Antral follicle count and FSH concentration after clomiphene citrate challenge test in the prediction of ovarian response during IVF treatment

Machine Learning-Based Modeling of Ovarian Response and the Quantitative Evaluation of Comprehensive Impact Features

Appropriate ovarian responses to the controlled ovarian stimulation strategy is the premise for a good outcome of the in vitro fertilization cycle. With the booming of artificial intelligence, machine learning is becoming a popular and promising approach for tailoring a controlled ovarian stimulation strategy. Nowadays, most machine learning-based tailoring strategies aim to generally classify the controlled ovarian stimulation outcome, lacking the capacity to precisely predict the outcome and evaluate the impact features. Based on a clinical cohort composed of 1365 women and two machine learning methods of artificial neural network and supporting vector regression, a regression prediction model of the number of oocytes retrieved is trained, validated, and selected. Given the proposed model, an index called the normalized mean impact value is defined and calculated to reflect the importance of each impact feature. The proposed models can estimate the number of oocytes retrieved with high precision, with the regression coefficient being 0.882% and 89.84% of the instances having the prediction number ≤ 5. Among the impact features, the antral follicle count has the highest importance, followed by the E2 level on the human chorionic gonadotropin day, the age, and the Anti-Müllerian hormone, with their normalized mean impact value > 0.3. Based on the proposed model, the prognostic results for ovarian response can be predicted, which enables scientific clinical decision support for the customized controlled ovarian stimulation strategies for women, and eventually helps yield better in vitro fertilization outcomes.

An in silico model using prognostic genetic factors for ovarian response in controlled ovarian stimulation: A systematic review

PURPOSE

To study the use of in silica model to better understand and propose new markers of ovarian response to controlled ovarian stimulation before IVF.

METHODS

A systematic review and in silica model using bioinformatics. After the selection of 103 papers from a systematic review process, we performed a GRADE qualification of all included papers for evidence-based quality evaluation. We included 57 genes in the silica model using a functional protein network interaction. Moreover, the construction of protein-protein interaction network was done importing these results to Cytoscape. Therefore, a cluster analysis using MCODE was done, which was exported to a plugin BINGO to determine Gene Ontology. A p value of < 0.05 was considered significant, using a Bonferroni correction test.

RESULTS

In silica model was robust, presenting an ovulation-related gene network with 87 nodes (genes) and 348 edges (interactions between the genes). Related to the network centralities, the network has a betweenness mean value = 102.54; closeness mean = 0.007; and degree mean = 8.0. Moreover, the gene with a higher betweenness was PTPN1. Genes with the higher closeness were SRD5A1 and HSD17B3, and the gene with the lowest closeness was GDF9. Finally, the gene with a higher degree value was UBB; this gene participates in the regulation of TP53 activity pathway.

CONCLUSIONS

This systematic review demonstrated that we cannot use any genetic marker before controlled ovarian stimulation for IVF. Moreover, in silica model is a useful tool for understanding and finding new markers for an IVF individualization.

PROSPERO

CRD42020197185.

Predicting the outcome of different protocols of in vitro fertilization with anti-Muüllerian hormone levels in patients with polycystic ovary syndrome

Objective

This study evaluated associations of basal serum and follicular fluid (FF) anti-Muüllerian hormone (AMH) levels with in vitro fertilization (IVF) outcomes in polycystic ovary syndrome (PCOS) patients.

Methods

This prospective study included 179 consecutive women undergoing IVF, including 59 with PCOS and non-PCOS controls. Thirty PCOS cases had long gona-dotrophin-releasing hormone agonist (GnRH-a) and 29 had antagonist (GnRH-ant) protocols. Controls underwent conventional GnRH-a. Associations of basal serum and FF AMH levels with IVF outcomes were assessed.

Results

Median serum and FF AMH levels, antral follicle count (AFC), oestradiol human chorionic gonadotropin injection day (peak E2), and retrieved oocyte numbers were higher in PCOS patients than in controls (all P < 0.01). Oocyte maturation and high-quality embryo rates were lower in PCOS patients than in controls (P < 0.01), but both groups had similar fertilization, implantation, clinical pregnancy, and newborn rates. Peak E2 was higher in GnRH-ant than in GnRH-a protocols (16.5 nmol/L vs. 12.1 nmol/L, P < 0.05). AMH levels were correlated with AFC in PCOS patients (P < 0.01). Peak E2 and FF AMH levels were independent predictors of oocyte number. Peak E2 predicted the fertilization rate.

