Cumulative conception and live birth rates in natural (unstimulated) IVF cycles

Venous thromboembolism associated with medically assisted reproduction (MAR): British fertility society policy and practice guidance for assessment and prevention

The association between Medically Assisted Reproduction (MAR) and thromboembolic complications has been reported widely in multiple published studies. Although venous thromboembolism (VTE) is not thought to be a common complication of MAR, it is associated with high morbidity and is often preventable. Since VTE usually occurs after completion of MAR treatment and is often managed outside of the treating fertility unit, these complications are likely to be underreported and there may be limited awareness of the risks among clinicians. As we continue to see a rise in the total number of MAR treatment cycles, particularly in women over 40 years of age, along with a steady increase in the number of fertility preservation cycles for both medical and social indications, it is likely that we will see an increase in absolute numbers of VTE complications. Currently, there is a lack of management guidance and reporting of VTE events associated with assisted conception treatment. The aim of this guidance is to provide clinicians with information on VTE risk factors, guidance on assessing VTE risk and the best practice recommendations on risk reducing strategies for individuals at risk of VTE undergoing ovarian stimulation and embryo transfer cycles.

Therapeutic exposures and pubertal testicular dysfunction are associated with adulthood milestones and paternity after childhood cancer

BACKGROUND

Childhood cancer therapy may cause long-term effects. This cross-sectional study evaluated adulthood milestones in male childhood cancer survivors (CCS).

METHODS

The study population comprised 252 male CCS with 6 to 42 years of survival diagnosed at the Children's Hospital in Helsinki (1964-2000) at the age of 0 to 17 years. Sex-, age-, and area of residence-matched population controls were randomly selected from the Finnish national registries. Data on moving away from the parental home, marital status, offspring, and adoption in CCS were compared with the population controls. We analyzed the influence of chemotherapy and radiation exposures and testicular dysfunction (ever nontestosterone-substituted serum follicle stimulating hormone >15 IU/L, luteinizing hormone >15 IU/L, testosterone <2 ng/mL (5 nmol/L), need of testosterone replacement therapy, or testicular volume <12 mL at the end of puberty) during pubertal maturation on long-term social outcomes.

RESULTS

CCS moved away from their parental home as frequently as population controls (97.8% vs. 98.5%, p = .45). CCS were less likely to marry or live in a registered relationship (46.4% vs. 57.5%, p < .001), especially when diagnosed at a young age (<4 years). Among those married, the probability of divorce was similar between CCS and population controls (27.4% vs. 23.8%, p = .41). Survivors were less likely to sire a child (38.5% vs. 59.1%, p < .001) and more likely to adopt (2% vs. 0.4%, p = .015). Lower probability of paternity was associated with hematopoietic stem cell therapy, testicular radiation dose >6 Gy, pubertal signs of testicular dysfunction (nontestosterone-substituted serum follicle stimulating hormone >15 IU/L, luteinizing hormone  >15 IU/L, testosterone <2 ng/mL (5 nmol/L), or need of testosterone replacement therapy during puberty, or testicular volume <12 mL at the end of puberty) or azoospermia after puberty.

CONCLUSIONS

This study emphasizes the value of pubertal monitoring of testicular function to estimate future probability of paternity. If no signs of dysfunction occurred during pubertal follow-up, paternity was comparable to population controls. Testicular radiation dose >6 Gy appeared to be the strongest risk factor for decreased paternity.

PLAIN LANGUAGE SUMMARY

Treatment with intensive therapies, including hematopoietic stem cell therapy, testicular radiation dose >6 Gy, and signs of testicular dysfunction, during puberty are important risk factors for lower rates of fertility. Intensive therapies and testicular dysfunction itself do not similarly hamper psychosocial milestones in adulthood; cancer diagnosis at a very young age (<4 years) lower the probability of marriage. This study accentuates the importance of monitoring of pubertal development, emphasizing on testicular function, not only sperm analysis, to estimate future fertility among male childhood cancer survivors.

Oocyte donation outcomes in endometriosis patients with multiple IVF failures

RESEARCH QUESTION

What are the reproductive outcomes and the prognostic factors of live birth rates in patients with endometriosis referred to oocyte donation after multiple IVF failures?

DESIGN

Observational cohort study including all women with endometriosis-related infertility and two or more failed IVF/intracytoplasmic sperm injection (ICSI) cycles referred to oocyte donation between January 2013 and June 2022. Endometriosis was diagnosed based on published imaging criteria, and was confirmed histologically in women who had a history of surgery for endometriosis. The main outcome measured was the cumulative live birth rate (CLBR). The characteristics of women who had a live birth were compared with those who did not using univariate and multivariate analysis to identify determinant factors of fertility outcome.

RESULTS

Fifty-seven patients underwent 90 oocyte donation cycles after 244 failed autologous IVF cycles. The mean ± SD age of the population was 36.8 ± 3.3 years, with a mean duration of infertility of 3.6 ± 2.2 years, and a mean number of autologous IVF/ICSI cycles of 4.4 ± 2.3 cycles per patient. Three patients (5.3%) had superficial peritoneal endometriosis, two patients (3.5%) had ovarian endometriomas, and 52 patients (91.2%) had deep infiltrating endometriosis, among which 30 patients (57.7%) had bowel lesions. Thirty patients (52.6%) had associated adenomyosis. Overall, CLBR per patient was 36/57 (63.2%). After multivariate analysis, only being nulligravida (P=0.002) remained an independent negative predictive factor of the live birth rate. Previous surgery did not impact reproductive outcomes.

CONCLUSION

This study suggests that oocyte donation appears to be a viable option to optimize the live birth rate in women with endometriosis-related infertility and recurrent IVF failures.

Risk factors for low oocyte retrieval in patients with polycystic ovarian syndrome undergoing in vitro fertilization

BACKGROUND

The number of oocytes retrieved does not always coincide with the number of follicles aspirated in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment. Patients with high expectation of retrieval sometimes obtain few oocytes, which may be induced by improper operation or therapeutic factors. The purpose of this study was to evaluate the distribution data of oocyte retrieval rate (ORR) and to explore the risk factors for low ORR in patients with polycystic ovary syndrome (PCOS) undergoing IVF/ICSI.

