Prevention of ovarian hyperstimulation syndrome (OHSS): British Fertility Society policy and practice guideline

This British Fertility Society (BFS) Policy and Practice guideline aims to support clinicians in preventing ovarian hyperstimulation syndrome (OHSS) in patients undergoing gonadotropin ovarian stimulation. A systematic literature search of the medical databases was performed. The Guideline Development Group (GDG) identified the risk factors of OHSS before and during ovarian stimulation. The relation of different pre-treatment measures and different ovarian stimulation protocols with OHSS was evaluated. The optimal monitoring during treatment was assessed. The current evidence on preventive strategies during and after ovarian stimulation and the available adjuvant preventive agents were examined. Based on this, the GDG developed evidence-based, graded recommendations for clinical practice. The evidence was evaluated within context, considering the effectiveness, cost and practical problems of assisted reproductive technology for patients and healthcare providers. Early identification and application of preventive measures identified in this guideline may reduce the incidence of OHSS or reduce its severity. Suggestions for future research on OHSS prevention are provided.

Embryo utilisation rate and transferable embryo to oocyte ratio correlate positively with livebirth rate but negatively with oocyte number: analysis of 14,156 fresh IVF/ICSI cycles

BACKGROUND

The live birth rates (LBRs) do not rise after a certain number of oocytes are collected in fresh IVF cycles. Although the detrimental effect of high ovarian response on the endometrium has been recognised, the effect of high oocyte yield on oocyte competency remains disputed. The purpose of this study was to examine whether high oocyte yield adversely affect the competency of oocytes or embryos. We retrospectively analysed UK's National database (published by Human Fertilisation and Embryology Authority (HFEA)- year 2015-2016) including couples who underwent first IVF treatment with single embryo transfer or had no available embryo, due to tubal or unexplained infertility among women aged < 40 years.

RESULTS

Retrospective analysis of 14,156 fresh IVF/ ICSI cycles that met the inclusion criteria revealed an inverse correlation between Embryo Utilisation Rate (EUR) and the oocyte yield (r= -0.250047, p < 0.0001). The Transferable Embryo to Oocyte Ratio (TEOR) also inversely correlated with the number of retrieved oocyte (r = - 0.331431, p < 0.0001). The number of oocytes that did not produce transferable embryos had a stronger positive correlation with oocyte yield (r = 0.916676, p < 0.0001) than those produced transferable embryos (r = 0.569972, p < 0.0001). Both EUR (p = 0.01) and TEOR (P < 0.0001) correlated positively with the live birth except in the women age-group of 38-39 years. Although fertilisation rates remained similar, both EUR and TEOR declined steadily with the increasing number of oocytes until it reached a nadir at around 8-9 oocytes. At this point the LBR in fresh cycles reached its peak.

CONCLUSION

The EUR and TEOR decline with increasing oocyte yield while both the ratios have a positive correlation with live birth. Despite declining EUR and TEOR, increasing oocyte yield can still boost fresh cycle LBR until the proportions of transferable embryos fall to a nadir. Thus, the focus needs to be on finding more efficient method for embryo selection and avoid generating too many wasteful oocytes that only pose more risk or raise cost without improving fresh cycle LBR.

TRIAL NUMBER

Being a retrospective study, prior registration of the trial was not required.

CLINICAL TRIAL NUMBER

Not applicable.

GnRH-a use before programmed frozen embryo transfer cycles for women with PCOS: a retrospective cohort study

BACKGROUND

Programmed protocols are most commonly chosen as endometrial preparation for women with polycystic ovarian syndrome (PCOS) undergoing frozen-thawed embryo transfer (FET) cycles. However, the efficacy of gonadotropin-releasing hormone agonist (GnRH-a) pretreatment before programmed cycles is still up for debate. This study was to compare the pregnancy and perinatal outcomes of PCOS patients receiving programmed cycles with and without GnRH-a pretreatment as endometrial preparation in FET cycles.

METHODS

This is a retrospective cohort study conducted in the Reproductive Medicine Centre of Tongji Hospital. The primary analysis included 2733 FET cycles (223 were programmed cycles combined with GnRH-a pretreatment; 2510 were programmed cycles) during Jan. 2016 and Sept. 2022 from 1934 women with PCOS. Patients who had undergone both endometrial preparation protocols were further analyzed as a subgroup. The primary outcomes were pregnancy outcomes including live birth rate, clinical pregnancy rate, biochemical pregnancy loss rate, ectopic pregnancy rate, and multiple pregnancy rate. The secondary outcomes were perinatal outcomes. Propensity score matching (PSM) and generalized estimating equation were employed to eliminate essential confounders and account for patients with multiple cycles. The subgroup analysis included patients who underwent both endometrial preparation regimens and utilized the Wilcoxon's matched pairs test to compare the adjusted pregnancy outcomes rate, calculated by dividing the number of pregnancy outcomes by the number of cycles.

RESULTS

The essential baseline variables of the patients were balanced after conducting PSM. Pregnancy outcomes of the total PCOS population exhibited no variances (P > 0.05) between protocols after adjustments. When focusing on patients who had received both protocols, GnRH-a administration was associated with increased adjusted live birth rates (P < 0.001), singleton live birth rates (P < 0.001), multiple live birth rates (P = 0.049), clinical pregnancy rates (P < 0.001), and lower miscarriage rates (P = 0.028). Further analysis of these patients indicated that the pregnancy outcomes of therapy with GnRH-a were superior to those without only in the second transfer cycle. No significant difference was exhibited in singleton perinatal outcomes in terms of gestational age, birth weight, delivery mode, gender, obstetric complications, and adverse birth outcomes between the two groups (P > 0.05).

CONCLUSIONS

GnRH-a pretreatment before programmed cycles may not affect pregnancy or perinatal outcomes of general women with PCOS in FET cycles but may be beneficial for PCOS patients who did not achieve a live birth during the first cycle receiving a programmed protocol. The conclusion should be considered with caution. Further well-designed studies are required to validate our findings.

Expert opinion on refined and extended key performance indicators for individualized ovarian stimulation for assisted reproductive technology

OBJECTIVE

To assess the adequate ovarian follicular development and oocyte recovery between ovarian potential (antral follicle count [AFC]) before the start of ovarian stimulation (OS) and oocyte quantity and quality at oocyte retrieval. A holistic overview of the current key performance indicators (KPIs) was applied to identify the complementary strengths and identify where the current repertoire can be expanded.

DESIGN

Expert opinion.

INTERVENTION

None.

MAIN OUTCOME MEASURES

To formulate a proposal for a refined and expanded repertoire of KPIs for individualized OS for assisted reproductive technology.

RESULTS

The performance and outcomes of OS on ovarian follicular development can be evaluated through the application of defined KPIs. Current KPIs for OS are the ovarian sensitivity index, follicular output rate (FORT), oocyte retrieval rate, and follicle-to-oocyte index (FOI). Notably, there are no specific KPIs dedicated to the assessment of follicular development (i.e., recruitment, selection, growth, and dominance). In light of this, we recommend expanding the current KPIs for OS to include "early FORT" (accounting for the number of follicles measuring ≥10 to 11 mm on day 5/6 of OS relative to AFC) and "modified FORT" (the ratio between the number of follicles measuring ≥12 mm at the time of oocyte maturation triggering and AFC); the extension of oocyte retrieval rate to include two discrete categories at oocyte retrieval-follicles measuring ≥12 mm and ≥16 mm-to ensure that all responsive follicles are accounted for; and FOI to be measured at oocyte maturation triggering and oocyte retrieval ("advanced FOI").

CONCLUSION

Once validated and adopted in clinical practice, we envisage that the proposed expanded KPIs measuring the effect of OS on follicular development (recruitment, selection, growth, and dominance) will increase the understanding of the relationship between ovarian reserve, measured by AFC, and oocyte quantity and quality at oocyte retrieval. This understanding will enable physicians to better evaluate the direct effect of different gonadotropins and doses on ovarian response, leading to a more personalized approach to OS in the context of assisted reproductive technology treatment.

Development and validation of a gonadotropin dose selection model for optimized ovarian stimulation in IVF/ICSI: an individual participant data meta-analysis

BACKGROUND

The ovarian response to gonadotropin stimulation varies widely among women, and could impact the probability of live birth as well as treatment risks. Many studies have evaluated the impact of different gonadotropin starting doses, mainly based on predictive variables like ovarian reserve tests (ORT) including anti-Müllerian hormone (AMH), antral follicle count (AFC), and basal follicle-stimulating hormone (bFSH). A Cochrane systematic review revealed that individualizing the gonadotropin starting dose does not affect efficacy in terms of ongoing pregnancy/live birth rates, but may reduce treatment risks such as the development of ovarian hyperstimulation syndrome (OHSS). An individual patient data meta-analysis (IPD-MA) offers a unique opportunity to develop and validate a universal prediction model to help choose the optimal gonadotropin starting dose to minimize treatment risks without affecting efficacy.

OBJECTIVE AND RATIONALE

The objective of this IPD-MA is to develop and validate a gonadotropin dose-selection model to guide the choice of a gonadotropin starting dose in IVF/ICSI, with the purpose of minimizing treatment risks without compromising live birth rates.

SEARCH METHODS

Electronic databases including MEDLINE, EMBASE, and CRSO were searched to identify eligible studies. The last search was performed on 13 July 2022. Randomized controlled trials (RCTs) were included if they compared different doses of gonadotropins in women undergoing IVF/ICSI, presented at least one type of ORT, and reported on live birth or ongoing pregnancy. Authors of eligible studies were contacted to share their individual participant data (IPD). IPD and information within publications were used to determine the risk of bias. Generalized linear mixed multilevel models were applied for predictor selection and model development.

