Basal antral follicle number and mean ovarian diameter predict cycle cancellation and ovarian responsiveness in assisted reproductive technology cycles

Ovarian response to controlled stimulation and its predictors in a limited-resource setting

BACKGROUND

Infertility remains a serious health concern for Ethiopian women. Most of its treatment approaches entail controlled ovarian stimulation, the responses of which vary. However, there are no data on ovarian response to stimulation or its predictors in our situation. Thus, the current study aimed to assess the ovarian response to controlled stimulation and identify predictors.

METHODS

A retrospective follow-up study was undertaken from April 1, 2021, to March 31, 2022, among patients who had first-cycle controlled ovarian stimulation at St.Paul's Hospital Fertility Center in Addis Ababa, Ethiopia. Clinical data were extracted using a checklist. SPSS-26 for data analysis and Epidata-4.2 for data entry were employed. The binary logistic regression model was fitted. A p-value < 0.05 indicated a significant association. The ROC curve was used to determine cutoff values and identify accurate predictors.

RESULTS

A total of 412 study participants were included in the final analysis. The patients had a mean age of 32.3 ± 5.1 years (range: 20 - 4). The good ovarian response rate was 67% (95% CI: 62.2-71.5). An anti-Mullerian hormone (AMH) concentration < 1.2ng/ml (AOR = 0.19, 95% CI (0.06-0.57)), an antral follicle count (AFC) < 5 (AOR = 0.16, 95% CI (0.05-0.56)), and an induction length < 10 days (AOR = 0.23, 95% CI (0.06-0.93)) were significantly associated with ovarian response. The prediction accuracies for the AFC and AMH concentrations were 0.844 and 0.719, respectively. The optimal cutoff point for prediction was 5.5 AFC, which had a sensitivity of 77.2% and a specificity of 72.8%. However, its positive and negative predictive values were 85.2% and 61.1%, respectively. For AMH, the optimal cutoff value was 0.71ng/mL, with a corresponding sensitivity and specificity of 65.2% and 66%. At this value, the positive and negative predictive values were 63.8% and 67.3%, respectively.

CONCLUSION

Only two-thirds of our patients achieved a good ovarian response. Induction duration, AMH concentration, and AFC were found to be predictors, with the AFC being the strongest predictor. Therefore, the AFC should be performed on all of our patients, and the AMH is selectively employed. Future research must verify the best cutoff points and investigate additional factors affecting ovarian response.

Determination of idiopathic female infertility from infrared spectra of follicle fluid combined with gonadotrophin levels, multivariate analysis and machine learning methods

By in vitro fertilization, oocytes can be removed and the embryo can be cultured, and then trans cervically replaced when they reach cleavage or when the blastocyst stage. The characterization of the follicular fluid is important for the treatment process. Women who applied to the Academic Hospital in vitro fertilization (IVF) Center diagnosed with idiopathic female infertility (IFI) were sought in the patient group. Demographics and clinical gonadotropin measurements of the study population were recorded. Of the 116 follicular fluid samples (n=58 male-induced infertility; n=58 control) were analyzed using the FTIR system. To identify FTIR spectral characteristics of follicular fluids associated with an ovarian reserve and reproductive hormone levels from control and IFI, six machine learning methods and multivariate analysis were used. To assess the quantitative information about the total biochemical composition of a follicular fluid across various diagnoses. FTIR spectra showed a higher level of vibrations corresponding to lipids and a lower level of amide vibrations in the IFI group. Furthermore, the T square plot from Partial Last Square (PLS) analysis showed, that these vibrations can be used to distinguish IFI from the control group which was obtained by principal component analysis (PCA). Proteins and lipids play an important role in the development of IFI. The absorption dynamics of FTIR spectra showed wavenumbers with around 100% discrimination probability, which means, that the presented wavenumbers can be used as a spectroscopic marker of IFI. Also, six machine learning methods showed, that classification accuracy for the original set was from 93.75% to 100% depending on the learning algorithm used. These results can inform about IFI women's follicular fluid has biomacromolecular differentiation in their follicular fluid. By using a safe and effective tool for the characterization of changes in follicular fluid during in vitro fertilization, this study builds upon a comprehensive examination of the idiopathic female infertility remodeling process in human studies. We anticipate that this technology will be a valuable adjunct for clinical studies.

Changing stimulation protocol on repeat conventional ovarian stimulation cycles does not lead to improved laboratory outcomes

OBJECTIVE

To evaluate whether physicians' choice of ovarian stimulation protocol is associated with laboratory outcomes.

DESIGN

Retrospective cohort study.

SETTING

Single academic center.

PATIENT(S)

The subjects were 4,458 patients who completed more than one in vitro fertilization ovarian stimulation cycle within 1 year. On second stimulation, 49% repeated the same protocol and 51% underwent a different one.

INTERVENTION(S)

Estradiol priming antagonist, antagonist +/- oral contraceptive pill priming, long luteal protocol, Lupron (Lupron [AbbVie Inc, North Chicago, IL]) stop protocol, and flare were compared. Logistic or linear regression with cluster robust standard errors to account for covariates and paired data was used.

MAIN OUTCOME MEASURE(S)

Oocytes collected (OC), fertilization rate, blastocyst progression (BP), usable embryos (UE), and euploid rate (ER).

RESULT(S)

First stimulation outcomes were comparable across all protocols for FR, BP, UE, and ER but were different for OC, after adjustment for covariates. For OC, the effect of switching protocols differed according to the type of the second stimulation. There was improvement in OC if the same stimulation was repeated, except for flare. In addition, there were slight, significant improvements in fertilization rate (difference in values or coefficient of 0.02; 95% confidence interval [CI], 0.004, 0.4) and UE (coefficient 1.25; 95% CI, 0.79, 1.72) when the same stimulation was repeated. There were no changes in BP (coefficient 0.03; 95% CI, -0.01, 0.08) or ER (coefficient 0.01; 95% CI, -0.04, 0.06) when protocols were changed. In a low-BP subgroup, greater improvement was seen when the same protocol was repeated (coefficient 0.03; 95% CI 0.01, 0.04).

CONCLUSION(S)

There was a slight but significant improvement in laboratory outcomes when the same stimulation protocol was repeated, so careful consideration should be made before switching stimulation protocols for the purpose of improving laboratory outcomes.

