Serum anti-Mullerian hormone levels are negatively related to Follicular Output RaTe (FORT) in normo-cycling women undergoing controlled ovarian hyperstimulation

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V.K. Genro1,2,3,4, M. Grynberg1,2,3, J.B. Scheffer1,2,3, I. Roux1,2,3, R. Frydman1,2,3 and R. Fanchin1,2,3,*

1Service de Gynécologie-Obstétrique et Médecine de la Reproduction, AP-HP, Hôpital Antoine Béclère, 157, rue de la Porte de Trivaux, Clamart F-92141, France

2Univ Paris-Sud, Clamart F-92140, France

3INSERM, U782, Clamart F-92140, France

4Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Porto Alegre, Brazil *Correspondence address. Tel: +33-1-45-37-40-53; Fax: +33-1-45-37-49-80; E-mail: renato.fanchin{at}abc.ap-hop-paris.frReceived August 25, 2010. Revision received November 9, 2010. Accepted November 24, 2010. BACKGROUND Since in rodents anti-Müllerian hormone (AMH) has been shown to inhibit antral follicle responsiveness to FSH, we aimed at verifying whether a relationship exists between serum AMH levels and antral follicle responsiveness to exogenous FSH in normo-cycling women.

METHODS Serum AMH, estradiol (E2) and FSH levels were prospectively measured on cycle day 3 in patients undergoing controlled ovarian hyperstimulation (COH) with a time-release GnRH agonist and standardized FSH doses. In 162 patients, follicles were counted after pituitary suppression and before FSH administration (baseline; small antral follicles; 3–8 mm), and on the day of hCG (dhCG; pre-ovulatory follicles; 16–22 mm). Antral follicle responsiveness to FSH was estimated by the Follicular Output RaTe (FORT), determined by the ratio pre-ovulatory follicle count on dhCG × 100/small antral follicle count at baseline.

RESULTS Serum AMH levels were positively correlated with the number of small antral follicles at baseline (r = 0.59; P < 0.0001) and pre-ovulatory follicles on dhCG (r = 0.17; P < 0.04). Overall, FORT was 47.5 ± 1.4% and failed to be influenced by the woman's age, BMI or basal E2 and FSH level. Conversely, multiple regression analysis showed that FORT was negatively correlated with AMH levels (r = -0.30; P < 0.001), irrespective of duration of COH and total FSH dose.

CONCLUSIONS The percentage of follicles that effectively respond to FSH by reaching pre-ovulatory maturation is negatively and independently related to serum AMH levels. Although the mechanisms underlying this finding remain unclear, it is in keeping with the hypothesis that AMH inhibits follicle sensitivity to FSH.

© The Author 2010. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (3): 671-677. doi: 10.1093/humrep/deq361 First published online: December 21, 2010

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Social age deadlines for the childbearing of women and men

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F.C. Billari1,*, A. Goisis1,2, A.C. Liefbroer3,4, R.A. Settersten5, A. Aassve1, G. Hagestad6 and Z. Spéder7

1Department of Decision Sciences, Carlo F. Dondena Centre for Research on Social Dynamics and IGIER, Bocconi University, Roentgen 1, 20136 Milan, Italy

2Department of Social Policy, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK

3Netherlands Interdisciplinary Demographic Institute, PO Box 11650, 2502 AR The Hague, The Netherlands

4Department of Social Research Methodology, VU University Amsterdam, De Boelelaan 1081, 1081 HV Amsterdam, The Netherlands

5Department of Human Development and Family Sciences, Oregon State University, Corvallis, OR 97331, USA

6NOVA/ Norwegian Social Research, PO Box 3223 Elisenberg, 0208 Oslo, Norway

7Demographic Research Institute HCSO, Buday László 1-3, H-1024 Budapest, Hungary *Correspondence address. E-mail: billari{at}unibocconi.itReceived August 2, 2010. Revision received November 9, 2010. Accepted November 24, 2010. BACKGROUND This study examines whether social age deadlines exist for childbearing in women and men, how they vary across countries, whether they are lower than actual biological deadlines and whether they are associated with childbearing at later ages and the availability of assisted reproduction techniques (ARTs).

METHODS This study is based on the European Social Survey, Round 3 (2006–2007), which covers 25 countries. Data were gathered on social age deadlines for childbearing in women (21 909 cases) and men (21 239 cases) from samples of representative community-dwelling populations aged 15 and older.

