Cumulative pregnancy rates after three cycles of minimal stimulation IVF and results according to subfertility diagnosis: a multicentre cohort study

Effect of ovarian stimulation on developmental speed of preimplantation embryo in a mouse model

Ovarian stimulation protocols are widely used to collect oocytes in assisted reproductive technologies (ARTs). Although the influence of ovarian stimulation on embryo quality has been described, this issue remains controversial. Here, we analyzed the influence of ovarian stimulation on developmental speed and chromosome segregation using live cell imaging. Female mice at the proestrus stage were separated by the appearance of the vagina as the non-stimulation (-) group, and other mice were administered pregnant mare serum gonadotropin (PMSG) and human chorionic gonadotropin (hCG) as the stimulation (+) groups. The cumulus-oocyte complexes from both groups were inseminated with sperm suspensions from the same male mice. Fertilization rates and developmental capacities were examined, and the developmental speed and frequency of chromosome segregation errors were measured by live-cell imaging using a Histone H2B-mCherry probe. The number of fertilized oocytes obtained was 1.4-fold more frequent in the stimulation (+) group. The developmental rate and chromosome stability did not differ between the groups. Image analysis showed that the mean speed of development in the stimulation (+) group was slightly higher than that in the non-stimulation (-) group. This increase in speed seemed to arise from the slight shortening of the 2- and 4-cell stages and third division lengths and consequent synchronization of cleavage timing in each embryo, not from the emergence of an extremely rapidly developing subpopulation of embryos. In conclusion, ovarian stimulation does not necessarily affect embryo quality but rather increases the chances of obtaining high-quality oocytes in mice.

Effects of controlled ovarian stimulation regimens on top-quality blastocyst development and perinatal outcomes with the freeze-all strategy: A retrospective comparative study

OBJECTIVE

This study aimed to determine the effect of ovarian stimulation regimens on the top-quality blastocyst development rate and perinatal outcomes with the freeze-all strategy.

METHODS

A retrospective comparative cohort analysis of 149 in vitro fertilization (IVF) cycles using the freeze-all strategy was conducted. The IVF cycles were stimulated with either a gonadotropin-releasing hormone antagonist or clomiphene citrate along with gonadotropin based on the patient's serum anti-Müllerian hormone level. Oocyte retrieval, fertilization, and embryo culture were performed following standard procedures. All good-quality blastocysts were cryopreserved and used for frozen-thawed embryo transfer (FET) in subsequent cycles. The fertilization, blastulation, and top-quality blastocyst development rates were calculated. The perinatal outcomes of FET cycles, gestational period, and birth weight were assessed.

RESULTS

The main outcome of this study was the top-quality blastocyst development rate, and the secondary outcomes were perinatal parameters (e.g., gestational period and birth weight) between the stimulation regimens. Despite the higher number of usable-quality embryos in the antagonist group, the blastocyst development rate remained comparable (p=0.105). Similarly, perinatal outcomes were comparable in subsequent FET cycles (p=0.538).

CONCLUSION

These findings suggest that the choice between antagonist and clomiphene citrate with gonadotropin as stimulation in controlled ovarian stimulation regimens may not affect the top-quality blastocyst development rate. The IVF outcomes (e.g., clinical pregnancy, miscarriage, and live birth rates) remained unaffected in subsequent FET cycles. Unlike fresh embryo transfer, the birth weight and gestational length were not associated with prior controlled ovarian stimulation regimens when the freeze-all strategy was used.

Minimal Stimulation Using Gonadotropin-Releasing Hormone Antagonist is Associated with Higher Live Birth Rates: A National Study of 13,050 Cycles

BACKGROUND

The optimal protocol for minimal stimulation in vitro fertilization (IVF) has yet to be established. This study aims to determine if the use of gonadotropin-releasing hormone (GnRH) antagonist during minimal stimulation improves outcomes.

MATERIALS AND METHODS

All cycles designated as minimal stimulation from 2014 to 2016 from the Society for Assisted Reproductive Technology Clinic Online Reporting System were identified. Cycles in which GnRH antagonist was administered (n = 5984) were compared to those that did not receive it (n = 7066). Wilcoxon's rank-sum test and chi-square test were used to analyze continuous and categorical variables.

RESULTS

A total of 6750 patients undergoing 13,050 cycles were included. GnRH antagonist use was associated with a significantly higher total gonadotropin dosage (median 975.0 [interquartile range, IQR, 600.0, 1575.0] vs. median 660.0 [IQR 375.0, 975.0], p < 0.001), lower cycle cancelation rate (11.3% vs. 13.6%, p < 0.001; OR 1.24, 95% CI 1.12-1.38, p < 0.001), and higher live birth rate (4.3% vs. 2.1%, p < 0.001; OR 0.47, 95% CI 0.39-0.58, p < 0.001). GnRH antagonist use was associated with a significantly higher live birth rate in women ≥35 years of age (2.7% vs. 0.9%, p < 0.001; OR 0.34, 95% CI 0.25-0.47, p < 0.001) and antimullerian hormone <1 (4.9% vs. 2.6%, p = 0.004; OR 0.52, 95% CI 0.33-0.81, p = 0.004).