Effect of antagonist start day on cycle outcomes in poor responders

Background:

Despite the great advances in Assisted Reproductive Technologies (ART), management of poor responders has remained a great challenge. Gonadotropin releasing hormone antagonist (GnRH-ant) has been offered as a patient friendly protocol. In the literature, conflicting data exists about the effect of the GnRH-ant starting day on cycle outcomes.

Aim:

The aim of this study is to evaluate the effect of GnRH-ant starting day on cycle outcomes of patients with poor ovarian response defined by Bologna criteria.

Setting and Design:

This retrospective cohort study was conducted at an ART clinic of a tertiary hospital.

Materials and Methods:

A total of 361 cycles using flexible GnRH-ant, 195 in Group A (GnRH-ant administered before day 6 of stimulation) and 166 cycles in Group B (GnRH-ant started on or after day 6), were selected retrospectively for the study.

Statistical analysis:

Statistical analysis of data was carried out using using IBM SPSS Statistics Software (20.0, SPSS Inc., Chicago, IL, USA). Independent samples t-test and Mann–Whitney U test were used to analyze the variables.

Results:

Total antral follicle count was significantly higher in Group A compared to Group B (P = 0.009). Duration of stimulation was significantly shorter (P < 0.01) and total dose of gonadotropin used was lower in Group A when compared to Group B (P < 0.01). While higher number of oocytes was retrieved from Group A (P = 0.037), no between-group differences were observed in number of mature oocytes, fertilized oocytes, clinical pregnancy rate or ongoing pregnancy rate (OPR) per embryo transfer (P > 0.05).

Conclusion:

Early GnRH-ant start may point out a favourable response to ovarian stimulation in poor responders. However, clinical or OPRs were not different from the late GnRH-ant start group.

A Chinese practice guideline of the assisted reproductive technology strategies for women with advanced age

More women postpone childbearing nowadays while female fertility begins to decline with advancing age. Furthermore, with the rolling out of the two-child policy, there is a huge demand for a second child for Chinese aged women. There are various assisted reproductive technology (ART) strategies applied for age-related infertility without solid evidence. On behalf of the Society of Reproductive Medicine, Chinese Medical Association, we would like to develop a Chinese guideline of ART strategies for age-related infertility. This guideline was produced following the recommendations for standard guidelines described in the 2012 WHO Handbook for guideline development. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was also followed. A protocol was formulated and a Guideline Development Group was formed with specialists of reproductive medicine, methodologists from Chinese GRADE working group, and patient representative. Questions regarding the ART strategies for aged infertility were formulated and 8 most important ones were chosen to be structured in PICO format (Population, Intervention, Comparison, Outcomes). Comprehensive search and review of the literature were performed and the quality of the evidence was assessed and rated based on certain criteria and be categorized as high, moderate, low, or very low. Twenty-five recommendations were formulated among members of the Guidelines Development Group (Delphi method) basing on the overall quality of the evidence, in addition to the balance between benefits and harms, values and preferences, and resource implications. The final recommendations were agreed on by consensus during face-to-face meetings. This is the first Chinese practice guideline in reproductive medicine developed following the standard and scientific method.

Decline in ovarian reserve may be an undiagnosed reason for unexplained infertility: a cohort study

INTRODUCTION

Unexplained infertility refers to the absence of a definable cause for a couple's failure to achieve pregnancy. Reproductive aging plays a role in pathogenesis of unexplained infertility. We investigated the results of ovarian reserve tests in unexplained infertility.

MATERIAL AND METHODS

The patients were divided into two groups: unexplained infertility (n = 148) and male factor infertility (n = 112). Follicle-stimulating hormone, estradiol, inhibin b levels and anti-Müllerian hormone levels were evaluated. Antral follicle count and ovarian volume measurements were performed.

RESULTS

The demographic variables were comparable. Follicle-stimulating hormone levels were higher in the unexplained infertility group than the male factor infertility group, although this difference did not reach statistical significance (p = 0.071). Estradiol levels, inhibin b concentrations and ovarian volume showed no difference between groups. However, antral follicle count was significantly lower in the unexplained infertility group than the male factor infertility group (p = 0.023). The median anti-Müllerian hormone concentrations were significantly lower in the unexplained infertility group 1.42 (0.4-6.2) than in the male factor infertility group (2.04 (0.64-8.2); p = 0.001).

CONCLUSIONS

Although anti-Müllerian hormone values and antral follicle count were higher than the low thresholds, a statistically significant decline of ovarian reserve in the unexplained infertility group was found in the present study. This might be an undiagnosed reason for unexplained infertility.

Antimüllerian hormone levels and antral follicle counts are not reduced compared with community controls in patients with rigorously defined unexplained infertility

OBJECTIVE

To test the hypothesis that women with unexplained infertility demonstrate evidence of diminished ovarian reserve when compared with a population of community controls.

DESIGN

Cross-sectional study.

SETTING

Multicenter university-based clinical practices.

PATIENT(S)

Study participants included 277 healthy, normo-ovulatory female partners with rigorously defined unexplained infertility randomly selected from a multicenter trial (Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation). Controls included 226 healthy, normo-ovulatory women not seeking treatment for fertility from a community-based cohort (Ovarian Aging study).

INTERVENTION(S)

Serum antimüllerian hormone (AMH) assay at a central laboratory, FSH, fasting serum metabolic testing, transvaginal ultrasonography for antral follicle counts (AFCs), anthropometric measurements.

MAIN OUTCOME MEASURE(S)

Average AMH, AFC, and AMH/AFC were compared between infertile and control women by age. Analyses of covariance compared these outcomes while controlling for confounders, including age, race, body mass index, smoking history, and study site.

RESULT(S)

In our models, AMH, AFC, and AMH/AFC ovarian reserve indices did not differ between infertile women and community-based controls, after controlling for age, race, body mass index, smoking history, and study site.

CONCLUSION(S)

Currently utilized predictors of ovarian reserve do not discriminate women with rigorously defined unexplained infertility from healthy community-based women of similar demographic characteristics. Contrary to our hypothesis, among women with FSH in the normal range (≤12 IU/L), women with unexplained infertility did not show evidence of decreased ovarian reserve as measured by AMH and AFC. Ovarian reserve markers in isolation may not serve as predictors of future fertility.

