Defining ovarian reserve to better understand ovarian aging

Understanding oocyte ageing

Females are born with a finite and non-renewable reservoir of oocytes, which therefore decline both in number and quality with advancing age. A striking characteristic of oocyte quality is that "ageing" effects manifest whilst women are in their thirties and are therefore still chronologically and physically young. Furthermore, this decline is unrelenting and not modifiable to any great extent by lifestyle or diet. Since oocyte quality is rate-limiting for pregnancy success, as the proportion of good-quality oocytes progressively deteriorate, the chance of successful pregnancy during each 6-12-month period also decreases, becoming exponential after 37 years. Unlike oocyte quality, age-related attrition in the size of the ovarian reservoir is less impactful for natural fertility since only one mature oocyte is typically ovulated per menstrual cycle. In contrast, oocyte numbers are pivotal for in-vitro fertilization success, since larger numbers enable better-quality oocytes to be found and is important for buffering the inefficiencies of the IVF process. The ageing trajectory is accelerated in ~10% of women, so-called premature ovarian ageing, with ~1% of women at the extreme end of this spectrum with loss of ovarian function occurring before 40 years of age, termed premature ovarian insufficiency. The aim of this review was to analyze how ageing impacts the size and quality of the oocyte pool along with emerging interventions for combating low oocyte numbers and improving quality.

The Reproductive Lifespan of Ovarian Follicle

The functional unit within mammalian ovaries is the ovarian follicle. The development of the ovarian follicle is a lengthy process beginning from the time of embryogenesis, passing through multiple different stages of maturation. The purpose of this review is to describe the most basic events in the journey of ovarian follicle development, discussing the importance of ovarian reserve and highlighting the role of several factors that affect oocyte quality and quantity during aging including hormonal, genetic and epigenetic factors. Novel, promising anti-aging strategies are also discussed.

Cuproptosis-Related Gene FDX1 Identified as a Potential Target for Human Ovarian Aging

Cuproptosis is a recently discovered mode of cell death that has garnered attention due to its association with various diseases. However, the intricate genetic relationship between cuproptosis and ovarian aging has remained largely unexplored. This study aimed to bridge this knowledge gap by leveraging data sets related to ovarian aging and cuproptosis. Through comprehensive bioinformatics analyses, facilitated by R software, we uncovered FDX1 as a potential cuproptosis-related gene with relevance to ovarian aging. To gain insights into FDX1's role, we conducted spatial transcriptome analyses in the ovaries of both young and aged female mice. These experiments revealed a significant reduction in FDX1 expression in the aging group compared to the young group. To substantiate these findings at the genetic level, we turned to clinical infertility biopsies. Impressively, we observed consistent results in biopsies from elderly infertile patients, reinforcing the link between FDX1 and ovarian aging. Moreover, we delved into the pharmacogenomics of ovarian cell lines and discovered that FDX1 expression levels were intricately associated with heightened sensitivity to specific small molecule drugs. This observation suggests that modulating FDX1 could potentially be a strategy to influence drug responses in ovarian-related therapies. In sum, this study marks a pioneering effort in identifying FDX1 as a cuproptosis-related gene implicated in ovarian aging. These findings hold substantial promise, not only in shedding light on the underlying mechanisms of ovarian aging but also in positioning FDX1 as a potential diagnostic biomarker and therapeutic target. With further research, FDX1 could play a pivotal role in advancing precision medicine and therapies for ovarian-related conditions.

A phenomenological exploration of the mental health experiences of young women with diminished ovarian reserve

Infertility is a reproductive disease affecting one in six individuals that renders an individual unable to conceive. One cause of infertility is diminished ovarian reserve (DOR), which reduces the quantity and/or quality of a female's oocyte pool. Although typically indicating normal ovarian aging during the late 30s and early 40s, DOR can also impact younger women, increasing their risk for psychological distress from an unexpected diagnosis of infertility. A phenomenological approach examined the mental health experiences and perceptions of infertility-related mental health care of young women with DOR. Women diagnosed with DOR by age 35 in the United States who experienced emotional distress during infertility were recruited from infertility-specific social media and via snowball sampling. Participants completed a demographic survey and semi-structured individual interview that was audio-recorded, transcribed verbatim, and analyzed using a phenomenological approach. Ten women ages 27-41 completed the study. On average, participants were 30 years of age at the time of DOR diagnosis (age range 25-35), primarily Caucasian (90%), and married (90%). Two main themes were found: (1) Young women with DOR feel like a "forgotten community" coping with an invisible disease; and (2) Not all fertility clinics are created equal. Participants perceived their diagnosis as devastating and hopeless and urged others to find a provider with ample experience treating patients with DOR. This study helped to understand how young women with DOR perceive their mental health and identified a significant need for advancing towards more holistic infertility healthcare that encompasses both physical and mental health.

Risk factors associated with changes in serum anti-Müllerian hormone levels before and after laparoscopic cystectomy for endometrioma

Background

The objective of our study was to investigate the risk factors for a decrease in ovarian reserve in patients with endometriomas after standardized laparoscopic procedures and evaluation to provide corresponding clinical guidance for patients with fertility requirements.

Methods

Anti-Müllerian hormone (AMH) levels and other clinical data from 233 patients with endometriomas and 57 patients with non-endometrioma ovarian cysts admitted to the Peking Union Medical College Hospital between January 2018 and September 2023 were prospectively analysed. The pretreatment AMH levels of the study groups were compared to assess the impact of endometrioma on ovarian reserve, and the decrease in AMH after treatment was analysed to determine potential risk factors contributing to this change.

Results

Pretreatment AMH levels did not significantly differ between patients with endometriomas and those with non-endometrioma ovarian cysts. Within the endometrioma group, older age, higher body mass index (BMI), and shorter menstrual cycles were found to be associated with decreased AMH levels prior to treatment (p<0.05). Participants presenting with bilateral cysts, advanced surgical staging, or a completely enclosed Douglas pouch demonstrated significantly lower levels of AMH prior to treatment compared to those without these conditions (p<0.05). Furthermore, their AMH levels further declined within one year after undergoing laparoscopic cystectomy (p<0.05). However, there was no difference in AMH levels after surgery between patients who successfully became pregnant and those who did not (p>0.05).

Conclusion

Laparoscopic removal of endometriomas can adversely affect ovarian reserve, especially during bilateral cysts removal and when patients are diagnosed as having a higher stage of endometriosis, further impacting ovarian function. It should be noted that a decrease in AMH levels may not necessarily indicate an absolute decline in fertility. Therefore, it is crucial to conduct thorough patient evaluations and provide comprehensive patient education to offer appropriate guidance for fertility preservation.

Impact of endometriosis on the ovarian follicles

A significant body of evidence has supported a negative impact of endometriosis on ovarian follicles; however, the origin and relevance of this ovarian impairment in endometriosis is still a matter of debate. The ovarian damage can be caused by endometriosis itself or by surgeries aiming to remove endometriotic lesions. In this review, we summarized the existing knowledge on the mechanisms by which endometriosis can impact the ovarian follicles, from molecular to clinical points of view. From a molecular standpoint, the presence of endometriosis or its consequences can induce oxidative stress, inflammation, aberrant mitochondrial energy metabolism and inappropriate steroid production in granulosa cells, phenomena that may impair the quality of oocytes to variable degrees. These alterations may have clinical relevance on the accelerated exhaustion of the ovarian reserve, on the ovarian response to gonadotrophin stimulation in IVF cycles and on the competence of the oocytes. Critical points to be considered in current clinical practices related to fertility issues in endometriosis are discussed.

A Systematic Review of Genetics and Reproductive Health Outcomes: Asian Perspective

In the last four decades, advances in assisted reproductive technology (ART) have offered hope to individuals with fertility problems to conceive. However, a closer examination of the clinical outcomes of ART shows a stark contrast in Asian women compared to Caucasians, with majority of studies reporting lower reproductive success among Asian women. We performed a systematic review to elucidate the genes associated with ART clinical outcomes, with a focus on Asian ethnicities. We completed a database search to identify all studies associated with reproductive outcomes in women of different ethnic backgrounds. Following PRISMA, 128 studies were analyzed. Pathway analysis of gene sets was done using Cytoscapev3.4.0. We observed that age at menarche (AAM) was correlated with the timing of the first pregnancy, with Hawaiians having the lowest age (22.2 years) and Japanese the highest age (25.0 years). LIN28 mutations were associated with AAM and prevalent in both Chinese and American populations. FMR1 was most associated with ovarian reserve. Network analysis highlighted a close association between FMR1, FSHR, ESR1, BMP15, and INHA, through biological functions affecting menstrual cycle and hypothalamic-pituitary axis and therefore ovarian follicle development. Leveraging these findings, we propose the development of a personalized, ethnic-specific biomarker panel which would enhance patient stratification to address every woman's unique reproductive potential.

