Comparison of miscarriage rates in low prognosis patients according to the POSEIDON criteria

OBJECTIVE

The POSEIDON criteria stratified patients with poor ovarian response into four subgroups with exclusive characteristics and assisted reproductive technology success rates. However, limited studies focused on miscarriage in the POSEIDON population. This study aimed to explore whether the miscarriage rate different among low prognosis patients according to POSEIDON criteria.

MATERIALS AND METHODS

This is a retrospective observational study. All clinical pregnancies achieved after in vitro fertilization or intracytoplasmic sperm injection treatment between January 1998 and April 2021 were analyzed. The primary outcome was miscarriage, defined as the pregnancy loss before 20 weeks of gestation age. Miscarriage rate was estimated per clinical pregnancy and gestational sac.

RESULTS

A total of 1222 clinical pregnancies from 1088 POSEIDON patients met the inclusion criteria. The miscarriage rates per clinical pregnancy in each POSEIDON subgroup were as follows: Group 1: 11.7 %, Group 2: 26.5 %, Group 3: 20.9 %, and Group 4: 37.5 %. The miscarriage rate per gestational sac showed a similar trend as the clinical miscarriage rate. Multivariate regression analysis showed that advanced maternal age is an independent factor for miscarriage (Group 2 vs. 1: OR 2.476; Group 4 vs. 3: OR 2.252). Patients with diminished ovarian reserve (DOR) have higher miscarriage risks but without significance (Group 3 vs. 1: OR 1.322; Group 4 vs. 2: OR 1.202).

CONCLUSION

Miscarriage rates differed among low prognosis patients according to the POSEIDON criteria. Age remains a determined risk for miscarriage. DOR might be a potential factor for miscarriage, but it didn't account for a significant impact in POSEIDON patients.

Triphenyl phosphate delayed pubertal timing and induced decline of ovarian reserve in mice as an estrogen receptor antagonist

Although concerns have been raised about the adverse effects of triphenyl phosphate (TPhP) on female fertility, its risk to ovarian functioning remains unknown. In this study, female C57BL/6 mice at postnatal day 21 were exposed on a daily basis to TPhP dose of 2, 10, and 50 mg/kg for 40 days. A significant delay in pubertal timing was observed in the mice exposed to 50 mg/kg of TPhP. An estrogen-responsive reporter transgenic mice assay demonstrated that TPhP significantly downregulated the estrogen receptor (ER) signaling by 45.1% in the whole body in the 50 mg/kg group, and by 14.7-43.7% in the uterus for all exposure groups compared with the control. This strong antagonistic activity of TPhP toward ER explained the delay in pubertal timing. A significant reduction in the number of follicles in all stages was observed in mice after being exposed to TPhP for 40 days at concentrations of 10 and 50 mg/kg, resulting in a decline of the ovarian reserve. The elevation of the follicle-stimulating hormone concentration may have contributed to this phenomenon, as controlled by the antagonistic activity of TPhP toward ER in the brain. The toxic effects of TPhP on ovarian functioning highlight this chemical as a potential risk factor for female fertility.

Diminished ovarian reserve: is it a neglected cause in the assessment of recurrent miscarriage? A cohort study

OBJECTIVE

To study whether diminished ovarian reserve is associated with recurrent miscarriage.

DESIGN

Cross-sectional clinical study.

SETTING

Tertiary-care center.

PATIENT(S)

Women with history of recurrent miscarriage (RM; n = 71) and sequentially selected age-matched fertile women who were seeking contraception (control; n = 70).

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURES(S)

Serum levels of FSH, LH, E2, and antimüllerian hormone (AMH); FSH/LH ratio; ovarian volumes; and antral follicle count (AFC).

RESULT(S)

The levels of FSH were 8.6 ± 3.7 U/L in the RM group and 7.1 ± 3.9 U/L in the control group; this difference was statistically significant. The levels of AMH were significantly lower in the RM group than in the control group (2.9 ± 1.7 ng/mL vs. 3.6 ± 1.7 ng/mL). The percentage of women with levels of FSH ≥11 U/L was significantly higher in the RM group than in the control group (18.3% vs. 4.3%). In the RM group, the percentage of women with levels of AMH ≤1 ng/mL was significantly higher than in the control group (19.7% vs. 5.7%).

