REVIEW

published: 30 August 2021

doi: 10.3389/fcell.2021.710292

Oocyte Competence Biomarkers

Associated With Oocyte Maturation:
A Review
Batara Sirait 1,2* , Budi Wiweko 3,4,5 , Ahmad Aulia Jusuf 6 , Dein Iftitah 5 and R. Muharam 3,4,5
1
Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta, Indonesia, 2 Morula
IVF Jakarta Clinic, Jakarta, Indonesia, 3 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and
Gynecology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia, 4 Yasmin IVF Clinic, Dr. Cipto Mangunkusumo
General Hospital, Jakarta, Indonesia, 5 Human Reproductive, Infertility, and Family Planning Research Cluster, Indonesia
Medical Education and Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia,
6
Department of Histology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Oocyte developmental competence is one of the determining factors that influence

the outcomes of an IVF cycle regarding the ability of a female gamete to reach
maturation, be fertilized, and uphold an embryonic development up until the blastocyst
stage. The current approach of assessing the competency of an oocyte is confined
to an ambiguous and subjective oocyte morphological evaluation. Over the years, a
myriad of biomarkers in the cumulus-oocyte-complex has been identified that could
Edited by: potentially function as molecular predictors for IVF program prognosis. This review
Francesca Elizabeth Duncan,
aims to describe the predictive significance of several cumulus-oocyte complex (COC)
Northwestern University,
United States biomarkers in evaluating oocyte developmental competence. A total of eight acclaimed
Reviewed by: cumulus biomarkers are examined in the study. RT-PCR and microarray analysis
Lynda K. McGinnis, were extensively used to assess the significance of these biomarkers in foreseeing
University of Southern California,
United States
oocyte developmental competence. Notably, these biomarkers regulate vital processes
Xiongbo Peng, associated with oocyte maturation and were found to be differentially expressed in COC
Wuhan University, China
encapsulating oocytes of different maturity. The biomarkers were reviewed according
*Correspondence:
to the respective oocyte maturation events namely: nuclear maturation, apoptosis, and
Batara Sirait
batarasirait@gmail.com extracellular matrix remodeling, and steroid metabolism. Although substantial in vitro
evidence was presented to justify the potential use of cumulus biomarkers in predicting
Specialty section:
oocyte competency and IVF outcomes, the feasibility of assessing these biomarkers as
This article was submitted to
Molecular and Cellular Reproduction, an add-on prognostic procedure in IVF is still restricted due to study challenges.
a section of the journal
Frontiers in Cell and Developmental Keywords: oocyte competence, oocyte maturation, cumulus-oocyte complex (COC), biomarker, in-vitro
fertilization
Biology
Received: 15 May 2021
Accepted: 10 August 2021
Published: 30 August 2021
INTRODUCTION
Citation: Controlled ovarian stimulation is a critical step of a successful IVF cycle conducted to stimulate
Sirait B, Wiweko B, Jusuf AA, the development of multiple follicles in the ovaries, thereby increasing the chances of harvesting
Iftitah D and Muharam R (2021)
viable eggs that could potentially become viable blastocysts. Depending on the patients’ ovarian
Oocyte Competence Biomarkers
Associated With Oocyte Maturation:
response status, there are a number of available ovarian stimulation protocols offered by IVF
A Review. clinics. The protocols generally comprise of administering a combination of gonadotrophin
Front. Cell Dev. Biol. 9:710292. analogs namely gonadotropins-releasing hormone (GnRH) agonist or antagonist, estradiol
doi: 10.3389/fcell.2021.710292 inhibitors, recombinant follicle-stimulating hormone (FSH), and luteinizing hormone (LH)

Frontiers in Cell and Developmental Biology | www.frontiersin.org 1 August 2021 | Volume 9 | Article 710292
Sirait et al. Oocyte Competence Biomarkers

