Ten years of in vitro fertilization in Indonesia: Access to infertility care in a developing country

OBJECTIVE

This research was conducted to assess access to assisted reproductive technologies (ART) and the current status of the in vitro fertilization (IVF) program that have been implemented in Indonesia over the last 10 years.

METHODS

We established a retrospective cohort study and descriptive analysis of the current state of access to infertility care in Indonesia. The data were collected from all IVF centers, clinics, and hospitals in Indonesia from 2011 to 2020, including the number of IVF clinics, total ART cycles, retrieved fresh and frozen embryos, average age of IVF patients, IVF pregnancy rate, and causes of infertility.

RESULTS

The number of reported fertility clinics in Indonesia has increased from 14 clinics in 2011 to 41 clinics by 2020. As many as 69 569 ART cycles were conducted over the past 10 years, of which 51 892 cycles used fresh embryos and 17 677 cycles used frozen embryos. The leading cause of consecutive infertility diagnosis was male infertility. Nearly half of the women who underwent IVF procedures (48.9%) were under 35 years old. The pregnancy rate outcome of women who underwent IVF ranged from 24.6% to 37.3%.

CONCLUSION

Developments in ART in Indonesia have led to improvements in the ART cycles performed throughout the 10 year period. The identification of key areas that require improvement can provide an opportunity to enhance access to infertility care.

Embryo ploidy status classification through computer-assisted morphology assessment

BACKGROUND

Preimplantation genetic testing for aneuploidy has been proven to be effective in determining the embryo's chromosomal or ploidy status. The test requires a biopsy of embryonic cells on day 3, 5, or 6 from which complete information on the chromosomes would be obtained. The main drawbacks of preimplantation genetic testing for aneuploidy include its relatively invasive approach and the lack of research studies on the long-term effects of preimplantation genetic testing for aneuploidy.

OBJECTIVE

Computer-assisted predictive modeling through machine learning and deep learning algorithms has been proposed to minimize the use of invasive preimplantation genetic testing for aneuploidy. The capability to predict morphologic characteristics of embryo ploidy status creates a meaningful support system for decision-making before further treatment.

STUDY DESIGN

Image processing is a component in developing a predictive model specialized in image classification through which a model is able to differentiate images based on unique features. Image processing is obtained through image augmentation to capture segmented embryos and perform feature extraction. Furthermore, multiple machine learning and deep learning algorithms were used to create prediction-based modeling, and all of the prediction models undergo similar model performance assessments to determine the best model prediction algorithm.

RESULTS

An efficient artificial intelligence model that can predict embryo ploidy status was developed using image processing through a histogram of oriented gradient and then followed by principal component analysis. The gradient boosting algorithm showed an advantage against other algorithms and yielded an accuracy of 0.74, an aneuploid precision of 0.83, and an aneuploid predictive value (recall) of 0.84.

CONCLUSION

This research study proved that machine-assisted technology perceives the embryo differently than human observation and determined that further research on in vitro fertilization is needed. The study finding serves as a basis for developing a better computer-assisted prediction model.

The origin and possible mechanism of embryonic cell-free DNA release in spent embryo culture media: a review

The presence of cell-free DNA in spent embryo culture media (SECM) has unveiled its possible utilization for embryonic ploidy determination, opening new frontiers for the development of a non-invasive pre-implantation genetic screening technique. While a growing number of studies have shown a high concordance between genetic screening using cell-free DNA (cfDNA) and trophectoderm (TE), the mechanism pertaining to the release of cfDNA in SECM is largely unknown. This review aims to evaluate research evidence on the origin and possible mechanisms for the liberations of embryonic DNA in SECM, including findings on the self-correction abilities of embryos which might contribute to the presence of cfDNA. Several databases including EMBASE, PUBMED, and SCOPUS were used to retrieve original articles, reviews, and opinion papers. The keywords used for the search were related to the origins and release mechanism of cfDNA. cfDNA in SECM originates from embryonic cells and, at some levels, non-embryonic cells such as maternal DNA and exogenous foreign DNA. The apoptotic pathway has been demonstrated to eliminate aneuploid cells in developing mosaic embryos which might culminate to the release of cfDNA in SECM. Nonetheless, there is a recognized need for exploring other pathways such as cross-talk molecules called extracellular vesicles (EVs) made of small, round bi-layer membranes. During in vitro development, embryos physiologically and actively expel EVs containing not only protein and microRNA but also embryonic DNA, hence, potentially releasing cfDNA of embryonic origin into SECM through EVs.

