Development of a nomogram based on markers of ovarian reserve for the individualisation of the follicle-stimulating hormone starting dose in in vitro fertilisation cycles

Deep learning-based prediction of individualized Real-time FSH doses in GnRH agonist long protocols

BACKGROUND

Individualizing follicle-stimulating hormone (FSH) dosing during controlled ovarian stimulation (COS) is critical for optimizing outcomes in assisted reproduction but remains difficult due to patient heterogeneity. Most existing models are limited to static predictions of initial doses and do not support real-time adjustments throughout stimulation.

METHODS

We developed a deep learning model that integrates cross-temporal and cross-feature encoding (CTFE) to predict personalized daily FSH doses in patients undergoing COS using the GnRH agonist long protocol. A total of 13,788 IVF/ICSI cycles conducted between January 2018 and December 2020 were retrospectively analyzed. Women with baseline antral follicle counts between 7 and 30 were included. Data were randomly divided into training (n = 6761), validation (n = 2898), and test (n = 4135) sets. The model encodes both static (e.g., age, BMI, basic hormone levels) and dynamic (e.g., follicle development, hormone trends during COS) variables across stimulation days. Final dose predictions were generated using a K-nearest neighbor algorithm applied to low-dimensional latent representations derived from the deep encoder layers.

RESULTS

The CTFE model achieved a dose classification accuracy of 0.737 (± 0.004) and a weighted F1-score of 0.732 (± 0.005) on the test set. On key stimulation days 1 and 5, the CTFE model significantly outperformed traditional LASSO regression models (F1-score: 0.832 vs 0.699 on day 1; 0.817 vs 0.523 on day 5; p < 0.001). Prediction performance was maintained beyond day 13 using a sliding window mechanism, despite reduced data availability in longer stimulation cycles.

CONCLUSIONS

This is the first study to apply a cross-temporal and cross-feature deep learning framework for daily, individualized FSH dose prediction across the full duration of COS. The model demonstrated superior performance over conventional approaches and offers a promising tool for standardizing COS management. Although currently limited by its retrospective, single-center design, the model may support future clinical decision-making and improve COS outcomes. Prospective, multicenter validation studies are warranted to confirm its utility and generalizability.

A retrospective study "myo-inositol is a cost-saving strategy for controlled ovarian stimulation in non-polycystic ovary syndrome art patients."

BACKGROUND

Fertility care represents a financial burden on patients and healthcare services alike and can represent a barrier to entry for many couples. Controlled ovarian stimulation (COH) is routinely used as part of in vitro fertilization and intracytoplasmic sperm injection (ICSI) procedures, as such the use of gonadotropins is a major contributing factor to the cost of the procedure. Recent studies have shown that myo-Inositol (myo-ins) may reduce the amount of gonadotrophins required in assisted reproductive technology (ART) procedures. This retrospective study measured the effect of myo-ins on the number of recombinant follicular stimulating hormone (rFSH) units used in IVF and ICSI and the relative cost to verify if this may be a cost saving strategy. We also investigated the oocyte and embryo quality, implantation rate, abortion rate, clinical pregnancy, and ovarian hyperstimulation syndrome.

METHODS

A total of 300 women undergoing either IVF or ICSI were distributed between two distinct and equal patient groups of 150 women. In control group (group A), folic acid (FA) alone was prescribed, meanwhile the treated group (group B) were prescribed FA, myo-Inositol (myo-ins) and alpha-lactalbumin (α-LA), both groups started this oral treatment in the middle of the luteal phase.

RESULTS

Myo-Ins supplementation in the treatment group significantly reduced the number of units of rFSH used in COH vs. the control group (2526 vs. 1647, p < 0.05); however, no changes were seen in other measured outcomes, likely due to the short treatment period.

CONCLUSIONS

The use of myo-Ins presents a safe method for reducing the amount and subsequent costs of rFSH usage in ART protocols.

TRIAL REGISTRATION

The trial was retrospectively registered with the Institutional Review Board of ALMA RES IVF Center, trial number n°2/2024.

Development of a novel calculator to predict gonadotropin dose and oocyte yield in oocyte cryopreservation cycles

PURPOSE

To develop a predictive model for estimating the total dose of gonadotropins and the number mature oocytes in planned oocyte cryopreservation cycles.

METHODS

In this retrospective study, oocyte cryopreservation cycles recorded in the Society for Assisted Reproductive Technology Clinic Outcome Reporting System Database from 2013 to 2018 were analyzed. Bivariate copula additive models for location, scale, and shape were performed to create a predictive model for estimating total dose of gonadotropins and number of mature oocytes.

RESULTS

A total of 15,806 oocyte cryopreservation cycles between 2013 and 2018 were included in the analysis. The average age of participants was 35.4 years, the mean duration of stimulation was 11.8 days, and the average number of mature oocytes retrieved was 11.8. The treatment dose increased with age, FSH levels, BMI ≥ 35 kg/m2, smoking, and history of diminished ovarian reserve, while it decreased with increasing AMH, ovulatory disorder, and BMI < 25 kg/m2. The number of mature oocytes retrieved was positively correlated with AMH and negatively correlated with age, FSH levels, Asian race, and diminished ovarian reserve. With a maximum gonadotropin dosage of 450 IU per day for 12 ± 3 days of stimulation and a tolerance level of six mature oocytes, the predictive model achieved 70% accuracy. An interactive version of the equation was created as an online tool.

CONCLUSIONS

We developed a predictive model to estimate the total treatment dosage and the number of mature oocytes. This calculator, utilizing objective patient variables, can assist in patient counseling prior to planned oocyte cryopreservation cycles.

Machine learning tool for predicting mature oocyte yield and trigger day from start of stimulation: towards personalized treatment

RESEARCH QUESTION

Can machine learning tools predict the number of metaphase II (MII) oocytes and trigger day at the start of the ovarian stimulation cycle?

DESIGN

A multicentre, retrospective study including 56,490 ovarian stimulation cycles (primary dataset) was carried out between 2020 and 2022 for analysis and feature selection. Of these, 13,090 were used to develop machine learning models for trigger day and the number of MII prediction, and another 5103 ovarian stimulation cycles (clinical validation dataset) from 2023 for clinical validation. Machine learning algorithms using deep learning were developed using optimal features from the primary dataset based on correlation.

RESULTS

A tool with two novel progressive machine learning algorithms using deep learning was able to predict the trigger day and number of MII oocytes: mean absolute error 1.60 (95% CI 1.56 to 1.64) and 3.75 (95% CI 3.65 to 3.86), respectively. The R2 value for the algorithm to predict the number of MII in the interquartile (Q3-Q1/P75-P25) range was 0.88; the entire dataset was 0.70 after removing the outliers at the planning phase of the stimulation cycle, which shows high accuracy. The interquartile root mean square error was 1.10 and 0.66 for the trigger day and the number of oocytes algorithm, respectively.

CONCLUSION

The tool using deep learning algorithms has high prediction power for trigger day and number of MII outcomes, and can be retrieved from patients at the start of the ovarian stimulation cycle; however, inclusion of more data and validation from different clinics are needed.

Physiological premature aging of ovarian blood vessels leads to decline in fertility in middle-aged mice

Ovarian function declines significantly as females enter middle-age, but the mechanisms underlying this decline remain unclear. Here, we utilize whole-organ imaging to observe a notable decrease in ovarian blood vessel (oBV) density and angiogenesis intensity of middle-aged mice. This leads to a diminished blood supply to the ovaries, resulting in inadequate development and maturation of ovarian follicles. Utilizing genetic-modified mouse models, we demonstrate that granulosa cell secreted VEGFA governs ovarian angiogenesis, but the physiological decline in oBV is not attributed to VEGFA insufficiency. Instead, through single-cell sequencing, we identify the aging of the ovarian vascular endothelium as the primary factor contributing to oBV decline. Consequently, the administration of salidroside, a natural compound that is functional to reverse oBV aging and promote ovarian angiogenesis, significantly enhances ovarian blood supply and improve fertility in older females. Our findings highlight that enhancing oBV function is a promising strategy to boost fertility in females.

A simple and practical approach to elective egg freezing to control costs and expand access to care

Social elective egg freezing (EEF) is now widely used globally but in many countries is unaffordable to many women because of high costs and lacking insurance coverage. Efforts to reduce costs, therefore, are of importance. Surprisingly, a simple, well-defined and practical approach ensuring optimal outcomes for EEF has, however, so-far not been published. We, therefore, conducted a narrative review of the literature for relevant articles regarding the different steps of ovarian stimulation (OS) in the EEF process, in order to define such a standard protocol. This review revealed that in order to maximize oocyte yields with minimal number of OS cycles - while ensuring patient safety - a multiple-dose GnRH antagonist protocol with a daily gonadotropin dose of 300 IU appears best, unless patients demonstrate a polycystic ovarian phenotype, suggestive of likely high responses. The initial gonadotropin should be recFSH, while LH supplementation should be co-administered with the addition of GnRH antagonist. Final follicular maturation should be triggered by GnRH agonist trigger, with a dual trigger (1000-1500 IU hCG) considered for suboptimal responders to GnRH agonist trigger, optionally with Cabergoline to mitigate ovarian hyperstimulation syndrome (OHSS) in high responders.

Predictive model of IVF outcomes for polycystic ovarian morphology and polycystic ovary syndrome in GnRH antagonist protocol using AMH-MoM and ovarian sensitivity index

AIM

To evaluate the relationship between AMH and ovarian response to controlled ovarian hyperstimulation in women with PCOM and PCOS.