CONCLUSION

The use of GnRH antagonist suppression during minimal stimulation IVF is associated with an improved live birth rate, especially in older women and in women with diminished ovarian reserve. Although GnRH antagonist use may increase costs, it significantly decreases cancelation rate, increases number of embryos cryopreserved, and should be encouraged for minimal stimulation IVF.

Determining the optimal follicle size at trigger in patients undergoing ovarian stimulation with a clomiphene citrate plus gonadotropin and GnRH antagonist protocol for in vitro fertilization

OBJECTIVE

Determine the optimal follicle size at trigger in clomiphene citrate-based IVF protocols.

STUDY DESIGN

This is a retrospective cohort study performed in at a single academic institution that included first IVF cycles with clomiphene citrate-based protocols at our center between 01/01/2013-03/31/2019. Patients were dichotomized by whether they had ≥2 follicles >20 mm on trigger day. Group A consisted of patients with <2 follicles >20 mm on trigger day and Group B consisted of patients with ≥2 follicles >20 mm on trigger day. The primary outcome was the number of mature oocytes retrieved. Secondary outcomes included pregnancy and live birth rates.

RESULTS

A total of 635 patients were included: (Group A = 399 patients and Group B = 236 patients). The median (IQR) diameter of the largest follicle was 20.0 mm (19.0-21.0) in Group A and 22.7 mm (21.8-24.0) in Group B (p < 0.001). Among the entire cohort, mean number of oocytes retrieved was significantly higher in Group B (9.9 ± 6.5; RR 1.08 (95% CI 1.03-1.14)) compared to Group A (9.2 ± 6.3). In a subgroup analysis of patients in the upper quartile for age (≥41.7 years), Group B had significantly more oocytes retrieved (8.1 ± 5.9 vs. 6.7 ± 4.5; RR 1.23 (95% CI 1.10-1.38)), more mature oocytes retrieved (6.0 ± 4.0 vs. 5.2 ± 3.4; RR 1.16 (95% CI 1.02-1.33)), and more zygotes (4.7 ± 3.5 vs. 3.6 ± 2.8; RR 1.32 (95% CI 1.13-1.55)). In the secondary analysis, pregnancy and live birth rates after fresh transfer were similar between groups.

CONCLUSIONS

In clomiphene citrate-based IVF protocols, administering the ovulatory trigger at larger follicle sizes yielded more total oocytes retrieved without a significant difference in mature oocyte number. In older patients, larger follicle sizes at trigger yielded more mature oocytes and zygotes per retrieval. Based on these results, in older patients it may be advantageous to administer the ovulatory trigger in clomiphene-based IVF cycles when two or more follicles measures >20 mm. However, this benefit was not observed when assessed among all ages combined.

The myths surrounding mild stimulation in vitro fertilization (IVF)

So-called mild controlled ovarian hyperstimulation (mCOH) has in recent years increased in popularity, claiming to be safer and more patient-friendly, while also improving in vitro fertilization (IVF) outcomes. We here challenge the International Society for Mild Approaches in Assisted Reproduction (ISMAAR) definition of mild stimulation, and especially address four fundamental issues, where our review found conventional COH (cCOH) advantageous over mCOH. They are: prevalence of severe ovarian hyperstimulation syndrome (OHSS), oocyte/embryo quality, pregnancy/live birth rates, and cost. We conclude that an objective review of the literature does not support the routine utilization of mCOH in assisted reproduction.

Outcomes of 1503 cycles of modified natural cycle in vitro fertilization: a single-institution experience

PURPOSE

A retrospective cohort study was conducted in a single academic center to determine if modified natural cycle in vitro fertilization (mnIVF) is an acceptable treatment for the infertile couple.

METHODS

Cycles performed between July 2005 and December 2011 were included. In our center's mnIVF protocol, a GnRH antagonist, gonadotrophin, as well as Indocid are given on a daily basis from detection of a dominant follicle until ovulation induction. The primary outcomes were clinical pregnancy rates (CPR) per cycle started and per embryo transfer (ET). Outcomes were stratified by female patient age (≤35 years and ≥36 years). They were further stratified in each age group by ovarian response status according to the 2011 Bologna criteria.

RESULTS

A total of 1503 cycles of mnIVF, performed in 782 patients, were analyzed. CPRs were 13.7 % per started cycle and 32.5 % per ET. Stratification by ovarian response status (normal or poor) in each age group showed similar CPRs in patients ≤35 years (p = 0.373), and divergent CPRs per ET in patients ≥36 years old (26.26 vs 6.25 %).

CONCLUSION

MnIVF is an acceptable treatment option for patients considering IVF, particularly for women ≤35 years old and for women ≥36 years old with normal ovarian response.

Presence of bile acids in human follicular fluid and their relation with embryo development in modified natural cycle IVF

STUDY QUESTION

Are bile acids (BA) and their respective subspecies present in human follicular fluid (FF) and do they relate to embryo quality in modified natural cycle IVF (MNC-IVF)?

SUMMARY ANSWER

BA concentrations are 2-fold higher in follicular fluid than in serum and ursodeoxycholic acid (UDCA) derivatives were associated with development of top quality embryos on Day 3 after fertilization.

WHAT IS KNOWN ALREADY

Granulosa cells are capable of synthesizing BA, but a potential correlation with oocyte and embryo quality as well as information on the presence and role of BA subspecies in follicular fluid have yet to be investigated.