RESULTS Social age deadlines for childbearing were perceived more frequently for women than men. These deadlines are often lower than actual biological limits, and for women and men alike: 57.2% of respondents perceived a maternal social age deadline =40 years of age; 46.2% of the respondents perceived a paternal social age deadline =45 years of age. There is also considerable variability in deadlines across countries, as well as within them. At the country level, the presence of social age deadlines for the childbearing of women was negatively associated with birth rates at advanced ages and the prevalence of ART, and later deadlines were positively associated with these factors.

CONCLUSIONS It is important to understand the factors that increase and limit late fertility. While biological factors condition fertility, so do social expectations. These findings provide widespread evidence across Europe that social limits exist alongside biological ones, though both sets of factors are more binding for women.

© The Author 2010. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

This ArticleHum. Reprod. (2011) 26 (3): 616-622. doi: 10.1093/humrep/deq360 First published online: December 15, 2010

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A pilot study assessing art therapy as a mental health intervention for subfertile women

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Edward G. Hughes* and Alicia Mann da Silva

Department of Obstetrics and Gynecology, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5*Correspondence address. hughese{at}mcmaster.caReceived August 13, 2010. Revision received October 13, 2010. Accepted November 15, 2010. BACKGROUND Subfertility is a common but hidden source of anxiety, depressive symptoms and hopelessness. Counselling reduces this emotional burden and may even enhance the likelihood of pregnancy. Art therapy may be a useful intervention, because it facilitates the expression of feelings, both visually and verbally, and may ease emotional distress.

METHODS Weekly 2-h art therapy group courses were held for a total of 21 subfertile women. The impact of subfertile women's support systems and barriers to coping were all explored. The effectiveness of art therapy was assessed using Beck Hopelessness, Depression and Anxiety Inventories, administered before and after participation, as well as a qualitative exit questionnaire.

RESULTS The mean age of participants was 35.7 (SD 2.1) years and duration of infertility was 64 (12.0) months. Mean Beck Hopelessness Scale fell from 6.1 (3.8) to 3.5 (3.1, P = 0.01) after therapy. Beck Depression Inventory-II Score fell from 19.8 (11.0) to 12.5 (10.2, P = 0.01) and Beck Anxiety Inventory Score changed from 12.4 (8.4) to 8.4 (5.2, P = 0.3). Based on the exit questionnaire, women felt the course was insightful, powerful and enjoyable.

CONCLUSIONS Art therapy is an inexpensive, non-pharmacological intervention, which was associated with decreased levels of hopelessness and depressed mood in subfertile women. It also provides insight into the meaning and emotional implications of subfertility for patients and caregivers. This pilot study highlights the need for further research in this field.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (3): 611-615. doi: 10.1093/humrep/deq385 First published online: January 18, 2011

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Haplotype analysis of chemokine CXCL12 polymorphisms and susceptibility to premature ovarian failure in Chinese women

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Binbin Wang1,2,†, Peisu Suo1,2,†, Beili Chen3, Zhaolian Wei2, Lu Yang3, Sirui Zhou1,2, Jing Wang1,2, Yunxia Cao3 and Xu Ma1,2,4,*

1Center for Genetics, National Research Institute for Family Planning, 12, Dahuisi Road, Haidian, Beijing 100081, China

2Peking Union Medical College, Beijing, China

3Reproductive Medicine Center, First Affiliated Hospital, Anhui Medical University, Hefei, China

4World Health Organization Collaborating Centre for Research in Human Reproduction, Beijing, China *Correspondence address. Tel: +86-10-62176870; Fax: +86-10-62179151; E-mail: genetic{at}263.net.cn?† These authors contributed equally to the work.

Received June 5, 2010. Revision received December 19, 2010. Accepted January 5, 2011. BACKGROUND Chemokine (C-X-C motif) ligand 12 (CXCL12/stromal cell-derived factor 1) has been suggested to play an essential role in primordial germ cell migration, colonization and survival, and in the primordial to primary follicle transition. This study was performed to investigate an association of polymorphisms in CXCL12 with the risk of premature ovarian failure (POF) in Chinese patients.

METHODS Tagging single nucleotide polymorphisms (SNPs) were selected using the Chinese HapMap database. Five SNPs (rs4948878, rs1801157, rs266087, rs266093 and rs1029153) were genotyped by direct sequencing in 111 patients with POF and 183 healthy controls recruited from the First Affiliated Hospital, Anhui Medical University, China.

