Progestin-primed ovarian stimulation: for whom, when and how?

Fertility preservation in women with endometriosis: A retrospective non-Inferiority study comparing Dienogest in the PPOS protocol to antagonist and agonist protocols

BACKGROUND

Endometriosis is a common pathology that can lead to a decrease in fertility and is therefore a medical indication for preserving fertility. Traditionally, gonadotropin-releasing hormone (GnRH) antagonist and agonist protocols are used to stimulate the ovaries. However, the recent introduction of the progestin-primed ovarian stimulation (PPOS) protocol, using progestins to prevent LH surges, offers a new alternative. Dienogest, a progestin commonly used to treat endometriosis, could be incorporated into the PPOS protocol for patients with endometriosis, allowing them to maintain their background therapy during ovarian stimulation. The aim of this study was to assess the non-inferiority of using Dienogest in the PPOS protocol compared to antagonist and agonist protocols in terms of the number of mature oocytes retrieved from patients with endometriosis undergoing fertility preservation (FP).

METHODS

This retrospective, multicenter, non-inferiority study was conducted in patients with endometriosis, comparing the PPOS protocol with Dienogest, the antagonist protocol, and the agonist protocol. The primary endpoint was the number of mature oocytes retrieved. The secondary endpoint included ovarian response parameters, treatment complications, and tolerance assessed by validated questionnaires.

RESULTS

The study included 201 cycles performed in 130 patients. Non-inferiority of the PPOS-Dienogest protocol was demonstrated in pairwise comparisons against antagonist protocol (p = 0.0062) and agonist protocol (p = 0.0360) in the number of mature oocytes retrieved. Using Dienogest in the PPOS protocol was not associated with a smaller number of mature oocytes retrieved than with the GnRH antagonist or agonist conventional protocols. Additionally, no significant differences were found in ovarian response parameters, treatment tolerance, or complications between protocols.

CONCLUSION

The PPOS protocol with Dienogest appears to be a promising alternative for FP compared to traditional protocols for patients with endometriosis, without adversely affecting the number of mature oocytes retrieved. Larger prospective studies are required to confirm these results.

Euploidy rate and pregnancy outcomes in preimplantation genetic testing for aneuploidy cycles using progestin-primed ovarian stimulation versus GnRH antagonist protocol

BACKGROUND

Previous studies has yielded contradictory findings regarding the relationship between controlled ovarian hyperstimulation (COH) protocol and euploid blastocyst rate. This study aimed to investigate whether progestin-primed ovarian stimulation (PPOS) influences the euploidy rate and pregnancy outcomes in preimplantation genetic testing for aneuploidy (PGT-A) cycles compared to GnRH antagonist protocol.

METHODS

The retrospective study analyzed data from 598 PGT-A cycles conducted between January 2017 and October 2022 utilizing either PPOS (medroxyprogesterone acetate) or the GnRH antagonist protocol. The biopsied trophectoderm from 2218 blastocysts was collected for euploidy analysis via next-generation sequencing.

RESULTS

Biopsied blastocyst number was comparable between PPOS group and GnRH antagonist group (3.51 ± 2.93 vs. 3.91 ± 3.19, P = 0.116), although PPOS yielded fewer MII oocytes (10.27 ± 6.59 vs. 11.60 ± 6.71, P = 0.015). The euploidy rate (43.3% vs. 45.0%, P = 0.423), aneuploidy rate (36.9% vs. 36.0%, P = 0.127), and mosaic rate (19.4% vs. 17.6%, P = 0.127) were similar between the PPOS and GnRH antagonist protocols. Additionally, PPOS demonstrated comparable pregnancy outcomes to GnRH antagonist protocol, including clinical pregnancy rates (58.1% vs. 59.8%, P = 0.713) and live birth rates (51.1% vs. 46.9%, P = 0.364). But lower miscarriage rate was shown in the PPOS protocol (7.9% vs. 16.8%, P = 0.019).

