Serum AMH Research Articles

THE EFFECT OF CLOMIPHENE, METFORMIN, OR BOTH ON ANTI- MÜLLERIAN HORMONE (AMH) LEVELS: A NEW LOOK AT THE PREGNANCY IN POLYCYSTIC OVARIAN SYNDROME TRIAL (PPCOS I)

To examine serum AMH levels in infertile women with polycystic ovarian syndrome (PCOS) before and after treatment with metformin, clomiphene citrate, or both.

Growth, puberty and testicular function in boys born small for gestational age with a nonspecific disorder of sex development

Brief Summary: This retrospective case-control study used data from the international DSD registry to investigate the long-term outcomes of males born small for gestational age (SGA) with hypospadias/DSD. A large cohort of 179 boys (115 males born SGA; 64 appropriate for gestational age) was investigated for growth, pubertal development, and gonadal functions (serum LH, FSH, testosterone, AMH, and inhibin B levels) at minipuberty and puberty.

Does the dose or type of gonadotropins affect the reproductive outcomes of poor responders undergoing modified natural cycle IVF (MNC-IVF)?

ObjectiveDoes the dose or type of gonadotropin affect the reproductive outcomes of poor responders undergoing IVF in a modified natural cycle (MNC-IVF)? Study DesignThis is a retrospective cohort study including patients attending a tertiary referral University Hospital from 1st January 2017 until 1st March 2020. All predicted poor responders (Poseidon groups 3 and 4) who underwent MNC-IVF in our center were included. Mild ovarian stimulation (rFSH/uFSH/hp-hMG) was started when a follicle with a mean diameter of 12–14 mm was observed on ultrasound scan; GnRH antagonist was added from the next day onwards. Mature oocytes were inseminated using ICSI. ResultsIn total 484 patients undergoing 1398 cycles were included. Mean (SD) age and serum AMH were 38.2 (3.7) years and 0.28 (0.26) ng/ml, respectively. The daily dose of gonadotropins was either < 75 IU/d [11/1398 (0.8 %)] or 75 to < 100 IU/d [1303/1398 (93.2 %)] or ≥ 100 to 150 IU/d [84/1398 (6 %)]. Patients were stimulated with rFSH [251/1398 (18 %)], uFSH [45/1398 (3.2 %)] or hp-hMG [1102/1398 (78.8 %)]. Clinical pregnancy rate was 119/1398 (8.5 %). Live birth was achieved in 80/1398 (5.7 %) of cycles. There was no significant difference in rates of pregnancy and live birth across different types and doses of gonadotropins. The GEE multivariate regression analysis, adjusting for relevant confounders, showed that the type of treatment strategy (rFSH/uFSH/hp-hMG) and the daily dose of gonadotropins were not associated with live birth rates (LBR) (p value 0.08 and 0.8, respectively). ConclusionsThe type and daily dose of gonadotropins do not affect the reproductive outcome of poor responders undergoing MNC-IVF.

Variation in Anti-Mullerian Hormone Levels with Age in Women Accessing In Vitro Fertilization Services in Ghana

Background: The emergence of AMH as a reliable biomarker for assessing ovarian reserve and optimization of assisted reproductive technology (ART) remains a promising tool for the evaluation and prediction of controlled ovarian stimulation (COS) outcomes. This study assessed the association between serum AMH levels and maternal age in females receiving in vitro fertilization (IVF) treatment in Ghana. Methods: We conducted a prospective cohort study at a specialized fertility center in Ghana. Descriptive analysis was performed, and the differences between maternal age and AMH categories were assessed by the Kruskal–Wallis test. Results: We included 426 women with mean (±SD) age and AMH levels of 35.25 ± 6.33 years and 2.80 ± 2.60 ng/mL, respectively. Women with very-low AMH levels (0.94 ± 73 ng/mL) were older (&gt;40 years), whereas the younger (20–25 years) group had higher levels (4.85 ± 3.34 ng/mL). There was a significant negative correlation between women’s age and serum AMH levels (R = −0.46; p &lt; 0.001). None of the younger women had AMH levels &lt;0.30 ng/mL, while 70% of women who had AMH levels of &lt;0.30 ng/mL were older women (&gt;40years). In addition, none of the older women had AMH levels &gt;4 ng/mL with only 5% having AMH levels between 2.20 and 4.0 ng/mL. Conclusions: AMH levels ≤0.3 ng/mL are archetypal of 70% of Ghanaian women &gt;40 years old receiving fertility treatment. A combined assessment of AMH levels and age supports clinical decisions in predicting ovarian response to controlled ovarian stimulation (COS) and may be valuable in predicting of IVF success. Further research to evaluate the combined use of age, AMH, and other ovarian reserve markers in assessing ovarian response to COS is recommended.

