Current Opinion in Obstetrics & Gynecology JUNE 2010

Editorial introduction Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful ser...

Author: Aydin Arici

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Editorial introduction

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal’s Section Editors for this issue.

Section Editor Aydin Arici

Dr Arici received his medical degree from Istanbul Medical School in Turkey, and completed a residency in obstetrics and gynecology at Columbia University, College of Physicians and Surgeons, in New York City. His postgraduate training also included a fellowship in reproductive endocrinology and infertility at the University of Texas Southwestern Medical Center in Dallas. His is currently Professor of Obstetrics, Gynecology and Reproductive Sciences at Yale University School of Medicine in New Haven, Connecticut, and the Director of Women’s Health Department at Anadolu Foundation Health Care System in Turkey. Dr Arici is the recipient of many National Institutes of Health and pharmaceutical industry-sponsored research

grants and has trained more than 75 postdoctoral fellows. His clinical research focuses on the pathogenesis of endometriosis, and in particular the investigation of cellular and molecular mechanisms in endometrial physiology and pathology. He is a member of the Editorial Board of Journal of Clinical Endocrinology and Metabolism, Journal of Reproductive Immunology, Gynecologic and Obstetric Investigation. Guest Editor of Obstetrics and Gynecology Clinics of North America and Seminars in Reproductive Medicine, and serves as a reviewer for more than 30 scientific journals, including the New England Journal of Medicine, Science, The Lancet, Human Reproduction, Fertility and Sterility, American Journal of Obstetrics and Gynecology, Molecular and Cellular Endocrinology, Biology of Reproduction, and Journal of Clinical Investigation. More than 270 articles by Dr Arici have been published in these and other leading journals and his book chapters have appeared in such texts as Textbook of Reproductive Medicine and Reproductive Endocrinology. He is the Senior Editor of the book titled ‘Non-invasive Management of Gynecologic Disorders’. He is a frequent invited speaker and has presented at numerous national and international medical and scientific symposia. His main interests include research on infertility, hormonal problems, endometriosis, menopause and early pregnancy loss. Dr Arici is a Fellow of the American College of Obstetricians and Gynecologists and served as a clinical director of the Society for Assisted Reproductive Technology. He also serves as an ad hoc grant reviewer for the National Institutes of Health. Dr Arici is a member of 15 professional societies, including the American Society for Reproductive Medicine, the Society of Reproductive Endocrinology and Infertility, the Endocrine Society, and the European Society of Human Reproduction and Embryology.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Does the ovarian reserve decrease from repeated ovulation stimulations? Janelle Luk and Aydin Arici Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Dr Janelle Luk, Division of reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA Tel: +1 203 606 2689; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:177–182

Purpose of review The majority of infertility patients require more than one in-vitro fertilization cycles to achieve pregnancy, which results in repeated stimulation in the ovaries. There have been raising concerns for patients about the effect of repetitive assisted reproductive technology (ART) cycles on ovarian response in subsequent cycles. Whether or not there is deterioration in ovarian response with repetitive treatment will allow clinicians to provide better counseling to patients before treatment. Recent findings The single determinant factor that has been shown in affecting ovarian reserve for patients undergoing repeated ART cycles is age. Current evidence has suggested that repetitive ovarian stimulation cycles with intrauterine insemination can be performed without clinically impairing ovarian response. Oocyte donors can be invited for at least three cycles without a negative effect on ovarian response to gonadotropins, number of mature oocytes retrieved, embryo quality, or pregnancy rates. Summary There are limited available published data on this topic. Research studies have shown that there is no detrimental effect on ovarian function of egg donors who undergo repetitive ovarian hyperstimulation. Overall findings also show that there is no significant decline in ovarian reserve in patients who undergo up to three repeated in-vitro fertilization cycles. For patients undertaking more than three cycles, the results become equivocal because age becomes a determinant factor with both pregnancy and live birth rate declining with repetitive cycles. Keywords ART cycles, donors, ovarian reserve, repeated IVF cycles Curr Opin Obstet Gynecol 22:177–182 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Ovulation induction and in-vitro fertilization (IVF) have become common therapies that are given to couples who have infertility problems. In the United States alone, the total number of IVF cycles undertaken in 2007 provided by Center for Disease Control numbers is 142 415, which represents data from 430 fertility clinics in operation. Data presented at the annual conference of the European Society of Human Reproduction and Embryology (ESHRE) in 2006 have also shown that more than three million babies have been born using IVF and other assisted reproductive technology (ART) since the world’s first IVF baby was born in 1978. With the continued improvements to treatment protocols, advancements in technology and refinements in scientific techniques have resulted in steadily increasing success rates for ART. Despite the improvements in the success of ART, it remains the fact that the majority of patients require more than one cycle of treatment to achieve pregnancy 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

and live birth. Furthermore, the use of egg donation has also helped in increasing the success rates for ART; most of the egg donors repeat more than one cycle. The question ‘Does the ovarian reserve decrease from repeated ovulation stimulations?’ has become even more important today as ART has become a worldwide phenomenon with its ever growing number of patients in need of this therapy. There have been two reviews in the last 10 years on the effect of repeated reproductive techniques on ovarian response [1,2]. However, not much progress has been accomplished since the 2005 review. Experiments and observations in humans show that in primates, early antral follicles are present in ovaries throughout the follicular as well as the luteal phase and even prior to the onset of puberty [3]. It is generally accepted that the stages of follicular development up to and including the early antral follicle are relatively independent of the pituitary gonadotropins, follicle-stimulating hormone (FSH) and DOI:10.1097/GCO.0b013e328338c165


178 Fertility Table 1 Relevant published data on consecutive controlled ovarian hyperstimulation cycles for IVF and ovulation induction protocols

OI-HUI Diamond et al. [7] Ahmed Ebbiary et al. [8] Jacobs et al. [9] IVF Yovel et al. [14] Hoveyda et al. [13] Kolibianakis et al. [11] De Boer et al. [12] Donors Jain et al. [23] Caligara et al. [22] Opsahl et al. [24]

Number of cycles per patient

Size of the studies

ART

3–12 3–6 1–2

151 cycles 347 cycles 486 cycles

Clomiphene citrate/hMG Clomiphene citrate/nMG Clomiphene citrate/hMG

3 3 2–6 7

426 cycles 570 cycles 9379 cycles 330 cycles

IVF IVF IVF IVF

3 2–9 1–6

45 donors 284 donors 135 donors

IVF IVF IVF

hMG, human menopausal gonadotropin.

luteinizing hormone [3,4]. The main role of FSH is to stimulate the formation of a large preovulatory follicle from a preantral follicle [3]. If FSH secretion and stimulation does not occur at the appropriate time, and if maintenance of this secretion does not occur, the cohort of follicles would undergo atresia [5]. If the cohort of antral follicles has already been selected independent of the pituitary gonadotropins, the amount of FSH would only affect the development of preovulatory follicles coming from the antral pool that otherwise would be atretic due to dominant follicle selection. If so, the increase of FSH during the late luteal phase would not affect the overall number of follicles in the cohort. As a result, the repeated cycles should not affect the ovarian reserve. However, if the increase of FSH increases the number of follicles recruited into the cohort, the treatment may increase the depletion of the follicle pool by stimulating the resting follicles to grow [5]. This may result in the depletion of the number of oocytes available and may affect the overall ovarian reserve in repeated cycles. This is one way of thinking about it if one believes in the premise that germ cell production in female mammals ceases at birth. On the contrary, Johnson et al. [6] is the first group that introduces the concept of ongoing oocyte regeneration de novo postnatally within the ovary. Many studies that follow since 2004 support the idea of continuous germ cell renewal providing replenishment of oocytes in the ovary. This exerts a new way of thinking of the effects of ovarian stimulation on ovarian reserve and oocyte development. With the ever changing biological understanding of the process of folliculogenesis, the available literature concerning ovarian response in repeated ovarian stimulation cycles is, at the same time, inconclusive and limited. The first part of the review is to examine whether there is evidence in supporting that repeated cycles would decrease ovarian reserve in patients who are undergoing repetitive conservative ovarian stimulation and IVF cycles. Then, we will examine the effect of repeated ART cycles in patients with endometriosis. Finally, we

will focus on the potential long-term sequelae of multiple cycles of treatment on the well being of the ovary itself. Table 1 summarizes some of the studies mentioned in this review. The answer to the main question of this review is crucial in terms of counseling patients as well as oocyte donors about the available clinical evidence in reporting the clinical consequence of repeated ovarian stimulation.

Ovarian response to consecutive cycles of ovulation induction In this section, we would first review available clinical studies (Table 1) on whether repeated ovulation induction would deteriorate ovarian response with repetitive treatment. Secondly, we would then review the data available on the effect of IVF repetitive cycles on ovarian reserve. Ovarian stimulation combined with intra-uterine insemination (IUI) is an effective treatment of nontubal infertility but most women undergo several cycles of treatment to achieve a pregnancy. Diamond et al. [7] were one of the first groups to evaluate ovarian response in consecutive cycles of women undergoing ovulation induction with human menopausal gonadotropins (hMG) and/or clomiphene citrate. It was concluded that hMG can be administered in multiple successive cycles without clinically impairing ovarian response which, estimated by peak E2 levels and the day of hCG administration, remained similar in 3– 12 immediately successive cycles. In a prospective study of 86 women, Ahmed Ebbiary et al. [8] assessed the consistency of ovarian response and the effect of ovarian stimulation protocols (i.e. sequential clomiphene citrate or hMG stimulation, hMG-only or combined gonadotrophinreleasing hormone analog – hMG) on this consistency in consecutive cycles of ovarian stimulation and IUI in women with nonovulatory infertility. Using each patient as her own control, the study demonstrated that the ovarian response was similar in patients undergoing three to six cycles of ovarian stimulation and IUI. However, in a


Decrease in ovarian reserve from repeated ovulation stimulations Luk and Arici 179

retrospective study of 486 cycles from 225 ovulatory infertile women undergoing hMG superovulation IUI, Jacobs et al. [9] had found a decreased ovarian response to an increased amount of stimulation, as measured by steroidogenesis and follicular recruitment with increasing age of the women. When the age variable was taken out from the analysis, there was no significant difference in the mean estradiol level per preovulatory follicle among the different age groups.

Ovarian response to consecutive cycles of in-vitro fertilization Even though there are many similarities in the process of hormonal manipulation within the cycle with conservative ovulation hyperstimulation versus IVF, the difference is marked between the two protocols. Compared to ovulation induction, IVF involves usually higher dosage of medication and also a surgical process which is the oocyte retrieval process in which the actual puncture can have destructive effect on the capillaries and follicles of the ovary, the effect of which may accumulate during repeated punctures. Repeated punctures may also induce the release of autoantigens causing a decline of the follicle pool [10]. If this is true, a decrease in the number of retrieved oocytes in women with many IVF cycles is to be expected. As a result, compared to conservative ovarian stimulation cycles combined with IUI cycles, IVF protocols appear more invasive with higher dosage of gonadotropins medication and ovarian puncture for oocyte retrieval. However, the results are found to be similar to those for conservative ovarian induction and IUI cycles. In a retrospective analysis of 3249 patients, Kolibianakis et al. [11] was one of the first groups that included 9379 cycles of IVF cycles or intracytoplasmic sperm injection (ICSI) cycles (minimum two, maximum six cycles per patient). It demonstrated that repeated ART cycles did not exert a significant effect on the mean number of cumulus oocyte complexes retrieved per attempt. Across repeated ART attempts, an increase in the mean number of ampoules used per cycle was observed which was secondary to the effect of maternal age. After controlling for the effect of maternal age, there was no decrease in the number of retrieved cumulus oocyte complexes among subsequent cycles. In a nationwide retrospective cohort study in the Netherlands with a total of 330 cycles, De Boer et al. [12] investigated whether there was a decreasing trend in the number of retrieved oocytes in women who had all undergone at least seven consecutive IVF cycles. Reassuringly, there was no significant decrease in the number of retrieved oocytes over six cycles. On adjusting for the number of ampoules and the stimulation protocol, a

significant 20% decrease in the number of retrieved oocytes between cycle numbers 1 and 6 was found but the effect was secondary to age. In a study of 190 women, Hoveyda et al. [13] assessed the results of three consecutive cycles of ovarian stimulation in the same woman. Each woman served as her own control. There were no significant differences in the number of follicles produced or the number of oocytes retrieved over the three cycles, with an average of 12 follicles and 8 oocytes produced per cycle. The number and the quality of embryos produced did not change significantly over the three cycles. To find whether age plays a role in the two age groups, they stratified and analyzed the data according to two age groups: below 35 y/o (n ¼ 112) and above 35 y/o (n ¼ 78). Both groups were noted to have significant increase in the number of ampoules of gonadotropin required per follicle over the three consecutive cycles. However, there is a significantly higher increase of ampoules of gonadotropins over the consecutive IVF cycles needed for the age group above 35 y/o compared to the younger age group. And this finding was consistent with previous studies showing an increased need for number of ampoules of gonadotropins dependent on age. Yovel et al. [14] assessed 194 women who underwent four to eight IVF cycles and the women aged from 25 to 46 years. The patients underwent from four (169 women) to eight (27 women) treatment cycles, using four established protocols for induction of ovulation. The pregnancy rates in cycles 4–8 were not statistically different with mean pregnancy rate at 16.2% per cycle. On the contrary, there were a few retrospective studies done on a large number of women in the 1990s showing that the successive IVF cycles after the third cycle decreased ovarian reserve with decreasing pregnancy and birth rate with subsequent cycles [15,16]. They included thousands of cycles to study the numerous factors that can affect the success of an IVF cycle. A large review of 36 961 cycles done by the Human Fertilisation and Embryology Authority (HFEA) who has been collecting information on all IVF cycles revealed a decline in live birth rate associated with increasing age and a decrease associated with the duration of infertility and with each subsequent cycle of treatment [16]. Even after adjustment for age, there was a significant decrease in live birth rate with increasing duration of infertility from 1 to 12 years (P < 0.001). The main goal of this database was to identify the factors that affect the outcome of IVF treatment. Even though these studies consisted of large numbers of women their treatment protocol consisted of a group of heterogeneous protocols with different dosage treatments. These studies did not assess the same group of women over consecutive IVF cycles. As a result, these


180 Fertility

studies are not ideal to answer the main question of this review. Even though the available literature is limited, the published evidence demonstrates that repeated IVF cycles do not appear to affect the ovarian reserve with three repetitive IVF cycles. Ovarian response persists with subsequent cycles of controlled ovarian hyperstimulation in the number of oocytes retrieved and the number of embryos transferred from each stimulatory cycle. However, it appears that successive IVF cycles after the third cycle may decrease ovarian reserve, and that there is an increased gonadotropin requirement with each subsequent IVF cycle across all age groups.

Effect of repeated controlled ovarian stimulation in patients with endometriosis It has been a controversial matter on the extent to which endometriosis affects IVF outcome. It has been suggested that women with endometriosis have a lower ovarian response to ART treatment. The effect of endometriosis on pregnancy outcome after IVF-ET is controversial. Many authors have reported a detrimental effect [17,18], but not all have concurred with this finding [19,20]. Most of these studies have been relatively small or multicenter in design, and have not been able to specifically assess the impact of endometriosis stage on IVF-ET outcome. IVF is an effective infertility treatment for women with endometriosis, but most women need to undergo several cycles of treatment to become pregnant. In this case-control study, Al-Azemi et al. [21] compared outcome measures in 40 women with a history of surgically confirmed ovarian endometriosis and 80 women with tubal infertility, all of whom had at least three IVF treatment cycles. This was designed to assess how consistently women with ovarian endometriosis respond to ovarian stimulation in consecutive treatment cycles compared to women with tubal infertility. The ovarian endometriosis group had a significantly poorer ovarian response and required significantly more ampoules of FSH per cycle, a difference that became greater with each subsequent cycle. However, cumulative pregnancy (63.3 versus 62.6% by fifth cycle) and live birth (46.8 versus 50.9% by fifth cycle) rates were similar in both groups. In conclusion, despite decreased ovarian response to FSH, ovarian endometriosis does not decrease the chances of successive IVF treatment.

Effect of ovarian reserve in egg donors who undergo repeated in-vitro fertilization cycles Egg donation has become a common mode of therapy for the treatment of premature ovarian failure or recurrent unsuccessful IVF attempts. As a result, egg donation has become a common practice and egg donors who have

good track record (i.e. producing good-quality embryos and with successful pregnancy) are likely being recruited for multiple cycles. In a retrospective study of 284 donors who underwent at least two cycles with 4 donors undergoing up to nine cycles, Caligara et al. [22] studied the effect of repeated IVF cycles on the oocyte quality, assessed as fertilization, implantation and pregnancy rates. The study demonstrated that the number of retrieved oocytes was maintained during five repeated IVF cycles. Moreover, with the same dosage of stimulation used over multiple cycles, there was no difference in the oocyte quality, as shown by comparable fertilization, implantation and pregnancy rates in the recipients over multiple cycles of donation. The results from this study were confirmed by two other studies. In a retrospective chart review of 45 oocyte donors in 107 IVF cycles, Jain et al. [23] demonstrated that donors could undergo up to three stimulation cycles without a negative effect on the ovarian response to gonadotropins and the embryo quality. This finding may be due to the young age of the donors who were recruited and the relatively short interval between treatment cycles, as demonstrated by the mean age per cycle of the donors. Opsahl et al. [24] also evaluated the pregnancy rate of each IVF cycle from individual oocyte donors who underwent multiple sequential donations. Donors were grouped by the interval between cycles and the cycle number. Cumulative delivered pregnancy rates for cycles 1–6 were ranging between 51.5 and 57.6%, when the pregnancy rates did not vary by the interval between cycles. The study concluded that young healthy donors can reliably donate oocytes for at least six cycles with the expectation of consistently high pregnancy rates.

Adverse effect on ovaries with repeated cycles Preliminary studies report that ovulation-inducing medications were associated with a small increase in the risk of ovarian tumors (i.e. borderline tumors) and that the risk increased with the extended use of ovulation-inducing agents for many months [25,26]. In the study cohort of 3837 women, Rossing et al. [25] found that the risk of clomiphene citrate use was dose-dependent and the risk increased with duration of usage. After controlling for the presence of ovulatory abnormalities, the relative risk of developing ovarian tumors associated with long-term use of clomiphene citrate (12 months or more) was 11.1 [95% confidence interval (CI) 1.5–82] [24]. This was a statistically significant finding and the result was similar among gravid and nulligravid women, as well as among women with or without ovulatory abnormalities. The researchers concluded that the prolonged use of clomiphene citrate may increase the risk of a borderline or invasive ovarian


Decrease in ovarian reserve from repeated ovulation stimulations Luk and Arici 181

tumor. The results were consistent with Whittemore et al. [26] study in which they found significant risk occurred among 13 nulligravid women who had used infertility drugs. However, no such effect was found in Mosgaard et al. [27] case control study including Danish women (below the age of 60 years) with ovarian cancer in the analysis. They compared patients who developed ovarian cancer (n ¼ 684) with an age-matched control group (n ¼ 1721) and found that there was no added risk in those with a history of fertility treatment [27]. One must wonder how infertility may also play a role in the risk of developing ovarian cancer. In a multicenter study, Ness et al. [28] pooled interviews on infertility and fertility drug use from eight case-control studies conducted between 1989 and 1999 in the USA, Denmark, Canada, and Australia. The analysis includes 5207 cases and 7705 controls [28]. It shows that the risk of ovarian cancer increased 2.67-fold among nulligravid women who attempted for more than 5 years to get pregnant compared with women who needed less than a year. Fertility drug use in nulligravid women is associated with borderline serous tumors but not with any invasive histologic subtypes. The study suggests a role for specific biologic causes of infertility, but not for infertility drugs in overall risk for ovarian cancer. Some practitioners believe that infertility itself is a more powerful risk factor for ovarian tumors than the treatment with ovulation-inducing medication. Most of these epidemiological studies on fertility drug use and risk of ovarian cancer are hampered by methodological problems, such as small study size, short follow-up time, and low prevalence of ovarian cancer. It is difficult to draw a definitive conclusion on the role of infertility in the risk of development of ovarian cancer from these studies. The most common presentation of ovarian cancer is in the sixth decade of life. The widespread availability of ovulation-inducing medication began in the 1980s; thus, we may not see the effect of ovulation-inducing medication for at least another decade. It is highly possible that the effect of fertility drug use on ovarian cancer risk has been underestimated.

suggests that successive stimulation cycles do not impair ovarian response in terms of quantity and quality of the oocytes obtained in good donors. This finding may be due to the young age of the donors who were recruited and the relatively short interval between treatment cycles, as demonstrated by the mean age per cycle of the donors reported in the studies. As for women who are undergoing IVF and ovulation induction, the results have been equivocal when they repeat more than three cycles. Overall, the finding shows that there is no significant decline in ovarian reserve in patients undertaking up to three repeated IVF cycles. Age becomes a determinant factor with both pregnancy and live birth rate declining with repetitive cycles. The consistent finding from this review is that the mean number of ampoules used per cycle increases in line with age. Consequently, an increased amount of ampoules per attempt is likely to be used in older (compared with younger) women in each ART cycle performed. Age-associated decline in ovarian reserve is known to affect the size and the activity of the cohort of follicles available to respond to gonadotropin stimulation, resulting in the increased quantity of medication needed for ovarian stimulation. Further studies into this subject are needed to better counsel patients who will be undergoing ART treatment. The potential association of repeated cycles of induction treatments and the later development of ovarian cancer has been suggested by a number of studies. However, there is no evidence-based guideline about the appropriate duration of gonadotropin administration. However limited, the current body of evidence is reassuring on this issue. Given the possibility that such agents can cause harm, it seems appropriate to use them sparingly and only with clear cut indications.

References 1

Kelly SM, Buckett WM, Tan SL. Effect of repeated assisted reproductive technology on ovarian response. Curr Opin Obstet Gynecol 2003; 15:219– 224.

2

Serna J, Garcia-Velasco JA. Effect of repeated assisted reproduction techniques on the ovarian response. Curr Opin Obstet Gynecol 2005; 17:233– 236.

3

Zeleznik AJ, Wildt L, Schuler HM. Characterization of ovarian folliculogenesis during the luteal phase of the menstrual cycle in rhesus monkeys using [3H]thymidine autoradiography. Endocrinology 1980; 107:982–988.

4

Zeleznik AJ. The physiology of follicle selection. Reprod Biol Endocrinol 2004; 2:31.

5

Gougeon A. Ovarian follicular growth in humans: ovarian ageing and population of growing follicles. Maturitas 1998; 30:137–142.

6

Johnson J, Canning J, Kaneko T, et al. Germline stem cells and follicular renewal in the postnatal mammalian ovary. Nature 2004; 428:145–150.

7

Diamond MP, DeCherney AH, Baretto P, Lunenfeld B. Multiple consecutive cycles of ovulation induction with human menopausal gonadotropins. Gynecol Endocrinol 1989; 3:237–240.

8

Ahmed Ebbiary NA, Morgan C, Martin K, et al. Ovarian response in consecutive cycles of ovarian stimulation in normally ovulating women. Hum Reprod 1995; 10:536–543.

Conclusion Repetitive fertility treatment can have a significant degree of psychological stress, with potentially important consequences for the couple and their relationship. Even with the advances in ART treatment, most couples would need to undergo more than one cycle before they can succeed. As a result, the question whether the repeated ovulation induction cycles would affect the ovarian reserve is crucial in counseling patients who are planning to undergo infertility treatments. The available data on this topic are limited. Overall, the analysis of the data


182 Fertility Jacobs SL, Metzger DA, Dodson WC, Haney AF. Effect of age on response to human menopausal gonadotropin stimulation. J Clin Endocrinol Metab 1990; 71:1525–1530.

19 Dmowski WP, Rana N, Michalowska J, et al. The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates. Fertil Steril 1995; 63:555–562.

10 Gobert B, Barbarino-Monnier P, Guillet-May F, et al. Anti-ovary antibodies after attempts at human in vitro fertilizationiduced by follicular puncture rather than hormonal stimulation. J Reprod Fertil 1992; 96:213–218.

20 Olivennes F, Feldberg D, Liu HC, et al. Endometriosis: a stage by stage analysis: the role of in vitro fertilization. Fertil Steril 1995; 64:392– 398.

11 Kolibianakis E, Osmanagaoglu K, Camus M, et al. Effect of repeated assisted reproductive technology cycles on ovarian response. Fertil Steril 2002; 77:967–970.

21 Al-Azemi M, Bernal AL, Steele J, et al. Ovarian response to repeated controlled stimulation in in-vitro fertilization cycles in patients with ovarian endometriosis. Hum Reprod 2000; 15:72–75.

12 de Boer EJ, Den Tonkelaar I, Burger CW, et al. The number of retrieved oocytes does not decrease during consecutive gonadotrophin-stimulated IVF cycles. Hum Reprod 2004; 19:899–904.

22 Caligara C, Navarro J, Vargas G, et al. The effect of repeated controlled ovarian stimulation in donors. Hum Reprod 2001; 16:2320–2323.

9

13 Hoveyda F, Engmann L, Steele J, et al. Ovarian response in three consecutive in vitro fertilization cycles. Fertil Steril 2002; 77:706–710. 14 Yovel I, Geva E, Lessing JB, et al. Analysis of the fourth to eighth in-vitro fertilization treatments after three previously failed attempts. Hum Reprod 1994; 9:738–741. 15 Meldrum DR, Silverberg KM, Bustillo M, Stokes L. Success rate with repeated cycles of in vitro fertilization-embryo transfer. Fertil Steril 1998; 69:1005– 1009.

23 Jain A, Robins JC, Williams DB, Thomas MA. The effect of multiple cycles in oocyte donors. Am J Obstet Gynecol 2005; 192:1382–1384. 24 Opsahl MS, Blauer KL, Black SH, et al. Pregnancy rates in sequential in vitro fertilization cycles by oocyte donors(1). Obstet Gynecol 2001; 97:201– 204. 25 Rossing MA, Daling JR, Weiss NS, et al. Ovarian tumors in a cohort of infertile women. N Engl J Med 1994; 331:771–776.

16 Templeton A, Morris JK, Parslow W. Factors that affect outcome of in-vitro fertilisation treatment. Lancet 1996; 348:1402–1406.

26 Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. IV. The pathogenesis of epithelial ovarian cancer. Collaborative Ovarian Cancer Group. Am J Epidemiol 1992; 136:1212–1220.

17 Pellicer A, Oliveira N, Ruiz A, et al. Exploring the mechanism(s) of endometriosis-related infertility: an analysis of embryo development and implantation in assisted reproduction. Hum Reprod 1995; 10 (Suppl 2):91–97.

27 Mosgaard BJ, Lidegaard O, Kjaer SK, et al. Infertility, fertility drugs, and invasive ovarian cancer: a case-control study. Fertil Steril 1997; 67:1005– 1012.

18 Arici A, Oral E, Bukulmez O, et al. The effect of endometriosis on implantation: results from the Yale University in vitro fertilization and embryo transfer program. Fertil Steril 1996; 65:603–607.

28 Ness RB, Cramer DW, Goodman MT, et al. Infertility, fertility drugs, and ovarian cancer: a pooled analysis of case-control studies. Am J Epidemiol 2002; 155:217–224.


Economics of assisted reproductive technologies Baris Ataa and Emre Selib a

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada and b Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Emre Seli, MD, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 310 Cedar Street, LSOG 304D, New Haven, CT 06520-8063, USA Tel: +1 203 785 7873; fax: +1 203 785 7134; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:183–188

Purpose of review To give an overview of the economic aspects of assisted reproductive technologies (ART) and assess the implications of economic factors for utilization and practice of ART. Recent findings The out-of-pocket expenses for the couple seem to be the key determinant of ART utilization. Countries with reimbursement plans, which minimize out-of-pocket expenses, achieve the highest ART utilization rates. The economic burden of ART on national healthcare expenditure is modest even for countries offering the most generous reimbursement policies. Downstream costs of ART arise from multiple pregnancies and associated prematurity-related complications. These costs can outweigh the cost of ART itself. Public reimbursement plans accompanied by strict regulations for number of embryos to be transferred seem to increase not only ART utilization rates but also the uptake of single embryo transfers. Summary Although ART is expensive for individuals, it is affordable for the society, at least in the industrialized world. Public reimbursement relieves the pressure on both the physicians and the patients for achievement of pregnancy with the minimum number of treatment attempts, consequently leading to a decrease in the number of embryos transferred and in multiple pregnancies. Keywords assisted reproductive technologies, cost, cost effectiveness, economics, in vitro fertilization, utilization Curr Opin Obstet Gynecol 22:183–188 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Failure to conceive after 12 months of regular, unprotected intercourse is the most commonly used definition of infertility and it is a common problem estimated to affect approximately 15% couples with a more or less similar incidence all around the world [1]. Although there is a perception that the prevalence of infertility is rising and concerns exist about a possible decline in human fertility, this has not been corroborated with factual data as of yet [2–4], and at least in the United States, the prevalence of infertility has remained unchanged over the last decades, with an estimated 13% in 1965, and 14% in 1988 [5]. Among the treatment options available to infertile couples, those utilizing assisted reproductive technologies (ART) are associated with the highest success rates. Consequently, the number of patients treated using ART has been steadily increasing across the world. The International Committee for Monitoring Assisted Reproductive Technologies (ICMAART) estimated 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

that in the year 2002 approximately 600 000 ART cycles have been performed worldwide [6]. The number of treatment cycles reported to the European in-vitro fertilization (IVF) Monitoring Programme and the Society for Assisted Reproductive Technologies have been steadily increasing over the years [7,8]. If the growth rates are maintained consistently, it is anticipated that the total number of ART cycles per annum will reach one million by the year 2010 and two million by the year 2015 (Fig. 1).

Utilization of assisted reproductive technologies Despite the consistent increase in the number of ART cycles performed each year, the overall utilization of ART is still less than the estimated numbers had all couples in need had access to these technologies [2]. ART services require highly trained personnel and expensive equipment. Therefore, limited availability of the services and the cost of treatment can be considered major factors limiting utilization of ART. In a DOI:10.1097/GCO.0b013e3283373c13


184 Fertility Figure 1 Current and estimated number of ART treatment cycles per year

1200000

1000000

600000

400000

United states

Number of cycles

800 000

European union Japan Australia/New Zealand Other countries

200000

0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Data source for the United States: Centers for Disease Control; Actual figures through 2005; projected cycles based on 4% growth rate per year. Data source for the European Union: ESHRE, ICMART; Actual figures through 2003; projected cycles based on 9% growth rate per year. Data source for Japan: Japanese Society of Obstetrics and Gynecology; Actual figures through 2004; projected cycles based on 8% growth rate per year. Data source for Australia and New Zealand: Australian and New Zealand Assisted Reproductive Database; Actual figures through 2005; projected cycles based on 9% growth rate per year. Data source for other countries: International Committee for Monitoring Assisted Reproductive Technologies; Actual figures through 2002; projected cycles based on 5% growth rate per year. Graph courtesy of James T. Poslico, Ph.D.

detailed review article on health economics of ART, infant mortality was the only healthcare measure that was significantly associated with the availability of ART services at a national level [1]. Infant mortality is regarded as an indicator of overall quality of a national healthcare system [9], and it is plausible that countries with high infant mortality rates can have priorities for other basic healthcare services rendering less resources available for ART services [1]. However, the utilization of ART in most developed countries with low infant mortality rates is still below 1500 ART cycles per million population (c.p.m.) per annum, which is considered a conservative underestimate of the actual need [1,2,10]. The observed difference in ART utilization between countries with similar low infant mortality rates seem to be partly due to differences in the availability of public reimbursement for ART. As an example, despite similar infant mortality rates, the average number of ART c.p.m. per annum ranged between 1450 and 2209 in the year 2005 in Scandinavian countries with full public reimbursement for ART [7], whereas the same figure was only 353 in Canada for the same year [11], where there was no federal government reimbursement for ART and only one province provided

partial reimbursement excluding cost of medication [10].

Cost of assisted reproductive technologies The cost of an ART treatment cycle can be categorized as direct and indirect costs. Direct costs are more or less similar for all patients in a given center and arise from physicians’ consultations, nursing services, medication, ultrasound scanning, laboratory tests, ART procedures [oocyte collection, anesthesia, sperm preparation, invitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), various embryology services, and embryo transfer], hospital charges, and administrative charges. The immediate indirect costs mainly include costs associated with loss of working hours and traveling to the treatment center. The actual amount of indirect costs depends on the conditions of a particular patient rather than the center. In general, indirect costs are relatively much less than the direct costs and, therefore, considered negligible. The costs arising from the multiple pregnancies following ART, that is, hospitalization costs for women and infants, costs of neonatal complications associated with


Economics of assisted reproductive technologies Ata and Seli

prematurity, etc. are significant downstream costs of ART and they will be discussed in detail below. The cost of an ART cycle differs widely between countries. Collins [1] estimated the average cost of a single IVF cycle in 26 countries and expressed the figures in 2002 US$. The estimates ranged from 1272 US$ in Iran and Pakistan to 6361 US$ in Hong Kong, excluding the United States where the cost at 9547 US$ was much higher than the rest of the included countries. More recently, Chambers et al. [10] reported similar information for selected developed countries; the costs as they occurred in the year 2003 were expressed in 2006 US$. Although the United States remained the most expensive country with the average cost of a standard fresh IVF cycle at 12 513 US$ (2006), the cost of a fresh IVF cycle was the lowest in Japan with 3956 US$ (2006). The cost of medication comprised a significant proportion of overall treatment cost in all countries. The proportion was highest in Canada, where medication costs were 41.5% of overall treatment cost, and the lowest in Japan, where it was 13% of overall treatment cost [10]. These differences partly arise from the different marketing price of commonly used medications, partly from differences in prescribing patterns, that is, less gonadotropins per stimulated cycle being used in one country versus another etc. It is noteworthy that the actual cost of an ART treatment cycle per se is of limited value for understanding the economic implications of treatment costs on utilization of ART. Although a single IVF cycle costs more in North America where utilization is lower, the cost of a single treatment cycle is not the lowest in Scandinavian countries or Australia where the utilization of ART is the highest [1,10].

Affordability of assisted reproductive technologies To better determine the economic burden of ART treatment on an individual couple’s budget, ART cost should be assessed relative to disposable income. For this purpose, annual household expenditures and gross national income (GNI) per capita have been used as indicators of disposable income [1,10]. When Chambers et al. [10] calculated the cost of ART treatment cycle as a percentage of GNI per capita, the figures were directly proportional to the absolute cost of ART treatment. In their study, the cost of a cycle in developed countries ranged from 10% of GNI per capita in Japan to 28% of GNI per capita in the United States. The results were similar to figures reported by Collins in a former report [1]. However, the cost of an ART treatment cycle can be greater than 50% of GNI per capita in developing countries [1]. For instance, the 1272 US$ (2002) cost of an ART cycle in Iran and Pakistan, the lowest value reported for countries

185

included in the analysis by Collins, was greater than 50% of GNI per capita in respective countries [1]. Although the number of ART c.p.m. per annum was only four in Pakistan, it was 301 in Iran, a figure greater than 126, 190 and 101 c.p.m. per annum reported for the United States, Canada and Japan in the same period. Therefore, the proportion of cost of an ART cycle to disposable income does not seem to be the only factor determining utilization.