Inter-cycle and inter-observer variability of the antral follicle count in routine clinical practice

Antral follicle count (AFC) is a reliable predictor of ovarian response to stimulation and its inter-cycle and inter-observer variability has been extensively studied on in vitro fertilization (IVF), mostly in highly selected populations within studies not originally designed for this purpose. In this retrospective cohort study, we assess the inter-cycle variation of AFC in a setting similar to that of the daily practice. We included only patients undergoing mild stimulation for intrauterine insemination (IUI). One hundred and forty-eight patients had two (62 patients, group A), three (49 patients, group B) or four (37 patients, group C) IUI cycles and AFC was measured on early follicular phase of each cycle by one of the members of the medical team within daily practice. Intra-class correlation coefficients were used to estimate variability. Inter-cycle variability rendered ICCs above 0.70 in all groups improving along with the number of cycles [Group A ICC 0.78 (95%CI 0.66-0.86), Group B ICC 0.87 (95%CI 0.80-0.92) and Group C ICC 0.91 (95%CI 0.85-0.95)]. Inter-observer variability showed a high degree of concordance with ICCs above 0.95. We provide the closest approximation to real inter-cycle and inter-observer AFC variability expected in routine clinical practice.

Age as A Predictor of Embryo Quality Regardless of The Quantitative Ovarian Response

Background

One determining factor of a successful in vitro fertilization (IVF) cycle is embryo quality. The aim of the present study was to evaluate associations of embryo quality and reserve markers like age, FSH and AMH.

Materials and Methods

In this prospective study, 120 infertile women, aged 21-44 years, undergoing routine exploration during an unstimulated cycle preceding assisted reproductive technology (ART) at our center were studied prospectively, from February 2011 to December 2014. Descriptive parameters and patient characteristics were reported as mean (SD) or median (range) depending on the distribution. Student’s t test was performed for continuous variables, Wilcoxon and Pearson’s Test were used for not distributed variables and Fisher’s Test was performed for categorical variables. P<0.05 was considered statistically significant.

Results

Overall, at the time of investigation, patients had a mean age of 33.03 ± 4.15 years old. On cycle day three, serum anti-Mullerian hormone (AMH) level was 3.50 ± 1.54 ng/mL, serum follicle-stimulating hormone (FSH) level was 6.29 ± 1.53 mUI/ mL, at baseline, women had 16.57 ± 7.0 antral follicles. The mean of collected oocytes was 11.80 ± 5.25, embryo I+II was 2.46 ± 2.11. A greater number of embryos I+II was observed in young patients. By evaluating 120 patients, a significant relationship was observed between age and FSH (r=0.24, P=0.01), age with AMH (r=-0.22, P=0.02), age with collected oocytes (r=-0.23, P=0.03) and age with embryo I+II (r=-0.22, P=0.03). A significant relationship was also observed between antral follicle count (AFC) and AMH (r=0.29, P=0.01), AFC and the number of transferred embryo (r=-0.18, P=0.03), AFC and total dose of the drugs (r=-0.23, P=0.03). Significant relationship of FSH with total dose of drugs (r=0.19, P=0.02) was also observed. In addition, we determined significant relationships between AMH and the number of collected oocytes (r=0.38, P=0.01), AMH and the number of metaphase II oocytes (r= 0.35, P=0.01), AMH and the number of embryo (r=0.19, P=0.04) as well as AMH and total dose of the drugs (r=-0.25, P=0.01).

Conclusion

Commonly used clinical markers of ovarian reserve are reflection of the ovarian reserve, while the outcome measurements of ART and age are the best predictors of embryo quality.

Anti-Mullerian Hormone: Above and Beyond Conventional Ovarian Reserve Markers

Management of ovarian dysfunctions requires accurate estimation of ovarian reserve (OR). Therefore, reproductive hormones and antral follicle count (AFC) are assessed to indicate OR. Serum anti-Mullerian hormone (AMH) is a unique biomarker that has a critical role in folliculogenesis as well as steroidogenesis within ovaries. Secretion from preantral and early antral follicles renders AMH as the earliest marker to show OR decline. In this review we discuss the dynamics of circulating AMH that remarkably vary with sex and age. As it emerges as a marker of gonadal development and reproductive disorders, here we summarize the role of AMH in female reproductive physiology and provide evidence of higher accuracy in predicting ovarian response to stimulation. Further, we attempt to compile potential clinical applications in children and adults. We propose that AMH evaluation has a potential role in effectively monitoring chemotherapy and pelvic radiation induced ovarian toxicity. Furthermore, AMH guided ovarian stimulation can lead to individualization of therapeutic strategies for infertility treatment. However future research on AMH levels within follicular fluid may pave the way to establish it as a marker of "quality" besides "quantity" of the growing follicles.

Assessing ovarian response: antral follicle count versus anti-Müllerian hormone

Oocyte number and quality decline with age; however, fertility varies significantly even among women of the same age. Various measures have been developed to predict response to ovarian stimulation and reproductive potential. Evaluation of ovarian reserve can identify patients who may experience poor response or hyper-response to exogenous gonadotrophins and can aid in the personalization of treatment to achieve good response and minimize risks. In recent years, two key methods, antral follicle count (AFC), an ultrasound biomarker of follicle number, and the concentration of serum anti-Müllerian hormone (AMH), a hormone biomarker of follicle number, have emerged as preferred methods for assessing ovarian reserve. In this review, a live debate held at the American Society for Reproductive Medicine 2013 Annual Meeting is expanded upon to compare the predictive values, merits, and disadvantages of AFC and AMH level. An ovarian reserve measure without limitations has not yet been discovered, although both AFC and AMH have good predictive value. Published evidence, however, as well as the objectivity and potential standardization of AMH level and the convenience of testing any time throughout the menstrual cycle, leans towards AMH level becoming the gold-standard biomarker to evaluate ovarian reserve and predict ovarian response to stimulation.

Comparisons of the effects of long-acting and short-acting GnRH agonists on embryo quality, endometrial thickness and pregnancy rate in human in vitro fertilization

INTRODUCTION

The aim was to compare the efficacy of long-acting and short-acting gonadotropin-releasing hormone (GnRH) agonists by long protocol on embryo quality, endometrial thickness and pregnancy rate in in vitro fertilization.

