chromosomes 13, 18, 21, X and Y. Results of embryo transfer following PGS were evaluated and compared with those in the control group.

RESULTS

Implantation rates obtained in the PGS and control groups were 30 and 32% respectively and not significantly different (P>0.05).

CONCLUSION

PGS for chromosomes 13, 18, 21, X and Y does not increase implantation rate in women over 35 years of age and therefore the regular use of PGS in AMA is not recommended.

Assisted reproduction: Ethical and legal issues

Since inception, the use of assisted reproductive technologies (ART) has been accompanied by ethical, legal, and societal controversies. Guidelines have been developed to address many of these concerns; however, the rapid evolution of ART requires their frequent re-evaluation. We review the literature on ethical and legal aspects of ART, highlighting some of the most visible and challenging topics. Of specific interest are: reporting of ART procedures and outcomes; accessibility to ART procedures; issues related to fertility preservation, preimplantation genetic testing, gamete and embryo donation, and reproductive outcomes after embryo transfer. Improvements in ART reporting are needed nationally and worldwide. Reporting should include outcomes that enable patients to make informed decisions. Improving access to ART and optimizing long-term reproductive outcomes, while taking into account the legal and ethical consequences, are challenges that need to be addressed by the entire community of individuals involved in ART with the assistance of bioethicists, legal counselors, and members of society in general.

Pregnancy outcome of non-anonymous oocyte donation: a case-control study

OBJECTIVE

To evaluate the maternal and neonatal outcome of non-anonymous oocyte donation compared to in vitro fertilization. Study design We compared 84 oocyte donation pregnancies with a 251 matched in vitro fertilization cohort. Maternal and neonatal outcomes were retrieved from a nationwide perinatal registry. Oocyte donation and in vitro fertilization pregnancies were matched for maternal age, study center, ZIP code and embryo transfer date. Both maternal and neonatal complications and outcome were compared between oocyte donation and in vitro fertilization with univariate and multivariate logistic regression analyses, adjusting for maternal age, donor age, socio-economic status, ethnicity, and parity.

RESULTS

In total, 277 women underwent 541 oocyte donation cycles. The median recipient age was 34.9 years (IQR: 31.5-38.5), while the median donor age was 34.4 years (IQR: 31.7-37.0). Clinical pregnancy rate was 26.6%, which is comparable to standard in vitro fertilization treatment. Donor age in years (OR 0.93, 95% CI 0.88-0.99) and a previous pregnancy of the recipient (OR 1.69, 95% CI 1.02-2.78) were significantly associated with clinical pregnancy rate. Both singleton and multiple oocyte donation pregnancies were associated with pregnancy-induced hypertension compared with in vitro fertilization singleton and multiple pregnancies (OR 1.99, 95%CI 1.02-3.89, OR 6.43, 95% CI 1.67-24.72, respectively). No significant differences in neonatal outcome were observed.

CONCLUSION

Oocyte donation pregnancies are associated with an increased incidence of pregnancy-induced hypertension compared with age-matched in vitro fertilization controls. However, no significant differences in neonatal outcome were observed between oocyte donation and in vitro fertilization.

Effect of local endometrial injury on pregnancy outcomes in ovum donation cycles

OBJECTIVE

To evaluate the effect of local endometrial injury (LEI) on clinical outcomes in ovum donation recipients.

DESIGN

Retrospective cohort analysis of ovum donation cycles conducted from 2005 to 2012.

SETTING

Two private IVF centers.

PATIENT(S)

Total 737 ovum donation cycles.

INTERVENTION(S)

LEI by endometrial "scratch" with the use of a Pipelle catheter.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth rates.

RESULT(S)

No statistically significant differences were found in clinical pregnancy rates and live birth rates in cycles subjected to LEI compared with those without. Combination of LEI with fibroid uterus resulted with significantly higher clinical pregnancy rates compared with LEI in normal uterine anatomy.

