Natural cycle as first approach in aged patients with elevated follicle-stimulating hormone undergoing intracytoplasmic sperm injection: a pilot study

The Effects of Maternal and Paternal Body Mass Index on Live Birth Rate after Intracytoplasmic Sperm Injection Cycles

Background

We designed the present study to evaluate the simultaneous effect of obesity in couples on in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) outcomes.

Materials and Methods

In this cross-sectional study, performed at Royan Institute between January 2013 and January 2014, we evaluated the recorded data of all patients during this time period. The study population was limited to couples who underwent ICSI or IVF/ICSI cycles with autologous oocytes and fresh embryo transfers. We recorded the heights and weights of both genders and divided them into groups according to body mass index (BMI). Multilevel logistic regression analysis was used to determine the odds ratio for live births following ICSI or IVF/ICSI.

Results

In total, 990 couples underwent IVF/ICSI cycles during the study period. Among the ovulatory women, a significant difference existed between the BMI groups. There was a 60% decrease [95% confidence interval (CI): 0.11-0.83] in the odds of a live birth among overweight subjects and 84% (95% CI: 0.02-0.99) decrease among obese subjects. Among the anovulatory women, the association between the BMI and live births presented no clear tendencies. We did not observe any significant relationship between male BMI and live birth rate. The results demonstrated no significant association between the couples' BMI and live birth rate.

Conclusion

Based on the present findings, increased female BMI independently and negatively influenced birth rates after ICSI. However, increased male BMI had no impact on live births after ICSI, either alone or combined with increased female BMI.

Does the use of gonadotropin-releasing hormone antagonists in natural IVF cycles for poor responder patients cause more harm than benefit?

Poor ovarian response to controlled ovarian stimulation (COS) is one of the most critical factors that substantially limits the success of assisted reproduction techniques (ARTs). Natural and modified natural cycle IVF are two options that could be considered as a last resort. Blocking gonadotropin-releasing hormone (GnRH) actions in the endometrium via GnRH receptor antagonism may have a negative impact on endometrial receptivity. We analysed IVF outcomes in 142 natural (n = 30) or modified natural (n = 112) IVF cycles performed in 82 women retrospectively. A significantly lower proportion of natural cycles reached follicular aspiration compared to modified natural cycles (56.7% vs. 85.7%, p < 0.001). However, the difference between the numbers of IVF cycles ending in embryo transfer (26.7% vs. 44.6%) was not statistically significant between natural cycle and modified natural IVF cycles. Clinical pregnancy (6.7% vs. 7.1%) and live birth rates per initiated cycle (6.7% vs. 5.4%) were similar between the two groups. Notably, the implantation rate was slightly lower in modified natural cycles (16% vs. 25%, p > 0.05). There was a trend towards higher clinical pregnancy (25% vs. 16%) and live birth (25% vs. 12%) rates per embryo transfer in natural cycles compared to modified natural cycles, but the differences did not reach statistical significance.

Age-specific serum anti-mullerian hormone and follicle stimulating hormone concentrations in infertile Iranian women

Background

Anti-Müllerian hormone (AMH) is secreted by the granulosa cells of growing follicles during the primary to large antral follicle stages. Abnormal levels of AMH and follicle stimulating hormone (FSH) may indicate a woman’s diminished ability or inability to conceive. Our aim is to investigate the changes in serum AMH and FSH concentrations at different age groups and its correlation with ovarian reserves in infertile women.

Materials and Methods

This cross-sectional study analyzed serum AMH and FSH levels from 197 infertile women and 176 healthy controls, whose mean ages were 19-47 years. Sample collection was performed by random sampling and analyzed with SPSS version 16 software.

Results

There were significantly lower mean serum AMH levels among infertile women compared to the control group. The mean AMH serum levels from different ages of infertile and control group (fertile women) decreased with increasing age. However, this reduction was greater in the infertile group. The mean FSH serum levels of infertile women were significantly higher than the control group. Mean serum FSH levels consistently increased with increasing age in infertile women; however mean luteinizing hormone (LH) levels were not consistent.

Conclusion

We have observed increased FSH levels and decreased AMH levels with increasing age in women from 19 to 47 years of age. Assessments of AMH and FSH levels in combination with female age can help in predicting ovarian reserve in infertile women.

Natural cycle IVF: evaluation of 463 cycles and summary of the current literature

PURPOSE

Natural cycle (NC) IVF/ICSI has proven to be an alternative to conventional IVF/ICSI cycles.

METHODS

Within our retrospective, observational study (n = 159) infertile couples underwent (n = 463) cycles of NC-IVF/ICSI from May 2007 until December 2011. Oocyte pick-up was performed within a pure natural cycle excluding any hormonal stimulation except of hCG for ovulation induction. Oocytes were fertilized by IVF/ICSI and embryo transfer took place 2 or 3 days later. In addition, the current literature was analysed concerning pregnancy rates in NC-IVF/ICSI cycles.

