Undetectable basal ovarian stromal blood flow in infertile women is related to low ovarian reserve

Therapeutic roles of platelet-rich plasma to restore female reproductive and endocrine dysfunction

Millions of women worldwide are infertile due to gynecological disorders, including premature ovarian insufficiency, polycystic ovary syndrome, Asherman syndrome, endometrial atrophy, and fallopian tube obstruction. These conditions frequently lead to infertility and have a substantial impact on the quality of life of the affected couples, primarily because of their psychological implications and high financial costs. Recently, using platelets to stimulate cell proliferation and tissue differentiation has emerged as a promising approach in regenerative medicine. Platelet-rich plasma (PRP) shows considerable potential for promoting endometrial hypertrophy and follicle development, making it a promising therapeutic option for tissue repair or replacement. This review provides an overview of the recent advancements and underlying mechanisms of PRP therapy for various female reproductive diseases and presents new therapeutic options for addressing female infertility.

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.

Ovarian Rejuvenation Using Autologous Platelet-Rich Plasma

Advanced maternal age is associated with the natural oocyte depletion, leading to low oocyte yield, high infertility treatment cancellation rates, and eventual decreases in pregnancy rates. Various innovative interventions have been introduced to improve the outcome of infertility treatment for aging patients. Numerous published data demonstrated that early follicle development was regulated by intraovarian growth factors through autocrine or paracrine mechanisms. Platelet-rich plasma (PRP), a plasma fraction of peripheral blood with a high concentration of platelets, has been implemented in regenerative medicine in the last decade. The plasma contains a variety of growth factors that were suggested to be able to enhance angiogenesis regeneration and the cell proliferation process. The initial report showed that an intraovarian injection of PRP improved the hormonal profile and increased the number of retrieved oocytes in patients with diminished ovarian reserve. Subsequently, several studies with larger sample sizes have reported that this approach resulted in several healthy live births with no apparent complications. However, the use of ovarian PRP treatment needs to be fully investigated, because no randomized controlled trial has yet been performed to confirm its efficacy.

Reactivating Ovarian Function through Autologous Platelet-Rich Plasma Intraovarian Infusion: Pilot Data on Premature Ovarian Insufficiency, Perimenopausal, Menopausal, and Poor Responder Women

Intraovarian platelet-rich plasma (PRP) infusion was recently introduced in the context of addressing ovarian insufficiency. Reporting on its effectiveness prior to adopting in clinical routine practice is imperative. This study aims to provide pilot data regarding PRP application for ovarian rejuvenation. Four pilot studies were conducted on poor ovarian response (POR), premature ovarian insufficiency (POI), perimenopause, and menopause, respectively. Each pilot study reports on thirty patients, 120 participants were recruited in total. All participants provided written informed consent prior to treatment. Primary outcome measures for the POR pilot study were levels of anti-müllerian hormone (AMH), antral follicle count (AFC) and oocyte yield. For the POI, perimenopausal and menopausal pilot studies primary outcome measures were restoration of menstrual cycle, and Follicle Stimulating Hormone (FSH) levels. A significant improvement on the hormonal profile and the ovarian reserve status was noted, along with improved intracytoplasmic sperm injection (ICSI) cycle performance concerning POR participants. Menstruation recovery was observed in 18 out of 30 POI patients, along with a statistically significant improvement on levels of AMH, FSH, and AFC. Similarly, 13 out of 30 menopausal women positively responded to PRP treatment. Finally, menstruation regularity, improved hormonal levels and AFC were reported for 24 out of 30 perimenopausal women. To conclude, PRP infusion appears to convey promising results in addressing ovarian insufficiency.

The root of reduced fertility in aged women and possible therapentic options: current status and future perspects

It is well known that maternal ageing not only causes increased spontaneous abortion and reduced fertility, but it is also a high genetic disease risk. Although assisted reproductive technologies (ARTs) have been widely used to treat infertility, the overall success is still low. The main reasons for age-related changes include reduced follicle number, compromised oocyte quality especially aneuploidy, altered reproductive endocrinology, and increased reproductive tract defect. Various approaches for improving or treating infertility in aged women including controlled ovarian hyperstimulation with intrauterine insemination (IUI), IVF/ICSI-ET, ovarian reserve testing, preimplantation genetic diagnosis and screening (PGD/PGS), oocyte selection and donation, oocyte and ovary tissue cryopreservation before ageing, miscarriage prevention, and caloric restriction are summarized in this review. Future potential reproductive techniques for infertile older women including oocyte and zygote micromanipulations, derivation of oocytes from germ stem cells, ES cells, and iPS cells, as well as through bone marrow transplantation are discussed.

