A follicular volume of >0.56 cm3 at trigger is the cutoff to predict oocyte maturity: a starting point for novel volume-based triggering criteria.

OBJECTIVE: To determine the minimum follicular volume on the day of trigger that will correspond to a mature oocyte at egg retrieval by individualized follicular puncture and to calculate the mean follicular growth from ovulation induction to egg retrieval using SonoAVCfollicle. DESIGN: A prospective observational study of 53 women undergoing in vitro fertilization, in which it was possible to identify unequivocally one or more follicles at trigger and egg retrieval using three-dimensional ultrasound. SETTING: University-affiliated private in vitro fertilization center. PATIENTS: The final sample included 206 follicles from 14 oocyte donors and 39 patients. INTERVENTIONS: A three-dimensional ultrasound with SonoAVCfollicle was performed at trigger and egg retrieval. The same operator selected follicles that were identified easily on both scans and verified that they were apt to be aspirated individually. Follicles were punctured individually, recording the real aspirated volume and the maturity stage of the oocyte. MAIN OUTCOME MEASURES: The primary outcome was the relationship between follicular volume on the day of the trigger and the oocyte maturity stage. The secondary outcome was the rate of follicular growth from the day of trigger to the day of oocyte retrieval, as measured using SonoAVCfollicle. RESULTS: On the day of trigger 206, follicles were selected. Of these, 5 could not be identified on the day of oocyte retrieval, probably because of follicular rupture (mean volume: 4 cm3, range: 2-7 cm3), and in 48, an oocyte was not obtained. The relationship between follicular volume and oocyte maturity was studied in 153 follicles: 125 (82%) contained mature and 28 (18%) contained immature oocytes. Receiver operating characteristic curves showed an area under the curve value of 0.73 (95% confidence interval: 0.65-0.80). A follicular volume of >0.56 cm3 is the cutoff point, with the highest Youden index having a sensitivity of 85% and a specificity of 64% to predict oocyte maturity. The mean follicular growth from trigger to egg retrieval was 26%-50% in 53% of cases. CONCLUSION: A follicular volume of >0.56 cm3 at trigger is the cutoff point with the optimal balance between sensitivity and specificity for oocyte maturity. Follicles of >2-3 cm3 may undergo spontaneous rupture before egg retrieval. Given these findings, we propose new volume-based criteria for trigger: 70% of follicles of >0.6 cm3 and dominant follicles between 2 and 3 cm3. These findings need validation by randomized controlled trials.

Volume-based follicular output rate improves prediction of the number of mature oocytes: a prospective comparative study.

OBJECTIVE: To test whether volume-based follicular output rate (FORT-V) is superior to diameter based follicular output rate (FORT-D) in predicting the number of mature oocytes. The follicular output rate (FORT) is the ratio between preovulatory follicle count (PFC) and antral follicle count (AFC) and has been proposed as a better predictor of the ovarian response compared with AFC alone. DESIGN: A prospective observational study of 215 consecutive women (80 oocyte donors and 135 in vitro fertilization [IVF] patients) undergoing ovarian stimulation for IVF. SETTING: University affiliated private IVF center. PATIENT(S): Women undergoing ovarian stimulation between May 2018 and September 2021. INTERVENTION(S): Manual two-dimensional ultrasound and computer-generated (three-dimensional ultrasound, [3D]) AFCs were performed at baseline. During ovulation induction, follicular growth was monitored in each patient using both two-dimensional and 3D ultrasound. Preovulatory follicles were defined as those with a mean diameter of 16-22 mm. The trigger was based on the follicular volume according to our standard protocol: at least 2 follicles with a volume of >2 cc with 70% of the follicles having a volume of >0.7 cc. MAIN OUTCOME MEASURE(S): The primary outcome was the difference between FORT-V and FORT-D in their ability to predict the mature oocyte output rate. RESULT(S): In both IVF patients and oocyte donors, the computer-generated AFC was greater than the manual AFC. The FORT-V was higher than the FORT-D for both computer-generated (the difference was 35 [95% CI {confidence interval}, 32-45] in oocyte donors and 21 [95% CI, 5-46] in IVF patients) and manual FORT (the difference was 38 [95% CI, 32-45] in oocyte donors and 15 [95% CI, 3-43] in IVF patients) and was closer to the mature oocyte output rate. There was a direct correlation between the computer-generated AFC and the PFC based on volume and between PFC based on volume and the number of mature oocytes in oocyte donors and IVF patients. CONCLUSION(S): In this prospective study of 215 women, the FORT based on 3D ultrasound derived follicular volume (FORT-V) was superior to the FORT-D in determining the ovarian response in both oocyte donors and IVF patients. Moreover, our results support the non-inferiority of the computer-generated method compared with the manual method for the determination of AFC. Further studies on the role of computer-generated antral follicle characteristics may be useful in evaluating follicle stimulation regimens.