METHODS

A total of 2478 patients with PCOS undergoing IVF/ICSI were involved in this retrospective case-control study from March 2016 to October 2021. The oocyte retrieval rate was calculated as the ratio of the number of obtained oocytes to the number of follicles (≥ 12 mm) on the trigger day. Patients were divided into a low ORR and a normal ORR group with the boundary of one standard deviation from the mean value of ORR. The patient characteristics, treatment protocols, serum hormone levels, and embryonic and pregnancy outcomes were analyzed.

RESULTS

The ORR exhibited a non-normal distribution, with a median of 0.818. The incidence of complete empty follicle syndrome was 0.12% (3/2478). The proportion of patients in the low ORR group who received the progestin-primed protocol was significantly higher than that in the normal ORR group (30.30% vs. 17.69%). A logistic regression analysis showed that the serum estradiol level/follicle (≥ 12 mm) ratio (OR: 0.600 (0.545-0.661)) and progesterone level (OR: 0.783 (0.720-0.853)) on the trigger day were significant factors in the development of a low ORR, with optimal cutoff values of 172.85 pg/ml and 0.83 ng/ml, respectively, as determined by receiver operating curve. Fewer high-quality embryos (2 vs. 5) and more cycles with no available embryos (5.42% vs. 0.43%) were found in the low ORR group.

CONCLUSIONS

For patients with PCOS, low estradiol levels/follicles (≥ 12 mm) and progesterone levels on the trigger day and the use of the progestin-primed protocol could be risk factors for low ORR, which leads to a limited number of embryos and more cycle cancellations.

Comparing the IVM laboratory outcomes between stimulated IVF with unstimulated natural cycles

Recently, more attention has been raised towards fertility preservation in women with cancer. One option is in vitro maturation (IVM) of the immature oocytes as there is not enough time for induction of an ovarian stimulation protocol. The aim was to compare the IVM laboratory outcomes between stimulated and unstimulated (natural) in vitro fertilization (IVF) cycles. In total, 234 immature oocytes collected from 15 cancer patients who underwent an IVM programme (natural IVM) and 23 IVF cycles with a controlled ovarian hyperstimulation protocol (stimulated IVM) were analyzed. The oocyte morphology, zona pellucida (ZP), and meiotic spindle presence were measured using PolScope technology. Also, the rates of oocyte maturation and fertilization were assessed in both groups. The IVM rate was higher in the stimulated cycle (P < 0.05), but the fertilization rate was insignificant in comparison with unstimulated cycles. There were no significant differences in the spindle visualization and ZP birefringence scoring between the groups (P > 0.05). The oocyte normal morphology was better in the stimulated cycle compared with the natural cycle (P < 0.05). In conclusion, IVM can be recommended for cancer patients as an alternative treatment when there is insufficient time for conventional IVF before chemotherapy initiation.

Poor ovarian response and the possible role of natural and modified natural cycles

About 20% of women undergoing in vitro fertilization struggle with poor ovarian response, indicating a poor prognosis related to low response following ovarian stimulation. Indeed, poor ovarian response, that is associated with both high cancelation rates and low live birth rates, still represents one of the most important therapeutic challenges in in vitro fertilization. In this context, natural cycle/modified natural cycle–in vitro fertilization, as a ‘milder’ approach, could be a reasonable alternative to high-dose/conventional ovarian stimulation in poor ovarian responders, with the aim to retrieve a single oocyte with better characteristics that may result in a single top-quality embryo, transferred to a more receptive endometrium. Moreover, modified natural cycle–in vitro fertilization may be cost-effective because of the reduced gonadotropin consumption. Several studies have been published during the last 20 years reporting conflicting results regarding the use of natural cycle/modified natural cycle–in vitro fertilization in women with poor ovarian response; however, while most of the studies concluded that mild stimulation regimens, including natural cycle/modified natural cycle–in vitro fertilization, have low, but acceptable success rates in this difficult group of patients, others did not replicate these findings. The aim of this narrative review is to appraise the current evidence regarding the use of natural cycle/modified natural cycle–in vitro fertilization in poor ovarian responders.

Effect of ovarian stimulation on embryo aneuploidy and mosaicism rate

There is a high incidence of chromosome abnormalities in human embryos that leads to a failed IVF cycle. Different studies have shown that maternal age is the determining factor in the appearance of chromosomal alterations in the embryo. However, the possible influence of ovarian stimulation on oocyte and embryo aneuploidies and mosaicism is controversial. A retrospective study was carried out in which 835 embryos from 280 couples undergoing reproductive treatment using their oocytes were chromosomally analyzed. A binary logistic regression analysis was performed to evaluate the relationship between different parameters characterizing controlled ovarian stimulation (COS) and the rate of aneuploidy and embryonic mosaicism. The embryo aneuploidy rate showed no association with the use of oral contraceptives, type, total and daily doses of gonadotropins, stimulation protocol type, and drugs used for ovulation trigger (p > 0.05). In contrast, the duration of the ovarian stimulation treatment was correlated with the aneuploidy rate: patients requiring more days of stimulation presented a lower rate of aneuploid embryos (p = 0.015). None of the variables studied showed any association with the rate of embryo mosaicism. However, the duration of COS showed association with the appearance of aneuploidy, suggesting that faster recruitment could be deleterious for those reassuming meiosis, yielding more abnormal karyotype.Abbreviations: IVF: in vitro fertilization; COS: controlled ovarian stimulation; PGT-A: preimplantation genetic test for aneuploidy; hCG: human chorionic gonadotropin; GnRH: gonadotropin-releasing hormone; LH: luteinizing hormone; FSH: follicle-stimulating hormone; NGS: next-generation sequencing; a-CGH: comparative genomic hybridization; TUNEL: Terminal transferase dUTP Nick End Labeling; FISH: fluorescent in situ hybridization.

Success rates in minimal stimulation cycle IVF with clomiphene citrate only

PURPOSE

To determine age-adjusted overall success rates for patients undergoing clomiphene citrate only minimal stimulation cycle (mini) in vitro fertilization (IVF) without any gonadotropin administration.