CONCLUSION(S)

This is the first study done in ovum recipients who underwent LEI by a "scratch" procedure after failed implantation. Unlike most previous reports, which found improved pregnancy rates with the use of "scratch effect" or "minor endometrial injury" after repeated implantation failures in standard IVF with own eggs, we did not find any changes in implantation rates in a population of egg recipients following this procedure. In view of a possible positive effect of LEI in cycles with a previous four or more failures, prospective randomized controlled studies are warranted to better define the target population who may benefit from this intervention.

Predictors of twin live birth following cryopreserved double embryo transfer on day 3

PURPOSE

To determine embryo and cycle-specific parameters associated with twin live birth in day 3 cryopreserved double embryo transfer (DET) cycles, and to propose a new prediction model for external validation.

METHODS

All cycles with autologous or donor cryopreserved DET of day 3 embryos from 2002 to 2011 at a single academic institution with a singleton or twin live birth were included (n = 207). Patient characteristics, post-thaw embryo morphology and freeze-thaw parameters were compared between patients with a single and twin live birth.

RESULTS

Demographic characteristics were similar, except that patients delivering twins were younger at age of cryopreserved embryo transfer (CET), fewer were parous and more were anovulatory. Duration of embryo storage, time in culture post-thaw, endometrial thickness and use of assisted hatching were comparable. Six predictors of twin delivery were identified: patient age <35 year at CET, intact survival of the lead embryo, resumption of mitosis, 7-8 viable cells in the non-lead embryo, transfer of a lead embryo with ≥7 cells and a sum of ≥14 viable cells in the two transferred embryos. Regression modeling predicted a step-wise increase in the probability of twins with addition of each predictor; with all six present, the risk of twins was predicted to be 53 % and with none present, the risk decreased to 6 %.

CONCLUSIONS

The six identified variables associated with twin live birth following day 3 cryopreserved DET have been applied to derive a prediction model for estimating the risk of twin delivery. External validation of the model is required prior to clinical application.

A study of recipient related predictors of success in oocyte donation program

BACKGROUND:

Oocyte donation is an invaluable therapy for couples with impending or complete ovarian failure. In addition, oocyte donation affords a scientific opportunity to study the unique biologic participation of the uterus in the process of human embryo implantation.

AIM:

To identify the recipient variables that may have a significant impact on pregnancy outcome in order to optimize results of an oocyte donation program.

DESIGN AND SETTINGS:

A prospective study conducted from March 1, 2010 to March 31, 2011 at a private tertiary care IVF Clinic. Materials and methods A total of 270 recipients resulting in embryo transfer as a result of oocyte donation were enrolled. Clinical and Ongoing pregnancy rates, Implantation rates were calculated according to different age groups, Endometrial thickness, Indication, Day and number of embryos transferred. Data was evaluated as chi square analyses with comparative significance determined at P <.05.

RESULTS:

In recipients less than 40 years of age, higher ongoing pregnancy and implantation rates (41.9% and 24.6%) were seen as compared to recipients above 40 years (21.8% and 13.18%) respectively. Pregnancy and implantation rates increased with increasing endometrial thickness but the difference was not statistically significant. A higher ongoing pregnancy rate (40.9% vs.28.8%) and implantation rate (23% vs.19.6%) was demonstrated with Day 3 embryo transfer compared to Day 2 transfer.

CONCLUSION:

A declining endometrial receptivity may result in lower implantation and pregnancy rates in recipients above the age of 40 years, more pronounced after the age of 45 years. An endometrial thickness of >8 mm is considered ideal before transfer. Transfer of two selected embryos on day 3 yields a favorable pregnancy outcome with reduced multiple pregnancy rates. Recipient's age above 45 years has negative impact on pregnancy outcome whereas embryo transfers on Day 3 yields better pregnancy

Different ovarian response by age in an anti-Müllerian hormone-matched group undergoing in vitro fertilization

BACKGROUND

Recently, serum anti-Müllerian hormone (AMH) has been used as a good marker of ovarian response during in vitro fertilization (IVF). However, in the clinical setting, we felt that ovarian response was clearly different by age with the same AMH level. Then in this study we evaluated the relationship between serum AMH, age and parameters related to ovarian response and compared these parameters in regard to age within serum AMH-matched group.

