1
|
Boudry L, Mateizel I, Wouters K, Papaleo E, Mackens S, De Vos M, Racca A, Adriaenssens T, Tournaye H, Blockeel C. Does dual oocyte retrieval with continuous FSH administration increase the number of mature oocytes in low responders? An open-label randomized controlled trial. Hum Reprod 2024; 39:538-547. [PMID: 38199789 DOI: 10.1093/humrep/dead276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/21/2023] [Indexed: 01/12/2024] Open
Abstract
STUDY QUESTION Is there an increase in the total number of metaphase II (MII) oocytes between a conventional ovarian stimulation (OS) and a double uninterrupted stimulation? SUMMARY ANSWER There is no increase in the total number of MII oocytes when comparing one conventional OS to a continuous stimulation with double oocyte aspiration. WHAT IS KNOWN ALREADY Based on the concept of multiple follicular waves, the combination of two stimulations in the same ovarian cycle has gained interest in patients with a low ovarian reserve. This so-called dual stimulation approach is usually characterized by a discontinuation of FSH administration for ∼5 days and appears to have a favourable impact on the number of retrieved oocytes without affecting the embryo quality or ploidy status. The outcomes of dual uninterrupted OS have not yet been studied. STUDY DESIGN, SIZE, DURATION This was an open-label randomized controlled trial (RCT) with superiority design, performed in a single tertiary centre. Subjects were randomized with a 1:1 allocation into two groups between October 2019 and September 2021. All patients underwent a conventional stimulation with recombinant FSH. When two or more follicles of 17 mm were present, the final inclusion criterion was assessed; randomization occurred only in the presence of ≤9 follicles of ≥11 mm. In Group A, ovulation was triggered with hCG, and oocyte retrieval (OR) was performed 34-36 h later, followed by a fresh single or double embryo transfer (SET or DET) on Day 3/5. In Group B, ovulation was triggered with GnRH agonist, followed by another OS, without discontinuation of the FSH administration. In the presence of one or more follicles of ≥17 mm, the second stimulation was completed with hCG. A freeze-all strategy (Day 3/5) was applied for both retrievals, followed by transfer of one or two embryos in an artificially prepared frozen-thawed cycle. In the absence of one or more follicles of ≥17 mm after 13 additional days of stimulation, the second cycle was cancelled. All ORs were executed by a senior fertility specialist who was blinded for the first treatment, and all follicles >10 mm were aspirated, according to routine clinical practice. The primary outcome was the total number of MII oocytes. Patients were followed up until all embryos were transferred, or until live birth was achieved. Other secondary outcomes included the number of cumulus-oocyte complexes (COCs), the number of good quality embryos (Day 3/5), the ongoing pregnancy rate, and gonadotropin consumption. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients between 25 and 40 years old, with an anti-Müllerian hormone level of ≤1.5 ng/ml, antral follicle count of ≤6, or ≤5 oocytes after a previous stimulation, were included. At the start, 70 patients were eligible for participation in the trial, of whom 48 patients fulfilled the final inclusion criterium and were randomized. After drop-out of two patients, 23 patients were randomized to a single round of OS (Group A), and 23 patients were randomized to two uninterrupted rounds of OS (Group B). MAIN RESULTS AND THE ROLE OF CHANCE Baseline characteristics were similar between both groups. The cumulative number of COCs and MII oocytes after completion of the second OR was similar in Group A and Group B [5.3 ± 2.7 versus 5.3 ± 3.0 (P = 0.95); 4.1 ± 2.4 versus 4.3 ± 2.7 (P = 0.77)]. Likewise, a comparable number of excellent and good quality embryos was available on Day 3 (3.0 ± 2.0 versus 2.7 ± 2.0; P = 0.63). In Group B, the cancellation rate due to insufficient response to the second round of stimulation was 39.1% (9/23). When focusing on the first stimulation in both groups, there were no significant differences regarding basal FSH, gonadotropin consumption, and the number of preovulatory follicles. After the first OR, the mean number of COC and MII oocytes was significantly higher in Group A (who had hCG triggering), compared to Group B (who had GnRH agonist triggering) [5.3 ± 2.7 versus 3.3 ± 2.2; difference 95% CI (0.54 to 3.45), P = 0.004 and 4.1 ± 2.4 versus 3.0 ± 2.2; difference 95% CI (-0.15 to 2.6), P = 0.05, respectively]. Likewise, the number of excellent and good quality embryos on Day 3 was significantly higher (3.0 ± 2.0 versus 1.9 ± 1.7; P = 0.02) in Group A. LIMITATIONS, REASONS FOR CAUTION This study was powered to demonstrate superiority for the number of MII oocytes after dual stimulation. Investigating the impact of dual stimulation on pregnancy rates would have required a larger sample size. Furthermore, the heterogeneity in embryo vitrification and transfer policies precluded a correct comparison of embryologic outcomes between both groups. WIDER IMPLICATIONS OF THE FINDINGS This is the first RCT investigating the role of continuous stimulation with double aspiration in low responders. Our results show no statistically significant differences in the cumulative number of MII oocytes between one conventional stimulation with fresh ET and two consecutive stimulations with a freeze-only approach. Furthermore, the observed suboptimal oocyte yield after agonist ovulation triggering in low responders in the dual uninterrupted OS group is a reason for concern and further scrutiny, given that previous RCTs have shown similar outcomes in normal and high responders after hCG and GnRH agonist triggers. STUDY FUNDING/COMPETING INTEREST(S) This work was supported in part by a research grant from Organon. H.T. received honoraria for lectures and presentations from Abbott, Cooper Surgical, Gedeon-Richter, Cook, Goodlife, and Ferring. L.B. received fees for lectures from Merck & Organon and support for attending ESHRE 2023. M.D.V. reports fees for lectures from Ferring, Merck, Organon, IBSA, Gedeon Richter, and Cooper Surgical and support for attending ASRM 2023. S.M. received honoraria for lectures and presentations from Abbott, Cooper Surgical, Gedeon-Richter, IBSA, and Merck. C.B. was on the Advisory board and received consulting fees from Theramex and received honoraria for lectures and presentations from Abbott, Ferring, Gedeon-Richter, IBSA, and Merck. TRIAL REGISTRATION NUMBER NCT03846544. TRIAL REGISTRATION DATE 19 February 2019. DATE OF FIRST PATIENT’S ENROLMENT 28 October 2019.
Collapse
Affiliation(s)
- L Boudry
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - I Mateizel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K Wouters
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - E Papaleo
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Mackens
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M De Vos
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Racca
- Department of Gynaecology and Reproductive Medicine, Instituto Bernabeu Venezia, Venezia, Italy
| | - T Adriaenssens
- Laboratory of Follicle Biology, Vrije Universiteit Brussel, Brussels, Belgium
| | - H Tournaye
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - C Blockeel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
2
|
Malhotra J, Devi MG, Patil M. Best Practice Recommendations for Infertility Management. J Hum Reprod Sci 2024; 17:S1-S240. [PMID: 38495807 PMCID: PMC10942128 DOI: 10.4103/jhrs.jhrs_isar_ifs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Aim The objective of this document is to provide guidance to the infertility specialist, gynecologist, embryologist, and counselors on the management of sub-fertility and brief them with the recent advances in the field. These recommendations will aid the aforementioned healthcare professionals in everyday clinical decisions about appropriate and effective care of their patients with the best available evidence. Participants Extensive deliberations, discussion, and brainstorming was done between different reproductive medicine (RM) specialists, to develop the recommendations. Evidence A systematic review of the literature published up to June 2019 was carried out using PubMed and Cochrane Collaboration Library. International guidelines, cohort studies, case series, observational studies, and randomized controlled trials currently available in the literature were reviewed. Indian data whatever available was also reviewed. Process Primary meetings were held with leading reproductive medicine specialists. Each topic was brainstormed on by a group of reproductive medicine experts, who then prepared the first draft of the recommendation. These recommendations then were reviewed by Dr. Jaideep Malhotra, Dr. Gouri Devi, and Dr. Madhuri Patil along with the chief co-ordinator of each consensus to finalize the final draft. Conclusions From the literature and discussion of the available evidence, several topics were identified for which evidence is inconsistent, insufficient, or non-existing. For the benefit of couples undergoing several treatments, the working committee recommends that future research, where possible in well-designed RCTs, will help in establishing evidence for a particular practice. In the Indian context, one also needs to take into consideration facilities and options available, cost, lack of insurance coverage, experimental nature of some advanced techniques used.
Collapse
Affiliation(s)
- Jaideep Malhotra
- Managing Director - Rainbow IVF, Agra, U.P., President ISAR (2019)
| | - M. Gouri Devi
- President, Indian Fertility Society, Director, Ridge Fertility and IVF Group
| | - Madhuri Patil
- Address: No1, Uma Admirality, Bannerghatta Road, Bangalore, India
| |
Collapse
|
3
|
Liu YL, Lee CI, Liu CH, Cheng EH, Yang SF, Tsai HY, Lee MS, Lee TH. Association between Leukemia Inhibitory Factor Gene Polymorphism and Clinical Outcomes among Young Women with Poor Ovarian Response to Assisted Reproductive Technology. J Clin Med 2023; 12:jcm12030796. [PMID: 36769444 PMCID: PMC9917712 DOI: 10.3390/jcm12030796] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Does the presence of single-nucleotide polymorphisms (SNPs) in the leukemia inhibitory factor (LIF) gene affect ovarian response in infertile young women? METHODS This was a case-control study recruiting 1744 infertile women between January 2014 to December 2015. The 1084 eligible patients were stratified into four groups using the POSEIDON criteria. The gonadotropin-releasing hormone receptor (GnRHR), follicle-stimulating hormone receptor (FSHR), anti-Müllerian hormone (AMH), and LIF SNP genotypes were compared among the groups. The distributions of LIF and FSHR among younger and older patients were compared. Clinical outcomes were also compared. RESULTS The four groups of poor responders had different distributions of SNP in LIF. The prevalence of LIF genotypes among young poor ovarian responders differed from those of normal responders. Genetic model analyses in infertile young women revealed that the TG or GG genotype in the LIF resulted in fewer oocytes retrieved and fewer mature oocytes relative to the TT genotypes. In older women, the FSHR SNP genotype contributed to fewer numbers of mature oocytes. CONCLUSIONS LIF and FSHR SNP genotypes were associated with a statistically significant reduction in ovarian response to controlled ovarian hyperstimulation in younger and older women with an adequate ovarian reserve, respectively.
Collapse
Affiliation(s)
- Yung-Liang Liu
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, No. 161, Sec. 6, Minquan E. Rd., Neihu Dist., Taipei 11490, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - Chun-I Lee
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
- Division of Infertility Clinic, Lee Women’s Hospital, Taichung 40602, Taiwan
| | - Chung-Hsien Liu
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - En-Hui Cheng
- Division of Infertility Clinic, Lee Women’s Hospital, Taichung 40602, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - Hsueh-Yu Tsai
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
| | - Maw-Sheng Lee
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
- Division of Infertility Clinic, Lee Women’s Hospital, Taichung 40602, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - Tsung-Hsien Lee
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
- Correspondence:
| |
Collapse
|
4
|
Jirge PR, Patil MM, Gutgutia R, Shah J, Govindarajan M, Roy VS, Kaul-Mahajan N, Sharara FI. Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective. J Hum Reprod Sci 2022; 15:112-125. [PMID: 35928474 PMCID: PMC9345274 DOI: 10.4103/jhrs.jhrs_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.
Collapse
Affiliation(s)
- Padma Rekha Jirge
- Shreyas Hospital and Sushrut Assisted Conception Clinic, Kohlhapur, India
| | | | | | - Jatin Shah
- Mumbai Fertility Clinic & IVF Centre, Mumbai, India
| | | | | | | | - Faddy I Sharara
- Virginia Center for Reproductive Medicine, Reston; Department of O&G, George Washington University, Washington, DC, USA
| |
Collapse
|
5
|
Canosa S, Carosso AR, Mercaldo N, Ruffa A, Evangelista F, Bongioanni F, Benedetto C, Revelli A, Gennarelli G. Effect of rLH Supplementation during Controlled Ovarian Stimulation for IVF: Evidence from a Retrospective Analysis of 1470 Poor/Suboptimal/Normal Responders Receiving Either rFSH plus rLH or rFSH Alone. J Clin Med 2022; 11:jcm11061575. [PMID: 35329901 PMCID: PMC8954443 DOI: 10.3390/jcm11061575] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/10/2022] Open
Abstract
We retrospectively studied a real-life population of 1470 women undergoing IVF, with poor/suboptimal/normal ovarian responsiveness to controlled ovarian stimulation (COS), comparing the cumulative live birth rate (cLBR) when COS was performed using rFSH alone or rFSH + rLH in a 2:1 ratio. Overall, we observed significantly higher cLBR in the rFSH alone group than in the rFSH + rLH group (29.3% vs. 22.2%, p < 0.01). However, considering only suboptimal/poor responders (n = 309), we observed comparable cLBR (15.6% vs. 15.2%, p = 0.95) despite the fact that patients receiving rFSH + rLH had significantly higher ages and worse ovarian reserve markers. The equivalent effectiveness of rFSH + rLH and rFSH alone was further confirmed after stratification according to the number of oocytes retrieved: despite basal characteristics were still in favor of rFSH alone group, the cLBR always resulted comparable. Even subdividing patients according to the POSEIDON classification, irrespective of differences in the baseline clinical characteristics in favor of FSH alone group, the cLBR resulted comparable in all subgroups. Despite the retrospective, real-life analysis, our data suggest that rLH supplementation in COS may represent a reasonable option for patients with predictable or unexpected poor/suboptimal ovarian responsiveness to FSH, those matching the Bologna criteria for poor responsiveness, and those included in the POSEIDON classification.
