- Email: [email protected]
Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone
FERTILITY AND STERILITYt VOL. 72, NO. 1, JULY 1999 Copyright ©1999 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.
Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone David B. Seifer, M.D.,* Richard T. Scott, Jr., M.D.,† Paul A. Bergh, M.D.,† Laura K. Abrogast, M.S.,‡ Chad I. Friedman, M.D.,‡ Caryn K. Mack, M.S.,† and Douglas R. Danforth, Ph.D.‡ Received December 3, 1998; revised and accepted February 23, 1999. Supported in part by grant AG15425 from the National Institutes of Health, National Institute on Aging, Bethesda, Maryland (D.B.S.). Presented at the 53rd Annual Meeting of the American Society for Reproductive Medicine, Cincinnati, Ohio, October 18 –22, 1997. Reprint requests: David B. Seifer, M.D., University Center for Reproduction, Endocrinology and Fertility, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, 303 George Street, Suite 250, New Brunswick, New Jersey 08902 (FAX: 732235-7318; E-mail: seiferdb @umdnj.edu). * Department of Obstetrics, Gynecology and Reproductive Sciences, University Center for Reproduction, Endocrinology and Fertility, University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School. † The Institute of Reproductive Medicine and Science at St. Barnabas Medical Center. ‡ Department of Obstetrics and Gynecology, Ohio State University College of Medicine. 0015-0282/99/$20.00 PII S0015-0282(99)00193-4
University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, New Brunswick, and The Institute of Reproductive Medicine and Science at St. Barnabas Medical Center, Livingston, New Jersey; and Ohio State University College of Medicine, Columbus, Ohio
Objective: To test the hypothesis that women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B levels before a rise in day 3 serum FSH levels. Design: Case-control study. Setting: Tertiary care fertility center. Patient(s): One hundred nine women with nonovarian infertility (tubal factor or male factor) and 47 women with declining ovarian reserve who underwent assisted reproductive techniques. Intervention(s): None. Main Outcome Measure(s): Serum inhibin B and FSH levels, number of ampules of gonadotropins administered, E2 levels on the day of hCG administration, number of oocytes retrieved, clinical pregnancy rate, and cycle cancellation rate. Result(s): Women who had declining ovarian reserve as demonstrated by an increased gonadotropin requirement, a decreased E2 response, fewer retrieved oocytes, a lower clinical pregnancy rate, and a higher cycle cancellation rate had lower day 3 serum inhibin B levels despite having nonelevated day 3 FSH levels similar to those of women with nonovarian infertility. Conclusion(s): Women with declining ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve had decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH concentrations. Declining ovarian reserve may be demonstrated by a decrease in day 3 inhibin B levels before a rise in day 3 FSH levels. (Fertil Sterilt 1999;72:63–5. ©1999 by American Society for Reproductive Medicine.) Key Words: Inhibin B, FSH, ovarian reserve
Early follicular phase serum FSH and inhibin B levels are known to change as a function of a woman’s age (1, 2). Although it has been established that pituitary FSH secretion increases with declining ovarian reserve, FSH levels alone may be an unreliable indicator of reproductive potential in older women. In general, direct measures of the aging ovary have been elusive. Ovarian E2 secretion does not correlate with pituitary FSH secretion in older women, and it is likely that ovarian inhibin is important in regulating pituitary FSH secretion. Whereas the day 3 serum FSH level offers an
indirect assessment of ovarian reserve, the inhibin B level may offer a more direct assessment because inhibin B is produced by granulosa cells (2– 4). It recently was shown in 25 regularly menstruating volunteers that both luteal phase inhibin A levels and day 3 inhibin B levels are significantly lower in older women (46 –52 years of age) compared with younger women (39 – 45 years of age) despite similar day 3 FSH levels (2). Examination of granulosa cells from the follicles of women with declining ovarian reserve who were undergoing assisted repro63
ductive techniques revealed a reduced number of cells per follicle (5), less steroid production per cell (6), less inhibin production per cell (6, 7), decreased proliferation (8), and increased apoptosis (5) compared with granulosa cells from the follicles of younger women. Despite the follicular changes that are associated with declining ovarian reserve, the temporal sequence of hormonal changes that signals the onset of declining ovarian reserve has not been described. The purpose of this study was to test the hypothesis that women with declining ovarian reserve may have decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH levels.