METHODS AND RESULTS

The relationship of these parameters were evaluated retrospectively in patients undergoing their first IVF cycle under a GnRH agonist flare up protocol (n = 456) between October 2008 and October 2010 in our clinic. To understand the relations between variables described above, principal component analysis (PCA) was performed. PCA revealed patients' age was at the different dimension from serum AMH and other variables. Therefore at first we segregated all patients into Low, Normal and High responder groups by their serum AMH using cut-off value of receiver operator characteristics curve analysis. Secondary, we divided each responder group into four subgroups according to patients' age. The high aged subgroups required a significantly higher dose of gonadotropin and a longer duration of stimulation; however, they had significantly lower peak E2 and a smaller number of total oocytes as well as M2 oocytes compared to the low aged subgroups.

CONCLUSIONS

The influence of aging on the ovarian response was clearly seen in all groups; the ovarian response tended to decrease as patients' age increased with the same AMH level. Therefore serum AMH in combination with age is a better indicator than AMH alone.

Assisted hatching in assisted reproduction: a state of the art

The World Health Organization estimates that one in six couples experience some delay in conception and an increasing number require treatment by the assisted conception (AC) procedures of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).The implantation rate of embryos resulting from in vitro fertilization cycles is generally less than 20%. The exposure of oocytes and embryos to the artificial conditions of in vitro culture may have negative effects on the embryo's ability to undergo normal hatching, resulting in low rates of implantation following IVF and embryo transfer. Human embryos resulting from superovulation develop more slowly in vitro compared to embryos in vivo, manifest a relatively high degree of cytogenetic abnormalities and undergo cellular fragmentation. Artificially disrupting the zona pellucida is known as assisted hatching (AH) and there is some evidence that embryos that have undergone zona manipulation for assisted hatching tend to implant one day earlier than unhatched embryos. A variety of techniques have since been employed to assist embryo hatching, including partial mechanical zona dissection, zona drilling and zona thinning, making use of acid tyrodes, proteinases, piezon vibrator manipulators and lasers. This review will consider the impact of IVF conditions on zona pellucida physiology, zona hardening, different techniques of assisted hatching, who may benefit from assisted hatching and potential hazards.

Egg sharing for assisted conception: a window on oocyte quality

The steep decline in both natural fertility and success after assisted reproduction treatment with increasing maternal age is universally recognized. Large variations in the developmental competence of oocytes collected are seen during assisted cycles,and a link between the biological competence of oocytes retrieved and age has been confirmed. Patients who require donated oocytes can benefit from egg sharing programmes, in which a proportion of oocytes collected from selected patients aged 35 years undergoing conventional assisted reproduction treatment are shared with a matched recipient. The reproductive outcomes of the egg provider and recipient can thus be compared to quantify the significance of oocyte quality. Data gathered from two comparable treatment centres resulted in 285 pairs of egg sharing providers and their recipients that could be analysed statistically. The chief finding was donor pregnancy as a predictor of recipient pregnancy given embryo transfer (odds ratio 2.15, 95% confidence interval 1.33–3.46, P ≈ 0.002), despite an appreciably higher mean age of the recipients. The probability of a recipient pregnancy increased by almost 0.2. Such results strongly indicate the key importance of oocyte quality for a successful clinical outcome in egg sharing practices and assisted reproduction treatment more generally.

Routine morphological scoring systems in assisted reproduction treatment fail to reflect age-related impairment of oocyte and embryo quality

Routine morphological scoring systems in assisted reproduction treatment are based on parameters that presumably correlate with the biological quality of gametes and embryos, including chromosome abnormalities. Maternal age is a key factor predicting pregnancy and live birth, and it is therefore of considerable interest to identify age-related indicators of oocyte and embryo quality in assisted reproduction treatment. The purpose of this study was to examine whether routine morphological scoring systems reflect age-related impact on oocyte and embryo quality among 4587 couples undergoing their first assisted reproduction treatment. This study assessed over 43,000 oocytes, 25,000 embryos and 7900 transferred embryos and analysed the associations among the following parameters: number of oocytes retrieved, oocyte quality, including maturity, fertilization rates, embryo quality, based on morphological features, and treatment outcome. Advanced chronological age was found to be associated with fewer oocytes retrieved, fewer embryos available for cryopreservation, as well as lower pregnancy, implantation, live birth rates and a higher miscarriage rate. No age-related correlation was found between fertilization rates, oocyte or embryo quality. Routinely-used morphological scoring systems, such as assessment of blastomere count, shape and fragmentation, fail to reflect age-related impact on oocyte and embryo quality.