Conclusion

Serum basal AMH levels are predictive of oocyte quantity, but not oocyte quality or IVF outcomes. Serum AMH, FF AMH, and outcomes are similar among protocols.

Impact of pituitary suppression on antral follicle count and oocyte recovery after ovarian stimulation

OBJECTIVE

To investigate the potential influence of short-term pituitary suppression on antral follicle count (AFC) and correlate the AFC with the number of oocytes retrieved after ovarian stimulation.

DESIGN

Retrospective study.

SETTING

University fertility center.

PATIENT(S)

A total of 1,479 infertile patients.

INTERVENTION(S)

Patients had baseline AFC, when they were not on any medications known to cause pituitary suppression, and follow-up AFC (suppressed AFC) while on E2, GnRH agonist (GnRH-a), oral contraceptive (OC) pills, or OC pills/GnRH-a in preparation for ovarian stimulation, performed within 6 months of initial baseline AFC.

MAIN OUTCOME MEASURE(S)

The AFC at baseline, AFC during pituitary suppression, and the number of oocytes retrieved.

RESULT(S)

Although there was an average unadjusted decline of 0.4, 0.9, 2.2, and 3.0 in AFC while patients were on E2, GnRH-a, OC pills, and OC pills/GnRH-a, respectively, this decline was driven by age, baseline AFC, and the hormones used. Although baseline and suppressed AFC were found to be good predictors of the number of oocytes retrieved after ovarian stimulation, statistically, suppressed AFC was found to be a marginally better predictor.

CONCLUSION(S)

Short-term pituitary suppression has a negative impact on AFC. This decline in AFC may influence the number of oocytes retrieved, suggesting the suppressive impact of exogenous hormones on the biological capacity of the ovary during stimulation.

Prediction of an excessive response in in vitro fertilization from patient characteristics and ovarian reserve tests and comparison in subgroups: an individual patient data meta-analysis

OBJECTIVE

To evaluate whether ovarian reserve tests (ORTs) add prognostic value to patient characteristics, such as female age, in the prediction of excessive response to ovarian hyperstimulation in patients undergoing IVF, and whether their performance differs across clinical subgroups.

DESIGN

Authors of studies reporting on basal FSH, antimüllerian hormone (AMH), or antral follicle count (AFC) in relation to ovarian response to ovarian hyperstimulation were invited to share original data. Random intercept logistic regression models were used to estimate added value of ORTs on patient characteristics, while accounting for between-study heterogeneity. Receiver operating characteristic regression analyses were performed to study the effect of patient characteristics on ORT accuracy.

SETTING

In vitro fertilization clinics.

PATIENT(S)

A total of 4,786 women for the main analysis, with a subgroup of 1,023 women with information on all three ORTs.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Excessive response prediction.

RESULT(S)

We included 57 studies reporting on 32 databases. Female age had an area under the receiver operating characteristic curve of 0.61 for excessive response prediction. Antral follicle count and AMH significantly added prognostic value to this. A model with female age, AFC, and AMH had an area under the receiver operating characteristic curve of 0.85. The combination of AMH and AFC, without age, had similar accuracy. Subgroup analysis indicated that FSH performed significantly worse in predicting excessive response in higher age groups, AFC did significantly better, and AMH performed the same.

CONCLUSION(S)

We demonstrate that AFC and AMH add value to female age in the prediction of excessive response and that, for AFC and FSH, the discriminatory performance is affected by female age.

The interovarian variation in three-dimensional ultrasound markers of ovarian reserve in women undergoing baseline investigation for subfertility

OBJECTIVE

To evaluate differences in the three-dimensional (3D) ultrasound markers of ovarian reserve between the ovaries within an individual undergoing investigation for subfertility.

DESIGN

Prospective observational study.

SETTING

University-based assisted conception unit.

