Does ovarian reserve predict egg quality in unstimulated therapeutic donor insemination cycles?

Capsule:
Antral follicle count is not predictive of pregnancy or miscarriage in patients undergoing unstimulated therapeutic donor insemination cycles for indications of an azoospermic male partner or the absence of a male partner.

Authors:
Mike Ripley, M.D., F.R.C.S.C., Andrea Lanes, M.Sc., Marie-Claude Léveillé, Ph.D., Doron Shmorgun, M.D., F.R.C.S.C.

Volume 103, Issue 5, Pages 1170-1175

Abstract:

Objective:
To compare reproductive outcomes of patients with very low, low, normal, and high antral follicle counts undergoing unstimulated therapeutic donor insemination (TDI) cycles.

Design:
Retrospective cohort study.

Setting:
University-affiliated regional fertility clinic.

Patient(s):
Four hundred fifty-nine patients who had 1,107 TDI treatment cycles from January 2006 to December 2013.

Intervention(s):
Unstimulated therapeutic donor insemination.

Main Outcome Measure(s):
Clinical pregnancy rates and miscarriage rates as surrogate markers for oocyte quality.

Result(s):
The overall pregnancy rate per cycle start was 12.46% in the study population. There was no difference in per-cycle or cumulative pregnancy rates among patients with very low, low, average, or high antral follicle counts within each patient age group of ≤35, 36–39, and ≥40 years. The overall miscarriage rate per pregnancy was 13.61%. When stratified by patient age, there was no correlation between miscarriage rate and antral follicle count.

Conclusion(s):
AFC is not a predictor of pregnancy or miscarriage rates in patients undergoing unstimulated TDI.

  • Dr.P.Surya

    Dear sir/Madam,
    We read with great interest the very informative article “Does ovarian reserve predict the egg quality in therapeutic donor insemination cycles”.
    We congratulate the authors for this very useful finding.
    However, we have few questions to be raised on the article.
    1.We are surprised that there were patients more than 40 years of age who had Antral follicle count of more than 24.This is never been our observation.
    2. We were also surprised to find that the authors chose to do intrauterine insemination as against intracervical or intravaginal insemination which would suffice for donor insemination.
    The procedures described in the paper while being simple and straight forward, adds more complexity by doing sperm preparation for intrauterine insemination.
    Thank you,
    With regards,
    Dr.P.Surya.

  • Mike Ripley

    Shverta,
    That’s an excellent question.
    All patients in this study had a BMI under 40 as per clinic policy.
    I agree that a higher BMI could have affected the exposure (likely by underestimating AFC in patients with higher BMIs because they are more difficult to image) and the outcome (patients with higher BMI might have had lower pregnancy rates, as there are a few IUI studies that show it is a negative prognosticator). Fortunately, these effects would have biased the results toward a finding that AFC does affect pregnancy rate, which is not what we found.
    In hindsight, BMI probably should have been controlled for. From a practical standpoint, the study period spanned a time of changeover from paper charts to an electronic medical record at our clinic, and BMI data collection on all patients would have been somewhat challenging.

    • Shvetha Zarek

      Thanks for taking the time to reply with a thoughtful answer. This is such a great study (as highlighted in Dr. Santoro’s piece) and is thought-provoking. It seems like the best markers of ovarian reserve still cannot predict oocyte quality. Thanks!!

  • Mike Ripley

    Jason,
    We’re a bit hesitant to extrapolate these results to infertility patients. We limited our study to the patient’s first 3 TDI cycles to try to exclude patients with undiagnosed but underlying infertility.
    Ovarian reserve is clearly an important predictor of the response to ovarian stimulation, so, unfortunately, infertile patients who go on to have treatments are justified in their anxiety about their ovarian reserve testing results.
    On the other hand, I’m not convinced that an isolated finding of low ovarian reserve (after a full infertility work-up) in younger infertile patients is actually the cause of their infertility. There is some IVF data that seems to indicate that egg quality is not related to ovarian reserve in this population either. Stoop et al. looked at oocyte utilization rate as a marker of oocyte quality and published some pretty interesting data on this (Stoop et al. Hum Reprod. 2012: 27(7); 2030-5), showing that oocyte quality was fairly consistent until age 37-38 regardless of the number of oocytes retrieved per IVF cycle.

  • Shvetha Zarek

    Thank you very much for a well done study evaluating antral follicle count in TDI cycles! Can the authors kindly comment on their statistical reasoning in not adjusting for BMI as a covariate that could be affecting both the exposure and the outcome?

  • Jason M. Franasiak

    Thank you for this interesting manuscript. The authors state in the conclusion that erroneously counseling patients with low AFC that they may have poor egg quality would add undue anxiety. Do the authors feel this can be extrapolated to the infertile population readily as all patients in the study were theoretically fertile? Thank you for your comment.

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