Age-related changes in ovarian volume, antral follicle counts and basal follicle stimulating hormone levels: comparison between fertile and infertile women

The clinical outcomes of fresh versus frozen embryos transfer in women ≥40 years with poor ovarian response

Objective

To compare the clinical outcomes of fresh embryo transfers (ETs) and frozen-thawed embryo transfers (FETs) after a freeze-all cycle in women ≥40 years old with poor ovarian response (POR).

Methods

We performed a single-center, retrospective, case-control study of patients who underwent in vitro fertilization between January 2014 and June 2019. We included a total of 192 patients aged 40 years or older from whom 3 or fewer oocytes had been retrieved and who were receiving cleavage-stage ET in this study. Of these patients, 101 and 91 patients underwent fresh ET and FET, respectively. The primary outcome was the live birth rate (LBR) after the first ET. Logistic regression analysis was used to compare the IVF outcomes and neonatal characteristics between the fresh ET and FET groups, adjusting for maternal age, body mass index, luteinizing hormone, and the number of good quality embryos transferred.

Results

The mean maternal ages and number of oocytes retrieved (43.2 years and 2.3 in both groups, P=0.902 and P=0.927, respectively) were similar in the fresh ET and FET groups. No significant difference was observed between the LBRs of the fresh ET and FET groups (adjusted odds ratio, 1.28; 95% confidence interval, 0.29–5.70). The clinical pregnancy and miscarriage rates, and neonatal characteristics (birth weights and premature infant rates) were similar between the 2 groups.

Conclusions

FET after the freeze-all strategy had no beneficial impact on the clinical outcomes of women ≥40 years with POR.

Effects of uterine artery occlusion during myomectomy on ovarian reserve: Serial follow-up of sex hormone levels, ultrasound parameters and Doppler characteristics

AIM

To evaluate the influence of uterine artery occlusion at myomectomy (UAO + M) on ovarian reserve based on serum sex hormone levels, ultrasound and color Doppler examinations.

METHODS

In this cohort study, nine women with symptomatic uterine myomas underwent UAO + M were recruited. Each woman was assessed preoperatively and 3, 6 months postoperatively, through a serial of hormonal, ultrasound parameters and Doppler examination for ovarian stromal blood flow. The data were analyzed using generalized estimating equations.

RESULTS

There was no significant difference in serum anti-Müllerian hormone (AMH) or follicle-stimulating hormone (FSH) levels before and 3, 6 months after UAO + M. The ovarian volume, antral follicle count (AFC) and ovarian stromal blood flow had significant changes in the right ovary. Ovarian volume and AFC significantly reduced at 3 months and recovered at 6 months postoperatively (P = 0.046, P = 0.019, respectively). Peak systolic velocity and end diastolic velocity significantly decreased at 3 months and leveled off at 6 months (P < 0.001, P = 0.001, respectively). Resistance index significantly increased at 3 months and decreased at 6 months (P = 0.037). A similar trend in ultrasound and Doppler findings was observed in the left ovary, but no statistical significance was found.

CONCLUSION

UAO + M had no detrimental effect on ovarian reserve 6 months postoperatively based on AMH and FSH levels. AFC, ovarian volume and stromal blood flow were transiently decreased in 3 months and recovered in 6 months.

Antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) are the predictors of natural fecundability have similar trends irrespective of fertility status and menstrual characteristics among fertile and infertile women below the age of 40 years

BACKGROUND

Despite being born with a significant number of primordial cells which representing the ancestor cells of the germ-line, women experience a depletion of ovarian reserve and sub-fertility mid-way into their healthy lives. The poor ovarian response is a substantial limiting factor amplified with higher maternal age and associated with a considerably lower likelihood of pregnancy.

METHODS

A present analytical prospective cross-sectional study was conducted to explore whether infertile women below the age of 40 years have low ovarian reserve than fertile women of same age, assessed by Antral follicle count (AFC) and anti-Müllerian hormone (AMH), at tertiary care infertility center: Lahore Institute of Fertility and Endocrinology, Hameed Latif Hospital. The study population including 423 infertile and 388 fertile female patients from June 2013 to November 2016. Patients and controls were aged between 25 and 39 years. Serum levels of FSH, LH, AMH were assessed, and AFC was measured by transvaginal sonography on cycle days 2 or 3.