Celastrol and Melatonin Modify SIRT1, SIRT6 and SIRT7 Gene Expression and Improve the Response of Human Granulosa-Lutein Cells to Oxidative Stress.

An excess of oxidative stress (OS) may affect several physiological processes fundamental to reproduction. SIRT1, SIRT6 and SIRT7 are involved in protection stress systems caused by OS, and they can be activated by antioxidants such as celastrol or melatonin. In this study, we evaluate SIRT1, SIRT6 and SIRT7 gene expression in cultured human granulosa-lutein (hGL) cells in response to OS inductors (glucose or peroxynitrite) and/or antioxidants. Our results show that celastrol and melatonin improve cell survival in the presence and absence of OS inductors. In addition, melatonin induced SIRT1, SIRT6 and SIRT7 gene expression while celastrol only induced SIRT7 gene expression. This response was not altered by the addition of OS inductors. Our previous data for cultured hGL cells showed a dual role of celastrol as a free radical scavenger and as a protective agent by regulating gene expression. This study shows a direct effect of celastrol on SIRT7 gene expression. Melatonin may protect from OS in a receptor-mediated manner rather than as a scavenger. In conclusion, our results show increased hGL cells survival with melatonin or celastrol treatment under OS conditions, probably through the regulation of nuclear sirtuins' gene expression.

Celastrol Prevents Oxidative Stress Effects on FSHR, PAPP, and CYP19A1 Gene Expression in Cultured Human Granulosa-Lutein Cells.

Regulation of oxidative stress (OS) is important to prevent damage to female reproductive physiology. While normal OS levels may have a regulatory role, high OS levels may negatively affect vital processes such as folliculogenesis or embryogenesis. The aim of this work was to study OS induced by glucose, a reactive oxygen species generator, or peroxynitrite, a reactive nitrogen species generator, in cultured human granulosa-lutein (hGL) cells from oocyte donors, analyzing expression of genes involved in oocyte maturation (FSHR, PAPP, and CYP19A1) and OS damage response (ALDH3A2). We also evaluated the effect of celastrol as an antioxidant. Our results showed that although both glucose and peroxynitrite produce OS increments in hGL cells, only peroxynitrite treatment increases ALDH3A2 and PAPP gene expression levels and decreases FSHR gene expression levels. Celastrol pre-treatment prevents this effect of peroxynitrite. Interestingly, when celastrol alone was added, we observed a reduction of the expression of all genes studied, which was independent of both OS inductors. In conclusion, regulation of OS imbalance by antioxidant substances such as celastrol may prevent negative effects of OS in female fertility. In addition to the antioxidant activity, celastrol may well have an independent role on regulation of gene expression in hGL cells.

Granulosa-Lutein Cell Sirtuin Gene Expression Profiles Differ between Normal Donors and Infertile Women.

