==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2703178410.5144/0256-4947.2016.31.3.1700asm-2-116Original ArticleAssociation of blood groups with ovarian reserve and outcome of in vitro fertilization treatment Awartani Khalid aAl Ghabshi Rahma aAl Shankiti Hanan aAl Dossari Mohamed bCoskun Serdar b a Department of OB-Gyne Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia b Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.Correspondence: Dr. Khalid Awartani, Department of OB-Gyne Department, King Faisal Specialist Hospital and Research Center, MBC 52 Riyadh, 11211, Saudi Arabia, T: +966114423783 F: +9661144237393, kawartani@kfshrc.edu.saMar-Apr 2016 36 2 116 120 Copyright © 2016, Annals of Saudi Medicine2016This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND The association between ABO blood groups and ovarian reserve in infertile patients has been a point of controversy. OBJECTIVES The aim of this study was to assess the correlation of certain blood groups with ovarian reserve and response to treatment in patients undergoing infertility treatment. DESIGN Retrospective medical record review. SETTING Infertility clinic in the assisted reproductive technology (ART) unit at King Faisal Specialist Hospital and Research Center, Riyadh Saudi Arabia. PATIENTS AND METHODS All patients under 40 years of age who attended the infertility clinic at a tertiary care centre in 2010 and underwent in vitro fertilization (IVF) treatment in 2010 and 2011 were divided into groups according to blood type, and clinical parameters were compared. MAIN OUTCOME MEASURE(S) The association between blood groups and ovarian reserve using day 3 luteinzing hormone (LH) and follicular stimulating hormone (FSH) levels, and antral follical count (AFC). RESULTS In 424 patients who underwent 566 IVF cycles, age, LH, FSH and AFC were similar among the different blood groups (P=.9, .1, .5, respectively). With controlled ovarian stimulation, no difference was observed among the four groups in menopausal gonadotrophin (hMG) dose or the duration of stimulation. The number of oocytes retrieved, fertilization rate, cleavage rate, and number of embryos transferred were similar. There was no difference in the cancellation rate or pregnancy rate among the groups. CONCLUSION There was no significant association between blood type and ovarian reserve or response during IVF treatment in our population. LIMITATIONS Anti-Mullerian hormone levels are best correlated with ovarian reserve testing. Unavailability of AMH levels. Retrospective design. ==== Body For the vast majority of women undergoing in vitro fertilization (IVF) treatment, controlled ovarian hyperstimulation (COH) is used and the outcome of the IVF treatment is affected by the ovarian response to COH and the number of the oocytes retrieved during the treatment cycle.1,2 The treatment is usually tailored according to the ovarian reserve of the woman. Various factors, such as age, follicular stimulating hormone (FSH) level, antral follicular count (AFC) and anti-Mullerian hormone (AMH), are used to predict the ovarian reserve for couples undergoing fertility treatment.3 The results of ovarian reserve testing are an important part of patient counselling before starting treatment. Since its introduction, the relationship to different pathologies to ABO blood groups has been of interest to researchers. Aird et al4 reported the relationship of blood groups to gastric cancer. Later, Solish and Gershowitz5 failed to find any correlation between infertility and blood groups. Recently, a predominance of blood group A was shown in patients with endometriosis. 