Evaluation of at-home serum anti-Müllerian hormone testing: a head-to-head comparison study

BackgroundFor optimal fertility testing, serum anti-Müllerian hormone levels are used in combination with other testing to provide reliable ovarian reserve evaluations. The use of the ADx 100 card is widely commercially available for at-home reproductive hormone testing, but data demonstrating that its results are reproducible outside of a clinical setting are limited, as well as comparisons of its performance with other newer blood collection techniques. This study aimed to evaluate the concordance of serum AMH levels found via standard venipuncture and self-administered blood collection using the TAP II device (TAP) and ADx card in women of reproductive age.MethodsThis was a prospective, head-to-head-to-head within-person crossover comparison trial that included 41 women of reproductive age (20–39 years). It was hypothesized that the TAP device would be superior to the ADx card both in terms of agreement with venipuncture reference standard and patient experience. Each subject had their blood drawn using the three modalities (TAP, ADx, and venipuncture). We evaluated the concordance of AMH assays from samples obtained via the TAP device and ADx card with the gold standard being venipuncture. Two-sided 95% CIs were generated for each method to compare relative performance across all three modes. Patient preference for the TAP device versus the ADx card was based on self-reported pain and Net Promoter Score (NPS).ResultsThe TAP device was superior to the ADx card on all outcome measures. TAP R-squared with venipuncture was 0.99 (95% CI 0.99, > 0.99), significantly higher than the ADx card, which had an R-squared of 0.87 (95% CI 0.80, 0.94) under most favorable treatment. TAP sensitivity and specificity were both 100% (no clinical disagreement with venipuncture), versus 100 and 88%, respectively, for the ADx card. Average pain reported by users of the TAP device was significantly lower than the ADx card (0.75 versus 2.73, p < 0.01) and the NPS was significantly higher than the ADx card (+ 72 versus − 48, p < 0.01).ConclusionsThe TAP was non-inferior to venipuncture and superior to the ADx card with respect to correlation and false positives. Moreover, the TAP was superior to both alternatives on patient experience.Trial registrationNCT04784325 (Mar 5, 2021).

Higher Doses of FSH Used for Superovulation Do Not Adversely Affect Embryonic Ploidy: A Randomised Controlled Trial (Stimulation Resulting in Embryonic Aneuploidy Using Menopur (STREAM) Trial)

Background: High dose gonadotropin stimulation protocols may increase costs, patient discomfort, likelihood of ovarian hyper stimulation syndrome (OHSS), ovarian torsion and increased bleeding after multiple ovarian punctures. In addition, it is possible that high dose stimulation may result in impaired oocyte “quality” with adverse effect of embryonic ploidy. This may negate any benefits seen from a higher oocyte yield after high dose stimulation. Aim: To determine the proportion of euploid blastocysts resulting from higher versus lower dose ovarian stimulation protocols. Method: Multicentre randomised controlled trial recruiting 57 women who were treated with ovarian stimulation using either 150 or 300 IU Menopur per day. In Vitro Fertilisation (IVF) or Intracytoplasmic Sperm Injection (ICSI) were performed according to individual unit protocol and embryos were cultured to blastocyst stage. A trophectoderm biopsy was performed for preimplant action genetic testing for aneuploidy. Results: The number of oocytes obtained from women randomised to 150 IU Menopur was between 3–17 (mean=9), whereas the number of oocytes obtained from women randomised to 300 IU Menopur was between 3–24 (mean=11). There was a positive linear relationship between serum AMH concentration and oocyte yield in both the 150 &amp; 300 IU Menopur groups (R=0.3359, R2=0.1129 &amp; R=0.3741, R2=0.1399). 63% of blastocysts were euploid in the 150 IU Menopur group and 75% in the 300 IU Menopur group (p=0.17). Conclusion: The higher dose ovarian stimulation protocol did not significantly increase the number of oocytes retrieved, nor did the higher dose protocol reduce the proportion of euploid embryos created. This study does not support the hypothesis that use of higher doses of gonadotropin for ovarian stimulation results in a reduction in the proportion of euploid embryos obtained after IVF.

Cigarette smoke is associated with up-regulation of inducible NOS and COX-2 protein expression and activity in granulosa cells of women undergoing in vitro fertilization

Cigarette smoke exposure represents a well-established ovotoxic exogenous stress, but the molecular mechanisms underlying of this effect are still unclear. Cigarette smoke upregulates inflammatory genes in the female reproductive organs, therefore an abnormal inflammation response may contribute to the impairment of female fertility. In this study we investigated for the first time the effect of cigarette smoke exposure on NOS and COX expression and activity and on their transcription factors (CREB and NF-kB) in human GCs and on the release of NO and PGE2 in the FF in smoking and non-smoking patients undergoing IVF treatment. In addition, correlation analysis between AMH serum levels, an index of ovarian reserve, and smoking exposure or iNOS and COX-2 protein expression levels were performed using a Pearson correlation method. Cigarette smoke exposure resulted in a significant increase of iNOS and COX-2 protein expression together with an increase of iNOS activity and PGE2 levels. pNF-kB and pCREB protein expression were upregulated in the GCs of smokers compared to non-smokers. The habit of smoking was negatively correlated with serum AMH levels, and positively correlated with iNOS and COX-2 protein expression levels. The data presented in the current study revealed a novel molecular mechanism underlying the toxic effects of cigarette smoke on fertility. Additional pathways mediating the effects of cigarette smoke exposure in human GCs cannot be excluded and should be investigated in future studies.

