Sustained fertility from 22 to 41 years of age in women with polycystic ovarian syndrome

Assessing the clinical diagnostic value of anti-Müllerian hormone in polycystic ovarian syndrome and its correlation with clinical and metabolism indicators

BACKGROUND

This study investigated the association between Anti-Müllerian Hormone (AMH) and relevant metabolic parameters and assessed its predictive value in the clinical diagnosis of polycystic ovarian syndrome (PCOS).

METHODS

A total of 421 women aged 20-37 years were allocated to the PCOS (n = 168) and control (n = 253) groups, and their metabolic and hormonal parameters were compared. Spearman correlation analysis was conducted to investigate associations, binary logistic regression was used to determine PCOS risk factors, and receiver operating characteristic (ROC) curves were generated to evaluate the predictive value of AMH in diagnosing PCOS.

RESULTS

The PCOS group demonstrated significantly higher blood lipid, luteinizing hormone (LH), and AMH levels than the control group. Glucose and lipid metabolism and hormonal disorders in the PCOS group were more significant than in the control group among individuals with and without obesity. LH, TSTO, and AMH were identified as independent risk factors for PCOS. AMH along with LH, and antral follicle count demonstrated a high predictive value for diagnosing PCOS.

CONCLUSION

AMH exhibited robust diagnostic use for identifying PCOS and could be considered a marker for screening PCOS to improve PCOS diagnostic accuracy. Attention should be paid to the effect of glucose and lipid metabolism on the hormonal and related parameters of PCOS populations.

Adding a ketogenic dietary intervention to IVF treatment in patients with polycystic ovary syndrome improves implantation and pregnancy

Patients with polycystic ovary syndrome (PCOS) on a high-carbohydrate diet intrinsically suffer from exacerbated glucotoxicity, insulin resistance (IR), and infertility. Lowering the carbohydrate content has improved fertility in patients with IR and PCOS; however, the effects of a well-controlled ketogenic diet on IR and fertility in PCOS patients undergoing in vitro fertilization (IVF) have not been reported. Twelve PCOS patients with a previous failed IVF cycle and positive for IR (HOMA1-IR>1.96) were retrospectively evaluated. Patients followed a ketogenic diet (50 g of total carbohydrates/1800 calories/day). Ketosis was considered when urinary concentrations were > 40 mg/dL. Once ketosis was achieved, and IR diminished, patients underwent another IVF cycle. The nutritional intervention lasted for 14 ± 11 weeks. Carbohydrate consumption decreased from 208 ± 50.5 g/day to 41.71 ± 10.1 g/day, which resulted in significant weight loss (-7.9 ± 1.1 kg). Urine ketones appeared in most patients within 13.4 ± 8.1 days. In addition, there was a decrease in fasting glucose (-11.4 ± 3.5 mg/dl), triglycerides (-43.8 ± 11.6 mg/dl), fasting insulin (-11.6 ± 3.7 mIU/mL), and HOMA-IR (-3.28 ± 1.27). All patients underwent ovarian stimulation, and compared to the previous cycle, there was no difference in oocyte number, fertilization rate, and viable embryos produced. However, there was a significant improvement in the implantation (83.3 vs. 8.3 %), clinical pregnancy (66.7 vs. 0 %), and ongoing pregnancy/live birth rates (66.7 vs. 0 %). Here, restriction in carbohydrate consumption in PCOS patients induced ketosis, improved key metabolic parameters, and decreased IR. Even though this did not affect oocyte or embryo quality or quantity, the subsequent IVF cycle significantly improved embryo implantation and pregnancy rates.

Comparison of IVF/ICSI outcomes in advanced reproductive age patients with polycystic ovary syndrome and advanced reproductive age normal controls: a retrospective cohort study

BACKGROUND

At present, there are few studies on whether there is reproductive advantage in advanced polycystic ovary syndrome (PCOS) patients, and the existing research results are also controversial. Some research results show that the reproductive window of advanced reproductive age patients with polycystic ovary syndrome is longer than that of the normal control group, and the clinical pregnancy rate and cumulative live birth rate of in vitro fertilization / intracytoplasmic sperm injection(IVF/ICSI)are higher. However, some studies have contradicted the results, and believed that the clinical pregnancy rate and cumulative live birth rate in IVF/ICSI in advanced PCOS patients and normal control groups were roughly similar. This retrospective study aimed to compare IVF/ICSI outcomes in advanced reproductive age patients with PCOS and in advanced reproductive age patients with tubal factor infertility alone.

