To the Editor:
We read the article by Lamb et al. (1) with great interest. They proposed to determine whether follicular steroid hormone levels are associated with fertilization outcome after intracytoplasmic sperm injection (ICSI). Oocytes that fertilized normally had higher estradiol and testosterone concentrations compared with those that degenerated with ICSI. Oocytes that fertilized normally had also higher estradiol and progesterone concentrations compared with those that failed to fertilize in the study.
The study would be better if the authors defined the indications for ICSI. There may be a relationship between follicular fluid steroid hormone concentrations and the etiology of infertility. Moreover, some studies have demonstrated that follicular fluid steroid hormone concentrations were different in hormone dependent diseases such as endometriosis and polycystic ovary syndrome (2,3).The authors compared the follicular fluids of the patients due to their fertility status but the group was not homogeneous and consisted of different etiologies of infertility. The results of the study would be better if the authors studied in a specific infertility group or classified the follicular fluids in their etiologic factors.
Although the authors defined the fertilization outcome as the presence of two pronuclei, the quality of embryo is an another important predictor. Was there any relationship between follicular steroid hormone concentrations and the quality of embryo? We think that after the oocyte was fertilized, it could be classified in terms of embryo quality in the study. The manuscript would be more satisfying if the embryos were scored and evaluated as to whether there was any association between follicular fluid steroid hormones and high quality of embryos.
Studies have demonstrated that there was a close relationship between ovarian stimulation protocols and intrafollicular steroid hormone levels (4,6). However, the controlled ovarian stimulation protocol was not defined in the study. What was the stimulation protocol in the study? Was the same stimulation protocol applied to all participants in the study? Did they use recombinant, urinary FSH or HMG? Was recombinant LH added in the study protocol? What was the beginning gonadotropin dose? Was the FSH dose adjusted on individual basis? We think that all of these points must be stressed in the study.
Some other demographic characteristics of the patients, such as age range, body mass index, day 3 estradiol levels, antral follicle count, previous pregnancies, live births, infertility period, and recurrent ICSI failures must also be defined to show the study population. Were there any poor responders in the group? Did they also use the same stimulation protocol in poor responders? Moreover, the characteristics study population would be defined better if they revealed the inclusion and exclusion criteria in the study.
Fatma Ferda Verit, M.D.
Department of Obstetrics and Gynecology
Harran University, Faculty of Medicine
Dr.Gulnaz Sahin, M.D.
Family Planning-Infertility Research and Treatment Center
Ege University School of Medicine
Bornova, Izmir, Turkey
Ege Nazan Tavmergen Goker, M.D.
Family Planning-Infertility Research and Treatment Center, Ege University School of Medicine
Bornova, Izmir, Turkey
Nese Gul Hilali, M.D.
Department of Obstetrics and Gynecology
Harran University, Faculty of Medicine
1. Lamb JD, Zamah AM, Shen S, McCulloch C, Cedars MI, Rosen MP. Follicular fluid steroid hormone levels are associated with fertilization outcome after intracytoplasmic sperm injection. Fertil Steril. 2010 Aug;94(3):952-7.
2. Naessen T, Kushnir MM, Chaika A, Nosenko J, Mogilevkina I, Rockwood AL, Carlstrom K, Bergquist J, Kirilovas D. Steroid profiles in ovarian follicular fluid in women with and without polycystic ovary syndrome, analyzed by liquid chromatography-tandem mass spectrometry. Fertil Steril. 2010 Feb 18. [Epub ahead of print]
3. Wunder DM, Mueller MD, Birkhäuser MH, Bersinger NA. Steroids and protein markers in the follicular fluid as indicators of oocyte quality in patients with and without endometriosis. J Assist Reprod Genet. 2005 Jun;22(6):257-64.
4. Garcia-Velasco JA, Isaza V, Vidal C, Landazábal A, Remohí J, Simón C, Pellicer A. Human ovarian steroid secretion in vivo: effects of GnRH agonist versus antagonist (cetrorelix). Hum Reprod. 2001;16(12):2533-9.
5. Dor J, Bider D, Shulman A, Levron JL, Shine S, Mashiach S, Rabinovici J. Effects of gonadotrophin-releasing hormone agonists on human ovarian steroid secretion in vivo and in vitro-results of a prospective, randomized in-vitro fertilization study Hum Reprod. 2000;15(6):1225-30.
6. Tavmergen E, Tavmergen EN, Capanoğlu R. Do analogues of gonadotrophin releasing hormone influence follicular fluid steroid levels, oocyte maturity and fertilization rates? Hum Reprod. 1992 ;7(4):479-82.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.11.030
The Authors Respond:
We thank Dr. Verit and colleagues for the interest in our paper (1).
The first question regarding the indications for ICSI and the relationship between follicular fluid (FF) steroid hormone concentrations and the etiology of infertility is well stated. In our clinic approximately 70% of IVF cycles utilize ICSI based on either an indication of male factor infertility (oligozoospermia with concentrations <10 mllion/mL, asthenospermia with motility <20%, or teratospermia with strict morphology <5%) or a history of low fertilization with conventional IVF.