Correlation of serum anti-Mullerian hormone with hormonal and environmental parameters in Brazilian climacteric women

This study aimed to identify the correlation among anti-Mullerian Hormone serum levels and 25-OH-D, obesity, metabolic syndrome (MetS), and sexual hormones in climacteric women classified according to stages of reproductive aging (SRA). A cross-sectional study was conducted with a total of 177 Brazilian climacteric women between 40 and 64 years old. Concentrations of AMH were measured using the Access 2 Immunoassay System. A multiple linear regression analysis was used to identify the relationship among AMH, 25-OH-D, obesity, MetS, sexual hormones, sociodemographic and lifestyle factors. AMH levels decreased with increased age (B = − 0.059; p < 0.001), and reproductive aging (B = − 0.483; p < 0.001). Obesity indicators, lifestyle characters, 25-OH-D levels and MetS were not significantly associated with AMH serum concentration. Negative correlation was found for FSH (B = − 0.009; p < 0.001) and LH (B = − 0.006; p = 0.004); positive correlation for E2 (B = 0.001; p = 0.011), DHEAS (B = 0.003; p < 0.001) and SHBG (B = 0.003; p = 0.005). In the model adjusted for SRA, FSH levels (p < 0.001) and DHEAS (p = 0.014) were associated with AMH. Although, with the adjustment for age, only FSH remained with a significant association (p = 0.001). Of the other analytes, none was associated with AMH, regardless of the model fit. Our findings confirm that serum AMH level decreased with age and FSH levels, but there is no correlation between AMH with obesity, 25-OH-D, MetS or other sexual hormones in Brazilian climacteric women.

Laparoscopic guided minilaparotomy: a modified technique for management of benign large ovarian cysts

BackgroundThe aim of the study is to evaluate the efficiency and safety of a novel technique to treat large benign ovarian cysts combining benefits of laparoscopic management along with mini-laparotomy without affection of the ovarian reserve.MethodsThe study included 112 women with large benign ovarian cyst candidate for ovarian cystectomy. The technique started with laparoscopy followed by guided cyst aspiration followed by exteriorization of the ovary through minilaprotomy and completion of cystectomy through microsurgical technique. The primary outcome was ipsilateral recurrence of the cyst. Other outcomes included ovarian reserve assessment and postoperative pain.ResultsThe number of women with recurrence in the ipsilateral ovary after 12, 18 and 24 months were 5 (4.5%),16 (14.3%),20 (17.85%) respectively. Assessment of ovarian reserve revealed a significant decrease in the level of serum AMH (2.82 ± 0.44 vs. 2.50 ± 0.42) and a significant increase in AFC (3.5 ± 1.7 vs. 4.9 ± 1.3) after our novel technique in surgical treatment of ovarian cysts (P value < 0.001). The operative time was 50 ± 7 and 62 ± 7 min in unilateral and bilateral cysts respectively.ConclusionsLaparoscopic guided minilaparotomy is a safe and effective technique for the management of large benign ovarian cysts with minimal recurrence rate, ovarian reserve affection and adhesions.Trial registration: clinical trial registry no. NCT03370952. Registered 13 December 2017,https://clinicaltrials.gov/ct2/show/NCT03370952

O-240 Circulating AMH molecular forms throughout pregnancy of women with PCOS and controls: a systematic longitudinal follow-up

Abstract Study question Are circulating levels of molecular forms of AMH throughout pregnancy still higher in women with PCOS than in controls? Summary answer AMH and its molecular forms decrease significantly throughout pregnancy, remaining higher in women with PCOS, without modification in the proportion of AMH molecular forms. What is known already AMH injection in late gestational mice causes a “PCOS” phenotype in the offspring’s, possibly via a gestational hyperandrogenism. AMH could therefore play a role in the heritability of PCOS in women. Circulating AMH exists in different molecular forms, cleaved (active) and uncleaved. In normal women, serum AMH decreases during pregnancy. In women with PCOS, cross-sectional or partial longitudinal studies have shown higher AMH levels in the second trimester of pregnancy and at the time of delivery in women with PCOS compared to controls. To date, no longitudinal dynamic monitoring of AMH throughout pregnancy in women with PCOS has been performed. Study design, size, duration Systematic prospective quarterly longitudinal monocentric comparative follow up of 30 women with PCOS and 29 controls before and during pregnancy from April 2019 to September 2021. To demonstrate a high effect size with 90% power and 5% first-species risk, it was necessary to include 23 subjects per arm. With a calculated loss of follow-up rate of 20%, 29 patients must be recruited per group. Participants/materials, setting, methods Women aged 18 to 43y, with a pre-conception dosage of AMH, were included during the first trimester of a singleton pregnancy. PCOS group was defined according to the modified Rotterdam criteria. In the control group, the patients had normal ovarian reserve. During the first, second and third trimester of pregnancy, all women were tested for serum AMH and its molecular forms with a Beckman automatic analyser, and for serum estradiol, LH and androgen levels. Main results and the role of chance Before pregnancy, patients with PCOS had higher levels of AMH (58.9 vs. 18.3pmol/L; p = &amp;lt;0.001), LH (5.9 vs. 3.3IU/L; p = 0.004) and total testosterone (TT) (0.35 vs. 0.29ng/ml; p = 0.019) than controls. Within each group, the levels of AMH and cleaved AMH were significantly lower in the third trimester than before pregnancy. The serum AMH level in the third trimester remained significantly higher in women with PCOS than in controls (18.4 vs. 6.5pmol/L; p = 0.002). At all times, the amount of cleaved AMH was higher in women with PCOS than in controls. The proportion of AMH molecular forms was not different between women with PCOS and controls and did not change throughout pregnancy. The LH level, mostly undetectable, was significantly lower in the third trimester than before pregnancy in both groups. In the first trimester, it remained higher in women with PCOS (0.6 vs 0.4IU/L; p = 0.018). In each group, the TT level was significantly higher in the third trimester than before pregnancy. TT level remained higher in women with PCOS than in control women in the first (0.76 vs 0.55ng/ml; p = 0.022) and second trimesters 0.82 vs. 0.61ng/ml; p = 0.013). In the third trimester, it was no longer significantly different (0.97 vs 0.64ng/ml; p = 0.069). Limitations, reasons for caution Only free testosterone is active, and only TT was measured. Additional SHBG and albumin measurements are needed. Our control population is a population of infertile women who have no ovarian problem but who have undergone, for most of them, ART treatments to obtain pregnancy with a possible impact on implantation. Wider implications of the findings Elevated serum AMH level could be instrumental in the modification of the in-utero androgenic environment that is believed to promote the transmission of the syndrome. The impact of AMH could be different depending on the clinical or metabolic phenotype of the patients and needs to be explored further. Trial registration number NCT03483792