OUTCOMES

A total of 14 RCTs with data of 3455 participants were included. After extensive modeling, women aged 39 years and over were excluded, which resulted in the definitive inclusion of 2907 women. The optimal prediction model for live birth included six predictors: age, gonadotropin starting dose, body mass index, AFC, IVF/ICSI, and AMH. This model had an area under the curve (AUC) of 0.557 (95% confidence interval (CI) from 0.536 to 0.577). The clinically feasible live birth model included age, starting dose, and AMH and had an AUC of 0.554 (95% CI from 0.530 to 0.578). Two models were selected as the optimal model for combined treatment risk, as their performance was equal. One included age, starting dose, AMH, and bFSH; the other also included gonadotropin-releasing hormone (GnRH) analog. The AUCs for both models were 0.769 (95% CI from 0.729 to 0.809). The clinically feasible model for combined treatment risk included age, starting dose, AMH, and GnRH analog, and had an AUC of 0.748 (95% CI from 0.709 to 0.787).

WIDER IMPLICATIONS

The aim of this study was to create a model including patient characteristics whereby gonadotropin starting dose was predictive of both live birth and treatment risks. The model performed poorly on predicting live birth by modifying the FSH starting dose. On the contrary, predicting treatment risks in terms of OHSS occurrence and management by modifying the gonadotropin starting dose was adequate. This dose-selection model, consisting of easily obtainable patient characteristics, aids in the choice of the optimal gonadotropin starting dose for each individual patient to lower treatment risks and potentially reduce treatment costs.

Oocyte yield and live birth rate after follitropin delta dosing and fresh embryo transfer: an individual patient data meta-analysis

RESEARCH QUESTION

What number of retrieved oocytes is associated with the optimum chance of achieving a live birth for women undergoing ovarian stimulation with individualized follitropin delta?

DESIGN

An individual patient data meta-analysis was performed on 1772 patients from five randomized controlled trials using individualized follitropin delta for ovarian stimulation with fixed daily dosing based on serum anti-Müllerian hormone (AMH) level and body weight. Live birth rate (LBR) and ovarian hyperstimulation syndrome (OHSS) were evaluated in relation to the number of oocytes retrieved. Predicted LBR was obtained using a logistic regression analysis with fractional polynomials. Subgroup analyses were performed based on number of oocytes retrieved, age and AMH level.

RESULTS

The analysis included patients treated with follitropin delta who had at least one oocyte retrieved. The mean number of oocytes retrieved was 10.4, and overall LBR was 32.1%. Predicted LBR increased with the number of oocytes retrieved, reaching >34% for patients with 8-14 oocytes retrieved, and peaking at 34.9% for patients with 11 oocytes retrieved. LBR declined gradually beyond retrieval of 14 oocytes. LBR was 27.8%, 33.6% and 30.9% for patients with 1-7, 8-14, and ≥15 oocytes retrieved, respectively. LBR decreased with increasing age: 32.7%, 30.7% and 23.4% at <35, 35-37 and 38-42 years, respectively. The incidence of OHSS (any grade) was 2.1%, 5.2% and 17.0% for patients with 1-7, 8-14, and ≥15 oocytes retrieved, respectively.

CONCLUSIONS

After ovarian stimulation with individualized follitropin delta, LBR in fresh transfer cycles was highest for patients with 8-14 oocytes retrieved, and peaked in patients with 11 oocytes retrieved. The results support the appropriateness of the follitropin delta dosing algorithm.

Ovarian stimulation protocols: impact on oocyte and endometrial quality and function

Ovarian stimulation (OS) truly is an art. There exists a myriad of protocols used to achieve the same goal: stimulating the ovaries to produce more than one mature oocyte to improve the chance of a live birth. However, considerable debate remains as to whether OS impacts oocyte and endometrial quality to affect in vitro fertilization outcomes. Although "more is better" has long been considered the best approach for oocyte retrieval, this review challenges that notion by examining the influence of stimulation on oocyte quality. Likewise, improved outcomes after frozen blastocyst transfer suggest that OS perturbs endometrial preparation and/or receptivity, although correlating changes with implantation success remains a challenge. Therefore, the focus of this review is to summarize our current understanding of perturbations in human oocyte quality and endometrial function induced by exogenous hormone administration. We highlight the need for further research to identify more appropriate markers of oocyte developmental competence as well as those that define the roles of the endometrium in the success of assisted reproductive technology.

The quality of human eggs and its pre-IVF incubation

Background

Multi-factors influence the success rate of infertility treatments, and one of the important points is to obtain good quality eggs.

Methods

Based on the literatures and unpublished data, the factors affecting egg quality were summarized.

Main Findings Results

Egg quality is an important determinant in successful infertility treatment. In addition to maternal age, controlled ovarian hyperstimulation (COH) protocols also play a key role in affecting the quality of the egg. After egg retrieval, the insemination occurs 3-6 h after collection, with a pre-IVF incubation time by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) (39-42 h post-HCG injection). The pre-IVF incubation refers to the short period time of 3 to 6 h after oocyte retrieval and before the insemination by IVF or ICSI. The pre-IVF incubation of collected eggs in the designed culture medium improves egg quality in terms of maturation and early embryonic development.

Conclusions

Pre-IVF incubation of the collected eggs contributes to the improvement of the quality of eggs; therefore, it may increase subsequent pregnancy and implantation rates following embryo transfer.

Influencing factors and effects of low oocyte retrieval in patients with polycystic ovary syndrome undergoing in-vitro fertilization

OBJECTIVE

To investigate influencing factors and effects of low oocyte retrieval in patients with polycystic ovary syndrome (PCOS) undergoing in-vitro fertilization (IVF).

METHODS

In total, 720 patients with PCOS undergoing IVF were enrolled in this retrospective study from January 2017 to December 2022. The oocyte retrieval rate (ORR) was defined as the ratio of the number of oocytes retrieved to the number of follicles ≥ 12 mm in diameter on the trigger day. Using 1 standard deviation from the mean ORR as the boundary value, patients were divided into low and normal ORR groups. Patient characteristics, stimulation protocols, serum hormone levels, oocyte maturity, embryo developmental quality, and pregnancy outcomes of fresh transfer cycles were analysed.

RESULTS

ORR ranged from 0.06 to 2.69, with a mean value of 1.02. Compared with the normal ORR group (ORR ≥ 0.65), patients in the low ORR group (ORR < 0.65) had a higher body mass index; higher antral follicle count (AFC); more days of gonadotrophin stimulation; and lower serum oestradiol (E2) level, lower progesterone level and lower E2 level/follicle (≥12 mm) on the trigger day. Multivariate logistic regression analysis showed AFC [adjusted odds ratio (aOR) 1.05, 95 % confidence interval (CI) 1.0120-1.0940], E2 level/follicle (≥12 mm) (aOR 0.99, 95 % CI 0.9888-0.9972) and progesterone level (aOR 0.41, 95 % CI 0.2402-0.6649) on the trigger day were significantly associated with low ORR. Receiver operator characteristic curve analyses revealed that serum E2 level/follicle (≥12 mm) had an area under the curve of 0.7036 (95 % CI 0.65-0.76; p < 0.01). The cut-off value was 169.2 pg/ml, with sensitivity of 65 % and specificity of 65 %, for predicting low ORR. Low ORR was associated with fewer top-quality embryos and more cycles with no embryos available for transfer. The rates of metaphase II oocytes, top-quality embryos, clinical pregnancy and live birth did not differ between the two groups.

CONCLUSION

Serum E2 level/follicle (≥12 mm) on the trigger day may be used as a predictive factor for low ORR in patients with PCOS. Low ORR may not affect oocyte and embryo developmental potential under appropriate ovarian stimulation management, but likely increases the risk of no embryos being available for transfer.

Required number of blastocysts transferred, and oocytes retrieved to optimize live and cumulative live birth rates in the first complete cycle of IVF for autologous and donated oocytes

PURPOSE

To investigate live birth rate (LBR) and cumulative live birth rate (CLBR) to achieve the first newborn per blastocyst transferred and oocyte retrieved in the first complete IVF cycle of autologous and donated oocytes and identify the possible success factors.

METHODS

This was a retrospective cohort study of a private IVF center. There were 1867 cycles, 1241 of which were fresh transfers and 626, their subsequent thawing transfers.

RESULTS

We found significant variables by binary logistic regression. For LBR, female infertility and the day of blastocyst transferred were relevant; however, for CLBR, the numbers of blastocysts available for future transfers, oocyte age, and maternal age were more critical. Oocyte age is a negative factor that begins to affect CLBR gradually beyond 36 years; from that age, there are significant worse results in polycystic ovary syndrome and poor responder patients.

CONCLUSION

The LBR and CLBR were optimized for oocyte recipients when eight oocytes were retrieved (63.6%; 87.9%); at most, fourteen oocytes should be assigned to avoid freezing surplus blastocysts. Thirteen autologous oocytes (69.2%; 92.3%) were ideal for optimization. CLBR optimized after three blastocysts in donor oocytes (81.8%) and four for autologous oocyte patients (80.9%). Our outcomes are valuable for doctors and infertile couples, and they give us information on what we can expect from a first complete IVF cycle.

From patient classification to optimized treatment in ART: the AMPLITUDE Delphi consensus

Introduction

A Delphi consensus was performed to evaluate expert opinions on the management of key aspects of ovarian stimulation.

Methods

A Scientific Committee developed eleven statements for patient profiles corresponding to predicted ovarian responses (low, normal, and high) based on antral follicle count (AFC) and anti-Müllerian hormone (AMH). The statements were distributed (online survey) to French and Belgian fertility specialists. Consensus was reached when ≥66.7% of participants agreed or disagreed.

Results

Among 52 respondents, a consensus agreement was reached for each patient profile for personalizing the initial dose of gonadotropin, taking age, weight, body mass index, nature of the cycle, and the decision to perform a fresh transfer or a freeze-all strategy into consideration. The respondents preferred a fresh transfer for low and normal responders and a freeze-all strategy in case of high risk of hyperstimulation, newly diagnosed uterine or tubal pathology and premature progesterone elevation. A consensus was reached for 10-15 oocytes as optimal oocyte target from the first round of voting. The panel agreed to increase the gonadotropin dose in case of insufficient response and preferred a GnRH antagonist protocol for a subsequent cycle in case of excessive response. Finally, a consensual answer was obtained for using LH/hCG activity in case of hypogonadotropic hypogonadism, advanced age, inadequate response during first stimulation and suspected FSH receptor polymorphism.