New insights into the role of LH in early ovarian follicular growth: a possible tool to optimize follicular recruitment

Evidence shows that LH participates in enhancing transition from the early stage to the antral stage of folliculogenesis. It has been demonstrated that functional LH receptors are expressed, albeit at a very low level and even in smaller follicles, during the phase that was traditionally considered to be gonadotrophin independent, suggesting a role for LH in accelerating the rate of progression of non-growing and primary follicles to the preantral/antral stage. Hypogonadotropic hypogonadism, together with other clinical conditions of pituitary suppression, has been associated with reduced functional ovarian reserve. The reduction in LH serum concentration is associated with a low concentration of anti-Müllerian hormone. This is the case in hypothalamic amenorrhoea, pregnancy, long-term GnRH-analogue therapy and hormonal contraception. The effect seems to be reversible, such that after pregnancy and after discontinuation of drugs, the functional ovarian reserve returns to the baseline level. Evidence suggests that women with similar primordial follicle reserves could present with different numbers of antral follicles, and that gonadotrophins may play a fundamental role in permitting a normal rate of progression of follicles through non-cyclic folliculogenesis. The precise role of gonadotrophins in early folliculogenesis, as well as their use to modify the functional ovarian reserve, must be investigated.

Effect of actinomycin D on ovarian reserve in low-risk gestational trophoblastic neoplasia

OBJECTIVE

This study aimed to explore the single-agent chemotherapy actinomycin D on ovarian reserve by measuring the anti-Mullerian hormone (AMH) levels before, during, and after chemotherapy.

METHODS

This study recruited premenopausal women aged 15 to 45 with a newly diagnosed low-risk gestational trophoblastic neoplasia needing actinomycin D. AMH was measured at baseline, during chemotherapy, and 1, 3, and 6 months after the last chemotherapy. The reproductive outcomes were also documented.

RESULTS

Of the 42 women recruited, we analyzed 37 (median: 29 years; range 19-45) with a complete dataset. The follow-up was 36 months (range 34-39). Actinomycin D significantly decreased AMH concentrations during treatment, from 2.38±0.92 ng/mL to 1.02±0.96 ng/mL (p<0.05). Partial recovery was seen at 1 month and 3 months after treatment. Full recovery was reached 6 months after treatment among patients younger than 35 years. The only factor correlated with the extent of AMH reduction at 3 months was age (r=0.447, p<0.05). Notably, the number of courses of actinomycin D was not associated with the extent of AMH reduction. A total of 18 (90%) of 20 patients who had a desire to conceive had live births with no adverse pregnancy outcomes.

CONCLUSION

Actinomycin D has a transient and minor effect on ovarian function. Age is the only factor that impacts the patient's rate of recovery. Patients will achieve favorable reproductive outcomes after actinomycin D treatment.

Associations between Residential Greenspace and Fecundability in a North American Preconception Cohort Study

BACKGROUND

Residential green space can have positive physiological effects on human health through various mechanisms, including reducing stress and/or depression or facilitating physical activity. Although green space has been consistently associated with improved birth outcomes in several studies, there has been limited study of its effect on other reproductive outcomes, including fertility.

OBJECTIVE

We examined associations between residential green space and fecundability, the per-cycle probability of conception.

METHODS

We analyzed data from 8,563 female participants enrolled between 2013 and 2019 in Pregnancy Study Online (PRESTO), a prospective preconception cohort study of North American couples attempting conception. Participants completed a baseline questionnaire on sociodemographic, behavioral, and reproductive factors, and bimonthly follow-up questionnaires for up to 12 months to ascertain pregnancies. Using geocoded addresses, we calculated residential green space exposure using the Normalized Difference Vegetation Index (NDVI) within 50-, 100-, 250-, and 500 -m buffers across multiple temporal scales: annual maximum, seasonal maximum, and seasonal mean. We used proportional probabilities regression models to estimate fecundability ratios (FRs), adjusting for sociodemographic, behavioral, and neighborhood characteristics. We also evaluated the extent to which associations were mediated by reductions in perceived stress or depressive symptoms and increased physical activity.

RESULTS

When comparing the highest (≥ 0.8 ) with the lowest (< 0.2 ) NDVI exposures within 50 m , we observed positive associations in the annual maximum NDVI [FR: 1.33; 95% confidence interval (CI): 1.06, 1.67] and seasonal maximum NDVI (FR: 1.19; 95% CI: 1.00, 1.41) models, but little association in the seasonal mean NDVI models (FR: 0.98; 95% CI: 0.73, 1.30). Restricted cubic splines showed evidence of nonlinearity in this association. Results were similar across buffer distances. Perceived stress, depressive symptoms, and physical activity explained ≤ 5 : 0 % of mediation across all NDVI metrics.

DISCUSSION

In this cohort, greater residential green space was associated with a modest increase in fecundability. https://doi.org/10.1289/EHP10648.

Female Reproductive Aging and Oxidative Stress: Mesenchymal Stem Cell Conditioned Medium as a Promising Antioxidant

The recent tendency to delay pregnancy has increased the incidence of age-related infertility, as female reproductive competence decreases with aging. Along with aging, a lowered capacity of antioxidant defense causes a loss of normal function in the ovaries and uterus due to oxidative damage. Therefore, advancements have been made in assisted reproduction to resolve infertility caused by reproductive aging and oxidative stress, following an emphasis on their use. The application of mesenchymal stem cells (MSCs) with intensive antioxidative properties has been extensively validated as a regenerative therapy, and proceeding from original cell therapy, the therapeutic effects of stem cell conditioned medium (CM) containing paracrine factors secreted during cell culture have been reported to be as effective as that of direct treatment of source cells. In this review, we summarized the current understanding of female reproductive aging and oxidative stress and present MSC-CM, which could be developed as a promising antioxidant intervention for assisted reproductive technology.

Ovarian Morphometric and Histologic Characteristics and Correlation with Clinical Factors: A Cross-Sectional Study

Reproductive lifespan is determined by the reserve of ovarian follicles; their quality and quality determine the fertility potential at a given point in time for a particular individual. Inter-individual variations related to morphometry, laterality, medical history, demographic characteristics and ethnicity may impact ovarian histology, which however, has not been extensively studied or documented. The present cross-sectional study aims to investigate the potential association of clinical factors (age, medical and obstetric history) with ovarian morphometry and histology in females of reproductive age in the local population. The sample included 31 specimens of whole human ovaries, obtained from surgical/autopsy procedures in reproductive-aged women, processed at the Pathology Department. Morphometric characteristics were assessed, including shape, color, length, width, thickness and gross ovarian pathology. Random samples of specific dimensions were histologically examined to determine follicular counts. The results were analyzed statistically in correlation to morphometric characteristics and medical history. The majority of the patients had oval-shaped ovaries (77.8% right; 92.3% left; p = 0.368) of whitish color (38.9% right; 46.2% left; p > 0.999). Right ovaries had significantly greater length, width and volume (p-values 0.018, 0.040 and 0.050, respectively). Thickness was equivalent, as well as follicular distribution of all classes. Age correlated inversely with ovarian volume and primordial/primary follicular count on histology. Women with a caesarian-section history yielded significantly lower primordial/primary follicular counts. As estimated by ovarian histology, macroscopic and clinical factors may be significantly associated with actual ovarian reserve.

Impacts of endometrioma on ovarian aging from basic science to clinical management

Endometriosis is a common reproductive disorder characterized by the presence of endometrial implants outside of the uterus. It affects ~1 in 10 women of reproductive age. Endometriosis in the ovary, also known as endometrioma (OMA), is the most frequent implantation site and the leading cause of reproductive failure in affected women. Ovarian aging is one of the characteristic features of OMA, however its underlying mechanism yet to be determined. Accumulated evidence has shown that pelvic and local microenvironments in women with OMA are manifested, causing detrimental effects on ovarian development and functions. Whilst clinical associations of OMA with poor ovarian reserve, premature ovarian insufficiency, and early menopause have been reported. Moreover, surgical ablation, fenestration, and cystectomy of OMA can further damage the normal ovarian reservoir, and trigger hyperactivation of primordial follicles, subsequently resulting in the undesired deterioration of ovarian functions. Nevertheless, there is no effective treatment to delay or restore ovarian aging. This review comprehensively summarised the pathogenesis and study hypothesis of ovarian aging caused by OMA in order to propose potential therapeutic targets and interventions for future studies.

