Cumulative live birth rates in low-prognosis women

Association between female waist-hip ratio and live birth in patients undergoing in vitro fertilization: a retrospective cohort study

Background

Maternal obesity is associated with adverse pregnancy outcomes. It negatively affects IVF/ICSI outcomes and offspring health. However, it is unclear whether waist-hip ratio (WHR) has an impact on outcomes of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles.

Methods

A retrospective cohort study screened 943 patients who underwent IVF/ICSI treatment between February and June 2020 in Shanghai, China, and 828 patients were finally included in the analyses. The body weight, height, waist circumference and hip circumference were measured before ovarian stimulation, and their IVF/ICSI outcomes were followed up. The cut-off point of WHR was determined by the area under the receiver operating characteristic (ROC) curve. Live birth rate from the first embryo transfer cycle was the primary outcome. The secondary outcomes included cumulative live birth, miscarriage rate and birthweight.

Results

Women with relatively high WHR (≥0.783) showed lower live birth rate (adjusted odds ratio (aOR): 0.657, 95%CI: 0.466-0.926), lower cumulative live birth rate (aOR: 0.580, 95%CI: 0.413-0.814), and higher miscarriage rate (aOR=2.865, 95%CI: 1.300-6.316) as compared with those with low WHR (<0.783), independently of BMI. Joint WHR and BMI analyses showed that, compared with the reference group (those with low WHR and normal weight), those with high WHR and normal BMI had lower live birth rate (aOR=0.653, 95%CI: 0.447-0.954) and cumulative live birth rate (aOR=0.600, 95%CI: 0.413-0.872), and higher miscarriage rate (aOR=2.865, 95%CI: 1.229-6.676), Whereas the patients with both high WHR and high BMI only showed a significant lower cumulative live birth rate (aOR=0.612, 95%CI: 0.404-0.926). Moreover, there was no significant association between BMI and pregnancy outcomes, or between maternal WHR and birth weights.

Conclusions

Our results demonstrated that higher WHR was associated with lower fecundability in women undergoing IVF/ICSI cycles, independently of BMI. Interestingly, the adverse effects of central obesity were more evident in patients with lower BMI. Thus WHR appears to be a better predictor of female fertility treatment outcomes as compared with BMI.

Morphokinetic embryo behaviour in low-prognosis patients according to the POSEIDON criteria: an analysis of 3326 injected oocytes

The objective of this cohort study was to investigate whether embryo quality and morphokinetic behaviour differ in the four groups of low-prognosis women as stratified by the POSEIDON criteria. The study was performed in a private university-affiliated in vitro fertilization (IVF) centre, and included 3326 injected oocytes from 846 women undergoing ICSI cycles between March 2019 and April 2022. Kinetic markers from the point of insemination were recorded in the EmbryoScope incubator. Generalized mixed models followed by Bonferroni post hoc were used to compare morphokinetics among the POSEIDON groups. Embryos derived from patients in the POSEIDON groups 2, 3 and 4 showed significantly slower divisions compared to those from POSEIDON 1 group. The KIDScore rank was significantly lower for embryos deriving from POSEIDON groups 2, 3 and 4 (2: 4.4 ± 0.7 vs. 3: 4.2 ± 0.2 vs. 4: 3.0 ± 0.4) compared to those deriving from POSEIDON 1 group (4.8 ± 0.1, p < 0.001). Group POSEIDON 1 showed improved implantation (26.9% vs. 2: 22.4% vs. 3: 20.0% vs. 4: 14.0, p < 0.001) and miscarriage rates (5.6% vs. 2: 31.2% vs. 4: 50.0%, p = 0.013). Embryo quality and morphokinetic behaviour differ across the POSEIDON groups, being more favourable in POSEIDON group 1, as well as implantation and miscarriage rates. Embryo development was more favourable in POSEIDON group 1 (young age and adequate ovarian reserve), suggesting that oocyte quality is determinant of embryo developmental potential. These findings show the reasonability of classifying POR by the POSEIDON criteria and provide information for counselling of POR regarding their possible prognosis.

Frozen versus fresh embryo transfer in women with low prognosis for in vitro fertilisation treatment: pragmatic, multicentre, randomised controlled trial

OBJECTIVE

To test the hypothesis that a freeze-all strategy would increase the chance of live birth compared with fresh embryo transfer in women with low prognosis for in vitro fertilisation (IVF) treatment.

DESIGN

Pragmatic, multicentre, randomised controlled trial.

SETTING

Nine academic fertility centres in China.

PARTICIPANTS

838 women with a low prognosis for IVF treatment defined by ≤9 oocytes retrieved or poor ovarian reserve (antral follicle count <5 or serum anti-Müllerian hormone level <8.6 pmol/L).

INTERVENTIONS

Eligible participants were randomised (1:1) to undergo either frozen embryo transfer or fresh embryo transfer on the day of oocyte retrieval. Participants in the frozen embryo transfer group had all of their embryos cryopreserved and underwent frozen embryo transfer later. Participants in the fresh embryo transfer group underwent fresh embryo transfer after oocyte retrieval.

MAIN OUTCOME MEASURES

The primary outcome was live birth, defined as the delivery of neonates with a heartbeat and respiration at ≥28 weeks' gestation. Secondary outcomes were clinical pregnancy, singleton or twin pregnancy, pregnancy loss, ectopic pregnancy, birth weight, maternal and neonatal complications, and cumulative live birth after embryo transfers within one year after randomisation.

RESULTS

In an intention-to-treat analysis, the rate of live birth was lower in the frozen embryo transfer group than in the fresh embryo transfer group (32% (132 of 419) v 40% (168 of 419); relative ratio 0.79 (95% confidence interval 0.65 to 0.94); P=0.009). The frozen embryo group had a lower rate of clinical pregnancy than the fresh embryo group (39% (164 of 419) v 47% (197 of 419); 0.83 (0.71 to 0.97)). The cumulative live birth rate was lower in the frozen embryo transfer group compared with the fresh embryo transfer group (44% (185 of 419) v 51% (215 of 419), 0.86 (0.75 to 0.99)). No difference was observed in birth weight, incidence of obstetric complications, or risk of neonatal morbidities.

CONCLUSIONS

Fresh embryo transfer may be a better choice for women with low prognosis in terms of live birth rate compared with a freeze-all strategy. The treatment strategies that prevent fresh embryo transfers, such as accumulating embryos with back-to-back cycles or performing routine preimplantation genetic testing for aneuploidy, warrant further studies in women with a low prognosis.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100050168.

The Effect of Traditional Chinese Medicine Treatment on the Cumulative Live Birth Rate of Patients with Poor Ovarian Response to the Patient-Oriented Strategies Encompassing Individualized Oocyte Number Criteria

Objective

This study analyzed the role of traditional Chinese medicine (TCM) treatment on the cumulative live birth rate (CLBR) in women with poor ovarian response to the patient-oriented strategies encompassing individualized oocyte number (POSEIDON) criteria.

Methods

This cohort study selected 3347 patients with low ovarian response and divided them into four subgroups according to the POSEIDON criteria: Group 1 (n=947), Group 2 (n=778), Group 3 (n=164), and Group 4 (n=1458). Logistic regression analysis was used to evaluate the role of TCM treatment on the CLBR of patients with poor ovarian response to POSEIDON criteria.

Results

In the unadjusted model, TCM treatment might be related to the heightened CLBR (OR=2.052, 95% CI: 1.745-2.413). After adjusting for the POSEIDON group, a higher CLBR was identified in those with TCM treatment (OR=1.927, 95% CI: 1.615-2.300). In Model 3, covariates including the POSEIDON group, age, body mass index (BMI), anti-mullerian hormone (AMH), and/or antral follicle count (AFC) were adjusted, and TCM treatment was associated with elevated CLBR of patients with poor ovarian response to the POSEIDON criteria (OR=1.905, 95% CI: 1.586-2.289). This suggested that TCM increased CLBR by 19.05% in patients who used TCM compared with those who did not. Subgroup analysis indicated that TCM treatment might increase the CLBR of patients in POSEIDON criteria Group 1 (OR=1.83, 95% CI: 1.33-2.51), indicating that TCM elevated the CLBR by 8.3% in POSEIDON criteria Group 1.

Conclusion

TCM treatment was related to increased CLBR in patients with poor ovarian response to the POSEIDON criteria.

Altered Immune Cell Profiles in the Follicular Fluid of Patients with Poor Ovarian Response According to the POSEIDON Criteria

Objective

This study aims to investigate alterations in immune cell counts within preovulatory follicles of patients with poor ovarian response (POR) during assisted reproductive technology (ART), classified according to the POSEIDON criteria.

Methods

This single-centre cross-sectional study included 543 women undergoing IVF/ICSI treatment, selected based on specific inclusion and exclusion criteria: 292 with normal ovarian response and 251 with poor response. Follicular fluid (FF) was collected on the day of oocyte retrieval and analysed by flow cytometry to determine the proportions of macrophages (Mφs), M1 and M2 Mφs, T cells (CD4 and CD8 T cells), dendritic cells (DCs), including type 1 conventional dendritic cells (cDC1) and type 2 conventional dendritic cells (cDC2), and neutrophils. Multivariable logistic regression assessed the relationship between immune cell counts and POR, Pearson correlation determined associations with the number of retrieved oocytes, and receiver operating characteristic (ROC) curves evaluated the predictive power of immune cell counts for POR.

Results

Immune cells accounted for 52.57% (±23.90%) of the total cell population in the follicular microenvironment, which was approximately equal to that of granulosa cells, with Mφs being the most abundant, followed sequentially by T cells, DCs, and neutrophils. In patients with POR, overall Mφs infiltration in the follicular microenvironment decreased, whereas M1 and M2 polarization increased. T cell infiltration increased, with a decrease in the CD4/CD8 ratio. Both cDC1 and cDC2 were significantly elevated. Moreover, multivariable logistic regression revealed that the total macrophage count, CD4 T cell count, and cDC2 count were independent predictors of POR. Notably, cDC2 showed the largest area under the ROC curve, suggesting its strong potential as a biomarker for predicting POR.

Conclusion

The proportion of immune cells in preovulatory follicles were significantly altered in patients with POR. These findings suggest that immune cell dynamics in the follicular microenvironment may play a crucial role in determining ovarian response and prognosis, indicating that targeted immunomodulatory strategies could be considered in future therapeutic approaches.

Patients with low prognosis in ART: a Delphi consensus to identify potential clinical implications and measure the impact of POSEIDON criteria

BACKGROUND

Currently, there is no consensus on the optimal management of women with low prognosis in ART. In this Delphi consensus, a panel of international experts provided real-world clinical perspectives on a series of literature-supported consensus statements regarding the overall relevance of the POSEIDON criteria for women with low prognosis in ART.

METHODS

Using a Delphi-consensus framework, twelve experts plus two Scientific Coordinators discussed and amended statements and supporting references proposed by the Scientific Coordinators (Round 1). Statements were distributed via an online survey to an extended panel of 53 experts, of whom 36 who voted anonymously on their level of agreement or disagreement with each statement using a six-point Likert-type scale (1 = Absolutely agree; 2 = More than agree; 3 = Agree; 4 = Disagree; 5 = More than disagree; 6 = Absolutely disagree) (Round 2). Consensus was reached if > 66% of participants agreed or disagreed.

RESULTS

The extended panel voted on seventeen statements and subcategorized them according to relevance. All but one statement reached consensus during the first round; the remaining statement reached consensus after rewording. Statements were categorized according to impact, low-prognosis validation, outcomes and patient management. The POSEIDON criteria are timely and clinically sound. The preferred success measure is cumulative live birth and key management strategies include the use of recombinant FSH preparations, supplementation with r-hLH, dose increases and oocyte/embryo accumulation through vitrification. Tools such as the ART Calculator and Follicle-to-Oocyte Index may be considered. Validation data from large, prospective studies in each POSEIDON group are now needed to corroborate existing retrospective data.

