Pretreatment transvaginal ultrasound examination predicts ovarian responsiveness to gonadotrophins in in-vitro fertilization

Evaluation of correlation between antral follicle diameters with Follicular Output Rate (FORT) in women under controlled ovarian hyperstimulation for assisted reproductive techniques

Background

This study aimed to determine the association of diametrical antral follicles with the ovarian response by Follicular Output Rate (FORT) ratio in 100 females undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). This study selected 100 women undergoing controlled ovarian hyperstimulation (COH). The number of antral follicles (diameter of 3–10 mm) was calculated with two-dimensional vaginal sonography on days 1–3 of the cycle. Then, on a triggering day with human chorionic gonadotropin (HCG), the number of follicles (with a diameter of 16–22 mm) and the ratio of FORT were determined. The correlation among FORT with age, antral follicle count (AFC), AFC ≤ 5, AFC > 5, number of preovulatory follicles (16–20 mm), number of metaphase II (MII) oocytes, body mass index (BMI), infertility period, and anti-Mullerian hormone (AMH) was assessed.

Results

There was a significant correlation between FORT and total AFC, AFC > 5, number of preovulatory follicles (16–20 mm), and number of MII oocytes retrieved. There is no significant relationship between FORT and examined two variables (AMH and AFC ≤ 5). Multiple linear regression analysis showed no significant relationship between FORT and examined two variables (AMH and AFC > 5). There was a significant correlation between MII oocytes retrieved and age, total AFC, AFC ≤ 5, AFC > 5, number of preovulatory follicles (16–20 mm), and AMH. A significant positive relationship existed between MII oocytes retrieved and examined two variables (AFC ≤ 5 and AFC > 5).

Conclusion

There was not much difference in the correlation between the AFC ≤ 5 and AFC > 5, and both positively correlated with the number of MII oocytes retrieved.

Evaluation of Female Fertility-AMH and Ovarian Reserve Testing

CONTEXT

Evaluation of the infertile female requires an understanding of ovulation and biomarkers of ovarian reserve. Antimüllerian hormone (AMH) correlates with growing follicles in a menstrual cycle. Increasingly, AMH has been used as a "fertility test." This narrative review describes how to integrate the use of AMH into diagnosis and treatment.

METHODS

A PubMed search was conducted to find recent literature on measurements and use of serum AMH as a marker of ovarian reserve and in treatment of infertility.

RESULTS

Serum AMH estimates ovarian reserve, helps determine dosing in ovarian stimulation, and predicts stimulation response. As such, AMH is a good marker of oocyte quantity but does not reflect oocyte health or chances for pregnancy. Screening of AMH before fertility treatment should be used to estimate expected response and not to withhold treatment. Low AMH levels may suggest a shortened reproductive window. AMH levels must be interpreted in the context of the endogenous endocrine environment where low follicle-stimulating hormone, due to hypogonadotropic hypogonadism or hormonal contraceptive use, may lower AMH without being a true reflection of ovarian reserve. In addition, there is an inverse correlation between body mass index and AMH that does not reflect ovarian response.

CONCLUSION

AMH is a useful marker of ovarian reserve in reproductive-aged women. Increased screening of noninfertile women requires a thorough knowledge of situations that may affect AMH levels. In no situation does AMH reflect oocyte health or chances for conception. Age is still the strongest driver in determining success rates with fertility treatments.

Ovarian Sensitivity Decreased Significantly in Patients With Insulin Resistance Undergoing in vitro Fertilization and Embryo Transfer

