Serum anti-Mullerian hormone levels affect the rate of ongoing pregnancy after in vitro fertilization

[Pharmacological profile, clinical efficacy, and safety of Follitropin Delta produced by recombinant DNA technology in a human cell line (REKOVELLE® PEN for S.C. Injection 12 μg, 36 μg, 72 μg)]

Follitropin Delta (Rekovellle Subcutaneous Injection 12 μg/ 36 μg/72 μg Pen) is a recombinant human follicle-stimulating hormone (rFSH) developed by Ferring Pharmaceuticals Co., Ltd. Because human follicle-stimulating hormone (FSH) gene is incorporated into a human-derived cell line (human embryonic retinoblastoma: PER.C6), the Follitropin Delta is produced with having α2.3 and α2.6 linked sialic acid sugar chain which is similar to natural human FSH. Containing these two types of sialic acids linkage, similar blood dynamics with natural FSH can be expected due to the reduction of hepatic clearance. Furthermore, an individual dose algorithm defined by patient blood anti-Müllerian hormone (AMH) level and body weight can be expected to obtain optimal follicle development and reduce the safety risk. In the phase II studies, efficacy and safety of Follitropin Delta are confirmed in a dose-dependent manner, and it is confirmed the individualized dose algorism for non-Japanese is also applicable for Japanese women by the population pharmacokinetic/pharmacodynamic analysis. In the phase III studies the non-inferiority of Follitropin Delta to Follitropin Alfa or Beta is confirmed in ongoing pregnancy rate and the number of oocytes retrievable. In addition, the number of subjects who developed total ovarian hyperstimulation syndrome and/or who underwent prophylactic intervention in the Follitropin Delta was significantly lower than comparators. In conclusion, the clinical benefits of individualized doses of Follitropin Delta were confirmed in infertile women undergoing controlled ovarian stimulation (COS) in assisted reproductive technology (ART), and we propose that Follitropin Delta may provide new options to patients and real clinical settings.

Anti-Müllerian hormone as a predictor of pregnancy in women under 35 years with unexplained infertility undergoing ICSI: a retrospective study

BACKGROUND

Anti-Müllerian hormone (AMH) is a well-established marker for the determination of ovarian reserve. However, its role in the prediction of pregnancy is still under debate. In this retrospective study, we aimed to evaluate the relationship of serum AMH levels with pregnancy rates in patients with unexplained infertility undergoing ICSI. Moreover, we compared the predictive value of AMH with that of antral follicle count (AFC).

METHODS

Records of 76 patients under 35 years of age with AMH levels between 1 and 3.5 ng/ml were examined retrospectively. Participants were divided into groups based on their AMH level and age.

RESULTS

AMH levels in women under 30 years were found significantly higher than those in women over 30 years (P=0.033). 57 of 76 patients (75%) were pregnant. Age did not have a significant effect on the pregnancy rates in the selected study group (P=0.252). On the other hand, despite the poor predictive accuracy, serum AMH was shown to have a predictive value with a cut-off point of 1.95 ng/mL. Logistic regression tests demonstrated a higher pregnancy rate (3.396 fold) with an AMH level 1.95 or above. There was no significant relationship between AFC and pregnancy.

CONCLUSIONS

AMH might have a role in the prediction of pregnancy after ICSI in patients under 35 years with unexplained infertility.

AMH has no role in predicting oocyte quality in women with advanced age undergoing IVF/ICSI cycles

