How vitamin D level influences in vitro fertilization outcomes: results of a systematic review and meta-analysis.

OBJECTIVE: To investigate the impact of serum vitamin D level on in vitro fertilization (IVF) outcomes. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENTS: Infertile women undergoing conventional IVF or intracytoplasmic sperm injection (ICSI). INTERVENTIONS: Systematic search of PubMed, MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database, and Web of Science from inception until July 2019 with cross-checking of references from relevant articles in English. Vitamin D levels were categorized into three groups: deficient (<20 ng/mL), insufficient (20-30 ng/mL), and replete (>30 ng/mL). Before starting the data extraction, we registered the review protocol in PROSPERO (CRD42019134258). MAIN OUTCOME MEASURES: We consider clinical pregnancy rate (CPR), live birth rate (LBR), and/or ongoing pregnancy rate (OPR) as primary outcomes. Likewise, the miscarriage rate was considered as a secondary outcome. RESULTS: Primary analysis showed that women with a replete level of vitamin D had higher CPR and LBR/OPR compared to those with a deficient of insufficient level of vitamin D. However, sensitivity analysis led to non-significant differences between the comparators for CPR (odds ratio 0.71, 95% confidence interval 0.47-1.08, I2 = 61%) and OPR/LBR (odds ratio 0.78, 95% confidence interval 0.56-1.08], I2 = 61%). Also, for miscarriage a statistically different rate was not reached. CONCLUSION: Serum vitamin D levels do not influence IVF outcomes in terms of CPR, LBR/OPR, and miscarriage rate. Future large cohort studies are warranted to determine whether the threshold of vitamin D affects reproductive outcomes. Currently, there is a lack of consensus between the appropriate vitamin D threshold to predict reproductive outcomes compared to the one established for bone health. PROSPERO NUMBER: CRD42019134258.

Gonadotrophins versus clomiphene citrate with or without IUI in women with normogonadotropic anovulation and clomiphene failure: a cost-effectiveness analysis.