6 There has been interest in whether there could be an association between blood groups and ovarian reserve recently. Blood group A might be associated with early onset of ovarian hyperstimulation syndrome.7,8 Nejat et al9 showed that blood type O was associated with diminished ovarian reserve and that the A blood group antigen appears to be protective of ovarian reserve. However, this finding was challenged by two different studies showing no correlation of blood groups to ovarian reserve.10,11 On the contrary, Lin et al12 showed that Chinese women with blood type O had less diminished ovarian reserve than women with blood types B and AB, who had more diminished ovarian reserve while blood type A was not associated with ovarian reserve. Pereira et al13 studied the subgroups of patients with diminished ovarian reserve and found no difference in response to ovarian stimulation. Since all ovarian reserve testing is performed to estimate the response of ovaries to exogenous gonadotrophin treatment, we analyzed the number of follicles grown and the number of oocytes obtained following COH to correlate to blood types as well as the final outcome of IVF, for an association with blood types. The aim of our study was to assess whether ovarian reserve and IVF treatment outcome are associated with certain blood groups. PATIENTS AND METHODS All new patients who attended the infertility clinic in the ART unit at King Faisal Specialist Hospital and Research Center, Riyadh Saudi Arabia, in 2010 who had complete records were identified from our electronic database and their records were reviewed. Patients who were under 40 years old and had an IVF treatment cycle from 1 January 2010 to 31 December 2011 were included. The study was approved by institution Research Ethics Committee. Data on the early follicular phase serum levels of FSH, luteinizing hormone (LH), antral follicle count (AFC) using the 3-dimensional -GE Voluson-I ultrasound scanner, dose of human menopausal gonadotrophin (hMG) used, days of stimulation, number of follicles grown beyond 10 mm, number of oocytes obtained, the cycle outcome, pregnancy rate, ovarian hyperstimulation syndrome (OHSS), blood type (A,B,AB and O) and the patient age were recorded in an Excel worksheet. Patients had COH by either a long or short pituitary down regulation protocol. Human menopausal gonadotrophin (Menegon, Ferring, Germany) was used in all cases as the medication for stimulation. When there were at least three follicles ≥18 mm, 10 000 IU human chorionic gonadotrophin (hCG, Choriomon, IBSA, Swizerland) was administered to induce final follicular maturation. Oocyte retrieval was performed 36 hours following hCG injection. Fertilization was achieved by IVF or ICSI according to the indication. A maximum of two embryos were transferred under trans-abdominal ultrasound guidance with a full bladder on day 3. The patients started on a vaginal suppository (progesterone, Cyclogest 200 mg, Actavis, UK) three times per day on the day of embryo transfer for luteal phase support. Clinical pregnancy was confirmed by ultrasound for fetal cardiac activity three weeks after a positive hCG test. Patients were divided into four groups according to blood type. All groups were compared for the various parameters. The association between blood groups and ovarian reserve using day 3 LH and FSH levels, and AFC were analyzed as the primary outcome measures. The association between blood group and the dose of gonadotrophins used, days of stimulation and number of oocytes obtained as well as the pregnancy outcomes served as the secondary outcome measures. Statistical analysis was performed using S-plus 2000 (Mathsoft Inc., http://goo.gl/oaeH6y). The proportions of the different blood types were compared by the chisquared test. For the other variables, ANOVA was used for parametric data, the sign-rank test for non-parametric data, and the chi-squared test for binomial data. P values <.05 were considered statistically significant. RESULTS The 424 patients included in the study underwent 566 IVF/intracytoplasmic sperm injection (ICSI) cycles during the study period. Group O blood type was the most common among our patient population (53.5%), while the AB blood type was seen only in 