Day 5 inhibin B serum concentrations as predictors of assisted reproductive technology outcome in cycles stimulated with gonadotrophin-releasing hormone agonist-gonadotrophin treatment

Inhibin A-A Promising Predictive Parameter for Determination of Final Oocyte Maturation in Ovarian Stimulation for IVF/ICSI

The number of mature oocytes is a key factor in the success of Assisted Reproductive Techniques (ART). Exogenous gonadotropins are administered during ovarian stimulation in order to maximize the number of oocytes available for fertilization. During stimulation, monitoring is mandatory to evaluate individual response, to avoid treatment complications and assist in the determination of the optimal day for final oocyte maturation and oocyte retrieval. Routine monitoring during stimulation includes transvaginal ultrasound examinations and measurement of serum estradiol (E2). Due to multifollicular growth of follicles of varying size, serum E2 levels are commonly supraphysiological and often variable, rendering E2-measurement during ovarian stimulation unreliable as a determinant of oocyte maturity. In contrast to serum E2, serum Inhibin A levels increase once a minimum follicle size of 12-15 mm is achieved. Due to this fact, serum Inhibin A levels could present in combination with ultrasound monitoring a more reliable parameter to determine the optimal follicle size for final oocyte maturation, as only follicles with a size of 12 mm and beyond will contribute to the serum Inhibin A level. This prospective observational, cross-sectional study demonstrates, that on the day of final oocyte maturation serum Inhibin A is strongly correlated to the number of follicles ≥15 mm (0.72) and to the number of retrieved and mature oocytes (ρ 0.82/0.77, respectively), whereas serum E2 is moderately correlated to the parameters mentioned above (ρ 0.64/0.69/0.69, respectively). With an area under the curve (AUC) of 0.91 for Inhibin A, compared to an AUC of 0.84 for E2, Inhibin A can be regarded as a better predictor for the optimal timing of trigger medication with a threshold number of ≥10 mature oocytes. It can be concluded from this data that serum Inhibin A in combination with transvaginal ultrasound monitoring may be a more powerful tool in the decision making process on trigger timing as compared to E2.

Testing and interpreting measures of ovarian reserve: a committee opinion

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

Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up

OBJECTIVE

To investigate the effect of two laparoscopic techniques for treatment of ovarian endometriomas on recurrence rate.

DESIGN

Prospective randomized clinical trial.

SETTING

University teaching hospital.

PATIENT(S)

Ninety women with ovarian endometriomas.

INTERVENTION(S)

Patients were randomly selected to undergo either laparoscopic cystectomy (group 1) or laser vaporization (group 2) of ovarian endometrioma.

MAIN OUTCOME MEASURE(S)

Recurrence, evaluated by ultrasound scan examination, was assessed at 12 and 60 months of follow-up.

RESULT(S)

Endometrioma recurrence rate was higher, though not significantly different, in group 2 at 60 months of follow-up. Nevertheless, at 12 months of follow-up recurrences were statistically higher in group 2.

CONCLUSION(S)

The comparison between laparoscopic laser ablation and laparoscopic cystectomy for ovarian endometriomas after long-term follow-up showed earlier recurrences and a higher recurrence rate in the laser group, although at 5 years of follow-up there were no statistically significant differences.

Day-5 inhibin B serum concentrations and antral follicle count as predictors of ovarian response and live birth in assisted reproduction cycles stimulated with gonadotropin after pituitary suppression

OBJECTIVE

To investigate the usefulness of day-5 inhibin B and antral follicle count (AFC) in predicting ovarian response and live birth in the first cycle of assisted reproduction.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENT(S)

Ninety-eight infertile women treated with in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) comprising 72 normal responders and 26 poor responders.

INTERVENTION(S)

Ovarian stimulation with gonadotropin-releasing hormone agonist-gonadotropin treatment.

MAIN OUTCOME MEASURE(S)

Basal ultrasonographic (AFC, total ovarian volume) and basal (follicle-stimulating hormone, estradiol, and inhibin B) and stimulation day-5 (estradiol, inhibin B) hormone parameters.

RESULT(S)

The AFC had the best predictive value among the basal variables for outcome of ovarian stimulation. Among the dynamic hormone measurements, day-5 inhibin serum measurement emerged as the best predictive variable of poor response in IVF-ICSI cycles, but it was not statistically significantly better than basal AFC. The association of day-5 inhibin B with live-birth rate was statistically significant and stronger than the effect of any other variable investigated.

CONCLUSION(S)

Basal AFC and day-5 inhibin B have similar predictive properties for ovarian response in assisted reproduction cycles stimulated with gonadotropin after pituitary suppression, but day-5 inhibin B is a superior predictor of live birth.

Controlled clinical trial assessing the effect of laparoscopic uterine arterial occlusion on ovarian reserve

STUDY OBJECTIVE

To assess the effect on ovarian reserve function after laparoscopic uterine artery occlusion (LUAO) compared with laparoscopic surgery supracervical hysterectomy (LSH) and laparoscopic myomectomy (LM).