Ovarian sensitivity could affect the outcome of in vitro fertilization and embryo transfer (IVF-ET). The objective of this study was to explore the relationship between the ovarian sensitivity index (OSI) and traditional ovarian response makers and observe the relationship between OSI and insulin resistance (IR). The patients enrolled in this study included 131 patients with polycystic ovary syndrome (PCOS) with IR (PCOS-IR), 52 patients with PCOS without IR (PCOS-N), 164 patients with control with IR (control-IR), 133 patients with control without IR (control-N), 295 patients with IR, 184 patients with non-IR, 183 patients with PCOS, and 297 patients with control (patients with non-PCOS). All patients received standard long protocol or the gonadotropin-releasing hormone (GnRH) antagonist protocol to induce follicular development. The two protocols downregulated the pituitary function or blocked the pituitary luteinizing hormone (LH) secretion with a GnRH antagonist. Both protocols can block premature LH surges because premature luteinization is not conducive to follicular development. All patients underwent IVF or intracytoplasmic sperm injection (ICSI). Embryo transfer was carried out according to the specific situation of each patient. The OSI was significantly reduced in patients with IR. The OSI had a significant positive relationship with anti-Müllerian hormone (AMH), antral follicle count (AFC), basal LH/follicle-stimulating hormone (FSH), dominant follicle number on trigger day, retrieved oocytes, embryo number, and high-quality embryo number. OSI had a significant negative relationship with age, body mass index (BMI), basal FSH, initial dose of Gn, and total dose of Gn. The receiver operating characteristic (ROC) curve of OSI demonstrated a better accuracy in distinguishing patients with positive pregnancy and clinical pregnancy, with an area under the curve (AUC) of 0.662 (95% CI, 0.598–0.727) and 0.636 (95% CI, 0.577–0.695), respectively. Patients could get a higher rate of dominant follicle count (p < 0.0001) through the treatment of standard long protocol when compared with GnRH antagonist protocol. The OSI has a significant correlation with traditional ovarian response markers and could be a good predictor of positive pregnancy and clinical pregnancy for patients with IR.

Antral follicle responsiveness assessed by follicular output RaTe(FORT) correlates with follicles diameter

BACKGROUND

The antral follicle count is a marker of ovarian reserve. Follicular Output RaTe (FORT) evaluates the proportion of follicles responsive to exogenous follicle stimulating hormone (FSH) during controlled ovarian stimulation. Our objective was to evaluate whether the diameter (AFC6: ≤ 6 mm or AFC > 6: > 6 mm) of the follicular cohort could be a predictor for ovarian responsiveness, assessed by FORT, in a prospective cohort with 92 women with IVF indication, regular cycles and no abnormality in both ovaries.

RESULTS

The mean age (±SD) of the women was 36.03 years (± 3.87 years), the median FORT was 43.30%. We found correlation between the FORT and AFC6 (r = - 0.237, P 0.023) but not between the FORT and AFC > 6 (r = - 0.055, P 0.602).

CONCLUSIONS

The inverse correlation between FORT and AFC6 suggests that those follicles were less responsive to the exogenous FSH.

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.

Strategies for Fertility Preservation in Female and Male Cancer Survivors

Improved survival rates and quality of life following modern cancer treatment have resulted in a growing number of patients requesting maintenance of reproductive capacity, both before and after completion of treatment. Several established options are currently available. In men, sperm banking should be offered as soon as the diagnosis of any malignant disease is established, irrespective of the expected cryosurvival rate. In such cases, conception can be achieved with frozen-thawed spermatozoa following either intrauterine insemination (IUI) or intracytoplasmic sperm injection (ICSI). In women, depending on the type of cancer, the presence of an adequate ovarian reserve, and time to delay cancer treatment, in vitro fertilization (IVF) with embryo cryopreservation constitutes a valid alternative. On the other hand, cryopreservation of mature oocytes following IVF/ICSI offers some advantages, but it is still limited by its low success rate. Emerging and exciting techniques of germ cell/gonadal tissue cryopreservation (banking) followed by autotransplantation have been clinically explored, particularly in women. Novel cryotechnologies of ovarian and testicular tissue have proven efficacious and new transplantation strategies promise improved results. However, only one live birth following autotransplanted frozen-thawed ovarian tissue has been established and there are still no pregnancies reported from autotransplanted cryopreserved testicular tissue in the human. Efficiency and safety of these techniques needs to be demonstrated. Methods for gamete in vitro maturation also need further development. Gonadal tissue cryopreservation and transplantation should be considered experimental in humans for the present time until greater evidence regarding efficacy and safety is accrued.

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.

How to define, diagnose and treat poor responders? Responses from a worldwide survey of IVF clinics

Poor responders represent a significant percentage of couples treated in IVF units (10-24%), but the standard definition of poor responders remains uncertain and consequently optimal treatment options remain subjective and not evidence-based. In an attempt to provide uniformity on the definition, diagnosis and treatment of poor responders, a worldwide survey was conducted asking IVF professionals a set of questions on this complex topic. The survey was posted on www.IVF-worldwide.com, the largest and most comprehensive IVF-focused website for physicians and embryologists. A total of 196 centres replied, forming a panel of IVF units with a median of 400 cycles per year. The present study shows that the definition of poor responders is still subjective, and many practices do not use evidence-based treatment for this category of patients. Our hope is that by leveraging the great potential of the internet, future studies may provide immediate large-scale sampling to standardize both poor responder definition and treatment options.

