Ovarian Reserve Markers to Identify Poor Responders in the Context of Poseidon Classification

Clinical factors associated with unexpected poor or suboptimal response in Poseidon criteria patients

RESEARCH QUESTION

What clinical factors are associated with 'unexpected' poor or suboptimal responses to IVF ovarian stimulation per POSEIDON's criteria, and which AMH and AFC threshold values distinguish this population?

DESIGN

Tri-centre retrospective cohort study (2015-2017) involving first-time IVF and ICSI cycles with conventional ovarian stimulation (≥150 IU/day of FSH). Eligibility criteria included sufficient ovarian reserve markers according to POSEIDON's classification (AMH ≥1.2 ng/ml; AFC ≥5). Ovarian response categories were poor (<4 oocytes), suboptimal (4-9 oocytes) and normal (≥9 oocytes). Primary outcomes included clinical factors associated with an unexpected poor or suboptimal response to conventional ovarian stimulation using logistic regression analyses, and the threshold values of AMH and AFC predicting increased risk of such responses using ROC curves.

RESULTS

A total of 7625 patients met the inclusion criteria: 204 (9.3%) were poor and 1998 (90.7%) were suboptimal responders. Logistic regression identified significant clinical predictors for a poor or suboptimal response, including AFC, AMH, total gonadotrophin dose, gonadotrophin type and trigger type (P ≤ 0.02). The ROC curves indicated that AMH 2.87 ng/ml (AUC 0.740) and AFC 12 (AUC 0.826) were the threshold values predicting a poor or suboptimal response; AMH 2.17 ng/ml (AUC 0.741) and AFC 9 (AUC 0.835) predicted a poor response; and AMH 2.97 ng/ml (AUC 0.722) and AFC 12 (AUC 0.801) predicted a suboptimal response.

CONCLUSIONS

The threshold values of AMH and AFC predicting 'unexpected' poor or suboptimal response were higher than expected. These findings have critical implications for tailoring IVF stimulation regimens and dosages.

Nomogram to predict the probability of clinical pregnancy in women with poor ovarian response undergoing in vitro fertilization/ intracytoplasmic sperm injection cycles

BACKGROUND

Poor ovarian response (POR) is associated with decreased clinical pregnancy rates, emphasizing the need for developing clinical prediction models. Such models can improve prognostic accuracy, personalize medical interventions, and ultimately enhance live birth rates among patients with POR.

OBJECTIVE

This study aims to develop and validate a prognostic model for predicting clinical pregnancy outcomes in individuals with POR undergoing in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) cycles.

METHODS

A retrospective cohort of 969 patients with POR undergoing fresh embryo transfer cycles at the Reproductive Center of Fujian Maternal and Child Health Center from January 2018 to January 2022 was included. The cohort was randomly divided into model (n = 678) and validation (n = 291) groups in a 7:3 ratio. A single-factor analysis was performed on the model group to identify variables influencing clinical pregnancy. Optimal variables were selected using LASSO regression, and a clinical prediction model was constructed using multivariate logistic regression analysis. The model's calibration and discrimination were assessed using receiver operating characteristic (ROC) and calibration curves, while the clinical utility was evaluated using decision curve analysis.

RESULTS

Multivariate logistic regression analysis revealed that the age of the women (odds ratio [OR] 0.936, 95% confidence interval [CI] 0.898-0.976, P = 0.002), body mass index (BMI) ≤ 24 (OR 2.748, 95% CI 1.724-4.492, P < 0.001), antral follicle count (AFC) (OR 1.232, 95% CI 1.073-1.416, P = 0.003), anti-Müllerian hormone (AMH) (OR 1.67, 95% CI 1.178-2.376, P = 0.004), number of mature oocytes (OR 1.227, 95% CI 1.075-1.403, P = 0.003), number of embryos transferred (OR 1.692, 95% CI 1.132-2.545, P = 0.011), and transfer of high-quality embryos (OR 3.452, 95% CI 1.548-8.842, P = 0.005) were independent predictors of clinical pregnancy in patients with POR. According to the receiver operating characteristic (ROC) analysis, the prediction model exhibited an area under the curve (AUC) of 0.752 (0.714, 0.789) in the model group and 0.765 (0.708, 0.821) in the validation group. The clinical decision curve demonstrated that the model held maximum clinical utility in both cohorts when the threshold probability of clinical pregnancy ranged from 6-81% to 12-82%, respectively.

CONCLUSION

Clinical pregnancy outcomes in patients with POR who underwent IVF/ICSI treatment were influenced by several independent factors, including the age of the women, BMI, AFC, AMH, number of mature oocytes, number of embryos transferred, and transfer of high-quality embryos. A clinical prediction model based on these factors exhibited favorable clinical predictive and applicative value. Therefore, this model can serve as a valuable tool for clinical prognosis, intervention, and facilitating personalized medical treatment.

Low and High-Normal FMR1 Triplet Cytosine, Guanine Guanine Repeats Affect Ovarian Reserve and Fertility in Women Who Underwent In Vitro Fertilization Treatment? Results from a Cross-Sectional Study

Dynamic mutations in the 5' untranslated region of FMR1 are associated with infertility. Premutation alleles interfere with prenatal development and increase infertility risks. The number of CGG repeats that causes the highest decrease in ovarian reserves remains unclear. We evaluated the effect of FMR1 CGG repeat lengths on ovarian reserves and in vitro fertilization (IVF) treatment outcomes in 272 women with alleles within the normal range. FMR1 CGG repeat length was investigated via PCR and capillary electrophoresis. Alleles were classified as low-normal, normal, and high-normal. Serum levels of follicle-stimulating hormone and anti-Mullerian hormone (AMH) in the follicular phase of the menstrual cycle were measured, and antral follicles (AFC) were counted. IVF outcomes were collected from medical records. Regarding FMR1 CGG repeat length alleles, 63.2% of women presented at least one low-normal allele. Those carrying low-normal alleles had significantly lower AMH levels than women carrying normal or high-normal alleles. Low-normal/low-normal genotype was the most frequent, followed by low-normal/normal and normal/normal. A comparison of ovarian reserve markers and reproductive outcomes of the three most frequent genotypes revealed that AFC in the low-normal/normal genotype was significantly lower than the low-normal/low-normal genotype. The low number of FMR1 CGG repeats affected AMH levels and AFC but not IVF outcomes per cycle of treatment.

Efficacy of intra-ovarian injection of autologous platelet-rich plasma in women with poor responders: a systematic review and meta-analysis

CONTEXT

The effect of platelet-rich plasma (PRP) on ovarian reserve markers in poor ovarian response (POR) is challenging.

AIM

This systematic review and meta-analysis was, therefore, designed to evaluate the effectiveness of intra-ovarian injection of autologous PRP on improving ovarian reserve markers and assisted reproductive technology (ART) outcomes in infertile women with POR.

METHODS

A systematic search was conducted for the efficacy of intra-ovarian injection of autologous PRP on the improvement of ovarian reserve markers and ART outcomes in infertile women with POR. The methodological quality of the included studies was checked and eligible studies were included in the meta-analysis to find pooled results. Keywords were primary ovarian insufficiency, premature menopause, poor responder, poor ovarian response, diminished/decreased ovarian reserve, platelet-rich plasma, and intra-ovarian or a combination of them. The effect of PRP on fertility indices was evaluated using the standardized mean difference (SMD). The analysis was performed through STATA version 13.

KEY RESULTS

13 studies containing 1289 patients were included. Mean age, body mass index (BMI) and duration of infertility was 37.63 ± 2.66 years, 24 ± 1.23 kg/m2 and 4.79 ± 1.64 years, respectively. Most of the studies measured the outcomes 2-3/3 months after intra-ovarian injection of autologous PRP. The antral follicular count (AFC) after treatment by PRP is higher with an SMD of 0.95 compared to before treatment. The day 3 follicle-stimulating hormone (FSH) after treatment by PRP is lower with an SMD of - 0.25 compared to before treatment. The day 3 estradiol (E2) after treatment by PRP is higher with an SMD of 0.17 compared to before treatment. The anti-Mullerian hormone (AMH) after treatment by PRP is higher with an SMD of 0.44 compared to before treatment. The total oocytes number after treatment by PRP is higher with an SMD of 0.73 compared to before treatment. The number of MII oocytes after treatment by PRP is higher with an SMD of 0.63 compared to before treatment. The number of cleavage-stage embryos after treatment by PRP is higher with an SMD of 1.31 compared to before treatment. The number of day 5 embryo after treatment by PRP is higher with an SMD of 1.28 compared to before treatment. Pooled estimation of a meta-analysis of prevalence studies reported a prevalence of 22% for clinical pregnancy, 5% for spontaneous pregnancy and 21% for ongoing pregnancy following PRP therapy.

CONCLUSION

Intra-ovarian injection of PRP improved ovarian reserve markers with increasing AFC, serum level of AMH and day 3 E2 and decreasing serum level of day 3 FSH. In addition, this treatment improved ART outcomes through the increasing of number total oocytes, number of MII oocytes, number of cleavage-stage embryos and number of day 5 embryos in POR women.

IMPLICATIONS

Although treatment of POR women remains challenging, the use of intra-ovarian injection of autologous PRP in POR patients prior to IVF/ICSI cycles is a sign of new hope for increasing the success of IVF/ICSI. However, further well-organized, randomized controlled trials should be conducted to substantiate this result and recommend intra-ovarian injection of PRP as part of routine treatment in women with POR.

Investigation of the Effect of Dehydroepiandrosterone (DHEA) on In Vitro Fertilization (IVF) Outcomes in a Patient With Poor Ovarian Reserve: A Case Report

This study represents a case of a 42-year-old female patient who had a history of infertility, undergoing treatment at the in vitro fertilization (IVF) centre in Sawangi, India. The patient presented with a medical history marked by recurrent medical termination of pregnancies, a small uterus diagnosed through metroplasty, and a significant impediment to fertility treatment attributed to poor ovarian reserve. Clinical assessment revealed the male partner's history of alcohol consumption and cigarette smoking, along with benazepril usage for hypertension (5 mg/day). Despite normal semen parameters, intrauterine insemination (IUI) proved unsuccessful, prompting a recommendation for IVF utilizing the intracytoplasmic sperm injection (ICSI) procedure. The patient displayed low anti-Mullerian hormone (AMH) levels, indicative of insufficient ovarian reserve. Dehydroepiandrosterone (DHEA) supplementation was advised orally for a period of one month to enhance ovarian function. Subsequent evaluation demonstrated a notable increase in AMH levels, facilitating the retrieval of six oocytes, comprising average-quality metaphase II (MII) oocytes and one dysmorphic metaphase I (MI) oocyte. Following ICSI, successful fresh embryo transfer ensued, resulting in a positive beta-human chorionic gonadotropin (β-hCG) test with serum β-hCG levels measuring 1676 mIU/mL, confirming the successful implantation of one of the two transplanted embryos. This case underscores the significance of DHEA supplementation in augmenting ovarian reserve and achieving favorable IVF-ICSI outcomes in patients with primary infertility. The holistic approach, encompassing lifestyle modifications and tailored medication, contributed to a positive pregnancy outcome. Further research is warranted to explore the broader implications of DHEA therapy in the management of infertility.

Luteinizing hormone supplementation in controlled ovarian stimulation: the Iran Delphi consensus

Introduction

Numerous consensus documents worldwide address luteinizing hormone (LH) supplementation in controlled ovarian stimulation, yet to the best of our knowledge, only one consensus paper has been published in the Arab region. This study presents a Delphi consensus by seven Iranian infertility experts, offering real-world clinical perspectives. The aim was to develop evidence-based opinions on LH's role alongside FSH in various aspects of assisted reproductive technology (ART), including LH levels, monitoring, r-hLH use, and suggested activity.

Methods

Employing the Delphi consensus approach, the Iran consensus unfolded in three steps. In Step 1, eight out of 10 statements gained approval, while two unclear statements were removed. In Step 2, the 20-member extended panel voted on the remaining eight statements.