Sirtuins are a family of deacetylases that modify structural proteins, metabolic enzymes, and histones to change cellular protein localization and function. In mammals, there are seven sirtuins involved in processes like oxidative stress or metabolic homeostasis associated with aging, degeneration or cancer. We studied gene expression of sirtuins by qRT-PCR in human mural granulosa-lutein cells (hGL) from IVF patients in different infertility diagnostic groups and in oocyte donors (OD; control group). Study 1: sirtuins genes' expression levels and correlations with age and IVF parameters in women with no ovarian factor. We found significantly higher expression levels of SIRT1, SIRT2 and SIRT5 in patients ≥40 years old than in OD and in women between 27 and 39 years old with tubal or male factor, and no ovarian factor (NOF). Only SIRT2, SIRT5 and SIRT7 expression correlated with age. Study 2: sirtuin genes' expression in women poor responders (PR), endometriosis (EM) and polycystic ovarian syndrome. Compared to NOF controls, we found higher SIRT2 gene expression in all diagnostic groups while SIRT3, SIRT5, SIRT6 and SIRT7 expression were higher only in PR. Related to clinical parameters SIRT1, SIRT6 and SIRT7 correlate positively with FSH and LH doses administered in EM patients. The number of mature oocytes retrieved in PR is positively correlated with the expression levels of SIRT3, SIRT4 and SIRT5. These data suggest that cellular physiopathology in PR's follicle may be associated with cumulative DNA damage, indicating that further studies are necessary.

The Ovarian Renin-Angiotensin System (OVRAS): A Major Factor in Ovarian Function and Disease.

This contribution summarizes the pivotal role of the ovarian renin-angiotensin system (OVRAS) in ovarian physiology and disease, with particular emphasis on human clinical implications and established translational applications. The presence of a complete OVRAS in all studied species has been known for decades. The OVRAS has major effects on follicle development/atresia and ovulation and steroid hormone secretion, that is, it is necessary for normal reproduction. It is well established that OVRAS activity is regulated by gonadotropins and depends on activation of proteases in the area of growing follicles. Angiotensin and angiotensin receptors are widely distributed in the ovarian follicle, preovulatory theca and granulosa cells, and postovulatory mural granulosa-lutein cells and regulate steroidogenesis. Molecular blockade of the OVRAS inhibits oocyte maturation and ovulation. Pathologically abnormal OVRAS function has been associated with infertility, polycystic ovarian syndrome (PCOS), ovarian hyperstimulation syndrome (OHSS), and ovarian cancer. Both hyperandrogenism in PCOS and third space fluid accumulation in OHSS have been convincingly linked to overexpression of renin and angiotensin. Blockade of angiotensin receptors is under study for the treatment of gynecologic cancer, OHSS, and PCOS. However, a full understanding of the OVRAS and translational applications is lacking. In part, this is due to the discovery in recent years of previously unknown renin-angiotensin system (RAS) components and novel functions of "classical" RAS components that remain to be integrated into translational studies; newer, more specific agents to block RAS components are available only now for such research and treatment. The need for further studies is evident.

Oxidative Stress in Granulosa-Lutein Cells From In Vitro Fertilization Patients.

Ovarian aging is associated with gradual follicular loss by atresia/apoptosis. Increased production of toxic metabolites such as reactive oxygen species (ROS) and reactive nitrogen species as well as external oxidant agents plays an important role in the process of ovarian senescence and in the pathogenesis of ovarian pathologies such as endometriosis and polycystic ovary syndrome (PCOS). This review provides a synthesis of available studies of oxidative stress (OS) in the ovary, focusing on the most recent evidence obtained in mural granulosa-lutein (GL) cells of in vitro fertilization patients. Synthesis of antioxidant enzymes such as peroxiredoxin 4, superoxide dismutase, and catalase and OS damage response proteins such as aldehyde dehydrogenase 3, member A2 decreases with aging in human GL cells, favoring an unbalance in ROS/antioxidants that mediates molecular damage and altered cellular function. The increase in OS in the granulosa cell correlates with diminished expression of follicle-stimulating hormone receptor (FSHR) and a dysregulation of the FSHR signaling pathway and may be implicated in disrupted steroidogenic function and poor response to FSH in women with aging. Women with endometriosis and PCOS have lower antioxidant production capacity that may contribute to abnormal follicular development and infertility. Further investigation of the signaling pathways involved in cellular response to OS could shed light into molecular characterization of these diseases and development of new treatment strategies to improve reproductive potential in these women.

Follicular Volume Predicts Oocyte Maturity: A Prospective Cohort Study Using Three-Dimensional Ultrasound and SonoAVC.

