Polycystic ovarian syndrome and the risk of spontaneous abortion following assisted reproductive technology treatment

Systematic review and meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome

Screening for polycystic ovary syndrome (PCOS) in antenatal care is inadequate, largely owing to the lack of clarity around whether PCOS is an independent risk factor for pregnancy complications. This systematic review and meta-analysis include 104 studies and 106,690 pregnancies in women with and without PCOS from inception until 13th July 2022. We report that women with PCOS are younger and have higher body mass index (BMI) around conception and have greater gestational weight gain. The odds of miscarriage, gestational diabetes mellitus, gestational hypertension, pre-eclampsia and cesarean section are higher in women with PCOS. The increased odds of adverse outcomes in PCOS remain significant when age and BMI are matched and when analyses are restricted to high-quality studies. This work informed the recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome, emphasizing that PCOS status should be captured in all women who are planning to, or have recently become pregnant to facilitate prevention of adverse outcomes and improve pregnancy outcomes.

Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I

Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.

Polycystic ovary syndrome and recurrent pregnancy loss, a review of literature

Objective

PCOS is a syndrome of ovarian dysfunction associated with recurrent pregnancy loss. Several correlating factors have been investigated that influence the risk of pregnancy loss in PCOS. However, uncertainty remains about their contribution to pregnancy loss and prognosis. This review of literature aims to identify what is known and what requires further investigation on the relationship between PCOS and recurrent pregnancy loss, to guide future research and optimize medical guidance throughout pregnancy.

Study design

a review of literature was performed on several search engines using the following terms; polycystic ovarian syndrome, PCOS, recurrent pregnancy loss, recurrent miscarriage, RPL, aborted fetus, abortus provocatus, miscarriage and habitual abortion.

Results

37 articles were included; 3 systematic reviews, 1 meta-analysis, 2 randomized controlled trials, 6 prospective cohort studies, 22 case-control studies and 3 case series. The main objectives investigated by studies were pregnancy complications, pregnancy loss and live birth in the PCOS population.

Conclusion

Studies that investigated the relationship between PCOS and recurrent pregnancy loss are few and inconsistent and warrant further research. Factors apt for further investigation include the extent to which PCOS phenotypes, BMI, obesity, insulin resistance, hyperandrogenemia, SHBG, hs-CRP, CTRP6, adiponectin, plasma leptin, homocysteine, AMH and thrombophilia contribute to further risk of miscarriage. Other factors requiring further exploration in relation to risk for miscarriage in PCOS patient with RPL include sOB-R, PAI-Fx and the Factor-V-Leiden mutations.

Associations between obesity, smoking behaviors, reproductive traits and spontaneous abortion: a univariable and multivariable Mendelian randomization study

Background

The correlation between potential risk factors such as obesity (leg fat percentage (left), arm fat percentage (left), waist circumference, body fat percentage, trunk fat percentage), smoking behaviors (past tobacco smoking, smoking initiation, smoking/smokers in household, current tobacco smoking) and reproductive traits (age first had sexual intercourse (AFS), age at menarche (AAM), and age at first birth (AFB)) have been linked to the occurrence of spontaneous abortion (SA). However, the causal associations between these factors and SA remain unclear.

Methods

We conducted univariable and multivariable Mendelian randomization (MR) analyses to evaluate the associations of obesity, smoking behavior and reproductive traits with SA. To select appropriate genetic instruments, we considered those that had reached the genome-wide significance level (P < 5 × 10-8) in their corresponding genome-wide association studies (GWAS) involving a large number of individuals (ranging from 29,346 to 1,232,091). SA was obtained from the FinnGen consortium, which provided summary-level data for 15,073 SA cases and 135,962 non-cases.

Results

Assessed individually using MR, the odds ratios (ORs) of SA were 0.728 (P = 4.3608×10-8), 1.063 (P = 0.0321), 0.926 (P = 9.4205×10-4), 1.141 (P = 7.9882×10-3), 5.154 (P = 0.0420), 1.220 (P = 0.0350), 1.228 (P = 0.0117), 0.795 (P = 0.0056), 1.126 (P = 0.0318), for one standard deviation (SD) increase in AFS, AAM, AFB, smoking initiation, smoking/smokers in household, arm fat percentage (left), leg fat percentage (left), waist circumference and body fat percentage, 0.925 (P = 0.4158) and 1.075 (P = 0.1479) for one SD increase in past tobacco smoking, trunk fat percentage for one SD increase in SA. In multivariable MR (MVMR), only AFS (OR = 0.802; P = 0.0250), smoking initiation (OR = 1.472, P = 0.0258), waist circumference (OR = 0.813, P = 0.0220) and leg fat percentage (left) (OR = 4.446, P = 0.043) retained a robust effect.

Conclusion

Smoking behaviors, reproductive traits and obesity-related anthropometric indicators are potential causal factors for SA. Higher leg fat percentage; smoking initiation; and lower waist circumference and AFS may increase the risk of SA. Understanding the causal relationship for SA may provide more information for SA intervention and prevention strategies.

Pregnancy and neonatal outcomes of monozygotic twins resulting from assisted reproductive technology: a 10-year retrospective study

BACKGROUND

Monozygotic twins (MZTs) are associated with high risks of maternal and fetal complications. Even with the widely used elective single embryo transfer (SET), the risk of MZTs following assisted reproductive technology (ART) treatments remains. However, most studies of MZTs focused on the relevant etiology, with few studies describing pregnancy and neonatal outcomes.

METHODS

This retrospective cohort study included 19,081 SET cycles resulting from in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), preimplantation genetic testing (PGT) and testicular sperm aspiration (TESA) performed between January 2010 and July 2020 in a single university-based center. A total of 187 MZTs were included in this investigation. The main outcome measures were the incidence, pregnancy and neonatal outcomes of MZTs. Multivariate logistic regression analysis was performed to figure out the risk factors for pregnancy loss.

RESULTS

The overall rate of MZTs from ART treatment in SET cycles was 0.98%. No significant difference was found in the incidence of MZTs among the four groups (p = 0.259). The live birth rate of MZTs in the ICSI group (88.5%) was significantly more favorable than in the IVF, PGT and TESA groups (60.5%, 77.2% and 80%, respectively). IVF resulted in a significantly increased risk of pregnancy loss (39.4%) and early miscarriage (29.5%) in MZT pregnancies compared to ICSI (11.4%, 8.5%), PGT (22.7%, 16.6%) and TESA (20%, 13.3%). The total rate of twin-to-twin transfusion syndrome (TTTS) in MZTs was 2.7% (5/187); however, the TESA group had the highest rate at 20% and was significantly higher than the PGT group (p = 0.005). The four ART groups had no significant effect on the occurrence of congenital abnormalities or other neonatal outcomes in newborns from MZT pregnancies. Multivariate logistic regression analysis revealed that infertility duration, cause of infertility, the total dose of Gn used, history of miscarriages, and the number of miscarriages were not related to the risk of pregnancy loss (p > 0.05).

CONCLUSIONS

The rate of MZTs was similar among the four ART groups. The pregnancy loss and the early miscarriage rate of MZTs was increased in IVF patients. Neither the cause of infertility nor the history of miscarriage was correlated with the risk of pregnancy loss. MZTs in the TESA group had a higher risk of TTTS, placental effects influenced by sperm and paternally expressed genes may play a role. However, due to the small total number, studies with larger sample sizes are still needed to validate these result. Pregnancy and neonatal outcomes of MZTs after PGT treatment seem to be reassuring but the duration of the study was short, and long-term follow-up of the children is needed.

Risk factors for clinical pregnancy loss after IVF in women with PCOS

RESEARCH QUESTION

Which factors are associated with the risk of clinical pregnancy loss in women with polycystic ovary syndrome (PCOS) undergoing IVF?

DESIGN

Case-control study nested in a multicentre randomized trial comparing live birth rates between fresh and frozen embryo transfer in women with PCOS. Women with the outcome of clinical pregnancy loss were selected as the case group, those with live birth as the control group. Parameters before IVF treatment and variables during ovarian stimulation and embryo transfer were compared.