DESIGN

Prospective cohort study (Canadian Task Force classification II-1).

SETTING

Hospital with experience in gynecologic minimal access surgery.

PATIENTS

Ninety patients with uterine myomas operated on from August through December 2007.

INTERVENTION

Ninety patients were divided into 3 groups of 30 patients each: the study group underwent LUAO and myomectomy (LUAO-M), control group 1 underwent LSH, and control group 2 underwent LM only.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected before surgery and at 1, 3, and 6 months postoperatively. Concentrations of follicle-stimulating hormone (FSH), leuteinizing hormone (LH), and estradiol (EZ) were determined using an immunoassay, and serum inhibin B (INHB) concentration was evaluated using an enzyme-linked immunosorbent assay. No significant differences in preoperative hormone concentrations between the 3 groups were found (p>.05). In the LSH group, FSH, LH, and E2 concentrations were significantly increased, whereas the INHB concentration was significantly decreased at 1 month postoperatively (p<.05); after 3 months, only the INHB concentration was significantly decreased (p<.05). However, in the LOUA-M and LM groups, there were no significant differences between preoperative and postoperative hormone concentrations (p>.05). Serum concentrations of FSH, LH, and INHB in the LSH group were significantly different from those in the study group at 1 and 3 months postoperatively (p<.05); however, the differences in postoperative hormone concentrations between the study group and the LM group were not significant (p>.05).

CONCLUSION

At short-term follow-up, no significant effect on ovarian reserve in patients with myoma who underwent LUAO was found.

Dynamic measurements of serum inhibin B and estradiol: a predictive evaluation of ovarian response to gonadotrophin stimulation in the early stage of IVF treatment

OBJECTIVE

We dynamically measured serum inhibin B and estradiol in the early stage of hormonal stimulation to predict the ovarian response in in vitro fertilization (IVF) treatment.

METHODS

A total of 57 patients (<40 years of age) who underwent the first cycle of long protocol IVF or introcytoplasmic sperm injection (ICSI) treatment were included. Serum inhibin B, estradiol, follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured four times: (1) on Day 3 of the menstrual cycle (basal); (2) on the day before the first administration of gonadotrophin (Gn) (Day 0); (3) on Day 1 of Gn therapy; and (4) on Day 5 of Gn therapy. Comparisons of these measurements with ovarian responses and pregnancy outcomes were made and analyzed statistically.

RESULTS

(1) On Day 1 and Day 5 of recombinant FSH (rFSH) stimulation, ovarian response, i.e., numbers of follicles, oocytes, fertilized oocytes, and embryos, had a positive correlation (r(s)=0.46~0.61, P=0.000) with raised inhibin B and estradiol concentrations, but a negative correlation (r(s)=-0.67~-0.38, P=0.000 or P<0.01) with total rFSH dose and total days of rFSH stimulation. (2) No significant variation (P>0.05) between the pregnant and non-pregnant groups on the basis of mean age or on all hormone concentrations at four times of the IVF cycle was observed. However, all the seven patients aged >35 years did not reach pregnancy.

CONCLUSIONS

(1) Serum inhibin B and estradiol concentrations obtained shortly after Gn therapy may offer an accurate and early prediction of ovarian response; (2) Low levels of serum inhibin B and estradiol obtained shortly after Gn stimulation indicate the need for a longer period of Gn treatment and a higher daily dosage; (3) No obvious pregnancy difference among patients of age <35 years was found; however, IVF pregnancy outcome is significantly lower in women of age >35 years.

Functional AR signaling is evident in an in vitro mouse follicle culture bioassay that encompasses most stages of folliculogenesis

Androgens have distinct physiological functions within the ovary. The biological action of androgens is primarily exerted through transcriptional regulation by the nuclear androgen receptor (AR), but the molecular cascades governed by AR remain largely unknown. At present, there is imminent concern that environmental man-made chemicals with antiandrogenic properties, among others, are capable of modulating hormonal responses, thereby interfering with normal physiological processes that are critical to fertility. In the present study, we aimed to further characterize a standardized and reproducible follicle culture system in terms of AR expression during in vitro folliculogenesis to be able to use it as a bioassay to study effects of antiandrogens on follicular and oocyte growth, steroid secretion profile, and oocyte meiotic maturation capacity. Immunohistochemical analysis revealed that cytoplasmic AR protein was translocated to the nucleus of granulosa and theca cells in response to endogenous androgen production in theca cells during preantral follicular development. During the antral phase in vitro, AR was differentially expressed in mural and cumulus cells, implying an oocyte-mediated regulation. Treatment of follicles with hydroxyflutamide or bicalutamide, two model antiandrogenic compounds, resulted in reduced follicular growth during the preantral phase, altered steroidogenic environment, and arrest in oocyte meiotic maturation in response to human chorionic gonadotropin. Androgen receptor expression in the culture model corresponded well to what is described in vivo, and this system revealed several ovarian functions targeted by AR antagonists that can be further investigated using more in-depth molecular techniques.

