What number of oocytes is appropriate for defining poor ovarian response?

Young women with poor ovarian response exhibit epigenetic age acceleration based on evaluation of white blood cells using a DNA methylation-derived age prediction model

STUDY QUESTION

Is poor ovarian response associated with a change in predicted age based on a DNA methylation-derived age prediction model (the Horvath algorithm) in white blood cells (WBCs) or cumulus cells (CCs)?

SUMMARY ANSWER

In young women, poor ovarian response is associated with epigenetic age acceleration within WBC samples but is not associated with age-related changes in CC.

WHAT IS KNOWN ALREADY

The majority of human tissues follow predictable patterns of methylation which can be assessed throughout a person's lifetime. DNA methylation patterns may serve as informative biomarkers of aging within various tissues. Horvath's 'epigenetic clock', which is a DNA methylation-derived age prediction model, accurately predicts a subject's true chronologic age when applied to WBC but not to CC.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was carried out involving 175 women undergoing ovarian stimulation between February 2017 and December 2018. Women were grouped according to a poor (≤5 oocytes retrieved) or good (>5 oocytes) response to ovarian stimulation. Those with polycystic ovary syndrome (PCOS) (n = 35) were placed in the good responder group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

DNA methylation patterns from WBC and CC were assessed for infertile patients undergoing ovarian stimulation at a university-affiliated private practice. DNA was isolated from peripheral blood samples and CC. Bisulfite conversion was then performed and a DNA methylation array was utilized to measure DNA methylation levels throughout the genome. Likelihood ratio tests were utilized to assess the relationship between predicted age, chronologic age and ovarian response.

MAIN RESULTS AND THE ROLE OF CHANCE

The Horvath-predicted age for WBC samples was consistent with patients' chronologic age. However, predicted age from analysis of CC was younger than chronologic age. In subgroup analysis of women less than 38 years of age, poor ovarian response was associated with an accelerated predicted age in WBC (P = 0.017). Poor ovarian response did not affect the Horvath-predicted age based on CC samples (P = 0.502). No alternative methylation-based calculation was identified to be predictive of age for CC.

LIMITATIONS, REASONS FOR CAUTION

To date, analyses of CC have failed to identify epigenetic changes that are predictive of the aging process within the ovary. Despite the poor predictive nature of both the Horvath model and the novel methylation-based age prediction model described here, it is possible that our efforts failed to identify appropriate sites which would result in a successful age-prediction model derived from the CC epigenome. Additionally, lower DNA input for CC samples compared to WBC samples was a methodological limitation. We acknowledge that a universally accepted definition of poor ovarian response is lacking. Furthermore, women with PCOS were included and therefore the group of good responders in the current study may not represent a population with entirely normal methylation profiles.

WIDER IMPLICATIONS OF THE FINDINGS

The process of ovarian and CC aging continues to be poorly understood. Women who demonstrate poor ovarian response to stimulation represent a common clinical challenge, so clarifying the exact biological changes that occur within the ovary over time is a worthwhile endeavor. The data from CC support a view that hormonally responsive tissues may possess distinct epigenetic aging patterns when compared with other tissue types. Future studies may be able to determine whether alternative DNA methylation sites can accurately predict chronologic age or ovarian response to stimulation from CC samples. Going forward, associations between epigenetic age acceleration and reproductive and general health consequences must also be clearly defined.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for the study and there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Optimal numbers of mature oocytes to produce at least one or multiple top-quality day-3 embryos in normal responders

Objective

We attempted to identify the optimal cutoff numbers of mature oocytes that would produce at least one or multiple top-quality (grade A) day-3 embryos in normal responders undergoing stimulated in vitro fertilization (IVF) cycles.

Methods

We selected 210 fresh IVF cycles performed in 170 infertile women at a single center from January 2014 to November 2019. Four to 14 (total) oocytes were obtained in all cycles after conventional ovarian stimulation. A receiver operating characteristic curve analysis was performed to find the moderate and extreme cutoff numbers of mature oocytes that would produce ≥ 1, ≥ 2, ≥ 3, ≥ 4, and ≥ 5 top-quality embryos.

Results

The cutoff number of mature oocytes was significantly correlated with the number of top-quality embryos (r = 0.467, p= 0.000). The moderate cutoff number of mature oocytes was ≥ 3, ≥ 5, ≥ 5, ≥ 6, and ≥ 6 for obtaining ≥ 1, ≥ 2, ≥ 3, ≥ 4, and ≥ 5 top-quality embryos, respectively. The extreme cutoff number of mature oocytes was ≥ 9, ≥ 9, ≥ 10, ≥ 10, and ≥ 11 for obtaining ≥ 1, ≥ 2, ≥ 3, ≥ 4, and ≥ 5 top-quality embryos, respectively.

Conclusion

We present the optimal cutoff numbers of mature oocytes that would yield ≥ 1, ≥ 2, ≥ 3, ≥ 4, and ≥ 5 top-quality embryos with 95% specificity. Our findings could help infertility clinicians to set target mature oocyte numbers in women undergoing stimulated IVF cycles.

