IVF outcome in anovulatory infertility (WHO group 2)--including polycystic ovary syndrome--following previous unsuccessful ovulation induction

Impact of body mass index on assisted reproductive technology outcomes in patients with polycystic ovary syndrome: a meta-analysis

The effect of obesity on pregnancy outcomes of patients with polycystic ovary syndrome (PCOS) undergoing assisted reproductive technology (ART) remains unclear. As such, a meta-analysis of recent studies was conducted to probe the effect of being overweight or obese on ART pregnancy outcomes in patients with PCOS. PubMed, Embase, MEDLINE, Scopus and Web of Science were searched from inception to 22 July 2023 without language restrictions. The main indicators were: live birth rate, clinical pregnancy rate, spontaneous abortion rate and multiple pregnancy rate. Ten studies were analysed, with a combined sample size of 247,845. Among patients with PCOS undergoing ART who were overweight or obese, the live birth rate, clinical pregnancy rate, implantation rate and number of retrieved oocytes were lower than in normal-weight patients with PCOS, and the spontaneous abortion rate was higher than in normal-weight patients with PCOS. Obese patients with PCOS undergoing ART had a lower multiple pregnancy rate and a lower number of mature oocytes compared with normal-weight patients with PCOS. The data showed that, among patients with PCOS, being overweight or obese has a negative effect on ART pregnancy outcomes. This meta-analysis may inform guidelines for pregnancy with ART, and encourage overweight or obese patients with PCOS to lose weight.

Association between maternal polycystic ovarian syndrome undergoing assisted reproductive technology and pregnancy complications and neonatal outcomes: a systematic review and meta-analysis

BACKGROUND

Polycystic ovarian syndrome (PCOS) is recognized as the most prevalent endocrine disorder among women of reproductive age. While the utilization of assisted reproductive technology (ART) has resulted in favorable outcomes for infertility treatment in PCOS patients, the inherent pathophysiological features of the condition give rise to complications and consequences during pregnancy and delivery for both the mother and offspring. This study was to assess the correlation between maternal PCOS and various pregnancy complications and neonatal outcomes undergone ART.

METHODS

A systematic search was conducted on PubMed, EmBase, and the Cochrane Library to identify observational studies that investigated the association between PCOS and the risk of various pregnancy complications and neonatal outcomes, including gestational diabetes mellitus (GDM), hypertension in pregnancy (PIH), preeclampsia (PE), preterm birth, abortion, congenital malformations (CA), small for gestational age (SGA), large for gestational age (LGA), low birth weight (LBW), macrosomia, neonatal intensive care unit (NICU) admission and birth weight. Eligible studies were selected based on predetermined inclusion and exclusion criteria. The meta-analysis was conducted using Review Manager and Stata software, with odds ratios (ORs) or mean difference (MD), confidence intervals (CIs), and heterogeneity (I2) being calculated. The search was conducted up to March 2023.

RESULTS

A total of 33 studies with a combined sample size of 92,810 participants were identified. The findings indicate that PCOS is significantly associated with an increased risk of GDM (OR 1.51, 95% CI:1.17-1.94), PIH (OR 1.72, 95% CI:1.25-2.39), PE (OR 2.12, 95% CI:1.49-3.02), preterm birth (OR 1.29, 95% CI:1.21-1.39), and LBW (OR 1.29, 95% CI:1.14-1.47). In subgroup analyses, the risks of GDM (OR 1.80, 95% CI:1.23-2.62) and abortion (OR 1.41, 95% CI:1.08-1.84) were elevated in fresh embryo transferred (ET) subgroup, whereas elevated risk of PE (OR 1.82, 95% CI:1.17-2.83) and preterm birth (OR 1.31, 95% CI:1.21-1.42) was identified in frozen ET subgroup. Whatever with or without hyperandrogenism, patients with PCOS had a higher risk in preterm birth (OR 1.69, 95% CI: 1.31-2.18; OR 1.24, 95% CI:1.02-1.50) and abortion (OR 1.38, 95% CI:1.12-1.71; OR 1.23, 95% CI:1.06-1.43).

CONCLUSION

Our findings suggest that individuals with PCOS undergone ART are at a notably elevated risk for experiencing pregnancy complications and unfavorable neonatal outcomes. Nevertheless, to establish a definitive association between PCOS and pregnancy-related outcomes, it is necessary to conduct extensive prospective, blinded cohort studies and effectively control for confounding variables.

Serum steroid metabolome on the day of oocyte retrieval in women with polycystic ovarian syndrome and its association with pregnancy outcome of in vitro fertilization

Steroid hormone level is a crucial factor affecting the outcomes of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). The purpose of this study was to evaluate serum steroid metabolome on the day of oocyte retrieval in women with polycystic ovarian syndrome (PCOS) and explore whether specific steroids can be potential indicators to improve the prediction of pregnancy outcomes in PCOS patients undergoing IVF/ICSI. In this study, the serum levels of 21 steroids in 89 women with PCOS and 73 control women without PCOS on the day of oocyte retrieval of the first IVF/ICSI treatment cycle were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS). All patients subsequently received good-quality embryo transfer, and the correlation between their steroid profiles and pregnancy outcomes of the first embryo transfer (ET) was retrospectively analyzed. We found PCOS patients had aberrant levels of 11 out of 21 steroid hormones compared to control individuals, with androgen steroid hormones being considerably enhanced. Enzyme activity evaluation indicated that PCOS women might have abnormal activity of CYP17A1, CYP21A2, CYP11B2, CYP19A1, HSD3B, HSD11B, and HSD17B. Additionally, the level of 18-hydroxycorticosterone (p = 0.014), corticosterone (p = 0.035), and 17-hydroxypregnenolone (p = 0.005) were markedly higher in live birth group than in non- live birth group for PCOS women following frozen embryo transfer (FET). Multiple logistic regressions indicated that 18-hydrocorticosterone and 17-hydroxypregnenolone were independently associated with live birth outcomes of PCOS women following FET. Receiver operating characteristic (ROC) curve analysis revealed that 0.595ng/mL for 18-hydrocorticosterone level (AUC: 0.6936, p = 0.014).and 2.829ng/mL for 17-hydroxypregnenolone level (AUC: 0.7215, p = 0.005) were the best cutoff values to predict live birth outcomes of PCOS. In conclusion, the blood steroid metabolome was closely related to the IVF/ICSI outcomes of PCOS patients. 18-hydroxycorticosterone and 17-hydroxypregnenolone might be potential indicators to predict pregnancy outcomes of PCOS undergoing IVF/ICSI treatment. AVAILABILITY OF DATA AND MATERIALS: The data used in the current study are available from the database of Women's Hospital, School of Medicine, Zhejiang University on reasonable request.

