Prolonged gonadotropin stimulation for assisted reproductive technology cycles is associated with decreased pregnancy rates for all women except for women with polycystic ovary syndrome

Prolonged Ovarian Stimulation Does Not Worsen Neonatal Outcomes After Fresh Embryo Transfers

OBJECTIVE

To investigate the relationship between prolonged ovarian stimulation and neonatal outcomes after autologous fresh embryo transfer (fET).

DESIGN

A retrospective cohort study.

SETTING

University-affiliated centres.

POPULATION

3529 patients underwent autologous in vitro fertilisation (IVF) cycles between August 1, 2016 and December 31, 2022, with a live singleton birth after fET.

METHODS

Univariate and multivariate regression analyses were used to determine the relationship between prolonged ovarian stimulation and neonatal outcomes. Propensity score matching (PSM) was applied to evaluate independent effects.

MAIN OUTCOME MEASURES

Neonatal outcomes.

RESULTS

Multivariate regression showed no significant association between simulation duration and birthweight (adjusted β: 4.19, 95% confidence interval [CI]: -13.86 to 22.23; p = 0.6494) or gestational age (GA) (adjusted β: -0.01, 95% [CI]: -0.09 to 0.06; p = 0.7403) Categorical analysis of neonatal outcomes, including low birthweight (LBW) (adjusted Odds Ratio [OR]: 0.94, 95% [CI]: 0.70 to 1.25; p = 0.6501), macrosomia (adjusted OR: 0.95, 95% [CI]: 0.78 to 1.16; p = 0.6294), small for gestational age (SGA) (adjusted OR: 0.95, 95% [CI]: 0.75 to 1.19; p = 0.6465), large for gestational age (LGA) (adjusted OR: 1.02, 95% [CI]: 0.85 to 1.21; p = 0.8542) and preterm (adjusted OR: 0.93, 95% [CI]: 0.77 to 1.11; p = 0.4191), revealed no associations with stimulation duration. PSM analysis confirmed these findings.

CONCLUSIONS

Prolonged ovarian stimulation does not appear to increase adverse neonatal outcomes in singleton newborns after autologous fET.

Ovarian Hyperstimulation Syndrome (OHSS): A Narrative Review and Legal Implications

BACKGROUND

Infertility is a highly meaningful issue with potentially life-changing consequences, and its incidence has been growing worldwide. Assisted reproductive technology (ART) has made giant strides in terms of treating many infertility conditions, despite the risk of developing ovarian hyperstimulation syndrome (OHSS), a potentially life-threatening complication.

METHODS

This narrative review draws upon scientific articles found in the PubMed database. The search spanned the 1990-2024 period. Search strings used included "OHSS" or "ovarian hyperstimulation" and "IVF" and "GnRH" and "hCG"; 1098 results were retrieved and were ultimately narrowed down to 111 suitable sources, i.e., relevant articles dealing with the condition's underlying dynamics, management pathways, and evidence-based criteria and guidelines, crucial both from a clinical perspective and from the standpoint of medicolegal tenability.

RESULTS

The following features constitute OHSS risk factors: young age, low body weight, and polycystic ovarian syndrome (PCOS), among others. GnRH antagonist can substantially lower the risk of severe OHSS, compared to the long protocol with a gonadotropin-releasing hormone (GnRH) agonist. However, a mild or moderate form of OHSS is also possible if the antagonist protocol is used, especially when hCG is used for the final maturation of oocytes. For women at risk of OHSS, GnRH agonist trigger and the freeze-all strategy is advisable. OHSS is one of the most frequent complications, with a 30% rate in IVF cycles.

CONCLUSION

Providing effective care for OHSS patients begins with early diagnosis, while also evaluating for comorbidities and complications. In addition to that, we should pay more attention to the psychological component of this complication and of infertility as a whole. Compliance with guidelines and evidence-based best practices is essential for medicolegal tenability.

Early or late response in poor responders: does it make a difference in cycle outcome?

