Ovarian and adrenal androgens may be useful markers to predict oocyte competence and embryo development in older women

The Polymorphism Asn680Ser on the FSH Receptor and Abnormal Ovarian Response in Patients with Normal Values of AMH and AFC

After the controlled ovarian stimulation (COS), the number of cumulus oocyte complexes collected is lower than predicted. The aim of this study is to understand if there is a possible reason for that deficient ovarian response. It was hypothesized that this is associated with the SNP (single-nucleotide polymorphism) of the FSH receptor (FSHr), specifically c.2039A > G, resulting in Asn680Ser. Two groups of patients were enrolled for this purpose: the normal (n = 36) and abnormal responses (n = 31). To predict the number of retrievable oocytes, according to the anti-Mũllerian hormone (AMH) and the antral follicle count (AFC), the following formula was applied in a log scale: the number of oocytes retrieved = 2.584 − 0.015 × (age) − 0.035 × (FSH) + 0.038 × (AMH) + 0.026 × (AFC). Then, when the number of oocytes collected was less than 50% of the calculated value, it was proposed that the patients result in an abnormal response. DNA sample blood was collected from the women, and then the genetic assessment for the Asn680Ser of the FSHr was evaluated in both groups. The differences between the two categories were statistically analyzed with an independent samples t test, a Mann−Whitney U test and a Chi-squared test. In a patient with an abnormal response, a significant prevalence of the amino acid serine at position 680 of the FSHr compared to the counterpart group (p < 0.05) was detected. In conclusion, according to the results, the genetic evaluation of the FSHr could represent an accurate and predictive feature for patients undergoing assisted reproductive technology treatment.

Basal serum level of Δ4-androstenedione reflects the ovaries' ability to respond to stimulation in IVF cycles: setting up a new reliable index of both ovarian reserve and response

PURPOSE

Adequate androgen levels are necessary for regular follicular growth, progression beyond the pre-antral stage, and prevention of follicular atresia. The main purpose of this study was to investigate whether baseline androgen levels had a predictive value on stimulation outcomes in IVF cycles. The secondary purpose was to compare the possible predictive value of androgens with that of already known markers.

METHODS

The study included 91 infertile patients aged 30-45 years awaiting the first IVF cycle. All women underwent the same stimulation protocol and the same starting dose of recombinant FSH. As stimulation outcomes, the number of follicles recruited, estradiol and progesterone levels on the day of trigger, the total dose of gonadotropins administered, and the number of oocytes collected were recorded. Multiple linear regression and multivariate logistic regression were used to evaluate the significant predictive value of the variables for response to controlled ovarian stimulation (COS). By studying the reliability of different markers, an attempt was made to develop a single index with the highest predictive value.

RESULTS

Pearson's correlation revealed a statistically significant inverse correlation between oocytes collected and age (r =  - 0.333, p < 0.001) and a positive correlation with AMH (anti-müllerian hormone) (r = 0.360, p < 0.001), antral follicle count (AFC) (r = 0.639, p < 0.001), and androstenedione (Δ4-A) (r = 0.359, p < 0.001). No significant correlation was reported with FSH (r =  - 0.133, p = 0.207) and total testosterone (r = 0.180, p = 0.088). In COS good responders, the G-index (= AMH ng/mL*AFC/Δ4-A ng/dL) revealed a significantly higher level (p < 0.001) than AMH, AFC, and Δ4-A alone.

CONCLUSION

Baseline serum Δ4-A, presumably crucial for ensuring a regular follicular growth, is a reliable marker of ovarian response to stimulation. Since the ovarian capacity to respond to gonadotropins does not depend exclusively on the presence of follicles, we suggest a new index, the G-index, able to contemplate both the ovarian reserve and the Δ4-A level.

The Role of FSHR SNPs and AMH in Follicular Fluid and Serum in Ovarian Response during COS: A Pilot Study

Background

Several studies have investigated on the polymorphism Ser680Asn of FSHR and its use as a predictive indicator of response to an IVF/ICSI protocol. Furthermore, measurement of AMH in serum and follicular fluid is a useful prognostic indicator for the outcome of an assisted reproduction attempt. The purpose of this study is to examine the FSH receptor Ser680Asn polymorphism in combination with AMH levels in both serum and follicular fluid, on the day of oocyte collection.