RESULTS

A total of 35.6% of infertile women stated a menstrual cycle length shorter than 21 days, while 21% had a regular cycle length between 24 and 38 days, and 43.2%, longer than 38 days. Overall, the two cohorts did not significantly differ on cycle length. The age-specific reduction of the ovarian reserve was similar in both cohorts; serum AMH concentration decreased by 6% (95% Cl: 5-8%) and AFC decline by 4.5% (95% Cl: 5-7%) per year with increased age. Aged patients (36-39 years) had a 5.3% (95% Cl, 1.5; 7.2) higher risk ratio of having an AMH level < 0.7 ng/ml than women of younger age groups (Kruskal-Wallis test, p < 0.01).

CONCLUSION

This study indicates that the possible common observation of low respondent in ART might not be a result of over-representation of patients with an early age-specific decline in the ovarian reserve, but rather primarily as a consequence of age-specific depletion in the stock of developing follicles at the time of recruitment and selection.

Polycystic ovary morphology: age-based ultrasound criteria

OBJECTIVE

To determine age-based criteria for polycystic ovary morphology.

DESIGN

Cross-sectional, case-control design.

SETTING

Outpatient setting.

SUBJECT(S)

Women with polycystic ovary syndrome (PCOS) defined by hyperandrogenism and irregular menses (n = 544) and controls with regular menses and no evidence of hyperandrogenism (n = 666) participated. Parameters were tested in a second cohort of women with PCOS (n = 105) and controls (n = 32) meeting the same criteria.

INTERVENTION(S)

Subjects underwent a pelvic ultrasound documenting ovarian volume and maximum follicle number in a single plane.

MAIN OUTCOME MEASURE(S)

A receiver operating characteristic curve was constructed to determine the ovarian volume and follicle number with the best sensitivity and specificity to define PCOS for age groups at approximately 5-year intervals from age 18 to >44 years.

RESULT(S)

The best sensitivity and specificity were obtained using a threshold volume of 12 mL and 13 follicles for ages ≤24 years, 10 mL and 14 follicles for ages 25-29 years, 9 mL and 10 follicles for ages 30-34 years, 8 mL and 10 follicles for ages 35-39 years, 10 mL and 9 follicles for ages 40-44 years, and 6 mL and 7 follicles for ages >44 years. Data from a second cohort confirmed the need to decrease volume and follicle number with increasing age to diagnose PCOS. Polycystic ovary morphology was most accurate at predicting the PCOS diagnosis for women ages 30-39 years.

CONCLUSION(S)

The ovarian volume and follicle number threshold to define polycystic ovary morphology should be lowered starting at age 30.

Use of electroacupuncture and transcutaneous electrical acupoint stimulation in reproductive medicine: a group consensus

With the rapid development of assisted reproductive technology, various reproductive disorders have been effectively addressed. Acupuncture-like therapies, including electroacupuncture (EA) and transcutaneous electrical acupoint stimulation (TEAS), become more popular world-wide. Increasing evidence has demonstrated that EA and TEAS are effective in treating gynecological disorders, especially infertility. This present paper describes how to select acupoints for the treatment of infertility from the view of theories of traditional Chinese medicine and how to determine critical parameters of electric pulses of EA/TEAS based on results from animal and clinical studies. It summarizes the principles of clinical application of EA/TEAS in treating various kinds of reproductive disorders, such as polycystic ovary syndrome (PCOS), pain induced by oocyte retrieval, diminished ovarian reserve, embryo transfer, and oligospermia/ asthenospermia. The possible underlying mechanisms mediating the therapeutic effects of EA/TEAS in reproductive medicine are also examined.

Follicle Stimulating Hormone and Anti-Müllerian Hormone among Fertile and Infertile Women in Ile-Ife, Nigeria: Is there A Difference?

Background

Reduced ovarian reserve predicts poor ovarian response and poor suc- cess rates in infertile women who undergo assisted reproductive technology (ART). Ovarian reserve also decreases with age but the rate of decline varies from one woman to another. This study aims to detect differences in ovarian reserve as measured by basal serum follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) between a matched cohort of fertile and infertile regularly menstruating women, 18-45 years of age.

