Endometriosis reduces ovarian response in controlled ovarian hyperstimulation independent of AMH, AFC, and women's age measured by follicular output rate (FORT) and number of oocytes retrieved

Expert opinion on refined and extended key performance indicators for individualized ovarian stimulation for assisted reproductive technology

OBJECTIVE

To assess the adequate ovarian follicular development and oocyte recovery between ovarian potential (antral follicle count [AFC]) before the start of ovarian stimulation (OS) and oocyte quantity and quality at oocyte retrieval. A holistic overview of the current key performance indicators (KPIs) was applied to identify the complementary strengths and identify where the current repertoire can be expanded.

DESIGN

Expert opinion.

INTERVENTION

None.

MAIN OUTCOME MEASURES

To formulate a proposal for a refined and expanded repertoire of KPIs for individualized OS for assisted reproductive technology.

RESULTS

The performance and outcomes of OS on ovarian follicular development can be evaluated through the application of defined KPIs. Current KPIs for OS are the ovarian sensitivity index, follicular output rate (FORT), oocyte retrieval rate, and follicle-to-oocyte index (FOI). Notably, there are no specific KPIs dedicated to the assessment of follicular development (i.e., recruitment, selection, growth, and dominance). In light of this, we recommend expanding the current KPIs for OS to include "early FORT" (accounting for the number of follicles measuring ≥10 to 11 mm on day 5/6 of OS relative to AFC) and "modified FORT" (the ratio between the number of follicles measuring ≥12 mm at the time of oocyte maturation triggering and AFC); the extension of oocyte retrieval rate to include two discrete categories at oocyte retrieval-follicles measuring ≥12 mm and ≥16 mm-to ensure that all responsive follicles are accounted for; and FOI to be measured at oocyte maturation triggering and oocyte retrieval ("advanced FOI").

CONCLUSION

Once validated and adopted in clinical practice, we envisage that the proposed expanded KPIs measuring the effect of OS on follicular development (recruitment, selection, growth, and dominance) will increase the understanding of the relationship between ovarian reserve, measured by AFC, and oocyte quantity and quality at oocyte retrieval. This understanding will enable physicians to better evaluate the direct effect of different gonadotropins and doses on ovarian response, leading to a more personalized approach to OS in the context of assisted reproductive technology treatment.

Precision surgery for endometriosis: preventing chronic pelvic pain in patients with higher pre-operative pain scores and in patients of advanced age

OBJECTIVE

Symptom relief can be achieved for many patients with endometriosis by tailored individual treatment. However, therapy resistance is observed in some patients. This study surveyed patient-reported long-term outcomes after laparoscopic endometriosis surgery and evaluated potential pre-operative predictors for insufficient symptom control.

METHODS

This retrospective study included patients with complete surgical endometriosis resection treated between 2013-2016 at the Department of Gynaecology and Reproductive Medicine, Jena University Hospital. Our 2020 survey gathered socio-demographic, reproductive, symptom-related, and subjective general condition data from 122 patients. Overall pain intensity was assessed using a numeric rating scale (NRS) from zero (no pain) to 100 (highest imaginable pain). Clinical records provided additional information.

RESULTS

Median time between surgery and interview was 6 years. Postoperatively, the proportion of patients reporting symptoms was considerably reduced (menstrual pain 32.0% vs. 85.2%, chronic pelvic pain [CPP] 40.2% vs. 67.2%, dyspareunia 34.4% vs. 59.8%, hypermenorrhea 17.2% vs. 49.2%; p < 0.001). The majority of respondents (70%) reported improved subjective general condition. Mean NRS Score significantly decreased from 77.2 to 26.6 (p < 0.001). Among pre-operatively infertile women, 45.2% reported successful pregnancies. However, 20-30% of patients did not respond to therapy in one of the analyzed domains. Multivariate logistic regression identified CPP as a strong predictor for failure in permanent pain reduction (OR 5.544, 95% CI 1.338-22.965, p = 0.018) and risk for reoperation (OR 5.191, 95% CI 1.100-24.501, p = 0.038). Higher pre-operative NRS scores and increasing age were associated with better long-term pain relief.

