Changes in circulating forms of anti-Muüllerian hormone and androgens in women with and without PCOS: a systematic longitudinal study throughout pregnancy.

STUDY QUESTION: What are the changes in serum concentration of total and cleaved anti-Muüllerian hormone (AMH) molecular forms and of androgens before and throughout pregnancy in women with and without polycystic ovary syndrome (PCOS) in a longitudinal follow-up investigation? SUMMARY ANSWER: Serum levels of total and cleaved AMH are higher from preconception to the third trimester of pregnancy in women with PCOS as compared to controls, whereas testosterone and androstenedione levels are higher in women with PCOS than in control women before pregnancy and during the second and third trimester of pregnancy. WHAT IS KNOWN ALREADY: Cross-sectional or partial longitudinal studies have shown higher AMH and androgen levels in pregnant women with PCOS as compared with non-PCOS women. To date, no complete longitudinal dynamic monitoring of the circulating forms of AMH and androgens from pre-conception to the third trimester of pregnancy have compared women with and without PCOS. STUDY DESIGN, SIZE, DURATION: This systematic prospective quarterly longitudinal monocentric study was a comparative follow-up of 30 women with PCOS and 29 controls before and during pregnancy from April 2019 to July 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women aged 18-43 years with a pre-conception measurement of AMH were included during the first trimester of a singleton pregnancy. The PCOS group was defined according to the Rotterdam diagnostic criteria. The control group patients included in the study had normal ovarian reserves. Circulating total and cleaved AMH, and serum estradiol, LH, and androgen levels were measured during the first, second, and third trimester of pregnancy in all study participants. MAIN RESULTS AND THE ROLE OF CHANCE: Before pregnancy, patients with PCOS had higher levels of AMH than controls. The total and cleaved AMH forms were significantly higher in women with PCOS than controls from pre-conception to the third trimester of pregnancy (all P < 0.001). Androgens (total testosterone and androstenedione) were higher in women with PCOS than controls from mid-pregnancy onwards. LIMITATIONS, REASONS FOR CAUTION: Our control population was a population of infertile women with no ovarian problems but most of them had undergone ART treatments to achieve pregnancy. WIDER IMPLICATIONS OF THE FINDINGS: These results strengthen the hypothesis that gestational hyperandrogenism as well as exposure to elevated AMH levels in utero could be driving forces predisposing female progeny to develop PCOS. STUDY FUNDING/COMPETING INTEREST(S): Funding was provided by INSERM, France (grant number U1172) and the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program, ERC-2016-CoG to P.G. grant agreement n° 725149/REPRODAMH. The authors have nothing to declare. TRIAL REGISTRATION NUMBER: NCT03483792.

Discordance between serum anti-Müllerian hormone concentrations and antral follicle counts: not only technical issues.

STUDY QUESTION: Do patient-specific features contribute to the differences between measured serum anti-Müllerian hormone (AMH) concentrations and AMH values expected from the corresponding antral follicle count (AFC)? SUMMARY ANSWER: Patient-specific features contribute to the differences between measured AMH values and AMH values expected from the corresponding AFC (AMHp), potentially through their effect on follicular AMH production. WHAT IS KNOWN ALREADY: Both patient counselling and patient management could be hampered by finding of disagreement between AFC and AMH if both are used for the prediction of ovarian response. The difference between measured AMH concentrations and AMH values expected according to the corresponding AFC cannot be entirely explained by the technical limitations of counting of antral follicles and analytical variability of the AMH assay used. STUDY DESIGN, SIZE, DURATION: This retrospective study analysed medical records of 1097 IVF patients collected between March 2011 and July 2013. PARTICIPANT/MATERIALS, SETTING, METHODS: The study population (N = 1097) included 705 (64.3%) women with normal ovarian morphology and 392 (35.7%) women with polycystic ovarian morphology, aged 20-44 years, who underwent their first IVF cycle in a single clinical centre. AMH was measured by a routine laboratory method and predicted AMH (AMHp) values were calculated using the linear regression equation (AMHp = -4.4 + 1.5 × AFC). The absolute value of the difference between AMH and AMHp was considered to be the measure of the degree of AMH-AFC agreement. The association of the difference between AMH and AMHp with clinical and biochemical parameters was investigated in both the higher-than-predicted (HTP) group comprising patients with AMH higher than AMHp (N = 466) and the lower-than-predicted (LTP) group comprising patients with AMH lower than AMHp (N = 631). MAIN RESULTS AND THE ROLE OF CHANCE: Patients in the HTP group had significantly longer menstrual cycle length and higher AMH and LH concentrations but lower AFC and FSH concentration than their counterparts in the LTP group. There was a significant association of absolute value of the difference between AMH and AMHp with age, menstrual cycle length, AFC, FSH and testosterone in both groups (P < 0.001). The difference between AMH and AMHp was exclusively correlated to LH in the HTP group (r = 0.159, P < 0.001) and to BMI in the LTP group (r = 0.231, P < 0.001), respectively. Multiple regression analysis revealed that only LH was significantly related to the difference between AMH and AMHp in the HTP group, independently from AFC. In the LTP group, BMI, menstrual cycle length, FSH and testosterone were found associated with the difference between AMH and AMHp, independently from AFC. LIMITATIONS, REASONS FOR CAUTION: The main limitation of the study is selection bias. Data analysed in this study were collected from medical records of patients undergoing IVF treatment in a single department of human reproduction which precludes generalization of the results to women of different geographic origin, ethnicity, race and reproductive status. WIDER IMPLICATION OF THE FINDINGS: AMH higher than expected for a given AFC could suggest up-regulated AMH secretion (a typical feature of polycystic ovary syndrome) while AMH lower than expected from the corresponding AFC suggest down-regulated AMH secretion that could be seen as an early symptom of diminished ovarian reserve and premature ovarian insufficiency. In other words, when challenged against AFC, the serum AMH level is not only a quantitative but also a qualitative follicle marker, in relation with clinical and endocrine parameters. STUDY FUNDING/COMPETING INTEREST(S): No study funding was obtained for this study. The authors have no conflict of interest(s) to declare. TRIAL REGISTRATION NUMBER: Non-applicable.