MATERIALS AND METHODS From October 1995 through July 1996, 156 women with a diagnosis of tubal factor infertility, male factor infertility, or declining ovarian reserve underwent a single cycle of assisted reproduction at The Institute of Reproductive Medicine and Science of St. Barnabas Medical Center. Of these 156 women, 109 had nonovarian infertility (tubal factor or male factor) and 47 had previously proven declining ovarian reserve. The diagnosis of declining ovarian reserve was based on a history of a poor response to exogenous gonadotropin stimulation in a previous ovulation induction or assisted reproduction cycle and was defined as a peak E2 level of ,500 pg/mL or fewer than four mature follicles ($16 mm in maximum diameter) during a prior cycle that included six ampules per day of gonadotropin stimulation. Comparisons were made of the 109 women with nonovarian infertility (tubal factor or male factor) and the 47 women with previously proven declining ovarian reserve. Day 3 serum samples were drawn before leuprolide acetate (Lupron; TAP Pharmaceuticals, North Chicago, IL) was administered and ovarian stimulation was begun. Day 3 serum FSH levels were determined and the remainder of the serum was stored at 220°C until it was assayed for inhibin B. The study was approved by the Institutional Review Board of St. Barnabas Medical Center. Stimulation protocols for assisted reproduction included four to six ampules per day of exogenous gonadotropins administered in a step-down fashion. Most patients were pretreated with leuprolide acetate beginning in the luteal phase of the prior cycle. Patients with a history of a poor response to stimulation (a peak E2 level of ,500 pg/mL or fewer than four mature follicles in a previous cycle) were treated with a microdose flare protocol. Patients received hCG when they had two follicles measuring 18 mm in maximum diameter or a single follicle measuring 20 mm in maximum diameter. Transvaginal oocyte retrieval was performed approximately 35 hours after the administration of hCG and ET was 64
Seifer et al.
Inhibin B decreases before rise in FSH
performed 72–78 hours after oocyte retrieval. All patients received supplemental progesterone in oil, 50 mg IM, each day until a pregnancy test was performed 14 days after oocyte retrieval. Serum FSH concentrations were determined using the Immulite assay (Diagnostic Products Corporation, Los Angeles, CA). This assay is standardized to the World Health Organization Second Internal Reference Preparation 78/549. Inhibin B was analyzed in duplicate with the use of a double-antibody ELISA (Serotech Limited, Indianapolis, IN). The inhibin B assay cross-reacts approximately 1% with inhibin A. The limit of detection for the inhibin B assay was 15 pg/mL. The intra-assay and interassay coefficients of variation for FSH and inhibin B were ,9%. Potential differences in fertilization rate, clinical pregnancy rate, cycle cancellation rate, and spontaneous abortion rate between women with nonovarian infertility and women with declining ovarian reserve were analyzed with the x2 test or Fisher’s exact test. All other potential differences between the two groups were analyzed with the Student’s t-test. All data are presented as means 6 SEM when appropriate. A value of P,.05 was considered statistically significant.
RESULTS Table 1 summarizes the data for the 109 patients with nonovarian infertility and the 47 patients with declining ovarian reserve. There were no differences in mean gravidity or day 3 serum FSH concentrations between the two groups despite differences in their mean (6 SEM) age (34 6 5.7 years versus 40 6 6.5 years; P,.0001) and day 3 serum inhibin B concentrations (108.1 6 6.1 pg/mL versus 80.2 6 7.3 pg/mL; P,.004). The women with declining ovarian reserve required 15% more ampules of gonadotropins for ovarian stimulation (P,.003), demonstrated ,50% of the E2 response (P,.0001) to stimulation, had fewer than 50% of the number of retrieved oocytes (P,.0001), had 53% of the clinical pregnancy rate per initiated cycle (P5.042), and had twice the cancellation rate per initiated cycle (P5.023) while demonstrating lower day 3 serum inhibin B levels (P,.004) despite having nonelevated day 3 FSH values similar to those of the women with nonovarian infertility.