P-697 The association between serum prolactin levels and outcomes of in vitro fertilization

Abstract Study question Is there an association between serum prolactin levels and outcomes of in vitro fertilization (IVF) in infertile women? Summary answer Serum prolactin levels are negatively associated with the proportion of good quality embryos from the total number of embryos obtained at IVF What is known already It is widely known that hyperprolactinemia is a powerful inhibitor of the hypothalamic-pituitary-ovarian axis leading to anovulation. However, few studies have tried to establish the impact of slightly higher PRL levels on the outcomes of in-vitro fertilization. Although some researchers have stipulated that PRL may play a positive role in oogenesis, embryo development and luteal function, due to the scarcity of data, this matter is considered an ongoing debate. Study design, size, duration We performed a retrospective study in the Department of Reproductive Medicine of a private hospital. The medical records of all consecutive patients who underwent IVF between January 2014 and December 2021 with all causes of infertility were reviewed. Participants/materials, setting, methods Patients with various causes of infertility undergoing IVF-ICSI were included in the study. Outcomes such as numbers of oocytes obtained, numbers of embryos were assessed and the proportion of good quality embryos from the total number of embryos (GQE/TNE) obtained was calculated. The study group included 544 patients with a mean age of 34.4±4.46 years, mean AMH of 3.99 1.34 ng/mL and mean serum prolactin levels of 25.07±23.7 ng/ml. Main results and the role of chance we found no association between serum prolactin levels and oocytes or embryos number. Serum level of prolactin was negatively correlated with the proportion of GQE/TNE (r = 0.101, p = 0.042). When patients were divided in subgroups according to ovarian reserve, the patients in the fourth quartile of prolactin had a lower proportion of GQE/TNE (p = 0.041) in comparison with those from the inferior quartiles only in the reduced ovarian reserve group (serum AMH below 1.1 ng/ml). Limitations, reasons for caution Patients included in this study are infertile patients with indications for IVF treatment. Therefore, the results of this study should be used with caution in other populations. Wider implications of the findings Our study suggest that serum prolactin levels might be negatively associated with in-vitro fertilization outcomes. If confirmed by further studies, treatment could be given to lower prolactin levels, even if mildly elevated, thus assuring more successful outcomes. Trial registration number NA

P-578 Oral, Vaginal or Intramuscular Progesterone in Programmed Frozen Embryo Transfer Cyles: A Pilot RCT

Abstract Study question What should be the optimal luteal phase support in programmed frozen embryo transfer (FET) cycles using vitrified-thawed blastocysts? Summary answer 40mg/day oral dydrogesterone, 180mg/day progesterone (P) vaginal gel and 100mg/day im P in oil revealed similar reproductive outcomes in programmed FET cycles. What is known already Luteal phase should be supported either in fresh (Yanushpolsky et al, 2015) or in FET cycles (Pabuccu et al, 2020). Endometrium preparation in FET cycles is outmost important for successful implantation. For this purpose, natural or programmed protocols have been suggested. In programmed FET cycles, exogenous P replacement is of critical importance, as estrogen use will inhibit ovulation and corpus luteum formation.Higher serum P level was associated with increased rates of ongoing pregnancy or live birth in programmed FET cycles (Melo et al 2021). Therefore, lack of a corpus luteum justifies precise and adequate luteal support. Study design, size, duration This was a randomized, parallel, phase IV-pilot RCT (NCT03948022), comparing 3 different luteal support options in programmed FET cycles. A total of 168 women aged between 20-40 years and having available blastocyst(s) were eligible for the study between April-December 2020. After excluding cases, 163 patients were randomly assigned to one of the P arms based on a computer- generated list to administer: 1-oral dydrogesterone 40mg/day (DYD) 2-vaginal %8 P gel 180mg/day (VAG) 3-im 100mg/day P (IM) Participants/materials, setting, methods Estradiol 2 mg TID was started on day 2 or 3 of menstruation for at least 7 days. On day 8, endometrial thickness was assessed. When it was &amp;gt;8 mm, each patient was randomly assigned to one of the intervention arms. After 5 days of P administration, ET was performed on the 6th day preceding serum P measurement. Primary outcome was ongoing pregnancy rate defined as viable healthy pregnancy beyond 20th week of gestation. Main results and the role of chance A total of 151 women out of 163 completed the primary follow-up after randomization. 12 patients were excluded from the final analysis mainly due to protocol violation and discontinuation of intervention. Each patient contributed to a single cycle in the analysis and given data does not include cumulative pregnancies including surplus frozen embryo transfers. Demographic data including; mean woman age, body mass index, serum AMH, TSH and infertility etiologies were comparable among all groups without statistically significance (p &amp;gt; 0.5) Limitations, reasons for caution Lack of a power analysis is the main limitation of this study, potentially coming with type-1 error. Properly designed and powered RCTs are needed. Wider implications of the findings There have been very limited data available for oral progestogen use particularly in FET cycles, unlike many reports for vaginal and im P. Comperable reproductive outcomes with significantly lower side effect profile of oral progestagen merits further attention in programmed FET cycles. Trial registration number NCT03948022