CONCLUSIONS

This Delphi consensus provides an overview of expert opinion on the clinical implications of the POSEIDON criteria for women with low prognosis to ovarian stimulation.

The impact of severe oligozoospermia on morphokinetic embryo development in low-prognosis patients according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number criteria: an analysis of 10,366 injected oocytes

OBJECTIVE

To study whether severe male factor infertility (SMF), reflected by oligozoospermia, impacts embryo morphokinetic behavior in low-prognosis women as stratified by the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria.

DESIGN

Cohort study.

SETTING

Private university-affiliated in vitro fertilization center.

PATIENT(S)

A total of 10,366 injected oocytes from 2,272 women who underwent intracytoplasmic sperm injection cycles between March 2019 and April 2022.

INTERVENTION(S)

Patients were divided into 8 groups according to the POSEIDON criteria (1-4) and the presence or absence of SMF. A control group of normoresponder patients was included. Kinetic markers from the point of insemination were recorded in the EmbryoScope incubator.

MAIN OUTCOME MEASURE(S)

Morphokinetic milestones and intracytoplasmic sperm injection clinical outcomes.

RESULT(S)

Embryos from patients in the POSEIDON 1 group showed significantly slower timing to pronuclear appearance, timing to pronuclear fading (tPNf), timing to 2 (t2), 3 (t3), 4 (t4), 6 (t6), and 7 (t7) cells than those from the control group. Known Implantation Diagnosis Score ranking was significantly different between the SMF and non-SMF (nSMF) subgroups in both POSEIDON 1 as well as control groups. Embryos from patients in the POSEIDON 2 group showed significantly slower timing to pronuclear appearance, t4, t6, t7, timing to 8 cells (t8), and timing to morulae than those from the control group. Embryos in the POSEIDON 2 SMF subgroup took longer than those in the POSEIDON 2 nSMF subgroup and those in both control subgroups to achieve tPNf, t2, t3, timing to 5 cells (t5), timing to start blastulation, and timing to blastulation. Known Implantation Diagnosis Score ranking was significantly different between the SMF and nSMF subgroups in both POSEIDON 2 as well as control groups. Embryos from patients in the POSEIDON 3 group showed significantly slower t8 and duration of the second cell cycle (t3-t2) than those from the control group. Known Implantation Diagnosis Score ranking was significantly different across the subgroups. Embryos derived from patients in the POSEIDON 4 group showed significantly slower tPNf, t2, t3, t4, t5, t6, t7, t8, timing to complete t4-t3 synchronous divisions, and timing to complete t8-t5 synchronous divisions than those from the control group. Known Implantation Diagnosis Score ranking was significantly different between the SMF and nSMF subgroups in both POSEIDON 4 as well as control groups. Irrespective of sperm quality, clinical outcomes significantly improved in the control subgroups compared with those in the POSEIDON 2 and 4 subgroups.

CONCLUSION(S)

Embryos in the SMF groups presented lower Known Implantation Diagnosis Score ranking than those in the nSMF groups in both POSEIDON 1-4 and control groups, suggesting that cumulative differences result in worse morphokinetic development when the algorithm is used.

Optimal ICSI timing on immature oocytes for low prognosis patients under the POSEIDON classification

BACKGROUND

The optimal timing of performing ICSI on immature oocytes for POSEIDON patients is still unknown to get better early embryonic development outcomes. The purpose of this study was to implore the most appropriate time to carry out ICSI on in vitro maturation GV and MI oocytes for POSEIDON patients.

METHODS

Two hundred thirty-nine immature oocytes from 163 POSEIDON patients were prospectively performed ICSI at different timings: P-ICSI (ICSI was performed on in vitro matured oocytes 4-6 h after the first polar body extrusion, N = 81), R-ICSI (ICSI was performed on in vitro matured oocytes less than 4 h after the first polar body extrusion, N = 80), and E-ICSI (ICSI was performed on in vitro matured oocytes the next day after oocytes retrieval, N = 78). Fertilization and embryonic development outcomes were collected and statistically analyzed. Mitochondria distribution of cytoplasm of in vitro matured oocytes with different time cultures after the first polar body (PB1) extrusion was stained.

RESULTS

Compared to the E-ICSI group, more day 3 embryos from P-ICSI became blastocysts after sequential culture though without statistical significance (OR = 3.71, 95% CI: 0.94-14.63, P = 0.061). Compared to the E-ICSI group, more embryos from both P-ICSI and R-ICSI groups were clinically used with statistical significance (OR = 5.67, 95% CI: 2.24-14.35, P = 0.000 for P-ICSI embryos; OR = 3.23, 95% CI: 1.23-8.45, P = 0.017 for R-ICSI embryos). Compared to the E-ICSI group, transferred embryos from P-ICSI and R-ICSI had a higher implantation rate though without statistical significance (35.3% for P-ICSI embryos; 9.1% or R-ICSI embryos and 0% for E-ICSI embryos, P = 0.050). Among the three group, there were most healthy babies delivered from the P-ICSI group (5, 1 and 0 for P-ICSI, R-ICSI and E-ICSI respectively). The mitochondria in the cytoplasm of in vitro matured oocytes with a less than 4 h and 4-6 h culture after PB1 extrusion presented semiperipheral and diffused distribution patterns, respectively.

CONCLUSIONS

Our results revealed P-ICSI (ICSI was performed on in vitro matured oocytes 4-6 h after the first polar body extrusion) provided the most efficient method to utilize the immaturation oocytes basing on embryos utilization and live birth outcome for low prognosis patients under the POSEIDON classification. The mitochondria distribution of the in vitro matured oocytes' cytoplasm from P-ICSI varied that from R-ICSI.

Poor ovarian response classification systems in the clinical setting - time for an update?

PURPOSE OF REVIEW

Poor ovarian response (POR) remains a key challenge to the success of assisted reproductive technology. Here, we offer a comprehensive review of the two main classification systems for POR, discussing their promises and pitfalls, evaluating their performance, and exploring potential avenues for improving upon these definitions of POR.

RECENT FINDINGS

The Bologna criteria represented the first meaningful attempt to create a universal POR definition. Subsequently, the POSEIDON classification system was published to provide a more nuanced view of POR, classifying patients into four groups based on age and ovarian reserve markers. A recent study evaluated the likelihood of achieving at least one euploid embryo for transfer and found that, indeed, these classification systems are effective predictors of this outcome.While these criteria provide an effective counseling tool, several limitations - not considering underlying conditions, selecting somewhat arbitrary cutoffs, and evaluating the number of oocytes retrieved regardless of maturity - highlight the importance of improving upon these systems to create a more useful tool to more accurately predict ovarian response for clinical and research purposes.

SUMMARY

In the era of personalized medicine, it is time to reconsider whether diagnostic criteria for a continuous metric such as ovarian response should be based on meeting all-or-nothing thresholds for specific parameters.

The effect of ovarian response parameters and the synergistic effect of assisted reproduction of poor ovarian response treated with platelet rich plasma: systematic review and meta-analysis

BACKGROUND

Poor ovarian response (POR) patients often encounter cycle cancellation and egg retrieval obstacles in assisted reproductive technology. Platelet rich plasma (PRP) ovarian injection is a potential treatment method, but the treatment methods are different, and the treatment results are controversial.

OBJECTIVE

This study adopts a systematic review and meta-analysis method based on clinical research to explore the efficacy and safety of PRP injection on POR.

METHOD

The following databases were searched for research published before March 2023; Medline (via PubMed), Web of Science, Scopus, Cochrane Library, Embase, Cochrane Library, and China National Knowledge Infrastructure Database (CNKI). The literature was then screened by two independent researchers, who extracted the data and evaluated its quality. Research was selected according to the inclusion criteria, and its quality was evaluated according to the NOS standard Cohort study. The bias risk of the included study was assessed with STATE 14.0. RevMan 5.3 software was used for meta-analysis.

MAIN RESULTS

Ten studies were included in the analysis, including 7 prospective cohort studies and 3 retrospective studies involving 836 patients. The results showed that after PRP treatment, follicle stimulating hormone (FSH) significantly decreased and anti-Mueller hormone (AMH) and luteinizing hormone (LH) significantly increased in POR patients, but estradiol did not change significantly; The number of antral follicles increased, and the number of obtaining eggs and mature oocytes significantly increased; The number of Metaphase type II oocytes, 2PN and high-quality embryos, and cleavage stage embryos significantly increased. In addition, the patient cycle cancellation rates significantly decreased. The rate of natural pregnancy assisted reproductive pregnancy and live birth increased significantly. Four reports made it clear that no adverse reactions were observed.

CONCLUSION

PRP may have the potential to improve pre-assisted reproductive indicators in POR patients, increase the success rate of in vitro fertilization-embryo transfer (IVF-ET) in POR patients, and improve embryo quality, and may be beneficial to the pregnancy outcome. There is no obvious potential risk in this study, but further clinical support is still needed.

Comparison of miscarriage rates in low prognosis patients according to the POSEIDON criteria

OBJECTIVE

The POSEIDON criteria stratified patients with poor ovarian response into four subgroups with exclusive characteristics and assisted reproductive technology success rates. However, limited studies focused on miscarriage in the POSEIDON population. This study aimed to explore whether the miscarriage rate different among low prognosis patients according to POSEIDON criteria.

MATERIALS AND METHODS

This is a retrospective observational study. All clinical pregnancies achieved after in vitro fertilization or intracytoplasmic sperm injection treatment between January 1998 and April 2021 were analyzed. The primary outcome was miscarriage, defined as the pregnancy loss before 20 weeks of gestation age. Miscarriage rate was estimated per clinical pregnancy and gestational sac.

RESULTS

A total of 1222 clinical pregnancies from 1088 POSEIDON patients met the inclusion criteria. The miscarriage rates per clinical pregnancy in each POSEIDON subgroup were as follows: Group 1: 11.7 %, Group 2: 26.5 %, Group 3: 20.9 %, and Group 4: 37.5 %. The miscarriage rate per gestational sac showed a similar trend as the clinical miscarriage rate. Multivariate regression analysis showed that advanced maternal age is an independent factor for miscarriage (Group 2 vs. 1: OR 2.476; Group 4 vs. 3: OR 2.252). Patients with diminished ovarian reserve (DOR) have higher miscarriage risks but without significance (Group 3 vs. 1: OR 1.322; Group 4 vs. 2: OR 1.202).

CONCLUSION

Miscarriage rates differed among low prognosis patients according to the POSEIDON criteria. Age remains a determined risk for miscarriage. DOR might be a potential factor for miscarriage, but it didn't account for a significant impact in POSEIDON patients.

The cumulative live birth rates of 18 593 women with progestin-primed ovarian stimulation-related protocols and frozen-thawed transfer cycles

STUDY QUESTION

What are the odds of achieving pregnancy when adopting progestin-primed ovarian stimulation (PPOS)-related protocols combined with repetitive frozen-thawed transfer (FET) cycles in patients with different clinical characteristics?

SUMMARY ANSWER

The cumulative live birth rates (CLBRs) of women undergoing different PPOS-related protocols can be significantly and consistently enhanced within six FET cycles when the female age is <40 years (or even <45 years) and when >5 oocytes are retrieved, regardless of antral follicle count (AFC).