Antral follicle count in normal (fertility-proven) and infertile Indian women

Background:

Antral follicle count (AFC) has been labeled as the most accurate biomarker to assess female fecundity. Unfortunately, no baseline Indian data exists, and we continue using surrogate values from the Western literature (inferred from studies on women, grossly different than Indian women in morphology and genetic makeup).

Aims:

(1) To establish the role of AFC as a function of ovarian reserve in fertility-proven and in subfertile Indian women. (2) To establish baseline cut-off AFC values for Indian women.

Settings and Design:

Prospective observational case-control study.

Materials and Methods:

Thirty patients undergoing workup for infertility were included and compared to equal number of controls (women with proven fertility). The basal ovarian volume and AFC were measured by endovaginal. USG the relevant clinical data and hormonal assays were charted for every patient.

Statistical Analysis Used:

SPSS platform was used to perform the Student's t-test and Mann-Whitney U-test for intergroup comparisons. Correlations were determined by Pearson's ranked correlation coefficient.

Results:

Regression analysis revealed the highest correlation of AFC and age in fertile and infertile patients with difference in mean AFC of both the groups. Comparison of the data recorded for cases and controls showed no significant difference in the mean ovarian volume.

Conclusions:

AFC has the closest association with chronological age in normal and infertile Indian women. The same is lower in infertile women than in matched controls. Baseline and cut-off values in Indian women are lower than that mentioned in the Western literature.

Role of ultrasonographic markers of ovarian reserve in prediction of IVF and ICSI outcome

The aim of the study was to assess correlation of ultrasonographic markers of ovarian reserve and IVF/ICSI outcome. Two-hundred twelve IVF/ICSI patients were included. Upon pituitary suppression confirmation, antral follicle count (AFC), ovarian volume (OV), and ovarian stromal indices [vascularization index (VI), flow index (FI), and vascularization flow index (VFI)] were assessed by three-dimensional (3D) and power Doppler (PD) ultrasound and correlated with the number of mature oocytes retrieved. The number of mature oocytes retrieved correlated strongly with AFC (r = 0.832, p ≤ 0.001) and OV (r = 0.835, p ≤ 0.001), but weakly with VI (r = 0.166, p = 0.016), FI (r = 0.151, p = 0.028), and VFI (r = 0.14, p = 0.041). AFC and OV correlate strongly with the number of mature oocytes retrieved in IVF/ICSI cycles, whereas 3D PD indices of the ovarian stromal vascularity have a weak correlation.

Estradiol Level on Day 2 and Day of Trigger: A Potential Predictor of the IVF-ET Success

OBJECTIVE

To evaluate role of serum estradiol levels in predicting likelihood of pregnancy in women undergoing GnRH-a protocol in IVF-ET cycles.

DESIGN

A 3-year retrospective analysis of estradiol levels on down-regulated day 2, day 6, and day of hCG trigger and subsequent clinical pregnancy rates.

SETTING

A university hospital tertiary referral centre.

POPULATION OR SAMPLE

Women undergoing IVF treatment.

METHODS

Hormonal assessment on the down-regulated day 2, day 6, and day of hCG trigger.

MAIN OUTCOME MEASURES

Comparison of hormonal profile, antral follicular count on day 2, endometrial thickness on day of trigger, and number of oocytes retrieved between pregnant and the non-pregnant group. The prediction of IVF success was based on the quantitative levels of estradiol on a specific day in down-regulated cycle.

RESULTS

The overall pregnancy rate was 32.25 % (50/160). Estradiol level on down-regulated day 2 was 31.9 ± 12.6 and on the day of trigger was 1,996.46 ± 1,252.36 in pregnant women, which was significantly higher as compared to estradiol levels in non-pregnant women (27.6 ± 12.3 and 1,525.1 ± 1,116.42, respectively). It was found to be a significant prognostic marker for successful IVF treatment. Estradiol levels on down-regulated day 6 were found to be non-significant between the two groups.

CONCLUSIONS

Estradiol level on down-regulated day 2 of menstrual cycle and on the day of trigger was found to have a significant impact on the success of IVF-ET.

Lateralization of ovarian follicles

BACKGROUND/AIM

To evaluate a possible lateralization of antral follicle count (AFC) based on the finding that endometriosis, if present, is more commonly found in the left hemipelvis.