CONCLUSION

Patients with higher pre-operative pain scores and patients of advanced age benefit significantly from precision surgery, experiencing sustained symptom relief and improved subjective general condition. However, younger patients with CPP and moderate pre-operative pain intensity showed a higher risk for therapy resistance and require multimodal treatment strategies.

Association of serum AMH levels with the number of oocytes retrieved in adolescent and young adult women undergoing controlled ovarian stimulation for fertility preservation

PURPOSE

To investigate whether the number of oocytes retrieved after controlled ovarian stimulation (COS) for fertility preservation (FP) can be predicted using serum anti-Müllerian hormone (AMH) levels in adolescent and young adult (AYA) women.

METHODS

This is a retrospective cohort study in a large university-affiliated fertility center. AYA women aged 11 to 25 years received COS using gonadotropin-releasing hormone (GnRH) antagonist protocols for FP were enrolled. Those with canceled cycles or incomplete data were excluded. The primary outcome is to determine whether the number of oocytes retrieved can be predicted through serum AMH levels using multiple linear regression analysis.

RESULTS

The mean numbers of oocytes retrieved, mature oocytes retrieved, and oocytes cryopreserved were 10.3 ± 7.6, 6.9 ± 6.2, and 8.5 ± 6.8, respectively. Multiple stepwise linear regression analysis revealed that serum AMH level independently predicts COS outcomes, including the total number of oocytes retrieved (adjusted R2 = 0.222, P < 0.001), the number of mature oocytes retrieved (adjusted R2 = 0.102, P = 0.013), and the number of oocytes cryopreserved (adjusted R2 = 0.153, P = 0.003).

CONCLUSION

Serum AMH level was a significant predictor of the number of oocytes retrieved after COS for FP in AYA women, while antral follicle count and age were not significantly related.

Decreased Expression of EZH2 in Granulosa Cells Contributes to Endometriosis-Associated Infertility by Targeting IL-1R2

The mechanism by which endometriosis, a common gynecological disease characterized by chronic pelvic pain and infertility, causes infertility remains elusive. Luteinized unruptured follicle syndrome, the most common type of ovulatory dysfunction, is a cause of endometriosis-associated infertility involving reduced numbers of retrieved and mature oocytes. Ovulation is controlled by luteinizing hormone and paracrine signals produced within the follicle microenvironment. Generally, interleukin (IL)-1β is elevated in endometriosis follicular fluid, whereby it amplifies ovulation signals by activating extracellular-regulated kinase 1/2 and CCAAT/enhancer binding protein β pathways. However, this amplification of ovulation by IL-1β does not occur in patients with endometriosis. To illuminate the mechanism of ovulatory dysfunction in endometriosis, we analyzed the effect of oxidative stress and IL-1β expression on endometriosis follicles. We found that oxidative stress decreased EZH2 expression and reduced H3K27Me3 levels in endometriosis ovarian granulosa cells (GCs). Selective Ezh2 depletion in mice ovarian GCs reduced fertility by disturbing cumulus-oocyte complex expansion and reducing epidermal growth factor-like factor expression. Gene expression and H3K27Me3 ChIP-sequencing (ChIP-Seq) of GCs revealed IL-1 receptor 2 (IL-1R2), a high-affinity IL-1β-receptor that suppresses IL-1β-mediated inflammatory cascades during ovulation, as a crucial target gene of the EZH2-H3K27Me3 axis. Moreover, IL-1β addition did not restore ovulation upon Ezh2 knockdown, indicating a vital function of IL-1R2 in endometriosis. Thus, our findings show that reducing EZH2 and H3K27Me3 in GCs suppressed ovulatory signals by increasing IL-1R2 expression, which may ultimately contribute to endometriosis-associated infertility.

Molecular Signatures Correlated With Poor IVF Outcomes: Insights From the mRNA and lncRNA Expression of Endometriotic Granulosa Cells