The numbers of 2- 5 and 6-9 mm ovarian follicles are inversely correlated in both normal women and in polycystic ovary syndrome patients: what is the missing link?

STUDY QUESTION: Is the negative correlation between the numbers of 2-5 and 6-9 mm follicles influenced by ovarian and/or metabolic parameter(s) in young control women and in patients with polycystic ovarian syndrome (PCOS)? SUMMARY ANSWER: Our study confirmed that the negative correlation between numbers of follicles sized 2-5 and 6-9 mm was stronger in PCOS than in young control women and was not linked to any ovarian or metabolic parameter. WHAT IS KNOWN ALREADY: Previous reports described a direct negative correlation between the number of small antral follicles (2-5 mm) and large antral follicle (6-9 mm) during the early follicular phase (cycle Days 2-5) in normal and PCOS women. Numerous factors, that could be either intrinsic to the ovary or secondary to metabolic influence and/or gonadotropin regulation, might account for this. STUDY DESIGN, SIZE, DURATION: Six hundred and thirty-nine patients with PCOS according to Rotterdam Criteria and 157 control women were recruited in this retrospective cross-sectional study from January 2009 to January 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were obtained from a database of clinical, hormonal and ultrasound (U/S) features recorded consecutively in a single reproductive medicine centre. Univariate correlations between the various parameters were analysed by the Spearman's correlation test. All variables significantly related to the 2-5 and/or 6-9 mm follicle numbers were included in a principal component analysis (PCA) in order to structure the data and to obtain collections of uncorrelated variables, called principal components (PC), which are linear combinations of the original variables. MAIN RESULTS AND THE ROLE OF CHANCE: By univariate analysis, the 2-5 and 6-9 mm follicle numbers were strongly but negatively correlated in both populations. Many other variables were correlated to the 2-5 and/or 6-9 mm follicle numbers and to each other. By PCA, these relationships were gathered into four independent PCs in each population. In both groups, the 2-5 and 6-9 mm follicle numbers correlated strongly and inversely to a specific PC. Among the other variables tested, only serum oestradiol level correlated weakly to this PC in the control group. Two other uncorrelated PCs gathered relationships between variables linked to the metabolic status and the gonadotropin regulation both in control and PCOS women. Lastly, a fourth PC included relationships which linked to ovarian ageing in controls and to follicle dysregulation in patients with PCOS. LIMITATIONS, REASONS FOR CAUTION: Our controls did not represent the general population since they were recruited in an ART centre; we used a modified Rotterdam classification for PCOS using follicle count and/or serum AMH level with in-house thresholds to define the follicle excess; the AMH assay used is no longer commercially available. WIDER IMPLICATIONS OF THE FINDINGS: Factor(s) regulating specifically the equilibrium between the 2-5 and 6-9 mm follicle numbers still need(s) to be identified. More attention should be paid to the oocyte. STUDY FUNDING/COMPETING INTEREST(S): None.

Recurrent maternal virilization during pregnancy in patients with PCOS: two clinical cases.

BACKGROUND: Maternal virilization during pregnancy is a rare phenomenon. Polycystic ovary syndrome (PCOS), luteoma and luteinic cysts are the most frequent and benign etiologies. This article presents two cases of recurrent maternal virilization during pregnancy. CLINICAL CASES: Our reported cases were young women with Afro-Caribbean and Nigerian origins. Data were collected by history-taking, clinical examination, laboratory investigations, transabdominal ultrasonographic examination and Magnetic Resonance Imaging. Both patients were diagnosed with PCOS according to the Rotterdam criteria. During each of their pregnancies they both developed an explosive hirsutism, a deepening in the voice, a clitoromegaly. Gestational diabetes occurred during pregnancies. There was no fetal virilization, despite raising androgen levels, more than tenfold to normal. Improvement of hirsutism and normalization of androgens were described in postpartum. CONCLUSION: Only few cases of maternal virilization during pregnancy were reported in literature and even fewer concern recurrent and bilateral ovarian etiology. Hyperplasia of ovarian theca cells seems to be the most likely explanation, which would suggest that PCOS belongs to a spectrum of abnormal reactivity of the ovary to human Chorionic Gonadotrophin (hCG) stimulation along with luteoma and luteinic cyst of pregnancy.  Insulin resistance could worsen hyperandrogenism but is not enough to explain virilization. Treatment should focus on protecting the fetus of possible virilization as well as its mother, but also on preserving the subsequent fertility in both.