Reproductive ecology and the endometrium: physiology, variation, and new directions

Endometrial function is often overlooked in the study of fertility in reproductive ecology, but it is crucial to implantation and the support of a successful pregnancy. Human female reproductive physiology can handle substantial energy demands that include the production of fecund cycles, ovulation, fertilization, placentation, a 9-month gestation, and often several years of lactation. The particular morphology of the human endometrium as well as our relative copiousness of menstruation and large neonatal size suggests that endometrial function has more resources allocated to it than many other primates. The human endometrium has a particularly invasive kind of hemochorial placentation and trophoblast that maximizes surface area and maternal-fetal contact, yet these processes are actually less efficient than the placentation of some of our primate relatives. The human endometrium and its associated processes appear to prioritize maximizing the transmission of oxygen and glucose to the fetus over efficiency and protection of maternal resources. Ovarian function controls many aspects of endometrial function and thus variation in the endometrium is often a reflection of ecological factors that impact the ovaries. However, preliminary evidence and literature from populations of different reproductive states, ages and pathologies also suggests that ecological stress plays a role in endometrial variation, different from or even independent of ovarian function. Immune stress and psychosocial stress appear to play some role in the endometrium's ability to carry a fetus through the mechanism of inflammation. Thus, within reproductive ecology we should move towards a model of women's fecundity and fertility that includes many components of ecological stress and their effects not only on the ovaries, but on processes related to endometrial function. Greater attention on the endometrium may aid in unraveling several issues in hominoid and specifically human evolutionary biology: a low implantation rate, high rates of early pregnancy loss, prenatal investment in singletons but postnatal support of several dependent offspring at once, and higher rate of reproductive and pregnancy-related pathology compared to other primates, ranging from endometriosis to preeclampsia. The study of the endometrium may also complicate some of these issues, as it raises the question of why humans have a maximally invasive placentation method and yet slow fetal growth rates. In this review, I will describe endometrial physiology, methods of measurement, variation, and some of the ecological variables that likely produce variation and pregnancy losses to demonstrate the necessity of further study. I propose several basic avenues of study that leave room for testable hypotheses in the field of reproductive ecology. And finally, I describe the potential of this work not just in reproductive ecology, but in the resolution of broader women's health issues.

Controlled ovarian hyperstimulation interventions in infertile women aged 40 years or older undergoing in vitro fertilization

BACKGROUND

The success of in vitro fertilization (IVF) treatment depends on adequate follicle recruitment following controlled ovarian hyperstimulation (COH). Women aged 40 years or older have a reduced ovarian reserve and various treatment protocols have been proposed that aim to increase their ovarian response.

OBJECTIVES

To compare the effectiveness of different COH treatment interventions in women undergoing IVF aged 40 years or older.

SEARCH STRATEGY

MEDLINE, the Cochrane Library, and the Chinese Biomedical database were searched for randomized controlled trials (RCTs).

SELECTION CRITERIA

Only RCTs comparing one type of COH intervention with another in women undergoing IVF aged 40 years or older were included.

DATA COLLECTION AND ANALYSIS

Two authors independently searched the abstracts, identified relevant papers, assessed inclusion and trial quality, and extracted the relevant data.

MAIN RESULTS

Four trials involving 4 different comparison groups were included in the review and enrolled a total of 611 randomized subjects.

CONCLUSION

There was insufficient evidence to support the routine use of any particular COH intervention to manage infertile women aged 40 years or older undergoing IVF. More robust data from good quality RCTs with relevant outcomes are needed.