PATIENT(S)

Two hundred seventy women undergoing baseline early follicular phase ultrasound as an investigation for subfertility.

INTERVENTION(S)

Three-dimensional ultrasound scan in early follicular phase between days 2 and 5 of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Variations in 3D ultrasound markers of ovarian reserve between the two ovaries within same individual.

RESULT(S)

Two hundred fifteen subjects were analyzed for ovarian volume and antral follicle count, and 205 subjects for 3D power Doppler indices. Significant differences were noted (median, range) in the number of antral follicles measuring >6.0 mm and ovarian volume. Significant correlation was noted between the two ovaries in antral follicles measuring 6.0 mm or less, ovarian volume, and 3D power Doppler indices. On stratifying the antral follicles according to size using sonography-based automated volume calculation with postprocessing, maximum variation was seen in follicles measuring more than 6.0 mm as measured using limits of agreement.

CONCLUSION(S)

There are significant differences in the antral follicles measuring >6.0 mm and ovarian volume, as measured using 3D ultrasound, that require consideration when comparing the two ovaries within an individual.

The antral follicle count: practical recommendations for better standardization

OBJECTIVE

To provide recommendations for the standardized use of the Antral follicle count (AFC) which is used to predict ovarian response to gonadotrophin stimulation during assisted reproductive technology treatment. However, the nature of the follicles that are visualized by ultrasound and the competence of the oocytes held within are largely unknown. In addition, there is considerable variability in the clinical definitions and technical methods used to count and measure antral follicles in both published studies and clinical practice.

DESIGN AND SETTING

In December 2007, specialist reproductive medicine clinicians and scientists attended a workshop in an effort to address these issues. Literature concerning the physiology and measurement of ovarian antral follicles was reviewed, clinical and technical considerations regarding antral follicle measurement were discussed, and an operational definition of AFC was developed.

PATIENT(S)

None.

INTERVENTION(S)

None.

OUTCOME MEASURES

Simple recommendations were established for the standardization of AFC assessment in routine clinical practice. The basic clinical and technical requirements required for AFC evaluation were agreed upon, and a systematic method of measuring and counting antral follicles in routine practice was proposed.

CONCLUSION(S)

The use of a standardized approach according to the practical recommendations for antral follicle counting as presented is encouraged in future clinical trials and routine practice. The authors also advocate a systematic evaluation of these recommendations as standardized study data become available.

The predictive value of the automated quantification of the number and size of small antral follicles in women undergoing ART

BACKGROUND

Sono-automatic volume calculation (SonoAVC) automatically identifies and measures the dimensions of hypoechogenic areas within datasets acquired using three-dimensional ultrasound. The objective of this study was to evaluate the predictive value of automated antral follicle counts according to their relative sizes in women undergoing assisted reproduction treatment (ART).

METHODS

A total of 156 subjects aged < or =40 years with a baseline FSH < or =15 IU that undergo their first cycle of ART were prospectively recruited. SonoAVC was used to measure the datasets and record the number of antral follicles measuring < or =9 mm in diameter. These follicles were then grouped into subsets according to their relative sizes: < or =2.0, 2.1-4.0, 4.1-6.0, 6.1-8.0 and 8.1-9.0 mm. The primary outcome was viable pregnancy confirmed on ultrasound 5 weeks following embryo transfer.

RESULTS

A total of 142 subjects were included for analysis of primary end-point. Those subjects who conceived had significantly more antral follicles measuring < or =2 (P = 0.041) and 2.1-4.0 mm (P < 0.001) than those who had unsuccessful treatment. There were no significant differences between the groups in the number of antral follicles measuring 4.1-6.0 (P = 0.191), 6.1-8.0 (P = 0.203) and 8.1-9.0 mm (P = 0.601). Multiple logistic regression showed that antral follicles measuring 2.1-4.0 mm were an independent predictor of pregnancy [Exp(B) = 1.234, 95% CI = 1.092-1.491; P = 0.004; AUC = 0.693].

CONCLUSION

SonoAVC provides automated measures of antral follicle number and size. Using this technique, the number of antral follicles measuring 2.1-4.0 mm in diameter is an independent, significant predictor of pregnancy following in vitro fertilization treatment.

