Abstract

Background: Angiogenesis constitutes a fundamental regulatory mechanism in folliculogenesis, oocyte maturation, endometrial receptivity and successful implantation, directly influencing assisted reproductive technology (ART) outcomes. Vascular endothelial growth factor (VEGF) is the principal pro-angiogenic factor in the ovary, whereas pigment epithelium-derived factor (PEDF) serves as a potent endogenous angiogenesis inhibitor. The relative balance between these factors is critical in determining follicular angiogenesis, oxidative stress, oocyte competence and pregnancy outcomes. Dysregulation of the angiogenic balance within the follicular microenvironment may adversely affect oocyte quality and pregnancy outcomes, particularly in assisted reproductive technology (ART) cycles. Objective: To evaluate serum and follicular fluid (FF) PEDF and VEGF concentrations, as well as the PEDF/VEGF index, and their correlation with oocyte quality and pregnancy outcomes in Iraqi women undergoing intracytoplasmic sperm injection (ICSI). Methods: This prospective study included ninety infertile women undergoing controlled ovarian stimulation and ICSI at High Institute for infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University, Baghdad, Iraq. Serum and FF samples were collected on the day of oocyte retrieval. PEDF and VEGF concentrations were measured using enzyme-linked immunosorbent assay (ELISA), and the PEDF/VEGF index was calculated. Oocyte maturity parameters and pregnancy outcomes were recorded. Results: Cycles resulting in clinical pregnancy demonstrated elevated PEDF/VEGF indices in both serum and FF compared with non-pregnant cycles. Higher indices were positively correlated with a greater proportion of mature (MII) oocytes, higher implantation rates, and cycles resulting in pregnancy. In contrast, elevated VEGF without a proportional increase in PEDF was associated with a predominance of immature oocytes and poorer outcomes. Conclusions: The PEDF/VEGF index in follicular fluid may serve as a reliable indicator of angiogenic homeostasis within the ovarian microenvironment and a potential predictor of oocyte quality and pregnancy success in Iraqi women undergoing ICSI. If confirmed, therapeutic modulation of PEDF/VEGF balance could be explored to improve ART outcomes.