P-795 Comparison of intra-ovarian platelet rich plasma versus autologous bone marrow derived stem cell instillation in women with diminished ovarian reserve for ovarian rejuvenation

Study questionTo compare role of intra-ovarian platelet rich plasma (PRP) versus marrow derived stem cell (SC) instillation for improvement in ovarian reserve (AFC, AMH and FSH)Summary answerBoth PRP and SC therapy improves the ovarian reserve however, response to PRP is superior to SC post interventionWhat is known alreadyWith increasing incidence of females with diminished ovarian reserve (DOR), posing a serious challenge in terms of limited treatment options for these couples. Clinicians are trying to find effective strategies besides oocyte donation or adoption Of late, novel ovarian rejuvenation approaches has been investigated which are currently available for research purposes only. Multiple studies are evaluating effect of intra-ovarian PRP or autologous SC instillation, the results are encouraging as they are showing improvement in ovarian reserve thus bringing a paradigm shift in treatment options. None of the published studies so far have compared PRP versus SC in DOR population.Study design, size, durationA prospective comparative study was conducted at Division of Reproductive Medicine of a tertiary care institute. 72 infertile females (20-39 years) with poor ovarian reserve (AMH <1.2 ng /ml; AFC<5) were enrolled in the study between January 2020 to December 2021. The two comparative groups underwent either intra-ovarian PRP instillation (n = 42) or autologous SC transplantation (n = 30).Participants/materials, setting, methodsAfter the two groups were matched (PRP vs SC) for baseline characteristics (Age, AMH, AFC, FSH, Estradiol), 30 subjects in each group were compared for change in serum FSH/AMH/Estradiol levels, AFC, right and left ovarian volume at 1st month and 3rd month post intervention from the baseline. This was also compared between the two groups using Student t-test. The cost and procedural pain measured using Visual analog scale (VAS) were also compared between the groups.Main results and the role of chanceAfter matching for baseline characteristics, significant ∼ 1.8/2 and ∼1.5/1.6 fold increase in AFC at 1st/3rd month post intervention (p<0.001) was observed after PRP instillation and SC transplantation respectively. This significant improvement was observed more in PRP group than SC group at 3rd month post intervention (7.07 vs 5.60, p=0.02), while no significant difference existed at 1st month of follow up. However, there was no significant improvement in serum FSH, AMH and Estradiol levels (p0.05) from the baseline at 1st and 3rd month post intervention in both the groups. Similarly, there was no significant difference between the two groups in serum FSH level (7.98 IU/ml vs 9.62 IU/ml, p=0.062; 8.26 IU/ml vs 9.50 IU/ml, p=0.15), AMH level (1.62 ng/ml vs 1.02 ng/ml, p=0.27; 1.35 ng/ml vs 0.95 ng/ml, p=0.24), Estradiol level (49.12 pg/ml vs 56.48 pg/ml p=0.443; 54.7 pg/ml vs 61.12 pg/ml, p=0.44), right ovarian volume (3.13 cm3 vs 2.49 cm3, p=0.06; 3.37 cm3 vs 2.74 cm3,p=0.063) and left ovarian volume (2.98 cm3 vs 2.47 cm3, p=0.102; 2.87 cm3 vs 2.34 cm3,p=0.103) at 1st and 3rd month post intervention respectively. PRP was more cost-effective and associated with less pain (32.5 mm vs 28.13 mm, p=0.02), and better patient compliance.Limitations, reasons for cautionThis was a comparative study and the participants were not randomized but were matched for the baseline characteristics. Also due to impact of Covid-19 causing intermittent pause in nonessential facilities like IVF services, a smaller sample size could be enrolled and also clinical outcomes could not be evaluatedWider implications of the findingsThis study, although comparative, for the first time highlights the beneficial role of PRP over SC, thus can establish superiority of PRP as minimally invasive, economical, patient friendly and a recommended therapy for ovarian rejuvenation and folliculogenesis, providing the DOR females an opportunity to produce their own offspring.Trial registration numberCTRI/2020/01/022726

P-603 Presence of an asymmetrical response to ovarian stimulation in patients with low ovarian reserve