RESULTS

Women with clinical pregnancy loss had higher maternal body mass index (BMI, P = 0.010), anti-Müllerian hormone (AMH, P = 0.032), 2-h glucose concentration after 75 g oral glucose tolerance test (OGTT, P = 0.025), and a higher proportion of fresh embryo transfers (P = 0.001). There were significant interactions between the types of transfer and antral follicle count (AFC, P = 0.013), 2-h glucose concentration after OGTT (P = 0.024) on clinical pregnancy loss in PCOS, indicating that these factors may have different effects on pregnancy loss after fresh versus frozen embryo transfer. When the multivariable logistic regression analysis was stratified by the fresh or frozen embryo transfer, AFC (adjusted odds ratio [aOR] 1.03, 95% confidence interval [CI] 1.01-1.05) was a risk factor for clinical pregnancy loss after fresh embryo transfer, while 2-hour glucose concentration after OGTT (aOR 1.13, 95% CI 1.01-1.25) was associated with clinical pregnancy loss in frozen embryo transfer (FET) cycles.

CONCLUSIONS

In women with PCOS, fresh embryo transfer, higher BMI, AFC and 2-h glucose concentration after OGTT were risk factors for clinical pregnancy loss. FET may be a better choice to decrease the risk of clinical pregnancy loss, especially for those with higher AFC. During FET, 2-h glucose after OGTT appears to be associated with clinical pregnancy loss and warrants close monitoring.

Use of pulsatile gonadotropin-releasing hormone (GnRH) in patients with functional hypothalamic amenorrhea (FHA) results in monofollicular ovulation and high cumulative live birth rates: a 25-year cohort

PURPOSE

To analyze outcomes of pulsatile administration of gonadotropin-releasing hormone (GnRH) in infertile women diagnosed with functional hypothalamic amenorrhea (FHA).

METHODS

A single-center retrospective cohort study was conducted from 1996 to 2020. Sixty-six patients with the diagnosis FHA that underwent therapy using the pulsatile GnRH pump for conception were included and analyzed. The primary outcome was the live birth rate (LBR). Secondary outcomes were the number of dominant follicles, ovulation rate, biochemical pregnancy rate (BPR), clinical pregnancy rate (CPR), miscarriage rate, and multiple pregnancy rate. A matched control group was selected to compare the birth weight of newborn children.

RESULTS

During the study period, 66 patients with FHA underwent 82 treatments (14 of 66 patients had more than one treatment) and a total of 212 cycles (ovulation induction attempts) using pulsatile GnRH. The LBR per treatment was 65.9%. The ovulation rate per cycle was 96%, and monofollicular ovulation was observed in 75% of cycles. The BPR per treatment was 80.5%, and the cumulative CPR per treatment was 74.4%. The miscarriage rate was 11.5%. One dizygotic twin pregnancy was observed (1.6%). Average newborn birth weight (NBW) from patients with FHA was comparable to the control group.

CONCLUSION(S)

In patients with FHA, excellent pregnancy rates were achieved using the subcutaneous GnRH pump. The high cumulative LBR with normal NBW as well as low rates of multiple gestation indicate that the pulsatile GnRH pump represents a safer and more physiologic alternative to ovulation induction with injectable gonadotropins.

TRIAL REGISTRATION

Ethics Committee Northwest and Central Switzerland (Ethikkommission Nordwest- und Zentralschweiz - EKNZ) - Project-ID 2020-01612.

Maternal Obesity: An Obstetric Risk

Objective: To analyze the obstetric risks and to evaluate the effects of maternal obesity during pregnancy and postpartum period.

Method: This is a retrospective study of pregnant women with a BMI of more the 30 conducted at Bahrain Defence Force Hospital, West Riffa, Bahrain, from September 2019 to August 2020. Data includes demographic characteristics, and course of pregnancy from gestational age 24 weeks, through intrapartum to the postpartum period. Adverse maternal effects and delivery complications were the primary study outcomes. The BMI was calculated at the time of the booking visit. Comparative analysis was done to calculate the odds of each outcome taking a non-obese group (BMI less than 30) as a reference. 

Results: The total number of pregnant women studied was 2972, out of which 1657 had BMI ≥30. In our study, women with high BMI were older (p<0.0001). High BMI was associated with high parity and higher miscarriage history. High BMI increased the risk of developing hypertension (OR 2.5; 95%CI 1.1-5.3). This analysis also found that high BMI was associated with increased risk of antepartum hemorrhage (OR 2.4; 95%CI 1-5.4), postpartum complications (OR1.6; 95%CI 1.1-2.2), and a hospital stay of more than five days (OR 1.6; 95%CI 1.3-2). High BMI patients were less likely to have Intrauterine growth restriction (OR 0.6; 95%CI 0.3-0.9). High BMI patients did not have an increased risk of gestational diabetes mellitus, induction of labor, or caesarean birth.

Conclusion: Higher BMI pregnant women are associated with higher incidences of hypertension. The high BMI group also had a significant relationship with antepartum hemorrhage and postpartum length of stay.

Comparison of two endometrial preparation methods for frozen-thawed embryo transfer in anovulatory PCOS patients: impact on miscarriage rate

OBJECTIVE

- Some studies have suggested that patients with polycystic ovary syndrome (PCOS) are at high risk of miscarriage. However, this still remains controversial. Several potential factors might explain this association: obesity, hyperinsulinemia and hyperandrogenism. Artificial and stimulated cycles appear to be comparable for endometrial preparation in frozen-thawed embryo transfer (FET) in PCOS patients. Only a few studies have assessed miscarriage rates specifically in PCOS. We have evaluated the impact of endometrial preparation on FET outcomes in anovulatory PCOS patients.

METHODS

- A retrospective cohort study was conducted at the Lille University Hospital, including 255 FET cycles in 134 PCOS patients between January 2011 and December 2017. PCOS was defined by the presence of at least two of the three Rotterdam's criteria. Patients were under 35 years old. Two endometrial preparation protocol were studied: stimulated cycle (gonadotropins on the second day of the cycle and luteal phase support including natural progesterone 600 mg/day) and artificial cycle (6 mg oral estradiol valerate and 800 mg micronized vaginal progesterone daily).

RESULTS

- 137 FET were performed under stimulated cycle and 118 FET under artificial cycle. Early pregnancy rates (30% versus 37.3%, p = NS), miscarriage rates (22% versus 25%, p = NS) and live birth rates (23.4% versus 26.3%, p = NS) were similar.

CONCLUSIONS

- In anovulatory PCOS women, the type of endometrial preparation does not influence FET outcomes, specifically regarding the miscarriage rate.

Different pregnancy outcomes according to the polycystic ovary syndrome diagnostic criteria: a systematic review and meta-analysis of 79 studies

OBJECTIVE

To correlate the distinct diagnostic criteria of polycystic ovary syndrome (PCOS) with the development of maternal and neonatal complications.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Pregnant women with PCOS.

INTERVENTION(S)

Maternal and neonatal complications were compared among women with PCOS diagnosed with different criteria.

MAIN OUTCOME MEASURE(S)

The primary outcomes of gestational diabetes mellitus and preeclampsia (PE) were assessed for every diagnostic criterion.

RESULT(S)

Seventy-nine studies were included. Regarding gestational diabetes, the overall pooled prevalence was 14% (95% confidence interval [CI], 11%-18%; I², 97%), reaching the highest level when polycystic ovarian morphology on ultrasound and 1 of the remaining 2 Rotterdam criteria (1/2 Rotterdam criteria) were used (18%; 95% CI, 13%-24%; I², 20%) and the lowest when polycystic morphology on ultrasound and hyperandrogenism were used (3%; 95% CI, 0%-19%; I², not applicable). Regarding PE, the overall pooled prevalence was 5% (95% CI, 4%-7%; I², 82%). The highest PE prevalence was reported when the National Institutes of Health criteria were used (14%; 95% CI, 5%-33%; I², 90%) and the lowest when menstrual irregularities and 1 of the 2 Rotterdam criteria were used (2%; 95% CI, 1%-3%; I², not applicable).

