Marker Of Ovarian Function Research Articles

Conditional loss of Brca1 in oocytes causes reduced litter size, ovarian reserve depletion and impaired oocyte in vitro maturation with advanced reproductive age in mice

An estimated 1 in 350 women carry germline BRCA1/2 mutations, which confer an increased risk of developing breast and ovarian cancer, and may also contribute to subfertility. All mature, sex steroid-producing ovarian follicles are drawn from the pool of non-renewable primordial follicles, termed the 'ovarian reserve'. The clinical implications of early ovarian reserve exhaustion extend beyond infertility, to include the long-term adverse health consequences of loss of endocrine function and premature menopause. We aimed to determine whether conditional loss of Brca1 in oocytes impacts ovarian follicle numbers, oocyte quality and fertility in mice with advancing maternal age. We also aimed to determine the utility of AMH as a marker of ovarian function, by assessing circulating AMH levels in mice and women with BRCA1/2 mutations, and correlating this with ovarian follicle counts. In this study, we addressed a longstanding question in the field regarding the functional consequences of BRCA1 inactivation in oocytes. To recapitulate loss of BRCA1 protein function in oocytes, we generated mice with conditional gene deletion of Brca1 in oocytes using Gdf9-Cre recombinase (WT: Brca1fl/flGdf9+/+; cKO: Brca1fl/flGdf9cre/+). While the length of the fertile lifespan was not altered between groups after a comprehensive breeding trial, conditional loss of Brca1 in oocytes led to reduced litter size in female mice. Brca1 cKO animals had a reduced ovarian reserve and oocyte maturation was impaired with advanced maternal age at postnatal day (PN)300, compared to WT animals. Serum anti-Müllerian hormone (AMH) concentrations (the gold-standard indirect marker of the ovarian reserve used in clinical practice) were not predictive of reduced primordial follicle number in Brca1 cKO mice versus WT. Furthermore, we found no correlation between follicle number or density and serum AMH concentrations in matched samples from a small cohort of premenopausal women with BRCA1/2 mutations. Together, our data demonstrate that BRCA1 is a key regulator of oocyte number and quality in females and suggest that caution should be used in relying on AMH as a reliable marker of the ovarian reserve in this context. This work was made possible through Victorian State Government Operational Infrastructure Support and Australian Government NHMRC IRIISS. This work was supported by funding from the Australian Research Council (ALW - DE21010037 and KJH - FT190100265), as well as the National Breast Cancer Foundation (IIRS-22-092) awarded to ALW and KJH. LRA, YML, LT, EOKS and MG were supported by Australian Government Research Training Program Scholarships. LRA, YML and LT were also supported by a Monash Graduate Excellence Scholarship. YC, SG and XC were supported by Monash Biomedicine Discovery Institute PhD Scholarships. LRA was also supported by a Monash University ECPF24-6809920940 Fellowship. JMS was supported by NHMRC funding (2011299). MH was supported by an NHMRC Investigator Grant (1193838).

P-351 Reproductive outcomes in a cohort of lymphoma patients

Abstract Study question What are the reproductive outcomes in women with malignant lymphoma Hodgkins (HD) and non-Hodgkins (NH) from a single, experienced center? Summary answer 74 children were born to 43 women (28 with HD, 15 with NH) giving a live birth rate (LBR) of 81% and 72%, respectively. What is known already The risk of premature ovarian insufficiency (POI) after HD and NH is related to female age, type and dose of gonadotoxic treatment. Where ABVD regimens in HD patients and CHOEP regimens in most young NH patients, rarely results in POI and reduced fertility, treatment with BEACOPP or BEAM and stem cell transplantation seems to be associated with a much higher risk of ovarian failure. However, studies are heterogeneous and there is still a need for studies with structural follow up on repeated measurements of ovarian function markers in relation to clinical outcomes. Study design, size, duration This cohort study was conducted as a single center study at the fertility clinic in a large public Danish university hospital. Data was collected retrospectively from medical records from 1999 to 2020 and prospectively from 2020 to 2023. We included all female patients with HD (n = 63) and NH (n = 32), who were referred to our clinic for fertility preservation between 1999 and 2022. End of follow up was December 31st, 2023. Participants/materials, setting, methods Age at referral ranged from 14 to 33 years. Information about diagnoses, gonadotoxic treatment, gynecologic (including endocrine parameters) and obstetric history was retrieved from medical records. Permission to obtain retrospective data from 1999 to 2020 was given by the Danish Patient Safety Authorities (jrn 3-3013-2790/1) and prospective data collection was given by informed consent from the patients from 2020 and onwards. Main results and the role of chance 33% of patients with HD had ABVD only, and the remaining BEACOPP or other high-dose alkylating regimens. 72% of patients with NH had CHOEP, and the rest other high-dose alkylating regimens. 78/95 women had fertility preservation. Of these, 95% had ovarian tissue cryopreservation (OTC), 5% had IVF with vitrification of oocytes or embryos. Following chemotherapy 33 women (52%) with HD and 18 (56%) with NH became pregnant. Of these, 28 women with HD had 51 deliveries, and 15 with NH had 23 deliveries. The LBR was 0,81 for HD and 0,72 for NH. For HD patients, 54% of the deliveries were achieved by women who had ABVD compared to about 40% after other high-dose alkylating regimens. For NH patients, 73% of deliveries were achieved by women who had CHOEP compared to 13% after other high-dose alkylating regimens. Most pregnancies were conceived spontaneously. A total of 15/74 women had ovarian tissue transplantation (OTT). Of these, 7 women with HD became pregnant resulting in 4 deliveries, and 4 women with NH became pregnant resulting in 2 deliveries giving an overall pregnancy rate of 73% in this group of women and a LBR of 40%. Limitations, reasons for caution This study is based on information from medical records in public Danish hospitals, containing information on all deliveries. Pregnancies and deliveries outside of Denmark might therefore not be included. Furthermore, for some women the follow-up period was only one year, which could underestimate the fertility in this group of patients. Wider implications of the findings This study shows a reassuringly high rate of spontaneous pregnancies in female survivors of malignant lymphomas. Only 20% of the women have so far used their tissue stored before chemotherapy. Current results might question whether we overtreat our lymphoma patients by offering OTC to the majority Trial registration number not applicable