METHODS

A retrospective analysis was performed on advanced reproductive age (age ≥ 35 years) patients who received their first IVF/ICSI cycle between January 1, 2018 and December 31, 2020. This study was divided into two groups, one group was PCOS group, the other group was control group, namely tubal factor infertility group, a total of 312 patients and 462 cycles were enrolled. Compare the differences in outcomes such as cumulative live birth rate and clinical pregnancy rate between the two groups.

RESULTS

In fresh embryo transfer cycles(ET), there was no statistically significant difference in live birth rate [19/62 (30.6%) vs. 34/117 (29.1%), P = 0.825] and clinical pregnancy rate [24/62 (38.7%) vs. 43/117 (36.8%), P = 0.797] between the PCOS and control groups.In the frozen embryo transfer (FET) cycle, the difference in cumulative live birth rate [63/217 (29.0%) vs. 14/66 (21.2%), P = 0.211] and clinical pregnancy rate [74/217 (34.1%) vs. 18/66 (27.3%), P = 0.300] were not statistically significant between the two groups.

CONCLUSIONS

The IVF/ICSI outcomes of advanced reproductive age patients with PCOS are similar to those of advanced reproductive age patients with tubal factor infertility alone, and the clinical pregnancy rate and live birth rate are roughly the same. Age is an important factor that affects clinical pregnancy rate. It is recommended that patients with PCOS complicated by infertility seek medical treatment as soon as possible to obtain better pregnancy outcomes.

A novel GnRH antagonist protocol based on LH levels versus traditional flexible GnRH antagonist protocol in PCOS patients undergoing in vitro fertilization: study protocol for a randomized controlled, non-inferiority trial

Background

The gonadotropin-releasing hormone (GnRH) antagonist protocol is advantageous given that it can avoid severe ovarian hyperstimulation syndrome (OHSS), especially for patients with polycystic ovary syndrome (PCOS). Basic and clinical evidence has shown that a threshold of luteinizing hormone (LH) stimulation is required for adequate follicular development and oocyte maturation. Ultra-low or high levels of LH are detrimental to pregnancy outcomes. We previously demonstrated that LH could be an indicator for the timing and dosage of antagonist administration in a retrospective study.

Methods/design

In this randomized, single-center, non-inferiority trial, we aim to test the hypothesis that there is no significant difference in cumulative ongoing pregnancy rates between PCOS patients stimulated with LH-based flexible protocol versus traditional flexible GnRH antagonist protocol. The primary efficacy endpoint will be the cumulative ongoing pregnancy rate per cycle. The secondary outcomes will be clinical pregnancy rate, cancelation rate, serious OHSS rate, and cost-efficiency. The cumulative ongoing pregnancy rate per cycle in PCOS women was 80%. Considering that a non-inferiority threshold should retain 80% of the clinical effect of a control treatment, a minimal clinical difference of 16% (two-sided: α, 2.5%; β, 20%) and a total of 196 patients were needed. Anticipating a 10% dropout rate, the total number of patients required was 216.

Discussion

The results of this study will provide evidence for the efficacy and safety of the LH-based flexible GnRH antagonist protocol in PCOS patients. Moreover, it evaluates the cost-efficiency of both protocols.

Trial registration

Chinese Clinical Trial Registry ChiCTR1800018129. Date assigned: 31 August 2018. Protocol version: 1.0 (18 July 2017)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06586-1.

Effect of Metformin therapy on lipid profile in obese and non-obese women with polycystic ovarian syndrome (PCOS)

Introduction and Aim: Polycystic ovarian syndrome (PCOS) is the most common endocrine condition affecting the reproductive system in women. It is characterized by obesity, irregular menstruation, anovulation, hirsutism, insulin resistance, and dyslipidemia. Metformin, an oral anti-diabetic drug is known to stabilize metabolic disturbances caused by PCOS. This study aims to determine the effect of metformin therapy on lipid profile in obese and non-obese women with polycystic ovarian syndrome.  Materials and Methods: It is a prospective, clinical, interventional study, participated by sixty women aged between 13 to 45 years, suffering with PCOS, who are attending the gynecology outpatient department at SVS medical college and hospital, from a year. The subjects were divided into two groups, Group-1 (Obese women) and Group-2 (non-obese women) and received the anti-diabetic drug, Metformin orally with doses of 500mg/day for a year. Approval of our study was done by Ethical Institutional Board. Demographic parameters age, BMI, and lipid profile including High-Density Lipoprotein (HDL), Low-Density Lipoprotein (LDL), Triglycerides (TAG), & Total Cholesterol (TC) were assessed. SPSS was applied for data analysis and p<0.001 was considered statistically significant. Results: A combined group study of obese and non-obese women subjects showed a BMI decrease in non-obese subjects at 6 months by Metformin therapy. HDL levels increased in non-obese women subjects with a statistical significance. LDL and TAG levels remained unchanged at 6 months by Metformin therapy in both groups. Total cholesterol levels were high in non-obese women and were decreased in the obese women group after Metformin treatment, this metformin therapy could be useful in controlling the metabolic disturbances in non-obese women suffering from PCOS. Conclusion: Metformin has an optimistic physiological effect on the BMI & lipid profile of women suffering from PCOS, hence can help control metabolic disturbances.