CONCLUSION(S)

Recurrent miscarriage may be associated with diminished ovarian reserve. Larger prospective randomized controlled trials are warranted to better determine the predictive potential of ovarian reserve markers in recurrent miscarriage.

Quantifying effect of combined oral contraceptive pill on functional ovarian reserve as measured by serum anti-Müllerian hormone and small antral follicle count using three-dimensional ultrasound

OBJECTIVES

Oral contraceptive pills suppress the hypothalomo-pituitary axis, which can affect the ultrasound and endocrine markers used to examine ovarian reserve. The objective of this study was to quantify the ultrasound and endocrine markers of functional ovarian reserve in women using a combined oral contraceptive pill (COCP) for more than a year.

METHODS

This was a prospective case-control study involving healthy volunteers: 34 women using for more than a year a COCP with hormone-free interval (HFI) were compared to 36 normo-ovulatory, age-matched controls who had not used hormonal contraception within the last year. Volunteers using a COCP underwent a 3D ultrasound examination and had a blood sample taken within the first 4 days of active pill ingestion and those in the control group had the scan and blood test in the early follicular phase (days 2-5) of menstrual cycle. The main outcome measure was the difference in antral follicle counts stratified according to size and anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) levels.

RESULTS

There were no significant differences in the number of small antral follicles measuring 2-6 mm. The COCP group had significantly fewer antral follicles measuring ≥ 6 mm (P < 0.001) and had significantly smaller ovaries (P < 0.001), which also had lower vascular indices than the control group (P < 0.05). While serum FSH, LH and E2 levels were significantly lower in the COCP group (P < 0.05), there was no significant difference in serum AMH levels between the two groups.

CONCLUSIONS

Prolonged use of COCP suppressed pituitary gonadotropins and antral follicle development beyond 6 mm, but had no effect on levels of serum AMH and number of small antral follicles.

The poor responder in IVF: is the prognosis always poor?: a systematic review

BACKGROUND In IVF treatment a considerable proportion of women are faced with a low number of oocytes retrieved. These poor responders have reduced pregnancy rates compared with normal responders. However, this may not be applicable to all poor responders. This review aims at identifying patient characteristics and ovarian reserve tests (ORT) that will determine prognosis for pregnancy in poor responders. METHODS A systematic search was conducted in PubMed, Embase, Cochrane and SCOPUS databases in April 2010. Studies regarding patient characteristics or ORT in poor responders and their pregnancy prospects were included. All included papers were summarized in descriptive tables. RESULTS Nineteen studies were included. Pooled data of six studies comparing poor and normal responders demonstrated clearly lower pregnancy rates in poor responders (14.8 versus 34.5%). Ten studies indicated that older poor responders have a lower range of pregnancy rates compared with younger (1.5-12.7 versus 13.0-35%, respectively). Four studies showed that pregnancy prospects become reduced when fewer oocytes are retrieved (0-7% with 1 oocyte versus 11.5-18.6% with 4 oocytes). Five studies concerning pregnancy rates in subsequent cycles suggested a more favourable outcome in unexpected poor responders, and if ≥2 oocytes were retrieved. CONCLUSIONS Poor responders are not a homogeneous group of women with regards to pregnancy prospects. Female age and number of oocytes retrieved in particular will modulate the chances for pregnancy in current and subsequent cycles. Applying these criteria will allow the identification of couples with a reasonable prognosis and balanced decision-making on the management of poor responders.

A lower antral follicle count is associated with infertility

OBJECTIVE

To determine whether infertile women have lower antral follicle counts (AFC) than age-matched normal women.

DESIGN

Case-control.

SETTING

Academic center.

PATIENT(S)

A total of 881 infertile women and 771 women from the community.

INTERVENTION(S)

Antral follicle count and basal hormone measurements.

MAIN OUTCOME MEASURE(S)

Median AFCs and FSH levels were compared between the two groups within 5-year age strata by using the median test. A subanalysis was performed by identifying women in the control group with a history of attempting conception without success (subfertile group) and with a spontaneous conception in fewer than 12 months resulting in a live birth (fertile group). Age-specific AFC percentiles were calculated and compared within strata determined by age at the time of attempted conception.

RESULT(S)

AFCs were significantly lower in infertile women than in control women across age groups up to 40 years of age. Average FSH levels were significantly higher in the younger-age infertile group versus the community. AFC percentiles differ significantly between fertile and subfertile women within the community up to 40 years of age.