Results

Only one (statement 3) lacked consensus (55% agreement), prompting a modification. The revised statement (noted as statement 3') obtained an 83% agreement.

Discussion

The clinical perspectives included in this consensus complement clinical guidelines and policies that help further improve treatment outcomes, especially for patients with FSH and LH deficiencies.

The impact of follicular fluid phthalate metabolites on the ovarian reserve and ovarian function in Indian women undergoing intracytoplasmic sperm injection

OBJECTIVE

To investigate the adverse effects of phthalate-induced ovarian toxicity on the ovarian reserve and ovarian function. To assess whether the accumulation of higher levels of selected phthalate metabolites in the follicular fluid (FF) of Indian women undergoing intracytoplasmic sperm injection (ICSI) was associated with a decline in their antral follicle count (AFC) and/or serum antimüllerian hormone (AMH) levels, suggesting a negative impact on the ovarian reserve. To evaluate the effects of follicular phthalate metabolites on peak serum estradiol (E2) levels and the total number of oocytes and mature metaphase II (MII) stage oocytes retrieved to assess the impact of phthalate toxicity on ovarian function.

DESIGN

A subanalysis of an ongoing prospective cohort study was conducted to examine the association between the levels of six phthalate metabolites, namely, mono-n-butyl phthalate (MBP), mono-ethyl phthalate (MEP), mono-isononyl phthalate (MiNP), mono-isodecyl phthalate (MiDP), mono(2-ethyl-5-oxohexyl) phthalate, and mono(2-ethyl-5-hydroxyhexyl) phthalate, in the FF of Indian women undergoing ICSI and their ovarian reserve markers (AFC and serum AMH levels). To investigate the association of these follicular phthalate metabolite levels with the peak E2 levels and the total number of oocytes and number of MII stage oocytes retrieved.

SETTING

In vitro fertilization center in a referral hospital in India.

PATIENT(S)

A total of 245 consenting Indian women who had undergone oocyte retrieval between April 2017 and mid-March 2020 were included. Each woman contributed one FF sample to the study. This was screened for six phthalate metabolites. The samples were collected before the coronavirus disease 2019 pandemic.

INTERVENTION(S)

Using liquid chromatography-tandem mass spectrometry, the total levels of six phthalate metabolites were quantified in the FF of 245 women. Using linear regression models that were unadjusted and adjusted for maternal age and body mass index (BMI), we evaluated the association between the follicular metabolites in these women and their AFC, serum AMH levels, peak E2 levels, total number of oocytes, and MII stage oocytes.

MAIN OUTCOME MEASURE(S)

To evaluate the impact of phthalate-induced ovarian toxicity on the ovarian reserve and ovarian function in Indian women undergoing ICSI by studying their accumulated levels in their FF.

RESULT(S)

For MiNP (a metabolite of di-isononyl phthalate), in linear regression models adjusted for age and BMI, we found that with increasing quartiles of follicular MiNP, there was a significant trend in the decrease in mean AFC (P-trend = 0.023) and a suggestive trend in the decrease in mean serum AMH levels (P-trend = 0.077). For MiDP (a metabolite of di-isodecyl phthalate), in the unadjusted regression model, we found that with increasing quartiles of follicular MiDP, there was a significant trend in the decrease in mean serum AMH levels (P-trend = 0.045). For MBP (a metabolite of dibutyl phthalate), in linear regression models adjusted for age and BMI, we found that with increasing quartiles of follicular MBP, there were significant trends in the decrease in the mean number of total oocytes retrieved (P-trend = 0.003), a decrease in the mean number of MII stage oocytes retrieved, (P-trend = 0.003) and a decrease in the mean peak E2 levels (P-trend = 0.016). Although we found that with increasing quartiles of follicular mono(2-ethyl-5-oxohexyl) phthalate there was a decrease in the mean number of total and MII stage oocytes retrieved and higher follicular MEP levels were negatively associated with the mean AFC and serum AMH levels, neither trend was statistically significant. We also found that although follicular MEP levels did not show an adverse impact on ovarian function, follicular mono(2-ethyl-5-hydroxyhexyl) phthalate levels did not show an adverse impact on both the ovarian reserve and function.

CONCLUSION

In this study of 245 Indian women, higher accumulated FF levels of MiNP and MiDP were negatively associated with AFC and serum AMH levels, suggesting an adverse effect on the ovarian reserve. Higher accumulated FF levels of MBP were negatively associated with the total number of oocytes, MII stage oocytes, and peak E2 values, suggesting a negative impact on ovarian function. Although we found that phthalate-induced ovarian toxicity was statistically significant for selected phthalate metabolites, the role of the cumulative effect of multiple phthalates in the ovarian microenvironment cannot be ruled out and needs to be investigated further.

Significance of serum AMH and antral follicle count discrepancy for the prediction of ovarian stimulation response in Poseidon criteria patients

PURPOSE

To determine the risk of not being a poor responder in ovarian stimulation (OS) for in vitro fertilization (IVF) when ovarian reserve markers are discordant-one falling within Poseidon's criteria normal range (e.g., anti-Müllerian hormone (AMH) ≥ 1.2 ng/mL or antral follicle count (AFC) ≥ 5), and the other in the poor ovarian reserve range.

METHODS

A tri-center retrospective cohort study (2015-2017) involving women with discordant AMH and AFC values undergoing their first IVF/ICSI cycle using conventional OS (cOS, ≥ 150 IU/day of follicle-stimulating hormone). Discordant serum AMH and AFC values were defined according to Poseidon's criteria (AMH < 1.2 ng/mL and AFC ≥ 5 or AMH ≥ 1.2 ng/mL and AFC < 5). Poor ovarian response (POR) was < 4 retrieved oocytes. Receiver operating characteristic (ROC) curves were used to determine AMH and AFC cut-offs for non-POR. Logistic regression analysis evaluated factors associated with non-POR.

RESULTS

Out of 8797 patients who underwent assessment with both AMH and AFC, 1172 (13.3%) exhibited discordant values. Of these, 854 (72.9%) had ≥ 4 oocytes retrieved. Within this group, 726 (85.0%) had "low" AMH values, whereas 128 (15.0%) had "low" AFCs. An AFC of 6 had 77% sensitivity and 52% specificity (AUC = 0.700), while AMH of 1.19 ng/mL had 31% sensitivity and 85% specificity (AUC = 0.492) for non-POR. AFC and the use of recombinant gonadotropins were positive predictors of non-POR.

CONCLUSIONS

When serum AMH is < 1.19 ng/mL, but AFC is ≥ 6, there is a moderate likelihood of a non-POR during stimulation. Conversely, if AFC is < 5 but serum AMH is ≥ 1.19 ng/mL, the chances of non-POR are low. Among patients with discordant markers, AFC emerges as the primary predictor of oocyte yield.

Ovarian response determines the luteinizing hormone suppression threshold for patients following the gonadotrophin releasing hormone antagonist protocol: A retrospective cohort study

Background

Ovarian reactivity to gonadotrophin stimulation varies, and individual adjustments to the timing and dose of gonadotrophin-releasing hormone (GnRH) antagonist administration are necessary to prevent excessive increases and decreases in luteinizing hormone (LH) levels in patients with different ovarian response following the GnRH antagonist (GnRH-A) protocol. The present study aims to investigate optimal LH suppression thresholds for patients with normal ovarian response (NOR), high ovarian response (HOR), and poor ovarian response (POR) following the GnRH-A protocol respectively.

Methods

A total of 865 in vitro fertilization (IVF) cycles using a flexible or fixed GnRH-A protocol were included. Patients were categorized into the HOR, NOR, or POR group according to their anti-Müllerian hormone (AMH) levels. Then, patients in each group were stratified into one of four subgroups according to the quartile (Q1-Q4) of the basal LH level to LH on triggering day ratio (bLH/hLH). The primary outcomes were the clinical pregnancy and live birth rates, and the secondary outcomes were the number of oocytes retrieved, MII oocytes, two pronucleus (2PN) embryos, and good-quality embryos.

Results

There were 526 patients with NOR, 180 with HOR, and 159 with POR. Basal LH level, LH on triggering day and bLH/hLH were identified as independent predictors of clinical pregnancy rate and live birth rate by logistics regression analysis. Compared to those with NOR, patients with POR had the lowest embryo implantation rate (22.6% vs. 32.8%, P < 0.05), clinical pregnancy rate (32.3% vs. 47.3%, P < 0.05) and live birth rate (22.6 vs. 37.8%, P < 0.05) of fresh embryo transfer (ET). The embryo implantation, clinical pregnancy and live birth rates of frozen embryo transfer (FET) were not significantly different among the three groups. In the subgroup analysis, patients with HOR had the highest embryo implantation rate (51.6%, P < 0.05), clinical pregnancy rate (68.4%, P < 0.05) and live birth rate (52.6%, P < 0.05) of ET in Q3, with a bLH/hLH ratio of 2.40-3.69. In the NOR group, the embryo implantation rate (41.9%, P < 0.05), clinical pregnancy rate (61.5%, P < 0.05) and live birth rate (50.8%, P < 0.05) of ET and live birth rate (53.1%, P < 0.05) of FET were highest in Q2, with a bLH/hLH ratio of 1.29-2.05. Patients with POR had the highest clinical pregnancy rate (57.1%, P < 0.05) and live birth rate (42.9%, P < 0.05) of ET in Q2, with a bLH/hLH ratio of 0.86-1.35.

Conclusions

In the present study, the bLH/hLH ratio represented the LH suppression threshold. The subgroup analysis of HOR, NOR and POR showed that, the LH suppression threshold varies according to ovarian response. We recommend LH suppression thresholds of 2.40-3.69 for HOR, 1.29-2.05 for NOR, and 0.86-1.35 for POR to obtain the highest clinical pregnancy rate and live birth rate. This study provides comprehensive and precise references for clinicians to monitor LH levels individually during controlled ovarian stimulation (COS) according to the patient's ovarian response following the GnRH-A protocol.

Evaluative effectiveness of follicular output rate, ovarian sensitivity index, and ovarian response prediction index for the ovarian reserve and response of low-prognosis patients according to the POSEIDON criteria: a retrospective study

The aim was to explore the implications of follicular output rate (FORT), ovarian sensitivity index (OSI), ovarian response prediction index (ORPI), and follicle-to-oocyte index (FOI) in low-prognosis patients defined by POSEIDON criteria. In total, 4030 fresh in vitro fertilization (IVF) cycles from January 2013 to October 2021 were included in this retrospective cohort analysis and were categorized into four groups based on the POSEIDON criteria. The FORT between Groups 1 and 2 (0.61 ± 0.34 vs. 0.65 ± 0.35, P = 0.081) and Groups 3 and 4 (1.08 ± 0.82 vs. 1.09 ± 0.94, P = 0.899) were similar. The OSI in the order from the highest to the lowest were 3.01 ± 1.46 in Group 1, 2.28 ± 1.09 in Group 2, 1.54 ± 1.04 in Group 3, and 1.34 ± 0.96 in Group 4 (P < 0.001). The trend in the ORPI values was consistent with that in the OSI. FORT, OSI, ORPI, and FOI complemented each other and offered excellent effectiveness in reflecting ovarian reserve and response, but they were not good predictors of clinical pregnancy rate (CPR) from IVF.

Predicting ovarian responses to the controlled ovarian hyperstimulation in elderly infertile women using clinical measurements and random forest regression

During the past decades, the number of elderly infertile women is obviously increasing in China, and more and more of them are likely to seek medical assisted reproductive technologies. As the in vitro fertilization/embryo transfer (IVF/ET) treatment presents special medical and psychological challenges to elderly infertile women, it is extremely helpful to perform the clinical evaluation and outcome prediction regarding IVF/ET outcomes. In this study, we retrospectively collected 12 clinical measurements in prior to the oocyte recovery for 689 elderly infertile patients (≥35 years of old), and used for predicting ovarian responses to the controlled ovarian hyperstimulation based on random forest regression models. Using different predictor sets and 10-fold cross validation approach, the Mean Square Error (±standard deviation) of prediction models varied from 7.56 ± 0.31 to 13.90 ± 0.37 in the training datasets, and the correlation coefficients between observed and predicted values ranged from 0.86 ± 0.02 to 0.72 ± 0.05 in the testing datasets. Among all clinical measurements involved in this study, the preovulatory follicle count (PFC), antral follicle count (AFC), and anti-Müllerian hormone (AMH) were revealed to be the most important features in prediction models. In conclusion, we successfully established the machine learning approach that could help the elderly infertile patients to better understand the most possible outcomes in subjecting to the controlled ovarian hyperstimulation.