Molecular Features of Polycystic Ovary Syndrome Revealed by Transcriptome Analysis of Oocytes and Cumulus Cells

Polycystic ovary syndrome (PCOS) is typically characterized by a polycystic ovarian morphology, hyperandrogenism, ovulatory dysfunction, and infertility. Furthermore, PCOS patients undergoing ovarian stimulation have more oocytes; however, the poor quality of oocytes leads to lower fertilization and implantation rates, decreased pregnancy rates, and increased miscarriage rates. The complex molecular mechanisms underlying PCOS and the poor quality of oocytes remain to be elucidated. We obtained matched oocytes and cumulus cells (CCs) from PCOS patients, compared them with age-matched controls, and performed RNA sequencing analysis to explore the transcriptional characteristics of their oocytes and CCs. Moreover, we validated our newly confirmed candidate genes for PCOS by immunofluorescence. Unsupervised clustering analysis showed that the overall global gene expression patterns and transposable element (TE) expression profiles of PCOS patients tightly clustered together, clearly distinct from those of controls. Abnormalities in functionally important pathways are found in PCOS oocytes. Notably, genes involved in microtubule processes, TUBB8 and TUBA1C, are overexpressed in PCOS oocytes. The metabolic and oxidative phosphorylation pathways are also dysregulated in both oocytes and CCs from PCOS patients. Moreover, in oocytes, differentially expressed TEs are not uniformly dispersed in human chromosomes. Endogenous retrovirus 1 (ERV1) elements located on chromosomes 2, 3, 4, and 5 are rather highly upregulated. Interestingly, these correlate with the most highly expressed protein-coding genes, including tubulin-associated genes TUBA1C, TUBB8P8, and TUBB8, linking the ERV1 elements to the occurrence of PCOS. Our comprehensive analysis of gene expression in oocytes and CCs, including TE expression, revealed the specific molecular features of PCOS. The aberrantly elevated expression of TUBB8 and TUBA1C and ERV1 provides additional markers for PCOS and may contribute to the compromised oocyte developmental competence in PCOS patients. Our findings may also have implications for treatment strategies to improve oocyte maturation and the pregnancy outcomes for women with PCOS.

Impact of body mass index on intracytoplasmic sperm injection in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a condition that affects fertility. There are two types of PCOS; the normal/lean type and overweight/obese type. The aim of this study was to assess baseline characteristics, ovarian response, quality of oocytes, embryos, pregnancy, implantation and live birth rates in normal/lean and overweight/obese patients with PCOS undergoing ICSI compared with patients without PCOS. This retrospective case-control analytical study included 38 normal/lean and 17 overweight/obese patients with PCOS, and 98 normal/lean and 17 overweight/obese patients without PCOS. Parameters were observed based on baseline characteristics, ovarian response to dosage and duration of gonadotropin administered, number of oocytes, matured oocytes, fertilization rate, embryo quality and development, pregnancy, implantation and live birth rates. Basal serum luteinizing hormone in normal/lean PCOS was significantly higher compared with non-PCOS groups. Total dosage of gonadotropin used was significantly lower in normal/lean PCOS compared with other groups. End estradiol levels in normal/lean PCOS was significantly higher compared with the non-PCOS groups. Number of follicles, retrieved oocytes and matured oocytes were significantly higher in PCOS groups compared with the non-PCOS groups. However, there were no differences in fertilized oocytes, cleavage, number of top-quality embryos, pregnancy, implantation, and live birth rates among groups. This present study suggests that normal/lean PCOS requires lower gonadotropin dosages and that patients with PCOS have more follicles and oocytes compared with patients without PCOS, however the number of fertilized oocytes and embryos from patients with PCOS were the same as those from patients without PCOS and suggested that the quality of retrieved oocytes in PCOS might be compromised.

Potential of Auraptene in Improvement of Oocyte Maturation, Fertilization Rate, and Inflammation in Polycystic Ovary Syndrome Mouse Model

Polycystic ovary with poor-quality oocytes has remained problematic in polycystic ovary syndrome (PCOS) patients. It is well documented that the inflammation and production of reactive oxygen species (ROS) in PCOS ovaries are significantly higher than normal voluntaries. In this study, we hypothesized that auraptene (AUR), as a coumarin derivative with anti-inflammatory properties, may be effective in improvement of oocyte maturation and fertilization rate in PCOS patients. For this purpose, PCOS model was induced in NMRI mice and confirmed by ovarian histopathology observations and hormonal assays. PCOS-induced mice were administrated with AUR (PCOS-AUR) and metformin (PCOS-MET), and their effects on inflammation, apoptosis rate, oocyte maturation, and in vitro fertilization capacity were determined and compared with those normal and PCOS animals treated with sesame oil (PCOS-sesame oil) and no treatment (PCOS). Treatment with AUR and MET decreased the inflammation and apoptosis rates in PCOS mice compared with PCOS animals with no treatment. PCOS-AUR and PCOS-MET oocytes also showed higher intracellular glutathione and lower ROS concentrations compared with PCOS mice, indicating improved oocyte maturation rate. PCOS-AUR and PCOS-MET groups showed higher percentages of expansion rate and MII stage oocytes, and lower rate of abnormal oocytes compared with PCOS with no treatment. The rate of fertilization in the oocytes isolated from PCOS-AUR and PCOS-MET groups was higher than PCOS-sesame oil and PCOS groups. Our findings suggest that AUR can be considered as a potential candidate for improvement of oocyte maturation and fertilization capacity in PCOS patients, comparable to MET.

Up-regulated FHL2 inhibits ovulation through interacting with androgen receptor and ERK1/2 in polycystic ovary syndrome

BACKGROUND

The ovulatory dysfunction mechanisms underlying polycystic ovary syndrome (PCOS) are not completely understood. There is no effective therapy for PCOS so far.

METHODS

We measured the expression of four and a half LIM domain 2 (FHL2) and other related-genes in human granulosa cells (hGCs) from patients with and without PCOS. To minimise the heterogeneity of patients with PCOS, we only included PCOS patients meeting all three criteria according to the revised Rotterdam consensus. The in vitro effects of FHL2 on ovulatory genes and the underlying mechanisms were examined in KGN cells. The role of FHL2 in ovulation was investigated in vivo by overexpressing FHL2 in rat ovaries via intrabursal lentivirus injection.

FINDINGS

Increased FHL2 and androgen receptor (AR) expression and decreased CCAAT/enhancer-binding protein β (C/EBPβ) expression were observed in hGCs from patients with PCOS. FHL2 inhibited the expression of ovulation-related genes, including phosphorylated ERK1/2, C/EBPβ, COX2 and HAS2 in KGN cells. It was partially by interacting with AR to act as its co-regulator to inhibit C/EBPβ expression and by binding to ERK1/2 to inhibit its phosphorylation. Moreover, FHL2 abundance in hGCs was positively correlated with the basal serum testosterone concentration of patients with PCOS, and dihydrotestosterone (DHT)-induced FHL2 upregulation was mediated by AR signalling in KGN cells. Additionally, lentiviral-mediated functional FHL2 overexpression in rat ovaries for 1 week contributed to an impaired superovulatory response, displaying decreased numbers of retrieved oocytes and a lower MII oocyte rate. 3-week FHL2 overexpression rat models without superovulation led to acyclicity and polycystic ovary morphology.

INTERPRETATION

Our findings provide novel insights into the mechanisms underlying the pathogenesis of PCOS, suggesting that FHL2 could be a potential treatment target for ovulatory obstacles in PCOS. FUND: National Key Research and Development Program of China, National Natural Science Foundation, National Institutes of Health project and Shanghai Commission of Science and Technology.

Transvaginal ovarian drilling followed by controlled ovarian stimulation from the next day improves ovarian response for the poor responders with polycystic ovary syndrome during IVF treatment: a pilot study

BACKGROUND

Poor response patients with PCOS who are not susceptible to gonadotropin stimulation are more likely to have canceled cycles or poor clinical outcomes during IVF treatment. However, some limitations exist in the present therapies. In this study, we evaluated the effects of using the transvaginal ovarian drilling (TVOD) followed by controlled ovarian stimulation (COS) from the second day of these poor responders.