Impact of GnRH ovarian stimulation protocols on intracytoplasmic sperm injection outcomes

BACKGROUND

Although a large number of studies have been conducted in relation to ovarian response and pregnancy after GnRH agonist and GnRH antagonist controlled ovarian hyperstimulation protocols, most of them used single or combinations of a few predictive factors, and none included the stimulation protocol in the multivariable analysis. The present study was thus primarily designed to investigate the predictive value of the stimulation protocol and to analyze the possible relationships between stimulation protocols and treatment outcomes after adjusting for a large set of variables that potentially affect reproductive outcomes. Factors related to pregnancy achievement and predictive of the number of oocytes retrieved and high quality of the embryos obtained were also analyzed.

METHODS

To analyze the impact of GnRH ovarian stimulation protocols on the independent predictors of ovarian response, high quality embryos and clinical pregnancy, two groups out of 278 ICSI treatment cycles were compared prospectively, 123 with a GnRH agonist and 155 with a GnRH antagonist, with multivariable analysis assessing outcomes after adjusting for a large set of variables.

RESULTS

Antagonists were significantly associated with lower length and total dose of GnRH, lower length of rFSH, and higher numbers of oocytes and high quality embryos, whereas the agonist presented a higher fertilization rate and probability of pregnancy. Significant predictors of retrieved oocytes and high quality embryos were the antagonist protocol, lower female age, lower serum levels of basal FSH and higher total number of antral follicles. Significant predictors of clinical pregnancy were the agonist protocol, reduced number of attempts, increased endometrial thickness and lower female age. The probability of pregnancy increased until 30 years-old, with a decline after that age and with a sharp decline after 40 years-old.

CONCLUSION

The models found suggest that not only the protocol but also factors as female age, basal FSH, antral follicles, number of attempts and endometrial thickness should be analyzed for counselling patients undergoing an ICSI treatment.

Antral follicle count at down-regulation and prediction of poor ovarian response

The aim of this study was to assess the accuracy of antral follicle count (AFC) performed after pituitary down-regulation (dAFC) in predicting poor ovarian response and the influence of using different thresholds of follicle size and count on its accuracy. Using three definitions of follicle size, three dAFC were determined for every patient in a consecutive cohort of 148 IVF cycles. The performance of the dAFC in predicting poor ovarian response (as expressed by area under the curve; AUC) for follicle size definitions of 2-5, 2-8, 2-10 mm, was not significantly different (AUC 0.80, 0.80, 0.79, respectively). Multilevel likelihood ratio for dAFC thresholds of <or=10, 11-15,16-20 and >20 were 5.43 (95% confidence interval 0.81-36.6), 3.06 (1.54-6.06), 1.63 (0.74-3.62) and 0.37 (0.19-0.75) with post-test probabilities of poor ovarian response of 50%, 36%, 23% and 6%, respectively, for a pretest probability of 15.5% for poor ovarian response. The single most important predictor of ovarian response was dAFC. The highest predictive performance was obtained in a model combining age and body mass index and dAFC (AUC = 0.82) showing only marginal improvement over dAFC alone. In conclusion, the performance of dAFC is the same regardless of the definition used for the size of antral follicles.

Elective single embryo transfer: a 6-year progressive implementation of 784 single blastocyst transfers and the influence of payment method on patient choice

OBJECTIVE

To evaluate efforts to reduce twin pregnancies through progressive implementation of elective single embryo transfer (eSET) among select patients over a 6-year period.

DESIGN

Retrospective review.

SETTING

Private practice IVF center.

PATIENT(S)

Infertile women undergoing 15,418 consecutive IVF-ET cycles.

INTERVENTION(S)

IVF-ET, including blastocyst-stage eSET among select patients with good prognosis and high risk of multiple pregnancy.

MAIN OUTCOME MEASURE(S)

Pregnancy, multiple pregnancy, method of payment.

