Age-related infertility and unexplained infertility: an intricate clinical dilemma

Application of Eight Machine Learning Algorithms in the Establishment of Infertility and Pregnancy Diagnostic Models: A Comprehensive Analysis of Amino Acid and Carnitine Metabolism

To explore the effects of altered amino acids (AAs) and the carnitine metabolism in non-pregnant women with infertility (NPWI), pregnant women without infertility (PWI) and infertility-treated pregnant women (ITPW) compared with non-pregnant women (NPW, control), and develop more efficient models for the diagnosis of infertility and pregnancy, 496 samples were evaluated for levels of 21 AAs and 55 carnitines using targeted high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS/MS). Three methods were used to screen the biomarkers for modeling, with eight algorithms used to build and validate the model. The ROC, sensitivity, specificity, and accuracy of the infertility diagnosis training model were higher than 0.956, 82.89, 66.64, and 82.57%, respectively, whereas those of the validated model were higher than 0.896, 77.67, 69.72, and 83.38%, respectively. The ROC, sensitivity, specificity, and accuracy of the pregnancy diagnosis training model were >0.994, 96.23, 97.79, and 97.69%, respectively, whereas those of the validated model were >0.572, 96.39, 93.03, and 94.71%, respectively. Our findings indicate that pregnancy may alter the AA and carnitine metabolism in women with infertility to match the internal environment of PWI. The developed model demonstrated good performance and high sensitivity for facilitating infertility and pregnancy diagnosis.

Unexplained infertility and age-related infertility: indistinguishable diagnostic entities but different IVF prognosis

STUDY QUESTION

Is IVF indicated for couples with age-related infertility?

SUMMARY ANSWER

IVF may be of doubtful utility for age-related infertility.

WHAT IS KNOWN ALREADY

A diagnosis of unexplained infertility is drawn when the diagnostic work-up fails to identify any patent cause. Although typically managed uniformly, unexplained infertility is likely to comprise a wide range of conditions, including age-related infertility (at least in older women). Unfortunately, no validated tests for the identification of age-related infertility exist and these women are typically treated as unexplained cases. However, homologous ART may be less effective for these women because these techniques may be unable to treat the detrimental effects of ageing on oocyte competence.

STUDY DESIGN, SIZE, DURATION

Women aged 18-42 years who underwent IVF procedures between January 2014 and December 2021 were selected retrospectively. In the first part of the study, we aimed to assess whether the proportion of women with unexplained infertility (i.e. without patent causes of infertility) increased with age. In the second part of the study, women with unexplained infertility were matched 1:1 by age, study period, and duration of infertility, to those with a patent cause of infertility. If our hypothesis is valid, the first part of the study should highlight an increase in the proportion of unexplained infertility with age. Moreover, in the second part of the study, one should observe a sharper decrease in the rate of IVF success of the procedure with age in women with an unremarkable work-up compared to those with a definite cause of infertility.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women were included if: they had been trying to conceive for more than 2 years, they had retrieved more than three oocytes, and had not undergone previous IVF attempts. We exclude couples with severe male factor (criptozoospermia), chronic anovulation, untreated hydrosalpinx, or intracavitary diseases. The first part of the study aimed at investigating the relative proportion of unexplained infertility with age. The outcome of the second part was the distribution of the live births between unexplained versus explained infertility, in women younger or older than 35 years. Only the results of the first IVF cycle were considered (including both fresh and frozen cycles). The live birth rate corresponded to the cumulative chance of a live birth per oocyte retrieval.

MAIN RESULTS AND THE ROLE OF CHANCE

One thousand five hundred and thirty-five women were selected for the first part of the study; 742 of them had unexplained infertility (48%). The frequency of this diagnosis was lower among women aged <35 years (40%) compared to those ≥35 years (52%) (P < 0.001). A clear gradient emerged when considering smaller intervals of age (P < 0.001). A total of 1134 women (567 unexplained cases and 567 explained cases) were selected for the second part of the study. Baseline variables were comparable between women with unexplained and explained infertility. Among women younger than 35 years (n = 229 unexplained cases and 229 explained cases), 108 live births were observed in women with unexplained infertility (47%) and 88 in those with explained infertility (38%). In comparison, among women older than 35 years, the live births occurred in 90 (27%) and 114 (34%) couples, respectively (P = 0.03). The adjusted odds ratio (OR) for a live birth in older women with unexplained infertility was 0.63 (95% CI: 0.43-0.94). In other words, the effectiveness of IVF in older women with unexplained infertility is reduced by an additional 37% when compared to women of similar age with a patent cause of infertility. Moreover, when considering smaller intervals of age, a gradient of the adverse effect of age on the distribution of live births between unexplained and explained infertility emerged (P = 0.003). Overall, these results support the hypothesis that IVF may be of modest benefit in women with age-related infertility. The decline in IVF success is sharper in women with unexplained infertility compared to those with explained infertility, indirectly suggesting that IVF cannot effectively treat age-related infertility.

LIMITATIONS, REASONS FOR CAUTION

We postulated that the greater decline in IVF success with age in the unexplained group could be related to the concomitant increase in the proportion of women with age-related infertility. However, even if this is theoretically logical, the unavailability of validated tools to diagnose age-related infertility makes our inference speculative. We cannot exclude that the prevalence of other unknown causes of infertility that cannot also be effectively overcome with IVF could increase with age.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest that IVF may be of modest utility for treating age-related infertility. Offering this procedure to older women with an unremarkable infertility work-up may be questioned. However, the diagnosis of age-related infertility remains challenging and identifying a biomarker that could reliably diagnose age-related infertility is a priority.

STUDY FUNDING/COMPETING INTEREST(S)

The study was partially funded by the Italian Ministry of Health-current research IRCCS and by a specific grant supported by Ferring. ES declares receiving honoraria for lectures at meetings from IBSA and Gedeon-Richter and he also handles private grants of research from Ferring, IBSA, Theramex, and Gedeon-Richter. All the other authors do not have any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Partnership trajectories preceding medically assisted reproduction

The number of people who undergo medically assisted reproduction (MAR) to conceive has increased considerably in recent decades. However, existing research into the demographics and the partnership histories of this growing subgroup is limited. Using unique data from Finnish population registers on nulliparous women born in Finland in 1971-77 (n = 21,129; ∼10 per cent of all women) who had undergone MAR treatment, we created longitudinal partnership histories from age 16 until first MAR treatment. We identified six typical partnership trajectories and used relative frequency sequence plots to investigate heterogeneity in partnership transitions within and between these groups. The majority of women (60.7 per cent) underwent MAR with their first partner, followed by women who underwent MAR in a second (21.5 per cent) or higher-order partnership (7.1 per cent), while 10.7 per cent underwent MAR without a partner. On average, women undergoing MAR were relatively young (with around half starting treatment before age 30) and were highly educated with high incomes.

Economic evaluations of assisted reproductive technologies in high-income countries: a systematic review

STUDY QUESTION

Which assited reproductive technology (ART) interventions in high-income countries are cost-effective and which are not?

SUMMARY ANSWER

Among all ART interventions assessed in economic evaluations, most high-cost interventions, including preimplantation genetic testing for aneuploidy (PGT-A) for a general population and ICSI for unexplained infertility, are unlikely to be cost-effective owing to minimal or no increase in effectiveness.

WHAT IS KNOWN ALREADY

Approaches to reduce costs in order to increase access have been identified as a research priority for future infertility research. There has been an increasing number of ART interventions implemented in routine clinical practice globally, before robust assessments of evidence on economic evaluations. The extent of clinical effectiveness of some studied comparisons has been evaluated in high-quality research, allowing more informative decision making around cost-effectiveness.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review and searched seven databases (MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS, and CINAHL) for studies examining ART interventions for infertility together with an economic evaluation component (cost-effectiveness, cost-benefit, cost-utility, or cost-minimization assessment), in high-income countries, published since January 2011. The last search was 22 June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two independent reviewers assessed publications and included those fulfilling the eligibility criteria. Studies were examined to assess the cost-effectiveness of the studied intervention, as well as the reporting quality of the study. The chosen outcome measure and payer perspective were also noted. Completeness of reporting was assessed against the Consolidated Health Economic Evaluation Reporting Standard. Results are presented and summarized based on the intervention studied.

MAIN RESULTS AND THE ROLE OF CHANCE

The review included 40 studies which were conducted in 11 high-income countries. Most studies (n = 34) included a cost-effectiveness analysis. ART interventions included medication or strategies for controlled ovarian stimulation (n = 15), IVF (n = 9), PGT-A (n = 7), single embryo transfer (n = 5), ICSI (n = 3), and freeze-all embryo transfer (n = 1). Live birth was the mostly commonly reported primary outcome (n = 27), and quality-adjusted life years was reported in three studies. The health funder perspective was used in 85% (n = 34) of studies. None of the included studies measured patient preference for treatment. It remains uncertain whether PGT-A improves pregnancy rates compared to IVF cycles managed without PGT-A, and therefore cost-effectiveness could not be demonstrated for this intervention. Similarly, ICSI in non-male factor infertility appears not to be clinically effective compared to standard fertilization in an IVF cycle and is therefore not cost-effective. Interventions such as use of biosimilars or HMG for ovarian stimulation are cheaper but compromise clinical effectiveness.