Unraveling female reproductive senescence to enhance healthy longevity

In a society where women often want successful careers and equal opportunities to men, the early nature of ovarian aging often forces women to make difficult life choices between career and family development. Fertility in women begins to decline after the age of 37 years and it is rare for pregnancies to occur after 45. This reproductive decline in women is inevitable and culminates in menopause, which is a major driver of age-related diseases. In a world where biomedical advances are leading to modifiable biological outcomes, it is time to focus on mitigating female reproductive senescence to maintain fertility and preserve age-related hormonal functions, with the goal of providing increased life choices and enhancing healthspan. To date, reproductive longevity research remains an understudied field. More needs to be done to unravel the biology of the ovarian follicles, which are the functional units of reproductive lifespan and are comprised of cell types including the oocyte (female gamete) and a group of specialized supporting somatic cells. Biological attempts to maintain the quality and quantity of follicles in animal models through manipulating pathways involved in aging can potentially prolong female reproductive lifespan and healthspan. Here, we summarize the molecular events driving ovarian aging and menopause and the interventional strategies to offset these events. Developing solutions to female reproductive senescence will open doors to discover ways to enhance true healthy longevity for both men and women.

Influence of Diminished Ovarian Reserve on Early Embryo Morphokinetics during In Vitro Fertilization: A Time-Lapse Study

There is great controversy as to whether women with Diminished Ovarian Reserve (DOR) exhibit only a quantitative decrease in ovarian reserve or also impaired oocyte and embryo quality. In this retrospective study, we aimed to evaluate the impact of DOR on embryo morphokinetic parameters with a time-lapse system. 1314 embryos were obtained from 256 couples undergoing IVF or ICSI cycles, with 242 embryos in the DOR group as classified by the Bologna and POSEIDON criteria and 1072 embryos derived from the Normal Ovarian Reserve (NOR) group. For each morphokinetic parameter (t2, t3, t4, t5, t8, tB, ECC2, cc2a, ECC3, s2, s3), a generalized linear mixed model was created to control for female age, BMI, smoking status, method of insemination and correlation between oocytes from a same cohort. No significant association was found between DOR and any of the morphokinetic parameters studied. In a secondary analysis, we evaluated the influence of maternal aging, comparing morphokinetic characteristics between two age groups (<37 and ≥37 years). In the univariate analysis, we found that embryos from older women displayed a slower embryo development (in particular for t3, t4, t5, tB, and ECC2), although without statistical significance in the multivariate analysis. In conclusion, our study did not reveal any substantial impact of ovarian aging on early morphokinetic parameters and suggested potential biases that may be a source of controversy in the literature.

Endometriosis-associated infertility: From pathophysiology to tailored treatment

Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.

Extended LH administration as a strategy to increase the pool of recruitable antral follicles in hypothalamic amenorrhea: evidence from a case series

New evidence is indicating a growing role of LH in promoting ovarian follicular growth and maturation, even at the early stages. LH seems to enhance the transition of follicles to the antral stage hence leading to an increase in the so-called functional ovarian reserve (recruitable antral follicles). Hypogonadotropic hypogonadism is characterized by low, and sometimes undetectable, serum LH and FSH levels, which may indeed explain the low anti-Müllerian hormone (AMH) levels and antral follicle count (AFC) found in patients affected by this condition. We report here the cases of two young women affected by hypothalamic amenorrhea (HA) that presented for fertility treatment with very low functional ovarian reserve. The two patients were treated with exogenous LH for 1 and 2 months (extended LH administration: ELHA) at the dose of 187.5 IU LH every day and 150 IU LH every other day, respectively. In both the cases there was an increase in serum AMH levels and in the AFC. In one patient, the AMH and AFC increased from a baseline 1.3 ng/ml and 8 to 2.3 ng/ml and 14 at end of treatment, respectively. In the second case, serum AMH and AFC increased from 0.4 ng/ml and 6 to 1.6 ng/ml and 13, respectively. One patient underwent ovarian stimulation before and after ELHA, showing an increase in the number of mature oocytes recruited (3 versus 8 metaphase II (MII) oocytes before and after, respectively). The second patient underwent an IVF cycle after ELHA resulting in the retrieval of six MII oocytes and an ongoing pregnancy following transfer of a single blastocyst. Women with HA are characterized by chronic, low levels of gonadotrophins, which may impact not only on the cyclic recruitment of follicles but also the progression of small growing follicles through the first stages of folliculogenesis. Some women with HA may in fact show very low serum AMH and AFC. Our case series shows that the administration of LH at a dose of at least 150–187.5 IU every day or every other day may contribute to a clinically evident increase in the functional ovarian reserve (AFC), and probably accounts for a positive effect of LH on the progression of follicles throughout the early stages of folliculogenesis.

Variation in Anti-Mullerian Hormone Levels with Age in Women Accessing In Vitro Fertilization Services in Ghana

Background: The emergence of AMH as a reliable biomarker for assessing ovarian reserve and optimization of assisted reproductive technology (ART) remains a promising tool for the evaluation and prediction of controlled ovarian stimulation (COS) outcomes. This study assessed the association between serum AMH levels and maternal age in females receiving in vitro fertilization (IVF) treatment in Ghana. Methods: We conducted a prospective cohort study at a specialized fertility center in Ghana. Descriptive analysis was performed, and the differences between maternal age and AMH categories were assessed by the Kruskal–Wallis test. Results: We included 426 women with mean (±SD) age and AMH levels of 35.25 ± 6.33 years and 2.80 ± 2.60 ng/mL, respectively. Women with very-low AMH levels (0.94 ± 73 ng/mL) were older (>40 years), whereas the younger (20–25 years) group had higher levels (4.85 ± 3.34 ng/mL). There was a significant negative correlation between women’s age and serum AMH levels (R = −0.46; p < 0.001). None of the younger women had AMH levels <0.30 ng/mL, while 70% of women who had AMH levels of <0.30 ng/mL were older women (>40years). In addition, none of the older women had AMH levels >4 ng/mL with only 5% having AMH levels between 2.20 and 4.0 ng/mL. Conclusions: AMH levels ≤0.3 ng/mL are archetypal of 70% of Ghanaian women >40 years old receiving fertility treatment. A combined assessment of AMH levels and age supports clinical decisions in predicting ovarian response to controlled ovarian stimulation (COS) and may be valuable in predicting of IVF success. Further research to evaluate the combined use of age, AMH, and other ovarian reserve markers in assessing ovarian response to COS is recommended.

Poor ovarian response is associated with air pollutants: A multicentre study in China

Background

Human evidence on the association between air pollution and ovarian response is scarce. Poor ovarian response (POR) with an incidence of 5–35% is a tricky problem in IVF treatment.

Methods

In this large-scale multicentre study, we included 2186 women with POR (< 4 oocytes retrieved) and 7033 women with a normal ovarian response (10–15 oocytes retrieved), who underwent their first in vitro fertilization treatment in five cities in northern China during 2015–2020. Average concentrations of six air pollutants (PM_2.5, PM₁₀, O₃, NO₂, CO, and SO₂) during different exposure windows (5 days, 1, 3, 6, and 12 months) before oocyte pick up (OPU) were calculated using data from the air monitoring station nearest to the residential site as approximate individual exposure. Logistic regression models were employed to assess the association between exposure to air pollutants and the risk of POR. Stratification analyses were conducted based on female age. Sensitivity analyses were performed in poor responders identified by Bologna criteria and women with unexpected POR.

Findings

We detected that increased SO₂ exposure during all exposure windows before OPU was associated with a higher risk of POR, especially for women ≤ 30 years old. In the stratified analysis, the effect sizes were larger for the unexpected poor ovarian response.

Interpretation

The findings provide human evidence for adverse effects of exposure to ambient air pollutants on ovarian response and underscore the need to reduce ambient air pollution exposure in women of reproductive age to protect human fertility.

Funding

This study was granted from the National Key Research and Development Program (2018YFC1004203), the Major Special Construction Plan for Discipline Construction Project of China Medical University (3110118033), the Shengjing Freelance Researcher Plan of Shengjing Hospital of China Medical University, and the National Natural Science Foundation of China (82071601), the Central Government Special Fund for Local Science and Technology Development (2020JH6/10500006).

Preliminary report of intraovarian injections of autologous platelet-rich plasma (PRP) in extremely poor prognosis patients with only oocyte donation as alternative: a prospective cohort study

STUDY QUESTION

Does intraovarian injection of platelet-rich plasma (PRP) change ovarian function in patients with extremely low functional ovarian reserve (LFOR) who, otherwise, would likely only have a chance of pregnancy through third-party oocyte donation?

SUMMARY ANSWER

No clinically significant effects of PRP treatment on ovarian function were observed over 1 year of follow-up.

WHAT IS KNOWN ALREADY

Several investigators have reported improved responses to ovulation induction after treatment with PRP. However, previous published reports have involved, at most, only small case series. Whether PRP actually improves ovarian performance is, therefore, still unknown. PRP is nevertheless widely offered as an ‘established’ fertility treatment, often under the term ‘ovarian rejuvenation’.