STUDY QUESTION: Are six cycles of ovulation induction with gonadotrophins more cost-effective than six cycles of ovulation induction with clomiphene citrate (CC) with or without IUI in normogonadotropic anovulatory women not pregnant after six ovulatory cycles with CC? SUMMARY ANSWER: Both gonadotrophins and IUI are more expensive when compared with CC and intercourse, and gonadotrophins are more effective than CC. WHAT IS KNOWN ALREADY: In women with normogonadotropic anovulation who ovulate but do not conceive after six cycles with CC, medication is usually switched to gonadotrophins, with or without IUI. The cost-effectiveness of these changes in policy is unknown. STUDY DESIGN, SIZE, DURATION: We performed an economic evaluation of ovulation induction with gonadotrophins compared with CC with or without IUI in a two-by-two factorial multicentre randomized controlled trial in normogonadotropic anovulatory women not pregnant after six ovulatory cycles with CC. Between December 2008 and December 2015 women were allocated to six cycles with gonadotrophins plus IUI, six cycles with gonadotrophins plus intercourse, six cycles with CC plus IUI or six cycles with CC plus intercourse. The primary outcome was conception leading to a live birth achieved within 8 months of randomization. PARTICIPANTS/MATERIALS, SETTING, METHODS: We performed a cost-effectiveness analysis on direct medical costs. We calculated the direct medical costs of ovulation induction with gonadotrophins versus CC and of IUI versus intercourse in six subsequent cycles. We included costs of medication, cycle monitoring, interventions, and pregnancy leading to live birth. Resource use was collected from the case report forms and unit costs were derived from various sources. We calculated incremental cost-effectiveness ratios (ICER) for gonadotrophins compared to CC and for IUI compared to intercourse. We used non-parametric bootstrap resampling to investigate the effect of uncertainty in our estimates. The analysis was performed according to the intention-to-treat principle. MAIN RESULTS AND THE ROLE OF CHANCE: We allocated 666 women in total to gonadotrophins and IUI (n = 166), gonadotrophins and intercourse (n = 165), CC and IUI (n = 163), or CC and intercourse (n = 172). Mean direct medical costs per woman receiving gonadotrophins or CC were €4495 versus €3006 (cost difference of €1475 (95% CI: €1457-€1493)). Live birth rates were 52% in women allocated to gonadotrophins and 41% in those allocated to CC (relative risk (RR) 1.24:95% CI: 1.05-1.46). The ICER was €15 258 (95% CI: €8721 to €63 654) per additional live birth with gonadotrophins. Mean direct medical costs per woman allocated to IUI or intercourse were €4497 versus €3005 (cost difference of €1510 (95% CI: €1492-€1529)). Live birth rates were 49% in women allocated to IUI and 43% in those allocated to intercourse (RR = 1.14:95% CI: 0.97-1.35). The ICER was €24 361 (95% CI: €-11 290 to €85 172) per additional live birth with IUI. LIMITATIONS, REASONS FOR CAUTION: We allowed participating hospitals to use their local protocols for ovulation induction and IUI, which may have led to variation in costs, but which increases generalizability. Indirect costs generated by transportation or productivity loss were not included. We did not evaluate letrozole, which is potentially more effective than CC. WIDER IMPLICATIONS OF THE FINDINGS: Gonadotrophins are more effective, but more expensive than CC, therefore, the use of gonadotrophins in women with normogonadotropic anovulation who have not conceived after six ovulatory CC cycles depends on society's willingness to pay for an additional child. In view of the uncertainty around the cost-effectiveness estimate of IUI, these data are not sufficient to make recommendations on the use of IUI in these women. In countries where ovulation induction regimens are reimbursed, policy makers and health care professionals may use our results in their guidelines. STUDY FUNDING/COMPETING INTEREST(S): This trial was funded by the Netherlands Organization for Health Research and Development (ZonMw number: 80-82310-97-12067). The Eudract number for this trial is 2008-006171-73. The Sponsor's Protocol Code Number is P08-40. CBLA reports unrestricted grant support from Merck and Ferring. BWM is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for Merck, ObsEva and Guerbet. TRIAL REGISTRATION NUMBER: NTR1449.

Assessment of oxytocin level, glucose metabolism components and cutoff values for oxytocin and anti-mullerian hormone in infertile PCOS women.

OBJECTIVE: Comparing oxytocin level and some other parameters between infertile women with or without polycystic Ovary Syndrome (PCOS), to evaluate the correlation between oxytocin with anti-mullerian hormone (AMH), Body Mass Index (BMI) and insulin resistance (IR). MATERIALS AND METHODS: This cross-sectional study was performed on 80 PCOS and 81 non-PCOS women as the control group. Oxytocin, various hormones, Oral glucose tolerance test (OGTT) and Homeostatic model assessment of insulin resistance (HOMA-IR) were compared between two groups. Correlations between parameters were assessed by the spearman's rank correlation coefficient. Cutoff values for oxytocin and AMH in PCOS were calculated by the ROC-Curve and DeLong method. RESULTS: The mean oxytocin level was statistically lower in the case group (p ≤ 0.001). The mean BMI, AMH, HOMA-IR, fasting insulin and insulin 2-h after 75-g glucose were significantly higher in the PCOS group. Oxytocin was negatively correlated to AMH when evaluated for all participants or only among controls. Moreover oxytocin was negatively correlated to HOMA-IR among all participants. However the relationship between oxytocin and BMI was not statistically significant. The calculated cutoff value for oxytocin was 125 ng/L and for AMH was 3.6 ng/mL in the PCOS group. CONCLUSION: The mean oxytocin level in the PCOS infertile women was lower than non-PCOS women. Oxytocin showed a significant reverse correlation with AMH and HOMA-IR.

There is a Positive Correlation Between Socioeconomic Status and Ovarian Reserve in Women of Reproductive Age.