Long-Term Ovarian Function Assessment After Haematopoietic Stem Cell Transplantation in Female Sickle Cell Anaemia Survivors.

Haematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for sickle cell anaemia (SCA). While HSCT offers the possibility of disease remission, it can also lead to long-term complications, including gonadal dysfunction and premature menopause. We conducted a retrospective cohort study of female survivors who had hydroxyurea therapy and those who underwent post-HSCT follow-up for SCA at a teaching hospital in Lagos, Nigeria, between January 2019 and December 2022. Participants were eligible if they were at least five years post-HSCT or hydroxyurea treatment and had available serum samples for markers of ovarian function measurement. Demographic and clinical data were collected from the hospital register and patients' medical records. Serum levels of oestradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and anti-Müllerian hormone (AMH) were measured using the Abbott Architect i1000SR chemiluminescent immunoassay analyzer (Abbott Diagnostics, Abbott Park, IL). Descriptive statistics and inferential analyses were used to assess the relationship between markers of ovarian function (FSH and AMH) and clinical parameters. There were statistically significant differences in the median serum levels of all the assessed endocrine hormones between the HSCT and non-HSCT (hydroxyurea) groups of SCA survivors. Up to 82.6% of the SCA survivors experienced ovarian dysfunction after HSCT treatment. Impaired ovarian function in SCA survivors was associated with a longer median follow-up duration than in SCA survivors who had normal ovarian function (12.0 vs. 7.5 years, p = 0.048). There were higher odds of impaired ovarian function in the SCA survivors who had myeloablative regimens than in those who had reduced intensity conditioning regimens (94.1% vs. 50.0%, p = 0.040). Our study highlights the significant impact of HSCT on long-term ovarian function in female SCA survivors. However, further prospective studies with larger sample sizes and longer follow-up periods are required to confirm our findings and elucidate the factors influencing ovarian function in SCA survivors of HSCT. In addition, studies are also needed to further elucidate the optimal transplant protocols and fertility preservation strategies to minimize gonadal toxicity and preserve reproductive potential in female SCA patients undergoing HSCT.

AMH and other markers of ovarian function in patients with Turner syndrome - a single center experience of transition from pediatric to gynecological follow up.

Turner syndrome (TS) is a chromosomal disorder that affects about 1 in 2500 female births and is characterized by the partial or complete absence of the second X chromosome. Depending on karyotype, TS is associated with primary ovarian insufficiency (POI). Approximately 50% of girls with a mosaic 45, X/46, XX karyotype may enter puberty spontaneously, but only 5-10% of women with TS achieve pregnancy without egg donation. In this review, we will evaluate the clinical use of markers of ovarian function in TS patients. Based on longitudinal studies of serum concentrations of reproductive hormones as well as ovarian morphology in healthy females and patients with TS, we will evaluate how they can be applied in a clinical setting. This is important when counseling patients and their families about future ovarian function essential for pubertal development and fertility. Furthermore, we will report on 20 years of experience of transition from pediatric to gynecological and adult endocrinological care in our center at Rigshospitalet, Copenhagen, Denmark.

Sleep symptoms signaling the menopausal transition.