MATERIAL AND METHODS

In this retrospective study, long-term pituitary downregulation, achieved with long- and short-acting GnRH agonists (GnRHa), was performed for patients undergoing in vitro fertilization (n = 175).

RESULTS

There were no significant differences between the long and short-acting GnRH group (63.16% vs. 66.26%, p > 0.05), and the secondary and primary infertility group (63.47% vs. 66.86%, p > 0.05) in embryo quality. Logistic regression analysis showed that type of infertility and endometrial thickness were significantly associated with pregnancy outcome. Patients in the long-acting GnRHa group had a thicker endometrium on the day of human chorionic gonadotrophin (hCG) administration (10.79 ±2.62 mm vs. 9.64 ±1.97 mm, p < 0.01), lower serum luteinizing hormone (LH) concentration (1.21 ±1.13 vs. 2.53 ±3.39) and a higher pregnancy rate (59.60% vs. 43.42%, p < 0.05) than those of patients in the short-acting GnRHa group.

CONCLUSIONS

This work suggests that types of agonist protocol and infertility may not affect embryo quality. Type of infertility and endometrial thickness may be positive predictors for clinical pregnancy, but the key finding is that the long-acting GnRHa protocol may be an effective method of improving endometrial thickness, endometrial receptivity and pregnancy rate in in vitro fertilization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biomarkers of ovarian reserve

Although it is widely appreciated that age is the primary determinant of the number of primordial follicles remaining within the ovary, it is now also recognized that for any given age two women can have a 100-fold difference in their ovarian reserve. Consequently, age alone has relatively poor accuracy in determining the reproductive potential for young women, and this has led to the development of additional biomarkers that more accurately reflect the ovarian reserve. In this review we discuss the strengths and limitations of the classical and novel biomarkers and provide a rationale for the adoption of biomarkers to facilitate the individualization of reproductive health.

Antral follicle count determines poor ovarian response better than anti-Müllerian hormone but age is the only predictor for live birth in in vitro fertilization cycles

PURPOSE

To determine the predictive value of serum anti-müllerian hormone (AMH) concentrations and antral follicle counts (AFC), on ovarian response and live birth rates after IVF and compare with age and basal FSH.

METHODS

Basal levels of AMH, FSH and antral follicle count were measured in 192 patients prior to IVF treatment. The predictive value of these parameters were evaluated in terms of retrieved oocyte number and live birth rates.

RESULTS

Poor responders in IVF were older, had lower AFC and AMH but higher basal FSH levels. In multivariate analysis AFC was the best and only independent parameter among other parameters and AMH was better than age and basal FSH to predict poor response to ovarian stimulation. Addition of AMH, basal FSH, age and total gonadotropin dose to AFC did not improve its prognostic reliability. Area under curve (AUC) for each parameter according to ROC analysis also revealed that AFC performed better in poor response prediction compared with AMH, basal FSH and age. The cut-off point for mean AMH and AFC in discriminating the best between poor and normal ovarian response cycles was 0.94 ng/mL (with a sensitivity of 70% and a specificity of 86%) and 5.5 (with a sensitivity of 91% and a specificity of 91%), respectively. However, age was the only independent predictor of live birth in IVF as compared to hormonal and ultrasound indices of ovarian reserve.

CONCLUSION

AFC is better than AMH to predict poor ovarian response. Although AMH and AFC could be used to predict ovarian response they had limited value in live birth prediction. The only significant predictor of the probability of achieving a live birth was age.

The anti mullerian hormone- a novel marker for assessing the ovarian reserve in women with regular menstrual cycles

BACKGROUND

Ovarian Reserve (OR) is a term which describes the functional potential of the ovary, which constitutes the size of the ovarian follicle pool and reflects the number and quality of the oocytes which are within it. Assessment of the OR helps in reflecting the reproductive potential of women. Various markers are available for assessing the OR and the best marker is the Anti Mullerian Hormone (AMH) which reflects the ovarian follicular pool in the ovary. In this study, the serum level of AMH/MIS(Mullerian Inhibiting Substance)was estimated to assess the ovarian reserve in both fertile and infertile women.

OBJECTIVE

To assess the ovarian reserve in women of the fertile and subfertile groups with regular cycles, who were in the age range of 26 -33yrs, by estimating the level of AMH and those of other hormones like FSH and E2 and also to calculate the ovarian volume and the Antral follicular count by an ultrasonographic method.

MATERIALS AND METHODS

Thirty fertile and thirty sub fertile women whose ages ranged from 26-33yrs were included as group 1 and group 2 respectively. The hormones like AMH ,FSH and oestradiol were assayed. Measurement of the ovarian volume and the antral follicular count by doing a transvaginal ultrasonogram, was done in all the subjects who were involved in both the groups. The correlation test was studied between the variables and the test of significance of the variables between the 2 groups was also analyzed by the Statistical Package Of Social Sciences (SPSS).

RESULTS

The Antral Follicular Count (AFC) and the ovarian volume were negatively correlated with the age. The ovarian volume was positively correlated with the AFC. The FSH negatively correlated with the AFC. The Anti Mullerian Hormone negatively correlated with the age, and it positively correlated with the AFC. The mean values of AFC, FSH, and AMH were also statistically significant between the two groups.

CONCLUSION

AMH can be considered as a marker for assessing the ovarian reserve, as it is cycle independent as compared to the other hormones. The women in the subfertile group with low levels of AMH should be insisted to proceed for ART as early as possible.

Testing and interpreting measures of ovarian reserve: a committee opinion

Currently, there is no uniformly accepted definition of decreased ovarian reserve (DOR), as the term may refer to three related but distinctly different outcomes: oocyte quality, oocyte quantity, or reproductive potential. Available evidence concerning the performance of ovarian reserve tests is limited by small sample sizes, heterogeneity among study design, analyses and outcomes, and the lack of validated outcome measures.