CONCLUSIONS

The PPOS protocol did not negatively impact euploid blastocyst formation or pregnancy outcomes compared to the GnRH antagonist protocol, indicating that medroxyprogesterone acetate was an alternate option to antagonists for women undergoing PGT-A.

Serum concentrations of medroxyprogesterone acetate were undetectable on OPU+5 days and had no effect on the serum progesterone level in patients undergoing the progestin-primed ovarian stimulation protocol

Objective

To evaluate the dynamics of serum medroxyprogesterone acetate (MPA) concentrations and their influence on serum progesterone (P) levels and pregnancy outcomes in the progestin-primed ovarian stimulation (PPOS) protocol. A total of 116 patients who underwent in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment using the PPOS protocol were included. Serum MPA levels were measured on the third, fifth, and seventh days of MPA use; on the day of human chorionic gonadotropin (hCG) trigger; and two and five days after oocyte pick-up (OPU).

Results

The serum MPA concentration was 2.26 ± 2.11 nmol/L on the hCG trigger day, 0.37 ± 0.40 nmol/L two days after OPU, and zero five days after OPU. There were no statistically significant differences in P levels on the hCG trigger day, total dosage of Gn, duration of Gn, number of oocytes retrieved, number of mature oocytes, fertilization rate, blastocyst progression rate, CPR, ectopic pregnancy rate, early pregnancy loss rate, or live birth rate (LBR) between the two cohorts (P > 0.05).

Conclusions

Serum concentrations of MPA had no effect on serum P levels or pregnancy outcomes in patients undergoing the PPOS protocol.

Impact of relative estradiol changes during ovarian stimulation on blastocyst formation and live birth in assisted reproductive technology

This study aimed to evaluate the predictive value of relative change in E2 levels during controlled ovarian stimulation (COS) on embryo development and pregnancy outcomes in assisted reproductive technology (ART). We retrospectively analyzed 9,376 patients who underwent their first fresh ART cycle from January 1, 2020, to December 31, 2022. Patients were classified into four groups based on relative change in E2 levels: low response group, moderate response group, moderate-high response group, and high response group. The primary outcomes were blastocyst formation rate, clinical pregnancy rate, and live birth rate, while secondary outcomes included miscarriage rate and ectopic pregnancy rate. Most cycles (96.5%) demonstrated an increase in E2 levels during COS. The blastocyst formation rate significantly increased across the groups (low response group: 0.13, moderate response group: 0.21, moderate-high response group: 0.28, high response group: 0.34; P < 0.001). Multivariable logistic regression showed significantly higher blastocyst formation rates in the moderate response group (adjusted OR = 2.012, 95% CI: 1.687-2.399), moderate-high response group (adjusted OR = 4.613, 95% CI: 3.853-5.523), and high response group (adjusted OR = 11.295, 95% CI: 9.192-13.880) compared to the low response group. Both clinical pregnancy rate and live birth rate were significantly higher in the moderate-high response group and high response group compared to the low response group (clinical pregnancy rate: 54.5% and 61.5% vs. 35.5%, adjusted RR = 1.21 [95% CI: 1.03-1.42] and 1.27 [95% CI: 1.08-1.51]; live birth rate: 44.9% and 52.0% vs. 25.7%, adjusted RR = 1.27 [95% CI: 1.06-1.52] and 1.35 [95% CI: 1.11-1.64]). However, no significant differences were observed in either clinical pregnancy rate or live birth rate between the moderate response group and low response group (clinical pregnancy rate: adjusted RR = 1.07 [95% CI: 0.91-1.25]; live birth rate: adjusted RR = 1.11 [95% CI: 0.92-1.33]). No significant differences in miscarriage rate or ectopic pregnancy rate were observed across the groups. Higher E2 responses were associated with improved embryo development and better pregnancy outcomes.