Collapse
Affiliation(s)
- Stefano Canosa
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
- Livet, GeneraLife IVF, 10126 Turin, Italy;
- Correspondence:
| | - Andrea Roberto Carosso
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
| | - Noemi Mercaldo
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
| | - Alessandro Ruffa
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
| | - Francesca Evangelista
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
- Livet, GeneraLife IVF, 10126 Turin, Italy;
| | | | - Chiara Benedetto
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
| | - Alberto Revelli
- Obstetrics and Gynecology 2U, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy;
| | - Gianluca Gennarelli
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant’Anna Hospital, University of Turin, 10126 Turin, Italy; (A.R.C.); (N.M.); (A.R.); (F.E.); (C.B.); (G.G.)
| |
Collapse
|
6
|
Miyano T, Irvine AD, Tanaka RJ. A mathematical model to identify optimal combinations of drug targets for dupilumab poor responders in atopic dermatitis. Allergy 2022; 77:582-594. [PMID: 33894014 DOI: 10.1111/all.14870] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/08/2021] [Accepted: 03/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several biologics for atopic dermatitis (AD) have demonstrated good efficacy in clinical trials, but with a substantial proportion of patients being identified as poor responders. This study aims to understand the pathophysiological backgrounds of patient variability in drug response, especially for dupilumab, and to identify promising drug targets in dupilumab poor responders. METHODS We conducted model-based meta-analysis of recent clinical trials of AD biologics and developed a mathematical model that reproduces reported clinical efficacies for nine biological drugs (dupilumab, lebrikizumab, tralokinumab, secukinumab, fezakinumab, nemolizumab, tezepelumab, GBR 830, and recombinant interferon-gamma) by describing system-level AD pathogenesis. Using this model, we simulated the clinical efficacy of hypothetical therapies on virtual patients. RESULTS Our model reproduced reported time courses of %improved EASI and EASI-75 of the nine drugs. The global sensitivity analysis and model simulation indicated the baseline level of IL-13 could stratify dupilumab good responders. Model simulation on the efficacies of hypothetical therapies revealed that simultaneous inhibition of IL-13 and IL-22 was effective, whereas application of the nine biologic drugs was ineffective, for dupilumab poor responders (EASI-75 at 24 weeks: 21.6% vs. max. 1.9%). CONCLUSION Our model identified IL-13 as a potential predictive biomarker to stratify dupilumab good responders, and simultaneous inhibition of IL-13 and IL-22 as a promising drug therapy for dupilumab poor responders. This model will serve as a computational platform for model-informed drug development for precision medicine, as it allows evaluation of the effects of new potential drug targets and the mechanisms behind patient variability in drug response.
Collapse
Affiliation(s)
- Takuya Miyano
- Department of Bioengineering Imperial College London London UK
| | - Alan D. Irvine
- Pediatric Dermatology Children’s Health Ireland at Crumlin Dublin Ireland
- Clinical Medicine Trinity College Dublin Dublin Ireland
| | - Reiko J. Tanaka
- Department of Bioengineering Imperial College London London UK
| |
Collapse
|
7
|
Quaas AM, Penzias AS, Adashi EY. The role of growth hormone in assisted reproduction. Front Endocrinol (Lausanne) 2022; 13:1055097. [PMID: 36531455 PMCID: PMC9755199 DOI: 10.3389/fendo.2022.1055097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/10/2022] [Indexed: 12/03/2022] Open
Abstract
In contemporary ART, the use of "add-ons" during ovarian stimulation has increased, especially in poor responders. Growth Hormone (GH) is an adjunctive therapy that has been studied extensively in the translational and clinical setting, with an ongoing scientific debate over its effectiveness and optimal use. In this review, we aim to provide an overview of the physiologic basis for the use of GH in ART, and to summarize the latest evidence regarding its clinical use, primarily as an adjunct to ovarian stimulation, but also in the IVF lab and with regards to its effects on the endometrium.
Collapse
Affiliation(s)
- Alexander M. Quaas
- Division of Reproductive Medicine and Gynecological Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
- *Correspondence: Alexander M. Quaas,
| | - Alan S. Penzias
- Boston IVF, Waltham, MA, United States
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | - Eli Y. Adashi
- Department of Medical Science, Warren Alpert Medical School, Brown University, Providence, RI, United States
| |
Collapse
|
8
|
Mauries C, Ranisavljevic N, Mollevi C, Brunet C, Hamamah S, Brouillet S, Anahory T. "Short agonist stop" protocol, an ovarian stimulation for poor responders in in vitro fertilization (IVF): A pilot study. Front Endocrinol (Lausanne) 2022; 13:1056520. [PMID: 36465628 PMCID: PMC9714551 DOI: 10.3389/fendo.2022.1056520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/26/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Poor responder patients remain a challenge in assisted reproductive technologies. The "short agonist stop" (SAS) stimulation protocol uses a double stimulation (flare up effect with the gonadotropin-releasing hormone (GnRH) agonist (GnRH-a) then gonadotropins) associated with a less strenuous blockage (discontinuation of GnRH-a) to favor follicular recruitment in order to obtain a better ovarian response. This study aims to compare the number of oocytes obtained after a SAS stimulation protocol with those obtained after the previous stimulation protocol, in the same women, with poor ovarian response (POR) diagnosed according to the POSEIDON criteria. DESIGN This therapeutic observational retrospective cohort from 2018 to 2022, with a case-control evaluation compared with the same patients' previous performance, included women with POR undergoing IVF with SAS stimulation protocol. The primary outcome was the number of total oocytes recovered and secondary outcomes were the numbers of mature oocytes, total embryos observed at day 2 and usable cleaved embryos and blastocysts (day 5/6). RESULTS 63 patients with SAS and previous cycles were included. In the SAS group, the mean number of oocytes was significantly higher: 7.3 vs 5.7, p=0.018 in comparison with the previous attempt. So was the number of mature oocytes (5.8 vs 4.1, p=0.032) and the total mean number of embryos obtained at day 2 (4.1 versus 2.7, p=0.016). The SAS stimulation generated 84 usable embryos: 57 cleaved embryos and 27 blastocysts. The mean number of usable embryos was similar in both groups (1.64 vs 1.31, respectively, p=0.178). In total, out of 63 patients, after the SAS protocol, and subsequent embryo transfers (fresh and frozen, n=54), 9 patients had ongoing pregnancies and no miscarriage occurred. The cumulative ongoing pregnancy rate (cOPR) after the SAS protocol was 14.3% (9/63) per oocyte pick-up and 16.7% (9/54) per transfer. CONCLUSION SAS stimulation is a short and original protocol strengthening the therapeutic arsenal of poor responders, that may offer promising results for those patients with low prognosis and previous failed IVF. Results must be confirmed with a randomized controlled trial.
Collapse
Affiliation(s)
- Charlotte Mauries
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
- *Correspondence: Charlotte Mauriès,
| | - Noemie Ranisavljevic
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Caroline Mollevi
- Institute Desbrest of Epidemiology and Public Health, Montpellier University Hospital, University of Montpellier, INSERM, Montpellier, France
| | - Cecile Brunet
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Samir Hamamah
- Department of Reproductive Biology-CECOS, Montpellier University Hospital, University of Montpellier, Montpellier, France
- Embryo Development Fertility Environment, University of Montpellier, INSERM 1203, Montpellier, France
| | - Sophie Brouillet
- Department of Reproductive Biology-CECOS, Montpellier University Hospital, University of Montpellier, Montpellier, France
- Embryo Development Fertility Environment, University of Montpellier, INSERM 1203, Montpellier, France
| | - Tal Anahory
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| |
Collapse
|
9
|
Riva A, Petrangolini G, Allegrini P, Perna S, Giacosa A, Peroni G, Faliva MA, Naso M, Rondanelli M. Artichoke and Bergamot Phytosome Alliance: A Randomized Double Blind Clinical Trial in Mild Hypercholesterolemia. Nutrients 2021; 14:108. [PMID: 35010984 DOI: 10.3390/nu14010108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 01/01/2023] Open
Abstract
Botanicals are natural alternatives to pharmacological therapies that aim at reducing hypercholesterolemia. In this context, despite bergamot being effective in modulating lipid profile, some subjects failed to achieve a satisfactory response to supplementation. The aim of this study was to evaluate whether the association of 600 mg of bergamot phytosome® (from Citrus Bergamia Risso) and 100 mg of artichoke leaf standardized dry extract (from Cynara cardunculus L.) can be an alternative in patients with mild hypercholesterolemia who are poor responders to bergamot in a 2-month randomized placebo-controlled trial. Sixty overweight adults were randomized into two groups: 30 were supplemented and 30 received a placebo. The metabolic parameters and DXA body composition were evaluated at the start, after 30 and 60 days. Between the two groups, total and LDL cholesterol in the supplemented group (compared to placebo) showed significant decreases overtime. A significant reduction of waist circumference and visceral adipose tissue (VAT) was recorded in the supplemented group (compared to placebo), even in subjects who did not follow a low-calorie diet. In conclusion, the synergism between Citrus Bergamia polyphenols and Cynara cardunculus extracts may be an effective option and may potentially broaden the therapeutic role of botanicals in dyslipidemic patients.
Collapse
|
10
|
Weng SL, Tzeng SL, Lee CI, Liu CH, Huang CC, Yang SF, Lee MS, Lee TH. Association between GnRH Receptor Polymorphisms and Luteinizing Hormone Levels for Low Ovarian Reserve Infertile Women. Int J Environ Res Public Health 2021; 18:7006. [PMID: 34209056 DOI: 10.3390/ijerph18137006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 11/25/2022]
Abstract
The choice of ovarian stimulation protocols in assisted reproduction technology (ART) cycles for low ovarian reserve patients is challenging. Our previous report indicated that the gonadotrophin-releasing (GnRH) agonist (GnRHa) protocol is better than the GnRH antagonist (GnRHant) protocol for young age poor responders. Here, we recruited 269 patients with anti-Müllerian hormone (AMH) < 1.2 ng/mL undergoing their first ART cycles for this nested case-control study. We investigated the genetic variants of the relevant genes, including follicular stimulating hormone receptor (FSHR; rs6166), AMH (rs10407022), GnRH (rs6185), and GnRH receptor (GnRHR; rs3756159) in patients <35 years (n = 86) and patients ≥35 years of age (n = 183). Only the genotype of GnRHR (rs3756159) is distributed differently in young (CC 39.5%, CT/TT 60.5%) versus advanced (CC 24.0%, CT/TT 76.0%) age groups (recessive model, p = 0.0091). Furthermore, the baseline luteinizing hormone (LH) levels (3.60 (2.45 to 5.40) vs. 4.40 (2.91 to 6.48)) are different between CC and CT/TT genotype of GnRHR (rs3756159). In conclusion, the genetic variants of GnRHR (rs3756159) could modulate the release of LH in the pituitary gland and might then affect the outcome of ovarian stimulation by GnRHant or GnRHa protocols for patients with low AMH levels.
Collapse
|
11
|
Tesarik J, Galán-Lázaro M, Mendoza N, Mendoza-Tesarik R. Double HCG trigger improves recovery of oocytes in women with a paucifollicular response to ovarian stimulation: A pilot study. Int J Gynaecol Obstet 2021; 157:149-153. [PMID: 33969486 DOI: 10.1002/ijgo.13735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/14/2021] [Accepted: 05/07/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine whether adding a second HCG trigger, 12.5 h after the first (36.5 h before ovarian puncture), can facilitate recovery of oocytes in women with a paucifollicular response to ovarian stimulation. METHODS A total of 85 women aged 35-42 years, with a paucifollicular response to ovarian stimulation and who had experienced a total failure of oocyte recovery after the standard HCG ovulation trigger 36.5 h before ovarian puncture, were subsequently treated by the same protocol but with the addition of a second HCG trigger 12.5 h later. The recovered oocytes were inseminated by intracytoplasmic sperm injection (ICSI) and all available embryos were transferred 3 days later. RESULTS The double trigger enabled recovery of cumulus oophorus cells from most of the follicles in the women who experienced failure of total recovery of oocytes after a single trigger. Fifteen patients became pregnant, and no signs of ovarian hyperstimulation syndrome were observed. Nine women delivered a healthy child. CONCLUSION In women aged 35-42 years with a paucifollicular response to ovarian stimulation, a double HCG trigger appears to improve the rate of oocyte recovery. The conclusion of this pilot study needs to be confirmed by larger prospective trials.