STUDY DESIGN, SIZE, DURATION

We are reporting a prospective cohort study of 80 consecutive patients at ages 28–54 with LFOR, defined by anti-Müllerian hormone &lt;1.1 ng/ml, FSH &gt;12 mIU/ml or at least one prior IVF cycle with ≤3 oocytes within 1 year. The women were followed for 1 year after an intraovarian PRP procedure.

PARTICIPANTS/MATERIALS, SETTING, METHODS

PRP (1.5 ml) was injected into the cortex of ovaries with an average of 12 injections per ovary. Study participants were followed every 3 days for 2 weeks after PRP treatment with estradiol and FSH measurements and vaginal ultrasound to observe follicle growth and thereafter followed weekly. Beginning 1 month after their PRP treatment, participants underwent one or more cycles of ovarian stimulation for IVF. Outcome measures were endocrine response, and numbers of oocytes and embryos produced in response to a maximal gonadotropin stimulation before and after PRP treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

In this study, women failed to demonstrate statistically significant outcome benefits from intraovarian PRP. However, two 40-year-old very poor-prognosis patients, with prior failed IVF cycles that never reached embryo transfer at other centers, achieved pregnancy, resulting in an ongoing pregnancy rate of 4.7% among patients who, following PRP, produced at least one oocyte (n = 42).

LIMITATIONS, REASONS FOR CAUTION

As an observational study of patients who performed poorly in past ovarian stimulation cycles, the improvement may be accounted for by regression to the mean. Similar considerations may also explain the occurrence of the two pregnancies.

WIDER IMPLICATIONS OF THE FINDINGS

This study demonstrates that, even in extremely poor prognosis patients due to LFOR, sporadic pregnancies are possible. The study, however, does not allow for the conclusion that those pregnancies were the consequence of PRP treatments. A case series, indeed, does not allow for such conclusions, even if results are more suggestive than here. This registered study, therefore, must be viewed as a preliminary report, with further data expected from this study but also from two other prospectively randomized ongoing registered studies with more controlled patient selection.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by intramural funds from The Center for Human Reproduction and the not-for-profit research Foundation for Reproductive Medicine, both in New York, NY, USA. N.G. and D.H.B. are listed as co-inventors on several US patents. Some of these patents relate to pre-supplementation of hypo-androgenic infertile women with androgens, such as dehydroepiandrosterone and testosterone and, therefore, at least peripherally relate to the subject of this manuscript. They, as well as D.F.A., have also received research support, travel funds and speaker honoraria from several pharmaceutical and medical device companies, though none related to the here presented subject and manuscript. N.G. is a shareholder in Fertility Nutraceuticals and he and D.H.B. receive royalty payments from Fertility Nutraceuticals LLC. E.M. has no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

NCT04275700

Deficiency of C1QL1 Reduced Murine Ovarian Follicle Reserve Through Intraovarian and Endocrine Control

Ovarian aging is associated with depletion of the ovarian follicle reserve, which is the key determinant of fertility potential in females. In this study, we found that the small, secreted protein complement 1Q-like (C1QL1) is involved in the regulation of follicle depletion through intraovarian and endocrine control in a multidimensional collaborative manner. C1ql1 was detected to be conserved in the ovary and showed high transcript levels during folliculogenesis. Blockade of C1QL1 by IP and ovarian intrabursal injection of C1QL1 antiserum into prepubertal mice impaired folliculogenesis accompanied by reductions in body weight, fat mass, and intraovarian lipid accumulation. An elevation of circulating estradiol levels, reduction of hypothalamic KISS1 and GnRH expression, and a decrease in serum FSH levels were found in C1QL1-deficient mice. In C1QL1-deficient ovaries, many primordial follicles were recruited and developed into medium follicles but underwent atresia at the large follicle stages, which resulted in depletion of follicle reserve. Depletion of C1QL1 alleviated the inhibitory effect of C1QL1 on granulosa cell apoptosis and the stimulatory effect of C1QL1 on granulosa cell autophagy, which resulted in accumulation in the preantral and early antral follicles and an increase in the atretic follicles. The abnormal profile of endocrine hormones accelerated the intraovarian effect of C1QL1 deficiency and further led to depletion of ovarian reserve. Altogether, this study revealed the expression patterns and the mechanism of action of C1QL1 during folliculogenesis and demonstrated that deficiency of C1QL1 caused ovarian follicular depletion.

Ultrastructural Evaluation of the Human Oocyte at the Germinal Vesicle Stage during the Application of Assisted Reproductive Technologies

After its discovery in 1825 by the physiologist J.E. Purkinje, the human germinal vesicle (GV) attracted the interest of scientists. Discarded after laparotomy or laparoscopic ovum pick up from the pool of retrieved mature oocytes, the leftover GV was mainly used for research purposes. After the discovery of Assisted Reproductive Technologies (ARTs) such as in vitro maturation (IVM), in vitro fertilization and embryo transfer (IVF-ET) and intracytoplasmic sperm injection (ICSI), its developing potential was explored, and recognized as an important source of germ cells, especially in the case of scarce availability of mature oocytes for pathological/clinical conditions or in the case of previous recurrent implantation failure. We here review the ultrastructural data available on GV-stage human oocytes and their application to ARTs.

Investigating the Clinical Utility of the Anti-Mullerian Hormone Testing for the Prediction of Age at Menopause and Assessment of Functional Ovarian Reserve: A Practical Approach and Recent Updates

Low ovarian reserve is a serious condition, leading to sterility in up to 10% of women in their mid-thirties. According to current knowledge, serum anti-Müllerian hormone (AMH) levels for age are the best available marker for the screening the quantity of a woman's functional ovarian reserve, better than age alone or other reproductive markers. This review summarizes recent findings, clinical utility and limitations in the application of serum AMH testing as an accurate marker for the screening of functional ovarian reserves and predicting age at menopause. AMH assessment hold promise in helping women make informed decisions about their future fertility and desired family size. However, screening of the functional ovarian reserve could be offered to all women at 26 years of age or older who seek to assess future fertility or in case of personal request, ovarian reserve screening may be considered beyond 30 years; however, it has never been advocated beyond 35 years, since it is not advisable to delay childbearing beyond this age. In this respect, an age-specific serum AMH levels lower than the 10th percentile may be used as a threshold for the identification of a low functional ovarian reserve in an individual woman. Its level should be interpreted with caution in the adolescent and young women aged below 25 years (since AMH levels peak at this age); recent users of hormonal contraceptives (since AMH levels transiently decrease until two months after discontinuation); and women with PCOS (which dramatically increases AMH levels). However, the ability of AMH levels to predict the time to menopause is promising but requires further investigation and routine AMH testing for the purposes of predicting the time to menopause is not recommended.

Anti-Müllerian Hormone in Pathogenesis, Diagnostic and Treatment of PCOS

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women. It is characterized by chronic anovulation, hyperandrogenism, and the presence of polycystic ovary in ultrasound examination. PCOS is specified by an increased number of follicles at all growing stages, mainly seen in the preantral and small antral follicles and an increased serum level of Anti-Müllerian Hormone (AMH). Because of the strong correlation between circulating AMH levels and antral follicle count on ultrasound, Anti-Müllerian Hormone has been proposed as an alternative marker of ovulatory dysfunction in PCOS. However, the results from the current literature are not homogeneous, and the specific threshold of AMH in PCOS and PCOM is, therefore, very challenging. This review aims to update the current knowledge about AMH, the pathophysiology of AMH in the pathogenesis of PCOS, and the role of Anti-Müllerian Hormone in the treatment of this syndrome.

Protective effect of small peptides from Periplaneta americana on cyclophosphamide-induced premature ovarian failure

AIM

To investigate the protective effect of small peptides from Periplaneta americana (SPPA) on cyclophosphamide (CP)-induced premature ovarian failure (POF) in mice. Silent mating type information regulation 2 homolog 1 (SIRT1) /tumor-associated protein 53 (p53) signaling pathway plays an important role in delaying POF. Hematopoietic progenitor cell antigen (CD34) reflects ovarian aging from the side. However, whether SPPA inhibits POF in mice by influencing the SIRT1/p53 pathway and CD34 expression remains to be studied.

METHODS

Forty female Kun Ming (KM) mice were divided into four groups: a control group (normal saline, n = 10), POF model group (160 mg/kg CP, n = 10), SPPA low-dosage group (160 mg/kg CP + 100 mg/kg SPPA, n = 10), and SPPA high-dosage group (160 mg/kg CP + 200 mg/kg SPPA, n = 10). CP administration route is intraperitoneal injection, and SPPA administration route is intragastric. Eyeball enucleation blood samples and the ovaries of mice were collected by midline laparatomy and oopherectomy, and the malondialdehyde (MDA), nitric oxide (NO), superoxide dismutase (SOD), follicle-stimulating hormone (FSH), and anti-Müllerian hormone (AMH) concentrations were tested. Immunohistochemical tests for the expressions of SIRT1, p53, and CD34 were carried out. Finally, ovarian mRNA levels of SIRT1 and p53 were detected with real-time fluorescence quantification PCR (qRT-PCR).