To describe changes in sleep quality and associated sleep symptoms as women begin menopausal transition compared with premenopausal controls. In a repeated-measures design, we analyzed data collected every 2-6 months from a community-based sample of 223 women aged 40-50 (45.6 ± 2.3) years old over a 2-year period. Each 6-month visit included urinary follicle-stimulating hormone (FSH) as a marker of ovarian function and the Pittsburgh Sleep Quality Index (PSQI) and other questionnaires (Center for Epidemiological Studies-Depression Scale; Perceived Stress Scale). Menstrual cycle and vasomotor symptoms (Seattle Women's Health Symptom Checklist) were tracked every 2 months by phone. For women entering menopausal transition (n = 68) we used data from the two consecutive visits prior to their FSH rise and the next two visits. Data from the last four consecutive visits were used for controls remaining premenopausal (n = 155). The transition group did not differ from controls on age, vasomotor symptoms (hot flashes/night sweats), stress, or depression but did have a higher body mass index. Measures were stable over time for controls. However, the transition group experienced an increase in PSQI scores (initial PSQI = 5.7 ± 3.2 and final PSQI = 6.3 ± 3.8; P = .030) and frequency of trouble sleeping because of feeling too hot (P = .016), which lagged the FSH rise by 6 months with no notable change in report of hot flashes/night sweats. Trouble sleeping because of feeling too hot, distinct from awareness of vasomotor symptoms, was the only uniform contribution to higher PSQI scores after the initial FSH increase and may signal the onset of the menopausal transition. Zak R, Zitser J, Jones HJ, Gilliss CL, Lee KA. Sleep symptoms signaling the menopausal transition. J Clin Sleep Med. 2023;19(8):1513-1521.

Serum GDF9 and BMP15 as potential markers of ovarian function in women with and without polycystic ovary syndrome.

Growth differentiation factor-9 (GDF9) and bone morphogenetic protein-15 (BMP15) are critical paracrine regulators of female fertility and are predominantly expressed by oocytes. However, it is unknown if serum concentrations reflect changes in ovarian function and/or reproductive endocrine disorders. This study aimed to determine if serum GDF9/BMP15 are associated with ovarian, pituitary, oestrogenic, androgenic and metabolic characteristics and the ovarian pathologies, polycystic ovarian morphology (PCOM) and polycystic ovary syndrome (PCOS). Women aged 21-45 years (n = 381) were included from a cross-sectional study at the National University Hospital, Singapore. Participants were volunteers and patients with possible PCOS. Anthropometric measurements, transvaginal ultrasound scans and serum sampling were performed and a questionnairecompleted. Serum GDF9 and BMP15 concentrations were matched with menstrual cycle length, ovarian protein and steroid hormone production, pituitary hormone production and metabolic assessments in women with PCOM or PCOS and those with neither (control). Serum GDF9 and BMP15 were detectable in 40% and 41% of women, respectively and were positively correlated with each other (r = 0.08, p = 0.003). GDF9, but not BMP15, was positively correlated with ovarian volume (p = 0.02) and antral follicle count(AFC) (p = 0.004), but not with anti-Müllerian hormone(p = 0.05). However, serum GDF9 and BMP15 concentrations were not significantly different between control, PCOM and PCOS women, nor associated with androgenic or metabolic PCOS features. However, the relationship between GDF9 and AFC differed between control, PCOM and PCOS women (p = 0.02). Serum GDF9 and BMP15 concentrations somewhat reflect ovarian but not androgenic or metabolic characteristics of PCOS, with increased GDF9 reflecting high AFC as seen in PCOM/PCOS.

Clinical Utilities of Anti-Müllerian Hormone

The anti-Müllerian hormone (AMH) plays an essential role in sex determination in early embryonic development. Through a series of sequential steps that follows inheriting an XY chromosome, Sertoli cell differentiation upregulates the expression of AMH-suppressing Müllerian duct development and maintains the AMH at a high level until puberty. In females, the AMH is produced by granulosa cells of follicles beginning in the second half of fetal life and continues through adulthood, with a steady decline through the reproductive years and severe decline at menopause, until levels eventually become undetectable. The AMH is essential for the regulation of follicular maturation via the recruitment of primordial follicles throughout folliculogenesis. AMH serum concentration in women strongly correlates with ovarian reserve quantity and reflects ovulation potential. Because the AMH is expressed almost exclusively by growing follicles before FSH-dependent selection, it commonly serves as a marker for ovarian function in various clinical situations, including in the diagnosis and pathogenesis of polycystic ovarian syndrome, artificial reproductive technology, and predictions of menopause or premature ovarian failure.

Mixtures of persistent organic pollutants and ovarian function in women undergoing IVF

Research questionDo internal levels of persistent organic pollutants (POP) in serum and follicular fluid affect ovarian function of women attending IVF? DesignThis cohort study included 136 women undergoing IVF in the assisted reproductive technology (ART) service of University Hospital from Nantes (France). Representative POP were measured using gas and liquid chromatography coupled with tandem mass spectrometry. Polyfluoroalkylated and perfluoroalkylated substances were measured in serum and polychlorinated biphenyls and organochlorinated pesticides in follicular fluid. Statistical associations between POP and ovarian reserve markers (anti-Müllerian Hormone [AMH] and antral follicle count [AFC], and ovarian responsiveness markers (Ovarian Sensitivity Index [OSI] and Follicular Output RaTe [FORT]), were explored in single and multipollutant regression models. ResultsTwenty-seven out of 53 POP congeners were frequently detected in almost all women attending IVF. Adjusted models did not show statistically significant associations between POP and ovarian reserve markers. Positive associations were found between some POP, i.e. hexachlorobenzene with FORT (β 0.42, 95% CI 0.13 to 0.71, P = 0.005) or PCB52 with Ovarian Sensitivity Index (β 0.22; 95% CI, 0.07 to 0.38, P = 0.005). Negative associations between some polyfluoroalkylated and perfluoroalkylated substances, PCB189 and trans-nonachlor with AFC and AMH were found among current smokers. ConclusionsGlobally, associations between POP and the markers of ovarian function or responsiveness were lacking. Nonetheless, the stratification analysis suggested that current smoking could be a risk modifier, and extension of the study to a larger population sample size is needed.