Collapse
Affiliation(s)
- Jan Tesarik
- Molecular Assisted Reproduction and Genetics, MAR&Gen Clinic, Granada, Spain
| | | | - Nicolas Mendoza
- Molecular Assisted Reproduction and Genetics, MAR&Gen Clinic, Granada, Spain.,Department of Obstetrics and Gynecology, School of Medicine, Granada, Spain
| | | |
Collapse
|
12
|
Tosun SA, Ozkaya E, Aru B, Yanikkaya Demirel G, Cogendez E, Sipahi M. Does LH supplementation in poor responders affect granulosa cells apoptosis rate in ART? A prospective randomised controlled trial. J OBSTET GYNAECOL 2021; 42:133-138. [PMID: 33908815 DOI: 10.1080/01443615.2021.1873921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The aim was to compare granulosa cell's (GCs) apoptosis rate with (group A) or without (group B) luteinising hormone (LH) supplementation in poor ovarian responders (PORs) during controlled ovarian stimulation (COS). After oocyte retrieval, the follicular fluid was analysed by cytoflowmetry. Primary outcomes were GCs apoptosis rate in terms of viability, early apoptosis, late apoptosis and necrosis. Secondary outcome was clinical pregnancy rate. The viability was 96.7{IQR: 8} and 83.5{IQR: 20} for groups A and B, respectively (p < .001). Late apoptosis rates were significantly lower in group A (median 1.5, {IQR: 3.1}) than group B (median 9.5, {IQR: 20.6}) (p < .001). Median early apoptosis rates were 1.4 {IQR: 2.9} and 5.2 {IQR: 6.5} for group A and B respectively (p = .04). No significant difference was observed in the clinical pregnancy rate. Although LH seems necessary in PORs to decrease late granulosa apoptosis rates, this does not improve clinical pregnancy rates.IMPACT STATEMENTWhat is already known on this subject? LH supplementation during COS has long been an issue in PORs to overcome the rFSH responsiveness due to the LH polymorphism. LH receptors have also been on GCs and their expression increases in preovulatory follicles. GCs apoptosis rates may show the oocyte quality and reproductive potential of oocyte retrieved and the requirement for LH supplementation.What do the results of this study add? The present study shows that LH supplementation during COS for PORs promotes the GC viability and reduces early/late apoptosis rates. Similarly, the number of MII oocytes was significantly higher in the LH regimen group. However, there was no significant difference in terms of clinical pregnancy rates.What are the implications of these findings for clinical practice and/or further research? The oocyte quality parameters such as higher GC viability and lower GC early/late apoptosis rates verify the LH supplementation in PORs during COS. However, the limited size of this study requires further multi-centre research in a larger cohort of patients. Results obtained with a sensitive and validated method will help clinicians to make better decisions in patient care.
Collapse
Affiliation(s)
- Sebnem Alanya Tosun
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Giresun University, Giresun, Turkey
| | - Enis Ozkaya
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Health Sciences University, Istanbul, Turkey
| | - Basak Aru
- Department of Immunology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | | | - Ebru Cogendez
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Health Sciences University, Istanbul, Turkey
| | - Mehmet Sipahi
- Faculty of Medicine, Department of Obstetrics and Gynaecology, Giresun University, Giresun, Turkey
| |
Collapse
|
13
|
Polyzos NP, Popovic-Todorovic B. SAY NO to mild ovarian stimulation for all poor responders: it is time to realize that not all poor responders are the same. Hum Reprod 2021; 35:1964-1971. [PMID: 32830232 DOI: 10.1093/humrep/deaa183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Over the last 25 years, a vast body of literature has been published evaluating different treatment modalities for the management of poor ovarian responders. Despite the evidence that maximizing ovarian response can improve the chances of live born babies in poor responders, there are still voices suggesting that all poor responders are the same, irrespective of their age and their actual ovarian reserve. This has resulted in the suggestion of adopting a mild ovarian stimulation approach for all poor responders, based on the results of several trials which failed to identity differences when comparing mild and more intense stimulation in predicted poor responders. The current article analyzes in detail these studies and discusses the shortcomings in terms of type of population included, outcomes and settings performed, which may actually be responsible for the belief that only mild stimulation should be used. In the era of individualization in medicine, it must be realized that there are subgroups of predicted poor responders who will benefit from an individual rather than 'one fits all' mild stimulation approach and thus we should provide the same standard of treatment for all our poor responder patients.
Collapse
Affiliation(s)
- N P Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | | |
Collapse
|
14
|
Datta AK, Maheshwari A, Felix N, Campbell S, Nargund G. Mild versus conventional ovarian stimulation for IVF in poor, normal and hyper-responders: a systematic review and meta-analysis. Hum Reprod Update 2020; 27:229-253. [PMID: 33146690 PMCID: PMC7902993 DOI: 10.1093/humupd/dmaa035] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mild ovarian stimulation has emerged as an alternative to conventional IVF with the advantages of being more patient-friendly and less expensive. Inadequate data on pregnancy outcomes and concerns about the cycle cancellation rate (CCR) have prevented mild, or low-dose, IVF from gaining wide acceptance. OBJECTIVE AND RATIONALE To evaluate parallel-group randomised controlled trials (RCTs) on IVF where comparisons were made between a mild (≤150 IU daily dose) and conventional stimulation in terms of clinical outcomes and cost-effectiveness in patients described as poor, normal and non-polycystic ovary syndrome (PCOS) hyper-responders to IVF. SEARCH METHODS Searches with no language restrictions were performed using Medline, Embase, Cochrane central, Pre-Medicine from January 1990 until April 2020, using pre-specified search terms. References of included studies were hand-searched as well as advance access articles to key journals. Only parallel-group RCTs that used ≤150 IU daily dose of gonadotrophin as mild-dose IVF (MD-IVF) and compared with a higher conventional dose (CD-IVF) were included. Studies were grouped under poor, normal or hyper-responders as described by the authors in their inclusion criteria. Women with PCOS were excluded in the hyper-responder group. The risk of bias was assessed as per Cochrane Handbook for the included studies. The quality of evidence (QoE) was assessed according to the GRADE system. PRISMA guidance was followed for review methodology. OUTCOMES A total of 31 RCTs were included in the analysis: 15 in the poor, 14 in the normal and 2 in the hyper-responder group. Live birth rates (LBRs) per randomisation were similar following use of MD-IVF in poor (relative risk (RR) 0.91 (CI 0.68, 1.22)), normal (RR 0.88 (CI 0.69, 1.12)) and hyper-responders (RR 0.98 (CI 0.79, 1.22)) when compared to CD-IVF. QoE was moderate. Cumulative LBRs (5 RCTs, n = 2037) also were similar in all three patient types (RR 0.96 (CI 0.86 1.07) (moderate QoE). Risk of ovarian hyperstimulation syndrome was significantly less with MD-IVF than CD-IVF in both normal (RR 0.22 (CI 0.10, 0.50)) and hyper-responders (RR 0.47 (CI 0.31, 0.72)), with moderate QoE. The CCRs were comparable in poor (RR 1.33 (CI 0.96, 1.85)) and hyper-responders (RR 1.31 (CI 0.98, 1.77)) but increased with MD-IVF among normal responders (RR 2.08 (CI 1.38, 3.14)); all low to very low QoE. Although fewer oocytes were retrieved and fewer embryos created with MD-IVF, the proportion of high-grade embryos was similar in all three population types (low QoE). Compared to CD-IVF, MD-IVF was associated with less gonadotrophin use and lower cost. WIDER IMPLICATIONS This updated review provides reassurance on using MD-IVF not only for the LBR per cycle but also for the cumulative LBR, with moderate QoE. With risks identified with ‘freeze-all’ strategies, it may be time to recommend mild-dose ovarian stimulation for IVF for all categories of women i.e. hyper, poor and normal responders to IVF.
Collapse
Affiliation(s)
| | | | | | - Stuart Campbell
- St George's University of London, London, UK.,Create Fertility, London, UK
| | - Geeta Nargund
- Create Fertility, London, UK.,St Georges University Hospitals NHS Trust London, London, UK
| |
Collapse
|
15
|
Maged AM, Nabil H, Dieb AS, Essam A, Ibrahim S, Deeb W, Fahmy RM. Prediction of metaphase II oocytes according to different levels of serum AMH in poor responders using the antagonist protocol during ICSI: a cohort study. Gynecol Endocrinol 2020; 36:728-733. [PMID: 31870186 DOI: 10.1080/09513590.2019.1706081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The aim of our study was to assess the value of serum AMH in prediction of metaphase II oocytes in poor responders. We performed a prospective cohort study included 206 poor responders candidate for ICSI using antagonist protocol. They were classified into 3 groups. Group I included 50 women with AMH < 0.3 ng/ml, group II included 85 women with AMH 0.3-0.7 ng/ml and group III included 71 women with AMH > 0.7-1.0 ng/ml. The primary outcome parameter was the number of MII oocytes. There was a highly significant difference between the study groups regarding E2 at triggering (481.41 ± 222.653, 648.17 ± 264.353 and 728.74 ± 305.412 respectively, number of oocyte retrieved (2.37 ± 1.178, 3.38 ± 1.622 and 3.80 ± 1.427 respectively), number of MII oocytes (1.66 ± 1.039, 2.35 ± 1.171 and 2.61 ± 1.080 respectively), number of fertilized oocytes (1.39 ± 0.919, 1.91 ± 0.983 and 2.21 ± 0.937 respectively), , total number of embryos (1.34 ± 0.938, 1.76 ± 0.956 and 2.09 ± 0.907 respectively), clinical pregnancy rates (4.9 vs. 7.7 and 19.7% respectively). We concluded that AMH is a good predictor for number of MII oocytes in poor responders undergoing ICSI.
Collapse
Affiliation(s)
- Ahmed M Maged
- Obstetrics and Gynecology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Hala Nabil
- Obstetrics and Gynecology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Amira S Dieb
- Obstetrics and Gynecology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Aimy Essam
- Obstetrics and Gynecology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Safaa Ibrahim
- Obstetrics and Gynecology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Wesam Deeb
- Obstetrics and Gynecology Department, Fayoum University, Faiyum, Egypt
| | - Radwa M Fahmy
- Obstetrics and Gynecology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| |
Collapse
|
16
|
Cozzolino M, Cecchino GN, Troiano G, Romanelli C. Growth hormone cotreatment for poor responders undergoing in vitro fertilization cycles: a systematic review and meta-analysis. Fertil Steril 2020; 114:97-109. [PMID: 32553470 DOI: 10.1016/j.fertnstert.2020.03.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/04/2020] [Accepted: 03/04/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of growth hormone (GH) supplementation in improving the in vitro fertilization (IVF) outcomes of poor responders. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Poor ovarian responders undergoing conventional IVF or intracytoplasmic sperm injection (ICSI). INTERVENTION(S) Randomized controlled trials (RCTs) of poor ovarian responders undergoing a single IVF/ICSI cycle with GH supplementation versus conventional controlled ovarian stimulation. This review was registered in the PROSPERO database before starting data extraction (CRD42020151681). MAIN OUTCOME MEASURE(S) Primary outcome was live birth rate. Clinical pregnancy rate, miscarriage rate, ongoing pregnancy rate, number of oocytes, number of mature (metaphase II [MII]) oocytes and the number of embryos available to transfer were considered as secondary outcomes. RESULT(S) Twelve RCTs were included; 586 women were assigned to the intervention group and 553 to the control group. The analysis revealed that patients receiving GH supplementation did not show an increased live birth rate, miscarriage rate, or ongoing pregnancy rate. However, GH supplementation in poor responders increased clinical pregnancy rate, number of oocytes retrieved (mean difference 1.62), number of MII oocytes (mean difference 2.06), and number of embryos available to transfer (mean difference 0.76). Sensitivity and subgroup analyses did not provide statistical changes to pooled results. CONCLUSION(S) The present meta-analysis provides evidence that GH supplementation may improve some reproductive outcomes in poor responders, but not live birth rates.
Collapse
Affiliation(s)
- Mauro Cozzolino
- IVIRMA, IVI Foundation, Health Research Institute La Fe, Valencia, Spain; Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut.
| | - Gustavo N Cecchino
- Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | | | - Chiara Romanelli
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| |
Collapse
|
17
|
Sfakianoudis K, Simopoulou M, Grigoriadis S, Pantou A, Tsioulou P, Maziotis E, Rapani A, Giannelou P, Nitsos N, Kokkali G, Koutsilieris M, Pantos K. Reactivating Ovarian Function through Autologous Platelet-Rich Plasma Intraovarian Infusion: Pilot Data on Premature Ovarian Insufficiency, Perimenopausal, Menopausal, and Poor Responder Women. J Clin Med 2020; 9:jcm9061809. [PMID: 32532000 PMCID: PMC7355907 DOI: 10.3390/jcm9061809] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022] Open
Abstract
Intraovarian platelet-rich plasma (PRP) infusion was recently introduced in the context of addressing ovarian insufficiency. Reporting on its effectiveness prior to adopting in clinical routine practice is imperative. This study aims to provide pilot data regarding PRP application for ovarian rejuvenation. Four pilot studies were conducted on poor ovarian response (POR), premature ovarian insufficiency (POI), perimenopause, and menopause, respectively. Each pilot study reports on thirty patients, 120 participants were recruited in total. All participants provided written informed consent prior to treatment. Primary outcome measures for the POR pilot study were levels of anti-müllerian hormone (AMH), antral follicle count (AFC) and oocyte yield. For the POI, perimenopausal and menopausal pilot studies primary outcome measures were restoration of menstrual cycle, and Follicle Stimulating Hormone (FSH) levels. A significant improvement on the hormonal profile and the ovarian reserve status was noted, along with improved intracytoplasmic sperm injection (ICSI) cycle performance concerning POR participants. Menstruation recovery was observed in 18 out of 30 POI patients, along with a statistically significant improvement on levels of AMH, FSH, and AFC. Similarly, 13 out of 30 menopausal women positively responded to PRP treatment. Finally, menstruation regularity, improved hormonal levels and AFC were reported for 24 out of 30 perimenopausal women. To conclude, PRP infusion appears to convey promising results in addressing ovarian insufficiency.