DISCUSSION Our findings are consistent with the hypothesis that declining ovarian reserve may be illustrated by a significant decrease in the day 3 serum inhibin B level before a rise in the day 3 serum FSH level. Women with decreased ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve demonstrated decreased day 3 serum inhibin B levels despite having similar day 3 serum FSH concentrations. Because ovarian production of inhibin is a direct marker of ovarian function, whereas pituitary FSH Vol. 72, No. 1, July 1999
TABLE 1 Data for 109 patients with nonovarian infertility and 47 patients with declining ovarian reserve. Patient group
Variable Mean (6 SEM) age (y) Mean (6 SEM) gravidity Mean (6 SEM) day 3 FSH level (IU/L) Mean (6 SEM) day 3 inhibin B level (pg/mL) Mean (6 SEM) ampules of gonadotropins administered Mean (6 SEM) day of hCG administration Mean (6 SEM) E2 level on the day of hCG administration (pg/mL) Mean (6 SEM) no. of oocytes retrieved per patient Mean (6 SEM) fertilization rate (%) Mean (6 SEM) no. of embryos transferred Clinical pregnancy rate per initiated cycle (%) Cancellation rate per initiated cycle (%) Spontaneous abortion rate per clinical pregnancy (%)
Nonovarian infertility (n 5 109)
Declining ovarian reserve (n 5 47)
P value
34.0 6 5.7 0.8 6 0.1 5.70 6 0.24 108.1 6 6.1 39.7 6 1.3 11.7 6 0.1 2,272 6 129 17.0 6 0.9 61.8 6 2.2 4.0 6 0.1 53 (58/109) 16 (17/109) 5.2 (3/58)
40.0 6 6.5 1.1 6 0.2 6.50 6 0.40 80.2 6 7.3 46.3 6 2.1 14.7 6 3.3 1,107 6 123 8.2 6 0.6 65.5 6 3.7 3.7 6 0.3 28 (13/47) 36 (17/47) 15.4 (2/13)
,.0001 NS NS ,.004 ,.003 NS (,.06) ,.0001 ,.0001 NS NS .042 .023 NS
Note: NS 5 not significant.
secretion is an indirect marker, it is perhaps not surprising that inhibin may be an earlier indicator of declining ovarian reserve. These findings extend those of a much smaller prospective study that examined 25 regularly menstruating women (2). Those aged 46 –52 years had lower luteal phase inhibin A levels and lower early follicular phase inhibin B levels than those aged 39 – 45 years despite having similar day 3 FSH levels. However, the study was limited by its small sample size. Because FSH is regulated by a variety of factors, including the inhibins, activins, and perhaps follistatins, there may be a sequential time course of change that occurs in these factors as women age. This possibility is particularly relevant to our attempts to identify more precise indicators of ovarian function and reserve. Longitudinal prospective studies that follow up a cohort of women over a 5- to 10-year period and examine perimenopausal and eventual menopausal endocrine and paracrine changes will better define this process.
FERTILITY & STERILITYt
References 1. Klein NA, Illingworth PJ, Groome NP, McNeilly AS, Battaglia DE, Soules MR. Decreased inhibin B secretion is associated with the monotropic FSH rise in older, ovulatory women: a study of serum andfollicular fluid levels of dimeric inhibin A and B in spontaneous menstrual cycles. J Clin Endocrinol Metab 1996;81:2742–5. 2. Danforth DR, Arbogast LK, Mroueh J, Kim MH, Kennard EA, Seifer DB, et al. Dimeric inhibin: a direct marker of ovarian aging. Fertil Steril 1998;70:119 –23. 3. Hofmann GE, Danforth DR, Seifer DB. Inhibin-B: the physiological basis of the clomiphene citrate challenge test for ovarian reserve screening. Fertil Steril 1998;69:474 –7. 4. Seifer DB, Lambert-Messerlian G, Hogan JW, Gardiner AC, Blazar AS, Berk CA. Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome. Fertil Steril 1997;67:110 – 4. 5. Seifer DB, Gardiner AC, Ferreira KA, Peluso JJ. Apoptosis as a function of ovarian reserve in women undergoing in vitro fertilization. Fertil Steril 1996;66:593– 8. 6. Pellicer A, Mari M, Santos MJ, Simon C, Remohi J, Tarin JJ. Effects of aging on the human ovary: secretion of immunoreactive alpha-inhibin and progesterone. Fertil Steril 1994;61:663– 8. 7. Seifer DB, Gardiner AC, Lambert-Messerlian G, Schneyer AL. Differential secretion of dimeric inhibin in cultured luteinized granulosa cells as a function of ovarian reserve. J Clin Endocrinol Metab 1996;81: 736 –9. 8. Seifer DB, Charland C, Berlinsky D, Penzias AS, Haning RV Jr, Naftolin F, et al. Proliferative index of human luteinized granulosa cells varies as a function of ovarian reserve. Am J Obstet Gynecol 1993;169:1531–5.