Bologna vs. POSEIDON criteria as predictors of the likelihood of obtaining at least one euploid embryo in poor ovarian response: an analysis of 6,889 cycles

OBJECTIVE

To study the likelihood of obtaining at least 1 euploid embryo for transfer in poor ovarian response (POR) diagnosed per Bologna and Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria, and compare it between groups and with patients without POR.

DESIGN

Retrospective cohort study.

PATIENTS

Women undergoing an ovarian stimulation cycle with intention to pursue preimplantation genetic testing for aneuploidy.

INTERVENTIONS

Bologna criteria and the POSEIDON classification system were applied to characterize each stimulation cycle as POR or not. Cycles identified as POR by POSEIDON were subdivided into groups I, II, III, and IV as defined by this classification system.

MAIN OUTCOME MEASURES

The proportion of cycles resulting in at least 1 euploid blastocyst. Other outcome measures included cycle yields (metaphase II oocytes, fertilized oocytes, blastocysts, and euploid blastocysts), and euploidy rate per embryo cohort.

RESULTS

A total of 6,889 cycles were included, of which 3,653 (53.0%) were classified as POR per POSEIDON criteria: 1.5% (100/6,889) in group I, 3.2% (222/6,889) in II, 11.9% (817/6,889) in III, and 36.5% (2,514/6,889) in IV. Per Bologna criteria, 23.4% (1,612/6,889) of cycles were classified as POR. Group I had similar likelihood of obtaining at least 1 euploid embryo (97.0%; 95% confidence interval, 91.5%-99.2%) as cycles not deemed POR (91.9%; 95% confidence interval, 90.9%-2.8%), whereas this decreased significantly with each subsequent POSEIDON group (II: 77.9%, 72.0%-82.9%; III: 70.5%, 67.3%-73.5%; IV: 44.8%, 42.9%-46.7%) and those meeting Bologna criteria had the lowest rates (31.9%, 29.7%-34.3%). Cycle yields correlated with ovarian reserve testing results, whereas euploidy rates were associated with age.

CONCLUSIONS

Although younger POSEIDON groups (I and III) have higher euploidy rates than older groups (II and IV), each incremental POSEIDON group poses a higher risk of having no euploid blastocysts; with POSEIDON I being no different from non-POSEIDON, and Bologna having the worst prognosis. Although ovarian reserve appears to have little impact on euploidy rates, it remains a key prognostic factor for having at least 1 euploid embryo available for transfer through its impact on oocyte yield. To our knowledge, this is the first study to provide the odds ratio of this outcome depending on the degree of POR.

RegEMR: a natural language processing system to automatically identify premature ovarian decline from Chinese electronic medical records

BACKGROUND

The ovarian reserve is a reservoir for reproductive potential. In clinical practice, early detection and treatment of premature ovarian decline characterized by abnormal ovarian reserve tests is regarded as a critical measure to prevent infertility. However, the relevant data are typically stored in an unstructured format in a hospital's electronic medical record (EMR) system, and their retrieval requires tedious manual abstraction by domain experts. Computational tools are therefore needed to reduce the workload.

METHODS

We presented RegEMR, an artificial intelligence tool composed of a rule-based natural language processing (NLP) extractor and a knowledge-based disease scoring model, to automatize the screening procedure of premature ovarian decline using Chinese reproductive EMRs. We used regular expressions (REs) as a text mining method and explored whether REs automatically synthesized by the genetic programming-based online platform RegexGenerator +  + could be as effective as manually formulated REs. We also investigated how the representativeness of the learning corpus affected the performance of machine-generated REs. Additionally, we translated the clinical diagnostic criteria into a programmable disease diagnostic model for disease scoring and risk stratification. Four hundred outpatient medical records were collected from a Chinese fertility center. Manual review served as the gold standard, and fivefold cross-validation was used for evaluation.

RESULTS

The overall F-score of manually built REs was 0.9444 (95% CI 0.9373 to 0.9515), with no significant difference (paired t test p > 0.05) compared with machine-generated REs that could be affected by training set sizes and annotation portions. The extractor performed effectively in automatically tracing the dynamic changes in hormone levels (F-score 0.9518-0.9884) and ultrasonographic measures (F-score 0.9472-0.9822). Applying the extracted information to the proposed diagnostic model, the program obtained an accuracy of 0.98 and a sensitivity of 0.93 in risk screening. For each specific disease, the automatic diagnosis in 76% of patients was consistent with that of the clinical diagnosis, and the kappa coefficient was 0.63.

CONCLUSION

A Chinese NLP system named RegEMR was developed to automatically identify high risk of early ovarian aging and diagnose related diseases from Chinese reproductive EMRs. We hope that this system can aid EMR-based data collection and clinical decision support in fertility centers.

Development of a quantitative fluorescence lateral flow immunoassay (LFIA) prototype for point-of-need detection of anti-Müllerian hormone

Objective

Anti-Müllerian Hormone (AMH) is a quantitative marker for ovarian reserve and is used to predict response during ovarian stimulation. Streamlining testing to the clinic or even to the physician's office would reduce inconvenience, turnaround time, patient stress and potentially also the total cost of testing, allowing for more frequent monitoring. In this paper, AMH is used as a model biomarker to describe the rational development and optimization of sensitive, quantitative, clinic-based rapid diagnostic tests.

Design and Methods

We developed a one-step lateral-flow europium (III) chelate-based fluorescent immunoassay (LFIA) for the detection of AMH on a portable fluorescent reader, optimizing the capture/detection antibodies, running buffer, and reporter conjugates.

Results

A panel of commercial calibrators was used to develop a standard curve to determine the analytical sensitivity (LOD = 0.41 ng/ml) and the analytical range (0.41-15.6 ng/ml) of the LFIA. Commercial controls were then tested to perform an initial evaluation of the prototype performance and showed a high degree of precision (Control I CV 2.18%; Control II CV 3.61%) and accuracy (Control I recovery 126%; Control II recovery 103%). Conclusions: This initial evaluation suggests that, in future clinical testing, the AMH LFIA will likely have the capability of distinguishing women with low ovarian reserve (<1 ng/ml AMH) from women with normal (1-4 ng/ml AMH) ovarian reserve. Furthermore, the LFIA demonstrated a wide linear range, indicating the assay's applicability to the detection of other health conditions such as PCOS, which requires AMH measurement at higher concentrations (>6 ng/ml).

Dysregulation of steroid metabolome in follicular fluid links phthalate exposure to diminished ovarian reserve of childbearing-age women

The widespread use of phthalates (PAEs) has drawn increasing attention due to their endocrine disruption and reproductive toxicity, while the steroid metabolome is essential for follicular development. However, the mechanism by which PAE exposure affects ovarian reserve through the steroid metabolome remains unclear. This study recruited 264 childbearing-age women in Tianjin (China) from April 2019 to August 2020 in a cross-sectional design. Target metabolome analysis of 16 steroids was performed in follicular fluid (FF) to compare diminished ovarian reserve (DOR) against normal ovarian reserve (NOR) women and differential steroids were identified using binary logistic analyses. Further analysis of eleven PAE metabolites (mPAEs) in FF was conducted, and the retrieved oocyte number (RON) representing ovarian reserve was counted. Multiple linear regression and quantile-based g-computation (qgcomp) models were used to associate individual mPAEs and mPAE mixture with the DOR-related differential steroids in FF. Mediation analysis was used to discuss the mediating effect of DOR-related steroids on the association between mPAEs and RON. Androstenedione (A4), corticosterone (CORT), cortisol (COR) and cortisone were significantly down-regulated in FF from women with DOR. Nine mPAEs with detection frequencies greater than 60% and median concentrations of 0.02-4.86 ng/mL were incorporated into statistical models. Negative associations with COR and CORT were found for mono-ethyl phthalate (mEP), mono-(2-ethyl-5-oxohexyl) phthalate (mEOHP), and mono-2-ethylhexyl phthalate (mEHP). A positive association with cortisone was found for mEOHP, mEHP, monobutyl phthalate (mBP), and mono (2-isobutyl) phthalate (miBP). The qgcomp and mediation analyses revealed that mEP and mEOHP not only significantly contributed to the decline of COR and CORT in the mixed exposure but also indirectly reduced RON through the mediating effects of COR and CORT. In conclusion, PAE exposure may decrease ovarian reserve by downregulating COR and CORT.

Cancer Treatment-Related Ovarian Dysfunction in Women of Childbearing Potential: Management and Fertility Preservation Options

PURPOSE

To review the complex concerns of oncofertility created through increased cancer survivorship and the long-term effects of cancer treatment in young adults.

DESIGN

Review chemotherapy-induced ovarian dysfunction, outline how fertility may be addressed before treatment initiation, and discuss barriers to oncofertility treatment and guidelines for oncologists to provide this care to their patients.

CONCLUSION

In women of childbearing potential, ovarian dysfunction resulting from cancer therapy has profound short- and long-term implications. Ovarian dysfunction can manifest as menstrual abnormalities, hot flashes, night sweats, impaired fertility, and in the long term, increased cardiovascular risk, bone mineral density loss, and cognitive deficits. The risk of ovarian dysfunction varies between drug classes, number of received lines of therapy, chemotherapy dosage, patient age, and baseline fertility status. Currently, there is no standard clinical practice to evaluate patients for their risk of developing ovarian dysfunction with systemic therapy or means to address hormonal fluctuations during treatment. This review provides a clinical guide to obtain a baseline fertility assessment and facilitate fertility preservation discussions.

Impact of Endocrine Disorders on IVF Outcomes: Results from a Large, Single-Centre, Prospective Study

Endocrine disorders negatively influence the ovarian function, and increasing incidence of endocrine diseases with age may have further negative effects on pregnancy rate. Prospective cohort study of 231 consecutively enrolled patients underwent IVF treatment. In patients with known endocrine disorders, the laboratory parameters were corrected before IVF treatment. One hundred sixty one patients (69.7%) had at least one known and treated endocrine disorder (study group), and 70 patients were endocrine negative (control group). Endocrine disorders diagnosed were thyroid disorders (32.5%), diminished ovarian reserve (23.8%), insulin resistance (22.5%), PCOS (15.2%), hyperprolactinaemia (13.4%), obesity (12.1%), hypogonadotropic hypogonadism (0.8%) and congenital adrenal hyperplasia (0.2%). Before the IVF treatment, systematic endocrine laboratory examinations were performed in all patients. Higher age, BMI and FSH were found in the study group, while AMH level was lower. There were no differences in LH, E2, prolactin, TSH, FT3, FT4, TT, DHEAS, androstendione, 17-OHP and SHBG level between the study and control groups. The study group had higher baseline glucose, baseline insulin, 120-min glucose and 120-min insulin level after oral glucose tolerance test. With no difference in the IVF cycles performed, pregnancy rate was lower in the study group (61.43% vs. 34.16%; p = 0.003), and this difference (p = 0.0151) remained in age-corrected rates, as well. The analyses were also performed in individual endocrinology groups. The prevalence of endocrine disorders is high in females participating in IVF programs, and they are often accompanying each other. Even after proper correction, the presence of the endocrine disorder negatively influences the pregnancy rate in IVF treatment.