METHODS

Eight hundred thirty-nine women (mean age: 38.4 ± 0.1 years; 2488 cycles) underwent clomiphene citrate only mini-IVF. Their first oocyte retrieval was between January 2009 and December 2009, with follow-up until December 2014. The cumulative live birth rate (CLBR) per oocyte retrieval cycle started and live birth rate per oocyte was retrospectively analyzed. The basic CLBR was calculated as the number of women who achieved a live birth divided by the total number of women who started oocyte retrieval.

RESULTS

The mean number of oocytes retrieved was 1.5. The basic CLBRs for all ages after the first and third cycles were 22.6% and 39.2%, respectively. For ≤ 34 years, 35-37 years, 38-40 years, 41-42 years, and ≥ 43 years, CLBRs after the first and third cycles were 42.5% and 70.1%, 32.9% and 49.1%, 20.0% and 38.6%, 12.6% and 25.2%, and 4.4% and 8.8%, respectively. These rates had a significant relationship with age (P < 0.01). The LBR per oocyte for all ages was 9.6%.

CONCLUSION

Acceptable overall IVF success rates can be achieved in clomiphene citrate only mini-IVF, as well as acceptable LBR. The CLBRs and LBRs per oocyte are evidently influenced by women's age.

Recommendations for good practice in ultrasound: oocyte pick up†

STUDY QUESTION

What is good practice in ultrasound (US), and more specifically during the different stages of transvaginal oocyte retrieval, based on evidence in the literature and expert opinion on US practice in ART?

SUMMARY ANSWER

This document provides good practice recommendations covering technical aspects of US-guided transvaginal oocyte retrieval (oocyte pick up: OPU) formulated by a group of experts after considering the published data, and including the preparatory stage of OPU, the actual procedure and post-procedure care.

WHAT IS KNOWN ALREADY

US-guided transvaginal OPU is a widely performed procedure, but standards for best practice are not available.

STUDY DESIGN SIZE DURATION

A working group (WG) collaborated on writing recommendations on the practical aspects of transvaginal OPU. A literature search for evidence of the key aspects of the procedure was carried out. Selected papers (n = 190) relevant to the topic were analyzed by the WG.

PARTICIPANTS/MATERIALS SETTING METHODS

The WG members considered the following key points in the papers: whether US practice standards were explained; to what extent the OPU technique was described and whether complications or incidents and how to prevent such events were reported. In the end, only 108 papers could be used to support the recommendations in this document, which focused on transvaginal OPU. Laparoscopic OPU, transabdominal OPU and OPU for IVM were outside the scope of the study.

MAIN RESULTS AND THE ROLE OF CHANCE

There was a scarcity of studies on the actual procedural OPU technique. The document presents general recommendations for transvaginal OPU, and specific recommendations for its different stages, including prior to, during and after the procedure. Most evidence focussed on comparing different equipment (needles) and on complications and risks, including the risk of infection. For these topics, the recommendations were largely based on the results of the studies. Recommendations are provided on equipment and materials, possible risks and complications, audit and training. One of the major research gaps was training and competence. This paper has also outlined a list of research priorities (including clarification on the value or full blood count, antibiotic prophylaxis and flushing, and the need for training and proficiency).

LIMITATIONS REASONS FOR CAUTION

The recommendations of this paper were mostly based on clinical expertise, as at present, only a few clinical trials have focused on the oocyte retrieval techniques, and almost all available data are observational. In addition, studies focusing on OPU were heterogeneous with significant difference in techniques used, which made drafting conclusions and recommendations based on these studies even more challenging.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on the management of good laboratory practice in ART. Some useful troubleshooting/checklist recommendations are given for easy implementation in clinical practice. These recommendations aim to contribute to the standardization of a rather common procedure that is still performed with great heterogeneity.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the WG were funded by ESHRE. The other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NA.ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Use of Cumulative Live Birth Rate per Total Number of Embryos to Calculate the Success of IVF in Consecutive IVF Cycles in Women Aged ≥35 Years

Objective

The use of cumulative live birth rate (CLBR) per ovarian stimulation cycle is proving to be an accurate method to calculate the success of IVF; however, the cycle outcome is closely associated with the number of embryos transferred (ET). Our aim was to report CLBR after IVF according to the number of embryos required to achieve a live birth in women aged ≥35 years, considering age, body mass index (BMI), and ethnicity.

Methods

We conducted a retrospective cohort study including 1344 patients who underwent IVF between January 2013 and June 2016 at the First Affiliated Hospital of Xinjiang Medical University. The cumulative probability of live birth for each couple was estimated using the Kaplan–Meier method, and survival curves were compared according to age, BMI, and ethnicity using the log-rank test.

Results

CLBR increased rapidly from 1 to 5 ETs, moderately from 6 to 10 ETs, and slowly thereafter. CLBR was significantly different across 4 categories based on BMI as well as across those based on age; low CLBR was significantly associated with the age of ≥42 years and obesity.

Conclusion

The association between CLBR and number of ET provides realistic and precise information regarding the success of IVF and can be applied to guide clinicians and patients.

Modified natural cycle IVF versus conventional stimulation in advanced-age Bologna poor responders

RESEARCH QUESTION

Do ongoing pregnancy rates (OPR) differ between modified natural cycle IVF (MNC-IVF) and conventional high-dose ovarian stimulation (HDOS) in advanced-age Bologna poor responders?

DESIGN

This was a retrospective cohort study including patients with poor ovarian response (POR) attending a tertiary referral university hospital from 1 January 2011 to 1 March 2017. All women who fulfilled the Bologna criteria for POR and aged ≥40 years who underwent their first intracytoplasmic sperm injection (ICSI) cycle in the study centre were included.

RESULTS

In total, 476 advanced-age Bologna poor responder patients were included in the study: 189 in the MNC-IVF group and 287 in the HDOS group. OPR per patient were significantly lower in the MNC-IVF group (5/189, 2.6%) compared with the HDOS group (29/287, 10.1%) (P = 0.002). However, after adjustment for relevant confounders (number of oocytes and presence of at least one top-quality embryo), the multivariate logistic regression analysis showed that the type of treatment strategy (HDOS versus MNC-IVF) was not significantly associated with OPR (odds ratio 2.56, 95% confidence interval 0.9-7.6).

CONCLUSIONS

In advanced-age Bologna poor responders, MNC-IVF, which is a more patient-friendly approach, could be a reasonable alternative in this difficult-to-treat group of women.