METHODS

A retrospective study was conducted on 559 patients who underwent the IVF-ET cycle between January 2018 and December 2022 at Gangnam Cha Hospital. Patients were divided into 3 groups matched for age and BMI: the PCOS group (n = 54), based on the new 2023 PCOS guideline; the PCOM group (n = 53); and the control group (n = 452) with normal ovaries. Serum AMH levels were converted to multiples of the median (MoM) for each corresponding age. The ovarian sensitivity index (OSI) was calculated as the number of retrieved oocytes divided by the total dose of recombinant FSH administered (per 1000 IU).

RESULTS

There were significant differences in AMH-MoM value among women with PCOS [2.7 ± 1.3 (95% CI 2.3-3.0)], those with PCOM [2.0 ± 1.0 (95% CI 1.7-2.3)], and controls [0.8 ± 0.7 (95% CI 0.8-0.9)] (p < 0.001). The abortion rates in the normoovulatory, PCOM, and PCOS groups were 18.2%, 21.1%, and 25.0%, respectively. OSI and live birth rate were positively correlated with the AMH-MoM value in normoovulatory women (r = 0.389, p < 0.05, r = 0.122, p < 0.05), while no such correlation was observed in women with PCOM and PCOS.

CONCLUSIONS

Ovarian response and live birth rate are possibly correlated with the AMH-MoM value in normoovulatory women, but not in women with PCOM and PCOS.

Exploring gonadotropin dosing effects on MII oocyte retrieval in ovarian stimulation

PURPOSE

Ovarian stimulation with gonadotropins is crucial for obtaining mature oocytes for in vitro fertilization (IVF). Determining the optimal gonadotropin dosage is essential for maximizing its effectiveness. Our study aimed to develop a machine learning (ML) model to predict oocyte counts in IVF patients and retrospectively analyze whether higher gonadotropin doses improve ovarian stimulation outcomes.

METHODS

We analyzed the data from 9598 ovarian stimulations. An ML model was employed to predict the number of mature metaphase II (MII) oocytes based on clinical parameters. These predictions were compared with the actual counts of retrieved MII oocytes at different gonadotropin dosages.

RESULTS

The ML model provided precise predictions of MII counts, with the AMH and AFC being the most important, and the previous stimulation outcome and age, the less important features for the prediction. Our findings revealed that increasing gonadotropin dosage did not result in a higher number of retrieved MII oocytes. Specifically, for patients predicted to produce 4-8 MII oocytes, a decline in oocyte count was observed as gonadotropin dosage increased. Patients with low (1-3) and high (9-12) MII predictions achieved the best results when administered a daily dose of 225 IU; lower and higher doses proved to be less effective.

CONCLUSIONS

Our study suggests that high gonadotropin doses do not enhance MII oocyte retrieval. Our ML model can offer clinicians a novel tool for the precise prediction of MII to guide gonadotropin dosing.

Development and validation of a prediction model for unexpected poor ovarian response during IVF/ICSI

Background

Identifying poor ovarian response (POR) among patients with good ovarian reserve poses a significant challenge within reproductive medicine. Currently, there is a lack of published data on the potential risk factors that could predict the occurrence of unexpected POR. The objective of this study was to develop a predictive model to assess the individual probability of unexpected POR during in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments.

Methods

The development of the nomogram involved a cohort of 10,404 patients with normal ovarian reserve [age, ≤40 years; antral follicle count (AFC), ≥5; and anti-Müllerian hormone (AMH), ≥1.2 ng/ml] from January 2019 to December 2022. Univariate regression analyses and least absolute shrinkage and selection operator regression analysis were employed to ascertain the characteristics associated with POR. Subsequently, the selected variables were utilized to construct the nomogram.

Results

The predictors included in our model were body mass index, basal follicle-stimulating hormone, AMH, AFC, homeostasis model assessment of insulin resistance (HOMA-IR), protocol, and initial dose of gonadotropin. The area under the receiver operating characteristic curve (AUC) was 0.753 [95% confidence interval (CI) = 0.7257-0.7735]. The AUC, along with the Hosmer-Lemeshow test (p = 0.167), demonstrated a satisfactory level of congruence and discrimination ability of the developed model.

Conclusion

The nomogram can anticipate the probability of unexpected POR in IVF/ICSI treatment, thereby assisting professionals in making appropriate clinical judgments and in helping patients to effectively manage expectations.

Personalizing the first dose of FSH for IVF/ICSI patients through machine learning: a non-inferiority study protocol for a multi-center randomized controlled trial

BACKGROUND

Adequately selecting the initial follicle-stimulating hormone (FSH) dose during controlled ovarian stimulation (COS) is key for success in assisted reproduction. The objective of COS is to obtain an optimal number of oocytes to increase the chances of achieving a pregnancy, while avoiding complications for the patient. Current clinical protocols do achieve good results for the majority of patients, but further refinements in individualized FSH dosing may reduce the risk of poor ovarian response while also limiting the risk of ovarian hyperstimulation syndrome (OHSS) risk. Models to select the first FSH dose in COS have been presented in literature with promising results. However, most have only been developed and tested in normo-ovulatory women under the age of 40 years.

METHODS

This is a randomized, controlled, multicenter, single blinded, clinical trial. This study will be performed in 236 first cycle in vitro fertilization (IVF) and/or ICSI (intracytoplasmic sperm injection) patients, randomized 1:1 in two arms. In the intervention arm, the dose of FSH will be assigned by a machine learning (ML) model called IDoser, while in the control arm, the dose will be determined by the clinician following standard practice. Stratified block randomization will be carried out depending on the patient being classified as expected low responder, high responder, or normo-responder. Patients will complete their participation in the trial once the first embryo transfer result is known. The primary outcome of the study is the number of metaphase II (MII) oocytes retrieved at ovarian pick up (OPU) and the hypothesis of non-inferiority of the intervention arm compared to the control. Secondary outcomes include the number of cycle cancelations (due to low response or no retrieval of mature oocytes), risk of ovarian hyperstimulation syndrome (OHSS), and clinical pregnancy and live birth rates per first transfer.

DISCUSSION

To our knowledge, this is the first randomized trial to test clinical performance of an all-patient inclusive model to select the first dose of FSH for COS. Prospective trials for machine learning (ML) models in healthcare are scarce but necessary for clinical application.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05948293 . Registered on 14 July 2023.

Individualised gonadotropin dose selection using markers of ovarian reserve for women undergoing in vitro fertilisation plus intracytoplasmic sperm injection (IVF/ICSI)

BACKGROUND

During a stimulated cycle of in vitro fertilisation or intracytoplasmic sperm injection (IVF/ICSI), women receive daily doses of gonadotropin follicle-stimulating hormone (FSH) to induce multifollicular development in the ovaries. A normal response to stimulation (e.g. retrieval of 5 to 15 oocytes) is considered desirable. Generally, the number of eggs retrieved is associated with the dose of FSH. Both hyper-response and poor response are associated with an increased chance of cycle cancellation. In hyper-response, this is due to increased risk of ovarian hyperstimulation syndrome (OHSS), while poor response cycles are cancelled because the quantity and quality of oocytes is expected to be low. Clinicians often individualise the FSH dose using patient characteristics predictive of ovarian response. Traditionally, this meant women's age, but increasingly, clinicians use various ovarian reserve tests (ORTs). These include basal FSH (bFSH), antral follicle count (AFC), and anti-Müllerian hormone (AMH). It is unclear whether individualising FSH dose improves clinical outcomes. This review updates the 2018 version.

OBJECTIVES

To assess the effects of individualised gonadotropin dose selection using markers of ovarian reserve in women undergoing IVF/ICSI.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, and two trial registers in February 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared (a) different doses of FSH in women with a defined ORT profile (i.e. predicted low, normal, or high responders based on AMH, AFC, and/or bFSH) or (b) an individualised dosing strategy (based on at least one ORT measure) versus uniform dosing or a different individualised dosing algorithm.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Primary outcomes were live birth/ongoing pregnancy and severe OHSS.

MAIN RESULTS

We included 26 studies, involving 8520 women (6 new studies added to 20 studies included in the previous version). We treated RCTs with multiple comparisons as separate trials for the purpose of this review. Meta-analysis was limited due to clinical heterogeneity. Evidence certainty ranged from very low to low, with the main limitations being imprecision and risk of bias associated with lack of blinding. Direct dose comparisons according to predicted response in women Due to differences in dose comparisons, caution is required when interpreting the RCTs in predicted low responders. All evidence was low or very low certainty. Effect estimates were very imprecise, and increased FSH dosing may or may not have an impact on rates of live birth/ongoing pregnancy, OHSS, and clinical pregnancy. Similarly, in predicted normal responders (10 studies, 4 comparisons), higher doses may or may not impact the probability of live birth/ongoing pregnancy (e.g. 200 versus 100 international units (IU): odds ratio (OR) 0.88, 95% confidence interval (CI) 0.57 to 1.36; I2 = 0%; 2 studies, 522 women) or clinical pregnancy. Results were imprecise, and a small benefit or harm remains possible. There were too few events for the OHSS outcome to enable inferences. In predicted high responders, lower doses may or may not affect live birth/ongoing pregnancy (OR 0.98, 95% CI 0.66 to 1.46; 1 study, 521 women), severe OHSS, and clinical pregnancy. It is also unclear whether lower doses reduce moderate or severe OHSS (Peto OR 2.31, 95% CI 0.80 to 6.67; 1 study, 521 participants). ORT-algorithm studies Eight trials compared an ORT-based algorithm to a non-ORT control group. It is unclear whether live birth/ongoing pregnancy and clinical pregnancy are increased using an ORT-based algorithm (live birth/ongoing pregnancy: OR 1.12, 95% CI 0.98 to 1.29; I2 = 30%; 7 studies, 4400 women; clinical pregnancy: OR 1.04, 95% CI 0.91 to 1.18; I2 = 18%; 7 studies, 4400 women; low-certainty evidence). However, ORT algorithms may reduce moderate or severe OHSS (Peto OR 0.60, 95% CI 0.42 to 0.84; I2 = 0%; 7 studies, 4400 women; low-certainty evidence). There was insufficient evidence to determine whether the groups differed in rates of severe OHSS (Peto OR 0.74, 95% CI 0.42 to 1.28; I2 = 0%; 5 studies, 2724 women; low-certainty evidence). Our findings suggest that if the chance of live birth with a standard starting dose is 25%, the chance with ORT-based dosing would be between 25% and 31%. If the chance of moderate or severe OHSS with a standard starting dose is 5%, the chance with ORT-based dosing would be between 2% and 5%. These results should be treated cautiously due to heterogeneity in the algorithms: some algorithms appear to be more effective than others.