Reimbursement of assisted reproductive technologies The regulation, provision and funding of ART services differ among countries and at times between different jurisdictions in the same country [10,12,13]. Historically, the arguments against public funding/insurance coverage for ART included lack of medical necessity, ART being regarded an experimental procedure, low effectiveness of ART procedures and resultant low cost effectiveness as a treatment option [12]. In the early days of the ART era, effectiveness of the technology has been questioned [14,15], and initial studies analyzing cost effectiveness of ART in comparison to alternative conventional therapies, that is, untreated observation, ovulation induction, and intrauterine insemination (IUI), suggested that where applicable conventional treatments were more cost effective, and the cost per additional live birth with IVF was too high to be considered feasible [16–18]. However, while the success rates of conventional treatments have remained stable [7,19], the success rates of ART have improved consistently over the years and live birth rate per treatment cycle has reached the range of 20–40% [7,8]. Currently, ART is regarded the most successful treatment modality in terms of pregnancy/live birth rates per attempt. To the contrary, the effectiveness of conventional treatments is being requestioned [19,20]. Parallel to the evolution of perception of infertility per se and of ART in both the medical and general community, an increasing number of countries are providing governmental reimbursement for ART services. However, the conditions and extent of reimbursement vary widely among countries. Although some countries provide government funding for ART treatments largely through public centers, private centers where patients pay mostly out-of-pocket remain the major service providers in others. In the United States, where no publicly funded healthcare services are available for persons in the reproductive age group, some states have mandates for fertility treatment coverage including ART by third-party payers [10,12,21]. Effect of reimbursement on the affordability of assisted reproductive technologies

Chambers et al. [10] adjusted the economic burden of an ART treatment cycle on a couple for the effect of


186 Fertility

reimbursement policy in practice in the countries analyzed. They expressed the cost of a standard IVF cycle as the percentage of annual disposable income with and without adjusting for government subsidization. Although the figure remained unchanged at 12% in Japan, where no government subsidization exists, it was only modestly changed from 50 to 44% in the United States where reimbursement exists in different forms in some states only. On the contrary, the average cost as a percentage of annual disposable income was almost halved after adjusting for government reimbursement in Scandinavian countries and was approximately 10%. The most dramatic change was in Australia with a relative reduction by 71% from 19% to 6% of annual disposable income. Effect of reimbursement on the utilization of assisted reproductive technologies: implications on national cost of healthcare

Countries with more generous reimbursement policies minimizing the out-of-pocket expenses for the patients seem to achieve highest utilization of ART [10]. Scandinavian countries and Australia are examples reaching ART utilization rates around 1500 c.p.m. per annum with reimbursement policies that cut the cost of treatment for the couple by at least 50% [10]. These observations suggest that the out-of-pocket cost to the patient is the key determinant of the utilization of ART services. As expected, ART enjoys a larger share of the total healthcare expenditure in countries that offer reimbursement. ART treatment costs comprise only 0.06% of the total healthcare expenditure in the United States, whereas they account for 0.19% and 0.25% of total healthcare expenses in the Scandinavian countries and Australia, respectively [10]. It is noteworthy that although ART is a relatively expensive treatment with a high cost per procedure, the number of couples in need for treatment can be considered small relative to the total population, and the overall treatment cost to the society as a whole remains within reasonable limits even in countries with extensive public reimbursement and highest utilization rates. In addition, considering the relatively high cost of ART treatment for a couple, consuming a substantial proportion of their disposable income, it can be concluded that ART is expensive for the couple but easily affordable by the society. For instance, in the United States the estimated direct cost of cardiovascular diseases is 313.8 billion US$ [22], whereas the estimated direct cost of ART is less than 2 billion US$ (estimated number of treatment cycles multiplied by the average cost of an IVF cycle in the United States, including the cost of medication).

in a given society. Two ‘willingness to pay’ studies conducted in the United States and Sweden assessed how individuals value ART services [23,24]. Although the Swedish study included infertile couples, the United States study also included individuals who did not know their fertility status at the time of the study. The amounts that both study populations expressed willingness to pay exceeded the actual cost of a live birth with ART treatment. In the United States study, the amount individuals were willing to pay increased proportionally to anticipated success rate of the ART procedure [23]. Therefore, given the increased success rates with ART, it can be speculated that individuals could be expected to regard ART as better value for money today as compared with 15 years ago when these studies were conducted. The general population surveyed in the United States study expressed willingness to pay 38 US$ and 62 US$ per year in taxes for a public insurance program that would cover ART services and provide 25% and 100% chance of pregnancy with treatment, respectively. Another study found that an insurance coverage that would provide 300 c.p.m. per annum in the United States would only require 9.41 US$ premium per full time employee in the year 1995, a figure that is less than what people were willing to pay [25]. Finally, a modeling study conducted in the United States estimated that the lifetime tax contribution of a child conceived with ART to the government exceeds by 7fold the initial government subsidy for ART treatment, suggesting providing a reasonable ART coverage financially benefits the government in the long run [26]. Assisted reproductive technologies reimbursement: implications for treatment strategies

There is evidence that decisions made by the practitioners and patients during an ART treatment cycle are affected by the extent of reimbursement. Most importantly, the number of embryos transferred seems to be dependent on whether the couple is paying out-ofpocket, or they are reimbursed for the treatment. Following an initial report by Reynolds et al. [27] suggesting that insurance affects transfer practices, Jain and Gupta [28] showed that state-mandated health insurance coverage for ART services was associated with greater use of ICSI for infertility that is not attributed to male-factor condition. Most recently, Martin et al. [29] reported that states without insurance coverage for ART have a higher multiple twin live birth rate associated with more embryos transferred per cycle.

The value of assisted reproductive technologies reimbursement

Downstream costs of assisted reproductive technologies associated with multiple births and related prematurity

Whether ART provides ‘value for money’ service for the society depends on the perception of infertility and ART

In the United States, the current success rates achieved with ART are attained in many cases through the


Economics of assisted reproductive technologies Ata and Seli

187

simultaneous transfer of multiple embryos, at the risk of multiple pregnancies. Consequently, while ART cycles account for only 1% of all births in the United States, 18% of multiple births result from ART, and 51% of all ART neonates are the products of multiple gestations [30], a frequency 15-fold–20-fold greater than with spontaneous conceptions [31]. Similar outcomes are probable in countries that demonstrate similar lack of strict regulations on the number of embryos to be transferred, although data are not readily available.

relatively modest. The trend towards using milder stimulation protocols and the actual decrease in the number of multiple pregnancies provided by transfer of fewer embryos will render ART a more cost effective treatment and can be anticipated to further decrease the costs of ART on healthcare systems. Reasonable reimbursement policies can increase not only utilization of ART treatments but also the uptake of single embryo transfers.

The increase in multiple pregnancies associated with ART treatment has significant consequences for public health. The higher rate of preterm delivery in neonates from multiple infant pregnancies compromises their survival chances and increases their risk of lifelong disability. Indeed, the incidences of infant death and cerebral palsy are increased 4–6-fold in twins and more than 15-fold in higher order pregnancies [32]. The increase in preterm delivery that results from ART-associated multiple pregnancies also has financial consequences for the society. It has been estimated that preterm births that result from ART-associated multiple pregnancies account for almost 1 billion US$ healthcare costs annually [33].

References and recommended reading

Complications associated with multiple pregnancies have led many countries to enact strict regulations with respect to IVF practice, limiting the number of oocytes fertilized and/or embryos transferred [32]. Stricter regulations have been implemented in countries where ART is reimbursed, and resulted in a significant decrease in multiple pregnancies without causing a decrease in cumulative pregnancy rates, as demonstrated by several recent studies [34,35]. Meanwhile in the United States and many other countries where ART is not reimbursed, although there are guidelines implemented by various organizations regarding the recommended number of embryos transferred, the decision is ultimately left to the individual practitioner. A reimbursement program that aligns incentives of both patients undergoing treatment and the healthcare system that pays the economic cost of multiples can prove useful in increasing the uptake of single/double embryo transfers.

Conclusion ART is the most successful treatment of infertility. However, in most parts of the world utilization of ART seems to be less than the anticipated need. ART utilization is higher in countries with reimbursement plans that substantially decrease the out-of-pocket expenses for the couple under treatment. Although the cost of an ART treatment cycle is high for individuals across the world, the overall burden of ART on national healthcare expenditures is

Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 255). 1

Collins J. An international survey of the health economics of IVF and ICSI. Hum Reprod Update 2002; 8:265–277.

2

ESHRE Capri Workshop Group. Social determinants of human reproduction. Hum Reprod 2001; 16:1518–1526.

3

Bhattacharya S, Porter M, Amalraj E, et al. The epidemiology of infertility in the North East of Scotland. Hum Reprod 2009; 24:3096–3107.

4

Joffe M. What has happened to human fertility? Hum Reprod 2010; 25:295– 307.

5

Mosher W, Pratt W. Fecundity and infertility in the United States, 1965– 1988. Advance data from vital and health statistics 1990; 192:192–193.

6

de Mouzon J, Lancaster P, Nygren KG, et al. World collaborative report on Assisted Reproductive Technology, 2002. Hum Reprod 2009; 24:2310– 2320.

7

Nyboe Andersen A, Goossens V, Bhattacharya S, et al. Assisted reproductive technology and intrauterine inseminations in Europe, 2005: results generated from European registers by ESHRE: ESHRE. The European IVF Monitoring Programme (EIM), for the European Society of Human Reproduction and Embryology (ESHRE). Hum Reprod 2009; 24:1267–1287.

8

The Society for Assisted Reproductive Technology. National Data Summary. wwwsartorg. 2007 [Accessed 15 December 2009]

9

Wise PH, Pursley DM. Infant mortality as a social mirror. N Engl J Med 1992; 326:1558–1560.

10 Chambers GM, Sullivan EA, Ishihara O, et al. The economic impact of assisted reproductive technology: a review of selected developed countries. Fertil Steril 2009; 91:2281–2294. Recent analysis and comparison of economic aspects of ART in developed countries. Authors report that out-of-pocket expenses after public reimbursement is the major determinant of utilization. 11 Gunby J, Bissonnette F, Librach C, Cowan L. Assisted reproductive technologies in Canada: 2005 results from the Canadian Assisted Reproductive Technologies Register. Fertil Steril 2009; 91:1721–1730. 12 Hughes EG, Giacomini M. Funding in vitro fertilization treatment for persistent subfertility: the pain and the politics. Fertil Steril 2001; 76:431–442. 13 Brown S. Patchwork ART legislation in Europe. Focus on reproduction 2009:23. 14 Jarrell JF, Labelle R, Goeree R, et al. In vitro fertilization and embryo transfer: a randomized controlled trial. Online J Curr Clin Trials 1993;Doc No 73:[3483 words; 37 paragraphs]. 15 Soliman S, Daya S, Collins J, Jarrell J. A randomized trial of in vitro fertilization versus conventional treatment for infertility. Fertil Steril 1993; 59:1239– 1244. 16 Garceau L, Henderson J, Davis LJ, et al. Economic implications of assisted reproductive techniques: a systematic review. Hum Reprod 2002; 17:3090– 3109. 17 Karande VC, Korn A, Morris R, et al. Prospective randomized trial comparing the outcome and cost of in vitro fertilization with that of a traditional treatment algorithm as first-line therapy for couples with infertility. Fertil Steril 1999; 71:468–475. 18 Goverde AJ, McDonnell J, Vermeiden JP, et al. Intrauterine insemination or invitro fertilisation in idiopathic subfertility and male subfertility: a randomised trial and cost-effectiveness analysis. Lancet 2000; 355:13–18.


188 Fertility 19 ESHRE Capri Workshop Group. Intrauterine insemination. Hum Reprod Update 2009; 15:265–277. 20 Practice Committee of the American Society of Assisted Reproductive Technology. Effectiveness and treatment for unexplained infertility. Fertil Steril 2006; 86:S111–S114. 21 ESHRE Data collection and consortia. http://www.eshre.com/ESHRE/ English/Data-collection-Consortia/Europe-map-reimbursement/page.aspx/ 739. [Accessed 16 December 2009] This article is an up-to-date interactive map providing detailed information about current legislation status and reimbursement policies in European countries. 22 American Heart Association. 2009 Update at a glance. Heart Disease and Stroke Statistics. 2009:33. 23 Neumann PJ, Johannesson M. The willingness to pay for in vitro fertilization: a pilot study using contingent valuation. Med Care 1994; 32:686–699. 24 Granberg M, Wikland M, Nilsson L, Hamberger L. Couples’ willingness to pay for IVF/ET. Acta Obstet Gynecol Scand 1995; 74:199–202. 25 Collins JA, Bustillo M, Visscher RD, Lawrence LD. An estimate of the cost of in vitro fertilization services in the United States in 1995. Fertil Steril 1995; 64:538–545. 26 Connolly MP, Pollard MS, Hoorens S, et al. Long-term economic benefits attributed to IVF-conceived children: a lifetime tax calculation. Am J Manag Care 2008; 14:598–604. 27 Reynolds MA, Schieve LA, Jeng G, Peterson HB. Does insurance coverage decrease the risk for multiple births associated with assisted reproductive technology? Fertil Steril 2003; 80:16–23. 28 Jain T, Gupta RS. Trends in the use of intracytoplasmic sperm injection in the United States. N Engl J Med 2007; 357:251–257.

29 Martin JR, Bromer JG, Patrizio P. Insurance coverage and IVF outcomes in USA: analysis of recent trends in patients younger than 35 years old. Fertil Steril 2009; 92 (Supplement 3):S52. Treatment outcomes are compared between states with and without mandate for assisted reproductive treatment. Number of embryos transferred and multiple pregnancy rates are lower in states with mandate for insurance coverage. Difference in overall pregnancy rates is minimal. 30 Wright VC, Chang J, Jeng G, Macaluso M. Assisted reproductive technology surveillance: United States, 2003. MMWR Surveill Summ 2006; 55:1–22. 31 Reddy UM, Wapner RJ, Rebar RW, Tasca RJ. Infertility, assisted reproductive technology, and adverse pregnancy outcomes: executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol 2007; 109:967–977. 32 Bromer JG, Seli E. Assessment of embryo viability in assisted reproductive technology: shortcomings of current approaches and the emerging role of metabolomics. Curr Opin Obstet Gynecol 2008; 20:234–241. 33 Bromer JG, Seli E. Preterm deliveries that result from ART-associated multiple pregnancies in the United States: a cost analysis. Fertil Steril 2008; 90 (Supplement 1):S210–S211. Modeling study assessing the cost of ART-associated multiple pregnancies and resultant prematurity. The costs are estimated to be around one billion US$ per annum, exceeding the cost of treatment itself. 34 Thurin A, Hausken J, Hillensjo T, et al. Elective single-embryo transfer versus double-embryo transfer in in vitro fertilization. N Engl J Med 2004; 351:2392– 2402. 35 Lukassen HG, Braat DD, Wetzels AM, et al. Two cycles with single embryo transfer versus one cycle with double embryo transfer: a randomized controlled trial. Hum Reprod 2005; 20:702–708.


Cumulative live-birth rates after assisted reproductive technology Vasiliki A. Moragianni and Alan S. Penzias Boston IVF, Waltham and Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA Correspondence to Alan S. Penzias, MD, Director, Fellowship Program in Reproductive Endocrinology & Infertility, Beth Israel Deaconess Medical Center; Associate Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, 330 Brookline Avenue KS-322, Boston, MA 02130, USA Tel: +1 781 434 6500; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:189–192

Purpose of review Despite the promising success rates of IVF, many couples have to undergo several cycles before achieving live birth. In counseling patients faced with subfertility, it is important to provide cumulative live-birth rates. This review evaluates the current knowledge on cumulative rates, summarizing recently published evidence. Recent findings Existing data have been mostly presented in the form of live-birth rates per IVF cycle as a function of maternal age or reason for subfertility. Recent publications have been reporting IVF success rates in terms of cumulative live-birth rate (CLBR) per woman, thus providing a more realistic estimate that becomes applicable to individual couples. In general, CLBR following IVF has been reported between 45 and 55%. Maternal age has been shown to significantly reduce these rates, as has preimplantation genetic diagnosis. On the contrary, techniques mostly used to decrease the chance of multiple births, such as elective single embryo transfer and natural cycle IVF, do not affect CLBR while achieving a significant reduction in the rates of multiples. Summary Couples should be counseled that CLBR following IVF lies mostly around 50% and that maternal age as well as genetics of transferred embryos remain factors that influence success. Keywords assisted reproductive technology, cumulative live birth rate, IVF Curr Opin Obstet Gynecol 22:189–192 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Since the delivery of the first IVF baby nearly 30 years ago, significant advances have been made in the area of assisted reproductive technology (ART). Nevertheless, most subfertile couples undergo more than one treatment cycle before attaining a live delivery. An integral part of counseling these couples is educating them on the success, failure and complication rates related to each procedure they undergo with the end result of conception and live infant delivery. Traditionally, most studies have reported these rates per treatment cycle, most frequently classifying them by maternal age and cause of infertility. Such information would be useful in population-wide assessment of ART outcomes and has extensively been utilized in outcome reporting by national registries in Europe, the Middle East, North America, Australia and New Zealand [1,2]. In these registries, the term ‘cumulative’ often refers to a collection of data from different countries that are being combined and reported together. However, this method of outcome reporting has only limited applicability to any individual couple undergoing treatment. Instead, what is much more useful for both clinicians and patients and has recently been gaining 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

increasing attention in medical literature is the cumulative success rate per patient undergoing any number of ART cycles. More specifically, the cumulative live-birth rate (CLBR) per woman provides a more accurate depiction of treatment success and becomes directly meaningful to the subfertile couple. The aim of this review is to examine the recent medical literature on reports of CLBR following ART. These data will be first presented in general and subsequently as a factor of maternal age, the number of embryos transferred, natural cycle IVF and utilization of preimplantation genetic diagnosis (PGD).

Cumulative live-birth rates after IVF Studies from large fertility centers worldwide have been providing cumulative rates derived from longitudinal observations of cohorts of patients followed over time. In US studies, data from states such as Massachusetts have lent themselves to some of the major reported results. Not only is it one of the 14 US states offering mandated private insurance coverage for ART but it is also ranked fifth in the United States for number of ART DOI:10.1097/GCO.0b013e328338493f


190 Fertility

cycles and births [3,4]. Similarly, useful data are derived worldwide from national databases, such as the Copenhagen Multi-Centre Psychosocial Research Program [5].

In 2009, Malizia et al. [3 ] reported data from 6164 patients undergoing 14 248 IVF cycles in a single ART center in Massachusetts. They performed a retrospective cohort study of patients receiving treatment at their center for at least 1 year and undergoing up to six IVF cycles. The first of the cycles analyzed for each patient was always a fresh one and only subsequent cycles included in the analysis were allowed to be cryopreserved. The primary outcome measured by the authors was the delivery of single or multiple live infants, information that was obtained from the patients’ medical records. The CLBR for their population was reported between 51 and 72% in ‘conservative’ and ‘optimistic’ terms, respectively. Because it is impossible to assess the success rates of patients who interrupt treatment before attaining a pregnancy, these two approaches were used to estimate rates while still accounting for dropout patients. For the ‘conservative’ approach, it was assumed that patients who did not return for further IVF treatment had no chance of a live delivery, whereas the ‘optimistic’ approach assumed that patients not returning for IVF treatment had the same chance of a live delivery as those who did return. In a historical cohort study of 27 906 successive, linked ART cycles performed between January 2004 and December 2006, Stern et al. [4] reported the CLBR for all patients to be 53.8%. The study excluded intrauterine insemination (IUI), ovulation induction and banking cycles, as well as any cycles following the first delivery. Their analysis was based on the assumption that future treatment cycles would not result in a pregnancy and that the first cycle for each patient was the first one being reported for the study period, providing a conservative estimate overall and thus being consistent with the conservative result of the study by Malizia et al. [3]. Pinborg et al. [5] reported results from a longitudinal prospective cohort study linking the self-administered questionnaires of 1338 infertile couples with data from the National Medical Birth Register in Denmark. In their study, the cumulative rate of first live delivery following cycles of IUI, IVF, intracytoplasmic sperm injection (ICSI), frozen embryo transfer and spontaneous conceptions was 74.7% after 5 years of follow-up. However, as the authors recognize, a major weakness of the study design is positive selection bias that artificially overinflates the delivery rate, as women who delivered would be more likely to complete the questionnaire. Moreover, the authors included IUI cycles and naturally conceived pregnancies, thus further artificially inflating the overall CLBR.

Maternal age and cumulative live-birth rates with IVF When evaluating IVF outcomes, the effect of maternal age cannot be overlooked, as it affects response to infertility treatment and pregnancy outcomes. As expected, the CLBR differs significantly with advancing maternal age. Women younger than 35 years were shown by both Malizia et al. [3] and Stern et al. [4] to have conservative CLBRs more than 60%. In contrast, women older than 40 and 42 years using autologous oocytes were reported to have conservative CLBRs of 23 and 8.7%, respectively. Again overestimating rates due to study design, Pinborg et al. [5] reported a CLBR of 74.9% in women younger than 35 years, a rate that was significantly higher than that of their older cohorts. In a retrospective study of women 41–43 years of age with favorable treatment prognoses who underwent a maximum of three IVF cycles with autologous oocytes, Van Disseldorp et al. [6] reported conservative and optimistic CLBRs of 15.4 and 18.4%, respectively. Likewise, an observational study by Sundstro¨m and Saldeen [7] reported an overall 66% CLBR among 370 women who either completed a series of three fresh IVF cycles or delivered after the first or second IVF cycle. However, CLBRs were 37 vs. 17% in women younger than and older than or equal to 36 years, respectively. This evidence collectively supports the understanding that IVF can help overcome subfertility in younger patients, but the effect of age on fertility becomes progressively more refractory to treatment, especially in women older than 40 years of age [3].

Single vs. double embryo transfer One of the most significant complications resulting from ART treatment is multiple gestation and its associated morbidities, ranging from spontaneous abortion and preterm delivery to long-term neurologic sequelae. Because the number of embryos transferred during IVF is the highest predictor of this complication, it has been one of the modifiable factors targeted in order to minimize the risk of multiple births. A policy of elective single-embryo transfer (e-SET) has been instituted in many centers and numerous studies have evaluated its outcomes. A systematic review and meta-analysis of six randomized controlled trials comparing e-SET with double embryo transfer (DET) of cleavage stage embryos published by Gelbaya et al. [8] revealed CLBRs that ranged from 35.8 to 46.3% but showed no statistically significant difference between the two groups. Moreover, cumulative multiple birth rates (CMBRs) decreased significantly from 13.1– 41.2% in the DET group to 0–0.8% in the e-SET group.


IVF cumulative live-birth rates Moragianni and Penzias 191

Similarly, a Cochrane meta-analysis [9] of five trials comparing e-SET and DET revealed no statistically significant difference in CLBR after two fresh e-SET cycles compared with one single fresh DET cycle [odds ratio (OR) 1.23, 95% confidence interval (CI) 0.56–2.69, P ¼ 0.60]. Veleva et al. [10] compared 2386 fresh cycles followed by 1272 frozen IVF cycles during an e-SET-predominant compared with a DET-predominant period in a large fertility practice. They found similar CLBRs in the two periods (48.7 vs. 45.0%, P ¼ 0.2) but significantly lower CMBRs in the e-SET period (8.9 vs. 19.6%, P < 0.0001). Furthermore, the final results of a multicenter trial of 661 patients randomized to e-SET or DET published by Thurin-Kjellberg et al. [11] once again failed to demonstrate a statistically significant difference between the CLBRs of the two groups (43.9 vs. 51.1%, P ¼ 0.08).

Natural cycle IVF Another technique that also aims at reducing the rate of multiple births from IVF while providing a patientfriendly approach and exceedingly low risk of ovarian hyperstimulation is the modified natural cycle IVF (MNC-IVF), which utilizes the one follicle that spontaneously develops during a natural cycle. To evaluate the outcomes of MNC-IVF, Pelinck et al. [12] studied a cohort of 109 patients who underwent up to nine cycles of MNC-IVF followed by controlled ovarian hyperstimulation IVF (COH-IVF) and reported CLBRs of 50% following the combination and 42.2% in COH-IVF patients alone. Of note, these patients were 18–35 years old, had no requirement for ICSI and the primary outcome measure of the study was ongoing pregnancy at 12 weeks gestational age.

Preimplantation genetic testing Preimplantation genetic testing (PGT) includes PGD and screening (PGS) and has been utilized since 1990 in an attempt to minimize the transfer of embryos affected by a known genetic aberration (in the case of PGD) or at risk for aneuploidy (in the case of PGS). Special considerations that apply to patients undergoing PGT include the potential compromise of embryos subjected to additional manipulation and biopsy, weighed against the fact that otherwise fertile couples undertake such treatment for purely genetic reasons. An assessment of CLBR in IVF cycles with PGT is, therefore, of paramount importance in the understanding of the strengths and limitations of this technology. Verpoest et al. [13] performed a prospective cohort study of 2753 fresh cycles of ICSI with PGD. The authors

report an observed CLBR of 29% compared with an expected CLBR of 62%, after a maximum of six cycles. Of note, the number of genetically unaffected embryos available for transfer, type of chromosomal abnormality being tested, fertility status of the couple, parity and mode of pituitary suppression did not influence the CLBR. However, maternal age (especially over 40 years) and number of oocytes retrieved contributed significantly and independently to the decreased rate.

Conclusion Most subfertile couples undergoing IVF treatment require a number of cycles to reach the desired outcome of a live infant delivery. The majority of studies report outcomes from IVF in terms of rates per cycle according to maternal age or cause of subfertility. Owing to its limited usefulness in this format, IVF data are alternatively being expressed as cumulative rate per woman. This review has summarized the most recent studies reporting CLBR following IVF and found the preponderance of rates to be between 45 and 75% depending on the source, with the majority of reported rates being around 50%. As predicted, advancing maternal age and PGD are both factors that decrease the success of IVF and hence CLBR. In contrast, e-SET and MNC-IVF do not affect CLBR but significantly decrease the rates of CMBR.

References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 255–256). 1

Nyboe Andersen A, Goossens V, Bhattacharya S, et al. Assisted reproductive technology and intrauterine inseminations in Europe, 2005: results generated from European registers by ESHRE: ESHRE. The European IVF Monitoring Programme (EIM), for the European Society of Human Reproduction and Embryology (ESHRE). Hum Reprod 2009; 24:1267–1287.

2

Gunby J, Bissonnette F, Librach C, Cowan L. Assisted reproductive technologies (ART) in Canada: 2006 results from the Canadian ART Register. Fertil Steril 2009. [Epub ahead of print]

3 Malizia B, Hacker MR, Penzias AS. Cumulative live-birth rates after in vitro fertilization. N Engl J Med 2009; 360:236–243. This is one of the largest studies to date reporting the cumulative live birth rates of IVF cycles. Stern JE, Brown MB Luke B, et al.; a SART Writing Group. Calculating cumulative live-birth rates from linked cycles of assisted reproductive technology (ART): data from the Massachusetts SART CORS. Fertil Steril. 2009. [Epub ahead of print] This study links ART cycles and evaluates the outcomes of a large database.

4

5

Pinborg A, Hougaard CO, Nyboe Andersen A, et al. Prospective longitudinal cohort study on cumulative 5-year delivery and adoption rates among 1338 couples initiating infertility treatment. Hum Reprod 2009; 24:991–999.

6

Van Disseldorp J, Eijkemans MJ, Klinkert ER, et al. Cumulative live birth rates following IVF in 41- to 43-year-old women presenting with favourable ovarian reserve characteristics. Reprod Biomed Online 2007; 14:455– 463.

7

Sundstro¨m P, Saldeen P. Cumulative delivery rate in an in vitro fertilization program with a single embryo transfer policy. Acta Obstet Gynecol Scand 2009; 88:700–706.


192 Fertility 8

Gelbaya TA, Tsoumpou I, Nardo LG. The likelihood of live birth and multiple birth after single versus double embryo transfer at the cleavage stage: a systematic review and meta-analysis. Fertil Steril 2009. [Epub ahead of print]

Pandian Z, Bhattacharya S, Ozturk O, et al. Number of embryos for transfer following in-vitro fertilization or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev 2009:CD003416. This review summarizes all studies to date evaluating the effect of e-SET on IVF outcomes.

9

10 Veleva Z, Karinen P, Toma´s C, et al. Elective single embryo transfer with cryopreservation improves the outcome and diminishes the costs of IVF/ICSI. Hum Reprod 2009; 24:1632–1639.

11 Thurin-Kjellberg A, Olivius C, Bergh C. Cumulative live-birth rates in a trial of single-embryo or double-embryo transfer. N Engl J Med 2009; 361:1812– 1813. This study substantiates existing evidence that e-SET not only significantly decreases CLBR but also significantly reduces the rate of multiple gestations. 12 Pelinck MJ, Knol HM, Vogel NE, et al. Cumulative pregnancy rates after sequential treatment with modified natural cycle IVF followed by IVF with controlled ovarian stimulation. Hum Reprod 2008; 23:1808–1814. 13 Verpoest W, Haentjens P, De Rycke M, et al. Cumulative reproductive outcome after preimplantation genetic diagnosis: a report on 1498 couples. Hum Reprod 2009; 24:2951–2959.


The role of anti-Mu¨llerian hormone assessment in assisted reproductive technology outcome Simone L. Broera, BenWillem Molb, Madeleine Do´llemana, Bart C. Fausera and Frank J.M. Broekmansa a

Department of Reproductive Medicine, Division of Obstetrics, Neonatology and Gynecology, University Medical Center Utrecht, Utrecht and bDepartment of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands Correspondence to Simone L. Broer, MD, University Medical Center Utrecht, Room F05.126, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands E-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:193–201

Purpose of review The purpose of this study is to summarize the role of anti-Mu¨llerian hormone (AMH) in assisted reproductive technology (ART) treatment. Recent findings AMH is a good marker in the prediction of ovarian response to controlled ovarian hyperstimulation. In clinical practice, this means that AMH may be used for identifying poor or excessive responders. So far, studies show that AMH is not a good predictor for the occurrence of pregnancy after ART treatment. Therefore, routine screening for a poor ovarian reserve status using AMH is not to be advocated. Still, ovarian response prediction using AMH may open ways for patient-tailored stimulation protocols in order to reduce cancellations for excessive response, possibly improve pregnancy prospects and reduce costs. Summary AMH is able to predict extremes in ovarian response to controlled ovarian hyperstimulation but cannot predict pregnancy after ART treatment. Its future clinical role may be in the individualization of ART stimulation protocols. Keywords anti-Mu¨llerian hormone, assisted reproductive technology, intracytoplasmic sperm injection, in-vitro fertilization, ovarian response Curr Opin Obstet Gynecol 22:193–201 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Anti-Mu¨llerian hormone (AMH) has been identified as a dimeric glycoprotein and a member of the transforming growth factor beta (TGFb) family of growth and differentiation factors [1]. The human gene encoding for AMH is located on chromosome 19p13.3. Until recently, AMH was predominantly known for its role in male sexual differentiation [2,3]. AMH is produced by Sertoli cells at the time of testicular differentiation and induces regression of the Mu¨llerian ducts. In the ovaries of female fetuses, AMH can first be detected at 32 weeks of gestation [4]. The absent production of AMH from primitive granulosa cells in the early stages of female fetal development will allow the Mu¨llerian ducts to develop into the uterus, fallopian tubes and the upper part of the vagina [5,6]. In recent years, a role for AMH in postnatal ovarian function has become evident from animal studies [7]. The release of AMH from ovarian granulosa cells leads to measurable serum levels, which are proportional to the number of developing follicles in the ovaries. Therefore, AMH is considered to be a marker for the process of ovarian aging, as the number of developing follicles 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

decreases with age in humans [8]. The degree of ovarian aging at a given time point, referred to as an ovarian reserve, is important for the prospects in assisted reproductive technology (ART) therapy. This review focuses on the role of AMH in the prediction of outcome in ART treatment in the infertile couple.

Physiology of anti-Mu¨llerian hormone First, we would like to start with a description of AMH in ovarian folliculogenesis and an explanation of the pattern and source of AMH. The role of anti-Mu¨llerian hormone in ovarian folliculogenesis

Follicle development in the ovaries comprises initial recruitment, by which primordial follicles start to mature, and cyclic recruitment, which leads to the growth of a cohort of small antral follicles, from which the dominant follicle destined to ovulate is subsequently selected [9]. Follicle-stimulating hormone (FSH) directs the cyclic recruitment and forms the basis of the menstrual cycle. In primordial follicles, AMH expression is absent. After follicles have started to mature, AMH expression in granulosa cells of primary follicles becomes apparent. DOI:10.1097/GCO.0b013e3283384911


194 Fertility Figure 1 Intraovarian function of anti-Mu¨llerian hormone

Intraovarian function of AMH Cycle recruitment

Initial recruitment AMH

Selection and dominance

Ovulation

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Graafian follicle Antral Atretic

Secondary

Primary Primordial

Atretic

Atretic

???

>120 days

71 days

14 days

First, AMH has an inhibitory role in the initial recruitment and thereby aids in regulating the number of follicles remaining in the primordial pool. Second, AMH has an inhibitory effect on follicular sensitivity to FSH and could therefore play a role in the process of dominant follicle selection. AMH, antiMu¨llerian hormone; FSH, follicle-stimulating hormone.