Collapse
Affiliation(s)
- Konstantinos Sfakianoudis
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Mara Simopoulou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
- Correspondence: ; Tel.: +30-2107462592; Fax: +30-2107462571
| | - Sokratis Grigoriadis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Agni Pantou
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Petroula Tsioulou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Evangelos Maziotis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Anna Rapani
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Polina Giannelou
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Nikolaos Nitsos
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Georgia Kokkali
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Michael Koutsilieris
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Konstantinos Pantos
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| |
Collapse
|
18
|
Malhotra N, Vignarajan CP, Dolkar D, Mahey R, Vanamail P. Follicular Flushing Versus Direct Aspiration at Oocyte Retrieval in Poor Responders Undergoing in vitro Fertilization: A Randomized Controlled Trial. J Hum Reprod Sci 2020; 13:150-154. [PMID: 32792765 PMCID: PMC7394092 DOI: 10.4103/jhrs.jhrs_59_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/25/2019] [Accepted: 02/28/2020] [Indexed: 11/04/2022] Open
Abstract
AIM This study aims to study the effect of follicular flushing at oocyte retrieval on Assisted Reproductive Technique (ART) outcomes in poor responders undergoing in vitro fertilization. SETTINGS AND DESIGN A prospective randomized controlled trial was conducted in the ART center of our hospital. MATERIALS AND METHODS A total of 71 patients who responded poorly during controlled ovarian stimulation were recruited. Patients were randomized to follicular flushing or to direct aspiration group. The primary outcomes of the study were the total number of oocytes retrieved and the number of metaphase (M II) oocytes retrieved. Secondary outcomes were anesthesia time, procedure time, fertilization rate, cleavage rate, total number of embryos, number of embryos transferred, number of Grade 1 embryos, failed oocyte recovery, failed fertilization, implantation rate, clinical pregnancy rate, miscarriage rate, and live birth rate. STATISTICAL ANALYSIS USED Chi-square test and Student's t-test. RESULTS The total number of oocytes retrieved, number of M II oocytes, fertilization rate, cleavage rate, total number of embryos, number of Grade 1 embryos, failed oocyte recovery, failed fertilization, implantation rate, miscarriage rate, and live birth rate were comparable between the two groups. The anesthesia and procedure time was significantly higher in the flushing group. CONCLUSIONS Follicular flushing does not result in a significant improvement in the ART outcomes despite increasing procedure and anesthesia times.Trial registration number CTRI/2017/07/009062.
Collapse
Affiliation(s)
- Neena Malhotra
- Department of Obstetrics and Gynaecology, ART Center, All India Institute of Medical Sciences, New Delhi, India
| | | | - Disket Dolkar
- Department of Obstetrics and Gynaecology, ART Center, All India Institute of Medical Sciences, New Delhi, India
| | - Reeta Mahey
- Department of Obstetrics and Gynaecology, ART Center, All India Institute of Medical Sciences, New Delhi, India
| | - Perumal Vanamail
- Department of Obstetrics and Gynaecology, ART Center, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
19
|
Romito A, Bardhi E, Errazuriz J, Blockeel C, Santos-Ribeiro S, Vos MD, Racca A, Mackens S, Kelen AVD, Panici PB, Vaiarelli A, Tournaye H, Drakopoulos P. Heterogeneity Among Poor Ovarian Responders According to Bologna Criteria Results in Diverging Cumulative Live Birth Rates. Front Endocrinol (Lausanne) 2020; 11:208. [PMID: 32373068 PMCID: PMC7179754 DOI: 10.3389/fendo.2020.00208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/24/2020] [Indexed: 02/03/2023] Open
Abstract
Research Question: Does reproductive outcome differ among the various subgroups of poor ovarian responders according to the Bologna criteria? Design: This was a retrospective, cohort study including poor ovarian responders according to Bologna criteria, undergoing an ICSI cycle from January 2011 until December 2017. Patients were divided into four groups: (1) age ≥ 40 years and abnormal ovarian response test, (2) age ≥ 40 years, abnormal ovarian reserve test and one previous poor response to stimulation, (3) age ≥ 40 years and one previous poor response, (4) abnormal ovarian reserve test and one previous poor response. Result(s): Overall, 846 cycles in 706 Bologna poor ovarian responders were included: 310 cycles in group 1, 169 in group 2, 52 in group 3, and 315 in group 4. There were significant differences in age, antral follicle count, antimüllerian hormone, cycle cancellation rates, and number of retrieved oocytes between the four groups. Live birth and cumulative live birth rate differed significantly between groups and were highest in Group 4 [Live birth rate: 7.4% (1) vs. 4.1% (2) vs. 5.8% (3) vs. 13.4% (4), p = 0.001 and Cumulative live birth rate: 8.3% (1) vs. 4.1 % (2) vs. 9.6% (3) vs. 16.8% (4) p < 0.001]. The multivariate GEE analysis revealed that the number of MIIs and the Bologna criteria pattern were the variables which were significantly associated with cumulative live birth rate. Conclusion(s): Poor ovarian responders represent a heterogeneous population. The young subpopulation has a better clinical prognosis in terms of fresh and cumulative live birth rate.
Collapse
Affiliation(s)
- Alessia Romito
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Erlisa Bardhi
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Joaquin Errazuriz
- Departamento de Ginecologia y Obstetricia Clinica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Obstetrics and Gynaecology, University of Zagreb, Zagreb, Croatia
| | | | - Michel De Vos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Annalisa Racca
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Shari Mackens
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alberto Vaiarelli
- Clinica Valle Giulia, G.E.N.E.R.A. Centre for Reproductive Medicine, Rome, Italy
| | - Herman Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
- *Correspondence: Panagiotis Drakopoulos
| |
Collapse
|
20
|
Abstract
The infertile patients with aging ovaries-also sometimes referred to as impending premature ovarian insufficiency (POI), impending premature ovarian failure (POF), or poor ovarian responders (POR), constitute a significant and increasing bulk of the patients appealing to IVF/ART. Different causes have been cited in the literature, among the identified etiologies, including chromosomal and genetic etiology, metabolic, enzymatic, iatrogenic, toxic, autoimmune, and infectious causes. Although the most successful and ultimate treatment of POI/POF/POR patients is egg donation (ED), many, if not most, of these infertile women are reluctant to consent to ED upon the initial diagnostic interview, requesting alternative solutions despite the low odds for success. Despite anecdotal case reports, no unequivocal treatment proved to be successful for these patients in prospective randomized controlled trials. Nevertheless, the addition of growth hormone (GH) to ovarian stimulation in POR with GH deficiency may improve the results of controlled ovarian hyperstimulation (COH) and the IVF success. In patients with autoimmune etiology for POR/POI, the combination of glucocorticosteroids, pituitary-ovarian suppression, and COH may be successful in achieving the desired conception.
Collapse
|
21
|
Orvieto R, Kirshenbaum M, Galiano V, Elkan-Miller T, Zilberberg E, Haas J, Nahum R. Stop GnRH-Agonist Combined With Multiple-Dose GnRH-Antagonist Protocol for Patients With "Genuine" Poor Response Undergoing Controlled Ovarian Hyperstimulation for IVF. Front Endocrinol (Lausanne) 2020; 11:182. [PMID: 32528403 PMCID: PMC7258857 DOI: 10.3389/fendo.2020.00182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/13/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To examine whether the Stop GnRH-agonist combined with multiple-dose GnRH-antagonist protocol may improve conventional IVF/intracytoplasmic sperm injection (ICSI) cycle in poor ovarian response (POR) patients. Design: Cohort historical, proof of concept study. Setting: Tertiary, University affiliated Medical Center. Patient(s): Thirty POR patients, defined according to the Bologna criteria, who underwent a subsequent Stop GnRH-agonist combined with multiple-dose GnRH-antagonist controlled ovarian hyperstimulation (COH) protocol, within 3 months of the previous failed conventional IVF/ICSI cycle, were included. For the purposes of this study, we eliminated a bias in this selection by including only "genuine" poor responder patients, defined as those who yielded up to 3 oocytes following COH with a minimal gonadotropin daily dose of 300 IU. Main Outcome Measure(s): Number of oocytes retrieved, number of top-quality embryos, COH variables. Result(s): The Stop GnRH-agonist combined with multiple-dose GnRH-antagonist COH protocol revealed significantly higher numbers of follicles >13 mm on the day of hCG administration, higher numbers of oocytes retrieved, and top-quality embryos (TQE) with an acceptable clinical pregnancy rate (16.6%). Moreover, as expected, patients undergoing the Stop GnRH-agonist combined with multiple-dose GnRH-antagonist COH protocol required significantly higher doses and a longer duration of gonadotropins stimulation. Conclusion(s): The combined Stop GnRH-ag/GnRH-ant COH protocol is a valuable tool in the armamentarium for treating "genuine" poor ovarian responders. Further, large prospective studies are needed to elucidate its role in POR and to characterize the appropriate patients subgroup (before initiating ovarian stimulation) that may benefit from the combined Stop GnRH-ag/GnRH-ant COH protocol.
Collapse
Affiliation(s)
- Raoul Orvieto
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- *Correspondence: Raoul Orvieto
| | - Michal Kirshenbaum
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Valentina Galiano
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Elkan-Miller
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Zilberberg
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jigal Haas
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ravit Nahum
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
22
|
González-Fernández R, Martín-Ramírez R, Rotoli D, Hernández J, Naftolin F, Martín-Vasallo P, Palumbo A, Ávila J. Granulosa-Lutein Cell Sirtuin Gene Expression Profiles Differ between Normal Donors and Infertile Women. Int J Mol Sci 2019; 21:ijms21010295. [PMID: 31906251 PMCID: PMC6981982 DOI: 10.3390/ijms21010295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/27/2019] [Accepted: 12/29/2019] [Indexed: 01/06/2023] Open
Abstract
Sirtuins are a family of deacetylases that modify structural proteins, metabolic enzymes, and histones to change cellular protein localization and function. In mammals, there are seven sirtuins involved in processes like oxidative stress or metabolic homeostasis associated with aging, degeneration or cancer. We studied gene expression of sirtuins by qRT-PCR in human mural granulosa-lutein cells (hGL) from IVF patients in different infertility diagnostic groups and in oocyte donors (OD; control group). Study 1: sirtuins genes’ expression levels and correlations with age and IVF parameters in women with no ovarian factor. We found significantly higher expression levels of SIRT1, SIRT2 and SIRT5 in patients ≥40 years old than in OD and in women between 27 and 39 years old with tubal or male factor, and no ovarian factor (NOF). Only SIRT2, SIRT5 and SIRT7 expression correlated with age. Study 2: sirtuin genes’ expression in women poor responders (PR), endometriosis (EM) and polycystic ovarian syndrome. Compared to NOF controls, we found higher SIRT2 gene expression in all diagnostic groups while SIRT3, SIRT5, SIRT6 and SIRT7 expression were higher only in PR. Related to clinical parameters SIRT1, SIRT6 and SIRT7 correlate positively with FSH and LH doses administered in EM patients. The number of mature oocytes retrieved in PR is positively correlated with the expression levels of SIRT3, SIRT4 and SIRT5. These data suggest that cellular physiopathology in PR’s follicle may be associated with cumulative DNA damage, indicating that further studies are necessary.
Collapse
Affiliation(s)
- Rebeca González-Fernández
- Laboratorio de Biología del Desarrollo, UD de Bioquímica y Biología Molecular and Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, Av. Astrofísico Sánchez s/n, 38206 La Laguna, Tenerife, Spain; (R.G.-F.); (R.M.-R.); (D.R.); (P.M.-V.)
| | - Rita Martín-Ramírez
- Laboratorio de Biología del Desarrollo, UD de Bioquímica y Biología Molecular and Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, Av. Astrofísico Sánchez s/n, 38206 La Laguna, Tenerife, Spain; (R.G.-F.); (R.M.-R.); (D.R.); (P.M.-V.)
| | - Deborah Rotoli
- Laboratorio de Biología del Desarrollo, UD de Bioquímica y Biología Molecular and Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, Av. Astrofísico Sánchez s/n, 38206 La Laguna, Tenerife, Spain; (R.G.-F.); (R.M.-R.); (D.R.); (P.M.-V.)
