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

PURPOSE

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

To provide an agreed upon definition of hyper-response for women undergoing ovarian stimulation (OS)?

METHODS

A literature search was performed regarding hyper-response to ovarian stimulation for assisted reproductive technology. A scientific committee consisting of 5 experts discussed, amended, and selected the final statements in the questionnaire for the first round of the Delphi consensus. The questionnaire was distributed to 31 experts, 22 of whom responded (with representation selected for global coverage), each anonymous to the others. A priori, it was decided that consensus would be reached when ≥ 66% of the participants agreed and ≤ 3 rounds would be used to obtain this consensus.

RESULTS

17/18 statements reached consensus. The most relevant are summarized here. (I) Definition of a hyper-response: Collection of ≥ 15 oocytes is characterized as a hyper-response (72.7% agreement). OHSS is not relevant for the definition of hyper-response if the number of collected oocytes is above a threshold (≥ 15) (77.3% agreement). The most important factor in defining a hyper-response during stimulation is the number of follicles ≥ 10 mm in mean diameter (86.4% agreement). (II) Risk factors for hyper-response: AMH values (95.5% agreement), AFC (95.5% agreement), patient's age (77.3% agreement) but not ovarian volume (72.7% agreement). In a patient without previous ovarian stimulation, the most important risk factor for a hyper-response is the antral follicular count (AFC) (68.2% agreement). In a patient without previous ovarian stimulation, when AMH and AFC are discordant, one suggesting a hyper-response and the other not, AFC is the more reliable marker (68.2% agreement). The lowest serum AMH value that would place one at risk for a hyper-response is ≥ 2 ng/ml (14.3 pmol/L) (72.7% agreement). The lowest AFC that would place one at risk for a hyper-response is ≥ 18 (81.8% agreement). Women with polycystic ovarian syndrome (PCOS) as per Rotterdam criteria are at a higher risk of hyper-response than women without PCOS with equivalent follicle counts and gonadotropin doses during ovarian stimulation for IVF (86.4% agreement). No consensus was reached regarding the number of growing follicles ≥ 10 mm that would define a hyper-response.

CONCLUSION

The definition of hyper-response and its risk factors can be useful for harmonizing research, improving understanding of the subject, and tailoring patient care.

P–785 Double versus sequential single blastocyst transfer in freeze all cycles?

Study question

Is double blastocysts transfer (DET) better than sequential single blastocyst transfer (seq-SET) in freeze all cycles?

Summary answer

Sequential single blastocyst transfer provides a higher live birth rate (LBR) per cycle initiated and eliminates multiple births in freeze-all cycles.

What is known already

Improvements in cryopreservation technology helped freeze-all strategy gain much popularity. The new debate is whether guidance for single embryo transfer should also be applied to frozen-thawed embryo transfers in freeze-all cycles.

Study design, size, duration

We performed a retrospective cohort analysis of 860 women in whom the entire cohort of embryos frozen at the blastocyst stage for various indications. All women aged 19–43 years, who had at least two blastocysts frozen and subsequently thawed and transferred were included. Preimplantation genetic testing cycles were excluded.The study period ranged from January 2016 to May 2019.

Participants/materials, setting, methods

Data regarding female age, number of embryos transferred, multiple pregnancy and live birth rates (LBR) were extracted from the electronic database. Women were categorized based on their age and the mode of embryo transfer. Primary outcome was live birth rate LBR per cycle initiated. Secondary outcomes were LBR per embryo transfer and multiple birth rate. Groups were compared using Fisher’s test, generalized estimating equation model and logistic regression analysis to adjust for confounding factors.

Main results and the role of chance

The study group comprised of 666 women (371 Seq-SET and 295 DET) who underwent 837 embryo transfer cycles. Second embryo transfer was affected in 46.1% of women in the Seq-SET group. Age, indication for freeze-all, and mode of transfer were related with the LBR. For women ≤ 35 (n = 370), LBRs per embryo transfer were similar in single and double embryo transfers (53.9% versus 64.2% respectively, p = 0.006, aOR=0.65, 95% CI:0.41–1.01). However, LBR per cycle initiated was significantly higher in Seq-SET group (78.9% versus 64.2% respectively, p = 0.004, aHR=2.09, 95% CI:1.28–3.41). While only one monochorionic twin delivery was observed with Seq-SET (0.5%), 19 out of 70 (27.1%) live births after DET were twins. For women >35 of age (n = 296) the likelihood of a live birth per embryo transfer was lower in single compared to double embryo transfers (33.2% versus 46.2%, respectively, p = 0.012, aOR=0.58 95% CI:0.38–0.88). Although LBR per cycle initiated was higher in Seq-SET (58.2%) than DET (46.2%), the difference did not reach statistical significance (p = 0.054, aHR=1.62, 95% CI:1.00–2.60). While no twin delivery was observed with Seq-SET, 8 out of 86 (9.3%) live births with DET were twins.

Limitations, reasons for caution

This was a retrospective study with small sample size performed at a single fertility center, which may limit the generalizability of our findings. Cost-efficiency was not studied.