CONCLUSION(S)

The prevalence of gestational diabetes mellitus in pregnant women with PCOS does not differ according to the criteria used; however, women diagnosed with PCOS per the National Institutes of Health criteria are at higher risk of PE.

Women with PCOS with a History of Early Pregnancy Loss Show a Higher Risk of Gestational Diabetes Mellitus

Background

Polycystic ovary syndrome (PCOS) is quite common among women of reproductive age and can cause infertility and adverse pregnancy outcomes. Current studies on PCOS mainly focus on the effect of PCOS on pregnancy. So far, it remains unelucidated whether a history of infertility or early pregnancy loss (EPL) has differential effects on obstetric outcomes for PCOS women.

Methods

This is a retrospective case control study. Ninety-two Chinese PCOS patients with a history of EPL or infertility were recruited in our study. A total of 112 Chinese non-PCOS patients with a history of EPL or infertility were taken as control group. Measurements included anthropometric data, serum total testosterone, fasting and two-hour plasma glucose levels, and antral follicle count. After they got pregnant (naturally or via assisted reproductive technology), all obstetric outcomes were observed and analyzed.

Results

PCOS women with a history of EPL showed a much higher cesarean section (CS) rate than PCOS women with primary infertility. PCOS women with a history of EPL showed a much higher possibility of GDM (gestational diabetes mellitus) compared with PCOS women with primary infertility. PCOS women with a history of EPL showed a much higher possibility of GDM compared with non-PCOS women with a history of EPL. PCOS women with a history of EPL showed increased possibility of GDM as their BMI increased. When BMI is above 28, the incidence of GDM is significantly higher in PCOS women with a history of EPL compared with that in PCOS women with infertility.

Conclusion

Both a history of EPL and obesity are risk factors for GDM for PCOS women, and higher BMI indicates a higher possibility of GDM among PCOS women with a history of EPL. Timely intervention is in need for PCOS women with EPL and a higher BMI.

The Risk of Subsequent Miscarriage in Pregnant Women with Prior Polycystic Ovarian Syndrome: A Nationwide Population-Based Study

Objective: To assess the risk of subsequent miscarriage in pregnant women with a prior diagnosis of polycystic ovarian syndrome (PCOS). Methods: Using a nationwide, population-based database (Taiwan National Health Insurance Research Database) during 1998-2012, the study retrieved 1,000,000 randomly-sampled insured citizens as research subjects. The women with a diagnosis of pre-pregnancy PCOS (n = 13,562) who had chromosomal anomalies, artificial abortion, inconsistent diagnoses, and who were initially diagnosed with PCOS at >45 or <15 year-old were excluded, respectively. The records of gynecologic ultrasonography and/or blood tests were checked to verify the accuracy of the diagnoses of both PCOS and miscarriage (ICD-9 CM codes). After pregnancy, every woman with prior PCOS was age-matched to four women without prior PCOS. Results: Pregnant women with prior PCOS (the case group; n = 1926) and those without prior PCOS (the control group; n = 7704) were compared. The incidence of subsequent miscarriage was much higher in the case group compared with the control group (33.80% vs. 4.09%, p < 0.0001). Logistic regression analysis revealed that the risk of subsequent miscarriage was significantly higher in the case group than the control group (odds ratio [OR] 11.98; 95% CI 10.34-13.87, p < 0.0001), and the result remained similar while adjusted with covariates (adjusted OR 11.97; 95% CI 10.27-13.95, p < 0.0001). In the case group, the patient who used metformin had a lower risk of subsequent miscarriage (adjusted OR 9.53; 95% CI 6.69-13.57) when compared with those who did not receive metformin treatment (adjusted OR 12.13; 95% CI 10.38-14.18). Conclusion: For pregnant women, a pre-pregnancy diagnosis of PCOS is an independent and significant risk factor for subsequent miscarriage. The risk of subsequent miscarriage is reduced by about 1/4 for the PCOS patients who undergo metformin treatment compared with those who do not.

Pregnancy outcomes in women with polycystic ovarian syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) is the most common endocrinological disease of reproductive-aged women, with an estimated incidence ranging from 5% to 15%. The clinical manifestations of PCOS are heterogeneous and vary according to the age of the patient. Insulin resistance (IR), hyperandrogenism, and obesity are widely assumed to play a pivotal role in the pathophysiological mechanism of PCOS. As previously stated by many conducted meta-analyses, PCOS can cause a rising risk of pregnancy complications, including maternal, fetal, and neonatal complications. Pregnancy-induced hypertension (PIH), preeclampsia (PE), gestational diabetes mellitus (GDM), spontaneous preterm birth (PTB), and an increased necessity for a cesarean section (CS) are the most documented maternal implications. Regarding fetal outcomes, PCOS has also been correlated with elevated neonatal morbidity, prematurity, fetal growth restriction (FGR), birth weight variations (large for gestational age (LGA) and small for gestational age (SGA), and transfer to the neonatal intensive care unit (NICU). Owing to the variability of the studies performed, the association of PCOS with an elevated risk of adverse pregnancy outcomes is still controversial. This variability is found in the diagnosis and clinical presentations of PCOS, and can be influenced by pre-pregnancy circumstances and therapies as well as particular population and environmental features. The Amsterdam consensus guidelines confirm that obesity and IR can worsen maternal and fetal complications; thus, a closer follow-up should be offered to PCOS women during pregnancy.

Does blastocyst mitochondrial DNA content affect miscarriage rate in patients undergoing single euploid frozen embryo transfer?

PURPOSE

To determine whether the blastocyst mitochondrial DNA (mtDNA) content is related to the miscarriage rate in patients undergoing single euploid frozen embryo transfer (SEFET).

METHODS

A total of 355 single euploid frozen embryo transfer cycles were studied retrospectively between April 2017 and December 2018. A trophectoderm biopsy was performed on day 5/6 blastocysts. Post next-generation sequencing (NGS), the mtDNA content was calculated as the ratio of mitochondrial DNA over nuclear DNA, and the association between blastocyst mtDNA content and miscarriage rate was evaluated.

RESULT(S)

Three hundred fifty-five euploid blastocysts were selected for SEFET in 314 patients with an average age of 33.7 ± 5.6 years; 255 were biopsied on day 5 (71.8%) and 100 on day 6 (28.2%). Frozen embryo transfer (FET) was performed either in a hormone replacement therapy (HRT) cycle (71.8%; n = 255) or in a natural cycle (NC) (28.2%; n = 100). A pregnancy rate of 66.2% (235/355) was obtained with clinical pregnancy and miscarriage rates of 52.4% (n = 186) and 5.6% (n = 20), respectively. There was no significant difference neither between the blastocyst mtDNA content of pregnant and nonpregnant patients (27.7 ± 9.2 vs. 29.4 ± 8.6, P = 0.095) nor between patients with a clinical pregnancy and miscarriage (30.5 ± 9.3 vs. 27.3 ± 9.2, P = 0.136). Multivariate logistic regression analysis showed the same nonsignificant relationship, except for the miscarriage rate and BMI (OR 1.149, 95% CI 1.03-1.28; P = 0.012).

CONCLUSION(S)

Mitochondrial DNA content is unable to predict the miscarriage of implanted human euploid blastocysts.

Polycystic Ovarian Syndrome and Fertility

Polycystic ovary syndrome (PCOS) is a common endocrinopathy that has been associated with impaired fertility. This chapter reviews the underlying pathophysiology of PCOS and the associated fertility barriers of the condition. Psychologic concerns, hypothalamic-pituitary, ovarian, and mitochondria dysfunction, obesity, and the role of vitamin D in PCOS are considered with respect to fertility. Lastly, pregnancy risk factors associated with PCOS are also reviewed.

Risk Factors for Different Types of Pregnancy Losses: Analysis of 15,210 Pregnancies After Embryo Transfer

OBJECTIVE

To evaluate the risk factors for different types of pregnancy losses after embryo transfer (ET).

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine center.

PARTICIPANTS

A total of 15,210 pregnancies after fresh and frozen-thawed embryo transfer between January 2014 and June 2019.