An efficient infertility evaluation

The biological clock is a major adversary to human reproduction. Not only does fecundity wane with time, but so does an infertility patient's emotional reserve. Therefore, a well-organized approach to evaluating, treating, and referring patients to subspecialty centers when necessary is critical to optimally manage infertility. The initial infertility evaluation has undergone evidence-based improvements in efficiency and has demonstrated that less testing has given more useful knowledge.

The value of human chorionic gonadotropin stimulation test in predicting ovarian response during in-vitro fertilization

PURPOSE

To assess the predictive value of human Chorionic Gonadotropin (hCG) theca-stimulation test for ovarian reserve in women undergoing in-vitro fertilization (IVF) treatments.

METHODS

39 women were included in the study. All participants received a single hCG 10000 IU injection on cycle day 2-3. Serum levels of estradiol, testosterone, androstenedione and 17-OH progesterone were measured prior to the injection and on days 1, 3 and 7 following the injection. hCG-induced hormone levels were compared with ovarian response during the subsequent IVF cycle.

RESULTS

There were 11 good responders (>10 oocytes) and 22 low responders (<3 oocytes). Before hCG stimulation serum E2 levels were higher in low responders compared to good responders (370.3 ± 443 vs. 138.3 ± 54 pmol/ml). Following hCG stimulation, day 3 androstendione levels showed an increase in good responders compared to low responders. The ratio between day 3 androstendione and day 0 estradiol was significantly different between the two groups (p = 0.03). ROC analysis of this test revealed area = 0.837 (good prediction), which was much better than day 3 FSH (area = 0.635, poor prediction).

CONCLUSIONS

These preliminary results demonstrate the potential use of the hCG theca stimulation test in differentiating between good and poor responders. Larger series are needed for further verification of the test in routine clinical application.

Cycle 1 as predictor of assisted reproductive technology treatment outcome over multiple cycles: an analysis of linked cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System online database

OBJECTIVE

To determine whether the first cycle of assisted reproductive technology (ART) predicts treatment course and outcome.

DESIGN

Retrospective study of linked cycles.

SETTING

Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.

PATIENT(S)

A total of 6,352 ART patients residing or treated in Massachusetts with first treatment cycle in 2004-2005 using fresh, autologous oocytes and no prior ART. Women were categorized by first cycle as follows: Group I, no retrieval; Group II, retrieval, no transfer; Group III, transfer, no embryo cryopreservation; Group IV, transfer plus cryopreservation; and Group V, all embryos cryopreserved.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cumulative live-birth delivery per woman, use of donor eggs, intracytoplasmic sperm injection (ICSI), or frozen embryo transfers (FET).

RESULT(S)

Groups differed in age, baseline FSH level, prior gravidity, diagnosis, and failure to return for Cycle 2. Live-birth delivery per woman for groups I through V for women with no delivery in Cycle I were 32.1%, 35.9%, 40.1%, 53.4%, and 51.3%, respectively. Groups I and II were more likely to subsequently use donor eggs (14.5% and 10.9%). Group II had the highest use of ICSI (73.3%); Group III had the lowest use of FET (8.9%).

CONCLUSION(S)

Course of treatment in the first ART cycle is related to different cumulative live-birth delivery rates and eventual use of donor egg, ICSI, and FET.

Correlation of ovarian reserve tests with histologically determined primordial follicle number

OBJECTIVE

To investigate the relationship between clinical markers of ovarian reserve and the true ovarian reserve as determined by the ovarian primordial follicle number.

DESIGN

Prospective investigation.

SETTING

Academic medical center.

PATIENT(S)

Forty-two healthy women (aged 26-52 years) undergoing oophorectomy for benign gynecologic indications.

INTERVENTION(S)

Transvaginal ultrasound examination for the determination of the ovarian antral follicle count (AFC) and serum measurements of clinical markers of ovarian reserve. All measurements were obtained within 2 weeks of surgery, irrespective of cycle day. Ovarian primordial follicle count was then determined using a validated fractionator/optical disector method.

MAIN OUTCOME MEASURE(S)

Univariate and partial correlations between ovarian reserve markers and ovarian primordial follicle count.

RESULT(S)

There were significant correlations between the ovarian primordial follicle count and AFC (r=0.78), anti-Müllerian hormone (AMH; r=0.72), FSH (r=-0.32), inhibin B (r=0.40), and chronological age (r=-0.80). After adjusting for age, significant correlations were identified between the ovarian primordial follicle count and AFC (r=0.53) and AMH (r=0.48).

CONCLUSION(S)

The ovarian AFC and serum levels of AMH correlate with the ovarian primordial follicle number even after adjustment for chronological age.

Is antral follicle count a genetic trait?

OBJECTIVE

The aim of this study was to determine the relationship between maternal age of menopause and antral follicle count.

METHODS

This was a cross-sectional study of 124 women aged 25 to 48 years presenting with infertility. Women reported their mother's age of menopause and underwent transvaginal ultrasound to assess antral follicle count. Participant age, age greater than 37 years, and maternal age of menopause, as well as interactions among these, were incorporated into a multiple linear regression model to predict antral follicle count. Three different ages of maternal menopause were inputted into this model to illustrate the relationship between maternal age of menopause and rate of decline in antral follicle count.

RESULTS

Women with a lower maternal age of menopause have lower antral follicle counts but also a slower decline until the age of 37 years.

CONCLUSIONS

Maternal age of menopause predicts antral follicle count and its decline, indicating a genetic component to this trait.

Antral follice counts (AFC) predict ovarian response and pregnancy outcomes in oocyte donation cycles

PURPOSE

Antral follicle count (AFC) is used as a marker of ovarian response. We assessed its value in predicting pregnancy outcomes in ovum donation cycles by retrospective review.

METHODS

Oocyte donors (n = 94) underwent ovarian hyperstimulation using rFSH and GnRH-antagonists. Recipients were synchronized using GnRH-agonist down-regulation followed by fixed dose of estrogen and progesterone following hCG. Outcomes measured included correlation of AFC to pregnancy outcomes and cycle characteristics in those with and without clinical and ongoing-delivered cycles.

RESULTS

AFC significantly correlated with clinical [Exp beta 1.12; 95% CI: 1.02-1.23, p < 0.05] and ongoing-delivered pregnancy [Exp beta 1.10; 95% CI: 1.01-1.20, p < 0.05]. Significantly greater AFC, total and M-2 oocytes, and cycles resulting in cryopreserved embryos were seen in clinical and ongoing-delivered cycles.