Discussion

The AMPLITUDE consensus supports the importance of optimizing the ovarian stimulation protocol for patients undergoing assisted reproductive technology treatment. Additional studies could complete these findings and guide fertility specialists in their daily practice to improve ovarian stimulation outcomes.

Cumulative live birth rates in a freeze-all or fresh transfer strategy after one ART cycle in ovulatory women

RESEARCH QUESTION

Are cumulative live birth rates similar following a freeze-all strategy compared with a fresh transfer strategy including all subsequent vitrified-warmed cycles from the same oocyte retrieval?

DESIGN

The study related to the secondary outcome in a multicentre randomized controlled trial including 460 women allocated in a 1:1 ratio to: (i) a freeze-all strategy including a gonadotrophin-releasing hormone agonist trigger and single vitrified-warmed blastocyst transfer in a subsequent modified-natural frozen-thawed embryo transfer (FET) cycle; or (ii) a fresh transfer strategy with a human chorionic gonadotrophin trigger and single blastocyst in the fresh cycle. Women were recruited over a 2-year period from May 2016 to September 2018. The minimum follow-up time from the start of ovarian stimulation was 2 years.

RESULTS

Baseline and treatment-related characteristics were similar between the two groups, and an equal number of participants had an additional FET following the initial fresh or frozen transfer in the two groups. Combining all FET from the included oocyte retrievals, the cumulative live birth rate was 42.6% (95/223) in the freeze-all group versus 41.7% (96/230) in the fresh strategy group (risk ratio 1.0, 95% CI 0.87-1.19; P = 0.93). The median time (interquartile range) to the first pregnancy was 106.0 (80.5-156.5) versus 29.0 (27.0-113.5) days in the freeze-all and fresh transfer group, respectively. The total number of deliveries from all subsequent FET cycles was similar between the freeze-all strategy and fresh transfer strategy group: 15.2% (34/223) versus 12.6% (29/230), respectively (P = 0.5).

CONCLUSIONS

When comparing a freeze-all strategy with a fresh transfer strategy in a randomized controlled trial setting, no significant difference was found in the cumulative live birth rates between the two strategies.

Assessing the Impact of the Novel Sperm Selection Technique 'Annexin-V Coated Polystyrene Bead Technique' on Mouse Assisted Reproductive Techniques Outcomes: Preliminary Findings

ICSI is one of the most commonly used techniques to treat infertility. The sperm selection for the procedure is done 'randomly' by the embryologist according to the motility and morphology parameters which is known not to reflect the potential of a sperm for fertilization, pregnancy and a healthy childbearing. Since the apoptosis rate is higher in sperm cells of infertile patients, it is more likely to choose an apoptotic sperm by the 'random selection method'. We recently introduced a novel sperm selection technique namely 'Annexin-V coated polystrene bead technique'(APB-Tech), for the selection of non-apoptotic sperm cells. The principal of the technique is based on the binding affinity of an apoptotic sperm to 'Annexin-V covered beads' enabling to distinguish a viable and a healthy sperm by light microscopy. The aim of the present study was to observe the effects of this technique on ICSI outcomes in mice. Sibling-oocyte trial was conducted and the outcome measures were compared with the results of traditional sperm selection method. Embryo and blastocyst qualities and blastocyst development rates were significantly increased in APB-Tech group, while the other parameters were not affected. Promising results obtained from the technique reflect its promising potential as a new and powerful tool for sperm selection and thus infertility techniques.

The construction of machine learning-based predictive models for high-quality embryo formation in poor ovarian response patients with progestin-primed ovarian stimulation

OBJECTIVE

To explore the optimal models for predicting the formation of high-quality embryos in Poor Ovarian Response (POR) Patients with Progestin-Primed Ovarian Stimulation (PPOS) using machine learning algorithms.

METHODS

A retrospective analysis was conducted on the clinical data of 4,216 POR cycles who underwent in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) at Sichuan Jinxin Xinan Women and Children's Hospital from January 2015 to December 2021. Based on the presence of high-quality cleavage embryos 72 h post-fertilization, the samples were divided into the high-quality cleavage embryo group (N = 1950) and the non-high-quality cleavage embryo group (N = 2266). Additionally, based on whether high-quality blastocysts were observed following full blastocyst culture, the samples were categorized into the high-quality blastocyst group (N = 124) and the non-high-quality blastocyst group (N = 1800). The factors influencing the formation of high-quality embryos were analyzed using logistic regression. The predictive models based on machine learning methods were constructed and evaluated accordingly.

RESULTS

Differential analysis revealed that there are statistically significant differences in 14 factors between high-quality and non-high-quality cleavage embryos. Logistic regression analysis identified 14 factors as influential in forming high-quality cleavage embryos. In models excluding three variables (retrieved oocytes, MII oocytes, and 2PN fertilized oocytes), the XGBoost model performed slightly better (AUC = 0.672, 95% CI = 0.636-0.708). Conversely, in models including these three variables, the Random Forest model exhibited the best performance (AUC = 0.788, 95% CI = 0.759-0.818). In the analysis of high-quality blastocysts, significant differences were found in 17 factors. Logistic regression analysis indicated that 13 factors influence the formation of high-quality blastocysts. Including these variables in the predictive model, the XGBoost model showed the highest performance (AUC = 0.813, 95% CI = 0.741-0.884).

CONCLUSION

We developed a predictive model for the formation of high-quality embryos using machine learning methods for patients with POR undergoing treatment with the PPOS protocol. This model can help infertility patients better understand the likelihood of forming high-quality embryos following treatment and help clinicians better understand and predict treatment outcomes, thus facilitating more targeted and effective interventions.

Monitoring of controlled ovarian stimulation in IVF

Since the inception of in vitro fertilization (IVF), monitoring of controlled ovarian stimulation (COS) has traditionally involved numerous appointments for ultrasound and laboratory testing to guide medication use and dosing, determine trigger timing, and allow for measures to reduce the risk of ovarian hyperstimulation syndrome (OHSS). Recent advances in the field of assisted reproductive technology (ART) have called into question the timing and frequency of COS monitoring appointments, as discussed in this commentary.

Comparative analysis of pregnancy outcomes in preimplantation genetic testing for aneuploidy and conventional in vitro fertilization and embryo transfer: a stratified examination on the basis of the quantity of oocytes and blastocysts from a multicenter randomized controlled trial

OBJECTIVE

To investigate variations in pregnancy outcomes between preimplantation genetic testing for aneuploidy (PGT-A) and conventional in vitro fertilization and embryo transfer (IVF-ET) treatment across distinct groups categorized by oocyte and blastocyst counts. Because the live birth rate (LBR) of assisted reproductive technology treatment is influenced by the number of oocytes and blastocysts retrieved. Our previous study indicated comparable cumulative LBRs (CLBRs) between conventional IVF-ET and PGT-A.

DESIGN

A post hoc exploratory secondary analysis of data from a multicenter randomized controlled trial compared the CLBRs between conventional IVF-ET and PGT-A.

SETTING

Academic fertility centers.

SUBJECTS

A total of 1,212 infertile women with a good prognosis for a live birth after PGT-A or conventional IVF-ET were included.

INTERVENTION

Women underwent PGT-A or conventional IVF-ET.

MAIN OUTCOME MEASURE(S)

Cumulative LBR, cumulative clinical pregnancy loss (CPL) rate, and good birth outcome.

RESULT(S)

In the study, all participants were divided into 4 groups on the basis of quartiles of the number of oocytes retrieved, or blastocysts. There was an interaction between whether to perform PGT-A and the oocyte numbers category on cumulative CPL and biochemical pregnancy loss. Chi-square analysis revealed that the PGT-A group showed a lower cumulative frequency of CPL compared with the IVF-ET group (PGT-A vs. IVF-ET: 5.9% vs. 13.7%; relative risk = 0.430; 95% confidence interval, 0.243-0.763) when the number of oocytes retrieved was <15. Although there was no interaction on CLBR when the retrieved oocyte count ranged from 19-23 (19≤ oocytes <23) the PGT-A group exhibited a lower CLBR than the conventional IVF-ET group (PGT-A vs IVF-ET: 75.6% vs 87.1%; relative risk = 0.868; 95% confidence interval, 0.774-0.973), and the average body weight of newborns from the PGT-A group was approximately 142 g lower than that of the conventional IVF-ET group (PGT-A vs. IVF-ET: 3,334 ± 479 g vs. 3,476 ± 473 g). However, no statistically significant difference in the CLBR was observed between the PGT-A and IVF-ET groups in the other oocyte or blastocyst groups.

CONCLUSION

When the number of retrieved eggs was <15, the PGT-A group exhibited a lower cumulative CPL rate but no higher CLBR than the conventional IVF-ET group.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03118141.

Live birth rate per fresh embryo transfer and cumulative live birth rate in patients with PCOS under the POSEIDON classification: a retrospective study

Background

Ovarian stimulation (OS) for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) in women with PCOS often results in multiple follicular development, yet some individuals experience poor or suboptimal responses. Limited data exist regarding the impact of poor/suboptimal ovarian response on pregnancy outcomes in women with PCOS.

Objectives

The aim of this study was to evaluate whether the live birth rate (LBR) per fresh embryo transfer and cumulative live birth rate (CLBR) per aspiration cycle differ in women with PCOS defined by the Patient-Oriented Strategy Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria.

Methods

A retrospective study involving 2,377 women with PCOS who underwent their first IVF/ICSI cycle at Sun Yat-sen Memorial Hospital from January 2011 to December 2020 was used. Patients were categorized into four groups based on age, antral follicle count, and the number of oocytes retrieved, according to the POSEIDON criteria. The LBR and CLBR were compared among these groups. Logistic regression analysis was performed to assess whether the POSEIDON criteria served as independent risk factors and identify factors associated with POSEIDON.