AUTHORS' CONCLUSIONS

We did not find that tailoring the FSH dose in any particular ORT population (low, normal, high ORT) affected live birth/ongoing pregnancy rates, but we could not rule out differences, due to sample size limitations. Low-certainty evidence suggests that it is unclear if ORT-based individualisation leads to an increase in live birth/ongoing pregnancy rates compared to a policy of giving all women 150 IU. The confidence interval is consistent with an increase of up to around six percentage points with ORT-based dosing (e.g. from 25% to 31%) or a very small decrease (< 1%). A difference of this magnitude could be important to many women. It is unclear if this is driven by improved outcomes in a particular subgroup. Further, ORT algorithms reduced the incidence of OHSS compared to standard dosing of 150 IU. However, the size of the effect is also unclear. The included studies were heterogeneous in design, which limited the interpretation of pooled estimates. It is likely that different ORT algorithms differ in their effectiveness. Current evidence does not provide a clear justification for adjusting the dose of 150 IU in poor or normal responders, especially as increased dose is associated with greater total FSH dose and cost. It is unclear whether a decreased dose in predicted high responders reduces OHSS, although this would appear to be the most likely explanation for the results.

Verification of the utility of the gonadotropin starting dose calculator in progestin-primed ovarian stimulation: A comparison of empirical and calculated controlled ovarian stimulation

Purpose

To validate the effectiveness of a gonadotropin starting dose calculator for progestin-primed ovarian stimulation (PPOS), we conducted a study comparing the outcomes of oocyte retrieval between a group assigned gonadotropin doses via the calculator and a control group, where doses were determined by the clinician's empirical judgment.

Methods

Patients underwent controlled ovarian stimulation (COS) using the PPOS method, followed by oocyte retrieval. We assessed and compared the results of COS and oocyte retrieval in both groups. Additionally, we examined the concordance rate between the number of oocytes actually retrieved and the target number of oocytes in each group.

Results

The calculated group demonstrated a significantly higher number of preovulation follicles and a higher ovarian sensitivity index than the control group. Furthermore, the discrepancy between the target and actual number of oocytes retrieved was notably smaller in the calculated group. The concordance rate between the target and actual number of oocytes was significantly greater in the calculated group.

Conclusions

The gonadotropin starting dose calculator proved to be effective within the PPOS protocol, offering a reliable method for predicting the approximate number of oocytes to be retrieved, irrespective of the COS protocol employed.

Ovarian sensitivity index can be used as a more sensitive indicator than follicular output rate to predict IVF/ICSI outcomes in patients of normal expected ovarian response stimulated with GnRH antagonist protocol

This retrospective study was performed to investigate the predictive power of the Ovarian Sensitivity Index (OSI) for IVF/ICSI outcomes in infertile patients who were of normal expected ovarian response. A total of 912 infertile patients who underwent GnRH antagonist protocol between January 2017 to August 2019 at the Medical Center for Human Reproduction, Beijing Chao-Yang Hospital were included. All patients completed the full oocyte retrieval cycle and either had a live birth or had no embryos left. OSI was significantly lower in patients with a live birth (196.0 ± 120.4 in the live birth group vs 276.4 ± 235.7 in the non-live birth group, p < 0.001) while follicular output rate (FORT, defined as the ratio of pre-ovulatory follicle count on hCG day x 100/small antral follicle count at baseline) showed no significant difference. Patients were divided into low, average and high OSI groups and analysed in tertiles. From the low to the high OSI group, the cumulative live birth rate (CLBR) decreased dramatically (72.7 vs 67.2 vs 54.8%, p < 0.001). Multivariate regression analysis showed that OSI was an independent factor affecting CLBR (OR: 0.996, 95%CI: 0.995-0.998, p < 0.001) in our study population. In conclusion, OSI can be used as an independent indicator to distinguish fecundity in infertile patients with normal expected ovarian response and is probably more sensitive than FORT.

Predicting the total number of retrieved oocytes following double ovarian stimulation (DuoStim)

STUDY QUESTION

Can anti-Müllerian hormone (AMH) help predict how many oocytes will be retrieved following double stimulation (DuoStim)?

SUMMARY ANSWER

A simple clinical tool can use serum AMH values to predict ovarian response following DuoStim in IVF cycles.

WHAT IS ALREADY KNOWN

The knowledge that multiple follicular waves arise during a single ovarian cycle has led to the introduction of unconventional ovarian stimulation protocols. The DuoStim protocol involves two successive ovarian stimulations performed during a single ovarian cycle and has been proposed as an approach for patients with poor ovarian response and for medical fertility preservation. As AMH has been used as a marker of ovarian reserve and stimulation response, the current study aimed to investigate the diagnostic performance of AMH in predicting the number of retrieved oocytes following DuoStim.

STUDY DESIGN, SIZE, DURATION

This is a retrospective observational study involving 116 patients who received IVF treatment from January 2021 to September 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a private IVF centre. Only patients who had their AMH measured prior to treatment and had complete patient records regarding their clinical and IVF/ICSI cycle characteristics were included. The primary outcome was the correlation between AMH values and the number of oocytes retrieved following DuoStim. Parametric and non-parametric tests were used to compare baseline characteristics and outcomes. Spearman's R was used to analyse correlations between variables, while the C statistic was used to calculate the diagnostic performance of AMH.

MAIN RESULTS AND THE ROLE OF CHANCE

AMH levels were significantly correlated with the total number of oocytes retrieved after the DuoStim (R 0.61; CI 0.44-0.70; P < 0.0001). The difference in the total number of oocytes retrieved between the first (median 4 oocytes, interquartile range (IQR) 2-6) and second (median 6 oocytes, IQR 3.2-8) stimulation was statistically significant (P < 0.0001). However, there was no significant difference in the number of mature oocytes that were retrieved (median of 3 and 4 in the first and second stimulations, respectively). After the first stimulation, 68% of patients had at least one blastocyst available, while after the second stimulation, 74% did (NS). Based on linear regression, each 0.25 ng/ml increase in basal AMH corresponds to one additional oocyte recovered at the end of both stimulations (R2: 0.32, P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

The results are limited owing to the observational nature of the study and the number of participants.

WIDER IMPLICATIONS OF THE FINDINGS

Counselling infertile couples regarding the intermediate outcome of IVF (i.e. number of retrieved oocytes) is one of the most demanding tasks that clinicians face. To our knowledge, this is the first study that provides an easy-to-use clinical tool that enables the quantitative prediction of ovarian response following DuoStim, based on serum AMH values.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Effectiveness and Safety of Recombinant Human Follicle-Stimulating Hormone (Follitrope™) in Inducing Controlled Ovarian Stimulation in Infertile Women in Real-World Practice: a Prospective Cohort Study

To evaluate the safety and effectiveness of recombinant human follicle-stimulating hormone (rhFSH [Follitrope™]) in infertile women undergoing in vitro fertilization (IVF). To identify predictors of ovarian response that induce optimal clinical outcomes. This multicenter prospective study enrolled infertile women who were scheduled to undergo IVF after ovarian stimulation with rhFSH (Follitrope™) following the gonadotropin-releasing hormone (GnRH) agonist or GnRH antagonist protocol. Predictive factors for ovarian response were identified in the GnRH antagonist group based on the number of oocytes retrieved. A total of 516 infertile women were enrolled, among whom 136 (except one who withdrew before administration) received rhFSH using the GnRH agonist protocol and 379 using the antagonist protocol. The mean number of oocytes retrieved was 13.4 in the GnRH agonist group and 13.6 in the GnRH antagonist group. The clinical pregnancy rates were 32.3% (30/93) and 39.9% (115/288) in the GnRH agonist and antagonist groups, respectively. The incidence of ovarian hyperstimulation syndrome was 1.8% and 3.4% in the GnRH agonist and antagonist groups, respectively. No other significant safety risks associated with rhFSH administration were identified. Body mass index, basal serum FSH and anti-Müllerian hormone levels, and antral follicle count were identified as predictors of ovarian response by multiple regression with backward elimination, and the final regression model accounted for 26.5% of the response variability. In real-world practice, rhFSH (Follitrope™) is safe and effective in inducing ovarian stimulation in infertile women. Patient characteristics identified as predictors can be considered to be highly related to optimal clinical outcomes.

Dose Nomogram of Individualization of the Initial Follicle-Stimulating Hormone Dosage for Patients with Polycystic Ovary Syndrome Undergoing IVF/ICSI with the GnRH-Ant Protocol: A Retrospective Cohort Study

INTRODUCTION

For high responders with polycystic ovary syndrome (PCOS), there is no clear recommendation for the initial follicle-stimulating hormone (FSH) dosage to ensure an optimal number of retrieved oocytes and avoid ovarian hyperstimulation syndrome (OHSS). The aim of this study was to determine the ideal initial FSH dosage of in patients with PCOS undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) using the gonadotropin-releasing hormone antagonist (GnRH-ant) protocol to obtain the optimal number of retrieved oocytes and minimize the risk of OHSS.