Preimplantation genetic screening in women of advanced maternal age caused a decrease in clinical pregnancy rate: a randomized controlled trial

BACKGROUND

Advanced maternal age (AMA) is an important parameter that negatively influences the clinical pregnancy rate in IVF, in particular owing to the increased embryo aneuploidy rate. It has thus been suggested that only transferring euploid embryos in this patient group would improve the pregnancy rate. The purpose of this study was to test whether employing preimplantation genetic screening (PGS) in AMA patients would increase the clinical pregnancy rate.

METHODS

We conducted a two-center, randomized controlled trial (RCT) to analyze the outcome of embryo transfers in AMA patients (>or=38 years of age) after PGS using FISH analysis for chromosomes X, Y, 13, 16, 18, 21 and 22. The PGS group was compared with a control group. The primary outcome measure was clinical pregnancy rate after 6-7 weeks of gestation per randomized patient.

RESULTS

The study was terminated early as an interim analysis showed a very low conditional power of superiority for the primary outcome. Of the 320 patients calculated to be included in the study, 56 and 53 patients were randomized into the PGS and control groups, respectively. The clinical pregnancy rate in the PGS group was 8.9% (95% CI, 2.9-19.6%) compared with 24.5% (95% CI, 13.8-38.3%) in the control group, giving a difference of 15.6% (95% CI, 1.8-29.4%, P = 0.039).

CONCLUSIONS

Although the study was terminated early, this RCT study provides evidence against the use of PGS for AMA patients when performing IVF.

TRIAL REGISTRATION NUMBER

ISRCTN38014610.

An experimental study on the effect of different types of textiles on conception

To study the effect of different types of textiles on conception. A total of 35 female dogs were divided into five equal groups: four test and one control. Each of the four test groups was dressed in one type of textile underpants made of either 100% polyester, 50/50% polyester-cotton mix, 100% cotton, or 100% wool. The pants were worn for 12 months. The dogs were followed during this period and for 6 months after removal of the pants by measuring the serum oestradiol 17beta and progesterone and by mating. Electrostatic potentials were also measured on the textile-covered skin. Eight bitches wearing polyester-containing textile showed diminished serum progesterone in the oestrus of the oestrous cycle, and did not conceive on mating or insemination. Five months after pants had been removed, serum progesterone of the eight dogs had normalised, and they conceived. Electrostatic potentials were detected on the skin of all dogs dressed in polyester-containing textile. The low serum progesterone and non-conception of the eight dogs could point to anovulation and failure of luteinisation. It is suggested that the electrostatic potentials detected on the skin create an 'electrostatic field' that inhibits the ovarian function. However, the effect proved to be reversible.

Potential use of biomarkers for analyzing interpopulation and cross-cultural variability in reproductive aging

OBJECTIVE

The aims of this study were (1) to document the extent of variability in physiological aspects of reproductive aging; (2) to outline those areas where more work is needed to expand our knowledge of this variability; (3) to outline available biomarkers that can be used to measure aspects of reproductive aging, such as ovarian reserve and declining hormone levels; and (4) to note potential problems with the use of these biomarkers in cross-cultural settings.

DESIGN

Literature review of English and French publications using PubMed with no date restrictions.

RESULTS

Substantial variability exists in both cultural and physiological aspects of reproductive aging and menopause. However, the extent of variability across populations for many areas of reproductive aging needs better documentation as well as explanation of sources of this variability. Several biomarkers exist for use in cross-cultural research, including ovarian characteristics such as ovarian volume, ovarian reserve, follicular development, and atresia, and levels of hormones such as follicle-stimulating hormone, inhibin B, and anti-mullerian hormone.

CONCLUSION

We urge that further work be undertaken to evaluate and describe variability in physiological aspects of reproductive aging in cross-cultural settings. Some problems exist in the use of biomarkers to record this variability, particularly in remote settings with few logistical resources.