MAIN OUTCOME MEASURES

The primary outcome was pregnancy loss (PL) throughout the entire pregnancy. Secondary outcomes were non-visualized PL, early miscarriage, late miscarriage, and stillbirth.

METHODS

The effect of patients' baseline characteristics and IVF/ICSI cycle-specific factors on the risk of PL after fresh and frozen-thawed ET was determined by multivariate logistic regression analysis.

RESULTS

Compared to women under 35 years old, those between 35 and 40 had an increased risk of early miscarriage [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.22-1.83], while those after 40 appeared to have an increased risk of both early miscarriage (OR 3.82, 95% CI 2.65-5.51) and late miscarriage (OR 2.79, 95% CI 1.64-4.77). Overweight patients were observed to have a higher risk of late miscarriage (OR 1.38, 95% CI 1.16-1.65), while obese patients showed a higher risk of both early miscarriage (OR 1.47, 95% CI 1.14-1.91) and late miscarriage (OR 1.80, 95% CI 1.33-2.44). Polycystic ovary syndrome (PCOS) was an independent risk factor for late miscarriage (OR 1.58, 95% CI 1.28-1.96), and the detrimental effect of PCOS was independent of obesity status. Women with uterine factors had a higher risk of early miscarriage (OR 1.77 (95% CI 1.32-2.38) than women without uterine factors. A negative correlation was observed between the thickness of the endometrium and PL (OR 0.95 95% CI 0.92-0.97). There was an increased risk of PL after frozen-thawed ET versus fresh ET (OR 1.12, 95% CI 1.01-1.24). Women who transferred ≥2 embryos showed lower risk of overall PL than women who transferred a single embryo, with adjusted ORs ranged from 0.57~0.94. However, women who transferred three embryos demonstrated a higher risk of late miscarriage than women who transferred a single embryo (OR 2.23, 95% CI 1.36-3.66).

CONCLUSIONS

Patients with uterine factors demonstrated higher risk of early miscarriage and stillbirth. Being overweight, PCOS, and transferring three embryos was associated with late miscarriage. Being aged 40 and over, obese, and using frozen embryo transfer was associated with early and late miscarriage.

Polycystic Ovary Syndrome and the Forgotten Uterus

Polycystic ovary syndrome (PCOS) is a common disorder that affects various facets of fertility. Although the ovarian and metabolic aspects of the disease is well studied, its role in uterine dysfunction is not well understood. Our objective was to review the features of endometrial and uterine aberrations in women with PCOS. A systematic literature search was performed in PubMed, Medline, and the Cochrane Library databases for papers published in English up to March 2020. The following key words were used for the search: polycystic ovary syndrome, poly cystic ovarian disease, polycystic ovaries, PCOS, PCOD, PCO, PCOM, oligoovulation, anovulation, oligomenorrhea, amenorrhea, hyperandrogenism and this was combined with terms; endometrium, infertility, uterus, progesterone resistance, endometrial hyperplasia, pregnancy outcomes, preterm delivery. In this review, we highlight various uterine pathologies that are associated with PCOS and explore its impact on fertility. We also discuss key uterine molecular pathways that are altered in PCOS that may be related to infertility, endometrial hyperplasia and cancer.

High BMI and Insulin Resistance Are Risk Factors for Spontaneous Abortion in Patients With Polycystic Ovary Syndrome Undergoing Assisted Reproductive Treatment: A Systematic Review and Meta-Analysis

Background

The risk of spontaneous abortion in patients with polycystic ovary syndrome (PCOS) undergoing assisted reproductive treatment (ART) is higher than that in patients without PCOS, however, no definitive risk factors have been confirmed to associate with the high spontaneous abortion rate in PCOS patients undergoing ART. This study was performed to assess the impact of relevant risk factors on spontaneous abortion in patients with PCOS. Clinical questions were formulated and organized according to the PICOS principle.

Methods

A systematic review and meta-analysis were conducted on all published studies on PCOS and spontaneous abortion in Embase, PubMed, Web of Science and Cochrane Library. Related risk factors included body mass index (BMI), age, insulin resistance (IR), hyperandrogenism, and chromosome aberrations. All patients were diagnosed as PCOS using the Rotterdam criteria. The primary endpoint was miscarriage and live birth rate. Fixed-effect models were used to analyze homogeneous data, and subgroup and sensitivity analyses were performed on heterogeneous data. The source of heterogeneity was evaluated, and the random effect model was used to summarize the heterogeneity.

Results

Among 1836 retrieved articles, 22 were eligible and included in the analysis with 11182 patients. High BMI (OR = 1.48, 95% CI [1.32, 1.67], MD = 1.35, 95% CI [0.58,2.12]) and insulin resistance (MD = 0.32, 95% CI [0.15, 0.49]) were associated with an increased risk of spontaneous abortion in PCOS patients undergoing ART. Older age (OR = 0.29, 95% CI [0.29, 0.44], MD = 2.01, 95% CI [0.04, 4.18]), embryonic chromosomal aberrations (OR = 0.75, 95%CI [0.31,1.77]), and hyperandrogenism (MD = 0.10, 95% CI [- 0.02, 0.22]) were not associated with the high spontaneous abortion rate in patients with PCOS. A subgroup analysis of BMI showed that there was no statistically significant difference in the effect between overweight and obesity on spontaneous abortion in PCOS patients undergoing ART (OR = 1.34, 95% [0.97, 1.85]).

Conclusion

High BMI and insulin resistance are two risk factors for an increased risk of spontaneous abortion in PCOS patients undergoing ART, and losing weight and mitigating insulin resistance may decrease the spontaneous abortion rate in these patients undergoing ART.

Maternal and neonatal outcomes among pregnant women with different polycystic ovary syndrome phenotypes: A cross-sectional study

Background

Pregnancy is a process associated with various metabolic and hormonal changes, and polycystic ovary syndrome (PCOS) can affect this process.

Objective

This study aimed to evaluate and compare the maternal and neonatal outcomes among pregnant women with different polycystic ovary syndrome phenotypes.

Materials and Methods

In this cross-sectional study, 200 pregnant women with PCOS according to the 2003 ESHRE/ASRM criteria were categorized into four phenotype groups (A-D). The maternal outcomes include gestational diabetes mellitus, pregnancy-induced hypertension, premature rupture of membranes, preterm labor, small-for-gestational age birth, intrauterine growth restriction, intrauterine mortality, preeclampsia, abortion, amniotic fluid disorders, delivery method, and cause of cesarean section were studied between groups. Additionally, neonatal outcomes such as neonatal weight, neonatal recovery, 5-min Apgar score, neonatal icter, the need for NICU admission, the cause of hospitalization, and infant mortality rate were investigated and compared among the groups.

Results

According to the results, phenotype D (37%) was the most common phenotype among the participants. The risk of gestational diabetes was more common in phenotype A than in the other phenotypes, whereas pregnancy-induced hypertension was most common in phenotype B. No significant differences were observed in the neonatal complications among the PCOS phenotypes.

Conclusion

Considering the higher risk of gestational diabetes mellitus and pregnancy-induced hypertension in PCOS phenotypes A and B, women with these phenotypes need more precise prenatal care.

Association between the TOX3 rs3803662 C>T polymorphism and recurrent miscarriage in a southern Chinese population

BACKGROUND

Studies have shown that some genetic polymorphisms associated with breast cancer susceptibility may also be associated with abortion. The TOX3 gene plays a key role during the onset of breast cancer, and reproductive factors such as abortion are risk factors for breast cancer. However, there is currently no study describing the relationship between the TOX3 rs3803662 C>T polymorphism and the risk of recurrent miscarriage. Therefore, we investigated whether the TOX3 rs3803662 C>T polymorphism is associated with recurrent miscarriage susceptibility in this case-control study.

METHODS

We recruited 248 recurrent miscarriage patients and 392 healthy controls from the southern Chinese population and performed genotyping using the TaqMan method.