METHODS

The data of 1898 patients with PCOS aged 20-40 years from January 2017 to December 2020 were retrospectively analyzed to explore the factors related to the number of retrieved oocytes. Statistically significant variables were used to construct a dose nomogram and it was then validated using an independent cohort of patients with PCOS from January 2021 to December 2021.

RESULTS

Multivariate analyses demonstrated that body mass index (BMI) was the most significant factor to predict the number of retrieved oocytes compared to body weight (BW) and body surface area (BSA). Among patients with PCOS aged 20-40 years undergoing their first IVF cycles with the GnRH-ant protocol, age was not a significant predictor of the initial FSH dosage. We developed a nomogram based on BMI, basal FSH, basal luteinizing hormone (bLH), anti-Müllerian hormone (AMH), and antral follicle count (AFC) to calculate the ideal initial FSH dosage for patients with PCOS undergoing IVF/ICSI using the GnRH-ant protocol. In addition, low BMI and high bLH and AMH levels and AFC appear to be risk factors for OHSS.

CONCLUSIONS

We clearly demonstrated that the initial FSH dosage for patients with PCOS undergoing IVF/ICSI with the GnRH-ant protocol may be calculated on the basis of the woman's BMI and ovarian reserve markers. The nomogram will help guide clinicians in the selection of the most appropriate initial FSH dose in the future.

AMHconverter: an online tool for converting results between the different anti-Müllerian hormone assays of Roche Elecsys®, Beckman Access, and Kangrun

Background

The anti-Müllerian hormone (AMH) is gaining attention as a key factor in determining ovarian reserve and polycystic ovarian syndrome, and its clinical applications are becoming more widespread worldwide.

Objective

To identify the most accurate formula for converting AMH assay results between different platforms, so that the developed AMH converter can be used to reduce the need for multiple AMH tests at different hospitals.

Methods

Assuming that the Beckman Access, Kangrun, and Roche Elecsys^® AMH assays fit a linear relationship from the lowest to the highest concentration (a global relationship), we used Passing-Bablok regression to determine the conversion equation between each two assays. When the relationship between two AMH assays was a local one, spline regression was used. Bland-Altman plots were drawn to check systemic bias and heterogeneity of variance across different ranges of values. The fitting effects of the models were evaluated using the squared coefficient of determination (r²), adjusted r², root mean square error (RMSE), Akaike information criterion (AIC), and corrected AIC.

Results

The coefficient of variance for multiple controls in the Kangrun, Roche, and Beckman assays was lower than 5%, and the bias of multiple controls was lower than 7%. A global linear relationship was observed between the Kangrun and Roche assays, with the intercept being zero, for which Passing-Bablok regression was employed for data conversion between the two platforms. For the other two pairs of platforms, i.e., Roche and Kangrun or Beckman and Kangrun, spline regression was applied, with the intercepts not including zero. The six corresponding formulas were developed into an online AMH converter (http://121.43.113.123:8006/).

Conclusion

This is the first time Passing-Bablok plus spline regression has been used to convert AMH concentrations from one assay to another. The formulas have been developed into an online tool, which makes them convenient to use in practical applications.

The impact of menopause on multiple sclerosis

Menopause, defined as the permanent cessation of ovarian function, represents a period of significant fluctuation in sex hormone concentrations. Sex hormones including oestrogen, progesterone, testosterone and anti-Mullerian hormone are thought have neuroinflammatory effects and are implicated in both neuroprotection and neurodegeneration. Sex hormones are thought to have a role in modifying clinical trajectory in multiple sclerosis (MS) throughout the lifespan. Multiple sclerosis predominantly effects women and is typically diagnosed early in a woman's reproductive life. Most women with MS will undergo menopause. Despite this, the effect of menopause on MS disease course remains unclear. This review examines the relationship between sex hormones and MS disease activity and clinical course, particularly around the time of menopause. It will consider the role of interventions such as exogenous hormone replacement therapy in modulating clinical outcomes in this period. Understanding the impact of menopause on multiple sclerosis is fundamental for delivering optimal care to women with MS as they age and will inform treatment decisions with the aim of minimising relapses, disease accrual and improving quality of life.

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

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

The Polymorphism Asn680Ser on the FSH Receptor and Abnormal Ovarian Response in Patients with Normal Values of AMH and AFC

After the controlled ovarian stimulation (COS), the number of cumulus oocyte complexes collected is lower than predicted. The aim of this study is to understand if there is a possible reason for that deficient ovarian response. It was hypothesized that this is associated with the SNP (single-nucleotide polymorphism) of the FSH receptor (FSHr), specifically c.2039A > G, resulting in Asn680Ser. Two groups of patients were enrolled for this purpose: the normal (n = 36) and abnormal responses (n = 31). To predict the number of retrievable oocytes, according to the anti-Mũllerian hormone (AMH) and the antral follicle count (AFC), the following formula was applied in a log scale: the number of oocytes retrieved = 2.584 − 0.015 × (age) − 0.035 × (FSH) + 0.038 × (AMH) + 0.026 × (AFC). Then, when the number of oocytes collected was less than 50% of the calculated value, it was proposed that the patients result in an abnormal response. DNA sample blood was collected from the women, and then the genetic assessment for the Asn680Ser of the FSHr was evaluated in both groups. The differences between the two categories were statistically analyzed with an independent samples t test, a Mann−Whitney U test and a Chi-squared test. In a patient with an abnormal response, a significant prevalence of the amino acid serine at position 680 of the FSHr compared to the counterpart group (p < 0.05) was detected. In conclusion, according to the results, the genetic evaluation of the FSHr could represent an accurate and predictive feature for patients undergoing assisted reproductive technology treatment.

The gonadotropins starting dose calculator, which can be adjusted the target number of oocytes and stimulation duration days to achieve individualized controlled ovarian stimulation in Japanese patients

Purpose

To create a gonadotropin starting dose calculator for controlled ovarian stimulation, which can adjust the target number of oocytes and stimulation duration for each facility to achieve individualized controlled ovarian stimulation among the Japanese patients.

Methods

The patients received controlled ovarian stimulation using the gonadotropin-releasing hormone antagonist protocol, and oocytes were retrieved. Using single regression analysis, we selected age, anti-Müllerian hormone (AMH), and initial serum follicle-stimulating hormone as variables to predict the number of oocytes retrieved per gonadotropin dose (oocyte sensitivity index). Each variable was then analyzed using backward stepwise multiple regression.

Results

Age and AMH were selected as predictive variables from the backward stepwise multiple regression, and we developed a multiple regression equation. We decomposed the equation as the number of oocytes retrieved/(gonadotropin starting dose × stimulation duration days) and created a calculation formula to predict the gonadotropin starting dose from the target number of oocytes and stimulation duration days.

Conclusions

This is the first study to develop an individualized dosing algorithm for gonadotropins among Japanese patients. Our calculator will improve controlled ovarian stimulation performance and enable national standardization by allowing all physicians, regardless of their years of experience, to determine the appropriate starting dose of gonadotropins equally.

Prediction model of gonadotropin starting dose and its clinical application in controlled ovarian stimulation

Background

Selecting an appropriate and personalized Gn starting dose (GSD) is an essential procedure for determining the quality and quantity of oocytes in the controlled ovarian stimulation (COS) process of the in-vitro fertilization (IVF) treatment cycle. The current approach for determining the GSD is mainly based on the experience of a clinician, lacking unified and scientific standards. This study aims to establish a prediction model of GSD, based on which good COS outcomes can be achieved with the influencing factors comprehensively evaluated quantitatively.

Material and methods

We collected a total of 1555 patients undergoing the first oocytes retrieving cycle and conducted correlation analysis to find the significant factors related to the GSD. Two GSD models are built based on two popular machine learning approaches, and the one with better model performance is selected as the final model. Finally, clinical application and validation were conducted to verify the effectiveness of the proposed model.

Results

(1) Age, duration of infertility, type of infertility, body mass index (BMI), antral follicle count (AFC), basal follicle stimulating hormone (bFSH), estradiol (E₂), luteinizing hormone (LH), anti-Müllerian hormone (AMH) and COS treatment regimen were closely related to the GSD (P < 0.05). (2) The selected model has good modeling performance in terms of both root mean square error (RMSE) (29.87 ~ 34.21) and regression coefficient R (0.947 ~ 0.953). (3) A comprehensive evaluation of influencing factors for GSD is conducted and shows that the top four most significant factors are age, AMH, AFC, and BMI. (4) The proposed GSD can approximate the actual value well in the clinical application, with the mean absolute error of only 11.26 units, and the recommended results can prompt the number of oocytes retrieved (NOR) close to the optimal number.

Conclusion

Modeling the GSD value with machine learning approaches is feasible and effective, and the proposed model has good clinical application for determining the GSD in the IVF treatment cycle.

