Intensive hormone monitoring in women with unexplained infertility: evidence for subtle abnormalities suggestive of diminished ovarian reserve

Overview of infertility

Having a child is an innate trait in animals, including humans, and is required for the continued existence of all animal species. Therefore, for most women, the inability to conceive or to do so in a timely fashion - termed infertility - to enable the continuation of the family line can be emotionally distressing. The definition of infertility is controversial because of its separation into primary and secondary. This is further complicated by the loosely used term subfertility, which relates to couples who have reduced ability because they take longer than the natural time to conceive, as opposed to those who are infertile and are entirely unable to conceive after 6 to 12 months, depending on age. Infertility evaluation requires a thorough male and female history, physical examination of both partners, and targeted investigation to determine the cause of infertility in a particular couple. Various treatments apply to infertile couples depending on the age of the female partner, the results of investigations, the reason for infertility, the presence of inheritance of abnormal genes, the pregnancy rates the couple is happy with, the resources available, how desperate the couple is to achieve a live birth, and how much they want to commit to treatment. Infertility treatment could include counseling and expectant management only, intrauterine insemination in a natural or stimulated cycle, and IVF and or ICSI. Men with azoospermia will need surgical options to retrieve sperm for IVF/ ICSI, but rarely for IUI. This review overviews infertility's etiology, diagnosis, investigations, and treatment.

Evaluation of growth hormone deficiency in women with unexplained infertility

PURPOSE

Growth hormone (GH) has been recognized to play a regulatory role in female reproduction. It has been reported that infertile GH deficient patients regained fertility after GH replacement. The frequency of GH deficiency is not established in patients diagnosed with unexplained infertility. Here, we aim to present the prevalence of GH deficieny in this patient group.

METHODS

We included patients diagnosed with unexplained infertility throughout 18 months. Insulin tolerance test (ITT) and glucagon stimulation tests (GST) were performed and insufficient response to both tests was required for the diagnosis of GH deficiency.

RESULTS

Twenty-five patients were included in the study, the mean age was 27.4 ± 4.5 years and the median duration of infertility was 60 months (min:14, max:120). Two patients were GH deficient according to GST and 14 to ITT. Two patients (8%) showed lack of response on both tests and were diagnosed with GH deficiency.

CONCLUSION

The rate of GH deficiency among women with unexplained infertility was 8% in this preliminary study. There is need for further studies with larger patient groups to verify the results.

Infertility and cortisol: a systematic review

Introduction

Stress and infertility form a complex relationship. In line with this, various stress-related biological markers have been investigated in infertility.

Methods

This systematic review was performed using PRISMA guidelines (i) to report whether cortisol is highly present in infertile patients compared to fertile control; (ii) to report whether there is any significant difference in the cortisol level in infertile subjects that conceive and those that didn't at the end of assisted reproduction treatments. Original articles involving human (male and female) as subjects were extracted from four electronic databases, including the list of references from the published papers. Sixteen original full-length articles involving male (4), female (11), and both genders (1) were included.

Results

Findings from studies that compared the cortisol level between infertile and fertile subjects indicate that (i) Male: three studies reported elevated cortisol level in infertile patients and one found no significant difference; (ii) Female: four studies reported increased cortisol level in infertile subjects and three studies found no significant difference. Findings from studies that measured the cortisol level from infertile patients that conceived and those that didn't indicate that (i) Male: one study reported no significant difference; (ii) Female: one study reported elevated cortisol in infertile patients that conceived, whereas two studies reported increased cortisol in infertile patients that was unable to conceive. Five studies found no significant difference between the groups.

Discussion

In the present review we only included the cortisol value that was measured prior to stimulation or IVF treatment or during natural or spontaneous cycles, despite this, there are still variations in the sampling period, assessment techniques and patients' characteristics. Hence, at present, we are still unable to conclude that cortisol is significantly elevated in infertile patients. We warrant future studies to standardize the time of biological sample collection and other limitations that were addressed in the review to negate the unwanted influencing factors.

Special characteristics, reproductive, and clinical profile of women with unexplained infertility versus other causes of infertility: a comparative study

PURPOSE

To investigate whether women with unexplained infertility (UI) demonstrate different demographic and IVF characteristics compared to those with other causes of infertility.

METHODS

Data on 245 couples that underwent a total of 413 IVF/ICSI cycles were analyzed (UI 114 cycles, 73 women; anovulation (PCO/PCOS) 83 cycles, 51 women; tubal factor 85 cycles, 47 women; male factor 131 cycles, 74 women). Features of UI were compared versus other infertility groups, after adjustment for multiple comparisons. Generalized least squares (GLS) and random-effects logistic regression analysis were also performed.

RESULTS

Live birth rates, consisting of the primary outcome, were similar in all compared infertility groups. Compared to male infertility, UI was associated with woman's older age at cycle, lower body mass index (BMI), and higher follicle-stimulating hormone (FSH). Compared to tubal infertility, UI was linked to lower endometrial thickness at oocyte retrieval and lower BMI; compared to anovulatory infertility related to PCO/PCOS, UI was linked to woman's older age, more frequent smoking, and poorer ovarian reserve tests (FSH and antral follicle count). After adjustment for other types of infertility, woman's age, age at menarche, and FSH levels, anovulatory infertility presented with higher odds of clinical pregnancy compared to UI (adjusted OR = 2.13, 95% C: 1.01-4.52).

CONCLUSIONS

Infertile women with UI undergoing assisted reproduction demonstrate different demographic and clinical characteristics compared to those of other causes of infertility, albeit live birth rates are similar.