LIMITATIONS, REASONS FOR CAUTION

Lack of both preference-based and standardized outcomes limits the comparability of results across studies. The selection of efficacy evidence offered for some interventions for economic evaluations is not always based on high-quality randomized trials and systematic reviews. In addition, there is insufficient knowledge of the willingness to pay thresholds of individuals and state funders for treatment of infertility. There is variable quality of reporting scores, which might increase uncertainty around the cost-effectiveness results.

WIDER IMPLICATIONS OF THE FINDINGS

Investment in strategies to help infertile people who utilize ART is justifiable at both personal and population levels. This systematic review may assist ART funders decide how to best invest to maximize the likelihood of delivery of a healthy child.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. E.C. and R.W. receive salary support from the National Health and Medical Research Council (NHMRC) through their fellowship scheme (EC GNT1159536, RW 2021/GNT2009767). M.D.-T. reports consulting fees from King Fahad Medical School. All other authors have no competing interests to declare.

REGISTRATION NUMBER

Prospero CRD42021261537.

Retinoic acid enhances ovarian steroidogenesis by regulating granulosa cell proliferation and MESP2/STAR/CYP11A1 pathway

INTRODUCTION

Ovarian steroidogenesis not only affects the embryonic development and pregnancy outcome, but also associates with many diseases in mammals and women. Exploring the nutrients and mechanisms influencing ovarian steroidogenesis is critical to maintaining the optimal reproductive performance, as well as guaranteeing body health.

OBJECTIVES

This research aimed to explore the effect of retinol metabolism on ovarian steroidogenesis and the underlying mechanisms.

METHODS

Comparative transcriptomic analysis of ovaries from normal and low reproductive performance sows were performed to identify the main causes leading to low fertility. The metabolites regulating steroid hormones synthesis were investigated in ovarian granulosa cells. Gene interference, overexpression, dual-luciferase reporter assays, chromatin immunoprecipitation and transcriptome analysis were further conducted to explore the underlying mechanisms of Aldh1a1 mediating ovarian steroidogenesis.

RESULTS

Transcriptome analysis of ovaries from normal and low reproductive performance sows showed the significant differences in both retinol metabolism and steroid hormones synthesis, indicating retinol metabolism probably influenced steroid hormones synthesis. The related metabolite retinoic acid was furtherly proven a highly active and potent substance strengthening estrogen and progesterone synthesis in ovarian granulosa cells. For the first time, we revealed that retinoic acid synthesis in porcine and human ovarian granulosa cells was dominated by Aldh1a1, and required the assistance of Aldh1a2. Importantly, we demonstrated that Aldh1a1 enhanced the proliferation of ovarian granulosa cells by activating PI3K-Akt-hedgehog signaling pathways. In addition, Aldh1a1 regulated the expression of transcription factor MESP2, which targeted the transcription of Star and Cyp11a1 through binding to corresponding promoter regions.

CONCLUSION

Our data identified Aldh1a1 modulates ovarian steroidogenesis through enhancing granulosa cell proliferation and MESP2/STAR/CYP11A1 pathway. These findings provide valuable clues for improving ovarian health in mammals.

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Assisted reproductive technology outcomes and gene expression in unexplained infertility patients

Background: Unexplained infertility (UI) can be a frustrating and challenging diagnosis for doctors and couples as it can be difficult to understand why they are unable to conceive despite increasing diagnostic tools. Assisted reproductive technology (ART) procedures have been successfully applied to many couples aiming to overcome UI. However, they can be not only expensive but also require multiple cycles to achieve a successful pregnancy. The endometrium and the follicular fluid have been investigated as target tissues not only to determine the cause of UI but also to increase conception rates. Results: In this study, we analyzed the outcomes of ART in 223 UI couples and gene expression associated with DNA modification, cell death, immune response and senescence (TET1, TET2, BCL2, BAK1, HMGA2, IL-6, IL-8) in infertile women's endometrium and follicular fluid. We found significant differences in women who successfully got pregnant compared to women unable to conceive depending on age, duration of infertility, number of retrieved oocytes, zygotes, transferred embryos. Further, the expression of genes BAK1 (pro-apoptotic), TET2 (associated with epigenetic DNA modification) and IL-6 (associated with immune responses) were significantly higher in the endometrium of women who successfully got pregnant. Conclusion: Younger parental age couples showed higher ART success rates, shorter duration of infertility, higher number of retrieved oocytes, zygotes and transferred embryos. The gene expression analysis revealed significant changes in the endometrium depending on genes associated with cell death and immune response which were upregulated in females with diagnosed unexplained infertility.

Association between serum uric acid and female infertility: a cross-sectional study of National Health and Nutrition Examination Survey (NHANES) 2013-2018

BACKGROUND

Female infertility is a major problem for women of reproductive-age worldwide. Oxidative stress and inflammation are involved in processes related to female infertility. Serum uric acid levels, an indicator of oxidative stress and inflammation, have rarely been reported to be associated with female infertility. This study aimed to investigate the relationship between serum uric acid levels and female infertility.

METHODS

This cross-sectional study included women aged 18-44 years from the National Health and Nutrition Examination Survey (NHANES) between 2013 and 2018. All data were extracted from NHANES questionnaires and laboratory measurements. Weighted univariable and multivariable logistic regression analyses were utilized to explore the relationship between serum uric acid and female infertility. Stratified analyses were performed based on body mass index (BMI, < 25 kg/m² and ≥ 25 kg/m²) and age (≤ 30 years and > 30 years). The odds ratio (OR) with 95% confidence interval (CI) was used to report associations.

RESULTS

A total of 2,884 women were included, of which 352 (13.30%) had infertility. Women with high serum uric acid concentrations were related to higher odds of infertility (OR = 1.20, 95%CI: 1.03-1.39) after adjusting for confounders. Compared with serum uric acid concentrations ≤ 3.72 mg/dL, women with uric acid concentrations of 4.43-5.13 mg/dL (OR = 1.65, 95%CI: 1.02-2.67) and > 5.13 mg/dL (OR = 1.86, 95%CI: 1.10-3.13) were related to higher odds of infertility. Stratified analyses showed that high serum uric acid concentrations were associated with higher odds of infertility in women with a BMI < 25 kg/m² (OR = 1.41, 95%CI: 1.04-1.93), but not in women with a BMI ≥ 25 kg/m² (P = 0.056). In addition, high serum uric acid concentrations were associated with higher odds of infertility in women aged > 30 years (OR = 1.23, 95%CI: 1.04-1.45), but not in women aged ≤ 30 years (P = 0.556).

CONCLUSION

Women with high serum uric acid concentrations were associated with higher odds of infertility, and this association may vary by BMI and age.

Fertility and reproductive outcomes following high-energy pelvic fractures: A systematic review and meta-analysis

BACKGROUND

There is a need to decipher the effect of pelvic fractures (PFs) upon female fertility and live birth rate, as data including treatment regimens in large, unselected populations remain scarce.

OBJECTIVES

To assess the effect of high energy PFs upon female fertility and live birth rate.

SEARCH STRATEGY

Literature search for relevant studies was performed up to March 2022 in five databases: Embase, MEDLINE, CAB Abstracts, ClinicalTrials.gov, and Google Scholar.

SELECTION CRITERIA

Retrospective studies assessing live birth, infertility, and dyspareunia rates following PFs.

DATA COLLECTION AND ANALYSIS

Data were extracted from studies independently by two authors. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS) for observational studies.

MAIN RESULTS

A total of 763 female patients of median age 27.8 years (95% CI 22-38 years) were included with median follow up of 5 years. Among PF patients, infertility hazard ratio (HR) 1.18 (95% CI 0.76-1.84, P = 0.47; I²  = 18%) and dyspareunia HR 0.60 (95% CI 0.34-1.08, P = 0.09; I²  = 66%), did not significantly differ from the age-matched literature-reported rates among non-PF patients.

CONCLUSIONS

No significant differences of live birth, infertility, and dyspareunia rates across patients with PFs were found compared with non-PF counterparts.

Effect of Teach-back and Douyin platform short video health education in women receiving infertility treatment

Objective

To evaluate the effect of intervention by Teach-back and Douyin platform short video health education on stigma, reproductive quality of life, family intimacy and family adaptability in women receiving infertility treatment.