Variation in Anti-Mullerian Hormone Levels with Age in Women Accessing In Vitro Fertilization Services in Ghana

Background: The emergence of AMH as a reliable biomarker for assessing ovarian reserve and optimization of assisted reproductive technology (ART) remains a promising tool for the evaluation and prediction of controlled ovarian stimulation (COS) outcomes. This study assessed the association between serum AMH levels and maternal age in females receiving in vitro fertilization (IVF) treatment in Ghana. Methods: We conducted a prospective cohort study at a specialized fertility center in Ghana. Descriptive analysis was performed, and the differences between maternal age and AMH categories were assessed by the Kruskal–Wallis test. Results: We included 426 women with mean (±SD) age and AMH levels of 35.25 ± 6.33 years and 2.80 ± 2.60 ng/mL, respectively. Women with very-low AMH levels (0.94 ± 73 ng/mL) were older (>40 years), whereas the younger (20–25 years) group had higher levels (4.85 ± 3.34 ng/mL). There was a significant negative correlation between women’s age and serum AMH levels (R = −0.46; p < 0.001). None of the younger women had AMH levels <0.30 ng/mL, while 70% of women who had AMH levels of <0.30 ng/mL were older women (>40years). In addition, none of the older women had AMH levels >4 ng/mL with only 5% having AMH levels between 2.20 and 4.0 ng/mL. Conclusions: AMH levels ≤0.3 ng/mL are archetypal of 70% of Ghanaian women >40 years old receiving fertility treatment. A combined assessment of AMH levels and age supports clinical decisions in predicting ovarian response to controlled ovarian stimulation (COS) and may be valuable in predicting of IVF success. Further research to evaluate the combined use of age, AMH, and other ovarian reserve markers in assessing ovarian response to COS is recommended.

Biomaterials and advanced technologies for the evaluation and treatment of ovarian aging

Ovarian aging is characterized by a progressive decline in ovarian function. With the increase in life expectancy worldwide, ovarian aging has gradually become a key health problem among women. Over the years, various strategies have been developed to preserve fertility in women, while there are currently no clinical treatments to delay ovarian aging. Recently, advances in biomaterials and technologies, such as three-dimensional (3D) printing and microfluidics for the encapsulation of follicles and nanoparticles as delivery systems for drugs, have shown potential to be translational strategies for ovarian aging. This review introduces the research progress on the mechanisms underlying ovarian aging, and summarizes the current state of biomaterials in the evaluation and treatment of ovarian aging, including safety, potential applications, future directions and difficulties in translation.

Evaluation of Female Fertility-AMH and Ovarian Reserve Testing

CONTEXT

Evaluation of the infertile female requires an understanding of ovulation and biomarkers of ovarian reserve. Antimüllerian hormone (AMH) correlates with growing follicles in a menstrual cycle. Increasingly, AMH has been used as a "fertility test." This narrative review describes how to integrate the use of AMH into diagnosis and treatment.

METHODS

A PubMed search was conducted to find recent literature on measurements and use of serum AMH as a marker of ovarian reserve and in treatment of infertility.

RESULTS

Serum AMH estimates ovarian reserve, helps determine dosing in ovarian stimulation, and predicts stimulation response. As such, AMH is a good marker of oocyte quantity but does not reflect oocyte health or chances for pregnancy. Screening of AMH before fertility treatment should be used to estimate expected response and not to withhold treatment. Low AMH levels may suggest a shortened reproductive window. AMH levels must be interpreted in the context of the endogenous endocrine environment where low follicle-stimulating hormone, due to hypogonadotropic hypogonadism or hormonal contraceptive use, may lower AMH without being a true reflection of ovarian reserve. In addition, there is an inverse correlation between body mass index and AMH that does not reflect ovarian response.

CONCLUSION

AMH is a useful marker of ovarian reserve in reproductive-aged women. Increased screening of noninfertile women requires a thorough knowledge of situations that may affect AMH levels. In no situation does AMH reflect oocyte health or chances for conception. Age is still the strongest driver in determining success rates with fertility treatments.

The Essential Role of Body Weight in Adjusting Gn Dosage to Prevent High Ovarian Response for Women With PCOS During IVF: A Retrospective Study

Polycystic ovarian syndrome (PCOS) is the major cause of anovulatory infertility. Since women with PCOS are often accompanied by increased body weight and hyper response to controlled ovarian stimulation, individualized gonadotropin (Gn) dose is required to achieve a therapeutic effect while minimizing the risk of ovarian hyperstimulation simultaneously. We aimed to investigate the essential role of body weight in optimizing initial Gn dosage for PCOS patients during in vitro fertilization (IVF). We retrospectively included 409 infertile PCOS patients who used gonadotropin-releasing hormone (GnRH)-antagonist fixed protocol and underwent their first cycle of IVF in West China Second University Hospital from January 2019 to June 2021. Baseline characteristics controlled ovarian stimulation parameters, and reproductive outcomes were compared between patients with different body weights and different ovarian responses. Multivariable linear regression analyses were adopted to investigate the relationship between body weight and initial Gn dosage. Receiver operating characteristic (ROC) curves were drawn to find the optimal cut-off value of body weight in predicting the starting Gn dosage so as to prevent high ovarian response (HOR). We found that luteinizing hormone (LH) level and Anti-Mullerian hormone (AMH) level were lowest in the group with body weight over 70 kg and was highest in the group with body weight less than 50 kg. Increased body weight was significantly correlated to the rise of initial Gn dosage (Beta = 0.399, t = 8.921, p < 0.001). Normal ovarian response (NOR) patients had significantly less fresh cycle cancel rate and ovarian hyperstimulation syndrome (OHSS) rate which outweighed the fewer embryos compared with HOR patients. Using ROC curves, 53.25 kg (sensitivity, 84.2%; specificity, 53.8%) and 70.5 kg (sensitivity, 58.8%; specificity, 93.0%) were identified as the optimal cut-off values to predict the initial Gn dosage of no more than 150 IU and 225 IU, respectively. In conclusion, adjusting the initial Gn dosage based on body weight is crucial to preventing ovarian hyperstimulation while not influencing reproductive outcomes for PCOS patients during IVF.

Do we trust scientific evidence? A multicentre retrospective analysis of first IVF/ICSI cycles before and after the OPTIMIST trial

STUDY QUESTION

Has the practice of individualizing the recombinant-FSH starting dose been superseded after the largest randomized controlled trial (RCT) in assisted reproduction technology (ART), the OPTIMIST trial?

SUMMARY ANSWER

The OPTIMIST trial has influenced our ART daily practice to a limited degree, but adherence is still generally poor.

WHAT IS KNOWN ALREADY

Although the 'one size fits all' approach has been discouraged for decades by most authors, the OPTIMIST study group demonstrated in a large prospective RCT that, in general, dosage individualization does not improve the prospects for live birth, although it may decrease ovarian hyperstimulation syndrome (OHSS) risk in expected high responders.

STUDY DESIGN, SIZE, DURATION

Retrospective analysis of all first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles from 1st January 2017 to 31st December 2018, before and after the OPTIMIST publication on November 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two thousand six hundred and seventy-seven patients, between 18 and 42 years old, undergoing their first IVF-ICSI cycle in seven Italian fertility centres, were included. Patients were allocated to three groups according to their ovarian reserve markers: predicted poor ovarian responders (POR), predicted normo-responders (NR) and expected hyper-responders (HRs).

MAIN RESULTS AND THE ROLE OF CHANCE

Between 2017 and 2018, there was an overall increase in prescription of the standard 150 IU dose proposed by the OPTIMIST trial and a reduction in the use of a starting dose >300 IU. After subgroup analysis, the decrease in doses >300 IU remained significant in the POR and NR sub-groups.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study. Physicians need time to adapt to new scientific evidence and a comparison between 2017 and 2019 may have found a greater impact of the Optimist trial, although other changes over the longer time span might have increased confounding. We cannot be sure that the observed changes can be attributed to knowledge of the OPTIMIST trial.

WIDER IMPLICATIONS OF THE FINDINGS

Clinicians may be slow to adopt recommendations based on RCTs; more attention should be given to how these are disseminated and promoted.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. E.P. reports grants and personal fees from MSD, grants from Ferring, from IBSA, grants and personal fees from Merck, grants from TEVA, grants from Gedeon Richter, outside the submitted work. E.S. reports grants from Ferring, grants and personal fees from Merck-Serono, grants and personal fees from Theramex, outside the submitted work. All other authors do not have conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Dose adjustment of follicle-stimulating hormone (FSH) during ovarian stimulation as part of medically-assisted reproduction in clinical studies: a systematic review covering 10 years (2007-2017)

BACKGROUND

Individualization of the follicle-stimulating hormone (FSH) starting dose is considered standard clinical practice during controlled ovarian stimulation (COS) in patients undergoing assisted reproductive technology (ART) treatment. Furthermore, the gonadotropin dose is regularly adjusted during COS to avoid hyper- or hypo-ovarian response, but limited data are currently available to characterize such adjustments. This review describes the frequency and direction (increase/decrease) of recombinant-human FSH (r-hFSH) dose adjustment reported in clinical trials.

METHODS

We evaluated the proportion of patients undergoing ART treatment who received ≥ 1 r-hFSH dose adjustments. The inclusion criteria included studies (published Sept 2007 to Sept 2017) in women receiving ART treatment that allowed dose adjustment within the study protocol and that reported ≥ 1 dose adjustments of r-hFSH; studies not allowing/reporting dose adjustment were excluded. Data on study design, dose adjustment and patient characteristics were extracted. Point-incidence estimates were calculated per study and overall based on pooled number of cycles with dose adjustment across studies. The Clopper-Pearson method was used to calculate 95% confidence intervals (CI) for incidence where adjustment occurred in < 10% of patients; otherwise, a normal approximation method was used.

