Anti-Mullerian hormone (AMH) levels in serum and follicular fluid as predictors of ovarian response in stimulated (IVF and ICSI) cycles

Factors associated with the efficacy of mature oocyte production after dual-trigger controlled ovarian stimulation using a GnRH antagonist protocol

BACKGROUND

The number of mature oocytes retrieved plays a significant role in determining embryo development and pregnancy outcomes of in vitro fertilization (IVF). However, studies investigating factors predictive of the efficacy of mature oocyte production (EMOP) after dual-trigger controlled ovarian stimulation (COS) are rare. This study aims to identify key predictors of EMOP during dual-trigger COS with a gonadotropin-releasing hormone (GnRH) antagonist protocol for IVF.

METHODS

This retrospective cohort study included 359 first-time IVF patients undergoing dual-trigger COS with a GnRH antagonist protocol. EMOP was defined as the ratio of metaphase II (MII) oocyte count to antral follicle count (AFC). Based on EMOP results, patients were divided into two groups: group A (EMOP <70%; n = 232) and group B (EMOP ≥70%; n = 127).

RESULTS

Multivariate logistic regression analysis revealed that day-2 follicle-stimulating hormone (FSH), stimulation duration, and total oocyte count were the most significant predictors of EMOP ( p < 0.05; odds ratios: 1.637, 3.400, and 1.530, respectively). Receiver operating characteristic analysis demonstrated that total oocyte count <9.5 (area under the curve [AUC], 0.782; sensitivity, 76.2%; specificity, 69.2%; p < 0.001) and stimulation duration <9.5 days (AUC, 0.725; sensitivity, 63.5%; specificity, 66.7%; p < 0.001) significantly predicted EMOP <70%. Stimulation duration combined with total oocyte count exhibited the highest power in predicting EMOP <70% (AUC, 0.767; sensitivity, 92.3%; specificity, 42.4%).

CONCLUSION

Stimulation duration combined with total oocyte count was identified as the most important factor associated with the EMOP during dual-trigger COS in IVF using a GnRH antagonist protocol.

Comparison of anti-Müllerian hormone and antral follicle count in the prediction of ovarian response: a systematic review and meta-analysis

BACKGROUND

Increasingly studies reported that the Anti-Müllerian hormone (AMH) seems to be a promising and reliable marker of functional ovarian follicle reserve, even better than the AFC test. Our study aimed to conduct a meta-analysis to assess the predictive value of AMH and AFC for predicting poor or high response in IVF treatment. An electronic search was conducted, and the following databases were used: PubMed, EMBASE, and the Cochrane Library (up to 7 May 2022). The bivariate regression model was used to calculate the pooled sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve. Subgroup analyses and meta-regression also were used in the presented study. Overall performance was assessed by estimating pooled ROC curves between AMH and AFC.

RESULTS

Forty-two studies were eligible for this meta-analysis. Comparison of the summary estimates for the prediction of poor or high response showed significant difference in performance for AMH compared with AFC [poor (sensitivity: 0.80 vs 0.74, P < 0.050; specificity: 0.81 vs 0.85, P < 0.001); high (sensitivity: 0.81 vs 0.87, P < 0.001)]. However, there were no significant differences between the ROC curves of AMH and AFC for predicting high (P = 0.835) or poor response (P = 0.567). The cut-off value was a significant source of heterogeneity in the present study.

CONCLUSIONS

The present meta-analysis demonstrated that both AMH and AFC have a good predictive ability to the prediction of poor or high responses in IVF treatment.

The intrafollicular concentration of leptin as a potential biomarker to predict oocyte maturity in in-vitro fertilization