Methods

This study is a quasi-experimental study. The intervention period is 6 weeks, and the study was implemented between January 2022 and August 2022. A total of 80 women (40 in the control group and 40 in the observation group) receiving infertility treatment were included in the study. The control group was given routine health education intervention, and the observation group was given Teach-back and Douyin platform short video health education on the basis of routine health education. The Chinese version of the Infertility Stigma Scale, the Infertility Quality of Life Questionnaire and the Family Intimacy and Adaptability Scale were used to evaluate the effects before and after the intervention.

Results

After the intervention, the total score of stigma in the observation group was significantly lower and lower than that of the control group (P < 0.05) and the total score of reproductive quality of life in the observation group was significantly higher than that of the control group (P < 0.05). The dissatisfaction score of family intimacy in the observation group was significantly lower than that of the control group (P < 0.05), and the dissatisfaction score of family adaptability in the observation group was significantly lower than that of the control group (P < 0.05).

Conclusion

Teach-back and Douyin platform short video health education can reduce the stigma in women receiving infertility treatment and improve their reproductive quality of life, family intimacy and family adaptability.

The impact of small and asymptomatic intramural and subserosal fibroids on female fertility: a case-control study

STUDY QUESTION

Do small and asymptomatic intramural and subserosal uterine fibroids affect female fertility?

SUMMARY ANSWER

Small and asymptomatic fibroids that do not encroach the endometrial cavity appear to not markedly affect female fertility.

WHAT IS KNOWN ALREADY

The available evidence on uterine fibroids and fertility is limited. Most information has been obtained in IVF settings by comparing the success in women affected and not affected by fibroids. These studies have shown a detrimental effect of submucosal and possibly intramural fibroids. However, this study design provides information only on embryo implantation, not on female fertility in general.

STUDY DESIGN SIZE DURATION

A retrospective observational case-control study on 200 women whose partner was diagnosed with severe male infertility and 200 women with unexplained infertility was conducted. If the null hypothesis (that fibroids do not affect fertility) is valid, one would expect a similar prevalence of fibroids in the two study groups. Conversely, if fibroids do impact fertility, one would expect a higher prevalence among women with unexplained infertility. The study was carried out at the Infertility Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico covering a 5-year period between January 2014 and June 2020.

PARTICIPANTS/MATERIALS SETTING METHODS

We retrospectively recruited women seeking pregnancy whose partner was repeatedly documented to have a sperm concentration below 1 million/ml and matched them by age and study period to a group of women with unexplained infertility. The latter group of women was considered as a case group (infertile subjects), while the former group of women was considered as a control group (reflecting the general female population). Women with fibroids could be included in both study groups; only those with submucosal lesions were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

Fibroids were diagnosed in 31 women (16%) with unexplained infertility and in 32 women (16%) with severe male factor infertility. The adjusted odds ratio of carrying fibroids in women with unexplained infertility was 0.91 (95% CI: 0.52-1.58). Subgroup analyses according to number, dimension and location of fibroids failed to highlight an increased risk of infertility in any group.

LIMITATIONS REASONS FOR CAUTION

This is a retrospective study and some inaccuracies in fibroids detection cannot be ruled out. Moreover, the relatively small sample size hampers robust subgroup analyses. Even though we excluded women with patent causes of infertility, some women with specific causes of infertility could have been included among controls (yet are expected to account for <10% of the group).

WIDER IMPLICATIONS OF THE FINDINGS

This study suggests that small fibroids that do not encroach the endometrial cavity do not markedly affect female fertility. This information is clinically relevant when counseling infertile women with small fibroids and an otherwise unremarkable diagnostic work-up. Surgery may still be considered but only in selected cases.

STUDY FUNDING/COMPETING INTERESTS

This study was partially funded by Italian Ministry of Health: current research IRCCS. E.S. reports grants from Ferring, grants and personal fees from Merck, and grants and personal fees from Theramex outside the submitted work. All the other authors do not have any competing interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Should we adopt a prognosis-based approach to unexplained infertility?

The treatment of unexplained infertility is a contentious topic that continues to attract a great deal of interest amongst clinicians, patients and policy makers. The inability to identify an underlying pathology makes it difficult to devise effective treatments for this condition. Couples with unexplained infertility can conceive on their own and any proposed intervention needs to offer a better chance of having a baby. Over the years, several prognostic and prediction models based on routinely collected clinical data have been developed, but these are not widely used by clinicians and patients. In this opinion paper, we propose a prognosis-based approach such that a decision to access treatment is based on the estimated chances of natural and treatment-related conception, which, in the same couple, can change over time. This approach avoids treating all couples as a homogeneous group and minimizes unnecessary treatment whilst ensuring access to those who need it early.

Associations between epigenetic age acceleration and infertility

STUDY QUESTION

Is the use of ART, a proxy for infertility, associated with epigenetic age acceleration?

SUMMARY ANSWER

The epigenetic age acceleration measured by Dunedin Pace of Aging methylation (DunedinPoAm) differed significantly between non-ART and ART mothers.

WHAT IS KNOWN ALREADY

Among mothers who used ART, epigenetic age acceleration may be associated with low oocyte yield and poor ovarian response. However, the difference in epigenetic age acceleration between non-ART and ART mothers (or even fathers) has not been examined.

STUDY DESIGN, SIZE, DURATION

The Norwegian Mother, Father and Child Cohort Study (MoBa) recruited pregnant women and their partners across Norway at around 18 gestational weeks between 1999 and 2008. Approximately 95 000 mothers, 75 000 fathers and 114 000 children were included. Peripheral blood samples were taken from mothers and fathers at ultrasound appointments or from mothers at childbirth, and umbilical cord blood samples were collected from the newborns at birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among the MoBa participants, we selected 1000 couples who conceived by coitus and 894 couples who conceived by IVF (n = 525) or ICSI (n = 369). We measured their DNA methylation (DNAm) levels using the Illumina MethylationEPIC array and calculated epigenetic age acceleration. A linear mixed model was used to examine the differences in five different epigenetic age accelerations between non-ART and ART parents.

MAIN RESULTS AND THE ROLE OF CHANCE

We found a significant difference in the epigenetic age acceleration calculated by DunedinPoAm between IVF and non-ART mothers (0.021 years, P-value = 2.89E-06) after adjustment for potential confounders. Further, we detected elevated DunedinPoAm in mothers with tubal factor infertility (0.030 years, P-value = 1.34E-05), ovulation factor (0.023 years, P-value = 0.0018) and unexplained infertility (0.023 years, P-value = 1.39E-04) compared with non-ART mothers. No differences in epigenetic age accelerations between non-ART and ICSI fathers were found. DunedinPoAm also showed stronger associations with smoking, education and parity than the other four epigenetic age accelerations.

LIMITATIONS, REASONS FOR CAUTION

We were not able to determine the directionality of the causal pathway between the epigenetic age accelerations and infertility. Since parents' peripheral blood samples were collected after conception, we cannot rule out the possibility that the epigenetic profile of ART mothers was influenced by the ART treatment. Hence, the results should be interpreted with caution, and our results might not be generalizable to non-pregnant women.

WIDER IMPLICATIONS OF THE FINDINGS

A plausible biological mechanism behind the reported association is that IVF mothers could be closer to menopause than non-ART mothers. The pace of decline of the ovarian reserve that eventually leads to menopause varies between females yet, in general, accelerates after the age of 30, and some studies show an increased risk of infertility in females with low ovarian reserve.

STUDY FUNDING/COMPETING INTEREST(S)

This study was partly funded by the Research Council of Norway (Women's fertility, project no. 320656) and through its Centres of Excellence Funding Scheme (project no. 262700). M.C.M. has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme (grant agreement number 947684). The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Influencing Factors of Dyadic Coping Among Infertile Women: A Path Analysis

BACKGROUND

The infertility prevalence of married couples in China is increasing gradually. The dyadic coping level and its influencing factors of infertile women in China are poorly reported. The relationship between dyadic coping and the family cohesion and adaptability in infertile women was investigated.

METHODS

A total of 482 infertile women in the reproductive clinics of three affiliated hospitals of the Lanzhou University were selected by the convenience sampling method. The self-made general information questionnaire, family adaptability and cohesion evaluation scale, and dyadic coping questionnaire were used in this study.

RESULTS

The average age of infertile women was 31.73 ± 4.57 years, the duration of infertility was 28.66 ± 27.99 months, the total score of dyadic coping was 132.66 ± 25.49, the total score of family cohesion and adaptability was 101.48 ± 20.96. A significant positive correlation between dyadic coping and family cohesion and adaptability was observed (r = 0.74, p < 0.01). The multiple linear regression analysis showed that religious belief, number of miscarriages, relationship between family members, family intimacy, and adaptability were the influencing factors of dyadic coping level in the family of infertile women (R ² = 0.566, p < 0.01).

CONCLUSIONS

The dyadic coping level of infertile women is in the medium level, which is significantly positively correlated with family intimacy and adaptability. In clinical nursing, nurses try to improve the family relationship of patients to increase the level of dyadic coping of infertile women.

