Comparison of two models predicting IVF success; the effect of time trends on model performance

STUDY QUESTION

How well does the recently developed UK model predicting the success rate of IVF treatment (the 2011 Nelson model) perform in comparison with a UK model developed in the early 1990s (the Templeton model)?

SUMMARY ANSWER

Both models showed similar performance, after correction for the increasing success rate over time of IVF.

WHAT IS KNOWN ALREADY

For counselling couples undergoing IVF treatment it is of paramount importance to be able to predict success. Several prediction models for the chance of success after IVF treatment have been developed. So far, the Templeton model has been recommended as the best approach after having been validated in several independent patient data sets. The Nelson model, developed in 2011 and characterized by the largest development sample containing the most recently treated couples, may well perform better.

STUDY DESIGN, SIZE, DURATION

We tested both models in couples that were included in a national cohort study carried out in the Netherlands between the beginning of January 2002 and the end of December 2004.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analysed the IVF cycles of Dutch couples with primary infertility (n = 5176). The chance of success was calculated using the two UK models that had been developed using the information collected in the Human Fertilisation and Embryology Authority database. Women were treated in 1991-1994 (Templeton) or 2003-2007 (Nelson). The outcome of success for both UK models is the occurrence of a live birth after IVF but the outcome in the Dutch data is an ongoing pregnancy. In order to make the outcomes compatible, we used a factor to convert the chance of live birth to ongoing pregnancy and use the overall terms 'success or no success after IVF'. The discriminative ability and the calibration of both models were assessed, the latter before and after adjustment for time trends in IVF success rates.

MAIN RESULTS AND THE ROLE OF CHANCE

The two models showed a similarly limited degree of discriminative ability on the tested data (area under the receiver operating characteristic curve 0.597 for the Templeton model and 0.590 for the Nelson model). The Templeton model underestimated the success rate (observed 21% versus predicted 14%); the Nelson model overestimated the success rate (observed 21% versus predicted 29%). When the models were adjusted for the changing success rates over time, the calibration of both models considerably improved (Templeton observed 21% versus predicted 20%; Nelson observed 21% versus predicted 24%).

LIMITATIONS, REASONS FOR CAUTION

We could only test the models in couples with primary infertility because detailed information on secondary infertile couples was lacking in the Dutch data. This shortcoming may have negatively influenced the performance of the Nelson model.

WIDER IMPLICATIONS OF THE FINDINGS

The changes in success rates over time should be taken into account when assessing prediction models for estimating the success rate of IVF treatment. In patients with primary infertility, the choice to use the Templeton or Nelson model is arbitrary.

Prenatal famine, birthweight, reproductive performance and age at menopause: the Dutch hunger winter families study

STUDY QUESTION

Is there an association between acute prenatal famine exposure or birthweight and subsequent reproductive performance and age at menopause?

SUMMARY ANSWER

No association was found between intrauterine famine exposure and reproductive performance, but survival analysis showed that women exposed in utero were 24% more likely to experience menopause at any age.

WHAT IS KNOWN ALREADY

Associations between prenatal famine and subsequent reproductive performance have been examined previously with inconsistent results. Evidence for the effects of famine exposure on age at natural menopause is limited to one study of post-natal exposure.

STUDY DESIGN, SIZE, DURATION

This cohort study included men and women born around the time of the Dutch famine of 1944-1945. The study participants (n = 1070) underwent standardized interviews on reproductive parameters at a mean age of 59 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were grouped as men and women with prenatal famine exposure (n = 407), their same-sex siblings (family controls, n = 319) or other men and women born before or after the famine period (time controls, n = 344). Associations of famine exposure with reproductive performance and menopause were analysed using logistic regression and survival analysis with competing risk, after controlling for family clustering.

MAIN RESULTS AND THE ROLE OF CHANCE

Gestational famine exposure was not associated with nulliparity, age at birth of first child, difficulties conceiving or pregnancy outcome (all P> 0.05) in men or women. At any given age, women were more likely to experience menopause after gestational exposure to famine (hazard ratio 1.24; 95% CI 1.03, 1.51). The association was not attenuated with an additional control for a woman's birthweight. In this study, there was no association between birthweight and age at menopause after adjustment for gestational famine exposure.

LIMITATIONS, REASON FOR CAUTION

Age at menopause was self-reported and assessed retrospectively. The study power to examine associations with specific gestational periods of famine exposure and reproductive function was limited.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings support previous results that prenatal famine exposure is not related to reproductive performance in adult life. However, natural menopause occurs earlier after prenatal famine exposure, suggesting that early life events can affect organ function even at the ovarian level.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the NHLBI/NIH (R01 HL-067914).

TRIAL REGISTRATION NUMBER

Not applicable.

[Sensible family planning: pitfalls and dilemmas]

In a recent article in this journal it was stated that Dutch women were sensible in having their first child between the ages of 25 and 35 years. One of the conclusions was that associated health risks increase after the age of 35 but are still acceptable even at the age of 40. We demonstrate that these conclusions were based on flawed assumptions. Postponing pregnancy until after the age of 30 increases the risks of infertility and breast cancer. Motherhood at a later age is associated with an increase in obstetrical complications, miscarriage and other adverse effects on the child. Therefore, for couples planning a family with 2 children or more, it would be sensible to have the first pregnancy not long after the mother reaches the age of 30 years, or even earlier. Couples should be informed on the risks of late parenthood in order to be able to take the right decisions concerning family planning.

[Reduction of patient discomfort, risks and costs, but not pregnancies, by a mild strategy for in-vitro fertilisation]

OBJECTIVE

To compare a so-called mild in-vitro fertilisation (IVF) treatment strategy with the standard IVF treatment on the following aspects: the chance of a pregnancy resulting in full-term live birth within 1 year, patient discomfort, multiple pregnancies, and costs.

DESIGN

Randomised, open-label, prospective trial (www.controlledtrials.com, number ISRCTN35766970).