Abstract Study question Does ovarian reserve decline with a symmetrical manner between right and left ovaries in poor responders (POR) with diminished ovarian reserve (DOR)? Summary answer Asymmetrical ovarian response to ovarian stimulation with the left-side dominance was found in POR with DOR. What is known already Ovarian follicles are produced during fetal stage and not regenerated after birth. Thus, the number of ovarian follicles declines with age, resulting in infertile POR with DOR. In the morphometric study of human neonatal ovaries, no significant difference was found in the number of follicles between the right and left ovaries in the same individual. A previous study demonstrated that there is a difference in the number of follicles between right and left ovaries in patients with normal ovarian reserve with the right-side dominance, suggesting the asymmetrical activation and growth of follicles. Study design, size, duration A retrospective analysis was conducted in patients with POR with DOR based on the Bologna Criteria. Inclusion criteria was patients who received more than five times of ovarian stimulations followed by oocyte retrievals. Data were obtained from a total of 265 participants who received IVF-ET treatments from April 2015 to March 2021 after receiving written informed consents under an approval from the institutional ethical committee. Patients with the history of previous ovarian surgery were excluded. Participants/materials, setting, methods The enrolled patients were received ovarian simulation under short or GnRH antagonist protocols for oocyte retrieval. We collected the data of retrieved oocyte number as well as the outcome of IVF from medical chart. We defined the right-left asymmetry of ovarian reserve (%) based on the number of retrieved oocytes from dominant side ovary per total number of retrieved oocytes. Statistical significance was determined using Dunnett or chi-square tests, with P &amp;lt; 0.05 being statistically significant. Main results and the role of chance The average age of participants was 37.2±5.99 years of age exhibiting low serum AMH levels (average 0.09±0.20 ng/ml). We analyzed 2,181 cycles of ovarian stimulation (average 8.3±3.9 cycles/patient). The number of retrieved oocytes were 3, 882 in total cycles (average 12.8±7.1/patient). Among participants, 22 cases (8.4%) showed left and right equal in the number of retrieved oocytes, whereas &amp;gt;70% asymmetry was observed in 107 cases (40.7%) and &amp;gt;80% asymmetry was detected in 60 cases (22.8%). In 18 cases (6.9%), oocytes were collected from one side ovary only showing 100% asymmetry. In the cases with &amp;gt;70 and 100% asymmetry, the left-side dominance was 1.3-fold and 5.0-fold higher than right-side dominance, respectively. In cases with 100% asymmetry, there was no difference in the number of cryopreserved high-quality embryos between left and right sides of ovary. Limitations, reasons for caution Although we enrolled POR with DOR patients who received ovarian stimulations more than five times, the duration of ovarian stimulation was different among patients. It affects the numbers of ovarian stimulation cycles and retrieved oocytes in each patient. Wider implications of the findings Considering the finding of right-side dominance in the number of follicles with normal ovarian reserve, the activation and development of follicles might be accelerated in the right side due to asymmetric blood supply to the ovaries, and thus follicles are likely remained in the left-side ovary with low ovarian reserve. Trial registration number not applicable

O-243 Progesterone levels measured on the day of blastocyst transfer in modified natural cycle frozen-thawed embryo transfer (mNC-FET) cycles: a sub-study of an ongoing RCT

Abstract Study question What is the serum progesterone level on blastocyst transfer day in mNC-FET and is the level related to the ongoing pregnancy rate? Summary answer One-quarter of all women had a progesterone level below 29.4 nmol/L on blastocyst transfer day, but the ongoing pregnancy rate was not compromised. What is known already It is widely recognized that a serum progesterone level above a certain threshold (30-35 nmol/L), at the time of blastocyst transfer improves ongoing pregnancy rates in artificial cycle FET (AC-FET). However, some studies have indicated that the progesterone level may also become too high. Similar results have been found in natural cycle FET; a recent retrospective study reported that low progesterone levels the day before blastocyst transfer was negatively associated with live birth. As for mNC-FET, data on optimal luteal phase progesterone levels are still missing. Study design, size, duration We present data from an ongoing multicentre, randomised, controlled, single-blinded trial planned to include 604 women undergoing mNC-FET with a single good-quality blastocyst. Women are randomised (1:1:1:1) to: 1) Luteal phase support (LPS) and transfer day 6 following hCG trigger 2) LPS and transfer day seven 3) No LPS and transfer day six 4) No LPS and transfer day seven Only women randomized to the groups not receiving LPS were included in this sub-study. Participants/materials, setting, methods The RCT is still ongoing and by the end of December 2021, 188 normo-ovulatory women aged 18-41 had been randomized to study groups 3) and 4). Of these, 170 had blood drawn on the day of blastocyst transfer and were included in this sub-study. All blastocysts transferred were derived from the patient’s oocytes and had a Gardner score ≥3BB at vitrification. No preimplantation genetic testing for aneuploidies was performed. Main results and the role of chance The study participants had the following characteristics: The median (IQR) age was 34 years (30-37), BMI 22.6 kg/m2 (21.0-25.8 kg/m2), cycle length 28 days (27-30 days), and serum AMH level 19 pmol/L (13-29 pmol/L). In mNC-FET without LPS, the median progesterone level on the day of transfer was 36.6 nmol/L, ranging from 9.6 to 91.8 nmol/L (except two outliers). The 25th, 10th, and 5th percentiles were 29.4, 22.0, and 17.7 nmol/L respectively, which means that 25% of the women had a progesterone level below 29.4 nmol/L. The pregnancy rate was 56.1% (23/41) among women with a progesterone level &amp;lt;29.4 nmol/L compared to 60.6% (77/127) among women with a progesterone level above 29.4 nmol/L (P = 0.715). The ongoing pregnancy rate below and above the lowest progesterone quartile was 41.5% (17/41) and 43.8% (53/121) respectively (P = 0.856). Multivariate logistic regression analyses showed no effect of progesterone level on ongoing pregnancy rate, neither in simple analysis nor when adjusting for age and BMI. Limitations, reasons for caution The serum progesterone level on the day of transfer in mNC-FET without LPS was not a primary endpoint of the RCT. Thus, the number of women included might be too small to draw firm conclusions on progesterone levels and ongoing pregnancy rate in mNC-FET. Wider implications of the findings Optimal serum progesterone levels on the day of blastocyst transfer in mNC-FET have yet to be determined and seem to differ substantially from levels in AC-FET. Ongoing pregnancy rates in mNC FET without LPS are good even with progesterone levels in the lowest quartile. Trial registration number 2018-002207-34