Results

For patients <35 years old, there was no significant difference in the clinical pregnancy rate between POSEIDON and non-POSEIDON patients, whereas POSEIDON patients exhibited lower rates of implantation and live birth. POSEIDON Group 1a displayed lower rates of implantation, clinical pregnancy, and live birth. However, no significant differences were observed in the rates of clinical pregnancy and live birth between POSEIDON Group 1b and non-POSEIDON groups. For patients ≥35 years old, there were no significant differences in the rates of implantation, clinical pregnancy, and live birth between POSEIDON and non-POSEIDON patients. CLBRs were significantly lower in POSEIDON Groups 1 and 2, compared with the non-POSEIDON groups. The levels of body mass index (BMI), follicle-stimulating hormone (FSH), and antral follicle count (AFC) were associated with POSEIDON hypo-response. POSEIDON was found to be associated with lower CLBR, but not LBR per fresh embryo transfer.

Conclusions

In patients with PCOS, an unexpected suboptimal response can achieve a fair LBR per fresh embryo transfer. However, CLBR per aspirated cycle in POSEIDON patients was lower than that of normal responders. BMI, basal FSH level, and AFC were independent factors associated with POSEIDON. Our study provides data for decision-making in women with PCOS after an unexpected poor/suboptimal response to OS.

Poor Response to Gonadotropin Stimulation and Perinatal Outcomes in Fresh In Vitro Fertilization Embryo Transfer Cycles-A Retrospective Cohort Study

Objective: The objective was to examine the association between poor ovarian response to gonadotropin stimulation for in vitro fertilization (IVF) and adverse perinatal outcomes in singleton gestations in young patients. Methods: This was a retrospective cohort study including women aged 17-39 who underwent fresh embryo transfer and delivered a singleton neonate at a single center (pre-implantation genetic testing excluded) (2007-2022). Patients were classified as one of the following categories: poor responders-daily follicle-stimulating hormone (FSH) ≥ 150 IU yielding ≤ 3 retrieved oocytes; normal responders-4-15 oocytes; and high responders with ≥16 oocytes. The primary outcome was a composite of pre-eclampsia (mild or severe), small-for-gestational-age, gestational diabetes mellitus, and preterm birth (<37 weeks). We compared maternal and neonatal outcomes between the three groups. Multivariable logistic regression was used to control for confounders. Results: Overall, 507 women met the inclusion criteria. Of them, there were 44 (8.68%) poor responders, 342 (67.46%) normal responders, and 121 (23.87%) high responders. Poor responders, compared to normal and high responders, were characterized by a higher maternal age (34.64 ± 4.01 vs. 31.4 ± 5.04 vs. 30.01 ± 4.93, p < 0.001, respectively) and total FSH dosage (3028.41 ± 1792.05 IU vs. 2375.11 ± 1394.05 IU vs. 1869.31 ± 1089.63 IU, p < 0.001). The perinatal outcomes examined, including cesarean delivery (CD) rate and the composite outcome, were comparable between groups. Using multivariable logistic regression and adjusting for ovarian response group, maternal age, nulliparity, and estradiol level and endometrial thickness before ovulation triggering, poor response was not associated with CD rate or the composite outcome, with maternal age associated with CD (p = 0.005), and nulliparity with the composite outcome (p = 0.007). Similar results were obtained when comparing poor responders to each other group separately or to all other responders. Conclusions: Poor ovarian response is not associated with increased adverse maternal or neonatal outcomes.

Factors associated with oocyte recovery rates during in-vitro fertilization among Nigerian women

Introduction

the availability of oocytes is fundamental to in vitro fertilization (IVF). The factors associated with optimal or suboptimal oocyte recovery rates (ORR) in low-resource settings are not well known. This study aimed to determine the factors associated with ORR by comparing demographic and IVF cycle data of women undergoing IVF in our Centre.

Methods

this was a prospective study of 110 infertile women undergoing IVF at Nisa Premier Hospital, Abuja Nigeria, from October 2020 to September 2021. All women had reached the stage of oocyte retrieval or further, after receiving ovarian stimulation with our routine protocols. Treatment was monitored by serial transvaginal ultrasonography. The oocyte retrieval procedures were performed under conscious sedation, 36 hours after the ovulatory trigger. Optimal ORR was when eggs were obtained from at least 80% of follicles punctured. Sub-optimal ORR was when it was less than 80%. Data analyses utilized SPSS statistical software and a p-value of < 0.05 was considered significant.

Results

the mean age of all women was 34.1±4.9 years. Sixty-nine women (62.7%) had sub-optimal ORR while 41 (37.3%) had optimal ORR. Six women (5.5%) had no oocytes retrieved. Significantly more women with sub-optimal ORR were obese (70.6 vs 29.4%) and had higher follicle-stimulating hormone (FSH) levels (8.11 vs 6.34 miu/ml), p-value- 0.039. Women with sub-optimal ORR had higher mean prolactin levels (17.10 ± 13.93 miu/ml) than women with optimal ORR 11.43 ± 6.65 miu/ml), p-value- 0.019). Significantly more oocytes (5.99 vs 10.37, p-value 0.001), and MII oocytes (5.78 vs 7.56, p-value 0.035) were retrieved in women with optimal than sub-optimal ORR. The duration of stimulation, total amounts of gonadotropins administered, and fertilized oocytes were not significantly different among both groups (p-value >0.05).

Conclusion

this study has shown the factors associated with ORR in our setting to be basal FSH, prolactin, and obesity.

Efficacy and safety of follitropin delta for ovarian stimulation in vitro fertilization/ intracytoplasmic sperm injection cycles: a systematic review with meta-analysis

BACKGROUND

Follitropin delta is a novel recombinant follicle stimulating hormone preparation uniquely expressed in a human fetal retinal cell line by recombinant DNA technology. To date, no systematic review was available about the safety and the efficacy of the follitropin delta. The objective of this study was systematically reviewing the available literature and to provide updated evidence regarding the efficacy-safety profile of follitropin delta when compared to other gonadotropin formulations for ovarian stimulation in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles.

METHODS

An extensive search was performed to identify phase 1, phase 2 and phase 3 RCTs in humans focused on follitropin delta use for ovarian stimulation in IVF/ICSI cycles. The risk of bias and the overall quality of the evidence was analyzed. All data were extracted and analyzed using the intention-to-treat principle and expressed per woman randomized.

RESULTS

A total of 7 RCTs (1 phase 1 RCT, 2 phase 2 RCTs and 4 phase 3 RCTs) were included in the qualitative analysis, whereas data of three phase 3 RCTs were meta-analyzed. All trials compared personalized recombinant follitropin delta treatment versus conventional recombinant follitropin alfa/beta administration in potentially normo-responder patients who receive ovarian stimulation in GnRH antagonist IVF/ICSI cycles. No difference between two regimens was detected for clinical pregnancy rate [odds ratio (OR) 1.06; 95% confidence intervals (CI): 0.90, 1.24; P = 0.49; I2 = 26%], ongoing pregnancy rate (OR 1.15; 95%CI: 0.90, 1.46; P = 0.27; I2 = 40%), and live birth rate (OR 1.18; 95%CI: 0.89, 1.55; P = 0.25; I2 = 55%). No data were available regarding cumulative success rates. The rate of adoption of strategies to prevent ovarian hyperstimulation syndrome (OHSS) development (OR 0.45; 95%CI: 0.30, 0.66; P < 0.0001; I2 = 0%), and the rate of both early OHSS (OR 0.62; 95%CI: 0.43, 0.88; P = 0.008; I2 = 0%) and all forms of OHSS (OR 0.61; 95%CI: 0.44, 0.84; P = 0.003; I2 = 0%) were significantly lower in the group of patients treated with personalized follitropin delta treatment compared to those treated with conventional follitropin alfa/beta administration.

CONCLUSION

Personalized follitropin delta treatment is associated with a lower risk of OHSS compared to conventional follitropin alfa/beta administration in potentially normo-responder patients who receive ovarian stimulation in GnRH antagonist IVF/ICSI cycles. The absence of cumulative data does not allow definitive conclusions to be drawn regarding the comparison of the effectiveness of the two treatments.

PROTOCOL STUDY REGISTRATION

CRD42023470352 (available at http://www.crd.york.ac.uk/PROSPERO ).

Total Fertilization Failure: A Single Center Analysis

Our main objective was to identify the male and female parameters associated with total fertilization failure (TFF) in IVF with nonmasculine indications. The present work, IRB equivalent INS 63209, is a case-control study that evaluated all cases with TFF after conventional IVF at the Center for Human Reproduction from January 2010 to December 2019 (n = 154). As a control group, we analyzed all patients who did not experience fertilization failure after conventional IVF in the same period (n = 475). We evaluated various parameters, both male and female, assessed during infertility treatment, and only cases without masculine etiology (normal seminal parameters) were included. Ages (female and male) were not different between the groups. Moreover, AMH (anti-Müllerian hormone), semen volume, preprocessing concentration and preprocessing motility were not significantly different (P > 0.05). However, the number of collected oocytes (study versus control groups, median [25-75 interquartile]: 2 [1-5] and 5 [3-8]); MII (2 [1-4] and 5 [2-7]); and postprocessing motility (85 [70-90] and 90 [80-95]) were significantly different between both groups (P < 0.05). Furthermore, a logistic regression analysis including all significant data demonstrated that the number of collected oocytes was significantly related to IVF failure. Patients with fewer than 5 oocytes had an OR of - 1.37 (- 0.938 to - 1.827) for TFF after conventional IVF. Our results showed that a lower follicular response to controlled ovarian stimulation, evidenced by a decreased number of collected oocytes, was the most important parameter associated with IVF failure in nonmasculine infertility.