(Gallos et al., 2017). While the drug regimens hold paramount Notably, some biomarkers have different or interconnected
importance for IVF and have been established and refined modes of action in regulating oocyte maturation and are hereby
through years of clinical practice and research, the incidence of assorted based on the processes that they associate with during
asynchronous ovarian response persists (Braga et al., 2020). This oocyte maturation.
is evident in the miscellaneous yield of abnormal, immature, and
poor-quality oocytes at retrieval. Furthermore, a portion of the
immature oocytes would not progress to maturity during in vitro OOCYTE NUCLEAR MATURATION
culture and could not be subjected to sperm injections while the
poor-quality oocytes are at risk of forming aneuploid embryos Nuclear maturation that is characterized by germinal vesicle
(Figueira et al., 2010; Bosch et al., 2016). Hence, oocyte quality breakdown denotes the continuation of meiosis I division from
assessment is carried out prior to syngamy as a predictive marker prophase I to metaphase II. The majority of intra-ovarian
of oocyte competence and IVF outcomes. oocytes are arrested at prophase I due to the low activity of
To date, the oocytes quality assessment is mostly based on maturation promoting factors (MFP), which consist of two sub-
morphology (Wang and Sun, 2007). The morphological grading unit proteins namely cyclin-dependent kinase 1 (CDK1) and
system is mainly based on extra-cytoplasmic and cytoplasmic Cyclin B1. Physiologically, low activity of intra-oocyte MPF is
observations, which may give insight into the nuclear and instigated by the presence of adenosine monophosphate (cAMP)
cytoplasmic maturity state (Balaban et al., 2012). A spectrum produced by intra-follicular somatic cells or the oocytes itself
of publications has supported the relevancy of one or more (Edry et al., 2006), and cyclic guanosine monophosphate (cGMP)
of the oocyte morphological characteristics in predicting the produced by follicular somatic cells (Norris et al., 2009). Both
quality of the subsequent stages of embryo development. Tilia of these molecules are transported into the oocyte via gap
et al. (2020) inferred that oocyte meiotic spindle morphology is junctions. cAMP prevents the activation of CDK1 through
correlated to embryo developmental stages and embryo ploidy the protein kinase A (PKA) signaling pathway, while a high
and that the oocyte morphology scoring system could be useful in concentration of cGMP inhibits the degradation of cAMP by
determining embryos competent to achieve successful pregnancy phosphodiesterase PDE3A enzyme. The inhibitory actions of
(Lazzaroni-Tealdi et al., 2015). However, the accuracy of this the signaling molecules altogether ensue the low MPF activity
morphological grading method in predicting IVF outcomes is still that in turn leads to maturation arrest (Adhikari and Liu,
unconvincing due to its subjectivity and the lack of correlation to 2014). Luteinizing hormone (LH) plays a significant role in
the quality or competence of the oocytes (Ruvolo et al., 2013). counteracting the inhibitory signaling molecules by restricting
This has led to the current trend of research which attempts to the translation of Cx-43 protein, which is an essential backbone
utilize more definitive molecular parameters, such as biomarkers, protein for the construction of gap-junction (Kalma et al.,
in outlining the predictive models for IVF outcomes. 2004). Diminished expression of Cx-43 protein alters cell-to-cell
A few studies on the transcriptomes of COC have become communication between intrafollicular somatic cells leading to
prominent over the years due to the ease of deriving cumulus the low levels of intra-oocyte cAMP and cGMP; thus, inducing
cells without jeopardizing the conditions of the oocytes (Wyse the continuation of meiosis prophase I up till the metaphase II
et al., 2020). Through methodologies for genotyping and gene arrest. At this stage, oocyte nuclear maturity is discernible by the
expression analysis mainly DNA microarray, RT-qPCR (Reverse- presence of the first polar body and the emergence of a meiotic
Transcription quantitative Polymerase Chain Reaction), and spindle that is otherwise not observed in immature oocytes.
Next Generation Sequencing (NGS), a large number of vital LH is engaged in regulating the expression of specific genes
biomarkers and their roles were unveiled. Correspondingly, that concern the EGF (Epidermal Growth Network) and gap
complex signal transduction pathways involved in oocyte junction permeability to achieve nuclear maturation and finally
maturation were gradually assembled, heightening our oocyte competency prior to fertilization (Conti et al., 2012).
understanding of the pathophysiology of immature oocytes LH receptor (LHR) plays a central role in the stimulating
obtained during a controlled ovarian stimulation in IVF mechanism of the hormone and the availability of the G-protein
(Chronowska, 2014). The implementation of COC biomarker coupled LH receptors in human granulosa cells make it a
analysis as an effective IVF predictor could ultimately safeguard valuable biomarker for oocytes nuclear maturation. Findings by
patients’ assurance throughout the program as they prepare for Maman et al. (2012) describe that LHR mRNA is expressed
the next step. These biomarkers were not only anticipated to higher in granulosa cells of mature oocytes than granulosa
revolutionize oocyte selection in IVF but also pave attainable cells of immature oocytes, metaphase 1, and germinal vesicle
approaches that could improve in vitro maturation of oocytes, oocytes, but higher expression of LHR mRNA was found to be
thus possibly increasing the success rate of IVF. associated with decreased fertilization rate. Moreover, Wiweko
Findings on a total of eight biomarkers were dissected in this et al. (2019) investigated the expression of LHR mRNA on
study (Table 1). These biomarkers are mainly regulatory RNA, oocyte maturation and fertilization rate of two groups of IVF
proteins, receptors, growth factors, gap junctions, and proteases patients, namely poor responders, and non-poor responders.
that are involved in the complex process of oocyte maturation. The results indicated that the LHR mRNA relative value was
Most prospective studies are selected with subjects of discussion higher but not significant in poor responders compared to non-
being the evidence-based breakthroughs of these biomarkers poor responders. Furthermore, the expression of LHR mRNA
as possible prognostic indicators for an IVF cycle (Figure 1). had a positive correlation with oocyte maturity and fertilization