P-625 In vitro maturation of oocytes: a breakthrough for treating infertility in inactivating mutation of the luteinizing hormone/choriogonadotropin receptor

Abstract Study question How can pregnancy and live birth be achieved in patients with inactivating homozygous luteinizing hormone/choriogonadotropin receptor (LHCGR) mutation? Summary answer We report the first live birth after in vitro maturation (IVM) in a patient with a novel homozygous inactivating LHCGR mutation (exon 6, c.470 A&amp;gt;G). What is known already LH plays a fundamental role in female reproductive physiology and is responsible for steroidogenesis, oocyte maturation, ovulation and subsequent progesterone production by the corpus luteum. LH binds to the LHCGR located on the membrane of theca cells and mature granulosa cells. Inactivating mutations of the LHCGR lead to the impossibility to obtain final oocyte maturation both during natural cycles and after ovarian stimulation for in vitro fertilization purposes. Therefore, egg donation represents the only option for treating their infertility. Study design, size, duration A case report. Participants/materials, setting, methods A 35 year-old nulliparous patient referred to our university hospital for primary infertility. Main results and the role of chance The 35-year-old nulliparous patient presented with primary spaniomenorrhea but timely and spontaneous onset of secondary sexual characteristics. Serum LH levels were high (ranging from 15 to 30 IU/L) and to a lesser extent so were FSH levels. The ovarian reserve was normal for age, as assessed by serum AMH levels and ultrasound. There was no argument for polycystic ovarian syndrome, 21-hydroxylase deficiency, Cushing’s syndrome or hyperprolactinemia. Two previous attempts of controlled ovarian stimulation with gonadotropins and ovulation trigger with hCG and GnRH-agonist trigger had failed, resulting in low estradiol levels despite correct follicular growth on ultrasound and absence of ovulation after trigger. However, genetic analysis identified a novel homozygous inactivating LHCGR mutation (exon 6, c.470A&amp;gt;G) which had never been described previously. IVM was performed. A total of 7 oocytes were obtained after IVM, resulting in 4 Day 3 embryos. All embryos were frozen. Subsequently, 2 Day 3 embryos were replaced after endometrial preparation by hormone replacement therapy. The patient became pregnant and gave birth to a healthy baby. Two Day 3 embryos remain. Limitations, reasons for caution By definition, a case-report requires further studies to confirm our findings. Wider implications of the findings We describe a novel inactivating LHCGR mutation with subsequent live birth after IVM. As a growing number of gonadotropin receptor mutations are identified, this successfully achieved live birth places IVM as the only reliable option for these patients to conceive with their own eggs. Trial registration number Not applicable.

Effect of a single-dose denosumab on semen quality in infertile men (the FITMI study): study protocol for a randomized controlled trial

BackgroundInfertility is a common problem globally and impaired semen quality is responsible for up to 40% of all cases. Almost all infertile couples are treated with either insemination or assisted reproductive techniques (ARTs) independent of the etiology of infertility because no medical treatment exists. Denosumab is an antibody that blocks RANKL signaling and inhibition of testicular RANKL signaling has been suggested to improve semen quality in a pilot study. This RCT aims to assess whether treatment with denosumab can improve spermatogenesis in infertile men selected by serum AMH as a positive predictive biomarker. This paper describes the design of the study.Methods/designFITMI is a sponsor-investigator-initiated, double-blinded, placebo-controlled 1:1, single-center, randomized clinical trial. Subjects will be randomized to receive either a single-dose denosumab 60 mg subcutaneous injection or placebo. The study will be carried out at the Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen. The primary outcome of the study is defined as the difference in sperm concentration (millions pr. mL) one spermatogenesis (80 days) after inclusion.DiscussionWe describe a protocol for a planned RCT aimed at evaluating whether treatment with denosumab can improve the semen quality in infertile men selected by using serum AMH as a positive predictive biomarker. The results will provide evidence crucial for future treatment in a patient group where there is a huge unmet need.Trial registrationClinical Trials.gov NCT05212337. Registered on 14 January 2022.EudraCT 2021–003,451-42. Registered on 23 June 2021.Ethical committee H-21040145. Registered on 23 December 2021.

Relationship Between Ovary Size and Anti-Müllerian Hormone Levels in Holstein-Friesian Cows.

The aim of this study was to verify the association between ovarian size and blood AMH levels in HF cows. Sixty multiparous HF cows from three herds were included in this study. The data required for calculating the ovarian volume included the “major axis (length),” “minor axis (width),” and “thickness” of the ovary. All ultrasonography (US) images were acquired at the outermost ends/poles of both the ovaries and of the follicles (>8 mm) and corpus luteum (CL); concomitantly, the blood was sampled from the jugular or coccygeal vein. Based on the ovarian images of each cow, the following ovarian size patterns were calculated using an image analysis software: (1) total area of both the left and right ovaries, (2) individual size of the large ovary, and (3) individual size of the small ovary. For each ovary area pattern, two properties were assessed: (A) presence of follicles (>8 mm) and CL, which may not secret AMH, in the ovaries and (B) absence of follicles (>8 mm) and CL in the ovaries. Serum AMH levels were measured using enzyme-linked immunosorbent assay. The correlation between ovary size and serum AMH levels was measured in terms of the aforementioned patterns and was evaluated statistically. The results of our preliminary study with ovaries from slaughter-house cows (n = 22) revealed that the “thickness” of the ovary was not necessary for estimating ovarian volume and that length and width were sufficient. A strong correlation was observed among ovarian length, width, and thickness (r > 0.96). No significant difference was observed (p > 0.05) in the mean ages or parities among the three herds. Among the ovary sizes measured in this study, the highest correlation was found between the total size of an individual large ovary (including follicular and luteal size) and AMH levels (r = 0.387, p = 0.002). This is the first study to demonstrate the correlation between total size of individual large ovaries and serum AMH levels in HF cows. US observations of the ovaries will allow for estimation of differences in AMH levels and help predict ovarian activity and superovulation performance of cows.