METHODS

We evaluated the records of 6,617 baseline ultrasounds conducted at our Reproductive Center between 2007 and 2011 in a university teaching hospital setting. We included all ultrasounds with an AFC of 1 or greater and excluded those with incomplete documentation or with ovarian cyst, including endometriotic cysts (n = 909). The main outcome measure was the comparison of the number of antral follicles between the right and left ovary.

RESULTS

The number of antral follicles in the right ovary (median 18, range 15-22) was significantly higher than in the left ovary (median 16, range 13-20) among women with polycystic ovaries (PCO, AFC ≥24). Similarly, the number of antral follicles in the right ovary (median 8, range 6-10) was significantly higher than in the left ovary (median 7, range 5-9) in women with no PCO but normal ovarian reserve (AFC 10-23).

CONCLUSIONS

In women with PCO and non-PCO with normal ovarian reserve, the right ovary contains a higher number of antral follicles than the left ovary.

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

OBJECTIVE

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

DESIGN

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

SETTING

In vitro fertilization clinics.

PATIENT(S)

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

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Excessive response prediction.

RESULT(S)

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

CONCLUSION(S)

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

Do estrogen receptor alpha polymorphisms have any impact on the outcome in an ART program?

PURPOSE

To investigate two of the most studied estrogen receptor alpha polymorphisms (PvuII and XbaI) in combination, in order to evaluate their impact on an ART program outcome.

METHODS

203 normally ovulating women who underwent IVF or ICSI treatment were genotyped for PvuII and XbaI polymorphisms in ESR1 intron 1 using Real-Time PCR. The relationship between the presence of polymorphic alleles and the ovulation induction parameters and outcome was examined.

RESULTS

Women were grouped according to the number of polymorphic alleles they carried in two groups (0-2 versus 3-4 polymorphic alleles). The presence of 3 or more polymorphic alleles was associated with significantly lower E2 levels on the day of hCG administration and a significantly lower rate of good quality embryos.

CONCLUSION

There is an association between ESR1 polymorphisms and some ART parameters such as the level of E2 on the day of hCG administration and the quality of the embryos. These results underline the importance of ESR1 as a candidate gene for the prediction of ovarian response to IVF/ICSI protocols. Future research work concerning several more genes is necessary for a better evaluation of patients before entering an IVF/ICSI program.

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.

In vitro fertilisation treatment and factors affecting success

The efficacy of assisted reproductive technologies has improved significantly over the past decades. The main indications for in vitro fertilisation include tubal obstruction, severe male-factor infertility, severe endometriosis, ovulatory dysfunction, diminished ovarian reserve, and infertility of unexplained cause. In vitro fertilisation has also become an effective treatment option for couples wishing to undergo pre-implantation genetic diagnosis or screening, and for those wishing to cryopreserve their oocytes or embryos for preservation of fertility. The management of women in late reproductive age poses a major challenge; the optimum in vitro fertilisation treatment for poor responders remains elusive. The success of in vitro fertilisation treatment can be optimised by taking an individualised, patient-centered approach to controlled ovarian hyperstimulation. Key components involve selection of an appropriate controlled ovarian protocol, close-cycle monitoring, adjustment of gonadotropin dosage to avoid hyper-response, and individualised timing of human chorionic gonadotropin injection. Future directions of assisted reproductive technologies include development of non-invasive embryo selection methods, use of transcriptomics, proteomics, metabolomics, and time-lapse imaging technologies.

The predictive value of antral follicle count remains unchanged across the menstrual cycle

OBJECTIVE

To explore whether the predictive value of antral follicle count (AFC) changes when measured at different times during the menstrual cycle. Antimüllerian hormone (AMH) and AFC are considered to be equally predictive of poor ovarian response; however, AMH is considered to have an advantage over AFC, because AMH concentrations can be measured at any time during the menstrual cycle.

DESIGN

Retrospective cohort study.

SETTING

Private IVF clinic.

PATIENT(S)

A total of 3,117 patients with a transvaginal ultrasound within 3 months before their first IVF cycle.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Receiver operating curves (ROCs) were constructed for AFC as a screening test for poor ovarian response (fewer than four eggs collected). The areas under the curve (AUCs) were compared for ROCs from patients at different phases of the cycle.

RESULT(S)

When all patients except those with polycystic ovaries were included, the AUC was 0.79. Further subgroup ROC analyses revealed that the AUCs did not differ significantly when AFC was measured at different phases of the menstrual cycle.