Counting ovarian antral follicles by ultrasound: a practical guide.

This Consensus Opinion summarizes the main aspects of several techniques for performing ovarian antral follicle count (AFC), proposes a standardized report and provides recommendations for future research. AFC should be performed using a transvaginal ultrasound (US) probe with frequency ≥ 7 MHz. For training, we suggest a minimum of 20-40 supervised examinations. The operator should be able to adjust the machine settings in order to achieve the best contrast between follicular fluid and ovarian stroma. AFC may be evaluated using real-time two-dimensional (2D) US, stored 2D-US cine-loops and stored three-dimensional (3D) US datasets. Real-time 2D-US has the advantage of permitting additional maneuvers to determine whether an anechoic structure is a follicle, but may require a longer scanning time, particularly when there is a large number of follicles, resulting in more discomfort to the patient. 2D-US cine-loops have the advantages of reduced scanning time and the possibility for other observers to perform the count. The 3D-US technique requires US machines with 3D capability and the operators to receive additional training for acquisition/analysis, but has the same advantages as cine-loop and also allows application of different imaging techniques, such as volume contrast imaging, inversion mode and semi-automated techniques such as sonography-based automated volume calculation. In this Consensus Opinion, we make certain recommendations based on the available evidence. However, there is no strong evidence that any one method is better than another; the operator should choose the best method for counting ovarian follicles based on availability of resources and on their own preference and skill. More studies evaluating how to improve the reliability of AFC should be encouraged. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Polycystic ovarian morphology and the diagnosis of polycystic ovary syndrome: redefining threshold levels for follicle count and serum anti-Müllerian hormone using cluster analysis.

STUDY QUESTION: Can cluster analysis be used to differentiate between normo-ovulatory women with normal ovaries and normo-ovulatory women with polycystic ovarian morphology (PCOM) in a non-subjective manner? SUMMARY ANSWER: Cluster analysis can be used to accurately and non-subjectively differentiate between normo-ovulatory women with normal ovaries and normo-ovulatory women with PCOM. WHAT IS KNOWN ALREADY: Currently, PCOM is diagnosed using a fixed threshold level, i.e. 12 or more follicles per ovary, and is one of the diagnostic criteria of polycystic ovary syndrome (PCOS). However, PCOM is also encountered in normo-ovulatory women, suggesting that it could just represent a normal variant. On the other hand, recent studies have shown subtle endocrine abnormalities in women with isolated PCOM that resemble those found in women with PCOS. Because of the strong correlation between anti-Müllerian hormone (AMH) and follicle number, a high serum AMH level has been proposed as a surrogate marker for PCOM and could, therefore, be integrated in the diagnostic classifications for PCOS. STUDY DESIGN, SIZE, DURATION: This was a retrospective observational cohort study. Original cohorts had been recruited for previous studies between 1998 and 2010. Two hundred ninety-seven regularly cycling women and 700 women with PCOS were eligible for inclusion. PARTICIPANTS/MATERIALS, SETTING, METHODS: Cluster analysis was performed in 297 regularly cycling women. After exclusion of 'PCOM' clusters, each 'non-PCOM' cluster (young, n = 118 and old, n = 100) was included in the construction of a receiver operating characteristics curve to test the diagnostic performance of follicle number per ovary (FNPO) and serum AMH in discriminating similarly aged full-blown PCOS patients (n = 411 and 237, respectively) from normal regularly cycling non-PCOM women. MAIN RESULTS AND ROLE OF CHANCE: The optimal number of clusters was four; age was the most important classifying variable, followed by the FNPO and serum AMH. Two distinct clusters of normo-ovulatory women with PCOM were isolated and differed solely by age, i.e. 'young' and 'old'. Both 'PCOM' clusters had their similarly aged counterpart of 'non-PCOM' clusters. Likewise, two clusters comprised women younger than 30 years, with (n = 28, 'PCOM regularly cycling women') or without (n = 118, 'normal regularly cycling women') features of PCOM (increased FNPO and/or serum AMH). The two other clusters in older women could be labelled 'normal regularly cycling women' or 'PCOM regularly cycling women' (n = 100 and 51, respectively). The prevalence of PCOM was significantly greater in old than in young regularly cycling women controls. In the young population, after exclusion of the 'PCOM regularly cycling women', the diagnostic performance of AMH, expressed by area under the curve (AUC) (AUC = 0.903; CI (0.876-0.930)) to differentiate PCOS women from normal regularly cycling women was similar to that using the FNPO (AUC = 0.915, CI (0.891-0.940)) (P = 0.25), confirming results from earlier studies. In the old population, the diagnostic performance of AMH was greater than that of FNPO (AUCs = 0.948 (0.927-0.970) vs 0.874 (0.836-0.912), respectively, P = 0.00035). Cut-off levels of AMH and antral follicle count distinguishing regularly cycling non-PCOM women from PCOS women were higher in young women than in older women. LIMITATIONS, REASONS FOR CAUTION: Data of normal women were obtained from earlier studies, aiming to measure normal endocrine values. Apparently, the strong effect of age in cluster analysis revealed a dichotomy in the age distribution among the cohort of regularly cycling women included. This was involuntary since in none of the original studies, eligibility was limited by age and there was considerable overlap in age ranges of the cohorts. Transvaginal ultrasound was performed using a 6.5-8 mHz probe and our data confirm that this threshold level for FNPO is still valid if using such probe frequencies, although the use of devices with a maximum frequency lower than 8 mHz has become obsolete. Obviously, newer ultrasound scanner using higher transducer frequency will facilitate the detection of more follicles. WIDER IMPLICATIONS OF THE FINDINGS: Our data support the use of AMH as a surrogate for ultrasound to define PCOM, which is one of the three items of the Rotterdam classification. They also show that age should be taken into account to define the optimal threshold. The fact that the prevalence of PCOM was increased in the older regularly cycling women, may be due to 'attenuated' PCOS, a phenomenon that has been described in ageing women with PCOS. These women might have had anovulatory cycles in the past and have become ovulatory with increasing age, and were, therefore, eligible for this study. However, since most women included at older age have had spontaneous pregnancies in the past, PCOM at older age may be associated with a subclinical form of PCOS, which may also be present in young regularly cycling women. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study. J.S.E.L. has received grants and support from Ferring, MSD, Organon, Merck-Serono, Schering Plough and Serono during recruitment and analysis of data for this study. S.L.F., A.D. and D.D. do not have any conflict of interest.