Materials and Methods

A total of 32 women who underwent IVF/ICSI were included. Women were grouped into 2 groups: those who received rFSH (n = 11) and those who received hMG (n = 21). Serum AMH was measured on day 3 of the cycle, and AMH in the follicular fluid on the day of oocyte retrieval; the same day peripheral blood was collected for the genotyping of Ser680Asn.

Results

No statistical significant difference was found between serum AMH and follicular fluid AMH regarding the FSH receptor genotype for the Ser680Asn polymorphism. Regarding the sAMH/ffAMH ratio in the 3 genotypes, the value was lower in Asn/Asn women than Ser/Ser and Ser/Asn, but no statistical difference was obtained. Women who carry the Ser allele have a higher number of follicles, retrieved oocytes, and mature oocytes than women who do not contain the Ser allele. Women with AMH < 2.22 ng/ml presented lower AMH follicular fluid levels and lower serum AMH/follicular fluid AMH ratio in a statistically significant manner. Concerning the genotype for the polymorphism Ser680Asn of FSHR in relation to AMH levels, no statistically significant differences were found.

Conclusions

The identification of polymorphisms, such as Ser680Asn of FSHR, along with the determination of endocrine markers in the follicular fluid, such as AMH, could lead at some point, to the personalized therapy setting per woman.

Biopsying, fragmentation and autotransplantation of fresh ovarian cortical tissue in infertile women with diminished ovarian reserve

STUDY QUESTION

Can ovarian biopsying per se and/or autotransplantation of fragmented ovarian cortical tissue activate dormant follicles and increase the number of recruitable follicles for IVF/ICSI in women with diminished ovarian reserve (DOR)?

SUMMARY ANSWER

Ovarian biopsying followed by immediate autotransplantation of fragmented cortical tissue failed to increase the number of recruitable follicles for IVF/ICSI 10 weeks after the procedure either at the graft site or in the biopsied ovary, but 12 of the 20 women subsequently had a clinical pregnancy during the 1-year follow-up.

WHAT IS KNOWN ALREADY

Infertile women with DOR constitute a group of patients with poor reproductive outcome mainly due to the low number of mature oocytes available for IVF/ICSI. Recent studies have shown that in vitro activation of residual dormant follicles by both chemical treatment and tissue fragmentation has resulted in return of menstrual cycles and pregnancies in a fraction of amenorrhoeic women with premature ovarian insufficiency.

STUDY DESIGN, SIZE, DURATION

This is a prospective clinical cohort study including 20 women with DOR treated at the fertility clinic, Rigshospitalet, Denmark, during April 2016-December 2017. Non-pregnant patients were on average followed for 280 days (range 118-408), while women who conceived were followed until delivery. Study follow-up of non-pregnant patients ended in September 2018.

PARTICIPANTS, MATERIALS, SETTING, METHODS

The study included infertile women aged 30-39 years with preserved menstrual cycles, indication for IVF/ICSI and repeated serum measurements of anti-Müllerian hormone (AMH) ≤ 5 pmol/L. Patients were randomized to have four biopsies taken from either the left or the right ovary by laparoscopy followed by fragmentation of the cortical tissue to an approximate size of 1 mm3 and autotransplanted to a peritoneal pocket. The other ovary served as a control. Patients were followed weekly for 10 weeks with recording of hormone profile, antral follicle count (AFC), ovarian volume and assessment for ectopic follicle growth. After 10 weeks, an IVF/ICSI-cycle with maximal ovarian stimulation was initiated.