RESULTS

Initially, 1409 publications were identified, of which 318 were excluded during initial screening and 1073 were excluded after full text review for not meeting the inclusion criteria. Eighteen studies (6630 cycles) reported dose adjustment: 5/18 studies (1359 cycles) reported data for an unspecified dose adjustment (direction not defined), in 10/18 studies (3952 cycles) dose increases were reported, and in 11/18 studies (5123 cycles) dose decreases were reported. The studies were performed in women with poor, normal and high response, with one study reporting in oocyte donors and one in obese women. The median day that dose adjustment was permitted was Day 6 after the start of treatment. The point estimates for incidence (95% CI) for unspecified dose adjustment, dose increases, and dose decreases were 45.3% (42.7, 48.0), 19.2% (18.0, 20.5), and 9.5% (8.7, 10.3), respectively.

CONCLUSIONS

This systematic review highlights that, in studies in which dose adjustment was allowed and reported, the estimated incidence of r-hFSH dose adjustments during ovarian stimulation was up to 45%.

In-Vitro Fertilization Outcome Predictors in Women With High Baseline Follicle-Stimulating Hormone Levels: Analysis of Over 1000 Cycles From A Tertiary Center

OBJECTIVE

The present study aimed to evaluate reproductive outcomes and determine the predictors of clinical pregnancy and live birth in women with elevated baseline follicle-stimulating hormone (FSH) levels, who have undergone intracytoplasmic sperm injection (ICSI) treatment.

METHODS

This retrospective study included 1011 ICSI cycles of women with high baseline FSH levels (> 10 IU/L), from a tertiary university IVF center between 2010 and 2015. Logistic regression analysis was performed to evaluate the prognostic factors of clinical pregnancy and live birth.

RESULTS

Among the 1011 ICSI cycles, the clinical pregnancy and live birth rates per oocyte retrieval were 19.5% and 14.3%, respectively. The live birth rates were 21.1% and 1.7% in women aged ≤30 years and those aged ≥40 years, respectively. In addition, the live birth rate was 1.47-fold higher in women from whom >3 oocytes were retrieved, compared to those from whom ≤3 oocytes were retrieved (p=0.047). Logistic regression analysis indicated that the age categories ≤30y, 36-39y and ≥40y, level of baseline FSH (≥20 IU/L) and the ovarian response (≤3 or >3 oocytes retrieved) were significantly associated with live birth.

CONCLUSIONS

Our study indicated that age, baseline FSH level, and ovarian response are independent predictive factors for clinical pregnancy and live birth among women with baseline FSH levels >10 IU/L.

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).

The interchangeability of two assays for the measurement of anti-Müllerian hormone when personalizing the dose of FSH in in-vitro fertilization cycles

OBJECTIVE

Study the interchangeability of Roche Elecsys and Beckman Coulter Access anti-Müllerian Hormone (AMH) assays to select the gonadotropin starting dose in IVF cycles.

METHODS

Patients' AMH was measured using both Elecsys and Access automated assays. AMH values were then used to calculate the FSH starting dose. The main outcome is the percentage of women that would have been stratified to a different dose of gonadotropin due to differences in AMH values from the two tests.

RESULTS

The Access assay systematically gives higher values compared with the Elecsys assay (slope = 0.88). For Follitropin Alfa, the difference in starting dose was > 15% in 2/113 patients, when Access AMH was used instead of Elecsys. For Follitropin Delta the difference in the starting dose was >15% in 21/113 patients when using Access AMH. When considering women with high ovarian reserve, only 4/51 would have received a Follitropin Delta dose that exceeded a 15% difference using Access AMH as a substitute for the Elecsys value.

CONCLUSIONS

The use of the Roche Elecsys or Beckman Coulter Access leads to modest differences in AMH values, which seem to little affect the calibration of FSH dose used for ovarian stimulation.

Serum anti-Müllerian hormone levels are not associated with aneuploidy rates in human blastocysts

RESEARCH QUESTION

Anti-Müllerian hormone (AMH) is the most established biomarker for estimating ovarian reserve. No reliable marker of oocyte quality, however, is available. Is there an association between the rates of aneuploidy and the different ranges of serum AMH levels?

DESIGN

Retrospective, single-centre study of 1718 patients undergoing intracytoplasmic sperm injection and preimplantation genetic testing with aneuploidy at the blastocyst stage between January 2015 and December 2019. Patients were stratified into six different categories of AMH (ng/ml) according to percentile distribution.

RESULTS

Although a higher number of biopsied embryos were found for higher AMH levels (P = 0.017), a lower rate of biopsied blastocysts per metaphase II (P = 0.019) and per fertilized oocyte (0.023) was observed in this group of high AMH. A higher number of euploid embryos was found for higher AMH values (P = 0.031); however, the rate of aneuploid embryos per metaphase II or per fertilized oocyte was not significantly different across the six groups. No differences were observed in the implantation, pregnancy and ongoing pregnancy rate, or in the miscarriage and biochemical loss rate. Regression analysis did not show any significant correlation between AMH and aneuploid embryos.

CONCLUSIONS

In this large series of patients, AMH was not related to embryo aneuploidy.

Optimising Follicular Development, Pituitary Suppression, Triggering and Luteal Phase Support During Assisted Reproductive Technology: A Delphi Consensus

BACKGROUND

A Delphi consensus was conducted to evaluate global expert opinions on key aspects of assisted reproductive technology (ART) treatment.

METHODS

Ten experts plus the Scientific Coordinator discussed and amended statements plus supporting references proposed by the Scientific Coordinator. The statements were distributed via an online survey to 35 experts, who voted on their level of agreement or disagreement with each statement. Consensus was reached if the proportion of participants agreeing or disagreeing with a statement was >66%.

RESULTS

Eighteen statements were developed. All statements reached consensus and the most relevant are summarised here. (1) Follicular development and stimulation with gonadotropins (n = 9 statements): Recombinant human follicle stimulating hormone (r-hFSH) alone is sufficient for follicular development in normogonadotropic patients aged <35 years. Oocyte number and live birth rate are strongly correlated; there is a positive linear correlation with cumulative live birth rate. Different r-hFSH preparations have identical polypeptide chains but different glycosylation patterns, affecting the biospecific activity of r-hFSH. r-hFSH plus recombinant human LH (r-hFSH:r-hLH) demonstrates improved pregnancy rates and cost efficacy versus human menopausal gonadotropin (hMG) in patients with severe FSH and LH deficiency. (2) Pituitary suppression (n = 2 statements): Gonadotropin releasing hormone (GnRH) antagonists are associated with lower rates of any grade ovarian hyperstimulation syndrome (OHSS) and cycle cancellation versus GnRH agonists. (3) Final oocyte maturation triggering (n=4 statements): Human chorionic gonadotropin (hCG) represents the gold standard in fresh cycles. The efficacy of hCG triggering for frozen transfers in modified natural cycles is controversial compared with LH peak monitoring. Current evidence supports significantly higher pregnancy rates with hCG + GnRH agonist versus hCG alone, but further evidence is needed. GnRH agonist trigger, in GnRH antagonist protocol, is recommended for final oocyte maturation in women at risk of OHSS. (4) Luteal-phase support (n = 3 statements): Vaginal progesterone therapy represents the gold standard for luteal-phase support.

CONCLUSIONS

This Delphi consensus provides a real-world clinical perspective on the specific approaches during the key steps of ART treatment from a diverse group of international experts. Additional guidance from clinicians on ART strategies could complement guidelines and policies, and may help to further improve treatment outcomes.

A Novel Nomogram for Individualized Gonadotropin Starting Dose in GnRH Antagonist Protocol

Controlled ovarian stimulation (COS) is one of the most vital parts of in vitro fertilization-embryo transfer (IVF-ET). At present, no matter what kinds of COS protocols are used, clinicians have to face the challenge of selection of gonadotropin starting dose. Although several nomograms have been developed to calculate the appropriate gonadotropin starting dose in gonadotropin releasing hormone (GnRH) agonist protocol, no nomogram was suitable for GnRH antagonist protocol. This study aimed to develop a predictive nomogram for individualized gonadotropin starting dose in GnRH antagonist protocol. Single-center prospective cohort study was conducted, with 198 women aged 20-45 years underwent IVF/intracytoplasmic sperm injection (ICSI)-ET cycles. Blood samples were collected on the second day of the menstrual cycle. All women received ovarian stimulation using GnRH antagonist protocol. Univariate and multivariate analysis were performed to identify predictive factors of ovarian sensitivity (OS). A nomogram for gonadotropin starting dose was developed based on the multivariate regression model. Validation was performed using concordance statistics and bootstrap resampling. A multivariate regression model based on serum anti-Müllerian hormone (AMH) level, antral follicle count (AFC), and body mass index (BMI) was developed and accounted for 59% of the variability of OS. An easy-to-use predictive nomogram for gonadotropin starting dose was established with excellent accuracy. The concordance index (C-index) of the nomogram was 0.833 (95% CI, 0.829-0.837). Internal validation using bootstrap resampling further showed the good performance of the nomogram. In conclusion, gonadotropin starting dose in antagonist protocol can be predicted precisely by a novel nomogram.

Recombinant Human Follicle-Stimulating Hormone Alfa Dose Adjustment in US Clinical Practice: An Observational, Retrospective Analysis of a Real-World Electronic Medical Records Database

PURPOSE

To determine the pattern of dose adjustment of recombinant human follicle-stimulating hormone alfa (r-hFSH-alfa) during ovarian stimulation (OS) for assisted reproductive technology (ART) in a real-world setting.

METHODS

This was an observational, retrospective analysis of data from an electronic de-identified medical records database including 39 clinics in the USA. Women undergoing OS for ART (initiated 2009-2016) with r-hFSH-alfa (Gonal-f^® or Gonal-f RFF Redi-ject^®) were included. Assessed outcomes were patients' baseline characteristics and dosing characteristics/cycle.