Pregnancy after intracytoplasmic sperm injection following extended sperm preparation and hormone therapy in an azoospermic man with maturation arrest and microlithiasis: a case report and literature review.

In the management of azoospermia, a combination of testicular sperm extraction and intracytoplasmic sperm injection (ICSI) is usually the most successful option for fatherhood. However, an outstanding question remains: How can at least a few spermatozoa be obtained from the ejaculate, thus avoiding the need for a surgical procedure? A 36-year-old man presented to Assisted Reproduction Unit with his 26-year-old wife. The ultrasound assessment revealed bilateral microlithiasis. Two spermograms revealed absolute azoospermia. Levels of follicle-stimulating hormone (FSH) and luteinising hormone were normal-low. The patient underwent 10 months of treatment with clomiphene citrate. A bilateral testicular sperm extraction failed to retrieve spermatozoa and revealed a maturation arrest at spermatocyte/spermatid stages depending on the tubules. Clomiphene citrate was replaced with recombinant FSH (rFSH). After 9-month treatment with rFSH, motile spermatozoa from droplets of ejaculate pellet were cryopreserved as a single straw. Ovarian stimulation was provided using classic antagonist protocol, and five mature oocytes were collected. Two consecutive fresh semen samples on the day of ICSI yielded seven motile spermatozoa, and fertilisation was achieved in all five oocytes. On day 3, two embryos were transferred, yielding positive beta-human chorionic gonadotropin and a healthy delivery of a boy and a girl.

The phenotypic diversity in per-follicle anti-Müllerian hormone production in polycystic ovary syndrome.

STUDY QUESTION: Is intrinsic dysregulation of granulosa cells (GC) and consequent increases in the per-follicle production of anti-Müllerian hormone (AMH), correlated with the phenotypic presentation of women with polycystic ovaries? SUMMARY ANSWER: Involvement of intrinsic GC dysregulation in oligo-anovulation associated with polycystic ovary syndrome (PCOS) is likely because among women with PCOS, those with oligo-amenorrhea have higher per-follicle AMH production than those who ovulate normally, irrespective of their androgen and/or metabolic status. WHAT IS KNOWN ALREADY: Women with PCOS have higher serum AMH level than non-PCOS women due to an increased follicle number and excessive AMH production per follicle, the latter reflecting a putative GC dysfunction that may vary between PCOS phenotypes. STUDY DESIGN, SIZE, DURATION: This is a retrospective analysis of data collected from 1021 women undergoing infertility evaluation from March 2011 to October 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included women with polycystic ovarian morphology (PCOM) who met the Rotterdam criteria for PCOS (n = 272), women with PCOM only (n = 168) and controls (n = 581). MAIN RESULTS AND THE ROLE OF CHANCE: We used serum AMH to antral follicle count (AFC) ratio (AMH/AFC) as a marker of per-follicle AMH production and checked whether this ratio was associated with the PCOS phenotype and to the menstrual, androgen and metabolic status in women with PCOS, women with PCOM only and in controls. AMH/AFC was significantly higher in oligo-amenorrheic women with PCOS than in eumenorrheic women with PCOS or PCOM (P < 0.001) but also in the latter group compared with controls (P < 0.001) regardless of androgen status. Stepwise discriminant analysis yielded a significant score for the menstrual status with a discriminant power of 26.5% (P < 0.001). This score included AFC, AMH/AFC, waist circumference and LH with partial R(2) of 0.172, 0.042, 0.024 and 0.023, respectively. LIMITATIONS, REASONS FOR CAUTION: The AMH to AFC ratio as a surrogate marker for average AMH may be subject to error because follicles below the sensitivity limit of the ultrasonography used may also contribute to serum AMH concentration and secondly, AFC can be subjective. WIDER IMPLICATIONS OF THE FINDINGS: The higher AMH/AFC in women with PCOM only than in controls suggests that isolated PCOM may represent a PCOS-like phenotype in which an inherent dysfunction of GC exists but is too mild to affect the ovulatory process. STUDY FUNDING/COMPETING INTERESTS: No funding was obtained for this study. There are no conflicts of interest to be declared. TRIAL REGISTRATION NUMBER: Non-applicable.