65
Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone David B. Seifer, M.D.,* Richard T. Scott, Jr., M.D.,† Paul A. Bergh, M.D.,† Laura K. Abrogast, M.S.,‡ Chad I. Friedman, M.D.,‡ Caryn K. Mack, M.S.,† and Douglas R. Danforth, Ph.D.‡ Received December 3, 1998; revised and accepted February 23, 1999. Supported in part by grant AG15425 from the National Institutes of Health, National Institute on Aging, Bethesda, Maryland (D.B.S.). Presented at the 53rd Annual Meeting of the American Society for Reproductive Medicine, Cincinnati, Ohio, October 18 –22, 1997. Reprint requests: David B. Seifer, M.D., University Center for Reproduction, Endocrinology and Fertility, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, 303 George Street, Suite 250, New Brunswick, New Jersey 08902 (FAX: 732235-7318; E-mail: seiferdb @umdnj.edu). * Department of Obstetrics, Gynecology and Reproductive Sciences, University Center for Reproduction, Endocrinology and Fertility, University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School. † The Institute of Reproductive Medicine and Science at St. Barnabas Medical Center. ‡ Department of Obstetrics and Gynecology, Ohio State University College of Medicine. 0015-0282/99/$20.00 PII S0015-0282(99)00193-4
University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, New Brunswick, and The Institute of Reproductive Medicine and Science at St. Barnabas Medical Center, Livingston, New Jersey; and Ohio State University College of Medicine, Columbus, Ohio
Objective: To test the hypothesis that women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B levels before a rise in day 3 serum FSH levels. Design: Case-control study. Setting: Tertiary care fertility center. Patient(s): One hundred nine women with nonovarian infertility (tubal factor or male factor) and 47 women with declining ovarian reserve who underwent assisted reproductive techniques. Intervention(s): None. Main Outcome Measure(s): Serum inhibin B and FSH levels, number of ampules of gonadotropins administered, E2 levels on the day of hCG administration, number of oocytes retrieved, clinical pregnancy rate, and cycle cancellation rate. Result(s): Women who had declining ovarian reserve as demonstrated by an increased gonadotropin requirement, a decreased E2 response, fewer retrieved oocytes, a lower clinical pregnancy rate, and a higher cycle cancellation rate had lower day 3 serum inhibin B levels despite having nonelevated day 3 FSH levels similar to those of women with nonovarian infertility. Conclusion(s): Women with declining ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve had decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH concentrations. Declining ovarian reserve may be demonstrated by a decrease in day 3 inhibin B levels before a rise in day 3 FSH levels. (Fertil Sterilt 1999;72:63–5. ©1999 by American Society for Reproductive Medicine.) Key Words: Inhibin B, FSH, ovarian reserve
Early follicular phase serum FSH and inhibin B levels are known to change as a function of a woman’s age (1, 2). Although it has been established that pituitary FSH secretion increases with declining ovarian reserve, FSH levels alone may be an unreliable indicator of reproductive potential in older women. In general, direct measures of the aging ovary have been elusive. Ovarian E2 secretion does not correlate with pituitary FSH secretion in older women, and it is likely that ovarian inhibin is important in regulating pituitary FSH secretion. Whereas the day 3 serum FSH level offers an
indirect assessment of ovarian reserve, the inhibin B level may offer a more direct assessment because inhibin B is produced by granulosa cells (2– 4). It recently was shown in 25 regularly menstruating volunteers that both luteal phase inhibin A levels and day 3 inhibin B levels are significantly lower in older women (46 –52 years of age) compared with younger women (39 – 45 years of age) despite similar day 3 FSH levels (2). Examination of granulosa cells from the follicles of women with declining ovarian reserve who were undergoing assisted repro63
ductive techniques revealed a reduced number of cells per follicle (5), less steroid production per cell (6), less inhibin production per cell (6, 7), decreased proliferation (8), and increased apoptosis (5) compared with granulosa cells from the follicles of younger women. Despite the follicular changes that are associated with declining ovarian reserve, the temporal sequence of hormonal changes that signals the onset of declining ovarian reserve has not been described. The purpose of this study was to test the hypothesis that women with declining ovarian reserve may have decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH levels.