RESULTS

Oocyte pick-up was performed in n = 463 NC and was successful in n = 342 cases (IVF n = 135, ICSI n = 207). 203 oocytes were fertilized (IVF n = 87, ICSI n = 116, FR 59.4 %) and lead to 192 embryo transfers. Finally, 25 pregnancies were reached (PR 13.0 % per transfer) resulting in four biochemical pregnancies, 7 (33.3 %) miscarriages, one pregnancy of unknown outcome and 13 live births. Within the current literature (n = 27 studies), PR in NC-IVF/ICSI cycles varied between 10.2 and 50 %.

CONCLUSIONS

Within our study, pregnancy rates in pure NC-IVF/ICSI remained below 15 %. Although this may be linked to unfavourable preconditions like patients' age >40 years, low ovarian reserve or long duration of infertility, further improvement is necessary to increase pregnancy rates.

[Cancellation of IVF-ET cycles: poor prognosis, poor responder, or variability of the response to controlled ovarian hyperstimulation? An analysis of 142 cancellations]

INTRODUCTION

This retrospective study aimed at analyzing IVF-ET management and outcome after cancellation of a first cycle for poor response.

PATIENTS AND METHOD

One hundred and forty-two infertile patients were included in this observational study. After an overall analysis on the outcome of the second IVF-ET attempt, a sub-analysis was performed according to the presence or the absence of poor prognostic criteria defined as mentioned: patient age superior to 38 years old, antral follicle count (3-9 mm in diameter) inferior to 10 on cycle day 3 and day 3 serum AMH and FSH levels less than 1 ng/mL and more than 10 IU/mL, respectively. Main outcome measures were the cancellation rates, pregnancy and live birth rates.

RESULTS

When a controlled ovarian stimulation was performed, patients with poor prognosis had higher cancellation rates (37.8% vs. 13.3%, P<0.004) and lower pregnancy and live birth rates (22.2% vs. 35.0%, P<0.05 and 11.1% vs. 26.1%, P<0.05, respectively) as compared to good prognosis women.

CONCLUSION

The relatively high cancellation rate in patients with poor prognosis raises the question of the use of IVF modified natural cycle in this group.

Natural cycle IVF/IVM may be more desirable for poor responder patients after failure of stimulated cycles

OBJECTIVE

To describe pregnancies and live births resulted from natural cycle IVF combined with in-vitro maturation (natural-cycle IVF/IVM) for three poor responder women after failure of stimulated cycles.

METHODS

For case 1 and 2, the mature oocytes from aspirated follicles were inseminated by intracytoplasmic sperm injection (ICSI) immediately; immature oocytes were matured in vitro, and the embryos from mature and immature oocytes transferred on day 3 after oocyte retrieval. For case 3, 3 consecutive natural cycles were performed, in which the matured oocytes from in vivo or in vitro were vitrified in the first and second cycle, and warmed on the retrieval day of the third fresh cycle. Then the embryos resulted from vitrified-warmed and fresh oocytes were transferred.

RESULTS

A total of 15 oocytes were obtained from the 7 retrieval cycles for the three cases. The case 1 was successfully pregnant at her first natural cycle, and case 2 was pregnant after two consecutive cycles. The two cases had successfully delivered and case 3 was in her ongoing pregnancy at the time of submission.

CONCLUSION

These results demonstrate that natural-cycle IVF/IVM might be a reasonable and efficient treatment alternative for poor responder patients when stimulated cycle has failed.

Reduced neurotrophin receptor tropomyosin-related kinase A expression in human granulosa cells: a novel marker of diminishing ovarian reserve

OBJECTIVE

To determine whether human mural and cumulus granulosa cell neurotrophin and neurotrophin receptor content correlate to ovarian reserve markers.

DESIGN

Prospective, laboratory-based study.

SETTING

Academic assisted reproductive technology (ART) program.

PATIENT(S)

Twenty-three women undergoing ART.

INTERVENTION(S)

Mural and cumulus granulosa cells were collected from women undergoing oocyte retrieval during ART cycles. Relative messenger RNA (mRNA) levels of neurotrophins and their receptors were measured by quantitative reverse transcription-polymerase chain reaction and correlated to serum antimüllerian hormone (AMH) levels and the number of oocytes retrieved.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved.

RESULT(S)

Mural and cumulus granulosa cell nerve growth factor receptor tropomyosin-related kinase A (TrkA) mRNA correlated strongly to the number of oocytes retrieved. Similarly, higher serum AMH was associated with higher cumulus granulosa cell TrkA mRNA. Both mural and cumulus granulosa cell p75(NTR)/TrkA ratios were lower in women with higher serum AMH, and the number of oocytes retrieved was greater among women with low p75(NTR)/TrkA ratio. No significant associations were found between brain-derived neurotrophic factor (BDNF) and its specific receptor tropomyosin-related kinase B (TrkB) and ovarian reserve markers. Although BDNF and TrkB expression were higher in cumulus compared with mural granulosa cells, no such association was found between TrkA and granulosa cells. Antimüllerian hormone and cumulus TrkA mRNA, in a model incorporating both, correlated strongly to the number of oocytes retrieved (R(2) = 0.84).