RESULT(S)

Pregnancy rates were similar for autologous eSET versus double-blastocyst transfer (65% vs. 63%), while twin rates were much lower (1% vs. 44%). For recipients of donor oocytes, pregnancy rates were slightly lower with eSET (63% vs. 74%), while twin rates were much lower (2% vs. 54%). There was no decrease in overall pregnancy rates, despite a dramatic rise in eSET use over time (1.5% to 8.6% of all autologous transfers and 2.0% to 22.5% of all transfers to donor oocyte recipients between 2002 and 2007). Overall singleton pregnancy rates increased, while twin pregnancy rates declined significantly over time. Use of eSET was significantly more common among patients with insurance coverage or who were participating in our Shared Risk money-back guarantee program.

CONCLUSION(S)

Selective eSET use among good-prognosis patients can significantly reduce twin pregnancies without compromising pregnancy rates. Patients are more likely to choose eSET when freed from financial pressures to transfer multiple embryos.

Antral follicle count (AFC) can be used in the prediction of ovarian response but cannot predict the oocyte/embryo quality or the in vitro fertilization outcome in an egg donation program

OBJECTIVE

To verify whether the antral follicle count (AFC) could predict ovarian response, oocyte/embryo quality, and IVF outcome.

DESIGN

Prospective study.

SETTING

Instituto Universitario-Instituto Valenciano de Infertilidad, Valencia, Spain.

PATIENT(S)

One thousand seventy-four donors and 975 oocyte recipient cycles.

INTERVENTION(S)

Controlled ovarian hyperstimulation (COH), endometrial preparation, IVF/intracytoplasmic sperm injection, ET.

MAIN OUTCOME MEASURE(S)

COH and oocyte/embryo quality parameters and IVF outcome.

RESULT(S)

We observed lower E(2) levels and fewer mature retrieved oocyte numbers among donors who showed an AFC that was <10. These donors also showed significantly higher cancellation and no-donation rates; poor and/or insufficient response was the principal cause (82%). However, there were no differences among the groups regarding embryo development parameters and IVF outcome.

CONCLUSION(S)

AFC is a noninvasive and simple tool that can improve the oocyte donor's selection of an egg donation program. This study suggests that AFC is a good predictor of ovarian response but cannot be used to predict oocyte/embryo quality or IVF outcome.

Prediction of ovarian response and IVF/ICSI outcome by three-dimensional ultrasonography and power Doppler angiography

OBJECTIVE

The objective was to evaluate whether three-dimensional ultrasonography (3D-US) and power Doppler angiography (PDA) measurements can predict ovarian response and/or are associated with IVF/ICSI outcome.

STUDY DESIGN

A prospective clinical study in 65 women undergoing IVF cycles. Ovarian volume (OV), number of antral follicles > or =2mm (NAF) and PDA indices: vascularisation index (VI), flow index (FI), and vascularisation flow index (VFI) were evaluated by 3D-US and PDA on the day of pituitary suppression control. These measurements, age and BMI were correlated with the number of follicles>10mm on the hCG day and the number of oocytes retrieved.

RESULTS

Ovarian volume, NAF, VI, FI and FVI correlate significantly (P<0.01) with the number of follicles and oocytes recovered. Ovarian volume and the number of antral follicles predicted significantly the number of follicles (R=0.67; adjusted R(2)=0.43) and oocytes retrieved (R=0.63; adjusted R(2)=0.37). The oestradiol peak and the number of follicles, oocytes and Grade 1 embryos transferred were higher in the pregnant group.

CONCLUSIONS

Three-dimensional ultrasound and PDA make it easier to evaluate all the sonographic parameters implied in ovarian response. Ovarian volume and the number of antral follicles are the only independent predictors of the number of follicles developed and oocytes retrieved.

Performance of different ovarian reserve markers for predicting the numbers of oocytes retrieved and mature oocytes

OBJECTIVE

To assess the performance of different ovarian reserve tests for predicting the total numbers of oocytes retrieved and mature oocytes.

METHODS

A retrospective study was performed on 71 women undergoing their first IVF/intracytoplasmic sperm injection treatment. Basal ovarian reserve screening was performed on days 2-3 of a spontaneous cycle. Patients were down-regulated with the GnRH agonist, whereas ovarian stimulation was carried out with recombinant FSH, starting from day 2 to 3 of the cycle. The main outcome measures were the numbers of oocytes retrieved and mature oocytes.