Cumulative live birth rates in more than 3,000 patients with poor ovarian response: a 15-year survey of final in vitro fertilization outcome

OBJECTIVE

To estimate the cumulative live birth rates (CLBRs) in women with poor ovarian response (POR) diagnosed according to the Bologna criteria.

DESIGN

A 15-year population-based observational cohort study.

SETTING

Teaching hospital.

PATIENT(S)

Between 2002 and 2016 a total of 3,391 women with POR were followed from their first fresh, nondonor IVF cycle until they had a live birth or discontinued treatment. All IVF and intracytoplasmic sperm injection (ICSI) cycles and cryocycles were included.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth rates per initiated cycle, the conservative and optimistic CLBR for multiple IVF cycles.

RESULT(S)

The CLBRs after six IVF cycles were 14.9% for the conservative and 35.3% for the optimistic estimate. The CLBR decreased from 22% for women ≤30 years to 18.3% for women aged 31-34 years, 17.2% for 35-37 years, 13.5% for 38-40 years, 10.5% for 41-43 years, and 4.4% among women >43 years in the conservative analysis. There was a significant decreased CLBR starting at age 38 years compared with women <35 years. After adjusting for age, antral follicle count, basal FSH level, and IVF cycle number, natural cycles were associated with the lowest CLBR among all the protocols, and this difference was significant compared with the other protocols.

CONCLUSION(S)

For women with POR, the CLBR declined with increasing age. Women with advanced age (≥38 years) achieved a significantly lower CLBR than young poor responders (<35 years). Very low CLBR was associated with women aged >43 years old. Natural cycle IVF is of no benefit for these patients.

Decrease in preovulatory serum estradiol is a valuable marker for predicting premature ovulation in natural/unstimulated in vitro fertilization cycle

Background

Premature ovulation occurs at a high rate in natural-cycle in vitro fertilization (IVF), and cycle cancellation further hampers the overall efficiency of the procedure. While lower levels of estradiol (E2) are observed in preovulatory follicles, it is unclear whether declines in E2 can be used as an effective marker of premature ovulation.

Methods

This retrospective analysis includes 801 natural/unstimulated IVF/ICSI cycles undergoing scheduled ovum pick-up (OPU) and 153 natural/unstimulated IVF/ICSI cycles undergoing emergency OPU at a university IVF center from May 2014 to February 2017.

Results

Among the 801 IVF/ICSI cycles undergoing scheduled OPU, preovulatory E2 levels increased by more than 10% in 403 (50.31%) cycles of the sample (Group A), while 192 (23.97%) cycles experienced a plateau (increased or decreased by 10%; Group B), and 206 (25.72%) cycles decreased by more than 10% (Group C). Group C had more patients who experienced premature LH surges, premature ovulation, as well as the fewest oocytes retrieved, frozen embryos, and top-quality embryos. A multivariate logistic regression analysis indicated that premature ovulation was associated with preovulatory E2/−1E2 ratio and premature LH surge. Moreover, preovulatory E2/−1E2 ratio served as a valuable marker for differentiating premature ovulation, with an AUC (area under the receiver operating curve) of 0.708 and 0.772 in cycles with premature LH surges and cycles without premature LH surges, respectively. Emergency OPU resulted in a significantly decreased rate of premature ovulation and increased number of frozen embryos.

Conclusion

Decreases in preovulatory serum E2 was a valuable marker for premature ovulation in natural/unstimulated IVF cycle. Emergency OPU based on the preovulatory E2/−1E2 ratio decreased the rate of premature ovulation in cycles that experienced E2 decreases.

Electronic supplementary material

The online version of this article (10.1186/s13048-018-0469-x) contains supplementary material, which is available to authorized users.

Mild stimulation for in vitro fertilization

It has been proven that the use of high gonadotropin dose does not necessarily improve the final outcome of IVF. Mild ovarian stimulation is based on the principle of optimal utilization of competent oocytes/embryos and endometrial receptivity. There is growing evidence that the pregnancy or live birth rates with mild-stimulation protocols are comparable to those with conventional IVF; the cumulative pregnancy outcome has been shown to be no different, despite having fewer numbers of oocytes or embryos available with milder ovarian stimulation. Although equally effective, mild-stimulation IVF is associated with a greater safety profile, in terms of the incidence of ovarian hyperstimulation syndrome and venous thromboembolism. It is also found to be better tolerated by patients and less expensive. Emerging research evidence may lead to widespread acceptance of mild IVF, by both patients and IVF providers, and make IVF more accessible to women and couples worldwide.

Development of in vitro maturation techniques for clinical applications

In vitro maturation (IVM) refers to maturation in culture of immature oocytes at different stages that may or may not have been exposed to short courses of gonadotropins. The source of immature oocytes is an important feature for subsequent embryonic development, pregnancy, and healthy live births. IVM is an effective treatment that has already achieved significant outcomes of acceptable pregnancy and implantation rates and has led to the births of several thousand healthy babies. As the development of IVM treatment continues, an attractive possibility for improving the already successful outcome is to combine a natural-cycle in vitro fertilization (IVF) treatment with immature-oocyte retrieval followed by IVM of those immature oocytes. If the treatment processes can be simplified for immature-oocyte retrieval, different types of infertile women may be able to take advantage of these treatments. Mild-stimulation IVF combined with IVM treatment may represent a viable alternative to the standard treatment. Although IVM treatment is still considered to be experimental, it is now time to reconsider the IVM technology and its development. Mild-stimulation IVF combined with IVM may prove to be not just alternatives to standard treatments, but potentially first-line treatment choices.

Potential role of polyunsaturated fatty acids, with particular regard to the signaling pathways of arachidonic acid and its derivatives in the process of maturation of the oocytes: Contemporary review

Oocyte meiotic maturation is one of the significant physiological requirements for ovulation and fertility. It is believed that Cyclic Adenosine Monophosphate, protein kinase A and protein kinase C pathways along with eicosanoids, particularly prostaglandin E_2, and steroids are the key factors regulating mammalian oocyte maturation. The aim of the current study was to highlight the molecular events triggered by arachidonic acid during oocyte meiotic arrest and resumption at the time of gonadotrophin surge. It should be noted that arachidonic acid release is tightly regulated by Follicle-stimulating and Luteinizing hormones during oocyte development.