WHAT IS KNOWN ALREADY

There have been numerous studies on the live birth rate of the first FET cycle in patients with PPOS-related protocols. These studies have focused mainly on comparing pregnancy outcomes with those of other stimulation protocols. However, owing to the unique features of the PPOS-related strategy, such as its flexible timing of oocyte retrieval and repeated transfer of frozen embryos, studies using the CLBR as an overall indicator of success and investigating which types of patients would benefit from this protocol are lacking.

STUDY DESIGN SIZE DURATION

This retrospective cohort study included 18 593 women who underwent PPOS-related protocols (dydrogesterone + hMG, medroxyprogesterone acetate + hMG, micronized progesterone + hMG treatment, and luteal-phase ovarian stimulation protocol) from 1 March 2011 to 31 September 2022 in our centre.

PARTICIPANTS/MATERIALS SETTING METHODS

The population was categorized by female age, number of oocytes retrieved, and AFC in the analysis of CLBR within six FET cycles. The age groups (Groups 1-5, respectively) were <30, 30-34, 35-39, 40-44, and ≥45 years. The number of oocytes retrieved was grouped as 1-5, 6-10, 11-15, 16-20, and >20. AFC was grouped as <5, 5-10, 11-15, and >15. The Kaplan-Meier analysis (optimistic method), which hypothesized that patients who did not continue treatment had the same chance of achieving a live birth as those who continued, and the competing risk method (conservative method) which hypothesized they had no chance of achieving a live birth, were applied. In further analyses, the Cox model and Fine-Gray model were adopted: the former corresponds to the optimistic scenario, and the latter corresponds to the pessimistic scenario.

MAIN RESULTS AND THE ROLE OF CHANCE

CLBR had a declining trend with female age over six FET cycles (Groups 1-5, respectively: optimistic: 96.9%, 96.6%, 91.4%, 67.3%, and 11.7%; conservative: 87.3%, 85.0%, 74.0%, 41.3%, and 7.5%), requiring more FET cycles to achieve a success rate of at least 50% (Groups 1-5, respectively: optimistic: 2, 2, 2, 4, and >6 cycles; conservative: 2, 2, 2, >,6 and >6 cycles). CLBR showed an increasing trend with the number of oocytes retrieved (Groups 1-5, respectively: optimistic: 93.8%, 94.3%, 95.8%, 96.0%, and 95.6%; conservative: 66.2%, 78.3%, 85.6%, 88.9%, and 91.0%). All groups needed the same number of FET cycles to achieve a success rate of at least 50% (Groups 1-5, respectively: optimistic: 2, 2, 2, 2, and 2 cycles; conservative: 2, 2, 2, 2, and 2 cycles). Furthermore, the CLBR within six FET cycles had an increasing trend with AFC number (Groups 1-4, respectively: optimistic: 89.2%, 94.8%, 95.9%, and 96.3%; conservative: 67.4%, 78.2%, 83.9%, and 88.1%), with all four groups achieving a success rate of at least 50% by the second FET cycle.

LIMITATIONS REASONS FOR CAUTION

The current research is limited by its retrospective design and single-centre nature, which may restrict the generalizability of our findings.

WIDER IMPLICATIONS OF THE FINDINGS

This work describes two models (the Kaplan-Meier analysis and the competing risk method) to evaluate the clinical outcome of patients using PPOS-related protocols, which are especially useful for patients of advanced age or those with diminished ovarian reserve. Our findings encourage patients below 45 years old, especially younger than 40 years, and patients with lower AFCs and fewer retrieved oocytes to try this new protocol. Moreover, this study demonstrates the degree of improvement in the CLBR within six FET cycles for patients with different clinical characteristics, providing a valuable point of reference to determine whether to continue ART after a transfer failure.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by grants from the National Natural Science Foundation of China (82071603 to L.W., 82001502 to Y.L.). There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Who may benefit from an increased gonadotropin dosing in predicted poor responders undergoing IVF/ICSI? A secondary analysis assessing treatment selection markers of a randomized trial

OBJECTIVE

To evaluate whether we can identify patient characteristics that serve as treatment selection markers to distinguish which women with expected poor response benefit from increased dosing of follicle-stimulating hormone (FSH) in terms of improving the cumulative live birth rate compared to standard FSH dosing and which women.

STUDY DESIGN

We performed a secondary analysis of an RCT performed between March 2019 and October 2021 comparing cumulative live birth after increased dosing (N = 328) who received 225 or 300 IU/day according to their antral follicle count (AFC) and standard dosing (N = 333) who received 150 IU/day of gonadotropin.

RESULTS

The MFPI analysis showed the benefit of the increased dosing of FSH on cumulative live birth starts to emerge when women were older than 30 years (women > 30 years: 46.5 % vs. 34.2 %; adjusted relative risk (aRR) 1.32, 95 % confidence interval (95 %CI) 1.05-1.66; women ≤ 30 years: 54.7 % vs. 58.6 %; aRR 0.91, 95 % CI 0.72-1.14; p for interaction 0.019). Only those who had AFC between 1 and 3 benefited from the increased FSH dose (AFC 1-3: 38.5 % vs. 6.5 %; aRR 5.88, 95 % CI 1.50-23.15; AFC 4-9: 50.3 % vs. 46.0 %; aRR 1.08, 95 % CI 0.92-1.27; p for interaction 0.023). Expected poor responders defined by the Bologna criteria and POSEIDON criteria did not significantly benefit from the increased dosing of FSH.

CONCLUSIONS

Women who are aged >30 years or have AFC 1-3 are likely to benefit from increased dosing of FSH by having a higher cumulative live birth rate.

Diminished ovarian reserve causes adverse ART outcomes attributed to effects on oxygen metabolism function in cumulus cells

BACKGROUND

Declining oocyte quality in women with advanced age has been a major impediment to assisted reproductive treatments' (ART) success rate. However, aging is often accompanied by a diminished ovarian reserve (DOR). Cumulus cells (CCs) are known to play an important role in the development and maturation of oocytes, and the quality of CCs actually reflects the quality of the oocyte. In this study, CCs were used to investigate the real reasons for the decline in oocyte quality in older women.

METHODS

Ninety-nine CC samples were subdivided into 4 different groups according to the different age and ovarian reserve status. Other than clinical ART results, transcriptional expression profiles were performed in CCs to detect the differences.

RESULTS

The results were that DOR, no matter in young or advanced age group, was found to be significantly associated with adverse ART outcomes. Of note, there were no statistically significant changes in ART outcomes in the group at advanced age with normal ovarian reserve (NOR), compared to the young with NOR. DOR induced a series of transcriptional variations in CCs commonly enriched in oxygen metabolism.

CONCLUSION

Our results revealed that the ART outcomes in advanced patients were attributable to the DOR. The oxygen metabolic changes may interfere with CCs' function of supporting oocytes. This study can provide guidance for ART practice that not age but ovarian reserve status is the main predictor for ART outcomes, and ovarian reserve status should be timely assessed when the clinical manifestations are still mild in elderly women.

Comparison of Cumulative Live Birth Rates between Flexible and Conventional Progestin-Primed Ovarian Stimulation Protocol in Poor Ovarian Response Patients According to POSEIDON Criteria: A Cohort Study

RESEARCH QUESTION

To compare the cumulative live birth rate (CLBR) per oocyte retrieval cycle of a conventional progestin-primed ovarian stimulation (cPPOS) regimen with a flexible progestin-primed ovarian stimulation (fPPOS) regimen in poor ovarian response patients, according to POSEIDON criteria.

DESIGN

Poor ovarian response women, according to POSEIDON criteria, who underwent the first PPOS protocol for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) between January 2018 and December 2020 were included. The fPPOS group involved 113 participants, and the cPPOS group included 1119 participants. In the cPPOS group, medroxyprogesterone acetate (MPA) (10 mg/d) was administrated on the gonadotropin injection the same day as gonadotropin injections in the cPPOS group, while MPA was started either on the day when the leading follicle with mean diameter > 12mm was present and/or serum E2 was >300 pg/mL in the fPPOS protocol group. The primary outcome was CLBR.

RESULTS

The fPPOS protocol had higher CLBR per oocyte retrieval cycle compared to the cPPOS group, even without a statistically significant difference (29.6% vs. 24.9%, p = 0.365). The fPPOS group had fewer numbers of retrieved oocytes (2.87 ± 2.03 vs. 3.76 ± 2.32, p < 0.001) but a higher MII oocyte rate (89.8% vs. 84.7%, p = 0.016). In addition, the number of available embryos in the two groups was comparable (1.37 ± 1.24 vs. 1.63 ± 1.38, p = 0.095). There were five women in the fPPOS group, and 86 women in the cPPOS group had a premature LH surge (4.2% vs. 6.8%, p = 0.261). In the fPPOS group, there was one instance of premature ovulation, while in the cPPOS group, there were six occurrences of premature ovulation (0.8 vs. 0.5%, p = 1.000).

CONCLUSION(S)

The novel fPPOS protocol appears to achieve higher CLBR even without significant differences and with MPA consumption compared with cPPOS protocol in low-prognosis patients.

Bologna vs. POSEIDON criteria as predictors of the likelihood of obtaining at least one euploid embryo in poor ovarian response: an analysis of 6,889 cycles

OBJECTIVE

To study the likelihood of obtaining at least 1 euploid embryo for transfer in poor ovarian response (POR) diagnosed per Bologna and Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria, and compare it between groups and with patients without POR.

DESIGN

Retrospective cohort study.

PATIENTS

Women undergoing an ovarian stimulation cycle with intention to pursue preimplantation genetic testing for aneuploidy.

INTERVENTIONS

Bologna criteria and the POSEIDON classification system were applied to characterize each stimulation cycle as POR or not. Cycles identified as POR by POSEIDON were subdivided into groups I, II, III, and IV as defined by this classification system.

MAIN OUTCOME MEASURES

The proportion of cycles resulting in at least 1 euploid blastocyst. Other outcome measures included cycle yields (metaphase II oocytes, fertilized oocytes, blastocysts, and euploid blastocysts), and euploidy rate per embryo cohort.

RESULTS

A total of 6,889 cycles were included, of which 3,653 (53.0%) were classified as POR per POSEIDON criteria: 1.5% (100/6,889) in group I, 3.2% (222/6,889) in II, 11.9% (817/6,889) in III, and 36.5% (2,514/6,889) in IV. Per Bologna criteria, 23.4% (1,612/6,889) of cycles were classified as POR. Group I had similar likelihood of obtaining at least 1 euploid embryo (97.0%; 95% confidence interval, 91.5%-99.2%) as cycles not deemed POR (91.9%; 95% confidence interval, 90.9%-2.8%), whereas this decreased significantly with each subsequent POSEIDON group (II: 77.9%, 72.0%-82.9%; III: 70.5%, 67.3%-73.5%; IV: 44.8%, 42.9%-46.7%) and those meeting Bologna criteria had the lowest rates (31.9%, 29.7%-34.3%). Cycle yields correlated with ovarian reserve testing results, whereas euploidy rates were associated with age.

CONCLUSIONS

Although younger POSEIDON groups (I and III) have higher euploidy rates than older groups (II and IV), each incremental POSEIDON group poses a higher risk of having no euploid blastocysts; with POSEIDON I being no different from non-POSEIDON, and Bologna having the worst prognosis. Although ovarian reserve appears to have little impact on euploidy rates, it remains a key prognostic factor for having at least 1 euploid embryo available for transfer through its impact on oocyte yield. To our knowledge, this is the first study to provide the odds ratio of this outcome depending on the degree of POR.

Elective Single Cleavage-Stage Embryo Transfer in IVF Patients with Suboptimal Ovarian Response is Not Detrimental to Cumulative Pregnancy and Reduces Multiple Pregnancy Rates

Purpose

To evaluate whether elective single embryo transfer in patients with suboptimal response to ovarian stimulation is detrimental to pregnancy rates compared to double embryo transfer.