RESULTS

Of 33,962 ART cycles, 13,823 (40.7%) underwent dose adjustments: 23.4% with ≥1 dose increase, 25.4% with ≥1 dose decrease, and 8.1% with ≥1 increase and ≥1 decrease. Patients who received dose adjustments were younger (mean [SD] age 34.8 [4.58] years versus 35.9 [4.60] years, p<0.0001) and had lower BMI (25.1 [5.45] kg/m² versus 25.5 [5.45] kg/m², p<0.0001) than those who received a constant dose. The proportion of patients with non-normal ovarian reserve was 38.4% for those receiving dose adjustment versus 51.9% for those with a constant dose. The mean (SD) number of dose changes/cycle was 1.61 (0.92) for cycles with any dose adjustment, 1.72 (1.03) for cycles with ≥1 dose increase, 2.77 (1.00) for cycles with ≥1 dose increase and ≥1 decrease (n=2,755), and 1.88 (1.03) for cycles with ≥1 dose decrease.

CONCLUSIONS

Dose adjustment during OS is common in clinical practice in the USA and occurred more often in younger versus older patients, those with a high versus non-normal ovarian reserve or those with ovulation disorders/polycystic ovary syndrome versus other primary diagnoses of infertility.

The Frequency of Ovarian Hyperstimulation Syndrome and Thromboembolism with Originator Recombinant Human Follitropin Alfa (GONAL-f) for Medically Assisted Reproduction: A Systematic Review

Background

Recombinant human follitropin alfa (r-hFSH) is used for ovarian stimulation as part of medically assisted reproduction. There is a risk for ovarian hyperstimulation syndrome (OHSS) with r-hFSH treatment, and an increased risk for thromboembolic events in the presence of pregnancy with OHSS.

Objectives

To report the frequency of OHSS and thromboembolism with originator follitropin alfa (GONAL-f) based on the Global Safety Database of Merck KGaA, Darmstadt, Germany and a systematic review of published data.

Data Sources

Reports of OHSS and thromboembolism were obtained from the Global Safety Database of Merck KGaA, Darmstadt, Germany from 20 October 1995 to 19 October 2018. The systematic review was based on MEDLINE and Embase searches from inception to 19 October 2018.

Study Eligibility Criteria

Patients receiving GONAL-f for ovulation induction or ART, with a starting dose within the range included in the prescribing information and providing information on the occurrence of OHSS and/or thromboembolism.

Study Appraisal and Synthesis Matches

In the Global Safety Database of Merck KGaA, Darmstadt, Germany there were an estimated 16,525,975 treatment cycles since 20 October 1995; 1110 reported cases of OHSS and 80 reported cases of thromboembolic events (reporting rates 6.7 and 0.48 per 100,000 treatment cycles, respectively). The systematic review identified 45 studies (5186 patients exposed to GONAL-f; 5240 treatment cycles). There were 272 reports of OHSS (5190 [5.19%] per 100,000 treatment cycles), including 10 cases of severe OHSS (191 [0.19%] per 100,000 treatment cycles).

Limitations

There may be the potential for under-reporting of safety outcomes in the literature, and under-reporting is a well-known phenomenon in spontaneous reporting databases.

Conclusion and Implications of Key Findings

Our analyses demonstrate low rates of OHSS and thromboembolism with GONAL-f.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01512-w) contains supplementary material, which is available to authorized users.

Impaired implantation in endometriosis compared with couples with male subfertility after transfer of equal quality embryos: a matched cohort study

RESEARCH QUESTION

Is implantation impaired in patients with endometriosis undergoing IVF and intracytoplasmatic sperm injection (ICSI) cycles?

DESIGN

A retrospective matched cohort study was carried out on IVF/ICSI cycles with fresh single embryo transfer at the Department of Assisted Reproductive Medicine, Ghent University Hospital, Belgium, between July 2015 and August 2017 (n = 1053). A total of 118 endometriosis cases were matched 1:1 to 118 couples diagnosed with male subfertility and stratified by embryo quality (identical ALPHA grading categories), female age (±1 year) and parity (±1 delivery). Transvaginal ultrasound, magnetic resonance imaging or laparoscopy was used to diagnosed endometriosis, and the revised American Society for Reproductive Medicine score was used to classify the endometriosis into grade I/II versus grade III/IV. Male subfertility was defined in accordance with World Health Organization criteria (fifth edition).

RESULTS

Compared with endometriosis cases, control couples with male subfertility had significantly higher rates of positive HCG test on day 16 (P = 0.047, OR 2.077, CI 1.009 to 4.276), ongoing implantation (defined as a positive fetal heart rate on transvaginal ultrasound at a gestational age of at least 6.5-7 weeks) (P = 0.038, OR 2.265, CI 1.048 to 4.893), ongoing pregnancy (defined by a vital pregnancy at 11 weeks) (P = 0.046, OR 2.292, CI 1.016 to 5.173) and live birth (P = 0.043, OR 2.502, CI 1.029 to 6.087).

CONCLUSIONS

After matching for embryo quality, woman's age and parity, rates of positive HCG tests, ongoing implantation, ongoing pregnancy and live birth were more than twice as high in the control group compared with the endometriosis group.

Initial ovarian sensitivity index predicts embryo quality and pregnancy potential in the first days of controlled ovarian stimulation

BACKGROUND

To determine if a modified ovarian sensitivity index (MOSI), based on initial follicular measurements and the initial follicle-stimulating hormone (FSH) dose, can predict the production of high-quality embryos for successful implantation during in vitro fertilization (IVF).

METHODS

This study consisted of two phases: 1) a retrospective study and 2) a prospective observational study. For the first phase, 363 patients charts were reviewed, of which 283 had embryos transferred. All women underwent a standardized antagonist-based IVF protocol. At the first follow-up (Day 3/4), the number and size of the follicles were determined. MOSI was calculated as ln (number follicles (≥6 mm) × 1000 / FSH initial dose). Afterward, the number and quality of the ova, embryo development, and the number and quality of the blastocysts were determined. Embryo implantation was confirmed by β-hCG. For the second phase, 337 IVF cycles were followed to determine MOSI's accuracy.

RESULTS

MOSI could predict the production of ≥4 high-quality embryos by Day 2 (AUC = 0.69, 95%CI:0.63-0.75), ≥2 blastocysts (AUC = 0.74, 95%CI:0.68-0.79), and ≥ 35% rate of blastocyst formation (AUC = 0.65, 95%CI:0.58-0.72). Using linear regression, MOSI was highly associated with the number of ova captured (β = 5.15), MII oocytes (β = 4.31), embryos produced (β = 2.90), high-quality embryos (β = 0.98), and the blastocyst formation rate (β = 0.06, p < 0.01). Using logistic regression, MOSI was highly associated with achieving ≥4 high-quality embryos (odds ratio = 2.80, 95%CI:1.90-4.13), ≥2 blastocysts (odds ratio = 3.40, 95%CI:2.33-4.95), and ≥ 35% blastocysts formation rate (odds ratio = 1.96, 95%CI:1.31-2.92). This effect was independent of age, BMI, and antral follicle count. For implantation, MOSI was significantly associated with successful implantation (odds ratio = 1.79, 95%CI:1.25-2.57). For the prospective study, MOSI was highly accurate at predicting ≥6 high-quality embryos on Day 2 (accuracy = 68.5%), ≥6 blastocysts (accuracy = 68.0%), and a blastocyst formation rate of ≥35% (accuracy = 61.4%).

CONCLUSION

MOSI was highly correlated with key IVF parameters that are associated with achieved pregnancy. Using this index with antagonist cycles, clinicians may opt to stop an IVF cycle, under the assumption that the cycle will fail to produce good blastocysts, preventing wasting the patient's resources and time.

Establishing the follitropin delta dose that provides a comparable ovarian response to 150 IU/day follitropin alfa

RESEARCH QUESTION

The objective of this investigation was to determine the daily follitropin delta dose (µg) providing a similar ovarian response to 150 IU/day follitropin alfa.

DESIGN

The study was a post-hoc analysis of ovarian response in 1591 IVF/intracytoplasmic sperm injection (ICSI) patients undergoing ovarian stimulation in a gonadotrophin-releasing hormone antagonist protocol in two recent randomized, assessor-blind, controlled trials in the development programme for follitropin delta: a phase II dose-response trial with a reference arm of a fixed daily dose of 150 IU follitropin alfa throughout stimulation, and a phase III efficacy trial with a comparator arm of 150 IU/day follitropin alfa as a starting dose.

RESULTS

Daily follitropin delta doses of 10.0 µg (95% confidence interval [CI] 7.9-12.8) and 10.3 µg (95% CI 9.7-10.8) yielded the same number of oocytes as 150 IU/day follitropin alfa for all patients participating in the phase II and III trials, respectively. When analysing patients with either normal or high ovarian reserve (based on serum anti-Mullerian hormone ≥15 pmol/l) and no dose changes, the same number of oocytes was obtained with 150 IU/day follitropin alfa and daily doses of follitropin delta of 9.7 µg (95% CI 7.5-12.4) and 9.3 µg (95% CI 8.6-10.1) in the two trials. Daily follitropin delta doses in the range 9.5-10.4 µg were consistently estimated to correspond to 150 IU/day follitropin alfa for serum oestradiol concentration and number of follicles ≥12 mm at the end of stimulation across analysis populations in the phase III trial.

CONCLUSIONS

A daily follitropin delta dose of 10 µg provides a similar ovarian response to 150 IU/day follitropin alfa in IVF/ICSI patients.

Age-dependent changes in anti-Müllerian hormone levels in Lebanese females: correlation with basal FSH and LH levels and LH/FSH ratio: a cross-sectional study

Background

To investigate the age-dependent changes in circulating anti-Müllerian hormone (AMH) levels in healthy Arabic-speaking Lebanese women, and to correlate changes in serum AMH levels with serum FSH and LH values, and LH/FSH ratio.