3.5% of the patients. Blood groups A and B were present 27.6 and 15.3% of the patients, respectively (Table 1). The patients’ ages were similar among the different blood groups (P=.33, Table 1). Likewise, the proportions of patients older than 35 years were comparable among the blood groups. Early follicular phase antral follicle count was similar among the different blood groups (P=.38) and no difference was seen in the mean levels of LH and FSH among in the four groups (Table 1). The proportions of women whose FSH level was ≤10 mIU/mL or >10mIU/mL were not significantly different across the different blood groups (P=.1, Table 1). Table 2 shows the characteristics of treatment cycles. During COH, no difference was observed among the four groups in hMG dose, duration of stimulation, and number of follicles >10 mm on the day of hCG injection. Moreover, the number of oocytes retrieved was also similar among the different blood groups (P=.68, Table 2). Similarly, the embryological parameters in terms of percent immature oocytes, fertilization rate, cleavage rate, embryo quality, and number of embryos transferred were also comparable among the different blood groups (Table 2). The groups had a similar cancellation rate during stimulation and there was no significant difference in the rate of development of OHSS among the women in the four blood groups. The pregnancy rates were also similar among all groups (Table 2). DISCUSSION The distribution of blood groups in this study was similar to that reported in a larger population study that included over 57 000 blood donors in Eastern Saudi Arabia.14 The frequency of blood groups O, A, B and AB were 52%, 26%, 18% and 4%, respectively.14 Therefore, these data further support the earlier information about the absence of any relationship between blood groups and infertility in different populations.5 Ovarian reserve is an important factor in the success of assisted reproductive technologies and there are still major difficulties in understanding the pathophysiology of ovarian reserve in reproductive medicine. There have been multiple studies trying to link certain genetic or environmental factors, which have been associated with the dynamics of the ovarian follicular pool, and ovarian response during COH.15–18 There has been recent interest on the effects of different blood groups on ovarian reserve and ovarian stimulation. Previous studies indicated that blood groups have differing implications for ovarian reserve. Specifically, that women with blood group O have been reported to have elevated baseline FSH levels compared with those with blood type A or AB,9 and this elevation was independent of age. On the contrary, Chinese women with blood group O seem to have less diminished ovarian reserve.12 In our study, we observed no relation of blood groups to the ovarian reserve. Early follicular phase FSH levels were similar among different blood groups. Moreover, the proportion of women having high FSH was also comparable. Similarly, de Mouzon et al10 failed to show any relationship between blood groups and ovarian reserve by using AMH as a marker. AMH has been shown to be a better predictor of ovarian reserve than the classical markers including FSH.19 We included AFC to assess the ovarian reserve in relation to blood groups. Apparently, blood groups were not predictive of the ovarian reserve assessed by early follicular phase AFC in addition to FSH levels. Our data used to assess ovarian reserve is limited by the fact that we did not use AMH testing due to the unavailability of the test in our laboratory. However, we used the number of oocytes obtained as a real indicator of ovarian reserve since all testing for ovarian reserve estimates the response to ovarian stimulation and has failed to find any difference between blood groups. Similar results have also been reported in other studies recently.11,13,20 Contradictory results in one report9 might