Early pregnancy loss in patients with polycystic ovary syndrome after IVM versus standard ovarian stimulation for IVF/ICSI

In vitro maturation in subfertile women with polycystic ovarian syndrome undergoing assisted reproduction

BACKGROUND

Polycystic ovarian syndrome (PCOS) occurs in 8% to 13% of all women of reproductive age and 50% of women presenting with infertility (i.e. inability to reach a pregnancy after 12 months or more of regular unprotected sexual intercourse). A proportion of these women ultimately need assisted reproductive technology. In vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) are assisted reproduction techniques used to raise the chances of a pregnancy. In women with PCOS, the supra-physiological doses of gonadotrophins used for controlled ovarian hyperstimulation (COH) often result in an exaggerated ovarian response characterised by the development of a large cohort of follicles of uneven quality, retrieval of immature oocytes, and increased risk of ovarian hyperstimulation syndrome (OHSS). A potentially effective intervention for women with PCOS-related infertility involves earlier retrieval of immature oocytes at the germinal-vesicle stage followed by in vitro maturation (IVM). This is the third update of this Cochrane review on the subject (after the last update on 27 June 2018).

OBJECTIVES

To assess the benefits and harms of IVM followed by IVF or ICSI versus conventional IVF or ICSI among women with PCOS.

SEARCH METHODS

On 27 February 2023, we searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, and the Open Grey database. We further searched the National Institute for Health and Care Excellence (NICE) fertility assessment and treatment guidelines. We also searched reference lists of relevant papers and Google Scholar for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing IVM before IVF or ICSI with conventional IVF or ICSI for infertile women with PCOS, irrespective of language and country of origin.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, extracted data from studies, and, where needed, attempted to contact the authors for missing data. Our primary outcomes were live birth per woman randomised and miscarriage. We performed statistical analysis using Review Manager. We assessed the certainty of the evidence using GRADE and the risk of bias using the Cochrane RoB 2 tool.

MAIN RESULTS

We found four published trials suitable for inclusion in this update. The studies involved 810 subfertile women undergoing assisted reproductive technology. Two of four were already included in the previous version of the review, were published as abstracts in international conferences, and were at high risk of bias. The two new studies were at low risk of bias in all domains and in terms of all outcomes. We implemented the random-effects model for the quantitative analyses and restricted the primary analysis to studies at low risk of bias in all domains. We are very uncertain about the effect of IVM or capacitation IVM (a new biphasic IVM system improving the developmental competence of oocytes) on live birth when compared to IVF when a GnRH antagonist protocol was applied (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.17 to 1.32; I2 = 91%; 2 studies, 739 participants; very low-certainty evidence). This suggests that if the chance of live birth following standard IVF is assumed to be 45.7%, then the chance of IVM would be 12.5% to 52.6%. In contrast, IVM or capacitation IVM increases miscarriage per clinical pregnancy (where clinical pregnancy was defined as evidence of a fetal heart beat on ultrasound at seven gestational weeks) in women with PCOS when compared to IVF (OR 1.66, 95% CI 1.02 to 2.70; I2 = 0%; 2 studies, 378 clinical pregnancies; high-certainty evidence). This suggests that if the chance of miscarriage following standard IVF is assumed to be 20.1%, then the chance using IVM would be 20.4% to 40.4%. Results remained similar when using the risk ratio (RR) as the measure of effect. We are uncertain about the effect of IVM or capacitation IVM on clinical pregnancy when compared to IVF when a GnRH antagonist protocol was applied (OR 0.49, 95% CI 0.14 to 1.70; I2 = 94%; 2 studies, 739 participants; very low-certainty evidence). The results were similar after pooling the RRs. IVM or capacitation IVM results in a large reduction in the incidence of moderate or severe OHSS as compared to IVF when a GnRH antagonist protocol was applied (OR 0.08, 95% CI 0.01 to 0.67; I2 = 0%; 2 studies, 739 participants; high-certainty evidence). This suggests that if the incidence of OHSS following IVF is assumed to be 3.5%, then the incidence with IVM would be 0% to 2.4%. Also, there is probably little to no difference in preterm birth between IVM or capacitation IVM and IVF after the application of a GnRH antagonist protocol (OR 0.69, 95% CI 0.31 to 1.52; I² = 45%; 2 studies, 739 participants; moderate-certainty evidence). As for congenital anomalies, one study reported no events, while another showed an uncertain effect of IVM (OR 0.33, 95% CI 0.01 to 8.24; 1 study, 351 participants; low-certainty evidence). Results remained similar when using the RR as the measure of effect. There were no data from any of the studies for cycle cancellation, oocyte fertilisation, or subgroup analyses.

AUTHORS' CONCLUSIONS

There is continuous scientific interest in IVM, and promising data have been published. Concerning live birth and clinical pregnancy, we are very uncertain about the effect of the technique when compared to IVF after using a GnRH antagonist protocol. In contrast, high-certainty evidence shows that IVM increases miscarriage per clinical pregnancy and reduces the incidence of moderate or severe OHSS in women with PCOS compared to IVF after a GnRH antagonist protocol. Regarding the rest of the outcomes, low- to moderate-certainty evidence showed little to no difference in preterm birth and risk of congenital anomalies between the two modalities. We eagerly anticipate further evidence from high-quality trials in the field (we found five ongoing trials).