RESULTS

A mouse model of POF was generated using 160 mg/kg of CP. Compared with POF group, we found that plasma NO, MDA, and FSH decreased, while AMH and SOD increased in the SPPA low-dose group. Compared with the POF group, the SPPA low- and high-dosage groups achieved significant growth in the number of primordial, primary, and total number of healthy follicles at all levels, but sharp reductions in the number of atretic follicles. In addition, we found downregulated protein and mRNA expression of SIRT1, and upregulated that of p53 were observed in ovarian tissues of treated mice with POF, in immunohistochemistry experiments and qPCR experiments. In contrast, high protein and mRNA expression of SIRT1, and low that of p53 were observed in SPPA treatment groups. And the results of CD34 protein expression were consistent with that of SIRT1.

CONCLUSION

In total, SPPA significantly inhibited POF caused by CP in mice via activation of the SIRT1/p53 signaling pathway in the mouse ovary.

The molecular mechanisms that underlie fragile X-associated premature ovarian insufficiency: is it RNA or protein based?

The FMR1 gene contains a polymorphic CGG trinucleotide sequence within its 5′ untranslated region. More than 200 CGG repeats (termed a full mutation) underlie the severe neurodevelopmental condition fragile X syndrome, while repeat lengths that range between 55 and 200 (termed a premutation) result in the conditions fragile X-associated tremor/ataxia syndrome and fragile X-associated premature ovarian insufficiency (FXPOI). Premutations in FMR1 are the most common monogenic cause of premature ovarian insufficiency and are routinely tested for clinically; however, the mechanisms that contribute to the pathology are still largely unclear. As studies in this field move towards unravelling the molecular mechanisms involved in FXPOI aetiology, we review the evidence surrounding the two main theories which describe an RNA toxic gain-of-function mechanism, resulting in the loss of function of RNA-binding proteins, or a protein-based mechanism, where repeat-associated non-AUG translation leads to the formation of an abnormal polyglycine containing protein, called FMRpolyG.

Correlations among anti-Müllerian hormone levels, body mass index and lipid profile in reproductive-aged women: The Korea Nurses' Health Study

Aim

This study aimed to evaluate the correlations among anti‐Müllerian hormone levels, body mass index and lipid profile in female nurses of reproductive age.

Design

This is a descriptive cross‐sectional study that used data from the Korea Nurses' Health Study, based on Nurses' Health Study 3 in the United States.

Methods

Participants included 448 female nurses of reproductive age. They provided details about their work experience, shift work, body mass index and history of polycystic ovary syndrome. Serum anti‐Müllerian hormone levels and lipid profile were measured using blood samples. Statistical analysis included quantile regression analysis using STATA 13.0. Data were collected between November 2016 and March 2017 from Module 5 of the Korean Nurses' Health Study.

Results

Approximately 12% of the participants were underweight, and roughly one‐tenth were either overweight or obese. Although linear regression showed no relationship between anti‐Müllerian hormone levels and body mass index, quantile regression showed that body mass index, total cholesterol levels and low‐density lipoprotein levels were negatively correlated with anti‐Müllerian hormone levels at the lower tails of the dependent variable. Meanwhile, high‐density lipoprotein levels were positively correlated with anti‐Müllerian hormone at the higher percentiles of anti‐Müllerian hormone levels.

Conclusion

These findings suggest the possibility that changes in the lipid profile may influence anti‐Müllerian hormone levels in women with diminished ovarian function, rather than obesity itself.

Predictive value of cytoplasmic granulation patterns during in vitro fertilization in metaphase II oocytes: part II, donor oocyte cycles

OBJECTIVE

To determine whether the ooplasm granulation patterns of donor oocytes, like those of oocytes from poor-prognosis patients, are predictive of in vitro fertilization (IVF) outcomes.

DESIGN

Retrospective cohort study.

SETTING

Academically affiliated private clinical infertility and research center.

PATIENT(S)

770 fresh and 381 vitrified-thawed metaphase II oocytes from young donors (aged 21.0-34.6 years) used for IVF during 2017-2020.

INTERVENTION(S)

Determination of granulation patterns in every oocyte during intracytoplasmic sperm injection as fine, central, uneven, dispersed, and peripheral (thawed only).

MAIN OUTCOME MEASURE(S)

Fertilization, pregnancy, and live birth rates in fresh and thawed donor oocytes. Both overall and known-outcome analyses were performed for pregnancy and live birth.

RESULT(S)

In fresh donor oocytes, 2 pronuclei rates trended down from 96.1% to 90.2%, 88.9%, and 69.7% from fine to central, uneven, and dispersed granulations; overall pregnancy rates trended down from 50.4% to 29.0%, 17.7%, and 6.9%, as well as live birth rates (43.4%, 21.6%, 12.5%, and 6.4%), from fine to uneven, central, and dispersed granulations. Known pregnancy and known-live birth analyses showed similar findings. Thawed donor oocytes demonstrated similar trends in differences in fertilization, pregnancy, and live birth analyses with relatively worse outcomes. Peripheral granulation, unique to vitrification and thawing, always demonstrated the worst IVF outcomes. Moreover, granulation patterns were relatively disassociated from embryo morphological grades in fresh and largely disassociated in thawed donor oocytes.

CONCLUSION(S)

Predictive values of oocyte granulation patterns for fertilization, pregnancy, and live birth in IVF cycles are even more pronounced in young donors than results in older poor-prognosis patients, further supporting integration of oocyte granulation patterns into embryo selection.

Machine Learning-Based Approach Highlights the Use of a Genomic Variant Profile for Precision Medicine in Ovarian Failure

Ovarian failure (OF) is a common cause of infertility usually diagnosed as idiopathic, with genetic causes accounting for 10-25% of cases. Whole-exome sequencing (WES) may enable identifying contributing genes and variant profiles to stratify the population into subtypes of OF. This study sought to identify a blood-based gene variant profile using accumulation of rare variants to promote precision medicine in fertility preservation programs. A case-control (n = 118, n = 32, respectively) WES study was performed in which only non-synonymous rare variants <5% minor allele frequency (MAF; in the IGSR) and coverage ≥ 100× were considered. A profile of 66 variants of uncertain significance was used for training an unsupervised machine learning model to separate cases from controls (97.2% sensitivity, 99.2% specificity) and stratify the population into two subtypes of OF (A and B) (93.31% sensitivity, 96.67% specificity). Model testing within the IGSR female population predicted 0.5% of women as subtype A and 2.4% as subtype B. This is the first study linking OF to the accumulation of rare variants and generates a new potential taxonomy supporting application of this approach for precision medicine in fertility preservation.

The influence of fine particulate matter on the association between residential greenness and ovarian reserve

BACKGROUND

Natural vegetation, or greenness, is thought to improve health through its ability to buffer and reduce harmful environmental exposures as well as relieve stress, promote physical activity, restore attention, and increase social cohesion. In concert, these effects could help mitigate the detrimental effects of air pollution on reproductive aging in women.

METHODS

Our analysis included 565 women attending the Massachusetts General Hospital Fertility Center (2004-2014) who had a measured antral follicle count (AFC), a marker of ovarian reserve. We calculated peak residential greenness in the year prior to AFC using 250 m² normalized difference vegetation index (NDVI) from the Terra and Aqua satellites operated by the United States National Aeronautics and Space Administration. Validated spatiotemporal models estimated daily residential exposure to particulate matter <2.5 μm (PM_2.5) for the 3 months prior to AFC. Poisson regression models with robust standard errors were used to estimate the association between peak greenness, average PM_2.5 exposure, and AFC adjusted for age, BMI, smoking status, education, year, and season.

RESULTS

Women in our study had a mean age of 35.2 years with a standard deviation (SD) of 4.3 years (min: 20 years, max: 45 years). The peak residential NDVI ranged from 0.07 to 0.92 with a SD of 0.18. There was no statistically significant association between peak residential greenness and AFC; however, higher exposure to PM_2.5 was associated with lower AFC (-6.2% per 2 μg/m³ [1 SD increase] 95% CI -11.8, -0.3). There was a significant interaction between exposure to PM_2.5 and peak greenness on AFC (P-interaction: 0.03). Among women with an average PM_2.5 exposure of 7 μg/m³, a SD increase in residential peak greenness was associated with a 5.6% (95% CI -0.4, 12.0) higher AFC. Conversely, among women with a PM_2.5 exposure of 12 μg/m³, a SD increase in residential peak greenness was associated with a 5.8% (95% CI -13.1, 2.1) lower AFC.

CONCLUSIONS

Residing in an area with high levels of greenness may slow reproductive aging in women only when exposure to PM_2.5 is low.