The cumulative dose of gonadotropins used for controlled ovarian stimulation does not influence the odds of embryonic aneuploidy in patients with normal ovarian response

OBJECTIVE

Controlled ovarian hyperstimulation (COH) promotes multifollicular growth, increasing the chance of obtaining euploid embryos that will successfully implant. Whether aneuploidy is increased from COH with exogenous gonadotropins interfering with natural selection of dominant follicles is a concern. This study evaluates the association between gonadotropin exposure and aneuploidy.

METHODS

This is a retrospective cohort study of 828 patients that underwent 1122 IVF cycles involving controlled ovarian stimulation and trophectoderm biopsy for preimplantation genetic screening (PGS), from 2010 to 2015. Polymerase chain reaction (PCR) was used to assess aneuploidy. Kruskal-Wallis tests and logistic regression with generalized estimating equations (GEEs) were used for data analysis.

RESULTS

Overall, after controlling for patient age, ovarian reserve, stimulation protocol, days of stimulation, and diagnoses, there was no significant association between cumulative gonadotropin (GND) dose and the odds of aneuploidy (adjusted OR = 1.049, p = 0.232). Similarly, in cycles where patients did not require COH beyond cycle day 12, there was no significant association between cumulative gonadotropin dose and the odds of aneuploidy (adjusted OR = 0.909, p = 0.148). However, in cases where patients were stimulated past cycle day 12, there was a significant increase in the odds of aneuploidy (adjusted OR = 1.20, 95% CI 1.125-1.282, p < 0.0001) with increasing cumulative gonadotropin dose, with a small effect size (Cohen's d = 0.10, 95% CI 0.08-0.12). In this cohort, there was a 16.4% increase in the odds of aneuploidy for each 1000-u increase in cumulative GND exposure (adjusted OR = 1.164, p = 0.002). When the analysis was restricted to low responders (peak estradiol <500 pg/mL or <4 mature follicles achieved; there was no significant association between gonadotropin dose and aneuploidy (adjusted OR = 1.12, 95% CI 0.982-1.28, p = 0.09), regardless of the duration of COH required to reach vaginal oocyte retrieval.

CONCLUSION

The degree of exposure to exogenous gonadotropins did not significantly modify the likelihood of aneuploidy in patients with a normal ovarian response to stimulation (not requiring COH beyond cycle day 12). Patients requiring prolonged COH were demonstrated to have elevated odds of aneuploidy with increasing cumulative gonadotropin dose. This finding may reflect an increased tendency towards oocyte and embryonic aneuploidy in patients with a diminished response to gonadotropin stimulation.

Does the use of gonadotropin-releasing hormone antagonists in natural IVF cycles for poor responder patients cause more harm than benefit?

Poor ovarian response to controlled ovarian stimulation (COS) is one of the most critical factors that substantially limits the success of assisted reproduction techniques (ARTs). Natural and modified natural cycle IVF are two options that could be considered as a last resort. Blocking gonadotropin-releasing hormone (GnRH) actions in the endometrium via GnRH receptor antagonism may have a negative impact on endometrial receptivity. We analysed IVF outcomes in 142 natural (n = 30) or modified natural (n = 112) IVF cycles performed in 82 women retrospectively. A significantly lower proportion of natural cycles reached follicular aspiration compared to modified natural cycles (56.7% vs. 85.7%, p < 0.001). However, the difference between the numbers of IVF cycles ending in embryo transfer (26.7% vs. 44.6%) was not statistically significant between natural cycle and modified natural IVF cycles. Clinical pregnancy (6.7% vs. 7.1%) and live birth rates per initiated cycle (6.7% vs. 5.4%) were similar between the two groups. Notably, the implantation rate was slightly lower in modified natural cycles (16% vs. 25%, p > 0.05). There was a trend towards higher clinical pregnancy (25% vs. 16%) and live birth (25% vs. 12%) rates per embryo transfer in natural cycles compared to modified natural cycles, but the differences did not reach statistical significance.

Scientific evidence shows the need for a fresh approach to IVF

Professor Dr Geeta Nargund is a pioneer in the field of Natural and Mild IVF and Advanced Ultrasound Technology in Reproductive Medicine, and founder and Medical Director of CREATE Fertility Natural and Mild IVF clinics. She is also an accredited trainer for special skills modules of the Royal College of Obstetricians & Gynaecologists London and the British Fertility Society. She pioneered the use of follicular Doppler in assessing ‘egg quality’ in humans. She also published the first scientific paper on ‘Cumulative live birth rates with natural cycle IVF’. As President of the International Society for Mild Approaches in Assisted Reproduction she has been the voice for women's choice, health and education in the field of Assisted Reproductive Technology globally. She promotes safer, less-drug-orientated and accessible ART. She is actively involved in research in making IVF more natural, accessible and safer for women and children. She is the Chief Executive of the UK National charity, Create Health Foundation. This Charity funds and supports women's health education in the UK and in Africa.

Ovarian stimulation for IVF: mild approaches

In contrast to current approaches, the aim of mild stimulation is to develop safer and more patient-friendly protocols in which the risks of the treatment as a whole are minimized. Mild stimulation is defined as the method when exogenous gonadotropins are administered at lower doses, and/or for a shorter duration in GnRH antagonist co-treated cycles, or when oral compounds (antiestrogens, aromatase inhibitors) are used for ovarian stimulation for IVF, with the aim of limiting the number of oocytes obtained to fewer than eight. In this chapter we discuss the relevant physiology of follicle development, the development of milder stimulation protocols, the implications of mild stimulation, the current state of affairs, and future developments.

Low-cost in vitro fertilization: current insights

Despite the development of in vitro fertilization (IVF) more than 30 years ago, the cost of treatment remains high. Furthermore, over the years, more sophisticated technologies and expensive medications have been introduced, making IVF increasingly inaccessible despite the increasing need. Globally, the option to undergo IVF is only available to a privileged few. In recent years, there has been growing interest in exploring strategies to reduce the cost of IVF treatment, which would allow the service to be provided in low-resource settings. In this review, we explore the various ways in which the cost of this treatment can be reduced.