Expectant Management Before In vitro Fertilization in Women Aged 39 or Above and Unexplained Infertility Does Not Decrease Live Birth Rates Compared to Immediate Treatment

Unexplained infertile couples can have further expectant management before starting assisted reproductive treatments. However, ovarian reserve and in vitro fertilization (IVF) outcomes rapidly decline after 39 years or more. It is thus important to clarify whether a waiting policy is also appropriate for women of advanced age. Couples who had access to a waiting list for approximately 1 year before receiving reimbursed public IVF were compared with those paying for access to immediate treatment. To allow for comparisons between these two strategies, we followed up couples who opted to pay for 1 year after the last embryo transfer from their first cycle. We calculated the proportion of live births in both groups and compared these using logistic regression models and a two-sample Z test for equality of proportions. Six hundred thirty-five couples were evaluated. Out of 359 couples in the immediate group, 70 (19.5%) had a live birth of which 11 after natural conception and 59 after IVF. Out of 276 couples in the waiting group, 57 (20.7%) had a live birth of which 37 after natural conception and 20 after IVF. There was no statistically significant difference between the two strategies in terms of the crude cumulative live birth rate (cLBR). The adjusted odds ratio of 0.69 (95%CI:0.39–1.22) did not change this conclusion as our sensitivity analyses. The cLBR for the ‘waiting before IVF’ and the ‘immediate’ strategies were similar. Further studies are needed to better characterize couples affected by unexplained infertility in order to individualize treatment strategies.

Intrauterine insemination + controlled ovarian hyperstimulation versus in vitro fertilisation in unexplained infertility: a systematic review and meta-analysis

BACKGROUND

IUI + COH is widely used in cases of unexplained infertility before resorting to IVF. Debate continues about what should be the first-line treatment for couples with unexplained infertility.

OBJECTIVES

This systematic review assessed the relative efficacy of IUI + COH compared with IVF in couples with unexplained infertility.

SEARCH STRATEGY

We searched Medline, Embase, CIHNL, Pscy Info, and Cochrane Library from 1980 to November 2019.

SELECTION CRITERIA

Only RCTs published articles in full text with female patients aged 18-43 years and diagnosed with unexplained infertility were included.

DATA COLLECTION AND ANALYSIS

Two authors reviewed citations from primary search independently and any disagreement was resolved by mutual discussion and consultation with a third author.

MAIN RESULT

In total, eight RCTs were included. The quality of evidence was moderate to low due to inconsistency across the trials and imprecision. The pooled result showed that IVF was associated with a statistically significant higher live birth rate (RR 1.53, 95% CI 1.01-2.32, P < 0.00001 I² = 86%) with no significant difference in multiple pregnancy rate or OHSS rate. Sensitivity analysis based on women's age and a history of previous IUI or IVF treatment showed no significant difference in the live birth rates (RR 1.01, 95% CI 0.88-1.15, I² = 0%, 3 RCTs) in treatment-naïve women younger than 38 years. In women over 38 years, the live birth rates were significantly higher in the IVF group (RR 2.15, 95% CI 1.16-4.0, I² = 42%, 1 RCT).

CONCLUSION

Further research using a standardised treatment protocol and taking into account important prognostic variables and cumulative live birth rates from fresh IVF and all sibling frozen embryos is required to further guide clinical practice.

[Prognostic factors of live-birth after in vitro fertilization for unexplained infertility: A cohort study]

OBJECTIVES

For 15 to 30% of infertile couples, no etiology can be found, leading to the diagnosis of "unexplained infertility". The aim of our study was to identify prognostic factors for live birth following in vitro fertilization (IVF) for these couples.

METHODS

A retrospective, monocentric study on a cohort of couples undergoing IVF for unexplained infertility with the woman aged≤40 years old. Primary analysis compared couples with a live birth following IVF versus childless couples following IVF.

RESULTS

Between January 2014 and December 2018, 104 couples were included, 196 transvaginal oocyte pickup were performed, followed by 234 embryo transfers (fresh or cryopreserved) which resulted in 43 deliveries. The cumulative live birth rate was 40.4% per couple. Before IVF attempts, no clinical or paraclinical prognostic factors between the two groups was observed. However, multivariate analysis showed several biological factors of good prognosis in course of treatment, such as a higher number of mature oocytes and better quality embryos in "live birth" group.

CONCLUSIONS

For a couple, the chances of having a child following IVF unexplained infertility are 40.4%. However, no clinical characteristic enabled us to identify favourable or unfavourable prognosis factors before starting ART. The prognostic factors identified during IVF cycle are interesting to advise or not to pursue IVF.

Fertility and pregnancy outcome among women undergoing assisted reproductive technology treatment in Windhoek, Namibia

PURPOSE

Infertility has been defined as a couple's failure to conceive after regular and unprotected coitus for 1 year or six months, depending on the age of the female counterpart. Although infertility can result from both the male and/or the female, often the female partner faces pressure since it is believed in some African cultures that a woman without children is like a tree without leaves. The aim of this study was to determine the prevalence of successful pregnancy outcomes among infertile women undergoing assisted reproductive technology (ART) treatment at the Cape Windhoek Fertility Clinic.

METHODS

This was a prospective and descriptive cross-sectional case reference study encompassing 178 infertile women visiting the Cape Windhoek Fertility Clinic for ART treatment.

RESULTS

The vast majority of the participants (81.5%) were married women. From the 178 infertile women, 96 (53.9%) suffered from primary and 82 (46.1%) from secondary infertility. The predominant cause of complications for infertility among the women studied was defective ovulation (28.7%) and the most common ART treatment administered was IVF/ICSI (52.2%). Only a third (33.1%) of the women who received ART treatment eventually fell pregnant.

CONCLUSION

The outcome of this study may not give a clear indication of the prevalence of infertility among women in the entire Namibian nation due to the costs involved with ART treatment offered mainly at privately owned hospitals and/or clinics, thereby resulting in those who cannot afford treatment to be left out despite being infertile.

Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple

Capsule

This expert opinion summarizes current knowledge on risk factors for infertility and identifies a practical clinical and diagnostic approach for the male and female partners of an infertile couple aimed to improve the investigation and management of fertility problems.

Background

Infertility represents an important and growing health problem affecting up to 16% of couples worldwide. In most cases, male, female, or combined factor can be identified, and different causes or risk factors have been related to this condition. However, there are no standardized guidelines on the clinical-diagnostic approach of infertile couples and the recommendations concerning infertility are sometimes lacking, incomplete, or problematic to apply.

Objective

The aim of this work is to provide an appropriate clinical and diagnostic pathway for infertile couples designed by a multidisciplinary-team of experts. The rationale is based on the history and physical examination and then oriented on the basis of initial investigations. This approach could be applied in order to reduce variation in practice and to improve the investigation and management of fertility problems.

Methods

Prominent Italian experts of the main specialties committed in the ART procedures, including gynecologists, andrologists, embryologists, biologists, geneticists, oncologists, and microbiologists, called "InfertilItaly group", used available evidence to develop this expert position.

Outcomes

Starting from the individuation of the principal risk factors that may influence the fertility of females and males and both genders, the work group identified most appropriate procedures using a gradual approach to both partners aimed to obtain a precise diagnosis and the most effective therapeutic option, reducing invasive and occasionally redundant procedures.

Conclusions

This expert position provides current knowledge on risk factors and suggests a diagnostic workflow of infertile couples. By using this step-by-step approach, health care workers involved in ART, may individuate a practical clinical management of infertile couples shared by experts.

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.

The Role of Oocyte Quality in Explaining "Unexplained" Infertility

Infertility is described as unexplained when pregnancy does not occur despite ovulation, patent Fallopian tubes, and normal semen parameters. Oocyte developmental competence (or quality) is rate-limiting for pregnancy success as oocytes provide virtually all the cellular building blocks including mitochondria required during embryogenesis. However, available tests estimate oocyte numbers (anti-Müllerian hormone, follicle-stimulating hormone and antral follicle count) and ovulation (luteal phase serum progesterone) but not the third, and most pivotal, oocyte-specific parameter, quality. Severe depletion of the follicular reserve manifests as premature ovarian insufficiency and is an obvious cause of anovulation with overt symptoms and clear diagnostic criteria. In contrast, there are no biomarkers of poor oocyte quality other than through in vitro fertilization when readouts of oocyte quality such as preimplantation embryo development can be assessed. The most common cause of poor oocyte quality is natural aging, which is strongly tied to reduced oocyte mitochondrial efficiency and increased oxidative stress. In younger women, quality may also be impaired due to accelerated aging or sporadic genetic mutations which cause severe defects during oocyte and embryo development. Thus, poor oocyte quality often provides an explanation for infertility, but because it cannot be measured using conventional tests, many cases of infertility are often incorrectly labeled "unexplained." Since female age remains the best predictor of oocyte quality, age over 37 years should be considered an independent diagnostic criterion.