METHOD

404 patients were assigned to undergo either a mild treatment, consisting of ovarian stimulation with a gonadotrophin releasing hormone (GnRH) antagonist combined with single embryo transfer, or the standard treatment consisting of prolonged stimulation with a GnRH agonist combined with the transfer of two embryos. The primary outcome measures were: (1) the percentage of cumulative pregnancies within one year after randomisation leading to full-term live birth; (2) total costs per couple and child up to 6 weeks after expected delivery; and (3) overall patient discomfort. Analysis was done according to the intention-to-treat principle and was intended to show that the mild treatment was not inferior to the standard treatment; the non-inferiority threshold was -12.5%.

RESULTS

The proportion of cumulative pregnancies resulting in full-term live birth after 1 year was 43.4% in the mild and 44.7% in the standard treatment group. The lower limit of the one-sided 95% confidence interval was equal to -9.8%. The respective proportion of couples with multiple pregnancies was 0.5% versus 13.1% (p < 0.0001), and the average total costs were Euro 8,333.- versus Euro 10,745.- (difference: Euro 2,412.-, 95% CI: 703-4,131). There were no statistically significant differences between the groups with regard to anxiety, depression, physical discomfort, and sleep quality.

CONCLUSION

After 1 year of treatment, the cumulative percentage of pregnancies leading to full-term live birth and the total patient discomfort were the same for the mild treatment (average 2.3 IVF-cycles) and the standard treatment (average 1.7 IVF-cycles). The mild treatment significantly reduced the number of multiple pregnancies and the overall costs.

[The consequences of postponing pregnancy]

The postponement of childbearing is determined by societal factors and is related to the fact that it is often difficult for women to combine an education, a job or a career with having children and taking care of a family. Especially gynaecologists are increasingly confronted with women who undergo the medical consequences of such postponement. Postponing the first pregnancy is accompanied by an increased risk of unwanted infertility. If women do succeed in becoming pregnant later in life, there is an increased risk of complications during pregnancy and delivery. The child runs a greater risk of chromosomal aberrations and of mental and physical handicaps related to increased numbers of premature births and fertility treatments. All these problems begin to increase after age 30, but especially after age 35. Finally, the risk of breast cancer is also increased if a woman delays the birth of her first child or remains childless.

Cumulative live birth rates following IVF in 41- to 43-year-old women presenting with favourable ovarian reserve characteristics

For women aged 41-43 years old, success rates in IVF are generally poor. This study aimed to assess cumulative live birth rate related to treatment costs over a maximum of three IVF cycles in selected women who were considered to still have adequate ovarian reserve. Fifty-five patients (38% of the total cohort, n = 144) were excluded from IVF treatment based on low antral follicle count (<5 follicles) and/or elevated basal FSH (>15 IU/l). Of those admitted, 66 (74%) actually started and completed a total of 125 IVF/intracytoplasmic sperm injection cycles. Treatment resulted in 10 live births (8% per cycle). Kaplan-Meier survival analysis revealed a realistic cumulative live birth rate after three cycles of 17%. The direct medical costs per live birth were calculated to be approximately 44,000 euro. These results show that selection towards favourable ovarian reserve status in the female age group 41-43 years yielded disappointing results in terms of cumulative live birth rates after IVF. In view of the costs raised per live birth, improvement of selection parameters for treatment in this age group is warranted.

Prevention of multiple pregnancies after IVF in women 38 and older: a randomized study

The objective of this study was to answer the question of whether a double instead of triple embryo transfer strategy in patients over 38 years would substantially reduce the number of multiple pregnancies while maintaining the chance of a term live birth at an acceptable level. A randomized controlled two-centre trial was performed. Forty-five patients, 38 years or older, were randomized. Double embryo transfer over a maximum of four cycles (DET group) or triple embryo transfer over a maximum of three cycles (TET group) was performed. The cumulative term live birth rate was 47.3% after four cycles in the DET group and 40.5% after three cycles in the TET group. The difference between the DET and the TET group was 6.8% in favour of the DET group (95% CI -25 to 38). The multiple pregnancy rates in the DET and TET group were 0% (95% CI 0 to 24) and 30% (95% CI 7 to 65) respectively (P = 0.05). In the DET patients, the mean number of treatment cycles was 2.9 compared with 2.1 in the TET group (P = 0.01). In women of 38 years and older, double embryo transfer after IVF may result in similar cumulative term live birth rates compared with triple embryo transfer, provided that a higher number of treatment cycles is accepted.

Use of stimulated serum estradiol measurements for the prediction of hyperresponse to ovarian stimulation in in vitro fertilization (IVF)

PURPOSE

In ovarian stimulation an exaggerated ovarian response is often seen and is related to medical complications, such as ovarian hyperstimulation syndrome (OHSS), and increased patient discomfort. If it were possible to identify hyperresponders at an early stage of the stimulation phase, adaptation of the stimulation protocol would become feasible to minimize potential complications. Therefore, we studied the usefulness of measuring stimulated serum estradiol (E2) levels in predicting ovarian hyperresponse.

METHODS

A total of 109 patients undergoing their first IVF treatment cycle using a long protocol with GnRH agonist was prospectively included. The E2 level was evaluated on day 3 and 5 of the stimulation phase. Two outcome measures were defined. The first was ovarian hyperresponse (collection of > or = 15 oocytes at retrieval and/or peak E2 > 10000 pmol/L, or cancellation due to > or = 30 follicles growing and/or peak E2 > 15000 pmol/L, or OHSS developed). The second outcome measure comprised a subgroup representing the more severe hyperresponders. named extreme-response (cancellation or OHSS developed).

RESULTS

The data of 108 patients were analyzed. The predictive accuracy of E2 measured on stimulation day 3 towards ovarian hyperresponse was clearly lower than that of E2 measured on stimulation day 5 (area under the receiver operating characteristic curve (ROCAUC) 0.75 and 0.81, respectively). For extreme-response the predictive accuracy of E2 measured on stimulation day 3 or 5 was comparable (ROCAUC 0.81 and 0.82, respectively). For both outcome measures the stimulated E2 tests yielded only acceptable specificity with moderate sensitivity at higher cutoff levels. Prediction of extreme-response seemed slightly more effective due to a lower error rate.

CONCLUSIONS

There is a significant predictive association between E2 levels measured on stimulation day 3 and 5 and both ovarian hyperresponse and extreme-response in IVF. However, the clinical value of stimulated E2 levels for the prediction of hyperresponse is low because of the modest sensitivity and the high false positive rate. For the prediction of extreme-response the clinical value of stimulated E2 levels is moderate.