Massive DVT from the proximal IVC to the pedal vein: Our approach using aspiration mechanical thrombectomy and open surgery thrombectomy

Deep venous thrombosis might present in an acute condition requiring early thrombus removal. Several endovascular and surgical approaches are available with a short treatment time and minimal complications compared to pharmacotherapies. However, due to a lack of evidence, these are not the first treatment choice for deep vein thrombosis. Our case report showed a successful multimodality treatment for an acute-on-chronic massive deep vein thrombosis from the inferior vena cava to the pedal vein. A 47-year-old with chief complaints of cold, significant swelling, and severe pain in her left leg was diagnosed with deep vein thrombosis through Doppler ultrasound and contrast-enhanced computed tomography. The patient received aspiration mechanical thrombectomy with the "kissing catheter" technique, adjunctive stent, percutaneous transluminal angioplasty, and open surgical thrombectomy by Fogarty catheter without recurrence and complication.

Factors affecting the distribution of serum anti-müllerian hormone levels among infertile Asian women: a multi-nation, multi-centre, and multi-ethnicity prospective cohort study

STUDY QUESTION

How do age, ethnicity, and other characteristics affect serum anti-mullerian hormone (AMH) levels in Asian women undergoing fertility treatment?

SUMMARY ANSWER

Age, ethnicity, obesity (BMI ≥ 30 kg/m2), and polycystic ovarian syndrome (PCOS) significantly impacted serum AMH levels, with the rate of decrease accelerating as age increased; a concentration of 4.0 ng/ml was the optimal cut-off for diagnosis of PCOS.

WHAT IS KNOWN ALREADY

There are significant differences in ovarian reserve among women from different races and ethnicities, and Asian women often have poorer reproductive outcomes during assisted reproductive treatment cycles.

STUDY DESIGN, SIZE, DURATION

A population-based multi-nation, multi-centre, multi-ethnicity prospective cohort study of 4613 women was conducted from January 2020 to May 2021. Infertile women of 20-43 years of age were enrolled. The exclusion criteria included: age <20 or >43, non-Asian ethnicity, and missing critical data.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were Asian women of Chinese, Japanese, Korean, Thai, Vietnamese, Malay, Indian, and Indonesian ethnicities from 12 IVF centres across Asia. These women were all naïve to ovarian stimulation cycles and attended IVF centres for fertility assessment. The AMH measurement was performed using an AMH automated assay on a clinically validated platform.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 4556 infertile Asian women were included in the final analyses. The mean ± SD for serum AMH concentrations (ng/ml) across specific age groups were: overall, 3.44 ± 2.93; age <30, 4.58 ± 3.16; 30-31, 4.23 ± 3.23; 32-33, 3.90 ± 3.06; 34-35, 3.21 ± 2.65; 36-37, 2.74 ± 2.44; 38-39, 2.30 ± 1.91; 40 and above, 1.67 ± 2.00. The rate of AMH decrease was ∼0.13 ng/ml/year in patients aged 25-33 and 0.31 ng/ml/year in women aged 33-43. The highest rates of PCOS were found in Indians (18.6%), Malays (18.9%), and Vietnamese (17.7%). Age (P < 0.001), ethnicity (P < 0.001), obesity (P = 0.007), PCOS (P < 0.001), and a history of endometrioma cystectomy (P = 0.01) were significantly associated with serum AMH values. Smoking status, pretreatment with GnRH agonist (GnRHa) or the oral contraceptive pill (OCP), freezing-thawing of blood samples, and sampling on Day 2 to Day 5 of the menstrual cycle or randomly did not appear to affect serum AMH levels. An AMH concentration of 4.0 ng/ml was the optimal cut-off for PCOS diagnosis with a sensitivity of 71.7% and specificity of 75.8% (AUC = 0.81, CI 95%: 0.79-0.83; P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The incidence of PCOS was supposedly high in this cohort as some IVF clinics were tertiary referral centres for managing specific fertility issues encountered by women with PCOS. Treatment with GnRHa or OCP before AMH testing was regionally and ethnically confined, mostly in Hong Kong SAR and Japan. Moreover, this reference for serum AMH value is limited to Asian women of the ethnicities examined and may not apply to other ethnicities not included in the study.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to collate and construct age-specific reference ranges for serum AMH levels using the same bioassay on Asian women of different ethnicities. The findings of this investigation can assist clinicians to counsel and prognosticate about Asian women's ovarian reserve and reproductive potential, thus providing better strategies for personalized fertility interventions.