METHODS

During IVF, 7 poor responders with PCOS and 28 PCOS patients (14 normal and 14 high responders) were recruited. All patients received COS with the gonadotropin-releasing hormone antagonist protocol. For the poor responders, after undergoing 10 to 14 days of ovulation induction with no response, the TVOD was applied and then ovarian stimulation was performed from the next day at the same gonadotropin dose. Serum samples during COS and follicular fluid samples from the dominant follicles on the oocyte pick-up (OPU) day in all three groups were collected. Besides, follicular fluid from small follicles (diameter < 1 cm) in the normal and high responders on the OPU day and those in the poor responders on the TVOD day were gathered. Hormonal levels were examined in all samples using immunometric assays.

RESULTS

All the poor responders restored ovary response after receiving TVOD. There was no significant difference in the stimulation duration, total gonadotrophin dose used and the clinical outcomes among the three groups. The body mass index, serum and follicular levels of anti-Müllerian hormone (AMH) and testosterone in poor responders were higher than those in the other two groups, and the application of TVOD significantly decreased the levels of AMH and testosterone in both serum and follicular fluid.

CONCLUSIONS

TVOD followed by ovulation induction from the next day is effective and convenient for poor responders with PCOS. The decline of AMH and testosterone resulted from TVOD may be the main reason resulting in the recovery of ovary sensitivity to gonadotropins. The small sample size is the primary limitation of this study, future studies using a large population cohort and monitoring the long-term outcomes of this strategy will be required.

TRIAL REGISTRATION

ChiCTR1900023612. Registered 04 June 2019-Retrospectively registered.

[Polycystic ovary syndrome does not affect blastulation nor cumulative live birth rates]

OBJECTIVES

Polycystic ovarian syndrome (PCOS) brings complications in the management of the assisted reproductive technology (ART) because of an oocyte quality probably impaired due to modifications of intra- and extra-ovarian factors. Our study aimed to investigate the extended culture in PCOS patients and its influence on the cumulative live birth rates.

METHODS

Fifty-nine PCOS patients (as defined by the Rotterdam criteria) and 114 normo-ovulatory patients (i.e. with tubal, male or idiopathic infertility, regular cycles and AMH>2ng/mL) aged<37years old who underwent a 1st or 2nd ART attempt with extended culture to day 6 were included from October 2015 to December 2017. The blastulation and cumulative live birth rates were compared between the two groups.

RESULTS

The PCOS and control patients were 32.22 and 32.91years old respectively (P=0.05). The median number of oocytes retrieved was significantly higher in the PCOS group and the median oocyte maturity rate significantly lower compared with controls. The blastulation rates were similar between the PCOS and the control groups, respectively 57.8% vs. 58.6%, P=0.88. Because of the risks of hyperstimulation syndrome, a freeze all strategy was achieved for 38.9% of PCOS patients vs. 14.0% of the control patients (P<0.01). The cumulative live birth rates were not statistically different: 31.7% in the PCOS group vs. 37.2% in the control group, P=0.50.

CONCLUSIONS

PCOS was not observed to affect the extended culture nor the cumulative live birth rates in comparison to normo-ovulatory patients, supporting the blastocyst transfer strategy as a suitable option to PCOS patients.

A meta-analysis of pregnancy-related outcomes and complications in women with polycystic ovary syndrome undergoing IVF

This meta-analysis aimed to study whether pregnancy-related outcomes and complications differed between patients with polycystic ovary syndrome (PCOS) and those with other causes of infertility who had undergone IVF. A systematic search of PubMed, Embase, the Cochrane Library and Chinese databases was carried out to identify relevant studies published before July 2018. Outcomes were expressed as odds ratios (OR) and 95% confidence intervals (CI). Subgroup analyses and sensitivity analyses were also conducted. Twenty-nine studies were identified for inclusion. Women with PCOS had higher risks of miscarriage (OR 1.41, 95% CI 1.04-1.91), ovarian hyperstimulation syndrome (OR 4.96, 95% CI 3.73-6.60), gestational diabetes mellitus (OR 2.67, 95% CI 1.43-4.98), pregnancy-induced hypertension (OR 2.06, 95% CI 1.45-2.91), preterm birth (OR 1.60, 95% CI 1.25-2.04) and large-for-gestational-age babies (OR 2.10, 95% CI 1.01-4.37). Women with PCOS showed similar rates of clinical pregnancy, multiple pregnancy, ectopic pregnancy, small for gestational age and congenital malformations, and a higher live birth rate, compared with women without PCOS. This study provides an update on and comprehensive evidence to support the observation that despite the fact that PCOS patients achieve a better live birth rate, physicians should continue to consider them to be at high risk of adverse pregnancy-related outcomes.

Can serum vaspin levels predict clomiphene resistance in infertile women with PCOS?

OBJECTIVE

To determine whether serum vaspin levels can predict the success of ovulation induction and clomiphene resistance in anovulatory women with PCOS.

STUDY DESIGN

We designed a prospective case control study. The study population (n=49) was composed of infertile women with PCOS who underwent ovulation induction with clomiphene citrate. Patients were divided into two groups based on their treatment response. Group I consisted of patients with failed ovulation induction, and group II consisted of patients with successful ovulation induction. The study group characteristics, including age, BMI, waist-to-hip ratio, parity, hormone profiles, fasting insulin and glucose levels, HOMA-IR, triglycerides, and cholesterol and serum vaspin levels, were compared between the study groups.

RESULT(S)

There were 29 patients in Group I with failed ovulation induction (59.2%), and Group II consisted of 20 patients with successful ovulation induction (40.8%). No differences in characteristics were found. However, serum vaspin levels were significantly lower in responders achieving ovulation (p=0.001; p<0.01). At a vaspin level of 3.74, the sensitivity, specificity, positive predictive and negative predictive values were 90%, 72.4%, 69.2% and 91.3%, respectively. The odds ratio was determined to be 14.87 (95% CI: 3.41-64.88) as the cut-off point. No significant correlation was found in serum vaspin measurements between pregnant and non-pregnant patients who had achieved successful ovulation induction (p=0.5).

CONCLUSION(S)

Serum vaspin level may be a useful marker for the prediction of ovulation induction success in treatment with clomiphene citrate, and increased vaspin levels (≥3.74ng/mL) are correlated with clomiphene resistance in patients with PCOS according to our study results.

Effects of previous ovarian drilling on cumulative ongoing pregnancy rates among patients with polycystic ovarian syndrome undergoing in vitro fertilization

OBJECTIVE

To determine if history of undergoing laparoscopic ovarian drilling (LOD) was associated with changes in cumulative ongoing pregnancy rates following in-vitro fertilization in patients with polycystic ovary syndrome (PCOS).

METHODS

The present retrospective study was performed in an in vitro fertilization unit in Xiamen, China, between June 1, 2008 and December 31, 2012. Patient characteristics and in vitro fertilization treatment outcomes were compared between patients with PCOS and a history of LOD (LOD group), patients with PCOS without a history of LOD (no-LOD group), and age-matched patients without PCOS and with no history of LOD (age-matched group).