Using cluster analysis to identify a homogeneous subpopulation of women with polycystic ovarian morphology in a population of non-hyperandrogenic women with regular menstrual cycles.

STUDY QUESTION: Can cluster analysis can be used to identify a homogeneous subpopulation of women with polycystic ovarian morphology (PCOM) within a very large population of control women in a non-subjective way? SUMMARY ANSWER: Identification and exclusion of the cluster corresponding to women with PCOM from controls improved the diagnostic power of serum anti-Müllerian hormone (AMH) level and follicle number per ovary (FNPO) in discriminating between women with or without polycystic ovary syndrome (PCOS). WHAT IS KNOWN ALREADY: There is disagreement as to whether women with PCOM should be excluded from the control population when establishing FNPO and AMH diagnostic thresholds for the definition of PCOS and how to identify such women. It has been demonstrated that cluster analysis can detect women with PCOM within the control population through a set of classifying variables among which the most relevant was AMH. The adequacy of this approach has not been confirmed in other clinical settings. STUDY DESIGN, SIZE, DURATION: This was a retrospective study using clinical and laboratory data derived from the computerized database. The data were collected from March 2011 to May 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included 893 patients referred for routine infertility evaluation and treatment. The patients were divided into three groups: (i) the control group (n = 621) included women with regular menstrual cycles and no signs of hyperandrogenism (HA), (ii) the full-blown PCOS group (n = 95) consisted of women who were diagnosed as having PCOS based on the presence of both HA and oligo/amenorrhoea (OA), (iii) the mild PCOS group included women with only two items of the Rotterdam classification, i.e. PCOM at ultrasonography according to the FNPO threshold of 12 or more and either OA (n = 110) or HA (n = 67). MAIN RESULTS AND THE ROLE OF CHANCE: After exclusion of women with PCOM from the controls, the AMH threshold of 28 pmol/l with specificity 97.5% and sensitivity 84.2% [area under the curve (AUC) 0.948 (95% confidence interval (CI) 0.915-0.982)] and FNPO threshold of 12 with specificity 92.5% and sensitivity 83.2% [AUC 0.940 (95% CI 0.909-0.971)] for identifying PCOS were derived from the receiver operating characteristic curve analysis. The AMH threshold of 28 pmol/l had the same specificity for discriminating the mild and the full-blown PCOS phenotypes from controls. LIMITATIONS, REASONS FOR CAUTION: There was no selection bias other than being evaluated for infertility treatment, however, this could also be considered as a limitation of the study as these women may not necessarily be a representative sample of the general population. The study demonstrated that serum AMH has intrinsically a very high potency to detect women with PCOM within a control group. However, the AMH threshold is specific for this method and clinical setting. WIDER IMPLICATIONS OF THE FINDINGS: AMH threshold value for the definition of PCOM is method specific and cannot be universally applied. This study confirmed the results of previous studies that cluster analysis can identify women with PCOM within the very large control population without using a predefined diagnostic threshold for FNPO, and that AMH can detect women with PCOM with a high specificity. The exclusion of PCOM women from the controls by using a cluster analysis should be considered when establishing reference intervals and decision threshold values for various parameters used to characterize PCOS. STUDY FUNDING/COMPETING INTERESTS: The authors have no funding/competing interest(s) to declare.

Polycystic ovaries at ultrasound: normal variant or silent polycystic ovary syndrome?

OBJECTIVE: It is not known whether polycystic ovaries (PCO) are an ovarian appearance without pathological meaning or whether they share with polycystic ovary syndrome (PCOS) the same ovarian follicle abnormality. There are few studies including strictly selected women with PCO but without other criteria of PCOS. In order to address these issues, we compared hormonal, metabolic and ultrasound parameters obtained from patients with PCO only, patients with PCOS and controls. METHODS: This was a comparative analysis including three age-matched groups of 95 patients, who were included consecutively in a database: controls, patients with sonographic PCO but no symptoms (PCO group) and patients with PCOS. A clinical examination, fasting serum sampling and pelvic ultrasound examination were performed between cycle days 2 and 5 and results were compared between groups. RESULTS: The median serum anti-Mullerian hormone (AMH) level in the PCO group was intermediate between that in controls and that in the PCOS group (33.6 pmol/L, 19.8 pmol/L and 63.3 pmol/L, respectively), the differences being significant after adjustment for follicle number (P < 0.05), while the mean androgen serum level in the PCO group was similar to that in the control group and significantly lower than that in the PCOS group (P < 0.05) (median serum testosterone levels: 0.90 nmol/L, 0.79 nmol/L and 1.39 nmol/L; median androstenedione levels: 5.25 nmol/L, 4.37 nmol/L and 6.09 nmol/L, respectively). Body mass index, waist circumference and insulin levels had no effect on these differences. CONCLUSION: PCO is an abnormal condition, affected women showing no evidence of hyperandrogenism but having higher AMH serum levels compared with controls, suggesting a granulosa cell abnormality in PCO similar to that observed in PCOS. The absence of hyperandrogenism in PCO does not seem linked to the metabolic status.

