The predictive value of anti-Müllerian hormone for natural conception leading to live birth in subfertile couples.

RESEARCH QUESTION: What is the predictive value of serum anti-Müllerian hormone (AMH) level for natural conception and its clinical effect on subfertile couples? DESIGN: A retrospective cohort of ovulatory women seeking fertility consultation in a private fertility clinic. Couples who had an immediate indication for IVF were excluded. All natural conceptions leading to live birth before the start of assisted reproductive technology were followed within 12 months of the initial consultation. A prediction model was developed by updating the Hunault model with serum AMH to predict the probabilities of achieving a natural conception leading to live birth. RESULTS: A total of 325 couples were included in the final analysis. The estimated cumulative proability of achieving natural conception leading to live birth within 12 months was 20.9% (95% CI 12.9% to 28.2%). The categorical net reclassification improvement of AMH is 7.6%. For couples with a predicted chance of natural conception changed from poor (<30%) by the reference model to good (≥30%) by the updated model, the cumulative natural conception rate leading to live birth was 52.0%. For couples who had predicted chance of natural conception changed from good to poor by the updated model, the rate was 18.9%. CONCLUSIONS: The addition of serum AMH to the routine fertility work-up may improve prognosis-based treatment policy and help to prevent unnecessary costs and stress for couples. Prospective validation of the updated model with AMH is required before clinical application.

An audit of clinical outcomes following ovarian administration of platelet-rich plasma (PRP) in women with severe diminished ovarian reserve.

BACKGROUND: Infertility caused by poor oocyte quality is one of the most difficult areas to manage. While oocyte donation is an effective treatment, for most women it is a treatment of last resort. Ovarian platelet-rich plasma (PRP) treatment is a relatively new adjunct therapy which has been reported to possibly improve oocyte quality and in vitro fertilisation (IVF) treatment outcomes in women with severe diminished ovarian reserve. AIMS: To audit IVF and pregnancy outcomes following ovarian PRP treatment in a cohort of women under 45 years of age with severe diminished ovarian reserve and previous IVF treatment failure. METHODS: An audit of 20 consecutive patients comparing embryology outcomes before and after ovarian PRP treatment, together with assessment of PRP-related pregnancies and treatment complications. RESULTS: Overall, PRP treatment produced no significant improvement in oocyte number, but did increase the number of embryos generated compared to patients' own pre-PRP IVF cycle (zero vs two embryos, P = 0.005). In total four patients conceived viable genetically normal pregnancies in their next IVF cycle, and a further two conceived naturally within 4 months of the PRP treatment. Five of these pregnancies were in women 40 years or older, all being euploid on non-invasive pregnancy screening and viable beyond 12 weeks gestation. No operative complications were observed. CONCLUSION: Ovarian PRP treatment appears to be low risk and may offer some promise in assisting pregnancy (natural and IVF-related), especially in women with reduced oocyte quality due to advanced maternal age. Future randomised controlled trials are urgently required to confirm this benefit.

PIEZO-ICSI increases fertilization rates compared with standard ICSI: a prospective cohort study.

RESEARCH QUESTION: Is PIEZO-intracytoplasmic sperm injection (ICSI) coupled with a new novel operational fluid (perfluoro-n-octane) superior to standard ICSI? DESIGN: A cohort of patients (n = 69) undertaking microinjection were recruited between January and November 2019 and were then prospectively case-matched. Patients required six or more mature oocytes for inclusion in the study. PIEZO-ICSI uses high-speed microinjection drilling to penetrate the zona and oolemma and deposit the spermatozoa into the cytoplasm, compared with the traditional 'cutting' action of ICSI. The primary outcome was fertilization, with secondary outcomes including oocyte degeneration, abnormal fertilization, embryo cryopreservation and embryo utilization. RESULTS: PIEZO-ICSI resulted in significantly higher fertilization rates (80.5 ± 2.4% vs 65.8 ± 2.3%, P < 0.0001) and lower oocyte degeneration rates (4.4 ± 1.3% vs 8.6 ± 1.2%, P = 0.019) and abnormal fertilization rates (2.9 ± 1.1% vs 7.4 ± 1.1%; P = 0.003) compared with standard ICSI. This improvement in fertilization was of most benefit in patients aged ≥38 years. This increase in fertilization increased the number of good quality embryos that were available for cryopreservation/transfer (3.8 ± 0.2 vs 3.1 ± 0.2; P = 0.038), such that patients on average had one extra usable embryo per cycle compared with standard ICSI. There were no differences to Day 5 embryo development or clinical pregnancy from fresh embryo transfer (57.1% PIEZO-ICSI vs 60.0% ICSI) between microinjection methods, although pregnancy outcomes were underpowered. CONCLUSIONS: PIEZO-ICSI significantly increased fertilization rates, thereby increasing the number of embryos available for cryopreservation compared with standard ICSI. Further prospective studies assessing cumulative pregnancy rates are warranted.