Meeting proceedings: International Society for Fertility Preservation Tokyo, 15-17 November, 2024

The 8 th International Congress of the ISFP was held in Tokyo, Japan, from November 15 to 17, 2024. The theme of this year's Congress was "Rethinking Personalized Fertility Preservation and Cancer Survivors-Opening a New Frontier". The congress featured special lectures, keynote addresses, and 25 sessions-including a dedicated session on nursing and oral presentations by young doctors and researchers-making it one of the largest and most comprehensive events in the ISFP's history. Additionally, the program incorporated sessions featuring the Japanese, Korean, and Chinese Societies for Fertility Preservation, providing a convenient platform for international participants from across the globe to showcase their work and discuss the unique characteristics and challenges of these areas within Asia. Participants also had the opportunity to attend workshops on ovarian tissue cryopreservation and oocyte cryopreservation, conducted by leaders in their respective fields exploring the latest technological and clinical advances and translational prospects for the future.

Renewing ovarian stimulation

Conventional ovarian stimulation protocols were designed for fresh embryo transfer. They start in the early follicular phase, i.e. the infamous day 2-3, gonadotrophin-releasing hormone analogues are used to prevent premature ovulation, and the stimulation is harnessed due to the fear of ovarian hyperstimulation syndrome and the decreasing chance of a live birth following a fresh transfer. The advent of vitrification allows a confident cancellation of fresh transfers and effective oocyte/embryo freezing for future use. Today, many stimulation cycles are not intended to involve a fresh embryo transfer. Ovarian stimulation for freeze-all cycles can be vastly different from conventional stimulation. The quantitative and qualitative oocyte yield seems independent of the starting day, and the early or late follicular or luteal phase may have distinct advantages for different needs. A variety of pituitary suppression protocols including oral progestins or not using exogenous suppression at all can be employed without compromising oocyte quantity and quality. Stimulation can cautiously aim for the patient's maximal potential since the agonist trigger without a fresh transfer curbs the risk of ovarian hyperstimulation syndrome. Patients can be even stimulated multiple times in a menstrual cycle when deemed beneficial. Ovarian stimulation is more patient and physician friendly than ever.

Effects of gonadotropin releasing hormone antagonist (GNRHant) and oral progestin-primed protocol on oocyte count over the punctured follicle number in consecutive two cycles: A comparative study

Objective

Controlled ovarian hyperstimulation plays a critical role in in vitro fertilization (IVF) success. However, premature luteinization and variations in oocyte yield can impact IVF outcomes. This comparative study aims to investigate the effects of gonadotropin releasing hormone antagonist (GNRHant) and oral progestin-primed protocol on the oocyte count over the punctured follicle number in the same patient group undergoing consecutive IVF cycles.

Materials and Methods

Forty-nine patients undergoing IVF were enrolled in this comparative study. Each participant underwent two consecutive IVF cycles. In the first cycle, GNRHant protocol was used. In the second cycle, the OPP protocol was used. The number of punctured follicles and oocytes retrieved was recorded and compared between the two cycles for each patient.

Results

The ratio of oocyte count per punctured follicle number was higher in the OPP group compared to the GNRHant group, without clinical significance (p>0.05). In the OPP, the ratio of oocytes retrieved over the punctured follicle number was 0.90±0.28; in the GNRHant group, it was recorded as 0.94±0.36, and the differences between the ratios were statistically insignificant.

Conclusion

Oocyte yield is a critical determinant of IVF success, and it can be influenced by various factors, including premature luteinization and follicular development. The use of GNRHant and OPP is known to prevent premature luteinization and improve follicular synchronization. This study demonstrates that neither of the protocols is superior in the success of oocyte retrieval over the punctured follicle count. Further research with larger sample sizes and randomized controlled trials is warranted to validate these results, and optimize clinical application of this combined protocol in IVF treatments.

Programming the onset of ovarian stimulation: from early follicular phase start to oral contraceptive pill, to luteal phase E2, Duostim, and random start oral contraceptive protocols

Ovarian stimulation has been the single most efficient measure ever taken in assisted reproductive technology for improving outcomes by harvesting multiple oocytes and ultimately, embryos. Today, ovarian stimulation protocols consist of administrating exogenous gonadotropins to override the natural mechanisms that control the ovulatory quota to one in humans. For practicality issues, there have been numerous attempts to control, or "program," when ovarian stimulation is initiated to improve functionality and in turn efficacy for assisted reproductive technology programs. The different options for controlling the onset of ovarian stimulation currently available are discussed here, as well as the novel possibility of using progestins for blocking premature ovulation.