CONCLUSION(S)

AFC can be measured regardless of the phase of the menstrual cycle without apparent effect on its predictive value for poor ovarian response.

ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria

The definition presented here represents the first realistic attempt by the scientific community to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. POR to ovarian stimulation usually indicates a reduction in follicular response, resulting in a reduced number of retrieved oocytes. It has been recognized that, in order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. By definition, the term POR refers to the ovarian response, and therefore, one stimulated cycle is considered essential for the diagnosis of POR. However, patients of advanced age with an abnormal ORT may be classified as poor responders since both advanced age and an abnormal ORT may indicate reduced ovarian reserve and act as a surrogate of ovarian stimulation cycle outcome. In this case, the patients should be more properly defined as 'expected poor responder'. If this definition of POR is uniformly adapted as the 'minimal' criteria needed to select patients for future clinical trials, more homogeneous populations will be tested for any new protocols. Finally, by reducing bias caused by spurious POR definitions, it will be possible to compare results and to draw reliable conclusions.

Serum anti-Müllerian hormone level as a predictor of poor ovarian response in in vitro fertilization patients

Purpose

To evaluate the clinical value of day 3 serum anti-Müllerian hormone (AMH) compared with day 3 serum follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG) day estradiol (E2) levels and antral follicle count (AFC) in the prediction of poor ovarian response in controlled ovarian hyperstimulation (COH).

Methods

AMH, FSH and AFC on day 3 as well as hCG day E2 levels were determined in 164 subjects. Receiver operating curve analyses and area under curves (AUC) of the study parameters were performed. Predictive values of the levels of day 3 AMH, FSH, AFC, and hCG day E2 as clinical parameters of ovarian response to COH were studied.

Results

Thirty-eight women were defined as poor responders. The day 3 AMH and hCG day E2 levels and AFC of normal responders were significantly higher than those of the poor responders. In predicting poor response, the AUC of day 3 AMH level was significantly higher than that of day 3 FSH level but was similar to the hCG day E2 level. Day 3 AMH, FSH and hCG day E2 levels and AFC were found to predict a poor response. Day 3 AMH and hCG day E2 levels were more predictive compared with day 3 FSH level and AFC. The cut-off level of AMH was ≤2 with a sensitivity of 78.9% and a specificity of 73.8%.

Conclusion

Day 3 AMH has the ability to predict a poor response to COH and it is more predictive than day 3 FSH and AFC.

Age-specific nomogram for the decline in antral follicle count throughout the reproductive period

OBJECTIVE

To investigate the relationship between antral follicle count (AFC) and chronological age and to establish normal values for AFC in women with regular menstrual cycles.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENT(S)

Four hundred fifteen premenopausal women were recruited for the study. Data from 362 patients were available for the statistical analysis.

INTERVENTION(S)

AFC was measured by transvaginal ultrasound examination.

MAIN OUTCOME MEASURE(S)

Estimating the relationship between AFC and age and developing the AFC nomogram.

RESULT(S)

The analysis showed a linear decline in AFC with age; for every year increase in age, the median AFC decreases by 0.4. The AFC corresponding to the 5th, 25th, 50th, 75th, and 95th centiles for each age have been calculated.

CONCLUSION(S)

A linear relationship of AFC to age was found. For the first time, a nomogram reporting normal and interquartile values for AFC, age by age, throughout the reproductive period has been provided. Until now, the interpretation of the measurement was mainly based on the individual experience of the operator, because no normative data were present. Therefore, the establishment of a nomogram of AFC values is the first step to counsel patients on a scientific basis.

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.

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.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Long-term effects of uterine fibroid embolization on ovarian reserve: a prospective cohort study

OBJECTIVE

To determine whether uterine fibroid embolization may advance ovarian follicular depletion in reproductive-aged women with apparently normal baseline ovarian function.

DESIGN

Prospective cohort study.

SETTING

University tertiary care center.

PARTICIPANT(S)

Thirty-six patients aged 26 to 39 years with fibroids, regular menstrual cycles, and day 3 serum FSH levels<10 mIU/mL and 36 matched control women.

INTERVENTION(S)

Day 3 serum FSH and E2 levels and ultrasound-based antral follicle count and ovarian volume were determined before (baseline) and at 12, 24, 36, 48, and 60 months after embolization and compared with those of the control group. Menstrual status was determined annually on the basis of prospectively recorded menstrual calendars.