[Premature ovarian failure: which protocols?]

This review shows the results of the various studies concerning the protocols applied to the women presenting a premature ovarian failure. Will be thus analyzed the natural cycles (or semi-natural), the increase in the dose of gonadotrophins, the clomiphene citrate and the anti-aromatases, the protocols with GnRH agonists long, short, stop or microdoses, the protocols with GnRH antagonists and the adjuvant treatments: aspirin, nitric oxyde, recombinant LH recombining, growth hormone and androgens. The interest of several protocols is to collect a sufficient number of oocytes (and thus of embryos to be transferred), making it possible to obtain reasonable rates of pregnancy. However, it arises that the rates of pregnancy observed among these women depend not only on their ovarian reserve and their age, but are also function of the type of infertility, of the cycle number and the uterus.

A systematic review of tests predicting ovarian reserve and IVF outcome

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

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

Leptin and inhibin B as predictors of reproductive recovery in patients with anorexia nervosa during weight gain

Introduction: Anorexia nervosa represents an eating disorder that is associated with substantial psychological, social and physiological abnormalities, involving 0.5-2% of female population. Objective: The secretion patterns of inhibin B, as marker of gonadal activity, and leptin, as an indicator of energy balance and body composition, were analyzed in our cross-sectional study in order to asses the restoration of reproductive function in patients with anorexia nervosa (AN) during gaining of normal weight. Method: The study included 20 patients with low weight AN (BMI 14.3?0.3 kg/mI), 22 partially recovered AN (BMI 17.4?0.1 kg/mI), and 29 gained regular weight, out of whom 16 had no restoration of menstrual cycle (BMI 19.5?0.1 kg/mI), and 13 had at least six consecutive menstrual cycles (BMI 19.3?1.0 kg/mI). Nineteen eumenorrheic females with BMI 19.8?0.4 kg/mI were the controls. Results: Significant correlation between leptin and inhibin B (?=0.446; p=0.000), leptin and delta LH (?=0.611; p<0.001), and inhibin B and delta LH (?=0.574; p<0.001) was found in patients with anorexia nervosa during weight gain. Leptin (p=0.0039), inhibin B (p=0.0173), LH (p=0.0323) and delta LH (p=0.0087) were important predictors of reproductive recovery in patients with anorexia nervosa during gaining of normal weight. Among aforementioned parameters, leptin (p=0.0057) appeared to be the most important. Conclusion: Leptin is the most important predictor of reproductive recovery in patients with anorexia nervosa during weight normalization. These findings suggest that decreased leptin levels may be responsible for several neuroendocrine abnormalities seen in anorexia nervosa. Thus, interventional studies involving administration of recombinant leptin are required to fully clarify the physiologic and potentially therapeutic role of leptin in anorexia nervosa.

Serum CA-125 levels in the second week after embryo transfer predict clinical pregnancy

OBJECTIVE

To correlate CA-125 concentrations in serum samples collected for routine hCG measurements 11 +/- 2 days after embryo transfer in relation to pregnancy and its outcome.

DESIGN

Retrospective study.

SETTING

University-based in vitro fertilization (IVF) program.

PATIENT(S)

One hundred and eighty-two consecutive pregnancies conceived after IVF or intracytoplasmic sperm injection, and 41 control cycles without pregnancy from the same patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Analysis of correlation between CA-125 concentrations and hCG and inhibin A levels. Predictive accuracy of these markers was compared by receiver-operating characteristic (ROC) analysis.

RESULT(S)

The CA-125 levels were statistically significantly higher in pregnant than in nonpregnant patients. Within pregnant cycles, CA-125 concentrations correlated positively with levels of hCG and inhibin A. The CA-125 levels were statistically significantly lower in preclinical abortions than in clinical pregnancies. No statistically significant difference was observed between early pregnancy losses and ongoing pregnancies or singleton and multiple pregnancies, respectively. The predictive accuracy of CA-125 measurements was statistically significantly lower than that achieved with hCG or inhibin A.

CONCLUSION(S)

Although CA-125 levels seem to be predictive of clinical pregnancy, they are not predictive of its outcome. Higher CA-125 concentrations may reflect higher endometrial receptivity but do not predict the number or viability of implanted embryos.

Antral follicle count in the prediction of poor ovarian response and pregnancy after in vitro fertilization: a meta-analysis and comparison with basal follicle-stimulating hormone level

OBJECTIVE

To assess the predictive performance of the antral follicle count (AFC) as a test for ovarian reserve in IVF patients and to compare this performance with that of basal FSH level.

DESIGN

Meta-analysis.

