Prognostic value of some ovarian reserve tests in poor responders

Assessment of ovarian reserve in euthyroid adolescents with Hashimoto thyroiditis

AIM

We aimed to investigate the ovarian function and reserve in euthyroid adolescents (TSH < 2.5 mIU/L) diagnosed with Hashimoto thyroiditis (HT).

METHODS

This case-control study included 30 adolescent girls (mean age 15.1 ± 1.4 years) newly diagnosed as HT with presence of high thyroid antibodies with gland heterogeneity in ultrasound and age-matched 30 healthy female subjects. Anti-ovarian antibody (AOAb), LH/FSH ratio, estradiol, anti-mullerian hormone (AMH), inhibin-B, total testosterone, antral follicle count, ovarian volumes and uterine length were measured. The clinical, laboratory, and ultrasound data of the HT and control groups were compared.

RESULTS

There were no significant differences between the girls with HT and healthy controls in relation to LH/FSH ratio, estradiol and inhibin-B levels. AOAb (p = 0.02), AMH (p = 0.007) and total testosterone levels were higher in HT group than the control group (p = 0.03). AOAb level was found to be positively correlated with LH/FSH ratio (p = 0.03), AMH (p = 0.01) and inhibin-B (p < 0.001) in HT group.

CONCLUSION

This study demonstrated that the adolescent girls diagnosed with autoimmune thyroiditis had normal ovarian reserve based on measurements of AMH, inhibin B, FSH, LH/FSH ratio, estradiol and antral follicle counts.

Serum estradiol level change after human chorionic gonadotropin administration had no correlation with live birth rate in IVF cycles

OBJECTIVE

To investigate the correlation between the estradiol (E2) level change after hCG administration and the live birth rate in GnRH agonist long or short protocols, and to explore the possible factors related to E2 dynamics after hCG administration during controlled ovarian hyperstimulation (COH).

STUDY DESIGN

A retrospective analysis was performed on 2868 patients who received IVF/intracytoplasmic sperm injection (ICSI) treatment with GnRH agonist long or short protocol. The patients were divided into three groups according to their serum E2 changes after hCG administration, and the live birth rates were compared among groups. The area under the receiver operating characteristic (ROC) curve was calculated to assess the predictive value of E2 change for the probability of live birth. Logistic regression analysis was also applied to exclude interference from various confounding factors. Finally, multivariate regression analysis was conducted to assess factors related to the E2 change after hCG administration.

RESULTS

No significant difference was observed in live birth rates (4.26%, 36.38% or 30.81% in long protocol (P=0.697); 25.81%, 26.71% or 30.81% in short protocol (P=0.697)) among patients with increasing, plateauing or decreasing E2 responses after hCG administration. The area under the ROC curve for the E2 change in prediction of live birth rate was 0.506 in long protocol, or 0.524 in short protocol. Logistic regression analysis showed that the serum E2 change after hCG administration had no correlation with live birth rate. Multivariate regression analysis showed that the percentage of mature follicles (larger than 14mm) and the duration of stimulation negatively correlated with the E2 change after hCG administration.

CONCLUSIONS

In GnRH agonist cycles, the serum E2 change after hCG administration had no correlation with live birth rate in fresh embryo transfer cycles, and this change negatively correlated with the percentage of mature follicles on the day of hCG administration.

Prediction of an excessive response in in vitro fertilization from patient characteristics and ovarian reserve tests and comparison in subgroups: an individual patient data meta-analysis

OBJECTIVE

To evaluate whether ovarian reserve tests (ORTs) add prognostic value to patient characteristics, such as female age, in the prediction of excessive response to ovarian hyperstimulation in patients undergoing IVF, and whether their performance differs across clinical subgroups.

DESIGN

Authors of studies reporting on basal FSH, antimüllerian hormone (AMH), or antral follicle count (AFC) in relation to ovarian response to ovarian hyperstimulation were invited to share original data. Random intercept logistic regression models were used to estimate added value of ORTs on patient characteristics, while accounting for between-study heterogeneity. Receiver operating characteristic regression analyses were performed to study the effect of patient characteristics on ORT accuracy.

SETTING

In vitro fertilization clinics.

PATIENT(S)

A total of 4,786 women for the main analysis, with a subgroup of 1,023 women with information on all three ORTs.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Excessive response prediction.

RESULT(S)

We included 57 studies reporting on 32 databases. Female age had an area under the receiver operating characteristic curve of 0.61 for excessive response prediction. Antral follicle count and AMH significantly added prognostic value to this. A model with female age, AFC, and AMH had an area under the receiver operating characteristic curve of 0.85. The combination of AMH and AFC, without age, had similar accuracy. Subgroup analysis indicated that FSH performed significantly worse in predicting excessive response in higher age groups, AFC did significantly better, and AMH performed the same.