STUDY FUNDING/COMPETING INTEREST(S)

This study was technically supported by Ferring Pharmaceuticals and received no specific grant from any funding agency. All authors have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

NCT04203355.

Ophthalmic artery Doppler for pre-eclampsia prediction at the first trimester: a Bayesian survival-time model

OBJECTIVE

To develop a Bayesian survival-time model for the prediction of pre-eclampsia (PE) at the first trimester using a combination of established biomarkers including maternal characteristics and history, mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI), and Placental Growth Factor (PlGF)) with an ophthalmic artery Doppler peak ratio (PR) analysis.

METHODS

The receiving operator curve (ROC) analysis was used to determine the area under the curve (AUC), detection rate (DR), and positive screening cut-off value of the model in predicting the occurrence of early-onset PE (< 34 weeks' gestation) and preterm PE (< 37 weeks' gestation).

RESULTS

Of the 946 eligible participants, 71 (7.49%) subjects were affected by PE. The incidences of early-onset and preterm PE were 1% and 2.2%, respectively. At a 10% false-positive rate, using the high-risk cut-off 1:49, with AUC 0.981 and 95%CI 0.965-0.998, this model had an 100% of DR in predicting early-onset PE. The DR of this model in predicting preterm PE is 71% when using 1:13 as the cut-off, with AUC 0.919 and 95%CI 0.875-0.963.

CONCLUSION

Combination ophthalmic artery Doppler PR with the previously established biomarkers could improve the accuracy of early and preterm PE prediction at the first trimester screening.

A Homogeneous Ensemble of Robust Pre-defined Neural Network Enables Automated Annotation of Human Embryo Morphokinetics

Background: The purpose of the current study was to reduce the risk of human bias in assessing embryos by automatically annotating embryonic development based on their morphological changes at specified time-points with convolutional neural network (CNN) and artificial intelligence (AI). Methods: Time-lapse videos of embryo development were manually annotated by the embryologist and extracted for use as a supervised dataset, where the data were split into 14 unique classifications based on morphological differences. A compilation of homogeneous pre-trained CNN models obtained via TensorFlow Hub was tested with various hyperparameters on a controlled environment using transfer learning to create a new model. Subsequently, the performances of the AI models in correctly annotating embryo morphologies within the 14 designated classifications were compared with a collection of AI models with different built-in configurations so as to derive a model with the highest accuracy. Results: Eventually, an AI model with a specific configuration and an accuracy score of 67.68% was obtained, capable of predicting the embryo developmental stages (t1, t2, t3, t4, t5, t6, t7, t8, t9+, tCompaction, tM, tSB, tB, tEB). Conclusion: Currently, the technology and research of artificial intelligence and machine learning in the medical field have significantly and continuingly progressed in an effort to develop computer-assisted technology which could potentially increase the efficiency and accuracy of medical personnel’s performance. Nonetheless, building AI models with larger data is required to properly increase AI model reliability.   

Birth of spinal muscular atrophy unaffected baby from genetically at-risk parents following a pre-implantation genetic screening: A case report

Background

Spinal muscular atrophy (SMA) is characterized by the homozygous deletion of the survival motor neuron-1 gene. Pre-implantation genetic testing for monogenic diseases through in-vitrofertilization program was developed to provide a reliable genetic diagnostic method for SMA.

Case presentation

The couple who was confirmed as carriers of SMA visited the Morula IVF Clinic, Jakarta, Indenesia seeking for an in-vitro fertilization expert opinion in relation to the pre-implantation genetic testing for SMA. Utilizing polymerase chain reaction-restriction fragment length polymorphism, we have successfully screened for unaffected embryos that were characterized by a normal presence of the survival motor neuron-1 exon 7-8 and survival motor neuron-2 exon 7-8. The frozen embryo was subsequently transferred and a healthy unaffected female baby was born with undetected deletion of the survival motor neuron-1 gene.