POSEIDON groups and their distinct reproductive outcomes: Effectiveness and cost-effectiveness insights from real-world data research

The Patient-Oriented Strategies Encompassing IndividualizeDOocyte Number (POSEIDON) criteria identify and classify the so-called 'low-prognosis' patients undergoing assisted reproductive technology (ART). Recent large-scale studies using real-world data (RWD) have shown that patients classified under this system have distinct reproductive outcomes. Moreover, these studies also confirm that POSEIDON patients are commonly found in fertility centers. RWD has substantiated the validity of the POSEIDON biomarkers' thresholds (antral follicle count [AFC] and/or anti-Müllerian hormone [AMH]) for patient classification. Lastly, a predictive model has been developed and validated to estimate the POSEIDON metric of success (i.e., number of oocytes needed to achieve at least one euploid blastocyst). Although more evidence is needed in this area, current insights from RWD research indicate that infertility patients can be counseled and managed more effectively under the POSEIDON scope, with potential gains for all parties involved.

The association of serum phthalate metabolites with biomarkers of ovarian reserve in women of childbearing age

Phthalates (PAEs) are widely used plasticizers drawing increasing concern due to reproductive toxicity. However, studies on serum PAEs metabolites (mPAEs) and their associations with human ovarian function remain very scarce. In this study, from April 2019 to August 2020, a total of 297 women of childbearing age were recruited in Tianjin, China. Eleven mPAEs were analyzed in serum samples and eight mPAEs were detected at frequencies > 65% with median concentrations of 0.43-15.3 ng/mL. In multinomial logistic analysis, an increase in serum mono (2-isobutyl) phthalate (miBP) was associated with decline in antral follicle count (AFC) (OR=1.26, 95% CI: 0.99, 1.61) and 5-mono-(2-ethyl-5-hydroxyhexyl) phthalate (mEHHP) was significantly associated with AFC increase (OR=1.43, 95% CI: 1.06, 1.92), which were aligned with the associations found between mPAEs and AMH through generalized linear regression. In multiple linear regression models, per 10% increase in serum mono (2-ethylhexyl) phthalate (mEHP), mono (2-ethyl-5-oxohexyl) phthalate (mEOHP) (oxo-mEHP), and principal component 1 featured for high concentrations of mono-n-butyl phthalate (mBP), miBP and mEHP were associated with 0.15 (95% CI: -0.29, -0.02), 0.01 (95% CI: -0.01, 0.00) and 0.01 (95% CI: -0.02, 0.00) ln-unit decrease in estradiol (E2) levels, respectively, while mono-[(2-carboxymethyl) hexyl] phthalate (mCMHP) (carboxymethyl-mEHP) was positively associated with 0.05 ln-unit increase of E2 (95% CI: 0.02, 0.08). The observed negative associations between mPAEs and the Anti-Müllerian hormone (AMH) also aligned with the change in AFC. Generalized linear regression also revealed nonlinear associations between mono-ethyl phthalate (mEP), mCMHP and follicle-stimulating hormone (FSH). Overall, serum mEHP and its metabolites were negatively associated with E2. miBP was negatively associated with AFC. The nonlinear associations between mPAEs and FSH, and AMH need further study.

Effect of Surgical Findings on Prediction of Postoperative Ovarian Reserve in Patients with Ovarian Endometrioma

Objective

Revised American Society for Reproductive Medicine (rASRM) classification for endometriosis is considered to have limited ability to predict fertility after surgery. This study evaluated the effect of surgical findings described by the rASRM classification on postoperative change in serum Anti-Müllerian hormone (AMH) in endometriosis.

Study Design

We retrospectively analyzed 112 patients with endometrioma who underwent laparoscopic ovarian cystectomy. The ovarian score was defined as the sum of the endometrioma score from the size and depth of endometrioma and the adhesion score from the extent and types of ovarian adhesion described in the rASRM classification. The ovarian score was correlated with the AMH levels before surgery (AMH0), 3 (AMH3), and 6 months (AMH6) after surgery. To design a model for predicting AMH6, using ovarian score and AMH0, we calculated the unstandardized predictive value of AMH6/AMH0 (UPV) by linear regression analysis. The predicted AMH6 (pAMH6) could be calculated by multiplying the UPV by AMH0. When AMH6 is less than 1.0 ng/mL, it was defined as a poor ovarian reserve group (PORG), and the accuracy of the predictive model was validated.

Results

The level of AMH declined more in rASRM stage IV compared to stage III after surgery. The ovarian score had a significant variable in the linear regression analysis with the ratio of AMH6/AMH0 (p = 0.001). The UPV was correlated with ovarian score negatively. The pAMH6 correlated with AMH6 positively and with age negatively. The pAMH6 showed sensitivity 0.564, specificity 0.909, positive predictive rate 0.786, and negative predictive rate 0.800 in the prediction of PORG (p < 0.001).

Conclusion

The pAMH6 predicted the PORG at 6 months after surgery. Based on the results of our study, the surgical findings, including the size and depth of the endometrioma and extent and types of adhesion could be useful indicators for ovarian reserve after surgery.

Age-Specific Distribution of Serum Anti-Mullerian Hormone and Antral Follicle Count in Indian Infertile Women

BACKGROUND

Ovarian reserve declines with age. However, there are considerable ethnic differences in the decline of ovarian reserve between individuals.

AIM

This study aimed to make age-specific percentile charts of anti-Mullerian hormone (AMH) and antral follicle count (AFC) in Indian infertile women and to find the proportion of young women with low ovarian reserve.

SETTING AND DESIGN

This was a retrospective data analysis of AMH and AFC of 5525 infertile women from August 2015 to December 2018.

MATERIALS AND METHODS

Infertile women aged 20- 44 years, with body mass index 18-32 kg/m2 and having both ovaries were included in the study. Women with pituitary/adrenal disorders, malignancy, total AFC >40, tuberculosis, endometriosis, autoimmune disorders, smoking, chemotherapy, radiotherapy and recent ovarian surgery were excluded from the study.

STATISTICAL ANALYSIS

Comparison between groups was done by Chi-square test.

RESULTS

About 14.5% of women <35 years and 50.5% of women >35 years had low AMH values (<1.1 ng/ml). In addition, 5.6% of women <35 years and 23.6% of women >35 years had a low AFC of ≤5. In this study, 55.7% of women who had low AMH and 50.7% who had low AFC were <35 years of age. The median AMH values were 4.23 ng/mL in 20-25 years' age group, 3.48 ng/mL in women aged 26-30 years, 2.43 ng/mL in women aged 31-35 years, 1.28 ng/mL in women aged 36-40 years and0.52 ng/mL in 40-44 years' age group. The median AFCs were 20, 18, 14, 10 and 6 for each of the age groups, respectively.

CONCLUSION

This study suggests that approximately more than half of the infertile women who were tested to have low ovarian reserve were <35 years of age.

Efficacy of the depot gonadotropin-releasing hormone agonist protocol on in vitro fertilization outcomes in young poor ovarian responders from POSEIDON group 3

OBJECTIVE

To investigate whether the depot gonadotropin-releasing hormone (GnRH) agonist protocol could improve in vitro fertilization (IVF) outcomes for young poor responders from POSEIDON group 3.

METHODS

This retrospective cohort study was carried out from June 2017 to June 2020. A total of 451 patients were assigned to three groups depending on the ovarian stimulation protocols. The outcome parameters of IVF were compared in each group.

RESULTS

Patients who received the depot GnRH agonist had significantly higher cumulative clinical pregnancy rates (50.88%, 32.02%, and 31.88%, respectively; P = 0.009 and P = 0.007) and cumulative live birth rate (48.25%, 26.97%, and 28.99%, respectively; P = 0.004 and P = 0.009) compared with mild ovarian stimulation protocol and GnRH antagonist protocol. They also had higher live birth rate per fresh embryo transfer cycle (47.78%, 32.35%, and 36.62%, respectively), but these differences were not statistically significant. Moreover, duration of stimulation, total dose of gonadotropins and endometrial thickness were significantly higher among women who received the depot GnRH agonist (P < 0.001). However, they had lower embryo transfer cancellation rate, and abnormal endometrium rate (P < 0.001).

CONCLUSION

The depot GnRH agonist protocol may improve cumulative clinical pregnancy rate and cumulative live birth rate for young women with poor ovarian response from POSEIDON group 3.

Evaluation of intra-ovarian platelet-rich plasma administration on oocytes-dependent variables in patients with poor ovarian response: A retrospective study according to the POSEIDON criteria

BACKGROUND

Poor ovarian response (POR) is among the common findings in infertile women with no significant underlying condition. The aim of this study was to investigate the intra-ovarian potential of platelet-rich plasma (PRP) administration on oocytes-dependent variables in the POR women grouped according to the POSEIDON criteria.

METHODS

This retrospective study was performed on POR women with no underlying condition who have undergone intra-ovarian PRP injection. As well as patients' age, the number of total and MI, MII, and GV oocytes were extracted from the files. The laboratory variables including anti-mullerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol were also gathered. In order to reduce any bias due to the possible differences in kits or devices, a single laboratory with the highest number of cases was selected and others were excluded from the study. Then, the included cases were grouped into four according to the POSEIDON criteria and analyzed for the mentioned variables by SPSS, version 25. The statistical significance level was set as P-value < 0.05.

RESULTS

From 383 cases, a total number of 96 women were enrolled in this study. According to the POSEIDON criteria, group 4 (Age ≥ 35 years, AMH < 1.2 ng/mL) with the ratio of 56/96 (58.3%) had the highest prevalence among others. As the analyses showed, changes in the laboratory variables (LH, FSH, AMH, and estradiol) were not significant in almost all the groups following the intervention. Regarding the total oocytes number, PRP administration caused a significant increase in the total number in all the groups (all P < 0.05). Also, the number of MII oocytes was significantly increased following the treatment in all groups except for group 2 (Age ≥ 35 years, AMH ≥ 1.2 ng/mL; all P < 0.05). Of 96 cases, 14 (14.6%) got clinically pregnant following assisted reproductive techniques which this number were significantly differed among the groups (P = 0.002).

CONCLUSION

This study showed that PRP treatment was effective on total and MII oocyte numbers in the patients with POR, however, further studies are required.

Evaluation of Ovarian Reserve Tests and Age in the Prediction of Poor Ovarian Response to Controlled Ovarian Stimulation-A Real-World Data Analysis of 89,002 Patients

Aims

This study aimed to explore the value of ovarian reserve tests (ORTs) for predicting poor ovary response (POR) and whether an age cutoff could improve this forecasting, so as to facilitate clinical decision-making for women undergoing in vitro fertilization (IVF).

Methods

A retrospective cohort study was conducted on poor ovary response (POR) patients using real-world data from five reproductive centers of university-affiliated hospitals or large academic hospitals in China. A total of 89,002 women with infertility undergoing their first traditional ovarian stimulation cycle for in vitro fertilization from January 2013 to December 2019 were included. The receiver operating characteristic (ROC) curve was performed to estimate the prediction value of POR by the following ORTs: anti-Mullerian hormone (AMH), antral follicle count (AFC), basal FSH (bFSH), as well as patient age.

Results

In this retrospective cohort, the frequency of POR in the first IVF cycle was 14.8%. Age, AFC, AMH, and bFSH were used as predicting factors for POR, of which AMH and AFC were the best indicators when using a single factor for prediction (AUC 0.862 and 0.842, respectively). The predictive values of the multivariate model included age and AMH (AUC 0.865), age and AFC (AUC 0.850), age and all three ORTs (AUC 0.873). Compared with using a single factor alone, the combinations of ORTs and female age can increase the predictive value of POR. Adding age to single AMH model improved the prediction accuracy compared with AMH alone (AUC 0.865 vs. 0.862), but the improvement was not significant. The AFC with age model significantly improved the prediction accuracy of the single AFC model (AUC 0.846 vs. 0.837). To reach 90% specificity for POR prediction, the cutoff point for age was 38 years old with a sensitivity of 40.7%, 5 for AFC with a sensitivity of 55.9%, and 1.18 ng/ml for AMH with a sensitivity of 63.3%.