Lifetime changes of the oocyte pool: Contributing factors with a focus on ovulatory inflammation

In mammalian species, females are born with a number of oocytes exceeding what they release via ovulation. In humans, an average girl is born with over a thousand times more oocytes than she will ovulate in her lifetime. The reason for having such an excessive number of oocytes in a neonatal female ovary is currently unknown. However, it is well established that the oocyte number decreases throughout the entire lifetime until the ovary loses them all. In this review, data published in the past 80 years were used to assess the current knowledge regarding the changing number of oocytes in humans and mice, as well as the reported factors that contribute to the decline of oocyte numbers. Briefly, a collective estimation indicates that an average girl is born with approximately 600,000 oocytes, which is 2,000 times more than the number of oocytes that she will ovulate in her lifetime. The oocyte number begins to decrease immediately after birth and is reduced to half of the initial number by puberty and almost zero by age 50 years. Multiple factors that are either intrinsic or extrinsic to the ovary contribute to the decline of the oocyte number. The inflammation caused by the ovulatory luteinizing hormone surge is discussed as a potential contributing factor to the decline of the oocyte pool during the reproductive lifespan.

Can time to menopause be predicted?

Menopause represents the definite end of a woman's reproductive life and the onset of a persistent hypoestrogenic state. This postmenopausal period will for most women last several decades. Although mean menopausal age seems to have increased somewhat during the last century, there is a significant individual variation in age at natural menopause. With efficient contraception, women of reproductive age can now, to some extent, choose when they want to have children. As a consequence of this and other sociodemographic changes, age at first birth has increased significantly over the last 50 years. It is well documented that long before a woman enters the menopausal transition and subsequent menopause, fertility declines and finally ceases. Being able to predict when a woman will enter menopause would therefore, from a reproductive perspective, be of major interest. Several sociodemographic, morphometric, and endocrine factors are associated with age at menopause or time to menopause. Unfortunately the sensitivity and specificity of these in predicting time to or age at menopause are low. Therefore, with the exception of anti-Müllerian hormone measurements, either alone or in combination with chronological age close to menopause, there are as of now no reliable ways of predicting when a woman will enter menopause.

Fertility Issues in Polycystic Ovarian Disease: A Systematic Approach

The triad of hirsutism, amenorrhea, and enlarged polycystic ovaries first was described in 1935 and later become known as polycystic ovarian syndrome (PCOS). Women with PCOS are more likely to have cardiometabolic challenges that also have an indirect relationship to their fertility and fertility outcomes. Despite these challenges, their fertile life span appears to be longer. Ovulation induction is considered first-line management of infertility in women with PCOS, with letrozole superior to clomiphene. Women with PCOS undergoing in vitro fertilization are high risk for ovarian hyperstimulation syndrome but also have a higher live birth rate compared with controls.

Comparison of Cumulative Live Birth Rate Between Aged PCOS Women and Controls in IVF/ICSI Cycles

The present study aimed to assess whether women with polycystic ovarian syndrome (PCOS) ≥35 years age undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles experienced a higher cumulative live birth rate (CLBR) over a two-year period compared with age- and body mass index (BMI)-matched patients with tubal factor infertility. Through propensity score matching (PSM) approach, the authors retrospectively analyzed the IVF/ICSI outcomes of 263 PCOS patients (35-46 years of age [mean, 37 years]) and 526 age- and BMI-matched tubal factor controls two years after oocyte retrieval. Multivariate regression analysis was performed to explore factors influencing cumulative live birth. Women with PCOS exhibited better ovarian reserve and response, and higher CLBR in two years compared with age- and BMI-matched controls (CLBR: 55.51% in PCOS vs. 38.02% in control, p<0.001). Multivariate logistic regression analysis revealed that the number of transferable embryos and antral follicle counts were both significant independent factors predicting cumulative live birth after adjusting for female age, female body mass index, percentage of transferred blastocysts, number of embryos transferred per embryo-transfer cycle, diagnosis of PCOS and freeze-all cycles (p<0.001, p=0.045). Women with PCOS ≥ 35 years of age demonstrated a higher CLBR over two years compared with age- and BMI-matched controls. This could be explained by favorable oocyte reserve and more available embryos compared with controls, which overcome the compromised oocyte quality in aged PCOS patients.