Comparison of in vitro fertilisation/intracytoplasmic sperm injection on live birth rates in couples with non-male factor infertility and advanced maternal age.

PURPOSE: To determine if the use of ICSI in women of advanced maternal age with non-male factor infertility increases chances of live birth. METHODS: Retrospective data analysis of 10 years of cycle data from a single Australian IVF clinic (Repromed). First cycle patients only of an advanced maternal age (≥ 35 years) with non-male factor infertility utilising standard IVF or ICSI insemination and having at least three oocytes collected at egg pick up were assessed for live birth following transfer of single genetically unscreened blastocyst (N = 577). Subanalysis of clinical pregnancy, miscarriage, fertilisation, embryo utilisation rate and having a blastocyst for transfer were considered. Unadjusted, covariate adjusted and propensity score weighted analysis were performed. RESULTS: The use of standard IVF insemination in women ≥ 35 years with non-male factor infertility increased the chance of a live birth compared with ICSI insemination (unadjusted OR = 2.72, 95% CI [1.78, 4.17]; adjusted OR = 2.64, 95% CI [1.64, 4.27] and weighted OR = 2.26, 95% CI [1.72, 2.98] 31% vs 14%). All other outcomes (fertilisation rate, embryo utilisation, blastocyst for embryo transfer and miscarriage rate) were unaffected. CONCLUSION: In couples with advanced maternal age and non-male factor infertility, standard IVF insemination appears to increase the chance of a live birth compared with ICSI. As such, the results of this study support the use of routine IVF as the preferred insemination technique for older women in non-male factor infertility. However, future randomised controlled trials are still required to assess this policy.

Can the use of diagnostic and prognostic categorisation tailor the need for assisted reproductive technology in infertile couples?

BACKGROUND: The complications associated with in vitro fertilisation (IVF) for both the offspring and mother, and its high cost make it essential to tailor the technology to those infertile couples who truly benefit from it. AIMS: To determine whether a simple prognostic algorithm could discriminate between couples who require immediate fertility treatments and couples in whom less invasive strategies should be offered first. MATERIALS AND METHODS: In this retrospective cohort study, couples were classified into six groups based on the medical necessity of IVF and their prognosis for natural conception: (i) tubal/severe semen factor mandating immediate IVF due to the very low chance of natural conception; (ii) pure anovulation infertility; (iii) female age ≥39 years; and (iv) unexplained/mild male infertility (no indication for immediate treatment) with (4A) good, (4B) moderate or (4C) poor prognosis of natural conception, as per an existing, validated prognostic model. For each group, we constructed Kaplan-Meier curves to measure natural conception and the effect of fertility treatment. RESULTS: The 12 months cumulative live birth rate for couples with unexplained or mild male infertility and poor prognosis increased from 1% without treatment to 35% after treatment (P < 0.001). In contrast, couples with good prognosis experienced a statistically insignificant increase in their cumulative live birth rate from 40% to 56% (P = 0.07). This demonstrates that a prognostic model could predict a couple's chances of natural conception and the benefit they derive from treatment. CONCLUSIONS: This prognostic mode allows fertility treatment to be individually tailored to reduce unnecessary IVF without compromising fertility chances.