Conclusion

AFC and AMH demonstrated a high accuracy when using ROC regression to predict POR. When testing is reliable, AMH can be used alone to forecast POR. When AFC is used as a prediction parameter, age is suggested to be considered as well. Based on the results of the cutoff threshold analysis, AFC ≤ 5 and AMH ≤ 1.18 ng/ml should be recommended to predict POR more accurately in IVF/ICSI patients.

The effect of prophylactic bilateral salpingectomy on ovarian reserve in patients who underwent laparoscopic hysterectomy

BACKGROUND

Bilateral salpingectomy has been proposed to reduce the risk of ovarian cancer, but it is not clear whether the surgery affects ovarian reserve. This study compares the impact of laparoscopic hysterectomy for benign disease with or without prophylactic bilateral salpingectomy on ovarian reserve.

METHODS

Records were reviewed for 373 premenopausal women who underwent laparoscopic hysterectomy with ovarian reserve for benign uterine diseases. The serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and three-dimensional antral follicle count (AFC) were assessed before surgery and 3 and 9 months postoperatively to evaluate ovarian reserve. Patients were divided into two groups according to whether they underwent prophylactic bilateral salpingectomy. The incidence of pelvic diseases was monitored until the ninth month after surgery.

RESULTS

There was no significant difference between the two surgery groups in terms of baseline AMH, E2, FSH, LH, and AFC (all P > 0.05). There was no difference in potential bias factors, including patient age, operative time, and blood loss (all P > 0.05). There was also no significant difference between the two groups 3 months after surgery with respect to AMH (P = 0.763), E2 (P = 0.264), FSH (P = 0.478), LH (P = 0.07), and AFC (P = 0.061). Similarly, there were no differences between groups 9 months after surgery for AMH (P = 0.939), E2 (P = 0.137), FSH (P = 0.276), LH (P = 0.07) and AFC (P = 0.066). At 9 months after the operation, no patients had malignant ovarian tumors. The incidences of benign ovarian tumors in the salpingectomy group were 0 and 2.68 % at 3 and 9 months after surgery, respectively, and the corresponding values in the control group were 0 and 5.36 %. The incidences of pelvic inflammatory disease in the salpingectomy group were 10.72 and 8.04 % at 3 and 9 months after surgery, respectively, while corresponding values in the control group were 24.13 and 16.09 %.

CONCLUSIONS

Prophylactic bilateral salpingectomy did not damage the ovarian reserve of reproductive-age women who underwent laparoscopic hysterectomy. Prophylactic bilateral salpingectomy might be a good method to prevent the development of ovarian cancer. Larger clinical trials with longer follow-up times are needed to further evaluate the risks and benefits.

Associations of FSHR and LHCGR gene variants with ovarian reserve and clinical pregnancy rates

RESEARCH QUESTION

Are there any associations between the variants of FSHR c.2039 G>A (p. Ser680Asn, rs6166) and LHCGR c.935A>G (p. Asn312Ser, rs2293275) and ovarian reserve, ovarian response, clinical pregnancy rate and POSEIDON group?

DESIGN

A total of 210 infertile women were enrolled in this prospective study. The gene variants were analysed by the Sanger method. The clinical parameters were analysed based on genotypes.

RESULTS

The frequency of heterozygous and homozygous G allele for FSHR c.2039 G>A in the low prognosis group was significantly higher than that in other response groups (P = 0.034); there was no significant association between LHCGR c.935 A>G and ovarian response. Moreover, the serum anti-Müllerian hormone (AMH) concentration, antral follicle count (AFC), oocytes retrieved, metaphase II (MII) oocytes and two-pronuclear (2PN) oocytes in patients with AG genotype for FSHR c.2039 G>A were significantly lower than those with AA genotype. The serum LH concentrations and clinical pregnancy rate of fresh embryo transfer in patients with GG genotype for LHCGR c.935 A>G were significantly higher than that of the AG genotype. In POSEIDON analysis, the low prognosis women with AA genotype for FSHR c.2039 G>A were more likely to appear in subgroup 1 (P = 0.038).

CONCLUSION

The FSHR c.2039 G>A variant has a significant beneficial influence on ovarian reserve and ovarian response. The LHCGR c.935 A>G variant is associated with increased clinical pregnancy rate of fresh embryo transfer in infertile women. In addition, the low prognosis women with AA genotype for FSHR c.2039 G>A tend to show better ovarian reserve and prognosis.

BRCA 1, 2 mutation and earlier menopause. Could BRCA 1, 2 be used as predictor of menopause?

Many studies have shown that BRCA mutation is not only related to cancer but also to ovarian aging. Studies in both human and mice oocytes have shown that Double-strand breaks (DSBs) accumulate with age. Genome-wide association studies (GWAS) have found 44 genetic loci that are related to variations when a female is about to have menopause. BRCA1 is involved in these 44 loci that are associated with the age of menopause. This review has gathered all results of literature search about the association between BRCA genes and early menopause. The majority of the articles found that women with BRCA mutation have earlier menopause compared to non-carriers. In conclusion, in the near future BRCA1,2 genes could be used as predictive biomarkers of menopause.

Antral follicle count and anti-Müllerian hormone to classify low-prognosis women under the POSEIDON criteria: a classification agreement study of over 9000 patients

STUDY QUESTION

What is the agreement between antral follicle count (AFC) and anti-Müllerian hormone (AMH) levels when used to patient classification according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria?

SUMMARY ANSWER

Our study indicates a strong agreement between the AFC and the AMH levels in classifying POSEIDON patients; thus, either can be used for this purpose, although one in four women will have discordant values when both biomarkers are used.

WHAT IS KNOWN ALREADY

According to the POSEIDON criteria, both AFC and AMH may be used to classify low-prognosis patients. Proposed AFC and AMH thresholds of 5 and 1.2 ng/ml, respectively, have their basis in published literature; however, no study has yet determined the reproducibility of patient classification in comparing one biomarker with the other, nor have their thresholds ever been validated within this patient population.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study involving 9484 consecutive patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were infertile women between 22 and 46 years old in their first in vitro fertilization/intracytoplasmic sperm injection cycle of standard ovarian stimulation with exogenous gonadotropins whose baseline ovarian reserves had been assessed by both AFC and AMH. Details of pre- and post-treatment findings were input into a coded research file. Two indicators of interest were created to classify patients according to the POSEIDON criteria based upon AFC and AMH values. Patients who did not fit any of the four POSEIDON groups were classified as non-POSEIDON. AFC was determined in the early follicular phase using two-dimensional (2D) transvaginal ultrasonography, whereas AMH values were based on the modified Beckman Coulter generation II enzyme-linked immunosorbent assay. Agreement rates were computed between AFC and AMH to classify patients using Cohen's kappa statistics. Logistic regression analyzes were carried out to examine the association between ovarian markers and low (<4) and suboptimal (4-9) oocyte yield.

MAIN RESULTS AND THE ROLE OF CHANCE

The degree of agreement in classifying patients according to POSEIDON groups was strong overall (kappa = 0.802; 95% CI: 0.792-0.811). A total of 73.8% of individuals were classified under the same group using both biomarkers. The disagreement rates were ∼26% and did not diverge when AFC or AMH was used as the primary biomarker criterion. Significant regression equations were found between ovarian markers and oocyte yield (P < 0.0001). For low oocyte yield, the optimal AFC and AMH cutoff values were 5 and 1.27 ng/ml with sensitivities of 0.61 and 0.66, specificities of 0.81 and 0.72, and AUC receiver operating characteristics of 0.791 and 0.751, respectively. For suboptimal oocyte yield respective AFC and AMH cutoffs were 12 and 2.97 ng/ml with sensitivities of 0.74 and 0.69, specificities of 0.76 and 0.66 and AUCs of 0.81 and 0.80.

LIMITATIONS, REASONS FOR CAUTION

Our study relied on 2D transvaginal sonography to quantify the AFC and manual Gen II assay for AMH determination and classification of patients. AMH data must be interpreted in an assay-specific manner. Treatment protocols varied across centers potentially affecting patient classification.

WIDER IMPLICATIONS OF THE FINDINGS

Three of four patients will be classified the same using either AFC or AMH values. Both biomarkers provide acceptable and equivalent accuracy in predicting oocyte yield further supporting their use and proposed thresholds in daily clinical practice for patient classification according to the POSEIDON criteria. However, the sensitivity of POSEIDON thresholds in predicting low oocyte yield is low. Clinicians should adopt the biomarker that may best reflect their clinical setting.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. The remaining authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

not applicable.

Can repeat IVF/ICSI cycles compensate for the natural decline in fertility with age? an estimate of cumulative live birth rates over multiple IVF/ICSI cycles in Chinese advanced-aged population

In order to find out to what extent ovarian aging could be compensated by the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments, a total of 4102 women above the age of 35 undergoing 6489 complete cycles from 2009 to 2015 with follow-up visits until 2017 were retrospectively analyzed. Cumulative live birth rates (CLBRs) across multiple IVF/ICSI cycles were compared in the study population stratified by age and ovarian reserve (classified by the POSEIDON criteria). Younger patients (aged between 35 and 40) could well benefit from repeat IVF treatments, with the optimal CLBRs ranging from 62%-72% for up to four complete cycles. However, the CLBRs sharply declined to 7.7%-40% in older patients (>40yrs). In light of ovarian reserve, the optimal-estimated-four-cycle CLBR of younger patients (35-40yrs) in POSEIDON group 2 could approached to those with normal ovarian response (non-POSEIDON), with 57.3%-70% versus 74.5%-81% respectively. However, the CLBR of older patients (>40yrs) in POSEIDON group 2 only reached 50% of their counterparts. Extending the number of IVF cycles beyond three or four is effective for advanced-aged women, especially in younger normal responders (non-POSEIDON) and unexpected poor/suboptimal responders (POSEIDON group 2). The real turning point at which female fecundity dropped after multiple IVF cycles is at the age of 40.

Machine-intelligence for developing a potent signature to predict ovarian response to tailor assisted reproduction technology

The prediction of poor ovarian response (POR) for stratified interference is a critical clinical issue that has received an increasing amount of recent concern. Anthropogenic diagnostic modes remain too simple for the handling of actual clinical complexity. Therefore, this study conducted extensive selection using models that were derived from a variety of machine learning algorithms, including random forest (RF), decision trees, eXtreme Gradient Boosting (XGBoost), support vector machine (SVM), and artificial neural networks (ANN) for the development of two models called the COS pre-launch model (CPLM) and the hCG pre-trigger model (HPTM) to assess POR based on different requirements. The results demonstrated that CPLM constructed using ANN achieved the highest AUC result of all the algorithms in COS pre-launch (AUC=0.859, C-index=0.87, good calibration), and HPTL constructed using random forest was found to be the most effective in hCG pre-trigger (AUC=0.903, C-index=0.90, good calibration). It is notable that CPLM and HPTM exhibited better performance than common clinical characteristics (0.895 [CPLM], and 0.903 [HPTM] in comparison to 0.824 [anti-Müllerian hormone (AMH)], and 0.799 [antral follicle count (AFC)]). Furthermore, variable importance figure elucidated the values of AMH, AFC, and E₂ level and follicle number on hCG day, which provides important theoretical guidance and experimental data for further application. Generally, the CPLM and HPTM can offer effective POR prediction for patients who are receiving assisted reproduction technology (ART), and has great potential for guiding the clinical treatment of infertility.

Comparative study of assisted reproductive outcomes between young patients with occult premature ovarian insufficiency and advanced-age patients

Objective

The purpose of this study was to compare the pregnancy outcomes among young patients with occult premature ovarian insufficiency (OPOI), advanced-age patients with diminished ovarian reserve (DOR), and advanced-age patients with normal ovarian reserve.

Methods

We retrospectively reviewed 324 women who underwent their first cycles of in vitro fertilization/intracytoplasmic sperm injection. The women were divided into the following groups: young women with OPOI, advanced-age women with DOR, and advanced-age women with normal ovarian reserve. The outcomes were compared among the different groups:

Results

The rates of live birth and embryo implantation in the young OPOI group were significantly higher than in the advanced-age DOR group, but comparable to those in the advanced-age normal ovarian reserve group. Moreover, the abortion rate was significantly lower in young OPOI patients compared with advanced-age patients with or without DOR.