A mediation analysis for a nonrare dichotomous outcome with sequentially ordered multiple mediators

Mediation analyses can help us to understand the biological mechanism in which an exposure or treatment affects an outcome. Single mediator analyses have been used in various applications, but may not be appropriate for analyzing intricate mechanisms involving multiple mediators that affect each other. Thus, in this article, we studied multiple sequentially ordered mediators for a dichotomous outcome and presented the identifiability assumptions for the path-specific effects on the outcome, that is, the effect of an exposure on the outcome mediated by a specific set of mediators. We proposed a closed-form estimator for the path-specific effects by modeling the dichotomous outcome using a probit model. Asymptotic variance of the proposed estimator is derived and can be approximated via delta method or bootstrapping. Simulations under a finite sample showed the validity of our method in capturing the path-specific effects when the probability of each potential counterfactual outcome is not small and demonstrated the utility of a computationally efficient alternative to bootstrapping for calculating variance. The method is applied to investigate the effects of polycystic ovarian syndrome on live birth rates mediated by estradiol levels and the number of oocytes retrieved in a large electronic in vitro fertilization database. We implemented the method into an R package SOMM, which is available at https://github.com/roqe/SOMM.

Reproductive Outcomes of Women with Polycystic Ovarian Syndrome Following In-Vitro Fertilization — A Meta-Analysis and Systematic Review

Background: Polycystic ovarian syndrome (PCOS) is a common cause of infertility in women. In-vitro fertilization (IVF) is required in 20–30% of women with PCOS trying to conceive. This is associated with increased risk of multiple gestation and ovarian hyperstimulation syndrome. Improvements in IVF techniques, safety standards, and the increased use of frozen embryos in recent years have lead to improved outcomes for women with PCOS. We performed a systematic review and meta-analysis to compare these outcomes with women without PCOS.

Search Methods: A search of PubMed, EMBASE, the Cochrane Central Register of clinical trials, and Scopus databases for all articles published until November 16th, 2017 identified 21 studies comparing IVF outcomes in PCOS and non-PCOS women. Inclusion criteria were Rotterdam criteria PCOS, comparable IVF regimes, immediate IVF outcomes, and pregnancy outcomes. Studies were excluded if the control group included any PCOS criteria, donor oocytes, or in-vitro maturation.

Outcomes: No difference was observed in live birth rate per cycle in women with vs. without PCOS (RR [Formula: see text] 1.01 [0.89, 1.16]; [Formula: see text] 82%), but the live birth rate per first cycle in PCOS cycles (RR [Formula: see text] 0.93 [0.88, 0.99]) was slightly lower. There was also no difference in the clinical pregnancy rate (RR 1.02 [0.89, 1.17]) or biochemical pregnancy rate (RR 1.03 [0.99, 1.08]) observed between the two groups. PCOS was associated with a significantly higher number of oocytes retrieved (mean difference [Formula: see text] 3.6; 95% CI [2.8, 4.4]), risk of miscarriage (RR 2.90 [2.09, 4.02]), and risk of ovarian hyperstimulation syndrome (RR 3.42 [2.28, 5.13]) per cycle.

Conclusion: Despite a widespread perception of poor reproductive potential, women with PCOS experience IVF outcomes similar to those without PCOS. Although there is a slightly lower live birth rate during their first stimulation cycle, success rates are similar after multiple cycles. PCOS is associated with a higher risk of ovarian hyperstimulation syndrome. Further studies are required to mitigate this risk.

Prediction of in vitro fertilization outcome at different antral follicle count thresholds combined with female age, female cause of infertility, and ovarian response in a prospective cohort of 8269 women