BACKGROUND The purpose of this study was to investigate the potential association between socioeconomic status and ovarian reserve, anti-Mullerian hormone level, antral follicle count, and follicle stimulating hormone level in women of reproductive age. MATERIAL AND METHODS A total of 101 married women between 20-35 years of age who presented to the Department of Obstetrics and Gynecology, Health Research System In Vitro Fertilization (HRS IVF) Center between October 2014 and November 2015 and met the inclusion criteria were included in this study. The participants were divided into three socioeconomic groups using Kuppuswamy's socioeconomic status scale. Thirty-one participants were assigned to the low socioeconomic status group, 37 to the middle socioeconomic status group, and 33 to the high socioeconomic status group. On days 3-6 of the menstrual cycle, 10 mL of blood was collected from the participants for follicle stimulating hormone and anti-Mullerian hormone measurements. Transvaginal ultrasonography was performed for both ovaries for the purpose of counting antral follicles measuring 2-10 mm in diameter. RESULTS Both ovarian reserve parameters, namely anti-Mullerian hormone level and antral follicle count, exhibited a significant association with socioeconomic status (p=0.000 and p=0.000, respectively). The association between follicle stimulating hormone level and socioeconomic status was also significant (p=0.000). CONCLUSIONS A low socioeconomic status aggravated by sources of stress such as undernutrition and financial hardships affects ovarian reserve, which should be remembered in approaching infertile patients.

Low progesterone levels and ovulation by ultrasound assessment in infertile patients.

OBJECTIVE: To assess the correlation between low levels of progesterone and ovulation by ultrasound monitoring in infertile patients with regular menstrual cycles. METHODS: Case-control study. The sample consisted of 302 women aged 20-40 years, treated from 2000 to 2014 in the Human Reproduction Laboratory of the University Hospital of the Federal University of Goiás and in the Department of Gynecology and Obstetrics in Goiânia, Goiás. Data collection was performed by analysis of physical records (Medical Records and Health Information Services) and electronic ones (Sisfert©, 2004) after approval by a Human Research Ethics Committee. Patients were classified according to their ovulatory status, evaluated by progesterone levels and ultrasound monitoring and divided into two groups: Group I (anovulatory cycle patients, n=74) and Group II (ovulatory patients, n=228). In both groups associations were made between the percentage of patients with normal progesterone (≥ 10 ng/ml) and percentage of patients with low progesterone (5.65 - 9.9 ng/ml). The groups were paired for comparisons related to age, body mass index, duration of infertility, follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), luteinizing hormone (LH) and estradiol (E2). RESULTS: There was a significant association between the percentage of ovulation by ultrasound monitoring and the percentages of patients who presented low levels of progesterone. CONCLUSION: The study suggests that low serum levels of progesterone are associated with low percentage of ovulation in infertile women with regular menstrual cycles and women with unexplained infertility.

An assessment of anti-Müllerian hormone in predicting mating outcomes in female hamsters that have undergone natural and chemically-accelerated reproductive aging.

In mammals, female fertility declines with age due in part to a progressive loss of ovarian follicles. The rate of follicle decline varies among individuals making it difficult to predict the age of onset of reproductive senescence. Serum anti-Müllerian hormone (AMH) concentrations correlate with the numbers of ovarian follicles, and therefore, AMH could be a useful predictor of female fertility. In women and some production animals, AMH is used to identify which individuals will respond best to ovarian stimulation for assisted reproductive technologies. However, few studies have evaluated AMH's predictive value in unassisted reproduction, and they have yielded conflicting results. To assess the predictive value of AMH in the context of reproductive aging, we prospectively measured serum AMH in 9-month-old Siberian hamsters shortly before breeding them. Female Siberian hamsters experience substantial declines in fertility and fecundity by 9months of age. We also measured serum AMH in 5-month-old females treated with 4-vinylcyclohexene diepoxide (VCD), which selectively destroys ovarian follicles and functionally accelerates ovarian aging. Vehicle-treated 5-month-old females served as controls. AMH concentrations were significantly reduced in VCD-treated females yet many females with low AMH reproduced successfully. On average, both young and old hamsters that littered had higher AMH concentrations than females that did not. However, some females with relatively high AMH concentrations failed to litter, whereas several with low AMH succeeded. Our results suggest that mean AMH concentration can predict mating outcomes on a population or group level, but on an individual basis, a single AMH determination is less informative.