It has been widely acknowledged that anti-Müllerian hormone (AMH) is a golden marker of ovarian reserve. Declined ovarian reserve (DOR), based on experience from reproductive-aged women, refers to both the quantitative and qualitative reduction in oocytes. This view is challenged by a recent study clearly showing that the quality of oocytes is similar in young women undergoing IVF cycles irrespective of the level of AMH. However, it remains elusive whether AMH indicates oocyte quality in women with advanced age (WAA). The aim of this study was to investigate this issue. In the present study, we retrospectively analysed the data generated from a total of 492 IVF/ICSI cycles (from January 2017 to July 2020), and these IVF/ICSI cycles contributed 292 embryo transfer (ET) cycles (from June 2017 to September 2019, data of day 3 ET were included for analysis) in our reproductive centre. Based on the level of AMH, all patients (= > 37 years old) were divided into 2 groups: the AMH high (H) group and the AMH low (L) group. The parameters of in vitro embryo development and clinical outcomes were compared between the two groups. The results showed that women in the L group experienced severe DOR, as demonstrated by a higher rate of primary diagnosis of DOR, lower antral follicle count (AFC), higher level of basal follicle stimulating hormone (FSH) and cancelation cycles, lower level of E2 production on the day of surge, and fewer oocytes and MII oocytes retrieved. Compared with women in the H group, women in the L group showed slightly reduced top embryo formation rate but a similar normal fertilization rate and blastocyst formation rate. More importantly, we found that the rates of implantation, spontaneous miscarriage and livebirth were similar between the two groups, while the pregnancy rate was significantly reduced in the L group compared with the H group. Further analysis indicated that the higher pregnancy rate of women in the H group may be due to more top embryos transferred per cycle. Due to an extremely low implantation potential for transfer of non-top embryos from WAA (= > 37 years old) in our reproductive centre, we assumed that all the embryos that implanted may result from the transfer of top embryos. Based on this observation, we found that the ratio of embryos that successfully implanted or eventually led to a livebirth to top embryos transferred was similar between the H and the L groups. Furthermore, women with clinical pregnancy or livebirth in the H or L group did not show a higher level of serum AMH but were younger than women with non-pregnancy or non-livebirth. Taken together, this study showed that AMH had a limited role in predicting in vitro embryo developmental potential and had no role in predicting the in vivo embryo developmental potential, suggesting that in WAA, AMH should not be used as a marker of oocyte quality. This study supports the view that the accumulation of top embryos via multiple oocyte retrieval times is a good strategy for the treatment of WAA.

The influence of age, body mass index, waist-to-hip ratio and anti-Mullerian hormone level on clinical pregnancy rates in ART

The aim of this study was to estimate the influence of age, body mass index, waist-to-hip ratio and anti-Mullerian hormone levels on clinical pregnancies in assisted reproduction technologies (ART). We used the database of the fertility clinic both the in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) units. A total of 1134 treatment cycles from 2013 through 2015 were analyzed. We evaluated clinical pregnancy rate in terms of age, body mass index, waist-to-hip ratio, anti-Mullerian hormone level. The clinical pregnancy rate was 39.9%. The live birth rate was 25.5%. Women who conceived where statistically significantly younger and had lower body mass index. No statistical differences across pregnancy groups were found for waist-to-hip ratio, and anti-Mullerian hormone levels. Low AMH levels do not influence pregnancy rates in younger patients (<36 years).

Anti-Müllerian hormone levels as a predictor of clinical pregnancy in in vitro fertilization/intracytoplasmic sperm injection-embryo transfer cycles in patients over 40 years of age

Objective

The aim of the current study was to determine the predictive value of anti-Müllerian hormone (AMH) levels for pregnancy outcomes in patients over 40 years of age who underwent in vitro fertilization or intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) cycles.

Methods

We retrospectively analyzed the medical records of 188 women aged 40 to 44 years who underwent IVF/ICSI-fresh ET cycles due to unexplained infertility in the fertility center of CHA Gangnam Medical Center. Patients were divided into group A, with AMH levels <1.0 ng/mL (n=97), and group B, with AMH levels ≥1.0 ng/mL (n=91). We compared the clinical pregnancy rate (CPR) in the two groups and performed logistic regression analysis to identify factors that had a significant effect on the CPR.

Results

The CPR was significantly lower in group A than group B (7.2% vs. 24.2%, p<0.001). In multivariate logistic regression analysis, AMH levels were the only factor that had a significant impact on the CPR (odds ratio, 1.510; 95% confidence interval, 1.172-1.947). The area under the receiver operating characteristic curve for AMH levels as a predictor of the CPR was 0.721. When the cut-off level of AMH was set at 1.90 ng/mL, the CPR was 6.731-fold higher in the group with AMH levels ≥1.90 ng/mL than in the group with AMH levels <1.90 ng/mL (p<0.001).

Conclusion

Our study showed that AMH levels were predictive of clinical pregnancy in infertility patients over 40 years of age. Further prospective studies should be conducted to validate the predictive capability of AMH levels for the outcome of clinical pregnancy.