RESULTS Compared with controls, there were significantly higher frequencies of the rs1801157 A allele and haplotype C-T-A-T-T in cases with POF [P = 6.38E-07, odds ratio (OR) = 3.10, 95% confidence interval (CI) 1.955–4.890 by allele; P = 7.0E-04, OR = 2.39, 95% CI 1.43–3.97 by haplotype]. No differences were observed for the other four SNPs between POF cases and controls.

CONCLUSIONS A strong association between a CXCL12 polymorphism and POF was established in Chinese patients, suggesting that CXCL12 might be a new candidate gene involved in POF. The A allele of CXCL12 polymorphism rs1801157 is a possible risk factor for developing POF. However, further independent studies are necessary to confirm our findings.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 950-954. doi: 10.1093/humrep/der001 First published online: February 4, 2011

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Dietary iron intake during early pregnancy and birth outcomes in a cohort of British women

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Nisreen A. Alwan1,*, Darren C. Greenwood2, Nigel A.B. Simpson3, Harry J. McArdle4, Keith M. Godfrey5,6 and Janet E. Cade1

1Nutritional Epidemiology Group, Centre for Epidemiology and Biostatistics, School of Food Science and Nutrition, University of Leeds, Leeds, LS2 9JT, UK

2Division of Biostatistics, Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, UK

3Department of Obstetrics and Gynaecology, University of Leeds, Leeds, UK

4Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen, UK

5MRC Lifecourse Epidemiology Unit, Southampton, UK

6NIHR Nutrition, Diet & Lifestyle Biomedical Research Unit, Southampton, UK *Correspondence address. Tel: +44-113-343-6990; Fax: +44-113-343-4877; E-mail: n.alwan{at}leeds.ac.ukReceived October 10, 2010. Revision received November 13, 2010. Accepted December 20, 2010. BACKGROUND Iron deficiency during pregnancy is associated with adverse birth outcomes, particularly, if present during early gestation. Iron supplements are widely recommended during pregnancy, but evidence of their benefit in relation to infant outcomes is not established. This study was performed in the UK, where iron supplements are not routinely recommended during pregnancy, to investigate the association between iron intake in pregnancy and size at birth.

METHODS From a prospective cohort of 1274 pregnant women aged 18–45 years, dietary intake was reported in a 24-h recall administered by a research midwife at 12-week gestation. Dietary supplement intake was ascertained using dietary recall and three questionnaires in the first, second and third trimesters.

RESULTS Of the cohort of pregnant women, 80% reported dietary iron intake below the UK Reference Nutrient Intake of 14.8 mg/day. Those reported taking iron-containing supplements in the first, second and third trimesters were 24, 15 and 8%, respectively. Women with dietary iron intake >14.8 mg/day were more likely to be older, have a higher socioeconomic profile and take supplements during the first trimester. Vegetarians were less likely to have low dietary iron intake [odds ratio = 0.5, 95% confidence interval (CI): 0.4, 0.8] and more likely to take supplements during the first and second trimesters. Total iron intake, but not iron intake from food only, was associated with birthweight centile (adjusted change = 2.5 centiles/10 mg increase in iron, 95% CI: 0.4, 4.6). This association was stronger in the high vitamin C intake group, but effect modification was not significant.

CONCLUSION There was a positive relationship between total iron intake, from food and supplements, in early pregnancy and birthweight. Iron intake, both from diet and supplements, during the first trimester of pregnancy was higher in vegetarians and women with a better socioeconomic profile.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

This ArticleHum. Reprod. (2011) 26 (4): 911-919. doi: 10.1093/humrep/der005 First published online: February 7, 2011

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Supportive care for women with unexplained recurrent miscarriage: patients' perspectives

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A.M. Musters1,*, E.F. Taminiau-Bloem2, E. van den Boogaard1, F. van der Veen1 and M. Goddijn1

1Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology (H4-240), Academic Medical Centre, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands

2Department of Medical Psychology, Academic Medical Centre, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands *Correspondence address. Tel: +31-20-5669111; Fax: +31-20-6971651/31-20-5669104; E-mail: a.m.musters{at}amc.uva.nl/a.m.musters{at}amc.nlReceived November 29, 2010. Revision received January 4, 2011. Accepted January 12, 2011. BACKGROUND Supportive care is currently the only ‘therapy’ that can be offered to women with unexplained recurrent miscarriage (RM). What these women themselves prefer as supportive care in their next pregnancy has never been substantiated. Therefore the aim of this study was to explore what women with unexplained RM prefer as supportive care during their next pregnancy.