Prospective study into the value of the automated Elecsys antimüllerian hormone assay for the assessment of the ovarian growing follicle pool.

OBJECTIVE: To evaluate a new fully automated assay measuring antimüllerian hormone (AMH; Roche Elecsys) against antral follicle count in women of reproductive age. DESIGN: Prospective cohort study. SETTING: Hospital infertility clinics and academic centers. PATIENT(S): Four hundred fifty-one women aged 18 to 44 years, with regular menstrual cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): AMH and antral follicle count (AFC) determined at a single visit on day 2-4 of the menstrual cycle. RESULT(S): There was a statistically significant variance in AFC but not in AMH between centers. Both AFC and AMH varied by age (overall Spearman rho -0.50 for AFC and -0.47 for AMH), but there was also significant between-center variation in the relationship between AFC and age but not for AMH. There was a strong positive correlation between AMH and AFC (overall spearman rho 0.68), which varied from 0.49 to 0.87 between centers. An agreement table using AFC cutoffs of 7 and 15 showed classification agreement in 63.2%, 56.9% and 74.5% of women for low, medium, and high groups, respectively. CONCLUSION(S): The novel fully automated Elecsys AMH assay shows good correlations with age and AFC in women of reproductive age, providing a reproducible measure of the growing follicle pool.

Anti-Müllerian hormone and assessment of ovarian reserve after ovarian toxic treatment: a systematic narrative review.

Since serum anti-Müllerian hormone (AMH) levels enable quantitative evaluation of ovarian damage, we conducted a computer-based search, using key words, of all articles published in English through the PubMed database from inception until September 2013 to summarize available studies evaluating ovarian reserve after ovarian toxic interventions to discuss the usefulness of serum AMH levels. We found that most of the studies demonstrated a decline in serum AMH levels when compared to control or pretreatment levels, with levels dependent on the type of treatment modality. Measurement of serum AMH levels enables quantitative evaluation of ovarian damage caused by ovarian toxic interventions, such as chemotherapy and radiotherapy, instead of qualitative evaluation using menstrual condition or basal follicle-stimulating hormone levels. Serum AMH levels are becoming indispensable to assess the ovarian reserve of patients who desire preservation of ovarian function for fertility and endogenous sex steroid hormones.

Progesterone-to-follicle index is better correlated with in vitro fertilization cycle outcome than blood progesterone level.

OBJECTIVE: To investigate the impact of late follicular phase progesterone (P) elevation in relation to ovarian response on cycle outcome. DESIGN: Cohort study. The progesterone-to-follicle index (PFI) was calculated by dividing the blood P by the number of follicles ≥14 mm. The clinical pregnancy rate was calculated against the range of PFI values and blood P levels. SETTING: In vitro fertilization unit. PATIENT(S): A heterogenous population undergoing IVF with pituitary suppression and gonadotropin stimulation resulting in 3-15 follicles ≥14 mm and blood P≤10 nmol/L on hCG day and resulting in fresh embryo transfer. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Association of blood P and PFI with clinical pregnancy rate. RESULT(S): Data were retrieved for 8,649 IVF cycles in normal responders. The (reverse) odd ratios for pregnancy were 1.112 (95% confidence interval [CI], 1.077-1.165) for blood P and 4.104 (95% CI, 3.188-5.284) for the PFI. Elevated P levels were associated with a lower pregnancy rate only when they reached the >93rd percentile. The PFI was inversely and linearly related to the pregnancy rate for the whole range of values. CONCLUSION(S): A late increase in P level is detrimental if it is a consequence of increased P production per follicle (high PFI) but not if it is a consequence of additional follicular recruitment. The PFI enables clinicians to differentiate these conditions.