RESULTS

The results showed no evidence that TOX3 rs3803662 C>T is associated with recurrent miscarriage (CT and CC: corrected OR = 1.038, 95% CI = 0.737-1.461, P = .8321; TT and CC: adjusted OR = 0.989, 95% CI = 0.591-1.656, P = .9659; dominant model: adjusted OR = 1.027, 95% CI = 0.742-1.423, P = .8712; recessive model: adjusted OR = 0.969, 95% CI = 0.600-1.566, P = .8975).

CONCLUSION

According to this study, the TOX3 rs3803662 C>T polymorphism may not be associated with recurrent miscarriage in the southern Chinese population. A larger multicenter study is needed to confirm the results.

Factors associated with spontaneous abortion following intracytoplasmic sperm injection (ICSI)

Objective:

The aim of this study was to describe the miscarriage rates and the factors associated with cases of spontaneous abortion observed in women offered intracytoplasmic sperm injection (ICSI).

Methods:

This cross-sectional study enrolled women who became pregnant with the aid of ICSI treated at the Babol Infertility Center (Iran) within a period of five years (2010-2015). Data were collected from patient charts and, in some cases, through phone calls. The study looked into the incidence of spontaneous abortion in women offered ICSI and the factors associated with miscarriage. The chi-square test, Fisher's exact test, and the t-test were used to analyze the data.

Results:

From a total of 145 pregnant women, 120 were included in our study. The prevalence of miscarriage was 20%. Galactorrhea was significantly more present in patients who had miscarriages (25% vs. 9.37%, p=0.04). There was a marked difference in the duration of infertility of miscarriage and non-miscarriage patients offered ICSI (6.6±8.3 vs. 4.9±7.3 years, p=0.05). No association was found between maternal age, BMI, cause of infertility, hormonal pattern, type of infertility, history of surgery, polycystic ovary syndrome, number of oocytes, or day of retrieval with miscarriage.

[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.

The usefulness of melatonin in the field of obstetrics and gynecology

Disorders of the female reproductive system, including those associated with hormone regulation, fertility rate and fetal health, are issues of great concern worldwide. More recently, melatonin supplementation has been suggested as a therapeutic approach in gynecological practice. In both animal models and in women, melatonin supplementation suggests a therapeutic and preventative potential, effects attributed mainly to its antioxidant properties and action as hormone modulator. The aim of this literature review is to further investigate the evidence available on the effects of melatonin supplementation in animal and human studies, focusing on its potential application to gynecology. Melatonin-containing supplements are easily found in online and high street retailers, and despite its supplementation deemed to be relatively safe, no consensus has been reached on effective dosage and supplementation period. Short term supplementation studies, of up to six months, suggest that a daily posology of 2-18 mg of melatonin may have the potential to improve fertility rate, oocyte quality, maturation and number of embryos. However, the evidence available so far on the effects of melatonin supplementation covering gestational age and gestational outcomes is very scarce. Clinical trials and longer-term supplementation studies are required to assess any clinical outcome associated with melatonin supplementation in the field of gynecology.

Maternal body mass index affects embryo morphokinetics: a time-lapse study

PURPOSE

To assess the effect of body mass index (BMI) on morphokinetic parameters of human embryos evaluated with time-lapse technology during in vitro culture.

METHODS

A retrospective analysis of ART cycles utilizing time-lapse technology was undertaken to assess the potential impact of maternal BMI on morphokinetic and static morphological parameters of embryo development. The cohort of patients was divided into four groups: 593 embryos from 128 underweight women in group A; 5248 embryos from 1107 normal weight women in group B; 1053 embryos from 226 overweight women in group C; and 286 embryos from 67 obese women in group D.

RESULTS

After adjusting for maternal age, paternal age, and cause of infertility, time to reach five blastomeres (t5) and time to reach eight blastomeres (t8) were longer in obese women compared with normoweight women [50.84 h (46.31-55.29) vs. 49.24 h (45.69-53.22) and 57.89 h (51.60-65.94) vs. 55.66 h (50.89-62.89), adjusted p < 0.05 and adjusted p < 0.01, respectively]. In addition, t8 was also delayed in overweight compared with normoweight women [56.72 h (51.83-63.92) vs. 55.66 h (50.89-62.89), adjusted p < 0.01]. No significant differences were observed among groups with regard to embryo morphology and pregnancy rate. Miscarriage rate was higher in underweight compared with normoweight women (OR = 2.1; 95% CI 1.12-3.95, adjusted p < 0.05).

CONCLUSION

Assessment with time-lapse technology but not by classical static morphology evidences that maternal BMI affects embryo development. Maternal obesity and overweight are associated with slower embryo development.

Increased maternal pregnancy complications in polycystic ovary syndrome appear to be independent of obesity-A systematic review, meta-analysis, and meta-regression

Polycystic ovary syndrome (PCOS) is associated with an increased risk of maternal pregnancy and delivery complications. However, the impact of clinical features of PCOS and other potential risk factors in PCOS is still unknown. We aimed to investigate the association of PCOS with maternal pregnancy and delivery complications with consideration of risk factors and potential confounders. The meta-analysis included 63 studies. PCOS was associated with higher miscarriage, gestational diabetes mellitus, gestational hypertension, pre-eclampsia, induction of labour, and caesarean section. The association of PCOS with these outcomes varied by geographic continent, PCOS phenotypes, and study quality. Pre-eclampsia and induction of labour were not associated with PCOS on body mass index-matched studies. No outcome was associated with PCOS on assisted pregnancies. Age was significantly associated with higher miscarriage on meta-regression. There were no studies assessing perinatal depression. We confirm that PCOS is associated with an increased risk of maternal pregnancy and delivery complications. The association of PCOS with the outcomes is worsened in hyperandrogenic PCOS phenotypes, in specific geographic continents, and in the highest quality studies but disappears in assisted pregnancies. Future studies in PCOS are warranted to investigate proper timing for screening and prevention of maternal pregnancy and delivery complications with consideration of clinical features of PCOS.

Influencing factors of pregnancy loss and survival probability of clinical pregnancies conceived through assisted reproductive technology

BACKGROUND

Pregnancies following assisted reproductive technology (ART) may have elevated potential risk of pregnancy loss (PL) when compared to natural conception. However, rare studies comprehensively analyzed the IVF/ICSI cycle-dependent factors for loss of clinical pregnancy. Therefore, we aimed to determine the ART subgroup-specific risks of PL throughout pregnancy and explore different risk factors for early miscarriage and late miscarriage among pregnancies conceived through ART.

METHODS

A retrospective cohort study was launched in two infertility treatment centers in Nanjing and Changzhou including 5485 IVF/ICSI embryo transfer cycles with known outcomes after clinical pregnancy by the end of 2015. Cox proportional hazards regression analysis was performed to estimate the hazard ratios and their 95% confidence intervals. The associations between survival time during pregnancy and demographics and clinical characteristics of clinical pregnancies were estimated using the Kaplan-Meier method and the Log-rank test.

RESULTS

The overall PL rate in current ART population was 12.5%. Among the 685 pregnancy loss cycles, a total of 460 ended as early miscarriage, 191 as late miscarriage. We found couples in ART pregnancies demonstrated a significantly increased risk of PL as maternal age (HR = 1.31, Ptrend < 0.001) grows. Pregnancies received controlled ovarian hyperstimulation (COH) protocol like GnRH antagonist protocol (HR = 3.49, P < 0.001) and minimal stimulation protocol (HR = 1.83, P < 0.001) had higher risk of PL than GnRH-a long protocol. Notably, in contrast to fresh cycle, women who received frozen cycle embryo had a significant increased risk of early miscarriage (P < 0.001), while frozen cycle was linked with lower risk of late miscarriage (P = 0.045). In addition, four factors (maternal age, COH protocol, cycle type and serum hCG level 14 days after transfer) had independent impact on miscarriage mainly before 12 weeks of gestational age.

CONCLUSIONS

With these findings in this study, clinicians may make it better to evaluate a patient's risk of PL based on the maternal age at the time of treatment, COH protocol, cycle type and serum hCG level 14 days after transfer and the gestational week of the fetus, and we hope that it contributes to future study on its etiology and guide the clinical prevention and treatment.