Effect of the anterior uterocervical angle in unexplained infertility: a prospective cohort study

OBJECTIVE

The present study aimed to evaluate an anatomical region, the anterior uterocervical angle (UCA), to determine whether it plays a role in unexplained infertility.

METHODS

In this prospective, cross-sectional study, unexplained infertile and healthy fertile (controls) women were compared. The longitudinal and transverse axes of the uterine cervix and uterine corpus were measured by transvaginal ultrasonography. The UCA was determined as the angle between two lines. One line was drawn between the internal and the external os, and the other was drawn through the internal cervical os and was parallel to the lower side of the front part of the uterine wall in the internal os. Demographic characteristics and uterocervical ultrasonographic measurements were compared between the two groups.

RESULTS

Eighty participants, aged from 20 to 35 years, were enrolled (unexplained infertile [n = 30] and healthy fertile women [n = 50)]. The mean lengths of the uterine corpus longitudinal axis, uterine corpus transverse axis, and uterine cervix longitudinal axis were similar between the groups. The mean UCA was significantly higher in healthy fertile women (131.9 ± 22.9 degrees) than in women with unexplained infertility (114.2 ± 17.3 degrees).

CONCLUSION

The present study shows that a narrow anterior UCA is associated with unexplained infertility.

Predictive serum markers for unexplained infertility in child-bearing aged women

PROBLEM

Unexplained infertility (UI) represents about 25%-40% of all infertility and is a formidable obstacle for successful pregnancy for child-bearing aged women. However, up to now, there is no reliable method to predict this condition with high accuracy, thereby hindering early management of this condition.

METHOD OF STUDY

Our prospective study consists of 84 child-bearing aged women that were clinically diagnosed UI. Forty-four matched healthy fertility (HF) women were served as controls. We examined the profiles of 25 hormones and cytokines that were likely related to pathogeneses and molecular pathways involved in UI with the technique of protein array. The samples were randomly stratified 7:3 into a training set and a testing set. We used the SMOTEboost model with 10 serum proteins in a clinical verification study to identify UI cases.

RESULTS

The predictor had an area under the receiver operating characteristic curve (AUC) of 0.788 with 24 serum protein features. The predictive performance in terms of AUC of the model with the top 10 important serum proteins in the clinical verification study to classify UI cases was 0.809. Three most significantly differentially expressed proteins (DEPs) were prolactin, monocyte chemotactic protein-1 (MCP-1), and leptin.

CONCLUSION

Examination of serum-based protein profile changes could help to identify child-bearing aged women at risk of UI. This would enable early detection and facilitate development of clinical strategies to treat UI and guide their planned parenthood. It may also give clues to pathogeneses of the condition of test subjects.

The role of anti-Mullerian hormone in predicting the response to clomiphene citrate in unexplained infertility

OBJECTIVE

To determine the role of anti-Mullerian hormone (AMH) levels in predicting the response to clomiphene citrate (CC) therapy for ovulation induction in women with unexplained infertility.

MATERIALS AND METHODS

For this retrospective study, fifty consecutive patients who responded to CC were taken as Group 1, while fifty consecutive patients who failed to show adequate ovulatory response with CC were taken as Group 2. We compared the AMH levels of the two groups and receiver operating characteristic (ROC) curve was used to determine the threshold for AMH in predicting the ovulatory response to CC therapy.

RESULTS

Mean age, body mass index, luteinizing hormone, prolactin, and thyroid-stimulating hormone values were similar in the two groups. AMH and antral follicle count (AFC) values were higher in Group 1 than in Group 2 (p = 0.001 and p = 0.001, respectively). There was a statistically significant negative correlation between FSH and AFC (r = -0.339, p = 0.001), while AFC and AMH displayed a statistically significant positive correlation (r = 0.713 and p = 0.001). AMH values and AFC were found to be predictors of the adequate ovulatory response to CC. The area under the ROC curve was 0.86 vs 0.80, respectively. At an AFC cutoff value of 14, the sensitivity and specificity for prediction of ovulation were 68% and 80%, respectively.

CONCLUSION

The AMH and AFC cut-off values for the prediction of positive ovarian response to CC in patients with unexplained infertility were 2.78 ng/mL and 14, respectively. If further prospective and randomized studies confirm our results, these thresholds may be useful to predict successful ovulation induction and reduce the unresponsive cycles.

Body symmetry and reproductive hormone levels in women

Fluctuating asymmetry (FA), a morphological marker of developmental stability, may be related to an individual's biological condition, e.g., health or fertility. The aim of this study was to test if the level of a woman's FA was related to her fertility and reproductive potential as measured by reproductive hormone levels. Fifty-three healthy, non-pregnant, naturally cycling women (mean age = 23.42, SD = 1.85 years), participated in the study, conducted in Wrocław (Poland) in May 2015. Early-follicular phase serum levels of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were measured. FA was calculated based on anthropometric measures of six bilateral body traits, and the composite FA index was used in statistical analyses. No relationship was observed between FA and the levels of FSH, LH, and AMH (p > .05), controlled for potential confounders. However, the level of E2 was positively correlated with FA (p < .05). Thus, in young women, FA was not related to hormones levels related to ovarian reserve, but more symmetrical women had lower E2 levels. As FA is an index of developmental stability, environmental, and genetic stress, the results of the study confirm previous research suggesting that developmental conditions may be related to women's endogenous estrogen levels.

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.

Leptin as a Predictive Marker in Unexplained Infertility in North Indian Population

INTRODUCTION

According to WHO, the primary infertility in India is about 3.9% (age-standardized to 25-49 year) and 16.8% (age-standardized to 15-49 year), using the "age but no birth" definition. Several factors which affect fertility include low sperm production in men, poor egg quality and blocked fallopian tubes in women and also hormonal imbalances. Leptin plays a critical role in women's reproduction and neuroendocrine health. It is used for treating exercise-induced bone loss, eating disorders and infertility.