Oocyte maturity is critical to the development potential of the embryo and pregnancy outcomes in natural and in-vitro fertilization (IVF). In IVF, oocyte maturity is typically evaluated using morphological criteria, although such assessment remains highly subjective. To identify reliable biomarkers of oocyte maturity, this study investigates the relationship between follicular cytokine concentrations and oocyte maturity in IVF patients with different ovarian reserves. In this prospective study, follicular fluid was collected during oocyte retrieval and the concentrations of cytokines involved in ovarian folliculogenesis were determined. Follicular fluid cytokine concentrations were compared between participants in three groups according to serum anti-Mullerian hormone (AMH) concentration, as follows: low AMH, < 2 ng/mL; normal AMH, 2-5 ng/mL; and high AMH, > 5 ng/mL. Pearson's correlation coefficient analysis showed that the number of mature oocytes correlated positively and strongly with serum AMH level (r = 0.719; p < 0.01). The leptin concentration in follicular fluid was significantly higher in women with normal AMH level than in those with low or high levels. ROC curve analysis showed that the follicular fluid levels of leptin (area under ROC curve, 0.829; 95% confidence interval, 0.659-0.998; p < 0.01) and SCF (area under ROC curve, 0.706; 95% confidence interval, 0.491-0.921; p = 0.087) were the best predictors of oocyte maturity. At an optimal cut-off value of 16 ng/mL, leptin had positive predictive value (sensitivity) up to 70% and negative predictive value (specificity) of 91% for indicating oocyte maturity. The concentration of leptin in follicular fluid is closely related to ovarian reserve and may serve as a biomarker to predict oocyte maturity.

The Predictive Levels of Serum Anti-Müllerian Hormone and the Combined Index of the Number of Retrieved Oocytes and Good-Quality Embryos in Advanced-Age Infertile Women

The primary objective of the study was to assess the values of serum anti-Müllerian hormone (AMH) levels and the combined index for the prediction of number of oocytes retrieved (NOR) and number of good-quality embryos (GQE) in infertile women undergoing IVF/ICSI treatment. A group of 521 infertile women aged 21-46 years were recruited as subject in this study. Serum AMH, hormones, and antral follicle count (AFC) were measured. The infertile women were categorized into three groups: 21-34 years (reproductive age), 35-39 years (reproductive age), and 40-46 years (advanced-age infertile). The predictive accuracy of variables was analyzed by the receiver operating characteristic (ROC) curve. AFC, AFC/age ratio, AMH/age ratio, and ovarian response prediction index (ORPI) decreased gradually, while AMH decreased significantly with increase in age. Moreover, NOR and GQE were positively correlated with AFC, AMH, AFC/age ratio, AMH/age ratio, and ORPI (P < 0.001). A statistical significance was observed in predicted oocyte retrieval including AMH, AMH/age ratio, and ORPI between 21-34 years and 35-46 years; especially in the 35-46 years group, these variables reached a "high" grade in the diagnostic accuracy because area under curve (AUC) ranged from 0.982 to 0.988 significantly. No statistical significance was observed for FSH, AMH, AFC, and related combined index predicting GQE. The predictive value of AFC and AFC/age ratio was limited regarding oocyte retrieval; however, AMH, AMH/age ratio, and ORPI concurrently had an excellent value for predicting NOR in reproductive-age women, especially in advanced-age infertile women.

VEGF Concentration in a Preovulatory Leading Follicle Relates to Ovarian Reserve and Oocyte Maturation during Ovarian Stimulation with GnRH Antagonist Protocol in In Vitro Fertilization Cycle

Serum vascular endothelial growth factor (VEGF) is involved in follicular vascularization, oxygenation, and consequently in oocyte maturation and embryo development. Unanswered questions remain regarding the relationship of intrafollicular VEGF level in preovulatory leading follicles to oocyte maturation and ovarian reserve during ovarian stimulation. We conducted this study to investigate the relationship of intrafollicular VEGF level in the fluid of single preovulatory leading follicles to ovarian reserve and oocyte maturation in patients receiving GnRH antagonist in vitro fertilization (IVF) protocol treatment. One hundred and eighty-five patients receiving IVF treatment were recruited and assigned to low-, normal-, and high-ovarian-reserve groups according to their serum anti-Müllerian hormone (AMH) level. Follicular fluid (FF) in preovulatory leading follicles, serum profiles, and clinical variables were collected for analysis. The result disclosed a significant among-group difference in FF VEGF concentration. Moreover, the serum AMH level was also negatively correlated with FF VEGF level. The oocyte maturation rate tended to be increased at higher AMH levels. FF VEGF concentration was significantly positively correlated with basal FSH level. In conclusion, FF VEGF concentration has a negative association with ovarian reserve level and oocyte maturation rate in patients undergoing GnRH antagonist IVF protocols.