Materials and Methods

This case-control study involved 64 fertile and 64 subfertile women matched by age at recruitment. Peripheral blood samples were taken from the women recruited from the Gynecological and Outpatient Clinics of Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria. Serum FSH and AMH were quantified using ELISA at the Metabolic Research Laboratory of LAUTECH Teaching Hospital, Ogbomoso, Nigeria.

Results

A significant difference existed in the mean FSH of fertile (6.97 ± 3.34) and infertile (13.34 ± 5.24, P=0.013) women. We observed a significant difference in AMH between fertile (2.71 ± 1.91) and infertile (1.60 ± 2.51, P=0.029) women. There was a negative correlation between FSH and AMH in both fertile (r=-0.311, P=0.01) and infertile (r=-0.374, P=0.002) women.

Conclusion

The difference in ovarian reserve observed in this study suggests that reduced ovarian reserve in regularly menstruating women may be associated with early ovarian ageing or subfertility.

Ovarian reserve markers in unexplained infertility patients treated with clomiphene citrate during intrauterine insemination

INTRODUCTION

The aim of this retrospective case control study was to identify predictors of ovarian response and pregnancy outcomes in intrauterine insemination (IUI).

MATERIAL AND METHODS

One hundred women undergoing IUI cycles with clomiphene citrate were enrolled. The number of antral follicles and the total ovarian volume by ultrasound, and the basal levels of follicle-stimulating hormone (FSH), estradiol, and inhibin B on cycle day 3 were measured in groups that were divided according to ovarian response. The tests were also evaluated according to ovarian response and pregnancy outcomes. All analyses were performed using the Statistical Package for the Social Sciences, version 15.0 (SPSS, Chicago, IL, USA).

RESULTS

The antral follicle count (AFC) was the best single predictor for ovarian response and pregnancy outcomes. The sensitivity and specificity for prediction of ovarian response were 81% and 78% for AFC at an optimum cutoff value of ≤ 13.1. Age was negatively correlated with ovarian volume (r = -0.280, p = 0.021) and AFC (r = -0.358, p = 0.003). Increasing FSH was associated with a reduction in AFC (r = -0.273, p = 0.025). The AFC was significantly correlated with ovarian volume (r = 0.660, p < 0.0001) and FSH (r = -0.273, p = 0.03).

CONCLUSIONS

Our data demonstrate that the AFC provides better prognostic information on the occurrence of ovarian response during clomiphene citrate stimulation for IUI.

Evaluation of the ovarian reserve function in patients with metabolic syndrome in relation to healthy controls and different age groups

OBJECTIVE

To evaluate the ovarian reserve function in female patients with metabolic syndrome (MetS).

METHODS

This study evaluated 136 subjects, 67 with MetS and 69 controls. Subjects were divided into three age groups. Group I included 49 subjects aged 20-29 years, 22 with MetS and 27 controls; group II included 45 subjects aged 30-39 years, 22 with MetS and 23 controls; and group III included 42 subjects aged 40-49 years, 23 with MetS and 19 controls. Demographic characteristics, anthropometrics, blood biochemistry, and gonadotrophic hormones were compared as total ovarian volume and antral follicle count on ovarian transvaginal ultrasonography.

RESULTS

Serum levels of FSH, LH, E2 and progesterone were similar in the MetS and control groups, while testosterone levels were significantly higher in MetS patients than controls, both in the overall population (p = 0.024) and in those aged 20-29 years (p = 0.018). Total ovarian volume was significantly lower in MetS patients than controls, in both the overall population (p = 0.003) and those aged 20-29 years (p = 0.018), while antral follicle counts were similar. Ovarian volume correlated positively with antral follicle count (AFC) (r = 0.37; p < 0.001) and negatively with age (r = 0.34; p < 0.001) and FSH concentration (r = 0.21; p = 0.013). AFC was negatively correlated with age (r = 0.36; p < 0.001).

CONCLUSION

Ovarian reserve function is significantly lower in MetS patients than in healthy control subjects, particularly in women aged 20-29 years.