Effects of different gonadotropin preparations in GnRH antagonist protocol for patients with polycystic ovary syndrome during IVF/ICSI: a retrospective cohort study

Purpose

To compare the effects of recombinant FSH alfa (rFSH-alfa), rFSH-beta, highly purified human menopausal gonadotropin (HP-hMG) and urinary FSH (uFSH) in women with polycystic ovarian syndrome who have undertaken the GnRH antagonist protocol during IVF/ICSI treatment.

Method

A single-center retrospective cohort study including women with PCOS who received the GnRH antagonist protocol from January 2019 to July 2022 was conducted. Patients were divided into rFSH-alfa group, HP-hMG group, uFSH group, and rFSH-beta group, and the number of oocytes retrieved, clinical pregnancy rate of the fresh cycle (primary outcomes), embryo quality, and severe OHSS rate (secondary outcomes) were compared.

Results

No statistical differences were found among the four groups in fresh cycle clinical pregnancy rate (p=0.426), nor in the subgroup analyses. The HP-hMG group had a smaller number of oocytes retrieved and a higher high-quality D3 embryo rate than the three FSH groups (p<0.05). No statistical differences were found among the four groups in the severe OHSS rate (p=0.083).

Conclusion

For women with PCOS undergoing the GnRH antagonist protocol, the clinical pregnancy rates of fresh IVF/ICSI-ET cycle are similar for all four types of Gn. With a lower risk of OHSS and a similar number of high-quality and available embryos, HP-hMG may have an advantage in the PCOS population.

Children born after assisted reproduction more commonly carry a mitochondrial genotype associating with low birthweight

Children conceived through assisted reproductive technologies (ART) have an elevated risk of lower birthweight, yet the underlying cause remains unclear. Our study explores mitochondrial DNA (mtDNA) variants as contributors to birthweight differences by impacting mitochondrial function during prenatal development. We deep-sequenced the mtDNA of 451 ART and spontaneously conceived (SC) individuals, 157 mother-child pairs and 113 individual oocytes from either natural menstrual cycles or after ovarian stimulation (OS) and find that ART individuals carried a different mtDNA genotype than SC individuals, with more de novo non-synonymous variants. These variants, along with rRNA variants, correlate with lower birthweight percentiles, independent of conception mode. Their higher occurrence in ART individuals stems from de novo mutagenesis associated with maternal aging and OS-induced oocyte cohort size. Future research will establish the long-term health consequences of these changes and how these findings will impact the clinical practice and patient counselling in the future.

Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline

Ovarian hyperstimulation syndrome is a serious complication associated with assisted reproductive technology. This systematic review aims to identify who is at high risk for developing ovarian hyperstimulation syndrome, along with evidence-based strategies to prevent it and replaces the document of the same name last published in 2016.

Association of ambient air pollution and pregnancy rate among women undergoing assisted reproduction technology in Fujian, China: A retrospective cohort study

BACKGROUND

Previous studies have reported the impact of ambient air pollutants on assisted reproduction. They concentrated on highly polluted environments and individual pollutants. It is unclear whether these effects continue at lower levels and as mixed effects. We aimed to study the influence of lower pollutant concentrations on pregnancy rates and identify vulnerable populations.

METHODS

We conducted a retrospective cohort study involving 9465 patients with infertility who received treatment from a local hospital between 2015 and 2021. Daily average levels of six pollutants (PM2.5, PM10, NO2, CO, SO2, and O3) were collected from air quality monitoring stations. We employed generalized linear regression models (logistic, linear, and lasso), weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR) to assess the impact of pollutants on pregnancy rates. Additionally, stratified analyses were performed to identify potentially vulnerable populations.

RESULTS

Findings from the generalized linear models revealed a significant negative correlation between interquartile range increment exposure to PM2.5 (OR = 1.17, 95 % CI = 1.09-1.26), PM10 (OR = 1.18, 95 % CI = 1.11-1.26), NO2 (OR = 1.21, 95 % CI = 1.13-1.30), CO (OR = 1.02, 95 % CI = 1.00-1.03), SO2 (OR = 1.11, 95 % CI = 1.05-1.17) and pregnancy rate when considering the effects of individual pollutants. The WQS index exhibited a negative correlation with pregnancy rates and the number of oocytes retrieved (aOR = 1.20, 95 % CI = 1.08-1.34). BKMR analyses indicated an overall significant trend of decreasing pregnancy rates as pollutant concentrations increased across percentiles. Stratified analysis unveiled heightened sensitivity to pollutants among individuals aged ≥35 years.

CONCLUSIONS

By comparing results obtained from diverse models, we observed that exposure to lower levels of air pollutants led to decreased pregnancy rates. Notably, PM10, NO2, SO2, and CO emerged as the four most prominent pollutants in this context. Moreover, stratified analyses highlighted that individuals aged ≥35 years exhibited heightened susceptibility to pollutants.

Efficacy and safety of follitropin delta versus follitropin alpha/beta in infertility treatment: A systematic review and meta-analysis

Background

Follitropin δ may be an alternative to conventional follitropin α/β for controlled ovarian stimulation (COS) within assisted reproductive treatment (ART), but its efficacy and safety remain unknown. We performed a random-effects meta-analysis to compare the efficacy and safety of follitropin δ and follitropin α/β.

Methods

We searched randomized controlled trials comparing follitropin δ and follitropin α/β using MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and WHO-ITCRP on December 14, 2022. The primary outcomes were the live birth rate and the incidence of moderate or severe ovarian hyperstimulation syndrome (OHSS). The certainty of the evidence was assessed using the grading of recommendations assessment, development, and evaluation approach. The protocol was registered on the Open Science Framework.

Results

Three studies involving 2682 participants were included in our meta-analysis. The results indicated that follitropin δ may result in little to no difference in live birth rates (risk ratio [RR], 1.12; 95% confidence interval [CI], 0.91-1.38; low certainty) and the incidence of moderate or severe OHSS (RR, 0.78; 95% CI, 0.48-1.26; low certainty) compared with follitropin α/β.

Conclusion

Follitropin δ may result in little to no difference in COS compared with follitropin α/β, especially in terms of live births and safety.

Cut-off point of mature oocyte for routine clinical application of rescue IVM: a retrospective cohort study

BACKGROUND

The rescue in vitro mature(Rescue IVM) technique allows the use of immature oocytes collected in conventional COH to obtain more mature oocytes for fertilization through in vitro maturation. Some studies have shown that Rescue IVM could improve clinical outcomes in patients undergoing IVF/ICSI, but the effectiveness and the indications for the clinical application of this technique remain controversial. It remains to be studied whether Rescue IVM should be universally applied in all conventional IVF/ICSI cycles.

METHOD

This is a large retrospective cohort study that included a total of 22,135 female patients undergoing their first IVF treatment cycles. The effect of the number of mature oocytes(metaphaseII[MII]) on the cumulative live birth rate was investigated in a population with routine IVF/ICSI first. The receiver operating characteristic curve(ROC) analysis was used to explore the cut-off point of the number of MII affecting CLBR. Secondly, Patients undergoing ICSI with Rescue IVM were included in the analysis with those who underwent ICSI only during the same period, grouped according to the MII cut-off values. Multi-factor binary logistic regression and inverse probability weighting (IPW) were used to investigate whether Rescue IVM influenced the final cumulative live birth rate(CLBR).

RESULTS

The CLBR increased with the number of MIIoocytes (P < 0.001). The ROC analysis showed the cut-off point for the number of MIIoocytes to have a significant effect on CLBR was 9 (sensitivity 0.715, specificity 0.656). Furthermore, 912 patients who underwent ICSI with Rescue IVM were included and compared to those who underwent ICSI only during the same period, and found Rescue IVM significantly increased the number of available MIIoocytes. For patients with MII numbers < 9, Rescue IVM significantly improves their clinical pregnancy rate(55.6% vs. 46.7%, P = 0.001) and CLBR(65.4% vs. 48.1%, P < 0.001), but not for those patients with MII numbers ≥ 9.

CONCLUSION

This study further clarifies the candidates for the application of Rescue IVM technique: patients with an MII oocytes < 9 in a conventional IVF/ICSI cycle. In contrast, it is not necessary for patients who already have sufficient mature oocytes(≥ 9), to avoid over-medication.

The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

Predicting the number of oocytes retrieved from controlled ovarian hyperstimulation with machine learning

STUDY QUESTION

Can machine learning predict the number of oocytes retrieved from controlled ovarian hyperstimulation (COH)?

SUMMARY ANSWER

Three machine-learning models were successfully trained to predict the number of oocytes retrieved from COH.

WHAT IS KNOWN ALREADY

A number of previous studies have identified and built predictive models on factors that influence the number of oocytes retrieved during COH. Many of these studies are, however, limited in the fact that they only consider a small number of variables in isolation.

STUDY DESIGN, SIZE, DURATION

This study was a retrospective analysis of a dataset of 11,286 cycles performed at a single centre in France between 2009 and 2020 with the aim of building a predictive model for the number of oocytes retrieved from ovarian stimulation. The analysis was carried out by a data analysis team external to the centre using the Substra framework. The Substra framework enabled the data analysis team to send computer code to run securely on the centre's on-premises server. In this way, a high level of data security was achieved as the data analysis team did not have direct access to the data, nor did the data leave the centre at any point during the study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The Light Gradient Boosting Machine algorithm was used to produce three predictive models: one that directly predicted the number of oocytes retrieved and two that predicted which of a set of bins provided by two clinicians the number of oocytes retrieved fell into. The resulting models were evaluated on a held-out test set and compared to linear and logistic regression baselines. In addition, the models themselves were analysed to identify the parameters that had the biggest impact on their predictions.