The aim of this study was to investigate whether the automatic measurement of follicular volume by three-dimensional (3D) ultrasound can predict the number of mature oocytes retrieved. A prospective cohort study including 47 women undergoing in vitro fertilization was conducted in a private fertility center. Follicular growth was monitored both manually and automatically using 3D scanning with SonoAVC on the day of human chorionic gonadotropin (hCG) administration. Regression analysis showed that under a standard protocol for hCG administration, the count of mature oocytes is well predicted by a multivariate model including the counts of follicles in the volume classes 2.00 to 5.00 cm3, 1.50 to 1.99 cm3, 1.00 to 1.49 cm3, and 0.60 to 0.99 cm3 In conclusion, this study shows that follicular volume as measured by SonoAVC on the day of hCG administration can be useful to predict oocyte maturity. Specifically, larger follicles and smaller size follicles (class 0.60-0.99 cm3) contribute to the mature oocyte count. This finding warrants the design of clinical trials to establish new criteria for hCG administration based on follicular volume.

Expression Levels of the Oxidative Stress Response Gene ALDH3A2 in Granulosa-Lutein Cells Are Related to Female Age and Infertility Diagnosis.

Oxidative stress (OS) plays an important role in all physiological processes. The effect of OS on cellular processes is modulated by the ability of the cell to express genes implicated in the reversal of lipid, protein, and DNA injury. Aldehyde dehydrogenase 3, member A2 (ALDH3A2) is a ubiquitous enzyme involved in lipid detoxification. The objective of this study was to investigate the expression ofALDH3A2in human granulosa-lutein (GL) cells of women undergoing in vitro fertilization (IVF) and its relationship with age, infertility diagnosis, and IVF outcome variables. Relative expression levels ofALDH3A2were determined by quantitative reverse transcription-polymerase chain reaction. To investigate the effect of age onALDH3A2expression, 72 women between 18 and 44 years of age with no ovarian factor (NOF) were analyzed. To evaluate the effect of infertility diagnosis onALDH3A2expression, the following groups were analyzed: 22 oocyte donors (ODs), 24 women >40 years old (yo) with tubal or male factor and no ovarian pathology, 18 poor responders (PRs), 19 cases with endometriosis (EM), and 18 patients with polycystic ovarian syndrome (PCOS). In NOF,ALDH3A2expression correlated positively with age and with the doses of follicle-stimulating hormone and luteinizing hormone administered and negatively with the number of total and mature oocytes. When different groups were analyzed,ALDH3A2expression levels were higher in patients >40 yo and in PR compared to OD. On the contrary, EM and PCOS levels were lower than expected for age. These data suggest that GL cellALDH3A2expression levels correlate with age, cause of infertility, and ovarian response to stimulation.

Patients with endometriosis and patients with poor ovarian reserve have abnormal follicle-stimulating hormone receptor signaling pathways.

OBJECTIVE: To study the integrity of the FSH receptor (FSHR) signaling pathway in granulosa-lutein cells at the time of egg retrieval and its relationship with the infertility diagnosis. DESIGN: In vitro assays. SETTING: University laboratory and private IVF center. PATIENT(S): Patients undergoing IVF: 35 controls (no ovarian factor, NOF), 28 poor responders (PR), 32 patients with endometriosis (EM), and 22 patients with polycystic ovary syndrome (PCOS). INTERVENTION(S): Quantitative reverse transcriptase-polymerase chain reaction (PCR) in granulosa-lutein cells from pooled follicles. MAIN OUTCOME MEASURE(S): Correlation between expression of FSHR and FSH-regulated genes PAPP/Cyp19A1. RESULT(S): Positive correlations among FSHR, PAPP, and Cyp19A1 expression levels are observed in NOF and are lost, with different patterns, in poor responder patients and those with endometriosis. Patients with endometriosis are an heterogeneous group including patients with poor ovarian reserve who behave like other poor responders patients (endometriosis-A) and patients with good response to ovarian stimulation (endometriosis-B) who show a specific alteration of the FSHR signaling pathway. CONCLUSION(S): These preliminary data suggest that the different signaling pathways activated through the FSHR in normal ovaries (NOF) are disrupted in poor responders and in patients with endometriosis. A better knowledge of the molecular origin of these errors may guide clinicians in the choice of personalized ovulation induction protocols for each type of ovarian dysfunction.