Current understanding of ovarian aging

The reproductive system of human female exhibits a much faster rate of aging than other body systems. Ovarian aging is thought to be dominated by a gradual decreasing numbers of follicles, coinciding with diminished quality of oocytes. Menopause is the final step in the process of ovarian aging. This review focuses on the mechanisms underlying the ovarian aging involving a poor complement of follicles at birth and a high rate of attrition each month, as well as the alternated endocrine factors. We also discuss the possible causative factors that contribute to ovarian aging, e.g., genetic factors, accumulation of irreparable damage of microenvironment, pathological effect and other factors. The appropriate and reliable methods to assess ovarian aging, such as quantification of follicles, endocrine measurement and genetic testing have also been discussed. Increased knowledge of the ovarian aging mechanisms may improve the prevention of premature ovarian failure.

Prospective evaluation of early follicular ovarian stromal blood flow in infertile women undergoing IVF-ET treatment

BACKGROUND

To evaluate the role of early follicular stromal flow studies in predicting ovarian response during IVF-ET treatment and to assess their correlation with ovarian reserve parameters and clinical pregnancy achievement.

MATERIALS & METHODS

One hundred and sixty-eight consecutive and unselected infertile women undergoing their first IVF-ET treatment were included in the study. Basal ovarian reserve and stromal Doppler flow studies were performed in a natural cycle before starting treatment. Four Doppler indices were measured; peak systolic velocity (PSV), pulsatility index (PI), resistance index (RI) and systole/diastole ratio (S/D). Following completion of IVF-ET treatment Pearson's correlation analysis was performed to examine the correlation between Doppler indices, ovarian response, basal ovarian reserve parameters and clinical pregnancy achievement.

RESULTS

A positive correlation was found between the number of ≥14 mm follicles on hCG day and PSV. The number of ≥14 mm follicles and retrieved oocytes had a significant negative correlation with RI and S/D ratio. As well, the number of fertilized oocytes had a significant negative correlation with S/D ratio. Absence of a Doppler signal in one or both ovaries was significantly higher in the women with poor response (31%) as compared to women with normal response (16%). In addition, RI correlated positively with basal FSH as well as FSH/LH ratio and negatively with AFC. The S/D ratio had a negative correlation with AFC (p = 0.027). A significant positive correlation between PSV, total ovarian volume (p = 0.011) and mean ovarian volume (p = 0.019) was detected. However, no correlation between all four Doppler indices and age was detected. Moreover, Doppler indices did not differ significantly between conception and non-conception cycles following IVF-ET treatment.

CONCLUSIONS

Early follicular stromal Doppler signals is correlated with ovarian response as well as basal ovarian reserve parameters, but have no correlation with age neither with clinical pregnancy achievement in infertile women undergoing IVF-ET treatment.

Ovarian aging: latest thoughts on assessment and management

PURPOSE OF REVIEW

In the past few decades, women have been intentionally delaying pregnancy and ovarian aging has become one of the most detrimental factors of pregnancy achievement. This review will discuss contemporary methods of ovarian aging assessment and present an overview of current management strategies.

RECENT FINDINGS

Antimullerian hormone (AMH) and antral follicle count (AFC) seem to be the most reliable predictors of ovarian aging appraisal. Nevertheless, they have not been shown to predict pregnancy achievement in assisted reproduction. Heritability has a high impact on ovarian aging. Employing several genetic approaches, it is now being widely investigated, but the task is far from being accomplished. Although multivariate models have not been proven to be superior to AFC, new data support the notion that chronological age and genetic markers inclusion may increase their reliability. Several strategies have been suggested to treat ovarian aging in assisted reproductive technology (ART) settings. None of the stimulation protocol manipulations have been found to be advantageous and individualization of treatment is still recommended. Ovarian priming by different androgen preparations has been shown to be promising but more randomized controlled trials are needed to support these findings. Except for oocyte donation other ART strategies have not shown a convincing benefit for ovarian aging. The new development of oocyte vitrification may well introduce opportunities for fertility preservation to women at risk of ovarian aging.

SUMMARY

Proper assessment and detection of ovarian aging, employing current or developing predictors of ovarian reserve, especially genetic tests, may enable health providers to recommend, at appropriate biological time, early pregnancy achievement or fertility preservation in women at risk.

Age-specific nomogram for the decline in antral follicle count throughout the reproductive period

OBJECTIVE

To investigate the relationship between antral follicle count (AFC) and chronological age and to establish normal values for AFC in women with regular menstrual cycles.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENT(S)

Four hundred fifteen premenopausal women were recruited for the study. Data from 362 patients were available for the statistical analysis.

INTERVENTION(S)

AFC was measured by transvaginal ultrasound examination.

MAIN OUTCOME MEASURE(S)

Estimating the relationship between AFC and age and developing the AFC nomogram.

RESULT(S)

The analysis showed a linear decline in AFC with age; for every year increase in age, the median AFC decreases by 0.4. The AFC corresponding to the 5th, 25th, 50th, 75th, and 95th centiles for each age have been calculated.