The Molecular Regulation in the Pathophysiology in Ovarian Aging

The female reproductive system is of great significance to women’s health. Aging of the female reproductive system occurs approximately 10 years prior to the natural age-associated functional decline of other organ systems. With an increase in life expectancy worldwide, reproductive aging has gradually become a key health issue among women. Therefore, an adequate understanding of the causes and molecular mechanisms of ovarian aging is essential towards the inhibition of age-related diseases and the promotion of health and longevity in women. In general, women begin to experience a decline in ovarian function around the age of 35 years, which is mainly manifested as a decrease in the number of ovarian follicles and the quality of oocytes. Studies have revealed the occurrence of mitochondrial dysfunction, reduced DNA repair, epigenetic changes, and metabolic alterations in the cells within the ovaries as age increases. In the present work, we reviewed the possible factors of aging-induced ovarian insufficiency based on its clinical diagnosis and performed an in-depth investigation of the relevant molecular mechanisms and potential targets to provide novel approaches for the effective improvement of ovarian function in older women.

Senataxin: A New Guardian of the Female Germline Important for Delaying Ovarian Aging

Early decline in ovarian function known as premature ovarian aging (POA) occurs in around 10% of women and is characterized by a markedly reduced ovarian reserve. Premature ovarian insufficiency (POI) affects ~1% of women and refers to the severe end of the POA spectrum in which, accelerated ovarian aging leads to menopause before 40 years of age. Ovarian reserve refers to the total number of follicle-enclosed oocytes within both ovaries. Oocyte DNA integrity is a critical determinant of ovarian reserve since damage to DNA of oocytes within primordial-stage follicles triggers follicular apoptosis leading to accelerated follicle depletion. Despite the high prevalence of POA, very little is known regarding its genetic causation. Another little-investigated aspect of oocyte DNA damage involves low-grade damage that escapes apoptosis at the primordial follicle stage and persists throughout oocyte growth and later follicle development. Senataxin (SETX) is an RNA/DNA helicase involved in repair of oxidative stress-induced DNA damage and is well-known for its roles in preventing neurodegenerative disease. Recent findings uncover an important role for SETX in protecting oocyte DNA integrity against aging-induced increases in oxidative stress. Significantly, this newly identified SETX-mediated regulation of oocyte DNA integrity is critical for preventing POA and early-onset female infertility by preventing premature depletion of the ovarian follicular pool and reducing the burden of low-grade DNA damage both in primordial and fully-grown oocytes.

Establishment of a homogeneous immunoassay-light-initiated chemiluminescence assay for detecting anti-Müllerian hormone in human serum

Anti-Müllerian hormone (AMH) is known as a reliable marker of ovarian reserve (OR). The determination of AMH is of great importance and most existed AMH detection methods are heterogeneous immunoassay. In this study, a novel homogeneous sandwich immunoassay-light-initiated chemiluminescence assay (LICA) for detecting AMH serum level was developed. This AMH-LICA was performed by incubating serum samples with AMH mouse monoclonal antibody coated with chemibeads, streptavidin-coated sensibeads, and biotinylated AMH mouse monoclonal antibody. Sensitivity, precision, accuracy and cross-reactivity of this assay were evaluated. Besides, a regression analysis showed a high correlation between AMH-LICA and Roche Elecsys® AMH assay (y = 0.9851x + 0.07147, R² = 0.9569). As a homogeneous immunoassay, this AMH-LICA could accurately and rapidly determine the serum level of AMH with high-throughput. Thus, this new developed assay may be a new useful analytical tool for the determination of AMH.

Predictive value of cytoplasmic granulation patterns during in vitro fertilization in metaphase II oocytes: Part I, poor-prognosis patients

OBJECTIVE

To determine whether 4 cytoplasmic granulation patterns of human metaphase II oocytes have a predictive value for in vitro fertilization outcomes.

DESIGN

A retrospective cohort study.

SETTING

An academically affiliated private clinical infertility and research center.

PATIENT(S)

A total of 2,690 consecutive fresh autologous oocytes collected from women aged 41.2 ± 5.0 years between 2017 and 2019.

INTERVENTION(S)

Determination of granulation pattern in every oocyte during intracytoplasmic sperm injection as fine, central, dispersed, and newly introduced uneven granulations.

MAIN OUTCOME MEASURE(S)

Fertilization outcomes (2 pronuclei [2PN], <2PN, and >2PN rates), pregnancy, and live birth rates for different granulation patterns at different ages.

RESULT(S)

Fine granulation produced the highest 2PN rate, followed by central, uneven, and dispersed granulation (91.8%, 83.9%, 77.9%, and 54.8%, respectively). Differences in fertilization were surprisingly relatively independent of age and other variables. Overall, compared with fine granulation, dispersed granulation resulted in lower pregnancy rates (4.6% vs. 10.7%) and known-outcome analysis (1.3% vs. 5.6%) as well as lower live birth rates (3.0% vs. 8.9%) and known-outcome analysis (0.6% vs. 5.6%). The known-outcome analysis demonstrated that uneven granulation had lower live birth rates than fine granulation (2.3% vs. 5.6%). Unexpectedly, the ooplasm granulation patterns were largely disassociated from embryo morphologic grades.

CONCLUSION(S)

We, for the first time, demonstrated that 4 distinct cytoplasmic granulation patterns in metaphase II oocytes had, largely independent of age and other variables, a predictive value for fertilization, pregnancy, and live birth outcomes in in vitro fertilization cycles of poor-prognosis patients. These data suggest that upstream ooplasm granulation patterns deserve closer attention in terms of embryo selection.

Are ovarian reserve tests reliable in predicting ovarian response? Results from a prospective, cross-sectional, single-center analysis

OBJETIVE

Several biomarkers of ovarian reserve have been proposed as possible predictors of the response to controlled ovarian stimulation (COS). We aimed to evaluate age, FSH, AMH, antral follicle count (AFC), and ovarian response prediction index (ORPI), as potential predictors of response to COS.

METHODS

Cross-sectional study enrolling of 188 infertile women who underwent the first cycle of IVF/ICSI. AFC was evaluated; serum FSH and AMH levels were measured by ELISA. ORPI was calculated as AMH x AFC/patient´s age.

RESULTS

As expected, hypo-responder group had less retrieved oocytes, MII, and embryos compared to the good responders. The hyper-response patients were younger, with lower FSH, increased AMH, AFC, and ORPI values. Regarding the assessment of the predictive capacity of ovarian reserve tests, none of them individually or combined showed a good predictive capacity for hypo-response. With respect to the hyper-responder group, individually AMH was the best predictor, while in the multivariable model, ORPI demonstrated the best predictive capacity. Furthermore, patients with serum AMH < 2.09 ng/mL (p25) had fewer AFC than patients with higher AMH values.

CONCLUSIONS

Our findings suggest that none of the ovarian reserve tests showed a good predictive capacity for hypo-response, while the ORPI was the strongest predictor of hyper-response in normovulatory infertile women.

Premature ovarian ageing following heterozygous loss of Senataxin

Premature loss of ovarian activity before 40 years of age is known as primary ovarian insufficiency (POI) and occurs in ∼1% of women. A more subtle decline in ovarian activity, known as premature ovarian ageing (POA), occurs in ∼10% of women. Despite the high prevalence of POA, very little is known regarding its genetic causation. Senataxin (SETX) is an RNA/DNA helicase involved in repair of oxidative stress-induced DNA damage. Homozygous mutation of SETX leads to the neurodegenerative disorder, ataxia oculomotor apraxia type 2 (AOA2). There have been reports of POI in AOA2 females suggesting a link between SETX and ovarian ageing. Here, we studied female mice lacking either one (Setx+/-) or both (Setx-/-) copies of SETX over a 12- to 14-month period. We find that DNA damage is increased in oocytes from 8-month-old Setx+/- and Setx-/- females compared with Setx+/+ oocytes leading to a marked reduction in all classes of ovarian follicles at least 4 months earlier than typically occurs in female mice. Furthermore, during a 12-month long mating trial, Setx+/- and Setx-/- females produced significantly fewer pups than Setx+/+ females from 7 months of age onwards. These data show that SETX is critical for preventing POA in mice, likely by preserving DNA integrity in oocytes. Intriguingly, heterozygous Setx loss causes an equally severe impact on ovarian ageing as homozygous Setx loss. Because heterozygous SETX disruption is less likely to produce systemic effects, SETX compromise could underpin some cases of insidious POA.

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.

Anti-Müllerian Hormone and Ovarian Reserve: Update on Assessing Ovarian Function

CONTEXT

Anti-müllerian hormone (AMH) is produced by granulosa cells of small, growing follicles in the ovary. Serum AMH levels strongly correlate with the number of growing follicles, and therefore AMH has received increasing attention as a marker for ovarian reserve. This review summarizes recent findings and limitations in the application of serum AMH in ovarian reserve assessment.