This expression is maximal in granulosa cells of preantral and small antral follicles (up to 6 mm in diameter). Several in-vitro and in-vivo studies [10–12], using AMH knockout mice, have shown that at the larger antral follicle stages (7 mm), when follicular growth has become FSH-dependent, AMH expression diminishes and becomes undetectable. AMH is not expressed in atretic follicles or theca cells [5,13,14]. This pattern of AMH expression, from early primary follicles until the antral stages of FSH-dependent growth, supports the findings that AMH has an inhibitory role at two distinct stages of folliculogenesis. First, animal studies have indicated that AMH inhibits the transition of follicles from primordial into maturation stages, and thereby has an important role in regulating the number of follicles remaining in the primordial pool. Second, it seems that AMH has an inhibitory effect on follicular sensitivity to FSH and could therefore play a role in the process of follicular selection [7] (Fig. 1). Pattern and source of serum anti-Mu¨llerian hormone levels

Serum AMH levels are detectable at birth in the female [15,16]. In prepubertal girls, AMH values are still low, with a tendency to rise toward the onset of puberty. In adult women, serum AMH levels will decline gradually with age and become undetectable a few years before

menopause has become established [17–19]. Longitudinal studies [20,21] have demonstrated that AMH is a good predictor of the timing of menopause. Moreover, serum AMH levels have been identified as independent of the phase of the menstrual cycle [22–24], although very mild fluctuations do occur [25], especially in women with relatively high levels of AMH [26]. Even under other endocrine influences such as hormonal contraception [27,28], gonadotrophin releasing hormone agonists [29] and pregnancy [30], AMH levels have shown to be remarkably stable. The independence of menstrual cycle stage and other influences, the proportional relationship with the primordial and antral follicle cohort [31,32], and the clear relationship with reproductive age make AMH a good candidate for assessment of ovarian reserve status in the female. The source of AMH that enters the blood circulation is believed to be the cohort of ultrasonically visible antral follicles, up till the phase at which AMH expression becomes absent, that is, in follicles over 7 mm in diameter. This hypothesis has been confirmed in ovarian hyperstimulation studies, in which the majority of FSHsensitive follicles, present at a certain moment, are stimulated into dominant follicle growth. In parallel to the development of these dominant follicles, a prominent decrease in AMH levels is seen, proportional to the decrease in small antral follicles [31]. However, levels


Role of AMH assessment in ART outcome Broer et al.

Figure 2 The source of anti-Mu¨llerian hormone that enters the blood circulation

Serum AMH is produced from the cohort of ultrasonically visible antral follicles up to 7 mm. Moreover, follicles below the sensitivity limits of ultrasonography may also contribute to serum levels. This is based on the observation that serum AMH levels do not fall to zero when FSHsensitive antral follicles (2–5 mm) are stimulated into larger, dominant follicles during ovarian hyperstimulation for IVF and interrupt their AMH production. The black line and dots represent the stages of antral follicles that contribute to serum AMH. The grey line represents the ultrasonically visible antral follicles. AMH, anti-Mu¨llerian hormone.

do not fall to zero, indicating that either at any stage of hyperstimulation, some antral follicles remain, or antral follicles with a diameter below the sensitivity limits of the ultrasound may also contribute to serum levels of AMH (Fig. 2).

Anti-Mu¨llerian hormone in the prediction of assisted reproductive technology outcome It has been long known that with increasing chronologic age, female fecundity – the ability to produce offspring – decreases. This has been clearly demonstrated by the age dependency of success rates in ART [33–35]. Agerelated female infertility [36,37] is mainly based on changes in ovarian reserve, defined as the number and quality of the remaining follicles and oocytes in the ovaries at a given age. Decline in follicle numbers determines the occurrence of irregular cycles and menopause, whereas quality decay of the oocytes results in decreasing fecundity [38]. Much like the substantial individual variation in the onset of menopause (mean age 51 years, range 40–60 years) [39,40], the rate of decline in fertility may vary considerably between women of the same age. For ovarian reserve testing prior to ART, female age remains the predictor of first choice. However, in view of the variation in the ovarian aging process, a test capable of providing reliable information regarding a woman’s individual ovarian reserve within a certain age category would enable the clinician to provide an individually tailored treatment plan. For

195

instance, in older women, the finding of a normal ovarian reserve may justify the decision to allow ART treatment, whereas in young women with exhausted reserve either early application, refusal of ART or choosing for egg donation could be the consequence. Ovarian reserve can be considered normal when stimulation for ART by exogenous gonadotropins results in the retrieval of some 6–14 healthy oocytes at follicle puncture [41–43]. With such a yield, the chances of producing a live birth through IVF are considered optimal [44], whereas in the case of producing less than six oocytes, prospects become increasingly poor. The preferred outcome in studies on the value of ovarian reserve testing would be live birth after a series of ART cycles as an expression of a couple’s fertility potential. However, other outcome measures [especially oocyte yield or follicle number and pregnancy after one IVF/intracytoplasmic sperm injection (ICSI) cycle] are in fact the most common. Also, ovarian reserve tests mainly relate to the size of the follicle cohort that is at any time responsive to FSH. This focus on quantity prohibits high expectations on the relation to oocyte quality and pregnancy as outcome. Ovarian reserve test evaluation should imply the assessment of predictive accuracy and clinical value of the test. Predictive accuracy refers to the degree by which the outcome condition (pregnancy or poor/excessive response) is predicted correctly and is expressed by the sensitivity and specificity [45,46]. Using the sensitivity and specificity for a range of cut-off levels, a receiver operating characteristic (ROC) curve can be drawn. The area under this curve (AUC) represents the overall predictive accuracy of the test. Values of 1.0 imply perfect and 0.5 completely absent discrimination. Assessment of the clinical value of the test is a complex process through which the applicability in daily practice should become clear. The overall accuracy represented by the ROC curve, the rate of abnormal tests at the cutoff used, the valuation of false-positive and false-negative test results, the consequence for patient management of an abnormal test, and finally the cost and patient burden of carrying out the test all need to be incorporated in the decision process [47]. Anti-Mu¨llerian hormone and the prediction of poor ovarian response

A certain proportion of women (2–30%) undergoing ovarian hyperstimulation will experience a poor response [44,48–50]. In updates of the initial systematic review by Broekmans et al. [51], the accuracy and clinical value of AMH as a prognostic factor for the occurrence of a poor response after IVF/ICSI treatment have been analyzed and compared with the antral follicle count (AFC) [52,53–70]. The ROC curves have revealed that


196 Fertility Figure 3 The predictive accuracy of anti-Mu¨llerian hormone for the occurrence of poor response and nonpregnancy after ovarian hyperstimulation for IVF in comparison to the antral follicle count

(a) Sensitivity

Accuracy poor response prediction

(b)

1

Sensitivity

Accuracy non pregnancy prediction 1

0.9

0.9

0.8

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sROC curve AFC

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sROC curve AMH

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sROC curve AFC sROC curve AMH

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The individual combinations of sensitivity/specificity as extracted from the individual studies, as well as the summary ROC curves are shown. (a) The ROC curves for both AMH and the AFC run toward the upper left, indicating a good capacity to discriminate between normal and poor responders at certain cut-off levels. (b) The ROC curves for both tests run almost parallel to or even cross the X ¼ Y line, indicating that the test will not perform better than flipping a coin in predicting who will become pregnant. The test is, then, considered useless for nonpregnancy prediction. AFC, antral follicle count; AMH, anti-Mu¨llerian hormone; ROC, receiver-operating characteristic.

AMH has an adequate capability to predict a poor responder to ovarian hyperstimulation, with an area under the ROC curve (ROC-AUC) of approximately 0.90. The predictive accuracy for the AFC appeared not clearly different (ROC-AUC 0.89) (Fig. 3a). Since the emergence of these meta-analyses, several additional studies have been published on the role of AMH in the prediction of a poor response [71,72,73–75], with results that are in line with the initial meta-analyses [52,53]. The findings in these studies have been depicted in Table 1 ([54,56–71,72,73–75,76,77]). Both the methodology and patient selection, as well as the reported sensitivity and specificity combinations (range 0.40–0.97 and 0.41–1.00, respectively) completely fit within the findings of the earlier reports. Therefore, in Fig. 3(a), the summary ROC curve for the prediction of a poor response represents the full range of published studies to date. It can be stated that, from the published literature, AMH presents itself as a reliable predictor of poor response to ovarian stimulation for IVF/ICSI. Although direct comparisons have been carried out only in a limited number of studies, AMH has demonstrated to be a better marker in the prediction of poor response than basal FSH, but equally well compared to the AFC. Anti-Mu¨llerian hormone and the prediction of excessive ovarian response

An excessive ovarian response to hyperstimulation may lead to a potentially life-threatening condition, the ovar-

ian hyperstimulation syndrome (OHSS). The risk of OHSS is highly linked to an exaggerated ovarian response to gonadotrophin stimulation. The syndrome may lead to severe illness requiring hospitalization and intensive care, with thromboembolism or multiple organ failure as potential life-threatening complications. Mild and moderate forms of OHSS may occur in 15–20% of all ovarian stimulation cycles, whereas the severe form of the syndrome has been reported as frequent as 1–3% [78]. Specific risk factors for OHSS include young age, low BMI, signs of polycystic ovarian syndrome and previous history of OHSS [79,80]. The main factor for preventing OHSS is the recognition of risk factors for OHSS leading to an individualized FSH stimulation protocol. Excessive response prediction by the use of ovarian reserve tests may also be a promising tool for treatment tailoring. The association between excessive response and higher serum levels of AMH [54,58,62,63,81] has prompted systematic research on the predictive value of AMH for the occurrence of an excessive response [67,74,76,77]. The results of the five studies identified from the literature search are shown in Table 1. The reported sensitivities varied between 0.57 and 0.93, and the specificities between 0.62 and 0.96, at varying cut-offs for an abnormal test. The accuracy values expressed by the ROC-AUC’s have shown to be very promising. Moreover, from a number of studies [72,76,77], it has been demonstrated that AMH was a better predictor of an excessive response than other patient factors such as female age, BMI, basal FSH or inhibin B. Still, much like for poor ovarian



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Table 1 Sensitivity and specificity values of the studies in the prediction of ovarian response and pregnancy References Poor response prediction Muttukrishna et al. [56] van Rooij et al. [54] van Rooij et al. [54] van Rooij et al. [54] Penarrubia et al. [57] Ebner et al. [63] Tremellen et al. [58] Ficicioglu et al. [61] La Marca et al. [62] La Marca et al. [62] McIlveen et al. [60] Kwee et al. [66] Kwee et al. [66] Kwee et al. [66] Kwee et al. [66] Kwee et al. [66] Freour et al. [65] Smeenk et al. [64] Nakhuda et al. [68] Nelson et al. [67] Nelson et al. [67] New studies Barad et al. [75] Jayaprakasan et al. [73] Jayaprakasan et al. [73] Jayaprakasan et al. [73] Jayaprakasan et al. [73] Jayaprakasan et al. [73] Riggs et al. [72] Nardo et al. [74] Gnoth et al. [71] Excessive response prediction Lee et al. [76] Lee et al. [76] Nelson et al. [67] Nelson et al. [67] Riggs et al. [72] Nardo et al. [74] Aflatoonian et al. [77] Nonpregnancy prediction van Rooij et al. [54] van Rooij et al. [54] van Rooij et al. [54] Penarrubia et al. [57] Ebner et al. [63] Eldar-Geva et al. [59] Smeenk et al. [64] Kwee et al. [66] Lekamge et al. [69] Elgindy et al. [70] New studies Gnoth et al. [71] Barad et al. [75]

Cutoff AMH (ng/ml)

Cycles (n)

Sensitivity

Specificity

PPV

NPV

LRþ

0.10 0.10 0.20 0.30 0.69 1.66 1.13 0.25a 0.50 0.75 1.25 0.80 1.00 1.20 1.40 1.60 1.30 1.40 0.35 0.14 0.70

69 119 119 119 80 141 75 44 48 48 84 104 104 104 104 104 69 80 66 340 340

0.76 0.49 0.54 0.60 0.40 0.69 0.80 0.91 0.83 0.83 0.58 0.54 0.64 0.68 0.75 0.79 0.44 0.62 0.91 0.38 0.70

0.88 0.94 0.90 0.89 0.92 0.86 0.85 0.91 0.83 0.92 0.75 0.93 0.93 0.88 0.86 0.78 1.00 0.73 0.82 0.99 0.91

0.68 0.77 0.70 0.70 0.62 0.63 0.67 0.77 0.63 0.77 0.76 0.75 0.78 0.68 0.66 0.56 1.00 0.31 0.71 0.87 0.58

0.92 0.81 0.83 0.84 0.82 0.89 0.92 0.97 0.94 0.94 0.57 0.85 0.88 0.88 0.90 0.91 0.92 0.91 0.95 0.90 0.94

6.63 8.16 5.70 5.60 4.80 4.86 5.50 10.00 5.00 10.00 2.33 8.14 9.77 5.73 5.18 3.51 – 2.29 5.00 36.10 7.42

0.50 0.59 0.70 0.80 0.90 0.99 0.83 1.00 1.26

76 135 135 135 135 135 123 165 132

0.87 0.53 0.60 0.73 0.87 0.94 0.82 0.87 0.97

0.84 0.93 0.90 0.86 0.80 0.73 0.79 0.67 0.41

0.85 0.47 0.43 0.39 0.35 0.33 0.27 0.21 0.36

0.86 0.94 0.95 0.96 0.98 0.99 0.98 0.98 0.98

5.50 7.11 6.00 5.18 4.33 3.48 3.82 2.60 1.66

1.99 3.36 2.10 3.50 1.59 3.50 4.83

262 262 314 316 123 165 159

0.90 0.62 0.88 0.57 0.84 0.88 0.93

0.62 0.87 0.79 0.96 0.67 0.70 0.78

0.42 0.58 0.26 0.52 0.53 0.24 0.63

0.95 0.88 0.99 0.97 0.90 0.98 0.97

2.38 4.64 4.10 13.80 2.56 2.90 4.26

0.10 0.20 0.30 Not stated 1.66 2.52 1.40 1.40 1.96 2.70

106 106 106 80 132 56 80 110 126 29

0.22 0.27 0.28 0.62 0.19 0.67 0.38 0.31 0.50 0.82

0.89 0.85 0.81 0.56 0.69 0.69 0.73 0.79 0.71 0.83

0.85 0.84 0.81 0.73 0.39 0.71 0.58 0.84 0.78 0.88

0.28 0.28 0.28 0.43 0.45 0.64 0.54 0.24 0.42 0.77

1.94 1.79 1.50 1.40 0.63 2.17 1.36 1.51 1.75 4.94

1.80 1.00

119 76

0.83 0.75

0.34 0.62

0.58 0.84

0.63 0.48

1.25 1.96

AMH, anti-Mu¨llerian hormone; NPV, negative predictive value; PPV, positive predictive value. a Value in pg/ml.

response prediction, the AFC may produce the same level of predictive accuracy [77]. It can be concluded that the accuracy of AMH as a predictor of excessive response prior to initiating ovarian hyperstimulation may be clearly sufficient to open ways of preventing such event by adaptation of the stimulation protocol.

Anti-Mu¨llerian hormone and prediction of pregnancy

A number of authors have tried to identify cut-off levels for AMH that are able to distinguish between patients who do or do not become pregnant after ART. The results of these studies have been summarized in the updates of the initial meta-analysis on ovarian reserve testing [51]. It has become clear from these updates that for the prediction of the outcome pregnancy, AMH is


198 Fertility

quite a poor performer, as demonstrated by the shape of the ROC curve in Fig. 3(b) [52,53]. The lack of sufficient overall predictive accuracy implies that the test will have only very limited value for daily clinical practice. Only when cut-off levels are chosen that lead to sensitivity– specificity combinations in the lower left corner of the ROC diagram, few nonpregnant cases can be identified, without wrongly accusing too many cases that do become pregnant. Cut-off levels will then be so extreme that only very low percentages of abnormal tests will be found, making the impact of applying the test only marginal. Several additional studies [75,82,83] have appeared on the prognostic value of AMH in the prediction of ongoing pregnancy, as summarized in Table 1. The results of the recently published studies are also very much in line with the previously mentioned meta-analyses. The reported sensitivity varied between 0.19 and 0.83, and the reported specificity between 0.34 and 0.89. The summary ROC curve of the studies depicted in Fig. 3(b), containing the sensitivity–specificity points of all published studies to date for the prediction of a nonpregnancy, therefore represents the current best estimate of predictive accuracy. Only one study [67] has been published relating AMH levels to live birth rate after IVF. In this prospective study in 340 patients, it was shown that the live birth rate dramatically increased with increasing AMH levels. Also, AMH appeared to be a better predictor of live birth (AUC ¼ 0.62) than either female age or FSH. However, after adding oocyte yield into a multivariable analysis, oocyte yield was the only variable that predicted live birth. These findings show that it is probably through the correlation with ovarian response that AMH is capable of predicting the occurrence of live birth. A possible new approach stems from the use of AMH follicle fluid levels and their relation to the probability of pregnancy. Fanchin et al. [84] have demonstrated that AMH measured in the follicular fluid is significantly associated with clinical pregnancy rates and embryo implantation rates, in contrast to other parameters such as patient age, the AFC and serum AMH. The study by Wunder et al. [82] has confirmed this finding by showing that AMH in follicular fluid was significantly increased in women who conceived as compared to those who did not. One of the complicating issues in pregnancy prediction is the fact that the vast majority of studies limit the observation of pregnancy occurring to one cycle per couple only. This may be not the proper way to relate a couple’s potential to become pregnant to a test result. A better way could be studying a series of cycles per couple. Hendriks et al. [85] have analyzed the predictive capacity of several ovarian reserve tests for the occurrence of ongoing pregnancy after three cycles. They have found that age

and AMH were the only significant predictors for ongoing pregnancy in three cycles. However, AMH failed to add any predictive power to the effect of knowing female age. This implies that female age is a very strong predictor of outcome pregnancy, and that the ovarian reserve tests relating to quantitative aspects will fail to provide additional information. Another way of getting information about chances of becoming pregnant is by predicting the quality of the oocytes and or the embryo. Several studies [63,64,84,86,87] have analyzed the relationship between serum AMH and characteristics of oocytes and/or embryo quality. Lie Fong et al. [87] demonstrated that there was no consistent correlation between serum AMH and embryo morphology and embryo aneuploidy rates, a finding that was confirmed by Smeenk et al. [64]. In contrast, Ebner et al. [63] and Silberstein et al. [86] did find a significant positive relationship between AMH levels and oocyte quality and embryo morphology. In view of such inconsistency, research on the relationship between AMH and surrogate measures of pregnancy seems not the way forward.

Anti-Mu¨llerian hormone and the clinical value in patient-tailored treatment The accuracy of AMH in the prediction of a nonpregnancy is poor. In clinical practice, this means that the rate of false positives would be too high, that is, too many patients would be falsely categorized in the nonpregnancy group. Therefore, AMH can only be used as a counseling regarding pregnancy chances, but it may not be the factor for the decision whether or not to treat a patient. More appropriate decisive factors would be the response in a first ART treatment or a combination of AMH with other prognostic factors, especially female age. If ovarian response was the endpoint of interest, then the clinical value of AMH as an ovarian reserve test could be considered highly satisfactory. Unfortunately though, no proven strategy to prevent the occurrence of poor response is currently known. Also, a poor response may not always imply a poor prognosis, especially in younger women [88]. The same may be true for ‘poor’ responders after the application of mild stimulation protocols [89]. In poor responders, in a first IVF cycle, it has become increasingly known that not any adaptation in the treatment protocol in a second cycle will improve the subsequent response or the prognosis for pregnancy if randomized trials are concerned [90,91]. This may indicate that in predicted poor responders, the expectations of adapted management may be marginal. Only few studies exist on the effect of adapting the dosage of FSH based on ovarian reserve tests in order



to obtain an optimal number of oocytes and improved prospects for pregnancy. Klinkert et al. [50] have shown that predicted poor responders, based on an AFC of below 5, did not benefit from a higher starting dosage of gonadotrophins in the first IVF treatment cycle. Also, Lekamge et al. [92], in a pseudo-randomized design, have demonstrated that there is no proven clinical value of increasing the dosage of FSH in patients with predicted low ovarian reserve. In contrast, in a study by Popovic-Todorovic et al. [42], an individualized dose regimen in IVF cases with normal basal FSH levels did increase the proportion of appropriate ovarian responses during controlled ovarian hyperstimulation. Even a higher ongoing pregnancy rate in the individualized dose group was reported. These findings together implicate the need for larger studies providing the final answer to the question whether a predicted poor responder will or will not benefit from the use of higher dosages of FSH. Regarding excessive response prediction, a comprehensive review and meta-analysis of the published literature will allow for final conclusions on the clinical value of AMH. To date, excessive responders in a first cycle may benefit from dose adaptation in a subsequent cycle, but there exist no comparative trials on this issue. The effect of individualized dose regimens on prior predicted excessive responders has been demonstrated by the results of the CONsistency in r-FSH Starting dOses for individualized tReatmenT (CONSORT) study [93]. On the basis of an algorithm for individualizing the FSH dosage using FSH, BMI, age and the AFC, excessive responses could be clearly prevented, without an obvious reduction in pregnancy prospects. Although AMH is a most consistent predictor of ovarian response, it has hardly been studied in patient-tailoring the stimulation protocol. Only one observational study [94] has individualized FSH dosage on the basis of prior measured AMH. It has been shown that the use of AMH to individualize the stimulation protocol could result in a reduced risk of OHSS, decreased treatment burden and maintained pregnancy rates. Prospective randomized studies on the true effects of preventive management in AMH-predicted poor/excessive responders are highly needed to confirm these results.

Conclusion Serum AMH is released from the granulosa cells of the antral follicle cohort that is visible at ultrasound. It highly correlates with the follicle numbers and therefore constitutes an important marker for individual ovarian reserve assessment. The cycle stability and operator independency make AMH a most attractive single predictor of both poor and excessive ovarian response to

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controlled ovarian hyperstimulation in ART treatment. Similar to other ovarian reserve tests, such as the AFC and FSH, AMH is not a good predictor of pregnancy. Whether adapted treatment based on AMH testing will eventually lead to improved outcome, higher safety and improved cost efficiency of ART must be further established.

Acknowledgements Dr F.J. Broekmans is a member of the external advisory board for Ferring Pharmaceuticals, Hoofddorp, The Netherlands. He receives no monetary compensation. Professor B.C. Fauser has received fees and grant support from the following companies (in alphabetic order): Andromed, Ardana, Ferring, Genovum, Merck Serono, Organon, Pantharei Bioscience, PregLem, Schering, Schering Plough, Serono, and Wyeth.

References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 256). 1

Cate RL, Mattaliano RJ, Hession C, et al. Isolation of the bovine and human genes for Mullerian inhibiting substance and expression of the human gene in animal cells. Cell 1986; 45:685–698.

2

Jost A. Research on the sexual differentiation of embryonic rabbit. Arch Anat Microsc Morphol Exp 1947; 36:271–315.

3

Josso N, Cate RL, Picard JY, et al. Antimullerian hormone: the Jost factor. Rec Prog Horm Res 1993; 48:1–59.

4

Rajpert-De Meyts E, Jorgensen N, Graem N, et al. Expression of anti-Mullerian hormone during normal and pathological gonadal development: association with differentiation of Sertoli and granulosa cells. J Clin Endocrinol Metab 1999; 84:3836–3844.

5

Munsterberg A, Lovell-Badge R. Expression of the mouse antimullerian hormone gene suggests a role in both male and female sexual differentiation. Development 1991; 113:613–624.

6

Lee MM, Donahoe PK. Mullerian inhibiting substance: a gonadal hormone with multiple functions. Endocr Rev 1993; 14:152–164.

7

Visser JA, Themmen AP. Anti-Mullerian hormone and folliculogenesis. Mol Cell Endocrinol 2005; 234 (1–2):81–86.

8

Kevenaar ME, Meerasahib MF, Kramer P, et al. Serum antimullerian hormone levels reflect the size of the primordial follicle pool in mice. Endocrinology 2006; 147:3228–3234.

9

McGee EA, Hsueh AJ. Initial and cyclic recruitment of ovarian follicles. Endocr Rev 2000; 21:200–214.

10 Durlinger AL, Visser JA, Themmen AP. Regulation of ovarian function: the role of anti-Mullerian hormone. Reproduction 2002; 124:601–609. 11 Weenen C, Laven JS, Von Bergh AR, et al. Anti-Mullerian hormone expression pattern in the human ovary: potential implications for initial and cyclic follicle recruitment. Mol Hum Reprod 2004; 10:77–83. 12 Durlinger AL, Gruijters MJ, Kramer P, et al. Antimullerian hormone attenuates the effects of FSH on follicle development in the mouse ovary. Endocrinology 2001; 142:4891–4899. 13 Ueno S, Kuroda T, MacLaughlin DT, et al. Mullerian inhibiting substance in the adult rat ovary during various stages of the estrous cycle. Endocrinology 1989; 125:1060–1066. 14 Hirobe S, He WW, Gustafson ML, et al. Mullerian inhibiting substance gene expression in the cycling rat ovary correlates with recruited or graafian follicle selection. Biol Reprod 1994; 50:1238–1243. 15 Bergada I, Milani C, Bedecarras P, et al. Time course of the serum gonadotropin surge, inhibins, and anti-Mullerian hormone in normal newborn males during the first month of life. J Clin Endocrinol Metab 2006; 91:4092–4098. 16 Guibourdenche J, Lucidarme N, Chevenne D, et al. Anti-Mullerian hormone levels in serum from human foetuses and children: pattern and clinical interest. Mol Cell Endocrinol 2003; 211 (1–2):55–63.


200 Fertility 17 van Rooij IA, Broekmans FJ, Scheffer GJ, et al. Serum antimullerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: a longitudinal study. Fertil Steril 2005; 83:979–987.

40 Thomas F, Renaud F, Benefice E, et al. International variability of ages at menarche and menopause: patterns and main determinants. Hum Biol 2001; 73:271–290.

18 de Vet A, Laven JSE, de Jong FH, et al. Anti-Mullerian hormone serum levels: a putative marker for ovarian aging. Fertil Steril 2002; 77:357–362.

41 Fasouliotis SJ, Simon A, Laufer N. Evaluation and treatment of low responders in assisted reproductive technology: a challenge to meet. J Assist Reprod Genet 2000; 17:357–373.

19 Sowers MR, Eyvazzadeh AD, McConnell D, et al. Antimullerian hormone and inhibin B in the definition of ovarian aging and the menopause transition. J Clin Endocrinol Metab 2008; 93:3478–3483. 20 van Rooij IA, Tonkelaar I, Broekmans FJ, et al. Antimullerian hormone is a promising predictor for the occurrence of the menopausal transition. Menopause 2004; 11 (6 Pt 1):601–606. 21 van Disseldorp J, Faddy MJ, Themmen AP, et al. Relationship of serum anti Mullerian hormone concentration to age of menopause. J Clin Endocrinol Metab 2008; 93:2129–2134. This article shows the relationship between AMH and age of menopause. 22 La Marca A, Stabile G, Artenisio AC, Volpe A. Serum anti-Mullerian hormone throughout the human menstrual cycle. Hum Reprod 2006; 21:3103–3107. 23 Tsepelidis S, Devreker F, Demeestere I, et al. Stable serum levels of antiMullerian hormone during the menstrual cycle: a prospective study in normoovulatory women. Hum Reprod 2007; 22:1837–1840. 24 Hehenkamp WJ, Looman CW, Themmen AP, et al. Anti-Mullerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation. J Clin Endocrinol Metab 2006; 91:4057–4063. 25 Wunder DM, Bersinger NA, Yared M, et al. Statistically significant changes of antimullerian hormone and inhibin levels during the physiologic menstrual cycle in reproductive age women. Fertil Steril 2008; 89:927–933. The authors of this study show that there might be fluctuations of AMH during a physiologic menstrual cycle. 26 Sowers M, McConnell D, Gast K, et al. Anti-Mullerian hormone and inhibin B variability during normal menstrual cycles. Fertil Steril 2009. [Epub ahead of print] This article demonstrates that in women with a higher AMH level, fluctuations during the cycle do occur. 27 Somunkiran A, Yavuz T, Yucel O, Ozdemir I. Anti-Mullerian hormone levels during hormonal contraception in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2007; 134:196–201. 28 Arbo E, Vetori DV, Jimenez MF, et al. Serum antimullerian hormone levels and follicular cohort characteristics after pituitary suppression in the late luteal phase with oral contraceptive pills. Hum Reprod 2007; 22:3192–3196. 29 Mohamed KA, Davies WA, Lashen H. Antimullerian hormone and pituitary gland activity after prolonged down-regulation with goserelin acetate. Fertil Steril 2006; 86:1515–1517. 30 La Marca A, Giulini S, Orvieto R, et al. Anti-Mullerian hormone concentrations in maternal serum during pregnancy. Hum Reprod 2005; 20:1569–1572. 31 Fanchin R, Schonauer LM, Righini C, et al. Serum anti-Mullerian hormone dynamics during controlled ovarian hyperstimulation. Hum Reprod 2003; 18:328–332. 32 Jayaprakasan K, Deb S, Batcha M, et al. The cohort of antral follicles measuring 2-6 mm reflects the quantitative status of ovarian reserve as assessed by serum levels of anti-Mullerian hormone and response to controlled ovarian stimulation. Fertil Steril 2009. [Epub ahead of print] This article describes and confirms the relationship and correlation between AMH and the small antral follicles. 33 Nyboe AA, Goossens V, Bhattacharya S, et al. Assisted reproductive technology and intrauterine inseminations in Europe, 2005: results generated from European registers by ESHRE – ESHRE. The European IVF Monitoring Programme (EIM), for the European Society of Human Reproduction and Embryology (ESHRE). Hum Reprod 2009; 24:1267–1287. 34 Templeton A, Morris JK, Parslow W. Factors that affect outcome of in-vitro fertilisation treatment. Lancet 1996; 348:1402–1406. 35 Centers for Disease Control and Prevention. Assisted reproductive technology success rates: national summary and fertility clinic reports; 2006. http:// www.cdc.gov/ART/ART2006/508PDF/2006ARTCover-National.pdf.

42 Popovic-Todorovic B, Loft A, Bredkjaeer HE, et al. A prospective randomized clinical trial comparing an individual dose of recombinant FSH based on predictive factors versus a ‘standard’ dose of 150 IU/day in ’standard’ patients undergoing IVF/ICSI treatment. Hum Reprod 2003; 18:2275–2282. 43 Nargund G, Fauser BC, Macklon NS, et al. The ISMAAR proposal on terminology for ovarian stimulation for IVF. Hum Reprod 2007; 22:2801– 2804. 44 van der Gaast MH, Eijkemans MJ, van der Net JB, et al. Optimum number of oocytes for a successful first IVF treatment cycle. Reprod Biomed Online 2006; 13:476–480. 45 Deeks JJ. Systematic reviews in healthcare: systematic reviews of evaluations of diagnostic and screening tests. BMJ 2001; 323:157–162. 46 Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005; 365:1500–1505. 47 Mol BW, Verhagen TE, Hendriks DJ, et al. Value of ovarian reserve testing before IVF: a clinical decision analysis. Hum Reprod 2006; 21:1816–1823. 48 El Toukhy T, Khalaf Y, Hart R, et al. Young age does not protect against the adverse effects of reduced ovarian reserve: an eight year study. Hum Reprod 2002; 17:1519–1524. 49 Ulug U, Ben Shlomo I, Turan E, et al. Conception rates following assisted reproduction in poor responder patients: a retrospective study in 300 consecutive cycles. Reprod Biomed Online 2003; 6:439–443. 50 Klinkert ER, Broekmans FJ, Looman CW, et al. Expected poor responders on the basis of an antral follicle count do not benefit from a higher starting dose of gonadotrophins in IVF treatment: a randomized controlled trial. Hum Reprod 2005; 20:611–615. 51 Broekmans FJ, Kwee J, Hendriks DJ, et al. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update 2006; 12:685–718. 52 Broer SL, Mol BW, Hendriks D, Broekmans FJ. The role of antimullerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. Fertil Steril 2009; 91:705–714. This conventional meta-analysis compares the predictive accuracy of AMH and AFC in the prediction of a poor response and pregnancy. 53 Broekmans FJ, Visser JA, Laven JS, et al. Anti-Mullerian hormone and ovarian dysfunction. Trends Endocrinol Metab 2008; 19:340–347. 54 van Rooij IA, Broekmans FJ, te Velde ER, et al. Serum anti-Mullerian hormone levels: a novel measure of ovarian reserve. Hum Reprod 2002; 17:3065– 3071. 55 Muttukrishna S, McGarrigle H, Wakim R, et al. Antral follicle count, antimullerian hormone and inhibin B: predictors of ovarian response in assisted reproductive technology? BJOG 2005; 112:1384–1390. 56 Muttukrishna S, Suharjono H, McGarrigle H, Sathanandan M. Inhibin B and anti-Mullerian hormone: markers of ovarian response in IVF/ICSI patients? BJOG 2004; 111:1248–1253. 57 Penarrubia J, Fabregues F, Manau D, et al. Basal and stimulation day 5 antiMullerian hormone serum concentrations as predictors of ovarian response and pregnancy in assisted reproductive technology cycles stimulated with gonadotropin-releasing hormone agonist–gonadotropin treatment. Hum Reprod 2005; 20:915–922. 58 Tremellen KP, Kolo M, Gilmore A, Lekamge DN. Antimullerian hormone as a marker of ovarian reserve. Aust N Z J Obstet Gynaecol 2005; 45:20–24. 59 Eldar-Geva T, Ben Chetrit A, Spitz IM, et al. Dynamic assays of inhibin B, antiMullerian hormone and estradiol following FSH stimulation and ovarian ultrasonography as predictors of IVF outcome. Hum Reprod 2005; 20:3178–3183.

36 Stephen EH, Chandra A. Declining estimates of infertility in the United States: 1982–2002. Fertil Steril 2006; 86:516–523.

60 McIlveen M, Skull JD, Ledger WL. Evaluation of the utility of multiple endocrine and ultrasound measures of ovarian reserve in the prediction of cycle cancellation in a high-risk IVF population. Hum Reprod 2007; 22:778–785.

37 Noord-Zaadstra BM, Looman CW, Alsbach H, et al. Delaying childbearing: effect of age on fecundity and outcome of pregnancy. BMJ 1991; 302:1361– 1365.

61 Ficicioglu C, Kutlu T, Baglam E, Bakacak Z. Early follicular antimullerian hormone as an indicator of ovarian reserve. Fertil Steril 2006; 85:592–596.

38 te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod Update 2002; 8:141–154.

62 La Marca A, Giulini S, Tirelli A, et al. Anti-Mullerian hormone measurement on any day of the menstrual cycle strongly predicts ovarian response in assisted reproductive technology. Hum Reprod 2007; 22:766–771.

39 Morabia A, Costanza MC. International variability in ages at menarche, first livebirth, and menopause. World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives. Am J Epidemiol 1998; 148:1195– 1205.

63 Ebner T, Sommergruber M, Moser M, et al. Basal level of anti-Mullerian hormone is associated with oocyte quality in stimulated cycles. Hum Reprod 2006; 21:2022–2026.