Mitochondrial SIRT5 is present in follicular cells and is altered by reduced ovarian reserve and advanced maternal age

Women with reduced ovarian reserve or advanced maternal age have an altered metabolic follicular microenvironment. As sirtuin 5 (SIRT5) senses cellular metabolic state and post-translationally alters protein function, its activity may directly impact on oocyte viability and pregnancy outcome. Therefore, we investigated the role of SIRT5 in relation to ovarian reserve and maternal age. Women (n=47) undergoing routine IVF treatment were recruited and allocated to one of three cohorts based on ovarian reserve and maternal age. Surplus follicular fluid, granulosa and cumulus cells were collected. SIRT5 mRNA, protein and protein activity was confirmed in granulosa and cumulus cells via qPCR, immunohistochemistry, western blotting and desuccinylation activity. The presence of carbamoyl phosphate synthase I (CPS1), a target of SIRT5, was investigated by immunohistochemistry and follicular-fluid ammonium concentrations determined via microfluorometry. Women with reduced ovarian reserve or advanced maternal age had decreased SIRT5 mRNA, protein and desuccinylation activity in granulosa and cumulus cells resulting in an accumulation of follicular-fluid ammonium, presumably via alterations in activity of a SIRT5 target, CPS1, which was present in granulosa and cumulus cells. This suggests a role for SIRT5 in influencing oocyte quality and IVF outcomes.

Effects of anti-Müllerian hormone and follicle stimulating hormone levels on in vitro fertilization pregnancy rate

OBJECTIVES

To analyze the relationship between in vitro fertilization (IVF) pregnancy rate and basal serum hormone levels before patients begin an IVF course.

MATERIALS AND METHODS

In this retrospective study, we analyzed patients with anti-Müllerian hormone (AMH) data and IVF data from January 2009 to October 2012. Pregnancy rates were calculated by AMH and follicle stimulating hormone quartiles and analyzed using the independent samples t test. Furthermore, patients were divided into three groups by age. The Chi-square test was used to assess the association between the parameters and IVF pregnancy rates.

RESULTS

From the 910 IVF treatment courses, 377 (41.4%) clinical pregnancies resulted. The pregnant and nonpregnant groups differed significantly in age and FSH and AMH levels. The pregnancy rate was 53.3% for patients aged <32 years and 22.1% for patients aged >38 years. The pregnancy rate was 53.4% for patients with FSH levels <5.6 mIU/mL and 25.8% for patients with FSH levels >8.9 mIU/mL. The pregnancy rate was 56.8% for patients with AMH levels >4.0 ng/mL and 20.0% for patients with AMH levels <1.1 ng/mL. Furthermore, among patients aged <40 years, AMH and FSH were significantly associated with pregnancy rate. Higher pregnancy rates were found among the groups with higher AMH levels than in groups with lower AMH levels.

CONCLUSION

For patients aged <40 years, basal serum AMH level and FSH level affected the IVF pregnancy rate, and patients with higher AMH levels had better pregnancy rates.

Continuous high-dose estrogen controls serum FSH and LH levels: new treatment strategy for extremely low ovarian reserve patients, two case reports

At present, there are no proven therapies to improve ovarian function in women with premature ovarian insufficiency (POI) or in those with extremely low ovarian reserve (LOR). We report successful IVF outcomes achieved with continuous high-dose estrogen supplementation in patients with LOR. Patients were 33- and 42-year-old nulligravidae with high-serum FSH (over 30 IU/L) and undetectable serum AMH (under 0.1 ng/mL) levels; however, neither patient fulfilled the diagnostic criteria for POI. After cycle cancellation and unsuccessful IVF treatment, both patients received conjugated estrogen (CE) supplementation (2.5-3.75 mg/day) from day 2 of their menstrual cycle to the day of HCG administration in their IVF treatment cycles. Following continuous high-dose estrogen supplementation, oocytes were successfully retrieved from both patients and fertilized. Both patients also achieved ongoing pregnancy through frozen-thawed embryo transfer cycles. In conclusion, high-dose estrogen supplementation down-regulated serum FSH and LH within their physiological ranges, which led to functional follicle growth and prevented early luteinization. Further studies will be needed to confirm the effect of this treatment on POI patients and to establish a new and individualized protocol for LOR patients.

Mitochondrial SIRT3 and its target glutamate dehydrogenase are altered in follicular cells of women with reduced ovarian reserve or advanced maternal age

STUDY QUESTION

Is the activity of sirtuin 3 (SIRT3) altered in granulosa and cumulus cells from young women with reduced ovarian reserve or women of advanced maternal age?

SUMMARY ANSWER

SIRT3 mRNA and active protein in granulosa and cumulus cells were decreased in women with reduced ovarian reserve and advanced maternal age.

WHAT IS KNOWN ALREADY

Young women with reduced ovarian reserve or women of advanced maternal age have reduced oocyte viability, possibly due to altered granulosa and cumulus cell metabolism. The mitochondrial SIRT3 protein may be implicated in these processes as it is able to sense the metabolic state of the cell and alter mitochondrial protein function post-translationally.