Failure of intrauterine insemination as rescue treatment in low responders with adequate HCG timing with no oocytes retrieved

In this retrospective study, the efficiency of carrying out rescue intrauterine insemination (IUI) in low-responder patients undergoing IVF when no oocytes were retrieved after follicular aspiration and when HCG timing was adequate was analysed. A historical control group was used. Over 13 years, women undergoing IVF with failure to obtain oocytes at follicular aspiration underwent rescue IUI if the following criteria were met: adequate HCG timing; one normal tube; motile sperm count after preparation over 3 million/ml; and ultrasound visualization of one to six follicles over 13 mm. The rescue IUI was carried out 1 h after follicular aspiration. Results were compared with those of a standard IUI population (5394 cycles) in the same period. Confidence intervals were calculated using Poisson 97.5% confidence upper tail limits when no event was observed in the study sample. No pregnancies were achieved among the 54 cases who underwent rescue IUI (confidence interval: 0 to 6.8%). This pregnancy rate was lower than that observed in the general IUI population (17.5%) (relative risk, 19.2). After adjusting for age and endometriosis, the relative risk was 11.7. The rescue IUI is an inefficient procedure. Its efficacy is unlikely to exceed 7% pregnancy rate per IUI.

In vitro maturation: Clinical applications

Oocyte in vitro maturation (IVM) is an assisted reproductive technology in which oocytes are retrieved from the antral follicles of unstimulated or minimally stimulated ovaries. IVM of human oocytes has emerged as a promising procedure. This new technology has advantages over controlled ovarian stimulation such as reduction of costs, simplicity, and elimination of ovarian hyperstimulation syndrome. By elimination or reduction of gonadotropin stimulation, IVM offers eligible infertile couples a safe and convenient form of treatment, and IVM outcomes are currently comparable in safety and efficacy to those of conventional in vitro fertilization. IVM has been applied mainly in patients with polycystic ovary syndrome or ultrasound-only polycystic ovaries, but with time, the indications for IVM have expanded to other uncommon situations such as fertility preservation, as well as to normal responders. In this review, the current clinical experiences with IVM will be described.

Natural cycle IVF: evaluation of 463 cycles and summary of the current literature

PURPOSE

Natural cycle (NC) IVF/ICSI has proven to be an alternative to conventional IVF/ICSI cycles.

METHODS

Within our retrospective, observational study (n = 159) infertile couples underwent (n = 463) cycles of NC-IVF/ICSI from May 2007 until December 2011. Oocyte pick-up was performed within a pure natural cycle excluding any hormonal stimulation except of hCG for ovulation induction. Oocytes were fertilized by IVF/ICSI and embryo transfer took place 2 or 3 days later. In addition, the current literature was analysed concerning pregnancy rates in NC-IVF/ICSI cycles.

RESULTS

Oocyte pick-up was performed in n = 463 NC and was successful in n = 342 cases (IVF n = 135, ICSI n = 207). 203 oocytes were fertilized (IVF n = 87, ICSI n = 116, FR 59.4 %) and lead to 192 embryo transfers. Finally, 25 pregnancies were reached (PR 13.0 % per transfer) resulting in four biochemical pregnancies, 7 (33.3 %) miscarriages, one pregnancy of unknown outcome and 13 live births. Within the current literature (n = 27 studies), PR in NC-IVF/ICSI cycles varied between 10.2 and 50 %.

CONCLUSIONS

Within our study, pregnancy rates in pure NC-IVF/ICSI remained below 15 %. Although this may be linked to unfavourable preconditions like patients' age >40 years, low ovarian reserve or long duration of infertility, further improvement is necessary to increase pregnancy rates.

Differences in cumulus cells gene expression between modified natural and stimulated in vitro fertilization cycles

PURPOSE

The aim of our study was to determine whether there are any differences in the cumulus cell gene expression profile of mature oocytes derived from modified natural IVF and controlled ovarian hyperstimulation cycles and if these changes could help us understand why modified natural IVF has lower success rates.

METHODS

Cumulus cells surrounding mature oocytes that developed to morulae or blastocysts on day 5 after oocyte retrieval were submitted to microarray analysis. The obtained data were then validated using quantitative real-time PCR.

RESULTS

There were 66 differentially expressed genes between cumulus cells of modified natural IVF and controlled ovarian hyperstimulation cycles. Gene ontology analysis revealed the oxidation-reduction process, glutathione metabolic process, xenobiotic metabolic process and gene expression were significantly enriched biological processes in MNIVF cycles. Among differentially expressed genes we observed a large group of small nucleolar RNA's whose role in folliculogenesis has not yet been established.

CONCLUSION

The increased expression of genes involved in the oxidation-reduction process probably points to hypoxic conditions in modified natural IVF cycles. This finding opens up new perspectives for the establishment of the potential role that oxidation-reduction processes have in determining success rates of modified natural IVF.

Accumulation of oocytes from a few modified natural cycles to improve IVF results: a pilot study

PURPOSE

To evaluate the role of co-transfer of embryos derived from vitrified oocytes accumulated during the previous modified natural cycles and an embryo developed from the last one as an alternative to repetitive single embryo transfer ina fresh modified natural cycle.

METHODS

Thirty-six patients underwent ICSI procedure with three frozen natural oocytes supplemented by a fresh one obtained from the fourth modified natural cycle. Thirty-one controls received at least three consecutive single embryo transfer in a fresh modified natural cycle.

RESULTS

In the study group the oocyte retrieval, survival and total fertilization rate were 73.0 %, 78.1 %, and 64.5 %, respectively. Fifty-two embryos were transferred in 29 transfers. In the control group the oocyte retrieval and fertilization rate was 77.4 % and 83.7 %, respectively. Fifty single embryo transfers were performed. Of a total 14 pregnancies obtained in the study group 10 were defined as clinical and 4 as abortions. In the control group a total of 8 single clinical pregnancies and 2 miscarriages were encountered. The overall (20.0 % vs 48.2 %) and the clinical (16.0 % vs 34.4 %) pregnancy rate were significantly higher in the study group having cumulative embryo transfer following the oocyte accumulation.

CONCLUSIONS

These data demonstrate that the co-transfer of embryos derived from vitrified oocytes accumulated during the previous modified natural cycles and an embryo developed from the last fresh modified natural cycle assure an excellent clinical outcome with the overall and clinical pregnancy rate significantly higher compared to the repetitive single embryo transfer in a fresh modified natural cycle.