Role of AMH assessment in ART outcome Broer et al. 64 Smeenk JM, Sweep FC, Zielhuis GA, et al. Antimullerian hormone predicts ovarian responsiveness, but not embryo quality or pregnancy, after in vitro fertilization or intracyoplasmic sperm injection. Fertil Steril 2007; 87:223– 226. 65 Freour T, Mirallie S, Bach-Ngohou K, et al. Measurement of serum antiMullerian hormone by Beckman Coulter ELISA and DSL ELISA: comparison and relevance in assisted reproduction technology (ART). Clin Chim Acta 2007; 375 (1–2):162–164. 66 Kwee J, Schats R, McDonnell J, et al. Evaluation of AMH as test for the prediction of ovarian reserve. Fertil Steril 2008; 90:737–743. 67 Nelson SM, Yates RW, Fleming R. Serum anti-Mullerian hormone and FSH: prediction of live birth and extremes of response in stimulated cycles: implications for individualization of therapy. Hum Reprod 2007; 22:2414– 2421. 68 Nakhuda GS, Sauer MV, Wang JG, et al. Mullerian inhibiting substance is an accurate marker of ovarian response in women of advanced reproductive age undergoing IVF. Reprod Biomed Online 2007; 14:450–454. 69 Lekamge DN, Barry M, Kolo M, et al. Anti-Mullerian hormone as a predictor of IVF outcome. Reprod Biomed Online 2007; 14:602–610. 70 Elgindy EA, El-Haieg DO, El-Sebaey A. Anti-Mullerian hormone: correlation of early follicular, ovulatory and midluteal levels with ovarian response and cycle outcome in intracytoplasmic sperm injection patients. Fertil Steril 2008; 89:1670–1676. 71 Gnoth C, Schuring AN, Friol K, et al. Relevance of anti-Mullerian hormone measurement in a routine IVF program. Hum Reprod 2008; 23:1359– 1365. 72 Riggs RM, Duran EH, Baker MW, et al. Assessment of ovarian reserve with anti-Mullerian hormone: a comparison of the predictive value of anti-Mullerian hormone, follicle-stimulating hormone, inhibin B, and age. Am J Obstet Gynecol 2008; 199:202–208. This study compares AMH to several other ovarian reserve markers in their performances. 73 Jayaprakasan K, Campbell B, Hopkisson J, et al. A prospective, comparative analysis of anti-Mullerian hormone, inhibin-B, and three-dimensional ultrasound determinants of ovarian reserve in the prediction of poor response to controlled ovarian stimulation. Fertil Steril 2010; 93:855–864. 74 Nardo LG, Gelbaya TA, Wilkinson H, et al. Circulating basal anti-Mullerian hormone levels as predictor of ovarian response in women undergoing ovarian stimulation for in vitro fertilization. Fertil Steril 2009; 92:1586– 1593.

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80 Fauser BC, Diedrich K, Devroey P. Predictors of ovarian response: progress towards individualized treatment in ovulation induction and ovarian stimulation. Hum Reprod Update 2008; 14:1–14. 81 Nakhuda GS, Chu MC, Wang JG, et al. Elevated serum mullerian-inhibiting substance may be a marker for ovarian hyperstimulation syndrome in normal women undergoing in vitro fertilization. Fertil Steril 2006; 85:1541–1543. 82 Wunder DM, Guibourdenche J, Birkhauser MH, Bersinger NA. Anti-Mullerian hormone and inhibin B as predictors of pregnancy after treatment by in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril 2008; 90:2203– 2210. 83 Wu CH, Chen YC, Wu HH, et al. Serum anti-Mullerian hormone predicts ovarian response and cycle outcome in IVF patients. J Assist Reprod Genet 2009; 26:383–389. 84 Fanchin R, Mendez Lozano DH, Frydman N, et al. Anti-Mullerian hormone concentrations in the follicular fluid of the preovulatory follicle are predictive of the implantation potential of the ensuing embryo obtained by in vitro fertilization. J Clin Endocrinol Metab 2007; 92:1796–1802. 85 Hendriks DJ, te Velde ER, Looman CW, et al. Expected poor ovarian response in predicting cumulative pregnancy rates: a powerful tool. Reprod Biomed Online 2008; 17:727–736. This study has evaluated poor responders and cumulative pregnancy rates. 86 Silberstein T, MacLaughlin DT, Shai I, et al. Mullerian inhibiting substance levels at the time of HCG administration in IVF cycles predict both ovarian reserve and embryo morphology. Hum Reprod 2006; 21:159–163. 87 Lie Fong S, Baart EB, Martini E, et al. Anti-Mullerian hormone: a marker for oocyte quantity, oocyte quality and embryo quality? Reprod Biomed Online 2008; 16:664–670. A recent study that has shown no consistent relationship between AMH and quality measurements. 88 Lashen H, Ledger W, Lopez-Bernal A, Barlow D. Poor responders to ovulation induction: is proceeding to in-vitro fertilization worthwhile? Hum Reprod 1999; 14:964–969. 89 Verberg MF, Eijkemans MJ, Macklon NS, et al. The clinical significance of the retrieval of a low number of oocytes following mild ovarian stimulation for IVF: a meta-analysis. Hum Reprod Update 2009; 15:5–12. This meta-analysis shows that a low number of oocytes following mild stimulation do not necessarily indicate a poor prognosis. 90 Kyrou D, Kolibianakis EM, Venetis CA, et al. How to improve the probability of pregnancy in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril 2009; 91:749–766.

75 Barad DH, Weghofer A, Gleicher N. Comparing anti-Mullerian hormone (AMH) and follicle-stimulating hormone (FSH) as predictors of ovarian function. Fertil Steril 2009; 91 (4 Suppl):1553–1555.

91 Mochtar MH, van D, Ziech M, van WM. Recombinant luteinizing hormone (rLH) for controlled ovarian hyperstimulation in assisted reproductive cycles. Cochrane Database Syst Rev 2007:CD005070.

76 Lee TH, Liu CH, Huang CC, et al. Serum antimullerian hormone and estradiol levels as predictors of ovarian hyperstimulation syndrome in assisted reproduction technology cycles. Hum Reprod 2008; 23:160–167. One of the first studies to look at AMH and its role as a predictor of an excessive response.

92 Lekamge DN, Lane M, Gilchrist RB, Tremellen KP. Increased gonadotrophin stimulation does not improve IVF outcomes in patients with predicted poor ovarian reserve. J Assist Reprod Genet 2008; 25:515–521. This study demonstrates that poor responders may not benefit from increased gonadotrophin stimulation protocols.

77 Aflatoonian A, Oskouian H, Ahmadi S, Oskouian L. Prediction of high ovarian response to controlled ovarian hyperstimulation: anti-Mullerian hormone versus small antral follicle count (2-6 mm). J Assist Reprod Genet 2009; 26:319–325.

93 Olivennes F, Howles CM, Borini A, et al. Individualizing FSH dose for assisted reproduction using a novel algorithm: the CONSORT study. Reprod Biomed Online 2009; 18:195–204. This study reports a new algorithm for patient-tailored stimulation protocols with promising results.

78 Practice Committee of American Society for Reproductive Medicine. Ovarian hyperstimulation syndrome. Fertil Steril 2008; 90(5 Suppl):S188–S193. 79 Macklon NS, Stouffer RL, Giudice LC, Fauser BC. The science behind 25 years of ovarian stimulation for in vitro fertilization. Endocr Rev 2006; 27:170–207.

94 Nelson SM, Yates RW, Lyall H, et al. Anti-Mullerian hormone-based approach to controlled ovarian stimulation for assisted conception. Hum Reprod 2009; 24:867–875. This study is the first that used AMH for individualization of the stimulation protocol.


Ectopic pregnancy after assisted reproductive technology: what are the risk factors? Hye Jin Changa,b and Chang Suk Suhb,c a Health Promotion Center, bDepartment of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi and cDepartment of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea

Correspondence to Chang Suk Suh, MD, PhD, Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 300 Gumi, Bundang, Seongnam, Gyeonggi 463-707, South Korea Tel: +82 31 787 7251; fax: +82 31 787 4054; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:202–207

Purpose of review This review discusses recent publications that investigate risk factors associated with ectopic pregnancy after IVF. Recent findings Data on the risk factors for developing ectopic pregnancy after IVF are still inconsistent. Between fresh nondonor IVF and embryo transfer cycles, the significant risk factor for ectopic pregnancy was tubal factor infertility, and endometriosis, rather than male factor infertility. Higher ectopic pregnancy rate could be associated with zygote intrafallopian transfer, assisted hatching, large embryo transfer volume, deep fundal transfer, and frozen embryo transfer. The supraphysiologic progesterone level may decrease uterine contractility and enhance implantation in the uterine cavity in fresh embryo transfer compared with frozen embryo transfer cycles. Although recent results suggest reassurance in risk of ectopic pregnancy with frozen transfer, clinicians should be remembering this possibility while performing a frozen embryo transfer. Higher implantation potential per embryo at the blastocyst stage may increase the risk of ectopic pregnancy than cleavage stage. Especially, according to numbers of embryos transferred, different risk of ectopic pregnancy after IVF was noted. Summary Different hormonal milieu, the reproductive health characteristics of infertile women such as distorted tubal function, technical issues of IVF procedures, and the estimated embryo implantation potential are possible risk factors. How each factor contributes to the risk of occurring ectopic pregnancy after assisted reproductive technology is uncertain and needs further investigation. Keywords assisted reproductive technology, ectopic pregnancy, IVF and embryo transfer, risk factor Curr Opin Obstet Gynecol 22:202–207 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Ectopic pregnancy is a well known risk of IVF. The rate of ectopic pregnancy is higher in pregnancies resulting from assisted reproduction technologies (ARTs) than in spontaneous pregnancies. Society of Assisted Reproductive Technology (SART) guidelines for outcomes reporting documented that ectopic pregnancy was defined as the presence of an extrauterine gestation documented by ultrasound or salpingectomy, and heterotopic pregnancy was defined as ectopic pregnancy coexisting with a synchronous intrauterine pregnancy (IUP) [1]. Several possible theories for this finding have been proposed, including direct injection of embryos in transfer media to the fallopian tubes and migration of embryos via reflux expulsion from uterine contraction [2,3]. The majority of information on ectopic pregnancy after IVF stems from case reports or case series. There were a few studies with denominator data. However, the sample 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

size was considerably smaller and thus unable to evaluate sufficiently the risk of ectopic pregnancy by subgroup analysis. And when counting ectopic pregnancies, a heterotopic pregnancy was included in several studies and excluded in other studies. Because the incidence of heterotopic pregnancy has increased with the widespread use of ART and its frequency is as high as 1 : 500 to 1 : 100 [4,5], the heterotopic pregnancy included in ectopic pregnancy count may cause as certain bias. Therefore, it is difficult to understand specific factors in ART that may affect the rate of ectopic pregnancy. This review discusses recent publications that investigate the epidemiology and risk factors of ectopic pregnancy after IVF.

Epidemiology The incidence of ectopic pregnancy after IVF generally ranges from 2.1 to 8.6% of all clinical pregnancies [6,7], DOI:10.1097/GCO.0b013e32833848fd


Ectopic pregnancy after ART Chang and Suh 203

but in selected groups with tubal factor infertility, it is as high as 11% [8] compared with the estimated rate of 2.0 per 100 pregnancies for the general US population in 1990–1992 [9]. In 2007, SART [1] reported a decrease in the incidence of ectopic pregnancy to 1.6% of clinical pregnancies as compared with 2.0% in 2000. However, the incidence of ectopic pregnancy per transfer was similar: 0.8 vs. 0.7%, respectively. It compares favorably with the estimated overall incidence of ectopic pregnancy in the USA of 2% per reported pregnancy. This finding was attributable to the decrease in the proportion of couples with tubal factor infertility undergoing IVF procedure and a concomitant increase in couples with male factor infertility. The dominant adverse effect of female factor on outcomes was corroborated, whereas male factor infertility now appears to have a limited effect on outcomes because of the availability of intracytoplasmic sperm injection.

Risk factors Risk factors for ectopic pregnancy after natural conception, including previous ectopic pregnancy, pelvic inflammatory disease (PID), tubal disease or surgery, and smoking, have been well described [3]. However, data on the risk factors for developing ectopic pregnancy after IVF are still inconsistent. Theoretically, differences between natural conception and conception via ART may affect the risk of ectopic pregnancy. The four point views are important in assessing the risk of ectopic pregnancy after IVF: different hormonal milieu, the reproductive health characteristics of infertile women, technical aspects of IVF procedures, and the estimated embryo implantation potential. Different hormonal milieu

One of the differences between natural conception and IVF and embryo transfer (IVF-ET) cycles might be hormonal milieu at the time of embryo transfer. Higher hormone levels may affect tubal peristalsis and egg or zygote transport. Some insisted progesterone contributes to uterine quiescence [10]. Increased uterine contractility may allow decreased implantation within the uterine cavity and favor migration of the embryos into the fallopian tubes. In IVF-ET cycles supraphysiologic progesterone concentrations are produced by multiple corpus lutea and supplemented by luteal support. Thus, the progesterone level of IVF-ET cycle could exceed the level of normal conception and may result in more uterine relaxation in IVF-ET, whereas there is another effect of the high estradiol levels in IVF cycles on tubal peristalsis through the control of tubal smooth muscle contractility and ciliary activity [11]. However, Pyrgiotis et al. [12] did not demonstrate a difference in estradiol levels on the day of human chorionic gonadotropin administration between IVF-ET patients with and without ectopic

pregnancy. The possible relation between risk of ectopic pregnancy and estrogen–progesterone level at the time of embryo transfer should be further investigated. Reproductive health characteristics of infertile women

Infertile women who undergone IVF-ET procedures have different health characteristics compared with general population, and it may result in increased risk of ectopic pregnancy. Distorted tubal anatomy could be a strong predisposing factor due to any reasons such as previous tubal surgery, PID, endometriosis, and peritubal adhesion. We could also be able to investigate the association between risk of ectopic pregnancy and women’s reproductive health status, according to the comparison nondonor IVF and donor IVF/gestational surrogate. Tubal factor infertility, previous pelvic inflammatory disease, and endometriosis

A number of different tubal damages have been associated with varying results of IVF-ET. Hydrosalpinx, PID, and bacterial infection, as well as smoking habits are known to be negative factors to normal pregnancy [3]. As with naturally occurring pregnancy, tubal factor infertility has been identified as the most prominent risk factor for ectopic pregnancy after IVF. And a previous ectopic pregnancy and tubal surgery also affect the fertility of women. Several studies [2,7,12] have extensively suggested that the presence of damaged tubes does confer a higher risk for ectopic pregnancy in IVF. Clayton et al. [7] have recently analyzed the risk of ectopic pregnancy among 94 118 patients who conceived with ART procedures in US clinics between 1999 and 2001. Out of 94 118, 2009 (2.1%) were ectopic pregnancies. They found that women with tubal factor infertility had a two-fold increase in risk [odds ratio (OR) 2.0, 95% confidence interval (CI) 1.7–2.4; reference group is ART for male factor], and women with female factor infertility except tubal factors or with endometriosis had a 30–40% increased risk of ectopic pregnancy. And risk for ectopic pregnancy was significantly decreased among women with a previous live birth. The tubal damage was also reported among women with ectopic pregnancies who had used IVF because of endometriosis or unexplained infertility [8]. The increased risk of ectopic pregnancy in women with endometriosis or unexplained infertility might be related to tubal damage, that is, tubal disorder in those was less likely to be diagnosed. Keegan et al. [13] reported lower ectopic pregnancy rates (0.9%; 24/2688 pregnancies) compared with the national rate consistently reported by SART/American Society for Reproductive Medicine for USA clinics (2.1–2.2%). They insisted that their aggressive practice of documented tubal disease with salpingectomy might help prevent ectopic pregnancy after IVF. Although it is still unclear whether surgical management of tubal disease prevents chances of


204 Fertility

ectopic pregnancy with IVF, a randomized controlled trial of salpingectomy in women with clinically diagnosed tubal disorder could be considered to find advantage of their practice. To evaluate the prognosis for the patient who becomes pregnant after infertility treatment, Tomazevic and Ribic-Pucelj [14] analyzed the occurrence of ectopic pregnancy following 474 reconstructive microsurgical operations and 2119 stimulated IVF-ET for tubal infertility. The results presented that the ratio of patients who had repeated ectopic pregnancies to the number of operations was 12%, and to all pregnancies after surgery was 28%. In IVF-ET cycles for tubal infertility, ectopic pregnancy represented 2.8% of all pregnancies and 3% of all transfers. Although the risk for ectopic pregnancy after IVF-ET is much lower than the risk after tubal surgery, it is still rather high compared with the risk in the normal population. In the patients with severe tubal lesions, IVFET is preferable to tubal surgery considering ectopic pregnancy when deciding upon treatment. And, the results indirectly imply that a direct tubal damage by surgery is important role for occurring ectopic pregnancy rather than IVF-ET procedure itself. In respect to tubal surgery, another retrospective study [15] of 640 IVF-ET cycles in the tubal factor group showed that 359 cycles were performed in patients who had prior tubal reconstructive surgery; tubal pregnancies comprised 15.6% of the clinical pregnancies. In the remainder of the tubal factor group with no prior tubal surgery, 281 embryo transfer cycles yielded a tubal pregnancy rate of only 5.5% (P < 0.05). Women with prior reconstructive surgery for distal tubal disease are at highest risk of developing tubal pregnancy after IVF. It is possible that proximal occlusion or salpingectomy after failed distal tubal surgery may be a predisposing factor to tubal pregnancy after IVF-ET. Overall, in consideration of recent publications, distorted tubal anatomy could be a strong predisposing factor from any reasons such as previous tubal surgery, PID, endometriosis, and peritubal adhesion. The likelihood that women with tubal factor infertility have a greater risk than women with other factors has suggested an important role of tubal anatomy. Previous ectopic pregnancy history

Numerous investigators thought ‘tubal factors’ as a common reason for sterility and as an affecting factor on the rate of ectopic pregnancy [2,12,14]. Weigert et al. [16] investigated the influence of the condition of the fallopian tubes in women who experienced a tubal ectopic pregnancy in a previous pregnancy, on the incidence of a repeated tubal pregnancy in an IVF-ET cycle. Women with a prior tubal ectopic pregnancy significantly increased the risk per pregnancy for a further ectopic

pregnancy even in IVF-ET (8.95 vs. 0.75%, P < 0.001), especially if they are smoking. However, the number of tubal ectopic pregnancy events was too low, further analysis of effects of different subgroups on the risk for a tubal ectopic pregnancy could not be performed. Donor IVF vs. nondonor IVF

In comparison with the ectopic rate (2.2%) among pregnancies conceived with fresh, nondonor IVF-ET, the ectopic rate was significantly decreased when donor oocytes were used (1.4%) or when a gestational surrogate carried the pregnancy (0.9%) [7]. It means that embryo implantation potential is associated with risk because oocyte donors are young women without an infertility factor. Previous studies suggested that chromosomal abnormalities might play a role in the cause of ectopic pregnancy. The results were inconsistent, and limited by small sample size [17–19]. The characteristics of embryos in infertile women required further study to find whether they are related or not to the risk of ectopic pregnancy. In addition, the incidence of tubal disease in the donor egg population is thought to be significantly lower than in the fresh nondonor IVF population because the diminished ovarian reserve is the main cause of infertility in donor egg recipients [20]. Therefore, donor IVF might benefit from lower ectopic pregnancy rates compared with the fresh nondonor IVF. And low ectopic pregnancy rate of gestational surrogate represents that an anatomical factor of uterus and tube is also important in causing ectopic pregnancy after IVF. Technical aspects of IVF procedures

A technical problem of IVF procedures also may increase risk of ectopic pregnancy after IVF. Higher ectopic pregnancy rate might be associated with zygote intrafallopian transfer (ZIFT), assisted hatching, higher embryo transfer volume, deep fundal transfer, and frozen embryo transfer. Zygote intrafallopian transfer

Clayton et al. [7] have observed a significant increase in the risk of ectopic pregnancy after ZIFT (3.6%) compared with fresh nondonor IVF-ET cycles (2.2%) (OR 1.65, 95% CI 1.13–2.40). It is somewhat intuitive because embryos are transferred into the fallopian tubes in ZIFT. However, this effect was not observed in gamete intrafallopian transfer (GIFT) procedures, there was no increase in ectopic pregnancy risk (2.4%). The investigation whether ZIFT or GIFT has an effect on ectopic pregnancy risk is limited by small sample size. Small sample size excluded analysis of specific treatment risk factors among ZIFT pregnancies. The power may not be sufficient to detect such small statistical difference.


Ectopic pregnancy after ART Chang and Suh 205

Assisted hatching

In a retrospective analysis of 623 clinical pregnancies conceived after IVF, a 5.4% ectopic pregnancy rate (14/258 clinical pregnancies) was found in women in whom assisted hatching was performed compared with 2.2% (8/365) in the group without assisted hatching [21]. Embryos that have undergone assisted hatching have been reported to implant earlier compared with unhatched embryo [22,23]. A different finding was also reported that the assisted hatching did not increase the risk of ectopic pregnancy [7]. In a prospective randomized study [24] to evaluate the effect of assisted hatching on IVF outcome, there was no increase of ectopic pregnancy in the assisted hatching group compared with the unhatching embryo and blastocyst group. National data reported to SART and the Centers for Disease Control and Prevention or larger multicenter series should be analyzed in an attempt to elucidate the effect of assisted hatching on ectopic pregnancy. Embryo transfer volume

Knutzen et al. [25] performed a mock embryo transfer using 40 ml of radio-opaque dye; the dye was seen in the fallopian tube in 38% of all transfers. This suggests that with a transfer volume not much higher than what is commonly used by IVF programs, there is significant likelihood for the embryos to reach the fallopian tubes. Higher transfer volume had been associated with higher ectopic pregnancy risk [4]. Although in which type of fluid or media the embryo should be transferred has also been a matter of debate, in usual practice, the volume of media transferred is 15–20 ml. Deep fundal transfer

A randomized prospective study [6] was performed to compare the effects of a midfundal vs. a deep fundal transfer technique on subsequent intrauterine and ectopic pregnancy rates after IVF. This study [6] showed that the clinical pregnancy rate after the deep fundal transfer was 12.4% of IUPs per cycle with a 1.5% ectopic pregnancy rate (12.2%/clinical pregnancy), vs. 14.2% IUPs per cycle with a 0.4% ectopic pregnancy rate (3%/clinical pregnancy), after midfundal transfer. As a result of this study, deep fundal embryo transfer could be associated with an increased risk of ectopic pregnancy. Frozen embryo transfer vs. fresh embryo transfer

There may be a concern for a higher ectopic pregnancy rate in cryopreserved embryo transfers compared with fresh transfers as suggested by some reports in the literature [12,26,27]. There are several possible theories that explain these findings. Progesterone appears to play a role in reducing uterine contractility during the luteal phase of the menstrual cycle. Decreased uterine contractility may allow enhanced implantation in the uterine cavity as opposed to migration of the embryo into the

fallopian tubes. In fresh IVF cycles, the supraphysiologic progesterone concentrations produced by multiple corpora lutea in addition to exogenous progesterone supplementation far exceed the level of progesterone in frozen transfers and may result in better uterine relaxation in fresh transfer [10,28]. And, the developmental delay of thawed embryos may lead to a longer lag time before implantation in the uterus, increasing the opportunity for migration to the extrauterine space [27]. In addition, uterine dimensions could be different according to the ovarian stimulation. High estrogen level may lead to increase the uterine dimension larger than nonstimulated frozen cycle. There could be a tendency to transfer embryos to the same depth from external os during fresh and frozen embryo transfers, resulting in the injection of embryos closer to the fallopian tubes. However, Jun and Milki [29] recently reported that the rate of ectopic pregnancy is not significantly increased after the transfer of frozen thawed blastocysts compared with fresh blastocyst transfer (2.8 vs. 1.8%). We also performed a meta-analysis [30] to investigate the effect of frozen embryo transfer on rate of ectopic pregnancy. A meta-analysis was performed of data from seven comparative studies including 13 059 pregnancies that resulted from nondonor IVF cycles. The ectopic pregnancy rate was 2.31% (49/2125 pregnancies) for frozen embryo transfer and 1.48% (162/10 934 pregnancies) for fresh IVF-ET. These rates were statistically not different when assessed by random effect model (OR 1.66, 95% CI 0.62–4.41). These findings are in line with another large series by Check et al. [31] who noted no increase in ectopic pregnancy rate after day 3 frozen embryo transfer, by showing the same to be true after frozen blastocyst transfer. Although recent results suggest reassurance in risk of ectopic pregnancy with frozen transfer, clinicians should consider this possibility while performing a frozen embryo transfer. It may be helpful to use ultrasound guidance with emphasis on the distance away from the fundus, considering previous data in the literature and theoretical mechanisms. Estimated embryo implantation potential

The association between ectopic pregnancy risk and embryo implantation potential, based on the two indicators we were able to assess, varied according to the day of embryo transfer (day 3 vs. day 5) and number of embryos transferred. Day 3 vs. day 5

Generally, there has been a belief that blastocyst embryo transfer may reduce the ectopic pregnancy rate [28]. If this is true, ectopic pregnancy rate in a certain group will be altered according to a relative proportion of blastocyst


206 Fertility Table 1 Factors associated with ectopic pregnancy among pregnancies conceived using fresh nondonor IVF and embryo transfer, USA, 1999–2001 No. of embryos transferred related to estimated embryo implantation potential 3 embryos transferred D3 culture and no extra embryos cryopreserved D3 culture and extra embryos cryopreserved D5 culture and no extra embryos cryopreserved D5 culture and extra embryos cryopreserved 1–2 embryos transferred D3 culture and no extra embryos cryopreserved D3 culture and extra embryos cryopreserved D5 culture and no extra embryos cryopreserved D5 culture and extra embryos cryopreserved

AOR

95% CI

Reference 1.04 1.04 0.96

Reference 0.91–1.20 0.79–1.36 0.69–1.34

0.93 0.67 0.56 0.55

0.76–1.12 0.52–0.87 0.41–0.77 0.43–0.71

AOR, adjusted odds ratio; CI, confidential interval; D3, day 3; D5, day 5; IVF-ET, in-vitro fertilization and embryo transfer. Data from [7].

embryo transfer. On the contrary, the available literature does not support the idea that blastocyst embryo transfer lowers the ectopic pregnancy rate. There has been a study [32] demonstrating that blastocyst embryo transfer does not reduce the ectopic pregnancy rate compared with cleavage stage embryo transfer (3.9 vs. 3.5%, P ¼ 0.8). Moreover, a significant increase in the ectopic pregnancy rate was noted in blastocyst embryo transfer in a subsequent study [13] (1.6 vs. 0.5%, P ¼ 0.006). Rosman et al. [20] also reported that, of 4186 clinical pregnancies, the rate of ectopic pregnancy was 0.4% from day 3 transfer and 1.3% from day 5 transfer; this difference was statistically different (P ¼ 0.002). It has been proposed that decreased uterine contractility later in the luteal phase and the larger diameter of the blastocyst would interfere with its ability to reflux through ostium, protecting against tubal implantation. However, higher implantation potential per embryo at the blastocyst stage than cleavage stage may negate these effects. The number of embryos transferred

The risk of ectopic pregnancy among pregnancies in which three or more embryos had been transferred was 2.4–2.5%. However, when only less than two embryos were transferred, ectopic pregnancy rates varied according to embryo implantation potential indicators: 2.2% with neither indicator present, 1.6% when extra embryos had been available and cryopreserved, 1.4% when embryos were cultured for 5 days rather 3 days, and 1.4% when both of these conditions were met. These latter three rates were significantly different from the referent group. More than three embryos transferred with neither indicator for higher implantation potential (Table 1) [7]. After the logistic regression analysis, the transfer of two embryos or fewer was protective among three subgroups of women with at least one indicator of higher embryo implantation potential (ORs 0.6–0.7). Transfer of higher estimated embryo implantation potentials was associated with a decreased ectopic risk when two or fewer embryos were transferred, but not when three or more embryos were transferred. And these similar protective effects also could be observed among donor oocyte procedure, further supporting the

hypothesis that embryo implantation potential is associated with risk of ectopic pregnancy.

Conclusion The potential interfering factor in interaction of tubal function and transferred embryo is different hormonal milieu at the time of embryo transfer from hyperstimulation protocols. High level of progesterone and estradiol could affect tubal peristalsis, egg transport, and uterine relaxation. And distortion of normal anatomy of tube is a predisposing factor. The likelihood that women with tubal factor infertility have a greater risk than women with other factors has suggested an important role of tubal anatomy. Higher ectopic pregnancy rate may be associated with ZIFT, assisted hatching, high embryo transfer volume, deep fundal transfer, and frozen embryo transfer. Although recent results suggest reassurance in risk of ectopic pregnancy with frozen transfer, clinicians should consider this possibility while performing a frozen embryo transfer. The ectopic rate was significantly decreased when donor oocytes were used, and higher implantation potential per embryo at the blastocyst stage may increase the risk of ectopic pregnancy than cleavage stage. Transfer of higher estimated embryo implantation potentials was associated with a decreased ectopic risk when two or fewer embryos were transferred, but not when three or more embryos were transferred. Therefore, when transfer of blastocyst embryo is planned, it is better to restrict the number of embryos transferred for decreasing ectopic pregnancy rate.


Society for Assisted Reproductive Technology; American Society for Reproductive Medicine. Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry. Fertil Steril 2007; 87:1253–1266.


Ectopic pregnancy after ART Chang and Suh 207 2

Strandell A, Thorburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction. Fertil Steril 1999; 71:282–286.

19 Goddijn M, van der Veen F, Schuring-Blom GH, et al. Cytogenetic characteristics of ectopic pregnancy. Hum Reprod 1996; 11:2769–2771.

3

Sowter MC, Farquhar CM. Ectopic pregnancy: an update. Curr Opin Obstet Gynecol 2004; 16:289–293.

4

Marcus SF, Macnamee M, Brinsden P. Heterotopic pregnancies after in-vitro fertilization and embryo transfer. Hum Reprod 1995; 10:1232–1236.

5

Dor J, Seidman DS, Levran D, et al. The incidence of combined intrauterine and extrauterine pregnancy after in vitro fertilization and embryo transfer. Fertil Steril 1991; 55:833–834.

20 Rosman ER, Keegan DA, Krey L, et al. Ectopic pregnancy rates after in vitro fertilization: a look at the donor egg population. Fertil Steril 2009; 92:1791– 1793. A retrospective study compared the rates of ectopic pregnancy in fresh embryo transfer between nondonor IVF patients and donor egg recipients over a period of 8 years in a single institution. The rate of ectopic pregnancy was 0.9% for fresh IVF and 0.6% for donor IVF, which was not statistically different.

6

Nazari A, Askari HA, Check JH, et al. Embryo transfer technique as a cause of ectopic pregnancy in in vitro fertilization. Fertil Steril 1993; 60:919–921.

7

Clayton HB, Schieve LA, Peterson HB, et al. Ectopic pregnancy risk with assisted reproductive technology procedures. Obstet Gynecol 2006; 107:595–604.

8

9

Dubuisson JB, Aubriot FX, Mathieu L, et al. Risk factors for ectopic pregnancy in 556 pregnancies after in vitro fertilization: implications for preventive management. Fertil Steril 1991; 56:686–690. Centers for Disease Control and Prevention. Current trends in ectopic pregnancy: United States, 1990–1992. MMWR Surveill Summ 1995; 44:46–48.

10 Fanchin R, Righini C, de Ziegler D, et al. Effects of vaginal progesterone administration on uterine contractility at the time of embryo transfer. Fertil Steril 2001; 75:1136–1140. 11 Fernandez H, Coste J, Job-Spira N. Controlled ovarian hyperstimulation as a risk factor for ectopic pregnancy. Obstet Gynecol 1991; 78:656–659.

21 Jun SH, Milki AA. Assisted hatching is associated with a higher ectopic pregnancy rate. Fertil Steril 2004; 81:1701–1703. 22 Liu HC, Cohen J, Alikani M, et al. Assisted hatching facilitates earlier implantation. Fertil Steril 1993; 60:871–875. 23 Mandelbaum J. The effects of assisted hatching on the hatching process and implantation. Hum Reprod 1996; 11 (Suppl 1):43–50; discussion 51– 55. 24 Hagemann AR, Lanzendorf SE, Jungheim ES, et al. A prospective, randomized, double-blinded study of assisted hatching in women younger than 38 years undergoing in vitro fertilization. Fertil Steril 2010; 93:586–591. 25 Knutzen V, Stratton CJ, Sher G, et al. Mock embryo transfer in early luteal phase, the cycle before in vitro fertilization and embryo transfer: a descriptive study. Fertil Steril 1992; 57:156–162. 26 Kashyap S, Chung P, Kligman I, et al. 7 year descriptive summary of ectopic pregnancies occurring after fresh and frozen IVF cycles [abstract]. Fertil Steril 2002; 78:S137.

12 Pyrgiotis E, Sultan KM, Neal GS, et al. Ectopic pregnancies after in vitro fertilization and embryo transfer. J Assist Reprod Genet 1994; 11:79–84.

27 Silva C, Trimachi J, Keefe D, Frankfurter D. High incidence of ectopic pregnancy following frozen embryo transfer [abstract]. Fertil Steril 2003; 80 (Suppl 3):S178.

13 Keegan DA, Morelli SS, Noyes N, et al. Low ectopic pregnancy rates after in vitro fertilization: do practice habits matter? Fertil Steril 2007; 88:734–736.

28 Fanchin R, Ayoubi JM, Righini C, et al. Uterine contractility decreases at the time of blastocyst transfers. Hum Reprod 2001; 16:1115–1119.

14 Tomazevic T, Ribic-Pucelj M. Ectopic pregnancy following the treatment of tubal infertility. J Reprod Med 1992; 37:611–614.

29 Jun SH, Milki AA. Ectopic pregnancy rates with frozen compared with fresh blastocyst transfer. Fertil Steril 2007; 88:629–631.

15 Zouves C, Erenus M, Gomel V. Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: a role for proximal occlusion or salpingectomy after failed distal tubal surgery? Fertil Steril 1991; 56:691–695.

30 Jee BC, Suh CS, Kim SH. Ectopic pregnancy rates after frozen versus fresh embryo transfer: a meta-analysis. Gynecol Obstet Invest 2009; 68:53–57. A meta-analysis to investigate the effect of frozen embryo transfer on rate of ectopic pregnancy, showing frozen embryo transfer does not increase risk of ectopic pregnancy compared with fresh embryo transfer.

16 Weigert M, Gruber D, Pernicka E, et al. Previous tubal ectopic pregnancy raises the incidence of repeated ectopic pregnancies in in vitro fertilizationembryo transfer patients. J Assist Reprod Genet 2009; 26:13–17. 17 Karikoski R, Aine R, Heinonen PK. Abnormal embryogenesis in the etiology of ectopic pregnancy. Gynecol Obstet Invest 1993; 36:158–162.

31 Check JH, Choe JK, Katsoff B, et al. Ectopic pregnancy is not more likely following fresh vs frozen embryo transfer. Clin Exp Obstet Gynecol 2005; 32:95–96.

18 Toikkanen S, Joensuu H, Erkkola R. DNA aneuploidy in ectopic pregnancy and spontaneous abortions. Eur J Obstet Gynecol Reprod Biol 1993; 51:9–13.