CONCLUSION(S)

Cumulus TrkA and p75(NTR) mRNA correlate to ovarian reserve, whereas BDNF and TrkB are associated with the type of granulosa cell.

Random anti-Müllerian hormone (AMH) is a predictor of ovarian response in women with elevated baseline early follicular follicle-stimulating hormone levels

OBJECTIVE

To investigate the utility of random anti-Müllerian hormone (AMH) in assessing ovarian response among women with diminished ovarian reserve (DOR) diagnosed by elevated early follicular-phase FSH levels.

DESIGN

Retrospective study.

SETTING

Academic and academically affiliated assisted reproductive technology (ART) programs.

PATIENT(S)

Seventy-three women undergoing ART with elevated early follicular FSH levels.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved during ART cycle, number of day 3 embryos, and cycle cancellation and clinical pregnancy rates.

RESULT(S)

Random AMH levels were strongly correlated with the number of oocytes retrieved during an ART cycle among women with elevated FSH (r=0.55). Women with elevated FSH who had a random serum AMH level of 0.6 ng/mL or higher had twice the number of oocytes retrieved (11±1.3 vs. 5.6±0.6), a greater number of day 3 embryos (5.7±0.9 vs. 3±0.5), and approximately a third of the cycle cancellation rate (14% vs. 41%) compared with women with a random serum AMH below 0.6 ng/mL. The clinical pregnancy rate was also higher among women with a random serum AMH≥0.6 ng/mL (28% vs. 14%), however, the difference was not statistically significant.

CONCLUSION(S)

A random serum AMH level is useful in setting expectations for ART prognosis in women with elevated early follicular-phase serum FSH levels.

Pregnancy after modified natural cycle IVF: case report of a young patient with elevated FSH levels and male factor infertility

BACKGROUND

Although the first pregnancy obtained by IVF was in a natural cycle, this method was soon abandoned in favour of gonadotropin-stimulated protocols to improve pregnancy rates. In women who are poor responders to ovarian stimulation, the use of a natural cycle may provide a good alternative for achieving a pregnancy, although there is limited information on the success of modified natural cycle in vitro fertilization (MNC-IVF) in young patients with poor ovarian reserve.

CASE

A 35-year-old woman with significantly elevated FSH levels (consistently > 30 IU/L) but regular menses, and with severe male factor infertility, conceived using MNC-IVF with intracytoplasmic sperm injection (ICSI).

CONCLUSION

This case demonstrates that younger patients (aged 35 or under) with elevated basal serum FSH levels and regular menses can be offered MNC-IVF as an option prior to considering oocyte donation when a secondary cause of infertility necessitates IVF or ICSI.

Age, oestradiol and blastocysts can predict success in natural cycle IVF-embryo transfer

The aim of this study was to evaluate the influence of maternal age and oestradiol concentrations on blastocyst development and live birth rates in natural cycle IVF-embryo transfer. This observational study included 397 natural cycles with IVF embryo transfer for female infertility with embryo transfer on day 5. The cycles were divided into two groups according to the woman's age (<39 and > or = 39 years of age), and into two groups according to oestradiol concentrations on the day of human chorionic gonadotrophin (HCG) administration (0.4-0.49 nmol/l and 0.5-1.2 nmol/l). Comparison between the cycles in younger versus older age groups showed significant differences in blastocyst development rate, live birth rate per embryo transfer and live birth rate per cycle (55 versus 29%, 23 versus 3% and 13 versus 2% respectively) (P < 0.001). Comparison between cycles with lower versus higher oestradiol concentrations showed no significant differences in blastocyst development rate, live birth rate per embryo transfer and live birth rate per cycle (47 versus 49%, 18 versus 18%, and 11 versus 10% respectively). Advanced maternal age negatively predicts the success of natural cycle IVF, while low oestradiol concentrations on the day of HCG administration (ultrasound criteria fulfilled) do not negatively predict blastocyst development and success of natural cycle IVF.

Le cycle naturel en fécondation in vitro chez les mauvaises répondeuses

Since the beginning of IVF, natural cycle In Vitro Fertilization (NC-IVF) has been largely replaced by IVF with ovarian stimulation. However, natural cycle IVF has several advantages: low cost, no risk of ovarian hyper stimulation syndrome, very low risk of multiple pregnancy. Nevertheless, natural cycle IVF is less effective with a high risk of cancellation due to premature rise of LH, and an increased risk of failed oocyte retrieval. Using GnRH antagonists in a modified natural cycle decreases the occurrence of a premature LH rise. In the context of a poor responder patient, natural IVF could theoretically yield a better quality oocyte coming from a naturally selected follicle and allow a transfer on an endometrium whose receptivity has not been distorted by controlled ovarian stimulation. However, the real place for it has yet to be defined as we lack published data. Only one randomised controlled study in poor responders showed a similar pregnancy rate to a standard protocol representing a cost-effective alternative. Available retrospective data seem to show the same trend especially in the sub group of younger patients (below 38). Natural cycle IVF is a low-risk, low-cost procedure whose interesting results should be further confirmed by large scale prospective studies.