CONCLUSION(S)

A linear relationship of AFC to age was found. For the first time, a nomogram reporting normal and interquartile values for AFC, age by age, throughout the reproductive period has been provided. Until now, the interpretation of the measurement was mainly based on the individual experience of the operator, because no normative data were present. Therefore, the establishment of a nomogram of AFC values is the first step to counsel patients on a scientific basis.

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

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

Testing ovarian reserve to predict age at menopause

In modern society with women delaying pregnancy, predicting the age of the natural menopause with its preceding infertility will allow making informed choices about when to try starting to have children. Also if premature menopause could be predicted in young women, strategies could be instigated to reduce the long term health risks of early estrogen deficiency. This review examines the physiology of ovarian ageing, with the menopause being the final outcome. Long and short term predictive markers of the age of the menopause and the preceding natural infertility are evaluated. Many subtle changes in the endocrine regulation of ovarian function with advancing age may seem interesting but currently are not clinically useful as a predictive test. Examples are changes in concentrations of estradiol, progesterone, luteinizing hormone (LH) and activin, as well as follicle dynamics. Other features hold more promise. Among these are chronological age, family history, anti-Müllerian hormone (AMH), poor response to in vitro fertilization (IVF), basal follicle-stimulating hormone (FSH) and the antral follicle count for long term prediction. For short term prediction, cycle shortening and occurrence of vasomotor symptoms may prove useful. To date, none of these markers has been found to have sufficient predictive accuracy in individual women. Results of new and ongoing longitudinal studies may provide better predictive models. In particular, use of genetic profiles may add to the accuracy of currently known markers.

A simple multivariate score could predict ovarian reserve, as well as pregnancy rate, in infertile women

OBJECTIVE

To find a simple multivariate score that has the potential to predict ovarian reserve, as well as pregnancy rate, in infertile women.

DESIGN

A prospective study.

SETTING

A university-affiliated reproductive medicine unit.

PATIENT(S)

One hundred sixty-eight consecutive women undergoing their first IVF-ET treatment at our unit.

INTERVENTION(S)

Basal ovarian reserve studies, endocrine and sonographic, were performed before starting therapy. After completion of treatment, a logistic regression analysis was performed to examine which parameters significantly determined low ovarian reserve. These parameters were incorporated thereafter in a multivariate score to predict ovarian reserve, as well as clinical pregnancy rate.

MAIN OUTCOME MEASURE(S)

Low ovarian reserve defined as <or=3 oocytes on retrieval day and clinical implantation and pregnancy rates.

RESULT(S)

Logistic regression analysis revealed that age, antral follicle count, basal FSH, FSH/LH ratio, mean ovarian volume, infertility duration, number of previous cycle cancellations, and body mass index were all, in decreasing significance, independent factors that determine low ovarian reserve. The multivariate score was shown to have a distinctive prediction of ovarian reserve. A cumulative score of >14 was shown to be more accurate in predicting low ovarian reserve than age, day 3 FSH, or antral follicle count separately. Moreover, a score of >14 was shown to have a sensitivity of 88% and a specificity of 69% in predicting low ovarian reserve. More important, women with a score of >14 had significantly lower clinical implantation and pregnancy rates relative to women with a score of <or=14, corresponding to 6.7% versus 22.4%, and 11.3% versus 38.6%, respectively.

CONCLUSION(S)

A novel and simple multivariate score using clinical and basal endocrine and sonographic parameters has a distinctive prediction of low ovarian reserve in infertile women undergoing assisted reproductive technology treatment. Moreover, it has the potential to predict clinical implantation and pregnancy rates in women with low and good ovarian reserve.

First polar body and nucleolar precursor body morphology is related to the ovarian reserve of infertile women

This study was undertaken in order to gain insight into the morphology of the first polar body (PB1) and the two pronuclei (2PN) in ICSI patients, specifically the nucleolar precursor bodies (NPB). Whether early abnormalities in these structures are related to the ovarian reserve of infertile women was also studied. Eighty consecutive infertile women were prospectively investigated throughout their first ICSI cycles. Basal ovarian reserve studies were performed in all women. Cycles were evaluated with respect to PB1 and 2PN morphology of the transferred embryos. Cycles that had at least one transferred embryo with normal PB1 and 2PN morphology had significantly better basal ovarian reserve parameters compared with cycles in which all transferred embryos had abnormal PB1 and 2PN morphology. Moreover, the normal morphology group performed significantly better throughout the ovarian stimulation, compared with the abnormal morphology group. Furthermore, the clinical implantation and pregnancy rates were significantly higher in the normal compared with the abnormal morphology group, corresponding to 20.7% versus 10.6% and 42.4% versus 18.2%, respectively. The study concluded that the morphology of the PB1 in metaphase II oocytes as well as that of the NPB within the 2PN zygotes seems to be related to the ovarian reserve in infertile women.