Conclusion

This successful embryo pre-implantation screening case could potentially accommodate the demands of genetically at-risk couples who are apprehensive about conceiving a child who might inherit monogenic disorders such as SMA.

Machine Learning Approach to Predict Clinical Pregnancy Potential in Women Undergoing IVF Program

Objective: Hidden knowledge could be discovered within a large practical data of in vitro fertilization (IVF) practice. In this study, Machine learning-based data mining techniques were utilized to construct a reliable prediction model for clinical pregnancy in IVF.

Study Design: A retrospective cohort multicenter study involving 4.570 IVF cycles. All patients underwent fresh embryo transfer at either the cleavage or blastocyst stage between January 2015 and December 2019. The experiment focused on utilizing tree-based classifiers to generate and compare the most effective prediction model that could predict a clinical pregnancy through clinical data. Additionally, each classifier is optimized via a genetic algorithm technique, along with the selection of variables.

Results: Both the decision tree and random forest showed similar performance that was much better than the gradient boost. The two superior classifiers achieved a balanced accuracy of roughly 0.62. Additionally, each prediction model was shown to work optimally with different combinations of variables, with some variables being consistently included, such as female age, and some consistently excluded, which provides an insight into the relationship between the variables and each prediction model.

Conclusion: Machine learning algorithm remains effective for the purpose of data mining and knowledge extraction in IVF clinical datasets through which a relatively reliable prediction system for clinical pregnancy could be constructed, provided the available data is sufficient.

A comparative, observational study evaluating dosing characteristics and ovarian response using the recombinant human follicle-stimulating hormone pen injector with small-dose dial in assisted reproductive technologies treatment in Asia: IMPROVE study

BACKGROUND

Ovarian stimulation during medically assisted reproduction treatment should be individualized to optimize outcomes and reduce complications. This study assessed whether use of the recombinant human follicle-stimulating hormone (r-hFSH) pen injector allowing small 12.5 IU dose increments resulted in lower r-hFSH dose per oocyte retrieved in a subgroup of patients at risk of OHSS, compared with r-hFSH injection devices allowing only 37.5 IU increments.

METHODS

This multicenter, comparative, observational study evaluated patients from a prospective (study group) and historical (control group) cohort. The study group enrolled 1783 patients using the redesigned r-hFSH pen injector (GONAL-f®, Merck Healthcare KGaA, Darmstadt, Germany) from a prospective phase IV, non-interventional, open-label study, conducted in Korea, Vietnam, Indonesia, and China. The control group consisted of 1419 patients from a historical study using r-hFSH devices allowing 37.5 IU increments. In the study group, 397 patients were considered at risk of OHSS; this information was unavailable for the control group, so biomarkers and patient characteristics were used to match 123 patients from the study group and control group. Each center adhered to standard practice; starting dose and intra-cycle dose adjustments were allowed at any point. The primary endpoint, amount of r-hFSH (IU) administered per oocyte retrieved, was assessed in matched patients only. Additional outcomes and safety were assessed in the overall populations.

RESULTS

Baseline characteristics were comparable between groups. Mean (SD) total dose of r-hFSH administered per oocyte retrieved in patients at risk of OHSS, was significantly lower in the study group compared with the control group (132.5 [85.2] vs. 332.7 [371.6] IU, P < 0.0001, n = 123). Implantation rate, clinical pregnancy rate, and live birth rates in the overall study and control groups were 30.0 vs. 20.6%, 50.3 vs. 40.7%, and 43.8 vs. 34.0%, respectively. OHSS incidence was significantly lower in the study group compared with the control group (27/1783 [1.5%] vs. 57/1419 [4.0%] patients, P < 0.0001). AEs were reported by 5.0% of patients in the study group.

CONCLUSIONS

A significantly lower r-hFSH dose per oocyte retrieved and lower OHSS incidence were observed in patients using the redesigned injector compared with patients using other injection devices.