MAIN RESULTS AND THE ROLE OF CHANCE

On average, the model that directly predicted the number of oocytes retrieved deviated from the ground truth by 4.21 oocytes. The model that predicted the first clinician's bins deviated by 0.73 bins whereas the model for the second clinician deviated by 0.62 bins. For all models, performance was best within the first and third quartiles of the target variable, with the model underpredicting extreme values of the target variable (no oocytes and large numbers of oocytes retrieved). Nevertheless, the erroneous predictions made for these extreme cases were still within the vicinity of the true value. Overall, all three models agreed on the importance of each feature which was estimated using Shapley Additive Explanation (SHAP) values. The feature with the highest mean absolute SHAP value (and thus the highest importance) was the antral follicle count, followed by basal AMH and FSH. Of the other hormonal features, basal TSH, LH, and testosterone levels were similarly important and baseline LH was the least important. The treatment characteristic with the highest SHAP value was the initial dose of gonadotropins.

LIMITATIONS, REASONS FOR CAUTION

The models produced in this study were trained on a cohort from a single centre. They should thus not be used in clinical practice until trained and evaluated on a larger cohort more representative of the general population.

WIDER IMPLICATIONS OF FINDINGS

These predictive models for the number of oocytes retrieved from COH may be useful in clinical practice, assisting clinicians in optimizing COH protocols for individual patients. Our work also demonstrates the promise of using the Substra framework for allowing external researchers to provide clinically relevant insights on sensitive fertility data in a fully secure, trustworthy manner and opens a number of exciting avenues for accelerating future research.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the French Public Bank of Investment as part of the Healthchain Consortium. T.Fe., C.He., J.C., C.J., C.-A.P., and C.Hi. are employed by Apricity. C.Hi. has received consulting fees and honoraria from Vitrolife, Merck Serono, Ferring, Cooper Surgical, Dibimed, Apricity, and Fairtility and travel support from Fairtility and Vitrolife, participates on an advisory board for Merck Serono, was the founder and organizer of the AI Fertility conference, has stock in Aria Fertility, TMRW, Fairtility, Apricity, and IVF Professionals, and received free equipment from Planar in exchange for first user feedback. C.J. has received a grant from BPI. J.C. has also received a grant from BPI, is a member of the Merck AI advisory board, and is a board member of Labelia Labs. C.He has a contract for medical writing of this manuscript by CHU Nantes and has received travel support from Apricity. A.R. haș received honoraria from Ferring and Organon. T.Fe. has received a grant from BPI.

TRIAL REGISTRATION NUMBER

N/A.

Reproductive history does not compromise subsequent live birth and perinatal outcome following in-vitro fertilization: analysis of 25 329 first frozen-thawed embryo transfer cycles without preimplantation genetic testing for aneuploidy

OBJECTIVE

To investigate the effect of women's reproductive history on live-birth rate and perinatal outcome after first frozen-thawed embryo transfer (FET) without preimplantation genetic testing for aneuploidy.

METHODS

This was a retrospective cohort study of women who had undergone their first FET cycle between January 2014 and December 2020 at a university-affiliated fertility center. No transferred embryo underwent preimplantation genetic testing for aneuploidy. The women were categorized into five groups based on their reproductive history: no previous pregnancy; previous termination of pregnancy (TOP); previous pregnancy loss; previous ectopic pregnancy (EP); and previous live birth. The women with no previous pregnancy were considered as the reference group. The primary outcome was the live-birth rate and secondary endpoints included rates of positive pregnancy test, clinical pregnancy, pregnancy loss and EP as well as perinatal outcomes such as birth weight and preterm birth. Multivariable logistic regression analyses were used to control for a number of potential confounders, including age, body mass index, education level, duration and cause of infertility, insemination method, type of endometrial preparation, number of embryos transferred, embryo developmental stage, quality of the embryos transferred, year of treatment and endometrial thickness. Additionally, propensity score matching (PSM) was used to check the robustness of the main findings.

RESULTS

In total, 25 329 women were included in the final analysis. On univariate analysis, each reproductive-history type except for previous EP was significantly associated with worse pregnancy outcome following in-vitro fertilization (IVF), including rates of positive pregnancy test, clinical pregnancy, pregnancy loss and live birth, when compared with the group of women with no previous pregnancy. However, after correcting for several potential confounders, the differences in rates of live birth, pregnancy loss, positive pregnancy test and clinical pregnancy were no longer significant between the study and control groups on multivariable regression models, while the risk of EP after embryo transfer was elevated among women with a previous TOP or EP. There was no increased risk of adverse perinatal outcome associated with reproductive history compared with the control group. Notably, similar results were obtained from the PSM models, confirming the robustness of the main findings.

CONCLUSION

Relative to women without a previous pregnancy, those with a prior TOP, pregnancy loss, EP or live birth did not have compromised live-birth rate or perinatal outcomes following FET without preimplantation genetic testing for aneuploidy, with the exception of an increased risk of EP in those with prior TOP or EP. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Comparative effectiveness of gonadotropins used for ovarian stimulation during assisted reproductive technologies (ART) in France: A real-world observational study from the French nationwide claims database (SNDS)

This comparative non-interventional study using data from the French National Health Database (Système National des Données de Santé) investigated real-world (cumulative) live birth outcomes following ovarian stimulation, leading to oocyte pickup with either originator recombinant human follicle-stimulating hormone (r-hFSH) products (alfa or beta), r-hFSH alfa biosimilars, or urinaries including mainly HP-hMG (menotropins), and marginally u-hFSH-HP (urofollitropin). Using data from 245,534 stimulations (153,600 women), biosimilars resulted in a 19% lower live birth (adjusted odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.86) and a 14% lower cumulative live birth (adjusted hazard ratio (HR) 0.86, 95% CI 0.82-0.89); and urinaries resulted in a 7% lower live birth (adjusted OR 0.93, 95% CI 0.90-0.96) and an 11% lower cumulative live birth (adjusted HR 0.89, 95% CI 0.87-0.91) versus originator r-hFSH alfa. Results were consistent across strata (age and ART strategy), sensitivity analysis using propensity score matching, and with r-hFSH alfa and beta as the reference group.

Current Understanding of and Future Directions for Endometriosis-Related Infertility Research with a Focus on Ferroptosis

BACKGROUND

To date, the development of therapy for endometriosis and disease-related infertility remains a major challenge. Iron overload caused by periodic bleeding is a hallmark of endometriosis. Ferroptosis is an iron- and lipid-reactive oxygen species-dependent type of programmed cell death that is distinct from apoptosis, necrosis, and autophagy. This review summarizes the current understanding of and future directions for the research and treatment of endometriosis and disease-related infertility, with the main focus on the molecular basis of ferroptosis in endometriotic and granulosa cells.

METHODS

Papers published between 2000 and 2022 in the PubMed and Google Scholar databases were included in this review.

RESULTS

Emerging evidence suggests that ferroptosis is closely linked to the pathophysiology of endometriosis. Endometriotic cells are characterized by ferroptosis resistance, whereas granulosa cells remain highly susceptible to ferroptosis, suggesting that the regulation of ferroptosis is utilized as an interventional target for research into the treatment of endometriosis and disease-related infertility. New therapeutic strategies are urgently needed to efficiently kill endometriotic cells while protecting granulosa cells.

CONCLUSIONS

An analysis of the ferroptosis pathway in in vitro, in vivo, and animal research enhances our understanding of the pathogenesis of this disease. Here, we discuss the role of ferroptosis modulators as a research approach and potential novel treatment for endometriosis and disease-related infertility.

Live birth rates following individualized dosing algorithm of follitropin delta in a long GnRH agonist protocol

PURPOSE

To explore the efficacy and safety of individualized follitropin delta dosing, based on serum anti-Müllerian hormone (AMH) concentration and bodyweight, in a long gonadotropin-releasing hormone (GnRH) agonist protocol.

METHODS

Clinical outcomes after one treatment cycle are reported in women with AMH: 5-35 pmol/L. Oocytes were inseminated by intracytoplasmic sperm injection, blastocyst transfer was on Day 5 and remaining blastocysts were cryopreserved. Data collection included live births and neonatal health follow-up for all fresh/frozen transfers performed within one year after treatment allocation.

RESULTS

In total, 104 women started stimulation, of whom 101 had oocyte recovery and 92 had blastocyst transfer. The average daily dose of follitropin delta was 11.0 ± 1.6 µg and the duration of stimulation was 10.3 ± 1.6 days. The mean number of oocytes was 12.5 ± 6.4, the mean number of blastocysts was 5.1 ± 3.4, and 85% had at least one good-quality blastocyst. Following mostly single blastocyst transfer (95%), the ongoing pregnancy rate was 43%, the live-birth rate was 43%, and the cumulative live-birth rate was 58% per started stimulation. There were 6 cases of early OHSS (5.8%) graded as mild (n = 3) and moderate (n = 3) and 6 cases of late OHSS (5.8%) graded as moderate (n = 3) and severe (n = 3).

CONCLUSION

In this first evaluation of the individualized follitropin delta dosing in a long GnRH agonist protocol, the cumulative live-birth rate was high. A randomized trial comparing follitropin delta in a long GnRH agonist protocol versus in a GnRH antagonist protocol should provide further insight into the efficacy and safety of this treatment option.

TRIAL REGISTRATION NUMBER

NCT03564509; June 21, 2018.

Number of oocytes and IVF outcomes: Real-world evidence

Randomized controlled trials (RCTs) are gold standard to study the effect of an intervention and establish causation between the treatment and outcomes. However, RCTs have the disadvantage of being expensive, entailing high resource investments and involving only selected patient populations under experimental settings. Real-world evidence (RWE) from real-world data (RWD) involves a heterogenous patient population in real-world settings. RWE is less expensive and quicker than RCTs; it can provide complimentary evidence if methodological challenges, such as residual confounding and susceptibility to bias, are considered when interpreting the findings. This review examines RWE regarding the association between the number of oocytes following ovarian stimulation and IVF outcomes into shaping current IVF practices.

