Risk Factors for Infertility in Korean Women.

BACKGROUND: Female infertility is a crucial problem with significant implications for individuals and society. In this study, we explore risk factors for infertility in Korean women. METHODS: A total of 986 female patients who visited six major infertility clinics in Korea were recruited from April to December 2014. Fertile age-matched controls were selected from two nationwide survey study participants. Conditional logistic regression after age-matching was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of each risk factor for infertility. RESULTS: Women with a body mass index (BMI) < 18.5 kg/m² had 1.35 times higher odds of infertility (OR, 1.35; 95% CI, 1.03-1.77), while those with a BMI ≥ 25.0 kg/m² had even higher odds (OR, 2.06; 95% CI, 1.61-2.64) compared to women with a normal BMI (18.5 kg/m² ≤ BMI < 25 kg/m²). Ever-smokers exhibited 4.94 times higher odds of infertility compared to never-smokers (95% CI, 3.45-8.85). Concerning alcohol consumption, women who consumed ≥ 7 glasses at a time showed 3.13 times significantly higher odds of infertility than those who consumed ≤ 4 glasses at a time (95% CI, 1.79-5.48). Lastly, women with thyroid disease demonstrated 1.44 times higher odds of infertility compared to women without thyroid disease (95% CI, 1.00-2.08). CONCLUSION: Female infertility in Korea was associated with underweight, obesity, smoking, alcohol consumption, and thyroid disease.

Measurement of serum anti-Müllerian hormone by revised Gen II or automated assay: Reproducibility under various blood/serum storage conditions.

OBJECTIVE: We investigated the agreement between anti-Müllerian hormone (AMH) levels measured with revised Gen II (rev-Gen II) and automated AMH (Access) assays and evaluated the reproducibility of each method under various blood/serum storage conditions. METHODS: AMH levels in blood samples from 74 volunteers were measured by rev-Gen II and Access assays under various conditions: immediate serum separation and AMH measurement (fresh control); serum stored at -20 °C and AMH measured after 48 hours, 1 week, and 2 years; serum stored at 0 to 4 °C and AMH measured after 48 hours and 1 week; and blood kept at room temperature and delayed serum separation after 48 hours and 1 week, with immediate AMH measurement. RESULTS: In fresh controls, all rev-Gen II-AMH values were higher than comparable Access-AMH values (difference, 8.3% to 19.7%). AMH levels measured with the two methods were strongly correlated for all sample conditions (r=0.977 to 0.995, all p<0.001). For sera stored at -20 °C or 0 to 4 °C for 48 hours, Access-AMH values were comparable to control measurements, but rev-Gen II-AMH values were significantly lower. AMH levels in sera stored at -20 °C or 0 to 4 °C for 1 week were significantly lower than in fresh controls, irrespective of method. Across methods, long-term storage at -20 °C for 2 years yielded AMH measurements significantly higher than control values. When serum separation was delayed, rev-Gen II-AMH values were significantly lower than control measurements, but Access-AMH values varied. CONCLUSION: The rev-Gen II and Access-AMH assays showed varying reproducibility across blood/serum storage conditions, but automated Access yielded superior stability to rev-Gen II.

Effectiveness and Safety of Recombinant Human Follicle-Stimulating Hormone (Follitrope™) in Inducing Controlled Ovarian Stimulation in Infertile Women in Real-World Practice: a Prospective Cohort Study.