CONCLUSION(S)

Decreased AFC in infertile women suggests that factors affecting the size of the remaining follicle pool in younger women also affect oocyte quality and the likelihood of conception.

Defining ovarian reserve to better understand ovarian aging

Though a widely utilized term and clinical concept, ovarian reserve (OR) has been only inadequately defined. Based on Medline and PubMed searches we here define OR in its various components, review genetic control of OR, with special emphasis on the FMR1 gene, and discuss whether diminished OR (DOR) is treatable. What is generally referred to as OR reflects only a small portion of total OR (TOR), a pool of growing (recruited) follicles (GFs) at different stages of maturation. Functional OR (FOR) depends on size of the follicle pool at menarche and the follicle recruitment rate. Both vary between individuals and, at least partially, are under genetic control. The FMR1 gene plays a role in defining FOR at all ages. Infertility treatments have in the past almost exclusively only centered on the last two weeks of folliculogenesis, the gonadotropin-sensitive phase. Expansions of treatments into earlier stages of maturation will offer opportunity to significantly improve ovarian stimulation protocols, especially in women with DOR. Dehydroepiandrosterone (DHEA) may represent a first such intervention. Data generated in DHEA-supplemented women, indeed, suggest a new ovarian aging concept, based on aging of ovarian environments and not, as currently is believed, aging oocytes.

The cohort of antral follicles measuring 2-6 mm reflects the quantitative status of ovarian reserve as assessed by serum levels of anti-Müllerian hormone and response to controlled ovarian stimulation

OBJECTIVE

To evaluate the relationship between serum anti-Müllerian hormone (AMH) and antral follicle size, and to ascertain which cohort of antral follicles is most predictive of the response to controlled ovarian stimulation during assisted reproduction treatment (ART).

DESIGN

Prospective study.

SETTING

University-based Assisted Conception Unit.

PATIENT(S)

One hundred thirteen women undergoing first cycle of ART.

INTERVENTION(S)

Transvaginal 3D-ultrasound assessment and venipuncture in the early-follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Serum AMH levels, number of mature oocytes retrieved and poor ovarian response.

RESULT(S)

The antral follicle cohorts measuring 2 to 3 mm, >3 to 4 mm, >4 to 5 mm, and >5 to 6 mm were most significantly correlated with AMH (r = .30, .27, .30, and .41, respectively) and the number of mature oocytes retrieved (r = .28, .23, .29, and .34, respectively). Although these follicle cohorts of 2-6 mm were significant predictors of the number of mature oocytes retrieved on regression analysis, their discriminative ability (area under the curve [AUC]: 0.829) for the prediction of poor ovarian response was similar to total counts made using cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm (AUCs: 0.794, 0.812, 0.852, and 0.826, respectively).

CONCLUSION(S)

The number of antral follicles measuring 2 to 6 mm is most reflective of the quantitative ovarian reserve. However, the ability of this group of antral follicles to predict poor ovarian response appears similar to that of the follicular cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm.

Miscarriage risk for IVF pregnancies in poor responders to ovarian hyperstimulation

The increasing miscarriage rate with advancing female age is attributed to a decline in oocyte quality. A poor response to ovarian hyperstimulation is often an expression of a decrease in oocyte quantity. Although oocyte quality and quantity both decrease as a result of ovarian ageing, it is unclear whether these two processes are related to each other. To investigate the relationship between oocyte quantity and quality, we compared miscarriage rates between IVF treated women with a poor and normal response, respectively. Data were studied from a retrospective nationwide cohort of Dutch women undergoing IVF treatment from 1983 to 1995. Women achieving an ongoing pregnancy after their first complete IVF cycle (n=1468) were compared with those experiencing miscarriage (n=357) with respect to their ovarian response. Logistic regression analysis showed a statistically significant association between poor response (fewer than four retrieved oocytes) and miscarriage (P=0.001). Due to interaction, this association became stronger with increasing female age. Among women < 36 years, miscarriage rates between poor and normal responders did not differ, whereas among women 36 years poor responders had a statistically significant increased miscarriage rate compared with normal responders (P=0.001). These results support the hypothesis of a relationship between quantitative ovarian reserve and oocyte quality.