Serum GDF9 and BMP15 as Markers of Ovarian Function in Healthy Women and Women with Polycystic Ovary Syndrome

Background: The oocyte-secreted factors growth differentiation factor-9 (GDF9) and bone morphogenetic protein-15 (BMP15) are key regulators of female fertility and are predominantly expressed by oocytes. Recently, methods to quantitate these proteins in serum have demonstrated diagnostic potential. It is unknown if concentrations reflect ovarian and endocrine function, particularly in women with polycystic ovary syndrome (PCOS), where GDF9/BMP15 function is suggested to be aberrant. Aim: To determine if serum GDF9/BMP15 are associated with ovarian and endocrine parameters, and the ovarian pathologies, PCOM and PCOS. Method: Women aged 21-45 years (n=381) were from a cross-sectional study at the National University Hospital, Singapore, including healthy volunteers and referrals from gynecological clinics. Transvaginal ultrasound scans, blood tests and questionnaire were performed. Serum GDF9 and BMP15 were assessed relative to ovarian (cycle regularity, ovarian volume, AFC, AMH) and androgenic (testosterone, DHT, androstenedione, DHEAS, SHBG, mFG score) characteristics. PCOM and PCOS were determined using the Rotterdam criteria. Statistical analyses used parametric survival models and Kendall’s tau correlation appropriate for data containing values below the limit of detection. Results: Serum GDF9 and BMP15 were detectable in 40% and 41% of women, respectively. Serum GDF9 positively correlated with ovarian volume (p=0.02), AFC (p=0.004), and weakly with AMH (p=0.05). Furthermore, irregular menstrual cycles were associated with high GDF9 (p=0.005), and similar, although non-significant associations were seen for BMP15. When stratified into PCOS (n=130), PCOM (n=59), and control (n=192), GDF9 and BMP15 concentrations were not significantly different, and were not associated with the majority of androgenic features of PCOS. However, the relationship between GDF9 and AFC was significantly different between PCOM, PCOS and control women (p=0.02). Conclusion: These results suggest that serum GDF9 and BMP15 reflect ovarian characteristics but not androgenic characteristics of PCOS, and that the relationships between GDF9 and AFC may be aberrant in women with PCOM/PCOS.

Comparison of serum c-type natriuretic peptide levels in different genders: A pilot study

OBJECTIVE
 Firstly we aimed to compare serum C-type natriuretic peptide (CNP) levels in healthy male and female participants of similar age group and secondly to reveal the relationship between serum CNP values and ovarian function markers in women and sperm parameters in men.
 MATERIAL and METHODS
 In this prospective study, a total of 40 patients, who were admitted to the Department of Obstetrics and Gynecology at Near East University Hospital were included. Of these, 20 were female and 20 were male participants. Serum CNP levels of the patients were analyzed for all participants. Day 3 serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) for female participants and semen samples after 3-5 days of sexual abstinence for male participants were evaluated.
 RESULTS
 Serum CNP levels were similar in both genders. There was only a moderate, but statistically insignificant negative correlation between serum CNP and FSH in female group. In the correlation analysis performed in the male group, no significant correlation was observed between serum CNP level and any semen analysis parameter.
 CONCLUSION
 We showed that serum CNP levels were similar between healthy women and men. There was no relationship between levels of serum CNP and reproductive hormones in the early follicular phase of menstruation in women, and semen parameters in men.

Abstract P5-19-03: What are the barriers to assessment of ovarian toxicity in breast cancer clinical trials?