To evaluate the safety and effectiveness of recombinant human follicle-stimulating hormone (rhFSH [Follitrope™]) in infertile women undergoing in vitro fertilization (IVF). To identify predictors of ovarian response that induce optimal clinical outcomes. This multicenter prospective study enrolled infertile women who were scheduled to undergo IVF after ovarian stimulation with rhFSH (Follitrope™) following the gonadotropin-releasing hormone (GnRH) agonist or GnRH antagonist protocol. Predictive factors for ovarian response were identified in the GnRH antagonist group based on the number of oocytes retrieved. A total of 516 infertile women were enrolled, among whom 136 (except one who withdrew before administration) received rhFSH using the GnRH agonist protocol and 379 using the antagonist protocol. The mean number of oocytes retrieved was 13.4 in the GnRH agonist group and 13.6 in the GnRH antagonist group. The clinical pregnancy rates were 32.3% (30/93) and 39.9% (115/288) in the GnRH agonist and antagonist groups, respectively. The incidence of ovarian hyperstimulation syndrome was 1.8% and 3.4% in the GnRH agonist and antagonist groups, respectively. No other significant safety risks associated with rhFSH administration were identified. Body mass index, basal serum FSH and anti-Müllerian hormone levels, and antral follicle count were identified as predictors of ovarian response by multiple regression with backward elimination, and the final regression model accounted for 26.5% of the response variability. In real-world practice, rhFSH (Follitrope™) is safe and effective in inducing ovarian stimulation in infertile women. Patient characteristics identified as predictors can be considered to be highly related to optimal clinical outcomes.

Specific tail swelling pattern in hypo-osmotic solution as a predictor of DNA fragmentation status in human spermatozoa.

OBJECTIVE: The aim of this study was to investigate DNA fragmentation status in human spermatozoa according to specific tail swelling patterns determined via hypo-osmotic swelling test (HOST). METHODS: Frozen semen samples from 21 healthy donors were thawed and prepared by the swim-up technique for use in intracytoplasmic sperm injection. The semen samples were treated for 5 minutes as part of the HOST procedure and then underwent the sperm chromatin dispersion test using a Halosperm kit. DNA fragmentation status (large halo, medium halo, small halo, no halo, or degraded) and the specific tail swelling pattern ("a"-"g") were assessed at the level of a single spermatozoon. A total of 42,000 spermatozoa were analyzed, and the percentage of spermatozoa without DNA fragmentation (as evidenced by a large or medium halo) was assessed according to the specific tail swelling patterns observed. RESULTS: The HOST examinations showed that >93% of spermatozoa across all types displayed no DNA fragmentation. The percentage of spermatozoa without DNA fragmentation was 100% in type "d", 98.67% in type "g", and 98.17% in type "f" spermatozoa. CONCLUSION: We found that the type "d" spermatozoa displayed no DNA fragmentation, but the other types of spermatozoa also displayed very low rates of DNA fragmentation. This result may be associated with the processing of the spermatozoa by density gradient centrifugation and the swim-up technique.

Clinicopathological characteristics of miscarriages featuring placental massive perivillous fibrin deposition.

INTRODUCTION: Massive perivillous fibrin deposition (MPFD) is frequently associated with detrimental pregnancy outcomes, and extensive perivillous fibrin deposition results in severe placental dysfunction and loss of maternofetal interface. Unfortunately, the fundamental pathogenesis of MPFD remains unknown, and systematic analyses of MPFD in miscarriage is lacking. We analyzed the frequency and clinicopathological characteristics of MPFD in first trimester miscarriages. METHODS: We analyzed a consecutive series of miscarriages (n = 582) gathered between March 2012 and June 2016. MPFD was classified as fibrin-type (f-MPFD) and matrix-type (m-MPFD) by immunostaining for fibrin and collagen type IV. The control group consisted of miscarriage cases (MC, n = 18) that were matched to f-MPFD with normal chromosome (f-MPFD-nc) for number of previous miscarriages and placental chromosomal status. RESULTS: MPFD was identified in 2.7% of miscarriages. f-MPFD was associated with recurrent abortions. Compared with miscarriages without fibrin deposition, MPFD cases had higher proportion of those with normal placental chromosome (69.2% vs. 27.4%, P < 0.005) and higher frequency of villous syncytiotrophoblast C4d deposition (73.3% vs. 33.9%, P < 0.005). All C4d(+) f-MPFD patients had more than three recurrent miscarriages, whereas C4d(-) f-MPFD patients had no history of recurrent miscarriage (P < 0.05). Patients with f-MPFD-nc had significantly higher HLA PRA immunopositivity rate than did MC patients (P = 0.005). DISCUSSION: MPFD was more common in miscarriages than in preterm and term pregnancies. Placental massive fibrin-type fibrinoid deposition and villous C4d immunoreactivity were associated with recurrent miscarriage.