A multicycle approach through DuoStim with a progestin-primed ovarian stimulation (PPOS) protocol: a valuable option in poor prognosis patients undergoing PGT-A

PURPOSE

This study is to evaluate the effectiveness of a PPOS protocol in poor prognosis patients undergoing IVF with DuoStim and PGT-A versus the conventional protocol with GnRH antagonist.

METHODS

Retrospective cohort study encompassing 444 couples obtained matching one PPOS-DuoStim with two antagonist-DuoStim cycles at a private IVF center between 2020 and 2023 (average maternal age: 40 years, average cumulus-oocyte complexes collected after the first stimulation: 5). The study was powered to exclude a two-sided different euploid blastocyst rate per MII oocytes (EBR per MII) in the two groups (alpha = 0.05, power = 0.9, effect size = 0.3). All cycles involved ICSI, blastocyst stage PGT-A, and single vitrified-warmed euploid transfers. We compared all embryological and clinical outcomes within each group (first vs. second stimulations), and among the two study arms (first stimulation vs. first stimulation; second stimulations vs. second stimulation; overall). The overall EBR per MII was the primary study outcome. The cumulative-live-birth-rate per concluded cycles (CLBR) was the main secondary outcome.

RESULTS

In the second stimulations, we obtained a greater number of COCs and MIIs in both antagonist- and PPOS-DuoStim groups. No difference was observed for all embryological and clinical outcomes when comparing the two stimulations within each group. All embryological and clinical outcomes were comparable also between the two groups, including the EBR per MII. To date, 285 and 121 antagonist- and PPOS-DuoStim cycles were concluded. The CLBR was comparable between the groups: 26% vs. 29%.

CONCLUSIONS

PPOS-DuoStim holds potential for being an efficient, patient-friendly, and possibly cost-effective approach that does not compromise treatment efficacy. Future investigations must explore PPOS effect on follicular recruitment, neonatal, and long-term outcomes.

Cytoplasmic sperm injection (ICSI) - A systematic review of the literature

Background: Progestin-primed ovarian stimulation (PPOS) stimulates ovaries to block the premature surge of luteinizing hormone (LH) by using micronized progesterone or a progestin during the follicular phase instead of the conventional gonadotropin-releasing hormone (GnRH) analogues or GnRH antagonists downregulating LH to obtain multi-follicle engagement. Current work aims to assess the influence of progestogen treatment on ovarian stimulation and the ability to control LH surge, its efficacy and suitability in retrieving oocytes, without affecting the embryo quality and its benefit among infertile women long-term outcomes on children compared to standard stimulation protocols. Materials and Methods: The literature review used the randomized control trials published in the Pubmed database from January 2015 to April 2021. To generate the citation list, the following keywords were used: 'progestin-primed ovarian stimulation', 'PPOS', 'micronized progesterone', 'medroxyprogesterone', and/or 'dydrogesterone'. The selected articles analyzed the cohort, intervention, and scheme of the progestin-primed ovarian stimulation protocol in controlled ovarian stimulation (COS) for in-vitro fertilization (IVF)/intra cytoplasmic sperm injection (ICSI) used in Assisted Reproductive Technologies (ART). Results: Overall we concluded that PPOS for IVF/ICSI in ART results in a higher number of obtained embryos, lower incidence of OHSS, equal duration of stimulation, number of retrieved oocytes, and number of MII oocytes. It is also suggested that long-term safety in children shows no significant difference between the study and control groups. Conclusions: Despite the outcomes of progestin stimulation cycles among all cohorts, we concluded that poor ovarian responders, patients with PCOS, women of advanced age and oocyte donors benefit the most from using PPOS.