Natural cycle in vitro fertilisation (IVF) for subfertile couples

BACKGROUND

Subfertility affects 15% to 20% of couples trying to conceive. In vitro fertilisation (IVF) is one of the assisted reproduction techniques developed to improve chances of achieving pregnancy. In the standard IVF method with controlled ovarian hyperstimulation (COH), growth and development of multiple follicles are stimulated by using gonadotrophins, often combined with a gonadotrophin-releasing hormone (GnRH) agonist or antagonist. Although it is an established method of conception for subfertile couples, the treatment is expensive and has a high risk of adverse effects. Studies have shown that IVF in a natural cycle (NC) or a modified natural cycle (MNC) might be a promising low risk and low cost alternative to the standard stimulated IVF treatment since the available dominant follicle of each cycle is used. In this review, we included available randomised controlled studies comparing natural cycle IVF (NC and MNC) with standard IVF.

OBJECTIVES

To compare the efficacy and safety of natural cycle IVF (including both NC-IVF and MNC-IVF) with controlled ovarian hyperstimulation IVF (COH-IVF) in subfertile couples.

SEARCH METHODS

An extended search including of the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, conference abstracts in the Web of Knowledge, the World Health Organization International Trials Registry Platform search portal, LILACS database, PubMed and the OpenSIGLE database was conducted according to Cochrane guidelines. The last search was on 31st July 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing either natural cycle IVF or modified natural cycle IVF versus standard IVF in subfertile couples were included.

DATA COLLECTION AND ANALYSIS

Data selection and extraction and risk of bias assessment were carried out independently by two authors (TA and AC). The primary outcome measures were live birth rate and ovarian hyperstimulation syndrome (OHSS) rate per randomised woman. We calculated Mantel-Haenszel odds ratios for each dichotomous outcome and either the mean difference or the standardised mean difference (SMD) for continuous outcomes, with 95% confidence intervals (CIs). A fixed effect model was used unless there was substantial heterogeneity, in which case a random effects model was used.

MAIN RESULTS

Six randomised controlled trials with a total of 788 women were included. The largest of these trials included 396 women eligible for this review.No evidence of a statistically significant difference was found between natural cycle and standard IVF in live birth rates (OR 0.68, 95% CI 0.46 to 1.01, two studies, 425 women, I(2)= 0%, moderate quality evidence). The evidence suggests that for a woman with a 53% chance of live birth using standard IVF, the chance using natural cycle IVF would range from 34% to 53%. There was no evidence of a statistically significant difference between natural cycle and standard IVF in rates of OHSS (OR 0.19, 95% CI 0.01 to 4.06, one study, 60 women, very low quality evidence), clinical pregnancy (OR 0.52 95% CI 0.17 to 1.61, 4 studies, 351 women, I(2)=63%, low quality evidence), ongoing pregnancy (OR 0.72, 95% CI 0.50 to 1.05, three studies, 485 women, I(2)=0%, moderate quality evidence), multiple pregnancy (OR 0.76, 95% CI 0.25 to 2.31, 2 studies, 527 women, I(2)=0%, very low quality evidence), gestational abnormalities (OR 0.44 95% CI 0.03 to 5.93, 1 study, 18 women, very low quality evidence) or cycle cancellations (OR 8.98, 95% CI 0.20 to 393.66, 2 studies, 159 women, I(2)=83%, very low quality evidence). One trial reported that the oocyte retrieval rate was significantly lower in the natural cycle group (MD -4.40, 95% CI -7.87 to -0.93, 60 women, very low quality evidence). There were insufficient data to draw any conclusions about rates of treatment cancellation. Findings on treatment costs were inconsistent and more data are awaited. The evidence was limited by imprecision. Findings for pregnancy rate and for cycle cancellation were sensitive to the choice of statistical model: for these outcomes, use of a fixed effect model suggested a benefit for the standard IVF group. Moreover the largest trial has not yet completed follow up, though data have been reported for over 95% of women.

AUTHORS' CONCLUSIONS

Further evidence from well conducted large trials is awaited on natural cycle IVF treatment. Future trials should compare natural cycle IVF with standard IVF. Outcomes should include cumulative live birth and pregnancy rates, the number of treatment cycles necessary to reach live birth, treatment costs and adverse effects.

The need for new methods of ovarian stimulation

It is easy to diagnose sterility but much harder to diagnose subfertility, because minor defects are not necessarily associated with consistent impairment of fertility. Correct evaluation of the background fertility can avoid needless treatment of couples. Ovarian stimulation is a powerful strategy frequently used to re-establish or improve fertility in infertile couples, but it is often the cause of twin pregnancy. The risks and costs of multiple gestation are important factors that must be taken into full account in the pro-fertility decision. To avoid twins, inseminations should preferably be done in unstimulated cycles or in association with induced mono-ovulatory cycles. For the same reason, it is probably time to follow the policy of favouring single embryo transfer in young women undergoing IVF and intracytoplasmic sperm injection programmes. In addition, there is an urgent need to avoid an invasive multiple transfer policy in women over 38 and to select new strategies to improve the well-known age-related lower implantation rate.

GnRH antagonists: do they open new pathways to safer treatment in assisted reproductive techniques?

GnRH antagonists (GnRHnt) induce a rapid decrease in LH and FSH, preventing and interrupting LH surges. Their properties do not require a desensitization period and allow their use in the late follicular phase. GnRHnt could replace GnRH agonists (GnRHa) in ovarian stimulation without their side-effects and their long period of desensitivity. Both protocols using GnRHnt were associated with a smaller amount of gonadotrophin, a shorter stimulation period and a lower incidence of ovarian hyperstimulation syndrome (OHSS) with statistically comparable pregnancy rates. There is room for improvement of both protocols concerning the programming, the antagonist dose and the timing of antagonist administration. Luteal support should be maintained until the results of further studies. The perinatal outcome appears to be similar to that of other stimulation regimens. Triggering of ovulation can be facilitated by GnRHa for patients at risk of OHSS. Provided that pregnancy rates equivalent to those obtained with GnRHa are confirmed in larger series, GnRHnt will clearly represent a safer alternative to GnRHa protocols in IVF.