AIM

To evaluate the serum leptin levels in Indians and to ascertain the relationship between serum leptin levels, Unexplained Infertility (UI) and related variables [height, weight, Waist Hip Ratio (WHR), Body Mass Index (BMI)] between obese infertile, non-obese infertile and healthy subjects.

MATERIALS AND METHODS

The present case-control study was conducted at the Department of Obstetrics and Gynaecology, King George's Medical University (KGMU), Lucknow, India and funded by Department of Science and Technology, New Delhi, India. The study included 229 female participants in the age group of 18-40 years (120 cases and 109 controls) who were randomly selected. The blood samples were collected from the Infertility Clinic, Queen Mary's Hospital, KGMU, Lucknow, India. All the participants underwent complete physical examination. Initially, the participants were categorized into fertile and infertile groups, they were further divided on the basis of BMI, normal (BMI- 18.5-24.5) and overweight or obese (BMI≥25). Leptin level was measured by Active Human Leptin ELISA kit and BMI of all subjects was calculated in kg/m² (weight in kg and height in m).

RESULTS

A highly positive linear correlation (R=0.754, p<0.001) was found between BMI and serum leptin in unexplained infertile women, which indicates a strong relationship between BMI and serum leptin. The variation in serum leptin is explained by the independent variable, BMI. There was a partial positive linear correlation between BMI and serum leptin in the control group. Statistically there was no significant correlation (R=0.109, p=0.258) between BMI and serum leptin in the control group.

CONCLUSION

The present study clearly demonstrates that level of leptin is higher in unexplained infertile than in the fertile group, and also shows that a strong relationship exists between BMI and serum leptin in the obese group. Serum leptin level was significantly higher in obese than non-obese subjects. Thus, leptin is an important factor for normal reproductive function. Obesity, the main cause of infertility may be controlled by regulating the leptin concentration.

Prolactin and natural killer cells: evaluating the neuroendocrine-immune axis in women with primary infertility and recurrent spontaneous abortion

PROBLEM

An association between serum prolactin (PRL) and peripheral blood natural killer (NK) cells has been described in healthy women. We explored for the first time the PRL response to the thyrotrophin-releasing hormone (TRH) test and the association between PRL and NK cells in women with reproductive failure.

METHODS

A total of 130 women [31 primary infertility, 69 recurrent spontaneous abortion (RSA), and 30 fertile women] were evaluated by a TRH test to analyze the following: basal PRL (bPRL), peak-time PRL, PRL absolute and relative increase, decline-time PRL. Hyperprolactinaemia (HPRL) was defined as bPRL ≥15 ng/mL. NK cells were characterized by immunophenotyping.

RESULTS

Significantly higher bPRL levels were found in the infertile women than in controls. Both the infertile and the RSA women showed significantly elevated NK levels. bPRL levels correlated with NK cells in HPRL-infertile women.

CONCLUSIONS

In patients with HPRL, an association between NK cell and bPRL results. The dynamic test in the infertile women would help in the management of the pregnancy impairment.

Predictive value of hormonal parameters for live birth in women with unexplained infertility and male infertility

BACKGROUND

Infertile women might get pregnant sometime after fertility treatment, but today, there is no prediction model on who will eventually have children. The objective of the present study was to characterize hormone levels in an arbitrary menstrual cycle in women with unexplained infertility and male infertility, and to determine the predictive value for long-term possibility of live birth.

METHODS

In this cross-sectional study, with 71 infertile women with diagnosis unexplained infertility and male infertility, blood samples were obtained during the proliferative and secretory phases of an arbitrary menstrual cycle. Serum concentrations of FSH, LH, AMH, inhibin B, estradiol, progesterone, PRL and TSH were determined. The predictive value of ovulation and hormonal analysis was determined by identifying the proportion of women with at least one live birth. Mann Whitney U test, chi2 test and Spearman's correlation were used for statistical analysis. A value of p < 0.05 was considered statistically significant.

RESULTS

There were no differences in hormone values and live birth rates between women with unexplained infertility and male infertility. The best sole predictors of live birth were age of the women, followed by ovulatory cycle, defined as serum progesterone concentration of greater than or equal to 32 nmol/L, and a serum TSH concentration of less than or equal to 2.5 mIU/L. Combining the age with the ovulatory cycle and serum TSH less than or equal to 2.5 mIU/L or serum AMH greater than or equal to 10 pmol/L the predictive value was close to 90%.

CONCLUSIONS

Age in combination with the presence of an ovulatory cycle and serum TSH or serum AMH is predictive for long-term live birth. The advantage of serum AMH compared with serum TSH is the very little variation throughout the menstrual cycle, which makes it a useful tool in infertility diagnosis.

Infertility: evaluation and initial management

Treating the infertile client with competence and compassion is within the scope of practice for advanced practice clinicians. However, due to both a lack of emphasis on infertility treatment in many advanced practice education programs and confusion regarding diagnosis and treatment by many practitioners, infertility is often undertreated by these providers. A basic infertility evaluation, patient counseling, and prescriptive therapy with oral ovulation-inducing agents by a knowledgeable practitioner is cost-effective and may result in successful pregnancy in women who otherwise may not be adequately and quickly treated prior to referral to a reproductive endocrinologist. A diagnosis of infertility is often stressful and frustrating for a couple. Midwives and advanced practice nurses are uniquely qualified to provide both compassionate care and competent treatment during this time. This article provides the clinician with an overview of infertility diagnosis, evaluation, and initial management with lifestyle modifications and oral ovulation-inducing agents.