Single and repeated GnRH agonist stimulation tests compared with basal markers of ovarian reserve in the prediction of outcome in IVF

PURPOSE

To study the value of a single or repeated GnRH agonist stimulation test (GAST) in predicting outcome in IVF compared to basal ovarian reserve tests.

METHODS

A total of 57 women was included. In a cycle prior to the IVF treatment, on day 3, an antral follicle count (AFC) was performed and blood taken for basal FSH, inhibin B and E2 measurements, followed by a subcutaneous injection of 100 microg triptorelin for the purpose of the GAST. Twenty-four hours later blood sampling was repeated. All the tests were repeated in a subsequent cycle. From the GAST E2 and inhibin B response were used as test parameters. The outcome measures were poor ovarian response and ongoing pregnancy. Group comparisons were done using the Mann-Whitney or chi-square test. Univariate and multivariate logistic regression was applied to assess which test revealed the highest predictive accuracy as expressed in the area under receiver-operating characteristic curve (ROC(AUC)). Clinical value was compared by calculating classical test characteristics for the best logistic models.

RESULTS

All the basal and GAST variables were significantly different in the poor responders (n = 19) compared to normal responders (n = 38). In the univariate analysis on cycle 1 tests the AFC was the best predictor for poor ovarian response, while in cycle 2 the E2 response in the GAST performed best (ROC(AUC) of 0.91 for both). Multivariate analysis of the basal variables led to the selection of AFC and inhibin B in cycle 1, yielding a ROC(AUC) of 0.96. Mean E2 response was selected in a multivariate analysis of the repeated GAST variables (ROC(AUC) 0.91). At a specificity level of -0.90, several logistic models including GAST variables appeared to have a sensitivity (-0.80), positive predictive value (-0.82) and false positive rate (-0.18), comparable to a logistic model containing AFC and inhibin B. None of the test variables showed a significant relation with ongoing pregnancy.

CONCLUSIONS

The GAST has a rather good ability to predict poor response in IVF. However, comparing the predictive accuracy and clinical value of the GAST with a day 3 AFC and inhibin B, it appeared that neither a single nor a repeated GAST performed better. In addition, the predictive ability towards ongoing pregnancy is poor. Therefore, the use of the GAST as a predictor of outcome in IVF should not be advocated.

[The influence of sexual function on the chance of pregnancy]

There is a complex association between sexual behaviour and (in)fertility. Sexual dysfunction can cause a delay in conception, but can also be the result of not conceiving. If conception is not achieved, sexual function may become disturbed and can deteriorate further as the result of the hospital fertility protocol and medical intervention. In terms of fertility, optimal sexual function is important because it increases the chance of conception. The greatest chance of conception is achieved through sexual intercourse on multiple occasions during the fertile period, particularly on days with good quality cervical mucus, with the right interval between ejaculations (not too long and not too short), adequate arousal of both partners and without the use of artificial lubricants. Time and attentiveness are particularly important in the patient-physician contact to be able to properly advise couples on these matters.

Towards less confusing terminology in reproductive medicine: a proposal

The use of the term "infertility" and related terms in reproductive medicine is reviewed. Current terminology is found to be ambiguous, confusing and misleading. We recommend that the fertility investigation report of a couple should consist of statements concerning description, diagnosis and prognosis. The description concerns the duration of non-pregnancy before consulting the clinician. A system for prognostic grading is proposed. The fertility investigation report forms the basis for further action, including the possibility of waiting with treatment in case of almost normal or only slightly reduced fertility. The use of the terms infertility, subfertility and fecundity is not necessary, and it is recommended to avoid them.

Expected poor responders on the basis of an antral follicle count do not benefit from a higher starting dose of gonadotrophins in IVF treatment: a randomized controlled trial

BACKGROUND

The aim of this study was to evaluate the effect of doubling the starting dose of gonadotrophins on the ovarian response in IVF patients with a low antral follicle count (AFC).

METHODS

Fifty-two patients with an AFC of <5 follicles of 2-5 mm diameter before starting their first IVF cycle participated in this randomized controlled trial. They were randomized by opening a sealed envelope, receiving either 150 IU (group I, n = 26) or 300 IU (group II, n = 26) of rFSH as a starting dose. The main outcome measures of the study were number of oocytes, poor response (<4 oocytes at retrieval or cancellation due to insufficient follicle growth) and ongoing pregnancy (12 weeks of gestation).

RESULTS

The groups were comparable regarding patient characteristics and outcome of the IVF treatment. The median number of oocytes collected was 3 for both groups (P = 0.79). The difference in the mean number of oocytes was 0.3 oocytes in favour of group I (P=0.69). Sixty-five per cent of the patients in group I experienced a poor response and 62% in group II. The ongoing pregnancy rate was 8% in group I and 4% in group II (P = 0.55).

CONCLUSIONS

Expected poor response patients, defined as patients with an AFC <5, are likely not to benefit from a higher starting dose of gonadotrophins in IVF.

Kinetics of meiosis in azoospermic males: a joint histological and cytological approach

We have developed a protocol for the identification of aberrant chromosome behavior during human male meiosis up to metaphase of the secondary spermatocyte. Histological evaluation by the Johnsen score of a testicular biopsy was combined with immunofluorescence of first meiotic prophase spermatocytes, using antibodies against synaptonemal complex protein 3 (SYCP3) and the product of the ataxia telangiectasia and rad3-related gene (ATR). This combination enables accurate meiotic prophase substaging and the identification of pachytene spermatocytes with asynapsis. Furthermore, we also investigated the competence of late pachytene primary spermatocytes to complete the first meiotic division up to metaphase and of secondary spermatocytes to transform into metaphase by an in vitro challenge with okadaic acid (OA). We tested this protocol on five males with normal Johnsen scores that presented with obstructive azoospermia, five males with low Johnsen scores and non-obstructive azoospermia and six vasectomized control males of proven fertility and normal Johnsen scores. In all azoospermics, the profiling of meiotic prophase stages by immunofluorescence increases the resolving power of the Johnsen score. In both obstructive and non-obstructive azoospermic patients, relatively more leptotene meiotic prophase stages were counted compared to the controls. In non-obstructive azoospermics, a marked heterogeneity in spermatogenesis was found, after combining the results of all three approaches, pointing at functional mosaicism of the germinal epithelium. Asynaptic pachytene spermatocytes were rarely encountered. Also, when first meiotic metaphase could be induced by OA, chiasma counts were normal. In none of the non-obstructive azoospermic males did the pattern of spermatogenesis resemble that of knock-out mouse azoospermics. We conclude that this combined histological and cytological approach enables a detailed phenotypic classification of infertile males, at a level comparable to that applied for male-sterile knock-out mice with a meiotic defect. This may facilitate the identification of candidate genes for human male infertility.