An in silico model using prognostic genetic factors for ovarian response in controlled ovarian stimulation: A systematic review

PURPOSE

To study the use of in silica model to better understand and propose new markers of ovarian response to controlled ovarian stimulation before IVF.

METHODS

A systematic review and in silica model using bioinformatics. After the selection of 103 papers from a systematic review process, we performed a GRADE qualification of all included papers for evidence-based quality evaluation. We included 57 genes in the silica model using a functional protein network interaction. Moreover, the construction of protein-protein interaction network was done importing these results to Cytoscape. Therefore, a cluster analysis using MCODE was done, which was exported to a plugin BINGO to determine Gene Ontology. A p value of < 0.05 was considered significant, using a Bonferroni correction test.

RESULTS

In silica model was robust, presenting an ovulation-related gene network with 87 nodes (genes) and 348 edges (interactions between the genes). Related to the network centralities, the network has a betweenness mean value = 102.54; closeness mean = 0.007; and degree mean = 8.0. Moreover, the gene with a higher betweenness was PTPN1. Genes with the higher closeness were SRD5A1 and HSD17B3, and the gene with the lowest closeness was GDF9. Finally, the gene with a higher degree value was UBB; this gene participates in the regulation of TP53 activity pathway.

CONCLUSIONS

This systematic review demonstrated that we cannot use any genetic marker before controlled ovarian stimulation for IVF. Moreover, in silica model is a useful tool for understanding and finding new markers for an IVF individualization.

PROSPERO

CRD42020197185.

Novel molecular mechanisms underlying the ameliorative effect of N-acetyl-L-cysteine against ϒ-radiation-induced premature ovarian failure in rats

Radiotherapy represents a critical component in cancer treatment. However, premature ovarian failure (POF) is a major hurdle of deleterious off-target effects in young females, which, therefore, call for an effective radioprotective agent. The present study aimed to explore the molecular mechanism underlying the protective effects of N-acetyl-L-cysteine (NAC) against γ-radiation-provoked POF. Immature female Sprague-Dawley rats were orally-administered NAC (50 mg/kg) and were exposed to a single whole-body dose of 3.2 Gy ϒ-radiation. NAC administration remarkably reversed abnormal serum estradiol and anti-Müllerian hormone levels by 73% and 40%, respectively while ameliorating the histopathological and ultrastructural alterations-triggered by γ-radiation. Mechanistically, NAC alleviated radiation-induced oxidative damage through significantly increased glutathione peroxidase activity by 102% alongside with decreasing NADPH oxidase subunits (p22 and NOX4) gene expressions by 48% and 38%, respectively compared to the irradiated untreated group. Moreover, NAC administration achieved its therapeutic effect by inhibiting ovarian apoptosis-induced by radiation through downregulating p53 and Bax levels by 33% and 16%, respectively while increasing the Bcl-2 mRNA expression by 135%. Hence, the Bax/Bcl2 ratio and cytochrome c expression were subsequently reduced leading to decreased caspase 3 activity by 43%. Importantly, the anti-apoptotic property of NAC could be attributed to inactivation of MAPK signaling molecules; p38 and JNK, and enhancement of the ovarian vascular endothelial growth factor (VEGF) expression. Taken together, our results suggest that NAC can inhibit radiotherapy-induced POF while preserving ovarian function and structure through upregulating VEGF expression and suppressing NOX4/MAPK/p53 apoptotic signaling.

The role of Letrozole (LE) in controlled ovarian stimulation (COS) in patients at high risk to develop ovarian hyper stimulation syndrome (OHSS). A prospective randomized controlled pilot study

BACKGROUND

Recently, it has been shown that PCOS patients with extremely high anti-Mullerian hormone (AMH) level are more likely to experience OHSS during IVF, compared to PCOS patients with lower AMH level. While recent data questioned the effect of Letrozole (LE) on the occurrence of OHSS in non-PCOS patients, it role in PCOS patients with very high AMH level was never investigated in a prospective manners. Hence, our main objective was to evaluate the clinical outcome of PCOS patients at very high risk for OHSS undergoing two different COS protocols (with or without LE).