RESULTS

The study included 110 patients in the LOD group, 127 patients in the no-LOD group, and 990 patients in the age-matched group. A lower number of retrieved oocytes, fewer available embryos, and a lower number of cryopreserved embryos were observed in among patients in the LOD-group compared with the other groups (P≤0.001). No differences in birth rates following fresh embryo transfers were observed between the LOD-group, and the age-matched group (P=0.274) and the no-LOD group (P=0.120). A higher adjusted odds ratio of cumulative pregnancy per initiated in vitro fertilization cycle was observed in the no-LOD group when compared with the LOD group (1.976; 95% confidence interval 1.091-3.580).

CONCLUSION

LOD could compromise cumulative ongoing pregnancy rates during subsequent in vitro fertilization.

The impact of follicular fluid adiponectin and ghrelin levels based on BMI on IVF outcomes in PCOS

PURPOSE

This study aimed at evaluating the effects of polycystic ovary syndrome (PCOS) and body mass index (BMI) on follicular fluid (FF) adiponectin and ghrelin levels, and on in vitro fertilization outcomes in patients who underwent controlled ovarian hyperstimulation.

METHODS

This prospective cross-sectional study was performed with a total of 120 primary infertile women [group 1; non-PCOS = 60 (BMI <25 = 30, BMI ≥25 = 30) and group 2; PCOS = 60 (BMI <25 = 30, BMI ≥25 = 30)]. On the day of oocyte pickup, FF samples were collected.

RESULTS

The FF adiponectin levels were lower in the lean PCOS group than the lean non-PCOS group (p = 0.001), and these levels were lower in the overweight non-PCOS group compared to lean non-PCOS group (0.001). However, there was no difference in the FF ghrelin levels between the groups. Additionally, we could not find a relationship between clinical pregnancy and adiponectin and ghrelin levels.

CONCLUSION

The FF adiponectin and ghrelin levels have no effects on clinical pregnancy in PCOS. Therefore, further studies are needed to elucidate this issue.

Effect of body mass index and age on in vitro fertilization in polycystic ovary syndrome

OBJECTIVE

The aim of this study was to investigate age-related variations in the effect of body mass index (BMI) on in vitro fertilization (IVF) outcomes.

MATERIAL AND METHODS

This was a cohort study conducted by retrospectively investigating the IVF cycles of 653 polycystic ovary syndrome (PCOS) patients under the age of 40 years who were diagnosed based on the Rotterdam criteria in a private IVF clinic between 2005 and 2015. The study included data from 653 IVF cycles of PCOS patients. The patients were classified into three groups based on their BMI, i.e., normal weight (n=299), overweight (n=208), and obese (n=146). The patients were also grouped by age: 562 patients were under the age of 35 years and 91 patients were above the age of 35 years. Then, BMI- and age-related variations in the IVF cycle parameters and clinical pregnancy rates of patients with PCOS were investigated. The Mantel-Haenszel Chi-square statistical assessment method was used to determine whether the effect of BMI on IVF outcomes varies with age.

RESULTS

Variations in cycle variables with BMI and age showed that IVF cycles were negatively affected by increases in obesity and age. Clinical pregnancy rates were found to be lower in the obese group than in the other groups, particularly in the age group above 35 years; however, this difference could not be proven statistically.

CONCLUSION

The present study evaluated obesity and clinical pregnancy rates in IVF cycles in PCOS patients according to age groups, and particularly in the obese group, the clinical pregnancy rates were observed to be lower in the age group ≥35 years than in the other BMI groups; however, this difference was found to be statistically insignificant.

Direct effects of leptin and adiponectin on peripheral reproductive tissues: a critical review

Obesity is a risk factor for infertility and adverse reproductive outcomes. Adipose tissue is an important endocrine gland that secretes a host of endocrine factors, called adipokines, which modulate diverse physiologic processes including appetite, metabolism, cardiovascular function, immunity and reproduction. Altered adipokine expression in obese individuals has been implicated in the pathogenesis of a host of health disorders including diabetes and cardiovascular disease. It remains unclear whether adipokines play a significant role in the pathogenesis of adverse reproductive outcomes in obese individuals and, if so, whether the adipokines are acting directly or indirectly on the peripheral reproductive tissues. Many groups have demonstrated that receptors for the adipokines leptin and adiponectin are expressed in peripheral reproductive tissues and that these adipokines are likely, therefore, to exert direct effects on these tissues. Many groups have tested for direct effects of leptin and adiponectin on reproductive tissues including the testis, ovary, uterus, placenta and egg/embryo. The hypothesis that decreased fertility potential or adverse reproductive outcomes may result, at least in part, from defects in adipokine signaling within reproductive tissues has also been tested. Here, we present a critical analysis of published studies with respect to two adipokines, leptin and adiponectin, for which significant data have been generated. Our evaluation reveals significant inconsistencies and methodological limitations regarding the direct effects of these adipokines on peripheral reproductive tissues. We also observe a pervasive failure to account for in vivo data that challenge observations made in vitro. Overall, while leptin and adiponectin may directly modulate peripheral reproductive tissues, existing data suggest that these effects are minor and non-essential to human or mouse reproductive function. Current evidence suggests that direct effects of leptin or adiponectin on peripheral reproductive tissues are unlikely to factor significantly in the adverse reproductive outcomes observed in obese individuals.

miR-483-5p and miR-486-5p are down-regulated in cumulus cells of metaphase II oocytes from women with polycystic ovary syndrome

The aim of this study was to compare the expression of microRNAs (miRNAs) in cumulus cells from polycystic ovary syndrome (PCOS) and non-PCOS women. In the present study, miRNA expression profiles of the cumulus cell samples were determined by miRNA microarrays. Quantification of selected miRNAs and predicted target genes was performed using quantitative real-time PCR (qRT-PCR). The results showed that miR-483-5p and miR-486-5p are significantly decreased in cumulus cells of PCOS patients PCOS (fold change >2, false discovery rate <0.001). qRT-PCR found that four predicted genes, SOCS3, SRF, PTEN and FOXO1, were significantly increased in PCOS cumulus cells (all P < 0.001), and IGF2 (host gene of miR-483-5p) was significantly decreased in PCOS cumulus cells (P < 0.001). These results indicated that miR-483-5p might play an important role in reducing insulin resistance, and that miR-486-5p might promote cumulus cell proliferation through activation of PI3K/Akt. The findings from this study provided new insights into the complex molecular mechanisms involved in PCOS by revealing pathways possibly regulated by miRNAs. The differences in miRNAs (miR-483-5p, miR-486-5p) and their target gene expression in cumulus cells may provide clues for future research and help to explain aberrant follicular development and subfertility in women with PCOS.

Effect of body mass index on in vitro fertilization outcomes in women with polycystic ovary syndrome

OBJECTIVE

The objective of the investigation was to study the effect of body mass index (BMI) on in vitro fertilization (IVF) outcomes within a polycystic ovary syndrome (PCOS) population.

STUDY DESIGN

This was a retrospective cohort study including 101 cycles from 79 women younger than 40 years old with a clinically documented diagnosis of PCOS by Rotterdam criteria undergoing IVF at a university-based infertility clinic from 2001 through 2010. All participants were stratified by BMI calculated from height and weight recorded within 3 months of cycle start: lean (18.7-24.9 kg/m(2), n = 51), overweight (25-29.9 kg/m(2), n = 19), and obese (≥30 kg/m(2), n = 31). Linear, logistic, and Poisson regressions were used as appropriate to estimate the effect of a range of BMIs on IVF outcomes while adjusting for potential confounders.