Antral follicle count (AFC) has been widely investigated for the prediction of clinical pregnancy or live birth. This study discussed the effects of AFC quartile levels on pregnancy outcomes combined with female age, female cause of infertility, and ovarian response undergoing in vitro fertilization (IVF) treatment. At present, many research about AFC mainly discuss its impact on clinical practice at different thresholds, or the analyses of AFC with respect to assisted reproductive technology outcomes under using different ovarian stimulation protocols. Factors that include ovarian sensitivity index, female age, and infertility cause are all independent predictors of live birth undergoing IVF/intracytoplasmic sperm injection, while few researchers discussed influence of female-related factors for clinical outcomes in different AFC fields.A total of 8269 infertile women who were stimulated with a long protocol with normal menstrual cycles were enrolled in the study, and patients were categorized into 4 groups based on AFC quartiles (1-8, 9-12, 13-17, and ≥18 antral follicles).The clinical pregnancy rates increased in the 4 AFC groups (28.25% vs 35.38% vs 37.38% vs 40.13%), and there was a negative association between age and the 4 AFC groups. In addition, female cause of infertility like polycystic ovary syndrome, Tubal factor, and other causes had great significance on clinical outcome, and ovarian response in medium (9-16 oocytes retrieved) had the highest clinical pregnancy rate at AFC quartiles of 1 to 8, 9 to 12, 13 to 17, and ≥18 antral follicles.This study concludes that the female-related parameters (female cause of infertility, female age, and ovarian response) combined with AFC can be useful to estimate the probability of clinical pregnancy.

Fecundity among women with polycystic ovary syndrome (PCOS)—a population-based study

STUDY QUESTION

Does the long-term fecundity of women with polycystic ovary syndrome (PCOS) differ from those without PCOS?

SUMMARY ANSWER

Cumulative probability of childbirth is similar between women with and without PCOS.

WHAT IS KNOWN ALREADY

PCOS is the main cause of anovulatory infertility in women after menarche. Previous studies indirectly suggest that fecundity in women with PCOS over the longer term may not be lower than in women without PCOS.

STUDY DESIGN, SIZE, DURATION

This is a population-based study using four linked Swedish national registries. A total of 45 395 women with PCOS and 217 049 non-PCOS women were included. Follow-up began at the age of 18 years and continued for a maximum of 26 years, from 1989 to the end of 2015. Childbirth was the main outcome, as identified from the Medical Birth Register.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women born between 1971 and 1997 who were identified with a PCOS diagnosis in the Swedish Patient Registry between 1 January 2001 and 31 December 2016 were included in the study population. Five controls per women with PCOS were randomly drawn from the Total Population Registry. The control women were born in the same year and living in the same municipality as the patient. The fecundity ratio (FR) was calculated by clustered Cox regression using a robust variance, adjusted for maternal birth period, country of birth and level of education.

MAIN RESULTS AND THE ROLE OF CHANCE

The cumulative probability of childbirth was 80.2% (95% CI, 79.5–80.9%) in women with PCOS and 78.2% (95% CI, 77.9–78.5%) in those without PCOS. Adjusted FR was 0.81 (95% CI, 0.80–0.82) for first childbirth and 0.58 (95% CI, 0.57–0.60) for first childbirth following a spontaneous pregnancy. The FR for second childbirth was 0.79 (95% CI, 0.77–0.80). Women with PCOS had more than one child less frequently than the comparison group. Within the PCOS group, early age at diagnosis, later birth year, Nordic country of origin and low educational level positively influenced the FR.

LIMITATIONS, REASONS FOR CAUTION

Results are not adjusted for BMI, and time from intention to conceive to first childbirth could not be captured. Data on pregnancies, miscarriages or abortions and fertility treatment are unknown for women who did not give birth during the study period. Women with PCOS who did not seek medical assistance might have been incorrectly classified as not having the disease. Such misclassification would lead to an underestimation of the true association between PCOS and outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

While cumulative probability of childbirth is similar between groups, women with PCOS need longer time to achieve their first childbirth. Women with PCOS have a lower FR and give birth to fewer children per woman than women without PCOS. Early diagnosis of and information about PCOS may improve affected women’s reproductive potential.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Swedish Society of Medicine. Inger Sundström Poromaa has, over the past 3 years, received compensation as a consultant and lecturer for Bayer Schering Pharma, MSD, Gedeon Richter, Peptonics and Lundbeck A/S. The other authors declare no competing interests.

A Slower Age-Related Decline in Treatment Outcomes After the First Ovarian Stimulation for in vitro Fertilization in Women With Polycystic Ovary Syndrome