SETTING

Tertiary fertility center.

PATIENT(S)

Patients undergoing IVF.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Poor ovarian response, nonpregnancy.

RESULT(S)

We identified 11 studies on AFC and an updated total of 32 studies on basal FSH from the literature on the basis of preset criteria. The estimated summary receiver operating characteristic (ROC) curves showed AFC to perform well in the prediction of poor ovarian response. Also, prediction of poor ovarian response seemed to be more accurate with AFC compared with basal FSH. The estimated summary ROC curves for the prediction of nonpregnancy indicated a poor performance for both AFC and basal FSH.

CONCLUSION(S)

Transvaginal ultrasonography is an easy-to-perform and noninvasive method that provides essential predictive information on ovarian responsiveness. The predictive performance of AFC toward poor response is significantly better than that of basal FSH. Therefore, AFC might be considered the test of first choice in the assessment of ovarian reserve prior to IVF.

Use of serum inhibin B levels at the start of ovarian stimulation and at oocyte pickup in the prediction of assisted reproduction treatment outcome

OBJECTIVE

To assess whether serum inhibin B levels before gonadotropin administration and at oocyte pickup (OPU) are associated with pregnancy.

DESIGN

Retrospective case-control study.

SETTING

University-based IVF program.

PATIENT(S)

Fifty-five IVF pregnancies and 55 control cycles matched by age, type of infertility, E(2) at ovulation induction, number of oocytes retrieved, and number of embryos replaced.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Association between serum inhibin B at stimulation day 1 (SD1) and OPU and pregnancy; correlation between inhibin B with clinical and endocrine parameters; predictive accuracy of inhibin B measurements at OPU.

RESULT(S)

Inhibin B on SD1 was similar between pregnant and nonpregnant subjects, whereas it was significantly higher at OPU in pregnant cycles, but did not allow differentiation between pregnancy outcomes. Inhibin B on SD1 was positively correlated with same-day E(2) in both groups and inversely with age in pregnant cycles. In both groups, inhibin B at OPU correlated positively with number of oocytes collected and with E(2) at ovulation induction.

CONCLUSION(S)

Higher inhibin B concentrations at OPU are predictive of clinical pregnancy, independently of age, peak E(2), number of oocytes retrieved and number of embryos replaced. Inhibin B on stimulation day 1 did not prove to be a useful predictor.

Basal and stimulation day 5 anti-Mullerian hormone serum concentrations as predictors of ovarian response and pregnancy in assisted reproductive technology cycles stimulated with gonadotropin-releasing hormone agonist--gonadotropin treatment

BACKGROUND

Anti-Müllerian hormone (AMH) has been recently proposed as a marker for ovarian ageing and poor ovarian response to controlled ovarian hyperstimulation in assisted reproduction cycles. The present study was undertaken to investigate the usefulness of baseline cycle day 3 AMH levels and AMH serum concentrations obtained on the fifth day of gonadotropin therapy in predicting ovarian response and pregnancy in women undergoing ovarian stimulation with FSH under pituitary desensitization for assisted reproduction.

METHODS

A total of 80 women undergoing their first cycle of IVF/intracytoplasmic sperm injection (ICSI) treatment were studied. Twenty consecutive cycles which were cancelled because of a poor follicular response were initially selected. As a control group, 60 women were randomly selected from our assisted reproduction programme matching by race, age, body mass index, basal FSH and indication for IVF/ICSI to those in the cancelled group. For each cancelled patient, three IVF/ICSI women who met the matching criteria were included.

RESULTS

Basal and day 5 AMH serum concentrations were significantly lower in the cancelled than in the control group. Receiver-operating characteristic (ROC) analysis showed that the capacity of day 5 AMH in predicting the likelihood of cancellation in an assisted reproduction treatment programme was significantly higher than that for basal AMH measurement. However, the predictive capacity of day 5 AMH was not better than that provided by day 5 estradiol. In addition, neither basal nor day 5 AMH or estradiol measurements were useful in the prediction of pregnancy after assisted reproductive treatment.

CONCLUSIONS

AMH concentrations obtained early in the follicular phase during ovarian stimulation under pituitary suppression for assisted reproduction are better predictors of ovarian response than basal AMH measurements. However, AMH is not useful in the prediction of pregnancy. Definite clinical applicability of AMH determination as a marker of IVF outcome remains to be established.

Prognostic value of some ovarian reserve tests in poor responders

BACKGROUND

The objective of this study was to determine the prognostic value of the basal estradiol (E2) and inhibin-B levels, the antral follicle count (AFC), and the clomiphene citrate challenge test (CCCT) of ovarian response in controlled ovarian hyperstimulation (COH), in an outcome with normal follicle-stimulating hormone (FSH) concentration in the early follicular phase of the menstrual cycle.