Posthumous Reproduction and the Law: Tissue Transplantation, Property Rights and the Reproductive Relational Autonomy.

This paper examines the history of Australian superior court decisions on the retrieval of gametic material from deceased men. It examines the history of case law and legislation on the issue and then provides a summary of the current operative principles. The paper concludes with some reflections on the harms caused by posthumous retrieval of gametes, the role of property rights and the nature of reproductive autonomy.

Mechanistic insights into the aetiology of post-prandial decline in testosterone in reproductive-aged men.

Obesity is known to be associated with impaired testicular function potentially resulting in androgen deficiency and subfertility. While the underlying cause of obesity-related male hypogonadism is multi-factorial, here, we investigated the impact of dietary fat on testicular endocrine function. Ingestion of a high-fat "fast food" mixed meal, a common practice for obese men, produced a 25% fall in serum testosterone within an hour of eating, with levels remaining suppressed below fasting baseline for up to 4 hr. These changes in serum testosterone were not associated with any significant changes in serum gonadotrophins. The nadir in serum testosterone preceded the post-prandial increase in serum IL-6/IL-17 by several hours, suggesting that inflammation was unlikely the cause. Furthermore, intravenous administration of fat (Intralipid) had no impact on testosterone levels, while an identical oral dose of fat did suppress testosterone. These results suggest that fat does not directly impair Leydig cell function, but rather the passage of fat through the intestinal tract elicits a response that indirectly elicits a post-prandial fall in testosterone.

Endotoxin-initiated inflammation reduces testosterone production in men of reproductive age.

Inflammation, both acute and chronic, is associated with testosterone deficiency, raising the possibility of a direct causal link. One potential trigger for inflammation in obese men is the passage of intestinal bacteria into the circulation due to a breakdown in mucosal barrier integrity. Recently, we hypothesized that this endotoxin exposure may cause androgen deficiency in obese men. To test this hypothesis, we analyzed the relationship between serum levels of lipopolysaccharide-binding protein (LBP), an indirect measure of endotoxin exposure, against male reproductive hormones, inflammatory markers (C-reactive protein, IL-1ß, IL-6, TNF-α), and adiposity in 75 men. Adiposity was positively correlated with endotoxin exposure (LBP) and inflammation (C-reactive protein, IL-6) and negatively correlated with testosterone. Furthermore, endotoxemia (LBP) was negatively correlated with serum testosterone but positively correlated with IL-6. Multivariate analysis revealed a significant, negative correlation between serum IL-6 and free testosterone. In a second interventional study, low-dose endotoxin challenge in lean men produced a transient inflammatory response that was followed by a decline in serum testosterone, without changes in LH or FSH, providing further evidence that endotoxin-driven inflammation may result in impaired Leydig cell function.

Interferon-gamma inhibits seminal plasma induction of colony-stimulating factor 2 in mouse and human reproductive tract epithelial cells.

Seminal fluid interacts with the female reproductive tract to initiate a permissive immune response that facilitates embryo implantation and pregnancy success. The immune-regulatory cytokine interferon-γ (IFNG), which can be elevated in seminal plasma, is associated with reduced fertility. Here, we investigated how IFNG influences the female immune response to seminal fluid. In human Ect1 cervical epithelial cells, IFNG added at physiologically relevant concentrations substantially impaired seminal plasma-induced synthesis of key cytokines colony-stimulating factor 2 (CSF2) and interleukin-6 (IL6). Seminal fluid-induced CSF2 synthesis was also suppressed in the uterus of mice in vivo, when IFNG was delivered transcervically 12 h after mating. Transforming growth factor B1 (TGFB1) is the major seminal fluid signaling factor which elicits CSF2 induction, and IFNG exhibited potent dose-dependent suppression of CSF2 synthesis induced by TGFB1 in murine uterine epithelial cells in vitro. Similarly, IFNG suppressed TGFB1-mediated CSF2 induction in Ect1 cells and human primary cervical epithelial cells; however, IL6 regulation by IFNG was independent of TGFB1. Quantitative PCR confirmed that CSF2 regulation by IFNG in Ect1 cells occurs at the gene transcription level, secondary to IFNG suppression of TGFBR2 encoding TGFB receptor 2. Conversely, TGFB1 suppressed IFNG receptor 1 and 2 genes IFNGR1 and IFNGR2. These data identify IFNG as a potent inhibitor of the TGFB-mediated seminal fluid interaction with relevant reproductive tract epithelia in mice and human. These findings raise the prospect that IFNG in the male partner's seminal fluid impairs immune adaptation for pregnancy following coitus in women.