Exposure of antral follicles to medroxyprogesterone acetate during stimulation does not cause molecular perturbations in gonadotropin-responsiveness and steroidogenic function of granulosa cells in progestin-primed cycles

STUDY QUESTION

Does medroxyprogesterone acetate (MPA) exposure in progestin-primed ovarian stimulation (PPOS) cycles cause molecular perturbations in the steroidogenic function and gonadotropin responsiveness of the granulosa cells?

SUMMARY ANSWER

PPOS cycles are identical to traditional GnRH antagonist cycles not only for clinical IVF characteristics but also for gonadotropin receptor expression, response to gonadotropins, and steroidogenic function at the molecular level.

WHAT IS KNOWN ALREADY

PPOS is increasingly used as an alternative to GnRH antagonists due to the inhibitory effect of progesterone on LH release by reducing GnRH pulsatility at the hypothalamic level. Although a growing body of evidence from clinical studies did not indicate significant differences between PPOS and antagonist protocols for IVF cycle characteristics and obstetrical outcomes, it is still unknown whether exposure of the antral follicle cohort to progesterone or its synthetic derivatives during ovarian stimulation causes any subtle molecular aberrations in terms of steroidogenesis and gonadotropin responsiveness. To address this issue, detailed comparative molecular analyses were conducted in the luteinized mural granulosa cells (GCs) obtained from normal responding IVF patients undergoing PPOS and antagonist cycles.

STUDY DESIGN, SIZE, DURATION

A clinical translational research study was conducted with IVF patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included 55 normal responding IVF patients who underwent ovarian stimulation with either PPOS using MPA (5 mg twice daily) or GnRH antagonist cetrorelix acetate. Recombinant forms of FSH and hCG were used for ovarian stimulation and ovulation triggering, respectively. Luteinized mural GCs obtained during the oocyte retrieval procedure were used for the experiments. Cell culture, quantitative real-time PCR, immunoblotting, confocal time-lapse live cell imaging, and hormone assays were used.

MAIN RESULTS AND THE ROLE OF CHANCE

Demographic and IVF cycle characteristics of the patients undergoing ovarian stimulation with PPOS and GnRH antagonist were similar, including ovarian response, mature oocyte yield, and fertilization rates. Molecular analyses revealed that the expression of the enzymes involved in sex-steroid synthesis (StAR, SCC, 3β-HSD, 17β-HSD, aromatase) and the uptake/storage/utilization of cholesterol (LDL receptor, Hormone-sensitive lipase, hydroxy-methyl glutaryl Co-enzyme-A reductase, and Sterol O-acyltransferase1) in the GCs of the PPOS cycles were comparable to those of the antagonist cycles. The expression of the receptors for gonadotropins, estrogen, and progesterone hormones was also similar. Basal and hCG-induced increases in 3β-HSD expression and progesterone production and basal and FSH-induced increases in aromatase expression and E2 output of the GCs from PPOS patients did not exhibit any meaningful differences when compared with GCs from antagonist cycles. Furthermore, basal and hCG-induced up-regulation in the LDL receptor expression and cholesterol uptake did not differ between the groups. Confocal imaging also revealed similar patterns of expression for the steroidogenic enzymes and their co-localization with mitochondria. Lastly, the expression of the other important genes regulating cumulus expansion, ovulation, and luteal function [Relaxin, ADAMTS-1, and epidermal growth factor (EGF)-like growth factor amphiregulin] in the GCs of the PPOS and antagonist cycles were similar.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Caution should be exercised when interpreting our data which was derived from normally responding patients whose ovulation was triggered with hCG. It is unclear whether the molecular parameters assessed vary according to infertility etiologies, magnitude of ovarian response, mode of trigger, and any other underlying ovarian pathologies or systemic diseases. MPA was the progestin used for PPOS and whether these findings can be generalized to other progestins is unknown.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides reassuring molecular evidence that exposure of antral follicle cohorts to MPA during the follicular growth phase does not have any detrimental effects on steroidogenic, ovulatory, and luteal functions when compared with GnRH antagonist cycles.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the School of Medicine, the Graduate School of Health Sciences of Koc University and Koç University Research Center for Translational Medicine (KUTTAM), and equally funded by the Republic of Turkey Ministry of Development Research Infrastructure Support Program. All authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Undetected, natural conception pregnancies in luteal phase stimulations-case series and review of literature

STUDY QUESTION

What is the risk of an undetected natural conception pregnancy during luteal phase ovarian stimulation, and how does it impact the pregnancy's course?