Abstract Background Toxicity data are routinely collected in phase 3 (neo)adjuvant breast cancer (BC) clinical trials, but ovarian toxicity is infrequently assessed, despite its impact on fertility and long-term health. Thus, little is known about the ovarian effects of newer BC therapies. This results in an information gap for women when making treatment decisions. We explored the barriers to collecting ovarian toxicity data and/or including ovarian function as an endpoint in BC trials of anti-cancer drugs. Methods Semi structured interviews were conducted with key stakeholders involved in BC clinical trials (clinicians, consumers, pharmaceutical companies, drug regulatory advisors). Participants were asked detailed questions about how trial endpoints are selected, whether effects on the ovary are assessed, and barriers to and benefits of collecting ovarian function data to assess ovarian toxicity. Interviews were transcribed verbatim, coded in NVivo software and analysed using inductive thematic analysis. Results Saturation was reached after 25 interviews (9 clinicians, 7 consumers, 5 drug regulatory advisors, 4 pharmaceutical company advisors); half were female. Participants were from North America (20%), Europe (52%), Australia (24%), Asia (4%). Median age was 50 years and median time in breast cancer research or drug regulation was 16 years. The main reported barrier to the collection of ovarian toxicity data in clinical trials was that this issue was rarely considered. Reasons included that these data are considered less important than survival data and are not required for regulatory approval. Other barriers included limited resources, lack of knowledge regarding how to assess ovarian side effects and lack of relevance in certain settings (further detail in Table 1). Most participants believed assessing ovarian toxicity in trials would be beneficial to clinicians and to patients (eg. assisting treatment and family planning decisions). Strategies to increase ovarian toxicity assessment included its inclusion in clinical trial design guidelines, improving familiarity with ovarian function markers among trial design decision makers, and increased stakeholder interest. A stronger consumer voice and regulatory and clinician advocacy were regarded as important. Regarding trial endpoint selection, pharmaceutical companies were almost always identified as the main decision maker, but clinicians including cooperative trial group researchers, consumers, regulators, and statisticians were also important contributors. While most consumers and pharmaceutical company advisors felt clinicians and consumers influenced trial design, in contrast, some clinicians and regulators reported consumers and clinicians had little influence. Factors identified as important considerations in determining trial endpoints included the main goal of the trial (eg. regulatory approval), established standardised endpoints, resources, and the investigational agent studied. All pharmaceutical advisors reported that meeting the requirements for regulatory approval was the major factor considered during endpoint selection. Conclusion This qualitative analysis evaluates the barriers to including measures of ovarian function in BC clinical trials. Increased awareness, stronger advocacy and guidelines might lead to more frequent inclusion of this important endpoint in future trials that include premenopausal women with early BC. Table 1.Emergent themes regarding ovarian toxicity assessment in BC trialsThemeDomainCategory 1: Barriers to assessment of ovarian function Not prioritisedNot discussed or thought about;Not the primary question studied by clinical trial;Less important than other endpoints/data;Not required for regulatory approval;Data not related to survival is infrequently published;More appropriate for a follow up/registry studyToo resource intensive A burden on investigators and patients;Difficult to collect good quality data;Assessment not considered feasible;Time to obtaining results too long;Too costlyLack of knowledgeLack of clinician knowledge regarding ovarian function side effects;Lack of consensus regarding which markers to assess;Lack of preclinical data suggestive of ovarian toxicityData not relevant in certain settingsConcurrent use of gonadotoxic chemotherapy;Trials mandate contraception use;Want to suppress ovarian function in some breast cancer phenotypes;Low numbers of premenopausal women enrolled;Investigational agent already known to cause ovarian toxicity/suppressionCategory 2: Perceived benefits of assessing ovarian function Data important to patientsImproved ability to make informed cancer treatment decisions;Improved ability to make fertility and ovarian preservation decisions;Infertility and early menopause are relevant and important to patients;Preservation of ovarian function is important for quality of life;To avoid potential harm to patientsData important to cliniciansImproved ability to counsel patients;Improved understanding of the investigational agent;Improved understanding of the impact of ovarian function on disease outcomes;Holistic understanding of a patient’s experience on treatment;Prospective information is more robust than retrospective dataCategory 3: Strategies to improve inclusionIncreased stakeholder interestIncreased clinician advocacy;Increased consumer voice;Increased regulatory buy in;Increased cooperative trial group interest;Increased reproductive specialist involvement;Increased pharmaceutical company interestIncreased awareness regarding ovarian function and onco-fertilityTrial design guidelines and recommendations;Increased discussion and education;Improved familiarity with ovarian markers and ease of incorporation/collection;Use of social media and internet resources Citation Format: Wanyuan Cui, Kelly-Anne Phillips, Prudence A Francis, Sherene Loi, Richard A Anderson, Ann H Partridge, Louise A Keogh. What are the barriers to assessment of ovarian toxicity in breast cancer clinical trials? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-19-03.

Serum level of Total Antioxidant Status and Malondialdehyde in the Patients with Polycystic Ovarian Syndrome: a Comparative Study

Background: Polycystic ovary syndrome (PCOS) is a complex endocrine disorder in women of reproductive age and a major cause of infertility. Anti- Mullerian Hormone (AMH), a valid marker of ovarian function, is used for the diagnosis of PCOS. The aim of this study is to assess the serum level of total antioxidant status (TAS) and malondialdehyde (MDA) in the premenopausal women with PCOS. 
 Methods: A cross-sectional analytical study was conducted at Padmashree Diagnostics, Department of Gynecology, India from April 2016 to March 2017. Census method was used to select the samples. The oxidative stress was measured by measuring the level of TAS and MDA. The data was recorded in structured proforma and and enter in SPSS version 16.0. The data were expressed in frequency, percentage, mean and standard deviation and the results obtained were analyzed using pearson’s correlation and student’s t-test. The p-value less than 0.05 was taken as statistically significant.
 Results: The measured serum AMH level among the patients with PCOS was within normal range in 67.5% (27) and above normal range in 32.5% (13). The serum TAS level in normal AMH group was 814.0 + 291 µMol/L and in above normal range group was 720 + 240 µMol/L, (p <0.001). Similarly, the serum level of MDA in normal AMH group was 6.64 + 0.21 µMol/L, and in above normal range group was 8.78 + 0.22 µMol/L (p = 0.01). The measured level of AMH was significantly associated with the increased level of MDA (p<0.001) and decreased level of TAS (p<0.001). The measured MDA level in high AMH group did show statistically significant than the normal AMH group.
 Conclusions: Serum level of TAS and MDA along with AMH are valuable diagnostic biomarker for the diagnosis of PCOS in the resource poor settings where ultrasound facility is unavailable.