Expression of the genes for peroxisome proliferator-activated receptor-γ, cyclooxygenase-2, and proinflammatory cytokines in granulosa cells from women with polycystic ovary syndrome.

OBJECTIVE: To identify differences in the expression of the genes for peroxisome proliferator-activated receptor (PPAR)-γ, cyclooxygenase (COX)-2, and the proinflammatory cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)-α in granulosa cells (GCs) from polycystic ovary syndrome (PCOS) patients and controls undergoing controlled ovarian stimulation. METHODS: Nine patients with PCOS and six controls were enrolled in this study. On the day of oocyte retrieval, GCs were collected from pooled follicular fluid. Total mRNA was extracted from GCs. Reverse transcription was performed and gene expression levels were quantified by realtime quantitative polymerase chain reaction. RESULTS: There were no significant differences in age, body mass index, and total gonadotropin dose, except for the ratio of luteinizing hormone to follicle-stimulating hormone between the PCOS and control groups. PPAR-γ and COX-2 mRNA was significantly downregulated in the GCs of PCOS women compared with controls (p=0.034 and p=0.018, respectively), but the expression of IL-6 and TNF-α mRNA did not show significant differences. No significant correlation was detected between the expression of these mRNA sequences and clinical characteristics, including the number of retrieved oocytes, oocyte maturity, cleavage, or the good embryo rate. Positive correlations were found among the PPAR-γ, COX-2, IL-6, and TNF-α mRNA levels. CONCLUSION: Our data may provide novel clues regarding ovarian GC dysfunction in PCOS, and indirectly provide evidence that the effect of PPAR-γ agonists in PCOS might result from alterations in the ovarian follicular environment. Further studies with a larger sample size are required to confirm these proposals.

Reference Values for the Revised Anti-Müllerian Hormone Generation II Assay: Infertile Population-based Study.

Anti-Müllerian hormone (AMH) is now accepted as an important clinical marker of ovarian reserve and is increasingly measured as an initial evaluation at infertility clinics. The aim of this study was to establish reference values for the revised second generation (Gen II) assay using population-based data. In this population-based cohort study, AMH data from unselected infertile women aged 25-45 years from June 2013 to June 2014 (n = 15,801) were collected. The AMH values were measured using the revised Gen II assay. We established and validated 5 AMH-age regression models. Based on the optimal AMH-age model, reference values and centile charts were obtained. The quadratic model (log AMH = 0.410 × age -0.008 × age² -3.791) was the most appropriate for describing the age-dependent decrease in AMH measured using the revised Gen II assay. This is the largest population-based study to establish age-specific reference values of AMH using the revised Gen II assay. These reference values may provide more specific information regarding the ovarian reserve estimation of infertile women.

Nomogram to predict the number of oocytes retrieved in controlled ovarian stimulation.

OBJECTIVE: Ovarian reserve tests are commonly used to predict ovarian response in infertile patients undergoing ovarian stimulation. Although serum markers such as basal follicle-stimulating hormone (FSH) or random anti-Müllerian hormone (AMH) level and ultrasonographic markers (antral follicle count, AFC) are good predictors, no single test has proven to be the best predictor. In this study, we developed appropriate equations and novel nomograms to predict the number of oocytes that will be retrieved using patients' age, serum levels of basal FSH and AMH, and AFC. METHODS: We analyzed a database containing clinical and laboratory information of 141 stimulated in vitro fertilization (IVF) cycles performed at a university-based hospital between September 2009 and December 2013. We used generalized linear models for prediction of the number of oocytes. RESULTS: Age, basal serum FSH level, serum AMH level, and AFC were significantly related to the number of oocytes retrieved according to the univariate and multivariate analyses. The equations that predicted the number of oocytes retrieved (log scale) were as follows: model (1) 3.21-0.036×(age)+0.089×(AMH), model (2) 3.422-0.03×(age)-0.049×(FSH)+0.08×(AMH), model (3) 2.32-0.017×(age)+0.039×(AMH)+0. 03×(AFC), model (4) 2.584-0.015×(age)-0.035×(FSH)+0.038×(AMH)+0.026×(AFC). model 4 showed the best performance. On the basis of these variables, we developed nomograms to predict the number of oocytes that can be retrieved. CONCLUSION: Our nomograms helped predict the number of oocytes retrieved in stimulated IVF cycles.