METHODS

A prospective randomized controlled study (RCT) of 51 patients with specifically high levels of AMH undergoing one of two COS protocols. The control group (group A) consisted of 24 PCOS women who received low-dose gonadotropins using the multiple-dose GnRH-antagonist protocol, GnRH agonist-triggered and "freeze all". The study group (group B) consisted of 24 women with PCOS who received the same protocol combined with LE. High risk criteria for OHSS were: PCOS patients with low BMI, young age, and extremely high level of serum AMH (inclusion criteria for AMH > 50 pmol/L).

RESULTS

Cumulative live birth rates per retrieval were similar in both groups. While no single case of severe OHSS was observed in, in the study group (group B), the rate of moderate and mild OHSS was 5 times lower compared to the control group (P < 0.05).

CONCLUSION

In PCOS patients with extremely high AMH levels the LE co-administration to GnRH-Ant protocols results in reduced incidence of OHSS than conventional GnRH-Ant protocols. LE co-administration may prove to be highly effective in preventing OHSS, even in the women who are at high risk to these dangerous complications.

Repeated superovulation increases the risk of osteoporosis and cardiovascular diseases by accelerating ovarian aging in mice

Superovulation procedures and assisted reproductive technologies have been widely used to treat couples who have infertility problems. Although generally safe, the superovulation procedures are associated with a series of complications, such as ovarian hyper-stimulation syndrome, thromboembolism, and adnexal torsion. The role of long-term repeated superovulation in ovarian aging and especially in associated disorders such as osteoporosis and cardiovascular diseases is still unclear. In this study, we sought to determine if repeated superovulation by ten cycles of treatment with pregnant mare serum gonadotropin/human chorionic gonadotropin could affect ovarian reserve, ovarian function, bone density and heart function. Ovarian reserve and function were reflected by the size of the primordial follicle pool, anti-Mullerian hormone expressions, hormone levels and fertility status. Furthermore, we examined bone density and heart function by microCT and cardiovascular ultrasonography, respectively. After repeated superovulation, the size of the primordial follicle pool and the expression of anti-mullerian hormone decreased, along with the concentrations of estrogen and progesterone. Mice exposed to repeated superovulation showed an obvious decrease in fertility and fecundity. Furthermore, both bone density and heart ejection fraction significantly decreased. These results suggest that repeated superovulation may increase the risk of osteoporosis and cardiovascular diseases by accelerating ovarian aging.

Genes for anti-Müllerian hormone and androgen receptor are underexpressed in human cumulus cells surrounding morphologically highly graded oocytes

Objectives:

The aim of this study was to investigate the expression of genes crucial for the quality of the oocyte and whether expression levels of these genes in cumulus cells can be biological markers for the quality of the oocyte, zygote or embryo, or even for achievement of pregnancy after the assisted reproductive technology procedure. We examined the expression profile of the anti-Müllerian hormone (AMH) gene and its respective receptors: anti-Müllerian hormone receptor type 2 (AMHR2), follicle-stimulating hormone receptor (FSHR) and androgen receptor (AR) in cumulus cells (CCs) surrounding the oocyte, as well as AMH concentrations in follicular fluid of the associated follicle. The obtained gene expression levels were correlated with the morphological quality of the associated oocyte, zygote and embryo as well as with assisted reproductive technology outcome following the intracytoplasmic sperm injection procedure.

Methods:

This study involved 129 cumulus cells and 35 follicular fluid samples, taken from 58 patients undergoing the intracytoplasmic sperm injection procedure. Oocytes, zygotes and embryos were assessed for morphological quality. The relative gene expression of AMH, AMHR2, FSHR and AR was calculated using the delta–delta Ct method. Anti-Müllerian hormone concentrations in follicular fluids were measured by enzyme-linked immunosorbent assay.

Results:

The results yielded suggest a relationship between AMH, AR and oocyte morphology: AMH and AR gene expression levels in CCs surrounding morphologically optimal oocytes were significantly lower than in CCs surrounding oocytes with suboptimal morphology (p = 0.011 and p = 0.008, respectively). Statistically significant positive correlation was found between mRNA expression levels of AMH and FSHR (p < 0.001), AMH and AR (p = 0.001), AMHR2 and FSHR (p < 0.001), AMHR2 and AR (p < 0.001), as well as between FSHR and AR (p < 0.001).