Sequential clomiphene/corifollitrophin alpha as a technique for mild controlled ovarian hyperstimulation in IVF: a proof of concept study.

PURPOSE: Mild controlled ovarian hyperstimulation (COH), combined with oocyte retrieval (OR) under local anaesthesia (LA), may provide low-impact IVF. Since a single injection of corifollitrophin alfa (CFA) provides 7 days of COH, we hypothesised that clomiphene-citrate (CC) followed by CFA may provide adequate COH response from one single FSH injection. Therefore, the aim was to assess IVF outcomes after a novel clomiphene citrate/CFA (CC/CFA) protocol, compared to women undergoing standard rFSH COH protocols (good prognosis comparative cohort:GPCC) in a 1:2 matched design. MATERIALS AND METHODS: In this pilot study of 25 patients (ANZCTR id:ACTRN12612000740897, MINIVA:Minimal_Stimulation_in_IVF), we examined the effectiveness of oral clomiphene (100 mg-days 2-6) followed by CFA in a GnRH antagonist protocol producing a single injection COH stimulation regime. All OR were conducted under LA pre-ovarian block. Cycle outcomes were compared to a matched good prognosis comparative cohort (GPCC) undergoing standard rFSH COH. RESULTS: Mild stimulation was achieved with less oocytes being collected compared to the GPCC (6.4 ± 0.7 vs. 10.7 ± 0.9, p < 0.001), resulting in a reduced number of good quality embryos available for transfer/cryopreservation (3.7 ± 0.6 vs. 5.7 ± 0.5, p = 0.01). While embryo quality was similar between the two groups, endometrial thickness was significantly lower in the group receiving CC/CFA. Pregnancy rates were significantly lower in the CC/CFA cohort compared to GPCC (31.8 vs. 57.1%, p = 0.04) and 44% of CC/CFA participants required supplemental rFSH in order to achieve the hCG trigger criteria. CONCLUSION: Sequential clomiphene CFA protocol does not appear to be an optimal regime for low impact IVF treatment as it does not provide adequate COH from a single CFA injection and results in lower fresh embryo transfer pregnancy rates and fewer embryos for cryopreservation.

Seminal plasma pro-inflammatory cytokines interferon-γ (IFNG) and C-X-C motif chemokine ligand 8 (CXCL8) fluctuate over time within men.