SERUM ANTI-MÜLLERIAN HORMONE CONCENTRATIONS IMPACTS NOT ONLY THE QUANTITY, BUT ALSO THE QUALITY OF THE OVARIAN RESERVE: THE IMPORTANCE OF TIME-LAPSE IMAGING SYSTEM

Serum anti-müllerian hormone (AMH) concentration has been implicated as the most valuable marker of the ovarian reserve, as it correlates highly with the baseline antral follicle count. The AMH has been assigned as a marker of ovarian function mainly in the assessment of the quantitative aspect of the ovarian reserve. On the other side, the predictive value of AMH on oocyte quality and embryo developmental competence is controversial. Time-lapse imaging (TLI) systems allow for the assessment of morphological changes with the exact time-point of occurrence, and may be a valuable tool to evaluate the correlation between serum AMH concentration and the competences of both oocyte and developing embryo. The goal for the present study was to evaluate whether the serum AMH concentration impacts morphokinetic events in a TLI system. This retrospective cohort study was performed in a private university-affiliated IVF center from March 2019 to December 2020 and included 902 injected oocytes from 114 ICSI cycles, cultured in a TLI incubator until the fifth day of development. The effects of serum AMH concentrations on morphokinetic events and ICSI outcomes were evaluated by taking into account clustering of data (multiple embryos per cycle), using generalized mixed models. Evaluated kinetic markers were: pronuclei appearance (tPNa), timing to pronuclei fading (tPNf), timing to two (t2), three (t3), four (t4), five (t5), six (t6), seven (t7), and eight cells (t8), and timing to blastulation (tB). Durations of the second (t3-t2) and third (t5-t3) cell cycles (cc2 and cc3, respectively) and timing to complete synchronous divisions s1 (t2-tPNf), s2 (t4-t3), and s3 (t8-t5) were also evaluated. The post hoc achieved power was > 98.0%. Inverse relationships were observed between serum AMH concentrations and faster tPNf (B: -0.047, CI: -0.071 – -0.024, p<0.001), t3 (B: -0.070, CI: -0.102 – -0.039, p<0.001), t4 (B: -0.080, CI: -0.114 – -0.046, p<0.001), t5 (B: -0.075, CI: -0.123 – -0.028, p=0.002), t6 (B: -0.105, CI: -0.147 – -0.064, p<0.001), t7 (B: -0.120, CI: -0.165 – -0.075, p<0.001), t8 (B: -0.170, CI: -0.220 – -0.119, p<0.001), and tB (B: -0.153, CI: -0.224 – -0.082, p<0.001), cc2 (B: -0.041, CI: -0.062 – -0.019, p<0.001), and s3 (B: -0.086, CI: -0.129 - -0.044, p<0.001). There was a positive association between serum AMH concentration and implantation rate (B: -19.11, CI: -29.12 - -9.11, p<0.001). No significant associations were found between serum AMH concentrations and other morphokinetic parameters or clinical outcomes. Increased serum AMH concentrations correlate with faster embryo development in a TLI incubator and implantation rates.

Possible modification of BRSK1 on the risk of alkylating chemotherapy-related reduced ovarian function.