Luteal phase ovarian stimulation for poor ovarian responders

Objective

To compare the clinical outcomes of follicular versus luteal phase ovarian stimulation in women with poor ovarian response (Bologna criteria) undergoing IVF.

Methods

This retrospective study investigated 446 patients submitted to 507 cycles in three groups. First, the two larger cohorts were examined: 154 patients treated with luteal phase ovarian stimulation (Group Lu); and 231 patients administered follicular phase ovarian stimulation (Group Fo). Then the clinical outcomes of 61 patients submitted to double ovarian stimulation were analyzed. Clinical outcomes included number of retrieved oocytes, fertilization rate, cleavage rate, top-quality embryo rate, clinical pregnancy rate (CPR), and live birth rate (LBR).

Results

Longer stimulation, higher dosages of HMG, and higher MII oocyte rates were achieved in Group Lu (p<0.001). There were no significant differences in CPR and LBR between the two groups offered frozen-thawed embryo transfer (28.4% vs. 33.0%, p=0.484; 22.9% vs. 25.5%, p=0.666). In the double ovarian stimulation group, the number of oocytes retrieved in the luteal phase stimulation protocol was higher (p=0.035), although luteal phase stimulation yielded a lower rate of MII oocytes (p=0.031). CPR and LBR were not statistically different (13.8% vs. 21.4%, p=0.525; 10.3% vs. 14.3%, p=0.706).

Conclusion

Luteal phase ovarian stimulation may be a promising protocol to treat women with POR, particularly for patients unable to yield enough viable embryos through follicular phase ovarian stimulation or other protocols.

Utilization of the Bologna criteria: a promise unfulfilled? A review of published and unpublished/ongoing trials

OBJECTIVE

To study the use of the Bologna criteria (BC) for the definition of poor ovarian responders (POR) in clinical practice and research.

DESIGN

Systematic review of published and unpublished/ongoing trials between January 2012 and August 2017 on POR.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

The databases were searched using the relevant medical subject headings including all subheadings. The search was limited to humans and English language. The references of the included studies were cross-searched for possibly missed articles. Only clinical trials providing an evidence level ≥ III were included. Case reports, review, letters, and hypothetical articles were excluded.

MAIN OUTCOME MEASURE(S)

Extracted studies were divided into two groups: studies in which the BC were used or not.

RESULT(S)

One hundred nine published clinical studies analyzing a total of 30,540 women and 112 unpublished/ongoing trials were identified. The BC were used to define POR in 56 (51%) of the published and 44 (39%) of the unpublished trials. The use of the BC gradually increased from 29% to 53% from 2012 to 2017. Asian researchers were more likely to use the BC compared with European and North American researchers (65%, 49%, and 23%, respectively). Neither the design of the study nor the impact factor of the publishing journal was correlated with the use of the BC.

CONCLUSION(S)

There is still reluctance to use the BC for the definition of POR, which makes it difficult to combine data from small studies and reach a meaningful conclusion.

Proteomic analysis of human follicular fluid in poor ovarian responders during in vitro fertilization

Poor ovarian response (POR) in controlled ovarian stimulation is often observed during in vitro fertilization and embryo transfer cycles and it is a major problem. A POR has been found to be related to several factors, including advanced age, high body mass index, and history of ovarian or pelvic surgery. However, it is difficult to predict POR, as there are no specific biomarkers known. In this study, we used quantitative proteomic analyses to investigate potential biomarkers that can predict poor response during in vitro fertilization based on follicular fluid samples. A total of 1079 proteins were identified using a high-resolution orbitrap mass spectrometer coupled online to a nanoflow-LC system. It is notable that 65 upregulated and 66 downregulated proteins were found to be functionally enriched in poor responders. We also validated these differentially expressed proteins using a triple-quadrupole mass spectrometer for quantification of targeted proteins. Of the differentially expressed proteins, three proteins (pregnancy zone protein, renin, and sushi repeat-containing protein SRPX) were regarded as statistically significant (p < 0.05).

Outcome of ICSI with motile testicular spermatozoa obtained through microscopically assisted testicular sperm extraction in relation to the ovarian response

INTRODUCTION

To determine the relationship between AFC, basal FSH level, woman's age, the number of oocytes retrieved and the outcome of ICSI with testicular spermatozoa obtained with microscopically assisted testicular sperm extraction.

MATERIAL AND METHODS

In this retrospective cohort study, a total of 340 couples who underwent ICSI treatment with testicular sperm were enrolled. Women aged?40years and the first cycles of couples were included. ICSI was performed with motile testicular spermatozoa obtained from 89 men with obstructive azoospermia and 251 men with nonobstructive azoospermia. GnRH-antagonist protocol was used for ovulation induction. Simple linear regression was carried out to analyze relationship between the AFC, basal FSH, woman's age, the number of oocytes, and the live birth rate (LBR). Receiver operator characteristic curves (ROC) were formed to detect cut-off values below which LBR was significantly decreased. ROC curve analysis demonstrated that the cut-off level of the number of oocytes retrieved to predict the LBR was 7. According to this cut-off level, all patients were divided into two groups. Women with retrieved<7 oocytes were included in Group 1 and women with retrieved?7 oocytes were included in Group 2.