Conclusion

Higher embryo implantation and live birth rates and a lower abortion rate can be achieved in young patients with OPOI compared with older patients. The better outcomes in advanced-age patients with normal ovarian reserve compared with DOR may be related to egg quantity rather than quality.

Dose adjustment of follicle-stimulating hormone (FSH) during ovarian stimulation as part of medically-assisted reproduction in clinical studies: a systematic review covering 10 years (2007-2017)

BACKGROUND

Individualization of the follicle-stimulating hormone (FSH) starting dose is considered standard clinical practice during controlled ovarian stimulation (COS) in patients undergoing assisted reproductive technology (ART) treatment. Furthermore, the gonadotropin dose is regularly adjusted during COS to avoid hyper- or hypo-ovarian response, but limited data are currently available to characterize such adjustments. This review describes the frequency and direction (increase/decrease) of recombinant-human FSH (r-hFSH) dose adjustment reported in clinical trials.

METHODS

We evaluated the proportion of patients undergoing ART treatment who received ≥ 1 r-hFSH dose adjustments. The inclusion criteria included studies (published Sept 2007 to Sept 2017) in women receiving ART treatment that allowed dose adjustment within the study protocol and that reported ≥ 1 dose adjustments of r-hFSH; studies not allowing/reporting dose adjustment were excluded. Data on study design, dose adjustment and patient characteristics were extracted. Point-incidence estimates were calculated per study and overall based on pooled number of cycles with dose adjustment across studies. The Clopper-Pearson method was used to calculate 95% confidence intervals (CI) for incidence where adjustment occurred in < 10% of patients; otherwise, a normal approximation method was used.

RESULTS

Initially, 1409 publications were identified, of which 318 were excluded during initial screening and 1073 were excluded after full text review for not meeting the inclusion criteria. Eighteen studies (6630 cycles) reported dose adjustment: 5/18 studies (1359 cycles) reported data for an unspecified dose adjustment (direction not defined), in 10/18 studies (3952 cycles) dose increases were reported, and in 11/18 studies (5123 cycles) dose decreases were reported. The studies were performed in women with poor, normal and high response, with one study reporting in oocyte donors and one in obese women. The median day that dose adjustment was permitted was Day 6 after the start of treatment. The point estimates for incidence (95% CI) for unspecified dose adjustment, dose increases, and dose decreases were 45.3% (42.7, 48.0), 19.2% (18.0, 20.5), and 9.5% (8.7, 10.3), respectively.

CONCLUSIONS

This systematic review highlights that, in studies in which dose adjustment was allowed and reported, the estimated incidence of r-hFSH dose adjustments during ovarian stimulation was up to 45%.

Anti-Müllerian hormone as a predictor of pregnancy in women under 35 years with unexplained infertility undergoing ICSI: a retrospective study

BACKGROUND

Anti-Müllerian hormone (AMH) is a well-established marker for the determination of ovarian reserve. However, its role in the prediction of pregnancy is still under debate. In this retrospective study, we aimed to evaluate the relationship of serum AMH levels with pregnancy rates in patients with unexplained infertility undergoing ICSI. Moreover, we compared the predictive value of AMH with that of antral follicle count (AFC).

METHODS

Records of 76 patients under 35 years of age with AMH levels between 1 and 3.5 ng/ml were examined retrospectively. Participants were divided into groups based on their AMH level and age.

RESULTS

AMH levels in women under 30 years were found significantly higher than those in women over 30 years (P=0.033). 57 of 76 patients (75%) were pregnant. Age did not have a significant effect on the pregnancy rates in the selected study group (P=0.252). On the other hand, despite the poor predictive accuracy, serum AMH was shown to have a predictive value with a cut-off point of 1.95 ng/mL. Logistic regression tests demonstrated a higher pregnancy rate (3.396 fold) with an AMH level 1.95 or above. There was no significant relationship between AFC and pregnancy.

CONCLUSIONS

AMH might have a role in the prediction of pregnancy after ICSI in patients under 35 years with unexplained infertility.

Elevated levels of nitrous dioxide are associated with lower AMH levels: a real-world analysis

STUDY QUESTION

Are there any associations between environmental pollutants and ovarian reserve, expressed by anti-Mullerian hormone (AMH) serum levels?

SUMMARY ANSWER

In this first real-world approach to demonstrate the relationship between air pollutants and serum AMH levels, adverse associations were observed for nitrogen dioxide (NO2) but not with particulate matter.

WHAT IS KNOWN ALREADY

In recent years, air pollution has emerged as a potential disrupter to the homeostasis of physiological hormones, possibly affecting human reproduction. Although the influence of age and smoking on AMH levels is largely accepted, the relationship between AMH and the environment has not currently been established.

STUDY DESIGN, SIZE, DURATION

A longitudinal, observational, retrospective, real-world study was carried out, including all AMH measurements performed in a single laboratory from January 2007 to October 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serum AMH data were connected to patients' age and residential address, to include air pollution data after geo-localisation. The air pollution considered daily particulate matter (PM) and NO2 values.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1463 AMH measurements were collected (mean 1.94 ng/ml, median 0.90 ng/ml). AMH was inversely related to patients' age in women older than 25 years (adjusted R-squared 0.120, P < 0.001), but not in those younger than 25 years (adjusted R-squared 0.068, P = 0.055). AMH levels were inversely related to environmental pollutants, such as PM10 (Rho = -0.088, P = 0.001), PM2.5 (Rho = -0.062, P = 0.021) and NO2 (Rho = -0.111, P < 0.001). After subdividing the dataset into quartiles for PM10 and PM2.5, the influence of age on AMH serum levels was found to be a stronger influence than that exerted by PM (P = 0.833 and P = 0.370, respectively). On the contrary, considering NO2 quartiles, higher AMH levels were observed in third quartile compared to fourth quartile, even after adjustment for age (P = 0.028), indicating a stronger influence of NO2 exposure on AMH serum levels. Considering an AMH cut-off of 0.3 ng/ml, a significant higher frequency of women with severe ovarian reserve reduction in the fourth quartile was shown only for NO2 (P = 0.010).

LIMITATIONS, REASONS FOR CAUTION

Several limitations should be underlined, such as the lack of information about work and life habits of each patient and the retrospective nature of the analysis performed on real-world data.

WIDER IMPLICATIONS OF THE FINDINGS

Although the genetic component is highly predictive for defining the ovarian reserve at birth, potentially modifiable environmental factors could influence the rate of decline in AMH and ovarian reserve during adulthood.

STUDY FUNDINGCOMPETING INTEREST(S)

Authors have neither funding nor competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Controlled ovarian hyperstimulation for poor ovarian responders undergoing in vitro fertilisation/intracytoplasmic sperm injection: a protocol for systematic review and Bayesian network meta-analysis

INTRODUCTION

Controlled ovarian hyperstimulation (COH) is the routine regimen used to generate a sufficient number of follicles during in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Poor ovarian response is a challenge encountered by many clinicians during COH and poor ovarian responders (PORs) usually have higher follicle stimulating hormone levels, lower levels of anti-Mullerian hormone and few oocytes retrieved, which have been attributed mainly to advanced maternal age and poor follicle reserve or other reasons that could impair ovarian response during ovarian stimulation. Over the last few decades, researchers have proposed a series of strategies and ovarian stimulation protocols to improve pregnancy outcomes in patients with POR during their IVF/ICSI treatment. However, clinical decisions regarding COH protocols in PORs during IVF/ICSI treatment remain controversial. Traditional pairwise meta-analysis only allows the direct comparison of two protocols in COH for patients with POR. However, many of these COH protocols have not been compared directly in randomised controlled trials (RCTs). Thus, we aim to use network meta-analysis (NMA) to assess the clinical effectiveness and safety of COH protocols and to generate treatment rankings of these COH protocols for the most clinically important and commonly reported outcomes events.

METHODS AND ANALYSIS

The PubMed, Embase, Cochrane Library, Web of Science, SinoMed, CNKI, WanFang database and Chongqing VIP information databases will be searched for all RCTs of COH for POR women during IVF/ICSI from inception to 31 March 2020. Primary outcomes will include live birth rate and number of oocytes retrieved. Secondary outcomes will include ongoing pregnancy rate, clinical pregnancy rate, miscarriage rate, ovarian hyperstimulation syndrome rate, multiple pregnancy rate and cycle cancellation rate. Pairwise meta-analysis and Bayesian NMA will be conducted for each outcome. Subgroup analysis, meta-regression, and sensitivity analysis will be performed to assess the robustness of the findings. The generation of NMA plots and subsequent results will be performed by using R V.4.0.1. The assessment of confidence in network estimates will use the Confidence in Network Meta-Analysis)web application (see https://cinema.ispm.unibe.ch/).

ETHICS AND DISSEMINATION

This review does not require ethics approval and the results of the NMA will be submitted to a peer-review journal.

Metabolomic Profiling of Poor Ovarian Response Identifies Potential Predictive Biomarkers

OBJECTIVE

To characterize the serum metabolomic profile and its role in the prediction of poor ovarian response (POR).

PATIENTS

Twenty-five women with normal ovarian reserve (24-33 years, antral follicle count [AFC] ≥5, anti-Müllerian hormone [AMH] ≥1.2 ng/ml) as the control group and another twenty-five women with POR (19-35 years, AFC <5, AMH < 1.2 ng/ml) as the study group were collected in our study. The serum levels of the women in both groups were determined from their whole blood by untargeted liquid chromatography-mass spectrometry (LC-MS). Multivariate statistical analysis and cell signal pathways analysis were used to reveal the results.

RESULTS

A total of 538 different metabolites were finally identified in the two groups. Tetracosanoic acid, 2-arachidonoylglycerol, lidocaine, cortexolone, prostaglandin H2,1-naphthylamine, 5-hydroxymethyl-2-furancarboxaldehyde, 2,4-dinitrophenol, and D-erythrulose1-phosphate in POR were significantly different from control as were most important metabolites in support vector machines (p <0.05). Metabolomic profiling, together with support vector machines and pathway analysis found that the nicotinate and nicotinamide metabolism pathway, including L-aspartic acid, 6-hydroxynicotinate, maleic acid, and succinic acid semialdehyde, was identified to have significant differences in POR women compared to control women, which may be associated with ovarian reserve.

CONCLUSION

This study indicated that LC-MS-based untargeted metabolomics analysis of serum provided biological markers for women with POR. The nicotinate and nicotinamide metabolism pathway may offer new insight into the complementary prediction and therapeutic potential of POR. The functional associations of these metabolites need further investigation.

Improving Reporting of Clinical Studies Using the POSEIDON Criteria: POSORT Guidelines

The POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) criteria were developed to help clinicians identify and classify low-prognosis patients undergoing assisted reproductive technology (ART) and provide guidance for possible therapeutic strategies to overcome infertility. Since its introduction, the number of published studies using the POSEIDON criteria has increased steadily. However, a critical analysis of existing evidence indicates inconsistent and incomplete reporting of critical outcomes. Therefore, we developed guidelines to help researchers improve the quality of reporting in studies applying the POSEIDON criteria. We also discuss the advantages of using the POSEIDON criteria in ART clinical studies and elaborate on possible study designs and critical endpoints. Our ultimate goal is to advance the knowledge concerning the clinical use of the POSEIDON criteria to patients, clinicians, and the infertility community.