Background: Polycystic ovary syndrome (PCOS) patients have a better ovarian reserve and age-related improvement in endocrine disturbances than non-PCOS patients. The effects of age on in vitro fertilization (IVF) treatment outcomes associated with cumulative live birth rate (CLBR) remain unclear. Objectives: To study the effect of age on CLBR after the first ovarian stimulation in IVF in PCOS patients. Method: This retrospective cohort study included 3,502 PCOS patients and 18,596 patients with tubal factor infertility, who underwent their first IVF cycles and subsequent frozen embryo transfer (ET) attempts. The primary outcome was CLBR associated with a single stimulation cycle and secondary outcomes included the implantation rate, clinical pregnancy rate, live birth rate (LBR), large for gestational age (LGA) rate, small for gestational age (SGA) rate, and preterm birth (PTB) rate of fresh ET cycles. Results: PCOS patients over 40 years had a higher implantation rate (27.8 vs. 15.7%, P < 0.05), clinical pregnancy rate (51.4 vs. 26.1%, P < 0.05), LBR (42.3 vs. 18.2%, P < 0.05), and CLBR (50.0 vs. 21.5%, P < 0.05) than non-PCOS patients over 40 years. These rates were comparable between PCOS patients aged 35 to 40 years and those aged over 40 years (P = 0.263, 0.385, and 0.112, respectively). The changes in the implantation rate, clinical pregnancy rate, and CLBR by age were slower for PCOS patients than for non-PCOS patients (all P < 0.05). Among PCOS patients less than 35 years, BMI was negatively associated with CLBR [aOR: 0.961 (0.939-0.985); P < 0.05]; however, among PCOS patients over 35 years, instead of BMI (P = 0.353), age [aOR: 0.891 (0.803-0.990); P < 0.05] and the number of oocytes retrieved [aOR: 1.093 (1.002-1.078); P < 0.05] were significantly associated with CLBR. No significant differences in LGA, LGA, or PTB were detected between PCOS and non-PCOS patients over 35 years (all P > 0.05). Conclusions: The declines in treatment outcomes with age are slower for PCOS patients than for non-PCOS patients. For patients over 40 years, PCOS patients have reproductive advantages over non-PCOS patients. In contrast to younger PCOS patients (<35 years), older PCOS patients (≥35 years) may benefit less from taking time to lose weight before IVF treatment, and the immediate initiation of assisted reproductive treatment is essential.

Anti-Müllerian hormone reflects the severity of polycystic ovary syndrome

OBJECTIVE

To examine the relationship between anti-Müllerian hormone (AMH) and the severity of the phenotype of patients with polycystic ovary syndrome (PCOS) and whether AMH can act as a diagnostic marker for PCOS?

DESIGN

A prospective diagnostic utility study of AMH as a marker of PCOS.

PATIENTS

A consecutive series of women presenting to a tertiary infertility clinic (n = 164) plus a second series of women prepared for assisted conception treatments (n = 89) recruited between June 2012 and May 2013.

MEASUREMENTS

Polycystic ovary syndrome was diagnosed using the Rotterdam criteria. AMH was measured using the Generation II assay (Beckman Coulter). The diagnostic utility of AMH was established using receiver operator characteristic (ROC) curves. Cut-off values for the individual features of PCOS are proposed.

RESULTS

There was a significant difference in serum AMH concentration in women with normal ovaries (13·2 pmol/l), polycystic ovary morphology (PCOM) alone (37·8 pmol/l) and PCOS (53·2 pmol/l). Follicle number, increasing cycle length and evidence of hyperandrogenism were all independently associated with serum AMH concentration (P < 0·01). AMH was significantly affected by the different phenotypic presentations of PCOS with those with all components (PCOM, HA and OA) having the highest mean value [72·7 pmol/l (P < 0·01)].

CONCLUSIONS

Serum AMH has the capacity to act as a diagnostic test for PCOS. Moreover, since its value rises with the more marked phenotypes, different cut-off values need to be used to differentiate those patients with polycystic ovarian morphology (PCOM), hyperandrogenism (HA) and oligoanovulation (OA).

The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance

BACKGROUND

Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS).

OBJECTIVE AND RATIONALE

The aim of this paper was to present an evidence base for the management of anovulatory PCOS.

SEARCH METHODS

The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus.

OUTCOMES

Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is ≥35 kg/m2 and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed.

WIDER IMPLICATIONS

This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.

Fertility of patients with polycystic ovary syndrome undergoing in vitro fertilization by age

OBJECTIVE

To evaluate outcomes of in vitro fertilization (IVF) among patients with polycystic ovary syndrome (PCOS) by age.

METHODS

In a retrospective study, data were retrieved for patients with PCOS (Rotterdam 2003 criteria) and individuals with tubal factor infertility who underwent IVF at a center in Seoul, South Korea, between January 2003 and August 2012. IVF outcomes were compared by age group (A: 30-32 years; B: 33-35 years; C: 36-38 years; D: 39-41 years).

RESULTS

The analysis included 307 women with PCOS and 364 with tubal factor infertility. There was a significant difference between women with PCOS and those with tubal infertility factor in the live birth rate in group B (41.3% vs 28.6%, P=0.038) and in group C (40.4% vs 15.1%, P=0.002). Among women with PCOS, no significant differences in number of retrieved oocytes were observed between the age groups (18.8 ± 9.6, 19.1 ± 10.0, 17.7 ± 7.5, and 17.0 ± 13.8). However, the clinical pregnancy rate was significantly lower in group D than in group C (47.2% vs 18.8%, P=0.042).