The outcomes of in vitro fertilization (IVF) for endometriotic women are significantly worse than for patients without ovarian endometriosis (OEM), as shown by fewer retrieved oocytes. However, the exact pathophysiological mechanism is still unknown. Thus, we conducted a prospective study that analyzed mRNA and lncRNA transcriptome between granulosa cells (GCs) from patients with fewer retrieved oocytes due to OEM and GCs from controls with male factor (MF) infertility using an RNA sequencing approach. We found a group of significantly differentially expressed genes (DEGs), including NR5A2, MAP3K5, PGRMC2, PRKAR2A, DEPTOR, ITGAV, KPNB1, GPC6, EIF3A, and SMC5, which were validated to be upregulated and negatively correlated with retrieved oocyte numbers in GCs of patients with OEM, while DUSP1 demonstrated the opposite. The molecular functions of these DEGs were mainly enriched in pathways involving mitogen-activated protein kinase (MAPK) signaling, Wnt signaling, steroid hormone response, apoptosis, and cell junction. Furthermore, we performed lncRNA analysis and identified a group of differentially expressed known/novel lncRNAs that were co-expressed with the validated DEGs and correlated with retrieved oocyte numbers. Co-expression networks were constructed between the DEGs and known/novel lncRNAs. These distinctive molecular signatures uncovered in this study are involved in the pathological regulation of ovarian reserve dysfunction in OEM patients.

Randomized Controlled Study of the Effects of DHEA on the Outcome of IVF in Endometriosis

Objective

To investigate the effect of dehydroepiandrosterone (DHEA) on the outcome of in vitro fertilization (IVF) in patients with endometriosis (EMT).

Methods

Female patients diagnosed with EMT in our hospital from May 2018 to May 2019 were selected. The patients were divided into the control group (n = 22) and the DHEA group (n = 22) according to the random number table. Patients in the control group received placebo and patients in the DHEA group received DHEA. Patients in both groups received either DHEA (25 mg) or placebo orally 3 times a day for 90 days from the first day of menstruation. Patients were subsequently treated with an IVF cycle. In the control group, 22 patients completed the first cycle and 13 patients completed the second cycle. In the DHEA group, 22 patients completed the first cycle and 11 patients completed the second cycle. Serum sex hormone levels including serum E2 on hCG day, mean progesterone on hCG day, FSH on day 2, AMH on day 2, and gonadotropin dose were determined using a chemiluminescent immunoassay kit. The number of antral follicles of the bilateral ovaries was counted by transvaginal B-ultrasound, and the maximum length and transverse diameter of the ovaries were measured at the same time, to calculate the average diameter of the ovaries, observe the morphology of endometrium, and measure the thickness of the endometrium. The implantation rate, clinical pregnancy rate, persistent pregnancy rate, and live birth rate were compared between the two groups.

Results

There were no significant differences in serum E2, progesterone, endometrial thickness, recovered oocytes, mean number of transferred embryos, and mean score of leading embryo transfer between the DHEA group and the women who completed the first and second cycles (P > 0.05). The AMH, antral follicle count, serum E2 on hCG day, the number of recovered oocytes, fertilized oocytes, and the fertilization rate in the DHEA group were higher than those in the control group (P < 0.05). The doses of FSH on day 2, COH on day 3, and gonadotropin were lower than those in the control group (P < 0.05). There was no significant difference in the total number of embryos, the number of high-quality embryos, and the number of transplanted embryos between the two groups (P > 0.05). The implantation rate, clinical pregnancy rate, persistent pregnancy rate, and live birth rate in the DHEA group were higher than those in the control group (P < 0.05).

Conclusion

DHEA can significantly increase serum E2 level and improve IVF outcome by regulating the hormone synthesis process, thus improving oocyte and embryo quality.

The Effects of Endometriosis on Ovarian Functions

Infertility is a main manifestation of endometriosis, though the exact pathogenesis of endometriosis-associated infertility remains unclear. Compromised ovarian functions may be one of the causes of endometriosis related infertility. The ovarian function can be classified into three basic elements, (1) production of ovarian hormones, (2) maintenance of follicular development until ovulation, and (3) reservoir of dormant oocytes (ovarian reserve). The effects of endometriosis on ovarian hormone production and follicular development are inconclusive. Ovarian endometrioma is common phonotype of endometriosis. Development of endometrioma per se may affect ovarian reserve. Surgery for endometriomas further diminish ovarian reserve, especially women with bilateral involvement. Early intervention with surgery and/or medical treatment may be beneficial, though firm evidence is lacking. When surgery is chosen in women at reproductive age, specific techniques that spare ovarian function should be considered.

