Onco-fertility and personalized testing for potential for loss of ovarian reserve in patients undergoing chemotherapy: proposed next steps for development of genetic testing to predict changes in ovarian reserve

Pregnancy in classic galactosemia despite undetectable anti-Müllerian hormone

Study question Investigate whether screening for autoimmune etiologies is necessary in women with diminished ovarian reserve (DOR) as recommended in the evaluation of premature ovarian insufficiency (POI). Summary answer Adrenocortical antibodies (ACA) screening can be performed in the evaluation of women with idiopathic DOR, especially those with a family history of autoimmune disease. What is known already Autoimmune disorders are more common in POI than in the general population. The most important association is with autoimmune Addison’s disease. Measurement of ACA and / or 21 OH-A is recommended in every POI patients as they appear to be the marker with the highest diagnostic sensitivity for autoimmune POI. Also thyroid peroxidase autoantibodies (TPO-Ab) should be assayed due to the common association between thyroid disease and POI. The underlying etiologies of DOR in young women can be expected to be similar to the etiology of POI since they represent a continuum in the phenotypic expression of premature ovarian aging. Study design, size, duration This pilot case-control study was conducted between January 2019 and April 2020. The study group consisted of patients under the age of 35, who was diagnosed with idiopathic DOR by ovarian reserve tests during infertility work up. Controls were patients of the same age range who diagnosed with isolated tubal factor or male infertility and had normal ovarian reserve test results during infertility work up. Participants/materials, setting, methods Patients with a history of ovarian surgery, cancer, genetic or autoimmune disease were excluded. Abnormal ovarian reserve tests are defined as antral follicle count < 5 and AMH < 1.2 ng/dl corresponding to group 3 according to POSEIDON criteria. In total, 35 DOR patients and 35 controls were included in the study. ACA and TPO-Ab screening were performed in serum samples using indirect immunofluorescence method. Demographics and family history of autoimmune diseases were also evaluated. Main results and the role of chance A higher rate of ACA positivity was detected in the DOR group (34.3%) compare to controls (17.1%), although it was not found to be statistically significant (p = 0.101). The incidence of family history of autoimmune diseases in first degree relatives was positively correlated with ACA positivity (p = 0.006). In DOR group, autoimmune disease history in the family was significantly higher in ACA (+) patients compared to ACA (-) individuals (p = 0.03). TPO-Ab positivity rates were similar between 2 groups (17.1% vs%20, p = 0.75). Limitations, reasons for caution Since this is an observational study and also due to the small sample size, a causal conclusion cannot be reached. Wider implications of the findings: Even if there is no specific treatment option yet for autoimmune ovarian damage, screening for ACA or 21 OH-A may be considered in young women with idiopathic DOR based on knowledge that identification of women with autoimmune POI is clinically important for the identification of subclinical autoimmune Addison’s cases. Trial registration number non applicable

The impact of immunomodulating drugs on ovarian reserve in multiple sclerosis patients