Clinical outcomes from ART in predicted hyperresponders: in vitro maturation of oocytes versus conventional ovarian stimulation for IVF/ICSI

STUDY QUESTION

Do ongoing pregnancy rates (OPRs) differ in predicted hyperresponders undergoing ART after IVM of oocytes compared with conventional ovarian stimulation (OS) for IVF/ICSI?

SUMMARY ANSWER

One cycle of IVM is non-inferior to one cycle of OS in women with serum anti-Müllerian hormone (AMH) levels ≥10 ng/ml.

WHAT IS KNOWN ALREADY

Women with high antral follicle count and elevated serum AMH levels, indicating an increased functional ovarian reserve, are prone to hyperresponse during ART treatment. To avoid iatrogenic complications of OS, IVM has been proposed as a mild-approach alternative treatment in predicted hyperresponders, including women with polycystic ovary syndrome (PCOS) who are eligible for ART. To date, inferior pregnancy rates from IVM compared to OS have hampered the uptake of IVM by ART clinics. However, it is unclear whether the efficiency gap between IVM and OS may differ depending on the extent of AMH elevation.

STUDY DESIGN, SIZE, DURATION

This study is a retrospective cohort analysis of clinical and laboratory data from the first completed highly purified hMG (HP-hMG) primed, non-hCG-triggered IVM or OS (FSH or HP-hMG stimulation in a GnRH antagonist protocol) cycle with ICSI in predicted hyperresponders ≤36 years of age at a tertiary referral university hospital. A total of 1707 cycles were included between January 2016 and June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Predicted hyperresponse was defined as a serum AMH level ≥3.25 ng/ml (Elecsys® AMH, Roche Diagnostics). The primary outcome was cumulative ongoing pregnancy rate assessed 10-11 weeks after embryo transfer (ET). The predefined non-inferiority limit was -10.0%. The analysis was adjusted for AMH strata. Time-to-pregnancy, defined as the number of ET cycles until ongoing pregnancy was achieved, was a secondary outcome. Statistical analysis was performed using a multivariable regression model controlling for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 463 IVM cycles were compared with those from 1244 OS cycles. Women in the IVM group more often had a diagnosis of Rotterdam PCOS (434/463, 93.7%) compared to those undergoing OS (522/1193, 43.8%), were significantly younger (29.5 years versus 30.5 years, P ≤ 0.001), had a higher BMI (25.7 kg/m2 versus 25.1 kg/m2, P ≤ 0.01) and higher AMH (11.6 ng/ml versus 5.3 ng/ml, P ≤ 0.001). Although IVM cycles yielded more cumulus-oocyte complexes (COCs) (24.5 versus 15.0 COC, P ≤ 0.001), both groups had similar numbers of mature oocytes (metaphase II (MII)) (11.9 MII versus 10.6 MII, P = 0.9). In the entire cohort, non-adjusted cumulative OPR from IVM was significantly lower (198/463, 42.8%) compared to OS (794/1244, 63.8%), P ≤ 0.001. When analysing OPR across different serum AMH strata, cumulative OPR in both groups converged with increasing serum AMH, and OPR from IVM was non-inferior compared to OS from serum AMH levels >10 ng/ml onwards (113/221, 51.1% (IVM); 29/48, 60.4% (OS)). The number of ETs needed to reach an ongoing pregnancy was comparable in both the IVM and the OS group (1.6 versus 1.5 ET's, P = 0.44). Multivariable regression analysis adjusting for ART type, age, BMI, oocyte number, and PCOS phenotype showed that the number of COCs was the only parameter associated with OPR in predicted hyperresponders with a serum AMH >10 ng/ml.

LIMITATIONS, REASONS FOR CAUTION

These data should be interpreted with caution as the retrospective nature of the study holds the possibility of unmeasured confounding factors.

WIDER IMPLICATIONS OF THE FINDINGS

Among subfertile women who are eligible for ART, IVM, and OS resulted in comparable reproductive outcomes in a subset of women with a serum AMH ≥10 ng/ml. These findings should be corroborated by a randomised controlled trial (RCT) comparing both treatments in selected patients with elevated AMH.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. P.D. has been consultant to Merck Healthcare KGaA (Darmstadt, Germany) from April 2021 till June 2023 and is a Merck employee (Medical Director, Global Medical Affairs Fertility) with Merck Healthcare KGAaA (Darmstadt, Germany) since July 2023. He declares honoraria for lecturing from Merck KGaA, MSD, Organon, and Ferring. The remaining authors declared no conflict of interest pertaining to this study.

TRIAL REGISTRATION NUMBER

N/A.