STUDY DESIGN, SIZE, DURATION

This is a prospective cohort study, in which women (n = 72) undergoing routine IVF/ICSI were recruited and allocated to one of three cohorts based on age and ovarian reserve (as assessed by serum anti-Mullerian hormone level). Women were classified as young (≤35 years) or of advanced maternal age (≥40 years).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Granulosa and cumulus cells were collected. SIRT3 mRNA and protein levels and protein activity was analysed in granulosa and cumulus cells via quantitative PCR, immunohistochemistry and western blotting, and deacetylation activity, respectively. Activity of the glutamate dehydrogenase (GDH) enzyme, a known target of SIRT3, was assessed, and acetylated proteins in mitochondria isolated from granulosa and cumulus cells were separated by immunoprecipitation and acetylation of GDH assessed by western blotting. Data for women with good prognosis (young women with normal ovarian reserve) were compared with those from young women with reduced ovarian reserve and those of advanced maternal age.

MAIN RESULTS AND THE ROLE OF CHANCE

SIRT3 mRNA and active protein were present in granulosa and cumulus cells and co-localized to the mitochondria. SIRT3 mRNA in granulosa cells was decreased in young women with reduced ovarian reserve and advanced maternal age versus young women with normal ovarian reserve (P < 0.05). SIRT3 mRNA in cumulus cells was decreased in women of advanced maternal age versus young women with normal ovarian reserve only (P < 0.05). Granulosa cell GDH activity was decreased in young women with reduced ovarian reserve and in women of advanced maternal age (P < 0.05), whereas cumulus cell GDH activity was reduced in the advanced maternal age group only (P < 0.05). The acetylation profile of GDH in mitochondria revealed increased acetylation of GDH in granulosa and cumulus cells from women of advanced maternal age (P < 0.05) while young women with reduced ovarian reserve had increased GDH acetylation in granulosa cells only (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Although patients were allocated to groups based on maternal age and ovarian reserve and matched for BMI, other maternal factors may also alter the 'molecular health' of ovarian cells.

WIDER IMPLICATIONS OF THE FINDINGS

Our data suggest that SIRT3 post-translational modification of mitochondrial enzymes in human granulosa and cumulus cells may regulate GDH activity, thus altering the metabolic milieu surrounding the developing oocyte. Owing to the association between the decline in oocyte quality and pregnancy rates in women of advanced maternal age and the possible association with reduced ovarian reserve, knowledge of perturbed SIRT3 function in granulosa and cumulus cells may lead to novel therapies to improve mitochondrial metabolism in the oocyte and follicular cells in women undergoing IVF treatment.

STUDY FUNDING/COMPETING INTEREST(S)

No conflicts of interest to declare. Research was funded by an NHMRC project grant.

The predictive accuracy of anti-Müllerian hormone for live birth after assisted conception: a systematic review and meta-analysis of the literature

BACKGROUND

Anti-Müllerian hormone (AMH) is an established marker of ovarian reserve and a good predictor of poor or excessive ovarian response after controlled hyperstimulation. However, it is unclear whether it can predict the ultimate outcome of assisted conception, live birth. We undertook a systematic review and meta-analysis to examine whether AMH is a predictor of live birth in women undergoing assisted conception.

METHODS

The study was conducted according to the PRISMA guidelines. PubMed, Embase, Medline, Web of Knowledge and the Cochrane trial register and unpublished literature were searched. Studies fulfilling the eligibility criteria were included in the systematic review and those with extractable data were included in the meta-analysis. Quality assessment was performed with the QUADAS 2 checklist. A summary estimate of diagnostic odds ratio (DOR) was derived using the random effects model for binary data. A hierarchical summary receiver operating characteristic model provided pooled estimates before and after adjusting for age and AMH assay as covariates.

RESULTS

Out of 361 non-duplicate studies, 47 were selected; 17 met the eligibility criteria and 13 had extractable data and thus were included in the meta-analysis. Three out of the 13 studies included only women with expected low ovarian reserve and were analysed individually from the remaining 10 to minimize heterogeneity. The DOR for women with unknown ovarian reserve (n = 5764 women) was 2.39 (95% confidence interval (CI): 1.85-3.08). After adjustment for age the DOR was little changed at 2.48 (95% CI: 1.81-3.22) and the DOR adjusted for AMH assay was almost identical at 2.42 (95% CI: 1.86-3.14). For women with expected low ovarian reserve (n = 542 women) the DOR was 4.63 (95% CI: 2.75-7.81).