Placental C4d deposition is a feature of defective placentation: observations in cases of preeclampsia and miscarriage.

Placental C4d deposition is frequent in preeclampsia, and shallow placentation is a characteristic of both preeclampsia and miscarriage. This study was conducted to determine the relationship among placental C4d, maternal human leukocyte antigen (HLA) antibodies, and placental pathology in preeclampsia and miscarriage cases. The patient population (N = 104) included those with (1) preterm preeclampsia with fetal growth restriction (PE-FGR; n = 21), (2) preterm preeclampsia (PE; n = 20), (3) spontaneous preterm delivery (sPTD; n = 39), and (4) miscarriage (n = 24). C4d immunohistochemistry was performed, and the presence of maternal plasma HLA antibodies was examined. C4d staining of the syncytiotrophoblast was more frequent in PE-FGR patients (76.2 %) than in PE (10.0 %; p < 0.001) and sPTD (2.6 %; p < 0.001) patients. Maternal HLA antibody-positive rate was not different among the study groups. There was a significant correlation between C4d immunoreactivity and placental pathology consistent with maternal vascular underperfusion (p < 0.001) but not with maternal HLA antibody status. In miscarriages, the positive rates of C4d, HLA class I, and HLA class II antibodies were 58.3, 25.0, and 12.5 %, respectively. There was no correlation between the presence of maternal HLA class I or II antibodies and placental C4d immunoreactivity. This study confirms frequent placental C4d deposition in preeclampsia with fetal growth restriction and miscarriage. The association between placental C4d deposition and pathological findings of maternal vascular underperfusion suggests that C4d staining of the syncytiotrophoblast is a consequence of defective placentation rather than of a specific maternal immune response against fetal HLA. The study also demonstrates the usefulness of C4d as a biomarker of placentas at risk.

Diffuse decidual leucocytoclastic necrosis and NK cell aggregates: two distinct features of miscarriage.

AIMS: Primary histopathology of miscarriage remains undetermined in the majority of cases. This study was conducted to determine histological characteristics pertinent to miscarriage. METHODS: The study groups were composed of elective abortions (n=29) and miscarriages (n=45) comprised of chromosomally normal (n=15) and abnormal cases (n=30). Immunohistochemistry was done against CD3, CD8, TIA-1 and CD56. RESULTS: Two histological features--diffuse decidual leucocytoclastic necrosis (DDLN) and decidual natural killer cell aggregates (NKCA)--were relatively common in miscarriages. The frequencies of DDLN and NKCA were different between the groups (p<0.05 and p<0.05, respectively). DDLN was found in 13.8% (4/29) of elective abortions, while it was observed in 60.0% (9/15) and 23.3% (7/30) of chromosomally normal and abnormal miscarriages, respectively. DDLN was more frequent in chromosomally normal miscarriages than in elective abortions (p=0.004). NKCA was present in 13.8% (4/29) of elective abortions, while being found in 33.3% (5/15) and 43.3% (13/30) of chromosomally normal and abnormal miscarriages, respectively. NKCA was more frequent in chromosomally abnormal miscarriages than in elective abortions (p=0.020). CONCLUSIONS: The findings strongly suggest that defective placentation and abnormal maternal immune response are associated with miscarriage. DDLN and NKCA seem to have diagnostic values in the pathological evaluation of miscarriage.

Placental C4d as a common feature of chromosomally normal and abnormal miscarriages.