stem from the study design and population differences. First of all, the information for cycle day when FSH measurement was performed was not available in Nejat et al9 study. Estradiol values were used to estimate the early follicular phase while FSH measurements were strictly performed on cycle day 3 in our study. At the same time, population differences could be a factor since opposite results were obtained in Chinese women.12 Such population differences were also observed in the distribution of endometriosis among different blood groups. A higher incidence of endometriosis in blood group A was demonstrated in US and Korean centers, respectively.6,21 Demir et al22 failed to show any association in between blood groups and endometriosis in Turkish population. The results of our study and Bellver et al23 were not consistent with earlier reports of an association between blood groups and OHSS.7,8 The discrepancy could be explained by the fact that the sample size of patients having OHSS was very small in our study, especially when it was split into the four blood groups. Any correlation between OHSS and blood groups needs to be further evaluated in a larger study. We have also compared the characteristics and outcome of treatment cycles to blood groups. There was no significant difference in the doses of gonadotrophins used, days of stimulations, the number of the oocytes retrieved and fertilized, embryo quality and pregnancy rates among the four groups. Spitzer et al20 also failed to show any association between the cycle outcome measures and blood groups. Another limitation of our study was the retrospective design. In conclusion, we found no association between blood type and ovarian reserve, ovarian response or IVF treatment outcome. Conflict of interest The authors have no conflicts of interest. Table 1 Patient characteristics and blood group distribution (N=424). Blood group O A B AB P value Number of patients 227 117 65 15 Blood group (%) 53.5 27.6 15.3 3.5 Age (mean and SD) 31.5 (6.0) 31.5 (5.7) 31.0 (5.9) 28.8 (9.1) .33 Age >35 (%) 22.3 20.2 22.4 20.0 .9 Antral follicle count (mean and SD) 13.6 (9.3) 15.1 (10.2) 14.9 (10.4) 14.7 (10.3) .5 LH mIU/mL (mean and SD) 6.54 (4.5) 6.63 (3.9) 6.69 (4.7) 6.87 (4.0) .9 FSH mIU/mL (mean and SD) 6.99 (2.9) 6.37 (2.5) 6.79 (3.1) 5.78 (2.0) .1 Patients with FSH ≤10 209 (90%) 113 (95%) 65 (97%) 15 (100%) .1 Patients with FSH >10 24 (10%) 6 (5%) 2 (3%) 0 .1 hMG: human menopausal gonadotropin; IU: International unit; SD: Standard deviation; hCG: Human chorionic gonadotropin; OHSS: Ovarian hyper stimulation syndrome. Table 2 Characteristics of IVF cycle and outcome by blood groups. Blood group O A B AB P value Cycles 304 150 92 20 Average dose of hMG (IU) 3443 3630 3630 2978 .4 Days of stimulation (mean and SD) 11.2 (3.1) 11.4 (2.9) 11.5 (3.2) 11 (2.1) .87 Cycles to oocyte retrieval 285 113 84 18 Cancelled during stimulation (%) 18 (6) 6 (4) 6 (7) 1 (5) .17 Follicles >10 mm on the day of hCG (mean and SD) 13.9 (8.8) 15.4 (8.7) 15.0 (10.3) 14.9 (7.2) .38 Oocytes retrieved (mean and SD) 10.3 (6.5) 11.1 (6.5) 10.8 (7.0) 11.3 (5.8) .68 Immature oocyte (%) 10.4 9 11.5 17 .29 Fertilization (%) 66.2 63.9 70.1 56.1 .35 Cleavage (%) 95.2 93.3 93.9 94.8 .60 Embryos at 8-cell or more on day 3 (%) 40 42.8 43.7 50.5 .73 Good embryos (%) 53.6 51.6 53.9 48.5 .8 Poor embryos (%) 18.3 19.1 17.9 16.5 .22 Numbers of embryos transferred (mean and SD) 1.9 (0.6) 1.9 (0.3) 1.9 (0.3) 2 (0) .8 Rate of OHSS (%) 3 4 5 0 .71 Pregnant 104 53 33 9 Pregnancy rate/started cycle (%) 34 35 36 45 .8 Pregnancy rate/patients (%) 46% 45% 51% 60% .6 hMG: human menopausal gonadotropin; IU: International unit; SD: Standard deviation; hCG: Human chorionic gonadotropin; OHSS: Ovarian hyper stimulation syndrome. ==== Refs REFERENCES 1 Fatemi HM Doody K Griesinger G Witjes H Mannaerts B High ovarian response does not jeopardize ongoing pregnancy rates and increases cumulative pregnancy rates