Two new prediction rules for spontaneous pregnancy leading to live birth among subfertile couples, based on the synthesis of three previous models

BACKGROUND

Several models have been published for the prediction of spontaneous pregnancy among subfertile patients. The aim of this study was to broaden the empirical basis for these predictions by making a synthesis of three previously published models.

METHODS

We used the original data from the studies of Eimers et al. (1994), Collins et al. (1995) and Snick et al. (1997) on couples consulting for various forms of subfertility. We developed a so-called three-sample synthesis model for predicting spontaneous conception leading to live birth within 1 year after intake based on the three data sets. The predictors used are duration of subfertility, women's age, primary or secondary infertility, percentage of motile sperm, and whether the couple was referred by a general practitioner or by a gynaecologist (referral status). The performance of this model was assessed according to a 'jack-knife' analysis. Because the post-coital test (PCT) was not assessed in one of the samples, a synthesis model including the PCT was based on two samples only.

RESULTS

The ability of the synthesis models to distinguish between women who became pregnant and those who did not was comparable to the ability of the one-sample models when applied in the other samples. The reliability of the predictions by the three-sample synthesis model was somewhat better. Predictions improved considerably by including the PCT.

CONCLUSIONS

The synthesis models performed better and had a broader empirical basis than the original models. They are therefore better suitable for application in other centres.

Age-Related Changes in the Ultrastructure of the Resting Follicle Pool in Human Ovaries1

Age-related decline of fertility in women is the result of the decline in both quantity and quality of the resting ovarian follicle pool. The aim of the present study was to determine whether the decline of follicle quality with age is reflected by ultrastructural changes in the resting follicle pool. Ovarian biopsy specimens were obtained by laparoscopy from seven healthy women aged 25-32 yr (young group) and from 11 healthy women aged 38-45 yr (advanced-age group). A total of 182 resting follicles from the young group were compared with 81 resting follicles from the advanced-age group for signs of age-related changes by transmission-electron microscopy. The ooplasmic fraction of vacuoles was increased (P = 0.02), and the fraction of mitochondria decreased (P = 0.005), in the advanced-age group. Also, the density of the mitochondrial matrix (P < 0.001) and the frequency of dilated smooth endoplasmic reticulum (SER; P = 0.001) and Golgi complex (P = 0.02) were increased with age. The frequencies of ruptured mitochondrial membranes (P = 0.001) and dilated SER (P = 0.003) were increased with age in the granulosa cells. Overall follicle-quality scores, which should reflect atretic changes, were not different for the young and advanced-age groups. In conclusion, in resting follicles, the morphological changes with age are different from the changes seen in quality decline by atresia. The morphological changes with age specifically involved the mitochondria, the SER, and the Golgi complex, and they may be the cause of atresia on initiation of follicular growth because of the substantial increase in metabolic requirements.

Ovarian development in intrauterine growth-retarded and normally developed piglets originating from the same litter

Epidemiological studies in humans linking adult disease to growth in utero indicate that prenatal life is a critical period for the appropriate development of the reproductive axis. The aim of this study was to compare ovarian development in intrauterine growth-retarded and normally grown piglets originating from the same litter. Intrauterine growth-retarded piglets (runts) were identified on the basis of statistical analysis of the birth weight distribution within each litter. At birth, ovaries were collected from runt piglets (n=14) and their respective mean weight (normal, n=14) littermates. Ovaries were weighed and fixed, and development of ovarian germ cells was quantified in haematoxylin-eosin-stained paraffin wax sections using an image analysis system. Germ cell loss, using an in situ TdT-mediated dUTP nick-end labelling (TUNEL) assay for DNA fragmentation, and follicle cell activity, using immunohistochemistry to demonstrate vimentin, were studied in ovarian sections. At birth, body weight and absolute ovarian mass were significantly lower in runt piglets compared with their respective normally grown littermates (body weight: 733+/-38.5 versus 1530+/-39.7 g; ovarian mass: 51+/-3.0 versus 108+/-9.6 mg; P<0.001 for both). In the ovary, the proportion of nests of oogonia, the number of oocytes and TUNEL-positive cells, and the localization and intensity of vimentin immunoreactivity were not different between runt and normal littermates. However, runt piglets had more primordial follicles (268+/-18.6 versus 235+/-20.1 per mm(2) of cortex; P<0.05), fewer primary follicles (11+/-2.0 versus 20+/-3.0 per mm(2) of cortex; P<0.001) and no secondary follicles compared with normal piglets. These findings indicate that intrauterine growth retardation delayed follicular development in pig ovaries at birth.

Do cycle disturbances explain the age-related decline of female fertility? Cycle characteristics of women aged over 40 years compared with a reference population of young women

BACKGROUND

The cause of declining fertility with age, in women who still have regular menstrual cycles, is not clear.

METHODS

Follicle development, endometrial growth and hormonal patterns were evaluated in cycles of older women (aged 41-46 years; n = 26) who previously were normally fertile, and these cycles were compared with a reference group of relatively young fertile women (aged 22-34 years; n = 35).

RESULTS

Clearly abnormal cycles were found in only two women in the older age group, and in one woman in the younger group. The main differences between the age groups were a shorter follicular phase and cycle length in the older group, in combination with higher FSH levels in the late luteal and early follicular phase. In contrast to published data which suggest an "accelerated" follicle development in older women, sonographical and hormonal evidence was found of an "advanced" follicle growth, with an earlier start already during the luteal phase of the preceding cycle, and an advanced selection and ovulation of the dominant follicle.