CONCLUSIONS

AMH, independently of age, has some association with predicting live birth after assisted conception and may be helpful when counselling couples before undergoing fertility treatment. However, its predictive accuracy is poor.

Dehydroepiandrosterone supplementation improves predictive markers for diminished ovarian reserve: serum AMH, inhibin B and antral follicle count

OBJECTIVE

To evaluate the effect of dehydroepiandrosterone (DHEA) supplementation on ovarian reserve by measuring markers such as antral follicle count, serum anti-Müllerian hormone (AMH) and inhibin B in patients with diminished ovarian reserve.

STUDY DESIGN

This prospective study was undertaken at Dr. Zekai Tahir Burak Women's Health Research and Education Hospital, Ankara, Turkey. Forty-one patients with diminished ovarian reserve were included in the study and received supplementation with DHEA 25mg, t.i.d., for at least 6 weeks. Serum AMH, inhibin B, follicle-stimulating hormone (FSH) and oestradiol, and antral follicle count were determined before and after DHEA supplementation. Baseline ovarian reserve parameters such as antral follicle count, FSH, oestradiol, AMH, inhibin B, clinical and laboratory IVF outcomes, and pregnancy rates were studied.

RESULTS

There were significant differences in day 3 FSH, oestradiol, antral follicle count, AMH and inhibin B levels before and after DHEA supplementation in all patients (p=0.001, 0.001, 0.002, 0.001 and 0.001, respectively). The study population was divided into two age groups (<35 and ≥35 years) to determine whether there was a difference in the effect of DHEA supplementation between younger and older patients with diminished ovarian reserve. Significant differences were found in all of the parameters in both study groups (p<0.05).

CONCLUSIONS

DHEA supplementation is an effective option for patients with diminished ovarian reserve. Prior to assisted reproductive technology, patients with diminished ovarian reserve should be offered DHEA supplementation as an alternative to oocyte donation.

The predictive value of anti-Mullerian hormone on embryo quality, blastocyst development, and pregnancy rate following in vitro fertilization-embryo transfer (IVF-ET)

PURPOSE

The objective of this study was to investigate the predictive value of anti-Mullerian hormone (AMH) on fertilization rate (FR), blastocyst development, embryo quality, the outcome of the pregnancy and the live birth rate (LBR) following in vitro fertilization-embryo transfer (IVF-ET)/intracytoplasmic sperm injection (ICSI).

METHOD

In this prospective study outcomes were followed in 83 women undergoing cycles of IVF/ICSI within a university hospital. Basal serum AMH, follicle stimulating hormone (FSH), luteinizing hormone (LH) and antral follicle count (AFC) were measured on Day 3. Serum AMH (Gn6 AMH ) level was measured on Day 6 after the administration of gonadotrophin (Gn). AMH was measured in follicle fluid (FF AMH) on the day of ovum pick-up (dOPU). The numbers of retrieved and fertilized oocytes, good quality embryos and blastocysts were counted. Secondary outcome variables included clinical pregnancy rate (CPR) and LBR.

RESULTS

Spearman correlation analysis indicated that the numbers of oocytes, good quality embryos and blastocysts were associated with AMH (P < 0.05) and that LBR was correlated with FF AMH (r = 0.495, P < 0.05). No associations were found between FR and AMH (P > 0.05). Receiver operating characteristic analysis showed that the sensitivity of FF AMH at predicting CPR was 91.2%; the specificity was 86.5% and ROC(AUC) was 0.893 (P < 0.0001).

CONCLUSION

AMH parameters were correlated with good quality embryos and blastocysts, but only FF AMH showed a significant correlation with LBR and CPR.

Evaluation of ovarian reserve in infertile patients

Diminished ovarian reserve is a more common occurrence as more women postpone childbearing in modern societies due to social and demographic trends. Diminished ovarian reserve is one of the primary reasons for poor ART outcome. Due to high costs, side effects and heavy burden on patients on ART treatments, patient selection and counseling for prognosis is an important aspect before starting ART. Proper prediction of ovarian reserve before initiation of the treatment can decrease cycle cancellations, help clinicians to establish alternative treatment options (i.e.oocyte donation) for poor prognosis patients. However, indicators of ovarian reserve are not fully successful in predicting the outcome of the treatment. In this review, our aim was to discuss the efficacy of ovarian reserve tests on predicting poor ovarian response and treatment outcome in ART patients.