SUMMARY ANSWER

The risk for an undetected, natural conception pregnancy in luteal phase ovarian stimulation is low and it appears that ovarian stimulation is unlikely to harm the pregnancy.

WHAT IS KNOWN ALREADY

Random start ovarian stimulation appears to be similarly effective as early follicular stimulation start; and it allows ovarian stimulation to be started independent of the cycle day and throughout the cycle, in accordance with the patients' and clinics' schedule as long as there is no intention of a fresh embryo transfer in the same cycle. Starting ovarian stimulation in the luteal phase bears the possibility of an-at the timepoint of stimulation start-undetected, natural conception pregnancy that has already occurred. There is scarce data on the incidence of this event as well as on the possible implications of ovarian stimulation on the course of an existing pregnancy.

STUDY DESIGN, SIZE, DURATION

This retrospective observational study, performed between June 2017 and January 2024, analyzed luteal phase stimulations, in which a natural conception pregnancy was detected during the ovarian stimulation treatment for IVF/ICSI. Luteal phase stimulation was defined as ovarian stimulation started after ovulation and before the next expected menstrual bleeding, with a serum progesterone (P4) level of >1.5 ng/ml on the day of stimulation start or 1 day before.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who underwent a luteal phase ovarian stimulation in a tertiary referral ART center.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 488 luteal phase stimulation cycles were included in the analysis. Luteal phase stimulation was only started after a negative serum hCG measurement on the day or 1 day before commencement of ovarian stimulation. Ten patients (2.1%) had an undetected natural conception pregnancy at the time of luteal phase stimulation start. Eight of these patients underwent an ovarian stimulation in a GnRH-antagonist protocol and two in a progestin-primed stimulation protocol (PPOS). Recombinant FSH was used as stimulation medication for all patients, the patients with a PPOS protocol received additional recombinant LH. One pregnancy (0.2%) was detected after the oocyte retrieval, the other nine pregnancies were detected either due to persistent high serum progesterone levels or due to an increasing progesterone level after an initial decrease before oocyte retrieval. In the cycles with an undetected natural conception pregnancy, the median number of stimulation days was 8 days (range: 6-11 days) and median serum hCG at detection of pregnancy was 59 IU hCG (range: 14.91-183.1). From 10 patients with a pregnancy, three patients delivered a healthy baby, two patients had ongoing pregnancies at the time of summarizing the data, three patients had biochemical pregnancies (patient age: 30, 39, and 42 years), one patient had an ectopic pregnancy which required a salpingectomy, and one patient (age: 34 years) had an early pregnancy loss.

LIMITATIONS, REASONS FOR CAUTION

The retrospective study design and the small sample size can limit the accuracy of the estimates.

WIDER IMPLICATIONS OF THE FINDINGS

Overall, there is a small risk of undetected natural conception pregnancies when luteal phase stimulation is undertaken. It appears that there are no adverse effects through either direct effect on the embryo or indirectly through a detrimental effect on the corpus luteum function on the pregnancy in our cohort.

STUDY FUNDING/COMPETING INTEREST(S)

This study did not receive funding. The authors declare that there is no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Comparison of fixed and flexible progestin-primed ovarian stimulation in women classified in patient-oriented strategies encompassing individualized oocyte number (POSEIDON) group 4

PURPOSE

This study aimed to compare the fixed and flexible protocols for progestin-primed ovarian stimulation (PPOS) in poor ovarian responders.