METHODS

Fifty-two patients undergoing IVF treatment were included in the study. Blood samples were collected for assessment of basal E2, FSH, and inhibin-B levels. Transvaginal ultrasound of an unstimulated cycle was performed to determine the mean antral follicle count (AFC). Serum FSH concentration was measured again on day 10 for CCCT performance.

RESULTS

The mean values of women's age, and basal and day 10 FSH levels were significantly higher in cancelled cycles than in the control group, whereas basal inhibin-B and AFC were significantly higher in the latter. The mean basal E2 concentration was similar in both groups. The results from the logistic regression analysis show that CCCT (cut-off point FSH > 12.5 mIU/ml; AUCROC = 0.90) was a better single predictor of poor ovarian response than AFC (AUCROC = 0.85) and inhibin-B (AUCROC = 0.79) with a correct prediction for CCCT (86.5%), antral follicle count (84.6%), and for inhibin-B (82.7%).

CONCLUSIONS

In women with normal basal FSH level, the determination of E2 has no prognostic value for the outcome of poor responders. However, CCCT, AFC, and inhibin-B tests, when applied separately, produce good prognostic values. CCCT is the best single predictor of poor ovarian response, followed by antral follicle count and basal inhibin-B values. In spite of that, CCCT does not add significantly to the simpler AFC ultrasound test in the prediction of poor ovarian response.

Significance of inhibin in reproductive pathophysiology and current clinical applications

The human reproductive process is regulated by complex mechanisms that involve many organs, including the brain, gonads and endocrine system. It has been more than 70 years since the name 'inhibin' was used to describe a substance produced in the gonads that negatively regulates pituitary secretion. Inhibin B controls FSH secretion via a negative feedback mechanism. It is a glycoprotein hormone secreted by the Sertoli cells of the testis and granulosa and theca cells of the ovary. Serum inhibin B concentrations are positively related to testicular volume and sperm counts. Current understanding of inhibin physiology and pathology in the human suggests that inhibin B may be of importance as a marker of Sertoli cell function in men with infertility and as a prognostic indicator in women undergoing ovulation induction therapy. Inhibin concentrations are elevated in patients with granulosa cell tumours and in post-menopausal women with mucinous ovarian cancers. Immunoreactivity against the inhibin alpha-subunit was identified in all cases of adrenal cortical adenoma and carcinoma, and levels are suppressed in the malignant prostate disease. This article discusses the structure, regulation and clinical use of inhibin and other related substances.

Fertility in female cancer survivors: pathophysiology, preservation and the role of ovarian reserve testing

The improved long-term survival of adolescents and young women treated for cancer has resulted in an increased focus on the effects of chemotherapy on ovarian function and its preservation. These women may seek advice and treatment regarding their reproductive status, including ways of preserving their fertility and preventing a premature menopause--factors that can have a profound impact on their quality of life. This article comprehensively reviews ovarian reserve testing (ORT) in general. Special emphasis is placed on patients with cancer, including the pathophysiology of gonadal damage following chemotherapy, fertility preservation and the potential role of ORT. Baseline parameters of ovarian reserve [FSH LH, estradiol, inhibin B and anti-Mullerian hormone (AMH)] have not yet performed sufficiently well in predicting poor outcome in assisted reproduction, but biochemical markers of ovarian reserve appear to be better than chronological age. Inhibin B and AMH show potential for future use. Dynamic testing appears to show much promise, especially stimulated levels of inhibin B and estradiol. The most promising tests of ovarian reserve are the biophysical markers, where total antral follicle count was found to be most discriminatory followed by ovarian volume. Combination of biochemical, biophysical and clinical markers of ovarian reserve may also improve predictive capacity. However, there is a lack of data pertinent to ORT in cancer. As yet there is no single clinically useful test to predict ovarian reserve accurately. Patients with cancer represent a distinct cohort who have particular concerns about their future fertility and the possibility of a premature menopause, they can benefit greatly from knowledge of their functional ovarian reserve. Large, prospective, randomized, adequately controlled studies specific to different geographical areas are required in a control population of comparable reproductive age to determine the potential role of ORT in clinical practice.

Association of inhibin B serum levels with parameters of follicular response in a randomized controlled trial comparing gnRH agonist versus antagonist protocols for ovarian hyperstimulation

PURPOSE

To study the association of inhibin B with ovarian response to FSH stimulation, applying either GnRH agonist or antagonist.

METHODS

In a prospective randomized controlled trial, 46 patients undergoing COH received either triptorelin (group I, n = 15) or ganirelix (group II, n = 31). Parameters of follicular response and inhibin B serum levels were assessed.

RESULTS

Inhibin B before FSH stimulation was significantly lower in group I than group II. The FSH stimulation phase was significantly longer in group I than group II, and the total FSH dose was significantly higher with a comparable number of retrieved oocytes. Day 1 inhibin B in group I, but not group II, was significantly correlated with the number of large ovarian follicles and retrieved oocytes. In group II, but not group I, inhibin B on day 1 was inversely correlated with the daily and total FSH dose as well as FSH stimulation duration.