Conclusion:

Assessed results point to AMH and AR relation with oocyte maturity, but not with its fertilization potential, or with embryo quality.

The role of anti-Mullerian hormone in predicting the response to clomiphene citrate in unexplained infertility

OBJECTIVE

To determine the role of anti-Mullerian hormone (AMH) levels in predicting the response to clomiphene citrate (CC) therapy for ovulation induction in women with unexplained infertility.

MATERIALS AND METHODS

For this retrospective study, fifty consecutive patients who responded to CC were taken as Group 1, while fifty consecutive patients who failed to show adequate ovulatory response with CC were taken as Group 2. We compared the AMH levels of the two groups and receiver operating characteristic (ROC) curve was used to determine the threshold for AMH in predicting the ovulatory response to CC therapy.

RESULTS

Mean age, body mass index, luteinizing hormone, prolactin, and thyroid-stimulating hormone values were similar in the two groups. AMH and antral follicle count (AFC) values were higher in Group 1 than in Group 2 (p = 0.001 and p = 0.001, respectively). There was a statistically significant negative correlation between FSH and AFC (r = -0.339, p = 0.001), while AFC and AMH displayed a statistically significant positive correlation (r = 0.713 and p = 0.001). AMH values and AFC were found to be predictors of the adequate ovulatory response to CC. The area under the ROC curve was 0.86 vs 0.80, respectively. At an AFC cutoff value of 14, the sensitivity and specificity for prediction of ovulation were 68% and 80%, respectively.

CONCLUSION

The AMH and AFC cut-off values for the prediction of positive ovarian response to CC in patients with unexplained infertility were 2.78 ng/mL and 14, respectively. If further prospective and randomized studies confirm our results, these thresholds may be useful to predict successful ovulation induction and reduce the unresponsive cycles.

Decline in Female Fertility After 40 Years

Important factor related to the conception possibility is women age. The decline in fertility with aging is proven and evident in literature. Infertility is increasing and many couples seek help in advanced techniques such as IVF (in vitro fertilization) in order to overcome the problem caused by aging, but the quality of the oocytes is a significant limiting factor. With the aging the quantity and quality of oocytes decreases, such as the quality of the embryo after fertilization. The accelerated rhythm of life, liberty and women inclusion in all kinds of professions brought many benefits to women, but also increasingly postponing births. Each person is unique individual, and can be more or less fertile compared to the average at same age. Unfortunately, some women has a rapid decline in fertility - accelerate aging, very early, already in the early twenties and when testing them with different methods and exams, the result is very low number of oocytes, low value of anti-Müllerian hormone and also very poor quality of these oocytes, or low ovarian reserve. The problem is that when you have accelerate aging, even IVF techniques can not be of great help in achieving pregnancy. The pregnancy rate (17,65%) and the childbirth rate (5,88%) with the patients older than 40 is very low, although comparable to the data from the scientific literature and speaks in favour of the fact that the success of assisted reproductive techniques is very modest with women older than 44.

Age-related nomograms of serum anti-Mullerian hormone levels in female monkeys: Comparison of rhesus (Macaca mulatta) and cynomolgus (Macaca fascicularis) monkeys