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Frontiers in Cell and Developmental Biology | www.frontiersin.org

Sirait et al.
TABLE 1 | Summary table of eight cumulus biomarkers and their significance in assessing oocyte development competency and/or IVF outcomes.

Authors Biomarkers Oocyte Detection method Sample size Key findings

maturation
event

Maman et al. (2012) LHR Nuclear RT-PCR Granulosa cells from 70 IVF Expression of LHR is higher in metaphase II oocytes
maturation patients and 20 IVM (in vitro than in metaphase I and germinal vesicle oocytes
Maturation) patients (P < 0.05), but overexpression is associated with low
fertilization capacity (P < 0.05)
Wiweko et al. (2019) LHR RT-PCR Granulosa cells from 10 poor In poor responders: Positive correlation of LHR
responder IVF patients and 20 expression with oocyte maturity (r = 0.267), oocyte
non-poor responder patients morphology (r = 0.267), and fertilization rate (r = 0.430)
In non-poor responders:
Negative correlation of LHR expression with oocyte
maturity (r = −0.552), morphology (r = −0.164), and
fertilization rate (r = −0.340)
Gode et al. (2011) BMP15, GDF9 Western blot 81 individually derived Nuclear maturation of oocytes (P < 0.05) and quality of
cumulus-oocyte complexes (COCs) embryos (P < 0.05) are significantly correlated with the
and follicular fluids collected from level of mature GDF9 in follicular fluid
the first retrieved follicle of 81
IVF/ICSI patients
Li et al. (2014) BMP15, GDF9 qPCR. 2,426 COCs from 196 IVF/ICSI Expression of GDF9 and BMP15 mRNAs in cumulus
patients granulosa cells were highly correlated with oocyte
maturation, fertilization, and embryo quality (P < 0.05).
Pregnancy predicting capacity is evident (GDF9 with
3

4.82 cut-off value, 82% sensitivity, and 64% capacity;