Age-Related Structural and Metabolic Changes in the Pelvic Reproductive End Organs

In this work, we provide preliminary data and a review of the literature regarding normal structural and functional changes that occur in the aging uterus, ovary, testicle, and prostate gland. It is expected that such knowledge will help physicians to distinguish physiologic changes from pathologic changes at an early stage. We retrospectively reviewed pelvic magnetic resonance imaging (MRI) scans of 131 female and 79 male subjects ages 13 to 86 years to determine changes in volume of the uterus, ovary, and prostate gland with age. Scrotal ultrasound examinations of 150 male subjects ages 0 to 96 years also were analyzed retrospectively to determine changes in testicular volume with age. In addition, (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) scans of 145 male subjects ages 11 to 90 years were analyzed retrospectively to assess for changes in maximum standardized uptake value (SUV(max)) of the testicles with age. The uterus had a mean volume of 38.55 +/- 3.68 cm(3) at 17 to 19 years of age, increased to a peak volume of 71.76 +/- 19.81 cm(3) between 35 to 40 years, and then declined to 24.02 +/- 8.11 cm(3) by the eighth decade of life. The maximal ovarian volume per subject maintained a relatively stable size in early life, measuring 9.46 +/- 3.25 cm(3) during the second decade of life, 8.46 +/- 3.32 cm(3) in the mid-fourth decade of life, and 7.46 +/- 3.33 cm(3) at 45 years of age, after which it declined to 4.44 +/- 2.02 cm(3) by the late fifth decade of life. The ovaries were not identifiable on MRI in subjects beyond the sixth decade of life. The volume of the prostate increased from 23.45 +/- 6.20 cm(3) during the second decade of life to 47.5 +/- 41.59 cm(3) by the late eighth decade of life; the central gland of the prostate increased from 9.96 +/- 3.99 cm(3) to 29.49 +/- 28.88 cm(3) during the same age range. Mean testicular volume was 11.2 +/- 5.9 cm(3). Testicular volume increased with age from birth to 25 years. After age 25, there was a significant decline in the testicular volume. The mean SUV(max) for the testicles was 1.9 +/- 0.5. Testicular metabolic activity demonstrated an increasing trend until the age of 35 years. A plateau in SUV(max) was observed after the age of 35 years until the age of 65 years. A slight decrease in SUV(max) was observed after the age of 65 years. The pelvic structures of men and women change both structurally and functionally over the lifespan, and such changes can be quantified using ultrasound, MRI, and (18)F-FDG-PET.

Assessment of the proliferative status of epithelial cell types in the endometrium of young and menopausal transition women

BACKGROUND

We determined protein and mRNA expressions of markers of normal human endometrial proliferation and hypothesized that dysregulation of the endometrial response to estradiol (E(2)) and progesterone would be observed in the older menopausal transition (MT) women compared with mid-reproductive age (MRA) controls.

METHODS

Endometrial biopsies were prospectively obtained from MRA and MT non-randomized healthy volunteers during proliferative (+/- exogenous E(2)) and secretory (MRA only) menstrual cycle phases. mRNA and/or nuclear protein expressions of proliferative markers (MKI67, PCNA and MCM2), cell-cycle regulators (cyclins A1, E1 and D1 and cyclin dependent kinase Inhibitor B; CCNA1, CCNE1, CCND1 and CDKN1B) and sex-steroid receptors [estrogen receptor (ER) and progesterone receptor (PR)] were assessed in endometrial lumen, gland and stroma.

RESULTS

MRA women had significantly higher proliferative than secretory expression of MKI67, PCNA, MCM2, CCNA1, CCNE1, ESR1 and PGR in lumen and gland (minimal stromal changes), whereas CDKN1B protein expression was higher during the secretory phase. E(2)-treatment of MT women led to relatively less MKI67 glandular protein expression compared with MRA women; no other age-related differences were observed.

CONCLUSION

Although the MT does not appear to alter the proliferative cell phenotype of endometrial epithelium and stroma, the data suggest that prior to the MT, age is associated with a decrease in some proliferative markers and steroid receptor expression status within different endometrial cell types.

Gonadotropin stimulation demonstrates a ceiling effect on in vitro fertilization outcomes

OBJECTIVE

To determine the effect of number of oocytes retrieved and number of 2PN embryos developed on in vitro fertilization (IVF) outcomes.

DESIGN

Retrospective data analysis.

SETTING

University practice.

PATIENT(S)

Reproductive-aged women (n = 467).