Recurrent pre-clinical pregnancy loss is unlikely to be a 'cause' of unexplained infertility

BACKGROUND

A proportion of women with 'unexplained' infertility may present with subfertility because their pregnancies fail before they are clinically recognized. In order to test whether pre-clinical early pregnancy losses (EPL) occur more frequently in women with unexplained infertility, serial urinary hCG concentrations were measured to compare EPL per cycle rates following spontaneous conception in patients with unexplained infertility versus healthy volunteers.

METHODS

Sixty patients under 39 years of age with unexplained infertility and 60 healthy controls, who were trying to conceive spontaneously, participated in this study. All participants were asked to collect daily urine samples from cycle day 14 until menstruation for three consecutive cycles or until a positive pregnancy test was obtained. Urinary hCG and creatinine levels were measured by immunoassay. Implantation was detected when urinary hCG levels rose above reference levels constructed from samples obtained from 12 women not attempting to conceive. EPL rates were determined by a linear mixed model using logarithmically transformed hCG/creatinine data.

RESULTS

In the 133 cycles of 60 women with unexplained infertility, just one implantation was detected, which became an ongoing pregnancy. In contrast, in 103 such cycles in 46 control patients, 30 implantations were detected (24 clinical pregnancies, 6 cases of EPL). The odds ratio for EPL/cycle in the unexplained versus control group was 0 (95% confidence interval: 0-0.795, P = 0.026).

CONCLUSIONS

Our data do not support the hypothesis that recurrent EPL may present as unexplained infertility. Post-implantation failure is therefore unlikely to contribute significantly to the presentation of subfertility.

Vasomotor symptoms in infertile premenopausal women: a hitherto unappreciated risk for low bone mineral density

OBJECTIVE

To identify the prevalence of vasomotor symptoms (VMS) in a population of premenopausal infertile women and to determine whether VMS is associated with enhanced bone turnover and low bone mineral density (BMD).

DESIGN

Cross-sectional study.

SETTING

Academic infertility practice.

PATIENT(S)

Eighty-two premenopausal infertile, but otherwise healthy, women attending for routine infertility care.

INTERVENTION(S)

Bone mineral density testing, general health and Profile of Mood States questionnaires, and serum samples (cycle d 1-3).

MAIN OUTCOME MEASURE(S)

Vasomotor symptoms, specifically hot flashes (HF) and night sweats (NS); BMD z score, BMD categorized as low (Z -1.0); ovarian reserve assessment (biochemical and ovarian dimensions on transvaginal ultrasound); and serum markers of bone turnover (collagen N-terminal telo-peptide, tartrate-resistant acid phosphatase, and bone-specific alkaline phosphatase) and ovarian reserve (FSH, E(2), and inhibin B). Multivariable regression analyses determined the associations between VMS, BMD, and bone turnover (individual markers and composite turnover score).

RESULT(S)

The prevalence of VMS was 12% in this relatively young population (mean [+/- SD] age [years], 34.53 +/- 4.32). Symptomatic women were statistically significantly more likely to report sleep disturbances and to exhibit evidence of low BMD, as well as to exhibit enhanced bone turnover and poorer ovarian reserve parameters. Multivariable logistic regression analyses confirmed the statistical significance of both HF and NS as independent correlates to low BMD after adjusting for age, body mass index, smoking status, menstrual regularity, and ovarian reserve status. Multivariable linear regression analyses demonstrated that NS, but not HF, predicted higher bone turnover at a statistically significant level after adjusting for age, smoking, menstrual regularity, and ovarian reserve.

CONCLUSION(S)

We demonstrate, in a premenopausal population of infertile women, evidence of morbid accompaniments to VMS, including sleep disturbances and evidence of low BMD. Our data further suggest a state of enhanced bone turnover in association with VMS, specifically in those experiencing NS. Declining ovarian reserve may be the common pathophysiological mechanism underlying VMS and low BMD in the symptomatic population and merits further investigation.

An experimental study on the effect of different types of textiles on conception

To study the effect of different types of textiles on conception. A total of 35 female dogs were divided into five equal groups: four test and one control. Each of the four test groups was dressed in one type of textile underpants made of either 100% polyester, 50/50% polyester-cotton mix, 100% cotton, or 100% wool. The pants were worn for 12 months. The dogs were followed during this period and for 6 months after removal of the pants by measuring the serum oestradiol 17beta and progesterone and by mating. Electrostatic potentials were also measured on the textile-covered skin. Eight bitches wearing polyester-containing textile showed diminished serum progesterone in the oestrus of the oestrous cycle, and did not conceive on mating or insemination. Five months after pants had been removed, serum progesterone of the eight dogs had normalised, and they conceived. Electrostatic potentials were detected on the skin of all dogs dressed in polyester-containing textile. The low serum progesterone and non-conception of the eight dogs could point to anovulation and failure of luteinisation. It is suggested that the electrostatic potentials detected on the skin create an 'electrostatic field' that inhibits the ovarian function. However, the effect proved to be reversible.

Serum leptin level in women with unexplained infertility

INTRODUCTION

The aim of this study was to compare serum levels of leptin in women with unexplained infertility with fertile subjects.

MATERIAL AND METHOD

Serum leptin levels of 27 infertile and 30 fertile women on day 3 of the menstrual cycle were assessed and compared in this prospective age and body mass index (BMI) comparable controlled study.