Predictive Factors for Live Birth in Fresh In Vitro Fertilization/Intracytoplasmic Sperm Injection Treatment in Poor Ovarian Reserve Patients Classified by the POSEIDON Criteria

The mechanisms underlying poor ovarian response (POR) in assisted reproductive technology remain unclear, there is no consensus on the management of poor responders, the POSEIDON stratification classifies infertility patients into "expected" or "unexpected" groups to provide a more nuanced picture of POR, but few researchers have discussed the independent predictive factors (smoothed plots and the threshold effect) for live birth in POR patients classified by the new criteria. We conducted a retrospective cohort study using clinical data from 6,580 POR patients classified by the POSEIDON criteria in the First Affiliated Hospital of Zhengzhou University, and explored the live birth based on the results before and after the threshold inflection point of each independent influencing factor. Among 6,580 poor ovarian reserve patients classified by the POSEIDON criteria, 1,549 (23.54%) had live births, and 5,031 (76.46%) did not have live births. Multivariate logistic regression analysis showed that female age (OR 0.901; 95% CI 0.887~0.916; P < 0.001), body mass index (OR 0.963; 95% CI 0.951~0.982; P < 0.001), antral follicle counting (OR 1.049; 95% CI 1.009~1.042; P < 0.001) and controlled ovarian hyperstimulation protocol were independent factors predicting live birth in patients with POR. The threshold effect analysis found that the inflection point of female age was 34 years old, and when age was > 34 years old, the probability of live birth in POR patients dropped sharply (OR 0.7; 95% CI 0.7~0.8; P < 0.001). The inflection point of BMI was 23.4 kg/m², and BMI had a negative correlation with live birth (OR 0.963; 95% CI 0.951~0.982; P < 0.001). The threshold inflection point of AFC was 8n. Female age, BMI, AFC and COH protocol were independent predictive factors associated with live birth in POR patients classified by the POSEIDON criteria. The smooth curve fit and threshold effect analyses provide clinical management strategies for these patients. In addition, the early-follicular-phase long-acting GnRH-agonist long protocol seems to have a higher live birth rates than other protocols. It is worth highlighting that BMI should be considered as well in the POSEIDON criteria.

Low Prognosis by the POSEIDON Criteria in Women Undergoing Assisted Reproductive Technology: A Multicenter and Multinational Prevalence Study of Over 13,000 Patients

OBJECTIVE

To estimate the prevalence of low-prognosis patients according to the POSEIDON criteria using real-world data.

DESIGN

Multicenter population-based cohort study.

SETTINGS

Fertility clinics in Brazil, Turkey, and Vietnam.

PATIENTS

Infertile women undergoing assisted reproductive technology using standard ovarian stimulation with exogenous gonadotropins.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Per-period prevalence rates of POSEIDON patients (overall, stratified by POSEIDON groups and by study center) and the effect of covariates on the probability that a patient be classified as "POSEIDON".

RESULTS

A total of 13,146 patients were included. POSEIDON patients represented 43.0% (95% confidence interval [CI] 42.0-43.7) of the studied population, and the prevalence rates varied across study centers (range: 38.6-55.7%). The overall prevalence rates by POSEIDON groups were 44.2% (group 1; 95% CI 42.6-45.9), 36.1% (group 2; 95% CI 34.6-37.7), 5.2% (group 3; 95% CI 4.5-6.0), and 14.4% (group 4; 95% CI: 13.3-15.6). In general, POSEIDON patients were older, had a higher body mass index (BMI), lower ovarian reserve markers, and a higher frequency of female factor as the primary treatment indication than non-POSEIDON patients. The former required larger doses of gonadotropin for ovarian stimulation, despite achieving a 2.5 times lower number of retrieved oocytes than non-POSEIDON patients. Logistic regression analyses revealed that female age, BMI, ovarian reserve, and a female infertility factor were relevant predictors of the POSEIDON condition.

CONCLUSIONS

The estimated prevalence of POSEIDON patients in the general population undergoing ART is significant. These patients differ in clinical characteristics compared with non-POSEIDON patients. The POSEIDON condition is associated with female age, ovarian reserve, BMI, and female infertility. Efforts in terms of diagnosis, counseling, and treatment are needed to reduce the prevalence of low-prognosis patients.

Prevalence and clinical associations with premature ovarian insufficiency, early menopause, and low ovarian reserve in systemic sclerosis

The low prevalence of pregnancy in women with systemic sclerosis (SSc) is due to multi-factorial causes, including premature ovarian insufficiency (POI). The study aimed to determine the prevalence of POI, early menopausal status, and any clinical associations of these among Thai female SSc patients. An analytical cross-sectional study was conducted among female SSc patients between 18 and 45 years of age. The eligible patients underwent blood testing for follicle stimulating hormone and anti-mullerian hormone levels, gynecologic examination, and transvaginal ultrasound for antral follicle count. We excluded patients having surgical amenorrhea, previous radiation, and history of hormonal contraception < 12 weeks and pregnancy. A total of 31 patients were included. The majority (67.7%) had diffuse cutaneous systemic sclerosis. Three patients were POI with a prevalence of 9.7%. The factors associated with POI were a high cumulative dose of cyclophosphamide (CYC) (p = 0.02) and the long duration of CYC used (p = 0.02). After excluding POI, early menopause was detected in 10 patients with a prevalence of 35.7%. The factors associated with early menopause were long disease duration (p = 0.02), high cumulative dose of CYC (p = 0.03), and high cumulative dose of prednisolone (p = 0.02). Low ovarian reserve according to POSEIDON definition was found in 28 patients with the prevalence of 90.3%. POI in Thai SSc was uncommon, whereas early menopause and low ovarian reserve were frequently revealed. A high cumulative dose of CYC was associated with both POI and early menopause. Physicians should be aware of reproductive outcomes and advise patients at risk. Key Points • POI is revealed in patients with SSc particularly in who received high cumulative dose of cyclophosphamide, while early menopause and low ovarian reserve were major reproductive problem among SSc. • Prescriptions for CYC for female SSc-both for young patients of reproductive age and premenopausal middle-aged women-should be concerned of the long-term effects on gonadal function.

AMH assessment five or more years after an initially low AMH level

PURPOSE

Anti-Müllerian hormone (AMH) is a biomarker reflecting ovarian reserve. A low AMH level before 39 years may be associated with a risk of menopause between 40 and 45 years. The risk of onset of premature ovarian insufficiency (POI) is, however, poorly documented. The objective of the study was to determine the prevalence of POI 5-10 years after an AMH assay below 8 pmol/L.

METHODS

We included women aged younger than 36 years who underwent a complete workup for infertility between January 2008 and December 2013 at the University Hospital and had an AMH level less than 8 pmol/L. In 2018, 47 of these women were assessed clinically, and 21 of them agreed to undergo an ovarian reserve test.

RESULTS

The prevalence of POI after at least 5 years was 8/47, or 17 % [8 %-31 %]. The median time to diagnosis was 5.1 years [2.9-7.3]. There was a significant difference at T0 in the regularity of cycles between the two groups (p = 0.024) and in their baseline serum AMH level: 6.0 pmol/L in the non-POI group vs 4.2 pmol/L in the POI group (p = 0.002).

CONCLUSION

Serum AMH < 8 pmol/L before the age of 36 years appears to be a risk factor for POI. These women require regular follow-up, especially if their cycles are irregular.

Acupuncture for "poor ovarian response" of women to controlled ovarian hyperstimulation: A protocol for meta-analysis and systematic review

BACKGROUND

Poor ovarian response (POR) is a high-incidence disease of women, which cause in vitro fertilization failure. Various treatment options have been proposed for women with POR to improve their ovarian response, but with little effect. In recent years, there is a wide range of applications of acupuncture in the process of in vitro fertilization. The meta-analysis and systematic review are designed to analyze whether acupuncture is effective for patients with POR.

METHODS

The following databases will be searched from inception to March 2020: Electronic databases consist of MEDLINE, EMBASE, Allied and Complementary Medicine Database, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, the Chinese Scientific Journal Database, and Wanfang Database. Other literature resources will also be searched including clinical trial registries, key journals, and meeting records. The results of randomized controlled trials of acupuncture therapy on POR, which are published in Chinese or English, will be embedded. The primary outcome is the clinical pregnancy rate. Data identification, data selection, data extraction, and assessment of bias risk will be completed independently by 2 or more reviewers. STATA/IC 16 will be used to perform the meta-analysis. We will use the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate the quality of our evidence. A systematic narrative synthesis will be provided if the quantitative analysis is not available.

DISCUSSION

This study will provide the first meta-analysis and systematic review to evaluate the efficacy of acupuncture in treating POR. This protocol provides details to guide this study.

CONCLUSIONS

From this review may benefit POR patients or clinical decision-makers.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020169560.

Safety and effectiveness of acupuncture for POSEIDON patients in IVF/ICSI: A protocol for systematic review and meta-analysis

INTRODUCTION

The purpose of this paper is to evaluate the efficacy and safety of acupuncture for POSEIDON patients undergoing IVF/ICSI.

METHODS

and analysis We will electronically search Pubmed, Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trial, China National Knowledge Infrastructure, China Biomedical Literature Database, China Science Journal Database and Wan-fang Database from their inception. Also, we will manually retrieve other resources, including reference lists of identified publications, conference articles, and grey literature. The clinical randomized controlled trials or quasi randomized controlled trials related to acupuncture treatment for POSEIDON patients in IVF/ICSI will be included in the study. The language is limited to Chinese and English. Research selection, data extraction, and research quality assessment will be independently completed by two researchers. Data were synthesized by using a fixed effect model or random effect model depend on the heterogeneity test. The clinical pregnancy rate (CPR) and live birth rate (LBR) will be the primary outcomes. The ongoing pregnancy, miscarriage rate (MR) and adverse events will also be assessed as secondary outcomes. RevMan V.5.3 statistical software will be used for meta-analysis, and the level of evidence will be assessed by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Continuous data will be expressed in the form of weighted mean difference or standardized mean difference with 95% confidence intervals (CIs), while dichotomous data will be expressed in the form of relative risk with 95% CIs.

ETHICS AND DISSEMINATION

The protocol of this systematic review (SR) does not require ethical approval because it does not involve humans. We will publish this article in peer-reviewed journals and presented at relevant conferences.

SYSTEMATIC REVIEW REGISTRATION

OSF Registries, DOI: 10.17605/OSF.IO/6WP2F (https://osf.io/6wp2f).

Donor IUI is equally effective for heterosexual couples, single women and lesbians, but autologous IUI does worse

STUDY QUESTION

Are there differences in the clinical outcomes of IUI among different populational groups (heterosexual couples, single women and lesbian couples)?

SUMMARY ANSWER

The outcome of donor IUI (D-IUI) is similar in all populational groups and better than that seen with autologous insemination.

WHAT IS KNOWN ALREADY

A vast body of literature on clinical outcome is available for counselling heterosexual couples regarding decisions related to ART. The reproductive potential of single women, lesbian couples and heterosexual couples who need donor semen is assumed to be better, but there is a scarcity of data on their ART performance to actually confirm it.

STUDY DESIGN, SIZE, DURATION

In this retrospective multicentric cohort study, a total of 7228 IUI treatment cycles performed in 3807 patients between January 2013 and December 2016 in 13 private clinics belonging to the same reproductive medicine group in Spain were included. Patients with previous IUI attempts were excluded from the study. Only 1.9% of cycles were lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 5318 D-IUI cycles were performed in three different populational groups: heterosexual couples (D-HC, 1167 cycles), single women (SW, 2839 cycles) and lesbian couples (LC, 1312), while a total of 1910 autologous IUI cycles were performed in heterosexual couples (A-HC). This last one was considered the control group and was composed of cycles performed in couples with a male partner with sperm parameters equivalent to those requested from donors. In order to identify factors with an impact on clinical outcome, a multivariate logistic regression analysis was performed. Regarding live birth rate (LBR), mixed effect models were employed to control for the fact that different patients were submitted to different numbers of treatments.

MAIN RESULTS AND THE ROLE OF CHANCE

Parameters that were significant to the primary outcome (LBR) according to the multivariate analysis were the populational group (D-HC, SW, LC and A-HC) to which the patient belonged, female age and a diagnosis of low ovarian reserve. At the age range of good prognosis (≤37 years), LBR was similar in all groups that underwent D-IUI (18.8% for D-HC, 16.5% for SW and 17.6% for LC) but was significantly lower in the autologous IUI (A-HC) group (11%). For all these significant findings, the strength of the association was confirmed by P values <0.001. From 38 years of age on, no significant differences were observed among the populational groups studied, and for all of them, LBR was below 7% from 40 years of age on.