MAIN OUTCOME MEASURE(S)

Longitudinal changes in hormone levels, ultrasound measures, and bleeding patterns.

RESULT(S)

Although the FSH and E2 levels increased significantly and the antral follicle count and ovarian volume values declined significantly over time within the groups, no significant differences were found between the groups. The cycle remained regular in all but two women (one in the embolization group and one in the control group), who started having cycle irregularity after 24 months and 36 months follow-up, respectively.

CONCLUSION(S)

This long-term follow-up study suggests that fibroid embolization does not lead to an accelerated decline in ovarian reserve in younger patients.

Ultrasound tests of ovarian reserve; a systematic review of accuracy in predicting fertility outcomes

We conducted a systematic review of studies evaluating the diagnostic accuracy of all the ultrasound based tests of ovarian reserve, including antral follicle count (AFC), ovarian volume and stromal blood flow in predicting fertility outcomes and, where appropriate, performed a meta-analysis to determine the predictive_value at each cut-off value described in the literature. Included in the analysis were 17 studies for AFC, six studies for ovarian volume and six studies for stromal blood flow. Meta-analyses showed that women with AFC less than four were 8.7 times more likely not to get pregnant after IVF (two studies; 95% CI, 2.4-31.7) than women with AFC four or more. The sensitivity and specificity of AFC to predict cycle cancellation was 66.7% and 94.7%, respectively. Women with an AFC of less than four were 37 times (two studies; 95% CI, 13.68-100.45) more likely to have their cycle cancelled than women with AFC of four o r more. Ovarian volume measurement, at a cut off value of 3 cm3, showed specificity for prediction of cycle cancellation and non-pregnancy of 92% (three studies, 95% CI, 89-94) and 93% (three studies, 95% CI, 87-97), respectively. The clinical value of Doppler studies for ovarian stromal blood flow was unclear.

The effect of retrieved oocyte count on pregnancy outcomes in an assisted reproduction program

OBJECTIVE

To determine if women with less than five eggs retrieved do as well as women with more eggs retrieved in terms of pregnancy outcomes in our assisted reproduction program.

METHOD

Two hundred one women undergoing in vitro fertilization treatment at Fertility Unit in Royal Prince Alfred Hospital, University of Sydney, Australia were selected for retrospective evaluation. The women were grouped according to the number of oocytes retrieved at ovum pick-up. Group A consisted of women with less than 5 oocytes, group B with 5 to 10 oocytes and group C with 11 to 15 oocytes collected. Clinical and ongoing pregnancy rates were compared.

RESULTS

There was no difference between the groups in terms of clinical and ongoing pregnancy rates.

CONCLUSION

With good IVF lab conditions, if a patient reaches embryo transfer, the number of eggs retrieved should not affect the likelihood of pregnancy outcome in an assisted reproductive technology treatment.

Normal ovarian function and assessment of ovarian reserve in the survivor of childhood cancer

Increasingly young people survive cancer in childhood and as a result complications of its treatment are becoming more common and important. Premature ovarian failure is recognized as a complication of radiotherapy to a field that includes the pelvis and alkylating-agent-based chemotherapy. Young pre-pubertal girls are not protected from the effects of gonadal toxic therapy. A young woman, successfully treated for cancer during childhood, may experience regular periods in the presence of a significantly reduced ovarian reserve. There is, however, no reliable measure of ovarian reserve available for the individual woman. Assessment of ovarian function relies on the use of surrogate markers such as follicle stimulating hormone, inhibin-B, and anti-mullerian hormone as well as ultrasound assessment of ovarian volume and antral follicle count. We discuss the physiology of normal ovarian function, the effects of cancer treatments on ovarian function and the techniques for evaluation of ovarian reserve in survivors of childhood cancer.

The antral follicle count: practical recommendations for better standardization

OBJECTIVE

To provide recommendations for the standardized use of the Antral follicle count (AFC) which is used to predict ovarian response to gonadotrophin stimulation during assisted reproductive technology treatment. However, the nature of the follicles that are visualized by ultrasound and the competence of the oocytes held within are largely unknown. In addition, there is considerable variability in the clinical definitions and technical methods used to count and measure antral follicles in both published studies and clinical practice.

DESIGN AND SETTING

In December 2007, specialist reproductive medicine clinicians and scientists attended a workshop in an effort to address these issues. Literature concerning the physiology and measurement of ovarian antral follicles was reviewed, clinical and technical considerations regarding antral follicle measurement were discussed, and an operational definition of AFC was developed.