CONCLUSION(S)

We demonstrate that AFC and AMH add value to female age in the prediction of excessive response and that, for AFC and FSH, the discriminatory performance is affected by female age.

[Alterations of ovarian reserve tests in Human Immunodeficiency Virus (HIV)-infected women]

OBJECTIVES

Little is known about the impact of highly active antiretroviral therapy or HIV infection itself on the ovarian function. The aim of this study was to evaluate ovarian function in HIV-infected women in comparison with normal values from non-HIV infected women.

PATIENTS AND METHODS

This is a prospective pilot study using markers of ovarian function: the antral follicular count (AFC) defined between cycle days 7 and 10 and follicle-stimulating hormone (FSH), inhibin B and antimüllerian hormone (AMH) for early follicular phase hormonal assessments. A descriptive analysis according to age was performed.

RESULTS

Results from 78 HIV positive women are presented. AFC shows a high rate of abnormal values (63 %) occurring surprisingly early. The hormonal markers are concordant with a 36, 57 and 23 % abnormal rate for FSH, inhibin B and AMH respectively.

DISCUSSION AND CONCLUSION

In our series, HIV seropositivity was associated with stigmas of premature ovarian insufficiency. This may explain impaired fertility but also suggests premature menopause in this population that should therefore be monitored early for such changes.

Clinical biochemistry of assisted conception

Assisted reproductive technology has shown rapid advancement since the birth of the first 'test-tube' baby in Oldham, UK, in 1978. Since April 2005, women between the ages of 23 and 39, who meet the described eligibility criteria, are able to get one free in vitro fertilization cycle funded by the National Health Service. Private treatment costs anything from pound4000 to pound8000 for a single cycle of treatment. Almost 15% of the couples in UK are affected by fertility problems and undergo detailed investigations before being offered assisted conception. Assisted reproduction is the collective name for treatments designed to lead to conception by means other than sexual intercourse. These include intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection and gamete donation. This review is intended to summarize the principles of assisted conception and examine the role of the biochemistry laboratory in: (A) the diagnosis and subsequent management of ovulatory disorders; (B) assessing ovarian reserve before initiating fertility treatment and (C) monitoring fertility treatment. It touches on the screening of potential gamete donors and follow-up of children born after assisted conception. This article was prepared at the invitation of the Clinical Sciences Reviews Committee of the Association of Clinical Biochemistry.

Biomarkers of Ovarian Reserve

The primary function of the female ovary is the production of a mature and viable oocyte capable of fertilization and subsequent embryo development and implantation. At birth, the ovary contains a finite number of oocytes available for folliculogenesis. This finite number of available oocytes is termed "the ovarian reserve". The determination of ovarian reserve is important in the assessment and treatment of infertility. As the ovary ages, the ovarian reserve will decline. Infertility affects approximately 15%-20% of reproductive aged couples. The most commonly used biomarker assay to assess ovarian reserve is the measurement of follicle stimulating hormone (FSH) on day 3 of the menstrual cycle. However, anti-müllerian hormone and inhibin-B are other biomarkers of ovarian reserve that are gaining in popularity since they provide direct determination of ovarian status, whereas day 3 FSH is an indirect measurement. This review examines the physical tools and the hormone biomarkers used to evaluate ovarian reserve.

The predictive value for in vitro fertility delivery rates is greatly impacted by the method used to select the threshold between normal and elevated basal follicle-stimulating hormone

OBJECTIVE

To evaluate the predictive accuracy of different methodologies for selecting a basal FSH threshold level that prognosticates live birth after IVF.

DESIGN

Retrospective.

SETTING

Academic private practice.

PATIENT(S)

Eight thousand nineteen patients who had their basal FSH levels determined by the program's endocrinology laboratory.

INTERVENTION(S)

Thresholds between normal and elevated basal FSH levels were calculated by using six different methodologies.

MAIN OUTCOME MEASURE(S)

Live birth rate per initiated IVF cycle.

RESULT(S)

The thresholds selected by using the manufacturer's normal range or using 95% confidence intervals of a fertile population, the infertile population, or distinct age groups within the infertile population all proved unsatisfactory. The live birth rates for patients in whom there had been a previously elevated FSH level were <or=43.7%. The efficiency curves that were created for each of the five age groups were the most useful. With appropriately selected thresholds, the predictive value of an abnormal result approaches 100%.

