.. Assessment of the quality of the oocyte, prediction of IVF treatment outcome and improvement of IVF success rates based upon metabolic profile of follicular fluid, blood serum and urine.

Assessment of the quality of the oocyte, prediction of IVF treatment outcome and improvement of IVF success rates based upon metabolic profile of follicular fluid, blood serum and urine.

Infertility is an extremely prevalent problem, affecting one in every seven
couples, and as result in vitro fertilisation (IVF) has become increasingly
popular since it was pioneered in 1978.

As understanding of fertility and embryology has developed, the procedures
and techniques in assisted conception have been ever improving, and as a
result, the number of live births resulting from IVF or ICSI has increased
since the early 90s .

Worldwide, the live birth rate per IVF cycle varies from 17.2% to 31%.
These success rates are still unsatisfactorily low.

The development of controlled ovarian stimulation in the 1980s enabled the
production of multiple mature oocytes and hence multiple embryo transfer,
improving the chances of pregnancy in an IVF cycle.

Today, gonadotrophins are routinely administered to women undergoing IVF in
an attempt to improve the chances of conception. The drawback to multiple
embryo transfer, however, is that the patient has a greater chance of
developing a multiple pregnancy, which carries an increased risk of maternal
and infant morbidity.

Infants from multiple pregnancies are more likely to suffer late
midtrimester miscarriage or have a low birth weight and/or be born prematurely
and as a result may require intensive neonatal care facilities and are at
greater risk of being born with long term disabilities such as cerebral palsy,
deafness, and visual impairment requiring long term support services. The most
common maternal complications associated with multiple pregnancies include high
blood pressure, preeclampsia, increased likelihood of caesarean section, venous
thromboembolism, postpartum haemorrhage, and gestational diabetes.

While IVF is hampered by poor success rates and the increasing pressure to
reduce multiple embryo transfers, a major objective in reproductive medicine
currently is to find a method for identifying the best embryos for transfer.

Therefore a great body of research has been undertaken with aims of
identifying biomarkers to determine oocyte and embryo quality and predict IVF
outcome.

Infertility, subfertility and syndromes or conditions that influence
fertility such as Polycystic Ovary Syndrome (PCOS) Pelvic Inflammatory Disease
(PID) or Endometriosis. are manifested by specific changes in metabolic
pathways  which influence biofluids such
as Follicular Fluid (FF) and blood serum and urine.

Metabolomics can be applied to assisted conception by obtaining and
examining the metabolic profiles of the above mentioned biofluids providing us
the opportunity not only to predict IVF outcome but also to restore the
physiologic metabolic pathways, increase fertility, improve the quality of
oocytes and embryos and ameliorate IVF success rates.

Metabolomics has numerous applications  in female reproduction. These include
metabolomics of Follicular Fluid (FF), embryo culture medium, oocytes and their
related cells, and the introduction of metabolomics techniques to gynecologists
including applications on cervical mucus, uterine matter, the pelvis, ovarian
tissue, and FF.

Studies have
indicated that metabolic differences between embryos may be indicative of their
potential to result in a pregnancy.

Follicular Fluid (FF) composition and fertility

Metabolomics has been successfully used to identify FF markers of oocyte
quality specifically in IVF patients. Since composition of FF could be
indicative of the quality of the oocyte. FF may be predictive of IVF treatment
outcome.

FF levels of steroid hormones, predominantly progesterone, and oestradiol  may be indicative of  oocyte quality.

Similarly, prolactin levels have been found to be correlated with oocyte
quality FF luteinising hormone (LH)  androstenedione
 and testosterone have been associated
with oocyte quality; Other FF hormones such as growth hormone, inhibin B,
leptin, angiotensin II,  cyclic adenosine
monophosphate (cAMP), and  anti-Mullerian
hormone (AMH) have been found to correlate with oocyte potential,  whereas follicle stimulating hormone (FSH) has
been found to have no correlation.

Cytokines have also been measured in FF and correlated to oocyte quality,
but most of the cytokines studied were not found to have predictive value.  Other FF peptides and proteins have been
investigated as markers of oocyte potential.  FF levels of apolipoproteins have been found
to vary in young and old IVF patients and so could be implicated in age-related
infertility.

In terms of targeted analyses of low molecular weight entities, FF levels
of  metabolites involved in the
homocysteine pathway (vitamins B9, B12, and homocysteine), myo-inositol,
D-aspartic acid, alanine, and  glycine have
been found to have predictive value with regard to IVF outcome.

That is to say, the FF levels of these metabolites have been found to
correlate with various measures of IVF outcome (oocyte/embryo quality and
pregnancy rates) and so measuring their levels in FF may have predictive value
on IVF outcome.

The redox state of FF has also been investigated, revealing a significantly
elevated oxidised state in FF from oocytes that degenerated compared to those
that were normal.

Higher levels of reactive oxygen species (ROS) and lower levels of
antioxidants have been found in the FF of women who failed to become pregnant
following intracytoplasmic sperm injection (ICSI) compared to those who did.

Lower FF levels of nitrates and nitrites, produced from
granulosa-synthesised nitric oxide (NO), have been correlated with oocyte
maturation, fertilisation, embryo development, and implantation in humans.

Furthermore, a correlation between FF NO concentrations and peri-follicular
blood flow (PBF) has been found, and  a
higher PBF is known to be associated with a higher oocyte quality.