INTERVENTION(S)

First fresh nondonor cycle of IVF.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate

RESULT(S)

Clinical pregnancy rates increase until age 30 (odds ratio (OR) 1.72 per year (95% confidence interval 1.19-2.49)) before demonstrating a linear decline. In subjects < 37 years old, maximal clinical pregnancy rates are seen when 20 oocytes were retrieved (OR 1.03 (0.96-1.11)), five 2-pronuclei (2PN) embryos developed (OR 1.91 (1.29-2.87)), and no more than two embryos transferred (OR 0.72 (0.56-0.92) for each additional embryo transferred > 2). In subjects > or = 37 years old, maximum clinical pregnancy rates were achieved in subjects who had ten oocytes retrieved (OR 1.09 (1.01-1.18)), 20 2PN embryos developed (OR 1.29 (1.03-1.62)), and no more than two embryos transferred (OR 0.72 (0.56-0.92) for each additional embryo transferred > 2).

CONCLUSION(S)

The odds of achieving a successful clinical pregnancy with IVF are greatest with retrieval of approximately 20 oocytes, transfer of no more than 2 embryos, and the development of about five 2PN embryos in women < 37 years old and ten 2PN embryos in women > or = 37 years old.

The clomiphene citrate challenge test versus the exogenous follicle-stimulating hormone ovarian reserve test as a single test for identification of low responders and hyperresponders to in vitro fertilization

OBJECTIVE

This study was designed to compare the exogenous FSH ovarian reserve test (EFORT) versus the clomiphene citrate challenge test (CCCT), basal FSH, and basal inhibin B, with respect to their ability to predict poor and/or hyperresponders in an IVF population.

DESIGN

Prospective randomized controlled trial.

SETTING

Fertility center of a university hospital.

PATIENT(S)

One hundred ten patients undergoing their first IVF cycle, randomized into two groups.

INTERVENTION(S)

Fifty-six patients underwent a CCCT, and 54 patients underwent an EFORT. In all patients, the test was followed by an IVF treatment.

MAIN OUTCOME MEASURE(S)

Ovarian response, expressed by the total number of retrieved oocytes.

RESULT(S)

Univariate logistic regression showed that the best predictor for poor response is the CCCT (area under receiver operator characteristic curve [ROC-AUC] = 0.87), with maximal accuracy of 0.89. Multiple logistic regression analysis did not produce a better model in terms of improving the prediction of poor response. For hyper response, univariate logistic regression showed that the best predictor is the inhibin B increment in the EFORT (ROC-AUC = 0.92) but with a low maximal accuracy of 0.78. Again, multiple logistic regression analysis did not produce a better model in terms of predicting hyper response.

CONCLUSION(S)

Our study, the first which compares the CCCT with the EFORT for the prediction of poor and hyperresponders, shows that the CCCT is superior for identification of low responders. The EFORT (inhibin B increment) is superior for prediction of hyper response at the cost of a high rate of false positives. Neither of the two tests seems adequate to act alone for identification of both poor and hyperresponders.

The effect of women's occupational psychologic stress on outcome of fertility treatments

OBJECTIVE

The objective of this study was to examine the possible association between women's occupational stress and outcome of fertility treatments.

METHODS

A prospective cohort study was performed, including a consecutive group of 75 working women with a female fertility problem attending fertility clinics between the years 1999 and 2000. A structured questionnaire measuring burnout, job strain, and job satisfaction was used. Workload was assessed by number of working hours and shift work.

RESULTS

Women who perceived their job as more demanding were less likely to conceive (relative risk [RR], 0.6; 95% confidence interval [CI] = 0.42-0.96). Actual workload, measured by full-time versus part-time job, was found among women who conceived to be significantly associated with less likelihood to successfully complete a pregnancy (RR, 0.3; 95% CI = 0.11-0.96).

CONCLUSIONS

An inverse association was found between perceived higher workload and conceiving. The likelihood to deliver after fertility treatment was associated with less working hours.