CONCLUSIONS

AFC predicts cycle stimulation responses and clinical outcomes and may serve as a guide for dosing protocols and in choosing to proceed with the most optimal cycle.

[The role of ultrasound examination to evaluate ovarian reserve of infertile patients]

The accurate assessment of ovarian reserve is an essential step before the treatment of infertile couples. Ovarian reserve could either be evaluated through clinical or biological parameters, but ultrasound plays a remarkable role, since it permits the direct visualization and count of ovarian antral follicles. Nevertheless, the available literature data are conflicting about the real sensibility and specificity of this method to predict the exact number of retrieved oocytes or the occurrence of pregnancy after a procedure for medical assisted reproduction. New technologies have been developed, as the 3D-ultrasound, who does not ameliorate ultrasound accuracy, but permits the reduction of the time necessary for patient's examination and virtually eliminates inter- and intra-observer bias. The place of the ovarian artery flow evaluation by Doppler remains unclear and need more studies.

Antral follicle count at down-regulation and prediction of poor ovarian response

The aim of this study was to assess the accuracy of antral follicle count (AFC) performed after pituitary down-regulation (dAFC) in predicting poor ovarian response and the influence of using different thresholds of follicle size and count on its accuracy. Using three definitions of follicle size, three dAFC were determined for every patient in a consecutive cohort of 148 IVF cycles. The performance of the dAFC in predicting poor ovarian response (as expressed by area under the curve; AUC) for follicle size definitions of 2-5, 2-8, 2-10 mm, was not significantly different (AUC 0.80, 0.80, 0.79, respectively). Multilevel likelihood ratio for dAFC thresholds of <or=10, 11-15,16-20 and >20 were 5.43 (95% confidence interval 0.81-36.6), 3.06 (1.54-6.06), 1.63 (0.74-3.62) and 0.37 (0.19-0.75) with post-test probabilities of poor ovarian response of 50%, 36%, 23% and 6%, respectively, for a pretest probability of 15.5% for poor ovarian response. The single most important predictor of ovarian response was dAFC. The highest predictive performance was obtained in a model combining age and body mass index and dAFC (AUC = 0.82) showing only marginal improvement over dAFC alone. In conclusion, the performance of dAFC is the same regardless of the definition used for the size of antral follicles.

Ovarian reserve screening: what the general gynecologist should know

Ovarian reserve tests are an indirect measurement of a woman's remaining follicular pool and give an estimate of her sensitivity to ovarian stimulation and her prognosis for success with fertility treatments. They cannot be used to predict future fertility or the exact timing of the decline or cessation of fertility. It is important to become familiar with these tests and understand their correct performance and interpretation, including their limitations. We review the correct timing and interpretation of the most commonly accepted tests of ovarian reserve, and suggest which patient populations will benefit most from screening. Discussed in detail are the natural age-related decline in fecundity, basal follicle stimulating hormone and estradiol levels, the clomiphene citrate challenge test, and use of transvaginal ultrasound for antral follicle counts. Other tests, such as for ovarian volume, anti-Müllerian hormone, gonadotropin-releasing hormone agonist and exogenous follicle-stimulating hormone, are discussed briefly.

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.

Microdose follicular flare: a viable alternative for normal-responding patients undergoing in vitro fertilization?

OBJECTIVE

To compare cycle outcomes among normal-responding patients <or=30 years old receiving microdose follicular flare (MDF) and long-luteal agonist (LL).

DESIGN

Retrospective cohort study.

SETTING

Military-based assisted reproductive technology (ART) center.

PATIENT(S)

First autologous ART cycles among 499 women <or=30 years old from January 1999 to December 2005.

INTERVENTION(S)

After oral contraceptive pill (OCP) administration before cycle start, patients were nonrandomly assigned to either LL or MDF for LH surge suppression. Patients in the LL group received 1 mg/day leuprolide acetate (LA) on cycle day 21, which was reduced to 0.25 mg/day 10-14 days later. Patients in the MDF group received LA (40 microg twice a day) beginning 3 days after discontinuing OCPs. Both groups received a combination of hMG and recombinant FSH.

MAIN OUTCOME MEASURE(S)

Primary outcomes were implantation, clinical pregnancy, and live-birth rates; in-cycle variables included peak E(2), oocytes retrieved, oocyte maturity, and fertilization rate.

RESULT(S)

Multivariable models controlling for confounding by treatment indication found no significant differences between groups in implantation (MDF, 36%; LL, 38%), clinical pregnancy (MDF, 53%; LL, 56%), and live-birth rates (MDF, 47%; LL, 50%). No differences were observed in peak E(2), oocytes retrieved, oocyte maturity, fertilization rate, or embryos transferred.

CONCLUSION(S)

MDF use among normal-responding ART patients produced no differences in cycle outcome when compared with LL. Therefore, MDF may be a viable alternative for normal-responding patients.

Role of antral follicle count in controlled ovarian hyperstimulation and intrauterine insemination cycles in patients with unexplained subfertility

OBJECTIVE

To determine the predictive value of basal antral follicle count (AFC) as a marker for pregnancy, live birth rate, and ovarian response in COH and intrauterine insemination (IUI) cycles in couples with unexplained subfertility.

DESIGN

Prospective analysis.

SETTING

University-based infertility clinic.

PATIENT(S)

One hundred forty-five women who were treated during 283 COH and IUI cycles with recombinant FSH.

INTERVENTION(S)

Basal AFC by transvaginal ultrasonography and basal hormone levels were determined on the 3rd day of the treatment cycles.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth rate with regard to AFC.

RESULT(S)

Antral follicle count significantly correlated negatively with age and total dosage of gonadotropin and correlated positively with number of developing follicles on the day of hCG. Patients with pregnant cycles and live births had significantly more AFC, as compared with nonpregnant cycles. Multiple regression analysis revealed that AFC was the only factor to predict both clinical pregnancy and live birth. The area under the curve for AFC to discriminate clinical pregnancy and live birth, respectively, was 0.77 (95% confidence interval, 0.62-0.79) and 0.718 (95% confidence interval, 0.63-0.82). The cutoff value for AFC for predicting clinical pregnancy and live birth was 7.5 in both cases.