CONCLUSION

Fertility in patients with PCOS was maintained until age 38 years using IVF. Thereafter, the pregnancy rate decreased, although the number of oocytes retrieved by IVF remained stable.

New strategy for in vitro activation of primordial follicles with mTOR and PI3K stimulators

It had been known for decades that primordial follicles in mammalian ovaries are assembled with definite numbers and represent the ovarian reserve throughout the reproductive life. Intra-oocyte PI3K/mTOR pathways have been indicated to play a central role on the activation of primordial follicles. Genetic modified mouse models with chronic activation of PI3K/mTOR signals in primordial oocytes showed premature activation of all primordial follicles and eventually their exhaustion. On the other hand, this may suggest that, unlike chronic activation of PI3K/mTOR, its acute activation in infertility would activate primordial follicles, permitting fertility during the treatment. Previously, PI3K stimulators were reported as a temporary measure to accelerate primordial follicle activation and follicular development in both mouse and human, and were applied in the treatment of infertility in premature ovarian failure (POF) patients. To address whether mTOR stimulators could play similar role in the process, we transiently treated neonatal and aged mouse ovaries with mTOR stimulators-phosphatidic acid (PA) and propranolol. Our results demonstrated the stimulators increased activation of primordial follicles and the production of progeny. Human ovarian cortex cubes were also treated with mTOR or/and PI3K stimulators in vitro. When they were used separately, both of them showed similar promotive effects on primordial follicles. Surprisingly, after joint-treatment with the 2 kinds of stimulators together, synergistic effects on follicular development were observed. Based on increased efficiency of follicular activation in humans, here we propose in vitro transient treatment with mTOR and PI3K stimulators as an optimized protocol for the application in different clinical conditions with limited follicle reserve.

Age-related normogram for antral follicle count in women with polycystic ovary syndrome

Antral follicle count (AFC) has been shown to be a reliable marker for ovarian reserve. The aims of this study were to create an age-related normogram for AFC in infertile women with polycystic ovary syndrome (PCOS) and to compare age-related decline in AFC between infertile women with and without PCOS. A retrospective cohort study was conducted. Of a total of 4956 women, 619 women fit criteria for PCOS. In those with PCOS, there were large variations in the AFC between the 10th and 90th percentiles in all age groups. The rate of decline in AFC among women with PCOS was linear, while in those with non-PCOS, it was exponential until 30 years of age, and then became similar to that of PCOS. The rate of follicle loss per year was significantly slower in PCOS women compared with that in non-PCOS women. In both groups, the fastest period of follicle loss was between the ages of 18 and 30. The average follicle loss was 0.8 follicles/year in PCOS women and 1.7 follicles/year in those without PCOS (P<0.001). This study concludes that age-related decline in AFC among women with PCOS is slower than in those without PCOS. Antral follicle count (AFC) has been shown to be a reliable marker for ovarian reserve. The aims of this study were to create an age-related normogram for AFC in women with polycystic ovary syndrome (PCOS), and to compare age-related decline in AFC between women with and without PCOS. A retrospective cohort study was conducted. All patients underwent a baseline transvaginal ultrasound that was performed on day 2-4 of the menstrual cycle. The total number of antral follicles of 2-9mm in diameter was recorded. Of total 4956 women, 619 women fit criteria for PCOS. In those with PCOS, there were large variations in the AFC between the 10th 90th percentiles in all age groups. The rate of decline in AFC among women with PCOS was linear; while in those with non-PCOS, it was exponential until 30 years of age, and then became similar to that of PCOS. The rate of follicle loss per year was significantly slower in PCOS women compared with that in non-PCOS women. In both groups, the fastest period of follicle loss was between the ages 18-30 years. The average follicle loss was 0.8 follicles/year in PCOS women and 1.7 follicles/year in those without PCOS (P<0.001). We have concluded that age-related decline in AFC among women with PCOS is slower than in those without PCOS. Further studies are needed to determine if the AFC normogram in women with PCOS could be clinically relevant to select the optimal gonadotrophin dose for ovulation induction.