Wider implications of the findings: Seq-SET is associated with a comparable or higher likelihood of live birth per cycle initiated and a very low risk of twins when compared to DET. However, half of SET cases had to undergo two transfer cycles.

Trial registration number

NA

P–660 Impact of elevated late-follicular phase serum estrogen and progesterone levels on blastocyst utilization and cumulative live birth rates in freeze-all cycles

Study question

Does elevated late-follicular phase estrogen and progesterone levels have an impact on blastocyst utilization and/or cumulative live birth rates in freeze-all cycles?

Summary answer

High estrogen or progesterone on the day of ovulation trigger is associated with poor blastocyst utilization but comparable cumulative live birth rates in freeze-all cycles.

What is known already

Several studies suggest impaired clinical outcome in cycles with high estrogen (>3500 pg/ml) or progesterone (>1.5 ng/ml) levels. However, these data were derived from cycles where top-quality embryo(s) were transferred in the fresh cycle and surplus embryos were frozen. These findings might be confounded by alterations in endometrial receptivity. Freeze-all cycles might provide a better model to assess the impact of high late-follicular estrogen or progesterone levels on laboratory and clinical outcome.

Study design, size, duration

We performed a retrospective cohort study of all IVF cycles (n = 712) between 2016 and 2018 where the entire cohort of embryos was cryopreserved at the blastocyst stage. After excluding cases with <4 oocytes or preimplantation genetic test, the study group comprised 459 women who had 699 frozen-thawed embryo transfer cycles.

Participants/materials, setting, methods

Women were classified into four groups by the indication for freeze-all strategy as elevated progesterone (high P, n = 61), high estrogen (high E, n = 224), elective freezing (elective, n = 114) and tubal-endometrial pathologies (TEP, n = 60). The primary outcome was the cumulative live birth rate in subsequent thaw-transfer cycles and the secondary outcome was the blastocyst utilization rate. Groups were compared using ANOVA and Cox regression analyses to adjust for confounding variables.

Main results and the role of chance

The mean age of the study group was 32.8 ± 5.3 years, total number of oocytes and cryopreserved blastocysts were 15.0±7.6 and 4.2±3.0, respectively. The high-E group was younger (31.5 ± 5.2 years) and had higher peak E2 levels (4078.9 ± 588.4 pg/ml), number of oocytes (19.7 ± 7.0), cryopreserved embryos (5.3 ± 3.3) and transfer cycles (2.3 ± 1.4) than the other groups. Blastocyst utilization rate was significantly lower (40.4%) compared to elective freezing (53.6%) and TEP groups (55.7%) (both p = 0.001). The high-P group had higher peak progesterone levels (2.1 ± 0.5 ng/ml, p = 0.001), number of oocytes (14.0 ± 5.2) and frozen embryos (4.1 ± 3.5) compared to elective and TEP groups (both p = 0.04). Blastocyst utilization rate was lower (45.7%) than elective freezing and TEP groups but the difference lacked statistical significance (p = 0.33 and p = 0.21, respectively). Cumulative live birth rates were 42.6% in high-P, 59.8% in high-E, 44.7% in elective freezing and 46.7% in TEP groups. Significant predictors of cumulative live birth were female age (aHR: 0.97, 95%CI:0.95–0.99, p = 0.02) and number of frozen blastocysts (aHR:1.05, 95%CI:1.01–1.10), p = 0.02). When adjusted for these confounders, the cumulative live birth rate was not associated with high-E (aHR: 0.86, 95%CI:0.56–1.31) or high-P (aHR: 0.76,95%CI:0.44–1.32).

Limitations, reasons for caution

This was a retrospective study with small sample size performed at a single fertility center, which may limit the generalizability of our findings.

Wider implications of the findings: While lower blastocyst utilization rates are observed in women high late-follicular estradiol or progesterone levels, cumulative live birth rates in subsequent thaw-transfer cycles were not impaired. However, unfavorable outcome parameters observed in women with elevated progesterone deserve further research.

Trial registration number

Not applicable

Adhesions and Anti-Adhesion Systems Highlights

The peritoneal and intrauterine cavities are lined by fragile membranes with a high-wound healing capacity, e.g. repairing the endometrium in its cyclical "injury and scar-free repair process" during menstruation. However, peritoneal and intrauterine fibrosis and adhesions can develop after surgical trauma through activation of molecular, immune and genetic mechanisms. During procedures with a high-risk of adhesions, the use of new peritoneal and intrauterine conditions in combination with anti-adhesion substances are promising measures to preserve peritoneal and endometrial function and avoid the most common complication of gynecological surgery. Highlights of adhesions and anti-adhesion prevention techniques in laparoscopic, laparotomic and hysteroscopic surgeries are discussed in this paper. Unfortunately, evidence is lacking to prove the superiority of one technique over its counterparts in terms of postoperative adhesions, such as instrumentation, type of energy, distending media, and intracavitary pressure. Additionally, there is limited evidence about the efficacy and outcomes of techniques and adjuvant measures used during adhesiolysis. The definition of a universal intrauterine adhesions classification scheme as well as a prognostic scoring system to identify women at high risk of postoperative adhesions are necessary for advising those who could benefit the most of the use of antiadhesion barriers.