Methods

A case-control retrospective study was performed in a cohort of couples undergoing IVF at the Infertility Unit of the ASST Lariana with ≤ 9 oocytes and at least 2 viable embryos. A total of 424 women were analyzed in the "double embryo transfer" group (n = 212) and elective "single embryo transfer" group (n = 212); they were matched 1:1 for female age, ovarian reserve and number of previous cycles. Cumulative clinical pregnancy rate per oocyte retrieval was the main outcome.

Results

The cumulative pregnancy rate per cycle, including the fresh embryo and subsequent frozen embryo transfers, was 26% and 26%, respectively. Considering the main confounding factors, a binomial logistic model indicated that the cumulative clinical pregnancy rate was not significantly affected when a single embryo transfer was performed in women recovering up to nine oocytes.

Conclusion

Live birth rate was similar between the two groups, while twin pregnancies were significantly reduced in women receiving single embryo transfer suggesting that elective single embryo transfer in patients with a limited number of embryos is not detrimental to pregnancy rates.

Live birth rate following a failed first in vitro fertilization cycle with no embryos for transfer

After a failed in vitro fertilization (IVF) procedure in which no transferable embryo was obtained, the possibility of a subsequent pregnancy for the patient is unknown. We conducted a cohort retrospective study evaluating the live birth rate in the subsequent cycles of the patients with no embryo for transfer in their first IVF attempt between 2017and 2020. The first cycle variables of patients who conceived in subsequent cycles were compared to those who did not. Additionally, for patients who conceived at last, variables related to ovarian stimulation were compared between the first cycle and the conceiving cycle. In accordance with the inclusion criteria, 529 were enrolled during the study period, of which 230 had successful pregnancies and 192 gave birth to a live infant. Cumulative live birth rates (CLBR) per cycle and patient were 26% and 36% respectively. Moreover, 99% of the live births were obtained within the first three attempts, beyond six cycles, there was no pregnancy. Stimulating variables in the first cycle were not effective in predicting the likelihood of a patient's subsequent pregnancy. Overall, patients who did not have embryos available for transfer in the first cycle had a 36% chance of getting a live birth in subsequent attempts, and the cause of failure should be considered.

Comparison of Cumulative Live Birth Rate (CLBR) According to Patient Oriented Strategies Encompassing Individualized Oocyte Number (POSEIDON) Stratification Among Low Prognosis Women Undergoing IVF-ICSI Cycles

Background

The purpose of the current study was to evaluate patient-oriented strategies encompassing individualized oocyte number (POSEIDON) criteria, validate stratification of low prognosis women, and prognosticate their reproductive potential in terms of cumulative live birth rate (CLBR) in Indian women.

Methods

Out of 4048 women who underwent IVF/ICSI, 3287 women met the criteria for final evaluation of CLBR. They criteria were divided into (a) group 1a as cases with <4 oocytes retrieved and 1b with 4-9 oocytes retrieved; (b) group 2a as cases with <4 oocytes retrieved and 2b with 4-9 oocytes retrieved; (c) group 3 (<35 years, AMH <1.2 ng/ml, AFC <5); and (d) group 4 (≥35 years, AMH <1.2 ng/ml, AFC <5). Non-POSEIDON group was sub-divided into normo-responders (10-20 oocytes) and hyper-responder (>20 oocytes).

Results

Overall CLBR was two-fold lower in POSEIDON group as compared to non-POSEIDON group (p<0.001). For every one-year increase in the age, the odds of CLBR decreased by 4% (OR 0.96, CI 0.93-0.99) in POSEIDON group and by 5% (OR 0.95, CI 0.92-0.98) in non-POSEIDON group. For every unit increase in number of oocytes retrieved, the odds of CLBR increased by 1.22 times (OR1.22, CI 1.16-1.28) in POSEIDON group and by 1.08 times (OR 1.08, CI 1.05-1.11) in non-POSEIDON group. Among POSEIDON groups, the highest values in CLBR belonged to group 1b followed by 3, 2b, 4, 1a, and 2a.

Conclusion

POSEIDON stratification of low-prognosis women undergoing IVF may be considered valid to prognosticate and counsel women undergoing IVF. Prospective studies will strengthen its validity among different ethnic populations.

Determination of serum anti-Mullerian hormone levels in a low-prognosis women treated in-vitro fertilization/intracytoplasmic sperm injection: A cohort study

Background

Outcome prediction of participants treated with in-vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) using anti-Mullerian hormone (AMH) concentration has been widely used. According to the patient-oriented strategies encompassing individualized oocyte number (POSEIDON) definition, low prognosis Bologna responders have changed from poor. This definition divides low prognosis into 4 groups.

Objective

The purpose of this study was to assess blood AMH levels in the group of women treated with IVF/ICSI who were thought to have a low prognosis.

Materials and Methods

A retrospective cohort study among 252 suspected low-prognosis group participants was assessed between January 2016 and December 2019 at Morula IVF, National hospital, Surabaya, Indonesia. Observed AMH serum levels and pregnancy rates were compared among 4 subgroups.

Results

The AMH cutoff value was 1.7 ng/mL with a sensitivity of 86.7% and a specificity of 70% for diagnosing low-prognosis women using POSEIDON criteria. There was no difference in the pregnancy rate between those groups (p > 0.05).

Conclusion

AMH levels may indicate a poor prognosis for women having IVF/ICSI in accordance with POSEIDON guidelines. To predict the poor prognosis in women, the cutoff value must be identified.

Characteristics, prevalence and sources of stress in individuals who discontinue assisted reproductive technology treatments: a systematic review

By considering the reasons behind discontinuing assisted reproductive technology (ART) treatment, several studies have indicated that 'stress' is an important issue, but the prevalence of stressors and stress responses, either acute or chronic, remains unclear. In this systematic review, we evaluated the characteristics, prevalence and causes of what was perceived and reported as 'stress' by couples who discontinued ART treatment. Electronic databases were systematically searched, and studies were considered eligible if they evaluated stress as a possible reason for ART discontinuation. Twelve studies were included, with 15,264 participants from eight countries. In all studies, 'stress' was assessed through generic questionnaires or medical records, not by validated stress questionnaires or biomarkers. The prevalence of 'stress' ranged from 11-53%. When the results were pooled, 'stress' was cited as a reason for ART discontinuation by 775 out of 2507 participants (30.9%). Clinical factors associated with worse prognosis, physical discomfort due to treatment procedures, family demands, time pressure and economic burden were identified as sources of 'stress' that contributed to ART discontinuation. Precisely knowing the characteristics of the stress associated with infertility is essential to devise preventive or supportive interventions to help patients to cope and endure the treatments. Further studies are necessary to investigate whether the mitigation of stress factors can reduce ART discontinuation rates.

Cumulative live birth rates and birth outcomes after IVF/ICSI treatment cycles in young POSEIDON patients: A real-world study

OBJECTIVE

The aim of this study was to describe the cumulative live birth rates (CLBRs) of young women with or without low prognosis according to the POSEIDON criteria after IVF/ICSI cycles and to investigate whether the diagnosis of low prognosis increases the risk of abnormal birth outcomes.

DESIGN

Retrospective study.

SETTING

A single reproductive medicine center.

POPULATION

From January 2016 to October 2020, there were 17,893 patients (<35 years) involved. After screening, 4,105 women were included in POSEIDON group 1, 1,375 women were included in POSEIDON group 3, and 11,876 women were defined as non-POSEIDON.

INTERVENTIONS

Baseline serum AMH level was measured on the D2-D3 of menstrual cycle before IVF/ICSI treatment.

MAIN OUTCOME MEASURES

Cumulative live birth rate (CLBR), birth outcomes.

RESULTS

After four stimulation cycles, the CLBRs in POSEIDON group 1, POSEIDON group 3, and non-POSEIDON group reached 67.9% (95% CI, 66.5%-69.3%), 51.9% (95% CI, 49.2%-54.5%), and 79.6% (95% CI, 78.9%-80.3%), respectively. There was no difference in gestational age, preterm delivery, cesarean delivery, and low birth weight infants between the three groups, but macrosomia was significantly higher in non-POSEIDON group, after adjusting for maternal age and BMI.

CONCLUSIONS

The POSEIDON group shows lower CLBRs than the non-POSEIDON group in young women, while the risk of abnormal birth outcomes in the POSEIDON group will not increase.

Pregnancy rate in IVF patients with unexpected poor response to ovarian stimulation

OBJECTIVE

To evaluate whether an unexpected poor response (cases with ≤3 oocytes) leads to a reduction in the pregnancy rate in IVF cycles compared to a suboptimal response (controls with 4-9 oocytes) in women with adequate ovarian reserve.

METHODS

A nested case-control study performed in a retrospective cohort of couples undergoing IVF at the Infertility Unit of the ASST Lariana. Cases and controls had adequate ovarian reserve and were matched 1:1 for female age and number of previous cycles. Cumulative clinical pregnancy rate per oocyte retrieval was the main outcome.

RESULTS

Overall, 113 cases and 113 matched controls were included; the median number of available oocytes was 2 and 6, respectively. The cumulative pregnancy rate per cycle was significantly reduced in cases compared to controls with a crude odds ratio = 0.45 [95% Confidence Interval: 0.28-0.82]. A binomial logistic model indicated that an increase in one oocyte increases the odds for cumulative pregnancy rate per cycle by 1.27 in women with 9 oocytes or less. The cumulative pregnancy rates per cycle in cases and controls, according to female age were respectively: 29% versus 54% in patients aged <35 years (p = 0.036); 22% versus 43% in patients aged 36-39 years (p = 0.048) and 11% versus 13% in patients 40-45 years old (p = 0.72). Patients belonging to older age groups showed decreasing probability of cumulative clinical pregnancy rates both among cases and controls group (p < 0.05).

CONCLUSIONS

The number of available oocytes significantly affects the probability of success in IVF cycles with unexpected impaired ovarian response.

An audit of clinical outcomes following ovarian administration of platelet-rich plasma (PRP) in women with severe diminished ovarian reserve

BACKGROUND

Infertility caused by poor oocyte quality is one of the most difficult areas to manage. While oocyte donation is an effective treatment, for most women it is a treatment of last resort. Ovarian platelet-rich plasma (PRP) treatment is a relatively new adjunct therapy which has been reported to possibly improve oocyte quality and in vitro fertilisation (IVF) treatment outcomes in women with severe diminished ovarian reserve.

AIMS

To audit IVF and pregnancy outcomes following ovarian PRP treatment in a cohort of women under 45 years of age with severe diminished ovarian reserve and previous IVF treatment failure.

METHODS

An audit of 20 consecutive patients comparing embryology outcomes before and after ovarian PRP treatment, together with assessment of PRP-related pregnancies and treatment complications.

RESULTS

Overall, PRP treatment produced no significant improvement in oocyte number, but did increase the number of embryos generated compared to patients' own pre-PRP IVF cycle (zero vs two embryos, P = 0.005). In total four patients conceived viable genetically normal pregnancies in their next IVF cycle, and a further two conceived naturally within 4 months of the PRP treatment. Five of these pregnancies were in women 40 years or older, all being euploid on non-invasive pregnancy screening and viable beyond 12 weeks gestation. No operative complications were observed.

CONCLUSION

Ovarian PRP treatment appears to be low risk and may offer some promise in assisting pregnancy (natural and IVF-related), especially in women with reduced oocyte quality due to advanced maternal age. Future randomised controlled trials are urgently required to confirm this benefit.