RESULTS

The total number of oocytes was positively correlated with AFC (p<0.0001) and E(2) levels post-GnRH (p<0.004), whereas there was an inverse correlation with age (p<0.0001). The number of mature oocytes also correlated with AFC (p<0.008) and E(2) levels post-GnRH (p<0.009), and inversely with age (p<0.0004). Univariate linear regression of square root of number of oocytes (SQNO) shows that acceptable predictors of number oocytes, based on model significance and R(2) are AFC (R(2)=0.215), age (R(2)=0.24) and E(2) variation (R(2)=0.09). The following model is proposed to predict the number of mature oocytes: ln(MO)=ln(NO)-2.09+0.028 AGE+0.03 BMI.

CONCLUSION(S)

The number of antral follicles and patient age appear to be good markers of ovarian response in IVF treatments. Additional information is provided by stimulated E(2) levels.

A 47-year-old woman with fertility problems who desires a multiple pregnancy

Mrs Z is a 47-year-old woman with long-standing infertility who is about to undergo in vitro fertilization (IVF) using donor oocytes from an anonymous donor. She has already undergone an IVF cycle with her own oocytes and an IVF cycle using donor oocytes from a known donor without a successful pregnancy. Mrs Z has been advised by her infertility physician to consider the transfer of a single embryo, but she does not wish to decrease her likelihood of conception, and, after her long and expensive infertility saga, wishes to conceive twins. The science of IVF has evolved significantly in the last several years, increasing the likelihood of successful pregnancy and reducing the need to transfer more than 1 embryo with its inherent risks of multiple pregnancy. The state of the science and why patients may continue to want multiple embryos transferred, including costs and lack of insurance coverage for infertility treatments, are discussed.

Clomiphene citrate challenge test predicts outcome of intrauterine insemination in women aged under 37 years

The clomiphene citrate challenge test is a tool to predict ovarian reserve and fertility. It has mainly been used as a predictor of success of IVF/intracytoplasmic sperm injection (ICSI) cycles. Infertile young women with diminished ovarian reserve have a worse prognosis than women with adequate ovarian reserve attempting IVF/ICSI cycles. Nothing is known regarding the outcome of young women with diminished ovarian reserve undergoing low-complexity assisted reproductive treatment such as ovulation induction plus intrauterine insemination (IUI). This study included all women under 37 years who consulted in the authors' centre between May 2004 and August 2005 who underwent ovulation induction and IUI. Ninety-six women younger than 37 years with adequate ovarian reserve, and 50 women with diminished ovarian reserve were found. The pregnancy rate and pregnancy rate per cycle in the adequate ovarian reserve group were significantly higher than those of the diminished ovarian reserve group (46.7% versus 25%, P < 0.02 ; 15.9% versus 7.6%, P < 0.02 respectively). It is concluded that the clomiphene citrate challenge test is a good predictor of low-complexity infertility intervention outcome, and represents an effective tool to establish a prognosis. Therefore, it is very useful in planning therapy, and advising the infertile couple.

Ovarian stromal vascularity is not predictive of ovarian response and pregnancy

The role of ovarian stromal vascularity in the prediction of the ovarian response and pregnancy in infertile women was evaluated by comparing age of women, body mass index (BMI), basal FSH concentration, antral follicle count (AFC) and ovarian stromal vascularity indices measured by three-dimensional power Doppler ultrasound. A total of 111 women in their first IVF cycle were analysed. They were aged <40 years with basal FSH concentration <10 IU/l on recruitment for IVF treatment. AFC, mean ovarian volume and mean ovarian 3D power Doppler flow indices were determined on day 2 of the treatment cycle prior to a standard regimen of ovarian stimulation. Ovarian response was represented by the number of oocytes, serum oestradiol, the duration and dosage of gonadotrophins. AFC achieved the best predictive value in relation to the number of oocytes obtained, followed by age of women and BMI. Basal FSH concentration was the only predictive factor for the duration and dosage of gonadotrophin used. Mean ovarian 3D power Doppler flow indices were not predictive of pregnancy in a multiple logistic regression analysis. Ovarian 3D power Doppler flow indices measured after pituitary down-regulation were not predictive of the ovarian response and pregnancy in the IVF treatment.