32 Milki AA, Jun SH. Ectopic pregnancy rates with day 3 versus day 5 embryo transfer: a retrospective analysis. BMC Pregnancy Childbirth 2003; 3:7.


Is there a benefit in follicular flushing in assisted reproductive technology? Micah J. Hill and Eric D. Levens Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA Correspondence to Eric D. Levens, MD, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Building 10, CRC, Room E1-3140, 10 Center Drive, Bethesda, MD 20892, USA Tel: +1 301 496 5800; fax: +1 301 402 0884; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:208–212

Purpose of review Follicular flushing utilizing double-lumen retrieval needles attempts to increase oocyte yield during transvaginal retrieval. The original work on this topic, now more than 2 decades old, examined its utility in normal-responding assisted reproductive technologies (ART) patients. Newer studies examining its utility have focused on special populations expected to demonstrate benefit: poor responders, natural cycle and minimal stimulation ART, and in-vitro maturation cycles. This review assesses the current evidence regarding the effectiveness of ovarian follicular flushing in improving oocyte yield. Recent findings Follicular flushing offers no substantive benefit in oocyte yield, fertilization rates, or pregnancy outcomes for normal and poor-responding ART patients. Patients undergoing natural cycle or minimal stimulation ART may benefit from follicular flushing resulting in more mature embryos but unclear effects on cycle outcome. Summary Randomized controlled trials consistently demonstrate no benefit and increased procedural time with follicular flushing in both normal and poor-responding ART patients. Nonrandomized data suggest a possible role for follicular flushing in natural cycle or minimal stimulation ART and in those undergoing in-vitro maturation IVF cycles; however, randomized controlled trials are needed to verify this finding. Presently, there is insufficient evidence to recommend the routine use of follicular flushing. Keywords assisted reproductive technologies, double-lumen retrieval needle, oocyte retrieval, ovarian follicle flushing, poor responders Curr Opin Obstet Gynecol 22:208–212 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Prior to the early 1980s, oocyte retrieval was performed via laparoscopy, a cumbersome and expensive process requiring general anesthesia [1,2]. Laparoscopy was soon replaced by transvaginal retrieval under ultrasound guidance as the primary route to obtain oocytes for assisted reproductive technologies (ART) due to its safety, effectiveness, and the avoidance of general anesthesia [3–6]. The conversion to a transvaginal retrieval approach was followed by refinements in the oocyte retrieval needle design in an effort to maximize recovery and minimize patient discomfort [7–9]. Double-lumen needles (one channel to withdraw follicular fluid and another to instill isotonic saline into the follicle) were developed to allow for simultaneous or intermittent flushing and aspiration of ovarian follicles, a process that could not be accomplished with single-lumen retrieval needles [10]. A survey of ART clinics in 2001 reported that more than 50% performed follicular flushing in addition to direct aspiration of follicu1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

lar fluid [11]. Proponents of follicular flushing have contended that greater oocyte yield may be achieved by obtaining oocytes that might otherwise be retained within the follicle following direct aspiration, resulting in a higher potential for pregnancy [10,12]. This notion was supported by initial reports of improved oocyte recovery when performing follicular flushing compared with direct aspiration, thus fueling speculation that pregnancy outcomes may likewise be improved [13]. This article sets out to assess the current state of evidence regarding the effectiveness of ovarian follicular flushing in improving oocyte yield and the resulting benefits in ART cycle outcome in both an unselected ART population as well as populations with limited follicle development.

Unselected assisted reproductive technologies population Over the years, there have been several studies examining the utility of ovarian follicular flushing. The results of DOI:10.1097/GCO.0b013e3283373bfe


Benefits of follicular flushing Hill and Levens 209 Table 1 Summary of prospective, observational studies evaluating oocyte recovery in the initial aspirate and subsequent follicle flushes Oocytes obtained (%)

Author (year) Waterstone et al. [13] el Hussein et al. [14] Bagtharia et al. [15]

Follicles Oocytes Patients aspirated retrieved (n) (n) (n) 50 96 141

720 1181 1489

538 1046 1231

Direct aspirate (%)

1st flush (%)

2 flushes (%)

446 (83) 75 (14) 17 (3) 854 (82) 143 (14) 49 (5) 501 (40) 30 (3) 700 (57)

Pregnancy rates (%)

Fertilization rates (%)

Direct 1st 2 Direct 1 aspirate flush flushes aspirate flush (%) (%) (%) (%) (%) 56 62 55

43 66 58

24 36 NR

NR NR 26

NR NR 20

Procedure time (min) NR 25.8 11.1 NR

Percentage of the overall number of oocytes as obtained in each group; lower than the fertilization rate of the aspirate group (P < 0.05); lower this study performed up to six flushes. Only the results for the aspirate than the fertilization rate of both the aspirate and 1st flush groups (P < 0.01); and first two flushings reported in this Table.

the three prospective, observational studies performed to date have been summarized in Table 1 [13–15]. Although there were no control or comparison groups in these studies, the initial aspiration would be expected to approximate the yield obtained with direct aspiration using a single-lumen retrieval needle. Combined, these studies included 291 patients undergoing ART resulting in the aspiration of 2815 oocytes. Sixty-four percent of the oocytes were obtained in the initial follicle aspirate. The proportion of fertilized oocytes obtained in the second flush was significantly lower in the two studies reporting this proportion as compared with those obtained by aspiration [13,14]. The study by el Hussein et al. [14] reported an overall pregnancy rate of 28%, but had no resultant pregnancies from cycles that utilized embryos derived from oocytes obtaining from ovarian-follicle flushing. These findings suggested that while oocyte yield was increased, pregnancy outcomes were not affected by repetitive follicle aspirations. Another study reported aspirating all follicles at least 14 mm that were present at the time of oocyte retrieval [15]. The authors reported flushing each follicle up to six times. A notable drawback of this study was that the authors did not delineate the process by which follicles were selected for repetitive aspiration. This omission significantly undermined the conclusions drawn from this study. Nevertheless, the authors concluded that up to four follicle flushes allowed for the maximum number of oocytes to be retrieved, whereas not significantly impacting operating or anesthetic time. A large observational study of 2398 patients undergoing ART in Australia was performed when the authors’ practice protocol changed from routine flushing in all patients to direct aspiration alone [11]. The authors compared outcomes in patients from a time period immediately preceding and following the protocol change. During this time the ART protocol for the two groups was otherwise unchanged. The baseline characteristics including age, BMI, diagnosis of infertility, and peak estradiol levels between the two groups were

similar. The fertilization rates between groups did not differ whether ICSI, GIFT, or IVF was utilized. Recognizably not free from bias, the authors noted an increase in oocytes retrieved (direct: 8.8 oocytes, flushing: 8.2 oocytes) and in pregnancy rates (direct: 23%, flushing: 21%) with aspiration alone; however, the differences were limited and not statistically significant. Moreover, this study was unable to demonstrate a benefit in terms of clinical outcomes with follicular flushing and further provided evidence that follicular flushing might be detrimental to ART cycle outcome. Remarkably, there has been a paucity of randomized trials comparing follicle flushing to direct aspiration. To date, four trials including a total of 214 patients have been conducted that compare follicular flushing to direct aspiration in the normal-responding population [10,16– 18]. Unexpectedly, in these randomized studies, there were more oocytes retrieved in the aspiration only groups than among those undergoing follicle aspiration (direct: 8.9 oocytes, flushing: 7.5 oocytes) (Table 2). In addition, follicular flushing was associated with significantly longer retrieval times, accounting for approximately 15 min of additional procedural time [16,17]. The total number of pregnancies were similar between the two groups (direct: 15, flushing: 16) [16]. In both reports the authors reported total number of pregnancies, but not pregnancy rates nor specific P-values. In total, follicular flushing appears to offer no advantage over direct aspiration alone. Without a noted benefit, it remains difficult to justify the longer retrieval times associated with follicular flushing. As a result, we recommend that follicular flushing not be routinely performed in the normal-responding ART population.

Poor responders Women demonstrating a poor response to gonadotropin stimulation comprise approximately 10% of the total ART population and have significantly lower pregnancy outcomes as a result of limited follicular development


210 Fertility Table 2 Summary of studies directly comparing follicular aspiration alone to follicular aspiration with flushing Patients (n) Author Cohort Knight et al. [11] Randomized trials Haines et al. [10] Tan et al. [16] Kingsland et al. [17] Scott et al. [18] Average

Mean oocytes retrieved (n)

Fertilization rate (%) Aspirate

Flushing

Procedure time (minutes)

Aspirate

Flushing

Aspirate

Flushing

P value

1139

1139

8.25.1

8.85.6

NS

56

54

NS

18 50 16 22 106

18 50 18 22 108

0.22 NS NS NS

70 56 60 66 63

64 60 64 64 63

0.60 NS NS NS

6.8 11 8.5 6.3 8.9

5.6 9 7 5.9 7.5

P value

Aspirate

Flushing

–

–

– 15 20 – 17.5

– 30 35 – 32.5

P-value – – singleton Twin > singleton Twin > singleton

Twin > singleton Twin > singleton ART < control – –

Main effects

ART, assisted reproductive technology; ", symptoms increased in mothers/fathers of ART twins; #, symptoms decreased in mothers/fathers of ART twins; $, no difference. Waller Duncan post-hoc analyses, analysis of covariance, main effects: group $ART/control, parenthood $twin/singleton. All analyses were adjusted for the child’s birth weight. Data modified from Vilska et al. [30].

Sleeping difficulties Social dysfunction Fathers Depression Anxiety Sleeping difficulties Social dysfunction

$ $

Control twins, 20

Control singletons, 379

91

ART couples with twins, n ART singletons, 367

The second trimester of pregnancy

Data collection time

Table 3 Mental health symptoms (General Health Questionnaire – 36) of parents of twins conceived via assisted reproductive technology compared with parents of twins conceived spontaneously (control twins), parents of singletons conceived via assisted reproductive technology (assisted reproductive technology singletons) and parents of singletons conceived spontaneously (control singletons) and the overall effect of assisted reproductive technology and twin parenthood on mental health symptoms

224 Fertility


Mental health of parents of ART twins Vilska and Unkila-Kallio

within the same year. The control groups include a large number of couples with singletons conceived via ART as well as fertile couples with spontaneous singletons and smaller control group of fertile couples with spontaneous twins. Mental health was assessed in four dimensions – symptoms of depression, anxiety, social dysfunction and sleeping difficulties – at three time points: in the second trimester of pregnancy, 2 months after delivery and when the children were 1 year old. The full response rate was well satisfactory for statistical analysis for all other groups (60–73.6%) apart from the couples with spontaneously conceived twins (55%, n ¼ 11). Thus, the comparisons between parents with ART and spontaneously conceived 1-year-old twins have to be cautiously interpreted. However, this longitudinal setting with three control groups allowed an advanced statistical approach with multivariate analysis of covariance to evaluate the effect of ART and twinning on mental health. The previous study from the same material on parental mental health of singletons conceived via ART or spontaneously showed that successful ART did not predict impaired mental health during the transition to parenthood [31].

Maternal mental health during twin pregnancy achieved via assisted reproductive technology Data on maternal mental health during ART twin pregnancy exist only from the second trimester of pregnancy [30]. The symptoms of depression, anxiety as well as sleeping difficulties and social function in mothers of twins conceived via ART were comparable to mothers of singletons irrespective of the way of conception. However, when compared with mothers with spontaneously conceived twins, the mothers of twins conceived via ART had fewer symptoms of depression (Table 3).

Maternal mental health and twin parenthood following assisted reproductive technology Mothers of twins conceived via ART have more symptoms of depression at 2 months postpartum and with 1-year-old children than the mothers of singletons conceived via ART [30] (Table 3). The symptoms of anxiety were comparable. Further, in another large study [24], mothers of 2-year-old to preschool-aged twins conceived via IVF or ICSI had increased levels of depression when compared with matched mothers of singletons (Table 1). Similarly, clinical depression was more frequent in mothers of 1–2-year-old twins or triplets when compared with matched mothers of singletons [23]. However, the most recent, but small study [25] could not repeat this finding. Interestingly, first-time mothers were studied in a study of both twins and triplets and these mothers of multiples

225

conceived via ART had significantly more symptoms of depression than the counterpart mothers of singletons [21]. However, with 1-year-old children, no differences existed as regards the psychiatric disorders [22]. When comparing mental health of mothers with twins according to way of conception, similar mental health between ART and spontaneous conception has been found in different settings [9,27–29] (Table 2) except in the study by Vilska et al. [30]. Mothers with toddlerage twins conceived via ART had fewer symptoms of depression and anxiety than spontaneously conceived mothers of twins (Table 3). Taken together, mothers of ART twins have more symptoms of impaired mental health when compared with mothers of singletons conceived via ART. Mothers of twins conceived via ART have similar or better (one study) mental health than mothers of spontaneously conceived twins.

Paternal mental health during the partner’s twin pregnancy achieved via assisted reproductive technology Fathers of ART twins show similar mental health during their partner’s mid-pregnancy as fathers of singletons irrespective of the way of conception and fathers of spontaneously conceived twins [30] (Table 3).

Paternal mental health and twin parenthood following assisted reproductive technology The effect of twin parenthood on paternal mental health after successful ART has been studied in the recent study [30]. The fathers of twins conceived via ART had significantly more symptoms of depression and social dysfunction than fathers of singletons conceived via ART when the children were 2 months old (Table 3). With 1-year-old twins, the fathers who had experienced ART had more symptoms of depression and anxiety than the fathers of singletons irrespective of the way of conception. The recent small study [25] found no difference in clinical depression between fathers of twins or singletons conceived via ART and other infertility treatments. Way of conception, that is, ART, does not affect paternal mental health based on four studies [9,27,28,30] with series from 2-month-old to 5-year-old twins (Tables 2 and 3). In all, twin parenthood, not ART, is a risk factor for paternal mental health, especially with toddler-age twins.

Conclusion Existing data on mental health of parents with twins conceived via ART are very limited. ART twin pregnancy does not impair parental mental health during


226 Fertility

mid-pregnancy. However, it is evident that at postpartum and at toddler to preschool age of children, parental mental health is better with singletons than with twins conceived via ART. Twin birth rate after ART is high due to transfer of multiple embryos. ART personnel are encouraged to counsel infertile couples prior ART on the known medical and psychosocial consequences of twin births. More data from large, well conducted prospective longitudinal studies on parental, not only maternal, mental health are needed from families with twins conceived via ART. Studies covering also later life with school-aged and adolescent twins are desired.

Acknowledgement We thank Maija Tulppala, MD, PhD, for her professional comments and help during the preparation of the manuscript.

11 Ryan GL, Zhang SH, Dokras A, et al. The desire of infertile patients for multiple births. Fertil Steril 2004; 81:500–504. 12 Hojgaard A, Ottosen LD, Kesmodel U, et al. Patient attitudes towards twin pregnancies and single embryo transfer: a questionnaire study. Hum Reprod 2007; 22:2673–2678. 13 Pinborg A, Loft A, Schmidt L, et al. Attitudes of IVF/ICSI-twin mothers towards twins and single embryo transfer. Hum Reprod 2003; 18:621–627. 14 Child TJ, Henderson AM, Tan SL. The desire for multiple pregnancy in male and female infertility patients. Hum Reprod 2004; 19:558–561. 15 Singer LT, Salvator A, Guo S, et al. Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant. JAMA 1999; 281:799–805. 16 Hansen M, Colvin L, Petterson B, et al. Twins born following assisted reproductive technology: perinatal outcome and admission to hospital. Hum Reprod 2009; 24:2321–2331. This large study considering zygosity compared health of twins conceived spontaneously or by ART during the first 3 years of children. Higher risk for adverse perinatal outcome, admission to NICU and hospitalization in ART twins was found. 17 Helmerhorst FM, Perquin DA, Donker D, et al. Perinatal outcome of singletons and twins after assisted conception: a systematic review of controlled studies. BMJ 2004; 328:261. 18 D’Alton M. Infertility and the desire for multiple births. Fertil Steril 2004; 81:523–525; discussion 526.

References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 257). Zegers-Hochschild F, Adamson GD, de Mouzon J, et al. The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, 2009. Hum Reprod 2009; 24:2683–2687. This study reports internationally accepted standardized terminology in medically assisted reproduction to be used also in infertility research.

1

2

Templeton A, Morris JK. Reducing the risk of multiple births by transfer of two embryos after in vitro fertilization. N Engl J Med 1998; 339:573–577.

3

Thurin A, Hausken J, Hillensjo T, et al. Elective single-embryo transfer versus double-embryo transfer in in vitro fertilization. N Engl J Med 2004; 351:2392– 2402.

Pandian Z, Bhattacharya S, Ozturk O, et al. Number of embryos for transfer following in-vitro fertilisation or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev 2009:CD003416. This Cochrane Database systematic review updates the evidence of effectiveness of the embryo transfer policies.

4

5

6

Nyboe Andersen A, Goossens V, Bhattacharya S, et al. Assisted reproductive technology and intrauterine inseminations in Europe, 2005: results generated from European registers by ESHRE: ESHRE. The European IVF Monitoring Programme (EIM), for the European Society of Human Reproduction and Embryology (ESHRE). Hum Reprod 2009; 24:1267–1287. Sunderam S, Chang J, Flowers L, et al. Assisted reproductive technology surveillance: United States, 2006. MMWR Surveill Summ 2009; 58:1–25.

Hammarberg K, Fisher JR, Wynter KH. Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: a systematic review. Hum Reprod Update 2008; 14:395–414. This is a comprehensive review of research on psychosocial aspects of transition to parenthood after successful ART. The authors highlight methodological differences and inconsistencies in current evidence. The challenges of future research of the topic are discussed.

7

19 Ryan GL, Sparks AE, Sipe CS, et al. A mandatory single blastocyst transfer policy with educational campaign in a United States IVF program reduces multiple gestation rates without sacrificing pregnancy rates. Fertil Steril 2007; 88:354–360. 20 Schmidt L. Social and psychological consequences of infertility and assisted reproduction: what are the research priorities? Hum Fertil (Camb) 2009; 12:14–20. 21 Sheard C, Cox S, Oates M, et al. Impact of a multiple, IVF birth on postpartum mental health: a composite analysis. Hum Reprod 2007; 22:2058–2065. 22 Glazebrook C, Sheard C, Cox S, et al. Parenting stress in first-time mothers of twins and triplets conceived after in vitro fertilization. Fertil Steril 2004; 81:505–511. 23 Ellison MA, Hotamisligil S, Lee H, et al. Psychosocial risks associated with multiple births resulting from assisted reproduction. Fertil Steril 2005; 83:1422–1428. 24 Olivennes F, Golombok S, Ramogida C, et al. Behavioral and cognitive development as well as family functioning of twins conceived by assisted reproduction: findings from a large population study. Fertil Steril 2005; 84:725–733. This large study with relevant study design compares levels of depression in mothers of preschool-age twins and singletons conceived via ART. 25 Roca de Bes M, Gutierrez Maldonado J, Gris Martinez JM. Psychosocial risks associated with multiple births resulting from assisted reproduction: a Spanish sample. Fertil Steril 2009; 92:1059–1066. 26 Garel M, Salobir C, Lelong N, et al. Mothers of triplets and their children: course from 4 to 7 years after birth. Gynecol Obstet Fertil 2000; 28:792– 797. 27 Baor L, Bar-David J, Blickstein I. Psychosocial resource depletion of parents of twins after assisted versus spontaneous reproduction. Int J Fertil Womens Med 2004; 49:13–18. 28 Munro JM, Ironside W, Smith GC. Psychiatric morbidity in parents of twins born after in vitro fertilization (IVF) techniques. J In Vitro Fert Embryo Transf 1990; 7:332–336. 29 Tully LA, Moffitt TB, Caspi A. Maternal adjustment, parenting and child behaviour in families of school-aged twins conceived after IVF and ovulation induction. J Child Psychol Psychiatry 2003; 44:316–325.

8

Klock SC. Psychological adjustment to twins after infertility. Best Pract Res Clin Obstet Gynaecol 2004; 18:645–656.

9

Colpin H, Munter AD, Nys K, et al. Parenting stress and psychosocial well being among parents with twins conceived naturally or by reproductive technology. Hum Reprod 1999; 14:3133–3137.

30 Vilska S, Unkila-Kallio L, Punamaki RL, et al. Mental health of mothers and fathers of twins conceived via assisted reproduction treatment: a 1-year prospective study. Hum Reprod 2009; 24:367–377. In this prospective, longitudinal study, mental health of mothers and fathers of twins conceived via ART is assessed by General Health Questionnaire-36 over the transition to parenthood by comparisons with parents of ART singletons and with parents of spontaneously conceived twins and singletons.

10 Choi Y, Bishai D, Minkovitz CS. Multiple births are a risk factor for postpartum maternal depressive symptoms. Pediatrics 2009; 123:1147–1154. This large population-based well conducted study shows clearly the association of multiple births and maternal depressive symptoms 9 months after delivery.

31 Repokari L, Punama¨ki R-L, Poikkeus, et al. The impact of successful assisted reproduction treatment on female and male mental health during transition to parenthood: a prospective controlled study. Hum Reprod 2005; 20:3238– 3247.


Borderline ovarian tumors and fertility Joo-Hyun Nam Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Correspondence to Joo-Hyun Nam, MD, PhD, Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, #388-1 Poongnap-2 Dong, Songpa-Gu, Seoul 138-736, Republic of Korea Tel: +82 2 3010 3633; fax: +82 2 476 7331; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:227–234

Purpose of review Borderline ovarian tumors (BOTs) are a distinct diagnostic category of epithelial ovarian tumors, distinguished from both benign and invasive epithelial ovarian tumors. Because they affect young women of childbearing age, are diagnosed at an early stage, and are associated with excellent prognosis, fertility-sparing options are often used. In this review, we discuss recent findings on the outcomes of fertility-sparing treatments in patients with BOTs. Recent findings Reports on the use of fertility-sparing surgery in patients with advanced-stage BOTs and on the application of laparoscopy in fertility-sparing surgery are increasing. As potential alternative, experiences on ovarian tissue cryopreservation have been reported. Summary Fertility-sparing surgery is the best option to preserve childbearing capacity in young patients with BOTs. Fertility-sparing surgery is well tolerated not only in patients with early-stage BOTs but also in patients with advanced-stage BOTs with noninvasive extraovarian implants, if these implants can be resected completely. After fertilitysparing surgery, pregnancy outcomes are promising and most pregnancies are achieved spontaneously. There are few complications associated with pregnancy, and subsequent pregnancy seems to have little impact on disease course. Fertility drugs are well tolerated in patients with infertility after fertility-sparing surgery for early-stage BOTs, but caution should be exercised when using these drugs after surgery in patients with advanced-stage BOTs. If fertility-sparing surgery is technically not feasible owing to extensive tumor involvement of both ovaries, recent artificial reproductive technologies can be considered, including embryo, oocyte, and ovarian tissue freezing; use of donor oocytes; and surrogacy, but more experience with these options is required. Keywords borderline ovarian tumor, fertility, fertility-sparing surgery Curr Opin Obstet Gynecol 22:227–234 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Borderline ovarian tumor (BOT) is a distinct diagnostic category of epithelial ovarian tumor, distinguished from both benign epithelial ovarian tumor and invasive epithelial ovarian cancer [1,2]. BOTs account for 5% of all epithelial ovarian tumors and 15% of all epithelial ovarian cancers [3]. Pathologically, BOTs are characterized by features of malignant epithelial ovarian tumors, including stratification of the epithelial lining of the papillae, formation of microscopic papillary projections or tufts arising from the epithelial lining of the papillae, epithelial pleomorphism, atypicality, and mitotic activity, but do not demonstrate invasion of the underlying stroma [4]. Although uncommon, metastatic noninvasive or invasive implants may occur in patients with BOTs. Clinically, BOTs are distinct from invasive epithelial ovarian cancer in that more than 80% of BOTs are diagnosed as stage I 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

disease, they often affect young women who wish to preserve their fertility, and they have low potential for malignancy, including indolent behavior, longer patient survival, and later recurrence [5]. Nearly, all series have reported a 5-year survival rate of 100% for patients with stage I and IIA tumors [6]. Even when the tumor involves the pelvis or abdomen, the 5-year survival rate is about 80% [6]. BOTs are diagnosed at an early stage and in young women who wish to preserve their fertility, and are associated with excellent prognosis; hence, patients with BOTs are good candidates for fertility-preserving treatments. Fertility-sparing surgery has shown increased safety and efficacy in patients with BOTs, and outcomes have been reported for other fertility-preserving options in patients for whom fertility-sparing surgery is not applicable. DOI:10.1097/GCO.0b013e3283384928


228 Fertility

based on disease extent and the presence of factors associated with poor prognosis, including microinvasion, a micropapillary pattern, and invasive or noninvasive implants. Among the variables to consider during surgery are the type of adnexal surgery (cystectomy, oophorectomy, or salpingo-oophorectomy), the performance of wedge biopsy of the normal appearing contralateral ovary, and the use of a laparoscopic approach.

Text of review Of several options to preserve fertility, fertility-sparing surgery is the best option.

Fertility-sparing surgery Surgical removal of BOTs is the mainstay of patient management. Although the extent of surgery has been debated, the standard surgical procedures include total hysterectomy; bilateral salpingo-oophorectomy and peritoneal staging procedures, including peritoneal washings, multiple peritoneal biopsies, and resection of implants; omentectomy; and appendectomy (in patients with mucinous BOTs) [7]. Lymphadenectomy is usually not indicated owing to the rarity of lymph node metastasis and questions regarding the prognostic role of lymph node metastasis [8–11]. Because of recent changes in attitudes toward radical oncologic surgery, benefits are evaluated not only with respect to disease control but also to functional end results that may affect the patient’s quality of life. Preservation of fertility during surgery is regarded as one of the most important quality-of-life issues in younger patients with BOTs. Most studies, including this review, have defined fertility-sparing surgery as the preservation of the uterus and ovarian tissue in one or both adnexa in women of reproductive age, and defined radical surgery as approaches that include total hysterectomy, bilateral salpingo-oophorectomy, or both.

Early stage (International Federation of Gynecology and Obstetrics stage I)

Fertility-sparing surgery was initially performed in patients with early-stage or International Federation of Gynecology and Obstetrics (FIGO) stage I BOTs. Therefore, most studies compared the oncologic safety of fertility-sparing surgery and radical surgery in patients with early-stage BOTs (Table 1 [12–18,19,20]). Although recurrence rates were similar to or slightly higher in patients undergoing fertility-sparing surgery than in those undergoing radical surgery, fertility-sparing surgery did not compromise survival. Most recurrent lesions in patients who underwent fertility-sparing surgery were borderline tumors, which could be cured with complete surgical procedures at recurrence, similar to recurrences in patients who underwent radical surgery. Thus, fertility-sparing surgery was considered well tolerated in patients with early-stage BOTs. However, the patterns of recurrence were somewhat different in the two groups of patients. Fertility-sparing surgery was associated with lower rates of abdominal and pelvic recurrences than radical surgery. Rather, the most common type of recurrence in patients who underwent fertility-sparing surgery was isolated recurrence in the remaining ovary. This has important clinical implications

Oncologic safety

Because fertility-sparing surgery should not compromise the survival of patients with BOTs, this surgical approach should be reserved for young women who wish to preserve their fertility. The radicality of surgery should be

Table 1 Comparison of the outcome of fertility-sparing surgery with radical surgery in patients with early-stage borderline ovarian tumor Reference Ji et al. [12] Gotlieb et al. [13] Zanetta et al [14] Morice et al. [15] Romagnolo et al. [16] Donnez et al. [17] Fauvet et al. [18] Park et al. [19] De Iaco et al. (2009) [20]

Surgical management

Number of patients

Follow-up time (months, median)

Recurrence, n (%)

Radical Fertility-sparing Radical Fertility-sparing Radical Fertility-sparing Radical Fertility-sparing Radical Fertility-sparing

70 25 26 49 150 189 125 49 60 53

55 88 57

3 (4) 4 (16) 2 (8) 4 (8) 7 (5) 35 (19) 6 (5) 9(18) 4 (7) 9 (17)

Radical Fertility-sparing Radical Fertility-sparing Radical

59 16 194 164 176

NR NR 65

0 3 14 23 9

Fertility-sparing Radical Fertility-sparing

184 83 95

60 NR NR

9 (5) 5 (6.0) 22 (23)

70 109 NR NR 75

(0) (19) (7) (14) (5)

Location of recurrent disease at first recurrence 2, abdomen; 1, omentum 3, ovary; 1, abdomen 2, pelvis 2, ipsilateral ovary; 2, contralateral ovary NR NR NR 1, both ovary; 6, contralateral ovary; 2, NR 3, pelvis; 1, NR 2, pelvis; 3, ipsilateral ovary; 3, contralateral ovary; 1, NR 3, ovary NR NR 1, ovary; 1, ovary, pelvis; 1, pelvis; 2, pelvis, pelvic lymph nodes; 4, peritoneal seeding 7, ovary; 1, ovary, lung; 1, lung, pericardium 5, pelvis 20, ovary; 1, ovary, peritoneum; 1, peritoneum

NR, not reported.


Borderline ovarian tumors and fertility Nam 229

because isolated ovarian recurrences can be cured by secondary surgery, including a second round of fertility-sparing surgery in patients who wish to preserve their fertility. Several studies [19,20,21] have shown that a second round of fertility-sparing surgery was both well tolerated and effective. Advanced stage (International Federation of Gynecology and Obstetrics stages II–IV): extraovarian invasive or noninvasive implants

Recently, the application of fertility-sparing surgery has expanded to include patients with advanced-stage disease by noninvasive extraovarian implants. Implant invasiveness is an important factor when considering fertilitysparing surgery in patients with advanced-stage disease because invasiveness is the most important prognostic factor in these patients. Although several studies have reported the outcomes of fertility-sparing surgery in patients with advanced-stage BOTs (Table 2 [14,19, 20,22–24,25,26]), the number of study participants was too small to draw definitive conclusions. However, the overall survival of patients with noninvasive implants was excellent, with most patients who died after fertilitysparing surgery having had invasive implants [27,28,29]. Therefore, fertility-sparing surgery can be a viable treatment option in patients with noninvasive implants if the implants can be resected completely. Further evaluation is required to confirm these findings.

high, but only one patient with an extraovarian implant died of disease [36]. Although definitive conclusions are limited by the small sample size, the authors of this study suggested that fertility-sparing surgery could be safely proposed to a majority of patients with micropapillary BOTs who are carefully followed up [36]. Further evaluation, however, is warranted. Infrequently, microscopic foci of invasion of the stroma by single cells and nests of moderately atypical cells are found in patients with BOTs. If such foci measure less than 3 mm in the longest linear dimension and are 10 mm2 or less in area, the tumors are designated BOTs with microinvasion. Although studies [22,37] have suggested that the prognosis of patients with BOTs with microinvasion is similar to that of patients with BOTs without microinvasion, several recent studies have suggested that microinvasion ultimately has an impact on recurrence rate, survival, or both [24,38]. Few studies have addressed the outcome of fertility-sparing surgery in patients with BOTs with microinvasion, but a recent study [39] included 10 such patients with microinvasion but without micropapillary pattern. Although five of these patients had recurrent disease, all lesions developed on the remaining ovary and all patients with recurrence were salvaged successfully [39]. This suggests that fertility-sparing surgery may be well tolerated in patients with BOTs with microinvasion, but further evaluation is required.

Micropapillary pattern and microinvasion

BOTs with a micropapillary pattern [30,31] have been associated with more common bilateral ovarian involvement, extraovarian implants, and invasive implants [22,32]. Although some studies [31,32,33] have reported an increased risk of recurrence in patients with micropapillary type tumors, other studies [34,35] have not found this association. Few studies have evaluated the outcomes of fertility-sparing surgery in patients with micropapillary BOTs, although a recent study [36] included 15 such patients. The rates of bilateral ovarian involvement, extraovarian implants, and recurrence were

Type of adnexal surgery

Oophorectomy or salpingo-oophorectomy as fertilitysparing surgery in patients with BOTs has been reported to be associated with better oncologic safety because lessextensive surgery has been associated with higher recurrence rates. In some patients, however, cystectomy as fertility-sparing surgery may be the only viable option owing to previous history of unilateral oophorectomy or salpingo-oophorectomy or bilateral involvement of BOTs. Although limited data are currently available on the safety and outcomes of cystectomy in patients with

Table 2 The outcome of fertility-sparing surgery in patients with advanced-stage borderline ovarian tumor Reference

Type of implants

Zanetta et al. [14]

Noninvasive Invasive Noninvasive Invasive Noninvasive Invasive Noninvasive Invasive NR NR Noninvasive Noninvasive Invasive

Prat and De Nictolis [22] Camatte et al. [23] Longacre et al. [24] De Iaco et al. [20] Vigano et al. [25] Park et al. [19] Uzan et al. [26]

Number of patients

Recurrence

Death

18 7 9 1 14 3 21 0 21 10 3 38 3

5 5 2 1 7 2 5 0 4 6 1 20 2

0 0 0 1 0 0 0 0 NR 0 0 1 0

NR, not reported.


230 Fertility

BOTs, a recent retrospective study comparing the outcomes in 40 patients who underwent unilateral salpingooophorectomy with those in 22 patients who underwent cystectomy found that the recurrence rates were 22.7 and 27.5%, respectively. A recent prospective randomized controlled trial comparing the safety of bilateral cystectomy and unilateral oophorectomy along with contralateral cystectomy in patients with bilateral BOTs found no significant differences between the two groups. In addition, several retrospective studies have suggested that bilateral adnexectomy in patients with bilateral BOTs was associated with only an insignificant increase in recurrence rate. Taken together, these findings indicate that cystectomy is well tolerated for patients with BOTs, but that cystectomy should be limited to patients with a previous history of unilateral adnexectomy or bilateral BOTs.

Integration of laparoscopic surgery

Wedge biopsy of normal appearing contralateral ovary

Fertility outcomes

The rates of bilateral involvement of BOTs have been reported to be 25–50% for serous-type tumors and 5– 10% for mucinous-type tumors [4,5], suggesting the need for histopathologic evaluation of the contralateral ovary during fertility-sparing surgery. However, wedge biopsy of the remaining ovary may cause mechanical infertility or ovarian failure [15,40]. A study of 14 patients who underwent wedge biopsy of the contralateral ovary found that none was positive, and one patient with normal results had recurrent disease in the remaining ovary [15]. These findings indicate that histopathologic evaluation of the normal appearing contralateral ovary is not helpful in reducing the risk of recurrence in the remaining ovary. In a recent retrospective study [19] of 22 patients who underwent wedge biopsy of the normal appearing contralateral ovary, none was positive for BOTs, whereas 11 of the 22 patients who underwent cystectomy to remove benign-appearing cysts of the contralateral ovary had BOTs on the contralateral ovary. Thus, careful inspection of the surface of the contralateral ovary and biopsies of suspicious lesions or cysts should be adequate for screening.