CONCLUSIONS

Such an earlier start of follicle growth in a possibly less favourable hormonal environment, as well as a limited oocyte pool, may contribute to a decreased follicle and oocyte quality, resulting in diminished fertility in ageing women.

Serum anti-Müllerian hormone levels: a novel measure of ovarian reserve

BACKGROUND

Anti-Müllerian hormone (AMH) is produced by the granulosa cells of preantral and small antral follicles and its levels can be assessed in serum. Since the number of ovarian follicles declines with increasing age, AMH levels might be used as a marker for ovarian ageing. Therefore, we studied the relationship between AMH levels and ovarian response during ovarian stimulation for IVF.

METHODS

A total of 130 patients undergoing their first IVF treatment cycle using a long protocol with GnRH agonist was prospectively included. Blood withdrawal was performed and the number of antral follicles was assessed by ultrasound on day 3 of a spontaneous cycle. Poor response and the number of oocytes were used as primary outcome measures. In a random subset of 23 patients a GnRH agonist stimulation test was performed to investigate whether a rise in FSH and LH would affect AMH levels.

RESULTS

The data of 119 patients were analysed. Serum AMH levels were highly correlated with the number of antral follicles (r = 0.77; P < 0.01) and the number of oocytes retrieved (r = 0.57, P < 0.01). A negative association was found between AMH levels and poor ovarian response (fewer than 4 oocytes or cycle cancellation; OR 0.82, 95% CI 0.75-0.90, P < 0.01). Inclusion of inhibin B and FSH concentrations to AMH in a multivariate model improved the prediction of ovarian response. The post GnRH agonist rise in FSH and LH levels did not influence AMH values.

CONCLUSIONS

Poor response in IVF, indicative of a diminished ovarian reserve, is associated with reduced baseline serum AMH concentrations. In line with recent observations it appears that AMH can be used as a marker for ovarian ageing.

Ultrastructure of the resting ovarian follicle pool in healthy young women

In humans, follicle quantity and quality decline with age by atresia. In the present study we aimed to describe the quality of the follicle pool through an ultrastructural investigation of resting follicles in young healthy women. From ovarian biopsies of 7 women aged 25-32 yr, 182 small follicles were morphometrically assessed for various signs of atresia. Morphometric variables were analyzed by principal components analysis (PCA) to demonstrate correlations between variables and to construct an objective follicle score. One third of small follicles consisted of primordial follicles. Nucleus:cell ratios remained constant for oocytes and granulosa cells from primordial to primary follicles, suggesting that follicles up to primary stages belong to the resting pool. The distribution of follicle quality scores as derived from PCA showed that most follicles were of good quality and with little signs of atresia. Atresia in resting follicles appears to be a necrotic process, starting in the ooplasma. Early atresia was characterized by increasing numbers of multivesicular bodies and lipid droplets, dilation of smooth endoplasmic reticulum and Golgi, and irregular mitochondria with changed matrix density. In progressive atresia mitochondrial membranes ruptured, oocyte nuclear membranes were indented or ruptured, and the ooplasma showed extensive vacuolarization. The early involvement of mitochondria in this process suggests that damage is induced by oxygen radicals. PCA follicle quality scores can be reliably approximated using a reduced number of seven morphometric variables, which were selected by stepwise forward analysis. The algorithm to calculate these follicle scores is presented.

The role of genetic factors in age at natural menopause

BACKGROUND

Environmental factors explain only a small part of the age variance at which menopause commences. The variation in natural menopause is a trait predominantly determined by interaction of multiple genes, whose identity and causative genetic variation remains to be determined. Menopause is a retrospective marker for the reproductive capacity of preceding years, since subfertility and infertility precede menopause at distinct time-intervals. In the present study we have investigated the contribution of genetic factors to menopausal age.

METHODS

Data were collected from a random population sample of singleton and twin sisters participating in a prospective breast cancer screening project, who had subsequently experienced natural menopause. Heritability of menopausal age was estimated with analysis of variance, Mx modelling and Gibbs sampling.

RESULTS

All produced almost identical heritability estimates of 0.85-0.87 for singleton sisters, suggesting a strong genetic contribution to menopausal age. Twin data were used to distinguish additive genetic from common environmental effects; a heritability of 0.71-0.72 was determined, which does not deviate significantly from the estimate for singleton sisters.

CONCLUSIONS

According to our findings, a woman with a family history of early menopause risks early menopause and consequently early reproductive failure herself.

Oral contraceptive use in relation to age at menopause in the DOM cohort

BACKGROUND

We investigated the hypothesis that long-term use of oral contraceptives (OCs), in particular high-dose OCs, could postpone age at menopause.

METHODS

Data was used from 8701 women who participated in a breast cancer screening programme in Utrecht (DOM-3 cohort), and who did not use hormone replacement therapy (HRT) or OCs in the 4 years prior to their last menses. Data on OC-use, menopausal status, age at menopause, year of birth, parity, smoking behaviour, socio-economic status, body mass index and age at menarche was available. Use of high-dose OCs has been defined in this study as OC-use before 1972. The data was analysed by means of linear regression and Cox's proportional hazards analysis. Women still menstruating, women with surgical menopause and women lost to follow-up were censored at their last known date of menstruation. Endpoint was the natural menopause (n = 4589).

RESULTS

The use of high-dose OCs advanced the onset of menopause by approximately 1.2 months for every year of OC-use compared with no OC-use. High-dose OC-use for > or = 3 years, adjusted for confounding variables, increased the risk of earlier menopause compared with no OC-use (adjusted hazard ratio 1.12; 95% CI 1.03--1.21). The use of lower dose OCs did not increase the risk of earlier menopause (adjusted hazard ratio 1.00; 95% CI 0.91--1.09).

CONCLUSIONS

These results are inconsistent with the hypothesis that long-term use of OCs could postpone the onset of menopause by inhibiting follicle depletion. Possible explanations are discussed.