Morphokinetics of embryos after IMSI versus ICSI in couples with sub-optimal sperm quality: A time-lapse study

An investigation was conducted to determine the influence of two sperm selection modalities, IMSI and ICSI, on the morphokinetics, dynamic development and ploidy status of embryos derived from males with sub-optimal sperm profiles during IVF program. A total of 209 PGTA-tested top-quality blastocysts (IMSI = 129, ICSI = 80) from 84 couples (IMSI = 51, ICSI = 33) were assessed retrospectively. This study found that both IMSI and ICSI yielded comparable embryo morphokinetics, except for the T7, TEB and CC3 parameters (p < 0.05). A significant lower incidence of multinucleation was observed in the IMSI group when compared to the ICSI group (48.8% vs. 71.3%, p = 0.002), while other parameters of embryo development such as direct cleavage, distorted cytoplasmic movement, reverse cleavage and vacuole(s) appearance did not differ (p > 0.05). No differences were noticed in the proportion of generating chromosomally euploid embryos (44.2% vs. 51.3%, p = 0.394, respectively, for IMSI and ICSI). The implementation of IMSI or ICSI in couples with sub-optimal sperm profiles resulted in embryos with comparatively similar morphokinetics. Furthermore, the incidence of multinucleation at the two- to four-cell stage was lower following the practice of IMSI, although the method did not improve the proportion of gaining euploid embryos.

Robotic myomectomy for a non-pregnant reproductive age woman with severe acute urinary retention: A case report

Urinary retention in non-pregnant reproductive age women is a very rare condition. Hereby, we reported a rare case of acute urinary retention in a non-pregnant reproductive-age woman with hydronephrosis and hydroureter due to a large fibroid. The fibroid had resulted in constant pressure to the urethral sphincter, which causes urinary retention. Robotic myomectomy was performed after insertion of ureteric catheters. To our knowledge, this is the first case report of a robotic surgery being utilised to manage acute urinary retention in a non-pregnant individual due to large fibroid.

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We reported a rare case of acute urinary retention in a non-pregnant reproductive-age woman due to a large fibroid.

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Robotic surgery is an effective tool in management of acute cases.

Comparison of Highly Purified HMG versus Recombinant FSH with Antagonist Protocol in Poor Responder Patients

Background:Luteinizing hormone (LH) supplementation may have beneficial effect on the maturity and fertilizability of oocytes in poor ovarian reserve (POR) and may influence the progesterone level, thus increasing the pregnancy rate. However, previous studies on the effect of LH activity supplementation on poor responders have shown conflicting results. This study aimed to compare the clinical effectiveness of two different forms of gonadotropin (highly purified human menopausal gonadotropin (HP-HMG) vs. recombinant human follicle-stimulating hormone (r-hFSH)-only) in Indonesian population.

Methods: Women diagnosed with poor ovarian response who received gonadotropin-releasing hormone (GnRH) antagonist protocol with either HP-HMG or r-hFSH-only were investigated. Women who underwent freeze all cycles, mini stimulation, and natural stimulation were excluded. Multiple logistic regression was performed to assess the effect of follicle-stimulating hormone (FSH) + human chorionic gonadotropin (HCG)-driven LH activity combination in HP-HMG to pregnancy event adjusting for progesterone level, demographic variables, and clinical characteristic variables.

Results: A total of 101 subjects in the HP-HMG treatment group and 89 subjects in r-hFSH-only treatment group were involved in the study. There was no significant difference of clinical pregnancy rate between HP-HMG group and r-hFSH-only group (adjusted OR: 0.94, 95% CI: 0.39–2.25; p-value: 0.890).

Conclusion: Compared to r-hFSH-only group, combination of FSH + HCG-driven LH activity in HP-HMG group had similar effectiveness in poor responders undergoing in vitro fertilization (IVF) using the antagonist protocol.

Embryo Banking with Mild Ovarian Stimulation for IVF: An Alternative Strategy for Poor Prognosis Patients

BACKGROUND

Management of Poor Ovarian Reserve (POR) in in vitro fertilization remains a difficult challenge. The purpose of this retrospective cohort study was to compare the effectiveness of embryo banking strategy over a cohort of several mild stimulation cycles (Embryo Banking Strategy for Poor Prognosis/Embargo) to conventional full-dose antagonist protocol for IVF.

METHODS

Subjects identified as having poor ovarian response (POR) based on the Bologna criteria were recruited. In total, there were 113 subjects included in the analysis. Fifty-three subjects underwent embryo banking procedure (Embargo) protocol, and sixty subjects underwent the conventional full-dose antagonist protocol for IVF. The Chi-square test was used to compare the clinical pregnancy rate, miscarriage rate as well as live birth rate, while the Mann-Whitney U test was utilized to analyze the cost per clinical pregnancy between the two groups. A p<0.05 was considered statistically significant.