CONCLUSION(S)

Lower AFC on basal transvaginal ultrasonography is associated with lower clinical pregnancy and live birth rates in unexplained subfertile couples who are treated with COH and IUI. These data are comparable with those for IVF-intracytoplasmic sperm injection cycles.

A luteal estradiol protocol for expected poor-responders improves embryo number and quality

OBJECTIVE

To compare embryo and oocyte data between a standard protocol and a luteal phase estradiol protocol.

DESIGN

Retrospective paired cohort analysis.

SETTING

Private in vitro fertilization (IVF) center.

PATIENT(S)

60 poor-responder patients undergoing 120 IVF cycles.

INTERVENTION(S)

Addition of luteal estradiol to the standard IVF protocol.

MAIN OUTCOME MEASURE(S)

Number of embryos with > or = 7 cells on day 3 of development.

RESULT(S)

The luteal phase estradiol protocol showed a statistically significantly greater number of embryos with > or = 7 cells, oocytes retrieved, mature oocytes, and embryos than did the standard protocol. There was no difference between the two protocols with respect to basal antral follicle count, days of stimulation, number of follicles > or = 14 mm on day of surge, or endometrial thickness on day of surge. A trend toward improved pregnancy outcomes was found with the luteal estradiol protocol.

CONCLUSION(S)

Giving estradiol in the luteal phase preceding IVF hyperstimulation increases the number and the quality of embryos achieved in patients deemed to have a poor response to IVF. Ultimately, this may translate into improved pregnancy outcomes in these patients.

Simple tools for assessment of ovarian reserve (OR): individual ovarian dimensions are reliable predictors of OR

OBJECTIVE

To determine the association between individual ovarian dimensions, advancing age, and declining ovarian reserve (OR) in an infertile population.

DESIGN

An ongoing prospective observational study.

SETTING

Academic infertility practice.

PATIENT(S)

Sixty-nine premenopausal women presenting for the evaluation and management of infertility.

INTERVENTION(S)

Transvaginal ultrasound assessment of the ovarian dimensions (length, width, and overall diameter in cm) and evaluation of the OR status by measuring serum levels of FSH and E(2) in the early follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Relationship of the individual ovarian dimensions to age (years) and OR (reflected by historical maximal FSH levels).

RESULT(S)

A statistically significant decrease in three ovarian size parameters accompanied advancing age (ovarian width, r = -0.30; ovarian length, r = -0.24; and the mean overall ovarian diameter, r = -0.30). Levels of FSH demonstrated a significant and linear correlation with age (r = 0.39). Increasing levels of FSH (and hence declining OR) were associated with statistically significant declines in the mean ovarian width (r = -0.39), length (r = -0.38), and overall mean ovarian diameter (r = -.42), Patients with a known diagnosis of diminished OR demonstrated significantly reduced ovarian dimensions compared with patients with other infertility etiologies. Multivariate linear regression analysis confirmed individual ovarian measurements (width, length, and overall diameter) as independent predictors of OR (FSH levels) after adjusting for parameters that are known to influence ovarian size, i.e., age, smoking status, body mass index, and anovulation history. Ovarian width emerged as the strongest predictor of OR (largest beta coefficient and hence the strongest association with OR status), compared with ovarian length and the mean ovarian diameter.

CONCLUSION(S)

Single ovarian dimensions are reliable predictors of advancing age and declining OR status in premenopausal infertile women. The magnitude of this association is most robust for the ovarian width.

Performance of different ovarian reserve markers for predicting the numbers of oocytes retrieved and mature oocytes

OBJECTIVE

To assess the performance of different ovarian reserve tests for predicting the total numbers of oocytes retrieved and mature oocytes.

METHODS

A retrospective study was performed on 71 women undergoing their first IVF/intracytoplasmic sperm injection treatment. Basal ovarian reserve screening was performed on days 2-3 of a spontaneous cycle. Patients were down-regulated with the GnRH agonist, whereas ovarian stimulation was carried out with recombinant FSH, starting from day 2 to 3 of the cycle. The main outcome measures were the numbers of oocytes retrieved and mature oocytes.

RESULTS

The total number of oocytes was positively correlated with AFC (p<0.0001) and E(2) levels post-GnRH (p<0.004), whereas there was an inverse correlation with age (p<0.0001). The number of mature oocytes also correlated with AFC (p<0.008) and E(2) levels post-GnRH (p<0.009), and inversely with age (p<0.0004). Univariate linear regression of square root of number of oocytes (SQNO) shows that acceptable predictors of number oocytes, based on model significance and R(2) are AFC (R(2)=0.215), age (R(2)=0.24) and E(2) variation (R(2)=0.09). The following model is proposed to predict the number of mature oocytes: ln(MO)=ln(NO)-2.09+0.028 AGE+0.03 BMI.

CONCLUSION(S)

The number of antral follicles and patient age appear to be good markers of ovarian response in IVF treatments. Additional information is provided by stimulated E(2) levels.

Role of gonadotropin-releasing hormone antagonists in poor responders

OBJECTIVE

To evaluate the role of GnRH antagonists in poor-responder protocols.

DESIGN

Literature review.

CONCLUSION(S)

The optimum stimulation protocol for poor responders is unknown. Although many IVF programs currently use GnRH antagonists for poor responders, there have been only four prospective, randomized trials comparing GnRH antagonists to alternate protocols. None of these studies had sufficient power to evaluate a difference in pregnancy rates (PRs), and in all four cases, IVF outcomes were comparable. Nevertheless, interest in the use of GnRH antagonists in poor responders has continued. GnRH antagonists may be associated with simpler stimulation protocols, lower gonadotropin requirements, reduced patient costs, and shorter downtimes between consecutive cycles. However, the greatest advantage of GnRH antagonists may lie in the ability to assess ovarian reserves immediately prior to deciding whether or not to initiate gonadotropin stimulation. The ability to respond to cycle-to-cycle variation in antral follicle counts may allow the optimization of oocyte yield and reduce cycle cancellation rates. It remains to be seen if this approach (initiating gonadotropins only in cycles where an adequate antral follicle count is present) also translates into higher clinical PRs for poor responders.

Ageing and ART: a waste of time and money?