Ovarian response to stimulation mainly determines the length of stimulation. However, there is no clarity in the literature regarding the optimal duration required to achieve oocyte maturity in patients with the poor ovarian response (POR) defined by Bologna criteria. Therefore, a total of 267 cycles that fulfilled the inclusion criteria were selected retrospectively. Group A constitute of patients with a stimulation period < 9 d (n = 70); and group B included patients with a stimulation period ≥ 9 d (n = 133). The results showed that antral follicle count (5.72 ± 1.82 vs. 5.10 ± 1.78, p = 0.023), serum oestradiol level on hCG day (1286.88 ± 778.18 pg/mL vs. 820.14 ± 479.04 pg/mL, p = 0.001), and total gonadotropin dose used (2949.53 ± 727.92 IU vs 2020.94 ± 415.17 IU, p = 0.0001) were higher in group B when compared to group A. Although the number of total (5.47 ± 3.32 vs 3.86 ± 2.15, p = 0.0001) and mature oocytes retrieved (4.34 ± 2.88 vs 2.84 ± 1.67, p = 0.0001) were higher in group B, no significant difference was observed in the pregnancy rates between groups (25.6 vs 15.7%, p > 0.05). In conclusion, no deleterious effect of a shorter duration of stimulation on cycle outcome was seen in patients with POR.

Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective

Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.

Association Between the Ratio of Ovarian Stimulation Duration to Original Follicular Phase Length and In Vitro Fertilization Outcomes: A Novel Index to Optimise Clinical Trigger Time

The duration of ovarian stimulation which is largely dependent on the ovarian response to hormonal stimulation may influence in vitro fertilization (IVF) outcomes. Menstrual cycle length is potentially a good indicator of ovarian reserve and can predict ovarian response. Ovarian stimulation and the follicular phase of the menstrual cycle are both processes of follicular development. There is no published research to predict the duration of ovarian stimulation based on the length of the menstrual cycle. Our retrospective cohort study included 6110 women with regular menstrual cycles who underwent their first IVF treatment between January 2015 and October 2020. Cycles were classified according to quartiles of the ratio of ovarian stimulation duration to original follicular phase length (OS/FP). Multivariate generalized linear models were applied to assess the association between OS/FP and IVF outcomes. The odds ratio (OR) or relative risk (RR) was estimated for each quartile with the lowest quartile as the comparison group. OS/FP of 0.67 to 0.77 had more retrieved and mature oocytes (adjusted RR 1.11, 95% confidence interval [CI] 1.07-1.15, p for trend = 0.001; adjusted RR 1.14, 95% CI 1.09-1.19, p for trend = 0.001). OS/FP of 0.67 to 0.77 showed the highest rate of fertilization (adjusted OR 1.11, 95% CI 1.05-1.17, p for trend = 0.001). OS/FP > 0.77 had the lowest rate of high-quality blastocyst formation (adjusted OR 0.81, 95% CI 0.71-0.93, p for trend = 0.01). No apparent association was noted between OS/FP and clinical pregnancy, live birth, or early miscarriage rate. In conclusion, OS/FP has a significant effect on the number of oocytes, fertilization rate, and high-quality blastocyst formation rate. MCL could be used to predict the duration of ovarian stimulation with an OS/FP of 0.67 to 0.77, which provides a new indicator for the individualized clinical optimization of the trigger time.

"Short agonist stop" protocol, an ovarian stimulation for poor responders in in vitro fertilization (IVF): A pilot study

INTRODUCTION

Poor responder patients remain a challenge in assisted reproductive technologies. The "short agonist stop" (SAS) stimulation protocol uses a double stimulation (flare up effect with the gonadotropin-releasing hormone (GnRH) agonist (GnRH-a) then gonadotropins) associated with a less strenuous blockage (discontinuation of GnRH-a) to favor follicular recruitment in order to obtain a better ovarian response. This study aims to compare the number of oocytes obtained after a SAS stimulation protocol with those obtained after the previous stimulation protocol, in the same women, with poor ovarian response (POR) diagnosed according to the POSEIDON criteria.