BMP15 with 2.60 cut-off value, 78% sensitivity, and
52% capacity)
Hasegawa et al. (2007) Cx43 Apoptosis RT-PCR 105 CC samples from 29 IVF/ICSI No relationship of Cx43 with fertilization and cleavage
patients rate. Cx43 expression was significantly lower in good
morphology cleavage-stage embryos compared to
other groups (P = 0.035)
Wang et al. (2009) Cx43 RT-PCR, Cumulus cell (CC) samples from A positive correlation (P < 0.05) of Cx43 level with
Immunofluorescence 115 patients embryo quality (cleavage rate and morphology). Cx43
microscopy, Western blot, level is significantly higher in patients who became
gap junctional coupling pregnant (P < 0.01)
assay
Salehi et al. (2017) Pro apoptosis RT-PCR 100 CC from 20 PCOS IVF patients Caspase-3 and Caspase-7 expression were higher in
August 2021 | Volume 9 | Article 710292

proteins and 100 cumulus cells from 20 PCOS patients. Significant correlation of embryo quality
(Caspase-3, normal IVF patients (control group) with Caspase-3 (P = 0.0016) and Caspase-7
Caspase-7) (P = 0.084) expression in PCOS patients

Oocyte Competence Biomarkers

Devjak et al. (2012) SERPINE2 Extracellular Microarray, Quantitative 46 CC samples from 21 patients Positive correlation between microarray and qPCR data
matrix real-time PCR (qPCR) (r = 0.98, P = 0.02) indicating lower expression of
remodeling SERPINE2 mRNA in cumulus cells of mature oocytes
than in immature oocytes
Li et al. (2015) SERPINE2 RT-PCR 308 COC samples from 40 IVF Expression of SERPINE2 was significantly lower in
patients (53 immature oocytes and cumulus cells of mature oocytes than in immature
255 mature oocytes) oocytes (P = 0.0002)

(Continued)
Sirait et al. Oocyte Competence Biomarkers

rate in the poor responders, while a negative correlation was

ADAMTS-1 is associated with larger and more mature

PAPPA expression level is significantly higher in CC of

oocytes that led to euploid embryos resulting in a live
observed in the non-poor responders. Nonetheless, the studies

Differentially expressed genes identified between

have implied that the expression of LHR is indeed associated

follicles and is positively correlated with oocyte

with promoting oocyte nuclear maturation. However, there are
some limitations in utilizing LHR as biomarkers. Overexpression
of LHR has been presumed to give adverse impacts such as low
fertilization rate hence expression thresholds of LHR that signify
pro-maturation need to be determined. Moreover, as stated by

birth (P < 0.05, OR = 4.591)

oocytes of different maturity

Jeppesen et al. (2012), LHR protein expression might be too low
in the granulosa cells for proper detection through RT-qPCR
fertilization capacity

resulting in a tentative conclusion. There are some other notable

Key findings

findings that aim to evaluate prospective biomarkers and could

be the alternative or complementary biomarkers. A G protein-
coupled receptor, GPR3, that was mainly described and assessed
in rodents was associated with meiotic arrest in human oocytes
(DiLuigi et al., 2008).
Known as oocyte secreted factors (OSF) that belong to
the transforming growth factor-β (TGF-β) family, growth
163 CC samples from 15 patients

differentiation factor-9 (GDF-9), and bone morphogenetic

protein 15 (BMP-15), are proposed to have a potential value
22 COCs from 11 patients

as non-invasive markers for determining oocyte developmental

CC from 25 patients

potential. In the ovary, GDF-9 and BMP-15 play pivotal

roles during folliculogenesis, oocyte maturation, and ovulation
Sample size

(Gilchrist et al., 2004). Although OSFs are mainly secreted by

the oocytes, granulosa cells are also known to express the GDF-
9 and BMP-15. During the initial discovery, it was believed that
GDF-9 and BMP-15 exist as homodimers formed through non-
covalent linkage. However, a recent study has proven that both
proteins could prevail as heterodimers (GDF-9/BMP-15), later
Quantitative real-time PCR

Quantitative real-time PCR

known as cumulin, which possess a higher capability in inducing

(qRT-PCR), Western blot

differential expression,

the proliferation of granulosa cells compared to the respective

Detection method

pathway analysis,

homodimer forms (Mottershead et al., 2015).