STUDY DESIGN, SIZE, DURATION

Between January 2001 and June 2004, follicular fluid and serum samples were collected from 303 patients treated in a single academic centre that was involved in a multicentre cohort study on the effectiveness of MNC-IVF.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Material from patients who underwent a first cycle of MNC-IVF was used. Serum was not stored from all patients, and the available material comprised 156 follicular fluid and 116 matching serum samples. Total BA and BA subspecies were measured in follicular fluid and in matching serum by enzymatic fluorimetric assay and liquid chromatography-mass spectrometry, respectively. The association of BA in follicular fluid with oocyte and embryo quality parameters, such as fertilization rate and cell number, presence of multinucleated blastomeres and percentage of fragmentation on Day 3, was analysed.

MAIN RESULTS AND THE ROLE OF CHANCE

Embryos with eight cells on Day 3 after oocyte retrieval were more likely to originate from follicles with a higher level of UDCA derivatives than those with fewer than eight cells (P < 0.05). Furthermore, follicular fluid levels of chenodeoxycholic derivatives were higher and deoxycholic derivatives were lower in the group of embryos with fragmentation compared with those without (each P < 0.05). Levels of total BA were 2-fold higher in follicular fluid compared with serum (P < 0.001), but had no predictive value for oocyte and embryo quality.

LIMITATIONS, REASONS FOR CAUTION

Only samples originating from first cycle MNC-IVF were used, which resulted in 14 samples only from women with an ongoing pregnancy, therefore further prospective studies are required to confirm the association of UDCA with IVF pregnancy outcomes. The inter-cycle variability of BA levels in follicular fluid within individuals has yet to be investigated. We checked for macroscopic signs of contamination of follicular fluid by blood but the possibility that small traces of blood were present within the follicular fluid remains. Finally, although BA are considered stable when stored at -20°C, there was a time lag of 10 years between the collection and analysis of follicular fluid and serum samples.

WIDER IMPLICATIONS OF THE FINDINGS

The favourable relation between UDCA derivatives in follicular fluid and good embryo development and quality deserves further prospective research, with live birth rates as the end-point.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by a grant from the Netherlands Organisation for Scientific Research (VIDI Grant 917-56-358 to U.J.F.T.). No competing interests are reported.

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.

Comparison of results of cycles treated with modified mild protocol and short protocol for ovarian stimulation

The ovarian stimulation has been applied in order to increase the number of oocytes to compensate for the poor results of in vitro fertilization, allowing the selection of one or more embryos to be transferred. Our aim is to compare the results obtained in IVF/ICSI cycles using the short protocol for controlled ovarian stimulation to the results from the modified mild protocol used in our department. A total of 240 cycles were conducted from January 2010 to December 2011. When comparing both protocols, it could be observed that there was a significant difference in the quantity of gonadotropins doses in the mild protocol and in the short protocol. No significant difference was observed regarding pregnancy rates per cycle, 22% and 26.2%, in short and mild protocols, respectively. The protocols of controlled ovarian stimulation are often associated with high risk of complications such as ovarian hyperstimulation syndrome, excessive emotional stress, high rates of treatment dropouts, and abdominal discomfort. With the data obtained in this study, one can conclude that there are less risks and complications for the patient when using the mild stimulation protocol. It was also observed that in this group there was a slightly higher rate.

Ultrasound for monitoring controlled ovarian stimulation: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of monitoring controlled ovarian stimulation (COS) using ultrasonography.

METHODS

We performed a search in April 2013 for randomized controlled trials (RCTs). Studies that compared different methods for monitoring COS, including ultrasound assessment of follicles (alone or combined with hormonal assessment), in at least one group were considered eligible.

RESULTS

The search retrieved 1515 records, six of which were eligible. Five studies were included that compared ultrasonography alone with ultrasonography and hormonal assessment (estradiol and/or progesterone) and one study compared 2D and 3D ultrasound monitoring. None of the included studies reported on live birth. Four of the five studies reported on clinical pregnancy (RR, 0.95; 95% CI, 0.78–1.16; n = 611); the confidence interval (CI) was somewhat wide, but allowed us to conclude that ultrasonography alone differs little from ultrasonography combined with hormonal assessment. Three studies reported on the number of oocytes retrieved (mean difference (MD), 0.8 oocytes; 95% CI, –0.4 to 2.0; n = 474); the CI was somewhat wide and did not permit us to conclude whether ultrasonography alone is better than or similar to ultrasonography and hormonal assessment for this outcome. All five studies reported on ovarian hyperstimulation syndrome (OR, 1.02; 95% CI, 0.47–2.25; n = 725) and only one study reported on miscarriage (RR, 0.37; 95% CI, 0.07–1.79; n = 45); for these two outcomes, the CI was very wide and did not permit us to conclude whether ultrasonography alone is better, similar or less effective than ultrasonography combined with hormonal assessment. For the study comparing 2D and 3D ultrasound, the reported outcomes were clinical pregnancy (RR, 1.00; 95% CI, 0.58–1.73, n = 72) and the number of oocytes retrieved (MD, –0.4 oocytes; 95% CI, –3.6 to 2.9; n = 72); for both, the CI was very wide and did not permit us to conclude whether use of 3D ultrasound is better, similar or less effective than use of 2D ultrasound.