DESIGN

This therapeutic observational retrospective cohort from 2018 to 2022, with a case-control evaluation compared with the same patients' previous performance, included women with POR undergoing IVF with SAS stimulation protocol. The primary outcome was the number of total oocytes recovered and secondary outcomes were the numbers of mature oocytes, total embryos observed at day 2 and usable cleaved embryos and blastocysts (day 5/6).

RESULTS

63 patients with SAS and previous cycles were included. In the SAS group, the mean number of oocytes was significantly higher: 7.3 vs 5.7, p=0.018 in comparison with the previous attempt. So was the number of mature oocytes (5.8 vs 4.1, p=0.032) and the total mean number of embryos obtained at day 2 (4.1 versus 2.7, p=0.016). The SAS stimulation generated 84 usable embryos: 57 cleaved embryos and 27 blastocysts. The mean number of usable embryos was similar in both groups (1.64 vs 1.31, respectively, p=0.178). In total, out of 63 patients, after the SAS protocol, and subsequent embryo transfers (fresh and frozen, n=54), 9 patients had ongoing pregnancies and no miscarriage occurred. The cumulative ongoing pregnancy rate (cOPR) after the SAS protocol was 14.3% (9/63) per oocyte pick-up and 16.7% (9/54) per transfer.

CONCLUSION

SAS stimulation is a short and original protocol strengthening the therapeutic arsenal of poor responders, that may offer promising results for those patients with low prognosis and previous failed IVF. Results must be confirmed with a randomized controlled trial.

Effects of half-dose and full-dose GnRH antagonists on IVF-ET outcomes: a retrospective study

Background

Gonadotropin-releasing hormone antagonist(GnRH-ant) has been shown to have a negative effect on endometrial receptivity. Therefore, the use of lower doses of GnRH-ant during controlled ovarian stimulation (COS) may improve endometrial receptivity and clinical pregnancy rate. However, the GnRH-ant dose is relatively flexible and there is no fixed requirement for guidance. In this retrospective study, we determined the effects of half-dose and full-dose GnRH-ant on IVF-ET outcomes.

Methods

Of the 316 cycles in the 314 patients analyzed in this study, 149 received GnRH-ant half-dose (Group1), while 167 received GnRH-ant full-dose (Group2). The groups were further classified based on age and BMI. Age subgroups, were divided as age ≤ 35(subgroup A) and age > 35(subgroup B): 180 cycles in subgroup A (107 cycles in subgroup A1,73 cycles in subgroup A2), 136 cycles in subgroup B (42 cycles in subgroup B1,94 cycles in subgroupB2). The subgroups based on BMI were divided as BMI < 25 (subgroup C)and BMI ≥ 25 (subgroup D):208 cycles in subgroup C (94 cycles in subgroup C1,114 cycles in subgroup C2), 108 cycles in subgroup D (55 cycles in subgroup D1,53 cycles in subgroup D2).

Results

The number of fertilized oocytes, superior-quality embryos, clinical pregnancy rate, and live birth rate differed significantly between the two groups. However, the number of retrieved oocytes and available embryos were significantly higher in Group 1 than Group 2 (8.17 ± 4.10 vs. 7.07 ± 4.05, 2.96 ± 2.03 vs. 2.52 ± 1.62, respectively,p<0.05). Differences between the age subgroups were not statistically significant. However, in the subgroups based on BMI, the fertilized oocytes, available embryos, the number of superior-quality embryos, and the live birth rate differed significantly between the four subgroups. The number of retrieved oocytes was higher in subgroup C1 than in subgroup C2 (8.24 ± 4.04 vs. 6.83 ± 3.92,p < 0.05), In addition, the clinical pregnancy rate was slightly higher in subgroup D1 than in subgroup D2(45.45 vs. 24.53%, P < 0.05).