RNA sequencing,

The clinical value of GDF-9 in the follicular fluid has been

shown in a study conducted by Gode et al. (2011), in which
RT-PCR

(qPCR)

mature forms of GDF-9 protein were significant in association

with oocyte nuclear maturation. Similarly, a study that involved
196 infertile couples undergoing IVF, revealed that the COCs of
women who achieved pregnancy expressed higher GDF-9 and
Transcriptomics

BMP-15 mRNA concentrations than those who did not achieve

maturation

metabolism

pregnancy (Li et al., 2014). Furthermore, the study has also

of cumulus
Oocyte

successfully formulated the cut-off values of both markers (4.82

Steroid
event

cells

and 2.60, respectively, for GDF-9 and BMP-15) for predicting

pregnancy with sufficient sensitivity (78and 82%, respectively,
for GDF-9 and BMP-15). Both studies have provided essential
information on the expression of GDF-9 and BMP-15 in infertile
42 potential oocyte

couples undergoing IVF and the promising clinical use of the OSF
Biomarkers

as non-invasive markers to predict oocyte competence.

ADAMTS-1

biomarkers
maturation
PAPPA

APOPTOSIS IN OOCYTE MATURATION

TABLE 1 | Continued

Apoptosis or programmed cell death has been known to play

Kordus et al. (2019)

Wyse et al. (2020)

a role in influencing the oocyte maturation process. Apoptotic

Yung et al. (2010)

events in granulosa cells cause interference of the granulosa

cells-oocytes communication, limiting the maturation-inducing
Authors

factors (hormones, proteins, and metabolites) supply that are

necessary for oocytes to reach meiotic competency (Chaube et al.,

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Sirait et al. Oocyte Competence Biomarkers