Because most previous studies have been retrospective in design, information on baseline ovarian function and fertility status before surgery, postoperative ovarian function, and menstrual function was not available. In addition, information on pregnancy outcomes was also limited because only some of these previous studies reported pregnancy outcomes and some omitted some of the details of pregnancy outcomes. However, pregnancy outcomes seem promising because pregnancy rates ranged from 32 to 100% (Table 4 [9,12–14,16–18,19,26,44,46–51]). Most patients conceived spontaneously without infertility treatment and few patients suffered from infertility (Table 4). The rates of complications associated with pregnancy, including ectopic pregnancy, miscarriage, preterm delivery, and fetal anomaly, were not significant (Table 4).

Laparoscopic surgery has several advantages over laparotomy in the management of adnexal tumors. Owing to advances in laparoscopic instruments and surgical techniques, the use of laparoscopic surgery is continuously increasing in the surgical management of patients with BOTs and invasive epithelial ovarian cancers. It is now possible to perform all surgical staging procedures for BOTs and epithelial ovarian cancers laparoscopically [41,42]. Studies [41,42] have suggested the feasibility, safety, and accuracy of laparoscopic surgery for patients with early-stage epithelial ovarian cancer. Recurrence rates were found to be similar in patients undergoing laparoscopy or laparotomy, fertility-sparing surgery for BOTs (Table 3 [16–18,19,43,44,45]), indicating that laparoscopic surgery is a reasonable alternative to laparotomy in the surgical management of patients with BOTs.

The appropriate time to try to conceive after fertilitysparing surgery has not been determined, although successful pregnancies have been achieved as early as 3 months after surgery [26,44]. Because pregnancies complicated by recurrent disease during this early

Table 3 Comparison of laparoscopic and laparotomic fertility-sparing surgery in patients with borderline ovarian tumor Reference

Surgical approach

Donnez et al. [17]

Laparoscopy Laparotomy Laparoscopy Laparotomy Laparoscopy Laparotomy Laparoscopy Laparotomy Laparoscopy Laparotomy Laparoscopy Laparotomy Laparoscopy Laparotomy

Maneo et al. [43] Fauvet et al. [18] Boran et al. [44] Romagnolo et al. [16] Park et al. [19] Total

Number of patients 3 13 30 32 149 209 56 6 53 61 48 136 399 457

Recurrence (%) 3 0 11 7 18 19 4 0 7 6 2 7 45 39

(100) (0) (36.7) (21.9) (12.1) (9.1) (7.1) (0) (13.2) (9.8) (4.2) (5.1) (11.3) (8.5)


95 82 79 518 19 339 27 25 75 142 360 249 113 101 360 41

25 39 15 43 19 189 12 25 16 62 162 38 53 37 184 41

19 NR NR 24 10 NR 12 6 11 25 65 NR 12 NR 31 NR

9 (47) 15 6 12 (50) 6 (60) 44 6 (60) 6 (100) 7 (64) 10 (45) 21 (32) 3 7 (58) 13 27 (87) 14

NR 22 10 25 6 44 6 6 12 13 30 4 8 13 33 18

NR NR NR NR 6 NR NR 4 12 13 27 4 7 13 33 9

NR NR NR NR 0 NR NR 1b 0 0 3d 0 0 0 0 5f

NR NR NR 14a 0 NR NR 2c 0 0 8 NR 0 0 0 8g

NR, not reported. a Five patients had infertility before surgery. b Ovulation induction. c One patient had infertility before surgery. d Ovulation induction with intrauterine insemination in one patient, and in-vitro fertilization and embryo transfer in two patients. e Elective termination for personal reason in eight patients. f Ovulation induction in two patients and in-vitro fertilization with embryo transfer in three patients. g Ovulation induction in three patients and in-vitro fertilization with embryo transfer in five patients. h Including one molar pregnancy.

Ji et al. [12] Gotlieb et al. [13] Papadimitriou et al. [46] Morris et al. [47] Seracchioli et al. [48] Zanetta et al. [14] Demeter et al. [49] Chan et al. [50] Donnez et al. [17] Boran et al. [44] Fauvet et al. [18] Rao et al. [51] Romagnolo et al. [16] Camatte et al. [9] Park et al. [19] Uzan et al. [26]

Reference NR 0 NR NR NR 3 NR 1 0 3 8e 0 1 0 0 0

NR 0 NR NR 0 0 NR 0 0 0 0 0 0 0 0 4h

NR 3 NR NR 0 0 NR 0 0 0 0 0 0 NR 0 0

NR 0 NR NR 0 0 NR 0 0 0 0 0 0 NR 0 0

NR 19 NR NR 6 41 NR 4 12 10 17 4 7 NR 33 14

NR 0 NR NR 0 NR NR 0 0 0 0 0 0 NR 0 0

NR 0 5 1 0 NR NR 0 1 1 5 NR 2 0 0 NR

No. of No. of No. of patients Recurrence Total patients pregnancy No. of Pregnancy patients Ectopic Ongoing Preterm Term Fetal after no. of Conservative pregnancy achieved pregnancy Spontaneous with assisted fertility patients surgery attempt (%) achieved pregnancy reproduction treatment Abortion pregnancy pregnancy birth birth anomaly pregnancy

Table 4 Pregnancy outcome after fertility-sparing surgery in patients with borderline ovarian tumor

NR NR NR NR 24.5 15.7 NR NR NR NR 13.7 (3–36) 28.6 24.6 NR NR 39 NR 13.5 (3–183)

Mean time interval to pregnancy (months)

NR NR NR NR NR 11 NR NR NR NR NR NR NR NR 0 1

Radical surgery after completion of family planning



232 Fertility

follow-up period would be problematic, many physicians are reluctant to recommend that patients conceive within 1 or 2 years after fertility-sparing surgery. However, this delay may negatively influence pregnancy outcomes. In addition, because BOTs tend to recur later than invasive epithelial ovarian cancer, it is not reasonable to delay pregnancy until after a sufficient follow-up period. Therefore, married patients should try to conceive from 3 to 6 months after surgery. Although the influence of pregnancy on disease course has not been fully evaluated, recurrence rates after pregnancy were not high and there have been few reports of recurrences complicated by pregnancy (Table 4). If patients are unmarried, periodic follow-up with cancer antigen-125 and ultrasonography of the remaining ovary after 3–6 months is recommended before trying to conceive owing to the high rate of recurrence in the remaining ovary during the follow-up period. It is also not clear whether radical surgery, including hysterectomy and salpingo-oophorectomy, should be performed after patients complete their families. Although most studies have not reported the number of patients who underwent radical surgery after family completion (Table 4), most patients remained disease-free after a long followup period without radical surgery [14,19,26]. Most recurrent lesions were borderline tumors and were located in the remaining ovary; thus, these patients were salvaged successfully by secondary surgery. Therefore, it may be reasonable to delay radical surgery until recurrence. Because the preservation of ovarian function is another important goal of fertility-sparing surgery, it may also be reasonable to delay complete surgery until after menopause. The effect of infertility treatment, particularly ovulation induction, on the disease course after fertility-sparing surgery is unclear. Retrospective case–control studies [52,53] have suggested a link between the use of fertility drugs and ovulation induction with clomiphene citrate and the occurrence of epithelial ovarian cancer. One mechanism explaining the link between ovulation induction and the development of epithelial ovarian cancer may be the direct action of gonadotropins on ovarian epithelial cells [54]. However, a recent in-vitro study [55] using BOT and invasive epithelial ovarian cancer cell lines found that high doses of estrogens or gonadotropins did not induce tumor cell proliferation. In addition, a recent retrospective multicenter study [56] found that four of 25 early-stage BOT patients who underwent ovulation induction had recurrent disease, but all recurrent lesions were borderline tumors and all patients were salvaged successfully. These findings indicate that infertility drugs can be used safely in patients who experience infertility after fertility-sparing surgery of early-stage BOTs. However, induction of ovulation in some patients

with advanced-stage BOTs has been found to induce recurrences as rapidly progressive invasive carcinomas [26,57], although other patients did not experience recurrence [47,56,58]. Therefore, caution should be exercised regarding ovulation induction in patients with advanced-stage BOTs.

Other potential options to preserve fertility Patients ineligible for fertility-sparing surgery because the normal ovarian portion cannot be preserved due to massive bilateral ovarian involvement and only the uterus can be preserved have several alternative options for fertility preservation. These include embryo freezing, oocyte freezing, and ovarian tissue freezing. Embryo freezing is routinely used in infertility clinics and has a good success rate of 20–30% [59]. It can be considered for BOT patients before definitive surgery [60]. However, a life partner or sperm donor is required, and patients must delay cancer treatment for 2–6 weeks. Oocyte freezing is also a viable option for fertility preservation in patients with BOTs. More than 230 pregnancies from frozen oocytes have been reported worldwide, with live-birth rates per oocyte thawed of 1.9–4.6% [61]. To our knowledge, however, oocyte freezing has not yet been attempted in patients with BOTs. Although oocyte freezing does not require a life partner or sperm donor, it does require a 2–6-week delay in cancer treatment. Moreover, these two fertility preservation options are costly and both must be planned and performed before surgery. Thus, they are not applicable for most patients with BOTs because BOTs are usually diagnosed during surgery by frozen biopsy. Another option to preserve fertility is ovarian tissue freezing, which can be performed during surgery. To our knowledge, however, only three pregnancies from ovarian tissue freezing have been reported in the literature [62–64]. Delay in cancer treatment and a life partner or sperm donor are not required. A large number of immature oocytes can be frozen using this technique. Although several studies have reported a restoration of endocrine function and embryo development from this technique, it is still experimental, and cancer cells may be transmitted [65]. This technique has been used recently in patients with BOTs, but, to our knowledge, the cryopreserved fragments have not been reimplanted [66]. Donor oocytes can also be used [67,68], if none of these methods is feasible. Surrogacy can also be considered for patients who require hysterectomy, but this does not constitute fertility preservation.

Conclusion Fertility-sparing surgery is the best option to preserve childbearing capacity in young patients with BOTs. It can be safely performed not only in patients with early-stage BOTs but also in patients with advanced-stage BOTs



who have noninvasive extraovarian implants if these implants can be resected completely. Recurrence is more common in patients who undergo fertility-sparing surgery than those who undergo radical surgery. However, most recurrent lesions are borderline tumors and located in the remaining ovary. Hence, most patients with recurrent disease can be salvaged successfully by secondary surgery, and second-round fertility-sparing surgery may be feasible for patients who still wish to preserve their fertility. Pregnancy outcomes after fertility-sparing surgery are promising and most pregnancies are achieved spontaneously. The rate of pregnancy-associated complications is low and subsequent pregnancy has little impact on disease course. Fertility drugs are well tolerated in patients with early-stage BOTs who experience infertility after fertility-sparing surgery, but caution is warranted in patients with advanced-stage BOTs. If fertility-sparing surgery is technically not feasible due to extensive tumor involvement of both ovaries, other potential options can be considered, including embryo freezing, oocyte freezing, ovarian tissue freezing, use of donor oocytes, and surrogacy, but more experience with these options is required.

Acknowledgement There is no conflict of interest.


Classification and staging of malignant tumours in the female pelvis. Acta Obstet Gynecol Scand 1971; 50:1–7.

2

Serov SF, Scully RE, Sobin LH. The World Health Organization International Histological Classification of Ovarian Tumors: histological typing of ovarian tumors. Geneva, Switzerland: World Health Organization; 1973. pp. 37–38.

3

Scully RE. World Health Organization classification and nomenclature of ovarian cancer. Natl Cancer Inst Monogr 1975; 42:5–7.

4

Acs G. Serous and mucinous borderline (low malignant potential) tumors of the ovary. Am J Clin Pathol 2005; 123 (Suppl):S13–S57.

5

Tinelli R, Tinelli A, Tinelli FG, et al. Conservative surgery for borderline ovarian tumors: a review. Gynecol Oncol 2006; 100:185–191.

6

Ozols RF, Rubin SC, Thomas GM, et al. Epithelial ovarian cancer. In: Hoskins WJ, Perez CA, Young RC, editors. Principle and practice of gynecologic oncology, 4th ed. Philadelphia, Pennsylvania, USA: Lippincott Williams & Wilkins; 2005. pp. 895–987.

12 Ji H, Yliskoski M, Anttila M, et al. Management of stage-I borderline ovarian tumors. Int J Gynaecol Obstet 1996; 54:37–44. 13 Gotlieb WH, Flikker S, Davidson B, et al. Borderline tumors of the ovary: fertility treatment, conservative management, and pregnancy outcome. Cancer 1998; 82:141–146. 14 Zanetta G, Rota S, Chiari S, et al. Behavior of borderline tumors with particular interest to persistence, recurrence, and progression to invasive carcinoma: a prospective study. J Clin Oncol 2001; 19:2658–2664. 15 Morice P, Camatte S, El Hassan J, et al. Clinical outcomes and fertility after conservative treatment of ovarian borderline tumors. Fertil Steril 2001; 75:92–96. 16 Romagnolo C, Gadducci A, Sartori E, et al. Management of borderline ovarian tumors: results of an Italian multicenter study. Gynecol Oncol 2006; 101:255–260. 17 Donnez J, Munschke A, Berliere M, et al. Safety of conservative management and fertility outcome in women with borderline tumors of the ovary. Fertil Steril 2003; 79:1216–1221. 18 Fauvet R, Boccara J, Dufournet C, et al. Laparoscopic management of borderline ovarian tumors: results of a French multicenter study. Ann Oncol 2005; 16:403–410. 19 Park JY, Kim DY, Kim JH, et al. Surgical management of borderline ovarian tumors: the role of fertility-sparing surgery. Gynecol Oncol 2009; 113:75–82. This is one of the largest studies that compared the oncologic outcomes between radical surgery group and fertility-sparing surgery group and presented the reproductive outcomes of fertility-sparing surgery group. 20 De Iaco P, Ferrero A, Rosati F, et al. Behaviour of ovarian tumors of low malignant potential treated with conservative surgery. Eur J Surg Oncol 2009; 35:643–648. This study compared the oncologic outcomes between radical surgery group and fertility-sparing surgery group and presented the reproductive outcomes of fertilitysparing surgery group. 21 Cheng B, Wan X, Qian X, et al. Results of conservative surgery for recurrent borderline ovarian tumors. Eur J Gynaecol Oncol 2009; 30:75–78. This study evaluated the oncologic and reproductive outcomes after second-round fertility-sparing surgery for women with recurrent BOT after fertility-sparing surgery. 22 Prat J, De Nictolis M. Serous borderline tumors of the ovary: a long-term follow-up study of 137 cases, including 18 with a micropapillary pattern and 20 with microinvasion. Am J Surg Pathol 2002; 26:1111–1128. 23 Camatte S, Morice P, Pautier P, et al. Fertility results after conservative treatment of advanced stage serous borderline tumour of the ovary. BJOG 2002; 109:376–380. 24 Longacre TA, McKenney JK, Tazelaar HD, et al. Ovarian serous tumors of low malignant potential (borderline tumors): outcome-based study of 276 patients with long-term (> or ¼ 5-year) follow-up. Am J Surg Pathol 2005; 29:707– 723. 25 Vigano R, Petrone M, Pella F, et al. Surgery in advanced borderline tumors. Fertil Steril 2009. [Epub ahead of print] This is a retrospective study, which evaluated the oncologic and reproductive outcomes of fertility-sparing surgery in patients with advanced-stage BOTs. 26 Uzan C, Kane A, Rey A, et al. Outcomes after conservative treatment of advanced-stage serous borderline tumors of the ovary. Ann Oncol 2010; 21:55–60. This is the largest series, which evaluated the oncologic and reproductive outcomes of fertility-sparing surgery in patients with advanced-stage BOT. 27 Gershenson DM, Silva EG, Tortolero-Luna G, et al. Serous borderline tumors of the ovary with noninvasive peritoneal implants. Cancer 1998; 83:2157– 2163. 28 Gershenson DM, Silva EG, Levy L, et al. Ovarian serous borderline tumors with invasive peritoneal implants. Cancer 1998; 82:1096–1103.

7

Cadron I, Leunen K, Van Gorp T, et al. Management of borderline ovarian neoplasms. J Clin Oncol 2007; 25:2928–2937.

8

Seidman JD, Kurman RJ. Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators. Hum Pathol 2000; 31:539–557.

29 Kane A, Uzan C, Rey A, et al. Prognostic factors in patients with ovarian serous low malignant potential (borderline) tumors with peritoneal implants. Oncologist 2009; 14:591–600. This is a large series, which evaluated the prognostic factors in 168 patients who had BOT with extraovarian implants.

9

Camatte S, Morice P, Thoury A, et al. Impact of surgical staging in patients with macroscopic ‘stage I’ ovarian borderline tumours: analysis of a continuous series of 101 cases. Eur J Cancer 2004; 40:1842–1849.

30 Burks RT, Sherman ME, Kurman RJ. Micropapillary serous carcinoma of the ovary. A distinctive low-grade carcinoma related to serous borderline tumors. Am J Surg Pathol 1996; 20:1319–1330.

10 Desfeux P, Camatte S, Chatellier G, et al. Impact of surgical approach on the management of macroscopic early ovarian borderline tumors. Gynecol Oncol 2005; 98:390–395.

31 Seidman JD, Kurman RJ. Subclassification of serous borderline tumors of the ovary into benign and malignant types. A clinicopathologic study of 65 advanced stage cases. Am J Surg Pathol 1996; 20:1331–1345.

11 Cho YH, Kim DY, Kim JH, et al. Is complete surgical staging necessary in patients with stage I mucinous epithelial ovarian tumors? Gynecol Oncol 2006; 103:878–882.

32 Deavers MT, Gershenson DM, Tortolero-Luna G, et al. Micropapillary and cribriform patterns in ovarian serous tumors of low malignant potential: a study of 99 advanced stage cases. Am J Surg Pathol 2002; 26:1129–1141.


234 Fertility 33 Chang SJ, Ryu HS, Chang KH, et al. Prognostic significance of the micro papillary pattern in patients with serous borderline ovarian tumors. Acta Obstet Gynecol Scand 2008; 87:476–481. In this study, the presence of micropapillary pattern was significant prognostic factor in patients with BOT. 34 Slomovitz BM, Caputo TA, Gretz HF 3rd, et al. A comparative analysis of 57 serous borderline tumors with and without a noninvasive micropapillary component. Am J Surg Pathol 2002; 26:592–600. 35 Winter WE 3rd, Kucera PR, Rodgers W, et al. Surgical staging in patients with ovarian tumors of low malignant potential. Obstet Gynecol 2002; 100:671– 676. 36 Laurent I, Uzan C, Gouy S, et al. Results after conservative treatment of serous borderline tumors of the ovary with a micropapillary pattern. Ann Surg Oncol 2008; 15:3561–3566. This study included 15 patients with micropapillary BOT who underwent fertilitysparing surgery. 37 Kennedy AW, Hart WR. Ovarian papillary serous tumors of low malignant potential (serous borderline tumors). A long-term follow-up study, including patients with microinvasion, lymph node metastasis, and transformation to invasive serous carcinoma. Cancer 1996; 78:278–286. 38 Ren J, Peng Z, Yang K. A clinicopathologic multivariate analysis affecting recurrence of borderline ovarian tumors. Gynecol Oncol 2008; 110:162– 167. In multivariate analysis including 234 patients with BOT, surgical procedure, cyst rupture, stage of disease, microinvasion, and peritoneal implants were independent prognostic factors for disease-free survival. 39 Laurent I, Uzan C, Gouy S, et al. Results after conservative treatment of serous borderline tumours of the ovary with stromal microinvasion but without micropapillary pattern. BJOG 2009; 116:860–862. This study included 18 patients who underwent fertility-sparing surgery for BOT with stromal microinvasion but without micropapillary pattern. 40 Weinstein D, Polishuk WZ. The role of wedge resection of the ovary as a cause for mechanical sterility. Surg Gynecol Obstet 1975; 141:417–418. 41 Park JY, Bae J, Lim MC, et al. Laparoscopic and laparotomic staging in stage I epithelial ovarian cancer: a comparison of feasibility and safety. Int J Gynecol Cancer 2008; 18:1202–1209. 42 Park JY, Kim DY, Suh DS, et al. Comparison of laparoscopy and laparotomy in surgical staging of early-stage ovarian and fallopian tubal cancer. Ann Surg Oncol 2008; 15:2012–2019. 43 Maneo A, Vignali M, Chiari S, et al. Are borderline tumors of the ovary safely treated by laparoscopy? Gynecol Oncol 2004; 94:387–392. 44 Boran N, Cil AP, Tulunay G, et al. Fertility and recurrence results of conservative surgery for borderline ovarian tumors. Gynecol Oncol 2005; 97:845–851. 45 Tinelli R, Malzoni M, Cosentino F, et al. Feasibility, safety, and efficacy of conservative laparoscopic treatment of borderline ovarian tumors. Fertil Steril 2009; 92:736–741. This is a comprehensive review on the role of laparoscopic surgery in fertilitysparing management for young women with BOT. 46 Papadimitriou DS, Martin-Hirsch P, Kitchener HC, et al. Recurrent borderline ovarian tumours after conservative management in women wishing to retain their fertility. Eur J Gynaecol Oncol 1999; 20:94–97. 47 Morris RT, Gershenson DM, Silva EG, et al. Outcome and reproductive function after conservative surgery for borderline ovarian tumors. Obstet Gynecol 2000; 95:541–547. 48 Seracchioli R, Venturoli S, Colombo FM, et al. Fertility and tumor recurrence rate after conservative laparoscopic management of young women with earlystage borderline ovarian tumors. Fertil Steril 2001; 76:999–1004. 49 Demeter A, Csapo Z, Szantho A, et al. A retrospective study of 27 ovarian tumors of low malignant potential. Eur J Gynaecol Oncol 2002; 23:415–418.

50 Chan JK, Lin YG, Loizzi V, et al. Borderline ovarian tumors in reproductive-age women. Fertility-sparing surgery and outcome. J Reprod Med 2003; 48:756– 760. 51 Rao GG, Skinner EN, Gehrig PA, et al. Fertility-sparing surgery for ovarian low malignant potential tumors. Gynecol Oncol 2005; 98:263–266. 52 Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. II. Invasive epithelial ovarian cancers in white women. Collaborative Ovarian Cancer Group. Am J Epidemiol 1992; 136:1184–1203. 53 Rossing MA, Daling JR, Weiss NS, et al. Ovarian tumors in a cohort of infertile women. N Engl J Med 1994; 331:771–776. 54 Zheng W, Lu JJ, Luo F, et al. Ovarian epithelial tumor growth promotion by follicle-stimulating hormone and inhibition of the effect by luteinizing hormone. Gynecol Oncol 2000; 76:80–88. 55 Tourgeman DE, Lu JJ, Boostanfar R, et al. Human chorionic gonadotropin suppresses ovarian epithelial neoplastic cell proliferation in vitro. Fertil Steril 2002; 78:1096–1099. 56 Fortin A, Morice P, Thoury A, et al. Impact of infertility drugs after treatment of borderline ovarian tumors: results of a retrospective multicenter study. Fertil Steril 2007; 87:591–596. 57 Attar E, Berkman S, Topuz S, et al. Evolutive peritoneal disease after conservative management and the use of infertility drugs in a patient with stage IIIC borderline micro-papillary serous carcinoma (MPSC) of the ovary: case report. Hum Reprod 2004; 19:1472–1475. 58 Fauvet R, Poncelet C, Boccara J, et al. Fertility after conservative treatment for borderline ovarian tumors: a French multicenter study. Fertil Steril 2005; 83:284–290; quiz 525–526. 59 Abusief ME, Hornstein MD, Jain T. Assessment of United States fertility clinic websites according to the American Society for Reproductive Medicine (ASRM)/Society for Assisted Reproductive Technology (SART) guidelines. Fertil Steril 2007; 87:88–92. 60 Gallot D, Pouly JL, Janny L, et al. Successful transfer of frozen-thawed embryos obtained immediately before radical surgery for stage IIIa serous borderline ovarian tumour: case report. Hum Reprod 2000; 15:2347–2350. 61 Oktay K, Cil AP, Bang H. Efficiency of oocyte cryopreservation: a metaanalysis. Fertil Steril 2006; 86:70–80. 62 Donnez J, Dolmans MM, Demylle D, et al. Livebirth after orthotopic transplantation of cryopreserved ovarian tissue. Lancet 2004; 364:1405– 1410. 63 Meirow D, Levron J, Eldar-Geva T, et al. Pregnancy after transplantation of cryopreserved ovarian tissue in a patient with ovarian failure after chemotherapy. N Engl J Med 2005; 353:318–321. 64 Demeestere I, Simon P, Buxant F, et al. Ovarian function and spontaneous pregnancy after combined heterotopic and orthotopic cryopreserved ovarian tissue transplantation in a patient previously treated with bone marrow transplantation: case report. Hum Reprod 2006; 21:2010–2014. 65 Kim SS, Radford J, Harris M, et al. Ovarian tissue harvested from lymphoma patients to preserve fertility may be safe for autotransplantation. Hum Reprod 2001; 16:2056–2060. 66 Fain-Kahn V, Poirot C, Uzan C, et al. Feasibility of ovarian cryopreservation in borderline ovarian tumours. Hum Reprod 2009; 24:850–855. This study included 15 patients with micropapillary BOT who underwent fertilitysparing surgery. This is a retrospective study, which evaluated the feasibility of ovarian cryopreservation in 23 patients treated for BOT. 67 Navot D, Fox JH, Williams M, et al. The concept of uterine preservation with ovarian malignancies. Obstet Gynecol 1991; 78:566–568. 68 Lawal AH, B-Lynch C. Borderline ovarian cancer, bilateral surgical castration, chemotherapy and a normal delivery after ovum donation and in vitro fertilisation-embryo transfer. Br J Obstet Gynaecol 1996; 103:931–932.


Stem cells and reproduction Hongling Dua and Hugh S. Taylora,b a

Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine and bMolecular Cellular and Developmental Biology, Yale University, New Haven, Connecticut, USA Correspondence to Hugh S. Taylor, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, P.O. Box 208063, 333 Cedar St, New Haven, CT 06520, USA Tel: +1 203 785 4005; e-mail: [email protected] Current Opinion in Obstetrics and Gynecology 2010, 22:235–241

Purpose of review To review the latest developments in reproductive tract stem cell biology. Recent findings In 2004, two studies indicated that ovaries contain stem cells which form oocytes in adults and that can be cultured in vitro into mature oocytes. A live birth after orthotopic transplantation of cyropreserved ovarian tissue in a woman whose ovaries were damaged by chemotherapy demonstrates the clinical potential of these cells. In the same year, another study provided novel evidence of endometrial regeneration by stem cells in women who received bone marrow transplants. This finding has potential for the use in treatment of uterine disorders. It also supports a new theory for the cause of endometriosis, which may have its origin in ectopic transdifferentiation of stem cells. Several recent studies have demonstrated that fetal cells enter the maternal circulation and generate microchimerism in the mother. The uterus is a dynamic organ permeable to fetal stem cells, capable of transdifferentiation and an end organ in which bone marrow stem cells may differentiate. Finally stem cell transformation can be an underlying cause of ovarian cancer. Summary Whereas we are just beginning to understand stem cells, the potential implications of stem cells to reproductive biology and medicine are apparent. Keywords bone marrow, endometriosis, endometrium, oocyte, reproduction, stem cells Curr Opin Obstet Gynecol 22:235–241 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

Introduction Stem cells are defined as undifferentiated cells that are capable of reproducing themselves (self-renewal) and differentiating into many different cell types, which can produce at least one type of highly differentiated descendant. Embryonic stem cells are derived from the inner cell mass of the blastocysts. They were first isolated from mouse in 1981 and these cells have the developmental potential to form trophoblast and derivatives of all three germ layers in vitro [1,2]. Due to these characteristics of embryonic stem cells, research on embryonic stem cells raises the possibility of ‘designer’ tissue and organ engineering. However, ethical considerations question the instrumental use of embryos for the isolation of stem cells, even if those embryos are surplus to requirements for assisted reproduction and destined for destruction. One alternative is to explore the use of adult stem cells; however, their full potential remains to be determined. Nearly all postnatal organs and tissues contain populations of stem cells, which have the capacity for renewal after damage or ageing. In the past several years, studies on adult stem cell plasticity show that adult stem cells are 1040-872X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

able to differentiate into other cell types in new locations, in addition to their usual progeny in their organ of residence [3,4]. Bone marrow derived stem cells can differentiate into skeletal myoblasts, endothelium, cardiac myoblasts, renal parenchymal, hepatic and biliary duct epithelium, lung, gut and skin epithelia, and neuroectodermal cells [5]. These studies show that bone marrow-derived stem cells may be involved in the regeneration of damaged tissue. The concept of plasticity of stem cells also opens up the possibility of repairing an individual’s failing organ by transplanting. The adult stem cells are responsible for the growth, homeostasis and repair of many tissues. How can they balance self-renewal with differentiation, and make the proper lineage determination? In normal adult tissues, stem cells are ultimately controlled by the integration of intrinsic factors (such as nuclear transcription factors) and extrinsic factors (growth factors, cell–cell contact or external influences). In 1978, Schofield [6] proposed the stem cell niche hypothesis, which hypothesized that stem cells reside within fixed compartments, or niches. This physiological microenvironment, consisting of specialized cells, secretes signals and provides cell surface molecules to control the rate of stem cell DOI:10.1097/GCO.0b013e328338c152


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proliferation, determine the fate of stem cell progeny, and protect stem cells from death. Mammalian stem cells niches have been described in the hematopoietic, neural, epidermal, and intestinal systems [7]. Recent work has revealed that the interactions between stem cells and their niches may be more dynamic than originally believed. For example, hematopoietic stem cells (HSCs) may occupy two anatomically and physiologically distinct niches, an osteoblast niche and a vascular niche, and shuttle between them [8,9]. The vascular niche might explain stem cell survival in extramedullary haematopoietic sites, such as the liver and spleen, in which HSCs exist throughout adulthood without osteoblasts.

Germline stem cells in the postnatal ovary in mammal Germline stem cells (GSCs) are the self-renewing population of germ cells that serve as the source for gametogenesis. GSCs in Drosophila females maintain oocyte production in adult ovaries [10]. However, it was believed that ovaries of some vertebrates, especially those of mammals, did not contain self-renewing stem cells in adults. A long-held dogma in ovarian biology in mammals is that females are born with a finite population of nongrowing primordial follicles; oocyte numbers decline throughout postnatal life, eventually leaving the ovaries devoid of germ cells [11,12]. In humans, the decline in oocytes numbers is accompanied by exhaustion of the follicle pool and menopause before the end of life [13]. In 2004, Johnson et al. [14] provided evidence to challenge this doctrine. They demonstrated the existence of proliferative GSCs that give rise to oocytes and follicle production in the postnatal period of mammalian ovary [14]. In these experiments, the numbers of healthy (nonatretic) and degenerating (atretic) follicles in ovaries of C57BL/6 mice were counted; the numbers of nonatretic quiescent (primordial) and early-growing (primary) prenatal follicles in single ovaries were higher than expected, and the rate of depletion in the immature ovary was less than anticipated. In the same year, Bukovsky et al. [15] also claimed to identify GSCs and formation of new primary follicles in adult human ovaries. This group showed that cytokeratin-positive mesenchymal cells in ovarian tunica albuginea differentiate into ovarian surface epithelium (OSE) cells by a mesenchymal–epithelial transition. Germ cells can originate from surface epithelial cells which cover the tunica albuginea. The data also indicate that the pool of primary follicles in adult human ovaries may not represent a static, but rather a dynamic population of differentiating and regressing structures. These studies suggested the existence of proliferative germ cells that sustain oocyte and follicle production in the postnatal mammalian ovary, and indicate that oocytes are continuously formed in the adult. However, subsequent work has not demonstrated

offspring from donor-derived oocytes. The function of these ‘oocytes’ remains to be determined.

Origin of germ cells in adult ovary The origin of oocytes (and primary follicles) in ovaries of adult mammalian females has been disputed for over 100 years. In the 19th century, Weismann’s theory assumed that, before embryonic cells become committed along specific pathways, a set of germ cells is set aside, which are destined to give rise to the gametes. This theory was not questioned until the 1970s. In the early 2000s, evidence confirmed that functional mouse oocytes and sperm can be derived from mouse embryonic stem cells in culture [16–18]. Toyooka et al. [16] reported embryonic stem cells can form germ cells in vitro, and Geijsen et al. [17] found that injecting these cultured haploid male gametes into unfertilized egg led to embryo development to the early blastocyst stage. Hubner et al. [18] reported that mouse embryonic stem cells in culture can develop into oogonia that enter meiosis and recruit adjacent cells to form follicle-like structures and later developed into blastocysts. More than 10 years ago, Bukovsky et al. [19] proposed that in adult human females, the OSE was a source of germ cells. As mentioned before, in 2005, this group demonstrated that new primary follicles differentiated from the OSE, which arises from cytokeratin-positive mesenchymal progenitor cells residing in the ovarian tunica albuginea. OSE cells in-vitro culture confirmed their in-vivo observations that in adult human ovaries, the OSE is a bipotent source of oocytes and granulosa cells [20]. In 2005, Johnson et al. [21] reported that mammalian oocytes originate from putative germ cells in bone marrow and are distributed through peripheral blood to the ovaries. Their data showed that bone marrow transplantation restores oocyte production in wild-type mice sterilized by chemotherapy, as well as in ataxia telangiectasia-mutated gene-deficient mice, which are otherwise incapable of making oocytes. Donor-derived oocytes are also observed in female mice following peripheral blood transplantation. It was suggested that bone marrow is a potential source of germ cells that could sustain oocyte production in adulthood. In 2007, the same group reported that bone marrow transplantation generates immature oocytes and rescues long-term fertility in a preclinical mouse model of chemotherapy-induced premature ovarian failure [22]. However, these studies are challenged by some. To test directly the physiological relevance of circulating cells for female fertility, Wagers’ team established transplantation and parabiotic mouse models to assess the capacity of circulating bone marrow cells to generate ovulated oocytes, both in the steady state and after induced damage. Their studies showed no evidence that bone marrow cells, or any other normally circulating cells,


Stem cells and reproduction Du and Taylor 237

contribute to the formation of mature, ovulated oocytes. Instead, cells that travelled to the ovary through the bloodstream exhibited properties characteristic of committed blood leukocytes [23]. So far, the origin of germ cells in female mammals is still an open issue. Controversy will be sure to stimulate further research on GSCs.