METHODS We performed explorative, semi-structured, in-depth interviews. The interviews were performed with 15 women with unexplained RM who were actively seeking conception. All interviews were conducted by telephone. The interviews were fully transcribed and two researchers independently identified text segments from the transcribed interviews and categorized them in the appropriate domain.

RESULTS Women identified 20 different supportive care options; 16 of these options were preferred for their next pregnancy. Examples of the preferred supportive care were early and frequently repeated ultrasounds, ßHCG monitoring, practical advice concerning life style and diet, emotional support in the form of counselling, a clear policy for the upcoming 12 weeks and medication. The four supportive care options that were not preferred by the women were admittance to a hospital ward at the same gestational age as previous miscarriages, Complementary Alternative Medicine, ultrasound every other day and receiving supportive care from their general practitioner.

CONCLUSIONS Our study identified several relevant preferences for supportive care in women with unexplained RM. Many of these can be offered by the gynaecologist and will help in guaranteeing high-quality patient-centred care.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 873-877. doi: 10.1093/humrep/der021 First published online: February 11, 2011

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PC6 levels in uterine lavage are closely associated with uterine receptivity and significantly lower in a subgroup of women with unexplained infertility

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Sophea Heng1, Natalie J. Hannan1, Luk J.F. Rombauts2, Lois A. Salamonsen1 and Guiying Nie1,*

1Prince Henry's Institute of Medical Research, PO Box 5152, 246 Clayton Rd, Clayton, VIC 3168, Australia

2Department of Obstetrics and Gynecology, Monash University, Clayton, VIC 3168, Australia *Correspondence address. Tel: +61-3-9594-4380; Fax: +61-3-9594-6125; E-mail: guiying.nie{at}princehenrys.orgReceived November 15, 2010. Revision received December 19, 2010. Accepted December 29, 2010. BACKGROUND Embryo implantation requires a healthy embryo and a receptive uterus. Uterine incompetence contributes significantly to implantation failure and infertility. To date, there are no reliable biochemical methods that can determine whether the uterus is receptive. Proprotein convertase 5/6 (PC6) is tightly regulated in the uterus and critical for receptivity and implantation; its secretory nature predicts PC6 to be secreted into the uterine cavity. The present study examines whether PC6 is detectable in uterine lavage and whether there is any correlation between secreted PC6 levels and uterine receptivity.

METHODS Western blotting determined the presence of PC6 protein in uterine lavage. A sensitive and high-throughput activity assay was established and validated. This assay was applied to 103 lavages collected from different phases of the menstrual cycle from women with proven fertility or unexplained infertility.

RESULTS Uterine lavage contained PC6 protein with levels paralleling enzymatic activity. PC6 levels were significantly higher in the receptive than in the non-receptive phase in fertile women, and the putative receptive phase levels in a subgroup of women with unexplained infertility were significantly lower than in the fertile counterparts.

CONCLUSIONS PC6 levels in uterine lavage are significantly elevated in the luteal phase of fertile women and markedly reduced in a subgroup of women with unexplained infertility. Uterine fluid is a valuable source of material to evaluate uterine function. Detection of PC6 in uterine fluid may lead to the development of a rapid and relatively non-surgical assessment of uterine receptivity.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 840-846. doi: 10.1093/humrep/der002 First published online: January 27, 2011

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Novel alleles of HLA-DQ and -DR loci show association with recurrent miscarriages among South Indian women

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Meka Aruna1, Theeya Nagaraja1, Sadaranga Andal Bhaskar2, Surapaneni Tarakeswari3, Alla Govardhan Reddy4, Kumarasamy Thangaraj4, Lalji Singh4 and B. Mohan Reddy1,*

1Molecular Anthropology Group, Biological Anthropology Unit, Indian Statistical Institute, Street No. 8, Habsiguda, Hyderabad 500007, India