Expression of angiotensin II type 1 (AT1) and angiotensin II type 2 (AT2) receptors in human granulosa-lutein (GL) cells: correlation with infertility diagnoses.

OBJECTIVE: To correlate angiotensin II (AngII) receptor expression by granulosa-lutein (GL) cells from gonadotropin-stimulated follicles with infertility diagnosis and IVF parameters. DESIGN: The mRNA of angiotensin receptors type 1 (AT1) and type 2 (AT2) was studied in aspirated GL cells. SETTING: University laboratory and private IVF center. PATIENT(S): Seventy-three IVF patients. INTERVENTION(S): Reverse-transcription polymerase chain reaction analysis for relative expression of AT1 and AT2 receptor mRNA in women with no ovarian factor (NOF), poor ovarian reserve (PR), endometriosis (ENDO), and polycystic ovary syndrome (PCOS). MAIN OUTCOME MEASURE(S): Expression of AT1 and AT2 receptor mRNA. RESULT(S): There was a constant approximately 7:1 ratio between AT1 and AT2 receptors and a negative correlation between the AT1/AT2 ratio and patient age. There were statistically significant differences in AngII receptors in individual conditions: NOF showed a correlation between AT1 and AT2 receptors and a negative correlation between AT1 receptor expression, embryo fragmentation and number of metaphase II (MII) oocytes; PR showed a negative correlation between AT2 receptor expression and number of MII oocytes; PCOS AT1 receptor expression correlated negatively with the units of FSH administered and with patients' age; ENDO showed no significant correlations. CONCLUSION(S): Mural GL cells express AT1 receptor much more than AT2 receptor. AngII receptor expression varies with age and infertility diagnosis. Low expression of AngII receptors was associated with high-dose stimulation in women with PR. Embryo fragmentation in NOF is associated with decreased AT1 receptor expression, supporting a role for AngII in GL cell apoptosis.

FSH receptor, KL1/2, P450, and PAPP genes in granulosa-lutein cells from in vitro fertilization patients show a different expression pattern depending on the infertility diagnosis.

OBJECTIVE: To study the expression of mRNA for Kit ligand 1 (KL1), KL2, FSH receptor (FSHR), pregnancy-associated plasma protein (PAPP) and P450 in granulosa-lutein cells from IVF patients and its relationship with the infertility diagnosis and IVF outcome. DESIGN: In vitro assays. SETTING: University laboratory and private IVF center. PATIENT(S): A total of 113 women undergoing IVF. INTERVENTION(S): Quantitative reverse-transcription polymerase chain reaction in granulosa-lutein cells from pooled follicles. MAIN OUTCOME MEASURE(S): Expression of mRNA for KL1, KL2, FSHR, PAPP and P450 in infertility patients with different infertility diagnoses. RESULT(S): Infertile patients with healthy ovaries show positive correlations among KL1, KL2, FSHR, PAPP, and P450 gene expression levels. In patients with ovarian disease, the correlation between KL1 and KL2 gene expression is maintained, but correlations between KL1/KL2 and FSHR, PAPP and P450 are not present except for KL1/FSHR in endometriosis and KL2/P450 in polycystic ovary syndrome. FSHR/KL1 and FSHR/KL2 expression correlates positively only in women who became pregnant. CONCLUSION(S): Findings in healthy human ovaries agree with the feedback model of bone morphogenetic protein 15-KL1/KL2 cross-talk between oocyte and granulosa cells described in other species. The complex relationship between the expression of these genes seems to be disrupted in patients with infertility of ovarian origin. A normal pattern of gene expression and feedback seems to be associated with pregnancy.

Prospective evaluation of automated follicle monitoring in 58 in vitro fertilization cycles: follicular volume as a new indicator of oocyte maturity.