A predictive score for testicular sperm extraction quality and surgical ICSI outcome in non-obstructive azoospermia: a retrospective study.

BACKGROUND: In non-obstructive azoospermia (NOA), testicular sperm extraction (TESE) is successful in ≈ 50% of cases. A parameter for predicting TESE quality and pregnancy rates after ICSI of testicular spermatozoa is still lacking. METHODS: We retrospectively evaluated the total testicular volume (TTV), hormone levels and TESE quality in 280 patients with NOA. After successful TESE, the characteristics of the ICSI cycles and the take-home baby rates were evaluated. RESULTS: TESE was successful in 149 patients (53.2%). In a multivariate logistic regression analysis, only TTV, FSH and inhibin B were correlated with the TESE outcome. A score including these three parameters was the best predictor of successful TESE (positive likelihood ratio: +3.01). When the score was <18.5, TESE was successful in 77.4% of cases and 'sperm rich' (i.e. yielding >100 spermatozoa) in 91.1% of cases; 42.8% of couples took a baby home. The take-home baby rate did not depend on whether the score was <18.5 or between 18.5 and 3700. If the score was >3700, TESE was successful in 37.8% of cases and 'sperm rich' in 14.3% of cases; only one couple took a baby home (a rate of 7.7 versus 42.8% when the score was <18.5; P< 0.001). Owing to low sperm retrieval on the day of oocyte retrieval, fewer oocytes were injected when the score was >3700 than when <3700. CONCLUSIONS: Thanks to better knowledge of TESE quality, the present score could help to improve care and pre-ICSI counseling for patients with NOA.

Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries.

BACKGROUND: Polycystic ovarian morphology (PCOM) at ultrasound is currently used in the diagnosis of polycystic ovary syndrome (PCOS). We hypothesized that the previously proposed threshold value of 12 as an excessive number of follicles per ovary (FN) is no longer appropriate because of current technological developments. In this study, we have revisited the thresholds for FN and for the serum Anti-Müllerian hormone (AMH) level (a possible surrogate for FN) for the definition of PCOM. METHODS: Clinical, hormonal and ultrasound data were consecutively recorded in 240 patients referred to our department between 2008 and 2010 for exploration of hyperandrogenism (HA), menstrual disorders and/or infertility. RESULTS: According to only their symptoms, patients were grouped as: non-PCOS without HA and with ovulatory cycles (group 1, n = 105), presumption of PCOS with only HA or only oligo-anovulation (group 2, n = 73) and PCOS with HA and oligo-anovulation (group 3, n = 62). By cluster analysis using androgens, LH, FSH, AMH, FN and ovarian volume, group 1 appeared to be constituted of two homogeneous clusters, most likely a non-PCOM non-PCOS subgroup (n = 66) and a PCOM, non-PCOS (i.e. asymptomatic) subgroup (n = 39). Receiver operating characteristic curve analysis was applied to distinguish the non-PCOM non-PCO members of group 1 and to group 3. For FN and serum AMH respectively, the areas under the curve were 0.949 and 0.973 and the best compromise between sensitivity (81 and 92%) and specificity (92 and 97%) was obtained with a threshold values of 19 follicles and 35 pmol/l (5 ng/ml). CONCLUSIONS: For the definition of PCOM, the former threshold of >12 for FN is no longer valid. A serum AMH >35 pmol/l (or >5 ng/ml) appears to be more sensitive and specific than a FN >19 and should be therefore included in the current diagnostic classifications for PCOS.

Metabolic syndrome in young women with the polycystic ovary syndrome: revisiting the threshold for an abnormally decreased high-density lipoprotein cholesterol serum level.

OBJECTIVE: To verify whether the adult threshold for an abnormally decreased high-density lipoprotein cholesterol (HDL-C) serum level (0.5 g/l) is appropriate in young women with polycystic ovary syndrome (PCOS). DESIGN: Retrospective analysis of a database. SETTING: Academic Hospital. POPULATION: A total of 854 women aged 16-40 years having PCOS according to Rotterdam criteria. METHODS: Criteria defining the metabolic syndrome (MetS) (increased waist circumference, systolic and/or diastolic blood pressure, triglycerides, fasting glycaemia and decreased HDL-C) were separately analysed and compared in three different subgroups (16-20 years, 20-30 years and 30-40 years). The prevalence of the MetS was calculated using two different thresholds (0.5 and 0.4 g/l) for HDL-C in the 16-20 years group. MAIN OUTCOMES MEASURES: Prevalence of MetS. RESULTS: The prevalence of an abnormal HDL-C (<0.5 g/l) was higher in the youngest women (60%), whereas frequencies of abnormal waist circumference, systolic and/or diastolic blood pressure, triglycerides and fasting glycaemia were lower than in the two other groups. The prevalence of an abnormal HDL-C dropped to 27% when using a threshold of 0.4 g/l in the 16-20 years subgroup. The prevalence of the MetS in the 16-20 years subgroup was 11%, whatever the threshold, because HDL-C was <0.4 g/l in all women once they scored 3 or more. CONCLUSIONS: The adult threshold for HDL-C overestimates the prevalence of abnormal HDL-C in young women with PCOS. Until normative data about HDL-C in adult women under 20 years is available, we suggest using a threshold of 0.4 g/l or ignoring this criterion.