Ovarian Follicular Growth through Intermittent Vaginal Gonadotropin Administration in Diminished Ovarian Reserve Women

It is a challenge to obtain enough oocytes during in vitro fertilization (IVF) in women who have a poor ovarian response (POR) in achieving conception. We have adopted the characteristics of the first uterine pass effect, which we pioneered in employing the vaginal administration of gonadotropins in women receiving IVF treatments. In our previous study employing vaginal administration, faster absorption and slower elimination of gonadotropins were demonstrated, and, female subjects presented proper ovarian follicle growth and pregnancy rates. In this study, during 2016–2020, 300 to 675 IU of gonadotropins were administered vaginally every three days in 266 POR women for their controlled ovarian hyperstimulation (COH). The injections were performed with needles angled at 15–30° towards the middle-upper portions of the bilateral vaginal wall, with an injection depth of 1–2 mm. For the COH results, these women, on average, received 3.0 ± 0.9 vaginal injections and a total dose of 1318.4 ± 634.4 IU gonadotropins, resulting in 2.2 ± 1.9 mature oocytes and 1.0 ± 1.2 good embryos. Among these embryos, 0.9 ± 1.0 were transferred to reach a clinical pregnancy rate of 18.1% and a live birth rate of 16.7%. In conclusion, the intermittent vaginal administration of gonadotropins proved to be effective in POR women for their IVF treatments.

Effect of Female and Male Body Mass Index on Cumulative Live Birth Rates in the Freeze-all Strategy

CONTEXT

The impact of parental overweight/obese on cumulative live birth rate in in vitro fertilization/intracytoplasmic sperm injection using a freeze-all strategy is still unknown.

OBJECTIVE

To explore the effect of parental body mass index (BMI) on cumulative live birth rate (CLBR) in a freeze-all strategy over 1.5 years.

METHODS

This was a retrospective study in a tertiary care academic medical center; 23 482 patients (35 289 frozen-thawed embryo transfer cycles) were divided into 4 groups according to Asian BMI classification. The main outcome measure was CLBR.

RESULTS

Female overweight/obesity had a lower tendency in CLBR (groups 1-4: optimistic: 69.4%, 67.9%, 62.3%, and 65.7%; conservative: 62.9%, 61.1%, 55.4%, and 57.6%) and prolonged time (groups 1-4: 11.0, 12.2, 15.9, and 13.8 months for 60% CLBR in the optimistic method; 8.7, 9.5, 11.7, 11.0 months for 50% CLBR in the conservative method). The same trend to a lesser extent was also observed in male BMI groups. When combining parental BMI, "parental overweight/obesity" had lower CLBR and longer time for reaching CLBR >50% (optimistic: 4.5 months for 60% CLBR; conservative: 3 months for 50% CLBR), followed by "only female high BMI" (optimistic: 2.1 months for 60% CLBR; conservative: 1.7 months for 50% CLBR), while "only male high BMI" had no influence.

CONCLUSION

Our results showed the importance of parental BMI, female BMI, and male BMI on the 1.5-year CLBR using a freeze-all strategy; the time to reach the CLBR (60% in optimistic, 50% in conservative) for overweight and obese patients was several months, but it is not as long as losing weight.

Cumulative live birth rates for low-prognosis women over 5 years or 9 frozen-thawed embryo transfer cycles

Background

For heterogeneous populations of low-prognosis women, it remains unclear as to how long individuals should continue undergoing ART when attempting to have a baby, as there have been insufficient studies to date tracking the cumulative live birth rates (CLBRs) for these women over the entire course of their ART treatment, particularly over extended time periods.

Methods

This was a retrospective analysis of 17,698 women at a tertiary care academic medical center who had begun undergoing IVI/ICSI cycles using a progestin-primed ovarian stimulation (PPOS) approach between January 2013 and January 2019. Low-prognosis patients were stratified into four groups based upon POSEIDON criteria, with patients exhibiting normal or high ovarian reserves and response to stimulation (defined as AFC ≥5, > 9 oocytes retrieved) being included as controls (group 5). The CLBR within 5 years or 9 FET cycles from the ovum pick-up (OPU) day of the first cycle was the primary endpoint for this study, including all repetitive oocyte retrieval cycles and subsequent FET cycles. Optimistic and conservative approaches were used for the analysis of CLBRs and the depiction of cumulative incidence curves.

Results

Under both optimistic and conservative model analyses, normal and good responders exhibited the highest CLBR within 5 years or 9 FET cycles, followed by younger unexpected poor responders, younger expected poor responders, older unexpected poor responders, and older expected poor responders. Upward trends in CLBRs were evident across the five groups with the prolongation of time or an increase in FET cycle counts. Within the first 2 years or 3 FET cycles, the CLBRs rose rapidly, followed by more moderate increases over the following 2–3.5 years or 4–6 cycles, with expected poor responders exhibiting the most obvious improvements. All Patients reached a CLBR plateau after 3.5 years or 6 FET cycles.

Conclusions

All low-prognosis women should undergo ART treatment for a minimum of 2 years or 3 FET cycles, and exhibit better outcomes when extending ART treatment to 3.5 years or 6 FET cycles (particularly for POSEIDON groups 3 and 4), but should consider ceasing further treatment thereafter due to a lack of apparent benefit.

Correlation of hysterosalpingography and laparoscopy in the detection of tubal infertility factor

Background/Aim: Around 15-20 % of couples worldwide struggle with infertility, a difficult and aggravating gynaecological issue. Conception occurs in both partners, male and female, as they are both responsible for conception. This study aimed to evaluate the diagnostic accuracy of hysterosalpingography (HSG) in the detection of tubal infertility factors, by comparing the findings of HSG with the findings of laparoscopy (LPSC). Methods: A retrospective study from 1st January 2018, to 31st December 2019, is presented. Infertile patients who underwent LPSC, HSG and ultrasound to evaluate sterility during this timeframe were included in the research. Results: The study involved 63 infertile patients with a mean lifespan of 33.3 ± 4.7 years. The conclusions of LPSC and HSG, in general, were in good correlation and the percentage of agreement among the diagnostic procedures was 77.8 %. In the case of dichotomous categories, there is a good alignment between LPSC and HSG results with a percentage of 85.7 %. Hydrosalpinx: The findings of LPSC and HSG are quite similar. The percentage of agreement among the diagnostic techniques used was 79.2 %. Canal obturation: LPSC and HSG results are in good correlation with a percentage of 78.6 %. Terminal obturation: LPSC and HSG results are also in good agreement with the calculated percentage of 82.1 %. Conclusion: In determining tubal sterility factors, there is considerable consistency between LPSC and HSG results (c = 0.68; 95 % CI 0.54-0.83). There is a good correlation between LPSC and HSG findings of dichotomous categories (ch2 = 0.63; 95 % CI: 0.41-0.86). 86.2 % of subjects with peritubular appendages and 8.8 % of subjects without peritubular appendages had hydrosalpinx, which is a statistically significant difference (ch2 = 37.957; p < 0.001). Between LPSC and HSG data, there is a good agreement in the diagnosis of hydrosalpinx (c = 0.64; 95 % CI: 0.38-0.91).

"Short agonist stop" protocol, an ovarian stimulation for poor responders in in vitro fertilization (IVF): A pilot study

INTRODUCTION

Poor responder patients remain a challenge in assisted reproductive technologies. The "short agonist stop" (SAS) stimulation protocol uses a double stimulation (flare up effect with the gonadotropin-releasing hormone (GnRH) agonist (GnRH-a) then gonadotropins) associated with a less strenuous blockage (discontinuation of GnRH-a) to favor follicular recruitment in order to obtain a better ovarian response. This study aims to compare the number of oocytes obtained after a SAS stimulation protocol with those obtained after the previous stimulation protocol, in the same women, with poor ovarian response (POR) diagnosed according to the POSEIDON criteria.

DESIGN

This therapeutic observational retrospective cohort from 2018 to 2022, with a case-control evaluation compared with the same patients' previous performance, included women with POR undergoing IVF with SAS stimulation protocol. The primary outcome was the number of total oocytes recovered and secondary outcomes were the numbers of mature oocytes, total embryos observed at day 2 and usable cleaved embryos and blastocysts (day 5/6).

RESULTS

63 patients with SAS and previous cycles were included. In the SAS group, the mean number of oocytes was significantly higher: 7.3 vs 5.7, p=0.018 in comparison with the previous attempt. So was the number of mature oocytes (5.8 vs 4.1, p=0.032) and the total mean number of embryos obtained at day 2 (4.1 versus 2.7, p=0.016). The SAS stimulation generated 84 usable embryos: 57 cleaved embryos and 27 blastocysts. The mean number of usable embryos was similar in both groups (1.64 vs 1.31, respectively, p=0.178). In total, out of 63 patients, after the SAS protocol, and subsequent embryo transfers (fresh and frozen, n=54), 9 patients had ongoing pregnancies and no miscarriage occurred. The cumulative ongoing pregnancy rate (cOPR) after the SAS protocol was 14.3% (9/63) per oocyte pick-up and 16.7% (9/54) per transfer.

CONCLUSION

SAS stimulation is a short and original protocol strengthening the therapeutic arsenal of poor responders, that may offer promising results for those patients with low prognosis and previous failed IVF. Results must be confirmed with a randomized controlled trial.

Live Birth Rates after Active Immunization with Partner Lymphocytes

Although many potential causes have been established for recurrent implantation failure (RIF) and recurrent miscarriage (RM), about 50% of these remain idiopathic. Scientific research is focused on immunological risk factors. In the present study, we aim to evaluate live birth rates after immunization with paternal lymphocytes (lymphocyte immunotherapy (LIT)). This retrospective study consisted of 148 couples with a history of RM and/or RIF. The women underwent immunization with lymphocytes of their respective partners from November 2017 to August 2019. Fifty-five patients (43%) had live births. Stratified by indication (RM, RIF, combined), live birth rates in the RM and the combined group were significantly higher than that in the RIF group (53%, 59% and 33%, respectively, p = 0.02). The difference was especially noticeable during the first 90 days after immunization (conception rate leading to live births: 31%, 23% and 8% for RM, the combined group and RIF, respectively; p = 0.005), while there was no difference between groups during the later follow-up. LIT was associated with high live birth rates, especially in women with recurrent miscarriage. In view of the limited data from randomized studies, LIT cannot be recommended as routine therapy. However, it may be considered in individual cases.

Blastocyst euploidy rates in low-prognosis patients according to the POSEIDON criteria: a retrospective analysis of 3016 embryos

RESEARCH QUESTION

Do embryo euploidy rates differ in the four groups of women with low prognosis as stratified by the POSEIDON criteria?

DESIGN

This was a retrospective cohort study of low-prognosis patients who met the POSEIDON criteria and underwent preimplantation genetic testing for aneuploidies (PGT-A) from January 2013 to June 2020 at the Center for Reproductive Medicine, Shandong University, China. A total of 3016 blastocysts from 1269 PGT-A cycles were included in the study. The primary outcome was the euploidy rate of the blastocysts. For each group, regression analyses were performed to quantitatively describe the relationship between maternal age and embryo euploidy rate.

RESULTS

The euploidy rate of embryos in women with poor ovarian response (POR) was 39.1% in total. There were 727, 1052, 275 and 962 blastocysts in groups 1, 2, 3 and 4, respectively, with corresponding embryo euploidy rates of 57.2%, 34.9%, 52.4% and 26.2% (P < 0.001). Within each group, the euploidy rate decreased with age, especially in women aged 35 years or older (i.e. groups 2 and 4).