In many societies, more and more young women are delaying childbearing until the fourth decade of life. It is well known that fertility is remarkably reduced with increasing age of women in both natural conceptions and assisted reproductive technology (ART). In this chapter, the effect of ageing on the pregnancy rate in ART, and the options available to improve the reproductive outcomes in women of advanced age will be presented after understanding the mechanism of reproductive ageing and the effects of ageing on the reproductive outcomes in normal women. It is important to identify the predictive factors associated with a better treatment outcome.

A prospective analysis of the changes in ovarian morphology during hormonal pituitary suppression before in vitro fertilization

OBJECTIVE

To assess the change in ovarian morphology at three specific times integral to an IVF cycle, and to evaluate the factors associated with a change in ovarian morphology after pituitary desensitization.

DESIGN

Prospective cohort analysis.

SETTING

Academic IVF center.

PATIENT(S)

Infertile patients undergoing 85 IVF cycles.

INTERVENTION(S)

Eighty-five patients had a transvaginal ultrasound to assess ovarian morphology on unstimulated menstrual day 3, 21 days after starting oral contraceptives (OCs), and 14 days after starting GnRH agonist (GnRH-a).

MAIN OUTCOME MEASURE(S)

Ovarian morphology.

RESULT(S)

Compared with the basal total ovarian volume, ovarian volume was significantly decreased after 21 days of OCs and after 14 days of GnRH-a. A significant decrease was noted in the total number of antral follicles from the basal state to after 21 days of OCs and after 14 days of GnRH-a treatment. There was no significant effect on pregnancy outcome rates. Univariate analysis showed a significant correlation between ovarian morphology and IVF stimulation parameters.

CONCLUSION(S)

Hormonal suppression significantly alters ovarian morphology. If the use of ovarian morphology is to be used to counsel patients and predict IVF success as suggested by some studies, it should be standardized for the day the ovarian morphology is evaluated.

A systematic review of tests predicting ovarian reserve and IVF outcome

The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.

The number of basal antral follicles may predict ovarian responsiveness and pregnancy rates in in vitro fertilization/intracytoplasmic sperm injection treatment cycles

In this retrospective study we reviewed 135 women aged <or=35 years who underwent 151 IVF/ICSI cycles. The patients were divided into two groups: group 1 patients who had basal antral follicles <or=10 (n = 65) and group 2 patients who had basal antral follicles >or=11 (n = 70). Women with antral follicles <or=10 needed more stimulation days and higher total gonadotropin doses and tended to have lower pregnancy rates.

Basal and cycle androgen levels correlate with in vitro fertilization stimulation parameters but do not predict pregnancy outcome

OBJECTIVE

To evaluate androgen levels before and during IVF. To assess for an association between androgen levels and IVF stimulation parameters or IVF pregnancy outcome.

DESIGN

Prospective cohort study.

SETTING

Residency-based IVF program.

PATIENT(S)

One hundred seventeen infertility patients.

INTERVENTION(S)

Androgen levels were evaluated on basal day 3 and during the IVF stimulation cycle.

MAIN OUTCOME MEASURE(S)

Pregnancy outcome rates and IVF stimulation parameters.

RESULT(S)

Mean serum androgen levels did not differ among different pregnancy outcomes. Multiple linear regression analysis revealed that body mass index (BMI) and oocyte number had a significant positive association with basal testosterone levels. Mean ovarian volume correlated negatively and follicle number correlated positively with testosterone levels on day 6 of stimulation. Peak E(2) and BMI correlated positively with testosterone on day of hCG administration. The interval change in androgen levels throughout the IVF cycle was not associated with outcome rates. Likewise, threshold analysis did not reveal any significant androgen level that affected pregnancy outcome.

CONCLUSION(S)

Serum androgen levels during IVF correlate with IVF stimulation parameters. However, these data do not support an influence of serum androgen levels on IVF pregnancy outcome rates.

Outcomes From Assisted Reproductive Technology

The use of assisted reproductive technology (ART) for treating the infertile couple is increasing in the United States. The purpose of this paper is to review the short-term outcomes after ART. Pregnancy rates after ART have shown nearly continuous improvement in the years since its inception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Certain clinical diagnoses are associated with a poorer outcome from ART, including the presence of hydrosalpinges, uterine leiomyomata that distort the endometrial cavity, and decreased ovarian reserve. Multiple gestations are the major complication after ART. New laboratory techniques, including extended embryo culture, may allow the transfer of fewer embryos to maintain pregnancy rates while reducing the risk of multiple gestations. Although much of the morbidity in children born after ART is the result of multiples, recent analysis suggests that even singletons are at higher risk for perinatal morbidity, including preterm delivery and small for gestational age infants. In vitro fertilization may be associated with a slight increased risk for birth defects. The major short-term complication of ART in women is the development of ovarian hyperstimulation syndrome. This syndrome is difficult to predict, but new treatments are being developed that may limit its frequency. Because of its high pregnancy rate, couples are moving to ART more quickly in the management of their infertility. All outcomes of ART, including pregnancy rates and adverse complications, need to be compared with standard non-ART therapy when deciding the appropriate course of treatment for a given couple.

Mean ovarian diameter (MOD) as a predictor of poor ovarian response

PURPOSE

To determine the predictive value of mean ovarian diameter of ovarian response in controlled ovarian hyperstimulation (COH), in outcome with normal FSH level in early follicular phase of menstrual cycle.

METHODS

A prospective study established the prognostic value of the mean ovarian diameter of total 57 cases, including 17 patients undergoing IVF treatment with poor ovarian response and 40 patients (control group) with adequate ovarian response.

RESULTS

The mean ovarian diameter (MOD) of patients in the cancelled group was significantly lower (19.23 +/- 2.78) than in a comparable control group (24.67 +/- 3.38) [p < 0.001]. The mean ovarian diameter was a good predictor of poor ovarian response-area under receiver operating characteristic curve-ROCAUC = 0.88. The best criterion value discriminating between cancelled cycle and punctured was < or = 20.6 mm.

CONCLUSIONS

Our data demonstrate that the mean ovarian diameter provides good prognostic information in outcomes with poor ovarian response during controlled ovarian hyperstimulation in IVF. The test is easy to perform and it is a good informative resource.