[Spironolactone as a relay for cyproterone acetate in hyperandrogenic women]. / La spironolactone en relais de l'acétate de cyprotérone dans l'hyperandrogénie féminine.

OBJECTIVES: Cyproterone acetate is actually the first-line anti-androgenic treatment for severe hyperandrogenism in women. However, as this treatment is currently controversial, the objective of the study was to evaluate the safety and efficacy of spironolactone as a relay for cyproterone acetate. METHODS: This is a monocentric retrospective study conducted between December 2002 and January 2018 at the Jeanne de Flandre Hospital at the University Hospital Center of Lille. Patients with clinical hyperandrogenism who received treatment with cyproterone acetate and then spironolactone were included. A total of 37 patients were clinically and biologically evaluated before treatment, followed by cyproterone acetate and spironolactone. RESULTS: Clinically, the vast majority of patients were satisfied with the relay by spironolactone and found no difference between the two treatments. Biologically, testosterone and delta-4 androstenedione levels were significantly decreased with cyproterone acetate and spironolactone compared to no treatment. No significant differences were found when comparing levels under cyproterone acetate and under spironolactone. In addition, 87,5% of patients were free of side effects. CONCLUSIONS: The data collected show the clinical and biological efficacy of spironolactone as a relay for cyproterone acetate in the treatment of hyperandrogenism. This anti-androgen therefore appears as an effective and well-tolerated alternative, as a relay for cyproterone acetate in patients with hyperandrogenism.

LH/hCGR gene expression in human cumulus cells is linked to the expression of the extracellular matrix modifying gene TNFAIP6 and to serum estradiol levels on day of hCG administration.

BACKGROUND: Recent studies suggest a role for luteinizing hormone and human chorionic gonadotrophin receptor (LH/hCGR) signalling in the regulation of the oocyte-cumulus oophorus cell interplay. The present study aimed at assessing the LH/hCGR gene expression in cumulus cells (CCs) surrounding oocytes in patients undergoing controlled ovarian hyperstimulation (COS) before ICSI and to relate the LH/hCGR expression to other COS quality parameters. METHODS: CCs from single oocytes of normal responder patients were analysed by DNA microarrays. Concomitantly, estradiol levels on the day of hCG administration, CC morphology, total collected oocyte and metaphase II oocyte number were assessed in relation to LH/hCGR gene expression in CC. RESULTS: The transcriptome analysis of CC indicated a variable expression of LH/hCGR among the patients and intra-patients. LH/hCGR mRNA expression was negatively correlated with serum estradiol level on the day of hCG administration. Eighty-five genes were significantly modulated between CCs from patients with a high and a low LH/hCGR expression. These genes are involved principally in steroid metabolism and in the ovulation process and include TNFAIP6, a gene expressed during CC-oocyte complex (COC) expansion. There were no significant differences in LH/hCGR gene expression profile between COS protocols. CONCLUSIONS: LH/hCGR is expressed in CC under COS conditions. LH/hCGR expression level is associated with TNFAIP6 gene expression and negatively correlated with serum estradiol level on the day of hCG administration.

Identification of new biomarkers of human endometrial receptivity in the natural cycle.

BACKGROUND: Identification of new markers assessing endometrial receptivity may help in improving the clinical outcome of IVF. This study aimed at identifying genes expressed in human endometrium during the implantation window that could be used as such markers. METHODS: A series of normoresponder patients (n = 31) underwent endometrial biopsies (n = 62, 2 per patient) during the early secretory phase, 2 days after the LH surge (LH + 2) and the mid-secretory phase (LH + 7) of the same natural cycle that preceded a new ICSI attempt for male infertility factor. Samples were analyzed using DNA microarrays and gene expression profiles at the time of the implantation window were computed. Systems biology analysis allowed the identification of biological pathways that were over-represented in this signature. A new approach for class prediction applied to microarray experiments was then used to identify biomarkers putatively involved in endometrial receptiveness. RESULTS: Five genes expressed during the implantation window were all up-regulated in the LH + 7 samples compared with LH + 2 [laminin beta3 (P = 0.002), microfibril-associated protein 5 (P = 0.009), angiopoietin-like 1 (P = 0.005), endocrine gland-derived vascular endothelial growth factor (P = 0.049) and nuclear localized factor 2 (P = 0.007)]. Increased expression was validated by quantitative RT-PCR. CONCLUSIONS: Five genes have been identified for the first time as being up-regulated during the implantation window and are proposed as new biomarkers for exploration of endometrial receptiveness. As the endometrial biopsy procedure can be performed during a natural cycle, it would be worth testing this approach as a novel strategy in patients with poor implantation after IVF or ICSI.