CONCLUSIONS

The association of inhibin B serum levels with parameters of follicular response in COH is different in patients assigned to GnRH agonist vs. antagonist treatment protocols.

Inhibins and adult ovarian function

Inhibin B is predominantly produced by early healthy antral follicles during the luteo-follicular transition of the menstrual cycle. High inhibin B concentrations during the early follicular phase are responsible for the decline in FSH serum levels closing the FSH window and assuring single dominant follicle selection in the human. Early follicular phase inhibin B levels decrease over time, reflecting the recruitment of a diminished cohort of follicles with ovarian ageing. Hence, inhibin B is a predictor of poor response in IVF. In patients with PCOS inhibin B levels (potentially representing the number of healthy, early antral follicles) may be associated with the severity of ovarian dysfunction and consequently may predict ovulation induction outcome. However, inhibin B levels are normal in most PCOS patients suggesting a normal number of healthy follicles despite an increase in overall follicle number. Recent findings indicate that initial inhibin B concentrations can not predict the outcome of ovulation induction by either clomiphene citrate or FSH. Finally, inhibin B levels decrease over time in PCOS.

[Inhibins, activins and anti-Müllerian hormone: structure, signalling pathways, roles and predictive value in reproductive medicine]

Anti-Müllerian hormone (AMH), inhibins and activins are members of the transforming growth factor (TGFbeta) superfamily and are known to have a variety of actions concerning reproduction, hormonogenesis, development processes and differentiation. Inhibins and activins are dimeric glycoproteins that are defined by their actions on the pituitary gonadotroph cells. AMH, inhibins and activins have a vast array of actions usually exerted through paracrine and endocrine mechanisms. The recent availability of specific inhibin assays has demonstrated that inhibin B is the relevant circulating inhibin form in the human male. Inhibin B seems to be a useful marker of spermatogenesis, but serum and seminal inhibin B levels are not predictive parameters for the selection of azoospermic men as candidates for testicular sperm extraction (TESE). AMH in seminal plasma may be important for sperm production, and is a good marker for sertoli cell development. It might be the only one seminal marker of spermatogenesis in non-obstructive azoospermia. Nevertheless, many of these studies were carried out with small patient numbers, and consequently must be interpreted with caution. In women ongoing assisted reproductive therapy (ART), day 3 inhibin B and AMH levels predict the number of oocytes retrieved, but cannot predict likelihood of pregnancy. Further studies are needed to determine if AMH and inhibin predict ART outcomes better than classical parameters (age, FSH levels and follicular ultrasonography). AMH and inhibin are also specific markers of Sertoli- and granulosa-cell origin in gonadal tumors.

Initial analysis of variability among basal hormone biomarkers of ovarian reserve

The most commonly used biomarker tests of ovarian reserve are basal hormone measurements during the early follicular phase, including mainly FSH but also oestradiol, FSH:LH ratio, and inhibin B. This study was designed to assess prospectively the intra- and inter-cycle variability of serum values of those hormone biomarkers in the early follicular phase of consecutive cycles in a group of women candidates for assisted reproduction. Fifty eumenorrhoeic women underwent blood sampling for hormone measurement on cycle day 3 for three consecutive cycles, and during the first study cycle, daily samples were obtained on cycle days 2, 3, 4 and 5. No significant difference was detected among FSH concentrations and FSH:LH ratios during cycle days 2-5; in contrast, oestradiol and inhibin B were not constant through the early follicular phase. No difference in FSH or inhibin B serum concentrations and FSH:LH ratio on cycle day 3 during three consecutive cycles was noted; however, significant inter-cycle variability for oestradiol serum concentration on cycle day 3 was detected. FSH and inhibin serum concentrations, and FSH:LH ratio varied significantly less than oestradiol on cycle day 3, but inter-cycle variability was similar for the first three hormonal biomarkers of ovarian reserve. There was significantly less intra-cycle variability of FSH serum concentration and FSH:LH ratio than oestradiol and inhibin B serum concentrations. Basal FSH serum concentrations (or FSH:LH ratio) during the early follicular phase showed neither significant inter-cycle nor intra-cycle variability when measured during 3 consecutive months in an assisted reproduction patient population, thus offering greater flexibility of pretreatment sampling.