RESULTS

Obese PCOS women had 69% lower odds of clinical pregnancy per cycle start (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.86; P = .02) and 77% lower odds of clinical pregnancy per embryo transfer (OR, 0.23; 95% CI, -0.08 to 0.68; P = .008) compared with lean PCOS women. Among obese PCOS women, the odds of live birth were 71% lower per cycle start (OR, 0.29; 95% CI, 0.10-0.84; P = .02) and 77% lower per embryo transfer (OR, 0.23; 95% CI, 0.07-0.71; P = .01) compared with lean PCOS women. There was a trend toward decreased ovarian hyperstimulation syndrome incidence with increasing BMI among women with PCOS: 19.6% in lean, 10.5% in overweight, and 3.2% in obese.

CONCLUSION

PCOS is a broad syndrome, with our results demonstrating 2 distinct populations, lean and obese, which have different IVF outcomes including ovarian hyperstimulation syndrome risk profiles. This information is important for clinicians because it informs treatment decisions.

Prolonged gonadotropin stimulation for assisted reproductive technology cycles is associated with decreased pregnancy rates for all women except for women with polycystic ovary syndrome

PURPOSE

To determine if etiology of infertility modifies the relationship between the duration of ovarian stimulation and success during assisted reproductive technology (ART) cycles.

METHODS

A prospectively collected database was analyzed in an academic infertility practice. Eight hundred and twelve infertile women undergoing their initial fresh embryo, non-donor in vitro fertilization (IVF) or Intracytoplasmic Sperm Injection ICSI) cycle between January 1999 and December 2010 were evaluated. Clinical pregnancy was the main outcome measured.

RESULTS

Out of 663 cycles resulting in oocyte retrieval, 299 produced a clinical pregnancy (45.1%). Women who achieved a clinical pregnancy had a significantly shorter stimulation length (11.9 vs. 12.1 days, p = 0.047). Polycystic ovary syndrome (PCOS) was the only etiology of infertility that was significantly associated with a higher chance for clinical pregnancy and was a significant confounder for the association of duration and success of treatment. Women with 13 days or longer of stimulation had a 34 % lower chance of clinical pregnancy as compared to those who had a shorter cycle (OR 0.66, 95% CI:0.46-0.95) after adjustment for age, ovarian reserve, number of oocytes retrieved, embryos transferred and PCOS diagnosis.

CONCLUSION

Prolonged duration of stimulation is associated with decreased ART success for all couples, except for women with PCOS.

Analyzing the possible involvement of anti-Müllerian hormone and anti-Müllerian hormone receptor II single nucleotide polymorphism in infertility

PURPOSE

We performed TaqMan genotyping assays of anti-Mullerian hormone (AMH) and anti-Mullerian hormone receptor type II (AMHRII) single nucleotide polymorphisms (SNPs) in order to investigate how their frequency and distribution affect infertility treatment outcome.

METHODS

Eighty Japanese women (advanced age: n = 51, endometriosis: n = 18, male infertility as a control: n = 11) who undertook ART were included in the study, and all couples underwent a full infertility investigation protocol. In order to investigate the natural distribution of SNPs, a naturally pregnant group of 28 subjects was recruited from among women who conceived naturally and subsequently delivered in our department. Genomic DNA was extracted from peripheral blood and genotyping was conducted by TaqMan genotyping assay. The relationship of AMH and AMHRII SNPs and treatment outcome in infertile women. Comparison of allele and genotype frequencies of infertile patients with naturally pregnant women.

RESULTS

AMHRII -482 A>G homozygote mutation was complicated with ISV 5-6 C>T homozygote mutation and showed a significantly lower oocyte retrieval rate compared with a wild type. Two of 3 cases of AMHRII -482 A>G homozygote mutation were poor responders, and the distribution and frequency of each allele of naturally pregnant women showed no statistical difference compared with infertile women.

CONCLUSIONS

This study revealed the possible involvement of AMHRII -482 A>G polymorphism on the malfunction of follicular development in Japanese women.

Update in polycystic ovary syndrome: new criteria of diagnosis and treatment in Japan

Polycystic ovary syndrome (PCOS) is the most frequent endocrine disorder in women of reproductive age. In 2006 the Japanese Society of Obstetrics and Gynecology (JSOG) proposed new, revised diagnostic criteria that in the future could also be valued internationally. Based on the new diagnostic criteria, the JSOG has also proposed the revised treatment criteria in 2008. In PCOS obese patients desiring children, weight loss and exercise is recommended. Nonobese patients, or those obese women who do not ovulate after lifestyle changes, are submitted to ovulation-induction therapy with clomiphene citrate (CC). Obese CC-resistant patients who have impaired glucose tolerance or insulin resistance are treated with a combination of metformin and CC. If these treatments options are unsuccessful, ovulation induction with exogenous gonadotropin therapy or laparoscopic ovarian drilling (LOD) is recommended. A low-dose step-up regimen is recommended with careful monitoring in order to reduce the risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. Alternatively, with LOD high successful pregnancy rates of around 60 % are expected with a low risk of multiple pregnancies. If ovulation induction is unsuccessful, IVF-ET treatment is indicated. In high OHSS-risk patients, systematic embryo freezing and subsequent frozen embryo transfer cycles are recommended. In nonobese, anovulatory PCOS patients not desiring children, pharmacological treatments such as Holmström, Kaufmann regimens or low-dose oral anticonceptives are used to induce regular withdrawal bleeding. These treatments are especially important for preventing endometrial hyperplasia and endometrial cancer. These new diagnostic and treatment criteria hopefully will contribute to an improved care of PCOS patients in Japan.

[Impact of polycystic ovary syndrome on oocyte and embryo quality]

This review analyzes the literature concerning oocyte and embryo quality, in case of in vitro fertilization (IVF) for women with polycystic ovary syndrome (PCOS). Alterations in oocyte quality, and consequently in embryo quality, may be due to endocrine and intra-ovarian paracrine changes. However, most of publications find similar biological and clinical results after IVF, with or without microinjection, for women with PCOS compared to those obtained in control populations. Subgroups of more pejorative outcome probably exist within PCOS population. Finally, obesity, which is frequent in PCOS, is clearly deleterious, and multidisciplinary care, including lifestyle modifications, is then needed.

Early initiation of gonadotropin-releasing hormone antagonist in polycystic ovarian syndrome patients undergoing assisted reproduction: randomized controlled trial ISRCTN69937179

PURPOSE

To compare the implantation rates in two groups of women with Polycystic Ovary Syndrome (PCOS) after embryo transfer based on the initiation time of GnRH antagonist. Secondary outcome measures included clinical pregnancy, delivery and miscarriage rates.

METHODS

This is a prospective, randomized trial in which 140 PCOS patients underwent ICSI, with 122 having ET performed. GnRH-antagonist was started on day 1 of stimulation in 69 patients (Group 1) or day 5 in 71 patients (Group 2).

RESULTS

The overall implantation rate in Group 1 (46.2 %) was clinically higher than Group 2 (35.5 %), although not statistically significant (p = 0.075). For blastocysts transfer, the implantation rate in Group 1 was 55.1 %, compared to 40.4 % in Group 2 (p = 0.051). There was a clinically, but not statistically, higher clinical pregnancy rate (68.3 % vs. 56.5 %) and delivery rate (60.0 % vs. 53.2 %) per transfer in Group 1 compared to Group 2, respectively. There was a statistically significant lower biochemical pregnancy rate in Group 1 (2.4 %) compared to Group 2 (18.6 %) [p = 0.015]. There was no difference in miscarriage rates between the two groups.