Targeted studies attempting to identify FF biomarkers of oocyte quality specifically
in women with PCOS have also been performed, where leptin and homocysteine have
been found to have predictive value of oocyte quality and AMH does not.

Diet has a significant influence on the fatty acid content of FF and
alterations in certain fatty acids had a positive impact on oocyte quality.

Lower FF levels of lactate and choline/phosphocholine and higher levels of
glucose were associated with oocytes which failed to cleave as an embryo
compared to oocytes producing two-cell embryos.

In terms of pregnancy test outcome, patients who tested positive were
associated with a lower FF level of glucose and higher levels of proline, lactate,
leucine, and isoleucine.

Plasma and urine composition
and fertility

Correlations between FF plasma and urine may be of diagnostic value.

Since FF is part derived from blood plasma and can exchange metabolites
with blood via the blood-follicle barrier, the composition of the plasma may
have an influence on the quality of the oocyte.

Metabolic changes in serum will be reflected in the FF and, therefore,
could affect oocyte and granulosa cell quality. Blood plasma can be collected
relatively noninvasively, compared to FF, and so would be a preferable medium
for a test to predict IVF treatment outcome.

Several metabolites have been measured (glucose, 3-hydroxybutyrate (3HB),
lactate, urea, total protein, triglycerides, nonesterified fatty acids (NEFA),
total cholesterol, and ions). Significant correlations between serum and FF
were observed for chloride, glucose, 3HB, urea, total protein, triglycerides,
NEFA, and total cholesterol.

Insulin-like growth factor-1 (IGF-1) has been shown to have a beneficial
effect on embryo development in vitro.

Blood levels of IGF-1 and several other blood components (insulin, urea,
NEFA, 3HB, and cholesterol) were measured in embryo donor and recipients.
Correlations were found between IGF-1, insulin, and cholesterol levels and
embryo viability

Other hormones, such as 17-β oestradiol, and
progesterone have been shown to have predictive value of embryo quality.

Oocyte morphological quality has been corelated with several blood
constituents (plasma total protein, glucose, total cholesterol, high-density
lipoprotein cholesterol, urea, albumin levels, and the activities of aspartate
aminotransferase and lactate dehydrogenase).

It has been shown that high levels of NEFA may have a negative impact on
fertility through increased levels of NEFA in the FF.

In vitro, NEFA has been found to reduce the developmental potential of
oocytes and to hamper granulosa cell proliferation and steroid production.

Increased dietary fatty acids improved oocyte quality.The level of dietary
fat is more important to oocyte quality than the type of fat

The ovary moderates the uptake of individual plasma fatty acids so as to
keep the fatty acid profile to the oocyte constant.

Serum AMH has been found to correlate with oocyte and embryo quality in IVF
patients.

FSH has also been investigated as a potential predictor of IVF outcome,
with some success.

Plasma levels of apolipoproteins have been found to vary in young and old
IVF patients and so could be implicated in age-related infertility.

Apolipoprotein B levels were higher in younger patients than old, though
this difference was not statistically significant.

Apolipoprotein E levels were greater in older patients for low density
lipoprotein (LDL) and very low density lipoprotein (VLDL) complexes and apolipoprotein
A1 did not differ with age.

Protein and peptide levels in serum and FF may also be indicative of
follicle maturity and hence oocyte quality.

Higher serum levels of soluble triggering receptor expressed on myeloid
cells-1 (sTREM-1), which is a marker of infection and inflammation, have been
associated with poorer quality embryos.

In terms of lower molecular weight metabolites, high plasma levels of
vitamin B12 have been associated with better embryo quality.

Significant decreases in plasma amino acids, citrate, choline, and
glycerophosphocholine/phosphocholine, and increases in the levels of
dimethylamine (DMA), lactate, and N-acetyl glycoproteins in PCOS patients
compared to controls.

These trends reflect the perturbations in amino acid metabolism, impairment
of the tricarboxylic acid (TCA) cycle (citrate), increased activity of the gut
microflora (citrate, choline and glycerophosphocholine/phosphocholine) (which
has been linked to diabetes, obesity, and cardiovascular disease), increased
glycolytic activity (lactate and glucose (insignificant)), and inflammation
(glycoprotein).

Furthermore, greater metabolic deviations were observed in subgroups of
patients with obesity, metabolic syndrome, and hyperandrogenism.

Significant decreases in citrulline, lipids, arginine, lysine, ornithine,
proline, glutamate, acetone, citrate, and histidine have been found in PCOS patients
compared with controls.

Conclusion:

Infertility, subfertility and syndromes or conditions that influence
fertility such as Polycystic Ovary Syndrome (PCOS) Pelvic Inflammatory Disease
(PID) or Endometriosis. are manifested by specific changes in metabolic
pathways  which influence biofluids such
as Follicular Fluid  and blood serum and
urine.

Metabolomics can be applied to assisted conception by obtaining and
examining the metabolic profiles of the above mentioned biofluids providing us
the opportunity not only to predict IVF outcome but also to restore the
physiologic metabolic pathways, increase fertility, improve the quality of
oocytes and embryos and ameliorate IVF success rates.

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Dr. Dimitrakopoulos K. Ioannis MD, PhD, OB/GYN

Ιωάννης Κ. Δημητρακόπουλος 

Μαιευτήρας - Γυναικολόγος

Ιατρείο: Λεωφ. Δημητρίου Γούναρη 196  Γλυφάδα Τ.Κ. 166 74

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