Conclusions

The results showed that half-dose GnRH-ant was as effective as full-dose GnRH-ant for most patients. Moreover, half-dose GnRH-ant may be more suitable in patients with BMI greater than or equal to 25. The findings of this study need to be validated in a large sample RCT.

Trial registration

Retrospectively registered.

Factors Associated with In Vitro Fertilization Live Birth Outcome: A Comparison of Different Classification Methods

Background

In vitro fertilization (IVF) is a useful assisted reproductive technology to achieve pregnancy in infertile couples. However, it is very important to optimize the success rate after IVF by controlling for its influencing factors. This study aims to classify successful deliveries after IVF according to couples' characteristics and available data on oocytes, sperm, and embryos using several classification methods.

Materials and Methods

This historical cohort study was conducted in a referral infertility centre located in Tehran, Iran. The patients' demographic and clinical variables for 6071 cycles during March 21, 2011 to March 20, 2014 were collected. We used six different machine learning approaches including support vector machine (SVM), extreme gradient boosting (XGBoost), logistic regression (LR), random forest (RF), naïve Bayes (NB), and linear discriminant analysis (LDA) to predict successful delivery. The results of the performed methods were compared using accuracy tools.

Results

The rate of successful delivery was 81.2% among 4930 cycles. The total accuracy of the results exposed RF had the best performance among the six approaches (ACC=0.81). Regarding the importance of variables, total number of embryos, number of injected oocytes, cause of infertility, female age, and polycystic ovary syndrome (PCOS) were the most important factors predicting successful delivery.

Conclusion

A successful delivery following IVF in infertile individuals is considerably affected by the number of embryos, number of injected oocytes, cause of infertility, female age, and PCOS.

Length of ovarian stimulation does not impact live birth rate in fresh donor oocyte cycles: a SART CORS study

PURPOSE

To evaluate the effect of controlled ovarian hyperstimulation length and total gonadotropin (GN) dose on recipient live birth rate (LBR) in fresh donor oocyte cycles.

METHODS

Data was obtained from SART CORS on all fresh donor oocyte GnRH antagonist cycles (n = 1049) between 2014 and 2015 which resulted in a single embryo transferred. Donor and recipient demographic information and cycle characteristics were extracted. Binomial regression was used to estimate LBR with respect to days of stimulation (DOS) and total GN dose. Multivariate analysis was performed to evaluate these relationships after controlling for confounders.

RESULTS

Overall LBR in fresh donor oocyte cycles was 57%. Average stimulation length was 14.3 ± 4.9 days, and total GN dose was 2464 ± 1062 IU. On univariate analysis, neither days of stimulation (p = 0.5) nor total GN dose (p = 0.57) was independently correlated with LBR. However, in prolonged stimulations (> 15 days) with high total GN dose (> 3000 IU), as both the cycle length and total GN dose increased, LBR significantly decreased from 63.81 to 48.15% (p = 0.02) and from 67.61 to 48.15% (p = 0.01), respectively. Multivariate analysis showed no significant effect of either DOS or total GN dose on LBR.

CONCLUSIONS

LBR is significantly decreased in fresh donor oocyte cycles when cycles are prolonged with high total GN dose. However, after controlling for confounders neither DOS nor total GN dose significantly affects LBR.

Differential impact of controlled ovarian hyperstimulation on live birth rate in fresh versus frozen embryo transfer cycles: a Society for Assisted Reproductive Technology Clinic Outcome System study

OBJECTIVE

To study the impact of both controlled ovarian hyperstimulation (COH) length and total gonadotropin (GN) dose individually and in concert on live birth rates (LBR) in both fresh and freeze-all in vitro fertilization embryo transfer (IVF-ET) cycles.

DESIGN

Historical cohort study.

SETTING

Not applicable.