Background: Autoimmune disorders are more common in premature ovarian insufficiency (POI) than in the general population. The most important association is with autoimmune Addison’s disease. Measurement of adrenocortical antibodies (ACA) and/or 21-hydroxylase antibodies (21-OH) is recommended in every POI patients as they appear to be the marker with the highest diagnostic sensitivity for autoimmune POI. Also thyroid peroxidase autoantibodies (TPO-Ab) should be assayed due to the common association between thyroid disease and POI. The underlying etiologies of diminished ovarian reserve (DOR) in young women can be expected to be similar to the etiology of POI since they represent a continuum in the phenotypic expression of premature ovarian aging. Methods: This pilot case-control study was conducted between January 2019 and April 2020. The study group consisted of patients under the age of 35, who was infertile and diagnosed with idiopathic DOR by ovarian reserve tests during infertility work up. Controls were patients of the same age range who diagnosed with isolated tubal factor or male infertility and had functional ovarian reserve test results during infertility work up. Patients with a history of ovarian surgery, cancer, genetic or autoimmune disease were excluded. Abnormal ovarian reserve tests are defined as antral follicle count <5 and anti-mullerian hormone (AMH) <1.2 ng/dL corresponding to group 3 according to POSEIDON criteria. In total, 35 DOR patients and 35 controls were included in the study. ACA and TPO-Ab screening were performed in serum samples using indirect immunofluorescence method. Demographics and family history of autoimmune diseases were also evaluated. Results: A higher rate of ACA positivity was detected in the DOR group (34.3%) compare to controls (17.1%), although it was not found to be statistically significant (p = 0.101, p < 0.05). The incidence of family history of autoimmune diseases in first degree relatives was positively correlated with ACA positivity (p = 0.006, p < 0.05). In DOR group, autoimmune disease history in the family was significantly higher in ACA (+) patients compared to ACA (–) individuals (p = 0.03, p < 0.05). TPO-Ab positivity rates were similar between 2 groups (17.1% vs 20%, p = 0.759, p < 0.05). Conclusions: Even if there is no specific treatment option yet for autoimmune ovarian damage, screening for ACA or 21-OH antibodies may be considered in young women with idiopathic DOR, especially those with a family history of autoimmune disease, based on knowledge that identification of women with autoimmune POI is clinically important for the identification of subclinical autoimmune Addison’s cases.

Antral follicle count in clinical practice: building the bridge from ovarian reserve to in vitro fertilization outcome

Ovarian reserve in patients with FMR1 gene premutation and the role of fertility preservation

Emergency IVF versus ovarian tissue cryopreservation: decision making in fertility preservation for female cancer patients

Background and study aim: Primary Ovarian insufficiency, which is described by significantly reduced ovarian reserve, menstrual irregularity, or amenorrhea earlier than 40 years of age, affects 1% of women at reproductive age. Recently, platelet-rich plasma (PRP) has been widely used in regenerative treatment in different fields, as it is rich with cytokines and growth factors. Accumulation of platelet in a tissue stimulates cell proliferation and tissue regeneration through protein secretion in response to cytokines, and growth factors. Recently, it has been investigated in the cases of ovarian insufficiency. This study aimed to evaluate whether the intra-ovarian injection of autologous PRP would improve ovarian reserve through ovarian rejuvenation thus causing spontaneous pregnancy or menstrual recovery in women with primary ovarian insufficiency. Patients and Methods: This Quazi-Expermental study was conducted in the department of Obstetrics & Gynecology, Suez Canal University hospital. It was conducted on 38 Women of childbearing period presenting at the outpatient clinic of the Department of Obstetrics and Gynecology complaining of Primary ovarian insufficiency diagnosed according to ESHRE guideline. Results: Our study showed that FSH levels rose considerably, indicating a reduction in ovarian reserve. Although AMH levels remained relatively stable, there was a slight decrease in the median value, which could suggest a potential trend towards diminished reserve. AFC demonstrated a statistically significant decrease, with an increasing number of patients exhibiting 0 or 1 follicle after a two-month period.These results indicate a significant deterioration in ovarian reserve markers over 2 months, especially reflected by a rise in FSH and a drop in AFC. Conclusion: In contrast to previous reports demonstrating improved ovarian reserve markers following PRP treatment, this study did not observe a favorable change in ovarian reserve two months post-intraovarian PRP in women with established POI. The findings underscore the need for longer follow-up, larger sample sizes, and standardization of PRP protocols. Future research should focus on identifying patient subgroups most likely to benefit from PRP and establishing biological markers predictive of response.

The number of follicles present in human ovaries is finite. Ovarian reserve is currently defined as the number and quality of the follicles left in the ovary at any given time. As several novel tests for ovarian reserve, such as anti-Mullerian hormone (AMH) and antral follicle count (AFC), are widely introduced into gynecological practice recently, the knowledge on the physiology of follicular development and mechanism of maintenance of ovarian reserve are rapidly accumulating. Diminished ovarian reserve is a major concern in women with endometriosis-associated infertility. Cystectomy for endometriomas could negatively impact on postoperative ovarian reserve. Some women who had surgery for endometriomas suffer from poor ovarian response, which is directly linked to treatment results in infertility care. In addition, endometriomas themselves may be a cause of diminished ovarian reserve. Chronic inflammation in the local pelvic environment may affect the status of the dormant follicle in the ovarian cortex. Determination of ovarian reserve may serve as an important role in the management of reproductive health issues in women with endometriosis.