Survival of human ovarian follicles from fetal to adult life: apoptosis, apoptosis-related proteins, and transcription factor GATA-4

The majority of oocytes present in fetal ovaries are depleted before birth, and only about 400 will ovulate during the normal fertile life span. Studies on animals have shown that apoptosis is the mechanism behind oocyte depletion and follicular atresia. In the present study, we investigated the extent and localization of apoptosis in human fetal (aged 13-40 weeks) and adult ovaries. Furthermore, the expression of apoptosis-regulating proteins, bcl-2 and bax, and the relationship of transcription factor GATA-4 were studied. Apoptosis was found in ovarian follicles throughout fetal and adult life. During fetal development, apoptosis was localized mainly to primary oocytes and was highest between weeks 14-28, decreasing thereafter toward term. Expression of bcl-2 was observed only in the youngest fetal ovaries (weeks 13-14), and bax was present in the ovaries throughout the entire fetal period. In adult ovaries, apoptosis was detected in granulosa cells of secondary and antral follicles, and Bcl-2 and bax were expressed from primary follicles onwards. During fetal ovarian development, GATA-4 messenger RNA and protein were localized to the granulosa cells, with expression being highest in the youngest ovaries and decreasing somewhat toward term. The expression pattern of GATA-4 suggests that it may be involved in the mechanisms protecting granulosa cells from apoptosis from fetal to adult life. The results indicate that depletion of ovarian follicles in the human fetus occurs through intrinsic mechanisms of apoptosis in oocytes, and later in adult life the survival of growing follicles may be primarily determined by granulosa cell apoptosis.

Basal follicle-stimulating hormone levels are of limited value in predicting ongoing pregnancy rates after in vitro fertilization

OBJECTIVE

To evaluate whether basal FSH (bFSH; measured on menstrual day 1-4) adds relevant clinical information to the prediction of ongoing pregnancy rates (OPRs) after IVF, once age and diagnostic characteristics have been taken into account.

DESIGN

Retrospective.

SETTING

Academic fertility center.

PATIENT(S)

435 women undergoing their first IVF cycle.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate.

RESULT(S)

The likelihood ratio of bFSH as a single prognosticator for treatment failure at a cutoff level of 15 IU/L was 3.87. The proportion of patients with such a bFSH level was 5%. Multivariate logistic regression analysis selected age, bFSH level, and infertility diagnosis as relevant predictors of ongoing pregnancy. When compared to a predictive model for OPRs based on age and infertility diagnosis, the inclusion of bFSH into this model helped to identify more patients (22 vs. 1) whose predicted OPR decreased from a low level (5%-12%) towards an extremely low level (<5%).

CONCLUSION(S)

An acceptable performance of bFSH as a single test to predict treatment failure is only obtained above a high cutoff level. Thus, the number of patients for whom bFSH provides relevant information is small. The predictive model including bFSH identified significantly more patients with an extremely poor prognosis than did the predictive model without bFSH. However, predictions based solely on age and infertility diagnosis usually were already poor in these patients. Measurement of bFSH adds little in only a few patients and is, therefore, debatable.

Timed intercourse versus intra-uterine insemination with or without ovarian hyperstimulation for subfertility in men

BACKGROUND

Although intra-uterine insemination (IUI) is widely used, however its effectiveness remains a matter of debate. Although IUI is less invasive and expensive than IVF or GIFT, it should only be applied if the probability of conception is improved significantly as compared to the natural chance of conceiving. To increase the number of available oocytes at the site of fertilization, controlled ovarian hyperstimulation (COH) can be applied in conjunction with IUI. Uncontrolled studies suggest a beneficial effect of COH in combination with IUI, also when a male factor is present. To be able to draw firm conclusions whether IUI and/or COH improve the probability of conception, several comparisons should be performed in randomized controlled trials (RCTs).

OBJECTIVES

To determine for male subfertility whether intrauterine insemination (IUI) improves the probability of conception compared with timed intercourse and whether the addition of controlled ovarian hyperstimulation influences the results.

SEARCH STRATEGY

1. The specialist database of the Cochrane Menstrual Disorders and Subfertility Group. 2. Medline search. 3. Embase search. 4. DDFU search. 5. BIOSIS search. 6. SCIsearch. 7. Manual searching of references mentioned in the obtained studies. 8. Personal communication and write letters to experts (14) in the field. 9. Abstracts of The American Society for Reproductive Medicine and European Society for Human Reproduction and Embryology Meetings. When important information is lacking from the original publications the authors will be contacted.

SELECTION CRITERIA

Randomized controlled trials only.

DATA COLLECTION AND ANALYSIS

Independently by the first 2 authors: 1. Trial design characteristics. 2. Baseline characteristics of participants. 3. Types of intervention. 4. Outcomes where pregnancy is the outcome of main interest. Number of multiple pregnancies and number of cycles with ovarian hyperstimulation syndrome (OHSS) are secondary outcomes. Analysis of agreement between the two observers was determined for the following items: inclusion or exclusion of a trial, method of randomization, definition of male subfertility, design of the trial, number of pregnancies and completed cycles. Sensitivity analysis is performed.

MAIN RESULTS

Seventeen trials fulfilled the selection criteria for this review and were included. Four trials are pending. Crude agreement concerning inclusion or exclusion of trials occurred for 41 of 43 (95%) trials reviewed (kappa 0.90). The included trials comprised 3,662 completed cycles. In natural cycles intrauterine insemination (IUI) significantly improved the probability of conception compared with timed intercourse (TI) (combined odds ratio with 95% confidence intervals: 2.43, 1.54 - 3.83). In cycles with controlled ovarian hyperstimulation (COH) IUI significantly improved the probability of conception also compared with TI (combined odds ratio with 95% confidence intervals: 2.14, 1.30 - 3.51). Despite clinical heterogeneity, these results are based on strong evidence. Intrauterine insemination in cycles with COH improved the probability of conception compared with IUI in natural cycles but significance was not reached (combined odds ratio with 95% confidence intervals: 1.79, 0.98 - 3.25). Comparing IUI in COH-cycles with TI in natural cycles the first treatment modality significantly improved the probability of conception (combined odds ratio with 95% confidence intervals: 6.23, 2.35 - 16.52).

REVIEWER'S CONCLUSIONS

Intra-uterine insemination offers couples with male subfertility benefit over timed intercourse, both in natural cycles and in cycles with COH. In the case of a severe semen defect (with more than 1 million motile sperm after semen preparation and no triple sperm defect) IUI in natural cycles should be the treatment of first choice. The value of COH need to be further investigated in RCTs. Mild ovarian hyperstimulation with gonadotrophins is advised in cases with less sever

Antral follicle counts by transvaginal ultrasonography are related to age in women with proven natural fertility

OBJECTIVE

To investigate the relation between reproductive age and ultrasound (US)-based follicle counts and the reproducibility of follicle counts in regularly cycling women with proven fertility.