The second question regarding the relationship between follicular steroid hormone concentrations and the etiology of infertility has been investigated. Diagnoses such as endometriosis and PCOS could potentially affect hormone concentration in FF (2), but these patients make up a small minority of our IVF patient population (<10%). In our study, the most common etiology of infertility was either unexplained, male factor, multi-factorial or age related which is not known to effect FF concentrations in ART cycles (3). However, whether a relationship between the FF steroid hormone concentrations and embryo quality exists is controversial (4). It is noted that several studies have suggested high serum androgen levels are associated with embryo quality (2, 5). Embryo quality was not a targeted outcome in our study, but this question is interesting and should be investigated further.
The next point suggests that the FF hormone milieu may be affected by the medication or stimulation protocol. There is in fact evidence to suggest that the follicular steroid hormone concentrations are different depending on whether HP-HMG or rFSH is administered (6). However, in this study almost all patients received the combination of hMG and rFSH. And although patients were on variety of ovarian stimulation protocols, more than 70% were on a long luteal protocol. FSH doses were adjusted on an individual basis and stimulation protocol. For our long luteal protocol patients, the algorithm we use to determine starting doses of gonadotropin and dose tapering has been previously described (7). The effect of study protocol and dose changes on FF hormonal milieu remains to be determined.
Although advancing female age may be associated with changes in intra-follicular steroid content in spontaneous menstrual cycles, data from our center suggest that in stimulated ovarian cycles the intra-follicular steroid content does not significantly change with age once adjusted for intra-follicular gonadotropin levels (8,9). Our current study reports on a cohort of mature sized FF samples (16-25mm based on follicle volume) from a bank of follicular fluid, not on a cohort of patients. Important follow up studies will involve standardizing protocols and identifying other demographic and cycle predictors of follicular fluid hormone levels and their effect on fertilization rates, embryo quality, and pregnancy outcomes. In fact, a recent randomized controlled trial from our center was designed based on this association between follicular fluid hormone levels and fertilization outcomes. We randomized patients to an extra dose of FSH at time of hCG vs placebo and found higher FSH levels in the follicular fluid and higher fertilization rates in patients who received the extra FSH trigger (in review by Fertility and Sterility).
Julie D Lamb, M.D.
A. Musa Zamah, M.D., Ph.D.
Mitchell P. Rosen, M.D.
Department of Obstetrics, Gynecology and Reproductive Sciences
University of California at San Francisco
San Francisco, California
1. Lamb JD, Zamah AM, Shen S, McCulloch C, Cedars MI, Rosen MP. Follicular fluid steroid hormone levels are associated with fertilization outcome after intracytoplasmic sperm injection. Fertility and Sterility 2010;94:952-7.
2. Teissier MP, Chable H, Paulhac S, Aubard Y. Comparison of follicle steroidogenesis from normal and polycystic ovaries in women undergoing IVF: relationship between steroid concentrations, follicle size, oocyte quality and fecundability. Human Reproduction (Oxford, England) 2000;15:2471-7.
3. Rosen MP, Zamah AM, Shen S, Dobson AT, McCulloch CE, Rinaudo PF et al. The effect of follicular fluid hormones on oocyte recovery after ovarian stimulation: FSH level predicts oocyte recovery. Reprod Biol Endocrinol 2009;7:35.
4. Mendoza C, Cremades N, Ruiz-Requena E, Martinez F, Ortega E, Bernabeu S et al. Relationship between fertilization results after intracytoplasmic sperm injection, and intrafollicular steroid, pituitary hormone and cytokine concentrations. Human Reproduction (Oxford, England) 1999;14:628-35.
5. Fridstrom M, Carlstrom K, Sjoblom P, Hillensjo T. Effect of prednisolone on serum and follicular fluid androgen concentrations in women with polycystic ovary syndrome undergoing in-vitro fertilization. Human Reproduction (Oxford, England) 1999;14:1440-4.
6. Smitz J, Andersen AN, Devroey P, Arce JC. Endocrine profile in serum and follicular fluid differs after ovarian stimulation with HP-hMG or recombinant FSH in IVF patients. Human Reproduction (Oxford, England) 2007;22:676-87.
7. Zamah AM, Hsieh M, Chen J, Vigne JL, Rosen MP, Cedars MI et al. Human oocyte maturation is dependent on LH-stimulated accumulation of the epidermal growth factor-like growth factor, amphiregulin. Human Reproduction (Oxford, England) 2010;25:2569-78.
8. Klein NA, Battaglia DE, Miller PB, Branigan EF, Giudice LC, Soules MR. et al. Ovarian follicular development and the follicular fluid hormones and growth factors in normal women of advanced reproductive age. The Journal of Clinical Endocrinology and Metabolism. 1996 ;81(5):1946-51
9. Zamah AM Rosen MP, Sohn SH, Cedars MI. The effect of female age on granulosa/theca cell hormonal production. Fertility and Sterility Sept 2008; 90 Suppl 1:S126.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.11.031