EVIDENCE ACQUISITION

A PubMed search was conducted to find recent literature on the measurements and use of serum AMH as a marker for ovarian reserve.

EVIDENCE SYNTHESIS

Serum AMH levels are measured to assess the "functional ovarian reserve," a term that is preferred over "ovarian reserve," since AMH levels reflect the pool of growing follicles that potentially can ovulate. Serum AMH levels are used in individualized follicle-stimulating hormone dosing protocols and may predict the risk of poor response or ovarian hyperstimulation syndrome but has limited value in predicting ongoing pregnancy. Serum AMH levels are studied to predict natural or disease-related age of menopause. Studies show that the age-dependent decline rates of AMH vary among women. The generalized implementation of serum AMH measurement has also led to an increase in diagnostic assays, including automated assays. However, direct comparison of results remains problematic.

CONCLUSION

Serum AMH remains the preferred ovarian reserve marker. However, the lack of an international standard for AMH limits comparison between AMH assays. Furthermore, little is known about endogenous and exogenous factors that influence serum AMH levels, which limits proper interpretation of AMH values in a clinical setting.

Why is use of donor eggs not viewed as treatment failure? A call for improvements in treatments with autologous oocytes

Based on national registry reports, after age 42, the number of IVF cycles utilizing autologous oocytes is very small; after age 43, autologous oocyte use in US IVF cycles is almost non-existent. We here argue that the in vitro fertilization (IVF) field has created a self-fulfilling prophecy by basically abandoning the utilization of autologous oocytes after ages 42-43 years. This not only resulted in almost no IVF cycles with autologous oocytes being performed but also in abandonment of research that could lead to improvements in IVF outcomes in older women when using autologous oocytes. As a consequence, IVF has largely stagnated in this area. We further argue that third-party oocyte donation in clinical IVF should be considered a treatment failure, as it requires patients to choose a second rather than a first-choice treatment. Such a redesignation of third-party egg donation would not only be appropriate but could lead to necessary changes in physician attitudes, considering that women almost exclusively prefer to conceive with their autologous oocytes.

Sigma-1 receptor is involved in diminished ovarian reserve possibly by influencing endoplasmic reticulum stress-mediated granulosa cells apoptosis

Sigma non-opioid intracellular receptor 1 (sigma-1 receptor), a non-opioid transmembrane protein, is located on cellular mitochondrial membranes and endoplasmic reticulum. Current research has demonstrated that sigma-1 receptor is related to human degenerative diseases. This study is focused on the effects of sigma-1 receptor on the pathophysiological process of diminished ovarian reserve (DOR) and granulosa cells (GCs) apoptosis. Sigma-1 receptor concentration in follicular fluid (FF) and serum were negatively correlated with basal follicle-stimulating hormone (FSH) and positively correlated with anti-mullerian hormone (AMH), antral follicle count (AFC). Sigma-1 receptor reduction in GCs was accompanied by endoplasmic reticulum stress (ERS)-mediated apoptosis in women with DOR. Plasmid transfection was used to establish SIGMAR1-overexpressed and SIGMAR1-knockdown human granulosa-like tumor (KGN) cell and thapsigargin (TG) was used to induce ERS KGN cells. We found that KGN cells treated with endogenous sigma-1 receptor ligand dehydroepiandrosterone (DHEA) and sigma-1 receptor agonist PRE-084 showed similar biological effects to SIGMAR1-overexpressed KGN cells and opposite effects to SIGMAR1-knockdown KGN cells. DHEA may improve DOR patients' pregnancy outcomes by upregulating sigma-1 receptor and downregulating ERS-mediated apoptotic genes in GCs. Thus, sigma-1 receptor may be a potential ovarian reserve biomarker, and ligand-mediated sigma-1 receptor activation could be a future approach for DOR therapy.

Association of exposure to air pollution and green space with ovarian reserve hormones levels

Exposure to air pollution has been associated with adverse health effects while exposure to greenspace has been associated with public health benefits. However, the available evidence on the association of exposure to air pollution with ovarian reserve markers is still scarce, with no study on such an association with greenspace exposure. Therefore, this study aimed to investigate the association of exposure to particulate matter with diameter of less than 1, 2.5 and 10 μm (PM₁, PM_2.5, PM₁₀), traffic indicators (distance from women's residence to major roads and total street length in different buffers around women's residential address) and greenspace indicators (residential surrounding greenspace and distance to green spaces) with serum levels of anti-müllerian hormone (AMH) and follicle stimulating hormone (FSH) as markers of ovarian reserve. This cross-sectional study was based on 67 women residing in Sabzevar, Iran (2018). Basal serum levels of FSH and AMH were measured by the enzyme-linked immunosorbent assays (ELISA). Land use regression models were used to estimate PMs concentrations at residential addresses and the average of normalized difference vegetation index (NDVI) in different buffers was used to characterize residential surrounding greenspace. Multiple linear regression models were developed to estimate the association of AMH and FSH with exposure to air pollution, traffic, and greenspace (one at a time) controlled for relevant covariates. In fully adjusted models, there was an inverse association between exposure to PM₁, PM_2.5 as well as total street length in 100 m buffer around women's residence and AMH level (β = -0.89, 95% confidence interval (CI): -1.43, -0.35, P-value ≤ 0.01, β = -1.11, 95% CI: -1.67, -0.55, P-value ≤ 0.01 and β = -0.76, 95% CI: -1.48, -0.50, P-value = 0.03, respectively). Moreover, increase in distance from home to nearest major road as well as residential surrounding greenspace (100 m buffer) and decrease in residential distance to a green space larger than 5000 m² were associated with increase in serum level of AMH. However, we did not observe any significant association between exposure to air pollution, traffic, and greenspace with FSH level. Overall, our findings supported a beneficial association of exposure to greenspace and detrimental association of exposure to air pollution with ovarian reserve.

"So what happens next?" exploring the psychological and emotional impact of anti-Mullerian hormone testing

Research Question: Significant medical benefits could be derived from universal AMH screening for women in their mid to late twenties. We aimed to investigate the psychological and emotional responses of women to being informed of their anti-Mullerian hormone (AMH) result with a view to informing the possible introduction of universal AMH screening.Materials and methods: This was a prospective qualitative study using semi-structured in-depth interviews of women attending a reproductive medicine clinic who had ovarian reserve testing performed via measurement of serum AMH levels, as part of their gynecological investigations. A semistructured interview schedule was developed after a review of the literature. A purposive sample of women was recruited, and data collection continued until thematic saturation was reached (n = 10). The number of women interviewed is low as this was a pilot qualitative study of a two-part study. The next part of the study involves the development of a quantitative questionnaire related to the key themes identified in this study to be based on a much larger group of women. Interviews were audiotaped, transcribed verbatim and imported into QSR NVivo pro 11 for analysis.Results: Three key themes emerged from the data: the experience of AMH testing, the response to the AMH result, and suggested lessons for medical professionals. The theme of the experience of AMH testing describes and reflects two sub-themes: the reasons for ovarian reserve testing and the potential barriers that may prevent women from accessing testing. A further key focus of this study was the emotional and psychological responses to receiving an AMH result and this emerged as a major theme in the interviews. Women described the significant impact that their individual result had on a number of lifestyle and behavioral factors and how it impacted on their gender identity. Lessons for medical professionals including the appreciation of the patient's awareness of the test and how the test result was relayed to the patient were important factors in how they dealt with the result. There were mixed reactions and opinions from the group in relation to the introduction of AMH testing as a screening tool for all young women.Conclusions: Knowledge and communication of a low AMH result has a negative psychological impact. The findings from this study support the move to further explore the psychological and emotional impact of the test with the development of a quantitative questionnaire.

OVARIAN VOLUME BETWEEN FERTILE AND INFERTILE MARRIED WOMEN WITH TRANSVAGINAL SONOGRAPHY

Background: Infertility is a social problem and a big stigma. The objectives of the study were to determine the age wise distribution of ovarian volume and the difference in ovarian volume between married fertile and infertile women with transvaginal sonography. Materials & Methods: This comparative, cross-sectional study was conducted in the Department of Anatomy, Gomal Medical College, D.I.Khan, Pakistan from March 2013 to December 2013. Sample Size was 100 women selected by consecutive non probability sampling technique. Sample size was calculated using online calculator Raosoft. Inclusion criteria were women aged 18-50 years, married, fertile and infertile. Color Doppler sonoscape with multi frequency transvaginal probes were used in measurements on any day in the start of menstrual cycle by the same observer. The volume was calculated by applying formula for ellipsoid called Prolate ellipsoid formula. The total volume was represented by sum of volume of two ovaries. Data collection site was out patient department of Radiology DHQ Teaching Hospital, D.I.Khan. Demographic variable were age groups and presence of fertility. Research variable was ovarian volume. Mean and standard deviation were calculated for ovarian volume whereas frequency and percentages were calculated for age groups and presence of fertility. Descriptive statistics along with estimation of parameter was done at 95% confidence interval for proportion and mean. Student- t test was used for significance of difference in ovarian volume between fertile and infertile women with p value

The Effect of Dehydroepiandrosterone (DHEA) Supplementation on IVF or ICSI: A Meta-Analysis of Randomized Controlled Trials

Introduction A systematic review and meta-analysis were conducted to evaluate the efficacy of dehydroepiandrosterone (DHEA) supplementation in patients with diminished ovarian reserve (DOR) and/or poor ovarian response (POR) who were undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI).