Ovarian Stimulation with FSH Alone versus FSH plus a GnRH Antagonist for Elective Freezing in an Oocyte Donor/Recipient Programme: A Protocol for a Pilot Multicenter Observational Study

Preliminary data have shown that it is possible to attempt in vitro fertilization (IVF) treatment in fresh cycles without the use of a gonadotropin-releasing hormone (GnRH) antagonist or any other medication to prevent the luteinizing hormone (LH) surge during ovarian stimulation. To date, there is no information on this topic in the context of a prospective controlled trial. However, as prevention of the LH surge is an established procedure in fresh cycles, the question is whether such a study can be performed in frozen cycles. We aim to perform a pilot study in order to compare the efficacy of a protocol using FSH alone with that of a protocol using follicle-stimulating hormone (FSH) plus a GnRH antagonist for controlled ovarian hyperstimulation (COH) in cycles of elective freezing in the context of a donor/recipient program. This is a seven-center, two-arm prospective pilot cohort study conducted at the respective Assisted Reproductive Units in Greece. The hypothesis to be tested is that an ovarian stimulation protocol that includes FSH alone without any LH surge prevention regimens is not inferior to a protocol including FSH plus a GnRH antagonist in terms of the clinical outcome in a donor/recipient model. The results of the present study are expected to show whether the addition of the GnRH antagonist is necessary in terms of the frequency of LH secretory peaks and progesterone elevations >1 ng/mL during the administration of the GnRH antagonist according to the adopted frequency of blood sampling in all Units.

Association between the number of oocytes and cumulative live birth rate: A systematic review

The available literature is controversial regarding the association between the number of oocytes retrieved and the cumulative live birth rate (CLBR). Although some authors report a continuous increase in the CLBR with the number of oocytes retrieved, others have found a plateau. A systematic review was conducted, including all eligible studies published until June 2022, to determine the optimal number of oocytes retrieved to maximize the CLBR. We found a positive association between the number of oocytes and the CLBR. However, this association varies according to patients' age. While in patients younger than 35 years, little benefit is derived from increasing the number of oocytes above 25-30, in patients older than 35 years, the number of oocytes seems to improve the CLBR until the extreme of reproductive age is reached. In women aged 44 years or older, the CLBR will be consistently low, independent of the number of oocytes retrieved.

Treatment safety of ART cycles with extremely high oestradiol concentrations using GnRH agonist trigger

RESEARCH QUESTION

Are IVF treatments with extremely high peak oestradiol levels and gonadotrophin releasing hormone (GnRH) agonist trigger associated with higher complication rates?

DESIGN

A retrospective cohort study including patients from two large medical centres treated between 2019 and 2021. A study group with extremely high peak oestradiol levels (≥20,000 pmol/l on the day of ovarian stimulation, or ≥15,000 pmol/l on the previous day) and a control group with normal range oestradiol levels (3000-12000 pmol/l) that received GnRH agonist triggering. Patients were surveyed about complaints and medical care related to ovum retrieval and medical files were reviewed. Major complication rates and the need for medical assistance were compared.

RESULTS

Several differences between the study and control group were observed because of the study design: mean age was 33.01 ± 5.14 versus 34.57 ± 4.52 (P < 0.001), mean peak oestradiol levels was 26645.34 ± 8592.57 pmol/l versus 7229.75 ± 2329.20 pmol/l (P < 0.001), and mean number of oocytes were 27.55 ± 13.46 versus 11.67 ± 5.76 (P < 0.001) for the study and control group, respectively. Major complications and hospitalization rates were similar between the study and control groups (three [1.25%] versus one [0.48%]; P = 0.62 and three [1.25%] versus two [0.96%]; P = 1.0, respectively). Thirty-six patients (15.1%) in the study group and 11 (5.3%) in the control group sought medical care after retrieval, mostly due to abdominal pain, without the need for further workup or hospitalization (P < 0.001).

CONCLUSIONS

Extremely high oestradiol levels were not associated with thromboembolic events, higher major complication or hospitalization rates, and therefore may be considered safe. Nevertheless, patients may be informed of possible higher rates of discomfort, mostly abdominal pain. Larger studies are warranted to confirm our results.

Treatment algorithms for high responders: What we can learn from randomized controlled trials, real-world data and models

A high ovarian response to conventional ovarian stimulation (OS) is characterized by an increased number of follicles and/or oocytes compared with a normal response (10-15 oocytes retrieved). According to current definitions, a high response can be diagnosed before oocyte pick-up when >18-20 follicles ≥11-12 mm are observed on the day of ovulation triggering; high response can be diagnosed after oocyte pick-up when >18-20 oocytes have been retrieved. Women with a high response are also at high risk of early ovarian hyper-stimulation syndrome (OHSS)/or late OHSS after fresh embryo transfers. Women at risk of high response can be diagnosed before stimulation based on several indices, including ovarian reserve markers (anti-Müllerian hormone [AMH] and antral follicle count [AFC], with cutoff values indicative of a high response in patients with PCOS of >3.4 ng/mL for AMH and >24 for AFC). Owing to the high proportion of high responders who are at the risk of developing OHSS (up to 30%), this educational article provides a framework for the identification and management of patients who fall into this category. The risk of high response can be greatly reduced through appropriate management, such as individualized choice of the gonadotropin starting dose, dose adjustment based on hormonal and ultrasound monitoring during OS, the choice of down-regulation protocol and ovulation trigger, and the choice between fresh or elective frozen embryo transfer. Appropriate management strategies still need to be defined for women who are predicted to have a high response and those who have an unexpected high response after starting treatment.

Determinants of Severe Late Ovarian Hyperstimulation Syndrome in Fresh Embryo Transfer Cycles Based on Integration of Decision Tree Classification and Conditional Logistic Regression

Background: To explore possible predictors of severe late ovarian hyperstimulation syndrome (SL-OHSS) in fresh embryo transfer cycles. Methods: We conducted a historical cohort study in a Chinese tertiary hospital from January 2017 to December 2019, with a total of 6931 women who had the first fresh embryo transfer included. SL-OHSS was defined as severe symptoms of OHSS occurring 12–17 days after ovulation triggering. Possible determinants of the occurrence of SL-OHSS were identified by a detection decision tree, effects of which were estimated by conditional logistic regression and restricted cubic spline. Results: Elevated estradiol (E2) on the day of ovulation triggering and elevated Anti-Mullerian hormone (AMH) were associated with an increased risk of SL-OHSS (p < 0.001). Women with an E2 on trigger day of ≥3320.2 pg/mL (odds ratio (OR): 2.20; 95% confidence interval (CI): 1.03–4.68), or with an E2 on trigger day of <3320.2 pg/mL and an AMH of ≥4.62 ng/mL (OR: 5.44; 95% CI: 2.29–12.90), had an increased risk of SL-OHSS compared to their counterparts. Women with E2 on trigger day of >3320.2 pg/mL and AMH of >4.62 ng/mL had the highest risk of SL-OHSS (OR: 13.20; 95% CI: 3.87–45.02) when compared with E2 on trigger day of ≤3320.2 pg/mL and AMH of ≤4.62 ng/mL. This association was not linear. Conclusions: Serum E2 concentration on trigger day and AMH levels at baseline may predict SL-OHSS occurrence in fresh embryo transfer cycles. These biomarkers may be valuable in determining the optimum transfer strategy to limit the occurrence of SL-OHSS.

Correlation of IVF outcomes and number of oocytes retrieved: a UK retrospective longitudinal observational study of 172 341 non-donor cycles

OBJECTIVE

How do numbers of oocytes retrieved per In vitro fertilisation (IVF) cycle impact on the live birth rate (LBR) and multiple gestation pregnancy (MGP) rates?

DESIGN

Retrospective observational longitudinal study.

SETTING

UK IVF clinics.

POPULATION

Non-donor IVF patients.

MAIN OUTCOME MEASURES

LBR per IVF cycle and MGP levels against number of oocytes retrieved into subgroups: 0, 1-5, 6-15, 16-25, 26-49 oocytes and 50+ oocytes. Relative risk (RR) and 95% CIs were calculated for each group against the intermediate responder with '6-15 oocytes collected'.

RESULTS

From 172 341 attempted fresh oocyte retrieval cycles, the oocyte retrieved was: 0 in 10 148 (5.9%) cycles from 9439 patients; 1-5 oocytes in 42 574 cycles (24.7%); 6-15 oocytes in 91 797 cycles (53.3%); 16-25 oocytes in 23 794 cycles (13.8%); 26-49 oocytes in 3970 cycles (2.3%); ≥50 oocytes in 58 cycles (0.033%). The LBRs for the 1-5, 6-15, 16-25 and 26-49 subgroups of oocytes retrieved were 17.2%, 32.4%, 35.3% and 18.7%, respectively. The RR (95% CI) of live birth in comparison to the intermediate group (6-15) for 1-5, 16-25 and 26-49 groups was 0.53 (0.52 to 0.54), 1.09 (1.07 to 1.11) and 0.58 (0.54 to 0.62), respectively. The corresponding MGP rates and RR were 9.2%, 11.0%, 11.4% and 11.3%, respectively and 0.83 (0.77 to 0.90), 1.04 (0.97 to 1.11) and 1.03 (0.84 to 1.26), respectively.

CONCLUSION

There was only limited benefit in LBR beyond the 6-15 oocyte group going to the 16-25 oocytes group, after which there was significant decline in LBR. The MGP risk was lower in 1-5 group.

Metaphase-II oocyte competence is unlinked to the gonadotrophins used for ovarian stimulation: a matched case-control study in women of advanced maternal age

PURPOSE

An impact of different gonadotrophins selection for ovarian stimulation (OS) on oocyte competence has yet to be defined. In this study, we asked whether an association exists between OS protocol and euploid blastocyst rate (EBR) per metaphase-II (MII) oocytes.

METHODS

Cycles of first preimplantation genetic testing for aneuploidies conducted by women ≥ 35 years old with their own metaphase-II oocytes inseminated in the absence of severe male factor (years 2014-2018) were clustered based on whether recombinant FSH (rec-FSH) or human menopausal gonadotrophin (HMG) was used for OS, then matched for the number of fresh inseminated eggs. Four groups were outlined: rec-FSH (N = 57), rec-FSH plus rec-LH (N = 55), rec-FSH plus HMG (N = 112), and HMG-only (N = 127). Intracytoplasmic sperm injection, continuous blastocyst culture, comprehensive chromosome testing to assess full-chromosome non-mosaic aneuploidies and vitrified-warmed euploid single embryo transfers (SETs) were performed. The primary outcome was the EBR per cohort of MII oocytes. The secondary outcome was the live birth rate (LBR) per first SETs.