[Ovarian stimulation with gonadotrophins in patients with polycystic ovary syndrome]. / Stimulation ovarienne sous gonadotrophines chez des patientes atteintes de syndrome des ovaires polykystiques.

OBJECTIVES: The main objective of this study was to describe the ovulation rate in patients with polycystic ovary syndrome, treated with ovulation induction/intra-uterine insemination and follitropin alfa by gonadotrophins at a second attempt. METHODS: An observational, national and multicentre study was carried out: 51 French physicians (endocrinologists, gynaecologists) participated. Eligible patients were followed according to the usual clinical practices. The primary endpoint was the number of ovulations (spontaneous or triggered). Quality of life evaluation (by FertiQoL), compliance, and patient satisfaction were secondary endpoints. RESULTS: A total of 202 patients (mean age: 29.9 years; mean infertility: 2.9 years) were included: 78.4% met the Rotterdam definition. The ovulation rate was 93.3% (95% confidence interval [89.8; 96.8]%). At 12 weeks of gestation, 38 patients had an ongoing pregnancy. A difference of 10 points of the mean total FertiQoL score was observed between the two attempts. No patient reported missing injection. More than 9 in 10 patients said they were satisfied to very satisfied with the use of the pen injector for administration of follitropin alfa. Eight patients (4.0%) had hyperstimulation leading to cycle cancellation, and two patients (1.1%) reported ovarian hyperstimulation syndrome. CONCLUSIONS: At the second cycle of follitropin alfa stimulation, a high rate of ovulations, satisfactory compliance and tolerance profile associated with a change in quality of life were reported.

Factors associated with pregnancy after in vitro fertilization in infertile patients with posterior deep pelvic endometriosis: A retrospective study.

INTRODUCTION: The management of posterior deep endometriosis is not consensual. This is due to a great heterogeneity of data from the literature. Many series were small and overall, predictors of pregnancy were not all included and analyzed by multivariate analysis. We conducted this study to evaluate the factors associated with pregnancy during the first two in vitro fertilization (IVF) attempts in infertile women with posterior deep endometriosis. MATERIAL AND METHODS: 230 women were included in this retrospective observational study, between January 1st, 2007 and September 30th, 2013, at the University Hospital of Lille. A large set of variables were recorded and their association with the chance of pregnancy was analyzed by multivariate analysis (MVA), including patients' features, endometriosis items, surgery procedures and IVF data. RESULTS: After 2 IVF attempts, 48.7% of the 230 women achieved a pregnancy, including 39.1% of ongoing pregnancies. Logistic regression analysis retained five variables significantly associated to the chance of pregnancy: oocyte retrieval number (OR=0.468 (0.296-0.739) p=0.001), age (OR=0.888 (0.811-0.974) p=0.011), single embryo transfer number (OR=1.494 (1.036-2.153) p=0.031), presence of a recto-uterine nodule (OR=0.454 (0.235-0.877) p=0.019) and IVF technique (OR=0.509 (0.272-0.951) p=0.034). CONCLUSION: The presence of a recto uterine nodule is associated with a lower chance of pregnancy after IVF. It has to be checked by prospective studies whether the finding of a recto-uterine nodule whose pejorative effect has not been reported so far should encourage to perform surgery before IVF in patients with deep endometriosis.

[Why and how to assess hypospermia?]. / Pourquoi et comment réaliser un bilan d'hypospermie ?

Hypospermia is a semen volume lower than 2 mL on at least two semen analyses. The etiologies of hypospermia are many and may be divided into two pathophysiologic sub-groups: disturbances of ejaculation reflex leading to partial retrograde ejaculation and seminal glands and ducts anatomic and functional anomalies. In this last pathologic mechanism, the mutations of CFTR gene, involved in many different forms of cystic fibrosis, represent a possible cause of hypospermia. The molecular anomaly of CFTR gene's screening is very important for the potential descendents and for the patient himself. It must be considered any time clinic and/or paraclinic context is evocative.

Ectopic hyperprolactinaemia in a woman with a mesocolic perivascular epithelioid cell tumor ("PEComa").

Ectopic prolactin secretion remains exceptional and originates mainly from malignant tumors. We report the case of a 47-year-old woman who presented amenorrhea leading to unravel important hyperprolactinaemia (269 ng/mL) with no hypothalamo-pituitary mass on magnetic resonance imaging (MRI). Pelvic imaging revealed the presence of a large pelvic mass that originated from the mesocolon. After complete surgical extraction, histological examination was in favour of a "perivascular epithelioid cell tumor" (PEComa). Prolactin levels normalized after surgical extraction and remained normal after a 3-year follow-up, totally free of tumour recurrence and/or metastasis. This suggests that hyperprolactinaemia was most likely related to the PEComa, despite negative reactions with antiprolactin antibodies at immunohistochemistry. Alternatively to a direct prolactin secretion by the tumor, one could hypothesize that the tumour secreted a prolactin stimulating factor or a dopamine antagonist that could not be identified. In conclusion, in face of an important hyperprolactinaemia without any hypothalamic-pituitary mass, it remains important to search for an ectopic prolactin production, such as a PEComa.