Live birth after IVF in a 46-year-old woman

Pregnancies after IVF have been reported in women aged > or =44 years, but nobody older than 45 years at oocyte retrieval delivered. We report a case of birth of a healthy child after IVF in a 46-year-old infertile woman. Ovarian stimulation was performed with clomiphene citrate, 150 mg daily for 5 days. Three oocytes were retrieved and one embryo was replaced. The patient delivered a healthy male infant after Caesarean section at 39 weeks. A successful pregnancy after IVF with homologous oocytes can be achieved in women older than 45 years. At this age IVF is not a cost-effective treatment compared with oocyte donation, but it may be offered in countries in which gamete donation is forbidden.

Developmental potential of aged oocyte rescued by nuclear transfer following parthenogenetic activation and in vitro fertilization

Mouse oocyte aged in vitro cannot develop normally following activation. To investigate the roles of nucleus or cytoplasm elements in oocyte aged in vitro process and their subsequent development capability following activation, we reconstructed oocytes with MII chromosome spindle and cytoplasm from aged and fresh oocytes by nuclear transfer. The subsequent developmental potential after parthenogenetic activation (PA) or in vitro fertilization (IVF) was evaluated. After nuclear transfer, more than 75.6% of karyoplast and cytoplast pairs can be fused and reconstructed oocytes have a normal haploid karyotype. Following PA, aged oocytes cannot develop beyond four-cell stage, reconstructed oocytes from fresh nucleus and aged cytoplasm developed to blastocyst with a low percentage (9.1%). Instead, blastocyst formation rate of reconstructed oocyte from aged nucleus and fresh cytoplasm was higher (60.0%). Following IVF, zygote with diploid karyotype can be formed from zona pellucida (ZP)-free oocyte. After cultured in vitro, aged oocytes cannot develop beyond two-cell; reconstructed oocytes from fresh nucleus and aged cytoplasm developed to blastocyst with low percentage (15.0%). However, high blastocyst formation rate (86.2%) can be obtained from reconstructed oocytes from aged nucleus and fresh cytoplasm. Furthermore, after embryo transfer, three viable pups have been obtained, although the efficiency is very low. These observation demonstrated that cytoplasm is more crucial than nucleus to aging process. Fresh cytoplasm could partly rescue nucleus susceptibility to apoptosis from aging in vitro.

Antral follicle count, anti-mullerian hormone and inhibin B: predictors of ovarian response in assisted reproductive technology?

OBJECTIVE

The objective of this study was to evaluate the relationship between anti-mullerian hormone (AMH), inhibin B and antral follicle count (AFC) with ovarian response.

DESIGN

Retrospective study.

SETTING

Fertility unit.

SAMPLE

AFC was recorded, and a serum sample obtained on day 3 from all patients undergoing in vitro fertilisation (IVF). Patients were given 300 IU/L recombinant follicle stimulating hormone (FSH; Gonal F). The following day blood samples were collected. METHODS Serum samples were assayed for FSH, AMH and inhibin B using commercial immunoassay kits and oestradiol using an in house assay.

MAIN OUTCOME MEASURES

Response to gonadotrophin stimulation and the number of eggs collected.

RESULTS

AFC was negatively correlated to age (r=-0.426, P < 0.001). Delta inhibin B (levels of inhibin B on day 4 minus day 3) had the best association to the number of eggs collected (r= 0.533, P < 0.001) followed by basal AMH (r= 0.51, P < 0.001) and AFC (r= 0.505, P < 0.001). The number of eggs fertilised was significantly associated with basal AMH (r= 0.592, P < 0.001) and inhibin B (r= 0.548, P < 0.001). AMH with a cutoff of 0.2 ng/mL had the best sensitivity (87%) and specificity (64%) in predicting poor response. A cumulative score using basal FSH, basal AMH, delta E2 (levels of oestradiol on day 4 minus day 3), delta inhibin B, AFC and age gives the best predictive statistics to identify poor responders with 87% sensitivity and 80% specificity and a positive likelihood ratio of 4.36.

CONCLUSION

Delta inhibin B had the best positive association with the number of eggs collected and basal AMH is the single best predictor of poor response. AFC has a significant association with the number of eggs collected and is predictive of clinical pregnancy. It is evident that a single parameter is of limited value in predicting ovarian response. However, we have demonstrated a cumulative score using all the above markers could be useful in predicting poor response.