meiotic resumption inhibits the translation of gap junction

proteins (Kalma et al., 2004). The inhibition of gap junction
protein is presumably to limit the transfer of meiotic maturation
arresting factor, cAMP and cGMP, from the cumulus cells to
oocytes (Norris et al., 2008). In summary, the limitation of
Cx43 as a biomarker prevails in the uncertainty as to whether
the decreased or increased expression of Cx43 is related to
favorable oocyte quality.
Caspase is one of the other pro-apoptotic factors expressed in
granulosa cells that could become potential biomarkers. Caspase,
a cysteine protease, causes the inactivation of components
for physiological processes and morphological changes during
apoptosis. Caspase-3 and caspase-7 expressions were found to
be higher especially in polycystic ovary syndrome (PCOS) and
have a negative correlation to embryo quality (Salehi et al., 2017).
Evidently, caspase-3 is the main factor in apoptosis through its
association with chromatin condensation, DNA fragmentation,
nuclear breakdown, and plasma membrane protrusion, while
caspase-7 mainly contributes to the reactive oxygen species (ROS)
accumulation and detachment of cells from the extracellular
matrix (ECM) (Brentnall et al., 2013). FOXO3 is another gene
that is highly expressed during apoptosis and correlated positively
with poor quality oocytes in PCOS patients (Mikaeili et al., 2016).
FIGURE 1 | Oocyte competence in IVF could be defined as the ability of an
oocyte to achieve the mature oocyte stage, fertilization, embryo stage, and
ultimately pregnancy. Expression of the COC-derived genes discussed in this OOCYTE EXTRACELLULAR MATRIX
study have exhibited significant predictive values toward the respective IVF REMODELING
stages. a,b,c,d refers to the occyte maturation process that the gene regulate:
a Nuclear maturation, b Apoptosis, c Extracellular matrix remodeling,
d Steroid metabolism. The integrity of the COC extracellular matrix is vital for the
bidirectional intercellular communication between oocytes and
their surrounding cumulus cells. During oocyte maturation, the
dynamic surge of gonadotropins and oocyte-secreted paracrine
2014). Granulosa cells that do not have the access to all the factors stimulate several genes that participate in a process
necessary metabolites would gradually promote the autophagy known as cumulus expansion. The expressed proteins acquire
mechanism before eventually inducing apoptosis mechanism different functions including gap junctions and proteases
(Altman and Rathmell, 2012). Gap junctions that act as channels which predominantly regulate the remodeling of tissues
for these necessary metabolites play an important role in during folliculogenesis; all acting within the intercellular
regulating cell death, survival, and nutrients uptake. spaces of cumulus cells to promote oocyte maturation
Gap junctions, which allow cell-to-cell communication is (Robker et al., 2018).
found among intrafollicular cells, i.e., mural granulosa cells, SERPINE2 encodes for the serine protease inhibitor E2 that is
cumulus granulosa cells, and oocytes (Anderson and Albertini, not only indirectly associated with tissue plasminogen activator
1976; Gilula et al., 1978). Connexins are essential in forming in degrading matrix proteins but also plays a role as sperm
intercellular membrane channels of gap junctions. Connexin decapacitation factor. Li et al. (2015) highlighted the considerable
(Cx43), particularly, is expressed in granulosa cells and is difference in SERPINE2 gene expression between immature
associated with cell death and survival, and oocyte maturation in and mature oocytes in which RT-qPCR of RNA extracted
model animals (Vozzi et al., 2001; Krysko et al., 2004), making it from 308 COCs revealed a significantly lower expression of
a potential biomarker for human oocyte quality. SERPINE2 mRNA in a cumulus of mature oocytes compared
Wang et al. (2009) found that Cx43 expression level had a to the immature cohort (p = 0.0002). This corroborated a
positive correlation to embryo quality as in morphology and previous study that indicated SERPINE2 as one of the 116
pregnancy rate. It was presumed that low expression of Cx43 genes to be differentially expressed in the DNA microarray
is also followed by low availability of fundamental nutrients, analysis of cumulus samples between mature and immature
creating a metabolic shortage in oocytes that would impact oocytes (p = 0.02) (Devjak et al., 2012). Furthermore, the
the oocytes in the later developmental stages. This discovery is study particularly disclosed no substantial difference in cumulus
contradictory to findings by Hasegawa et al. (2007), whereby cell gene expression with regard to the ovarian stimulation
Cx43 expression was found to be lower in the good-morphology protocols. Recent experimentation which managed to construct
embryo group compared to other groups. This evidence is an NGS library to discern the transcriptomics of cumulus cells
supported by the fact that LH surge, which is central in also displayed a fourfold decrease in SERPINE2 expression in

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Sirait et al. Oocyte Competence Biomarkers