MATERIALS AND METHODS From October 1995 through July 1996, 156 women with a diagnosis of tubal factor infertility, male factor infertility, or declining ovarian reserve underwent a single cycle of assisted reproduction at The Institute of Reproductive Medicine and Science of St. Barnabas Medical Center. Of these 156 women, 109 had nonovarian infertility (tubal factor or male factor) and 47 had previously proven declining ovarian reserve. The diagnosis of declining ovarian reserve was based on a history of a poor response to exogenous gonadotropin stimulation in a previous ovulation induction or assisted reproduction cycle and was defined as a peak E2 level of ,500 pg/mL or fewer than four mature follicles ($16 mm in maximum diameter) during a prior cycle that included six ampules per day of gonadotropin stimulation. Comparisons were made of the 109 women with nonovarian infertility (tubal factor or male factor) and the 47 women with previously proven declining ovarian reserve. Day 3 serum samples were drawn before leuprolide acetate (Lupron; TAP Pharmaceuticals, North Chicago, IL) was administered and ovarian stimulation was begun. Day 3 serum FSH levels were determined and the remainder of the serum was stored at 220°C until it was assayed for inhibin B. The study was approved by the Institutional Review Board of St. Barnabas Medical Center. Stimulation protocols for assisted reproduction included four to six ampules per day of exogenous gonadotropins administered in a step-down fashion. Most patients were pretreated with leuprolide acetate beginning in the luteal phase of the prior cycle. Patients with a history of a poor response to stimulation (a peak E2 level of ,500 pg/mL or fewer than four mature follicles in a previous cycle) were treated with a microdose flare protocol. Patients received hCG when they had two follicles measuring 18 mm in maximum diameter or a single follicle measuring 20 mm in maximum diameter. Transvaginal oocyte retrieval was performed approximately 35 hours after the administration of hCG and ET was 64
Seifer et al.
Inhibin B decreases before rise in FSH
performed 72–78 hours after oocyte retrieval. All patients received supplemental progesterone in oil, 50 mg IM, each day until a pregnancy test was performed 14 days after oocyte retrieval. Serum FSH concentrations were determined using the Immulite assay (Diagnostic Products Corporation, Los Angeles, CA). This assay is standardized to the World Health Organization Second Internal Reference Preparation 78/549. Inhibin B was analyzed in duplicate with the use of a double-antibody ELISA (Serotech Limited, Indianapolis, IN). The inhibin B assay cross-reacts approximately 1% with inhibin A. The limit of detection for the inhibin B assay was 15 pg/mL. The intra-assay and interassay coefficients of variation for FSH and inhibin B were ,9%. Potential differences in fertilization rate, clinical pregnancy rate, cycle cancellation rate, and spontaneous abortion rate between women with nonovarian infertility and women with declining ovarian reserve were analyzed with the x2 test or Fisher’s exact test. All other potential differences between the two groups were analyzed with the Student’s t-test. All data are presented as means 6 SEM when appropriate. A value of P,.05 was considered statistically significant.
RESULTS Table 1 summarizes the data for the 109 patients with nonovarian infertility and the 47 patients with declining ovarian reserve. There were no differences in mean gravidity or day 3 serum FSH concentrations between the two groups despite differences in their mean (6 SEM) age (34 6 5.7 years versus 40 6 6.5 years; P,.0001) and day 3 serum inhibin B concentrations (108.1 6 6.1 pg/mL versus 80.2 6 7.3 pg/mL; P,.004). The women with declining ovarian reserve required 15% more ampules of gonadotropins for ovarian stimulation (P,.003), demonstrated ,50% of the E2 response (P,.0001) to stimulation, had fewer than 50% of the number of retrieved oocytes (P,.0001), had 53% of the clinical pregnancy rate per initiated cycle (P5.042), and had twice the cancellation rate per initiated cycle (P5.023) while demonstrating lower day 3 serum inhibin B levels (P,.004) despite having nonelevated day 3 FSH values similar to those of the women with nonovarian infertility.