Methods

Cross-sectional study, involving 1190 healthy females, age 17–54 years, with regular menses and both ovaries. Serum AMH levels (ng/ml) were measured by ELISA.

Results

There was an inverse proportion of AMH and subject’s age, which declined from median 6.71 (2.91) ng/ml in young subjects, to 0.68 (0.45) ng/ml in subjects older than 50 years. Average yearly decrease in median AMH levels was 0.27 ng/ml/year through age 35, but then diminished to 0.12 ng/ml/year afterwards. Receiver operating characteristic curve analysis demonstrated high sensitivity and specificity of age as determinant of AMH levels. In contrast to AMH, FSH levels increased progressively from 5.89 (0.11–62.10) ng/ml in young subjects, to 38.43 (3.99–88.30) ng/ml in subjects older than 50 years. On the other hand, age-dependent changes in LH/FSH ratio paralleled those of AMH. Linear regression modeling testing the independent effect of AMH on FSH and LH, adjusted for age, showed that AMH was significant predictor of FSH and LH/FSH ratio, but not LH. This did not contribute significantly to baseline LH and FSH prediction.

Conclusions

Circulating AMH levels are inversely related to age as also shown elsewhere, and are predictors of LH/FSH ratio and FSH but not LH levels in eumenorrheic females.

Severe early-onset ovarian hyperstimulation syndrome with liver dysfunction in an IVF segmentation cycle

Severe early-onset ovarian hyperstimulation syndrome (OHSS) with deranged liver function tests is an entity that cannot be eliminated wholly even after gonadotropin-releasing hormone (GnRH) agonist trigger without any luteal human chorionic gonadotropin (hCG) rescue in a GnRH antagonist protocol with the freeze-all approach. We describe a case of young polycystic ovary syndrome patient with prior history of severe early-onset OHSS in her last in vitro fertilisation cycle in which she received antagonist protocol followed by blastocyst transfer. Given her history, she was planned for agonist trigger and freeze all approach during the present cycle. Despite segmentation of the cycle without any luteal rescue hCG, she developed early-onset severe OHSS with markedly deranged liver function tests for which she underwent ascitic tapping and remained hospitalised for 8 days. Her symptoms improved with conservative management, and she was discharged satisfactorily. She underwent letrozole based frozen-thawed embryo transfer cycle after 4 months. One good quality blastocyst was transferred, and she conceived in the same cycle.

Label-free Paper-based Immunosensor with Graphene Nanocomposites for Electrochemical Detection of Follicle-stimulating Hormone

Follicle-stimulating hormone (FSH) is an important indicator of ovarian reserve function in women in clinical testing. In this work, a label-free paper-based immunosensor was developed for electrochemical rapid detection of FSH. A hydrophilic channel surrounded with hydrophobic barriers was firstly fabricated on the chromatography paper by wax printing technology. Then three electrodes were screen-printed on the circle zones of the channel, in which one carbon electrode further modified by reduced graphene-oxide /thionine /gold nanoparticles nanocomposites and FSH monoclonal antibody was used as the working electrode to provide sensitivity of the immunosensor. The detection of FSH is based on the decreased electrochemical current of Thi produced from the specific binding of the FSH and anti-FSH, and the decrease of the current is proportional to the concentration of the FSH. The experimental results exhibited that the immunosensor could be used to detect the standard FSH in range of 1-100 mIU/mL with the detection limit of 1 mIU/mL. And the proposed immunosensor had been successfully applied to detect FSH in serum samples.

A multicenter, randomized, phase III study comparing the efficacy and safety of follitropin alpha biosimilar and the original follitropin alpha

OBJECTIVE

The aim of the present study was to investigate the therapeutic equivalence between the follitropin alpha biosimilar and the reference medication in women undergoing assisted reproductive technologies (ART).

STUDY DESIGN

This multicenter, randomized (1:1), embryologist-blinded, parallel-group, comparative phase III study involved 110 women aged 20-35 years old with tubal and/or male factors of infertility. All of the subjects underwent controlled ovarian hyperstimulation (COH) using a gonadotropin-releasing hormone antagonist (GnRH-ant) protocol. Over the 5-day fixed-dose regimen, the women received 150 IU/day of follitropin alpha biosimilar (n = 55) or original follitropin alpha (n = 55), followed by dose adaptation. The primary endpoint for assessing the therapeutic equivalence was the number of retrieved oocytes using a pre-determined clinical equivalence margin of ± 3.4 oocytes.

RESULTS

Similar numbers of oocytes were retrieved in both groups: 12.16 ± 7.28 in the follitropin alpha biosimilar group and 11.62 ± 6.29 in the original follitropin alpha group, with mean difference of 0.546 ± 1.297 oocytes (95% confidence interval [CI]: -2.026, 3.116), p = 0.002 (intention-to-treat [ITT] population). Additionally, no statistically significant differences were found for secondary endpoints: the onset of biochemical (34.7% and 36.7%, p = 0.883), clinical pregnancy (26.5% and 32.7%, p = 0.507), delivery (26.5% and 24.5%, p = 0.817) and take-home baby rate (28.6% and 26.5%, p = 0.816) for the follitropin biosimilar and original follitropin groups (per-protocol [PP] population). Ovarian hyperstimulation syndrome was observed in subjects with a positive pregnancy test in 0% and 3.64% of cases and after triggering ovulation in 7.27% and 3.64% for the follitropin biosimilar and original follitropin groups, respectively.

CONCLUSIONS

This study demonstrated similar therapeutic equivalence and safety profiles between the follitropin alpha biosimilar and the reference follitropin in women who underwent COH in GnRH-ant cycles.

TRIAL REGISTRATION NUMBER

1. Name of the registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT03088137. Date of registration: 02.03.2017, retrospectively registered. Trial conducted between 08.02.2017 and 17.08.2018, the date of enrollment of the first participant - 08.02.2017. 2. Name of the registry: Russian Ministry of Health, grls.rosminzdrav.ru.

TRIAL REGISTRATION NUMBER

RCT 754. Date of registration: 26.10.2016, prospectively registered.

Anti-Müllerian hormone variability and its implications for the number of oocytes retrieved following individualized dosing with follitropin delta

OBJECTIVE

The stability of anti-Müllerian hormone (AMH) across and between menstrual cycles has been the subject of debate. The objective of this analysis was to study the inter- and intracycle variability in repeated measurements and assess the impact on an individualized gonadotropin dosing algorithm and predicted oocyte yield.

DESIGN

Retrospective analysis of repeat AMH measures from a randomized controlled trial.

PATIENTS

A total of 1326 women aged 18-40 years.

MEASUREMENTS

Serum AMH levels at screening and at cycle day 2-3 in up to three ovarian stimulation cycles. AMH variability and its impact on gonadotropin dose and the predicted number of oocytes.

RESULTS

Repeat serum AMH measurements were strongly correlated within individual women (correlation coefficient 0.92). AMH exhibited limited within-subject variation (coefficient of variation 23%), a small time-related decline (mean 6% decrease/y), but no systematic variation across the menstrual cycle. Irrespective of whether the AMH screening value or the AMH at the initiation of ovarian stimulation was used, for women with an AMH level <15 pmol/L, 93% would receive the same gonadotropin dose and attain an identical number of oocytes in 97% of cases. For women with an AMH level ≥15 pmol/L, 80% would receive an individualized dose within ±1.5 μg and 90% would attain ±1 oocyte.

CONCLUSION

AMH variability had limited impact on individualized gonadotropin dosing, with 95% of women predicted to obtain an oocyte yield that does not vary beyond 1 oocyte count, irrespective of whether a random or early follicular AMH measurement was used to determine the individualized gonadotropin dose.

A predictive formula for selecting individual FSH starting dose based on ovarian reserve markers in IVF/ICSI cycles

BACKGROUND

Although exogenous follicle-stimulating hormone (FSH) has been used for decades and millions of cycles have been performed worldwide until now, criteria for selecting the proper FSH starting dose have not been clearly identified. The aim of this study was to elaborate a formula based on markers of ovarian reserve for the calculation of the appropriate starting dose of FSH.

METHODS

A total of 931 patients underwent in vitro fertilization (IVF) treatment using long GnRH agonist protocol was retrospectively identified and reviewed. 673 cases of them with a normal ovarian response (4-14 retrieved oocytes) were used to analysis the predictive formula. All follicles 4-7 mm in diameter were counted in the same day of blood sample in both ovaries using transvaginal ultrasound scan. The modified protocol of each patient was recorded and analyzed in the same center. In another center were the numbers of retrieved oocytes of 750 validated patients recorded and analyzed.

RESULTS

A formula model based on age, AMH, and antral follicle count (AFC) was able to accurately predict the ovarian sensitivity and accounted for 57.2% of the variability of ovarian response to FSH. When tested in the same total population used to elaborate the model it predicts a high 46.88% rate of step-down protocol in higher-starting FSH dose group and about 57.92% of patients had their dose step-up modified in lower-starting FSH dose group during their treatment, respectively. And when tested in different population from another center used to elaborate the model it predicts a high 64.40% rate of ≥ 15 retrieved oocytes in higher-starting FSH dose group and about 22.50% of patients had ≤ 7 retrieved oocytes in lower-starting FSH dose group during their treatment, respectively.

CONCLUSIONS

In the present study we demonstrated that the individualized FSH starting dose may be calculated on the basis of a woman's age, AMH and AFC. The formula model might be a useful, immediate, and easily applicable tool for clinicians to predict the tailored starting dose of FSH during their daily clinical practice.