CONCLUSION(S)

The methodology used to select thresholds for basal FSH levels has enormous impact on the utility of the screening test. The use of anything other than clinical outcome-based methods to select the threshold greatly decreases the utility of the test and may lead to false conclusions or inaccurate patient counseling.

Effect of hysterectomy or LNG-IUS on serum inhibin B levels and ovarian blood flow

OBJECTIVES

Nearly one third of women complain of heavy menstrual bleeding during their reproductive years. Hysterectomy and levonorgestrel-releasing intrauterine system (LNG-IUS) are effective treatment options for menorrhagia. However, the influence of these two treatment modalities on ovarian function remains unclear. The aim of the study was to evaluate the effect of hysterectomy or LNG-IUS on ovarian function.

METHODS

Of 107 women, aged 35-49 years, referred for menorrhagia to the University of Helsinki, Finland, 54 were randomised to hysterectomy group and 53 to LNG-IUS group. Serum concentrations of inhibin B were measured at baseline, at 6-month, and at 12-month follow-up visits. The pulsatility indeces (PI) of ovarian and intraovarian arteries were measured by transvaginal ultrasound on the same visits. Changes in outcome measures between the groups were tested by Student's t-test for independent samples and within the group by Wilcoxon signed rank test. To test association between outcome variables and explaining factors a multiple linear regression model was used.

RESULTS

Serum inhibin B concentrations decreased after the first 6 months in both groups (P<0.05). No change was observed in PI of the ovarian arteries in either group. PI of the intraovarian arteries decreased at 6 and 12 months (P<0.05) in the hysterectomy group, which was not seen among LNG-IUS users. Change in PIs between the treatment arms was also significant (P<0.05). In multiple linear regression model treatment modality explained the change in serum inhibin B concentration and the change in PI of intraovarian artery (P<0.05).

CONCLUSIONS

Hysterectomy but not LNG-IUS alters intraovarian blood flow and may impair ovarian function.

Ultrasonography as a tool for the prediction of outcome in IVF patients: a comparative meta-analysis of ovarian volume and antral follicle count

OBJECTIVE

To investigate by meta-analysis the predictive capacity of ovarian volume as an ovarian reserve test in comparison to the antral follicle count (AFC).

DESIGN

Meta-analysis.

SETTING

Tertiary fertility center.

PATIENT(S)

Patients undergoing IVF.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Poor ovarian response, nonpregnancy.

RESULT(S)

A total of 10 studies were detected reporting on ovarian volume and 17 studies on AFC. Because of heterogeneity among studies, calculation of one summary point estimate for sensitivity and specificity was not meaningful. However, for both tests, summary receiver operating characteristic curves for the outcome measures poor response and nonpregnancy could be estimated and compared. The AFC performed statistically significantly better than ovarian volume in the prediction of poor response. The overall accuracy for predicting nonpregnancy was poor for both tests. The clinical value in poor response prediction was only evident for the AFC as a considerable number of cases can be identified who will have a high chance of producing a poor response to stimulation. The clinical value for nonpregnancy was virtually absent for both tests.

CONCLUSION(S)

In conclusion, the predictive performance of ovarian volume toward poor response is clearly inferior compared with that of AFC. Therefore, the AFC may be considered the test of first choice when estimating quantitative ovarian reserve before IVF. For the prediction of cases with a very low chance for pregnancy, ovarian reserve testing with the use of ultrasound appears inadequate.

Clomiphene citrate challenge test predicts outcome of intrauterine insemination in women aged under 37 years

The clomiphene citrate challenge test is a tool to predict ovarian reserve and fertility. It has mainly been used as a predictor of success of IVF/intracytoplasmic sperm injection (ICSI) cycles. Infertile young women with diminished ovarian reserve have a worse prognosis than women with adequate ovarian reserve attempting IVF/ICSI cycles. Nothing is known regarding the outcome of young women with diminished ovarian reserve undergoing low-complexity assisted reproductive treatment such as ovulation induction plus intrauterine insemination (IUI). This study included all women under 37 years who consulted in the authors' centre between May 2004 and August 2005 who underwent ovulation induction and IUI. Ninety-six women younger than 37 years with adequate ovarian reserve, and 50 women with diminished ovarian reserve were found. The pregnancy rate and pregnancy rate per cycle in the adequate ovarian reserve group were significantly higher than those of the diminished ovarian reserve group (46.7% versus 25%, P < 0.02 ; 15.9% versus 7.6%, P < 0.02 respectively). It is concluded that the clomiphene citrate challenge test is a good predictor of low-complexity infertility intervention outcome, and represents an effective tool to establish a prognosis. Therefore, it is very useful in planning therapy, and advising the infertile couple.