The Effect of Supraphysiological Estradiol on Pregnancy Outcomes Differs Between Women With PCOS and Ovulatory Women

CONTEXT

Supraphysiological estradiol exposure after ovarian stimulation may disrupt embryo implantation after fresh embryo transfer. Women with polycystic ovary syndrome (PCOS), who usually overrespond to ovarian stimulation, have a better live birth rate after frozen embryo transfer (FET) than after fresh embryo transfer; however, ovulatory women do not.

OBJECTIVE

To evaluate whether the discrepancy in live birth rate after fresh embryo transfer vs FET between these two populations is due to the variation in ovarian response (i.e., peak estradiol level or oocyte number).

DESIGN, SETTING, PATIENTS, INTERVENTION(S), AND MAIN OUTCOME MEASURE(S)

This was a secondary analysis of data from two multicenter randomized trials with similar study designs. A total of 1508 women with PCOS and 2157 ovulatory women were randomly assigned to undergo fresh or FET. The primary outcome was live birth.

RESULTS

Compared with fresh embryo transfer, FET resulted in a higher live birth rate (51.9% vs 40.7%; OR, 1.57; 95% CI, 1.22 to 2.03) in PCOS women with peak estradiol level >3000pg/mL but not in those with estradiol level ≤3000 pg/mL. In women with PCOS who have ≥16 oocytes, FET yielded a higher live birth rate (54.8% vs 42.1%; OR, 1.67; 95% CI, 1.20 to 2.31), but this was not seen in those with <16 oocytes. In ovulatory women, pregnancy outcomes were similar after fresh embryo transfer and FET in all subgroups.

CONCLUSIONS

Supraphysiological estradiol after ovarian stimulation may adversely affect pregnancy outcomes in women with PCOS but not in ovulatory women.

The correlation between raised body mass index and assisted reproductive treatment outcomes: a systematic review and meta-analysis of the evidence

Background

Public funding for fertility services within the United Kingdom is limited, and therefore, strict guidance exists regarding who can be offered treatment under the National Health Service (NHS). Body mass index (BMI) is a universal criteria adopted by both the public and private sector.

This study addresses an important aspect of the impact of a raised BMI on fertility treatment outcomes. We standardise the analysis of the data by only including studies incorporating the WHO BMI criteria; the current reference point for clinicians and clinical commissioning groups in ascertaining which group of patients should receive treatment. This study is an update of the previous systematic review performed in 2010, with the inclusion of a larger number of cycles from central databases such as the Society for Assisted Reproductive Technology (SART).

Methods

An electronic literature search was conducted through the Cochrane, Medline and Embase libraries. Data extraction for each outcome measure was pooled and expressed as an odds ratio with 95% confidence intervals. Where clinical heterogeneity was evident, the random effects model was used to calculate the risk ratio and a fixed effects model was used for the remaining studies. A p value < 0.05 was considered statistically significant.

Results

A total of 49 studies have been identified and included in this systematic review. Overweight and obese (BMI ≥ 25 kg/m²) women have a statistically significant lower live birth rate (OR 0.81, 95% CI 0.74–0.89, p < 0.00001) following Assisted Reproductive Technology (ART) when comparisons are drawn to women with a normal BMI. An increase is also demonstrated in the number of miscarriages experienced by women with a BMI ≥ 30 kg/m² (OR 1.52, 95% CI 1.28–1.81, p < 0.00001).

Conclusion

Although this review concludes that a clear impact of BMI on ART outcomes is demonstrated, there remains questions as to the pathophysiology underlying these differences. This review supports the government’s stringent criteria regarding BMI categories under which NHS funding is made available for ART, through a clear description of poor reproductive outcomes in women with a BMI ≥ 30 kg/m².

Differential rate in decline in ovarian reserve markers in women with polycystic ovary syndrome compared with control subjects: results of a longitudinal study

OBJECTIVE

To estimate rates of ovarian aging in polycystic ovary syndrome (PCOS) subjects versus a community control population.

DESIGN

Longitudinal.

SETTING

Tertiary academic center.

SUBJECT(S)

PCOS subjects diagnosed according to the 2004 Rotterdam criteria were systematically enrolled in a PCOS cohort study. The comparison control subjects were from the Ovarian Aging study, a prospective longitudinal study of ovarian aging in healthy women with regular menstrual cycles.

INTERVENTION(S)

Clinical data collection over two study visits.

MAIN OUTCOME MEASURE(S)

Antral follicle count (AFC), ovarian volume (OV), and antimüllerian hormone level (AMH).

RESULT(S)

PCOS subjects were found to have higher baseline values for all ovarian reserve markers compared with control subjects. Univariate models indicated that, compared with control subjects, PCOS patients experienced significantly faster rates of decline for both AFC and AMH. Change in OV did not differ significantly. To account for potential confounder effects, multiple analysis of covariance models were evaluated for the best fit, considering age, body mass index, and baseline ovarian reserve markers. Adjusted models demonstrated that PCOS patients do not experience a significant difference in AFC decline compared with control subjects, but they do experience a faster rate of decline in AMH (P<.01) and slower rate of decline in OV (P<.01).

CONCLUSION(S)

Ovarian aging in PCOS is characterized by a more rapid decline in AMH and a slower decline in OV compared with control subjects.

Mental health status assessment in polycystic ovarian syndrome infertility patients: A pilot study

Polycystic ovary syndrome (PCOS) is a major endocrine disorder afflicting women of reproductive age. Women with PCOS are more likely to suffer from mental health disturbances than healthy women. The "infertility" suffered by PCOS patients would also lead to mental health disturbances. Symptom Checklist 90 (SCL-90) and questionnaire which includes patients' socio-economic and demographic data were used to assess the mental health status of PCOS (n=103) and non-PCOS (n=110) infertile patients. Logistic regression analysis and t-tests were used for comparative analysis. The data demonstrated that scores of depression, interpersonal sensitivity, obsessive-compulsive, and hostility symptoms in PCOS infertile patients were significantly higher than those in the non-PCOS infertile patients (P<0.05). Logistic regression analysis revealed that acne had negative effect on mental health status (P<0.05). Secondary infertile PCOS patients were more easily to suffer from somatization, interpersonal sensitivity, obsessive-compulsive, anxiety, hostility and paranoid ideation symptoms than the primary infertile PCOS patients (P<0.05). The results suggested that the PCOS patients especially the secondary infertile PCOS patients had obvious mental health disturbances. The acne might play an importance role in the occurrence of mental health disturbances in PCOS patients. PCOS related symptoms may be risk factors of mental health status in PCOS patients with infertility. More attention should be paid to the PCOS infertile patients, and mental health therapy should be considered if necessary.

Comparison of In Vitro Fertilization/Intracytoplasmic Sperm Injection Cycle Outcome in Patients with and without Polycystic Ovary Syndrome: A Modified Poisson Regression Model

Background

Polycystic ovary syndrome (PCOS) is a frequent condition in reproductive age women with a prevalence rate of 5-10%. This study intends to determine the relationship between PCOS and the outcome of assisted reproductive treatment (ART) in Tehran, Iran.

Materials and Methods

In this historical cohort study, we included 996 infertile women who referred to Royan Institute (Tehran, Iran) between January 2012 and December 2013. PCOS, as the main variable, and other potential confounder variables were gathered. Modified Poisson Regression was used for data analysis. Stata software, version 13 was used for all statistical analyses.

Results

Unadjusted analysis showed a significantly lower risk for failure in PCOS cases compared to cases without PCOS [risk ratio (RR): 0.79, 95% confidence intervals (CI): 0.66-0.95, P=0.014]. After adjusting for the confounder variables, there was no difference between risk of non-pregnancy in women with and without PCOS (RR: 0.87, 95% CI: 0.72-1.05, P=0.15). Significant predictors of the ART outcome included the treatment protocol type, numbers of embryos transferred (grades A and AB), numbers of injected ampules, and age.

Conclusion

The results obtained from this model showed no difference between patients with and without PCOS ac- cording to the risk for non-pregnancy. Therefore, other factors might affect conception in PCOS patients.