STUDY QUESTION: Do seminal plasma pro-inflammatory cytokines interferon-γ (IFNG) and C-X-C motif chemokine ligand 8 (CXCL8) vary within individual men over time? SUMMARY ANSWER: IFNG exhibits substantial variation that is independent of duration of abstinence but correlates with lipopolysaccharide (LPS) content, while CXCL8 varies moderately in association with duration of abstinence. WHAT IS KNOWN ALREADY: Pro-inflammatory cytokines IFNG and CXCL8 in seminal fluid can adversely impact male and female fertility. Other cytokines as well as sperm parameters fluctuate considerably within individuals over time, but whether IFNG and CXCL8 vary similarly, and the determinants of variance, are unknown. STUDY DESIGN, SIZE, DURATION: Between two and seven semen samples were collected from 14 proven fertile donors at 6-10 week intervals over the course of ~12 months, to assess variation over time in cytokines and LPS, and to investigate relationships with sperm parameters and possible regulatory factors. PARTICIPANTS/MATERIALS, SETTING, METHODS: The concentrations and total amounts per ejaculate of IFNG and CXCL8 were determined using commercial ELISA. Sperm parameters were assessed according to World Health Organization (WHO) IV standards and LPS was measured by limulus amebocyte lysate (LAL) assay. Mixed model analysis was utilized to determine the relative contribution of between- and within-individual factors in explaining variance. Relationships between cytokines, LPS and sperm parameters, as well as effect of age and duration of abstinence, were investigated by correlation analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Within-individual variability contributed to total variance particularly for both IFNG, CXCL8 and LPS, and was a stronger determinant than between-individual variability for IFNG and LPS. Normal sperm motility correlated inversely with CXCL8, and sperm concentration correlated inversely with LPS. Duration of abstinence was a determinant of total CXCL8, but not IFNG or LPS. Associations between LPS, IFNG and CXCL8 suggest IFNG and perhaps CXCL8 are influenced by microbial populations. LIMITATIONS, REASONS FOR CAUTION: A limited number of donors from a single clinic were investigated. Clinical information on complete microbiology, BMI, nutrition, smoking and other lifestyle factors was unavailable. Further studies are required to determine whether the findings can be generalized to larger populations and different ethnicities. WIDER IMPLICATIONS OF THE FINDINGS: These data reveal substantial variation over time in pro-inflammatory seminal fluid cytokines and imply existence of microbial or other environmental regulatory factors. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grants from the National Health and Medical Research Council of Australia. The authors have no competing interests to disclose.

Increased miscarriage of euploid pregnancies in obese women undergoing cryopreserved embryo transfer.

Obesity is known to be associated with an increased risk of miscarriage after natural and assisted conception. Although most sporadic miscarriages are caused by genetic abnormalities, it is presently uncertain if genetics is also the underlying mechanism leading to increased pregnancy loss seen in obese women. Karyotyping of the products of conception suggests a reduced rate of fetal aneuploidy in miscarriages from obese compared with lean individuals. Karyotype analysis, however, is prone to false negative results because of inadvertent culture of maternal rather than fetal tissue. Therefore, to better analyse the effect of the genetic status on obesity-related miscarriage, we retrospectively analysed the outcomes 125 consecutive cryopreserved embryo transfer cycles resulting in a pregnancy after screening for genetic normality using comparative genomic hydridization. Lean individuals (body mass index 18.5-24.9 kg/m2) had a significantly lower rate of miscarriages (14.2%) than overweight (29.1%) or obese (41.9%) women (P = 0.001); this relationship remained significant (P = 0.023) even after adjusting for relevant confounders, e.g. maternal age, cause of infertility, number of previous IVF cycles, type of frozen embryo transfer cycle or past obstetric history. These results support a non-genetic cause for obesity-related miscarriage.

Should obese women's access to assisted fertility treatment be limited? A scientific and ethical analysis.

Obesity is associated with a reduction in fertility treatment success and increased risks to mother and child. Therefore guidelines of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) suggest that a body mass index exceeding 35 kg/m2 should be an absolute contraindication to assisted fertility treatment such as in vitro fertilisation IVF. In this paper we challenge the ethical and scientific basis for such a ban. Livebirth rates for severely obese women are reduced by up to 30%, but this result is still far better than that observed for many older women who are allowed access to IVF. This prohibition is particularly unjust when IVF is the only treatment capable of producing a pregnancy, such as bilateral tubal blockage or severe male factor infertility. Furthermore, the absolute magnitude of risks to mother or child is relatively small, and while a woman has a right to be educated about these risks, she alone should be allowed to make a decision on proceeding with treatment. We do not prohibit adults from engaging in dangerous sports, nor do we force parents to vaccinate their children, despite the risks. Similarly, we should not prohibit obese women from becoming parents because of increased risk to themselves or their child. Finally, prohibiting obese women's access to IVF to prevent potential harms such as 'fetal programing' is questionable, especially when compared to that child never being born at all. As such, we believe the RANZCOG ban on severely obese women's access to assisted reproductive treatment is unwarranted and should be revised.

Seminal plasma transforming growth factor-ß, activin A and follistatin fluctuate within men over time.