AMH is regarded as a promising predictor for ovarian reserve in humans and non-human primate, and widely used in human medicine to predict ovarian response to gonadotropin, menopause and premature ovarian failure. However, large data set on the range of AMH levels in nonhuman primates is still scarce, which limited its applications largely. In this study, age-related AMH nomograms of rhesus (Macaca mulatta) and cynomolgus (Macaca fascicularis) were produced and compared. 219 rhesus and 529 cynomolgus monkeys ranging from infancy to adult were included. In total, the mean serum AMH levels in cynomolgus monkeys were higher than that of rhesus monkeys (14.6 ± 5.3 ng/ml vs 9.5 ± 6.0 ng/ml, P < 0.001). AMH was inversely correlated with age (r = -0.371, P < 0.001) in rhesus, while the negative correlation did not reach statistical significance in cynomolgus monkeys (r = -0.044, P = 0.156). The maximum mean AMH levels were attained at the subgroup of 4-11 yr and the lowest AMH levels were obtained at the subgroup of ≧12 yr in both primates, corresponding to their fertility potential. In rhesus monkeys, from 1 to 11 years old, AMH level remained stable (1-3 yr: ß = 2.784, P = 0.340; 4-11 yr: r = 0.100, P = 0.110) whereas from 12 yr onward, an inverse correlation between AMH and age (r = -0.450, P = 0.02) was observed. Similarly, AMH appeared stable from 1 to 3 yr (ß = -2.289, P = 0.429) and showed an inverse correlation with age (r = -0.521, P < 0.001) from 12 yr onward in cynomolgus monkeys, while a positive correlation was observed (r = 0.156, P = 0.001) from 4 to 11 yr. AMH levels were relatively stable across the menstrual cycle in both primates and no seasonal difference for AMH levels was observed in rhesus monkeys. Body mass index did not affect serum AMH levels in both primates. Our nomograms of serum AMH provide a reference guide on AMH longitudinal distribution by age for Macaca monkeys and might facilitate its applications.

Relationship between anti-Müllerian hormone and fertility in the mare

The objectives of this study were to evaluate; 1) the stability of measured serum anti-Müllerian hormone (AMH) concentrations in samples after multiple freeze-thaw cycles, 2) the repeatability of AMH concentrations within mares during the same breeding season as well as across breeding seasons, and 3) the relationship between serum AMH concentrations and fertility (measured as first cycle pregnancy rates) in thoroughbred mares. For the first aim, AMH concentrations (n = 9) were examined across four freeze-thaw cycles with no significant change in measured AMH concentrations. For the second aim, serum AMH concentrations (n = 12) were examined over three successive estrous cycles and over two successive breeding seasons and AMH levels were significantly correlated for individual animals within (r; 0.71-82) or across breeding seasons (r = 0.81). For the third aim, Thoroughbred mares (n = 419) on farms in central Kentucky had blood samples taken during estrus. Pregnancy was determined with transrectal ultrasonography at Days 13-18 after mating and ovulation, and pregnancy outcome was recorded as open, pregnant or twins. The relationships between mare age, serum AMH concentrations and the interaction of age and AMH with pregnancy outcome was examined by nominal logistic regression, and the relationship between serum AMH concentrations and mare age, pregnancy outcome and the interaction of age and pregnancy outcome was examined by ANOVA. Data in this study were then stratified according to quartiles into lower (25%), mid-50% (second and third quartiles combined - 50%) and upper (25%) quartiles for age and serum AMH concentration for further analysis by logistic regression. There were significant effects of mare age and pregnancy outcome, but not their interaction on serum AMH concentrations which were higher (P = 0.04) in pregnant than in open mares (0.65 ± 0.03 vs 0.55 ± 0.04 ng/mL, respectively). Likewise, logistic regression revealed significant effect of mare age and AMH but not their interaction on pregnancy outcome on the first mated cycle. Mares in the lower AMH quartile were more likely to be open at Day 13-18 than mares in the middle (odds ratio (OR) = 1.87)=13 or upper quartile (OR = 2.62) for AMH concentrations. Mares in the mid-50% (OR = 3.91) or upper (OR = 4.97) age quartile were more likely to be open at Day 13-18 compared to mares in the young age quartile. Based upon a Chi-squared analysis, the proportion of pregnant mares differed across age quartiles (P < 0.0001) and was greater (P < 0.05) in the young mare quartile. The proportion of pregnant mares tended to differ across AMH quartile (P = 0.1), and when adjusted for age quartile using the Cochran-Mantel-Haenszel Test, the proportion of pregnant mares differed (P < 0.05) across AMH quartile. In conclusion, mares with peripheral AMH concentrations in the lowest quartile had lower fertility compared to mares in the mid-50% or upper quartile.