RESULTS

The mean age in the infertile group was 29.3 (range, 23-38), while this figure was 28.9 (range, 19-39) in the fertile group; the mean BMIs were 24.5 (range, 20.6-27.8) and 25.0 (range, 21.8-28.7), respectively. The mean serum leptin level was significantly higher in women with unexplained infertility compared with fertile subjects. Considering normal weight subjects, mean serum leptin levels were increased significantly in the unexplained infertile group compared with the fertile group (7.2 (range, 4.3-10.4) versus 3.5 (range, 1.9-6.2)ng/ml, respectively; p<0.0001, Mann-Whitney U-test). The significant increase in serum leptin levels was observed also in overweight patients (6.8 (range, 1.3-5.2) versus 3.3 (range, 4.2-8.9)ng/ml, respectively; p<0.0001, Mann-Whitney U-test).

CONCLUSION

A significant difference in serum leptin levels between unexplained infertile and fertile women suggests that this cytokine may be involved in pathophysiology of unexplained infertility.

Predictive value and clinical impact of Basal follicle-stimulating hormone in subfertile, ovulatory women

CONTEXT

Basal FSH is a marker for ovarian reserve.

OBJECTIVES

The objective of the study was to investigate the predictive value of basal FSH on spontaneous ongoing pregnancy in subfertile ovulatory women.

DESIGN

This was a prospective cohort study.

SETTING

The study was conducted in 19 fertility centers in The Netherlands.

PARTICIPANTS

Subfertile ovulatory women without two-sided tubal pathology and in whom the man had normal sperm parameters (total motile count > or = 3 x10(6)) participated in the study.

INTERVENTIONS

Interventions included a fertility work-up, including a basal FSH measurement on cycle d 3.

MAIN OUTCOME MEASURES

Spontaneous ongoing pregnancy was measured.

RESULTS

We included 3519 consecutive couples of which 562 (16%) had a spontaneous ongoing pregnancy within 1 yr. Basal FSH levels of 8 IU/liter or higher were associated with a decreased probability of spontaneous ongoing pregnancy [hazard ratio (HR) 0.93/IU.liter (95% confidence interval [CI] 0.87-0.98)]. In a multivariable analysis, female age (HR 0.97/yr, 95% CI 0.95-0.99), cycle length (HR 0.96/d, 95% CI 0.93-1.0), and FSH levels 8 IU/liter or greater (HR 0.93/IU.liter, 95% CI 0.87-0.99) were strong negative predictors for spontaneous ongoing pregnancy. Addition of FSH to a prediction model based on female age, duration of subfertility, previous pregnancy, referral status, and semen analysis changed the probability to conceive spontaneously from 30% or greater to less than 30% in 97 of 3219 couples (3.0%).

CONCLUSIONS

In ovulatory women, a basal FSH level of 8 IU/liter or higher is associated with decreasing fecundity, independent of female age and cycle length. Because the number of couples in whom the FSH level alters management decisions is low, we do not recommend routine testing of basal FSH in subfertile couples.

Ultrasound characteristics and histological dating of the endometrium in a natural cycle in infertile women compared with fertile controls

OBJECTIVE

To compare endometrial dating and ultrasound texture in a natural cycle before IVF and relate these to outcome and to fertile references.

DESIGN

Prospective study with a fertile reference group.

SETTING

Four university IVF clinics.

PATIENT(S)

Seventy-five IVF patients and 21 fertile women.

INTERVENTION(S)

Ultrasound, biopsy, blood sampling. In vitro fertilization-ET in the following cycle.

MAIN OUTCOME MEASURE(S)

Endometrial evaluation, P, IVF outcome.

RESULT(S)

At day LH+7, 42% infertile vs. 67% fertile women demonstrated endometria that were in phase (statistically nonsignificant difference). Nine percent had an accelerated endometrium, and 47% (infertile) vs. 24% (fertile) had a delayed endometrium (statistically nonsignificant difference). Statistically significantly fewer women with tubal factor and no hydrosalpinges had an endometrium in phase (20%) than was the case in fertile women (67%). Dating could not predict outcome. Statistically significantly more women in the hydrosalpinx group had a visible midline at day LH+7 compared with the case in other infertile groups. Forty-three percent conceived after IVF-ET. Plasma P was statistically significantly lower in nonpregnant women compared with in women with ongoing pregnancies and with fertile controls. A periovulatory hyperechogenic endometrium resulted in no ongoing pregnancies.

CONCLUSION(S)

In a natural cycle preceding IVF, a low midluteal P level predicts a low implantation rate. A periovulatory hyperechogenic endometrium or hydrosalpinges visible at ultrasound may have some predictive value. Endometrial dating was of no help.

Programming of GnRH feedback controls timing puberty and adult reproductive activity

The timing of puberty generally differs between sexes, and this may be due to sex differences in the organization of steroid feedback systems. We propose that the reproductive neuroendocrine default sex is female. If the individual is male, the feedback control of GnRH secretion is programmed early in development, and the pubertal GnRH rise is either advanced or delayed depending upon species. This developmental programming is by androgens. Early programming also reorganizes adult reproductive neuroendocrine function to change a pattern of cyclic gamete release (periodic ovulations) requiring multiple feedback systems to that of a continuous one (spermatogenesis) requiring only the negative feedback control. The multiple feedback systems underlying the complex ovulatory cycle are innate, and in the male the unnecessary feedbacks are abolished or rendered less sensitive during development by the estrogenic, as well as the androgenic metabolites of testosterone.