2Lakshmi Fertility Clinic, Pogathota, Nellore 524001, India

3Fernandez Hospital, Bogulkunta, Hyderabad 500001, India

4Centre for Cellular and Molecular Biology, Uppal Road, Hyderabad 500007, India *Correspondence address. E-mail: bmr{at}isi.ac.in; bmrisi{at}gmail.comReceived March 24, 2010. Revision received January 9, 2011. Accepted January 17, 2011. BACKGROUND In this study, recurrent miscarriages (RMs) are defined as loss of two or more clinically detectable pregnancies before 20 weeks of gestation. HLA has been thought to play a role in RM. However, the results of earlier studies on the role of different human leucocyte antigen (HLA) genes were conflicting and inconclusive. In the present study, we investigate HLA genes (HLA-DRA, HLA-DRB1, HLA-DQA1 and HLA-DQB1) in RM couples with unknown etiology and normal couples.

METHODS Blood samples from 143 RM couples and 150 control couples were analyzed, firstly to validate previously reported association studies and secondly to explore whether any novel alleles or haplotypes specific to Indian populations can be observed to be associated with RM. HLA typing was carried out by DNA sequencing.

RESULTS Results suggest an association of the DQB1*03:03:02 allele with RM (odd ratio = 2.66; pc = 0.02; confidence interval = 1.47–4.84). Haplotypes of the DQA1 and DQB1 risk alleles also showed a significant association with RM, albeit not after Bonferroni correction for multiple comparisons.

CONCLUSIONS HLA-DQB1 appears to have a strong involvement in the manifestation of RM in this population from South India. The current genetic analysis of RM and control couples not only highlights the genes exhibiting a strong etiological role but also reflects the protective nature of some HLA genes against RM. Nevertheless, most of these alleles/haplotypes were not those that are implicated in RM in other ethnic backgrounds, and hence require further validation in other populations of India, from different ethnic and/or geographic backgrounds.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 765-774. doi: 10.1093/humrep/der024 First published online: February 15, 2011

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Treating women under 36 years old without top-quality embryos on day 2: a prospective study comparing double embryo transfer with single blastocyst transfer

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F. Guerif1,2,3,4,*, C. Frapsauce1,2,3,4, C. Chavez1, V. Cadoret1,2,3,4 and D. Royere1,2,3,4

1Service de Médecine et Biologie de la Reproduction, CHRU de Tours, F-37044 Tours, France

2Université François Rabelais de Tours, F-37041 Tours, France

3INRA, UMR85 PRC, F-37380 Nouzilly, France

4CNRS, UMR6175 PRC, F-37380 Nouzilly, France *Correspondence address. Service de Medecine et Biologie de la Reproduction, 2 boulevard Tonnelle, 37000 Tours, France. E-mail: guerif{at}med.univ-tours.frReceived November 17, 2010. Revision received January 4, 2011. Accepted January 11, 2011. BACKGROUND Embryologists currently face a challenge when counselling patients regarding the stage and the number of embryos to transfer when no top-quality embryos (TQE) are available.

METHODS The aim of this study was to evaluate the efficacy of single blastocyst transfer (SBT) in comparison with the transfer of two cleavage-stage embryos in women under 36 years old. A total of 450 women under 36 years undergoing their first or second IVF treatment who had no TQE on Day 2 were included in this prospective study. Couples were assigned to either a SBT or a double cleavage-stage embryo transfer (DET). The clinical end-points monitored were rates of implantation, delivery and multiple deliveries.

RESULTS The rate of transfer was significantly lower for couples assigned to the SBT group compared with the DET group (88 versus 100%, respectively, P < 0.001) while the delivery rate per oocyte retrieval was similar in both groups (26.7%). By contrast, the rate of multiple deliveries was significantly lower in the SBT group compared with the DET group (3.3 versus 23.3%, respectively, P < 0.01). Blastocyst cryopreservation was twice as high in the SBT group compared with the DET group (39 versus 18%, respectively, P < 0.001).

CONCLUSIONS These findings show the value of extended embryo culture for couples without TQE. In such situations, delaying embryo transfer in order to select a single blastocyst with the highest potential for implantation can reduce the number of multiple pregnancies. Furthermore, our results demonstrate that extended culture allows blastocyst cryopreservation from embryos not available for Day 2 cryopreservation.

© The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com This ArticleHum. Reprod. (2011) 26 (4): 775-781. doi: 10.1093/humrep/der020 First published online: February 9, 2011

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