RESULTS

The two studied groups showed similar outcomes regarding clinical pregnancy rate, miscarriage rate, as well as live birth rate (p=0.966, p=0.310, and p= 0.469, respectively). Cost analysis of subjects who underwent mild ovarian stimulation followed by Embargo revealed the high cost of the protocol compared to conventional full-dose antagonist protocol ($10.507±6.181 vs. $9.533±2.530, p=0.002).

CONCLUSION

The clinical outcomes of both protocols were comparable. Embargo procedure was not efficient in improving the overall clinical outcomes in patients who were expected poor ovarian responders as the protocol costed more comparing with conventional full-dose antagonist protocol. A larger prospective randomized control trial is needed to evaluate this finding.

Ovarian leukocyte distribution and cytokine/chemokine mRNA expression in follicular fluid cells in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 5-10% of reproductive-aged women and is commonly associated with anovulatory infertility. Leukocytes, together with granulosa cells, may contribute to the pathogenesis of PCOS via their ability to secrete an array of cytokines implicated in follicle growth. The aim of this study was to examine leukocyte subtypes in follicular phase ovaries and to quantify cytokine and chemokine mRNA expression in follicular fluid cells obtained at the time of oocyte retrieval before IVF in women with and without PCOS.

METHODS

Ovaries were immunostained for various leukocyte markers [CD3, CD4, CD14, CD15, CD45, CD45RA, CD45RO, CD57 and major histocompatibility complex (MHC) class II]. In addition, follicular fluid cells were subjected to quantitative RT-PCR to evaluate colony-stimulating factor-1 (CSF-1), granulocyte-macrophage (GM)-CSF, interleukins (IL-1beta, IL-6, IL-8 and IL-10), monocyte chemotactic protein (MCP-1) and tumour necrosis factor (TNFalpha) mRNA expression relative to beta-actin.

RESULTS

CD45RO+ cells (activated/memory T lymphocytes) were reduced by 60% in the theca layer of follicles from PCOS women. The relative abundance of macrophages and neutrophils was unchanged. Cytokine and chemokine mRNA transcripts examined were not affected by PCOS status. There was an association between high BMI and high TNFalpha and low IL-6 mRNA expression in follicular cells. IL-6 expression was higher in women who subsequently achieved pregnancy.

CONCLUSIONS

T lymphocytes potentially play a role in the local pathological mechanisms of PCOS. Further studies are required to identify their contribution to the aetiology of this common condition.

160.Ovarian leukocytes and cytokines in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with anovulatory infertility and metabolic disturbances. PCOS has an unknown aetiology but is involved with aberration of substances that lead to follicular growth. The ovarian leukocyte/cytokine network is important in the ovary and has not been adequately examined in PCOS. The aim of the study was to look at the distribution of leukocytes in the ovaries of women with PCOS and to look at expression of cytokine and chemokine mRNA in follicular cells from these patients. Ovaries were obtained from PCOS (n�=�5) and non-PCOS (n�=�4) women undergoing gynaecological surgery for non-ovarian conditions prior to the menopause. They were immunostained for a wide variety of leukocyte markers and distribution counted using visual imaging software. Luteinising granulosa cells were obtained prior to ovulation in women undergoing in vitro fertilization with (n�=�11) and without (n�=�22) PCOS and mRNA studied using quantitative RT-PCR for various cytokines and chemokines. The CD45RO subset of leukocytes (principally activated/memory T-lymphocytes) were significantly decreased in ovaries from PCOS women compared to non-PCOS women. The other leukocytes were not different in distribution and numbers. Transcripts for CSF-1, IL-1β, IL-6, IL-8, IL-10, MCP-1 and TNFα were not different between PCOS and non-PCOS women whilst GM-CSF mRNA was not detectable in either group. There was an association between high testosterone levels and high IL1β and low TNFα transcripts. Women who became pregnant following IVF had higher levels of IL-10 mRNA. The role of T-lymphocytes in PCOS needs further examination, and if the leukocyte/cytokine network in PCOS is important, other cells and cytokines need examination. This is the first study to definitively describe the leukocyte/cytokine network within polycystic ovaries. While other cells and substances may be important in PCOS and intervention procedures such as ovarian drilling, it does not appear as though macrophages, neutrophils, B-lymphocytes and a variety of cytokines are involved in the aetiology of PCOS.