Antimüllerian hormone, the assessment of the ovarian reserve, and the reproductive outcome of the young patient with cancer.

The accurate assessment of the ovarian reserve has long been a key goal in reproductive medicine. The recognition that serum antimüllerian hormone provides an indirect measure of the ovarian reserve has led to its rapid adoption in assisted conception, and wide exploration of its potential across the reproductive lifespan from the neonate to the menopause. In this short review we discuss its relationship with the ovarian reserve in its varied meanings, and in various contexts. These include in childhood and adolescence, and in the assessment of the impact of cancer therapy on the female reproductive tract. These therapies can adversely impact all aspects of female reproduction, including hypothalamic, pituitary, and ovarian hormonal activity, and the ability of the uterus to support a successful pregnancy.

Utility of antimüllerian hormone level obtained for infertility assessment for alerting to ovarian tumor.

BACKGROUND: Antimüllerian hormone is a marker of ovarian reserve and is now routinely measured in women seeking infertility treatment. CASE: A 42-year-old woman, gravida 1, abortus 1, presented with secondary infertility. Obtained originally for assessment of ovarian reserve, an antimüllerian hormone of more than 160 ng/mL raised suspicion for a granulosa cell tumor. A laparoscopic right salpingo-oophorectomy, pelvic washings, dilation and curettage, and peritoneal and omental biopsies were performed. A well-differentiated granulosa cell tumor confined to the right ovary was consistent with stage 1A disease. CONCLUSION: As the use of antimüllerian hormone becomes more common for ovarian reserve testing, providers need to maintain an awareness for neoplastic disease with abnormal values.

Receptivity assessment of an ultrasonographic homogeneous endometrium in the late follicular phase of infertile women with natural cycles.

OBJECTIVE: The purpose of this study was to assess the receptivity of the homogeneous endometrium in the late follicular phase in infertile women with natural cycles. STUDY DESIGN: Twenty-eight infertile women with ultrasonographically homogeneous (group 1) or trilaminar (group 2) endometria in the late follicular phase underwent endometrial biopsies. Some molecular markers and development of pinopodes were evaluated. RESULTS: In the late follicular phase, the mean level of vascular endothelial growth factor was significantly lower in group 1 than in group 2 (0.96 ± 0.37 marks vs 1.39 ± 0.46 marks; P = .010). In the mid luteal phase, a decreased leukemia inhibitory factor and integrin alpha v beta 3 levels were found in group 1 (1.58 ± 0.99 marks vs 2.59 ± 0.61 marks; 1.85 ± 0.72 marks vs 2.60 ± 0.73 marks; 1.92 ± 0.91 marks vs 2.83 ± 0.57 marks; P = .003; P = .011; P = .004). The rate of fully developed pinopodes in the mid luteal phase was significantly decreased in group 1 (P = .018). CONCLUSION: An ultrasonographically homogeneous endometrium in the late follicular phase was associated with poor receptivity in infertile women with natural cycles.

Physicians should be more open-minded about performing in vitro fertilization-embryo transfer in women with diminished oocyte reserve and consider the couple's wishes and desires.

PURPOSE: By presenting anecdotal cases of women who conceived with IVF-ET despite very poor odds, this editorial hopes to make some of the infertility specialists to be more optimistic about the prognosis for pregnancy in women with diminished oocyte reserve. METHODS: Description of case reports where despite poor odds the couples elected to still attempt IVF-ET which appeared to be needed for conception to be possible. RESULTS: Five cases are presented where the couple was willing to deplete their financial resources to achieve a pregnancy with IVF-ET using their own gametes and were eventually successful. CONCLUSIONS: Physicians should restrain from being dogmatic and present all options to patients not merely the physicians' preference. It is embarrassing for a physician to insist that successful pregnancy is impossible only for the patient to prove that physician wrong. After receiving proper data patients should be allowed greater input into their treatment decision.