Regular menstrual cycling during the reproductive years is an indicator of spontaneous ovulation but sometimes falsely perceived as an indicator of preserved fertility. In contrast, menstrual cycle shortening, a physiologic occurrence preceding the menopausal transition, is not usually perceived as an indicator of decreased ovarian reserve in the general population. The individual decrease in menstrual cycle length (MCL) might represent a sensitive biomarker of diminishing ovarian reserve. The aim of this systematic review and meta-analysis is to examine the possible association between MCL in regularly cycling women (21-35days) and ovarian reserve tests (ORT), fecundability in natural cycles and IVF outcomes. An electronic database search employing PubMed, Web of Science, Trip, EBSCO, ClinicalTrials.gov and the Cochrane library was performed to identify research articles, only on human, published between January 1978 and August 2019. Search terms were pregnancy OR fertility OR fecundity OR fecundability, anti-Müllerian hormone OR AMH OR antral follicle count OR AFC OR ovarian reserve OR ovarian reserve test, in vitro fertilization OR ART OR assisted reproductive therapy OR assisted reproductive treatment OR assisted reproductive technology OR IVF OR ICSI, menstrual cycle length OR menstrual cycle characteristics. We combined these terms to complete the search. All prospective and retrospective studies exploring an association between MCL and proxies of ovarian reserve were included. The exclusions included studies of PCOS, ovarian failure, oral contraception treatment, prior chemotherapy and/or radiotherapy or ovarian surgery. The Newcastle-Ottawa scale was used to assess the quality of studies that were eligible for meta-analysis. Eleven studies were eligible for meta-analysis, including 12 031 women. The included studies had a low risk of bias. Short MCL (21-27days) was associated with lower ORT values as compared to normal (28-31days), long (32-35days) and all other (28-35days) MCL sets. The estimated weighted mean difference (WMD) of AMH level was -1.3ng/mL (95% CI: -1.75 to -0.86, P < 0.001) between the short and normal MCL sets. The estimated WMD of AFC values was -5.17 (95% CI: -5.96 to -4.37, P < 0.001) between the short and normal MCL sets. The weighted overall odds ratio (OR) of fecundability in natural cycles between women with short versus normal MCL sets was statistically significant (overall OR 0.81; 95% CI 0.72-0.91, P < 0.001). In the IVF setting, fewer oocytes were retrieved in short MCL in comparison to normal, long and all other MCL sets, with an estimated WMD of -1.8 oocytes (95% CI: -2.5 to -1.1, P < 0.001) in the short versus normal MCL sets. The weighted overall OR of clinical pregnancy rate between women with short versus all other MCL sets was statistically significant (overall OR 0.76; 95% CI: 0.60 to 0.96, P =0.02). Low levels of heterogeneity were found in most meta-analyses of MCL and qualitative ovarian reserve biomarkers, while heterogeneity was high in meta-analyses performed for quantitative measures. MCL in regularly cycling women is closely related to ovarian reserve biomarkers during the reproductive years. A short MCL, as compared to normal, is significantly associated with lower ORT values, reduced fecundability and inferior IVF outcomes, independent of age. The results imply that short MCL may be a sign of ovarian aging, combining the quantitative and qualitative facets of ovarian reserve. Educational efforts ought to be designed to guide women with short MCL at a young age, who desire children in the future, to seek professional counselling.