MAIN RESULTS AND THE ROLE OF CHANCE

No difference in the number of mature follicles after ovarian stimulation 10 weeks after the procedure in the biopsied versus the control ovaries was observed (1.0 vs. 0.7 follicles, P = 0.35). In only three patients, growth of four follicles was detected at the graft site 24-268 days after the procedure. From one of these follicles, a metaphase II (MII) oocyte was retrieved and fertilized, but embryonic development failed. Overall AMH levels did not change significantly after the procedure (P = 0.2). The AFC increased by 0.14 (95% CI: 0.06;0.21) per week (P < 0.005), and the biopsied ovary had on average 0.6 (95% CI: 0.3;-0.88) follicles fewer than the control ovary (P = 0.01). Serum levels of androstenedione and testosterone increased significantly by 0.63 nmol/L (95% CI: 0.21;1.04) and 0.11 nmol/L (95% CI: 0.01;0.21) 1 week after the procedure, respectively, and testosterone increased consecutively over the 10 weeks by 0.0095 nmol/L (95% CI: 0.0002;0.0188) per week (P = 0.045). In 7 of the 20 patients, there was a serum AMH elevation 5 to 8 weeks after the procedure. In this group, mean AMH increased from 2.08 pmol/L (range 1.74-2.34) to 3.94 pmol/L (range 3.66-4.29) from Weeks 1-4 to Weeks 5-8. A clinical pregnancy was obtained in 12 of the 20 (60%) patients with and without medically assisted reproduction (MAR) treatments. We report a cumulated live birth rate per started IVF/ICSI cycle of 18.4%.

LIMITATIONS, REASON FOR CAUTION

Limitations of the study were the number of patients included and the lack of a non-operated control group. Moreover, 9 of the 20 women had no male partner at inclusion and were treated with donor sperm, but each of these women had an average of 6.8 (range 4-9) unsuccessful MAR treatments with donor sperm prior to inclusion.

WIDER IMPLICATIONS OF THE FINDINGS

Although 12 out of 20 patients became pregnant during the follow-up period, the current study does not indicate that biopsying, fragmenting and autotransplanting of ovarian cortical tissue increase the number of recruitable follicles for IVF/ICSI after 10 weeks. However, a proportion of the patients may have a follicular response in Weeks 5-8 after the procedure. It could therefore be relevant to perform a future study on the possible effects of biopsying per se that includes stimulation for IVF/ICSI earlier than week 10.

STUDY FUNDING/COMPETING INTEREST(S)

This study is part of the ReproUnion collaborative study, co-financed by the European Union, Interreg V ÖKS. The funders had no role in the study design, data collection and interpretation, or decision to submit the work for publication. None of the authors have a conflict of interest.

TRIAL REGISTRATION NUMBER

NCT02792569.

The impact of dehydroepiandrosterone in poor ovarian responders on assisted reproduction technology treatment

One in six couples worldwide will experience at least one infertility problem during their reproductive years. Between 5.6% and 35.1% of women will exhibit poor ovarian response. A variety of methods have been applied to improve ovarian response, including dehydroepiandrosterone. In the ovaries, dehydroepiandrosterone promotes follicular development and granulosa cell proliferation by increasing intraovarian androgen concentrations while simultaneously enhancing the level of follicular insulin-like growth factor-1, which promotes folliculogenesis. Dehydroepiandrosterone supplementation may improve in vitro fertilization outcomes and ovarian response in patients with poor ovarian response. However, a few questions still loom over the effectiveness of dehydroepiandrosterone.

Do serum androgens influence blastocysts ploidy in karyotypically normal women?

The aim of the study was to determine if serum testosterone (T) and dehydroepiandrosterone (DHEAS) levels are a factor in determining increased risk for embryonic aneuploidy in karyotypically normal women undergoing in vitro fertilization (IVF) and preimplantation genetic testing screening for aneuploidy (PGT-A). This is a retrospective cohort study of IVF cycles with PGT-A performed during 2015-2016. A total of 256 cycles with 725 embryos were initially considered for inclusion. A total of 208 cycles and 595 embryos determined to be either euploid or aneuploid were included in the analysis. The mean age of women was 37.4 ± 4.4 years. There were 193 (32.44%) euploid, and 338 (56.81%) aneuploid blastocysts. Sixty-four (10.76%) had 'no diagnosis' after PGT-A. The 32 embryos with 'no diagnosis' after first PGT-A were biopsied again and after the second analysis, 7 were found to be euploid and 3 aneuploid. The remaining 32 embryos were not reanalyzed due to the lack of patients' consent for the second biopsy. The relationship between embryo ploidy and levels of serum testosterone and dehydroepiandrosterone sulfate was assessed using ordinal multivariable regression analysis. The model, adjusted for both anti-Mullerian hormone (AMH) and age, showed no association between ploidy status and serum levels of the two hormones. We concluded that the serum levels of testosterone and DHEAS do not influence embryo ploidy in karyotypically normal women undergoing IVF. Abbreviations: T: testosterone; DHEAS: dehydroepiandrosterone; IVF: in vitro fertilization; PGT-A: preimplantation genetic testing screening for aneuploidy; AMH: anti-Mullerian hormone; FSH: follicle-stimulating hormone; LH: luteinizing hormone; E2: oestradiol; P: progesterone.