Poland Syndrome in a Pregnancy From an Assisted Reproductive Technology (ART) Cycle With In Vitro Maturation (IVM) and Rescue Intracytoplasmic Sperm Injection (ICSI)

Poland syndrome is a congenital anatomical anomaly, characterised by partial or total aplasia of one side of the body causing abnormalities affecting the chest, shoulder, and upper limb. The exact mechanism that leads to this syndrome is unknown, but an abnormality in the vasculature formation or interruption of the blood supply of the subscapular artery and its branches early in development may be the main cause. Depending on the underlying mechanism, the syndrome has several expressions with some hardly being detectable and others not even being compatible with life. Here, we present a case of pregnancy from an assisted reproductive technology (ART) cycle with in vitro maturation (IVM) and rescue intra cytoplasmic sperm injection (ICSI), which resulted in the in-utero death of the foetus. The subsequent necropsy revealed a variation of Poland syndrome.

Outcomes of clinical in vitro maturation programs for treating infertility in hyper responders: a systematic review

Oocyte in vitro maturation (IVM) has been proposed as an alternative to conventional ovarian stimulation (COS) in subfertile women with polycystic ovary syndrome. To evaluate the effectiveness and safety of IVM compared with COS in women with predicted hyperresponse to gonadotropins, we searched the published literature for relevant studies comparing any IVM protocol with any COS protocol followed by in vitro fertilization or intracytoplasmic sperm injection. A systematic review was undertaken on 3 eligible prospective studies. Live birth rate was not significantly lower after IVM vs. COS (odds ratio [95% confidence interval] of 0.56 [0.32-1.01] overall, 0.83 [0.63-1.10] for human chorionic gonadotropin (hCG)-triggered IVM [hCG-IVM] and 0.45 [0.18-1.13] for non-hCG-triggered IVM [non-hCG-IVM]), irrespective of the stage of transferred embryos. Data from nonrandomized studies generally showed either significantly low or statistically comparable rates of live birth with IVM vs. COS. Most studies have not identified any significant difference between IVM and COS with respect to the rates of obstetric or perinatal complications, apart from a potentially higher rate of hypertensive disorders during pregnancy. The development of offspring from IVM and COS with in vitro fertilization or intracytoplasmic sperm injection appears to be similar. Additional research is needed to identify which patient populations will benefit most from IVM, to define the appropriate clinical protocol, and to develop the optimal culture system.

Present state and future outlook for the application of in vitro oocyte maturation (IVM) in human infertility treatment

In vitro oocyte maturation (IVM) is an assisted reproductive technology in which a meiotically immature oocyte (prophase I or germinal vesicle stage) is recovered from an antral follicle and matured in vitro prior to fertilization. This technology, although in widespread use in domestic livestock, is not typically implemented during human IVF cycles. This review examines how IVM is currently used in the clinical setting, including the various ways IVM is defined in practice. The role of IVM in patient care, and the major challenges for implementation are described. Efficiency and safety are critically explored. The role of IVM in oncofertility will also be discussed. Finally, the outlook for the future of clinical IVM is considered.

The Mare: A Pertinent Model for Human Assisted Reproductive Technologies?

Although there are large differences between horses and humans for reproductive anatomy, follicular dynamics, mono-ovulation, and embryo development kinetics until the blastocyst stage are similar. In contrast to humans, however, horses are seasonal animals and do not have a menstrual cycle. Moreover, horse implantation takes place 30 days later than in humans. In terms of artificial reproduction techniques (ART), oocytes are generally matured in vitro in horses because ovarian stimulation remains inefficient. This allows the collection of oocytes without hormonal treatments. In humans, in vivo matured oocytes are collected after ovarian stimulation. Subsequently, only intra-cytoplasmic sperm injection (ICSI) is performed in horses to produce embryos, whereas both in vitro fertilization and ICSI are applied in humans. Embryos are transferred only as blastocysts in horses. In contrast, four cells to blastocyst stage embryos are transferred in humans. Embryo and oocyte cryopreservation has been mastered in humans, but not completely in horses. Finally, both species share infertility concerns due to ageing and obesity. Thus, reciprocal knowledge could be gained through the comparative study of ART and infertility treatments both in woman and mare, even though the horse could not be used as a single model for human ART.

Predictors of pregnancy after intrauterine insemination in women with polycystic ovary syndrome

Objective

To evaluate the effects of body mass index (BMI) in patients with polycystic ovary syndrome (PCOS) undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI).

Methods

This retrospective study evaluated couples with PCOS undergoing COS and IUI. The relationship between cumulative IUI pregnancy outcomes and BMI, treatment cycles, treatment schemes, number of dominant follicles, endometrial thickness, infertility duration and type of infertility was analysed.

Results

The study evaluated 831 IUI cycles in 451 couples with PCOS. Compared with normoweight women, overweight and obese women required more human menopausal gonadotropin (hMG) doses and more days of COS. Gestational diabetes mellitus occurred more frequently in the obese group than in the other BMI groups. The clinical pregnancy and live birth rates in the hMG, clomiphene citrate (CC) + hMG and letrozole (LE) + hMG groups were significantly higher than those in the CC and LE groups. The clinical pregnancy rate was higher in the secondary infertility group compared with the primary infertility group.

Conclusion

Obese women might require more hMG doses and more days of COS to overcome the effects of weight. As BMI increases, the incidence of gestational diabetes might also increase. The number of cycles and type of infertility may have a predictive value for pregnancy outcomes.