PATIENT(S)

The U.S. national database from the Society of Assisted Reproductive Technology Clinic Outcome Reporting System from 2014 to 2015 was used to identify patients undergoing autologous GN stimulation IVF cycles with the use of GnRH antagonist-based suppression protocols where a single embryo transfer was performed as part of a fresh IVF-ET cycle (fresh, n = 14,866) or the first frozen embryo transfer after a freeze-all cycle (frozen, n = 2,964), and not including preimplantation genetic testing cycles. The patients' demographic and cycle characteristics, duration of COH, total GN dose, and pregnancy outcomes were extracted. Binomial regression models estimated trend and relative risk of live birth with respect to days of stimulation and total GN dose singularly, and after adjustment for a priori confounders including age, parity, body mass index, diagnosis, and maximum follicle-stimulating hormone in both fresh and frozen embryo transfer cycles. Both days of stimulation and total GN dose were then added to the multivariate model to show whether they were independently associated with LBR.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Live birth rate.

RESULTS

In both fresh and frozen cycles, length of COH was significantly associated with total GN dose. On univariate analysis, LBR decreased significantly with increasing length of stimulation and increasing total GN dose in both fresh and frozen cycles. On multivariable analysis including both days of stimulation and total GN dose, days of stimulation was no longer significantly correlated with LBR, whereas total GN dose remained significantly correlated with LBR in fresh cycles only. When total GN doses ranging from <2,000 IU through 5,000 IU to >5,000 IU were compared, a significant improvement in live birth rate was noted with lower total GN doses. Specifically, GN doses <2,000 IU had a 27% higher rate of live birth compared with GN dose >5,000 IU. For GN dose groups up to 4,000 IU, the estimated effect on LBR was similar. There was a marginal improvement (13%) in LBR with GN doses of 4,000 IU to 5,000 IU compared with >5,000 IU. When the multivariate model was applied to the frozen cycles, neither total GN dose nor days of stimulation was significantly associated with LBR.

CONCLUSIONS

High total GN dose but not prolonged COH is associated with decreasing LBRs in fresh cycles, whereas neither factor significantly affects LBR in frozen cycles. Consideration should be given to minimizing the total GN dose when possible in fresh autologous cycles, either by decreasing the daily dose or by limiting the length of stimulation to improve LBRs. In freeze-all cycles, the use of higher GN doses does not seem to adversely affect the LBR of the first frozen embryo transfer. High total GN dose likely exerts a negative impact on the endometrium and/or oocyte/embryo unrelated to the length of stimulation. The differential effect of total GN dose on LBR in fresh and frozen cycles may imply a greater impact exerted on the endometrium rather than the oocyte.

Total follicle stimulating hormone dose is negatively correlated with live births in a donor/recipient model with fresh transfer: an analysis of 8,627 cycles from the Society for Assisted Reproductive Technology Registry

OBJECTIVE

Oocyte donation has optimized our understanding of ovarian stimulation. Increasing the follicle-stimulating hormone (FSH) dose has been shown to adversely affect live birth rates in autologous cycles. Our objective is to assess whether this relationship holds true within the donor/recipient population.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENTS

Data from 2014-2016 included 8,627 fresh donor cycles.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Live birth, clinical pregnancy, and miscarriage rates.

RESULTS

The mean donor age ± standard deviation (SD) was 25.8 ± 2.8 years. Donors underwent a median of 16 days (interquartile range [IQR] 12, 19) of stimulation with a median (IQR) total FSH dose and daily dose of 2,350.0 (1,800.0, 3,025.0) and 153.8 (113.2, 205.0) IU, respectively. The live birth rate was 56.7% per transfer. For every 500-unit increase in FSH dose, there was a 3% reduction in the odds of a live birth (odds ratio [OR] 0.97; 95% confidence interval 0.95, 0.99), and a 3% reduction in the odds of a clinical pregnancy (OR 0.97; 95% confidence interval 0.95, 0.99). Days of stimulation and average daily dose were not significantly associated with live birth or clinical pregnancy. No significant association was found between miscarriage rates and total FSH dose, days of stimulation, or average daily dose.

CONCLUSION

This is a novel report of a negative association of total FSH dosage on fresh IVF live births, performed in the donor population to control for oocyte source and endometrial receptivity.