Placental C4d deposition is a feature of classical complement pathway activation and has been documented in various obstetrical settings. However, it is unknown whether placental C4d deposition is present in miscarriages and its frequency is different between chromosomally normal and abnormal miscarriages. This study was conducted to assess villous C4d deposition in miscarriages and to determine whether its frequency is different between chromosomally normal and abnormal miscarriages. Tissue samples (N = 58) of elective abortions (n = 20), miscarriages with normal chromosomes (n = 15), trisomy 16 (n = 13), and trisomy 22 (n = 10) were analyzed. Immunohistochemical staining for C4d and CD138 was done. Placental C4d deposition was defined as linear C4d immunoreactivity along the syncytiotrophoblast. Placental C4d immunoreactivity was detected in 73.3 % (11/15) and 56.5 % (13/23) of miscarriages with normal chromosomes and trisomy cases, respectively, while it was found in 5 % (1/20) of elective abortions (p < 0.05). Placental C4d deposition was more frequent in recurrent miscarriages (previous spontaneous abortion ≥2) than in sporadic miscarriages (76.5 vs. 30.0 %; p = 0.001). Chronic deciduitis was observed in 20.0 % (3/15) and 30.4 % (7/23) of miscarriages with normal chromosomes and trisomy cases, respectively, but not in elective abortions (p = 0.07 and 0.01, for each). The frequencies of C4d deposition (46.2 vs. 70.0 %) and chronic deciduitis (38.5 vs. 20.0 %) were not also different between trisomy 16 and trisomy 22 cases. Placental C4d deposition is a prominent feature of miscarriages regardless of their chromosomal status. The overall findings suggest that complement-mediated placental injury is a common pathology of miscarriage with diagnostic values in routine pathology practice.

The relationship between the number of CGG repeats and serum level of anti-Müllerian hormone in women without FMR1 premutation.

OBJECTIVE: To investigate the relationship between the number of CGG repeats in the fragile X mental retardation 1 (FMR1) gene and serum levels of anti-Müllerian hormone (AMH) in Korean infertility patients without premutation. STUDY DESIGN: A retrospective study of 228 infertile women who received fertility treatment in a single private in vitro fertilization (IVF) clinic from May 2010 to August 2012 was performed. Serum FSH and AMH were measured on menstrual day 3 and the number of CGG repeats was evaluated. RESULTS: The mean age of the study population was 33.3±3.8 years. No significant correlation was observed between CGG repeat count in both alleles and the serum FSH, AMH or multiples of median (MoM) of AMH in whole study subjects. In women with age ≥35 years, however, there was an increasing tendency in the MoM of AMH with increasing number of CGG repeats in allele 2 (R(2)=0.075, p=0.008). This correlation was not observed in patients aged less than 35 years. CONCLUSION: We observed a positive correlation between MoM of AMH and number of CGG repeats in allele 2 in women aged over 35 years. Our findings are discordant with other reports, and therefore further studies are needed to determine whether this discrepancy is due to ethnic differences.

Application of sperm selection using hyaluronic acid binding in intracytoplasmic sperm injection cycles: a sibling oocyte study.

The purpose of this study was to investigate whether sperm selection by hyaluronic acid (HA) binding could improve fertilization rate and embryo quality in intracytoplasmic sperm injection (ICSI) cycles. Two hundred nineteen oocytes obtained from eighteen women were injected with either HA-bound (n = 107) or conventionally selected spermatozoa (n = 112) in a randomized way. All of the participants were infertile couples who had normal sperm parameters but low fertilization rate in previous in vitro fertilization (IVF) cycle (n = 5) or experienced multiple IVF failures (n = 13). Lower fertilization (75.7% vs 83.0%) and cleavage rate on day 2 (72.9% vs 83.0%) was observed in oocytes injected with HA-bound spermatozoa than the conventional group, but the difference was not significant. Significantly lower cleavage rate was observed on day 3 in HA group (56.0% vs 69.6%, P = 0.038). Blastocyst formation rate and the number of transferred embryos were similar in both groups. In multiple IVF failure patients, significantly reduced fertilization rate (71.8% vs 85.3%, P = 0.046) and cleavage rate on day 2 (70.4% vs 85.3%, P = 0.029) and day 3 (53.5% vs 77.3%, P = 0.002) were noticed in HA group. Five women achieved pregnancy continuing more than 12 weeks after transfer (27.8%). Success of ICSI was not related with the number of embryos fertilized by HA-bound spermatozoa. Application of ICSI by sperm selection using HA binding is not helpful in couples with repeated poor fertilization or implantation despite normal sperm parameters.