Recovery of menses after functional hypothalamic amenorrhoea: if, when and why

BACKGROUND

Prolonged amenorrhoea occurs as a consequence of functional hypothalamic amenorrhoea (FHA) which is most often induced by weight loss, vigorous exercise or emotional stress. Unfortunately, removal of these triggers does not always result in the return of menses. The prevalence and conditions underlying the timing of return of menses vary strongly and some women report amenorrhoea several years after having achieved and maintained normal weight and/or energy balance. A better understanding of these factors would also allow improved counselling in the context of infertility. Although BMI, percentage body fat and hormonal parameters are known to be involved in the initiation of the menstrual cycle, their role in the physiology of return of menses is currently poorly understood. We summarise here the current knowledge on the epidemiology and physiology of return of menses.

OBJECTIVE AND RATIONALE

The aim of this review was to provide an overview of (i) factors determining the recovery of menses and its timing, (ii) how such factors may exert their physiological effects and (iii) whether there are useful therapeutic options to induce recovery.

SEARCH METHODS

We searched articles published in English, French or German language containing keywords related to return of menses after FHA published in PubMed between 1966 and February 2020. Manuscripts reporting data on either the epidemiology or the physiology of recovery of menses were included and bibliographies were reviewed for further relevant literature. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria served to assess quality of observational studies.

OUTCOMES

Few studies investigate return of menses and most of them have serious qualitative and methodological limitations. These include (i) the lack of precise definitions for FHA or resumption of menses, (ii) the use of short observation periods with unsatisfactory descriptions and (iii) the inclusion of poorly characterised small study groups. The comparison of studies is further hampered by very inhomogeneous study designs. Consequently, the exact prevalence of resumption of menses after FHA is unknown. Also, the timepoint of return of menses varies strongly and reliable prediction models are lacking. While weight, body fat and energy availability are associated with the return of menses, psychological factors also have a strong impact on the menstrual cycle and on behaviour known to increase the risk of FHA. Drug therapies with metreleptin or naltrexone might represent further opportunities to increase the chances of return of menses, but these require further evaluation.

WIDER IMPLICATIONS

Although knowledge on the physiology of return of menses is presently rudimentary, the available data indicate the importance of BMI/weight (gain), energy balance and mental health. The physiological processes and genetics underlying the impact of these factors on the return of menses require further research. Larger prospective studies are necessary to identify clinical parameters for accurate prediction of return of menses as well as reliable therapeutic options.

Gamete-level immunogenetic incompatibility in humans-towards deeper understanding of fertilization and infertility?

Human leukocyte antigen (HLA) immune genes play an important role in partner selection, but it has remained unclear if nonrandom pairing with respect to parental HLA genes could occur at the level of the gametes. We tested this possibility by investigating whether the sperm fertilization competence in humans is dependent on HLA genotype combination of the partners. We conducted a full-factorial experiment, in which the sperm physiological preparation for fertilization among multiple males was studied in the presence of follicular fluid (oocyte surrounding bioactive liquid) of several females. All the studied sperm pre-fertilization physiological parameters (motility, hyperactivation, acrosome reaction, and viability) were strongly dependent on male-female combination. In other words, follicular fluids (women) that induce strong sperm physiological response in some males often induce much weaker response in the other(s). Sperm physiological responses were stronger in HLA-dissimilar male-female pairs than in HLA-similar combinations, but none of the measured sperm traits were associated with genome-wide similarity. Together, these findings shed new light on the evolutionary and immunological mechanisms of fertilization. Furthermore, our results raise an intriguing possibility that against currently prevailing WHO's definition, infertility may not represent exclusively a pathological condition, but may also result from immunogenetic incompatibility of the gametes.

Ovarian reserve as a predictor of cumulative live birth

OBJECTIVES

Develop an up to date prediction model using recent cycle data and key pre-treatment predictor variables to estimate a couple's individualised probability of a cumulative live birth after one cycle of ovarian stimulation and transfer of all frozen embryos, before the first embryo transfer.

STUDY DESIGN

This was a retrospective cohort study. To estimate the cumulative live birth rate we only included couples who had used all embryos from their initial stimulation or achieved a live birth. We constructed a logistic regression model using live birth as a dependent variable and age group, duration of infertility, primary vs. secondary infertility, insemination method, cause of infertility, Anti-Mullerian Hormone (AMH), Follicle Stimulating Hormone (FSH) and antral follicle count (AFC) as our independent variables and used a backward elimination method to create the best fitting regression models to predict the probability of a cumulative live birth (p < 0.05 for elimination).

RESULTS

There were 516 complete cycles of ovarian stimulation resulting in 357 livebirths giving a cumulative livebirth rate of 69.2 % (95 % CI 66.0-74.0). Women with a live birth had significantly lower median age (34 years [IQR 31-37] vs. 36 years [IQR 33-39], p = 0.01) and FSH (6.7 iu/L [IQR 5.8-7.9] vs. 7.4 iu/L [IQR 6.2-8.6] and a significantly higher median AMH (22.1 pmol/L [IQR 12.1-30.9] vs. 10.5 pmol/L [IQR 7.3-20.7], p = 0.01) and AFC (18 [IQR 12-26] vs. 12 [IQR 9-19], p = 0.01). The backward conditional logistic regression model retained age category, FSH category and AMH category as significant independent predictors. The area under the curve for this model was 0.68 (95 % CI 0.63 - 0.73).

CONCLUSION

Our prediction model estimates a couple's individualised probability of achieving a live birth after their first complete cycle of IVF using all known pre-treatment predictors.

LIMITATIONS, REASONS FOR CAUTION

The study population were only those eligible for NHS funded IVF treatment which have strict ovarian reserve criteria. Exclusion of those with very low egg reserve is likely to influence the predictive capacity of out model. Furthermore, our model was developed using cycle data from one unit and thus its predictive capacity has not been assessed on an independent cohort of women. We therefore welcome external geographical validation of our model prior to its use in clinical practice.

Cervical stenosis and pregnancy rate after ultrasound guided cervical dilation in women undergoing saline infusion sonography

Aim

To assess the effect of ultrasound-guided cervical dilation on clinical pregnancy rates in women with cervical stenosis.

Methods

A prospective case control study was conducted in women with unexplained infertility. These women underwent saline infusion sonography and were suspected of having cervical stenosis if a 7 French Foley’s catheter could not be introduced into the cervical canal. Women with suspected stenosis who agreed to undergo ultrasound guided dilation were included as cases. Those with suspected stenosis who refused dilation were used as controls. Both groups were followed for one year. The primary outcome measure was women who had clinical pregnancy i.e. fetal heart beat present on transvaginal scan during the follow up period.

Results

During the study period, 1097 women who underwent SIS were included. A total of 117 (10.7%) patients had cervical stenosis. No statistically significant difference was there in both groups in terms of mean age (p = 0.617), mean body mass index (p = 0.598), duration of infertility (p = 0.588) and type of infertility (p = 0.167). However, both groups were significantly different in terms of history for risk factors i.e. endometriosis (p <0.001), prior surgery (p <0.001), polyps (p = 0.004) and pelvic inflammatory disease (p = 0.001). Eighty-nine women agreed to have dilation and were used as cases and 28 women refused and were used as controls. Of the cases, 70.45% conceived as compared to 18.5% of controls. The mean time to conception in months was also significantly lower in cases (8.10 ± 3.43 vs. 11.39 ± 1.97, p <0.001).

Conclusions

Our study shows that ultrasound-guided cervical dilation in women with cervical stenosis can lead to improved conception rates.

Special characteristics, reproductive, and clinical profile of women with unexplained infertility versus other causes of infertility: a comparative study

PURPOSE

To investigate whether women with unexplained infertility (UI) demonstrate different demographic and IVF characteristics compared to those with other causes of infertility.

METHODS

Data on 245 couples that underwent a total of 413 IVF/ICSI cycles were analyzed (UI 114 cycles, 73 women; anovulation (PCO/PCOS) 83 cycles, 51 women; tubal factor 85 cycles, 47 women; male factor 131 cycles, 74 women). Features of UI were compared versus other infertility groups, after adjustment for multiple comparisons. Generalized least squares (GLS) and random-effects logistic regression analysis were also performed.

RESULTS

Live birth rates, consisting of the primary outcome, were similar in all compared infertility groups. Compared to male infertility, UI was associated with woman's older age at cycle, lower body mass index (BMI), and higher follicle-stimulating hormone (FSH). Compared to tubal infertility, UI was linked to lower endometrial thickness at oocyte retrieval and lower BMI; compared to anovulatory infertility related to PCO/PCOS, UI was linked to woman's older age, more frequent smoking, and poorer ovarian reserve tests (FSH and antral follicle count). After adjustment for other types of infertility, woman's age, age at menarche, and FSH levels, anovulatory infertility presented with higher odds of clinical pregnancy compared to UI (adjusted OR = 2.13, 95% C: 1.01-4.52).