DISCUSSION Our findings are consistent with the hypothesis that declining ovarian reserve may be illustrated by a significant decrease in the day 3 serum inhibin B level before a rise in the day 3 serum FSH level. Women with decreased ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve demonstrated decreased day 3 serum inhibin B levels despite having similar day 3 serum FSH concentrations. Because ovarian production of inhibin is a direct marker of ovarian function, whereas pituitary FSH Vol. 72, No. 1, July 1999
TABLE 1 Data for 109 patients with nonovarian infertility and 47 patients with declining ovarian reserve. Patient group
Variable Mean (6 SEM) age (y) Mean (6 SEM) gravidity Mean (6 SEM) day 3 FSH level (IU/L) Mean (6 SEM) day 3 inhibin B level (pg/mL) Mean (6 SEM) ampules of gonadotropins administered Mean (6 SEM) day of hCG administration Mean (6 SEM) E2 level on the day of hCG administration (pg/mL) Mean (6 SEM) no. of oocytes retrieved per patient Mean (6 SEM) fertilization rate (%) Mean (6 SEM) no. of embryos transferred Clinical pregnancy rate per initiated cycle (%) Cancellation rate per initiated cycle (%) Spontaneous abortion rate per clinical pregnancy (%)
Nonovarian infertility (n 5 109)
Declining ovarian reserve (n 5 47)
P value
34.0 6 5.7 0.8 6 0.1 5.70 6 0.24 108.1 6 6.1 39.7 6 1.3 11.7 6 0.1 2,272 6 129 17.0 6 0.9 61.8 6 2.2 4.0 6 0.1 53 (58/109) 16 (17/109) 5.2 (3/58)
40.0 6 6.5 1.1 6 0.2 6.50 6 0.40 80.2 6 7.3 46.3 6 2.1 14.7 6 3.3 1,107 6 123 8.2 6 0.6 65.5 6 3.7 3.7 6 0.3 28 (13/47) 36 (17/47) 15.4 (2/13)
,.0001 NS NS ,.004 ,.003 NS (,.06) ,.0001 ,.0001 NS NS .042 .023 NS
Note: NS 5 not significant.
secretion is an indirect marker, it is perhaps not surprising that inhibin may be an earlier indicator of declining ovarian reserve. These findings extend those of a much smaller prospective study that examined 25 regularly menstruating women (2). Those aged 46 –52 years had lower luteal phase inhibin A levels and lower early follicular phase inhibin B levels than those aged 39 – 45 years despite having similar day 3 FSH levels. However, the study was limited by its small sample size. Because FSH is regulated by a variety of factors, including the inhibins, activins, and perhaps follistatins, there may be a sequential time course of change that occurs in these factors as women age. This possibility is particularly relevant to our attempts to identify more precise indicators of ovarian function and reserve. Longitudinal prospective studies that follow up a cohort of women over a 5- to 10-year period and examine perimenopausal and eventual menopausal endocrine and paracrine changes will better define this process.
FERTILITY & STERILITYt
References 1. Klein NA, Illingworth PJ, Groome NP, McNeilly AS, Battaglia DE, Soules MR. Decreased inhibin B secretion is associated with the monotropic FSH rise in older, ovulatory women: a study of serum andfollicular fluid levels of dimeric inhibin A and B in spontaneous menstrual cycles. J Clin Endocrinol Metab 1996;81:2742–5. 2. Danforth DR, Arbogast LK, Mroueh J, Kim MH, Kennard EA, Seifer DB, et al. Dimeric inhibin: a direct marker of ovarian aging. Fertil Steril 1998;70:119 –23. 3. Hofmann GE, Danforth DR, Seifer DB. Inhibin-B: the physiological basis of the clomiphene citrate challenge test for ovarian reserve screening. Fertil Steril 1998;69:474 –7. 4. Seifer DB, Lambert-Messerlian G, Hogan JW, Gardiner AC, Blazar AS, Berk CA. Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome. Fertil Steril 1997;67:110 – 4. 5. Seifer DB, Gardiner AC, Ferreira KA, Peluso JJ. Apoptosis as a function of ovarian reserve in women undergoing in vitro fertilization. Fertil Steril 1996;66:593– 8. 6. Pellicer A, Mari M, Santos MJ, Simon C, Remohi J, Tarin JJ. Effects of aging on the human ovary: secretion of immunoreactive alpha-inhibin and progesterone. Fertil Steril 1994;61:663– 8. 7. Seifer DB, Gardiner AC, Lambert-Messerlian G, Schneyer AL. Differential secretion of dimeric inhibin in cultured luteinized granulosa cells as a function of ovarian reserve. J Clin Endocrinol Metab 1996;81: 736 –9. 8. Seifer DB, Charland C, Berlinsky D, Penzias AS, Haning RV Jr, Naftolin F, et al. Proliferative index of human luteinized granulosa cells varies as a function of ovarian reserve. Am J Obstet Gynecol 1993;169:1531–5.
65