Effects of propylene glycol or elevated luteinizing hormone during follicle development on ovulation, fertilization, and early embryo development

Seventeen nonlactating Holstein cows were superovulated in a Latin-square designed experiment to determine the effects of increased propylene glycol (PROP) and luteinizing hormone (LH) during antral follicle development on ovarian function, fertilization, and early embryo quality. PROP was orally drenched every 4 h for 7 days to induce hyperinsulinemia and associated metabolic changes. LH concentrations were altered by increasing LH (3-fold) during last 2 days of superovulation. Treatment groups were as follows: (1) control-oral drenching with water plus low-LH preparation; (2) high LH(HLH)-water plus HLH preparation; (3) PROP-drenching with PROP plus low LH; (4) PROP/HLH-PROP plus HLH. PROP increased glucose (P < 0.05) and insulin (P < 0.02) concentrations at all time points analyzed. Neither PROP nor LH affected numbers of follicles > 9 mm at time of gonadotropin-releasing hormone-induced LH surge, although percentage of these follicles that ovulated was decreased by both PROP (P = 0.002) and LH (P = 0.048). In addition, PROP tended (P = 0.056) to decrease total number of ovulations. PROP reduced (P = 0.028) fertilization rate, while LH tended (P = 0.092) to increase fertilization rate. There was no effect of either PROP or LH on any measure of embryo quality including percentage of embryos that were degenerate, quality 1, or quality 1 and 2 of total structures collected or fertilized structures. These results indicate that acute elevation in insulin during the preovulatory follicular wave can decrease percentage of large follicles that ovulate, particularly when combined with increased LH, and reduce fertilization of ovulated oocytes.

Correlation between follicular fluid levels of sRAGE and vitamin D in women with PCOS

PURPOSE

The pro-inflammatory advanced glycation end products (AGEs) and their anti-inflammatory soluble receptors, sRAGE, play a role in the pathogenesis of PCOS. There is a correlation between vitamin D (vit D) and sRAGE in the serum, whereby vit D replacement increases serum sRAGE levels in women with PCOS, thus incurring a protective anti-inflammatory role.

OBJECTIVE

This study aims to compare levels of sRAGE, N-carboxymethyl-lysine (CML; one of the AGEs), and 25-hydroxy-vit D in the follicular fluid (FF) of women with or without PCOS, and to evaluate the correlation between sRAGE and 25-hydroxy-vit D in the FF.

MATERIAL AND METHODS

Women with (n = 12) or without (n = 13) PCOS who underwent IVF were prospectively enrolled.

RESULTS

Women with PCOS had significantly higher anti-Mullerian hormone levels, higher number of total retrieved and mature oocytes, and higher number of day 3 and day 5 embryos formed. Compared to women without PCOS, women with PCOS had significantly lower FF sRAGE levels. In women with PCOS, in women without PCOS, and in all participants together, there was a significant positive correlation between sRAGE and 25-hydroxy-vit D. sRAGE positively correlated with CML in women without PCOS but not in women with PCOS.

CONCLUSIONS

In women with PCOS, the low ovarian levels of the anti-inflammatory sRAGE suggest that sRAGE could represent a biomarker and a potential therapeutic target for ovarian dysfunction in PCOS. Whether there is a direct causal relationship between sRAGE and vit D in the ovaries remains to be determined.

[Quality of oocytes and embryos from women with polycystic ovaries syndrome: State of the art]

The frequency of polycystic ovary syndrome (PCOS) and the consequent fertility disorders cause many difficulties in the management of the assisted reproductive technics. Some studies are focused on different additional treatments, stimulation protocols or techniques that could optimize the in vitro fertilization cycles. The quality of the oocytes and embryos of these patients is also an outstanding issue. They remain difficult to actually evaluate during management, and none of the few published studies on this subject demonstrated any inferiority, compared to control patients. However, many differences have been highlighted, studying intra- and extra-ovarian factors. The advent of new genetic techniques could allow a better understanding of the pathophysiological mechanisms of the syndrome, as well as refining the evaluation of oocytes and embryos, in order to better predict the results of in vitro fertilization attempts. Pregnancy and birth rates, however, appear to be comparable to those of the general population.

Follicular fluid cerebellin and betatrophin regulate the metabolic functions of growing follicles in polycystic ovary syndrome

Objective

The aim of this study was to assess the changes of follicular fluid (FF) and serum levels of cerebellin precursor protein 1 (cbln1) and betatrophin in patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) with a gonadotropin-releasing hormone (GnRH) antagonist protocol.

Methods

Twenty infertile women with PCOS and 20 control women diagnosed as poor responders undergoing ovarian stimulation with a GnRH antagonist were included. Blood samples were obtained during ovum pick-up. Follicular fluid from a dominant follicle was collected from the subjects. Using enzyme-linked immunosorbent assays, FF and serum levels of cbln1 and betatrophin were measured in both groups of participants. Metabolic and hormonal parameters were also determined and correlated with each other.

Results

Both groups of women had similar serum and FF betatrophin levels (55.0±8.9 ng/mL vs. 53.1±10.3 ng/mL, p=0.11). The serum and FF betatrophin levels of poor responders were found to be similar (49.9±5.9 ng/mL vs. 48.9±10.7 ng/mL, p=0.22). Conversely, the FF cbln1 levels of PCOS women were found to be significantly higher than the serum cbln1 levels (589.1±147.6 ng/L vs. 531.7±74.3 ng/L, p<0.02). The FF cbln1 levels of control participants without PCOS were significantly higher than their serum cbln1 levels (599.3±211.5 ng/L vs. 525.3±87.0 ng/L, p=0.01). Positive correlations were detected among body mass index, insulin resistance, serum insulin, total testosterone, and betatrophin levels in the PCOS group.

Conclusion

Follicular fluid betatrophin and cbln1 concentrations may play a pivotal role on follicular growth in PCOS subjects undergoing IVF/ICSI with an antagonist protocol.

Avoiding OHSS: Controlled Ovarian Low-Dose Stimulation in Women with PCOS

The polycystic ovary syndrome is a common endocrine disorder which influences outcome and potential risks involved with controlled ovarian stimulation for artificial reproductive techniques (ART). Concrete practical recommendations for the dosage of gonadotropins, the preferred protocol and preventive methods to avoid ovarian hyperstimulation syndrome (OHSS) are lacking. We present retrospective data of 235 individually calculated gonadotropin low-dose stimulations for ART in a single center from 2012 to 2014. Clinical data and outcome parameter of patients diagnosed with PCOS according to Rotterdam criteria (n = 39) were compared with patients without PCOS (n = 196). The starting dose of gonadotropins was individually calculated depending on patients' age, BMI, ovarian reserve, ovarian response in previous cycles, and diagnostic criteria of PCOS. Mean age and duration of infertility did not differ between the groups, whereas mean BMI (p = 0.007) and AMH (p < 0.001) were higher in the PCOS-group. A lower mean FSH-starting and maximum dose was administered to women with PCOS (p < 0.001). The biochemical pregnancy rate of 42.4 % and the clinical pregnancy rate of 32.2 % for PCOS-patients did not differ from those of the control group (42.2 % and 34.4 % respectively). Neither mild, nor moderate or severe manifestation of OHSS occurred significantly more often in patients with PCOS. Our study supports the use of a calculated low-dose FSH-stimulation strategy in ART for patients with PCOS. Further randomized clinical trials should confirm this strategy and lead to define individual risk factors for OHSS, which can be used for recommendation of safer ART-techniques like in vitro maturation.

Poly Cystic Ovarian Syndrome: An Updated Overview

Poly Cystic Ovarian Syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. Women suffering from PCOS present with a constellation of symptoms associated with menstrual dysfunction and androgen excess, which significantly impacts their quality of life. They may be at increased risk of multiple morbidities, including obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease (CVD), infertility, cancer, and psychological disorders. This review summarizes what the literature has so far provided from guidelines to diagnosis of PCOS. It will also present a general overview about the morbidities associated with this disease, specifically with its more severe classic form. Finally, the review will stress on the various aspects of treatment and screening recommendations currently used in the management of this condition.