Curcumin exerts a protective effect against premature ovarian failure in mice

This study was designed to investigate the protective effect of curcumin against d-galactose (d-gal)-induced premature ovarian failure (POF) in mice. A mouse POF model was induced by subcutaneous injection of d-gal (200 mg/kg/day) daily for 42 days. Mice in the curcumin group received both d-gal treatment and intraperitoneal injection of curcumin (100 mg/kg/day) for 42 days. Ovarian function, oxidative stress and apoptosis were evaluated. The P, E2 and SOD levels were higher, and the FSH, LH and MDA levels were significantly lower in the curcumin group than those in the d-gal group. The proportion of primordial follicles was also significantly higher in the curcumin group than that in the d-gal group. In addition, curcumin treatment after d-gal administration resulted in significantly lower Sod2, Cat, 8-OhdG, 4-HNE, NTY and senescence-associated protein P16 expression levels, higher Amh expression levels and less apoptosis in granulosa cells than was observed in the d-gal group. Moreover, the p-Akt, Nrf2 and HO-1 protein expression levels were significantly higher and the apoptosis-related cleaved caspase-3 and -9 protein expression levels were markedly lower in the curcumin group than in the d-gal group. In conclusion, curcumin effectively inhibited d-gal-induced oxidative stress, apoptosis and ovarian injury via a mechanism involving the Nrf2/HO-1 and PI3K/Akt signaling pathways, suggesting that curcumin is a potential protective agent against POF.

Protective effects and mechanisms investigation of Kuntai capsule on the ovarian function of a novel model with accelerated aging ovaries

ETHNOPHARMACOLOGICAL RELEVANCE

Kuntai capsule, a traditional Chinese medicine, has been widely used for the clinical treatment of menopausal syndrome. However, its mechanisms remain poorly understood. Considering that aging ovaries are the primary cause of menopause, this study was designed to investigate the effects and mechanisms of Kuntai capsule on ovarian function in a novel mice model with accelerated aging ovaries.

MATERIALS AND METHODS

Seventy-five female C57BL/6 mice were chosen for this study. Fifteen of the mice were separated into the normal control group (NC). The remaining sixty were used to establish the novel accelerated aging ovary model by superovulation and oxidative stress and then by randomly dividing the mice into four equal groups. One group was considered the model group (Mod). The other three groups were treated with low (0.4g/kg), middle (0.8g/kg) and high (1.6g/kg) doses of Kuntai capsule intragastrically every day for 4 weeks. During the treatment, the body weight and fur condition of all mice were recorded. All the mice were forced to swim to record their exhaustive swimming time (EST), which measures their strength. Mice were then sacrificed for sampling. Ovarian reserve was evaluated using follicle counts and AMH expression. Ovarian function was evaluated using estrous cycle, sex hormone level and litter experiments. Ovarian follicles were categorized and counted to estimate ovarian reserve, and ovarian histologic sections were stained for terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) to detect apoptotic cells. The ultrastructure of ovarian cells was observed using transmission electron microscopy. Western blotting was used to measure expression of Bax, Bcl2, AMH and SOD2 protein.

RESULTS

Compared with the NC GROUP, the Mod group clearly displayed worse fur condition and ovarian function. These situations showed some improvement after Kuntai capsule treatment. Specifically, the fur condition and the EST of the Kuntai capsule groups were superior to the fur condition and EST of the Mod group. In cases of damaged ovarian function, Kuntai capsule can regulate the estrous cycles, increase hormone secretion and fertility and significantly decrease atretic follicles. The transmission electron microscopy results revealed that Kuntai capsule rescued the ovarian ultrastructure of mice. TUNEL staining confirmed that the apoptotic cells were reduced after Kuntai capsule treatment. Western blotting revealed that Kuntai capsule can increase AMH, SOD2, and Bcl2 protein expression and decrease Bax expression.

CONCLUSIONS

Kuntai capsule may improve damaged ovarian function, which may be related to its antioxidant and anti-apoptosis effects.

The use of serum anti-Mullerian hormone (AMH) levels and antral follicle count (AFC) to predict the number of oocytes collected and availability of embryos for cryopreservation in IVF

AIM

To investigate the predictive value of anti-Mullerian hormone (AMH) and antral follicle count (AFC) on the final number of oocytes retrieved and the availability of embryos for cryopreservation in in vitro fertilization (IVF) cycles.