RESULTS

Rec-FSH protocol was shorter and characterized by lower total gonadotrophin (Gn) dose. The linear regression model adjusted for maternal age showed no association between the Gn adopted for OS and EBR per cohort of MII oocytes. Similarly, no association was reported with the LBR per first SETs, even when adjusting for blastocyst quality and day of full blastulation.

CONCLUSION

In view of enhanced personalization in OS, clinicians shall focus on different endpoints or quantitative effects related to Gn action towards follicle recruitment, development, and atresia. Here, LH and/or hCG was administered exclusively to women with expected sub/poor response; therefore, we cannot exclude that specific Gn formulations may impact patient prognosis in other populations.

Does the outcome of fresh embryo transfer affect the outcome of subsequent thawed embryo transfers from sibling oocytes in patients that utilized all their embryos?

The association between fresh embryo transfer (ET) outcome and the subsequent frozen-thawed (FET) cycles that follow is not clear, mainly because of incomplete embryo cohort utilization. The aim of this study was to determine if the outcome of a fresh ET affects the frozen cumulative clinical pregnancy (CP) and live birth (LB) rates resulting from the utilization of all surplus embryos from sibling oocytes. Outcome measures were the FET cumulative CP and LB rates. Multivariate logistic regression was performed for the frozen cumulative CP rate and adjusted for age, the number of oocytes, fresh ET outcome and other confounders. A total of 1313 cycles met the inclusion criteria. The FET cumulative CP and LB rates were not affected by the outcome of the fresh ET. The FET cumulative CP rate increased with the number of oocytes collected regardless of whether a pregnancy was achieved in the fresh cycle or not. In multivariate analysis, age (OR = 0.96, 95% CI 0.94-0.98), protocol (OR = 0.13, 95% CI 0.03-0.57) and the number of oocytes (OR = 1.05, 95% CI 1.02-1.07) were associated with the frozen cumulative CP rate. It is concluded that fresh ET does not impact the outcome of the vitrified-thawed embryos from the same oocyte cohort.

Effects of controlled ovarian stimulation on thyroid function during pregnancy

Controlled ovarian stimulation (COS) is a major component of assisted reproductive technologies. Clinically, it has been observed that, some women experience changes in thyrotropin levels following COS, which then bring about subclinical hypothyroidism and may adversely affect conception. Studies have also shown that the specific degree as well as the tendency of changes in thyroid function vary with differences in thyroid function before pregnancy, thyroid autoimmunity, the COS regimen, and the observation time point. However, the associated pathophysiological mechanism of the effects of COS on pregnancy has not yet been fully elucidated. This may be because increased estradiol levels, caused by COS, induce increased levels of thyroxine-binding globulin, resulting in a decrease in free thyroxine (FT4) level and an increase in TSH level. Conversely, it has also been observed that human chorionic gonadotropin (hCG) can act directly on thyroid cells, exerting opposite effects on FT4 and TSH levels. Additionally, the effects of COS on thyroid function may be more pronounced, especially in women with autoimmune thyroid disease or thyroid dysfunction before pregnancy, ultimately leading to subclinical hypothyroidism. Here, we review recent research progress regarding the effects of COS on thyroid function during pregnancy.

IL-6 of follicular fluid and outcome of in vitro fertilization

The quality of an oocyte is influenced by its microenvironment, which includes cumulus cells and follicular fluid, as well as cells of the immune system and their products. The ovarian interleukins, which are secreted by the granulosa cells and other immune cells within the ovaries and follicles, regulate various functions between the cells. IL-6 is a cytokine that is present in the follicular fluid and may affect the quality of oocytes. There are some inconsistencies in the literature regarding the concentration of interleukin 6 in the follicular fluid. The main objective of this study was to examine whether the concentration of interleukin 6 in the follicular fluid affects the outcome of IVF. This study involved 83 patients who underwent IVF. Follicular fluid was used as the biological material for the analysis. Examination of the obtained follicular fluid and collection of oocytes under a stereomicroscope was performed in the embryological laboratory. The concentration of IL-6 in the follicular fluid was analyzed. IVF and ICSI methods were used as the fertilization methods. Pregnancy was confirmed by the positive serum β-hCG level. The software package SPSS 20 was used for statistical data processing. Analysis of the follicular fluid samples showed a correlation between the concentration of IL-6 in the follicular fluid and the outcome of IVF. The concentration of IL-6 in the follicular fluid was higher in patients with confirmed pregnancy (9.55 ± 7.47 ng/ml). Based on our results, we conclude that the concentration of IL-6 affects the outcome of IVF. If the range of IL-6 concentration is between 3,67 ng/ml and 10 ng/ml, we can expect good IVF outcome with vital pregnancy.

Choosing Wisely Canada: Canadian fertility and andrology society's list of top items physicians and patients should question in fertility medicine

PURPOSE

To create a Choosing Wisely Canada list of the top 5 diagnostic and therapeutic interventions that should be questioned in Reproductive Endocrinology and Infertility in Canada.

METHODS

The Canadian Fertility and Andrology Society (CFAS) National Working Group developed an initial list of recommendations of diagnostic and therapeutic interventions that are commonly used, but are not supported by evidence, and could expose patients to unnecessary harm. These were chosen based on their prevalence, cost, potential for harm, and quality of supporting evidence. A modified Delphi consensus was used over 5 rounds to generate ideas, review supporting evidence, assess clinical relevance, estimate recommendation impact and narrow the recommendations list to 5 items.

RESULTS

Fifty unique ideas were first proposed by the working group, and after 5 rounds including a survey of Canadian Fertility and Andrology Society (CFAS) members, the final list of recommendations was created, including topics related to unnecessary investigations and interventions for patients with infertility and recurrent pregnancy loss, and those undergoing IVF. In this article, we describe not only the Delphi process used to determine the list, but also provide a summary of the evidence behind each of the final recommendations.

CONCLUSIONS

The list of five recommendations highlights opportunities to initiate conversations between clinicians and patients about the risks, benefits, harms and costs of unnecessary fertility treatments and procedures in a Canadian context.

Algorithm-based individualization methodology of the starting gonadotropin dose in IVF/ICSI and the freeze-all strategy prevent OHSS equally in normal responders: a systematic review and network meta-analysis of the evidence

PURPOSE

Ovarian hyperstimulation syndrome (OHSS) represents a rare but dangerous condition associated with controlled ovarian stimulation (COS) in IVF/ICSI. Over the last decades, many strategies have been introduced into clinical practice with the objective of preventing this potentially life-threatening condition. Among these, the freeze-all policy has gained great popularity, thanks to improvements in vitrification. Nevertheless, not all clinics have adequate skills in vitrification procedures and patients may be dissatisfied with a longer time to pregnancy.

METHODS

This study is a systematic review and network meta-analysis of randomized controlled trials comparing different strategies of ovarian stimulation in IVF/ICSI cycles (freeze-all policy, algorithm-based individualization of the starting dose, experience-based individualization of the starting dose, standard dose) in terms of reduction of OHSS, in normal responders.

RESULTS

The results indicate that only the algorithm-based individualization of the starting gonadotropin dose reduces OHSS similarly to the freeze-all strategy.

CONCLUSION

Albeit in the era of the freeze-all policy, the personalization of the starting gonadotropin dose obtained by the use of algorithms should be pursued as a valid and safe option for IVF.

Second stimulation in the same ovarian cycle: an option to fully-personalize the treatment in poor prognosis patients undergoing PGT-A

PURPOSE

Our primary objective was to assess whether immediately undergoing a second stimulation in the same ovarian cycle (DuoStim) for advanced-maternal-age and/or poor-ovarian-reserve (AMA/POR) patients obtaining ≤ 3 blastocysts for preimplantation-genetic-testing-for-aneuploidies (PGT-A) is more efficient than the conventional-approach.

METHODS

All AMA/POR patients obtaining ≤ 3 blastocysts after conventional-stimulation between 2017 and 2019 were proposed DuoStim, and 143 couples accepted (DuoStim-group) and were matched for the main confounders to 143 couples who did not accept (conventional-group). GnRH-antagonist protocol with recombinant-gonadotrophins and agonist trigger, intra-cytoplasmatic-sperm-injection (ICSI) with ejaculated sperm, PGT-A and vitrified-warmed euploid single-blastocyst-transfer(s) were performed. The primary outcome was the cumulative-live-birth-delivery-rate per intention-to-treat (CLBdR per ITT) within 1 year. If not delivering, the conventional-group had 1 year to undergo another conventional-stimulation. A cost-effectiveness analysis was also conducted.

RESULTS

The CLBdR was 10.5% in the conventional-group after the first attempt. Only 12 of the 128 non-pregnant patients returned (165 ± 95 days later; drop-out = 116/128,90.6%), and 3 delivered. Thus, the 1-year CLBdR was 12.6% (N = 18/143). In the DuoStim-group, the CLBdR was 24.5% (N = 35/143; p = 0.01), 2 women delivered twice and 13 patients have other euploid blastocysts after a LB (0 and 2 in the conventional-group). DuoStim resulted in an incremental-cost-effectiveness-ratio of 23,303€. DuoStim was costlier and more effective in 98.7% of the 1000 pseudo-replicates generated through bootstrapping, and the cost-effectiveness acceptability curves unveiled that DuoStim would be more cost-effective than the conventional-approach at a willingness-to-pay threshold of 23,100€.

CONCLUSIONS

During PGT-A treatments in AMA/POR women, DuoStim can be suggested in progress to rescue poor blastocyst yields after conventional-stimulation. It might indeed prevent drop-out or further aging between attempts.