in a GnRH-antagonist protocol Hum Reprod 2013 28 442 52 23136144 2 Ji J Liu Y Tong XH Luo L Ma J Chen Z The optimum number of oocytes in IVF treatment: an analysis of 2455 cycles in China Hum Reprod 2013 28 2728 34 23887075 3 Broer SL van Disseldorp J Broeze KA Dolleman M Opmeer BC Bossuyt Added value of ovarian reserve testing on patient characteristics in the prediction of ovarian response and ongoing pregnancy: an individual patient data approach Hum Reprod Update 2013 19 26 36 23188168 4 Aird I Bentall HH Roberts JA A relationship between cancer of stomach and the ABO blood groups Br Med J 1953 1 4814 799 801 13032504 5 Solish GI Gershowitz H Distribution of ABO blood types among fertile and infertile women Am J Hum Genet 1969 21 23 35 4974135 6 Matalliotakis I Cakmak H Goumenou A Sifakis S Ziogos E Arici A ABO and Rh blood groups distribution in patients with endometriosis Arch Gynecol Obstet 2009 280 917 9 19301022 7 Binder H Flegel WA Emran J Muller A Cupisti S Beckmann MW Eckstein R Dittrich R Ringwald J Blood group A: an overseen risk factor for early-onset ovarian hyperstimulation syndrome? Reprod Biomed Online 2008 17 185 9 18681991 8 Binder H Flegel WA Emran J Muller A Cupisti S Beckmann MW Association of blood group A with early onset ovarian hyperstimulation syndrome Transfus Clin Biol 2008 15 395 401 18757223 9 Nejat EJ Jindal S Berger D Buyuk E Lalioti M Pal L Implications of blood type for ovarian reserve Hum Reprod 2011 26 2513 7 21708793 10 de Mouzon J Hazout A Cohen-Bacrie M Belloc S Cohen-Bacrie P Blood type and ovarian reserve Hum Reprod 2012 27 1544 5 22411904 11 Timberlake KS Foley KL Hurst BS Matthews ML Usadi RS Marshburn PB Association of blood type and patient characteristics with ovarian reserve Fertil Steril 2013 100 1735 9 24055049 12 Lin S Li R Chi H Huang S Zhang H Zheng X Effect of ABO blood type on ovarian reserve in Chinese women Fertil Steril 2014 102 1729 32 25313097 13 Pereira N Hutchinson AP Bender JL Lekovich JP Elias RT Rosenwaks Z Spandorfer SD Is ABO blood type associated with ovarian stimulation response in patients with diminished ovarian reserve? J Assist Reprod Genet 2015 32 985 90 25935137 14 Bashwari LA Al-Mulhim AA Ahmad MS Ahmed MA Frequency of ABO blood groups in the Eastern region of Saudi Arabia Saudi Med J 2001 22 1008 12 11744976 15 El-nemar A Al-Shawaf T Sabatini L Wilson C lower AM Grudzinskas JS Effect of smoking on ovarian reserve and ovarian stimulation in in-vitro fertilization and embryo transfer Human Reprod 1998 13 2192 98 16 Padhy N Gupta S Mahla A Latha M Varma T Demographic characteristics and clinical profile of poor responders in IVF/ICSI: a comparative study J Hum Repro Sci 2010 3 91 4 17 Wittenberger MD Hagerman RJ Shrman SL McConkie-Rosell A Welt CK Rebar RW Corrigan EC Simpson JL Nelson LM The FMRI permutation and reproduction Fertil Steril 2007 87 456 65 17074338 18 Freeman EW Gracia CR Sammel MD Lin H Lim LC Strauss JF Association of antimullerian hormone levels with obesity in late reproductive-age women Fertil Steril 2007 87 101 6 17109858 19 Fanchin R Schonäuer LM Righini C Guibourdenche J Frydman R Taieb J Serum anti-Müllerian hormone is more strongly related to ovarian follicular status than serum inhibin B, estradiol, FSH and LH on day 3 Hum Reprod 2003 18 323 7 12571168 20 Spitzer D Corn C Stadler J Wirleitner B Schuff M Vanderzwalmen P Grabher F Zech NH Implications of Blood Type for Ovarian Reserve and Infertility - Impact on Oocyte Yield in IVF Patients Geburtshilfe Frauenheilkd 2014 74 928 32 25364032 21 Kim DA Kim TY Associations of ABO blood groups with various gynecologic diseases Arch Gynecol Obstet 2010 282 229 30 20069305 22 Demir B Dilbaz B Zahran M ABO and Rh blood groups distribution in patients with endometriosis Arch Gynecol Obstet 2010 281 373 4 19471951 23 Bellver J Flerrando M Garrido N Pellicer A Blood group and ovarian hyperstimulation syndrome Fertil Steril 2010 93 270 1 19683228