PATIENTS AND METHODS

In this prospective study, one hundred and twenty women in their first IVF treatment were enrolled. The short stimulation agonist protocol was used for controlled ovarian hyperstimulation in all cases. Serum AMH levels were measured during the menstrual cycle preceding treatment. AFC was measured in cycle day 2, just before starting ovarian stimulation.

RESULTS

A strong, positive correlation between AMH, AFC and the number of collected oocytes was found. The patients with available and suitable supplementary embryos for cryopreservation had higher levels of AMH and larger numbers of AFC.

CONCLUSION

AMH and AFC appear to be valuable markers mainly for ovarian reserve and response to IVF treatment. Serum AMH levels and AFC are significantly associated with the number of retrieved oocytes. Also, a positive correlation with the availability of supernumerary embryos suitable for cryopreservation was observed.

A higher anti-Müllerian hormone level is associated with an increased chance of pregnancy in patients undergoing controlled ovarian stimulation and intrauterine insemination

Anti-Müllerian hormone (AMH) level has been found to be a useful marker of ovarian reserve, and a predictor of poor and hyper-responses in patients undergoing controlled ovarian stimulation (COS). The study aimed to determine the association of serum AMH level with achieving pregnancy in patients undergoing COS with intrauterine insemination. The cross-sectional study investigated 204 patients who underwent COS with intrauterine insemination at the Obstetrics and Gynecology Department of Taipei Medical University Hospital, from January 2011 to March 2012. The medical records of these patients were reviewed, and serum AMH levels were evaluated for association with successful clinical pregnancy. The AMH level in the patients who achieved clinical pregnancy was significantly higher than in patients who did not (median 2.7 vs 2.0 ng/ml, p = 0.005). Controlling for factors affecting infertility, AMH level had a significant independent influence on outcome; a higher AMH level was associated with a decreased risk of a non-pregnant outcome (odds ratio, OR = 0.895, p = 0.026). In patients undergoing COS and intrauterine insemination, a low AMH level is associated with a decreased chance of a clinical pregnancy, and this association remains irrespective of the presence or absence of endometriosis.

Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: from theory to practice

BACKGROUND

The main objective of individualization of treatment in IVF is to offer every single woman the best treatment tailored to her own unique characteristics, thus maximizing the chances of pregnancy and eliminating the iatrogenic and avoidable risks resulting from ovarian stimulation. Personalization of treatment in IVF should be based on the prediction of ovarian response for every individual. The starting point is to identify if a woman is likely to have a normal, poor or a hyper response and choose the ideal treatment protocol tailored to this prediction. The objective of this review is to summarize the predictive ability of ovarian reserve markers, such as antral follicle count (AFC) and anti-Mullerian hormone (AMH), and the therapeutic strategies that have been proposed in IVF after this prediction.

METHODS

A systematic review of the existing literature was performed by searching Medline, EMBASE, Cochrane library and Web of Science for publications in the English language related to AFC, AMH and their incorporation into controlled ovarian stimulation (COS) protocols in IVF. Literature available to May 2013 was included.

RESULTS

The search generated 305 citations of which 41 and 25 studies, respectively, reporting the ability of AMH and AFC to predict response to COS were included in this review. The literature review demonstrated that AFC and AMH, the most sensitive markers of ovarian reserve identified to date, are ideal in planning personalized COS protocols. These sensitive markers permit prediction of the whole spectrum of ovarian response with reliable accuracy and clinicians may use either of the two markers as they can be considered interchangeable. Following the categorization of expected ovarian response to stimulation clinicians can adopt tailored therapeutic strategies for each patient. Current scientific trend suggests the elective use of the GnRH antagonist based regimen for hyper-responders, and probably also poor responders, as likely to be beneficial. The selection of the appropriate and individualized gonadotrophin dose is also of paramount importance for effective COS and subsequent IVF outcomes.

CONCLUSION

Personalized IVF offers several benefits; it enables clinicians to give women more accurate information on their prognosis thus facilitating counselling especially in cases of extremes of ovarian response. The deployment of therapeutic strategies based on selective use of GnRH analogues and the fine tuning of the gonadotrophin dose on the basis of potential ovarian response in every single woman can allow for a safer and more effective IVF practice.