PATIENT(S)

None.

INTERVENTION(S)

None.

OUTCOME MEASURES

Simple recommendations were established for the standardization of AFC assessment in routine clinical practice. The basic clinical and technical requirements required for AFC evaluation were agreed upon, and a systematic method of measuring and counting antral follicles in routine practice was proposed.

CONCLUSION(S)

The use of a standardized approach according to the practical recommendations for antral follicle counting as presented is encouraged in future clinical trials and routine practice. The authors also advocate a systematic evaluation of these recommendations as standardized study data become available.

Prediction of high ovarian response to controlled ovarian hyperstimulation: anti-Müllerian hormone versus small antral follicle count (2-6 mm)

PURPOSE

To evaluate the predictive value of basal serum anti-müllerian hormone level and small antral follicle count for high ovarian response to controlled ovarian hyperstimulation.

METHODS

A total of 159 patients were prospectively included. Basal serum anti-müllerian hormone and small antral follicle count (2-6 mm) were measured.

RESULTS

Small antral follicle count and anti-müllerian hormone have similar predictive accuracy for high ovarian response with area under curve of 0.961 and 0.922, respectively. The sensitivity and specificity for prediction of high ovarian response were 89% and 92% for small antral follicle count and 93% and 78% for anti-müllerian hormone at the cutoff values of > or = 16 and > or = 34.5 pmol/l, respectively.

CONCLUSIONS

Small antral follicle count and anti-müllerian hormone are equally accurate predictors of high ovarian response and facilitate determination of the optimal strategy for controlled ovarian hyperstimulation.

Current status of the approach to assisted reproduction

Assisted reproductive technologies are important tools in the clinical armamentarium used to treat both female and male infertility disorders. Pre-implantation genetic diagnosis offers couples at risk of having children with inheritable disorders the ability to analyze the genetic make-up of embryos before transfer. For patients undergoing treatment of cancer with chemotherapy or radiation therapy, these technologies offer the potential for the preservation of future fertility. As technology evolves, it is likely the clinical applications of assisted reproduction will continue to develop and expand in the future to enhance fertility.

Individual ovarian volumes obtained from 2-dimensional and 3-dimensional ultrasound lack precision

Measuring ovarian volume has been suggested as a possible screening test to assess a woman's ovarian reserve. For such a screening tool to be clinically useful, knowledge of its precision and reproducibility is essential. Recent advances in ultrasound scanning techniques allow the measurement of volumes in three dimensions rather than the traditional estimation from two dimensions. Transvaginal 2-dimensional (2D) and 3-dimensional (3D) ultrasound examinations were performed on 49 women attending a tertiary centre for investigation or treatment for subfertility between January and May 2006. Two observers calculated ovarian volume using both 2D (prolate ellipsoid formula) and 3D techniques [virtual organ computer-aided analysis (VOCAL)] with rotation steps of 30 degrees (3D-30). For the four comparisons (inter- and intra-observer; 2D and 3D-30) intraclass coefficients of 0.97 to 0.98, and standard errors ranging from 17% to 14% (for inter-observer 2D and intra-observer 3D, respectively) were obtained. The corresponding coefficients of repeatability ranged from 33% to 28%. These results suggest that measurement of transvaginal ovarian volumes using both 2D and 3D ultrasound is imprecise for individuals. The imprecision is greater for lower ovarian volumes, which may be important in clinical practice. The average of two or more measurements is likely to be more accurate than a single measurement.

[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.

Is ovarian reserve diminished after laparoscopic ovarian drilling?

BACKGROUND

Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their use. However, the procedure, though effective, can be traumatic on the ovaries, which may cause postoperative adhesions and/or diminished ovarian reserve (DOR).

OBJECTIVE

To review the available literature, whether the LOD is harmful on the ovarian reserve markers.

SEARCH STRATEGY

A literature search was conducted using the keywords LOD, laparoscopic ovarian diathermy, PCOS, ovarian reserve, premature ovarian failure (POF). The MEDLINE and EMBASE databases and the Cochrane Database of Systematic Reviews were searched.

SELECTION CRITERIA

All trials, case reports and letters to the editor in the PubMed database were included.