Assessment of FSHR variants and antimüllerian hormone in infertility patients with a reduced ovarian response to gonadotropin stimulation.

OBJECTIVE: To study women with a poor response to ovarian hormone stimulation, known as low responders. Genetic defects in the FSH receptor gene (FSHR) were analyzed as well as antimüllerian hormone (AMH) for ovarian reserve. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENT(S): Two hundred fifty-nine patients total: 74 low responders; 88 patients receiving assisted reproduction therapy (ART) with a normal ovarian response; and 97 women with a normal fertility status. INTERVENTION(S): DNA from patients was analyzed using real-time polymerase chain reaction. Serum concentrations of AMH were assessed using ELISA. MAIN OUTCOME MEASURE(S): The FSHR variants Asn680Ser (rs6166), Ala189Val (rs121909658), Ile160Thr (rs121909659), Thr449Ile (rs28928870) and the serum AMH concentrations were assessed. RESULT(S): With the exception of the frequent Asn680Ser polymorphism, no homozygotic SNPs of FSHR were found. In the group of ART patients, Thr160/Ile160 variants were more frequent in comparison with women with normal fertility. The Ser680/Ser680 was more frequent in ART patients than in women with normal reproductive function. The rate of live births was markedly reduced, particularly in the low responder group. No difference was noted in the distribution of the Ala189Val and Thr449Ile variant. Low serum AMH values were observed in 75% of the low responder group. CONCLUSION(S): FSHR gene variations such as Asn680Ser, Ala189Val, Thr449Ile, and Ile160Thr did not seem to be a decisive factor of poor response to fertility treatment, whereas the low ovarian reserve determined by AMH is considered more crucial.

Assessment of ovarian reserve in adult childhood cancer survivors using anti-Müllerian hormone.

BACKGROUND: The aim was to assess possible treatment-induced gonadal damage in a cohort of adult female childhood cancer survivors (CCS) using anti-Müllerian hormone (AMH), the most sensitive marker of ovarian reserve. METHODS: A total cohort of 185 survivors was compared with 42 control subjects. The median follow-up time was 18.1 years (range 4.1-43.2 year). RESULTS: Median AMH concentrations in the analysed cohort were not different from controls (median 1.7 versus 2.1 microg/l; P = 0.57). However, AMH levels were lower than the 10th percentile of normal values in 27% (49/182) of our survivors. In addition, 43% (79/182) had AMH levels lower than 1.4 microg/l, a previously established cut-off value which predicts ongoing pregnancy after assisted reproduction. There were no differences in AMH levels in subgroups classified according to disease. However, survivors treated with three or more procarbazine containing chemotherapy cycles had significantly lower AMH levels than controls (median 0.5 microg/l; P = 0.004). Also survivors treated with abdominal or total body irradiation had significantly lower AMH levels than controls (median < 0.1 microg/l; P < 0.001). CONCLUSIONS: AMH can be used to identify subgroups of CCS at risk for decreased fertility or premature ovarian failure. In these survivors, options for fertility preservation should be considered prior to starting treatment since they may be at risk for poor chances of pregnancy after assisted reproductive treatment.

What can we expect if we measure hormones in eumenorrhoeic infertile patients?

This paper deals with the question of whether measuring hormones is necessary in eumenorrhoeic infertility patients. The answer presented here is yes, but there are some remaining and debatable problems. In our opinion, eumenorrhoea results from regular folliculogenesis, ovulation and luteal function. To be time- and cost-effective, only a limited number of hormones should be measured and assessment of the luteal phase in an eumenorrhoeic patient by measuring oestradiol and progesterone is questionable. The paper discusses the questions on the basis of the currently available literature.

The combined effect of age and basal follicle-stimulating hormone on the cost of a live birth at assisted reproductive technology.