STUDY QUESTION: Do seminal plasma transforming growth factor-ß (TGFB) cytokines vary within individuals over time, and does this relate to sperm parameters, age or prior abstinence? SUMMARY ANSWER: Activin A and follistatin, and to a lesser extent TGFB1, TGFB2 and TGFB3, vary within individuals over time, in association with duration of abstinence. WHAT IS ALREADY KNOWN: Seminal plasma TGFB cytokines can influence sperm function and reproductive success through interactions with the female reproductive tract after coitus. Over time, individual sperm parameters fluctuate considerably. Whether seminal fluid TGFB cytokines vary similarly, and the determinants of any variance, is unknown. STUDY DESIGN, SIZE, DURATION: Between two and seven semen samples were collected from each of 14 fertile donors at 6-10 week intervals over the course of 12 months, then seminal plasma cytokines and sperm parameters were measured. PARTICIPANTS/MATERIALS, SETTING AND METHOD: The concentrations and total amounts per ejaculate of TGFB1, TGFB2, TGFB3, activin A and follistatin were determined using commercial assays. Sperm parameters were assessed according to WHO IV standards. Mixed model analysis was utilised to determine the relative contribution of between- and within-individual factors to the variance. Relationships between cytokines and sperm parameters, as well as effect of age and duration of abstinence, were investigated by correlation analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Within-individual variability contributed to the total variance for all cytokines and sperm parameters, and was a stronger determinant than between-individual variability for activin A and follistatin as well as for total sperm concentration and sperm motility. Positive correlations between each of the three TGFB isoforms, and activin and follistatin, suggest co-regulation of synthesis. Duration of abstinence influenced total content of TGFB1, TGFB2, activin A and follistatin. TGFB1 correlated inversely with age. LIMITATIONS, REASONS FOR CAUTION: A limited number of donors from a single clinic were investigated. Clinical information on BMI, nutrition, smoking and other lifestyle factors was unavailable. Further studies are required to determine whether the findings can be generalised to larger populations and different ethnicities. WIDER IMPLICATIONS OF THE FINDINGS: These data reveal substantial variation over time in seminal fluid cytokines and indicate that repeated analyses are required to gain precise representative data on an individual's status. Within-individual variation in seminal fluid components should be taken into account when investigating seminal fluid cytokines. STUDY FUNDING/COMPETING INTERESTS: This study was supported by grants from the National Health and Medical Research Council of Australia, ID453556 and APP1041332. The authors have no competing interests to disclose.

For love or money? Australian attitudes to financially compensated (commercial) surrogacy.

BACKGROUND: Australian law allows for altruistic surrogacy but prohibits compensation of surrogates beyond their expenses, or the use of professional surrogacy agencies. These restrictions limit local access to surrogacy, driving Australians overseas where they can access commercial surrogacy. AIM: To assess the Australian public's views regarding the use of gestational surrogacy under various social and medical scenarios, together with their level of support for financial compensation of surrogates and the use of professional surrogacy agencies. MATERIALS AND METHODS: Online survey of 500 Australians of reproductive age (18-49 years) regarding views on surrogacy and acceptable levels of compensation, conducted during January 2016. RESULTS: The majority of respondents supported access to surrogacy for couples, irrespective of a couple's marital status or sexuality, with only 9% believing that surrogacy was unjustified under any circumstances. Of those who held a view on compensated surrogacy, over half (58%) believed the current ban was unjustified, with close to two-thirds (62%) also believing that Australians should be allowed to access commercial surrogacy overseas. In relation to compensation, most believed that payment should be determined by negotiation between the surrogate and commissioning parents, while also supporting additional payments for 'hardship' pregnancies. Half of the surveyed cohort supported the legalisation of professional surrogacy agencies, with only 17% being totally opposed. CONCLUSIONS: The majority of Australians support surrogacy, compensation for surrogates and professional surrogacy agencies. Therefore, the existing legal restrictions should be replaced with professional guidelines that protect the surrogate and commissioning parents, while also improving Australians' access to surrogacy.