- Institute of Endocrinology and Experimental Oncology (IEOS), CNR-National Research Council, 80131 Naples, Italy
| | - Jairo Hernández
- Centro de Asistencia a la Reproducción Humana de Canarias, 38202 La Laguna, Tenerife, Spain; (J.H.); (A.P.)
| | - Frederick Naftolin
- Department of Obstetrics and Gynecology, New York University, New York, NY 10016, USA;
| | - Pablo Martín-Vasallo
- Laboratorio de Biología del Desarrollo, UD de Bioquímica y Biología Molecular and Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, Av. Astrofísico Sánchez s/n, 38206 La Laguna, Tenerife, Spain; (R.G.-F.); (R.M.-R.); (D.R.); (P.M.-V.)
| | - Angela Palumbo
- Centro de Asistencia a la Reproducción Humana de Canarias, 38202 La Laguna, Tenerife, Spain; (J.H.); (A.P.)
- Department of Obstetrics and Gynecology, New York University, New York, NY 10016, USA;
| | - Julio Ávila
- Laboratorio de Biología del Desarrollo, UD de Bioquímica y Biología Molecular and Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, Av. Astrofísico Sánchez s/n, 38206 La Laguna, Tenerife, Spain; (R.G.-F.); (R.M.-R.); (D.R.); (P.M.-V.)
- Correspondence:
| |
Collapse
|
23
|
Abstract
Luteal estradiol pretreatment (LEP) to IVF protocols designed to improve follicle synchronization and retrieval of mature oocytes. We conducted a retrospective study including women undergoing IVF program who were given a course of 4 mg oral estradiol-17β daily from day 20 of the same cycle until day 1 of their next cycle before starting an antagonist protocol, forming LEP-group but control-group started on day 3 a stimulation without pretreatment. A total is divided into 2 groups (poor (group 1, n = 148) and normal responders (group 2, n = 244)). Our findings show for group 1 a significant decrease in cancelation rate (3% vs 14%) and a significant improvement in clinical outcomes (clinical pregnancy per transfer and live birth rate respectively: 47% and 44% vs 12% and 11%). For group 2, this pretreatment could increase significantly the maturation rate (77% vs 68%). The rate of frozen embryos was improved in both groups: (group 1: 11% vs 2% and group 2: 53% vs 41%). LEP increases the frozen embryos rate whatever the nature of the ovarian response, but especially for normal responders it coordinates follicular recruitment increasing the maturation rate. In the case of poor responders, it affects positively clinical outcomes decreasing the canceled cycles.
Collapse
Affiliation(s)
- Omar Sefrioui
- Anfa Fertility Center, Fertility clinic and cryopreservation, Casablanca, Morocco
| | - Aicha Madkour
- Biochemistry and Immunology Laboratory, Faculty of Sciences, Mohammed V University, Rabat, Morocco
| | - Ismail Kaarouch
- Anfa Fertility Center, Fertility clinic and cryopreservation, Casablanca, Morocco
- Biochemistry and Immunology Laboratory, Faculty of Sciences, Mohammed V University, Rabat, Morocco
- Human Reproduction Department, Labomac, Laboratory of Clinical Analysis, Casablanca, Morocco
| | - Noureddine Louanjli
- Anfa Fertility Center, Fertility clinic and cryopreservation, Casablanca, Morocco
- Human Reproduction Department, Labomac, Laboratory of Clinical Analysis, Casablanca, Morocco
| |
Collapse
|
24
|
Ezra O, Haas J, Nahum R, Maman E, Cohen Y, Segev-Zahav A, Orvieto R. Do poor-responder patients undergoing IVF benefit from splitting and increasing the daily gonadotropin dose? Gynecol Endocrinol 2019; 35:890-893. [PMID: 31032673 DOI: 10.1080/09513590.2019.1608520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
We aim to retrospectively evaluate the role of increasing the gonadotropin daily dose from 450 IU/day to 300 IU twice a day on IVF-ET outcome in poor responder patients. All consecutive women admitted to our IVF unit and underwent COH consisting of daily gonadotropin dose of 450 IU, followed by an IVF cycle using 300 IU twice a day, were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate was assessed. Twenty-three patients undergoing both cycles were evaluated. While there was no between-group difference in the duration of COH, number of 2PN embryos, fertilization rate and number of embryos transferred, patients receiving daily gonadotropin 300 IU twice a day achieved a significantly higher peak estradiol levels (3350.39 ± 2364.26 vs. 2223.74 ± 1299.91; p < .03, respectively), and yielded significantly higher number of follicles >15 mm in diameter on day of hCG administration (3.2 ± 2.4 vs 1.8 ± 1; p < .03, respectively) and higher number of oocytes retrieved (3.48 ± 2.54 vs 1.87 ± 1.1; p < .02, respectively) with an acceptable live birth rate (5%). To conclude, in poor responders undergoing COH a daily gonadotropin dose of 450 IU, increasing the dose to 300 IU twice daily may result in higher oocyte yield, with the possible improvement in IVF outcome.
Collapse
Affiliation(s)
- Osnat Ezra
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jigal Haas
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ravit Nahum
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ettie Maman
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoram Cohen
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aliza Segev-Zahav
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raoul Orvieto
- Infertility and IVF Unit Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
25
|
Cozzolino M, Vitagliano A, Cecchino GN, Ambrosini G, Garcia-Velasco JA. Corifollitropin alfa for ovarian stimulation in in vitro fertilization: a systematic review and meta-analysis of randomized controlled trials. Fertil Steril 2019; 111:722-733. [PMID: 30929731 DOI: 10.1016/j.fertnstert.2018.11.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of corifollitropin alfa in improving the success of IVF. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Infertile women undergoing conventional IVF or intracytoplasmic sperm injection (ICSI). INTERVENTION(S) Randomized controlled trials (RCTs) of infertile women undergoing a single IVF/ICSI cycle with either corifollitropin alfa or a conventional ovarian stimulation protocol based on daily injections. The review protocol was registered in PROSPERO before starting the data extraction (CRD42018088605). MAIN OUTCOME MEASURE(S) Primary outcomes were live birth rate and/or ongoing pregnancy rate. Clinical pregnancy rate, miscarriage rate, multiple pregnancies, number of oocytes and embryos obtained, cancellation rate, and rate of ovarian hyperstimulation syndrome and ectopic pregnancy were considered as secondary outcomes. RESULT(S) Eight randomized controlled trials were included; 2,345 women were assigned to the intervention group and 1,995 to the control group. The analysis of 4,340 IVF cycles did not reveal any difference in live birth rate and/or ongoing pregnancy rate between groups (risk ratio [RR], 0.92; 95% confidence interval [CI], 0.80-1.05). Similarly, no difference was found in clinical pregnancy rate (RR, 0.96; 95% CI, 0.88-1.05; I2 = 0%), miscarriage rate (RR, 0.94; 95% CI, 0.71-1.25; I2 = 0%), or multiple pregnancy rate (RR, 1.22; 95% CI, 0.99-1.50; I2 = 0%). Also, the rates of cycle cancellation, ovarian hyperstimulation syndrome, and ectopic pregnancy were similar in both groups. Sensitivity and subgroup analyses did not provide statistical changes to pooled results. CONCLUSION(S) Corifollitropin alfa seems to be an alternative for daily recombinant FSH injections in normal and poor responder patients undergoing ovarian stimulation in IVF/ICSI treatment cycles.
Collapse
Affiliation(s)
- Mauro Cozzolino
- IVIRMA Madrid, Madrid, Spain; Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain.
| | - Amerigo Vitagliano
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Gustavo Nardini Cecchino
- IVIRMA Madrid, Madrid, Spain; Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain; Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Guido Ambrosini
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Juan Antonio Garcia-Velasco
- IVIRMA Madrid, Madrid, Spain; Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain
| |
Collapse
|
26
|
Haas J, Zilberberg E, Nahum R, Mor Sason A, Hourvitz A, Gat I, Orvieto R. Does double trigger (GnRH-agonist + hCG) improve outcome in poor responders undergoing IVF-ET cycle? A pilot study. Gynecol Endocrinol 2019; 35:628-630. [PMID: 30810400 DOI: 10.1080/09513590.2019.1576621] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Many strategies are offered for the treatment of poor responders. However, no compelling advantage for one stimulation protocol over another has been hitherto established. In this study, we aimed to evaluate the role of different modes and timings of final follicular maturation trigger, on in vitro fertilization (IVF) cycle outcome of poor responder patients. In the present randomized controlled study, poor responder patients, according to the Bologna criteria, undergoing controlled ovarian hyperstimulation (COH) using the gonadotropin-releasing hormone (GnRH) antagonist protocol were randomly assigned to three different final follicular maturation trigger modes and timings: hCG 36 h before oocyte pick-up (OPU) (hCG trigger); GnRH agonist (GnRHag) 36 h before (OPU) and hCG on day of OPU (GnRHag trigger); and GnRHag and hCG, 40 and 34 h prior to OPU, respectively (double trigger). Pregnancy rate, number of oocytes, and top quality embryos (TQEs). Thirty-three poor responder patients were recruited and randomized to the different study groups. While there were no in-between groups' differences in patients' demographics and stimulation variables, patients in the double trigger group had a significantly higher number of TQE (1.1 ± 0.9 vs. 0.3 ± 0.8 and 0.5 + 0.7; p<.02) as compared to the hCG trigger and the GnRH-ag trigger groups, respectively, with an acceptable pregnancy rate. Double trigger offers an additional benefit to poor responder patients. Larger studies are required to support this new concept prior to its implementation to IVF practice.
Collapse
Affiliation(s)
- Jigal Haas
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Eran Zilberberg
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Ravit Nahum
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Aya Mor Sason
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Ariel Hourvitz
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Itai Gat
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Raoul Orvieto
- a Department of Obstetrics and Gynecology , Sheba Medical Center , Ramat-Gan , Israel
- b Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
- c The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine , Tel-Aviv University , Tel Aviv , Israel
| |
Collapse
|
27
|
Sfakianoudis K, Simopoulou M, Maziotis E, Giannelou P, Tsioulou P, Rapani A, Pantou A, Petroutsou K, Angeli I, Deligeoroglou E, Koutsilieris M, Pantos K. Evaluation of the Second Follicular Wave Phenomenon in Natural Cycle Assisted Reproduction: A Key Option for Poor Responders through Luteal Phase Oocyte Retrieval. ACTA ACUST UNITED AC 2019; 55:E68. [PMID: 30875815 DOI: 10.3390/medicina55030068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/08/2019] [Accepted: 03/06/2019] [Indexed: 12/24/2022]
Abstract
Background: Emergence of Luteal Phase Oocyte Retrieval (LuPOR) may revolutionize the practice regarding the time-sensitive nature of poor responders ascertaining a higher number of oocytes, in a shorter amount of time. This may be especially important in view of employing the approach of natural cycles for Poor Responders. We suggest the acronym LuPOR describing the clinical practice of luteal phase oocyte retrieval. The aim of the study is to offer insight regarding the identity of LuPOR, and highlight how this practice may improve management of the special subgroup of poor responders. Materials and Methods: The present retrospective observational clinical study includes the collection and statistical analysis of data from 136 poor responders who underwent follicular oocyte retrieval (FoPOR) and subsequent LuPOR in natural cycles, during their In Vitro Fertilization (IVF) treatment, from the time period of 2015 to 2018. All 136 participants were diagnosed with poor ovarian reserve (POR) according to Bologna criteria. The 272 cycles were categorized as follows: 136 natural cycles with only FoPORs (Control Group) and 136 natural cycles including both FoPORs and LuPORs. Results: Our primary results indicate no statistically significant differences with regards to the mean number of oocytes, the maturation status, and fertilization rate between FoPOR and LuPOR in natural cycles. Secondarily, we demonstrate a statistically significant higher yield of oocytes (2.50 ± 0.78 vs. 1.25 ± 0.53), better oocyte maturity status (1.93 ± 0.69 vs. 0.95 ± 0.59) and higher fertilization rate (1.31 ± 0.87 vs. 0.61 ± 0.60) in natural cycles including both FoPOR and LuPOR, when compared to cycles including only FoPOR. Conclusion: Our study may contribute towards the establishment of an efficient poor responders’ management through the natural cycle approach, paving a novel clinical practice and ascertaining the opportunity to employ oocytes and embryos originating from a luteal phase follicular wave.
Collapse
|
28
|
Datta AK, Campbell S, Felix N, Nargund G. Accumulation of embryos over 3 natural modified IVF (ICSI) cycles followed by transfer to improve the outcome of poor responders. Facts Views Vis Obgyn 2019; 11:77-84. [PMID: 31695860 PMCID: PMC6822952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Alternatives to improve treatment outcomes in poor responders are needed. For this we studied whether multiple (x3) Natural Modified (NM)-IVF(ICSI) cycles followed by an embryo transfer (ET) from the accumulated embryos can improve the treatment outcomes in poor responders. METHOD A retrospective analysis was applied to a pool of participants qualifying as poor responders according to the Bologna criteria. This was performed over a 2-year IVF center database with a Study Group including women with a minimum of 3 cycles of NM-IVF (ICSI) and subsequent vitrified-thawed ET. As a control, 1 NM-IVF (ICSI) cycle with fresh ET was used. The primary outcome accounted was the livebirth rate (LBRs) following one ET; the secondary outcome was clinical pregnancy rates (CPRs), miscarriage and cycle cancellation rates. Comparisons were held over mean numbers by t-test, over median by Mann-Whitney, and categorical data were treated by Chi-square. RESULTS The prognosis for livebirth in the study (n=125) and control (n=208) group was equally poor (mean age: 40.2 ± 3.0 vs 40.0 ± 3.3; median AMH: 2.1 vs 2.2 (pmol/L), AFC 4.0 vs 4.0). The LBR was significantly higher with the study protocol (30.6% vs 13.3%; p=0.002), particularly in women aged 35-39 years (31% vs 10.8%; p=0.05) and 40-44 years (26% vs 10.3%; p=0.02). Lower LBR in women aged ≥35 years in the control-group was mainly attributable to the higher miscarriage rate. With significantly more oocytes (mean: 6.5 ± 3.8 vs 2.0 ± 1.4; p <0.0001) and embryos available (mean: 3.6 ± 2.3 vs 0.9 ± 0.7; p<0.0001), only a minority ended up with no ET in the study-group (7.2% vs 35.6%; p<0.0001). None dropped-out while undergoing 3 cycles, whereas no patient opted for further attempts after one standalone cycle. CONCLUSION Accumulation of embryos through 3 NM-IVF cycles before transfer improves livebirth rates and reduces the risk of lacking an embryo for transfer in poor responders aged ≥35 years.