Polycystic ovary syndrome: Endometrial markers

Women with polycystic ovarian syndrome (PCOS) present with several endometrial abnormalities possibly explaining some of the adverse endometrium-related outcomes in these women. PCOS and an increased miscarriage rate have been suggested to coincide, but the results are conflicting. Recent studies have also shown increased risks of pregnancy-induced hypertension, preeclampsia, and premature delivery that may be related to altered decidualization/placentation in affected women. In the long run, PCOS per se is associated with the occurrence of endometrial cancer (EC), with obesity aggravating the risk. Most investigated markers of the endometrial abnormalities in women with PCOS are related to steroid hormone action (ERs (estrogen receptors), PRs (progesterone receptors), ARs (androgen receptors), and steroid receptor coactivators), endometrial receptivity/decidualization (HOXA10, αvβ3 integrin, and IGFBP-1 (insulin-like growth factor-binding protein 1)), glucose metabolism (IRs (insulin receptors), glucose transporters, IGFs) and inflammation/immune cell migration ((IL-6 (interleukin 6), CCL2 (CC motif ligand), and uNK (uterine natural killer) cells). Despite several endometrial abnormalities in women with PCOS, the clinical relevance of these findings still awaits future clarification; to date, no common screening protocols/recommendations for women with PCOS have been established.

Contemporary Reproductive Outcomes for Patients With Polycystic Ovary Syndrome: A Retrospective Observational Study

CONTEXT

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility and may be associated with adverse pregnancy and neonatal outcomes. However, it is difficult to establish how much of this risk is due to PCOS and how much to obesity.

OBJECTIVE

This study aimed to determine the effect of PCOS upon fertility, pregnancy, and neonatal outcomes.

DESIGN AND SETTING

Data were extracted from the Clinical Practice Research Datalink (CPRD), a longitudinal anonymized primary care research database in the United Kingdom. Patients with a diagnosis of PCOS were matched to controls (1:2) by age (±1 y), body mass index (± 3 U), and CPRD practice. Standardized fertility ratios before and after diagnosis (index date) were calculated. Rates of miscarriage, pre-eclampsia, gestational diabetes, premature delivery, delivery method, and neonatal outcomes were compared.

RESULTS

Nine thousand sixty-eight women with PCOS matched study criteria. Prior to index date the standardized fertility ratio for patients with PCOS was 0.80 (95% confidence interval, 0.77–0.83); following index date it was 1.16 (1.12–1.20). The adjusted odds ratios (95% CI) for miscarriage (1.70; 1.56–1.84), pre-eclampsia (1.32; 1.16–1.49), gestational diabetes (1.41; 1.2–1.66), and premature delivery (1.25; 1.1–1.43) were all increased compared with controls. Of PCOS births, 27.7% were by Caesarean section compared with 23.7% of controls (1.13; 1.05–1.21). Infants born to mothers with PCOS had an increased risk of neonatal jaundice (1.20; 1.03–1.39) and respiratory complications (1.20; 1.06–1.37).

CONCLUSIONS

PCOS is associated with subfertility but fertility rates are restored to those of the background population following diagnosis. Pregnancy complications and adverse neonatal outcomes are more prevalent for women with PCOS independently of obesity.

First trimester pregnancy loss after fresh and frozen in vitro fertilization cycles

OBJECTIVE

To characterize risks for early pregnancy loss after fresh and frozen IVF cycles and to investigate whether risk is modified by infertility diagnoses or transfer of embryos in fresh versus frozen cycles.

DESIGN

Retrospective cohort study using data from the National Assisted Reproductive Technology (ART) Surveillance System.

SETTING

Fertility centers.

PATIENT(S)

Clinical pregnancies achieved with fresh and frozen IVF cycles between 2007 and 2012 (N = 249,630).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

First trimester pregnancy loss.

RESULT(S)

A diagnosis of uterine factor was associated with an increased risk of loss in women aged 40 years and younger (<30 years: adjusted risk ratio (aRR) = 1.24, 95% confidence interval (CI) 1.04-1.48; 30-34 years: aRR = 1.27, 95% CI 1.17-1.38; 35-37 years: aRR = 1.12, 95% CI 1.03-1.21; 38-40 years: aRR = 1.08, 95% CI 1.01-1.17). There was an increased risk of loss in women with diminished ovarian reserve aged 30-34 years (aRR = 1.08, 95% CI 1.01-1.15) and in women with ovulatory dysfunction younger than 35 years (<30 years: aRR = 1.12, 95% CI 1.05-1.19; 30-34 years: aRR = 1.07, 95% CI 1.02-1.13). There was an increased risk of loss after frozen ETs versus fresh among women younger than 38 years, but this remained significant in the subanalysis of similar quality embryos only in women younger than 30 years (aRR = 1.16, 95% CI 1.04-1.32).

CONCLUSION(S)

Uterine factor had the largest increased risk of loss among infertility diagnoses, although the magnitudes of all risks were small. When transferring embryos of similar quality, the risks of loss were similar between fresh and frozen cycles.

Relationship between uterine natural killer cells and unexplained repeated miscarriage

OBJECTIVE

To evaluate the relation between uterine killer (uK) cells and unexplained repeated miscarriage (RM).

MATERIAL AND METHODS

Eighty women with unexplained repeated miscarriage and missed miscarriage of current pregnancy were studied. Fetal viability and gestational age of the current pregnancy were confirmed by ultrasound, followed by suction evacuation to collect abortion specimens and uterine wall curettage to collect decidua specimens. Abortion specimens were collected for long-term monolayer cell culture and subsequent chromosome analysis using conventional G-banding. Decidua specimens were subjected to immunohistochemical staining using monoclonal antibodies specific to CD56+ and CD16+ expressed by uK cells.

RESULTS

CD56+ CD16+ uK cells were found in 85% [68/80] of the studied decidua specimens of women with unexplained repeated miscarriage; 88.5% [54/61] had normal abortion karyotyping and 73.7% [14/19] had abnormal abortion karyotyping. Moreover, 73.75% [59/80] of the studied women with a past history of early miscarriage had CD56+ CD16+ uK cells in their decidua specimens, and 66.25% [53/80] of studied women with a past history of late miscarriage had CD56+ CD16+ uK cells in their decidua specimens; the association between early and late miscarriage and CD56+ CD16+ uK cells in decidua specimens was significant.

CONCLUSION

CD56+CD16+ uK cells were predominant in the decidua specimens of the studied women with repeated miscarriage. A significant association was found between the presence of CD56+ CD16+ uK cells in the studied decidua specimens and unexplained repeated miscarriage.

Successive and cyclic oral contraceptive pill pretreatment improves IVF/ICSI outcomes of PCOS patients and ameliorates hyperandrogenism and antral follicle excess

OBJECTIVES

To evaluate different oral contraceptive pill (OCP) pretreatment associated differential in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes of polycystic ovary syndrome (PCOS) patients and explore enhanced hormonal balance induced by the pretreatment.

METHODS

This retrospective study included 500 PCOS women and 565 normal ovulating counterparts undergoing IVF/ICSI. The PCOS patients were divided into three groups based on the OCP pretreatment regimens: non-OCP (without OCP pretreatment), unsuccessive OCP (the period of successive pretreatment ≤2 months) and successive OCP (the period of successive pretreatment ≥3 months) groups. Comprehensive hormonal and ultra-sonographic assessments were performed before/after IVF pretreatment. Confounding factors affecting pregnancy outcomes were analyzed with logistic regression.

RESULTS

PCOS patients with significant endocrine disorders had reduced implantation and pregnancy rates and increased miscarriage rate. Successive, not unsuccessive OCP pretreatment, significantly improved the implantation and pregnancy rates, and reduced the incidence of monotocous small-for-gestational age infants, which was accompanied by remarkably decreased hyperandrogenism and antral follicles.

CONCLUSION

PCOS is an independent risk factor for poor IVF outcome. Successive, not unsuccessive, OCP cyclical pretreatment could improve pregnancy outcome of PCOS patients, associated with reduction of hyperandrogenism and antral follicle excess.