The Polycystic Ovary Syndrome and recent human evolution

The Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder characterised both by reproductive and metabolic disturbance, and is the most common cause globally of ovarian infertility. It is also a familial polygenic condition, linked genetically to both Type 2 diabetes and the metabolic syndrome. The striking evolutionary paradox of this prominent genetically-based condition, which impairs fertility, is that not only should it have diminished in prevalence, but it should have done so rapidly - unless there has been some form of balancing selection. The emerging discipline of evolutionary medicine can provide important insights into the causes and patterns of occurrence of common diseases such as PCOS. In this paper we review the impacts of PCOS on infertility, fecundability and lifetime reproductive success and then critically appraise published hypotheses about the evolutionary origins of PCOS and related conditions.

Ontogeny of the ovary in polycystic ovary syndrome

Activation of primordial follicles into the growing pool, selection of the dominant follicle, and its eventual ovulation require complex endocrine and metabolic interactions as well as intraovarian paracrine signals to coordinate granulosa cell proliferation, theca cell differentiation, and oocyte maturation. Early preantral follicle development relies mostly upon mesenchymal-epithelial cell interactions, intraovarian paracrine signals, and oocyte-secreted factors, whereas development of the antral follicle depends on circulating gonadotropins as well as locally derived regulators. In women with polycystic ovary syndrome (PCOS), ovarian hyperandrogenism, hyperinsulinemia from insulin resistance, and altered intrafollicular paracrine signaling perturb the activation, survival, growth, and selection of follicles, causing accumulation of small antral follicles within the periphery of the ovary, giving it a polycystic morphology. Altered adipocyte-ovarian interactions further compound these adverse events on follicle development and also can harm the oocyte, particularly in the presence of increased adiposity. Finally, endocrine antecedents of PCOS occur in female infants born to mothers with PCOS, which suggests that interactions between genes and the maternal-fetal hormonal environment may program ovarian function after birth.

Modeling age at menopause using serum concentration of anti-mullerian hormone

CONTEXT

Anti-Mullerian hormone (AMH) has already been used for prediction of age at menopause with promising results.

OBJECTIVE

We aimed to improve our previous prediction of age at menopause in a population-based cohort by including all eligible subjects and additional follow-up time.

DESIGN AND SETTING

All reproductive-aged women who met our eligibility criteria were selected from the Tehran Lipid and Glucose Study. The serum concentration of AMH was measured at the time of recruitment, and participant's date of menopause was recorded over a 10-year follow-up.

SUBJECTS

A total of 1015 women, aged 20 to 50 years, with regular and predictable menstrual cycles at the initiation of the study were recruited.

MAIN OUTCOME MEASURE

The actual ages at menopause were compared with the predicted ones obtained from accelerated failure time model.

RESULTS

We observed 277 occurrences of menopause. Median menopausal age was 50 years (range 30.1-58.2 years). The median (SD) of differences between the actual menopausal age and those predicted by our model was 0.5 (2.5) years. Model adequacy (measured by C-statistics) for correct prediction of age at menopause was 92%. The estimated ages at menopause and their 95% confidence intervals for a range of values of AMH and age were calculated and summarized in a table.

CONCLUSIONS

Using a model built on age and AMH, we can predict age at menopause many years earlier. This could provide opportunities for interventions in those who are at risk of early or late menopause.

Marriage and motherhood are associated with lower testosterone concentrations in women

Testosterone has been hypothesized to modulate the trade-off between mating and parenting effort in males. Indeed, evidence from humans and other pair-bonded species suggests that fathers and men in committed relationships have lower testosterone levels than single men and men with no children. To date, only one published study has examined testosterone in relation to motherhood, finding that mothers of young children have lower testosterone than non-mothers. Here, we examine this question in 195 reproductive-age Norwegian women. Testosterone was measured in morning serum samples taken during the early follicular phase of the menstrual cycle, and marital and maternal status were assessed by questionnaire. Mothers of young children (age ≤3) had 14% lower testosterone than childless women and 19% lower testosterone than women who only had children over age 3. Among mothers, age of the youngest child strongly predicted testosterone levels. There was a trend towards lower testosterone among married women compared to unmarried women. All analyses controlled for body mass index (BMI), age, type of testosterone assay, and time of serum sample collection. This is the first study to look at testosterone concentrations in relation to marriage and motherhood in Western women, and it suggests that testosterone may differ with marital and maternal status in women, providing further corroboration of previous findings in both sexes.

Does PCOS have developmental origins?

PRO--The similarity of reproductive and metabolic phenotype between prenatally androgenized sheep, or monkeys, and women with PCOS provides strong supportive evidence for developmental programming being important in the etiology of PCOS. CON--While one would not exclude altogether developmental determinants of PCOS, it is difficult to view PCOS as purely developmental or resulting only from intrauterine exposures or simply an adaptation gone astray.