Ovarian tissue transplantation Ovarian transplantation has a long history, traced back 200 years. However, there was little progress until the middle of the 20th century. More recently Oktay and Karlikaya [24] have reported that ovulation occurred after laparoscopic transplantation of frozen-thawed ovarian tissue to the pelvic side wall in a 29-year-old patient who had undergone salpingo-oophorectomy. In 2004, the same group reported another case in which a four-cell embryo was obtained from 20 oocytes retrieved from tissue transplanted beneath the skin in a patient who had chemotherapy-induced menopause [25]. The same year, a live birth after ovarian tissue transplant was reported in a nonhuman primate [26]. Later in 2004, a successful pregnancy and live birth after orthotopic transplantation of cryopreserved ovarian tissue was reported by Donnez et al. [27]. In that case, a patient whose ovaries were damaged by cancer chemotherapy received frozenthawed ovarian tissue transplantation. These findings give new hope for fertility preservation, including immature oocyte retrieval, in-vitro maturation of oocytes, oocyte vitrification or embryo cryopreservation. However, one major concern over orthotopic auto-transplantation is the potential risk that the frozen-thawed ovarian cortex might harbor malignant cells. There is the potential that such cells could induce a recurrence of disease after re-implantation. Some studies have suggested that ovarian tissue transplantation in Hodgkin’s disease is well tolerated [28,29]. However, Shaw and colleagues [30] reported that ovarian grafts from a lymphoma prone strain of mice could transfer lymphoma to recipient animals. In 2005, Silber et al. [31] reported that a 24-year-old woman gave birth after a transplant of ovarian cortical tissue from her monozygotic twin sister. This patient had premature ovarian failure at the age of 14 years, whereas her sister had normal ovaries and three naturally conceived children. After unsuccessful egg-donation therapy, the sterile twin received a transplant of ovarian cortical tissue from her sister. About 1 year later, she delivered a healthy-appearing female infant. In 2007, Donnez et al. [32] reported another case of successful allograft of ovarian cortex between two genetically nonidentical sisters. In this case, the patient presented with beta-thalassemia major and underwent chemotherapy and total body irradiation before bone marrow transplantation (BMT) about 16 years ago. The treatment resulted in premature ovarian failure. After excision of ovarian cortical fragments from an

HLA-compatible sister, these fragments were immediately sutured to the ovarian medulla of the patient. Restoration of ovarian function was achieved after six months. In 2007, Silber et al. [33] reported 10 more successful ovary transplants in monozygotic twins after premature ovarian failure in one twin; two healthy babies have been delivered, and another three pregnancies are ongoing. Ovarian tissue transplantation not only brings hope to cancer patients, but also to those with ovarian dysgenesis or premature ovarian failure.

Stem cells in the uterus The uterine endometrium in mammals is one of the most dynamic human tissues and consists of a glandular epithelium and stroma that are completely renewed in each monthly menstrual cycle. Endometrial stem cells were thought to reside in the basalis layer and serve as a source of cells that differentiate to form the endometrium. Under systemic hormonal changes, such as the cyclic increase in the serum level of estradiol, stem cells migrate and give rise to a group of progenitor cells that become committed to specific types of differentiated cells, for example epithelial, stromal and vascular, within a certain microenvironment. These endogenous stem cells allow the rapid regeneration of the endometrium necessary to support pregnancy. There was no direct evidence to confirm this hypothesis until 2004. In that year, two studies from different labs provided evidence for the origin of this cyclic renewal [34,35]. A team led by Gargett demonstrated that human endometrium contains small populations of epithelial and stromal stem cells responsible for cyclical regeneration of endometrial glands and stroma and that these cells exhibited clonogenicity. The results showed that small numbers of epithelial (0.22%) and stromal cells (1.25%) initiated colonies in serum-containing medium and exhibit high proliferative potential [34]. In 2006, Gargett’s team used label-retaining cell (LRC) approach to identify somatic stem/progenitor cells and their location. The results demonstrated the presence of both epithelial and stromal LRC in mouse endometrium, which suggests that these stem-like cells may be responsible for endometrial regeneration [36]. Later on, another group also demonstrated that the human endometrium contains a low number of cells with the characteristics of endometrial stromal stem/ progenitor cells, which seem to belong to the family of the mesenchymal stem cells (MSCs) [37]. Our laboratory found that bone marrow is an exogenous source of endometrial cells [35]. In a 2004 study, we provided evidence of endometrial regeneration in bone marrow transplant recipients who received marrow from a single-HLA antigen mismatched donor BMT for leukemia. Donor-derived endometrial epithelial cells and stromal cells were detected in endometrial samples


238 Fertility

of bone marrow recipients by RT-PCR and immunohistochemistry. These cells appeared histologically to be endometrial epithelial and stromal cells and also express appropriate markers of endometrial cell differentiation. Cyclic mobilization of bone marrow-derived stem cells may be a normal physiologic process. In 2007, our group also reported that after BMT, male donor-derived bone marrow cells were found in the uterine endometrium of female mice, and, although uncommonly ( 25 kg/m2) women demonstrating longer follicular phases (P < 0.0001) and shorter luteal phases (P ¼ 0.006) than normal-weight controls. Overweight women were also found to have reduced urinary LH, FSH, and luteal phase pregnanediol glucuronide (Pdg, a progesterone metabolite) excretion, suggesting an adverse impact of obesity on corpus luteum function. Jain et al. [26] similarly demonstrated reduced LH pulse amplitude and lower levels of luteal urinary Pdg in 18 morbidly obese ovulatory premenopausal women compared with eumenorrheic normal-weight controls. Elevated levels of leptin, an adipokine secreted by white adipose tissue, provide another mechanism for the decreased fertility observed in obese women

Figure 1 Hormonal interaction between obesity and female fertility

(a) Nutrition is linked to the female reproductive system through the effects of leptin and insulin. The increase in body fat during normal adolescence is associated with insulin resistance and a compensatory increase in insulin secretion. Hyperinsulinemia results in reduction of sex-hormone-bindingglobulin (SHBG) with consequent elevations in free estrogens and androgens. Leptin influences secretion of GnRH, thereby stimulating secretion of gonadotropins. Insulin can also function directly on the ovary. (b) In overweight women and/or those with polycystic ovarian syndrome (PCOS), increased adiposity results in elevated leptin levels, leading to a preferential increase in LH, but not FSH, levels. The net effect is to stimulate the partial development of follicles that secrete supranormal levels of testosterone, but which rarely ovulate (hence low progesterone). These changes are exacerbated by insulin-induced reduction in SHBG, which amplifies ovarian testosterone production/action. Adapted from [19].


250 Fertility

[16,27]. Serum leptin concentration is proportional to total body adiposity and leptin receptors are present on human granulosa and theca cells as well as the endometrium [28]. Excess leptin has been shown to inhibit ovarian steroidgenesis and inhibit follicular growth in both human and animal models [29,30]. A small body of evidence suggests that obesity may be correlated with diminished ovarian reserve. The ovarian reserve markers Mullerian-inhibiting substance (MIS) and inhibin B have been shown to be significantly lower in obese perimenopausal women [31]. In a study of 16 reproductive age women undergoing bariatric surgery, mean MIS concentrations were found to decrease by 23.9% 2–3 months after surgical weight loss (P ¼ 0.034 as compared with preoperative levels) in women under the age of 35 [32]. The authors speculate that this decrease may be either a transient expression of postoperative stress or a permanent effect of surgery on MIS gene expression, although it could also theoretically reflect an acute depletion of the follicular pool. Observational studies have noted associations between body fat distribution and infertility. In a prospective study of 500 obese women undergoing donor insemination, central obesity had a significant impact on the probability of conception. Women with a waist–hip ratio of 0.8 or more were 30% less likely to conceive than those with a ratio of 0.7 or less [22]. Additionally, a recent survey of 1500 reproductive age women undergoing bariatric surgery observed an increased risk of PCOS and infertility among women who were self-reportedly obese before the age of 18 than those who became obese later in life [16].

Bariatric surgery and fertility Although the literature suggests improvement in spontaneous pregnancy rates after bariatric surgery, most studies are observational, poorly controlled, and do not differentiate between ovulatory and anovulatory obese women. A retrospective survey of 783 women after biliopancreatic diversion reported spontaneous postoperative conception (mean BMI ¼ 30 kg/m2) in 47% of patients who were unable to become pregnant preoperatively (mean BMI ¼ 47 kg/m2) [33]. In a small retrospective case series by Bilenka et al. [34], eight of nine patients conceived spontaneously after vertical banded gastroplasty as compared to one out of six who attempted pregnancy before undergoing surgery. Martin et al. [35] reported five spontaneous pregnancies after gastric banding in nulligravid women who were previously unable to conceive. Neither study had a separate control group or specified the ovulatory status of participants. A retrospective cohort study reported a higher rate of fertility treatment in diabetic patients following bariatric surgery

(21.4%) as compared with those who had not undergone surgery (5.5%; P < 0.001) [36,37]. Although controlling for patient age, obesity, and parity, the study did not adjust for ovulatory status or cause of infertility, making it difficult to form conclusions from these data. The impact of weight loss on anovulatory infertility has been studied extensively in women with PCOS, with several studies demonstrating improvements in insulin sensitivity, menstrual cyclicity, and ovulation rates with even modest weight loss [38–40]. Recent studies have specifically addressed the impact of bariatric surgery on anovulatory infertility. In a retrospective survey of reproductive age women who had undergone bariatric surgery, 71% of 98 patients who were anovulatory preoperatively regained menstrual cyclicity after surgery. The patients who regained ovulatory function had a greater average weight loss than those who remained anovulatory (61.4 vs. 49.9 kg; P ¼ 0.02) [41]. A survey of 109 morbidly obese women who lost greater than 50% of their excess body weight with bariatric surgery also demonstrated fewer menstrual irregularities (40.4% preoperatively vs. 4.6% postoperatively; P < 0.001) [42]. A third retrospective study of 24 morbidly obese oligomenorrehic women with PCOS revealed resumption of normal menstrual cycles after a mean of 3.4 2.1 months in all women [43]. Hyperandrogenism in women with PCOS has also been shown to improve after bariatric surgery. A prospective study of 17 women with PCOS showed decreased levels of hirsuitism, testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEA-S), as well as normalization of menstrual cycles after bariatric surgery [44]. Comparatively little is known about the impact of bariatric surgery on fertility in ovulatory obese women. A single study by Rochester et al. [45] looked at urinary hormone excretion in eumenorrheic morbidly obese women after bariatric surgery. Levels of urinary LH and Pdg during the luteal phase increased significantly after surgical weight loss (Fig. 2). Although postoperative luteal phase urinary LH levels were comparable to those seen in normal-weight women, luteal Pdg levels remained below that seen in controls, indicating only partial recovery of luteal function after bariatric surgery. The adipokines leptin and adiponectin have been postulated to adversely impact ovulation in obese women [46]. Leptin concentrations decrease with weight loss on low-calorie diets [47] or after bariatric surgery [48]. Murine models demonstrate reversal of subfertility with reduction of leptin levels after dietary modification [49]. Unlike most adipokines, adiponectin concentrations are lower in obesity and insulin-resistant states. Plasma adiponectin increases with significant weight loss following bariatric surgery [48], but not after more modest weight loss from caloric restriction [47]. The cytokines


Bariatric surgery and fertility Shah and Ginsburg 251 Figure 2 Reproductive hormone changes after bariatric surgery

Recent studies have described a number of hormonal alterations in women after bariatric surgery. Decreased adipose tissue results in lower levels of estradiol, which stimulates hypothalamic release of GnRH and gonadotropin secretion by the pituitary. Urinary metabolites such as peak LH and luteal Pdg have been shown to increase as a result. Surgical weight loss also lowers insulin levels, resulting in increased sex-hormone-binding-globulin (SHBG) and decreased peripheral testosterone secretions. MIS levels have also been shown to decrease after bariatric surgery. Adapted from [12].

interleukin-6 (IL-6) and plasminogen activator inhibitor1 (PAI-1) are increased in obese individuals, in whom they may contribute to ovulatory dysfunction (IL-6) [50] or implantation failure (PAI-1) [51]. Bariatric surgery has been shown to decrease levels of IL-6 [52] and PAI-1 [53]. Although the literature on adipokines and bariatric surgery is expanding, studies have yet to identify a specific role for these hormones in the treatment of obesity-related reproductive failure.

retrieved in addition to requiring higher doses of gonadotropins. Data from 48 682 IVF cycles presented at the American Society of Reproductive Medicine (ASRM) 2009 annual meeting reveal that odds of pregnancy decreased with increasing BMI in obese women and the odds of live birth decreased with increasing BMI in both overweight and obese women [64]. When IVF outcomes using donor oocytes were evaluated, there was no difference in pregnancy rates between obese, overweight, or normal-weight women, suggesting an adverse impact of obesity on oocyte quality or number [65].

Bariatric surgery and IVF outcomes Obesity has been shown to adversely impact IVF outcomes, although the data are inconsistent regarding which parameters are affected [54]. Recent literature demonstrates associations between obesity and decreased mature oocyte yield, need for increased gonadotropin stimulation, and increased cycle cancellation rates [55–57,58,59]. Although many studies also report decreased clinical pregnancy and live birth rates among obese or morbidly obese women [58,60,61], others have not [57,62]. A large retrospective study by Dokras et al. [57] demonstrated no difference in clinical pregnancy or live birth rates between obese or morbidly obese women and normal-weight controls. A systematic review by Maheshwari et al. [63] reported that women with a BMI of 25 kg/m2 or more have lower pregnancy rates and reduced numbers of oocytes

Little is published on the impact of surgical weight loss on IVF outcomes. A case report revealed empty follicle syndrome at the time of oocyte retrieval in a previously morbidly obese woman who had lost 175 lbs. after gastric bypass. Intramuscular hCG was used in a subsequent cycle with retrieval of 19 oocytes and successful pregnancy [66].

Bariatric surgery and miscarriage Obesity is associated with increased risk of miscarriage in ovulation induction cycles [67], with IVF-ICSI [59,68], as well as in morbidly obese women using donor oocytes [69]. These findings are supported by a recent metaanalysis demonstrating an increased risk of miscarriage in


252 Fertility

women with a BMI 25 kg/m2 or more as compared with normal-weight controls (odds ratio 1.67, 95% confidence interval 1.10–2.09), regardless of mode of conception [70]. This association persisted in subgroup analyses of women undergoing oocyte donation and ovulation induction, but there was no evidence for increased miscarriage rates after IVF-ICSI. A few studies have shown no detrimental impact of obesity on first trimester pregnancy failure [71,72]. The discrepancy in the data is likely related to variance in the definition of obesity. There may be a decline in miscarriage rates after bariatric surgery. A small cohort study of nine patients showed decreased miscarriage rates after gastric banding (six of 18 pregnancies ended in miscarriage prior to surgery as compared to one of 13 after) [34]. Friedman et al. [73] compared pregnancy outcomes in 1136 women before and after biliopancreatic diversion and found a 17% miscarriage rate before surgery as compared to 11% after it. A retrospective survey study of 700 women, however, showed no difference in self-reported miscarriage rates before and after biliopancreatic diversion [33].

Bariatric surgery and male fertility There are minimal data on surgical weight loss and male infertility. Obesity is associated with increased estrogen and reduced total testosterone in men [74,75]. A cohort study of 22 morbidly obese men after Roux-en-Y gastric bypass showed decreased serum estradiol and increased total and free testosterone as compared to 42 morbidly obese controls [76]. Interestingly, a case series of six morbidly obese men of proven fertility who presented with secondary infertility after Roux-en-Y gastric bypass suggested a negative impact of bariatric surgery on male fertility. Semen analysis and testicular biopsy revealed secondary azoospermia with complete spermatogenic arrest in all six men, despite normal sex hormone profiles. The authors speculate whether postoperative nutrient absorption was insufficient for spermatogenesis [77].

Timing of bariatric surgery relative to conception Because patients generally undergo a period of rapid weight loss after bariatric surgery, there is a theoretical concern that maternal or fetal nutrition may be compromised by a pregnancy in the immediate postoperative period [78]. Some bariatric surgery centers advocate nutritional monitoring for up to 2 years after surgery, finding that 30–50% of patients require supplementation of calcium, iron, or vitamin B12 [79]. Small studies comparing pregnancies within 12–18 months of bariatric surgery with later pregnancies found no difference in cesarean delivery rate, low birth weight, or congenital abnormalities [80,81]. A recent prospective cohort study

of 26 women stratified by time to conception after laparoscopic Roux-en-Y gastric bypass, however, did show a 50% rate of preterm delivery in pregnancies that occurred within the first 12 months (two out of four pregnancies) as compared with a 20% rate among those occurring more than 2 years postoperatively (two of 10 pregnancies) [82]. The general consensus is that pregnancy should be delayed 12–18 months after surgery to avoid nutritional deficiencies and promote weight loss [35,83,84], However, in their 2008 systematic review, Maggard et al. [15] conclude that there are insufficient data to support recommendations regarding the ideal timing for pregnancy after bariatric surgery.

Conclusion Obesity has been shown to adversely impact male and female fertility through a variety of mechanisms. Bariatric surgery is the most reliable way to achieve and sustain weight loss in the morbidly obese. Although bariatric surgery is associated with significant improvement in many parameters of reproductive function, the American College of Obstetricians and Gynecologists does not recommend it as a treatment for infertility [84]. Our practice is to recommend consultation with a bariatric surgeon for all morbidly obese infertile patients. Morbidly obese patients are also required to meet with maternal– fetal medicine specialists to discuss the increased risk of obstetrical complications such as gestational diabetes, preeclampsia, and cesarean delivery that are well established in this population [78,84,85]. It is worth noting that many obese infertile women chose not to undergo bariatric surgery secondary to the recommended postoperative delay in conception [86] or concerns about surgical complications. When counseling patients, the potential improvements in obstetrical outcome and pregnancy rates with weight loss must be balanced against the decreased likelihood of conception with increasing maternal age. Further studies are needed to determine the optimal timing of bariatric surgery relative to pregnancy and whether the benefits of preconception weight loss outweigh the higher risk of age-related infertility with delay of fertility treatment.

Acknowledgement There are no conflicts of interest.


World Health Organization Fact sheet 311. Obesity and overweight. http:// www.who.int/mediacentre/factsheets/fs311/en/index.html. [Accessed 28 October 2009]


Bariatric surgery and fertility Shah and Ginsburg 253 2

National Center for Health Statistics National Health and Nutrition Examination Survey Fast Stats. Obesity and overweight. http://www.cdc.gov/nchs/ fastats/overwt.html. [Accessed 6 October 2009]

30 Swain JE, Dunn RL, McConnell D, et al. Direct effects of leptin on mouse reproductive function: regulation of follicular, oocyte, and embryo development. Biol Reprod 2004; 71:1446–1452.

3

Eisenberg D, Duffy AJ, Bell RL. Update on obesity surgery. World J Gastroenterol 2006; 12:3196–3203.

4

Weiss EC, Galuska DA, Kettel Khan L, et al. Weight regain in U.S. adults who experienced substantial weight loss, 1999–2002. Am J Prev Med 2007; 33:34–40.

31 Freeman EW, Gracia CR, Sammel MD, et al. Association of antimullerian hormone levels with obesity in late reproductive-age women. Fertil Steril 2007; 87:101–106. 32 Merhi ZO, Minkoff H, Feldman J, et al. Relationship of bariatric surgery to Mullerian-inhibiting substance levels. Fertil Steril 2008; 90:221–224.

5

Li Z, Maglione M, Tu W, et al. Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med 2005; 142:532–546.

33 Marceau P, Kaufman D, Biron S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004; 14:318–324.

6

Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005; 142:547–559.

7

NIH Conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med 1991; 115:956–961.

34 Bilenka B, Ben-Shlomo I, Cozacov C, et al. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity. Acta Obstet Gynecol Scand 1995; 74:42–44.

8 Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical review. Hum Reprod Update 2009; 15:189–201. This is a systematic review of obstetric and postoperative complications after bariatric surgery.

35 Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000; 95:927–930. 36 Sheiner E, Levy A, Silverberg D, et al. Pregnancy after bariatric surgery is not associated with adverse perinatal outcome. Am J Obstet Gynecol 2004; 190:1335–1340.

Grundy MA, Woodcock S, Attwood SE. The surgical management of obesity in young women: consideration of the mother’s and baby’s health before, during, and after pregnancy. Surg Endosc 2008; 22:2107–2116.

37 Sheiner E, Menes TS, Silverberg D, et al. Pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery. Am J Obstet Gynecol 2006; 194:431–435.

10 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292:1724–1737.

38 Guzick DS, Wing R, Smith D, et al. Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil Steril 1994; 61:598– 604.

9

11 Pories WJ. Bariatric surgery: risks and rewards. J Clin Endocrinol Metab 2008; 93:S89–S96. 12 Merhi ZO. Impact of bariatric surgery on female reproduction. Fertil Steril 2009; 92:1501–1508. This is the most recently published review of bariatric and fertility and includes a discussion on bariatric surgery and sexual function.

39 Clark AM, Ledger W, Galletly C, et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 1995; 10:2705–2712. 40 Hollmann M, Runnebaum B, Gerhard I. Effects of weight loss on the hormonal profile in obese, infertile women. Hum Reprod 1996; 11:1884–1891.

13 Saber AA, Elgamal MH, McLeod MK. Bariatric surgery: the past, present, and future. Obes Surg 2008; 18:121–128.

41 Teitelman M, Grotegut CA, Williams NN, et al. The impact of bariatric surgery on menstrual patterns. Obes Surg 2006; 16:1457–1463.

14 Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006; 295:1549–1555.

42 Deitel M, Stone E, Kassam HA, et al. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr 1988; 7:147–153.

15 Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008; 300:2286–2296. 16 Gosman GG, King WC, Schrope B, et al. Reproductive health of women electing bariatric surgery. Fertil Steril 2009 Oct 6. [Epub ahead of print] This survey study correlates early-onset obesity with poor reproductive performance later in life and examines the desire for conception after bariatric surgery. 17 Gambineri A, Pelusi C, Vicennati V, et al. Obesity and the polycystic ovary syndrome. Int J Obes Relat Metab Disord 2002; 26:883–896. 18 Pasquali R, Gambineri A, Pagotto U. The impact of obesity on reproduction in women with polycystic ovary syndrome. BJOG 2006; 113:1148–1159. 19 Sharpe RM, Franks S. Environment lifestyle and infertility: an inter-generational issue. Nat Cell Biol 2002; 4 (Suppl):s33–s40. 20 Norman RJ, Noakes M, Wu R, et al. Improving reproductive performance in overweight/obese women with effective weight management. Hum Reprod Update 2004; 10:267–280. 21 Nelson SM, Fleming R. Obesity and reproduction: impact and interventions. Curr Opin Obstet Gynecol 2007; 19:384–389. 22 Zaadstra BM, Seidell JC, Van Noord PA, et al. Fat and female fecundity: prospective study of effect of body fat distribution on conception rates. BMJ 1993; 306:484–487. 23 Rich-Edwards JW, Goldman MB, Willett WC, et al. Adolescent body mass index and infertility caused by ovulatory disorder. Am J Obstet Gynecol 1994; 171:171–177. 24 Jensen TK, Scheike T, Keiding N, et al. Fecundability in relation to body mass and menstrual cycle patterns. Epidemiology 1999; 10:422–428. 25 Santoro N, Lasley B, McConnell D, et al. Body size and ethnicity are associated with menstrual cycle alterations in women in the early menopausal transition: The Study of Women’s Health across the Nation (SWAN) Daily Hormone Study. J Clin Endocrinol Metab 2004; 89:2622–2631. 26 Jain A, Polotsky AJ, Rochester D, et al. Pulsatile luteinizing hormone amplitude and progesterone metabolite excretion are reduced in obese women. J Clin Endocrinol Metab 2007; 92:2468–2473. 27 Metwally M, Ledger WL, Li TC. Reproductive endocrinology and clinical aspects of obesity in women. Ann N Y Acad Sci 2008; 1127:140–146. 28 Karlsson C, Lindell K, Svensson E, et al. Expression of functional leptin receptors in the human ovary. J Clin Endocrinol Metab 1997; 82:4144–4148. 29 Brannian JD, Zhao Y, McElroy M. Leptin inhibits gonadotrophin-stimulated granulosa cell progesterone production by antagonizing insulin action. Hum Reprod 1999; 14:1445–1448.

43 Eid GM, Cottam DR, Velcu LM, et al. Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005; 1:77– 80. 44 Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, et al. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. J Clin Endocrinol Metab 2005; 90:6364–6369. 45 Rochester D, Jain A, Polotsky AJ, et al. Partial recovery of luteal function after bariatric surgery in obese women. Fertil Steril 2009; 92:1410–1415. This is the only study examining the impact of bariatric surgery on luteal function in ovulatory obese women. 46 Gosman GG, Katcher HI, Legro RS. Obesity and the role of gut and adipose hormones in female reproduction. Hum Reprod Update 2006; 12:585–601. 47 Xydakis AM, Case CC, Jones PH, et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab 2004; 89:2697–2703. 48 Faraj M, Havel PJ, Phelis S, et al. Plasma acylation-stimulating protein, adiponectin, leptin, and ghrelin before and after weight loss induced by gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab 2003; 88:1594–1602. 49 Wang JG, Tortoriello DV. Subertility associated with dietary induced obesity in female Dba/2j mice can be reversed by diet modification. Fertil Steril 2005; 84 (Suppl 1):S256. 50 Amato G, Conte M, Mazziotti G, et al. Serum and follicular fluid cytokines in polycystic ovary syndrome during stimulated cycles. Obstet Gynecol 2003; 101:1177–1182. 51 Glueck CJ, Wang P, Fontaine RN, et al. Plasminogen activator inhibitor activity: an independent risk factor for the high miscarriage rate during pregnancy in women with polycystic ovary syndrome. Metabolism 1999; 48:1589–1595. 52 Vendrell J, Broch M, Vilarrasa N, et al. Resistin, adiponectin, ghrelin, leptin, and proinflammatory cytokines: relationships in obesity. Obes Res 2004; 12:962– 971. 53 Uzun H, Zengin K, Taskin M, et al. Changes in leptin, plasminogen activator factor and oxidative stress in morbidly obese patients following open and laparoscopic Swedish adjustable gastric banding. Obes Surg 2004; 14:659– 665. 54 Merhi ZO. Weight loss by bariatric surgery and subsequent fertility. Fertil Steril 2007; 87:430–432.


254 Fertility 55 Lintsen AM, Pasker-de Jong PC, de Boer EJ, et al. Effects of subfertility cause, smoking and body weight on the success rate of IVF. Hum Reprod 2005; 20:1867–1875.

70 Metwally M, Ong KJ, Ledger WL, et al. Does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? A metaanalysis of the evidence. Fertil Steril 2008; 90:714–726.

56 Esinler I, Bozdag G, Yarali H. Impact of isolated obesity on ICSI outcome. Reprod Biomed Online 2008; 17:583–587.

71 Roth D, Grazi RV, Lobel SM. Extremes of body mass index do not affect firsttrimester pregnancy outcome in patients with infertility. Am J Obstet Gynecol 2003; 188:1169–1170.

57 Dokras A, Baredziak L, Blaine J, et al. Obstetric outcomes after in vitro fertilization in obese and morbidly obese women. Obstet Gynecol 2006; 108:61–69. 58 Awartani KA, Nahas S, Al Hassan SH, et al. Infertility treatment outcome in sub groups of obese population. Reprod Biol Endocrinol 2009; 7:52. This is one of the few studies comparing IVF outcome between obese and morbidly obese women. 59 Fedorcsak P, Storeng R, Dale PO, et al. Obesity is a risk factor for early pregnancy loss after IVF or ICSI. Acta Obstet Gynecol Scand 2000; 79:43– 48. 60 Nichols JE, Crane MM, Higdon HL, et al. Extremes of body mass index reduce in vitro fertilization pregnancy rates. Fertil Steril 2003; 79:645–647. 61 Jungheim ES, Lanzendorf SE, Odem RR, et al. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome. Fertil Steril 2009; 92:256–261. This is one of the only studies specifically looking at IVF pregnancy rates in morbidly obese women with PCOS. 62 Lashen H, Ledger W, Bernal AL, et al. Extremes of body mass do not adversely affect the outcome of superovulation and in-vitro fertilization. Hum Reprod 1999; 14:712–715. 63 Maheshwari A, Stofberg L, Bhattacharya S. Effect of overweight and obesity on assisted reproductive technology–a systematic review. Hum Reprod Update 2007; 13:433–444. 64 Luke B, Brown MB, Stern JE, et al. Maternal obesity adversely affects assisted reproductive technology (ART) pregnancy rates and obstetric outcomes. Fertil Steril 2009; 92 (Suppl):S1. This abstract uses 2007 SART data to provide the largest analysis of BMI and ART outcomes. 65 Luke B, Brown MB, Stern JE, et al. The effect of maternal body mass index (BMI) and oocyte source on assisted reproductive technology (ART) pregnancy rates and obstetric outcomes. Fertil Steril 2009; 92 (Suppl):S52. Also using the SART database from 2007, this abstract is the largest looking at effect of maternal BMI on ART outcome in autologous and donor cycles. 66 Hirshfeld-Cytron J, Kim HH. Empty follicle syndrome in the setting of dramatic weight loss after bariatric surgery: case report and review of available literature. Fertil Steril 2008; 90:1199 e21–1199 e23. 67 Hamilton-Fairley D, Kiddy D, Watson H, et al. Association of moderate obesity with a poor pregnancy outcome in women with polycystic ovary syndrome treated with low dose gonadotrophin. Br J Obstet Gynaecol 1992; 99:128– 131. 68 Wang JX, Davies MJ, Norman RJ. Obesity increases the risk of spontaneous abortion during infertility treatment. Obes Res 2002; 10:551–554. 69 Bellver J, Rossal LP, Bosch E, et al. Obesity and the risk of spontaneous abortion after oocyte donation. Fertil Steril 2003; 79:1136–1140.

72 Styne-Gross A, Elkind-Hirsch K, Scott RT Jr. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. Fertil Steril 2005; 83:1629–1634. 73 Friedman D, Cuneo S, Valenzano M, et al. Pregnancies in an 18-year follow-up after biliopancreatic diversion. Obes Surg 1995; 5:308–313. 74 Zumoff B, Strain GW, Miller LK, et al. Plasma free and nonsex-hormonebinding-globulin-bound testosterone are decreased in obese men in proportion to their degree of obesity. J Clin Endocrinol Metab 1990; 71:929–931. 75 Schneider G, Kirschner MA, Berkowitz R, et al. Increased estrogen production in obese men. J Clin Endocrinol Metab 1979; 48:633–638. 76 Hammoud A, Gibson M, Hunt SC, et al. Effect of Roux-en-Y gastric bypass surgery on the sex steroids and quality of life in obese men. J Clin Endocrinol Metab 2009; 94:1329–1332. This is the largest, most recent study looking at the impact of bariatric surgery on male reproductive hormones. 77 di Frega AS, Dale B, Di Matteo L, et al. Secondary male factor infertility after Roux-en-Y gastric bypass for morbid obesity: case report. Hum Reprod 2005; 20:997–998. 78 ACOG Committee Opinion 315, September 2005. Obesity in pregnancy. Obstet Gynecol 2005; 106:671–675. 79 Patel JA, Colella JJ, Esaka E, et al. Improvement in infertility and pregnancy outcomes after weight loss surgery. Med Clin North Am 2007; 91:515– 528; xiii. 80 Rand CS, Macgregor AM. Medical care and pregnancy outcome after gastric bypass surgery for obesity. South Med J 1989; 82:1319–1320. 81 Dao T, Kuhn J, Ehmer D, et al. Pregnancy outcomes after gastric-bypass surgery. Am J Surg 2006; 192:762–766. 82 Patel JA, Patel NA, Thomas RL, et al. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 4:39–45. 83 Beard JH, Bell RL, Duffy AJ. Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations. Obes Surg 2008; 18:1023–1027. 84 ACOG practice bulletin 105: bariatric surgery and pregnancy. Obstet Gy necol 2009; 113:1405–1413. This is ACOG’s only practice bulletin looking at obstetric outcomes after surgical weight loss. 85 Weiss JL, Malone FD, Emig D, et al. Obesity, obstetric complications and cesarean delivery rate: a population-based screening study. Am J Obstet Gynecol 2004; 190:1091–1097. 86 Ginsburg ES. Reproductive endocrinology: pregnancy and fertility after bariatric surgery. Nat Rev Endocrinol 2009; 5:251–252. This is a critical appraisal of the 2008 JAMA study by Maggard et al. [6].


Bibliography Current World Literature This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2009 and 31 January 2010 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Contents Fertility 255 Economics of assisted reproductive technologies 255 Cumulative live-birth rates after assisted reproductive technology

Vol 22 No 3 June 2010

258 Does the ovarian reserve decrease from repeated ovulation stimulations? 258 Update on the role of leukemia inhibitory factor in assisted reproduction 258 Are first-trimester screening markers altered in ART pregnancies?

256 The role of anti-Mu¨llerian hormone assessment in assisted reproductive technology outcome 256 Borderline ovarian tumors and fertility 256 Stem cells and reproduction 256 Impact of male age in reproduction

Papers considered by the reviewers to be of special interest Papers considered by the reviewers to be of outstanding interest The number in square brackets following a selected paper, e.g. [7], refers to its number in the annotated references of the corresponding review. Current Opinion in Obstetrics and Gynecology 2010, 22:255–258 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X #

Fertility Economics of assisted reproductive technologies Review: (pp. 183–188) Bhan A. Bill to regulate assisted reproductive technologies on the anvil. Natl Med J India 2008; 21:331. Bromer JG, Seli E. Preterm deliveries that result from ART associated multiple pregnancies in the United States: a cost analysis. Fertil Steril 90(Supplement 1)2008:S210– S211. [33] Chambers GM, Sullivan EA, Ishihara O, Chapman MG, et al. The economic impact of assisted reproductive technology: a review of selected developed countries. Fertil Steril 2009; 91:2281–2294. Chambers GM, Sullivan EA, Ishihara O, et al. The economic impact of assisted reproductive technology: a review of selected developed countries. Fertil Steril 2009; 91:2281–2294. [10] Chaouat G. Funding for research in reproduction in the European union. Nat Med 2008; 14:1218– 1220. Connolly M, Gallo F, Hoorens S, Ledger W. Assessing long-run economic benefits attributed to an IVF-conceived singleton based on projected lifetime net tax contributions in the UK dagger. Hum Reprod 2009; 24:626–632. Critchley H, Saunders P. European funding for reproduction research-A multinational perspective. Nat Med 2008; 14:1224. Dobson R. One in four multiple pregnancies at London clinic resulted from fertility treatment overseas - art. no. b3054. BMJ 2009:B3054. Fiddelers AAA, Dirksen CD, Dumoulin JCM, van Montfoort APA, et al. Cost-effectiveness of seven IVF strategies: results of a Markov decision-analytic model. Hum Reprod 2009; 24:1648–1655. Habbema JDF, Eijkemans MJC, Nargund G, Beets G, et al. The effect of in vitro fertilization on birth rates in western countries. Hum Reprod 2009; 24: 1414–1419.