CONCLUSIONS

Euploidy rates were more favourable in groups 1 and 3, of a young age, re-emphasizing that oocyte quality is the primary factor determining embryo euploidy rate. The study's findings demonstrated the reasonability of categorizing women with POR by the POSEIDON criteria depending on female age and ovarian reserve biomarkers. These results also provide information for women with POR in different subgroups so they can receive proper counselling on the possible prognosis.

Cumulative delivery rate per aspiration IVF/ICSI cycle in POSEIDON patients: a real-world evidence study of 9073 patients

STUDY QUESTION

What is the cumulative delivery rate (CDR) per aspiration IVF/ICSI cycle in low-prognosis patients as defined by the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria?

SUMMARY ANSWER

The CDR of POSEIDON patients was on average ∼50% lower than in normal responders and varied across POSEIDON groups; differences were primarily determined by female age, number of embryos obtained, number of embryo transfer (ET) cycles per patient, number of oocytes retrieved, duration of infertility, and BMI.

WHAT IS KNOWN ALREADY

The POSEIDON criteria aim to underline differences related to a poor or suboptimal treatment outcome in terms of oocyte quality and quantity among patients undergoing IVF/ICSI, and thus, create more homogenous groups for the clinical management of infertility and research. POSEIDON patients are presumed to be at a higher risk of failing to achieve a live birth after IVF/ICSI treatment than normal responders with an adequate ovarian reserve. The CDR per initiated/aspiration cycle after the transfer of all fresh and frozen–thawed/warmed embryos has been suggested to be the critical endpoint that sets these groups apart. However, no multicenter study has yet substantiated the validity of the POSEIDON classification in identifying relevant subpopulations of patients with low-prognosis in IVF/ICSI treatment using real-world data.

STUDY DESIGN, SIZE, DURATION

Multicenter population-based retrospective cohort study involving 9073 patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women with infertility between 22 and 42 years old in their first IVF/ICSI cycle of standard ovarian stimulation whose fresh and/or frozen embryos were transferred until delivery of a live born or until all embryos were used. Patients were retrospectively classified according to the POSEIDON criteria into four groups based on female age, antral follicle count (AFC), and the number of oocytes retrieved or into a control group of normal responders (non-POSEIDON). POSEIDON patients encompassed younger (<35 years) and older (35 years or above) women with an AFC ≥5 and an unexpected poor (<4 retrieved oocytes) or suboptimal (4–9 retrieved oocytes) response to stimulation, and respective younger and older counterparts with an impaired ovarian reserve (i.e. expected poor responders; AFC <5). Non-POSEIDON patients were those with AFC ≥5 and >9 oocytes retrieved. CDR was computed per one aspirated cycle. Logistic regression analysis was carried out to examine the association between patient classification and CDR.

MAIN RESULTS AND ROLE OF CHANCE

The CDR was lower in the POSEIDON patients than in the non-POSEIDON patients (33.7% vs 50.6%; P < 0.001) and differed across POSEIDON groups (younger unexpected poor responder [Group 1a; n = 212]: 27.8%, younger unexpected suboptimal responder [Group 1b; n = 1785]: 47.8%, older unexpected poor responder [Group 2a; n = 293]: 14.0%, older unexpected suboptimal responder [Group 2b; n = 1275]: 30.5%, younger expected poor responder [Group 3; n = 245]: 29.4%, and older expected poor responder [Group 4; n = 623]: 12.5%. Among unexpected suboptimal/poor responders (POSEIDON Groups 1 and 2), the CDR was twice as high in suboptimal responders (4–9 oocytes retrieved) as in poor responders (<4 oocytes) (P = 0.0004). Logistic regression analysis revealed that the POSEIDON grouping, number of embryos obtained, number of ET cycles per patient, number of oocytes collected, female age, duration of infertility and BMI were relevant predictors for CDR (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Our study relied on the antral follicle count as the biomarker used for patient classification. Ovarian stimulation protocols varied across study centers, potentially affecting patient classification.

WIDER IMPLICATIONS OF THE FINDINGS

POSEIDON patients exhibit lower CDR per aspirated IVF/ICSI cycle than normal responders; the differences are mainly determined by female age and number of oocytes retrieved, thereby reflecting the importance of oocyte quality and quantity. Our data substantiate the validity of the POSEIDON criteria in identifying relevant subpopulations of patients with low-prognosis in IVF/ICSI treatment. Efforts in terms of early diagnosis, prevention, and identification of specific interventions that might benefit POSEIDON patients are warranted.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. J.F.C. declares receipt of statistical services fees from ANDROFERT Clinic. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. P.H. declares receipt of unrestricted research grants from Merck, Ferring, Gedeon Richter and IBSA and lecture fees from Merck, Gedeon Richter and Med.E.A. C.A. declares receipt of unrestricted research grants from Merck and lecture fees from Merck. The remaining authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Cumulative live birth rates of patients in the Peruvian Andes according to the POSEIDON criteria: a single-center retrospective analysis

Objective:

To identify low prognosis in-vitro fertilization (IVF) patients treated at Centro de Fertilidad y Ginecología del Sur (CFGS) based on the POSEIDON criteria.

Methods:

This retrospective study included 412 IVF patients and assessed them based on the POSEIDON criteria to describe the cumulative live birth rates seen in each group.

Results:

13.1% of patients met the POSEIDON criteria, and the proportion of cases in POSEIDON groups 1, 2, 3 and 4 were 20.4%, 31.5%, 14.8%, and 33.3%, respectively. The cumulative live birth rate for the individuals meeting the POSEIDON criteria was 25.9%, while for patients in POSEIDON groups 1, 2, 3, and 4 the rates were 45.5%, 29.4%, 25.0%, and 11%, respectively. The differences were not statistically significant due to the small number of cases.

Conclusions:

Patients belonging to the four POSEIDON groups were described at CFGS. Age and number of retrieved mature oocytes were determining parameters in the prognosis of pregnancy in IVF/ICSI patients.

Type and dose of gonadotropins in poor ovarian responders: does it matter?

Infertile patients with a diminished ovarian reserve, also referred to as poor ovarian responders, constitute a substantial and increasing population of patients undergoing in vitro fertilization. The management of patients with poor ovarian response is still a controversial issue. Almost a century has passed since the introduction of the first gonadotropin. A broad collection of urinary and recombinant gonadotropins, including biosimilars, is commercially available now. Despite great advances in assisted reproductive technology, there remains uncertainty about the optimal treatment regimen for ovarian stimulation in poor ovarian responders. Although oocyte donation is the most successful and ultimate remedy for poor ovarian responders, most patients persist on using their own oocytes in several attempts, to achieve the desired pregnancy. The aim of this review is twofold: first, to provide an overview of the commercially available gonadotropins and summarize the available evidence supporting the use of one or another for ovarian stimulation in poor ovarian responders, and second, to address the controversies on the dosage of gonadotropins for this specific in vitro fertilization population.

Antral follicle count and anti-Müllerian hormone to classify low-prognosis women under the POSEIDON criteria: a classification agreement study of over 9000 patients

STUDY QUESTION

What is the agreement between antral follicle count (AFC) and anti-Müllerian hormone (AMH) levels when used to patient classification according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria?

SUMMARY ANSWER

Our study indicates a strong agreement between the AFC and the AMH levels in classifying POSEIDON patients; thus, either can be used for this purpose, although one in four women will have discordant values when both biomarkers are used.

WHAT IS KNOWN ALREADY

According to the POSEIDON criteria, both AFC and AMH may be used to classify low-prognosis patients. Proposed AFC and AMH thresholds of 5 and 1.2 ng/ml, respectively, have their basis in published literature; however, no study has yet determined the reproducibility of patient classification in comparing one biomarker with the other, nor have their thresholds ever been validated within this patient population.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study involving 9484 consecutive patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were infertile women between 22 and 46 years old in their first in vitro fertilization/intracytoplasmic sperm injection cycle of standard ovarian stimulation with exogenous gonadotropins whose baseline ovarian reserves had been assessed by both AFC and AMH. Details of pre- and post-treatment findings were input into a coded research file. Two indicators of interest were created to classify patients according to the POSEIDON criteria based upon AFC and AMH values. Patients who did not fit any of the four POSEIDON groups were classified as non-POSEIDON. AFC was determined in the early follicular phase using two-dimensional (2D) transvaginal ultrasonography, whereas AMH values were based on the modified Beckman Coulter generation II enzyme-linked immunosorbent assay. Agreement rates were computed between AFC and AMH to classify patients using Cohen's kappa statistics. Logistic regression analyzes were carried out to examine the association between ovarian markers and low (<4) and suboptimal (4-9) oocyte yield.

MAIN RESULTS AND THE ROLE OF CHANCE

The degree of agreement in classifying patients according to POSEIDON groups was strong overall (kappa = 0.802; 95% CI: 0.792-0.811). A total of 73.8% of individuals were classified under the same group using both biomarkers. The disagreement rates were ∼26% and did not diverge when AFC or AMH was used as the primary biomarker criterion. Significant regression equations were found between ovarian markers and oocyte yield (P < 0.0001). For low oocyte yield, the optimal AFC and AMH cutoff values were 5 and 1.27 ng/ml with sensitivities of 0.61 and 0.66, specificities of 0.81 and 0.72, and AUC receiver operating characteristics of 0.791 and 0.751, respectively. For suboptimal oocyte yield respective AFC and AMH cutoffs were 12 and 2.97 ng/ml with sensitivities of 0.74 and 0.69, specificities of 0.76 and 0.66 and AUCs of 0.81 and 0.80.

LIMITATIONS, REASONS FOR CAUTION

Our study relied on 2D transvaginal sonography to quantify the AFC and manual Gen II assay for AMH determination and classification of patients. AMH data must be interpreted in an assay-specific manner. Treatment protocols varied across centers potentially affecting patient classification.

WIDER IMPLICATIONS OF THE FINDINGS

Three of four patients will be classified the same using either AFC or AMH values. Both biomarkers provide acceptable and equivalent accuracy in predicting oocyte yield further supporting their use and proposed thresholds in daily clinical practice for patient classification according to the POSEIDON criteria. However, the sensitivity of POSEIDON thresholds in predicting low oocyte yield is low. Clinicians should adopt the biomarker that may best reflect their clinical setting.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. The remaining authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

not applicable.

Can repeat IVF/ICSI cycles compensate for the natural decline in fertility with age? an estimate of cumulative live birth rates over multiple IVF/ICSI cycles in Chinese advanced-aged population

In order to find out to what extent ovarian aging could be compensated by the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments, a total of 4102 women above the age of 35 undergoing 6489 complete cycles from 2009 to 2015 with follow-up visits until 2017 were retrospectively analyzed. Cumulative live birth rates (CLBRs) across multiple IVF/ICSI cycles were compared in the study population stratified by age and ovarian reserve (classified by the POSEIDON criteria). Younger patients (aged between 35 and 40) could well benefit from repeat IVF treatments, with the optimal CLBRs ranging from 62%-72% for up to four complete cycles. However, the CLBRs sharply declined to 7.7%-40% in older patients (>40yrs). In light of ovarian reserve, the optimal-estimated-four-cycle CLBR of younger patients (35-40yrs) in POSEIDON group 2 could approached to those with normal ovarian response (non-POSEIDON), with 57.3%-70% versus 74.5%-81% respectively. However, the CLBR of older patients (>40yrs) in POSEIDON group 2 only reached 50% of their counterparts. Extending the number of IVF cycles beyond three or four is effective for advanced-aged women, especially in younger normal responders (non-POSEIDON) and unexpected poor/suboptimal responders (POSEIDON group 2). The real turning point at which female fecundity dropped after multiple IVF cycles is at the age of 40.