OBJECTIVES: To assess the practical use of SonoAVC in an IVF program, and to establish new criteria for hCG administration based on follicular volume. DESIGN: Prospective clinical study. SETTING: Private IVF Center. PATIENT(S): Fifty-eight women with infertility undergoing IVF. INTERVENTION(S): Two dimensional (2D) and three dimensional (3D) scanning on the day of hCG administration. MAIN OUTCOME MEASURE(S): Image quality, mean follicular diameter obtained by 2D and 3D sonography, follicular volume, number of oocytes retrieved, number of mature oocytes, time needed for each examination. RESULT(S): Approximately 60% of the patients included in this study had good image quality and could be monitored by 3D scans with subsequent application of the SonoAVC software. When image quality is good, measurements obtained by the automated mode are comparable to those obtained manually in 62% of cases. Automated monitoring is significantly quicker than conventional manual monitoring. Follicles with a measured volume >/=0.6 cc on the day of hCG administration are associated with the finding of mature oocytes at the time of egg retrieval. CONCLUSION(S): SonoAVC allows reliable evaluation of stimulated ovaries, and may help us establish new criteria for timing hCG administration based on follicular volume estimation rather than follicular size. Software improvements are needed to improve universal patient use.

Angiotensin II induces apoptosis in human mural granulosa-lutein cells, but not in cumulus cells.

OBJECTIVE: To test whether angiotensin II (AngII) could modulate apoptosis of human granulosa-lutein (GL) cells from gonadotropin-stimulated follicles. DESIGN: In vitro assays on mural and cumulus granulosa cells. SETTING: University laboratory and private IVF practice. PATIENT(S): One hundred six consecutive women undergoing 113 IVF cycles. INTERVENTION(S): Purified human GL mural or cumulus cells were cultured in serum-free media in the presence or absence of AngII with or without the AngII receptor blockers saralasin and CGP42112A. MAIN OUTCOME MEASURE(S): Detection of apoptosis using a fluorescent in situ marker for activated caspases. RESULT(S): Mural cells had approximately eightfold the amount of apoptosis compared with cumulus cells (average 0.23 vs. <0.03, respectively). With mural cells, AngII increased GL cell apoptosis versus untreated control samples (AngII 10(-)11 mol/L +6.5%; AngII 10(-9) mol/L +13.3%, and AngII 10(-7) mol/L +11.3%), an effect which was blocked by concurrent incubation with AngII receptor blockers. The AngII receptor blockers produced a significant decrease of apoptosis compared with control cultures (saralasin: 19.4%; CGP42112A: 28.9%). Neither AngII nor blockers had effect on cumulus cells. CONCLUSION(S): Preovulatory concentrations of AngII, most likely via AT2 receptors, increase apoptosis of cultured mural GL cells but have no effect on cumulus cells. Granulosa cells appear to be differentially regulated by AngII.

Apoptosis of cultured granulosa-lutein cells is reduced by insulin-like growth factor I and may correlate with embryo fragmentation and pregnancy rate.

OBJECTIVE: To correlate apoptosis of cultured human granulosa-lutein cells (GL cells) with the outcome of IVF (embryo fragmentation and pregnancy rate) and to study the effect of insulin and insulin-like growth factor I (IGF-I) on apoptosis. DESIGN: In vitro assays. SETTING: University laboratory and private IVF center. PATIENT(S): Eighty-one women undergoing IVF. INTERVENTION(S): Purified human GL cells from pooled follicles were cultured for 48 hours in serum-free media with or without insulin and IGF-I. Cumulus cells and mural GL cells were evaluated separately. MAIN OUTCOME MEASURE(S): Detection of apoptosis by using caspACE FITC-VAD-FMK, a fluorescent in situ marker for activated caspases; embryo fragmentation; and pregnancy. RESULT(S): Age younger than 38 years and successful pregnancy were associated with less apoptosis (33.0% +/- 17.2% vs. 43.2% +/- 18.0% and 30.2% +/- 14.0% vs. 40.4% +/- 19.5%, respectively). There was a linear correlation between embryo fragmentation and GL cell apoptosis. Insulin-like growth factor I decreased apoptosis in a dose-dependent fashion. A statistically significant effect (17% decrease) was reached at a dose of 10 nM. Insulin (10 nM) caused a small (8%) decrease in apoptosis, but this effect did not reach statistical significance. Cumulus cells consistently had <3% apoptosis. CONCLUSION(S): [1] Apoptosis of cultured GL cells may be associated with IVF outcome and ovarian reserve and [2] IGF-I decreases apoptosis of cultured GL cells.