257 Impact of previous artery embolization on fertility 257 Fertility in congenital adrenal hyperplasia 257 Ectopic pregnancy after assisted reproductive technology: what are the risk factors? 257 Mental health of parents of twins conceived via assisted reproductive technology 257 Bariatric surgery and fertility 257 Is there a benefit in follicular flushing in assisted reproductive technology?

Hammoud AO, Gibson M, Stanford J, White G, et al. In vitro fertilization availability and utilization in the United States: a study of demographic, social, and economic factors. Fertil Steril 2009; 91:1630–1635. Inhorn MC. Right to assisted reproductive technology: Overcoming infertility in low-resource countries. Int J Gynaecol Obstet 2009; 106:172–174. Jasienska G. Reproduction and Lifespan: Trade-offs, Overall Energy Budgets, Intergenerational Costs, and Costs Neglected by Research. Am J Hum Biol 2009; 21:524– 532. Klitzman R, Sauer MV. Payment of egg donors in stem cell research in the USA. Reprod Biomed Online 2009; 18:603–608. Mahajan NN, Turnbull DA, Davies MJ, Jindal UN, et al. Adjustment to infertility: the role of intrapersonal and interpersonal resources/vulnerabilities. Hum Reprod 2009; 24:906–912. Maheshwari A, Scotland G, Bell J, McTavish A, et al. The direct health services costs of providing assisted reproduction services in overweight or obese women: a retrospective cross-sectional analysis. Hum Reprod 2009; 24:633– 639. Martin JR, Bromer JG, Patrizio P. Insurance coverage and IVF outcomes in USA: analysis of recent trends in patients younger than 35 years old. Fertil Steril 92(Supplement 3)2009:S52. [29] McKelvey A, David AL, Shenfield F, Jauniaux ER. The impact of cross-border reproductive care or ’fertility tourism’ on NHS maternity services. BJOG 2009; 116:1520–1523, 2009 Oct. No Authors Given. ESHRE Data collection and consortia. http://www.eshre.com/ESHRE/ English/Data-collection-Consortia/Europe-mapreimbursement/page.aspx/739. [Accessed 16 December 2009] [21] Ombelet W. Reproductive healthcare systems should include accessible infertility diagnosis and treatment: An important challenge for resource-poor countries. Int J Gynaecol Obstet 2009; 106:168–171. Rukavina D. European funding for reproduction research-A multinational perspective. Nat Med 2008; 14:1223. Sharma S, Mittal S, Aggarwal P. Management of infertility in low resource countries [Review]. BJOG 2009; 116:77–83, 2009 Oct.

Simon C. European funding for reproduction research-A multinational perspective. Nat Med 2008; 14:1222. Strauss JF, De Paolo LV. Funding for the reproductive sciences in the US. Nat Med 2008; 14:1214–1217. Vayena E, Peterson HB, Adamson D, Nygren KG. Assisted reproductive technologies in developing countries: are we caring yet? Fertil Steril 2009; 92:413– 416. Veleva Z, Karinen P, Tomas C, Tapanainen JS, et al. Elective single embryo transfer with cryopreservation improves the outcome and diminishes the costs of IVF/ICSI. Hum Reprod 2009; 24:1632–1639. Wechowski J, Connolly M, Schneider D, McEwan P, et al. Costsaving treatment strategies in in vitro fertilization: a combined economic evaluation of two large randomized clinical trials comparing highly purified human menopausal gonadotropin and recombinant folliclestimulating hormone alpha. Fertil Steril 2009; 91:1067– 1076.

Cumulative live-birth rates after assisted reproductive technology Review: (pp. 189–192) Gleicher N, Oktay K, Barad DH. Patients are entitled to maximal IVF pregnancy rates. Reprod Biomed Online 2009; 18:599–602. Malizia B, Hacker MR, Penzias AS. Cumulative live-birth rates after in vitro fertilization. N Engl J Med 2009; 360:236– 243. [03] Malizia BA, Hacker MR, Penzias AS. Cumulative Live-Birth Rates after In Vitro Fertilization. N Engl J Med 2009; 360:236–243. Orji EO. Comparative study of the impact of past pregnancy outcome on future fertility. Singap Med J 2008; 49:1021– 1024. Pandian Z, Bhattacharya S, Ozturk O, et al. Number of embryos for transfer following in-vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2009:CD003416. [09] Sills ES, Walsh DJ, Walsh APH. Pregnancy and perinatal outcomes after assisted reproduction: a comparative study. Ir J Med Sci 2009; 178:119.

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256 Fertility Impact of male age in reproduction Stern JE, Brown MB, Luke B, et al. a SART Writing Group. Calculating cumulative live-birth rates from linked cycles of assisted reproductive technology (ART): data from the Massachusetts SART CORS. Fertil Steril. 2009. [Epub ahead of print] [04] Thurin-Kjellberg A, Olivius C, Bergh C. Cumulative live-birth rates in a trial of single-embryo or double-embryo transfer. N Engl J Med 2009; 361:1812–1813. [11]

The role of anti-Mu¨llerian hormone assessment in assisted reproductive technology outcome Review: (pp. 193–201) Aflatoonian A, Oskouian H, Ahmadi S, Oskouian L. Prediction of high ovarian response to controlled ovarian hyperstimulation: anti-Mullerian hormone versus small antral follicle count (2-6 mm). J Assist Reprod Genet 2009; 26:319–325. Broer SL, Mol BW, Hendriks D, Broekmans FJ. The role of antimullerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. Fertil Steril 2009; 91:705–714. [52] Broer SL, Mol BWJ, Hendriks D, Broekmans FJM. The role of antimullerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. Fertil Steril 2009; 91:705–714. Fong SL, Laven JSE, Hakvoort-Cammel FGAJ, Schipper I, et al. Assessment of ovarian reserve in adult childhood cancer survivors using anti-Mullerian hormone. Hum Reprod 2009; 24:982–990. Hendriks DJ, te Velde ER, Looman CW, et al. Expected poor ovarian response in predicting cumulative pregnancy rates: a powerful tool. Reprod Biomed Online 2008; 17:727–736. [85] Jayaprakasan K, Deb S, Batcha M, et al. The cohort of antral follicles measuring 2-6 mm reflects the quantitative status of ovarian reserve as assessed by serum levels of antiMullerian hormone and response to controlled ovarian stimulation. Fertil Steril 2009. [Epub ahead of print] [32] La Marca A, Broekmans FJ, Volpe A, Fauser BC, et al. AntiMullerian hormone (AMH): what do we still need to know? [Review]. Hum Reprod 2009; 24:2264–2275. Lee TH, Liu CH, Huang CC, et al. Serum antimullerian hormone and estradiol levels as predictors of ovarian hyperstimulation syndrome in assisted reproduction technology cycles. Hum Reprod 2008; 23:160–167. [76] Lekamge DN, Lane M, Gilchrist RB, Tremellen KP. Increased gonadotrophin stimulation does not improve IVF outcomes in patients with predicted poor ovarian reserve. J Assist Reprod Genet 2008; 25:515–521. [92] Lie Fong S, Baart EB, Martini E, et al. Anti-Mullerian hormone: a marker for oocyte quantity, oocyte quality and embryo quality? Reprod Biomed Online 2008; 16:664–670. [87] Nelson SM, Yates RW, Lyall H, et al. Anti-Mullerian hormone based approach to controlled ovarian stimulation for assisted conception. Hum Reprod 2009; 24:867–875. [94] Olivennes F, Howles CM, Borini A, et al. Individualizing FSH dose for assisted reproduction using a novel algorithm: the CONSORT study. Reprod Biomed Online 2009; 18:195–204. [93] Riggs RM, Duran EH, Baker MW, et al. Assessment of ovarian reserve with anti-Mullerian hormone: a comparison of the predictive value of anti-Mullerian hormone, folliclestimulating hormone, inhibin B, and age. Am J Obstet Gynecol 2008; 199:202–208. [72] Singer T, Barad DH, Weghofer A, Gleicher N. Correlation of antimullerian hormone and baseline follicle-stimulating hormone levels. Fertil Steril 2009; 91:2616–2619. Sowers M, McConnell D, Gast K, et al. Anti-Mullerian hormone and inhibin B variability during normal menstrual cycles. Fertil Steril 2009. [Epub ahead of print] [26] Streuli I, Fraisse T, Chapron C, Bijaoui G, et al. Clinical uses of anti-Mullerian hormone assays: pitfalls and promises. Fertil Steril 2009; 91:226–230. van Disseldorp J, Faddy MJ, Themmen AP, et al. Relationship of serum anti-Mullerian hormone concentration to age of menopause. J Clin Endocrinol Metab 2008; 93:2129– 2134. [21] Verberg MF, Eijkemans MJ, Macklon NS, et al. The clinical significance of the retrieval of a low number of oocytes following mild ovarian stimulation for IVF: a meta-analysis. Hum Reprod Update 2009; 15:5–12. [89] Wunder DM, Bersinger NA, Yared M, et al. Statistically significant changes of antimullerian hormone and inhibin levels during the physiologic menstrual cycle in reproductive age women. Fertil Steril 2008; 89:927–933. [25]

Borderline ovarian tumors and fertility Review: (pp. 227–234) Anderson RA, Wallace WH. Uncertainties in preserving fertility in cancer treatment - art. no. a2577. BMJ 2008:A2577. Bent CL, Sahdev A, Rockall AG, Singh N, et al. MRI appearances of borderline ovarian tumours [Review]. Clin Radiol 2009; 64:430–438. Broekmans FJ, Soules MR, Fauser BC. Ovarian Aging: Mechanisms and Clinical Consequences [Review]. Endocr Rev 2009; 30:465–493. Chang SJ, Ryu HS, Chang KH, et al. Prognostic significance of the micropapillary pattern in patients with serous borderline ovarian tumors. Acta Obstet Gynecol Scand 2008; 87:476–481. [33] Cheng B, Wan X, Qian X, et al. Results of conservative surgery for recurrent borderline ovarian tumors. Eur J Gynaecol Oncol 2009; 30:75–78. [21] Cheng B, Wan X, Qian X, Lv W, et al. Results of conservative surgery for recurrent borderline ovarian tumors. Eur J Gynaecol Oncol 2009; 30:75–78. Coumbos A, Sehouli J, Chekerov R, Schaedel D, et al. Clinical management of borderline tumours of the ovary: results of a multicentre survey of 323 clinics in Germany. Br J Cancer 2009; 100:1731–1738. De Iaco P, Ferrero A, Rosati F, et al. Behaviour of ovarian tumors of low malignant potential treated with conservative surgery. Eur J Surg Oncol 2009; 35:643–648. [20] De Iaco P, Ferrero A, Rosati F, Melpignano A, et al. Behaviour of ovarian tumors of low malignant potential treated with conservative surgery. Eur J Surg Oncol 2009; 35:643– 648. Duffy C, Allen S. Medical and Psychosocial Aspects of Fertility After Cancer. Cancer J 2009; 15:27–33. Fain-Kahn V, Poirot C, Uzan C, et al. Feasibility of ovarian cryopreservation in borderline ovarian tumours. Hum Reprod 2009; 24:850–855. [66] Forman EJ, Anders CK, Behera MA. Pilot Survey of Oncologists Regarding Treatment-Related Infertility and Fertility Preservation in Female Cancer Patients. J Reprod Med 2009; 54:203–207. Jensen A, Sharif H, Frederiksen K, Kjaer SK. Use of fertility drugs and risk of ovarian cancer: Danish population based cohort study - art. no. b249. BMJ 2009:B249. Kane A, Uzan C, Rey A, et al. Prognostic factors in patients with ovarian serous low malignant potential (borderline) tumors with peritoneal implants. Oncologist 2009; 14:591–600. [29] Ketefian A, Hu JF, Bartolucci AA, Azziz R. Fifteen-year trend in the use of reproductive surgery in women in the United States. Fertil Steril 2009; 92:727–735. Knopman JM, Noyes N, Talebian S, Krey LC, et al. Women with cancer undergoing ART for fertility preservation: a cohort study of their response to exogenous gonadotropins. Fertil Steril 2009; 91:1476–1478. Laurent I, Uzan C, Gouy S, et al. Results after conservative treatment of serous borderline tumors of the ovary with a micropapillary pattern. Ann Surg Oncol 2008; 15:3561– 3566. [36] Laurent I, Uzan C, Gouy S, et al. Results after conservative treatment of serous borderline tumours of the ovary with stromal microinvasion but without micropapillary pattern. BJOG 2009; 116:860–862. [39] Leblanc E, Narducci F, Ferron G, Querleu D. Indications and teaching of fertility preservation in the surgical management of gynecologic malignancies: European perspective. Gynecol Oncol 2009; 114:S32– S36. Minkoff H, Ecker J. The California octuplets and the duties of reproductive endocrinologists - art. no. 15.e1. Am J Obstet Gynecol 2009; 201:E1. Muzii L, Palaia I, Sansone M, Calcagno M, et al. Laparoscopic fertility-sparing staging in unexpected early stage ovarian malignancies. Fertil Steril 2009; 91:2632– 2637. Park JY, Kim DY, Kim JH, et al. Surgical management of borderline ovarian tumors: the role of fertility-sparing surgery. Gynecol Oncol 2009; 113:75–82. [19] Park JY, Kim DY, Kim JH, Kim YM, et al. Surgical management of borderline ovarian tumors: The role of fertility-sparing surgery. Gynecol Oncol 2009; 113:75–82. Ren J, Peng Z, Yang K. A clinicopathologic multivariate analysis affecting recurrence of borderline ovarian tumors. Gynecol Oncol 2008; 110:162–167. [38] Seamon LG, Holt CN, Suarez A, Richardson DL, et al. Paratubal borderline serous tumors. Gynecol Oncol 2009; 113:83– 85. Strowitzki T, von Wolff M. Preservation of Fertility in Patients with Cancer [Review] [German]. Geburtshilfe Frauenheilkd 2009; 69:599–604.

Tinelli R, Malzoni M, Cosentino F, et al. Feasibility, safety, and efficacy of conservative laparoscopic treatment of borderline ovarian tumors. Fertil Steril 2009; 92:736– 741. [45] Tinelli R, Malzoni M, Cosentino F, Perone C, et al. Feasibility, safety, and efficacy of conservative laparoscopic treatment of borderline ovarian tumors. Fertil Steril 2009; 92:736–741. Tsikouras P, Liberis V, Galazios G, Panagiotidou C, et al. A retrospective analysis of twenty-eight borderline ovarian tumours in adolescent girls. Eur J Gynaecol Oncol 2009; 30:49–53. Uzan C, Kane A, Rey A, et al. Outcomes after conservative treatment of advanced-stage serous borderline tumors of the ovary. Ann Oncol 2010; 21:55–60. [26] Vigano R, Petrone M, Pella F, et al. Surgery in advanced borderline tumors. Fertil Steril (in press). [25] Webb PM. Fertility drugs and ovarian cancer - art. no. a3075. BMJ 2009:A3075. Wo JY, Viswanathan AN. Impact of radiotherapy on fertility, pregnancy, and neonatal outcomes in female cancer patients [Review]. Int J Radiat Oncol Biol Phys 2009; 73:. Wright JD, Shah M, Mathew L, Burke WM, et al. Fertility Preservation in Young Women With Epithelial Ovarian Cancer. Cancer 2009; 115:4118–4126.

Stem cells and reproduction Review: (pp. 235–241) Bosch TCG. Hydra and the evolution of stem cells. Bioessays 2009; 31:478–486. Du H, Taylor HS. Stem Cells and Female Reproduction. Reprod Sci 2009; 16:126–139. Dubernard G, Aractingi S, Oster M, et al. Breast cancer stroma frequently recruits fetal derived cells during pregnancy. Breast Cancer Res 2008; 10:R14. [60] Leduc M, Aractingi S, Khosrotehrani K. Fetal-cell microchimerism, lymphopoiesis, and autoimmunity. Arch Immunol Ther Exp (Warsz) 2009; 57:325–329. [53] Sermon KD, Simon C, Braude P, Viville S, et al. Creation of a registry for human embryonic stem cells carrying an inherited defect: joint collaboration between ESHRE and hESCreg. Hum Reprod 2009; 24:1556–1560. Tian X, Pascal G, Fouchecourt S, Pontarotti P, et al. Gene Birth, Death, and Divergence: The Different Scenarios of Reproduction-Related Gene Evolution [Review]. Biol Reprod 2009; 80:616–621. Yanagimachi R. Germ Cell Research: A Personal Perspective [Review]. Biol Reprod 2009; 80:204–218.

Impact of male age in reproduction Alukal JP, Lipshultz LI. Why Treat the Male in the Era of Assisted Reproduction? Semin Rep Med 2009; 27:109–114. Amor DJ, Xu JX, Halliday JL, Francis I, et al. Pregnancies conceived using assisted reproductive technologies (ART) have low levels of pregnancy-associated plasma protein-A (PAPP-A) leading to a high rate of false-positive results in first trimester screening for Down syndrome. Hum Reprod 2009; 24:1330–1338. Coall DA, Meier M, Hertwig R, Wanke M, et al. Grandparental Investment: The Influence of Reproductive Timing and Family Size. Am J Hum Biol 2009; 21:455–463. Fisch H. The aging male and his biological clock. Geriatrics 2009; 64:14–17. Frattarelli JL, Miller KA, Miller BT, Elkind-Hirsch K, et al. Male Age Negatively Impacts Embryo Development and Reproductive Outcome in Donor Oocyte Assisted Reproductive Technology Cycles. J Urol 2009; 181:758. Hanna CW, Bretherick KL, Gair JL, Fluker MR, et al. Telomere length and reproductive aging. Hum Reprod 2009; 24:1206–1211. Joensen UN, Skakkebaek NE, Jorgensen N. Is there a problem with male reproduction? Nat Clin Pract Endocrinol Metabol 2009; 5:144–145. Niederberger C. Male Age Negatively Impacts Embryo Development and Reproductive Outcome in Donor Oocyte Assisted Reproductive Technology Cycles Comment. J Urol 2009; 181:758. Oberzaucher E, Grammer K. Ageing, Mate Preferences and Sexuality: A Mini-Review [Review]. Gerontology 2009; 55:371–378. Perheentupa A, Huhtaniemi I. Aging of the human ovary and testis [Review]. Mol Cell Endocrinol 2009; 299:2–13. Tavalaee M, Razavi S, Nasr-Esfahani MH. Influence of sperm chromatin anomalies on assisted reproductive technology outcome. Fertil Steril 2009; 91:1119–1126.


Fertility Is there a benefit in follicular flushing in assisted reproductive technology? 257 Toivonen JM, Partridge L. Endocrine regulation of aging and reproduction in Drosophila [Review]. Mol Cell Endocrinol 2009; 299:39–50. Winkle T, Rosenbusch B, Gagsteiger F, Paiss T, et al. The correlation between male age, sperm quality and sperm DNA fragmentation in 320 men attending a fertility center. J Assist Reprod Genet 2009; 26:41–46.

Srivastava R, Kay V. Clinical biochemistry of assisted conception [Review]. Ann Clin Biochem 2009; 46:197– 204. Tahirovic H, Toromanovic A, Grubic M, Grubic Z, et al. Untreated congenital adrenal hyperplasia due to 21hydroxylase deficiency. Eur J Pediatr 2009; 168:847– 849.

Impact of previous artery embolization on fertility

Ectopic pregnancy after assisted reproductive technology: what are the risk factors? Review: (pp. 202–207)

Brill AI. Treatment of fibroids via uterine artery occlusion (uterine artery embolization and Doppler-guided uterine artery occlusion): potential role in today’s armamentarium [Review]. Arch Gynecol Obstet 2009; 280:513–520. Cheng ZP, Xu LZ, Zhu Y, Dai H, et al. Laparoscopic Uterine Vessels Occlusion for the Treatment of Interstitial Pregnancy. J Laparoendosc Surg Adv Surg Techniques 2009; 19:509–512. Claahsen-van der Grinten HL, Otten BJ, Stikkelbroeck MML, Sweep FCGJ, et al. Testicular adrenal rest tumours in congenital adrenal hyperplasia. Best Pract Res Clin Endocrinol Metab 2009; 23:209–220. Delotte J, Novellas S, Koh C, Bongain A, et al. Obstetrical prognosis and pregnancy outcome following pelvic arterial embolisation for post-partum hemorrhage [Review]. Eur J Obstet Gynecol Reprod Biol 2009; 145. Duffy JMN, Johnson N, Ahmad G, Watson A. Postoperative procedures for improving fertility following pelvic reproductive surgery - art. no. CD001897 [Review]. Cochrane Database of Systematic Reviews 2009:1897. Fanchin R, Ayoubi JM. Uterine dynamics: impact on the human reproduction process [Review]. Reprod Biomed Online 2009; 18:S57–S62. Fiori O, Deux JF, Kambale JC, Uzan S, et al. Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility - art. no. 384.e1. Am J Obstet Gynecol 2009; 200:E1. Firouznia K, Ghanaati H, Sanaati M, Jalali AH, et al. Pregnancy After Uterine Artery Embolization for Symptomatic Fibroids: A Series of 15 Pregnancies. AJR Am J Roentgenol 2009; 192:1588–1592. Gaia G, Chabrot P, Cassagnes L, Calcagno A, et al. Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study. Eur Radiol 2009; 19:481–487. Hirakawa M, Tajima T, Yoshimitsu K, Irie H, et al. Uterine Artery Embolization Along With the Administration of Methotrexate for Cervical Ectopic Pregnancy: Technical and Clinical Outcomes. AJR Am J Roentgenol 2009; 192:1601–1607. Laurent A, Wassef M, Namur J, Martal J, et al. Recanalization and particle exclusion after embolization of uterine arteries in sheep: a long-term study. Fertil Steril 2009; 91:884– 892. Majd HS, Srikantha M, Majumdar S, B-Lynch C, et al. Successful use of uterine artery embolisation to treat placenta increta in the first trimester. Arch Gynecol Obstet 2009; 279:713–715. Takeda A, Koyama K, Imoto S, Mori M, et al. Successful management of interstitial pregnancy with fetal cardiac activity by laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization. Arch Gynecol Obstet 2009; 280:305–308. Tixier H, Loffroy R, Filipuzzi L, Grevoul J, et al. Uterine artery embolization with resorbable material prior to myomectomy [French]. J Radiol 2008; 89:1925–1929. Wakeman S, Benny P. Is it possible to predict a fertile cycle? Uteroovarian blood flow parameters in conception versus nonconception cycles. Fertil Steril 2009; 91:2726–2731. Yu B, Douglas NC, Guarnaccia MM, Sauer MV. Uterine artery embolization as an adjunctive measure to decrease blood loss prior to evacuating a cervical pregnancy. Arch Gynecol Obstet 2009; 279:721–724. Yu PC, Ou HY, Tsang LLC, Kung FT, et al. Prophylactic intraoperative uterine artery embolization to control hemorrhage in abnormal placentation during late gestation. Fertil Steril 2009; 91:1951–1955.

Fertility in congenital adrenal hyperplasia Casteras A, De Silva P, Rumsby G, Conway GS. Reassessing fecundity in women with classical congenital adrenal hyperplasia (CAH): normal pregnancy rate but reduced fertility rate. Clin Endocrinol (Oxf) 2009; 70:833–837. Reisch N, Flade L, Scherr M, Rottenkolber M, et al. High Prevalence of Reduced Fecundity in Men with Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2009; 94:1665–1670.

Agdi M, Tulandi T. Surgical treatment of ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol 2009; 23:519– 527. Cartwright J, Duncan WC, Critchley HD, Horne AW. Serum biomarkers of tubal ectopic pregnancy: current candidates and future possibilities [Review]. Reproduction 2009; 138:9–22. Jee BC, Suh CS, Kim SH. Ectopic pregnancy rates after frozen versus fresh embryo transfer: a meta-analysis. Gynecol Obstet Invest 2009; 68:53–57. [30] Kiley J, Shulman LP. Cesarean Scar Ectopic Pregnancy in a Patient with Multiple Prior Cesarean Sections A Case Report. J Reprod Med 2009; 54:251–254. Kuroda K, Takeuchi H, Kitade M, Kikuchi I, et al. Assessment of tubal disorder as a risk factor for repeat ectopic pregnancy after laparoscopic surgery for tubal pregnancy. J Obstet Gynaecol Res 2009; 35:520–524. Lautmann K, Staboulidou I, Wustemann M, Gunter H, et al. Heterotopic Pregnancy: Simultaneous Intrauterine and Ectopic Pregnancy Following IVF Treatment with the Birth of a Healthy Child. Ultraschall Med 2009; 30:71–73. Nama V, Manyonda I. Tubal ectopic pregnancy: diagnosis and management [Review]. Arch Gynecol Obstet 2009; 279:443–453. Rosman ER, Keegan DA, Krey L, et al. Ectopic pregnancy rates after in vitro fertilization: a look at the donor egg population. Fertil Steril 2009; 92:1791–1793. [20] Zarei A, Al-Ghafri W, Tulandi T. Tubal Surgery. Clin Obstet Gynecol 2009; 52:344–350.

Mental health of parents of twins conceived via assisted reproductive technology Review: (pp. 220–226) Agostini F, Monti F, Fagandini P, De Pascalis LLD, et al. Parental mental representations during late pregnancy and early parenthood following assisted reproductive technology. J Perinat Med 2009; 37:320–327. Alhamdan D, Bora S, Condous G. Diagnosing twins in early pregnancy. Best Pract Res Clin Obstet Gynaecol 2009; 23:453–461. Choi Y, Bishai D, Minkovitz CS. Multiple births are a risk factor for postpartum maternal depressive symptoms. Pediatrics 2009; 123:1147–1154. [10] de Bes MR, Maldonado JG, Martinez JMG. Psychosocial risks associated with multiple births resulting from assisted reproduction: a Spanish sample. Fertil Steril 2009; 92:1059–1066. Gleicher N, Barad D. Twin pregnancy, contrary to consensus, is a desirable outcome in infertility. Fertil Steril 2009; 91:2426–2431. Hammarberg K, Fisher JR, Wynter KH. Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: a systematic review. Hum Reprod Update 2008; 14:395–414. [07] Hansen M, Colvin L, Petterson B, et al. Twins born following assisted reproductive technology: perinatal outcome and admission to hospital. Hum Reprod 2009; 24:2321– 2331. [16] Hansen M, Colvin L, Petterson B, Kurinczuk JJ, et al. Twins born following assisted reproductive technology: perinatal outcome and admission to hospital. Hum Reprod 2009; 24:2321–2331. Hardin J, Carmichael SL, Selvin S, Shaw GM. Trends in the Probability of Twins and Males in California, 1983-2003. Twin Res Hum Genet 2009; 12:93–102, 2009 Feb.. Hur YM, Sonk TB. A Recent Rise in Twin Birthrates and Demographic Changes in Mothers of Twins in South Korea: 2003-2007. Twin Res Hum Genet 2009; 12:118– 122, 2009 Feb.. Kapoor M, Pal L. Epidemic of Plurality and Contributions of Assisted Reproductive Technology Therein. Am J Med Genet C 2009; 151C:128–135.

Luke B, Brown MB, Grainger DA, Stern JE, et al. The effect of early fetal losses on twin assisted-conception pregnancy outcomes. Fertil Steril 2009; 91:2586–2592. Machin G. Non-identical Monozygotic Twins, Intermediate Twin Types, Zygosity Testing, and the Non-Random Nature of Monozygotic Twinning [Review]. Am J Med Genet C 2009; 151C:110–127. Monti F, Agostini F, Fagandini P, La Sala GB, et al. Depressive symptoms during late pregnancy and early parenthood following assisted reproductive technology. Fertil Steril 2009; 91:851–857. Olivennes F, Golombok S, Ramogida C, et al. Behavioral and cognitive development as well as family functioning of twins conceived by assisted reproduction: findings from a large population study. Fertil Steril 2005; 84:725–733. [24] Pandian Z, Bhattacharya S, Ozturk O, et al. Number of embryos for transfer following in-vitro fertilisation or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2009:CD003416. [04] Vilska S, Unkila-Kallio L, Punamaki RL, et al. Mental health of mothers and fathers of twins conceived via assisted reproduction treatment: a 1-year prospective study. Hum Reprod 2009; 24:367–377. [30] Vilska S, Unkila-Kallio L, Punamaki RL, Poikkeus P, et al. Mental health of mothers and fathers of twins conceived via assisted reproduction treatment: a 1-year prospective study. Hum Reprod 2009; 24:367–377. Zegers-Hochschild F, Adamson GD, de Mouzon J, et al. The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, 2009. Hum Reprod 2009; 24:2683–2687. [01]

Bariatric surgery and fertility Review: (pp. 248–254) Awartani KA, Nahas S, Al Hassan SH, et al. Infertility treatment outcome in sub groups of obese population. Reprod Biol Endocrinol 2009; 7:52. [58] Ginsburg ES. Reproductive endocrinology: pregnancy and fertility after bariatric surgery. Nat Rev Endocrinol 2009; 5:251–252. [86] Ginsburg ES. Reproductive endocrinology Pregnancy and fertility after bariatric surgery. Nat Rev Endocrinol 2009; 5:251–252. Gosman GG, King WC, Schrope B, et al. Reproductive health of women electing bariatric surgery. Fertil Steril 2009 Oct 6. [Epub ahead of print] [16] Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical review. Hum Reprod Update 2009; 15:189–201. [08] Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical review [Review]. Hum Reprod Update 2009; 15:189–201. Hammoud A, Gibson M, Hunt SC, et al. Effect of Roux-en-Y gastric bypass surgery on the sex steroids and quality of life in obese men. J Clin Endocrinol Metab 2009; 94:1329–1332. [76] Jungheim ES, Lanzendorf SE, Odem RR, et al. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome. Fertil Steril 2009; 92:256–261. [61] Luke B, Brown MB, Stern JE, et al. Maternal obesity adversely affects assisted reproductive technology (ART) pregnancy rates and obstetric outcomes. Fertil Steril 92(Suppl)2009:S1. [64] Luke B, Brown MB, Stern JE, et al. The effect of maternal body mass index (BMI) and oocyte source on assisted reproductive technology (ART) pregnancy rates and obstetric outcomes. Fertil Steril 92(Suppl)2009:S52. [65] Merhi ZO. Impact of bariatric surgery on female reproduction. Fertil Steril 2009; 92:1501–1508. [12] No Authors Given. ACOG practice bulletin 105: bariatric surgery and pregnancy. Obstet Gynecol 2009; 113:1405–1413. [84] Rochester D, Jain A, Polotsky AJ, et al. Partial recovery of luteal function after bariatric surgery in obese women. Fertil Steril 2009; 92:1410–1415. [45]

Is there a benefit in follicular flushing in assisted reproductive technology? Review: (pp. 208–212) Levens ED, Whitcomb BW, Payson MD, et al. Ovarian follicular flushing among low-responding patients undergoing assisted reproductive technology. Fertil Steril 2009; 91:1381–1384. [21]


258 Fertility Are first-trimester screening markers altered in ART pregnancies? Levens ED, Whitcomb BW, Payson MD, Larsen FW. Ovarian follicular flushing among low-responding patients undergoing assisted reproductive technology. Fertil Steril 2009; 91:1381–1384. Mendez Lozano DH, Brum Scheffer J, Frydman N, et al. Optimal reproductive competence of oocytes retrieved through follicular flushing in minimal stimulation IVF. Reprod Biomed Online 2008; 16:119–123. [23] Uzelac PS, Christensen GL, Nakajima ST. Follicular flushing avoids multiple vaginal punctures and may aid in oocyte recovery in in vitro maturation (IVM). Fertil Steril 2009; 91:S5. [24]

Does the ovarian reserve decrease from repeated ovulation stimulations? Atsalis S, Videan E. Reproductive Aging in Captive and Wild Common Chimpanzees: Factors Influencing the Rate of Follicular Depletion [Review]. Am J Primatol 2009; 71:271–282. Deb S, Batcha M, Campbell BK, Jayaprakasan K, et al. The predictive value of the automated quantification of the number and size of small antral follicles in women undergoing ART. Hum Reprod 2009; 24:2124–2132. Martin-Johnston MK, Uhler ML, Grotjan HE, Lifchez AS, et al. Lower Chance of Pregnancy with Repeated Cycles with in Vitro Fertilization. J Reprod Med 2009; 54:67–72.

Sills ES, Alper MM, Walsh APH. Ovarian reserve screening in infertility: Practical applications and theoretical directions for research [Review]. Eur J Obstet Gynecol Reprod Biol 2009; 146.

Update on the role of leukemia inhibitory factor in assisted reproduction Review: (pp. 213–219) Aghajanova L, Simon C, Horcajadas JA. Functional genomic of human implantation: are favorite molecules of endometrial receptivity still in favor? Rev Exp Obstet Gynocol 2008; 3:487–501. [10] Altmae S, Martinez-Conejero JA, Salumets A, et al. Endometrial gene expression analysis at the time of embryo implantation in women with unexplained infertility. Mol Hum Reprod 2010; 16:178–187. [45] Brinsden PR, Alam V, de Moustier B, Engrand P. Recombinant human leukemia inhibitory factor does not improve implantation and pregnancy outcomes after assisted reproductive techniques in women with recurrent unexplained implantation failure. Fertil Steril 2009; 91:1445–1447. [36] Kang HJ, Feng Z, Sun Y, et al. Single-nucleotide polymorphisms in the p53 pathway regulate fertility in humans. Proc Natl Acad Sci U S A 2009; 106:9761– 9766. [42]

Paiva P, Menkhorst E, Salamonsen L, Dimitriadis E. Leukemia inhibitory factor and interleukin-11: critical regulators in the establishment of pregnancy. Cytokine Growth Factor Rev 2009; 20:319–328. [06] Srivastava R, Kay V. Clinical biochemistry of assisted conception [Review]. Ann Clin Biochem 2009; 46:197–204.

Are first-trimester screening markers altered in ART pregnancies? Feng C, Wang LQ, Dong MY, Huang HF. Assisted Reproductive Technology May Increase Clinical Mutation Detection in Male Offspring Editorial Comment. J Urol 2009; 181:1828–1829. Gjerris AC, Loft A, Pinborg A, Christiansen M, et al. Firsttrimester screening markers are altered in pregnancies conceived after IVF/ICSI. Ultrasound Obstet Gynecol 2009; 33:8–17. Kolialexi A, Anagnostopoulos AK, Mavrou A, Tsangaris GT. Application of proteomics for diagnosis of fetal aneuploidies and pregnancy complications [Review]. J Proteomics 2009; 72:731–739. Shamonki MI, Frattarelli JL, Bergh PA, Scott RT. Logarithmic curves depicting initial level and rise of serum beta human chorionic gonadotropin and live delivery outcomes with in vitro fertilization: An analysis of 6021 pregnancies. Fertil Steril 2009; 91:1760–1764.


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