Hydroxyurea Is a Potential Risk Factor for Diminished Ovarian Reserve in Young Adults with Sickle Cell Anemia

Does an association exist between high normal numbers of CGG trinucleotide repeats on the fragile X mental retardation 1 (FMR1) gene and diminished ovarian reserve (DOR)? This large data set demonstrated that a high normal number of CGG repeats (35-54 repeats) on the FMR1 gene was not significantly correlated with DOR. The FMR1 premutation (55-200 repeats) is a known cause of primary ovarian insufficiency. However, the relationship between high normal CGG repeat numbers (35-54 repeats) and ovarian reserve has yet to be conclusively demonstrated. This is a retrospective data analysis conducted between January 2012 and February 2014 that included 1287 women. Over 1140 women had complete data. All women, excluding oocyte donors, who presented to a large private practice specializing in reproductive endocrinology and infertility for treatment and who underwent both fragile X and ovarian reserve testing were included. All fragile X testing was performed using triplet repeat PCR, with confirmation of positives by Southern blot. CGG repeat numbers from both alleles were recorded, and the allele with the higher number of repeats was used for statistical calculations. We did not differentiate between patients with one or two high normal alleles. Women with >54 CGG repeats were excluded from the analysis. For our analysis, we considered both a 'high normal' number of CGG repeats (35-44) and an intermediate number of GCC repeats (45-54) as 'high normal'. Ovarian reserve testing was carried out on Cycle Day 2 or 3 and included measurements of FSH, anti-Müllerian hormone (AMH) and antral follicle count (AFC). A generalized linear regression model assuming gamma distribution and log link function that controlled for age was used to assess correlation between CGG repeat number and FSH, AMH and AFC. As expected, there was a significant correlation between increasing age and increasing FSH and decreasing AFC and AMH for the patients in this study. For every 1-year increase in age, FSH increased by a factor of 1.04, AFC decreased by a factor of 0.93 and AMH decreased by a factor of 0.89. After controlling for age, there was no significant correlation between FMR1 CGG trinucleotide repeat number and FSH (P = 0.23), AFC (P = 0.14) or AMH (P = 0.53). Three subgroup analyses were also performed. We found a significant relationship between increasing CGG repeat number and decreasing AMH levels (P = 0.01) in women >44 years old. The second subgroup analysis included only Caucasian patients and found no significant correlation between CGG repeat number and DOR. In a subgroup analysis comparing women with at least one allele <26 repeats, at least one allele >35 and women with both alleles between 29 and 32, there were no significant associations regarding ovarian reserve in any of these groups. One limitation of this study is that it involved a heterogeneous population of infertile women with mixed diagnoses. Factors that could affect ovarian reserve, such as medical comorbidities, prior surgeries, family history and endometriosis, were not accounted for. Finally, there was a lack of racial diversity, with Caucasians representing 67.8% of the total population. The findings of this study are generalizable to an infertility population and are in line with several previously published studies. Women who are found to have high normal CGG repeat numbers can be counseled that this is not causative for DOR. Further studies are needed to investigate whether increasing CGG repeat numbers are associated with ovarian responsiveness to gonadotrophin stimulation or IVF outcome.

Hormonal contraceptives (HCs) are commonly used by reproductive-age women. Long-term HC can transiently suppress ovarian reserve markers such as anti-Müllerian hormone (AMH) and antral follicle count (AFC) across routes and preparations. Suppression can occur within weeks and, in some women, may persist for several months after cessation, resulting in false positive diagnoses of diminished ovarian reserve (DOR) or primary ovarian insufficiency (POI). In this Brief Communications piece, we highlight the challenges of accurately assessing ovarian reserve in long-term HC users and provide strategies to avoid erroneous diagnoses of DOR and POI, thereby mitigating unnecessary patient anxiety and financial cost.