Ovarian Biopsy in Infertile Patients With Ovarian Dysfunction

Evaluation of ovarian histology is feasible by obtaining ovarian tissue through laparoscopy; however, the role of an ovarian biopsy in an infertility workup is not widely accepted. To gain insight into the role of ovarian biopsy in reproductive medicine, we conducted a cross-sectional study in infertile patients with ovarian dysfunction and correlated follicle stimulating hormone (FSH) and estradiol serum concentrations with ovarian follicular counts. Fifty women were recruited and classified into four groups: premature ovarian failure (POF), chronic anovulation, diminished ovarian reserve, and ovulatory patients (control group). Ovarian endocrine function was assessed by the determination of FSH, luteinizing hormone, and estradiol serum concentrations and correlated with the number of follicles present in the ovarian biopsies obtained by laparoscopy. The number of ovarian follicles observed for each individual biopsy varied extensively. Patients with POF presented significantly lower counts of primordial, primary, and secondary follicles. No significant differences were found in the other groups. In the total sample, primordial follicle counts correlated inversely with serum FSH levels (r = -0.4, p = 0.003) and directly with serum estradiol levels (r = 0.5, p = 0.001) however, such associations no longer remained after adjusting by group. We conclude that ovarian biopsies do not provide additional information to the clinical-hormonal criteria previously established in the workup of infertile patients. Therefore, its use cannot be generalized in the study of infertile patients with ovarian dysfunction. In contrast, ovarian biopsies may be useful to identify patients with POF when the ovarian reserve is likely altered.

Use of ovarian reserve tests for the prediction of ongoing pregnancy in couples with unexplained or mild male infertility

The chance of infertile patients conceiving is related to factors like female age and duration of infertility. This prospective observational study evaluated whether the results of ovarian reserve tests, including the novel marker serum anti-Mullerian hormone (AMH), were of additional value in predicting ongoing pregnancy. Two hundred and twenty-two patients diagnosed with unexplained infertility or mild male factor (total motile count>10x10(6)) on the basis of the infertility work-up were prospectively included. Antral follicle count, AMH, inhibin B, FSH and oestradiol concentrations were determined during the early follicular phase. Outcome measures were treatment-dependent and treatment-independent ongoing pregnancy and time to ongoing pregnancy. There were 159 ongoing pregnancies, 52 of which occurred spontaneously. Pregnant patients were significantly younger than those who did not become pregnant (median age 32.4 versus 34.9 years, P<0.001) and FSH concentrations were higher in non-pregnant patients (median 6.8 versus 7.6 IU/l, P=0.04). Only age (hazard ratio 0.93, 95% CI 0.90-0.97) and whether or not the patient was undergoing treatment (hazard ratio 8.10, 95% CI 5.66-11.61) were significantly associated with time to ongoing pregnancy. Ovarian reserve tests, other than chronological age, seem of limited value in predicting (time to) ongoing pregnancy in patients with unexplained and mild male infertility.

Are cause of subfertility and in vitro fertilization treatment risk factors for an earlier start of menopause?

OBJECTIVE

To study whether women diagnosed with unexplained subfertility reach the menopause transition and natural menopause earlier than women with tubal subfertility, in an in vitro fertilization (IVF)-treated population, and to examine the influence of the number of IVF cycles on the occurrence of an early menopause transition and natural menopause.

DESIGN

This retrospective cohort study included 12 IVF clinics in the Netherlands. A nationwide retrospective cohort study was conducted among women whose first IVF cycle was stimulated with gonadotrophins in the Netherlands between 1983 and 1995 (n = 7,842). Most of the women were in their late 30s at the end of the follow-up period (range 24-55 y). The main outcome measures were the relative risk (RR) of having reached natural menopause and the risks (RR) of having entered the menopause transition or natural menopause according to the cause of subfertility and the number of IVF cycles.

RESULTS

Women with unexplained subfertility did not have an increased risk of entering the menopause transition or natural menopause (adjusted RR = 0.5; 95% CI, 0.2-1.5; and RR = 0.8; 95% CI, 0.6-1.1). After a 5-year follow-up period, we found no increased risk for entering the menopause transition or natural menopause among women who had undergone six or more IVF cycles when compared with women who had undergone only one IVF cycle (adjusted RR = 0.4; 95% CI, 0.1-1.7; and RR = 0.9; 95% CI, 0.6-1.6).

CONCLUSIONS

Underlying causes of unexplained subfertility do not predispose women to an early start of menopause. Although the number of IVF cycles was not associated with early menopause, longer follow-up is needed.

Characterizing the endometrium in unexplained and tubal factor infertility: A multiparametric investigation

OBJECTIVE

To characterize endometrial development in unexplained and tubal factor infertility.

DESIGN

Prospective study of 20 women with unexplained infertility, 22 with tubal factor infertility, and 21 fertile controls in the midproliferative, periovulatory, and midluteal phases of the menstrual cycle.

SETTING

Reproductive Medicine Department of St. Mary's Hospital, Manchester, United Kingdom.

PATIENT(S)

Women awaiting assisted conception.

INVESTIGATION(S)

Serum hormone assays, transvaginal ultrasound, Doppler, and midluteal endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Serum levels of E2, P, and LH, endometrial ultrasound morphometry, uterine and subendometrial artery Doppler, and endometrial histology and biochemistry.

RESULT(S)

Women with unexplained infertility demonstrated significantly reduced uterine artery flow velocity in all phases, significantly elevated uterine and subendometrial artery impedance in the periovulatory and midluteal phases, and significantly reduced endometrial texture in the midproliferative phase. Women with tubal factor infertility demonstrated significantly reduced uterine artery flow velocity, without a concomitant increase in impedance, and significantly greater expression of endometrial glandular and luminal keratan sulphate.

CONCLUSION(S)

Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers. Tubal factor infertility is associated with endometrial developmental defects that might be corrected by salpingectomy. Endometrial ultrasound and Doppler studies are likely to become a vital tool in the investigation of infertility.