DESIGN

Prospective observational study.

SETTING

Tertiary fertility center.

PATIENT(S)

Healthy female volunteers with proven fertility, recruited by advertisement in local newspapers.

INTERVENTION(S)

The number of antral follicles sized 2-10 mm and ovarian volume were estimated by transvaginal US in the early follicular phase of the menstrual cycle in 162 women. A subgroup of 81 women underwent transvaginal US at several times in three subsequent cycles.

MAIN OUTCOME MEASURE(S)

Antral follicle count and total ovarian volume.

RESULT(S)

Women aged 25-46 years (n = 162) were studied. The relation of age with the US indices was computed after natural log transformation. Antral follicle count showed the clearest correlation with age (R = -0.67). A biphasic linear model gave the best fit to the data. Before the age of 37 years, the antral follicle count showed a mean yearly decline of 4.8%, compared with 11.7% thereafter. The reproducibility of the antral follicle count in two subsequent cycles was moderate.

CONCLUSION(S)

The number of small antral follicles in both ovaries as measured by US is clearly related to reproductive age and could well reflect the size of the remaining primordial follicle pool.

Pesticide exposure and decreased fertilisation rates in vitro

The effect of paternal occupational exposures on fertilising ability was investigated in 836 couples who sought in-vitro fertilisation treatment. Fertilisation rates were significantly decreased for couples with paternal pesticide exposure.

Hormone patterns after induction of ovulation with clomiphene citrate: an age-related phenomenon

Since the introduction of clomiphene citrate (CC), more than three decades ago, a discrepancy has been observed between ovulation and pregnancy rates for which as yet no explanation exists. To investigate if ovulation disorders or abnormal hormonal patterns occur more often in CC-stimulated seemingly ovulatory cycles, we performed hormonal and sonographic monitoring in first cycles of oligo- or amenorrheic patients who were stimulated with 50 mg CC, and compared the hormonal patterns to those in natural cycles of age-matched proven fertile women. Twenty-four first CC cycles were monitored. Twelve cycles appeared to be ovulatory, eleven showed no follicle development and one cycle exhibited the luteinized unruptured follicle (LUF) phenomenon. Ten ovulatory cycles were compared with 27 unstimulated control cycles. In four cycles stimulated by CC, a temporary decline in estradiol levels was apparent. In these cycles, estradiol reached a higher level on cycle day (CD) 7 or 8 compared to cycles without a decline. Such an estradiol decline was seen in only one control cycle. Furthermore, the estradiol levels on CD 7 or 8 appeared to be age-related. We conclude that the estradiol decline in CC-stimulated ovulatory cycles may be a consequence of a sharp rise after CC stimulation, and such a rise may be age-related and coincide with a diminished follicle quality. If this phenomenon is associated with a suboptimal cycle, and so contributes to the suboptimal pregnancy rates after ovulation-induction treatment with clomiphene citrate, is still unknown.

Predictors of chances to conceive in ovulatory patients during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility

The present prospective follow-up study was designed to identify whether clinical, endocrine, or ultrasound characteristics assessed by standardized initial screening of normogonadotropic oligo/amenorrheic infertile patients could predict conception in 160 women who reached ovulation after clomiphene citrate (CC) medication. Additional inclusion criteria were total motile sperm count of the partner above 1 million and a negative history for any tubal disease. Daily CC doses of 50 mg (increasing up to 150 mg in case of absent ovarian response) from cycle days 3-7 were used. First conception (defined as a positive urinary pregnancy test) was the end point for this study. A cumulative conception rate of 73% was reached within 9 CC-induced ovulatory cycles. Patients who did conceive presented more frequently with lower age (P < 0.0001) and amenorrhea (P < 0.05) upon initial screening. In a univariate analysis, patients with elevated initial serum LH concentrations (>7.0 IU/L) had a higher probability of conceiving (P < 0.01). In a multivariate analysis, age and cycle history (oligomenorrhea vs. amenorrhea) were identified as the only significant parameters for prediction of conception. These observations suggest that there is more to be gained from CC ovulation induction in younger women presenting with profound oligomenorrhea or amenorrhea. Screening characteristics involved in the prediction of ovulation after CC medication in normogonadotropic oligo/amenorrheic patients (body weight and hyperandrogenemia, as shown previously) are distinctly different from predictors of conception in ovulatory CC patients (age and the severity of cycle abnormality). This disparity suggests that the FSH threshold (magnitude of FSH required for stimulation of ongoing follicle growth and ovulation) and oocyte quality (chances for conception in ovulatory cycles) may be differentially regulated.

Occupationally related exposures and reduced semen quality: a case-control study

OBJECTIVE

To determine whether there is an association between abnormal semen parameters and occupational exposures to organic solvents, metals, and pesticides.

DESIGN

Case-control study using three case groups based on different cutoff values for semen parameters and one standard reference group.

SETTING

University Hospital Utrecht and University Hospital Rotterdam, the Netherlands.

PATIENT(S)

Male partners of couples having their first consultation at the two infertility clinics (n = 899).

INTERVENTION(S)

Men provided at least one semen sample. Occupational exposure was assessed with use of job-specific questionnaires, a job exposure matrix, and measurements of metals and metabolites of solvents in urine.

MAIN OUTCOME MEASURE(S)

Standard clinical semen analyses were used to define case groups and controls.

RESULT(S)

An association between aromatic solvents and reduced semen quality was demonstrated, irrespective of the exposure assessment method used. The associations were stronger if the case definition was based on stricter cutoff values for semen parameters. Risk estimates were higher if the analysis was restricted to primary infertile men. Exposure to other pollutants at the workplace was not associated with impaired semen quality.

CONCLUSION(S)

The findings indicated an association between aromatic solvent exposure and impaired semen parameters.

Diagnosis of subtle ovulation disorders in subfertile women with regular menstrual cycles: cost-effective clinical practice?