Duration of ovarian stimulation is predictive of in-vitro fertilization outcomes

BACKGROUND

The aim of this study is to evaluate the effect of ovarian stimulation duration on oocyte/embryo development and pregnancy outcome in an in-vitro fertilization cycle (IVF).

METHODS

Retrospective cohort study performed at University of South Florida reproductive center between January 2011 and December 2016. A total of 690 sub-fertile women who underwent autologous IVF cycle were included for analysis. The outcomes were compared between patients undergoing ovarian stimulation for ≤8 days and >8 days. Data was further categorized into accelerated stimulation group (≤8 days), normal duration stimulation group (9-12 days), and delayed stimulation group (≥13 days). Primary outcome was live birth rate. Secondary outcomes include oocyte development and embryo characteristics.

RESULTS

A total of 69 (10%) and 621 (90%) patients underwent ovarian stimulation for ≤8 and >8 days, respectively. Ovarian stimulation for >8 days had 2.1 times higher odds of live birth (35.7% vs. 20.8%, 95% CI: 1.02-4.44, P=0.04), and 1.9-fold-higher odds of clinical pregnancy (42.6% vs. 27.1%, 95% CI: 1.03-3.87, P=0.05). Number of matured oocytes (P=0.002), normally fertilized embryos (P=0.008), 6-8 cell stage embryos (P=0.003) and blastocysts (P=0.014) were higher in cycles with stimulation >8 days. Further analysis showed that live birth rate was highest in the group of patients with normal duration stimulation group (37.3%) compared to patients with delayed stimulation (25%) and accelerated stimulation (20.8%).

CONCLUSIONS

In an IVF cycle, optimal ovarian response and pregnancy outcome is associated with stimulation duration of at least 9 days. Both accelerated and delayed follicular recruitment are indicators for suboptimal response.

Influence of body mass index and polycystic ovarian syndrome on ICSI/IVF treatment outcomes: A study conducted in Pakistani women

BACKGROUND

Obesity may establish a crucial barrier for effective fertility treatment in polycystic ovary syndrome (PCOS) females.

OBJECTIVE

To compare results of intra-cytoplasmic sperm injection (ICSI) in females with and without polycystic ovarian syndrome and further appraise the effect of obesity in PCOS females.

MATERIALS AND METHODS

A cross-sectional study from June 2015 to July 2016 included non-PCOS and PCOS (recognized by Rotterdam criteria) females who underwent ICSI. The PCOS were further stratified into non-obese and Obese according to the South Asian criteria for body mass index. Results were categorized on the basis of beta-human chorionic gonadotropin (β-hCG) and transvaginal scan into non-pregnant (β-hCG <25 mIU/ml), preclinical abortion (β-hCG >25 mIU/ml with no fetal cardiac activity) and clinical pregnancy (β-hCG >25 mIU/ml with fetal cardiac activity on transvaginal scan). In addition, reproductive outcomes; implantation rate, clinical pregnancy rate and miscarriage rate among obese and non-obese PCOS and non-PCOS patients were compared.

RESULTS

Our results revealed 38.5% clinical pregnancy rate in non-PCOs females, 23.8% in non-obese PCOS females whereas 26.4% in obese PCOS. Preclinical abortions were found to be highest (31.5%) in non-obese PCOS females and were the lowest (26.2%) in non-PCOS females. In non-PCOS group and non-obese PCOS females 35.4% and 44.6%, respectively, failed to become pregnant.

CONCLUSION

The success after ICSI in terms of number of clinical pregnancies was more in non-PCOS patients as compared to PCOS. Increase in body mass index reflected a negative impact on the reproductive outcome in PCOS patients.