the immature oocyte cohort (Wyse et al., 2020). Concurrently, dehydrogenase 1 (Järvensivu et al., 2015). The enzyme, in the
Wyse et al. (2020) also identified a higher expression of presence of cofactors, regulates the reversible catalytic reaction
cumulus expansion-associated ADAM-metallopeptidase with of converting estrone to estradiol which possesses a higher
thrombospondin type 1 motifs-1 (ADAMTS-1) in COC of mature estrogenic activity. HSD17B1 has been extensively evaluated in
oocytes. This was previously exhibited in a study that specified animal models and the recent transcriptomic analysis of human
its essential role in the follicular rupture process. ADAMTS-1 COC samples corroborates the significantly reduced expression
expression was found to be correlated with oocyte fertilization of HSD17B1 in mature oocytes (Wyse et al., 2020), commencing
capacity in which oocytes that underwent successful fertilization possible research in the mechanism and roles of the gene in
acquired a threefold higher expression of cumulus ADAMTS-1 promoting the maturation process. Likewise, further research
compared to those that failed to fertilize (Yung et al., 2010). worth investigating would be on the affiliation of PAPPA,
While these studies might have proven the competency and HSD17B1 mRNA expression level in mature oocytes with
of SERPINE2 and ADAMTS-1 as biomarkers for oocyte their respective pregnancy outcomes. Such studies, however,
competency, they are limited to the small immature oocyte encounter inevitable challenges that demand a large sample of
sample sizes within the same cycles (controlled ovarian single embryo transfer procedures while still minimizing the
stimulation in IVF typically produces more mature oocytes) clinical and physiological heterogeneity among the samples.
hence a larger prospective study is still mandatory. A study on
bovine follicles demonstrated the influence of gonadotropins on
SERPINE2 expression in which FSH was found to manifest in the DISCUSSION
increased SERPINE2 expression while LH surge before ovulation
decreased its expression (Bédard et al., 2003). However, further Oocyte maturation is a complex process consisting of inter-
research is still required to unveil the pathology that leads to the and intra-connected signaling pathways that are regulated by
turnarounds in the expression of SERPINE2 and ADAMTS−1 a series of genes traceable within the COC. Gene expression
in the cumulus of immature oocytes so that the appropriate analyses of RNA samples extracted from COC have revealed that
intervention could be formulated to improve in vitro maturation. certain genes were particularly expressed differently in oocytes
of different maturity hence extending their potential purpose
as biomarkers capable of predicting IVF outcomes. The most
OOCYTE STEROID METABOLISM promising biomarkers thus far are GDF-9 and BMP-15 with
proven sensitivity and specificity of predicting pregnancy in
Steroidogenesis in animal models has been shown to directly a study with the largest sample size among others included
impact the meiosis of oocytes and contribute to spontaneous here. Furthermore, addition of these growth factors has shown
mammalian oocyte maturation (Jamnongjit and Hammes, 2005). to increase the efficiency of in vitro maturation, suggesting
While their exact regulatory mechanisms are still rather bleak, their significant roles in promoting oocyte maturation. The
steroids secreted by theca and granulosa cells in response potency of other biomarkers such as SERPINE2 and Cx43 require
to growth factors have been established to act as secondary additional investigations due to the relatively small sample size
messengers in pathways that lead to cumulus expansion and and contradicting results with previously established findings.
thus oocyte maturation. Of utmost interest, studies that explore Meanwhile, recognizing confounding variables are imperative to
the metabolomics of cumulus cells have unveiled pappalysin-1 identify underlying conditions in IVF patients which may affect
(PAPPA) mRNA as a potential predictor of oocyte maturation the expression of these biomarkers such as the significantly higher
status and, to a certain degree, the euploidy status of embryos expression of Caspase proteins in PCOS patients. Although
and pregnancy outcomes in IVF (Kordus et al., 2019). PAPPA substantial in vitro evidence was presented to justify the potential
is responsible for the expression of metalloproteinases which functions of these biomarkers, the clinical practice of examining
actively cleaves insulin-like growth factor binding proteins non-invasive oocyte biomarkers as IVF prognostic measures
(IGFB4) to provide the supply of intrafollicular IGF peptides is still far from achievable. Ideally, such approaches would
that in turn function as co-gonadotropin for the stimulation demand the acquisition of transcriptomic profiles of every oocyte
of steroidogenesis. Kordus et al. (2019) noted higher PAPPA retrieved during ovum pick up, enumerating the expression levels
expression levels in cumulus cells of mature oocytes that of all the genes mentioned above, in addition to many more.
ultimately developed to become euploid embryos compared to A large number of COC biomarkers are regulated by
the group of immature oocytes that culminated in arrested FSH and/or LH stimulation. Poor response toward the
embryos. Findings of the study also suggested a computable gonadotrophins have been shown to downregulate genes
interplay between the expression of PAPPA and other oocyte which, in turn, are associated with the increased p53-
maturation-associated mRNAs such as AREG (amphiregulin) pathway for apoptosis, resulting in a restricted maturation
and LHCGR (luteinizing hormone/choriogonadotropin receptor) process, as observed in immature COCs (Wyse et al., 2020).
which is a valuable steppingstone toward constructing an ideal Contrarily, adequate gonadotrophinresponses characterized by
predictive model that could gauge the prognosis of IVF. the upregulation of genes for the biosynthesis of estrogen and
Another steroidogenesis-associated gene that is also androgen are displayed in mature oocytes (Wyse et al., 2020).
adversely expressed differentially between mature and immature While these findings have collectively added knowledge to the
oocytes is HSD17B1 which encodes Hydroxysteroid (17beta) understanding of oocyte maturation process, correlating the