SAY NO to mild ovarian stimulation for all poor responders: it is time to realize that not all poor responders are the same

Over the last 25 years, a vast body of literature has been published evaluating different treatment modalities for the management of poor ovarian responders. Despite the evidence that maximizing ovarian response can improve the chances of live born babies in poor responders, there are still voices suggesting that all poor responders are the same, irrespective of their age and their actual ovarian reserve. This has resulted in the suggestion of adopting a mild ovarian stimulation approach for all poor responders, based on the results of several trials which failed to identity differences when comparing mild and more intense stimulation in predicted poor responders. The current article analyzes in detail these studies and discusses the shortcomings in terms of type of population included, outcomes and settings performed, which may actually be responsible for the belief that only mild stimulation should be used. In the era of individualization in medicine, it must be realized that there are subgroups of predicted poor responders who will benefit from an individual rather than 'one fits all' mild stimulation approach and thus we should provide the same standard of treatment for all our poor responder patients.

The POSEIDON stratification - moving from poor ovarian response to low prognosis

Poor ovarian response remains one of the most challenging tasks for an IVF clinician. In this review, we aim to highlight the ongoing research for optimizing the prognosis in poor ovarian response patients. The newly introduced POSEIDON criteria argue that the first step is to move from a poor response to a poor prognosis concept, while improving identification and stratification of the different sub-types of poor prognosis patients prior to ovarian stimulation. The immediate marker of success is the ability of the ovarian stimulation to retrieve the number of oocytes needed to obtain at least one euploid blastocyst for transfer in each patient. This surrogate marker of success should not replace live birth as the most important outcome, but it should be approached as a useful tool for clinicians to evaluate their strategy for achieving live birth in the shortest timespan possible in the individual patient/ couple.

Individualized ovarian stimulation in IVF/ICSI treatment: it is time to stop using high FSH doses in predicted low responders

In IVF/ICSI treatment, the FSH starting dose is often increased in predicted low responders from the belief that it improves the chance of having a baby by maximizing the number of retrieved oocytes. This intervention has been evaluated in several randomized controlled trials, and despite a slight increase in the number of oocytes—on average one to two more oocytes in the high versus standard dose group—no beneficial impact on the probability of a live birth has been demonstrated (risk difference, −0.02; 95% CI, −0.11 to 0.06). Still, many clinicians and researchers maintain a highly ingrained belief in ‘the more oocytes, the better’. This is mainly based on cross-sectional studies, where the positive correlation between the number of retrieved oocytes and the probability of a live birth is interpreted as a direct causal relation. If the latter would be present, indeed, maximizing the oocyte number would benefit our patients. The current paper argues that the use of high FSH doses may not actually improve the probability of a live birth for predicted low responders undergoing IVF/ICSI treatment and exemplifies the flaws of directly using cross-sectional data to guide FSH dosing in clinical practice. Also, difficulties in the de-implementation of the increased FSH dosing strategy are discussed, which include the prioritization of intermediate outcomes (such as cycle cancellations) and the potential biases in the interpretation of study findings (such as confirmation or rescue bias).

Validation study of the Access antimüllerian hormone assay for the prediction of poor ovarian response to controlled ovarian stimulation

OBJECTIVE

To evaluate the diagnostic performance of the antimüllerian hormone (AMH) level determined using the Access AMH assay for predicting poor ovarian response (POR) defined as ≤4 oocytes retrieved, including the validation of the predefined AMH cutoff of 0.93 ng/mL in both serum and plasma.

DESIGN

Prospective cohort study.

SETTING

Fifteen private and academic fertility centers (14 in the United States and 1 in Canada).

PATIENT(S)

Women aged 21-45 years planning controlled ovarian stimulation for in vitro fertilization.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved, categorized as POR and normal-to-high ovarian response (non-POR). The correlation of AMH level and antral follicle count.

RESULT(S)

Data were available for 472 participants who completed the study (74 with POR and 398 non-POR). The mean AMH serum level among those with POR was 0.99 ng/mL (median 0.76 ng/mL) compared with 2.83 ng/mL (median 2.36 ng/mL) among the normal-to-high responders. For confirmation of the 0.93 ng/mL AMH level cutoff as a predictor of POR, a receiver operating characteristic analysis gave an area under the curve of 0.852, with corresponding sensitivity and specificity of 63.5% and 89.2%, respectively. The associated positive predictive value was 52.2% and the negative predictive value was 92.9%. The AMH plasma values demonstrated a strong correlation with AMH serum values with an r value = 0.9980. The previously established AMH cutoff of 1.77 ng/mL for antral follicle count >15 resulted in a sensitivity of 83.8% (95% confidence interval [CI] 77.7-88.5) and a specificity of 59.9% (95% CI 54.2-65.4).

CONCLUSION(S)

This study validated the previously established AMH cut-point for the prediction of POR. Because this cut-point may vary depending on the assay used, the specific AMH assay should be reported in the literature whenever possible.

Improving Reporting of Clinical Studies Using the POSEIDON Criteria: POSORT Guidelines

The POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) criteria were developed to help clinicians identify and classify low-prognosis patients undergoing assisted reproductive technology (ART) and provide guidance for possible therapeutic strategies to overcome infertility. Since its introduction, the number of published studies using the POSEIDON criteria has increased steadily. However, a critical analysis of existing evidence indicates inconsistent and incomplete reporting of critical outcomes. Therefore, we developed guidelines to help researchers improve the quality of reporting in studies applying the POSEIDON criteria. We also discuss the advantages of using the POSEIDON criteria in ART clinical studies and elaborate on possible study designs and critical endpoints. Our ultimate goal is to advance the knowledge concerning the clinical use of the POSEIDON criteria to patients, clinicians, and the infertility community.

POSEIDON classification and the proposed treatment options for groups 1 and 2: time to revisit? A retrospective analysis of 1425 ART cycles

STUDY QUESTION

Do live birth outcomes differ when Patient-Oriented Strategy Encompassing IndividualizeD Oocyte Number (POSEIDON) stratified groups are compared with women with good prognosis (non-POSEIDON group) undergoing ART?

SUMMARY ANSWER

The current study showed no significant difference in the live birth rates (LBRs) per embryo transfer between POSEIDON groups 1 and 2 when compared with women in the non-POSEIDON group undergoing ART.

WHAT IS KNOWN ALREADY

Recently, there has been a lot of focus on the POSEIDON classification for low prognosis women undergoing ART and various management options have been advocated. For POSEIDON groups 1 and 2, low starting dose and gonadotrophin receptor polymorphism have been suggested as possible reasons for a hyporesponse, and increasing the starting gonadotrophin dose, the addition of recombinant LH and dual stimulation have been suggested as treatment options. Most of these treatment options are hypothetical in nature and need validation.

STUDY DESIGN SIZE DURATION

In the current cohort study, a total of 1425 cycles were analyzed retrospectively following a single cycle fresh embryo transfer. The study period was from January 2013 to June 2018.

PARTICIPANTS/MATERIALS SETTING METHODS

Women undergoing ART at a tertiary level infertility clinic were included. Clinical and treatment-related details were obtained from the hospital's electronic medical records. The ART outcomes in a non-POSEIDON group (women with an adequate ovarian reserve and/or optimal ovarian response i.e. >9 oocytes retrieved in the previous ART cycle) and a low prognosis group stratified by POSEIDON criteria were compared. We also examined the effectiveness of the modifications made in the current ART treatment protocols among women with an adequate ovarian reserve who had a history of poor/suboptimal response (POSEIDON 1 and 2).

MAIN RESULTS AND THE ROLE OF CHANCE

There was no statistically significant difference in the LBR per embryo transfer in POSEIDON group 1 (32/109, 29%) and group 2 (17/58, 29%) when compared with the non-POSEIDON group (340/1041, 33%) (adjusted odds ratio (aOR) 0.69; 95% CI 0.37-1.27 and aOR 0.93, 95% CI 0.43-1.97, respectively), while significantly lower LBR were observed in POSEIDON groups 3 (17/97, 17.5%) and 4 (12/120, 10%) (aOR 0.49; 95% CI 0.28-0.89 and aOR 0.38, 95% CI 0.19-0.74, respectively). The gonadotrophin dose alone was increased in one-quarter of the cycles and in another 27% the dose was increased along with the protocol change among POSEIDON group 1. In POSEIDON group 2, a change in the dose alone and in combination with protocol change was performed in 5 and 41% of cycles, respectively.

LIMITATIONS REASONS FOR CAUTION

A limitation of our study is the retrospective nature of the study with an inherent risk of unknown confounders influencing the outcomes. Other limitations are the lack of cumulative live birth data and the relatively small sample within POSEIDON group 2, which could lead to a type II error.

WIDER IMPLICATIONS OF THE FINDINGS

The current study showed no significant difference in the LBR between the POSEIDON groups 1 and 2 when compared with the non-POSEIDON group of women, while groups 3 and 4 had significantly lower LBR. The simple gonadotrophin/protocol changes in groups 1 and 2 resulted in LBRs comparable to women with good prognosis. These findings call for revisiting the proposed treatment strategies for POSEIDON groups 1 and 2.

STUDY FUNDING/COMPETING INTERESTS

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

Cumulative live birth rates do not increase after 4 complete cycles in women with poor ovarian response: a retrospective study of 1,825 patients

Objective

To investigate whether the cumulative clinical pregnancy rates (CCPR) and cumulative live birth rates (CLBR) increase as the oocyte retrieval cycle increases in women with poor ovarian response.

Design

Retrospective cohort study.

Setting

Not applicable.

Patient(s)

Women diagnosed of poor ovarian response (POR) according to the Bologna criteria and who completed in vitro fertilization or intracytoplasmic sperm injection cycles between January 2014 and December 2018.

Intervention(s)

Not applicable.

Main Outcome Measure(s)

The conservative and optimistic estimations of CCPR and CLBR.

Result(s)

The conservative and optimistic estimates of CCPR peaked at the 6th complete cycle, reaching 36.44% and 71.61%, respectively. However, the conservative and optimistic estimates of CLBR peaked at the 4th complete cycle, reaching 20.22% and 38.31%, respectively. The live birth rate per complete cycle of mild stimulation protocol was comparable to other protocols after adjusting for the confounding factors. For patients ≤35 years, the live birth rate per complete cycle of progestin-primed ovarian stimulation (adjusted odds ratio = 0.51, 95% confidence interval: 0.30–0.87) and gonadotropin-releasing hormone antagonist protocol (adjusted odds ratio=0.45, 95% confidence interval: 0.24–0.81) were significantly lower than that of the mild stimulation.

Conclusion(s)

It is not advisable to initiate more than four complete cycles for POR patients since CLBR do not increase after that. For POR patients ≤35 years, the live birth rate per complete cycle increased in women with mild stimulation protocol.

Beyond Premature Ovarian Insufficiency: Staging Reproductive Aging in Adolescent and Young Adult Cancer Survivors

CONTEXT

Although stages of reproductive aging for women in the general population are well described by STRAW+10 criteria, this is largely unknown for female adolescent and young adult cancer survivors (AYA survivors).

OBJECTIVE

This work aimed to evaluate applying STRAW + 10 criteria in AYA survivors using bleeding patterns with and without endocrine biomarkers, and to assess how cancer treatment gonadotoxicity is related to reproductive aging stage.

DESIGN

The sample (n = 338) included AYA survivors from the Reproductive Window Study cohort. Menstrual bleeding data and dried-blood spots for antimüllerian hormone (AMH) and follicle-stimulating hormone (FSH) measurements (Ansh DBS enzyme-linked immunosorbent assays) were used for reproductive aging stage assessment. Cancer treatment data were abstracted from medical records.