Study question Are young infertile patients with diminished ovarian reserve (DOR) elegible to perform the FMR1 premutation study? Summary answer Study of the FMR1 premutation should be considered in infertile young patients with DOR in order to give them an adequate genetic counselling. What is known already FMR1 gene may have some reproductive implications. Most notable is that FMR1 premutation expansions are associated with premature ovarian insufficiency (POI), diagnosed by amenorrhea or oligomenorrhea and FSH hormonal levels &amp;gt;25U/L before 40 years old. Presence of FMR1 premutation implies a risk of develop POI up to 24% and having an offspring with fragile X syndrome. The frequency of FMR1 premutation in general population is estimated in 0.3-0.7%. The role of FMR1 premutation expansions in diminished ovarian reserve (DOR) patients is not clearly established and could be considered as a previous step to POI that may be related to sterility. Study design, size, duration Retrospective review of the FMR1 gene study requested in patients of an Assisted Reproduction Unit of a tertiary Hospital in Barcelone from January-2016 to December-2019. A total of 307 cases were evaluated to determine the number of CGG repeat and AGG interruptions to assess the FMR1 gene status. Participants/materials, setting, methods A total of 307 samples were assessed. Clinical and reproductive data were collected. The FMR1 status was requested on patients who present: a) POI (n = 60); b) Family history of the FMR1 mutation (n = 11); c) Infertile normo-ovulatory and young (≤35 years old) women with DOR defined as antral follicle count (AFC) &amp;lt; 7 and antimüllerian hormone &amp;lt;0.8ng/ml (n = 71); d) Miscellaneous (n = 29) FMR1 was studied in 136 oocyte donors (screened by protocol), this was considered control group. Main results and the role of chance Mean age (±SD) of infertile DOR group was 32.7 +/- 2.1 years old (range 26-35) and showed altered ovarian reserve markers: AMH 0.43 ng/ml (SD ± 0.28) and AFC 4.27 (SD ± 2.1) follicles. In this group, 4 FMR1 premutation cases were found. Mean age (±SD) in control group was 26.28 +/- 5.2 years old and presented normal AMH and AFC values. One FRM1 premutation carrier was detected among 136 patients, prevalence comparable to the non-sterile population. The prevalence of FRM1 premutation was significantly higher in the DOR infertile group 5,6% vs 0,73% in the donors’ group (p = 0.02). Significant differences were observed also in terms of age and ovarian reserve markers between both groups. Very few cases of POI patients or family history of Fragile X Syndrome have been evaluated, due to the fact we are not a reference of these kind of patients. Among patients with a family history, 1 case from 11 (9.1%) was detected. In the POI group, three cases of premutation out of 60 (5%) were found. Limitations, reasons for caution This is a retrospective study with limited determinations of FMR1 studies. Donor screening and young infertile patients with significant low ovarian reserve are the main indications to request FMR1 status gene, so may lead to a selection bias. Wider implications of the findings These results should be confirmed prospectively in a higher population of infertile young patients with DOR, in order to identify the profile of infertile patient with diminished ovarian reserve who are elegible to perfom FMR1 gene premutation to give them an adequate clinical and genetic counselling. Trial registration number not apllicable

Childhood and adolescent cancer survivors (CACSs) are at risk of adverse reproductive outcomes. Assessment of follicle-stimulating hormone (FSH) levels is the most common test used to diagnose premature ovarian insufficiency (POI) whereas anti-m|llerian hormone (AMH) and antral follicle count (AFC) have been proposed as ovarian reserve markers. We assessed the correlation between these markers and treatment gonadotoxicity risk (GR) in CACSs. A total of 55 female CACSs were enrolled. GR was graded as low, medium, or high according to classifications based on disease and treatments and on cyclophosphamide equivalent dose score. FSH, AMH, and AFC were determined. POI was defined by amenorrhea and FSH>30 IU/L. For remaining patients, diminished ovarian reserve (DOR) was defined by AMH<5th centile. FSH and AFC cut-offs proposed in the literature as DOR markers were also considered (FSH>10 IU/L or >95th centile; AFC<8 or <5th centile). Ovarian reserve results to be compromised in 23 (41.8%) patients: 14 with DOR and 9 with an established POI. Results showed GR classifications to be a good predictor of ovarian reserve, with significantly lower AMH and AFC in the high-risk groups. AFC resulted to be directly correlated with AMH (r=0.75, p<0.001). In CACSs, GR classifications correlate with post-treatment AMH and AFC. These are useful tools in the early identification of young patients with DOR, who may benefit from reproductive and fertility preservation counseling. Further studies are needed to determine the rate and time of progression from DOR to POI in this population.