CONCLUSION

Our data suggest that early initiation of GnRH antagonist on day 1 of ovarian stimulation in PCOS patients undergoing ICSI-ET may improve implantation rates, especially after blastocyst transfer.

Complications and outcome of assisted reproduction technologies in overweight and obese women

BACKGROUND

Based on a presumed negative impact of overweight and obesity on reproductive capacity and pregnancy outcome, some national guidelines and clinicians have argued that there should be an upper limit for a woman's BMI to access assisted reproductive technologies (ART). However, evidence on the risk of complications or expected success rate of ART in obese women is scarce. We therefore performed a systematic review on the subject.

METHODS

We searched the literature for studies reporting on complications or success rates in overweight and obese women undergoing ART. Articles were scored on methodological quality. We calculated pooled odds ratios (ORs) to express the association between overweight and obesity on the one hand, and complications and success rates of ART on the other hand. We only pooled results if data were available per woman instead of per cycle or embryo transfer.

RESULTS

We detected 14 studies that reported on the association between overweight and complications during or after ART, of which 6 reported on ovarian hyperstimulation syndrome (OHSS), 7 on multiple pregnancies and 6 on ectopic pregnancies. None of the individual studies found a positive association between overweight and ART complications. The pooled ORs for overweight versus normal weight for OHSS, multiple pregnancy and ectopic pregnancy were 1.0 [95% confidence interval (CI) 0.77-1.3], 0.97 (95% CI 0.91-1.04) and 0.96 (95% CI 0.54-1.7), respectively. In 27 studies that reported on BMI and the success of ART, the pooled ORs for overweight versus normal weight on live birth, ongoing and clinical pregnancy following ART were OR 0.90 (95% CI 0.82-1.0), 1.01 (95% CI 0.75-1.4) and OR 0.94 (95% CI 0.69-1.3), respectively.

CONCLUSIONS

Data on complications following ART are scarce and therefore a registration system should be implemented in order to gain more insight into this subject. In the available literature, there is no evidence of overweight or obesity increasing the risk of complications following ART. Furthermore, they only marginally reduce the success rates. Based on the currently available data, overweight and obesity in itself should not be a reason to withhold ART.

Achieving a successful pregnancy in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a disease of complex and still poorly understood cause and of variable phenotypes. It is characterized by anovulation, hyperandrogenism, and polycystic ovaries. Infertility is commonly present. A variety of methods has been used successfully to achieve pregnancy in women with PCOS. Maintenance of pregnancy is complicated by a higher rate of premature spontaneous abortions and high risk of gestational diabetes, hypertension, and preeclampsia. However, with careful monitoring and treatment, the outcome of pregnancy in most women with PCOS is excellent.

Extra- and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte maturation and embryo developmental competence

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common metabolic dysfunction and heterogeneous endocrine disorder in women of reproductive age. Although patients with PCOS are typically characterized by increased numbers of oocytes retrieved during IVF, they are often of poor quality, leading to lower fertilization, cleavage and implantation rates, and a higher miscarriage rate.

METHODS

For this review, we searched the database MEDLINE (1950 to January 2010) and Google for all full texts and/or abstract articles published in English with content related to oocyte maturation and embryo developmental competence.

RESULTS

The search showed that alteration of many factors may directly or indirectly impair the competence of maturating oocytes through endocrine and local paracrine/autocrine actions, resulting in a lower pregnancy rate in patients with PCOS. The extra-ovarian factors identified included gonadotrophins, hyperandrogenemia and hyperinsulinemia, although intra-ovarian factors included members of the epidermal, fibroblast, insulin-like and neurotrophin families of growth factors, as well as the cytokines.

CONCLUSIONS

Any abnormality in the extra- and/or intra-ovarian factors may negatively affect the granulosa cell-oocyte interaction, oocyte maturation and potential embryonic developmental competence, contributing to unsuccessful outcomes for patients with PCOS who are undergoing assisted reproduction.

[Assisted reproductive technologies place]

There are three kinds of infertility treatment: medical treatment, surgical treatment and assisted reproductive technology (ART). ART includes intra uterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART technologies made a lot of progress last years and their field of applications extended. Through literature reviews, IUI is recommended for unexplained infertility and discussed for male or cervical infertility. IVF is recommended for tubal and unexplained infertility. Limits between IVF and ICSI in case of male infertility remains unclear. In non mal infertility ICSI is not recommended.

Follicular-fluid anti-Mullerian hormone concentrations are predictive of assisted reproduction outcome in PCOS patients

Serum anti-Mullerian hormone (AMH) concentrations constitute a sensitive marker for ovarian ageing. In addition, concentrations of AMH in the follicular fluid constitute a useful marker of embryo implantation in assisted reproduction cycles. The present study measured serum and follicular-fluid AMH concentrations on the day of oocyte retrieval. These data showed that clinical pregnancy rates (25.0, 34.1 and 42.1%, respectively, P < 0.001), embryo implantation rates (24.3, 35.0 and 44.4%, respectively, P < 0.001) and fertilization rates (59.2, 70.9 and 79.5%, respectively, P < 0.001) were markedly different among the low, moderate and high follicular-fluid AMH groups but not among the different serum AMH concentration groups. Follicular-fluid AMH concentrations were negatively correlated with follicular-fluid oestradiol concentrations. The results of this study suggest that follicular-fluid AMH concentration on the day of oocyte retrieval would appear to better reflect the reproductive outcome in PCOS patients undergoing assisted reproduction.

What can we learn from gene expression profiling of mouse oocytes?

Mammalian ooplasm supports the preimplantation development and reprograms the introduced nucleus transferred from a somatic cell to confer pluripotency in a cloning experiment. However, the underlying molecular mechanisms of oocyte competence remain unknown. Recent advances in microarray technologies have allowed gene expression profiling of such tiny specimens as oocytes and preimplantation embryos, generating a flood of information about gene expressions. So, what can we learn from it? Here, we review the initiative global gene expression studies of mouse and/or human oocytes, focusing on the lists of maternal transcripts and their expression patterns during oogenesis and preimplantation development. Especially, the genes expressed exclusively in oocytes should contribute to the uniqueness of oocyte competence, driving mammalian development systems of oocytes and preimplantation embryos. Furthermore, we discuss future directions for oocyte gene expression profiling, including discovering biomarkers of oocyte quality and exploiting the microarray data for ‘making oocytes’.

Comparison of oocyte quality and intracytoplasmic sperm injection outcome in women with isolated polycystic ovaries or polycystic ovarian syndrome

OBJECTIVE

To compare the oocyte quality and intracytoplasmic sperm injection performance in women with isolated polycystic ovaries or polycystic ovarian syndrome.

DESIGN

Retrospective study.

SETTING

Fertility unit.

POPULATION

Three study groups were identified: women with PCO-only morphology (50 cycles), PCOS (51 cycles) and age matched control group (104 cycles) with isolated male factor infertility necessitating ICSI.

METHOD

Controlled ovarian hyperstimulation and ICSI.