CONCLUSIONS

Current evidence suggests that monitoring COS only with ultrasonography is unlikely to substantially alter the chances of achieving a clinical pregnancy and the number of oocytes retrieved is similar to that when monitoring with ultrasonography and hormonal assessment. For the other outcomes and comparisons, the available data are inconclusive. We believe that more studies evaluating the optimal procedure for monitoring COS are needed.

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.

IVF with planned single-embryo transfer versus IUI with ovarian stimulation in couples with unexplained subfertility: an economic analysis

Couples with unexplained subfertility are often treated with intrauterine insemination (IUI) with ovarian stimulation, which carries the risk of multiple pregnancies. An explorative randomized controlled trial was performed comparing one cycle of IVF with elective single-embryo transfer (eSET) versus three cycles of IUI-ovarian stimulation in couples with unexplained subfertility and a poor prognosis for natural conception, to assess the economic burden of the treatment modalities. The main outcome measures were ongoing pregnancy rates and costs. This study randomly assigned 58 couples to IVF-eSET and 58 couples to IUI-ovarian stimulation. The ongoing pregnancy rates were 24% in with IVF-eSET versus 21% with IUI-ovarian stimulation, with two and three multiple pregnancies, respectively. The mean cost per included couple was significantly different: €2781 with IVF-eSET and €1876 with IUI-ovarian stimulation (P<0.01). The additional costs per ongoing pregnancy were €2456 for IVF-eSET. In couples with unexplained subfertility, one cycle of IVF-eSET cost an additional €900 per couple compared with three cycles of IUI-ovarian stimulation, for no increase in ongoing pregnancy rates or decrease in multiple pregnancies. When IVF-eSET results in higher ongoing pregnancy rates, IVF would be the preferred treatment. Couples that have been trying to conceive unsuccessfully are often treated with intrauterine insemination (IUI) and medication to improve egg production (ovarian stimulation). This treatment carries the risk of multiple pregnancies like twins. We performed an explorative study among those couples that had a poor prognosis for natural conception. One cycle of IVF with transfer of one selected embryo (elective single-embryo transfer, eSET) was compared with three cycles of IUI-ovarian stimulation. The aim of this study was to assess the economic burden of both treatments. The Main outcome measures were number of good pregnancies above 12weeks and costs. We randomly assigned 58 couples to IVF-eSET and 58 couples to IUI-ovarian stimulation. The ongoing pregnancy rates were comparable: 24% with IVF-eSET versus 21% with IUI-ovarian stimulation. There were two multiple pregnancies with IVF-eSET and three multiple pregnancies with IUI-ovarian stimulation. The mean cost per included couple was significantly different, €2781 with IVF-eSET and €1876 with IUI-ovarian stimulation. The additional costs per ongoing pregnancy were €2456 for IVF-eSET. In couples with unexplained subfertility, one cycle of IVF-eSET costed an additional €900 per couple compared to three cycles of IUI-ovarian stimulation, for no increase in ongoing pregnancy rates or decrease in multiple pregnancies. We conclude that IUI-ovarian stimulation is the preferred treatment to start with. When IVF-eSET results in a higher ongoing pregnancy rate (>38%), IVF would be the preferred treatment.

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.

Clinical impact of LH rises prior to and during ganirelix treatment started on day 5 or on day 6 of ovarian stimulation

BACKGROUND

We sought to evaluate the incidence and clinical impact of luteinizing hormone (LH) rises prior to and during gonadotropin-releasing hormone (GnRH) antagonist treatment started on day 5 or 6 of ovarian stimulation with recombinant follicle-stimulating hormone (rFSH).

METHODS

Pooled data from three trials with the GnRH antagonist ganirelix started on day 5 (n = 961) and from five trials with ganirelix started on day 6 (n = 1135) of ovarian stimulation with rFSH were retrospectively analyzed.

RESULTS

The incidence of LH rises (LH ≥ 10.0 IU/L) prior to ganirelix treatment was 2.3% and 6.6% on ganirelix start days 5 and 6, respectively (P < 0.01). During ganirelix treatment this incidence was 1.2% and 2.3%, respectively (P = 0.06). Women with LH rise on day 5 or 6 had a higher ovarian response with more oocytes recovered, mean ± SD, 12.9 ± 8.5 versus no LH rise, 10.2 ± 6.4 (P < 0.01). In women with and without LH rise prior to ganirelix treatment the ongoing pregnancy rates were similar (26.0% vs 29.9%; odds ratio [OR], 0.89; 95% confidence interval [CI], 0.55-1.44). Women with LH rise during ganirelix treatment had a lower ovarian response with 7.5 ± 6.7 oocytes recovered versus no LH rise, 10.2 ± 6.4 (P = 0.02) and a tendancy for a lower chance of ongoing pregnancy (16.7% vs 29.9%; OR, 0.52; 95% CI, 0.21-1.26).

CONCLUSIONS

The incidence of early and late LH rises was low but may be further reduced by initiating ganirelix on stimulation day 5 rather than on day 6. In contrast to women with an early LH rise, women with a late LH rise may have a reduced chance of ongoing pregnancy.

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.