Follicle number, not assessments of the ovarian stroma, represents the best ultrasonographic marker of polycystic ovary syndrome

OBJECTIVE

To compare the diagnostic potential of ultrasonographic markers of ovarian morphology, used alone or in combination, to predict polycystic ovary syndrome (PCOS).

DESIGN

A diagnostic test study using cross-sectional data collected from 2006-2011.

SETTING

Academic hospital and clinical research unit.

PATIENT(S)

Eighty-two women with PCOS and 60 healthy female volunteers.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Follicle number per ovary (FNPO), ovarian volume (OV), follicle number per single cross-section (FNPS), follicle distribution pattern, stromal area, ovarian area, stromal-to-ovarian area ratio (S:A), and stromal index (SI).

RESULT(S)

Follicle number per ovary best predicted PCOS (R(2) = 67%) with 85% sensitivity and 98% specificity, followed by OV (R(2) = 44%), and FNPS (R(2) = 36%). Neither S:A nor SI had predictive power for PCOS. In combination, FNPO+S:A and FNPO+SI most significantly predicted PCOS (R(2) = 74% vs. 73%, respectively). The diagnostic potentials of OV and FNPS were substantially improved when used in combination (OV+FNPO, R(2) = 55%).

CONCLUSION(S)

As a single metric, FNPO best predicted PCOS. Although the addition of S:A or SI improved the predictive power of FNPO, gains were marginal, suggesting limited use in clinical practice. When image quality precludes a reliable estimation of FNPO, measurements of OV+FNPS provide the next closest level of diagnostic potential.

The anti mullerian hormone- a novel marker for assessing the ovarian reserve in women with regular menstrual cycles

BACKGROUND

Ovarian Reserve (OR) is a term which describes the functional potential of the ovary, which constitutes the size of the ovarian follicle pool and reflects the number and quality of the oocytes which are within it. Assessment of the OR helps in reflecting the reproductive potential of women. Various markers are available for assessing the OR and the best marker is the Anti Mullerian Hormone (AMH) which reflects the ovarian follicular pool in the ovary. In this study, the serum level of AMH/MIS(Mullerian Inhibiting Substance)was estimated to assess the ovarian reserve in both fertile and infertile women.

OBJECTIVE

To assess the ovarian reserve in women of the fertile and subfertile groups with regular cycles, who were in the age range of 26 -33yrs, by estimating the level of AMH and those of other hormones like FSH and E2 and also to calculate the ovarian volume and the Antral follicular count by an ultrasonographic method.

MATERIALS AND METHODS

Thirty fertile and thirty sub fertile women whose ages ranged from 26-33yrs were included as group 1 and group 2 respectively. The hormones like AMH ,FSH and oestradiol were assayed. Measurement of the ovarian volume and the antral follicular count by doing a transvaginal ultrasonogram, was done in all the subjects who were involved in both the groups. The correlation test was studied between the variables and the test of significance of the variables between the 2 groups was also analyzed by the Statistical Package Of Social Sciences (SPSS).

RESULTS

The Antral Follicular Count (AFC) and the ovarian volume were negatively correlated with the age. The ovarian volume was positively correlated with the AFC. The FSH negatively correlated with the AFC. The Anti Mullerian Hormone negatively correlated with the age, and it positively correlated with the AFC. The mean values of AFC, FSH, and AMH were also statistically significant between the two groups.

CONCLUSION

AMH can be considered as a marker for assessing the ovarian reserve, as it is cycle independent as compared to the other hormones. The women in the subfertile group with low levels of AMH should be insisted to proceed for ART as early as possible.

Evaluation of ovarian reserve in infertile patients

Diminished ovarian reserve is a more common occurrence as more women postpone childbearing in modern societies due to social and demographic trends. Diminished ovarian reserve is one of the primary reasons for poor ART outcome. Due to high costs, side effects and heavy burden on patients on ART treatments, patient selection and counseling for prognosis is an important aspect before starting ART. Proper prediction of ovarian reserve before initiation of the treatment can decrease cycle cancellations, help clinicians to establish alternative treatment options (i.e.oocyte donation) for poor prognosis patients. However, indicators of ovarian reserve are not fully successful in predicting the outcome of the treatment. In this review, our aim was to discuss the efficacy of ovarian reserve tests on predicting poor ovarian response and treatment outcome in ART patients.