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Sirait et al. Oocyte Competence Biomarkers

expression level of these genes with the tracking of individual possibility to boost the competency of oocytes within laboratory
oocyte outcome throughout the IVF program is required before settings.
the genes could be denoted as potential IVF predictors. In that
note, in the transcriptomic profiling of COCs, there are several
novel discoveries on the differential expression of other explored CONCLUSION
genes between the cohorts of mature and immature oocytes such
as genes encoding for Epiregulin (EREG) in cumulus expansion In conclusion, the roles of eight cumulus biomarkers in
and Phosphodiesterase 3A (PDE3A) in cytoplasmic maturation promoting oocyte maturation and their expression profiles
(Wyse et al., 2020). Nonetheless, the exact mechanism and in oocytes of different maturity have been well-established
significance of these genes as indicators for assessing oocyte to possess statistical values in predicting an IVF cycle.
competence and thus the IVF outcomes are still rather bleak. However, the feasibility of assessing these biomarkers as an
While plenty of other biomarkers were not discussed here, add-on prognostic procedure in IVF is still restricted due
this review provides insights on the current progress of studies to sampling challenges. Indispensable investigations on the
pertaining to the evaluation of cumulus biomarkers. Common disputable molecular mechanisms are also still necessary for
challenges such as the difficulty in obtaining homogeneous study the realization of IVF predictive models that are based on the
subjects were highlighted, including the imbalance number of above-mentioned biomarkers.
mature and immature oocytes retrieved during ovum pick-up,
which understandably led to the resultant small sample sizes.
Additionally, in the attempts to correlate these biomarkers with AUTHOR CONTRIBUTIONS
IVF outcomes, a large assortment of confounding variables and
BS drafted the early version of this manuscript. BW, AAJ, DI,
appropriate statistical methodologies need to be recognized to
and RM critically reviewed and revised the content. All authors
provide convincing results and evade contradictory findings.
contributed to the article and approved the submitted version.
It is also imperative to expedite the identification of factors
that culminate to the shift in gene expression levels between
mature and immature oocytes, bringing about another limitation FUNDING
specifically in the selection of the appropriate model organisms.
Other routes of research worth investigating would be to classify This review was funded by an international research publication
metabolite analogs affiliated with the biomarkers and evaluate (PUTI) grant from Universitas Indonesia (contract number:
their effects during in vitro maturation process, with hopes for the NKB-1320/UN2.RST/HKP.05.00/2020).

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Endocrinol. 12:81. doi: 10.1186/1477-7827-12-81 Conflict of Interest: The authors declare that the research was conducted in the
Maman, E., Yung, Y., Kedem, A., Yerushalmi, G. M., Konopnicki, S., Cohen, B., absence of any commercial or financial relationships that could be construed as a
et al. (2012). High expression of luteinizing hormone receptors messenger RNA potential conflict of interest.
by human cumulus granulosa cells is in correlation with decreased fertilization.
Fertil. Steril. 97, 592–598. doi: 10.1016/j.fertnstert.2011.12.027 Publisher’s Note: All claims expressed in this article are solely those of the authors
Mikaeili, S., Rashidi, B. H., Safa, M., Najafi, A., Sobhani, A., Asadi, E., et al. and do not necessarily represent those of their affiliated organizations, or those of
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Mottershead, D. G., Sugimura, S., Al-Musawi, S. L., Li, J. J., Richani, D.,
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