Serum anti-Mullerian hormone production is not correlated with seasonal fluctuations of vitamin D status in ovulatory or PCOS women.

STUDY QUESTION: Is there a relationship between serum anti-Mullerian hormone (AMH) levels and seasonal variations in serum vitamin D in ovulatory and polycystic ovary syndrome (PCOS) women? STUDY ANSWER: Serum AMH levels were not associated with serum vitamin D status even after controlling for relevant co-variants, with this finding being consistent for all causes of infertility. As expected, seasonal variations in serum vitamin D were observed between summer and winter. WHAT IS KNOWN ALREADY: AMH plays an important role in maintaining ovarian reserve and modifying follicle sensitivity to FSH stimulation. Studies suggest that vitamin D has the ability to modify AMH production in vitro, yet only one clinical study reports the influence of vitamin D on AMH levels. STUDY DESIGN, SIZE, DURATION: This was a retrospective cohort study analyzing the potential interaction of AMH and vitamin D for 340 women (58 PCOS and 282 ovulatory women) aged less than 40 years collected as part of their routine fertility assessment between January and December 2013 at a private fertility clinic in Adelaide, South Australia. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patient data including age, BMI, cause of infertility, antral follicle counts (AFC), serum AMH and vitamin D levels, smoking status, and menstrual cycle length for women aged less than 40 years of age, with serum AMH and vitamin D sampled within the same 4-week period were retrieved from a database. The hours of sunlight per day and daily UV index were extracted from a database at the South Australian Bureau of Meteorology, South Australia. Serum vitamin D (25-hydroxyvitamin D) levels were analyzed against seasonal variation in sunlight and UV exposure and serum AMH levels, while controlling for relevant co-variants. MAIN RESULTS AND THE ROLE OF CHANCE: Seasonal variations in serum vitamin D were observed between summer and winter (30% variance; P < 0.001), while serum AMH levels (mean ± SEM) remained unaffected by season status (36.9 ± 3.3 versus 38.5 ± 2.7 pmol/l; P > 0.05), even after controlling for relevant co-variants. Overall, no correlation was observed between serum AMH and vitamin D levels, in either the PCOS or ovulatory cohort. Serum vitamin D levels were not significantly related to the underlying cause of infertility (PCOS, diminished ovarian reserve, 'fertile' ovulatory controls). LIMITATIONS, REASONS FOR CAUTION: The data used to generate the study findings are cross sectional in nature. While we acknowledge that a longitudinal study monitoring the relationship between serum AMH and vitamin D in individuals over the four seasons would have been ideal, we believe the current findings are robust as our four seasonal groups did not differ for any significant co-variant for serum AMH or vitamin D (age, BMI, PCOS status or AFC) and that there is no significant association between serum vitamin D concentration and AMH production. WIDER IMPLICATIONS OF THE FINDINGS: At present, while in vitro studies suggest vitamin D has the potential to modify AMH production, clinical study findings are conflicting. If vitamin D does influence AMH production, this could have important therapeutic implications. STUDY FUNDING/COMPETING INTERESTS: K.G. was supported through a University of South Australia summer scholarship. The authors have no competing interests.

Pregnancy and childhood health and developmental outcomes with the use of posthumous human sperm.

Although there is now considerable experience in obtaining sperm from a cadaver, there is little or no published data regarding pregnancy, birth and long-term childhood health and development outcomes when posthumous sperm is used in in vitro fertilisation (IVF). We report the results from treatment of four women undergoing IVF treatment using posthumously acquired human sperm from their deceased partners. In all cases, testicular tissue was obtained in a mortuary setting, and the duration from death to posthumous sperm retrieval ranged from 12 to 48 h. The age of women treated ranged from 31 to 41 years. Fertilization rates ranged from 40 to 100%. Singleton pregnancies were obtained for each of the four women. One pregnancy was complicated by preterm birth at 31 weeks; the other three delivered at term. One baby was growth restricted but morphologically normal; the other children had term birthweights in the normal range. All four children were have shown normal health and developmental outcomes, with the follow-up ranging from 1 to 7 years.