MAIN OUTCOME MEASURES

Response to gonadotropin stimulation, oocyte and embryo quality, clinical pregnancy rate and pregnancy outcome.

RESULTS

Despite a significantly lower total gonadotropin dose, a significantly higher serum E2 level was attained in both the PCOS and the PCO-only groups compared to the control group. Although significantly more oocytes were retrieved in the PCOS and PCO-only groups, the number of 2-pronuclear embryos was similar to controls. No significant differences were noted in the maturity of the oocytes, oocyte dysmorphism, embryo quality, implantation and pregnancy rates among the three groups. However the clinical miscarriage rate was significantly lower in women with PCO-only morphology group (15.4 versus 31%, P < 0.05) than in the PCOS group.

CONCLUSION

Women with PCO-only appearance have shown to have similar characteristics to women with PCOS in terms of ovarian response to hMG stimulation, oocyte and embryo quality and pregnancy rates. However miscarriage rates were significantly lower in the PCO-only group than the PCOS group. Our findings suggest that factors unrelated to oocyte and embryo morphology present in PCOS patients may be instrumental in adverse reproductive outcomes in these women.

Obstetric Outcomes After In Vitro Fertilization in Obese and Morbidly Obese Women

OBJECTIVE

In addition to numerous health detriments caused by obesity, fertility and pregnancy success may also be compromised. The aims of this study were to compare the effects of obesity and morbid obesity on in vitro fertilization (IVF) outcomes. We also investigated the effects of obesity on obstetric outcomes after IVF treatment.

METHODS

Retrospective study of women less than 38 years of age during their first fresh IVF cycle (January 1995 to April 2005).

RESULTS

A total of 1,293 women were included in the study, with 236 obese women (body mass index [BMI] = 30-39.9) and 79 morbidly obese women (BMI > or = 40). The morbidly obese group had a 25.3% IVF cycle cancellation rate compared with 10.9% in normal-weight women (odds ratio 2.73, 95% confidence interval 1.49-5.0), P < .001). Morbidly obese women without polycystic ovarian syndrome had an even higher cancellation rate (33%). Women with higher BMI required significantly more days of gonadotropin stimulation but had lower peak estradiol levels (P < .001). There were no significant differences in clinical pregnancy or delivery rates between the four BMI groups. Of the women who delivered, there was a significant linear trend for risk of preeclampsia, gestational diabetes, and cesarean delivery with increasing BMI (P < .03).

CONCLUSION

We report a significantly higher risk for IVF cycle cancellation in morbidly obese patients with no effect of BMI on clinical pregnancy or delivery rate. However, obese and morbidly obese subjects had a significantly higher risk for obstetric complications. This target population should be aggressively counseled regarding their increased obstetric risk and offered treatment options for weight reduction before the initiation of fertility therapy.

LEVEL OF EVIDENCE

II-2.

Outcome of intracytoplasmic sperm injection in patients with polycystic ovary syndrome or isolated polycystic ovaries

OBJECTIVE

To determine the intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) performance of patients with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian (PCO) morphology.

DESIGN

Case-control study.

SETTING

IVF Center, Hacettepe University Faculty of Medicine.

PATIENT(S)

Ninety-nine consecutive infertile women (n = 109 cycles) with PCOS and 58 patients (n = 58 cycles) with isolated PCO morphology were recruited. The control group consisted of 210 patients (n = 232 cycles) with isolated male factor infertility necessitating ICSI. All three groups were matched for female age and body mass index.

INTERVENTION(S)

Controlled ovarian hyperstimulation and ICSI.

MAIN OUTCOME MEASURE(S)

Oocyte number, fertilization rate, embryo quality, clinical pregnancy rate, implantation rate, and ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

Six (5.5%) cycles in the PCOS group, 6 (10.3%) cycles in the PCO-only group, and 10 cycles (4.3%) in the control group were canceled. Despite a significantly lower total FSH dose used, a significantly higher serum E2 level was attained in both the PCOS and the PCO-only groups compared to the control group. The PCOS and PCO-only groups had significantly higher numbers of retrieved oocyte-cumulus complexes and metaphase II oocytes compared to the control group. The fertilization rates did not differ among the three groups. The mean number of embryos transferred was comparable among the three groups; however, the mean number of grade 1 embryos was significantly higher in the PCOS and PCO-only groups compared to the controls. The clinical pregnancy rates per ET of both the PCOS (66%) and the PCO-only (60%) groups were significantly higher than that of the control group (44%). However, the implantation rates were comparable among the three groups. Four cycles (3.7%) in the PCOS group had OHSS necessitating hospitalization. The respective figures in the PCO-only and the control groups were 1 (1.7%) and 3 (1.3%).

CONCLUSION(S)

Patients with the full-blown picture of PCOS or isolated PCO-only morphology behave exactly in the same manner during all stages of assisted reproduction. Owing to the availability of more fertilized oocytes and grade 1 embryos, patients with PCOS or PCO-only morphology are associated with higher clinical pregnancy rates per ET compared to patients with isolated male factor infertility.

Teratology public affairs committee position paper: Maternal obesity and pregnancy

Compared to normal-weight women, obese women have an increased risk of infertility and pregnancy complications. The most consistently described pregnancy complications are hypertensive disorders, gestational diabetes mellitus, thromboembolic events, and cesarean section. Fetal and neonatal complications may include congenital malformations, macrosomia, and shoulder dystocia. The literature suggests that women with a body mass index (BMI) >or=30 have approximately double the risk of having a child with a neural tube defect (NTD) compared to normal-weight women, and the increased risk associated with higher maternal body weight does not appear to be modified by folic acid supplementation. The Public Affairs Committee of the Teratology Society supports the public health initiatives identified by the U.S. Food and Drug Administration in 2004 and the research initiatives identified by the National Institutes of Health in 2004. The Public Affairs Committee recommends that clinicians counsel women about appropriate caloric intake and exercise and that health-care providers educate parents about appropriate childhood nutrition. Breast-feeding should be encouraged based on evidence of a protective effect against childhood obesity, as well as other health advantages.

Obesity and assisted reproductive technology outcomes

Obesity is a rising health problem in Western societies. It has been related to increased morbidity and mortality rates due to several pathologies. In the field of gynaecology and reproduction, obesity is associated with menstrual disorders, hirsutism, infertility, miscarriage and obstetric complications. It is known to impair human reproduction through different mechanisms such as insulin resistance, hyperandrogenism and elevated leptin levels. Weight management and dietary intervention can reverse this situation and improve reproductive function. Obesity can also impair the outcome of assisted reproductive technologies. The lower probability of a healthy live birth described in obese women seems to be the result of a combination of lower implantation and pregnancy rates, higher preclinical and clinical miscarriage rates and increased complications during pregnancy for both mother and fetus. Studies performed in infertile women undergoing assisted reproduction technologies indicate that the ovary plays a leading, but not exclusive, role in the fertility prognosis of these patients. The endocrine and metabolic environment may affect oocyte quality and, therefore, embryo development, implantation and pregnancy outcome. The endometrium seems to play a subtle role in the more negative reproductive outcome of obese women, according to recent studies based on the ovum donation model.