OBJECTIVE: To predict the cost of a delivery following assisted reproductive technologies (ART). DESIGN: Cost analysis based on retrospective chart analysis. SETTING: University-based ART program. PATIENT(S): Women aged >or=26 and

Simple tools for assessment of ovarian reserve (OR): individual ovarian dimensions are reliable predictors of OR.

OBJECTIVE: To determine the association between individual ovarian dimensions, advancing age, and declining ovarian reserve (OR) in an infertile population. DESIGN: An ongoing prospective observational study. SETTING: Academic infertility practice. PATIENT(S): Sixty-nine premenopausal women presenting for the evaluation and management of infertility. INTERVENTION(S): Transvaginal ultrasound assessment of the ovarian dimensions (length, width, and overall diameter in cm) and evaluation of the OR status by measuring serum levels of FSH and E(2) in the early follicular phase of the menstrual cycle. MAIN OUTCOME MEASURE(S): Relationship of the individual ovarian dimensions to age (years) and OR (reflected by historical maximal FSH levels). RESULT(S): A statistically significant decrease in three ovarian size parameters accompanied advancing age (ovarian width, r = -0.30; ovarian length, r = -0.24; and the mean overall ovarian diameter, r = -0.30). Levels of FSH demonstrated a significant and linear correlation with age (r = 0.39). Increasing levels of FSH (and hence declining OR) were associated with statistically significant declines in the mean ovarian width (r = -0.39), length (r = -0.38), and overall mean ovarian diameter (r = -.42), Patients with a known diagnosis of diminished OR demonstrated significantly reduced ovarian dimensions compared with patients with other infertility etiologies. Multivariate linear regression analysis confirmed individual ovarian measurements (width, length, and overall diameter) as independent predictors of OR (FSH levels) after adjusting for parameters that are known to influence ovarian size, i.e., age, smoking status, body mass index, and anovulation history. Ovarian width emerged as the strongest predictor of OR (largest beta coefficient and hence the strongest association with OR status), compared with ovarian length and the mean ovarian diameter. CONCLUSION(S): Single ovarian dimensions are reliable predictors of advancing age and declining OR status in premenopausal infertile women. The magnitude of this association is most robust for the ovarian width.

Assessment of ovarian reserve by using the follicle-stimulating hormone isoform distribution pattern to predict the outcome of in vitro fertilization.

Changes in FSH isoforms occur at temporally specific times during the menstrual cycle and reproductive lifespan. Changes in ratio in FSH isoforms may provide a sensitive test of ovarian reserve before IVF.

High reproducibility of serum anti-Mullerian hormone measurements suggests a multi-staged follicular secretion and strengthens its role in the assessment of ovarian follicular status.

BACKGROUND: Our aim was to compare the intercycle reproducibility of serum anti-Mullerian hormone (AMH) measurements with that of other markers of ovarian follicular status. METHODS: Forty-seven normo-ovulatory, infertile women underwent serum AMH, inhibin B, estradiol and FSH measurements and early antral follicle (2-12 mm in diameter) counts by transvaginal ultrasound on cycle day 3 during three consecutive menstrual cycles. Reproducibility of measurements was estimated using intra-class correlation coefficient (ICC) calculation. We also assessed the number of replicate measurements theoretically needed to reach satisfactory reliability of results. RESULTS: Serum AMH showed significantly higher reproducibility (ICC, 0.89; 95% confidence interval, 0.83-0.94) than inhibin B (0.76; 0.66-0.86; P < 0.03), estradiol (0.22; 0.03-0.41; P < 0.0001) and FSH levels (0.55; 0.39-0.71; P < 0.01), and early antral follicle counts (0.73; 0.62-0.84; P < 0.001), and reached satisfactory reliability with a single measurement. CONCLUSIONS: The improved cycle-to-cycle consistency of AMH as compared with other markers of ovarian follicular status is in keeping with its peculiar production by follicles at several developmental stages and further supports its role as a cost-effective, reliable marker of ovarian fertility potential.