Ovarian responses to recombinant FSH or HMG in normogonadotrophic women following pituitary desensitization by a depot GnRH agonist for assisted reproduction

At present, there is considerable debate about the utility of supplemental LH in assisted reproduction treatment. In order to explore this, the present authors used a depot gonadotrophin-releasing hormone agonist (GnRHa) protocol combined with recombinant human FSH (rhFSH) or human menopausal gonadotrophin (HMG) in patients undergoing intracytoplasmic sperm injection (ICSI). The response to either rhFSH (75 IU FSH/ampoule; group rhFSH, 25 patients) or HMG (75 IU FSH and 75 IU LH/ampoule; group HMG, 25 patients) was compared in normo-ovulatory women suppressed with a depot triptorelin injection and candidates for ICSI. A fixed regimen of 150 IU rhFSH or HMG was administered in the first 14 days of treatment. Treatment was monitored with transvaginal pelvic ultrasonographic scans and serum measurement of FSH, LH, oestradiol, androstenedione, testosterone, progesterone, inhibin A, inhibin B and human chorionic gonadotrophin (HCG) at 2-day intervals. Although oestradiol serum concentrations on the day of HCG injection were similar, both the duration of treatment and the per cycle gonadotrophin dose were lower in group HMG. In the initial 16 days of gonadotrophin treatment, the area under the curve (AUC) of LH, oestradiol, androstenedione and inhibin B were higher in group HMG; no differences were seen for the remaining hormones measured, including the inhibin B:inhibin A ratio. The dynamics of ovarian follicle development during gonadotrophin treatment were similar in both study groups, but there were more leading follicles (>17 mm in diameter) on the day of HCG injection in the rhFSH group. The number of oocytes, mature oocytes and good quality zygotes and embryos obtained were significantly increased in the rhFSH group. It is concluded that in IVF patients undergoing pituitary desensitization with a depot agonist preparation, supplemental LH may be required in terms of treatment duration and gonadotrophin consumption. However, both oocyte, embryo yield and quality were significantly higher with the use of rhFSH.

Pregnancy after administration of high dose recombinant human LH alone to support final stages of follicular maturation in a woman with long-standing hypogonadotrophic hypogonadism

Traditionally, the roles of LH in folliculogenesis have been considered to be limited to stimulating theca cells androgen production, triggering ovulation and supporting the corpus luteum. However, in the late stages of follicle development, granulosa cells become receptive to LH stimulation and LH becomes capable of exerting its actions on both theca cells and granulosa cells. Thus, it has been postulated that once an appropriate (i.e. LH-responsive) stage of follicular development has been achieved in response to treatment with FSH, there are theoretical grounds for reducing or completely withdrawing FSH and maintaining tonic stimulation of the dominant follicle with exogenous LH. This hypothesis was tested in a woman with long-standing hypogonadotrophic hypogonadism, which is the best and only true model to investigate correctly any LH hypothesis. Ovulation induction treatment was carried out with daily s.c. injections of 150 IU recombinant human FSH (rhFSH) (increased to 225 IU daily on stimulation day 15) and 375 IU recombinant human LH (rhLH). When a 14-mm follicle was identified on stimulation day 26, rhFSH was discontinued and from treatment days 26 to 29 the patient was given only rhLH at the above-mentioned dose of 375 IU/day. On treatment day 30, the single dominant follicle measured 22 mm in diameter and oestradiol serum concentration was 148 pg/ml. Thus, an injection of 10,000 IU i.m. human chorionic gonadotrophin was given and sexual intercourse was advised. The patient conceived and a viable singleton intrauterine pregnancy was obtained.

Optimal treatment for poor responders to ovarian stimulation: does in vitro insemination offer any advantages to intrauterine insemination?

A retrospective study was performed of 1832 consecutive in vitro insemination (IVF)/intracytoplasmic sperm injection (ICSI) cycles over 18 months, to analyse the benefits or otherwise to the patient of continuing with in vitro treatment or converting the assisted conception cycle to intrauterine insemination (IUI). Two hundred and seventy cycles were identified in which three follicles or fewer were obtained after controlled ovarian hyperstimulation; in 143 of these cycles, the clinicians or patients elected to abandon all treatment, whereas treatment was continued in 127 patients. In 79 cycles, the patients proceeded with IVF/ICSI and in 48 patients, the cycles were converted to IUI. Data were analysed with regard to the clinical pregnancy rate. In addition, the data for IUI were compared with eight cycles of supraovulation IUI (S/IUI) performed over the same period. There were no significant differences in clinical pregnancy rates among any treatment modality 6/48 (12.5%), 6/79 (7.7%) and 1/8 (12.5%) for IUI, IVF and S/IUI, respectively (P = 0.64). The lowest total number of motile spermatozoa required to achieve pregnancy using IUI was 2.0 x 10(6). In conclusion, it appears that, if the treatment is suitable, patients who respond poorly to controlled hyperstimulation for IVF would not be disadvantaged in achieving a pregnancy by offering them conversion to the medically and financially less interventional IUI.

Inhibin B on the day of HCG-administration is a predictive factor for failure in assisted reproduction cycles

MATERIALS AND METHODS

This retrospective study was carried out in order to assess the value of inhibin B as a predictive factor for the assisted reproduction-outcome. Inhibin B on the day of HCG-administration (ovulation induction) was measured in 15 pregnant and 16 non-pregnant patients (defined as positive serum-HCG) and compared by single and multiple logistic regression analysis with classical predictive factors such as estrogen and oocyte number. Both groups were similar with respect to age and cause of infertility.