Patient-tailored conventional ovulation induction algorithms in anovulatory infertility

Conventional treatment of normogonadotropic anovulatory infertility is ovulation induction using the antiestrogen clomiphene citrate, followed by follicle-stimulating hormone. Multiple follicle development, associated with ovarian hyperstimulation, and multiple pregnancy remain the major complications. Cumulative singleton and multiple pregnancy rate data after different induction treatments are needed. Newer ovulation induction interventions, such as insulin-sensitizing drugs, aromatase inhibitors and laparoscopic ovarian electrocoagulation, should be compared with conventional strategies. Ovulation induction efficiency might improve if patient subgroups with altered chances for success or complications with new or conventional techniques could be identified, using multivariate prediction models based on initial screening characteristics. This would make ovulation induction more cost-effective, safe and convenient, enabling doctors to advise patients on the most effective and patient-tailored treatment strategy.

A meta-analysis of outcomes of conventional IVF in women with polycystic ovary syndrome

This meta-analysis was conducted to compare outcomes of conventional IVF in women presenting with polycystic ovary syndrome (PCOS) and non-PCOS patients. Studies in which PCOS patients undergoing IVF were compared with a matched--no male factor--control group were considered for this review. A definition consistent with the Rotterdam consensus criteria of PCOS was required, and all patients within a given study had to be treated with the same ovarian stimulation protocol. Information regarding patient characteristics and pregnancy outcome was also required. Nine out of 290 identified studies reporting data on 458 PCOS patients (793 cycles) and 694 matched controls (1116 cycles) fulfilled these inclusion criteria. PCOS patients demonstrated a significantly reduced chance of oocyte retrieval per started cycle, odds ratio (OR) = 0.5 [95% confidence interval (CI) = 0.2-1.0]. However, no difference was observed in chance of embryo transfer per oocyte retrieval between the groups (OR = 0.7, 95% CI = 0.4-1.3). Significantly more oocytes per retrieval were obtained in PCOS patients compared with controls [random effects estimate 3.4 [95% (CI) = 1.7-5.1)]. The number of oocytes fertilized did not differ significantly between PCOS patients and controls, weighted mean difference (WMD) 0.1 oocytes (95% CI = 21.4-1.6). No significant difference was observed in the clinical pregnancy rates per started cycle, OR = 1.0 (95% CI = 0.8-1.3). The incidence of ovarian hyperstimulation syndrome (OHSS) after oocyte retrieval was rarely reported. This meta-analysis demonstrates an increased cancellation rate, but more oocytes retrieved per retrieval and a lower fertilization rate in PCOS undergoing IVF. Overall, PCOS and control patients achieved similar pregnancy and live birth rates per cycle.

Individualized cost-effective conventional ovulation induction treatment in normogonadotrophic anovulatory infertility (WHO group 2)

BACKGROUND

Conventional treatment in normogonadotrophic anovulatory infertility (WHO 2) consists of clomiphene citrate (CC), followed by exogenous gonadotrophins (FSH) and IVF. Response to these treatments may be predicted on the basis of individual patient characteristics. We aimed to devise a patient-tailored, cost-effective treatment algorithm involving the above-mentioned treatment modalities, based on individual patient characteristics.

METHODS

Sixteen prognostic groups are defined, according to the presence or absence of: age >30 years, amenorrhea, elevated androgen levels and obesity. The chances of response with each of the three treatments were calculated using prediction models. Treatment costs were based on the data of 240 patients visiting a specialist academic fertility unit. Outcome was an ongoing pregnancy within 12 months after initiation of treatment. The costs per pregnancy of three different strategies were compared, with a threshold for cost-effectiveness of 10 000.

RESULTS

The strategy CC + FSH + IVF compared with FSH + IVF generated more pregnancies against lower costs. Compared with CC + IVF, it also produced more pregnancies, but at higher costs. For <30 years of age with normal androgen levels, costs per pregnancy were less than 10 000. For women >30 years old, costs per pregnancy were 25 000 and over 200 000, when presenting with normal or elevated androgen levels, respectively.

CONCLUSIONS

The conventional treatment protocol is efficient for women aged <30 years with normal androgen levels. For women >30 years old with elevated androgen levels, FSH may be skipped.

Body mass index in endometriosis

OBJECTIVE

Previous studies did not establish a clear correlation between the presence of endometriosis and the values of body mass index (BMI).

STUDY DESIGN

The BMI of 366 women with endometriosis was compared to that of 248 controls undergoing laparoscopy because of benign gynaecological conditions. Significant differences at univariate analyses were confirmed by using Analysis of covariance (ANCOVA) to control for potential confounding variables.

RESULTS

BMI was significantly lower in women with endometriosis than in controls (p < 0.001); this difference was confirmed when the analysis was restricted to subjects with normal BMI (18.50-24.99 kg/m(2)) (p = 0.002). 4.8% of control subjects and no woman with endometriosis were obese. No significant difference was observed in the BMI of women with mild (revised classification of the American Fertility Society, rAFS I-II) and severe endometriosis (rAFS III-IV).

CONCLUSION

Women with endometriosis have lower BMI and are less frequently obese than control subjects. Further studies should investigate the physiopathological basis of decreased BMI in women with endometriosis.

Impact of overweight and underweight on assisted reproduction treatment

BACKGROUND

Underweight and overweight may affect reproduction and interfere with treatment of infertility. The purpose of this report is to describe the independent effect of body weight on treatment with IVF and ICSI.

METHODS

Records of 5019 IVF or ICSI treatments in 2660 couples were reviewed. The influence of body mass index (BMI) on treatment outcome was examined, after accounting for differences in age and infertility diagnosis.

RESULTS

The cumulative live birth rate within three treatment cycles was 41.4% [95% confidence interval (CI) 32.1-50.7] in obese women with BMI > or =30 kg/m2 and 50.3 (95% CI 47.0-53.7) in normal weight women with BMI 18.5-24.9 kg/m2. Obesity was associated with an increased risk of early pregnancy loss occurring before 6 weeks gestation. Positive correlation between BMI and gonadotrophin requirement during stimulation and negative correlation between BMI and number of collected oocytes were observed. Underweight (BMI <18.5 kg/m2) was not related to an impaired outcome of IVF or ICSI.

CONCLUSIONS

Obesity is associated with lower chances for live birth after IVF and ICSI and with an impaired response to ovarian stimulation.

Assisted reproduction in the treatment of polycystic ovarian syndrome

Treatment of patients with polycystic ovary syndrome (PCOS) with assisted reproductive techniques is a great challenge for the infertility specialist. Patients with PCOS demonstrate many problems, such as excessive body weight and hyperinsulinaemia, that render management more complex. Prior to treatment with IVF, the PCOS patient should be thoroughly evaluated for disclosure of endometrial neoplasia, hyperinsulinaemia, and other general health related problems. Ovarian stimulation for IVF carries the risks of overstimulation and severe hyperstimulation, which should be avoidable in most cases with preventive measures. The outcome in terms of pregnancy and implantation rates is similar for patients with PCOS when compared with patients undergoing IVF for other indications. There are some questions regarding oocyte and embryo quality in women with PCOS. This manifests itself in lower fertilization rate and decreased embryo quality in some studies. However, increased numbers of oocytes available for insemination or ICSI compensate for decreased fertilization rates and embryo quality. More recent studies suggest higher cumulative conception rates in women with PCOS when compared with controls. In-vitro maturation (IVM) of oocytes retrieved from non-stimulated or minimally stimulated cycles represents a viable option that should be considered seriously when assisted conception is attempted. Results of IVM, however, should be improved further and generalized before the technique can be advocated as the initial treatment approach in these patients.