Effectiveness of indometacin to prevent ovulation in modified natural-cycle IVF: a randomized controlled trial

Modified natural-cycle IVF has a lower pregnancy rate per started cycle as compared with IVF with ovarian stimulation due to, for example, premature ovulation. Indometacin administered before ovulation prevents follicle rupture. Therefore, addition of indometacin may improve the effectiveness of modified natural-cycle IVF. This double-blind, randomized, placebo-controlled trial with indometacin or placebo in 120 women aged 27-36 years compared the number of patients without premature ovulation as compared with the number of patients with one or more ovulations in a maximum of six cycles. Indometacin had no significant influence on the probability of a premature ovulation in patients during the six cycles (OR 2.38, 95% CI 0.94-6.04). A subgroup analysis showed a significant influence of indometacin in decreasing the probability of a premature ovulation in cycles without LH surge at the day of human chorionic gonadotrophin administration (OR 8.29, 95% CI 1.63-42.3, P=0.009). Although this study could not detect a significantly lower ovulation rate in the indometacin group versus the placebo group, the data suggest that a subgroup of patients without LH surge prior to oocyte retrieval might benefit from indometacin in modified natural-cycle IVF.

Empty follicle syndrome

Empty follicle syndrome (EFS) is a condition in which no oocytes are retrieved after an apparently adequate ovarian response to stimulation and meticulous follicular aspiration. EFS can be classified into 'genuine' and 'false' types according to hCG levels. It is a rare condition of obscure etiology. The existence of genuine EFS has been questioned and is still controversial. The limitation around EFS is that the definition of EFS is obscure. Management of patients with EFS is a challenge to physicians. No single treatment is known to be universally effective. However, patients should be adequately informed regarding the importance of correct hCG administration because improper hCG administration is a common and preventable cause of EFS. EFS is a syndrome that deserves additional study because such investigation could lead to a further understanding of ovarian biology and infertility.

Live birth rates following natural cycle IVF in women with poor ovarian response according to the Bologna criteria

STUDY QUESTION

What is the effect of natural cycle IVF in women with poor ovarian response according to the new ESHRE definition for poor ovarian responders: the Bologna criteria?

SUMMARY ANSWER

Although natural cycle IVF is a promising treatment option for normal responders, poor ovarian responders, as described by the Bologna criteria, have a very poor prognosis and do not appear to experience substantial benefits with natural cycle IVF.

WHAT IS KNOWN ALREADY

Previous trials have shown that natural cycle IVF is an effective treatment for the general infertile population and might be an option for poor ovarian responders. However, none of the trials have examined the effect of natural cycle IVF in poor responders according to the Bologna criteria, the newly introduced definition by the ESHRE Working Group on Poor Ovarian Response Definition. In this trial, we examined the effect of natural cycle IVF in poor ovarian responders fulfilling the Bologna criteria.

STUDY DESIGN, SIZE, DURATION

In this retrospective cohort trial, 164 consecutive patients, undergoing 469 natural cycle IVFs between 2008 and 2011 were included. Patients were stratified as poor and normal responders: 136 (390 cycles) were poor ovarian responders according to the Bologna criteria, whereas 28 women (79 treatment cycles) did not fulfil the criteria and were considered as normal responders.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients were monitored with hormonal analysis and ultrasound scan every second day, from Day 7 or 8 of the cycle onwards. When a follicle of >16 mm was observed, ovulation was triggered with 5000 IU of i.m. hCG and oocyte retrieval was performed 32 h later.

MAIN RESULTS AND THE ROLE OF CHANCE

Live birth rates in poor responders according to the Bologna criteria were significantly lower compared with the control group of women; the live birth rate per cycle was 2.6 versus 8.9%, P = 0.006 and the live birth rate per treated patient was 7.4 versus 25%, P = 0.005. In poor responders according to the Bologna criteria, live birth rates were consistently low and did not differ among different age groups (≤ 35 years, 36-39 years and ≥ 40 years), with a range from 6.8 to 7.9%.

LIMITATIONS, REASONS FOR CAUTION

A limitation of our analysis is its retrospective design; however, taking into account that we included only consecutive patients treated with exactly the same protocol, the likelihood of selection bias might be considerably limited. In addition, the control group in our study refers to women of younger age and therefore the promising results among patients who did not fulfil the Bologna criteria apply only to women of younger age.

WIDER IMPLICATIONS OF THE FINDINGS

Our trial suggests that although natural cycle IVF is a promising treatment option for younger normal responders, its potential is very limited to poor ovarian responders as described by the Bologna criteria, irrespective of patient's age. This highlights the very poor prognosis of these women and therefore the urgent need for future trials to examine the effect of ovarian stimulation protocols in women with poor ovarian response as described by the Bologna criteria.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was used. There are no competing interests to declare.

Gonadotropin therapy: a 20th century relic

Gonadotropin therapy has been a cornerstone of infertility therapy for half a century. From the very beginning, its use has been associated with a high rate of multiple births, particularly high order multiples, and ovarian hyperstimulation syndrome. Initially, success rates seemed acceptable when used for superovulation (SO)/IUI therapy. However, as data from RCTs have emerged, reported outcomes suggest that we question the use of injectible gonadotropins. This manuscript examines the studies that have challenged gonadotropin use for SO/IUI and other research that supports reduced doses of gonadotropins for IVF. We examine the challenges for its continued use for SO/IUI and for moving to lower doses worldwide for IVF. We propose a future that views gonadotropins as a relic of the twentieth century.

The prevalence of genuine empty follicle syndrome

OBJECTIVE

To describe the prevalence of "genuine" empty follicle syndrome (EFS) and "false" EFS at assisted reproductive technology (ART).

DESIGN

Retrospective cohort.

SETTING

Large private fertility center.

PATIENT(S)

A total of 12,359 patients who underwent ART between 2004 and 2009.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The failure to recover an oocyte during oocyte retrieval at ART, with and without a detectable serum β-hCG on the day of retrieval.

RESULT(S)

Two cases of genuine EFS and nine cases of false EFS were identified in the cohort examined. The prevalence of genuine EFS was 0.016%, and the prevalence of false EFS was 0.072%. Only two out of 11 cases of EFS were considered genuine.

CONCLUSION(S)

Genuine EFS is a rare occurrence. Because this syndrome tends to recur with dismal pregnancy rates at ART, continued identification and further investigation of the syndrome are needed.