CONCLUSIONS

Infertile women with UI undergoing assisted reproduction demonstrate different demographic and clinical characteristics compared to those of other causes of infertility, albeit live birth rates are similar.

Fecundity disorders in older women: declines in follicular development and endometrial receptivity

Background

Little research is available on follicular development and endometrial receptivity in older women. This study aimed to assess follicular development and endometrial receptivity, and to evaluate ultrasonic parameters in predicting endometrial receptivity during the implantation window in older women.

Methods

For this prospective case-control study, 224 older women and 215 young women were recruited. The follicular development and endometrial thickness were monitored by transvaginal ultrasound. During the implantation window, the pulsatility index (PI) and resistance index (RI) of the uterine arteries and subendometrial region, endometrial volume, vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated between the two groups. The ultrasonic parameters were used to assess endometrial receptivity in older women.

Results

The serum anti-Mullerian hormone (AMH) concentration and antral follicle count (AFC) were significantly lower in older women than in young women. The average diameter of the dominant follicle on days 14, 16, and 18 of the menstrual cycle were significantly smaller, and the subendometrial region RI on days 12, 14, 16, and 18 of the menstrual cycle were significantly higher in older women than in young women. The normal ovulation rate was significantly lower in older women than in young women. The subendometrial region RI was significantly higher, and the endometrial VI, FI, and VFI were significantly lower in older women compared with young women. The biochemical pregnancy rate, clinical pregnancy rate and ongoing pregnancy rate of older women were significantly lower than in young women. The best ultrasonic parameter for predicting endometrial receptivity during the implantation window in older women was VI (AUC =0.889, sensitivity 92.6% and specificity 85.4%).

Conclusions

Older women present decreased serum AMH concentrations and AFC, defined as indicators of ovarian reserve function. Older women are characterized by decreased follicular development and endometrial receptivity, which may lead to fecundity disorders.

Effect of the anterior uterocervical angle in unexplained infertility: a prospective cohort study

OBJECTIVE

The present study aimed to evaluate an anatomical region, the anterior uterocervical angle (UCA), to determine whether it plays a role in unexplained infertility.

METHODS

In this prospective, cross-sectional study, unexplained infertile and healthy fertile (controls) women were compared. The longitudinal and transverse axes of the uterine cervix and uterine corpus were measured by transvaginal ultrasonography. The UCA was determined as the angle between two lines. One line was drawn between the internal and the external os, and the other was drawn through the internal cervical os and was parallel to the lower side of the front part of the uterine wall in the internal os. Demographic characteristics and uterocervical ultrasonographic measurements were compared between the two groups.

RESULTS

Eighty participants, aged from 20 to 35 years, were enrolled (unexplained infertile [n = 30] and healthy fertile women [n = 50)]. The mean lengths of the uterine corpus longitudinal axis, uterine corpus transverse axis, and uterine cervix longitudinal axis were similar between the groups. The mean UCA was significantly higher in healthy fertile women (131.9 ± 22.9 degrees) than in women with unexplained infertility (114.2 ± 17.3 degrees).

CONCLUSION

The present study shows that a narrow anterior UCA is associated with unexplained infertility.

Maternal age and risk of low birth weight and premature birth in children conceived through medically assisted reproduction. Evidence from Finnish population registers

STUDY QUESTION

Does the risk of low birth weight and premature birth increase with age among mothers who conceive through medically assisted reproduction (MAR)?

SUMMARY ANSWER

Among MAR mothers, the risk of poorer birth outcomes does not increase with maternal age at birth except at very advanced maternal ages (40+).

WHAT IS KNOWN ALREADY

The use of MAR treatments has been increasing over the last few decades and is especially diffused among women who conceive at older ages. Although advanced maternal age is a well-known risk factor for adverse birth outcomes in natural pregnancies, only a few studies have directly analysed the maternal age gradient in birth outcomes for MAR mothers.

STUDY DESIGN, SIZE, DURATION

The base dataset was a 20% random sample of households with at least one child aged 0-14 at the end of 2000, drawn from the Finnish population register and other administrative registers. This study included children who were born in 1995-2000, because the information on whether a child was conceived through MAR or naturally was available only from 1995 onwards.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The outcome measures were whether the child had low birth weight (LBW, <2500 g at birth) and whether the child was delivered preterm (<37 weeks of gestation). Conceptions through MAR were identified by examining data on purchases of prescription medication from the National Prescription Register. Linear probability models were used to analyse and compare the maternal age gradients in birth outcomes of mothers who conceived through MAR or naturally before and after adjustment for maternal characteristics (i.e. whether the mother suffered from acute/chronic conditions before the pregnancy, household income and whether the mother smoked during pregnancy).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 56 026 children, 2624 of whom were conceived through MAR treatments, were included in the study. Among the mothers who used MAR to conceive, maternal age was not associated with an increased risk of LBW (the overall prevalence was 12.6%) at ages 25-39. For example, compared to the risk of LBW at ages 30-34, the risk was 0.22 percentage points lower (95% CI: -3.2, 2.8) at ages 25-29 and was 1.34 percentage points lower (95% CI: -4.5, 1.0) at ages 35-39. The risk of LBW was increased only at maternal ages ≥40 (six percentage points, 95% CI: 0.2, 12). Adjustment for maternal characteristics only marginally attenuated these associations. In contrast, among the mothers who conceived naturally, the results showed a clear age gradient. For example, compared to the risk of LBW (the overall prevalence was 3.3%) at maternal ages 30-34, the risk was 1.1 percentage points higher (95% CI: 0.6, 1.6) at ages 35-39 and was 1.5 percentage points higher (95% CI: 0.5, 2.6) at ages ≥40. The results were similar for preterm births.

LIMITATIONS, REASON FOR CAUTION

A limited number of confounders were included in the study because of the administrative nature of the data used. Our ability to reliably distinguish mothers based on MAR treatment type was also limited.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to analyse the maternal age gradient in the risk of adverse birth outcomes among children conceived through MAR using data from a nationally representative sample and controlling for important maternal health and socio-economic characteristics. This topic is of considerable importance in light of the widespread and increasing use of MAR treatments.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this project was provided by the European Research Council (grant no. 803959 MARTE to Alice Goisis and grant no. 336475 COSTPOST to Mikko Myrskylä). E.S. reports personal fees from Theramex, personal fees from Merck Serono, personal fees from Health Reimbursement Arrangement, non-financial support from Merck Serono and grants from Ferring, grants from Theramex, outside the submitted work. The remaining authors have no competing interests.

TRIAL REGISTRTION NUMBER

N/A.

Predictive serum markers for unexplained infertility in child-bearing aged women

PROBLEM

Unexplained infertility (UI) represents about 25%-40% of all infertility and is a formidable obstacle for successful pregnancy for child-bearing aged women. However, up to now, there is no reliable method to predict this condition with high accuracy, thereby hindering early management of this condition.

METHOD OF STUDY

Our prospective study consists of 84 child-bearing aged women that were clinically diagnosed UI. Forty-four matched healthy fertility (HF) women were served as controls. We examined the profiles of 25 hormones and cytokines that were likely related to pathogeneses and molecular pathways involved in UI with the technique of protein array. The samples were randomly stratified 7:3 into a training set and a testing set. We used the SMOTEboost model with 10 serum proteins in a clinical verification study to identify UI cases.

RESULTS

The predictor had an area under the receiver operating characteristic curve (AUC) of 0.788 with 24 serum protein features. The predictive performance in terms of AUC of the model with the top 10 important serum proteins in the clinical verification study to classify UI cases was 0.809. Three most significantly differentially expressed proteins (DEPs) were prolactin, monocyte chemotactic protein-1 (MCP-1), and leptin.

CONCLUSION

Examination of serum-based protein profile changes could help to identify child-bearing aged women at risk of UI. This would enable early detection and facilitate development of clinical strategies to treat UI and guide their planned parenthood. It may also give clues to pathogeneses of the condition of test subjects.

Growth hormone supplementation may improve the pregnancy rate and endometrial receptivity among women aged more than 40 years undergoing in vitro fertilization

Background

Growth hormone (GH) supplements have been shown to improve pregnancy and live-birth rates, suggesting that GH has a beneficial effect on oocyte quality. However, the effects of GH on implantation and receptivity remain unknown. This study evaluated the efficacy of GH in women aged more than 40 years participating in assisted reproductive technology (ART) programs.

Methods

Cycles of in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) in women aged more than 40 years (range, 40–43 years) between January 2009 and March 2014 at a university-based reproductive center were reviewed. Women were divided into two groups, those with and without GH co-stimulation. ART outcomes were evaluated.

Results

Supplement of GH significantly lowered cycle cancellation rate by increasing the per cycle rates of harvesting at least one oocyte and transferring at least one embryo (80.2% vs. 69.4%). GH increased the per cycle clinical pregnancy (15.9% vs. 6.8%) and favorable ultrasonic endometrial pattern (60.9% vs. 39.3%) rates. GH also increased the per transfer clinical pregnancy (19.9% vs. 9.9%) and implantation (11.2% vs. 5.2%) rates and the rate of a favorable ultrasonic endometrial pattern (65.1% vs. 45.0%).