RESULTS

Among participants, mean age 34.0 ± 4.5 years and at a mean of 6.9 ± 4.6 years since cancer treatment, the most common cancers were lymphomas (31%), breast (23%), and thyroid (17%). Twenty-nine percent were unclassifiable by STRAW + 10 criteria, occurring more frequently in the first 2 years from treatment. Most unclassifiable survivors exhibited bleeding patterns consistent with the menopausal transition, but had reproductive phase AMH and/or FSH levels. For classifiable survivors (48% peak reproductive, 30% late reproductive, 12% early transition, 3% late transition, and 7% postmenopause), endocrine biomarkers distinguished among peak, early, and late stages within the reproductive and transition phases. Gonadotoxic treatments were associated with more advanced stages.

CONCLUSIONS

We demonstrate a novel association between gonadotoxic treatments and advanced stages of reproductive aging. Without endocrine biomarkers, bleeding pattern alone can misclassify AYA survivors into more or less advanced stages. Moreover, a large proportion of AYA survivors exhibited combinations of endocrine biomarkers and bleeding patterns that do not fit the STRAW + 10 criteria, suggesting the need for modified staging for this population.

Euploidy rates of embryos in young patients with good and low prognosis according to the POSEIDON criteria

RESEARCH QUESTION

Does an association exist between ovarian reserve, ovarian response and embryonic euploidy in female patients under age 35 years?

DESIGN

This was a retrospective analysis of intracytoplasmic sperm injection and preimplantation genetic testing for aneuploidies cycles among patients enrolled at Bahceci Fulya IVF Center between January 2016 and August 2019. A total of 133 patients in POSEIDON group 1 (suboptimal responder; female age <35 years, antral follicle count [AFC] ≥5, number of oocytes retrieved <10) (group A), 133 patients in POSEIDON group 3 (expected low responder; female age <35 years, AFC <5) (group B) and 323 in the non-low-prognosis group (female age <35 years, AFC ≥5 and number of oocytes retrieved >9) (group C) were included.

RESULTS

There was no significant difference in euploidy rate per embryo among the three groups (61.7% [145/235] for group A versus 53.5% [68/127] for group B versus 62% [625/1008] for group C; P = 0.13). The cancellation rate in cycles without a euploid blastocyst was significantly lower in group C than groups A and B (8.4% versus 12.8% and 16.5%; P = 0.034). Multivariate regression analysis indicated that the ovarian response group did not significantly affect the probability of obtaining a euploid embryo. Trophectoderm score 'C' (odds ratio 0.520, P = 0.007) and inner cell mass score 'C' (odds ratio 0.480, P < 0.001) were associated with a decreased probability of obtaining a euploid embryo.

CONCLUSIONS

These results confirm that POSEIDON group 1 and group 3 and non-low-prognosis patients have different probabilities of euploid embryos being obtained per cycle. However, euploidy rates per embryo are not affected by the patient's ovarian reserve and response.

Progestin-Primed Ovarian Stimulation Versus Mild Stimulation Protocol in Advanced Age Women With Diminished Ovarian Reserve Undergoing Their First In Vitro Fertilization Cycle: A Retrospective Cohort Study

OBJECTIVE

To assess and compare the feasibility of progestin-primed ovarian stimulation (PPOS) protocol with mild stimulation protocol for advanced age women with diminished ovarian reserve (DOR) undergoing their first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycle.

METHODS

Patients aged ≥35 years and DOR undergoing their first IVF/ICSI cycle were enrolled in this retrospective cohort study: 139 and 600 patients underwent the PPOS and mild stimulation protocols, respectively. The primary outcomes were cumulative clinical pregnancy rate (CCPR) and cumulative live birth rate (CLBR). The secondary outcomes were the number of oocytes retrieved and top-quality embryos.

RESULTS

There was nearly no significant difference of baseline characteristics between the two groups. Although a greater amount of total gonadotropin (1906.61 ± 631.04 IU vs. 997.72 ± 705.73 IU, P<0.001) and longer duration of stimulation (9 (10-7) vs. 6 (8-4), P<0.001) were observed in the PPOS group, the number of retrieved oocytes (3 (6-2) vs. 2 (4-1), P<0.001) and top-quality embryos (1 (2-0) vs. 1 (2-0), P=0.038) was greater in the PPOS group than the mild stimulation group. Meanwhile, the incidence of premature luteinizing hormone (LH) surge rate was significantly lower in the PPOS group (0.7% vs.8.3%, P=0.001) than the mild stimulation group. However, there was no significant difference in conservative CCPR, conservative CLBR, optimistic CCPR, and optimistic CLBR between the two groups (all P>0.05). A multivariate logistic regression model showed significant positive effects of the number of retrieved oocytes and number of top-quality embryos on conservative CCPR (OR=1.236, 95%CI: 1.048-1.456, P=0.012, OR=2.313, 95%CI: 1.676-3.194, P<0.001) and conservative CLBR (OR=1.250, 95%CI: 1.036-1.508, P=0.020, OR=2.634, 95%CI: 1.799-3.857, P<0.001) respectively, while significant negative effects of age were identified for conservative CCPR (OR=0.805, 95%CI: 0.739-0.877, P<0.001) and conservative CLBR (OR=0.797, 95%CI: 0.723-0.879, P<0.001).

CONCLUSION

The PPOS protocol is an effective alternative to the mild stimulation protocol for advanced age patients with DOR, as it provides comparable reproductive outcomes and better control of premature LH surge. Further, more oocytes and top-quality embryos were obtained in the PPOS group, which had a positive association with conservative CCPR and CLBR.

Low Prognosis by the POSEIDON Criteria in Women Undergoing Assisted Reproductive Technology: A Multicenter and Multinational Prevalence Study of Over 13,000 Patients

OBJECTIVE

To estimate the prevalence of low-prognosis patients according to the POSEIDON criteria using real-world data.

DESIGN

Multicenter population-based cohort study.

SETTINGS

Fertility clinics in Brazil, Turkey, and Vietnam.

PATIENTS

Infertile women undergoing assisted reproductive technology using standard ovarian stimulation with exogenous gonadotropins.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Per-period prevalence rates of POSEIDON patients (overall, stratified by POSEIDON groups and by study center) and the effect of covariates on the probability that a patient be classified as "POSEIDON".

RESULTS

A total of 13,146 patients were included. POSEIDON patients represented 43.0% (95% confidence interval [CI] 42.0-43.7) of the studied population, and the prevalence rates varied across study centers (range: 38.6-55.7%). The overall prevalence rates by POSEIDON groups were 44.2% (group 1; 95% CI 42.6-45.9), 36.1% (group 2; 95% CI 34.6-37.7), 5.2% (group 3; 95% CI 4.5-6.0), and 14.4% (group 4; 95% CI: 13.3-15.6). In general, POSEIDON patients were older, had a higher body mass index (BMI), lower ovarian reserve markers, and a higher frequency of female factor as the primary treatment indication than non-POSEIDON patients. The former required larger doses of gonadotropin for ovarian stimulation, despite achieving a 2.5 times lower number of retrieved oocytes than non-POSEIDON patients. Logistic regression analyses revealed that female age, BMI, ovarian reserve, and a female infertility factor were relevant predictors of the POSEIDON condition.

CONCLUSIONS

The estimated prevalence of POSEIDON patients in the general population undergoing ART is significant. These patients differ in clinical characteristics compared with non-POSEIDON patients. The POSEIDON condition is associated with female age, ovarian reserve, BMI, and female infertility. Efforts in terms of diagnosis, counseling, and treatment are needed to reduce the prevalence of low-prognosis patients.

The risk of poor ovarian response during repeat IVF

RESEARCH QUESTION

What are the incidence and risk factors for poor ovarian response (POR) during repeat IVF?

DESIGN

A retrospective analysis of 1224 consecutive patients who underwent at least two IVF stimulations in a single centre over a 6-year period. Risk factors from the initial treatment were assessed for association with POR during repeat IVF using logistic regression analysis. A simple, practical predictive model was constructed and evaluated for accuracy and calibration, based on the factors that demonstrated significant association with subsequent POR. POR during repeat IVF was defined as ≤3 retrieved oocytes or cancellation before retrieval following recruitment of ≤3 mature follicles.

RESULTS

The risk of POR during repeat IVF was approximately 11.5%. A higher POR risk during repeat IVF is associated with a reduced oocyte yield during the initial treatment (≤3 oocytes: odds ratio [OR] 14, 95% confidence interval [CI] 6.42-30.24; 4-9 oocytes: OR 4.13, 95% CI 2.00-8.54; 10-15 oocytes: OR 1) and low ovarian reserve (anti-Müllerian hormone [AMH] <5.4 pmol/l: OR 3.54, 95% CI 2.24-5.59; AMH 5.4-25 pmol/l: OR 1). Women with low ovarian reserve who experience POR during the initial IVF have the highest risk of suffering POR again during repeat IVF (57% within 1 year). Other groups, such as women with unexpected POR or expected poor responders with suboptimal ovarian response during the initial IVF, are also at risk of exhibiting POR during a subsequent treatment (28% within 1 year).

CONCLUSIONS

As there is a clear association between POR and lower live birth rates, this practical model may help manage patients' expectations during repeat IVF treatment.

Efficacy of the delayed start antagonist protocol for controlled ovarian stimulation in Bologna poor ovarian responders: a systematic review and meta-analysis

BACKGROUND

Patients with a poor ovarian response (POR) represent the most difficult group of population to deal with in the clinical fertility practice. Bologna criteria are the first uniform definition of POR. Choosing a suitable controlled ovarian stimulation (COS) protocol which could give adequate oocytes to maximize the chance of obtaining at least one euploid blastocyst is crucial in the management for such patients. The delayed start antagonist protocol is a novel COS protocol designed for POR patients, however, its real efficacy is controversial compared to conventional protocols. The present study aims to summarize all available studies on this topic and perform a meta-analysis to explore the real treatment effect of this novel protocol in terms of reproductive outcomes.

STUDY DESIGN

PubMed, EMBASE, Google Scholar, and the Cochrane Library from database establishment to June 2019 were searched. Randomized controlled trials (RCTs), which compared delayed start antagonist protocol (Del) to conventional controlled ovarian stimulation (COS) protocols (Con) in terms of reproductive outcomes, were included. The RevMan 5.3 was used to perform statistical analysis. The primary outcomes were the cycle cancellation rate, the clinical pregnancy rate and the miscarriage rate.

RESULTS

5 RCTs yielding 514 patients were eligible, of which 5, 5, 4 studies were included in analyzing the cycle cancellation rate, the clinical pregnancy rate, and the miscarriage rate respectively. Synthesized data of meta-analysis showed: delayed start antagonist protocol introduced a lower risk of cycle cancellation [risk ratio (RR) = 0.63, 95% confidence interval (CI) (0.45, 0.90), P = 0.01; 5 RCTs, 514 women (Del:Con = 256:258); I² = 0%; with rates of 16.02% (Del) vs. 26.36% (Con)], an increased chance to get clinical pregnancy [RR = 2.30, 95% CI (1.38, 3.82), P = 0.001; 5 RCTs, 514 women (Del:Con = 256:258); I² = 0%; with rates of 16.80% (Del) vs. 7.36% (Con)], and a comparable miscarriage rate [RR = 0.55, 95% CI (0.24, 1.23), P = 0.15; 4 RCTs, 58 women (Del:Con = 41:17) I² = 17%; with rates of 19.51% (Del) vs. 35.29% (Con)] compared to conventional COS protocols.

CONCLUSIONS

Delayed start antagonist protocol was a potentially valuable alternation for poor ovarian responders. However, future RCTs with large sample size and more scientific design are needed to verify its validity and draw a sound conclusion.