Androstenedione response to recombinant human FSH is the most valid predictor of the number of selected follicles in polycystic ovarian syndrome: (a case-control study)

Background

We aimed to test the hypothesis that the correlation of the changes in the blood Androstenedione (A₄) levels to the number of selected follicles during ovulation induction with low-dose recombinant human follicle stimulating hormone (rhFSH) is as strong as the correlation to changes in the blood Estradiol (E₂) levels in polycystic ovary syndrome (PCOS).

Methods

Prospective Case-control study conducted from October 2014 to January 2016. 61 non-PCOS control (Group I) and 46 PCOS (Group II) patients treated with the chronic low-dose step up protocosl with rhFSH. A₄, E₂, progesterone blood levels and follicular growth were monitored.. Univariate and hierarchical multivariable analysis were performed for age, BMI, HOMA-IR, A₄ and E₂ (with the number of selected follicles as the dependent variable in both groups). ROC analysis was performed to define threshold values for the significant determinants of the number of selected follicles to predict cyle cancellations due to excessive ovarian response.

Results

The control group (Group I) was comprised of 61 cycles from a group of primary infertile non-PCOS patients, and the study group (Group II) of 46 cycles of PCOS patients. The analysis revealed that the strongest independent predictor of the total number of selected follicles in Group I was the E₂(AUC) (B = 0.0006[0.0003-0.001]; P < 0.001); whereas for Group II, it was the A₄ (AUC) (B = 0.114[0.04-0.25]; P = 0.01). Optimum thresholds for the A₄ related parameters were defined to predict excessive response within Group II were 88.7%, 3.1 ng/mL and 5.4 ng*days for the percentage increase in A₄, the maximum A₄ value and area under the curve values for A₄, respectively.

Conclusion

A₄ response to low-dose rhFSH in PCOS has a stronger association with the number of follicles selected than the E₂ reponse. A₄ response preceding the E₂ response is essential for progressive follicle development. Monitoring A₄ rather than E₂ may be more preemptive to define the initial ovarian response and accurate titration of the rhFSH doses.

Trial registration

The study was registered as a prospective case-control study in the ClinicalTrials.gov registry with the identifier NCT02329483.

Androstenedione and testosterone levels correlate with in vitro fertilization rates in insulin-resistant women

BACKGROUND

The free androgen index (FAI) calculated using total testosterone measured by immunoassay does not correlate with oocyte fertilization rates; however, there is considerable cross-reactivity for testosterone with other androgens by immunoassay that is not found using isotope dilution liquid chromatography-tandem mass spectrometry (LC/MS/MS).

AIMS

This study was done to determine relationship between total testosterone and androstenedione measured by LC/MS/MS and fertilization rates.

STUDY DESIGN

49 infertile women without polycystic ovary syndrome were recruited preceding an in vitro fertilization (IVF) cycle. Serum testosterone and androstenedione were measured by LC/MS/MS and correlated with IVF parameters non-insulin resistant compared with insulin resistant (homeostatic model assessment >2.5) women.

RESULTS

For non-insulin resistant women, total testosterone FAI and androstenedione did not correlate with oocyte fertilization rates. In insulin-resistant women, there was a negative correlation between both testosterone and FAI and fertilization rates (r=-0.62, p<0.03) and r=-0.73, p=0.02, respectively). There was a positive correlation between androstenedione and fertilization rates (r=0.87, p<0.01).

CONCLUSION

For insulin-resistant women, increases in testosterone and FAI were associated with reduced fertilization rates and androstenedione was associated with increased fertilization rates when measured by LC/MS/MS that should be considered to be the measurement method of choice.