Conclusion

GH supplementation reduces the cycle cancellation rate in women aged more than 40 years, and increases the favorable ultrasonic endometrial pattern, pregnancy, and implantation rates by its beneficial actions on embryo quality and endometrial receptivity.

Ovulation induction: comparing success rates between anovulatory and ovulatory cycles using different treatment protocols

The management of patients with sub-fertility, particularly unexplained sub-fertility, is a sensitive and complex matter. This was a prospective observational study conducted from October 2016 to March 2017 in Galway, Ireland, the aim of which was to identify the clinical pregnancy rates (CPR) in women undergoing ovulation induction (OI) with timed sexual intercourse (TSI) or intrauterine insemination (IUI) and to compare them across two groups: (1) Anovulatory women and (2) ovulatory women with unexplained subfertility. Patients undergoing OI were recruited consecutively and OI regimens were prescribed as per local clinical protocol. The main observation was a higher CPR in the anovulatory group (18%) compared with the ovulatory group (CPR = 10%) (p < 0.05). No difference was observed in the CPR between the TSI and IUI groups. There are many studies to support the use of OI in the treatment of women with anovulatory subfertility, though the use of OI in ovulatory women is a more controversial issue. The treatment options offered to these patients need to be individualized to each couple and should consider their length of infertility, age, and financial means. Due to the lower cost and the less invasive nature of OI-treatment we conclude that a short treatment course could be offered as an acceptable alternative prior to IVF.

The motility-based swim-up technique separates bull sperm based on differences in metabolic rates and tail length

Swim-up is a sperm purification method that is being used daily in andrology labs around the world as a simple step for in vitro sperm selection. This method accumulates the most motile sperm in the upper fraction and leaves sperm with low or no motility in the lower fraction. However, the underlying reasons are not fully understood. In this article, we compare metabolic rate, motility and sperm tail length of bovine sperm cells of the upper and lower fraction. The metabolic assay platform reveals oxygen consumption rates and extracellular acidification rates simultaneously and thereby delivers the metabolic rates in real time. Our study confirms that the upper fraction of bull sperm has not only improved motility compared to the cells in the lower fraction but also shows higher metabolic rates and longer flagella. This pattern was consistent across media of two different levels of viscosity. We conclude that the motility-based separation of the swim-up technique is also reflected in underlying metabolic differences. Metabolic assays could serve as additional or alternative, label-free method to evaluate sperm quality.

Stem Cells as a Resource for Treatment of Infertility-related Diseases

Worldwide, infertility affects 8-12% of couples of reproductive age and has become a common problem. There are many ways to treat infertility, including medication, intrauterine insemination, and in vitro fertilization. In recent years, stem-cell therapy has raised new hope in the field of reproductive disability management. Stem cells are self-renewing, self-replicating undifferentiated cells that are capable of producing specialized cells under appropriate conditions. They exist throughout a human’s embryo, fetal, and adult stages and can proliferate into different cells. While many issues remain to be addressed concerning stem cells, stem cells have undeniably opened up new ways to treat infertility. In this review, we describe past, present, and future strategies for the use of stem cells in reproductive medicine

The impact of peak estradiol during controlled ovarian stimulation on the cumulative live birth rate of IVF/ICSI in non-PCOS patients

OBJECTIVE

The study aimed to investigate the impact of the peak E2 level during controlled ovarian hyperstimulation (COS) on the cumulative live birth rate (cLBR) in non-PCOS women with normal ovarian reserve.

MATERIALS AND METHODS

Women between 20 and 39 years were included. Donor cycles and patients who never experienced embryo transfer were excluded. Multivariable regression and smooth curve fitting were applied for statistical analysis.

RESULTS

A total of 1141 patients were included. The mean age, basal AFC, peak E2 level, and number of retrieved oocyte were 30.0 ± 3.7 years old, 16.8 ± 6.7, 3911.0 ± 1302.9 pg/ml, and 13.6 ± 5.5, respectively. In the overall population of the cohort, cLBR, miscarriage rate, and preterm birth rate were 66.9%, 7.4%, and 13.7%, respectively. The results of multivariable regression analysis failed to show the impact of peak E2 on the cLBR [OR (95%CI) 0.995 (0.982, 1.009), P = 0.486]. However, the result of smooth curve fitting indicated that when the peak E2 was lower than 2185 pg/ml, the cLBR increased about 12% with 100 pg/ml increasing of the peak E2. When the peak E2 was higher than 6136 pg/ml, the cLBR decreased about 10% with 100 pg/ml increasing of the peak E2.

CONCLUSION

We concluded that the peak E2 level on hCG trigger day is associated with the cLBR in a segmental pattern. There should be an appropriate range of the peak E2 level during COS to achieve a relative best cLBR in non-PCOS patients using stimulating protocol mainly based on GnRH agonist; however, the cutoff value must vary in different centers.

Towards a more pragmatic and wiser approach to infertility care

Infertility represents a very peculiar area of medicine. Contrary to other areas, where signs and symptoms lead to a diagnosis, which in turn leads to a specific treatment, in reproduction the lack of signs and symptoms for more than 12 months suggests the diagnosis of ‘unexplained subfertility’, and if this condition has lasted for some years, couples qualify for IVF. Diagnosis and treatments can extend over long periods of time (even years) and the accuracy of the diagnostic armamentarium is not optimal. Uncertainty about diagnosis and the need for significant perseverance is demanding on both couples and physicians, and actually constitute a very favourable situation for overdiagnosis (‘unexplained subfertility’) and overtreatment (IVF) on one hand, and, on the other, it may also affect compliance with treatments. To improve our capacity to properly handle this challenging situation, increased attention should be given to the duration of pregnancy seeking. Initiating treatments earlier in older women is unwise because this population has a lower fecundity and, therefore, duration of pregnancy seeking is even more important to achieve a reliable diagnosis of infertility. Moreover, if the infertility work-up is unremarkable, duration of pregnancy seeking should be extended up to more than 2 years prior to making a diagnosis of unexplained infertility regardless of age. An adequate period of pregnancy seeking is also required for couples who are diagnosed with conditions that can interfere with fertility to avoid overdiagnosis and overtreatment. Indeed, most causes of infertility will reduce but not impair natural conception. Within this sometimes long-term management, physicians should also pay attention to detrimental life habits in order to optimize the chances of both natural and assisted reproduction technology -mediated pregnancy. Even if interventional studies are not conclusive, it is advisable to address the problems of obesity and smoking. Focussing on frequency of sexual intercourse may be also beneficial for natural conception. Finally, there is the need for improving our capacity to handle compliance. Providing information on the importance of persevering at the start of treatment, promoting shared decision-making and tackling patient, clinic and treatment causes of drop-out can all improve the overall chances of parenthood. Thus, we plead for a wiser and more pragmatic approach to infertility, paying more attention to these neglected, but in our opinion essential, aspects of infertility care.

Do young women with unexplained infertility show manifestations of decreased ovarian reserve?

PURPOSE

To investigate whether unexplained infertility at a young age demonstrates manifestations of decreased ovarian reserve.

METHODS

A total of 100 women were divided into two equally sized groups. The study group comprised women aged ≤ 37 years diagnosed with unexplained infertility, and the control group included age-matched women with either mechanical factor or severe male factor infertility.

RESULTS

Both groups were comparable in their basic characteristics. Overall, women with unexplained infertility presented with inferior ovarian reserve results set against women of the control group. The number of ≥ 14-mm follicles on the day of hCG administration was significantly lower in the study compared with the control group (7.0 ± 4.5 vs. 10.4 ± 4.1 follicles, respectively, P < 0.001). Likewise, basal serum FSH was higher in the study compared with the control group (8.4 ± 5.5 vs. 6.4 ± 1.7 IU/L, respectively, P = 0.015), while antral follicle count was lower (10.9 ± 6.6 vs. 16.2 ± 6.6 follicles, respectively, P < 0.001). Furthermore, women with unexplained infertility required a higher total dose of FSH for ovarian stimulation (2,923 ± 1,701 vs. 2,196 ± 941 IU/L, respectively, P = 0.010), but exhibited a lower number of retrieved oocytes (9.3 ± 6.3 vs. 15.6 ± 7.9 oocytes, respectively, P < 0.001), alongside a lower number of achieved embryos (5.3 ± 4.0 vs. 8.0 ± 4.7 embryos, respectively, P = 0.002). Interestingly, the cumulative clinical pregnancy rate was not significantly different between the two groups (44% vs. 58%, respectively, P = 0.163).

CONCLUSIONS

Young women ≤ 37 years of age with unexplained infertility have clear manifestations of sub-optimal ovarian reserve set against controls. Our findings suggest that unexplained infertility at a young age may be a risk factor for developing poor ovarian response, specifically as a quantitative, rather than a qualitative, risk factor.