FSH replaced by low-dose hCG in the late follicular phase versus continued FSH for assisted reproductive techniques

BACKGROUND

During controlled ovarian hyperstimulation (COH) follicle-stimulating hormone (FSH) is frequently used for several days to achieve follicular development. FSH is a relatively expensive drug, substantially contributing to the total expenses of assisted reproductive techniques (ART). When follicles achieve a diameter greater than 10 mm they start expressing luteinising hormone (LH) receptors. At this point, FSH might be replaced by low-dose human chorionic gonadotropin (hCG), which is less expensive. In addition to cost reduction, replacing FSH by low-dose hCG has a theoretical potential to reduce the incidence of ovarian hyperstimulation syndrome (OHSS).

OBJECTIVES

To evaluate the effectiveness and safety of using low-dose hCG to replace FSH during the late follicular phase in women undergoing COH for assisted reproduction, compared to the use of a conventional COH protocol.

SEARCH METHODS

We searched for randomised controlled trials (RCT) in electronic databases (Menstrual Disorders and Subfertility Group Specialized Register, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS), trials registers (ClinicalTrials.gov, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform), conference abstracts (ISI Web of knowledge), and grey literature (OpenGrey); additionally we handsearched the reference list of included studies and similar reviews. The last electronic search was performed in February 2013..

SELECTION CRITERIA

Only true RCTs comparing the replacement of FSH by low-dose hCG during late follicular phase of COH were considered eligible; quasi or pseudo-randomised trials were not included. Cross-over trials would be included only if data regarding the first treatment of each participant were available; trials that included the same participant more than once would be included only if each participant was always allocated to the same intervention and follow-up periods were the same in both/all arms, or if data regarding the first treatment of each participant were available. We excluded trials that sustained FSH after starting low-dose hCG and those that started FSH and low-dose hCG at the same time.

DATA COLLECTION AND ANALYSIS

Study eligibility, data extraction, and assessment of the risk of bias were performed independently by two review authors, and disagreements were solved by consulting a third review author. We corresponded with study investigators in order to solve any query, as required. The overall quality of the evidence was assessed in a GRADE summary of findings table.

MAIN RESULTS

The search retrieved 1585 records; from those five studies were eligible, including 351 women (intervention = 166; control = 185). All studies were judged to be at high risk of bias. All reported per-woman rather than per-cycle data.When use of low-dose hCG to replace FSH was compared with conventional COH for the outcome of live birth, confidence intervals were very wide and findings were compatible with appreciable benefit, no effect or appreciable harm for the intervention (RR 1.56, 95% CI 0.75 to 3.25, 2 studies, 130 women, I² = 0%, very-low-quality evidence). This suggests that for women with a 14% chance of achieving live birth using conventional COH, the chance of achieving live birth using low-dose hCG would be between 10% and 45%.Similarly confidence intervals were very wide for the outcome of OHSS and findings were compatible with benefit, no effect or harm for the intervention (OR 0.30, 95% CI 0.06 to 1.59, 5 studies, 351 women, I² = 59%, very-low-quality evidence). This suggests that for women with a 3% risk of OHSS using conventional COH, the risk using low-dose hCG would be between 0% and 4%.The confidence intervals were wide for the outcome of ongoing pregnancy and findings were compatible with benefit or no effect for the intervention (RR 1.14, 95% CI 0.81 to 1.60, 3 studies, 252 women, I² = 0%, low-quality evidence). This suggests that for women with a 32% chance of achieving ongoing pregnancy using conventional COH, the chance using low-dose hCG would be between 27% and 53%.The confidence intervals were wide for the outcome of clinical pregnancy and findings were compatible with benefit or no effect for the intervention (RR 1.19, 95% CI 0.92 to 1.55, 5 studies, 351 women, I² = 0%, low-quality evidence). This suggests that for women with a 35% chance of achieving clinical pregnancy using conventional COH, the chance using low-dose hCG would be between 32% and 54%.The confidence intervals were very wide for the outcome of miscarriage and findings were compatible with benefit, no effect or harm for the intervention (RR 1.08, 95% CI 0.50 to 2.31, 3 studies, 127 pregnant women, I² = 0%, very-low-quality evidence). This suggests that for pregnant women with a 16% risk of miscarriage using conventional COH, the risk using low-dose hCG would be between 8% and 36%.The findings for the outcome of FSH consumption were compatible with benefit for the intervention (MD -639 IU, 95% CI -893 to -385, 5 studies, 333 women, I² = 88%, moderate-quality evidence).The findings for the outcome of number of oocytes retrieved were compatible with no effect for the intervention (MD -0.12 oocytes, 95% CI -1.0 to 0.8 oocytes, 5 studies, 351 women, I² = 0%, moderate-quality evidence).

AUTHORS' CONCLUSIONS

We are very uncertain of the effect on live birth, OHSS and miscarriage of using low-dose hCG to replace FSH during the late follicular phase of COH in women undergoing ART, compared to the use of conventional COH. The current evidence suggests that this intervention does not reduce the chance of ongoing and clinical pregnancy; and that it is likely to result in an equivalent number of oocytes retrieved expending less FSH. More studies are needed to strengthen the evidence regarding the effect of this intervention on important reproductive outcomes.