STUDY QUESTIONDo genetic variations in the DNA damage response pathway modify the adverse effect of alkylating agents on ovarian function in female childhood cancer survivors (CCS)?SUMMARY ANSWERFemale CCS carrying a common BR serine/threonine kinase 1 (BRSK1) gene variant appear to be at 2.5-fold increased odds of reduced ovarian function after treatment with high doses of alkylating chemotherapy.WHAT IS KNOWN ALREADYFemale CCS show large inter-individual variability in the impact of DNA-damaging alkylating chemotherapy, given as treatment of childhood cancer, on adult ovarian function. Genetic variants in DNA repair genes affecting ovarian function might explain this variability.STUDY DESIGN, SIZE, DURATIONCCS for the discovery cohort were identified from the Dutch Childhood Oncology Group (DCOG) LATER VEVO-study, a multi-centre retrospective cohort study evaluating fertility, ovarian reserve and risk of premature menopause among adult female 5-year survivors of childhood cancer. Female 5-year CCS, diagnosed with cancer and treated with chemotherapy before the age of 25 years, and aged 18 years or older at time of study were enrolled in the current study. Results from the discovery Dutch DCOG-LATER VEVO cohort (n = 285) were validated in the pan-European PanCareLIFE (n = 465) and the USA-based St. Jude Lifetime Cohort (n = 391).PARTICIPANTS/MATERIALS, SETTING, METHODSTo evaluate ovarian function, anti-Müllerian hormone (AMH) levels were assessed in both the discovery cohort and the replication cohorts. Using additive genetic models in linear and logistic regression, five genetic variants involved in DNA damage response were analysed in relation to cyclophosphamide equivalent dose (CED) score and their impact on ovarian function. Results were then examined using fixed-effect meta-analysis.MAIN RESULTS AND THE ROLE OF CHANCEMeta-analysis across the three independent cohorts showed a significant interaction effect (P = 3.0 × 10−4) between rs11668344 of BRSK1 (allele frequency = 0.34) among CCS treated with high-dose alkylating agents (CED score ≥8000 mg/m2), resulting in a 2.5-fold increased odds of a reduced ovarian function (lowest AMH tertile) for CCS carrying one G allele compared to CCS without this allele (odds ratio genotype AA: 2.01 vs AG: 5.00).LIMITATIONS, REASONS FOR CAUTIONWhile low AMH levels can also identify poor responders in assisted reproductive technology, it needs to be emphasized that AMH remains a surrogate marker of ovarian function.WIDER IMPLICATIONS OF THE FINDINGSFurther research, validating our findings and identifying additional risk-contributing genetic variants, may enable individualized counselling regarding treatment-related risks and necessity of fertility preservation procedures in girls with cancer.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by the PanCareLIFE project that has received funding from the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement no 602030. In addition, the DCOG-LATER VEVO study was funded by the Dutch Cancer Society (Grant no. VU 2006-3622) and by the Children Cancer Free Foundation (Project no. 20) and the St Jude Lifetime cohort study by NCI U01 CA195547. The authors declare no competing interests.TRIAL REGISTRATION NUMBERN/A.

Female reproductive function after treatment of childhood acute lymphoblastic leukemia.

The aim was to evaluate self-reported reproductive characteristics and markers of ovarian function in a nationwide cohort of female survivors of childhood acute lymphoblastic leukemia (ALL), because prior investigations have produced conflicting data. Self-reported reproductive characteristics were assessed by questionnaire among 357 adult 5-year survivors, treated between 1964 and 2002, and 836 controls. Ovarian function was assessed by serum levels of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), and inhibin B and by antral follicle count (AFC). Differences between controls and (subgroups of) survivors (total group, chemotherapy [CT]-only group, CT and radiotherapy [RT] group) were analyzed. Survivors treated with CT only do not differ from controls regarding timing of menarche, virginity status, desire for children, or pregnancy rates. Compared to controls, the CT+RT group was at significantly increased risk of a younger age at menarche (P<.01), virginity, an absent desire for children, and lower pregnancy rates (odds ratio [OR] [95% CI]: 0.3 [CI 0.1-0.6], 0.5 [0.3-0.9], and 0.4 [0.2-0.9], respectively). Survivors in the CT-only group were significantly younger at the birth of their first child. Pregnancy outcomes were not significantly different between any (sub)groups. Survivors treated with total body irradiation (TBI) or hematopoietic stem cell transplantation (HSCT) are at increased risk of abnormal markers of ovarian function. Reproductive function of ALL survivors treated with CT only does not differ from controls. However, survivors additionally treated with RT seem to be at an increased risk of certain adverse reproductive outcomes. Providing personalized counseling about (future) reproductive health risks in this group is imperative.

Genetic and Biochemical Markers of Ovarian Function and Their Impact on Women Reproductive Status

Endometriosis is a disease very common nowadays affecting 1-2% of the female population, by estrogen-dependent mechanism. The identification of mutations in the gene encoding for the FSH receptor (FSHR) has been reported since 1995. Physiology teaches us that follicle-stimulating hormone (FSH) is a hormone that is vital in the steroidogenesis regulation mechanisms, while FSH receptor (FSHR) activation helps to promote folliculogenesis and estrogensynthesis. Therefore, studies to show if there are any correlations between endometriosis and FSHR are acquired. Genotyping of FSHR gene polymorphisms were performed using PCR - Restriction Fragment Length Polymorphism (PCR-RFLP) analysis. We analysed a total of 78 patients, 44 infertile patients with endometriosis and 34 controls (non-infertile, pregnant patients). The endometriosis group included women with diagnosis of endo-metriosis confirmed by laparoscopy and /or laparotomy and histological evidence of disease with the endometriosis staging according to American Society for Reproductive Medicine (ASRM). Corroborated with the severity of endometriosis, A919G and A2039G tests found that 71.4% of the M (GG) results were associated with primary infertility, not statistically significant (p=0.994) and 42.9% of the total M results had moderate or severe forms of endometriosis (p = 0.185). The genetic involvement in different pathologies such as endometriosis, has yet to be understood, but knowing more about its mechanism, will help physician target the disease at a more profound level.

Navigating the body of literature assessing BRCA1/2 mutations and markers of ovarian function: a systematic review and meta-analysis.