Collapse
Affiliation(s)
- AK Datta
- Create Fertility, 150, Cheapside, St Paul’s London EC2 V6ET, United Kingdom
| | - S Campbell
- Create Fertility, 150, Cheapside, St Paul’s London EC2 V6ET, United Kingdom
| | - N Felix
- Create Fertility, 150, Cheapside, St Paul’s London EC2 V6ET, United Kingdom
| | - G Nargund
- Create Fertility, 150, Cheapside, St Paul’s London EC2 V6ET, United Kingdom
| |
Collapse
|
29
|
Abstract
Circulating anti-müllerian hormone (AMH) and antral follicle count (AFC) are the best predictors of IVF outcomes. However, in extreme low AMH range especially for young patients, AMH prediction power loose its specificity to give real idea of pregnancy chance with IVF treatments and good prognosis of an extremely reduced ovarian reserve and expected poor response. Indeed, this retrospective study was conducted to evaluate IVF outcomes in patients following IVF-ICSI program with extremely low AMH levels (≤0.4 ng/ml; n = 390) compared to those presenting normal AMH range (1.3-2.6 ng/ml; n = 352) considered as control group. As expected, number of oocytes retrieved per patient, and embryological outcomes were significantly lower in the extremely low AMH levels group compared to control. Moreover, it was same trend concerning clinical outcomes but we have to note that even in extreme low AMH, patients could reach ineligible satisfying clinical pregnancy rate compared to control (17% vs 41%). For patients younger than 35 years, clinical pregnancy rate improved to 27%. Women with extreme low AMH values and especially younger ones, still have reasonable chances of achieving pregnancy, highlighting the default view of this category generally excluded from IVF program.
Collapse
Affiliation(s)
- Omar Sefrioui
- a Anfa Fertility Center, Fertility clinic and cryopreservation , Casablanca , Morocco
| | - Aicha Madkour
- b Biochemistry and Immunology Laboratory , Mohammed V University, Faculty of Sciences , Avenue Ibn Batouta Agdal , Rabat , BP 1014 , Morocco
| | - Smahane Aboulmaouahib
- a Anfa Fertility Center, Fertility clinic and cryopreservation , Casablanca , Morocco
- c Labomac, Laboratory of clinical analysis , Casablanca , Morocco
| | - Ismail Kaarouch
- a Anfa Fertility Center, Fertility clinic and cryopreservation , Casablanca , Morocco
- b Biochemistry and Immunology Laboratory , Mohammed V University, Faculty of Sciences , Avenue Ibn Batouta Agdal , Rabat , BP 1014 , Morocco
- c Labomac, Laboratory of clinical analysis , Casablanca , Morocco
| | - Noureddine Louanjli
- a Anfa Fertility Center, Fertility clinic and cryopreservation , Casablanca , Morocco
- c Labomac, Laboratory of clinical analysis , Casablanca , Morocco
| |
Collapse
|
30
|
Errázuriz J, Romito A, Drakopoulos P, Frederix B, Racca A, De Munck N, Tournaye H, De Vos M, Blockeel C. Cumulative Live Birth Rates Following Stimulation With Corifollitropin Alfa Compared With hp-hMG in a GnRH Antagonist Protocol in Poor Ovarian Responders. Front Endocrinol (Lausanne) 2019; 10:175. [PMID: 30967840 PMCID: PMC6439614 DOI: 10.3389/fendo.2019.00175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/01/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Bologna criteria poor ovarian responders have a very low prognosis. Although, it has been proposed that LH supplementation could be beneficial in women with previous hypo-response to FSH. There are no studies comparing the cumulative live birth rates (LBRs) between corifollitropin alfa (CFA) and highly purified human menopausal gonadotrophin (hp-hMG). Objective: To compare cumulative LBRs in Bologna poor ovarian responders undergoing ovarian stimulation with CFA followed by hp-hMG vs. hp-hMG alone in a GnRH antagonist protocol. Design: This is a retrospective cohort study. We included in total 917 poor responders fulfilling the Bologna criteria for poor ovarian response (POR) at a university-affiliated tertiary center from January 2011 until March 2017. Patients were administered either fixed daily doses of 300-450 IU of hp-hMG (group A) or a single dose of 150 μg of CFA followed by daily injections of ≥300 IU of hp-hMG from Day 8 of stimulation until the day of ovulation trigger (group B), in a fixed GnRH antagonist protocol. Results: LBRs after fresh embryo transfer (ET) were similar in group A 71/510 (14%) and B 42/407 (10%). Cumulative LBR per cycle was significantly higher in group A (16.9%) compared to group B (11.8%); (P = 0.03). However, logistic regression analysis showed no association between the type of gonadotropin administered and cumulative LBR. Only age was significantly associated with cumulative LBR (OR = 0.93, P = 0.007). Conclusion: Cumulative LBRs are similar in Bologna poor responders stimulated with CFA followed by hp-hMG compared to hp-hMG monotreatment in an antagonist protocol.
Collapse
Affiliation(s)
- Joaquín Errázuriz
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Departamento de Ginecología y Obstetricia, Clínica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
- *Correspondence: Joaquín Errázuriz
| | - Alessia Romito
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Ginecological-Obstetrical and Urological Sciences, Sapienza University, Rome, Italy
| | - Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Billie Frederix
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Analissa Racca
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Academic Unit of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria San Martino (IRCCS), University of Genoa, Genova, Italy
| | - Neelke De Munck
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Obstetrics and Gynecology, University of Zagreb-School of Medicine, Zagreb, Croatia
| | - Herman Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel De Vos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Obstetrics and Gynecology, University of Zagreb-School of Medicine, Zagreb, Croatia
| |
Collapse
|
31
|
Chen Q, Chai W, Wang Y, Cai R, Zhang S, Lu X, Zeng X, Sun L, Kuang Y. Progestin vs. Gonadotropin-Releasing Hormone Antagonist for the Prevention of Premature Luteinizing Hormone Surges in Poor Responders Undergoing in vitro Fertilization Treatment: A Randomized Controlled Trial. Front Endocrinol (Lausanne) 2019; 10:796. [PMID: 31824419 PMCID: PMC6882854 DOI: 10.3389/fendo.2019.00796] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/31/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: Progestin was recently used as an alternative of gonadotropin-releasing hormone (GnRH) analog for preventing premature luteinizing hormone (LH) surge with the aid of vitrification techniques, however, limited data were available about the potential of progestin in poor responders undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment. We performed a randomized parallel controlled trial to investigate the difference of progestin and GnRH antagonist in poor responders. Methods: A total of 340 poor responders who met with Bologna criteria were randomly allocated into the progestin-primed ovarian stimulation (PPOS) group and GnRH antagonist group. Fresh embryo transfer was preferred in the GnRH antagonist group and freeze-all was performed in the PPOS group. The primary outcome was the incidence of premature LH surge, secondary outcomes were the number of retrieved oocytes, the number of viable embryos and the pregnancy outcomes. Results: The results showed that the incidence of premature LH surge in PPOS group was lower than that in antagonist group (0 vs. 5.88%, P < 0.05). In PPOS group, the average numbers of oocytes and viable embryos were comparable to those in GnRH antagonist group (3.7 ± 2.6 vs. 3.4 ± 2.4; 1.6 ± 1.7 vs. 1.4 ± 1.3, P > 0.05), the live birth rate was similar between the two groups (21.8 vs. 18.2%, RR 1.25 (95% confidence interval 0.73, 2.13), P > 0.05). Conclusions: The study demonstrated that PPOS had a more robust control for preventing premature LH rise than GnRH antagonist in poor responders, but PPOS in combination with freeze-all did not significantly increase the probability of pregnancy than GnRH antagonist protocol for poor responders.
Collapse
Affiliation(s)
- Qiuju Chen
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- *Correspondence: Qiuju Chen
| | - Weiran Chai
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yun Wang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Renfei Cai
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shaozhen Zhang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuefeng Lu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaojing Zeng
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lihua Sun
- Centre of Assisted Reproduction, Shanghai East Hospital, Tongji University, Shanghai, China
- Lihua Sun
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Yanping Kuang
| |
Collapse
|
32
|
Affiliation(s)
- Nikolaos P. Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- *Correspondence: Nikolaos P. Polyzos ;
| | - Panagiotis Drakopoulos
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
33
|
Kaviani M, Ghaderian SMH, Arefi S, Hashemi M, Afjeh SSA. Role of FSHR rs6165 and ESR2 rs4986938 polymorphisms in ovarian stimulation of Iranian women who underwent assisted reproduction treatment. Hum Antibodies 2018; 26:121-126. [PMID: 29036809 DOI: 10.3233/hab-170329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gonadotropin therapy was used to stimulate the ovary in infertile women who underwent assisted reproduction treatment (ART). Numerous studies indicated that infertile women showed different responses to gonadotropin therapy. Follicle stimulating hormone receptor (FSHR) and Oestrogen receptor (ER) polymorphisms have been reported to involve induction of folliculogenesis and ovarian response to treatment. METHODS In the present study, two polymorphisms, namely FSHR rs6165 and ESR2 rs4986938, were investigated in 198 Iranian infertile women aged less than 39 years who underwent ART. After DNA extraction, these polymorphisms were genotyped by TaqMan genotyping assay. According to the number of eggs released during ovulation, the patients were categorized into poor responders (PR) and good responders (GR). The results indicated that the good responders showed lower levels of FSH and LH than poor responders. RESULTS No association was observed between ESR2 rs4986938 and poor response in Iranian women patients. Instead, FSHR rs6165 showed a strong association with ovarian response to ART (p< 0.05). CONCLUSION The obtained results indicated that FSHR rs6165, not ESR2 rs4986938, could be suggested as a candidate marker to predict poor ovarian response.