Relationship of Anti-Mullerian Hormone in Polycystic Ovary Syndrome Patients with Different Subgroups

Objective: To determine the association between hyperandrogenism (HA) and polycystic ovarian morphology in a Chinese cohort of patients with polycystic ovary syndrome and the usefulness of anti-Mullerian hormone Methods: Patients who visited the Department of Obstetrics and Gynecology at Indus Medical College Tando Muhammad Khan between May 2020 and October 2020 were the subjects of a prospective case-control study. According to Rotterdam criteria, 50 females with Polycystic ovary syndrome (PCOS) and 50 females without the condition participated in the study. Results: An teenage patient clinic at our hospital enrolled 100 consecutive patients (50 by PCOS, 50 by healthy controls aged equal to the adolescent patients). Menstrual anomaly and hirsutism were most common in the study group, while vaginal discharge was most common in the control group. Analyses of anthropometric measures between the two groups showed a significant difference (p&lt;0.05). In the PCOS group, both plasma fasting insulin (p-value = 0.001) and HOMA index (p value =0.003) had statistically greater values. PCOS patients also had significantly higher means of fT and 17-OH-P, as well as LH and LH/FSH ratios. Serum AMH levels were found to be negatively correlated with FSH levels in all patients (r=-0.238, p=0.031). The AUC value indicated by ROC analysis for distinguishing PCOS was 0.678. However, the sensitivity and specificity scores according to the highest Youden index were 47.8% and 76.1%, respectively. Conclusion: The Anti-Mullerian hormone level is also linked to the existence of polycystic ovary morphology, which suggests that the AMH level might have a role in the diagnosis and treatment of PCOS. Keywords: Anti-Mullerian Hormone, Polycystic Ovary Syndrome, Polycystic Ovary Morphology

Influence of breast cancer prognostic factors on oocyte in vitro maturation outcomes performed for urgent fertility preservation.

Do breast cancer (BC) characteristics influence IVM of oocytes outcomes in patients undergoing fertility preservation (FP)? Scarff-Bloom-Richardson (SBR) III grade, triple-negative BC and HER2 overexpression are independent predictors of fewer oocytes or poor IVM outcomes in young women seeking FP. SBR grade, triple-negative status and overexpression of HER2, as well as a high Ki67 proliferation index are all established prognostic factors for BC, influencing patients' therapeutic management. Yet there are also concerns about the potential impact of cancer status on ovarian reserve and function. Previous studies analysing the results of ovarian stimulation in BC patients have shown conflicting findings. Nevertheless, there is no data on the potential impact of BC status and prognostic factors on IVM outcome in women undergoing urgent FP. We studied 321 BC patients, 18 to 41 years of age, who were also candidates for oocyte cryopreservation following IVM. The number of oocytes recovered, maturation rate and total number of cryopreserved oocytes were assessed. Ovarian reserve markers (antral follicle count [AFC] and serum anti-Müllerian hormone [AMH] levels) and IVM outcomes were compared according to BC characteristics (Ki67 proliferation index >20%, progesterone and/or oestrogen receptors expression, HER2 status and SBR grade). Logistic regression analysis was then performed to determine the variables that could be independently associated with poor IVM outcomes, such as oocyte retrieval rate <50%, oocyte maturation rate <60% and total number of frozen oocytes <5. Overall, the mean age of the population was 32.3 ± 4.1 years. Mean AFC and serum AMH levels were 22.8 ± 13.9 follicles and 3.8 ± 3.1 ng/ml, respectively. AMH levels were significantly lower in case of triple-negative BC when compared with ER/PR/HER2 status positive cancer (3.1 ± 2.6 ng/ml vs 4.0 ± 3.3 ng/ml, P = 0.02). The mean number of recovered oocytes was 10.2 ± 9.1. After a mean maturation rate of 58.0 ± 26.1%, 5.8 ± 5.3 mature oocytes were cryopreserved per cycle. The number of retrieved and cryopreserved oocytes after IVM were significantly lower in patients presenting with an SBR III tumour when compared with an SBR I or II tumour (9.6 ± 8.7 vs 11.7 ± 9.8, P = 0.02 and 5.4 ± 5.4 vs 6.6 ± 5.8, P = 0.02, respectively). Multivariate statistical analysis showed that HER2 positive status was associated with a mean maturation rate <60% (odds ratio: 0.54; 95% CI (0.30-0.97)). Ki67 and hormonal status were not correlated with poor IVM outcomes. A weakness is the retrospective nature of the study. Moreover, as with many studies focusing on FP in oncology patients, the lack of data after reutilization of IVM oocytes prevents drawing reliable conclusions on the fate of these frozen gametes. BC prognostic factors might influence IVM outcomes. Moreover, HER2 is likely to be involved in the ovarian function and oocyte maturation process. Further investigations are needed to better understand the mechanisms at play and their possible impact on the competence of IVM oocytes. No specific funding was used and there are no conflicts of interest. N/A.