Outcomes of preimplantation genetic diagnosis using either zona drilling with acidified Tyrode's solution or partial zona dissection.

OBJECTIVE: To review the outcomes of preimplantation genetic diagnosis (PGD) using zona drilling with acid Tyrode's solution (chemical zona pellucida drilling, chemical ZD) and those of partial zona dissection (PZD). METHODS: Clinical outcomes of seventy-one couples undergoing 85 PGD cycles from January 2005 to December 2010 were included. Blastocyst formation and the hatching rate, clinical pregnancy rate, ongoing pregnancy rate, implantation rate, and fetal gender ratio of the PZD and chemical ZD groups were compared. RESULTS: Application of PZD resulted in a significantly higher rate of clinical pregnancy (40.7% vs. 15.4%, p=0.022), ongoing pregnancy (35.6% vs. 11.5%, p=0.023), and implantation (18.1% vs. 5.7%, p=0.007) compared with chemical ZD. Among non-transferred embryos, the rate of blastocyst formation on day 5 (49.1% vs. 39.5%, p=0.016) and hatching on day 6 (47.2% vs. 26.5%, p<0.001) were also significantly higher in the PZD group. CONCLUSION: The mechanical zona dissection method showed better outcomes than chemical ZD in terms of the blastocyst development and pregnancy rate. In this study, the fact that chemical ZD was conducted in different period from mechanical method should be considered in interpreting the result.

Age-related distributions of anti-Müllerian hormone level and anti-Müllerian hormone models.

OBJECTIVE: To determine age-specific reference values for anti-Müllerian hormone (AMH) and to set up an optimal model for AMH changes by age for infertility investigations. DESIGN: Prospective study. SETTING: Several infertility clinics and two university hospitals. SAMPLE: A total of 21 226 AMH samples were obtained. METHODS: Data on patients' age, race/ethnicity, and AMH levels were available from the laboratory center data registry between November 2008 and January 2011. MAIN OUTCOME MEASURES: The distribution of AMH levels by age. From 16 972 women aged between 25 and 45 years, we established and validated five AMH-age regression models. RESULTS: The overall mean AMH level was 4.09 ± 3.71 ng/mL (median: 3.13 ng/mL). There was an inverse relation between AMH level and age. Among multiple regression models, the quadratic model was most appropriate to describe AMH-age relation (log AMH = 0.205 × age - 0.005 × age(2) - 0.047). CONCLUSIONS: AMH levels show a progressive decline with increasing age. Age-specific AMH values may provide more specific information useful for patients and clinicians. AMH-age models could play a role as a basic step to approach more accurate ovarian reserve estimation.

Impact of GnRH agonist treatment on recurrence of ovarian endometriomas after conservative laparoscopic surgery.

OBJECTIVE: To analyze the influence of postoperative GnRH agonist treatment on disease recurrence after conservative laparoscopic surgery for ovarian endometriomas according to duration of the treatment. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENT(S): One hundred nine consecutive premenopausal women who underwent conservative laparoscopic surgery for ovarian endometriomas (endometriosis stage III/IV) were enrolled in the study. The patients were divided into four treatment groups: expectant management (n = 37) and GnRH agonist therapy for 3 (n = 28), 4 (n = 21), and 6 months (n = 23). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): An ultrasound confirmed recurrence of ovarian endometriomas. RESULT(S): The overall crude recurrence rate was 16.5% after follow-up for an average of 20.1 months. The crude recurrence and the cumulative probabilities of disease recurrence at 24/36 months tended to be lower in patients who received a GnRH agonist for 6 months (4.3%, 5.3%/5.3%) compared with those who received it for 3 months (17.9%, 12.5%/25.0%) and 4 months (28.6%, 18.9%/39.2%) and patients with expectant management (16.2%, 22.4%/37.9%). However, the differences did not reach statistical significance. CONCLUSION(S): Treatment with GnRH agonist for six months had a beneficial impact on the recurrence rate after conservative laparoscopic surgery for ovarian endometriomas.