Validation of multi-detector computed tomography as a non-invasive method for measuring ovarian volume in macaques (Macaca fascicularis)

The purpose of this study was to validate low radiation dose, contrast-enhanced, multi-detector computed tomography (MDCT) as a non-invasive method for measuring ovarian volume in macaques. Computed tomography scans of four known-volume phantoms and nine mature female cynomolgus macaques were acquired using a previously described, low radiation dose scanning protocol, intravenous contrast enhancement, and a 32-slice MDCT scanner. Immediately following MDCT, ovaries were surgically removed and the ovarian weights were measured. The ovarian volumes were determined using water displacement. A veterinary radiologist who was unaware of actual volumes measured ovarian CT volumes three times, using a laptop computer, pen display tablet, hand-traced regions of interest, and free image analysis software. A statistician selected and performed all tests comparing the actual and CT data. Ovaries were successfully located in all MDCT scans. The iliac arteries and veins, uterus, fallopian tubes, cervix, ureters, urinary bladder, rectum, and colon were also consistently visualized. Large antral follicles were detected in six ovaries. Phantom mean CT volume was 0.702+/-SD 0.504 cc and the mean actual volume was 0.743+/-SD 0.526 cc. Ovary mean CT volume was 0.258+/-SD 0.159 cc and mean water displacement volume was 0.257+/-SD 0.145 cc. For phantoms, the mean coefficient of variation for CT volumes was 2.5%. For ovaries, the least squares mean coefficient of variation for CT volumes was 5.4%. The ovarian CT volume was significantly associated with actual ovarian volume (ICC coefficient 0.79, regression coefficient 0.5, P=0.0006) and the actual ovarian weight (ICC coefficient 0.62, regression coefficient 0.6, P=0.015). There was no association between the CT volume accuracy and mean ovarian CT density (degree of intravenous contrast enhancement), and there was no proportional or fixed bias in the CT volume measurements. Findings from this study indicate that MDCT is a valid non-invasive technique for measuring the ovarian volume in macaques.

Biomarkers of Ovarian Reserve

The primary function of the female ovary is the production of a mature and viable oocyte capable of fertilization and subsequent embryo development and implantation. At birth, the ovary contains a finite number of oocytes available for folliculogenesis. This finite number of available oocytes is termed "the ovarian reserve". The determination of ovarian reserve is important in the assessment and treatment of infertility. As the ovary ages, the ovarian reserve will decline. Infertility affects approximately 15%-20% of reproductive aged couples. The most commonly used biomarker assay to assess ovarian reserve is the measurement of follicle stimulating hormone (FSH) on day 3 of the menstrual cycle. However, anti-müllerian hormone and inhibin-B are other biomarkers of ovarian reserve that are gaining in popularity since they provide direct determination of ovarian status, whereas day 3 FSH is an indirect measurement. This review examines the physical tools and the hormone biomarkers used to evaluate ovarian reserve.

Ovarian reserve and reproductive age may be determined from measurement of ovarian volume by transvaginal sonography

BACKGROUND

The human ovary contains a fixed number of primordial follicles that decreases bi-exponentially with age, culminating in the menopause at an average age of 50-51 years. There currently is no reliable test of ovarian reserve for individual women that will accurately predict their remaining reproductive lifespan.

METHODS AND RESULTS

We use the Faddy-Gosden model of human primordial follicle population decline to describe the natural decay of the ovarian follicle pool. Assuming that the wide distribution for age at menopause is due to the wide variation in number of primordial follicles at birth, we describe follicle population decline for early and late menopausal women. Using published data on age-related ovarian volume as measured by transvaginal sonography, we have obtained a highly significant correlation between primordial follicle population and ovarian volume. We show that ovarian volume in women aged 25-51 years accurately reflects the number of primordial follicles remaining, and describe how measurement of ovarian volume by transvaginal sonography may determine ovarian reserve and reproductive age.

CONCLUSIONS

The accurate assessment of ovarian reserve will revolutionize the management of women requesting assisted conception, those who have had treatment for childhood cancer and those who are considering delaying a family for personal or professional reasons.