Pathogenesis of Endometriosis: The Origin of Pain and Subfertility

Endometriosis (EM) and adenomyosis (AM) are common conditions with pain and infertility as the principal symptoms. The pathophysiology of pain in EM and AM comprises sensory and somatoform pain mechanisms. Over time, these may aggravate and lead to individual complex disease patterns if not diagnosed and treated. Despite the known facts, several years often pass between the onset of symptoms and diagnosis. Chronic pain disorders with changes on a neuronal level frequently arise and are linked to depressive disorders, with the process becoming a vicious cycle. Additionally, women with EM and AM suffer from sub- and infertility. Low fecundity rates are caused by anatomical changes in combination with behavioral changes in the sexual activity of women with chronic pain as well as local proinflammatory factors that not only decrease implantation rates but also promote early abortions.

Antral follicle count is reduced in the presence of endometriosis: a systematic review and meta-analysis

Studies suggest that the presence of endometriosis may lead to impaired ovarian reserve, while results evaluating the changes in antral follicle count (AFC) in endometriosis remain controversial. A systematic search returned 15 studies, of which nine compared AFC between patients with and without endometriosis, five articles reported differences in AFC between affected and unaffected ovaries in patients with unilateral ovarian endometriosis and one reported both of the above two situations. Overall results showed a significant decrease in AFC and anti-Müllerian hormone (AMH) and increase in serum FSH concentrations in patients with endometriosis when compared with controls. Additionally, the AFC for the ovary with the endometrioma was also significantly lower than that of the contralateral ovary in patients with unilateral ovarian endometriosis. Moreover, it appears that the AFC in patients with endometriosis where the ovaries are not affected or in early stage were not significantly different in the control group. These findings demonstrate that endometriosis is associated with reduced AFC and AMH and elevated serum concentrations of FSH, suggesting a reduction in ovarian reserve in patients with endometriosis, especially in those with ovarian endometrioma and advanced stage.

Analysis of IVF/ICSI-FET Outcomes in Women With Advanced Endometriosis: Influence on Ovarian Response and Oocyte Competence

Aims: To determine the impact of advanced endometriosis (EMS) on in vitro fertilization/intracytoplasmic sperm injection and frozen-thawed embryo transfer (IVF/ICSI-FET) outcomes and analyze the influencing factors. Methods: A retrospective study was conducted on sterile women with ovarian endometriomas (OMAs), including patients who underwent laparoscopic cystectomy (n = 224, 224 IVF/ICSI cycles, 205 FET cycles) and aspiration (n = 139, 139 IVF/ICSI cycles, 148 FET cycles); peritoneal EMS (n = 96, 96 IVF/ICSI cycles, 89 FET cycles); and tubal factors (n = 360, 360 IVF/ICSI cycles, 474 FET cycles). Our main outcomes included the number of MII oocytes retrieved, fertilization rate, the number of viable embryos, viable embryo rate per oocyte retrieved in oocyte retrieval cycles, and clinical pregnancy rate per transfer, live birth rate per transfer, and cumulative clinical pregnancy rate of this oocyte retrieval cycle in FET cycles. Finally, binary logistic regression analysis was performed to generate a prediction model for cumulative clinical pregnancy. Results: The results showed that significantly fewer MII oocytes retrieved and viable embryos and lower viable embryo rate and cumulative clinical pregnancy rate were observed in women with EMS compared with the control. Women with peritoneal EMS had lower fertilization rate and viable embryo rate per oocyte retrieved than patients with OMA (all p < 0.05). However, the pregnancy outcomes were not significantly different between the two phenotypes. The patients who underwent laparoscopic cystectomy had fewer MII oocytes retrieved and viable embryos compared with those with intact endometrioma(s) but no significant difference in pregnancy outcomes between the two types of OMA patients. By binary logistic regression analysis, antral follicle count (AFC) was found to be an independent factor associated with cumulative clinical pregnancy in this oocyte retrieval cycle (odds ratio = 1.054; 95% confidence interval, 1.011-1.100; p = 0.014), and the AFC prediction model of cumulative clinical pregnancy was established, with an area under the curve of 0.60. Conclusions: Our data supported that advanced EMS has negative effect on cumulative clinical pregnancy per oocyte retrieval cycle, and AFC is an independent predictor, which is mainly caused by poor ovarian response associated with OMA per se or its surgery and the damage of peritoneal EMS to oocyte maturation.