The pregnancy outcomes of intrauterine insemination with husband's sperm in natural cycles versus ovulation stimulated cycles: A retrospective study

To compare the clinical outcomes of intrauterine insemination (IUI) with or without ovulation induction (OI), IUI cycles from January 2008 to December 2017 in Zhoushan Maternity and Child Healthcare Hospital were included, consisting of 455 natural cycles and 536 OI cycles. The overall clinical pregnancy rate did not differ between the two groups (P > 0.05). Stratified by OI medications such as clomiphene (CC), human menopausal gonadotropin (HMG) and follicle stimulating hormone (FSH), the pregnancy rates in HMG, CC, CC+HMG, and FSH/FSH+HMG groups were 11.70%, 13.58%, 15.95%, and 13.46%, respectively, but the difference was not significant compared with natural cycles (P > 0.05). Stratified by infertility etiology, the pregnancy rate was significantly higher in stimulated cycles than natural cycles with ovulation disorders (P < 0.01) and unexplained factors (P < 0.01) while it was significantly lower regarding cervical factors (P < 0.01), endometriosis (P < 0.05), male factor (P < 0.01) and other female factors. There was no strong difference of pregnancy rate for biparental causes (P > 0.05). Stratified by age category, women over 35 had higher pregnancy rate in stimulated cycles compared with natural cycles (18.75 vs. 12.24%; P < 0.05), while women under 35 had no significant difference of pregnancy rate between the two groups (13.65 vs 13.05%; P > 0.05). However, there was no significant difference between each ovarian stimulation group and natural cycle group regardless of the infertility causes or age categories. To conclude, IUI-OI could achieve a higher overall pregnancy rate for women over 35 and infertile patients with ovulation disorders and unexplained factors.

Fertility preservation in women harboring deleterious BRCA mutations: ready for prime time?

Fertility issues have become critical in the management and counseling of BRCA mutation carriers. In this setting four points deserve consideration. (1) Women in general lose their ability to conceive at a mean age of 41 years, thus the suggested policy of prophylactic bilateral salpingo-oophorectomy at age 40 for BRCA mutation carriers does not affect the chances of natural pregnancy. Conversely, if the procedure is chosen at 35 years old, oocyte cryopreservation prior to surgery should be considered. (2) Some evidence suggests that ovarian reserve may actually be partly reduced in BRCA mutations carriers and that the mutation may affect ovarian responsiveness to stimulation. However, these findings are still controversial. (3) Breast cancer is not rare before the age of 40 and fertility preservation after diagnosis can be requested in a significant proportion of BRCA mutation carriers. Thus, a policy of oocyte cryopreservation in young healthy carriers deserves consideration. The procedure could be considered at a young age and in an elective setting, when ovarian stimulation may yield more oocytes of better quality. (4) Preimplantation genetic diagnosis (PGD) could be considered in BRCA mutations carriers, particularly when good quality oocytes have been stored at a young age. Based on the current knowledge, a univocal approach cannot be recommended; in depth patient counseling is warranted.

Mitochondrial DNA copy number in peripheral blood: a potential non-invasive biomarker for female subfertility

PURPOSE

Low mitochondrial DNA (mtDNA) content in oocytes and in cumulus cells is an indicator of poor oocyte quality. Moreover, initial evidence showed a correlation between mtDNA content in cumulus cells and mtDNA copy number in peripheral blood cells. On these bases, we deemed of interest investigating the correlation between mtDNA copy number in peripheral blood and natural fecundity.

METHODS

This is a nested case-control study drawn from a prospective cohort of pregnant women referred for routine first trimester screening for aneuploidies (from 11 + 0 to 12 + 6 weeks of gestation) between January 2012 and March 2013 at the "Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico" of Milan, Italy. Cases were subfertile women who attempted to become pregnant for 12-24 months. Controls were the two subsequently age-matched women who became pregnant in less than 1 year. MtDNA was quantified using real-time PCR and normalized to nuclear DNA.

RESULTS

One hundred and four subfertile women and 208 controls were selected. The median (IQR) mtDNA copy number was 95 (73-124) and 145 (106-198), respectively (p < 0.001). The area under the ROC curve was 0.73 (95% CI 0.67-0.79) (p < 0.001). The Youden index was 105 mtDNA copy number. The crude OR for subfertility in women with mtDNA copy number below this threshold was 5.72 (95% CI 3.43-9.55). The accuracy of mtDNA copy number assessment in peripheral blood progressively decreased with increasing female age.

CONCLUSIONS

Low mtDNA copy number in peripheral blood is associated with an increased risk of subfertility and may represent a biomarker of natural fecundity.

A prognosis-based approach to infertility: understanding the role of time

The current definition of infertility acknowledges the importance of duration of pregnancy seeking but fails to recognize the prevalent negative impact of female age. In fact, the diagnosis of unexplained infertility increases with women's age because of our incapacity to discern between age-related infertility and real unexplained infertility. Physicians' response to the pressures of increased female age has been to take prompt refuge in assisted reproduction despite the lack of robust evidence and the inherent risks and costs of these procedures. Moreover, the prioritization of immediate health gains over those in the future, preference for accessing active treatment rapidly and reluctance to wait for spontaneous pregnancy expose patients to additional risks of overtreatment. Solutions are not simple to find but an alternative and innovative vision of infertility based on prognosis may be a valid solution. The availability of validated dynamic models based on real-life data that could predict both natural and ART-mediated conceptions may be of benefit. They could facilitate patients' counselling and could optimize the chances of success without exposing patients to unnecessary, expensive and demanding treatments.

Putative human sperm Interactome: a networks study

Background

For over sixty years, it has been known that mammalian spermatozoa immediately after ejaculation are virtually infertile. They became able to fertilize only after they reside for long time (hours to days) within female genital tract where they complete their functional maturation, the capacitation. This process is finely regulated by the interaction with the female environment and involves, in spermatozoa, a myriad of molecules as messengers and target of signals. Since, to date, a model able to represent the molecular interaction that characterize sperm physiology does not exist, we realized the Human Sperm Interactme Network3.0 (HSIN3.0) and its main component (HSNI3.0_MC), starting from the pathway active in male germ cells.

Results

HSIN3.0 and HSIN3.0_MC are scale free networks, adherent to the Barabasi-Albert model, and are characterised by an ultra-small world topology. We found that they are resistant to random attacks and that are designed to respond quickly and specifically to external inputs. In addition, it has been possible to identify the most connected nodes (the hubs) and the bottlenecks nodes. This result allowed us to explore the control mechanisms active in driving sperm biochemical machinery and to verify the different levels of controls: party vs. date hubs and hubs vs. bottlenecks, thanks the availability of data from KO mice. Finally, we found that several key nodes represent molecules specifically involved in function that are thought to be not present or not active in sperm cells, such as control of cell cycle, proteins synthesis, nuclear trafficking, and immune response, thus potentially open new perspectives on the study of sperm biology.

Conclusions

For the first time we present a network representing putative human sperm interactome. This result gives very intriguing biological information and could contribute to the knowledge of spermatozoa, either in physiological or pathological conditions.

Electronic supplementary material

The online version of this article (10.1186/s12918-018-0578-6) contains supplementary material, which is available to authorized users.

Conditional loss of hepatocellular Hedgehog signaling in female mice leads to the persistence of hepatic steroidogenesis, androgenization and infertility

The Hedgehog signaling pathway is known to be involved in embryogenesis, tissue remodeling, and carcinogenesis. Because of its involvement in carcinogenesis, it seems an interesting target for cancer therapy. Indeed, Sonidegib, an approved inhibitor of the Hedgehog receptor Smoothened (Smo), is highly active against diverse carcinomas, but its use is also reported to be associated with several systemic side effects. Our former work in adult mice demonstrated hepatic Hedgehog signaling to play a key role in the insulin-like growth factor axis and lipid metabolism. The current work using mice with an embryonic and hepatocyte-specific Smo deletion describes an adverse impact of the hepatic Hedgehog pathway on female fertility. In female SAC-KO mice, we detected androgenization characterized by a 3.3-fold increase in testosterone at 12 weeks of age based on an impressive induction of steroidogenic gene expression in hepatocytes, but not in the classic steroidogenic organs (ovary and adrenal gland). Along with the elevated level of testosterone, the female SAC-KO mice showed infertility characterized by juvenile reproductive organs and acyclicity. The endocrine and reproductive alterations resembled polycystic ovarian syndrome and could be confirmed in a second mouse model with conditional deletion of Smo at 8 weeks of age after an extended period of 8 months. We conclude that the down-regulation of hepatic Hedgehog signaling leads to an impaired hormonal balance by the induction of steroidogenesis in the liver. These effects of Hedgehog signaling inhibition should be considered when using Hedgehog inhibitors as anti-cancer drugs.