Cycle characteristics of day 3 embryo transfers with 4-cell embryos only

PURPOSE

Patient and cycle characteristics of day 3 transfers with developmentally lagging 4-cell embryos only were analyzed and related to the outcome of a live birth.

METHODS

Day 3 transfers with either 4-cell embryos only (study group; n = 138) or 8-cell embryos only (control group; n = 282) were compared retrospectively.

RESULTS

The total dose of FSH per treatment was higher, while the number of oocytes, zygotes, and transferred embryos was lower in the study group cycles compared to controls. The implantation, pregnancy, and live birth rates were dramatically lower in the study group compared to the control group. In the study group, the few cycles resulting in a live birth were characterized by a normal ovarian response to stimulation, similar to that of control group cycles with- or without a live birth.

CONCLUSIONS

In cycles characterized by intensive ovarian stimulation, but poor response, the chance for a live birth is extremely low after day 3 transfer of 4-cell embryos.

Present concept of unexplained infertility

Despite improvements in both diagnostic assessment and treatment of infertile couples, many couples still have no explanation for their infertility. Unexplained infertility (the failure to conceive of a couple in whom no definitive cause for infertility can be found) has an incidence of 10-20% in all infertile couples. The incidence varies with the population studied and with the criteria used. Unexplained infertility is not an absolute condition but rather a relative inability to conceive, and many of these couples may conceive without treatment. The treatment options for unexplained infertility are several and the treatment results are promising. Expectant management can be recommended if the woman is under 28-30 years of age and the infertility duration is less than 2-3 years. In vitro fertilization (IVF) has revolutionized the treatment of infertile couples, as well as profoundly increasing the basic understanding of human reproduction. IVF can be used as both a diagnostic and a therapeutic tool in couples with unexplained infertility. The pregnancy rates with IVF are good, at 40% per treatment cycle. In addition, the outcome of pregnancies among women with unexplained infertility is generally comparable to that of spontaneous and other pregnancies using assisted reproductive technologies.

Early ovarian ageing

Observations from reproductive biology, epidemiology, and clinical assisted reproduction support the hypothesis that the time interval between the onset of accelerated decline of the ovarian reserve and the menopause is more or less fixed. Thus, it is estimated that women who become menopausal by the age of 45 may have experienced an accelerated decline of their fertility before the age of 32. Up to 10% of women in the general population may fall into this category, which has been described as "early ovarian ageing". Because of the long latent phase and predictable natural history, this condition is suitable for screening. High-risk groups include, women with a family history of early menopause. IVF has provided a model for the development of ovarian reserve tests, some of which appear promising as potential screening tools for the detection of early ovarian ageing in asymptomatic women in the general population.

Efficacy of IVF using frozen donor semen in cases of previously failed DI cycles compared with tubal infertility: a cohort study

A cohort follow-up study was designed to compare the efficacy of IVF using frozen donor semen (IVF-D) following previously failed DI cycles (unexplained female infertility) and direct IVF-D treatment because of tubal infertility (control group). The cohort comprised 189 couples initiating IVF-D after previously failed DI cycles (n = 126) or directly (n = 63). Couples were followed until completion (success or drop-out for personal or medical reasons). Live births and drop-out were expressed both as rate per cycle and crude cumulative rate. Characteristics of IVF-D cycles were similar between the two groups. Moreover, overall outcome was also similar in terms of crude cumulative live birth rate (54.0 versus 57.1% for failed DI cycles and tubal infertility groups respectively). This is the first report on crude cumulative live birth rate based on a cohort follow-up study in unexplained previously failed DI cycles and tubal infertility. Previously failed DI cycles did not impair the chances of achieving a successful pregnancy using IVF-D in this series. Slight oocyte dysfunction, which might underlie the failure of DI cycles, might be overcome using IVF-D.

Elevated early follicular gonadotropin levels in women with unexplained infertility do not provide evidence for disordered gonadotropin-releasing hormone secretion as assessed by luteinizing hormone pulse characteristics

OBJECTIVE

To determine whether women with rigorously defined unexplained infertility demonstrated altered GnRH secretion, as reflected by serum LH secretion patterns.

DESIGN

Prospective observational study.

SETTING

National Center for Infertility Research at Michigan.

PATIENT(S)

Nine women with rigorously defined unexplained infertility and 11 healthy, parous age-matched control women.Gonadotropin-releasing hormone (25 ng/kg) as a bolus injection.

MAIN OUTCOME MEASURE(S)

Daytime pulse patterns of LH secretion measured every 10 minutes; mean serum concentrations of LH, FSH, E(2), P, PRL, and cortisol; and response to a physiologic dose of GnRH in the early follicular, late follicular, mid-luteal, and late luteal phases of the same menstrual cycle.

RESULT(S)

Serum LH pulse frequency and pulse amplitude and LH secretion in response to a physiologic bolus of GnRH were not significantly different in unexplained infertility patients at any phase of the cycle. Luteinizing hormone pulse frequency and amplitude, as well as response to GnRH, varied significantly across the cycle. Mean early follicular serum LH and FSH concentrations were significantly higher in unexplained infertility patients than in fertile control subjects (LH: 5.31 +/-.51 vs. 4.03 +/-.33 [mIU/mL +/- SEM]; FSH: 5.81 +/-.63 vs. 3.80 +/-.45) but were not different at any other phase of the cycle.

CONCLUSION(S)

These data do not support the hypothesis that unexplained infertility is caused by an abnormality in pulsatile GnRH secretion or abnormal pituitary sensitivity to GnRH. However, the results are consistent with a difference in negative feedback from the ovary to the pituitary in unexplained infertility patients that is suggestive of diminished ovarian reserve.