Serial monitoring by plasma progesterone measurement is advised in the literature for fertility work-up, to detect ovulation disturbances in women presenting with regular menstrual cycles. Three strategies to diagnose such 'subtle ovulation disorders' (SOD, defined as anovulation, inadequately timed ovulation or ovulation of a follicle of reduced size in regularly cycling women) were evaluated, in order to investigate costs of such a diagnosis. On the basis of a 'maximal', an 'ultrasound-only', and a 'preselection' strategy, total medical costs and costs including non-medical costs were calculated for each SOD diagnosis. A 'maximal' diagnostic strategy resulted in a total medical cost of ECU 9057 per diagnosis (including non-medical costs ECU 12,787); an 'ultrasound-only' strategy in ECU 4520 (ECU 6791) per diagnosis. By use of a 'preselection' strategy, 4.25% of the women were found to have an SOD, at a cost of ECU 3036 (ECU 6868) for each diagnosis. As the real significance of SOD diagnosis for the prognosis of the patient to become pregnant without treatment remains unclear, and as no randomized trials on treatment effectiveness have as yet been undertaken, it is questionable whether this approach is worthwhile.

[Exposure to pseudo-estrogens and the quality of sperm]

Some synthetic chemicals and natural compounds occurring in vegetables or animal food products mimic endogenous hormones, especially oestrogens, or may have a general action of disturbing hormonal status. It is assumed that intrauterine exposure to these compounds may have an adverse effect on development, differentiation and function of the genital organs of the male foetus. In a worldwide discussion a supposed drop in human sperm quality is related to foetal exposure to chemicals with oestrogen activity. Experimental animal evidence suggests that foetal exposure to compounds with oestrogenic activity may influence reproductive capabilities. In addition chemicals such as diethylstilbestrol (DES) in humans and dichlorodiphenyltrichloroethane (DDT) in wildlife influence the reproductive system. There is no conclusive evidence of decreasing semen quality in general.

Developmental and endocrine aspects of normal ovarian aging

Supplies of follicles are established during early fetal life and decrease exponentially thereafter by a process called atresia. Subfertility only starts at a mean age of about 30-31 years, when the remaining follicle reserve has become a fraction of its original number. Thereafter, a further decrease in both oocyte quantity and quality dictates the subsequent reproductive events including decrease of fertility, increased abortion rate, the end of fertility, the beginning of cycle irregularity and, when almost no follicles are left, the occurrence of menopause. The same remarkable variation of age at menopause almost certainly is also present for the preceding reproductive events. When quantity and quality of antral follicles drop below a critical threshold, there is a subsequent drop in inhibine B resulting in the selective FSH rise at a mean age of 37-38 years. This FSH rise explains the accelerated follicle depletion, the increased proportion of growing follicles reaching the selectable stage, the shortening of the follicular phase and the increased incidence of dizygotic twinning. The concurring decrease of oocyte quality is in line with the increased incidence of abortions and chromosomal aberrations after age 35.

General ageing and ovarian ageing

The age related decrease in female fertility is associated with a decrease in follicle numbers and oocyte quality. Meiotic division errors, mitochondrial DNA mutations and ageing itself have been suggested to play a part in the age associated reduction in oocyte quality. During the past decades several hypothesis have been proposed, trying to explain the underlying mechanisms. However, none of them is yet conclusive. This review will consider the main hypotheses regarding the age related reduction in oocyte quality. This will be reviewed together with recent results of studies analysing a possible relationship between ageing and ovarian ageing. On the basis of our own results and those presented in the literature, it is concluded that ovarian ageing may only be related to specific aspects of general ageing.

Ovarian reserve tests in infertility practice and normal fertile women

The decline in fecundity with the age of the woman is mainly attributed to the loss of follicles from the ovary and a decrease in oocyte quality. Evaluation of the aging status of the ovary in an individual woman has been hampered by a lack of knowledge with regard to the relative contribution of these two factors. Most if not all so called ovarian reserve tests (ORT) reflect indirectly the remaining follicle pool in the ovary. Direct a priori assessment of oocyte quality is not possible to date. In this section the predictive value of several ovarian reserve tests for the outcome of fertility treatment is listed and commented. In addition, the study of several of the ORTs in normal, fertile women is described. From the data presented dynamic testing of the ovarian function by the clomiphene citrate and GnRH agonist stimulation test, as well as static testing by the use of ultrasound based antral follicle counts seem to offer the highest clinical value. Studies performing direct comparison of these tests are needed, as well as analysis of the way these tests should direct decision making in infertility diagnosis and treatment.

Age at menopause as a marker of reproductive ageing

Ages of menopause and of the preceding reproductive events such as the beginning of subfertility and infertility, are likely to be dictated by the process of follicle depletion leading to loss of oocyte quantity and quality. To some extent this process is influenced by lifestyle factors like smoking, and possibly also by the use of oral contraceptives. Genetic factors and possibly also events during intrauterine life, probably play a more important role in the age-dependent decrease of female fertility.

Crossover or parallel design in infertility trials? The discussion continues

OBJECTIVE

To determine whether a crossover design results in a different estimate of treatment effect compared with a parallel design.

DESIGN

With the aid of a computer program, data sets of subfertile patients were simulated under different assumptions. These patients were subjected to 2 treatments that were compared in either a parallel-design or a crossover-design trial. Results were analyzed using logistic regression.

SETTING

University hospital.

PATIENT(S)

Simulated patients of a heterogeneous subfertile population.

INTERVENTION(S)

Two treatment modalities with a pregnancy rate of 10% and of 20% in the first cycle were offered for 6 cycles to simulated heterogeneous populations.

MAIN OUTCOME MEASURE(S)

After 1,000 simulations for each assumption, median pregnancy rates and odds ratios were compared between the crossover- and parallel-design trials.

RESULT(S)

No relevant difference in estimated treatment effect was found between the designs. The crossover design resulted in more pregnancies overall than the parallel design.

CONCLUSION(S)

In infertility research, parallel and crossover designs will lead to about the same results. Although the crossover design showed a slight tendency to overestimate the treatment effect of the most effective treatment, this overestimation is clinically not relevant and is small in relation to the random error. Because of its practical advantages and because more pregnancies are achieved, a crossover design should be the first choice in infertility research.