RESULTS

While estrogen, FSH and LH at the HCG-day did not differ, inhibin B, the number of cumulus oocyte complexes and metaphase II -oocytes were statistically significantly different. In a single variable logistic model inhibin B, cumulus oocyte complexes and metaphase II oocytes showed significant correlation with pregnancy. When reassessed in a multiple variable logistic model only inhibin B maintained a considerable influence. Further inspection revealed, that the predictive inhibin B value at HCG-day <1200 pg/ml for failure of ART (assisted reproduction techniques) was 91%. Inhibin >1200 pg/ml showed 70% predictivity for pregnancy.

CONCLUSION

In comparison to classical parameters inhibin B at HCG-day seems to be the better prognostic factor for the outcome of ART. Inhibin B <1200 pg/ml seems to be highly predictive for failure of ART.

The physiology and pathophysiology of inhibin, activin and follistatin in female reproduction

In the last 2 years, major advances have been made in the understanding of inhibin physiology. Discovery of an inhibin receptor and binding protein has expanded our knowledge of the mechanism whereby inhibin antagonizes activin action. Controlled experimental studies have clarified the regulation and physiology of inhibin A and inhibin B, providing evidence for their use as markers of ovarian function. Clinical studies continue to uphold the use of inhibin as a marker for ovarian cancer, but have not generally supported its use over standard prognostic markers in assisted reproductive technologies. Finally, ongoing work suggests alterations in inhibin and follistatin that may be linked to the pathophysiology of polycystic ovary syndrome. Thus, the mechanism of inhibin action and its role in normal and abnormal ovarian function continues to emerge.

Day 5 inhibin B levels in a treatment cycle are predictive of IVF outcome

BACKGROUND

Day 5 serum inhibin B during IVF treatment has been investigated as a predictor of outcome.

METHODS

A total of 54 women (< or = 39 years, normal menses and endocrine profiles) were treated with urinary gonadotrophins or recombinant FSH following pituitary down-regulation. Serum day 3 FSH in a preceding cycle was <8.5 IU/l. Plasma inhibin B, inhibin A and estradiol were determined after 4 days of gonadotrophin administration (day 5).

RESULTS

Day 5 inhibin B was the most highly correlated with the number of mature follicles (>14 mm), oocytes retrieved and fertilized. Receiver operating characteristic analysis gave high accuracy for day 5 inhibin B in predicting ovarian response and indicated that a threshold of 400 pg/ml may be helpful in the decision as to whether to continue treatment. Women with <400 pg/ml (n = 16) had lower numbers of follicles, mature follicles, oocytes retrieved, fertilized and cleaved compared with those >400 pg/ml (n = 36) and this threshold gave a positive likelihood ratio of 30, 92.9% sensitivity, 95.0% specificity and 86.7% positive predictive value to detect poor ovarian response. Day 5 inhibin B was the best predictor of pregnancy (no live births and four cycles cancelled, low inhibin group; nine live births and no cancelled cycles, high inhibin group).

CONCLUSIONS

Normogonadotrophic, normogonadal women with day 5 inhibin B <400 pg/ml in down-regulated cycles have a poor response to ovarian stimulation and are less likely to conceive compared with women with higher day 5 inhibin B.

[Comparison of predictive values of inhibins A and B, and plasma estradiol in IVF patients treated with GnRH agonists and recombinant FSH]

The objectives of this study were to determine the mean plasma inhibin A and B kinetics in normoovulatory patients treated by GnRH agonist and rec-FSH and to compare their predictive value with that of plasma estradiol on retrieved oocytes number and pregnancy rate. The study was carried out retrospectively in 36 normoovulatory IVF patients stimulated by GnRH agonist from D21 and rec-FSH from D2 of the following cycle. Two groups of 18 patients (having obtained or not a pregnancy) were paired for age and cause of infertility. Estradiol was measured by direct immunoassay. Inhibin A and B were measured by ELISA (Serotec Limited, Oxford, UK). Inhibin A was correlated with estradiol until P-2 (P0: day of follicles aspiration). Inhibin B rose earlier, its concentration reached its maximum at P-5. Plasma estradiol and inhibin A kinetics were not different among pregnant and nonpregnant women. There was a trend for a broader plasma Inhibin B surface under the curve in pregnant than in nonpregnant women. Estradiol and Inhibin A were correlated to the oocytes number at the end of stimulation (P-2 and D10). Inhibin B was correlated earlier than estradiol and inhibin A, at P-8 and D7. Plasma inhibin A did not demonstrate a better predictive value than estradiol neither of the oocytes number nor the chance of pregnancy. Inhibin B could be useful for early decision of cycle cancellation or stimulation adjustment.