DATA COLLECTION AND ANALYSIS

Along with the long-term clinical follow-up research articles, four that were specifically identifying the ovarian reserve tests were included in this review. Among these, three of them compared before and after LOD values, and one of them compared ovarian reserve markers among different groups of subjects; those with LOD, those with PCOS without LOD and those with normal ovulatory controls.

RESULTS

There were statistically significant differences between Day 3 FSH, inhibin B levels, ovarian volume and antral follicle count before and after LOD in some of the reports. Although the after LOD values were found to be lower than the before LOD values by means of ovarian reserve markers, the after values stayed higher than normal when compared with normal women without PCOS.

CONCLUSION

Although the available data in the literature is limited, there was no concrete evidence of a DOR or POF associated with LOD in women with PCOS. Most of the changes in the ovarian reserve markers observed after LOD could be interpreted as normalisation of ovarian function rather than a reduction of ovarian reserve. LOD, if applied properly, normalises the exaggerated ovarian morphologic and endocrinologic properties.

Variation in the ovarian reserve is linked to alterations in intrafollicular estradiol production and ovarian biomarkers of follicular differentiation and oocyte quality in cattle

The mechanisms whereby the high variation in numbers of morphologically healthy oocytes and follicles in ovaries (ovarian reserve) may have an impact onovarian function, oocyte quality, and fertility are poorly understood. The objective was to determine whether previously validated biomarkers for follicular differentiation and function, as well as oocyte quality differed between cattle with low versus a high antral follicle count (AFC). Ovaries were removed (n = 5 per group) near the beginning of the nonovulatory follicular wave, before follicles could be identified via ultrasonography as being dominant, from heifers with high versus a low AFC. The F1, F2, and F3 follicles were dissected and diameters determined. Follicular fluid and thecal, granulosal, and cumulus cells and the oocyte were isolated and subjected to biomarker analyses. Although the size and numerous biomarkers of differentiation, such as mRNAs for the gonadotropin receptors, were similar, intrafollicular concentrations of estradiol and the abundance of mRNAs for CYP19A1 in granulosal cells and ESR1, ESR2, and CTSB in cumulus cells were greater, whereas mRNAs for AMH in granulosal cells and TBC1D1 in thecal cells were lower for animals with low versus a high AFC during follicle waves. Hence, variation in the ovarian reserve may have an impact on follicular function and oocyte quality via alterations in intrafollicular estradiol production and expression of key genes involved in follicle-stimulating hormone action (AMH) and estradiol (CYP19A1) production by granulosal cells, function and survival of thecal cells (TBC1D1), responsiveness of cumulus cells to estradiol (ESR1, ESR2), and cumulus cell determinants of oocyte quality (CTSB).

Applications of estradiol and testosterone assays in the management of the infertile female patient

A collaborative effort to improve steroid hormone measurements in patient care was convened by the Centers for Disease Control in March 2008 to discuss the need for enhanced performance and standardization of clinical estradiol and testosterone assays. This article discusses the current status of estradiol and testosterone assays in the treatment of infertile women to include the assessment of ovarian reserve, ovulation induction and follicle tracking, ovarian hyperstimulation syndrome, and the role of testosterone in fertility management.

Antral follicle count (AFC) can be used in the prediction of ovarian response but cannot predict the oocyte/embryo quality or the in vitro fertilization outcome in an egg donation program

OBJECTIVE

To verify whether the antral follicle count (AFC) could predict ovarian response, oocyte/embryo quality, and IVF outcome.

DESIGN

Prospective study.

SETTING

Instituto Universitario-Instituto Valenciano de Infertilidad, Valencia, Spain.

PATIENT(S)

One thousand seventy-four donors and 975 oocyte recipient cycles.

INTERVENTION(S)

Controlled ovarian hyperstimulation (COH), endometrial preparation, IVF/intracytoplasmic sperm injection, ET.

MAIN OUTCOME MEASURE(S)

COH and oocyte/embryo quality parameters and IVF outcome.

RESULT(S)

We observed lower E(2) levels and fewer mature retrieved oocyte numbers among donors who showed an AFC that was <10. These donors also showed significantly higher cancellation and no-donation rates; poor and/or insufficient response was the principal cause (82%). However, there were no differences among the groups regarding embryo development parameters and IVF outcome.

CONCLUSION(S)

AFC is a noninvasive and simple tool that can improve the oocyte donor's selection of an egg donation program. This study suggests that AFC is a good predictor of ovarian response but cannot be used to predict oocyte/embryo quality or IVF outcome.