METHODS

This retrospective study included 95 poor ovarian responders classified using the Patient-Oriented Strategies Encompassing Individualized Oocyte Number group 4 criteria. Treatment involved assisted reproductive medicine using fixed and flexible PPOS protocols at Shiga University of Medical Science between July 2019 and August 2023. PPOS cycles were assigned to the fixed and flexible groups at the discretion of attending physicians. The results of assisted reproductive medicine were compared between groups.

RESULTS

The fixed and flexible groups included 68 and 27 patients, respectively. The flexible group obtained more retrieved oocytes and two pro-nuclei than the fixed group, without an early luteinizing hormone surge. Multiple linear regression analysis demonstrated that differences in protocols and anti-müllerian hormone (AMH) levels were related to the number of retrieved oocytes. The differences in protocols were more strongly correlated with the number of oocytes than with the AMH levels.

CONCLUSION

Among poor ovarian responders, the flexible PPOS protocol provided more retrieved oocytes than the fixed PPOS protocol, possibly because the total dosage of progestins was lower in the flexible group and progestins were not administered at the time when ovarian stimulation was initiated.

Clinical outcomes of three follitropin alfa preparations for ovarian stimulation using an oral micronized progesterone-primed protocol in an oocyte donation program

Introduction

This large multicenter study aimed to evaluate clinical outcomes using three follitropin alfa preparations within a progestin-primed ovarian stimulation (PPOS) protocol, while identifying contributing factors to cycle success.

Methods

A retrospective, anonymized cohort analysis was conducted on donor-recipient cycles from 12 clinics during 2019 to 2021. 7389 oocyte donors underwent ovarian stimulation (OS) with three follitropin alfa preparations (Ovaleap® [n=3231], Bemfola® [n=3542], Gonal-F® [n=616]) were included. Stimulation began on cycle days 2 or 3 with daily administration of 150-225 IU follitropin alfa. 10 mg medroxyprogesterone acetate (MPA) was administered daily until GnRH agonist trigger using a single dose of 0.2mg GnRH agonist for final follicular maturation. Statistical analysis included ANOVA, Chi-squared, and logistic regression.

Results

Whilst there were some differences in patient and stimulation characteristics, including donor age and number of retrieved oocytes, clinical variables did not significantly differ among the three study groups. Linear regression revealed donor age [0.986 (0.974-0.999)] and number of mature oocytes [1.027 (1.007-1.047)] significantly impacted ongoing pregnancy rates, while the type of follitropin alfa [1.048 (0.956-1.149)] used did not. No significant differences were observed in the cumulative live birth rate (CLBR) among oocytes obtained from stimulation with Bemfola (64.9%), Gonal-F (64.1%) and Ovaleap (66.1%), p= 0.385.

Discussion

This study demonstrated comparable clinical outcomes and CLBR between biosimilars and the reference product of follitropin alfa within PPOS protocols, hence they are interchangeable in a real-world patient setting.

Progestin-primed ovarian stimulation

PURPOSE OF REVIEW

The use of progestins as pituitary suppressors has increased progressively, along with more detailed indications for their use, thereby consolidating an alternative approach to the personalization of ovarian stimulation.

RECENT FINDINGS

Based on the ability of progesterone to inhibit ovulation, progestins have been used in ovarian stimulation (OS) follicular protocols to prevent a luteinizing hormone surge in patients undergoing in vitro fertilization (IVF), as an alternative to gonadotropin-releasing hormone (GnRH) analogue administration. This review explores the different types of progestogen protocols and their efficacy depending on the type of population or reproductive procedure in which they are administered and in comparison with that of GnRH analogues. Their effect on oocytes and embryos and their safety and cost-effectiveness are also analyzed.

SUMMARY

Progestins have proven their effectiveness as a gonadotropin adjuvant in terms of ovarian response, reproductive outcome, and safety. In addition, they offer the convenience of oral administration and a lower cost than GnRH analogues. Whereas oocytes or embryos should be vitrified as it displaces the receptive period with the consequent asynchrony between embryo and endometrium. The evidence endorses progestins as a more friendly approach to OS, especially when frozen-thawed embryo transfer is planned.