Collapse
Affiliation(s)
- Maryam Kaviani
- Department of Genetics, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | | | | | - Mehrdad Hashemi
- Department of Genetics, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | | |
Collapse
|
34
|
Drakopoulos P, Vuong TNL, Ho NAV, Vaiarelli A, Ho MT, Blockeel C, Camus M, Lam AT, van de Vijver A, Humaidan P, Tournaye H, Polyzos NP. Corifollitropin alfa followed by highly purified HMG versus recombinant FSH in young poor ovarian responders: a multicentre randomized controlled clinical trial. Hum Reprod 2018; 32:2225-2233. [PMID: 29040589 DOI: 10.1093/humrep/dex296] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/31/2017] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Does administration of corifollitropin alfa followed by highly purified (hp) HMG result in higher ongoing pregnancy rates compared with daily recombinant FSH (rFSH) in young poor responders? SUMMARY ANSWER Corifollitropin alfa followed by hp-HMG does not increase ongoing pregnancy rates compared with rFSH in young poor responders, although more supernumerary cryopreserved embryos were obtained with corifollitropin alfa and hp-HMG. WHAT IS KNOWN ALREADY Poor ovarian response remains one of the main therapeutic challenges in women undergoing ovarian stimulation, given that very low live birth rates of 6% have been reported in this particular group of infertile patients. Nevertheless, concerns have been raised that a degree of heterogeneity remains, as the prognostic effect of individual factors is still unclear, particularly for the young poor responder group. The rationale for conducting the current randomized trial was based on the results of a previous pilot study demonstrating promising results with the administration of hp-HMG following corifollitropin alpha in women younger than 40 years of age, fulfilling the 'Bologna' criteria. STUDY DESIGN, SIZE, DURATION A multicenter, phase III, superiority, randomized trial was conducted using a parallel two-arm design. The study included 152 patients younger than 40 years old and fulfilling the 'Bologna' criteria for poor ovarian response, from one tertiary referral centre in Europe and one tertiary referral centre in Asia. Enrolment was performed from March 2013 to May 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS Eligible patients were randomized to either administration of 150 μg corifollitropin alfa followed by 300 IU hp-HMG (Group A) or to 300 IU of daily recombinant FSH (Group B) in a fixed GnRH antagonist protocol. The randomization sequence was created using a computer generated randomization list stratified by centre, using 1:1 allocation. The primary outcome was ongoing pregnancy rate (defined as the presence of an intrauterine gestational sac with an embryonic pole demonstrating cardiac activity at 9-10 weeks of gestation). Secondary outcomes included embryo cryopreservation rates, clinical and biochemical pregnancy rates and number of oocytes retrieved. MAIN RESULTS AND THE ROLE OF CHANCE Overall, 152 poor ovarian responders defined by the 'Bologna' criteria were included in the study. Using an intention-to treat analysis, the ongoing pregnancy rates did not differ significantly between Group A 11/77 (14.3%) and Group B 11/70 (15.7%), absolute difference: -0.4 (-11.5 to 10.8), OR = 0.9 (0.4-2.4). Biochemical and clinical pregnancy rates, live birth rates and the number of oocytes retrieved were also comparable between the two groups. Nevertheless, more patients in the corifollitropin alfa group had cryopreserved embryos compared to the rFSH group [22 (28.6%) versus 10 (14.3%), OR = 2.4 (1.01-5.5)]. Incidentally, Asian patients had significantly lower cancellation rates compared to European poor responders [2/64 (3.1%) versus 17/83 (20.4%), OR = 0.12 (0.03-0.5)]. This discrepancy could be explained by the fact that Asian women were better prognosis patients than European patients, with significantly lower FSH [9.8 (5.3) versus 11.5 (5.4), P = 0.017] and significantly higher AMH [1.1 (0.9) versus 0.4 (0.3), P-value <0.001] levels. LIMITATIONS, REASONS FOR CAUTION Ongoing pregnancy rates close to 14% for both treatment groups differ significantly from the hypothesized primary outcome rates used in the power calculation. Therefore, our randomized trial might have been underpowered to detect smaller differences. The use of multiple secondary outcomes and multiple comparisons could have increased a Type 1 error. Finally, although the chance of selection biases remains low given the nature of the infertile population, the open-label design could have been a limitation. WIDER IMPLICATIONS OF THE FINDINGS Poor ovarian response represents a challenge and although a specific protocol may have increased the number of cryopreserved embryos, no difference was observed in ongoing pregnancy rates. Our study, being one of the largest RCTs in 'Bologna' criteria poor responders, highlights that baseline characteristics may play a crucial role in clinical prognosis of this population. Given that ovarian stimulation using novel protocols does not seem to significantly increase pregnancy rates even in young women, we suggest that future clinical research should focus on increasing the number of recruitable follicles and on oocyte quality rather than evaluating different stimulation protocols. STUDY FUNDING/COMPETING INTERESTS No external funding was used for this study. P.D., N.L.V., N.A.V.H., A.V., M.T.H., M.C., A.T.L. and A.V.V. have no conflict of interest to report. C.B. has received unrestricted research grants from MSD and Ferring as well as honoraria for lectures from Abbott, MSD, Merck and Ferring. P.H has received unrestricted research grants from MSD, Merck and Ferring as well as honoraria for lectures from Merck, MSD and IBSA. H.T. has received unrestricted research grants from MSD, Merck, Ferring, Cook, Roche Diagnostics, Besins International and Goodlife as well as consultation fees for research project in female infertility from Merck Finox, Abbott and ObsEva. N.P.P. has received unrestricted research grants from MSD, Ferring, Roche Diagnostics and Besins International as well as honoraria for lectures from MSD, Merck and Ferring. TRIAL REGISTRATION NUMBER The EUDRACT number of the trial was 2013-000583-29 and the study was registered at clinicaltrials.gov (NCT01816321). TRIAL REGISTRATION DATE 19 February 2013. DATE OF FIRST PATIENT ENROLMENT 28 February 2013.
Collapse
Affiliation(s)
- Panagiotis Drakopoulos
- Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, Avenue du Laerbeek 103, 1090 Jette, Belgium.,Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium
| | - Thi Ngoc Lan Vuong
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy at HCMC, 217 Hồng Bàng, 11th Ward, Quận 5, Hồ Chí Minh, Vietnam.,IVFMD, My Duc Hospital, 4 Núi Thành, 13, Tân Bình, Hồ Chí Minh, Vietnam
| | - Ngoc Anh Vu Ho
- IVFMD, My Duc Hospital, 4 Núi Thành, 13, Tân Bình, H? Chí Minh, Vietnam
| | - Alberto Vaiarelli
- Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, Avenue du Laerbeek 103, 1090 Jette, Belgium
| | - Manh Tuong Ho
- IVFMD, My Duc Hospital, 4 Núi Thành, 13, Tân Bình, Hồ Chí Minh, Vietnam.,Research Center for Genetics and Reproductive Health (CGRH), School of MedicineVietnam National University HCMC, Linh Trung, Thủ Ðức, Ho Chi Minh, Vietnam
| | - Christophe Blockeel
- Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, Avenue du Laerbeek 103, 1090 Jette, Belgium.,Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium.,Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Šalata ul. 2, 10000 Zagreb, Croatia
| | - Michel Camus
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium
| | - Anh Tuan Lam
- IVFMD, My Duc Hospital, 4 Núi Thành, 13, Tân Bình, H? Chí Minh, Vietnam
| | - Arne van de Vijver
- Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, Avenue du Laerbeek 103, 1090 Jette, Belgium.,Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium
| | - Peter Humaidan
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Nordre Ringgade 1, 8000 Aarhus C, Denmark
| | - Herman Tournaye
- Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, Avenue du Laerbeek 103, 1090 Jette, Belgium.,Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium
| | - Nikolaos P Polyzos
- Faculty of Medicine and Pharmacy, Department of Surgical and Clinical Science, Vrije Universiteit Brussel, Avenue du Laerbeek 103, 1090 Jette, Belgium.,Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium.,Department of Reproductive Medicine, Dexeus University Hospital, Gran Via Carles III, 71-75 - 08028 Barcelona, Spain.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Nordre Ringgade 1, 8000 Aarhus C, Denmark
| |
Collapse
|
35
|
Eser A, Devranoğlu B, Bostancı Ergen E, Yayla Abide Ç. Dual trigger with gonadotropin-releasing hormone and human chorionic gonadotropin for poor responders. J Turk Ger Gynecol Assoc 2018. [PMID: 29516855 PMCID: PMC5994809 DOI: 10.4274/jtgga.2017.0045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective: To compare metaphase II (MII) rate, fertilization rate, and embryo quality with dual trigger gonadotropin-releasing hormone agonist (GnRH) and normal dose human chorionic gonadotropin (hCG) versus a normal dose hCG trigger in antagonist intracytoplasmic sperm injection (ICSI) cycles of poor ovarian responders. Material and Methods: Patients defined as poor ovarian responders according to the Bologna criteria who underwent ICSI with GnRH antagonist protocol and triggered with dual trigger or hCG alone for oocyte maturation. Main outcome measures were MII rate, fertilization rate, and embryo quality. Results: Total gonadotropin doses and E2 levels on trigger day were higher in the hCG trigger group. There were no significant differences with regard to implantation rate (p=0.304), biochemical pregnancy rate (p=0.815), clinical pregnancy rate (p=0.378), and ongoing pregnancy rate (p=0.635) between the groups. Conclusion: Dual trigger of oocyte maturation with GnRH agonist and normal dose hCG in poor responders does not demonstrate improved oocyte maturation, clinical pregnancy, and ongoing pregnancy rates.
Collapse
Affiliation(s)
- Ahmet Eser
- Department of Gynecology Obstetrics and Reproductive Medicine, İstanbul Zeynep Kamil Woman and Child Diseases Training and Research Hospital, İstanbul, Turkey
| | - Belgin Devranoğlu
- Department of Gynecology Obstetrics and Reproductive Medicine, İstanbul Zeynep Kamil Woman and Child Diseases Training and Research Hospital, İstanbul, Turkey
| | - Evrim Bostancı Ergen
- Department of Gynecology Obstetrics and Reproductive Medicine, İstanbul Zeynep Kamil Woman and Child Diseases Training and Research Hospital, İstanbul, Turkey
| | - Çiğdem Yayla Abide
- Department of Gynecology Obstetrics and Reproductive Medicine, İstanbul Zeynep Kamil Woman and Child Diseases Training and Research Hospital, İstanbul, Turkey
| |
Collapse
|
36
|
Gonda KJ, Domar AD, Gleicher N, Marrs RP. Insights from clinical experience in treating IVF poor responders. Reprod Biomed Online 2017; 36:12-19. [PMID: 29223475 DOI: 10.1016/j.rbmo.2017.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/27/2017] [Accepted: 09/19/2017] [Indexed: 12/18/2022]
Abstract
'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.
Collapse
Affiliation(s)
| | - Alice D Domar
- Domar Center for Mind/Body Health, Waltham, MA, USA; Boston IVF, Waltham, MA, USA; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Norbert Gleicher
- Center for Human Reproduction, New York, NY, USA; Foundation for Reproductive Medicine, New York, NY, USA; Rockefeller University, New York, NY, USA; Medical University of Vienna, Vienna, Austria
| | | |
Collapse
|
37
|
Massin N. New stimulation regimens: endogenous and exogenous progesterone use to block the LH surge during ovarian stimulation for IVF. Hum Reprod Update 2017; 23:211-220. [PMID: 28062551 DOI: 10.1093/humupd/dmw047] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 12/11/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The advent of embryo and oocyte vitrification today gives reproductive specialists an opportunity to consider new strategies for improving the practice and results of IVF attempts. As the freezing of entire cohorts does not compromise, and may even improve, the results of IVF attempts, it is possible to break away from the standard sequence of stimulation-retrieval-transfer. The constraints associated with ovarian stimulation in relation to the potential harmful effects of the hormonal environment on endometrial receptivity can be avoided. OBJECTIVE AND RATIONALE This review will look at the new stimulation protocols where progesterone is used to block the LH surge. Thanks to 'freeze all' strategies, the increase in progesterone could actually be no longer a cause for concern. There are two ways of using progesterone, whether it be endogenous, as in luteal phase stimulation, or exogenous, as in the use of progesterone in the follicular phase i.e. progestin primed ovarian stimulation. SEARCH METHODS A literature search was carried out (until September 2016) on MEDLINE. The following text words were utilized to generate the list of citations: progestin primed ovarian stimulation, luteal phase stimulation, luteal stimulation, duostim, double stimulation, random start. Articles and their references were then examined in order to identify other potential studies. All of the articles are reported in this review. OUTCOMES The use of progesterone during ovarian stimulation is effective in blocking the LH surge, whether endogenous or exogenous, and it does not affect the number of oocytes collected or the quality of the embryos obtained. Its main constraint is that it requires total freezing and delayed transfer. A variety of stimulation protocols can be derived from these two methods, and their implications are discussed, from fertility preservation to ovarian response profiles to organization for the patients and clincs. These new regimens enable more flexibility and are of emerging interest in daily practice. However, their medical and economic significance remains to be demonstrated. WIDER IMPLICATIONS The use of luteal phase or follicular phase protocols with progestins could rapidly develop in the context of oocyte donation and fertility preservation not related to oncology. Their place could develop even more in the general population of patients in IVF programs. The strategy of total freezing continues to develop, thanks to technical improvements, in particular vitrification and PGS on blastocysts, and thanks to studies showing improvements in embryo implantation when the transfer take place far removed from the hormonal changes caused by ovarian stimulation.
Collapse
Affiliation(s)
- Nathalie Massin
- Centre d'Assistance Médicale à la Procréation, Centre Hospitalier Intercommual, Université Paris 12, 40 Avenue de Verdun, 94000Créteil, France
| |
Collapse
|
38
|
Siristatidis C, Salamalekis G, Dafopoulos K, Basios G, Vogiatzi P, Papantoniou N. Mild Versus Conventional Ovarian Stimulation for Poor Responders Undergoing IVF/ICSI. ACTA ACUST UNITED AC 2017; 31:231-237. [PMID: 28358705 DOI: 10.21873/invivo.11050] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/21/2017] [Accepted: 01/24/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND/AIM Mild stimulation protocols have been implemented to be offered to subfertile patients who respond poorly to ovarian stimulation. We aimed to compare the efficacy of mild versus conventional gonadotropin-releasing hormone (GnRH)-agonist and antagonist protocols in poor responders undergoing in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) cycles. PATIENTS AND METHODS A total of 58 poorly-responding patients were divided into two groups: mild group (n=33), receiving clomiphene citrate 100 mg and 0.25 mg of cetrorelix with 150 IU of gonadotrophins daily; conventional group (n=25), undergoing the long GnRH-agonist or -antagonist protocols. The primary outcome was the number of cumulus oocyte complexes (COCs) retrieved. RESULTS A lower number of COCs [median (range)=1 (0-4) vs. 3 (0-8.4), p<0.001] was retrieved in the mild stimulation compared to the conventional group. Secondary outcomes favored the conventional group, whereas live birth (9.1% vs. 12%), clinical pregnancy (12.1% vs. 20%) and miscarriage rate (40% vs. 40%) were similar in the two groups. CONCLUSION Mild ovarian stimulation is inferior to conventional regimes when applied to poor responders undergoing IVF/ICSI, in terms of the numbers of retrieved COCs.