Follicular growth, endometrial thickness, and serum estradiol levels in spontaneous and clomiphene citrate-induced cycles

OBJECTIVES

To evaluate follicular growth, endometrial thickness, and serum estradiol levels in spontaneous cycles and cycles induced by clomiphene citrate (CC).

METHODS

A 2-year prospective study of spontaneous cycle followed by a CC-induced cycle to compare paired data. Twenty couples with unexplained infertility were recruited from the Infertility Clinic of the Jawaharlal Institute of Postgraduate Medical Education and Research. An oral dose of 150 mg of CC was administered on days 5 through 9 of the CC-induced cycle. Each woman was evaluated using transvaginal sonography and serum estradiol level estimation from day 10 of the menstrual cycle until ovulation. Results were analyzed using the paired t-test.

RESULTS

The leading follicular diameter was significantly larger, endometrial thickness was significantly decreased, and serum estradiol levels were significantly higher in the follicular phase of CC-induced cycles.

CONCLUSIONS

Clomiphene citrate-induced cycles showed different follicular, endometrial growth patterns, and serum estradiol levels compared with spontaneous cycles.

Comparison of uterine and spiral artery blood flow in women with unexplained and tubal infertility

OBJECTIVE

To evaluate the possible difference in uterine and spiral artery impedance to blood flow among women with unexplained and tubal infertility during spontaneous and gonadotropin-stimulated cycles.

METHODS

We prospectively compared uterine and spiral artery pulsatility index and peak systolic velocity in a longitudinal study in women with either unexplained infertility (n = 20) or tubal infertility (n = 18). Measurements of uterine and spiral artery impedance were taken on days 11-12, 16-17 and 21-23 of the spontaneous cycle and on days 1, 5 and 10 during gonadotropin stimulation. In addition, measurements were taken on the days of oocyte pick-up and embryo transfer.

RESULTS

A clinical pregnancy was achieved in 8/20 (40%) women with unexplained and 6/18 (33.3%) women with tubal infertility with in-vitro fertilization treatment. There were no differences in the uterine artery pulsatility index or peak systolic velocity during the spontaneous or the in-vitro fertilization cycle between the two groups. The impedance to blood flow in the uterine or spiral artery did not differ between women conceiving with in-vitro fertilization-embryo transfer and those who did not. However, the spiral artery pulsatility index on the 5th day of gonadotropin stimulation was significantly lower among women with unexplained infertility (0.96 +/- 0.25) compared to women with tubal infertility (1.24 +/- 0.30; P < 0.05), but on the other days of gonadotropin stimulation the spiral artery pulsatility index and peak systolic velocity were similar.

CONCLUSIONS

Impaired uterine or spiral artery blood flow is not an important factor in unexplained infertility.

Natural cycle IVF in unexplained, endometriosis-associated and tubal factor infertility

BACKGROUND

To elucidate possible differences between unexplained and minimal peritoneal endometriosis-associated infertility, we studied their outcome in natural cycle IVF (NIVF).

METHODS

A prospective cohort study was carried out on unexplained (33 couples), minimal peritoneal endometriosis-associated (30 couples) and tubal factor (24 couples) infertility in 223 NIVF cycles, using human chorionic gonadotrophin (HCG) for ovulation induction.

RESULTS

During the first NIVF attempt, follicular and luteal phase oestradiol, FSH, LH and progesterone concentrations, as well as endometrial thickness and follicular diameter were similar among the three groups. Periovulatory follicular growth monitored from day of HCG administration to oocyte aspiration was significantly lowered in unexplained infertility compared with minimal endometriosis-associated and tubal factor infertility. The fertilization rate, clinical pregnancy rate per initiated cycle, per successful oocyte retrieval and per embryo transfer, in minimal endometriosis (80.0, 10.4, 16.0 and 23.5% respectively) were similar to that in tubal factor infertility patients (68.6, 5.8, 11.4 and 16.0%) but significantly higher (P < 0.05) than that of the unexplained infertility group (62.2, 2.6, 5.4 and 8.7%).

CONCLUSIONS

The significant reduction in follicular periovulatory growth, fertilization and pregnancy rates in unexplained infertility compared with minimal peritoneal endometriosis patients may be explained by sub-optimal follicular development with possibly reduced oocyte quality, intrinsic embryo quality factors or by impaired implantation. From a clinical point of view, NIVF is less suited to unexplained infertility treatment, but might represent an interesting treatment option for minimal peritoneal endometriosis-associated infertility.

Definition and measurement of follicle stimulating hormone

FSH has a key role in the development and function of the reproductive system and is widely used both diagnostically and therapeutically in developmental and reproductive medicine. The accurate measurement of FSH levels, in patients for diagnosis and monitoring and in therapeutic preparations for clinical use, is essential for safe and successful treatment. Historically, FSH was defined on the basis of classical in vivo endocrine activity, and early therapeutic preparations were calibrated using in vivo bioassays. There was early recognition that reference preparations were required for calibration if the results from different laboratories were to be comparable. In response to the perceived need, the World Health Organization established the first standard for such preparations in 1959. Subsequent developments in biotechnology have led to recognition that there is no single molecule that can be uniquely defined as FSH, and that FSH can induce a range of biological activities. Several highly purified standards for FSH are now available, but discontinuity and heterogeneity of estimates of FSH activity in terms of these standards made using in vitro assays and binding assays have been noted. It is thus essential that any measurement of FSH include specification both of the standard with which the measured FSH is compared and the assay method used for that comparison.