Flexible Low-Dose GnRH Antagonist Protocol Is Effective in Patients With Sufficient Ovarian Reserve in IVF

Gonadotropin-releasing hormone antagonist (GnRH-ant) has been shown to negatively influence endometrial receptivity. Reducing the GnRH-ant dose during controlled ovarian stimulation (COS) when using a GnRH-ant protocol may be beneficial to embryo implantation. However, whether or not the minimum daily GnRH-ant dose should be individualized remains uncertain. In this retrospective study, we aimed to elucidate the feasibility and effectiveness of moderately reducing the daily GnRH-ant dose to 0.125 mg, and then adjusting the dose to 0.25 mg based on subsequent luteinizing hormone (LH) levels. Of the 434 patients analyzed in this study, 209 received our new flexible low-dose GnRH-ant protocol (Group 1) and 225 received a conventional GnRH-ant protocol with a fixed daily dose of 0.25 mg (Group 2). Furthermore, 105 and 114 cycles from groups 1 and 2 received fresh embryo transfer. In Group 1, 30 patients whose dose of 0.125 mg GnRH-ant was adjusted according to their LH levels and 179 patients who received consistently low doses were further divided into subgroups 1 and 2, respectively. Neither the number of retrieved oocytes and available embryos nor the implantation rate, clinical pregnancy rate, and ongoing pregnancy rate significantly differed between the two groups. However, GnRH-ant dose and stimulation duration were much lower and shorter in Group 1 than in Group 2 (p < 0.05). Subgroup 1 exhibited higher basal follicle-stimulating hormone (FSH) and lower antral follicle count (AFC) than subgroup 2 significantly. The number of retrieved oocytes and available embryos were lower in subgroup 1 than in subgroup 2 (6.83 ± 3.28 vs. 11.83 ± 4.82, 2.93 ± 1.86 vs. 4.99 ± 3.46, respectively, p < 0.05), while more canceled cycles for pre-ovulation occurred in subgroup 1 than in subgroup 2 (3/30 vs. 1/179, p < 0.05). The results showed that the flexible low-dose GnRH-ant protocol was as effective as the conventional fixed-dose GnRH-ant protocol with 0.25 mg per day for most patients with normal ovarian reserve. This retrospective analysis and the small sample size are the main limitations of this study, and a large sample RCT will be carried out in the future.

The duration of gonadotropin stimulation does not alter the clinical pregnancy rate in IVF or ICSI cycles

BACKGROUND

Ovarian stimulation is an essential part of assisted reproduction treatments. Research on whether the duration of stimulation alters the success in assisted reproduction has not been conclusive.

AIM

The purpose of the study was to establish whether the duration of ovarian stimulation alters the success in assisted reproduction treatments.

METHODS

All fresh (non-donor) stimulation cycles performed in an academic tertiary referral ART centre over a period of 18 years, between 1st January 1997 and 31st December 2014, were identified. Data were prospectively and electronically collected. IVF and ICSI cycles were analysed independently. Each category was then subdivided into assisted reproduction cycles where the antagonist, long (down regulation) and flare protocol were used. Clinical pregnancy was the main outcome measured. A total of 10,478 stimulation cycles (6011 fresh IVF and 4467 fresh ICSI) reaching egg collection were included.

RESULTS

We showed no significant difference in CP rates in IVF cycles for the long (p = 0.082), antagonist (p = 0.217) or flare (p = 0.741) protocol cycles or in ICSI cycles with the long (p = 0.223), antagonist (p = 0.766) or the flare (p = 0.690) protocol with regards the duration of stimulation.

CONCLUSION

The duration of stimulation does not alter the CP rate in ICSI or IVF cycles using the long, antagonist or flare stimulation protocol.

Increased odds of live birth in fresh in vitro fertilization cycles with shorter ovarian stimulation

OBJECTIVE

To investigate the impact of prolonged ovarian stimulation on pregnancy outcomes in IVF cycles with fresh day 3 ET.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated center.

PATIENT(S)

All patients initiating their first IVF cycle with fresh day 3 ET. Prolonged ovarian stimulation was defined as a duration of more than two standard deviations (95th percentile) for the study cohort (i.e., >13 days).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth rate was considered the primary outcome and was compared between patients undergoing ovarian stimulation for ≤13 days and >13 days. Odds ratios (OR) with 95% confidence intervals (CI) for all pregnancy outcomes after day 3 ET were calculated. The OR for live birth was adjusted using logistic regression.