Clomiphene combined with gonadotropins and GnRH antagonist versus conventional controlled ovarian hyperstimulation without clomiphene in women undergoing assisted reproductive techniques: systematic review and meta-analysis

PURPOSE

To compare the effectiveness and safety of controlled ovarian hyperstimulation (COH) using clomiphene citrate associated with gonadotropin and GnRH antagonist (CC + Ant) versus conventional COH without clomiphene citrate (Non-CC) for women undergoing assisted reproductive techniques (ART).

METHODS

Systematic review and meta-analysis of randomized controlled-trials comparing CC + Ant versus non-CC. The last search was performed in Apr 13 2012. The following outcomes were retrieved from included trials and compared between CC + Ant versus non-CC: live birth, clinical pregnancy, ovarian hyperstimulation syndrome (OHSS), miscarriage, multiple pregnancy, endometrial thickness, total oocytes retrieved, MII oocytes retrieved, total gonadotropin used, and duration of COH.

RESULTS

Seven trials (702 participants) were included. There was no significant difference in live birth (55/182 = 30.2 % vs. 47/181 = 26.0 %, p = 0.26, CC + Ant vs. non-CC, respectively), clinical pregnancy (98/346 = 28.3 % vs. 84/356 = 23.6 %, p = 0.12), miscarriage (6/35 = 17.1 % vs. 7/32 = 21.9 %, p = 0.42), endometrial thickness, and on the number of oocytes retrieved. There was a significant reduction in OHSS (1/216 = 0.5 % vs. 9/217 = 4.1 %, p = 0.01), consumption of gonadotropins, and duration of COH.

CONCLUSIONS

Compared to non-CC, CC + Ant is likely to reduce the risk of OHSS, medication costs, and the duration of COH without evidence of effect on live birth and clinical pregnancy. More trials are still needed to improve the quality of the evidence. Future studies should evaluate women with PCOS or at increased risk of OHSS, quality of life, satisfaction with the treatment, total cost per live birth, and frequency of congenital anomalies.

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.

A short narrative review of the feasibility of adopting mild ovarian stimulation for IVF as the current standard of care

INTRODUCTION

Mild ovarian stimulation has been conceived, proposed and implemented in clinical practice as a safer and cheaper alternative to conventional strategies of controlled ovarian hyperstimulation in preparation for in vitro fertilization (IVF). Our aim was to summarize the key evidence on this topic and explore its possible role as the standard treatment option for women undergoing IVF.

MATERIALS AND METHODS

A short narrative review of the existing literature, with emphasis on mild ovarian stimulation clinical and cost effectiveness, as well as treatment limitations.

RESULTS

Numerous studies highlight mild ovarian stimulation's favorable characteristics with respect to oocyte/embryo quality, reduced patient risk, and ease of intervention. There is, however, a need for high-quality laboratory environment. Limitations regarding poor responders, older women, or those seeking ovarian stimulation for non-infertility indications should also be considered. Finally, outcomes on the cumulative success rates and the cost effectiveness of mild ovarian stimulation remain inconclusive.

CONCLUSION

Mild ovarian stimulation protocols for IVF should currently be implemented only in carefully selected populations. Further research is needed to clarify the remaining controversies in this IVF approach.

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.

Women's views on Friendly IVF: a qualitative preliminary study

OBJECTIVE

To study in the French Context women's experiences with a low-stimulation regimen of in vitro fertilisation (Friendly IVF) and to compare them with those of women undergoing standard IVF (S-IVF).

POPULATION AND METHODS

Two assisted reproduction technology centers participated in this preliminary study. Patients'views were explored qualitatively. In-depth interviews were conducted at the end of the second monitored cycle. Twelve friendly IVF patients and 13 S-IVF patients participated in the study.

RESULTS

The respondents indicated that the most positive aspect of Friendly IVF was the low doses of hormones used. Cancellation of cycles and failure of oocyte retrieval were perceived the most negatively. Women in the Friendly IVF group reported fewer side effects and expressed emotional distress less acutely than women in the S-IVF group. The Friendly IVF treatment was percieved as a first step, sustaining the hope of success with a standard treatment.

CONCLUSION

Friendly IVF, as practiced in the center studied, represents a valuable alternative for most respondents as a first step in IVF treatment.

Embryo quality and impact of specific embryo characteristics on ongoing implantation in unselected embryos derived from modified natural cycle in vitro fertilization

OBJECTIVE

To study the implantation potential of unselected embryos derived from modified natural cycle IVF according to their morphological characteristics.

DESIGN

Cohort study.

SETTING

Academic department of reproductive medicine.

PATIENT(S)

A series of 449 single embryo transfers derived from modified natural cycle IVF.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ongoing implantation rate according to embryo characteristics.

RESULT(S)

The best implantation was found in embryos with 4 and 8 cells on day 2 and 3 respectively, <or=10% fragmentation, and absence of multinucleated blastomeres. In contrast to findings from other studies, we found embryos with fewer than four blastomeres on day 2 to do relatively well. Furthermore, we found the implantation potential of embryos containing multinucleated blastomeres to be less severely impaired than expected.

CONCLUSION(S)

Findings from this study suggest that in currently used embryo scoring systems, the implantation potential of embryos with low numbers of blastomeres on day 2, as well as embryos containing multinucleated blastomeres, is underestimated. However, it is unclear whether the results of our study apply to embryos derived from controlled ovarian hyperstimulation cycles.