Patients and Methods We searched the PubMed, EMBASE, Web of Science, and Cochrane Library electronic databases for literature published until July 2018. The analysis included randomized controlled trials (RCTs) of the effects of DHEA versus placebo on IVF or ICSI. Two independent reviewers extracted information from the reports and evaluated the quality of the studies. Overall, we identified nine prospective RCTs involving 833 patients.

Results Compared to the controls, patients treated with DHEA exhibited increases in the number of retrieved oocytes (mean difference, 0.91; 95% confidence interval [CI], 0.23 – 1.59; p = 0.009), clinical pregnancy rate (relative risk [RR] = 1.27; 95% CI, 1.01 – 1.61; p = 0.04), and live birth rate (RR, 1.76; 95% CI, 1.17 – 2.63; p = 0.006). However, there was no intergroup difference in the miscarriage rate (RR, 0.37; 95% CI, 0.12 – 1.13; p = 0.08).

Conclusion DHEA supplementation improved the outcomes of IVF/ICSI in women with DOR or POR.

MicroRNA profiling and identification of let-7a as a target to prevent chemotherapy-induced primordial follicles apoptosis in mouse ovaries

Cancer treatments as cyclophosphamide and its active metabolites are highly gonadotoxic leading to follicle apoptosis and depletion. Considering the risk of subsequent infertility, fertility preservation is recommended. Beside the germ cells and gametes cryopreservation options, ovarian pharmacological protection during treatment appears to be very attractive. Meanwhile, the advances in the field of oncology have brought microRNAs into spotlight as a potential feature of cancer treatment. Herein, we investigated miRNAs expressions in response to chemotherapy using postnatal-day-3 (PND3) mouse ovaries. Our results revealed that several miRNAs are differently expressed during chemotherapy exposure. Amongst them, let-7a was the most profoundly downregulated and targets genes involved in crucial cellular processes including apoptosis. Thus we developed a liposome-based system to deliver the let-7a mimic in whole PND3 ovaries in vitro. We showed that let-7a mimic prevented the upregulation of genes involved in cell death and reduced the chemotherapy-induced ovarian apoptosis, suggesting that it can be an interesting target to preserve ovarian function. However, its impact on subsequent follicular development has to be further elucidated in vivo using an appropriate delivery system. In this study, we demonstrated that miRNA replacement approaches can be a useful tool to reduce chemotherapy-induced ovarian damage in the future.

Preoperative serum anti-Müllerian hormone level is a potential predictor of ovarian endometrioma severity and postoperative fertility

OBJECTIVE

To establish a model for predicting revised American Society of Reproductive Medicine (rASRM) scores before endometrioma surgery based on serum anti-Müllerian hormone (AMH) level and to identify factors that might reliably predict postoperative fertility of women diagnosed with endometrioma.

STUDY DESIGN

The study population was composed of 134 women with endometrioma, 58 with benign cyst, and 115 with non-ovarian lesion. Preoperative serum AMH level and clinical parameters were compared among three groups. Univariate correlation analyses and multivariate linear regression modeling with a stepwise method were performed for constructing an rASRM scores prediction model. Cox regression analysis was then used to identify predictive variables of spontaneous pregnancy following surgical treatment of endometrioma.

RESULTS

Preoperative AMH level were significantly lower in the endometrioma group than in the other two groups (p < 0.001). Multivariate linear regression analysis revealed that age (β=-0.324, p < 0.001), rASRM scores (β=-0.298, p < 0.001) and serum CA125 level (β=-0.176, p = 0.026) independently and negatively correlated with serum AMH level. Cox regression analysis of women with endometrioma who underwent surgical resection indicated that older age (per five-year increase, HR: 0.517; 95% CI, 0.299-0.896) and higher serum AMH level (cut-off value: >3.68 ng/ml, HR: 2.383; 95% CI, 1.093-5.197) were independent predictors for postoperative fertility.

CONCLUSION

Patients with advanced staged endometriosis tended to have a lower serum AMH level while postoperative infertility was more likely to occur in older patients with a lower level of serum AMH. Thus, timely detection of AMH levels to assess the severity of ovarian endometriosis and possibility for postoperative pregnancy success is necessary to ensure that optimal medical treatment can be provided.

The effect of endometriosis on the antimüllerian hormone level in the infertile population

PURPOSE

To determine whether the presence of endometriosis in infertile women without prior ovarian surgery influences markers of ovarian reserve, AMH and FSH.

METHODS

A retrospective cohort study included three groups of women who presented for IVF treatment at our tertiary care center from 04/27/2015 to 05/31/2017: women with endometriosis and prior ovarian surgery (EnSx), women with endometriosis without prior ovarian surgery (En), and women with a primary diagnosis of male factor infertility (MF; reference group).

RESULTS

There were 671 patients that met inclusion criteria (78 EnSx, 60 En, and 533 MF). Compared to the MF group (3.6 ± 3.0), a lower mean AMH level (ng/mL) was observed in the EnSx group (2.5 ± 2.5; aβ - 1.21; 95% CI [- 1.79, -0.62]) and in the En group (2.5 ± 2.2; aβ - 1.11; 95% CI [- 1.68, - 0.54]). Both endometriosis groups had a statistically significantly higher proportion of patients with an AMH < 1 (EnSx, 24.4%; OR, 2.39 [95% CI, 1.31, 4.36]; En, 28.3%; OR, 2.67 [95% CI, 1.41, 5.08]) compared to the MF group (13.9%). The mean baseline FSH level (lU/L) was statistically significantly higher in both endometriosis groups (EnSx, 8.6 ± 4.3; β, 1.37 [95% CI, 0.39, 2.34]; En, 8.4 ± 3.7; β, 0.96 [95% CI, 0.04, 1.87]) compared to the MF group (7.3 ± 2.2).

CONCLUSIONS

Among infertility patients with endometriosis, with and without a history of ovarian surgery, ovarian reserve markers were worse (lower AMH and higher FSH) and a higher proportion had decreased ovarian reserve as measured by AMH compared to women with MF.

BRCA carriers have similar reproductive potential at baseline to noncarriers: comparisons in cancer and cancer-free cohorts undergoing fertility preservation

OBJECTIVE

To investigate whether BRCA carriers with and without malignancy have decreased ovarian reserve at baseline compared with BRCA noncarriers.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

Seven-hundred and ninety-five oocyte cryopreservation patients, comprising BRCA carriers with and without malignancy (n = 57) and BRCA noncarriers (n = 738).

INTERVENTION(S)

Fertility preservation with oocyte cryopreservation.

MAIN OUTCOME MEASURE(S)

Antral follicle count (AFC), antimüllerian hormone (AMH) concentration, day-3 follicle-stimulating hormone (FSH) level, number of harvested oocytes, and number of mature/cryopreserved oocytes.

RESULT(S)

In the cancer cohort we compared BRCA-positive breast cancer (n = 38) with BRCA-negative breast cancer (n = 53) and with non-breast-cancer malignancies (n = 85). In the cancer-free cohort we compared BRCA carriers (n = 19) with women undergoing elective egg freezing (n = 600). We also compared the BRCA1 (n = 31) versus the BRCA2 carriers (n = 18). The patients' mean ages were 32.4 ± 3.6 years and 35.5 ± 4.3 years in the BRCA carrier and noncarrier cohorts, respectively. BRCA status was associated with a higher day-3 FSH level in the cancer cohort, but we found no changes in the other outcomes compared with the BRCA-negative cancer groups. BRCA carriers without cancer exhibited a higher AFC and number of mature oocytes compared with the patients undergoing planned egg freezing. Overall (cancer and cancer-free cohorts), the BRCA carriers had an increased AFC (15.5 ± 4.6 vs. 12.6 ± 5.7) and number of mature/cryopreserved oocytes (14.0 ± 7.9 vs. 10.4 ± 6.9) compared with the BRCA noncarriers but had no differences in other outcomes.

CONCLUSION(S)

BRCA carriers with and without malignancy exhibit comparable ovarian reserve and responses to ovarian stimulation compared with women with BRCA-negative cancers and cancer-free controls.