Twelve percent of women in the USA will develop invasive breast cancer in their lifetime, and that risk increases to 80% if they carry a BRCA1 or BRCA2 mutation. BRCA1/2 mutations are thought to potentially affect ovarian reserve and/or fertility. PubMed and PubMed Central were searched for publications on ovarian reserve-related outcomes (i.e., AMH and response to controlled ovarian hyperstimulation (COH) protocols) that were reported in relation to BRCA1 and/or BRCA2 mutations from 1950 through May 2019. A meta-analysis was conducted to create forest plots and summary effect measures using Review Manager 5.3. This article reviews the 16 qualifying publications. There were several fundamental methodological differences in the study designs and outcome details reported in AMH studies. Summary statistics found no difference in AMH levels between BRCA1/2+ women as compared with controls (Z overall test effects p ≥ 0.45). Regarding responses to COH, there were overall non-significantly fewer total and mature numbers of oocytes retrieved in BRCA1/2+ cases as compared with controls (meta-analysis Z overall test effects p ≥ 0.40). While the summary measures indicate no significant differences in AMH levels between BRCA1/2+ cases and controls, readers should be aware that there are significant methodological differences in the AMH reports. Additionally, the response to COH protocols does not seem to be significantly lower in BRCA1/2 mutation carriers in the existing literature. Continued research on both of these clinical parameters would be beneficial for patient counseling.

Application of machine learning tools for evaluating the impact of premenopausal hysterectomy on serum anti-mullerian hormone levels

Women who have had premenopausal total hysterectomy at a young age could probably experience partial or total loss of ovarian function. The purpose of this retrospective cross-sectional study is to investigate the ovarian function in women underwent hysterectomy at an early age. A total of 1165 subjects comprised of 685 hysterectomised women and 480 age matched controls were enrolled in the study. We found that there is a steady decline in serum Anti Mullerian Hormone (AMH) levels, a marker of ovarian function after every five years post - hysterectomy in early age groups (20-30 yr and 31-40 yr) followed by loss of ovarian function in the age group of 40-50 yr. The application of multiple linear regression and machine learning tools has revealed that AMH is positively correlated with LH and estradiol and negatively correlated with age, FSH, years since hysterectomy and vitamin D. Serum AMH level of &lt;0.08 ng/ml is associated with the increased of FSH, decreased LH and estradiol. The decreased ovarian function is associated with lower calcium levels, which are likely to influence the bone health. In conclusion, by utilizing multiple linear regression and machine learning tools, we found that serum FSH is the most important in predicting the AMH-mediated ovarian function.

Urinary levels of phthalate metabolites in women associated with risk of premature ovarian failure and reproductive hormones.

Phthalates, a class of high production-volume chemicals widely used as plasticizers, have been shown to impair ovarian functions in female animals, but epidemiological evidence is very limited. In this case-control study, the associations between phthalate exposure and premature ovarian failure (POF) in women were assessed. A total of 173 POF cases and 246 control women were recruited in Zhejiang, China. The urinary concentrations of 8 phthalate metabolites and the serum levels of ovary-related hormones were determined. Mono-isobutyl phthalate (MiBP) was the metabolite with the highest median concentration of 27.23 μg/g of creatinine in the whole group. Compared with the lowest quartile, higher urinary concentrations of MiBP were significantly associated with increased odds of POF (OR = 1.38, 95% CI: 0.73-2.61 for the fourth quartile; p for trend = 0.01). The estradiol/FSH ratio, a marker of ovarian function, in control women was significantly negatively associated with the urinary concentrations of most tested phthalate metabolites. Our results suggest that exposure to some phthalates may impair ovarian function and increase the odds of POF in women.

Anti-Mullerian Hormone (AMH) as a Novel Marker for Ovarian Function: A Review

Background: Anti-Mullerian Hormone (AMH) is a homodimeric glycoprotein linked by disulfide bonds which belongs to the Transforming Growth Factor (TGF) beta superfamily. AMH is produced by gonadal tissue namely testicular Sertoli cells and ovarian granulosa cells especially pre-antral and antral follicles. AMH involved in embryonic sexual differentiation in male, while it has an inhibitory effect on primordial follicle recruitment and responsiveness of the growing follicles to FSH, in female. Current studies show promising clinical utilities of AMH measurement in predicting ovarian function.Objective: This review aims to explore further about the physiology of AMH and its role as a novel marker for ovarian function.Method: A review of relevant literature was performed to elaborate AMH involvement in ovarian function. A total of 14 qualified published literature of all years until 2018 were collected from several electronic database and manual search and included in this review.Results: AMH level reflected ovarian follicular reserve, an important indicator in infertility treatment (assisted reproduction technique) and a sensitive marker for ovarian aging. AMH is also a valuable tool in diagnosis and recognition of recurrence granulosa cell tumors, and a marker of ovarian dysfunction particularly polycystic ovary syndrome. A low circulating AMH level is observed in obesity and male with fertility problems.Conclusion: AMH level can be used as primary or supplementary markers to aid in the diagnosis and treatment of several reproductive related conditions in males and females. A set of guidelines about sample storage and handling and age-specific standardized reference values are needed to optimize clinical application of AMH.