LIMITATIONS, REASONS FOR CAUTION

To the best of our knowledge, a smoking habit was the only known factor with a potential effect on ART outcome that could not be controlled for, due to the unavailability of this information in a significant percentage of the clinical files studied. Our study was not capable of precisely quantifying the impact of a diagnosis of low ovarian reserve on the LBR of both IUI and D-IUI, due to the number of cycles performed in patients with such diagnosis (n = 231, 3.2% of the total).

WIDER IMPLICATIONS OF THE FINDINGS

For the first time, a comparison among D-HC, SW, LC and A-HC was performed in a study with a robust sample size and controlling for potential sources of bias. There is now sound evidence that equivalent clinical outcome is seen in the three groups treated with donor semen (D-HC, SW and LC). Specifically, regarding the comparison between SW and LC, our findings rule out differences in LBR proposed by previous publications, with very similar clinical outcomes within the same age ranges. At age ranges of good prognosis (≤37 years), reproductive performance of D-IUI is significantly better than that seen in heterosexual couples undergoing autologous IUI, even when only cases of optimal sperm quality are considered in this last group. This finding is in agreement with the concept that, as a group, A-HC are more prone to have female factor infertility, even when their infertility assessment finds no contraindication to IUI. Age affects all these groups equally, with none of them reaching a 7% LBR after the age of 40 years. Our findings will be useful for the counselling of patients from the different populations studied here about ART strategies.

STUDY FUNDING/COMPETING INTEREST(S)

None.

The Conundrum of Poor Ovarian Response: From Diagnosis to Treatment

Despite recent striking advances in assisted reproductive technology (ART), poor ovarian response (POR) diagnosis and treatment is still considered challenging. Poor responders constitute a heterogeneous cohort with the common denominator of under-responding to controlled ovarian stimulation. Inevitably, respective success rates are significantly compromised. As POR pathophysiology entails the elusive factor of compromised ovarian function, both diagnosis and management fuel an ongoing heated debate depicted in the literature. From the criteria employed for diagnosis to the plethora of strategies and adjuvant therapies proposed, the conundrum of POR still puzzles the practitioner. What is more, novel treatment approaches from stem cell therapy and platelet-rich plasma intra-ovarian infusion to mitochondrial replacement therapy have emerged, albeit not claiming clinical routine status yet. The complex and time sensitive nature of this subgroup of infertile patients indicates the demand for a consensus on a horizontally accepted definition, diagnosis and subsequent effective treating strategy. This critical review analyzes the standing criteria employed in order to diagnose and aptly categorize POR patients, while it proceeds to critically evaluate current and novel strategies regarding their management. Discrepancies in diagnosis and respective implications are discussed, while the existing diversity in management options highlights the need for individualized management.

Cumulative live birth rate of low prognosis patients with POSEIDON stratification: a single-centre data analysis

RESEARCH QUESTION

Does patient-oriented strategies encompassing individualized oocyte number (POSEIDON) classification help stratify the reproductive potential of patients with low prognosis more effectively from the perspective of prognosis; and as cumulative live birth rate (CLBR) is an effect indication, how is CLBR in patients stratified using POSEIDON?

DESIGN

A retrospective cohort study of 10,615 women who underwent IVF treatment at the Peking University Third Hospital between January 2017 and December 2017. Patients were stratified according to POSEIDON criteria. Clinical characteristics, fresh embryo transfer outcomes and CLBR during the first two ovarian stimulation cycles were recorded.

RESULTS

Gonadotrophin-releasing hormone antagonist protocol was the most used treatment in both ovarian stimulation cycles. After the failure of the first IVF treatment, 2063 (29.2%) women continued the second treatment, and 10.9% of them switched to the micro-stimulation protocol. Compared with the non-POSEIDON group, the CLBR of the first cycle in each POSEIDON group was lower (P < 0.001). The CLBRs of the second cycle in older patients (POSEIDON groups 2b and 4) and in younger patients with poor ovarian reserve (POSEIDON group 3) were lower than that in non-POSEIDON group (group 2b, P = 0.001; group 3, P = 0.019; group 4, P < 0.001). Subgroup analysis showed that younger patients had higher CLBR than older patients in both cycles (P < 0.001).

CONCLUSION

The CLBRs vary among different POSEIDON groups. The results may help reproductive specialists to understand the characteristics of low prognosis patients better and to develop individualized treatment plans.

Cumulative live-birth, perinatal and obstetric outcomes for POSEIDON groups after IVF/ICSI cycles: a single-center retrospective study

Recently, perinatal outcomes and cumulative live birth rate (CLBR) have widely been utilized to assess the fertility outcomes and safety of assisted reproductive technology (ART), but more robust research is needed to address the success rates of live-healthy births resulting from this procedure, particularly for patients with low prognosis. This study aims to assess and comparative perinatal outcomes and CLBR per cycle of in vitro fertilization/Intracytoplasmic sperm injection (IVF/ICSI) between four groups of low prognosis characterized by POSEIDON criteria. A retrospective assessment was done among infertile women with a low prognosis undergoing IVF/ICSI at a reproductive center in China. Data were collected between January 2011 and December 2015 with a follow-up of at least two years, and censoring was defined by three-cycle completion, discontinuation, or having a live birth. Participants were grouped into 4 groups according to the POSEIDON classification (POSEIDON1, POSEIDON2, POSEIDON3, and POSEIDON4). The main outcomes were perinatal and obstetric outcomes with CLBR per cycle after IVF/ICSI procedure. And IVF/ICSI-technique outcomes as a secondary outcome. Statistical analyses were performed by SPSS, and a p value of < 0.05 was considered significant. A total of 461 eligible participants underwent a total of 825 IVF/ICSI cycles. POSEIDON1 had the best perinatal outcomes in terms of live births (≥ 28w) (54.8%). POSEIDON4 had a higher risk for perinatal and obstetric complications with abortion rate (9.8%); LBW (11.7%), PTD (23.5%), PROM (11.7%), and gestational diabetes (17.6%). POSEIDON2 had a high rate for malpresentation (14.2%), and cesarean delivery(57.2%), while POSEIDON3 was much associated with the occurrences of placenta previa (9.3%) compared to other groups (p value = 0.001). After adjusting odds ratio by age and BMI, POSEIDON4 had the least odds for biochemical pregnancy (p value = 0.019); and the least odds for clinical pregnancy (p value = 0.001) of the four groups. CLBR per cycle was better in POSEIDON1 and increased with an increasing number of cycles in all groups during the three cycles. Conservative CLBR after three complete cycles were 77.27%, 42.52%, 51.4% and 22.34%, while optimistic CLBR were 79.01%, 51.19%, 58.59% and 34.46% in POSEIDON1 to POSEIDON4, respectively. Younger women with low prognosis and normal ovarian reserve have a higher probability for live births and better perinatal outcomes compared with older women with poor or normal ovarian reserve. Besides, young women with low prognosis, despite ovarian reserve status, can increase their probability of conception and get relatively higher CLBR by undergoing multiple cycles of IVF/ICSI. Age is therefore considered as a critical parameter in predicting the perinatal outcome and CLBR.

Efficacies of different ovarian hyperstimulation protocols in poor ovarian responders classified by the POSEIDON criteria

We retrospectively analyzed clinical data from 45,912 in vitro fertilization/intracytoplasmic sperm injection cycles in our reproductive medical center. We compared the clinical outcomes of three different ovarian hyperstimulation protocols in poor ovarian responders (classified by the POSEIDON criteria) to determine the most effective protocol for each POSEIDON group. In POSEIDON groups 1 and 3, the early-follicular-phase long-acting GnRH-agonist long (EFLL) protocol was associated with higher pregnancy rates per transfer and higher live birth rates than the mid-luteal-phase short-acting GnRH-agonist long (MLSL) and GnRH-antagonist protocols. We also examined the relationship between advanced age and reproductive outcomes, and observed a negative correlation between age and live birth rate for each protocol (EFLL: OR = 0.890, 95% CI: 0.870 - 0.911, P < 0.001; MLSL: OR = 0.907, 95% CI: 0.885 - 0.926, P < 0.001; GnRH-antagonist: OR = 0.891, 95% CI: 0.857 - 0.926, P < 0.001). In terms of clinical outcomes, EFLL was the most effective protocol for young poor ovarian responders. However, there were no differences in the implantation rates, clinical pregnancy rates, or live birth rates among the protocols in older patients. Age is thus the most important determinant of oocyte quality, embryo ploidy, and delivery rate.

Anti-Müllerian hormone is an independent marker for oocyte survival after vitrification

RESEARCH QUESTION

This study explored the relationship between anti-Müllerian hormone (AMH) and oocyte survival after vitrification. The association between AMH and blastocyst formation after oocyte vitrification was also assessed.

DESIGN

A retrospective observational analysis was performed in a private IVF centre. A total of 4507 metaphase-II warmed oocytes were included from 450 couples, predominantly of Arab ethnicity. Between August 2015 and August 2018, couples underwent 484 intracytoplasmic sperm injection (ICSI) treatments using vitrified-warmed oocytes.

RESULTS

Patients' median age ± SD was 36.2 ± 6.1 years, AMH concentration 2.6 ± 3.4 ng/ml and body mass index (BMI) 26.5 ± 4.6 kg/m². The oocyte survival rate after vitrification was 87.37 ± 20.42%. AMH concentration showed a significant correlation (Kendall's tau 0.087, P = 0.0079) with oocyte survival rate independent of oocyte yield. Correlation was significant (odds ratio 1.041, 95% confidence interval 1.007-1.077, P = 0.018) when a multivariant model was applied that included AMH, age and BMI. The receiver operating characteristic curve showed an AMH cut-off value of 1.09 ng/ml that could obtain at least a 70% survival rate, with an area under the curve of 0.669. Regarding embryo development in ICSI cycles including fresh and warmed oocytes for the same patient, blastocyst formation rate was higher in fresh compared with warmed oocytes (P < 0.001). In this subgroup no significant correlation was seen between fertilization or blastocyst rate and AMH concentration.

CONCLUSIONS

AMH concentration showed a significant correlation with oocyte survival. Blastocyst formation was significantly lower after oocyte vitrification, but no correlation was found with AMH. Clinicians should carefully evaluate oocyte vitrification for patients with AMH below 1.09 ng/ml and consider embryo accumulation for these patients in preference to oocyte accumulation.

Heterogeneity Among Poor Ovarian Responders According to Bologna Criteria Results in Diverging Cumulative Live Birth Rates

Research Question: Does reproductive outcome differ among the various subgroups of poor ovarian responders according to the Bologna criteria? Design: This was a retrospective, cohort study including poor ovarian responders according to Bologna criteria, undergoing an ICSI cycle from January 2011 until December 2017. Patients were divided into four groups: (1) age ≥ 40 years and abnormal ovarian response test, (2) age ≥ 40 years, abnormal ovarian reserve test and one previous poor response to stimulation, (3) age ≥ 40 years and one previous poor response, (4) abnormal ovarian reserve test and one previous poor response. Result(s): Overall, 846 cycles in 706 Bologna poor ovarian responders were included: 310 cycles in group 1, 169 in group 2, 52 in group 3, and 315 in group 4. There were significant differences in age, antral follicle count, antimüllerian hormone, cycle cancellation rates, and number of retrieved oocytes between the four groups. Live birth and cumulative live birth rate differed significantly between groups and were highest in Group 4 [Live birth rate: 7.4% (1) vs. 4.1% (2) vs. 5.8% (3) vs. 13.4% (4), p = 0.001 and Cumulative live birth rate: 8.3% (1) vs. 4.1 % (2) vs. 9.6% (3) vs. 16.8% (4) p < 0.001]. The multivariate GEE analysis revealed that the number of MIIs and the Bologna criteria pattern were the variables which were significantly associated with cumulative live birth rate. Conclusion(s): Poor ovarian responders represent a heterogeneous population. The young subpopulation has a better clinical prognosis in terms of fresh and cumulative live birth rate.