Mild ovarian stimulation for IVF

BACKGROUND

Mild ovarian stimulation for in vitro fertilization (IVF) aims to achieve cost-effective, patient-friendly regimens which optimize the balance between outcomes and risks of treatment.

METHODS

Pubmed and Medline were searched up to end of January 2008 for papers on ovarian stimulation protocols for IVF. Additionally, references to related studies were selected wherever possible.

RESULTS

Studies show that mild interference with the decrease in follicle-stimulating hormone levels in the mid-follicular phase was sufficient to override the selection of a single dominant follicle. Gonadotrophin-releasing hormone antagonists compared with agonists reduce length and dosage of gonadotrophin treatment without a significant reduction in the probability of live birth (OR 0.86, 95% CI 0.72-1.02). Mild ovarian stimulation may be achieved with limited gonadotrophins or with alternatives such as anti-estrogens or aromatase inhibitors. Another option is luteinizing hormone or human chorionic gonadotrophin administration during the late follicular phase. Studies regarding these approaches are discussed individually; small sample size of single studies along with heterogeneity in patient inclusion criteria as well as outcomes analysed does not allow a meta-analysis to be performed. Additionally, the implications of mild ovarian stimulation for embryo quality, endometrial receptivity, cost and the psychological impact of IVF treatment are discussed.

CONCLUSIONS

Evidence in favour of mild ovarian stimulation for IVF is accumulating in recent literature. However, further, sufficiently powered prospective studies applying novel mild treatment regimens are required and structured reporting of the incidence and severity of complications, the number of treatment days, medication used, cost, patient discomfort and number of patient drop-outs in studies on IVF is encouraged.

Infertility and the provision of infertility medical services in developing countries

BACKGROUND

Worldwide more than 70 million couples suffer from infertility, the majority being residents of developing countries. Negative consequences of childlessness are experienced to a greater degree in developing countries when compared with Western societies. Bilateral tubal occlusion due to sexually transmitted diseases and pregnancy-related infections is the most common cause of infertility in developing countries, a condition that is potentially treatable with assisted reproductive technologies (ART). New reproductive technologies are either unavailable or very costly in developing countries. This review provides a comprehensive survey of all important papers on the issue of infertility in developing countries.

METHODS

Medline, PubMed, Excerpta Medica and EMBASE searches identified relevant papers published between 1978 and 2007 and the keywords used were the combinations of 'affordable, assisted reproduction, ART, developing countries, health services, infertility, IVF, simplified methods, traditional health care'.

RESULTS

The exact prevalence of infertility in developing countries is unknown due to a lack of registration and well-performed studies. On the other hand, the implementation of appropriate infertility treatment is currently not a main goal for most international non-profit organizations. Keystones in the successful implementation of infertility care in low-resource settings include simplification of diagnostic and ART procedures, minimizing the complication rate of interventions, providing training-courses for health-care workers and incorporating infertility treatment into sexual and reproductive health-care programmes.

CONCLUSIONS

Although recognizing the importance of education and prevention, we believe that for the reasons of social justice, infertility treatment in developing countries requires greater attention at National and International levels.

Natural-cycle in vitro fertilization in poor responder patients: a survey of 500 consecutive cycles

OBJECTIVE

To determine the role of the natural cycle for in vitro fertilization (IVF) in poor responder patients.

DESIGN

Retrospective survey.

SETTING

Private center for assisted reproduction.

PATIENT(S)

294 women who were poor responders in a previous IVF cycle.

INTERVENTION(S)

Analysis of 500 consecutive natural cycles IVF.

MAIN OUTCOME MEASURE(S)

Number of cycles with oocytes, pregnancy rate per cycle, per transfer, and implantation rate.

RESULT(S)

Oocytes were found in 391 cases (78.1%), and cleaving embryos suitable for transfer were obtained in 285 cycles (57.0%). Pregnancy was observed in 49 cases, with a pregnancy rate of 9.8% per cycle, 17.1% per transfer, and 16.7% per patient. The patients were subdivided arbitrarily by the women's age into three groups. Patients 35 years old or younger showed a pregnancy rate of 18.1% per cycle, 29.2% per transfer, and 31.7% per patient. Women aged between 36 and 39 years showed a pregnancy rate of 11.7% per cycle, 20.6% per transfer, and 20.3% per patient. Women 40 years old or older showed a pregnancy rate of 5.8% per cycle, 10.5% per transfer, and 9.7% per patient. No differences were found for any of the evaluated parameters, independent of which cycle was the first, the second, third, fourth, or fifth, or further consecutive cycle.

CONCLUSION(S)

In poor responder patients, natural-cycle IVF is an effective treatment, especially in younger women.

Pregnancy after in vitro fertilization-intracytoplasmic sperm injection obtained with a modified natural cycle in a BRCA1 mutation carrier

OBJECTIVE

To report a successful pregnancy after a semi-natural IVF cycle for a BRCA1 gene mutation carrier.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 26-year-old patient with BRCA1 gene mutation.

INTERVENTION(S)

Semi-natural IVF cycle and intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Pregnancy rate.