RESULTS

The mean age of men was 35.1±4.9years. The mean age, mean FSH level and mean AFC of women were 32.1±4.9years, 6.9±2.7 IU/L, 7.6±3.4, respectively. Significant correlations were found between AFC, the number of oocytes retrieved, and the LBR per ICSI cycle with testicular spermatozoa. The LBR was significantly lower in women with AFC<8 than those with AFC?8. Independently, the LBR was significantly lower in cycles with<7 oocytes retrieved compared to those with ?7. Embryo transfer was not achieved in 37 cycles with<7 oocytes (37/167, 22.1%) and 18 cycles with?7 (18/173, 10.4%) because of the absence of transfer-quality embryos (P=0.005). The LBRs were the lowest in cycles with one or two oocytes available (8.3 and 8.3%, respectively), but these rates were not statistically different than those in cycles with 3, 4, 5 and 6 oocytes (14.2, 17.2, 18.5, 17.6%, respectively, P=0.810).

CONCLUSIONS

AFC and the number of oocytes retrieved are important prognostic factors in an ICSI cycle with testicular sperm in women ?40years, yielding significantly diminished LBRs with<8 antral follicles and/or<7 oocytes retrieved.

In vitro fertilization outcomes in women with surgery induced diminished ovarian reserve after endometrioma operation: Comparison with diminished ovarian reserve without ovarian surgery

Objective

To compare the in vitro fertilization (IVF) outcomes between women with diminished ovarian reserve (DOR) after endometrioma operation and women with DOR without ovarian surgery.

Methods

This retrospective case-control study included 124 women aged under 40 and had DOR (serum anti-Müllerian hormone level <1.1 ng/mL or antral follicle count ≤6). They participated in fresh first and/or second IVF cycles between March in 2010 and December in 2015. Basal characteristics and IVF outcomes were compared between 47 cycles (32 women) with surgery-induced DOR and 119 cycles (92 women) with DOR without ovarian surgery.

Results

Basal characteristics were similar in both groups except that the median ages were lower in the surgery-induced DOR group compared to the DOR group without ovarian surgery. The data regarding the controlled ovarian stimulation and IVF cycle outcomes showed similar result in both groups. Also, clinical pregnancy and live birth rate were not different significantly between two groups.

Conclusion

In the same condition of DOR, clinical pregnancy and live birth rate were not different significantly between two groups regarding etiology of DOR.

The meaning of anti-Müllerian hormone levels in patients at a high risk of poor ovarian response

Measurements of ovarian reserve play an important role in predicting the clinical results of assisted reproductive technology (ART). The ideal markers of ovarian reserve for clinical applications should have high specificity in order to determine genuine poor responders. Basal follicle-stimulating hormone levels, antral follicle count, and serum anti-Müllerian hormone (AMH) levels have been suggested as ovarian reserve tests that may fulfill this requirement, with serum AMH levels being the most promising parameter. Serum AMH levels have been suggested to be a predictor of clinical pregnancy in ART for older women, who are at a high risk for decreased ovarian response. We reviewed the prognostic significance of ovarian reserve tests for patients undergoing ART treatment, with a particular focus on the significance of serum AMH levels in patients at a high risk of poor ovarian response.

Effect of normal sperm morphology rate (NSMR) on clinical outcomes and fertilization methods selection in the ultra-short-term GnRH-a protocol

PURPOSE

To investigate whether intracytoplasmic sperm injection (ICSI) can improve the clinical outcomes of the male patients with teratozoospermia in the ultra-short term GnRH-a protocol.

METHODS

Based on different normal sperm morphology rate (NSMR), the patients were divided into three groups as follows: NSMR = 0% group, 1% ≤NSMR <4% group and NSMR ≥4% group. Each group was compared with two fertilization type of in-vitro fertilization (IVF) and ICSI separately. Main outcomes compared were normal fertilization, high-quality embryo, transferrable embryo, implantation, pregnancy and abortion rate.

RESULTS

We observed that the total clinical pregnancy rate in single cleavage-stage embryo transfer (SET) group was significantly lower compared with double cleavage-stage embryo transfer (DET) group (23.87% versus 40.08%; p < 0.001). There was no significant difference in the aspects of female age, endometrial thickness, infertility duration and the number of retrieved oocytes among three groups (p > 0.05). The normal fertilization, high-quality embryo, transferrable embryo, implantation, pregnancy and abortion rate of IVF and ICSI showed no significant difference among three groups (p > 0.05).

CONCLUSION

ICSI cannot improve clinical outcomes of the patients with teratozoospermia in the ultra-short term GnRH-a protocol.