RESULT(S)

A total of 6,410 and 339 patients underwent ovarian stimulation for ≤13 days and >13 days, respectively. There were no differences in the demographics or mean number of day 3 embryos transferred between the two groups. Ovarian stimulation ≤13 days was associated with increased odds of clinical pregnancy (OR 2.15, 95% CI 1.19-3.89) and live birth (OR 2.35, 95% CI 1.25-4.43). The increased odds for live birth in the ≤13-day group remained unchanged after logistic regression. Patients with clinical pregnancies in the >13-day group were younger (34.6 ± 4.91 years) compared with those who did not conceive (38.2 ± 4.72 years).

CONCLUSION(S)

Our findings suggest that ovarian stimulation ≤13 days is associated with increased odds of clinical pregnancy and live birth. In patients undergoing ovarian stimulation >13 days, younger age is associated with live birth.

Characteristics and outcomes of in vitro fertilization in different phenotypes of polycystic ovary syndrome

Objective:

The aim of this study was to investigate whether polycystic ovary syndrome (PCOS) phenotype without polycystic ovaries (PCO) differs in terms of in vitro fertilization (IVF) outcomes compared with classic phenotypes.

Materials and Methods:

This retrospective controlled study included 262 patients who underwent IVF treatment with an indication of unexplained or tubal factor infertility (control group), ovulatory patients with PCO morphology (group 1), PCOS phenotype with oligoanovulation and hyperandrogenemia (group 2), PCOS phenotype with PCO morphology and oligoanovulation (group 3). Outcomes and baseline characteristics of IVF-embryo transfer treatments were compared among all groups.

Results:

PCOS phenotype without PCO morphology had similar IVF stimulation characteristics compared with classic phenotypes; however, a higher total gonadotropin dose was needed to achieve similar results compared with patients with PCO morphology with or without PCOS. Basal follicle-stimulating hormone level (beta coefficient=0.207, p=0.003), group (beta coefficient=-0.305, p<0.001) and age (beta coefficient=0.311, p<0.001) were significantly associated with the total gonadotropin dose. The number of good quality embryo on transfer day was significantly lower in patients with isolated PCO morphology and PCO morphology with oligoanovulation than in those with PCOS phenotype without PCO morphology.

Conclusion:

PCO morphology provides easier stimulation, whereas hyperandrogenemia provides better results as good quality embryos. However, the end point is similar in terms of biochemical, clinical, and ongoing pregnancy rates.

Association between the proportion of dominant follicles and oocyte developmental competence

PURPOSE

To explore the optimal timing for hCG triggering by investigating the impact of different proportion of dominant follicles on the oocyte developmental competence.

METHODS

One hundred ninety-eight infertile women were divided into three groups according to the proportion of dominant follicles on hCG day: (1) low: <15% (n = 66); (2) middle: 15-27% (n = 66); (3) high: >27% (n = 66). The grouping criteria were the bottom and top tertiles of the proportion of dominant follicles.

RESULTS

The gonadotropin dosage, duration and maximum follicle diameter in the low proportion group were lower than those in the middle and high proportion groups. Oocyte maturation and the abnormal fertilization rate in the low proportion group were lower than those in the middle and high proportion groups. The normal fertilization rate did not differ among the three groups. The cleavage rate and number of transferable embryos in the low proportion group were significantly higher than those in the high proportion group. The high-quality embryo rate, implantation rate, and pregnancy rate in the low proportion group were significantly higher than those in the middle and high proportion groups.

CONCLUSIONS

A high proportion of dominant follicles are closely associated with impaired oocyte developmental competence and low pregnancy rate. These findings suggest that follicular overgrowth induced by delayed hCG triggering may undermine oocyte developmental competence and the proportion of dominant follicles may be a potential parameters for hCG triggering.