RESULT(S)

A modified natural IVF cycle was performed, resulting in pregnancy and delivery.

CONCLUSION(S)

A modified natural IVF cycle is an effective and safe solution for BRCA1 or BRCA2 mutation gene carrier women with couple infertility.

Natural cycle IVF with and without terminal HCG: learning from failed cycles

Natural cycle IVF, without the use of LH down-regulation, is difficult because women start spontaneous LH surges at any time of the day and on any day of the week. This is not readily compatible with delivery of a routine IVF service and so historically the natural cycle has been modified by the use of human chorionic gonadotrophin (HCG) to make the natural cycle fit convenient clinical practice. This report re-evaluates data collected some years ago and seeks to determine whether the use of HCG is ultimately beneficial. Two large series of natural cycle IVF where only LH monitoring was performed (534 cycles) or where this was combined with HCG as necessary (241 cycles) were analysed. In essence, the use of HCG introduced as many problems as it overcame: there was no net benefit with respect to the number of eggs collected or clinical pregnancies generated. In fact there was an overall deterioration in all indices. The principle difficulties with natural cycle IVF are those associated with the prediction of follicle maturity and hence timing egg collection, and the conflict between costly and intrusively frequent monitoring with simpler but far less effective approaches.

Preferences of subfertile women regarding elective single embryo transfer: additional in vitro fertilization cycles are acceptable, lower pregnancy rates are not

With identical pregnancy rates after elective single embryo transfer (ET) and double ET strategies consisting of three cycles of IVF or intracytoplasmic sperm injection (ICSI) plus transfers of thawed/frozen embryos if available, 46% of the women undergoing IVF/ICSI favor elective single ET. If elective single ET lowers pregnancy chances with 1%, 3%, or 5%, the percentage of women preferring elective single ET drops to 34%, 24%, and 15%, respectively. If four, five, or six cycles with elective single ET are needed to match the success rate of three cycles with double ET, the percentage of women with a preference for elective single ET drops from 46% to 40%, 36%, and 35% respectively.

[In vitro fertilization (IVF): why doing it in stimulated cycles?]

Assisted reproductive technology is a difficult course for the couples. Our purpose is to be effective without damaging the patient and the child to be born. The cumulative rates of success are strictly dependent on the number of oocytes and on the obtained top quality embryos and thus on the realization of an effective stimulation. The risk of multiple pregnancies can be adjusted by an adapted policy of transfer. The transfer of a fresh embryo followed by cycles of frozen embryos transfers gives very satisfactory cumulative pregnancy rates.

En fécondation in vitro (FIV): pourquoi je ne stimule pas?

In vitro fertilization without stimulation, in natural or semi-natural cycles ("FIV-NAT") offers an interesting alternative to controlled ovarian hyperstimulation (COH) for some patients. This protocol may be proposed to patients suffering from altered ovarian status (AOS) with encouraging results. The second indication might be patients presenting repeated implantation failure (IMF). FIV-NAT allows avoiding possible adverse effects of HOC on the endometrium. Results are respectively 15.4 and 16.6% clinical pregnancy rate per oocyte retrieval for AOS and IMF, and 25.5 and 26.3% over 3 cumulative cycles. This treatment is less expensive and patient friendly.

Hopes and facts about mild ovarian stimulation

Over the last two decades, easier and less expensive stimulation treatments have been largely replaced by more complex and more demanding protocols. Since the mid-nineties, long-term gonadotrophin-releasing hormone agonist stimulation protocols have been widely used. Such lengthy expensive regimens are not free from short- and long-term risks and complications. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotrophins used and the mean number of oocytes retrieved. The proportion of high quality and euploid embryos seems to be higher compared with conventional stimulation protocols and the pregnancy rate per embryo transfer is comparable. Moreover, the reduced costs, the better tolerability for patients and the less time needed to complete an IVF cycle make mild approaches clinically and cost-effective over a given period of time. However, further prospective randomized studies are needed to compare cumulative pregnancy rates between the two protocols. Natural cycle IVF, with minimal stimulation, has been recently proposed as an alternative to conventional stimulation protocols in normo- and poor responder patients. Although acceptable results have been reported, further large prospective randomized studies are needed to better evaluate the efficacy of these minimal regimens compared with conventional stimulation approaches.

Coming soon to your clinic: patient-friendly ART

The current practice in medically assisted reproduction is still too exclusively focused on effectiveness and success rates. This has a number of considerable, and more importantly, avoidable drawbacks. Single embryo transfer was an important move away from this model to include safety and welfare of mother and child. Patient-friendly ART goes one big step further. It is composed of a mix of four criteria: cost-effectiveness, equity of access, minimal risk for mother and child and minimal burden for patients. All four components have a strong normative ethical basis: cost-effectiveness relies on the optimal use of community resources to maximise well-being; equity of access is based on justice, minimal risk is founded on the fundamental non-maleficence rule and minimal burden is largely based on the autonomy principle. The inclusion of the four criteria in decision-making about treatment would express these values in clinical practice.

Patient-friendly IVF: how should it be defined?

"Patient-friendly" IVF must be associated with a healthy newborn achieved in a safe, cost-effective, and timely manner. Patients are best served when physicians provide honest appraisal of treatment techniques and outcomes using the evidence available from scientific study.