Collapse
Affiliation(s)
- Charalampos Siristatidis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Salamalekis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Dafopoulos
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece
| | - George Basios
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Vogiatzi
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Papantoniou
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
39
|
Haydardedeoglu B, Gjemalaj F, Aytac PC, Kilicdag EB. Direct aspiration versus follicular flushing in poor responders undergoing intracytoplasmic sperm injection: a randomised controlled trial. BJOG 2017; 124:1190-1196. [PMID: 28276148 DOI: 10.1111/1471-0528.14629] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare follicle flushing three times with direct follicular aspiration in poor responders. Our hypothesis was that follicle flushing three times in poor responders would result in similar oocyte yield compared with direct aspiration in poor responders. DESIGN A randomised controlled trial performed between January 2015 and June 2015. SETTING University hospital. POPULATION OR SAMPLE Eighty eligible poor responders, who were defined as having five or fewer follicles ≥13 mm in average diameter with at least two follicles having maximum diameters >17 mm on the day of human chorionic gonadotrophin administration. Monofollicular cycles, including natural cycles, were excluded from the current trial. METHODS In the double-lumen needle group, oocyte retrieval was performed by flushing three times with 2 ml in each follicle and in the single-lumen group direct follicle aspiration was performed. MAIN OUTCOME MEASURE Number of metaphase II oocytes retrieved. RESULTS The mean number of metaphase II oocytes was similar in both groups (1.9 ± 0.1 versus 2.1 ± 0.1, respectively). The clinical pregnancy and live birth rates were similar in both groups (32.5% versus 25% and 25% versus 22.5%, respectively). The only significant difference between the two groups was the duration of oocyte retrieval (178.4 ± 13.4 versus 236.3 ± 24.1 seconds, respectively, P = 0.01). CONCLUSION Follicular flushing is time consuming and has similar results compared with direct follicle aspiration in poor responders. TWEETABLE ABSTRACT Direct follicle aspiration versus flushing in poor responders yields similar metaphase II oocytes.
Collapse
Affiliation(s)
- B Haydardedeoglu
- Division of Reproductive Endocrinology and IVF Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - F Gjemalaj
- Division of Reproductive Endocrinology and IVF Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - P C Aytac
- Division of Reproductive Endocrinology and IVF Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - E B Kilicdag
- Division of Reproductive Endocrinology and IVF Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, Baskent University, Adana, Turkey
| |
Collapse
|
40
|
Zebitay AG, Cetin O, Verit FF, Keskin S, Sakar MN, Karahuseyinoglu S, Ilhan G, Sahmay S. The role of ovarian reserve markers in prediction of clinical pregnancy. J OBSTET GYNAECOL 2017; 37:492-497. [PMID: 28421902 DOI: 10.1080/01443615.2016.1269730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To evaluate the role of ovarian reserve markers in the prediction of clinical pregnancy and embryo transfer accomplishment among poor responder IVF applicants. 304 female poor responder IVF applicants were included in this prospective cohort study conducted at the IVF-unit. Antral follicle count, FSH, LH, E2, AMH and IVF outcomes were compared in pregnant and non-pregnant groups as well as in ET vs. non-ET groups. The number of retrieved oocytes was significantly correlated positively with AMH and AFC, and negatively with FSH and age. Quartiles of FSH and AFC were similar to the rate of pregnancy. Quartiles of AMH (<25%/25-75% and <25%/>75%) were statistically significant. Mean serum levels for AMH were significantly lower in the non-ET group. Our findings seem to indicate that day 3 AMH values can predict ET accomplishment with a sensitivity of 96% and a specificity of 35%. Quartiles of AMH <25% (< 0.21 ng/mL) can predict the IVF results among poor responder IVF applicants. Impact statement Various cut-off values have been determined for day 3 serum AMH values. These values help to determine the groups that are expected to give normal, high or low response to stimulation and decide the treatment options. In contrast to other groups of patients, poor responders cannot reach the embryo transfer stage for several reasons. These are; absence of a mature oocyte after oocyte pick-up, fertilisation failure without male factor or poor embryo quality. In the present study; a cut-off value of 0.33 ng/mL for the prediction of ET accomplishment in poor responder patients was determined with a sensitivity of 96%. Additionally, clinical pregnancy could not be achieved under the value of 0.21 ng/mL day 3 AMH values. It is important to clarify the embryo transfer success of poor responder patients prior to expected treatment success. Pre-treatment counselling for these patients would lessen the disappointment that may develop after treatment. The cost-effectiveness of treatments below these AMH values can be determined by further studies.
Collapse
Affiliation(s)
- Ali G Zebitay
- a In vitro Fertilization Unit , Suleymaniye Maternity and Women's Disease Education and Research Hospital , Istanbul, Turkey
| | - Orkun Cetin
- a In vitro Fertilization Unit , Suleymaniye Maternity and Women's Disease Education and Research Hospital , Istanbul, Turkey
| | - Fatma F Verit
- a In vitro Fertilization Unit , Suleymaniye Maternity and Women's Disease Education and Research Hospital , Istanbul, Turkey
| | - Seda Keskin
- a In vitro Fertilization Unit , Suleymaniye Maternity and Women's Disease Education and Research Hospital , Istanbul, Turkey
| | - M Nafi Sakar
- a In vitro Fertilization Unit , Suleymaniye Maternity and Women's Disease Education and Research Hospital , Istanbul, Turkey
| | - Sercin Karahuseyinoglu
- b Department of Histology and Embryology , Koc University School of Medicine , Sariyer Istanbul , Turkey
| | - Gulsah Ilhan
- a In vitro Fertilization Unit , Suleymaniye Maternity and Women's Disease Education and Research Hospital , Istanbul, Turkey
| | - Sezai Sahmay
- c Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology , Istanbul University, Cerrahpasa School of Medicine , Istanbul , Turkey
| |
Collapse
|
41
|
Abstract
Ovarian stimulation of poor ovarian responders still remains a challenging issue. The incidence of poor responders among infertile women is reported in 9-24% IVF cycles and is associated with very low clinical pregnancy rates. Different treatments have been reported in the literature in an attempt to identify the best stimulation protocol for those patients. Administration of dehydroepiandrosterone acetate (DHEA) was suggested as a promising treatment. It is well known that androgens can influence ovarian follicular growth, augment steroidogenesis, promote follicular recruitment and increase the number of primary and pre-antral follicles. The purpose of this review is to evaluate the effect of DHEA supplementation on women with diminished ovarian reserve. Because of the uncertainty of published data, we suggest that well-designed multicentre RCTs are required to provide more insight on the effectiveness of DHEA. The absence of significant side effects should not be considered as an argument to support DHEA treatment.
Collapse
Affiliation(s)
| | - George Sigalos
- a 'Lito' Maternity Hospital , Reproductive Medicine Unit , Athens , Greece
| | - Nikos Vlahos
- b 2nd Department of Obstetrics and Gynecology , ' Aretaieion' Hospital, University of Athens , Athens , Greece.,c Research Network for the evaluation of DHEA administration in poor responders, University of Athens, Aristoteleion University of Thessaloniki, University of Ioannina , Greece.,d Department of Obstetrics and Gynecology , University of Ioannina , Greece
| |
Collapse
|
42
|
Polyzos NP, Davis SR, Drakopoulos P, Humaidan P, De Geyter C, Vega AG, Martinez F, Evangelou E, van de Vijver A, Smitz J, Tournaye H, Barri P. Testosterone for Poor Ovarian Responders: Lessons From Ovarian Physiology. Reprod Sci 2016; 25:980-982. [PMID: 27489169 DOI: 10.1177/1933719116660849] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Testosterone, an androgen that directly binds to the androgen receptor, has been shown in previous small randomized controlled trials to increase the reproductive outcomes of poor ovarian responders. In most of these studies, transdermal testosterone in relatively high doses was administered before ovarian stimulation with a duration varying from 5 to 21 days. Nevertheless, the key question to be asked is whether, based on ovarian physiology and testosterone pharmacokinetics, a short course of testosterone administration of more than 10 mg could be expected to have any beneficial effect on reproductive outcome. The rationale for asking this question lies in the existing scientific evidence derived from basic research and animal studies regarding the action of androgens during folliculogenesis, showing that their main effect in follicular development is defined during the earlier developmental stages. In addition, extreme testosterone excess is not only likely to induce adverse events but has also the potential to be ineffective and even detrimental. Thus, evidence from clinical studies is not enough to either "reopen" or "close" the "androgen chapter" in poor responders, mainly because the short administration and the high dose of testosterone is not in line with the ovarian actions of androgens and the presence of androgen receptors during follicular development.
Collapse
Affiliation(s)
- Nikolaos P Polyzos
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,2 Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Susan R Davis
- 3 Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Panagiotis Drakopoulos
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Peter Humaidan
- 2 Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Christian De Geyter
- 4 Clinic of Gynaecological Endocrinology and Reproductive Medicine, University Hospital, University of Basel, Basel, Switzerland
| | | | - Francisca Martinez
- 6 Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Evangelos Evangelou
- 7 Imperial College London, London, United Kingdom.,8 Department of Hygiene and Epidemeology, University of Ioannina Medical School, Ioannina, Greece
| | - Arne van de Vijver
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan Smitz
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herman Tournaye
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pedro Barri
- 6 Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | | |
Collapse
|
43
|
Vega MG, Gleicher N, Darmon SK, Weghofer A, Wu YG, Wang Q, Zhang L, Albertini DF, Barad DH, Kushnir VA. IVF outcomes in average- and poor-prognosis infertile women according to the number of embryos transferred. Reprod Biomed Online 2016; 33:370-5. [PMID: 27390063 DOI: 10.1016/j.rbmo.2016.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 11/19/2022]
Abstract
Outcome measures of IVF success, which account for effectiveness of IVF and perinatal outcome risks, have recently been described. The association between number of embryos transferred in average and poor-prognosis IVF patients, and the chances of having good or poor IVF and perinatal outcomes, was investigated. Good IVF and perinatal outcome was defined as the birth of a live, term, normal-weight infant (≥2500 g). Poor IVF and perinatal outcome was defined as no live birth or birth of a very low weight neonate (<1500 g) or severe prematurity (birth at <32 weeks gestation). Each neonate was analysed as a separate outcome. A total of 713 IVF cycles in 504 average and poor-prognosis patients from January 2010 to December 2013 were identified. The odds of having good IVF and perinatal outcomes increased by 28% for each additional embryo transferred. The odds of poor IVF and perinatal outcome decreased by 32% with an additional embryo transferred. The likelihood of live birth with good perinatal outcome in average- and poor-prognosis patients after IVF increases with additional embryos being transferred. These data add to recently reported evidence in favour of multiple embryo transfer in older women and those with average or poor IVF prognosis.
Collapse
Affiliation(s)
- Mario G Vega
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Norbert Gleicher
- The Center for Human Reproduction, New York, NY 10021, USA; The Foundation for Reproductive Medicine, New York, NY 10021, USA; Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY 10065-6399, USA
| | - Sarah K Darmon
- The Center for Human Reproduction, New York, NY 10021, USA
| | - Andrea Weghofer
- The Center for Human Reproduction, New York, NY 10021, USA; Vienna University School of Medicine, Vienna 1090, Austria
| | - Yan-Guang Wu
- The Center for Human Reproduction, New York, NY 10021, USA
| | - Qi Wang
- The Center for Human Reproduction, New York, NY 10021, USA
| | - Lin Zhang
- The Center for Human Reproduction, New York, NY 10021, USA
| | - David F Albertini
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Molecular and Integrative Physiology, The University of Kansas School of Medicine, Kansas City, KS 66160, USA
| | - David H Barad
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY 10065-6399, USA
| | - Vitaly A Kushnir
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Wake Forest University, Winston Salem, NC 27106, USA.
| |
Collapse
|
44
|
Bassiouny YA, Dakhly DMR, Bayoumi YA, Hashish NM. Does the addition of growth hormone to the in vitro fertilization/intracytoplasmic sperm injection antagonist protocol improve outcomes in poor responders? A randomized, controlled trial. Fertil Steril 2016; 105:697-702. [PMID: 26690008 DOI: 10.1016/j.fertnstert.2015.11.026] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/30/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of the addition of growth hormone (GH) to the antagonist protocol in IVF/intracytoplasmic sperm injection cycles in poor responders. DESIGN Parallel randomized, controlled, open-label trial. SETTING University hospital. PATIENT(S) A total of 141 patients (GH, n = 68; gonadotropins only, n = 73) were enrolled. Twenty-five patients had their cycles cancelled. Analysis was performed per cycle start as well as per ET. INTERVENTION(S) Patients received the antagonist protocol with or without GH supplementation. MAIN OUTCOME MEASURE(S) Mean number of cumulus complexes, metaphase II oocytes retrieved and fertilized, chemical and clinical pregnancy rates, early miscarriage rate, ongoing pregnancy and live birth rates. RESULT(S) The addition of GH significantly lowered duration of hMG treatment, duration of GnRH antagonist treatment, and dose of gonadotropin. It significantly increased mean E2 levels on the day of hCG administration, number of collected oocytes (7.58 ± 1.40 vs. 4.90 ± 1.78 [mean ± SD]), number of metaphase II oocytes (4.53 ± 1.29 vs. 2.53 ± 1.18), number of fertilized oocytes (4.04 ± 0.96 vs. 2.42 ± 1.03), and number of transferred embryos (2.89 ± 0.45 vs. 2.03 ± 0.81). There was no significant difference in the clinical pregnancy rate per cycle (22.1% vs. 15.1%) or live birth rate per cycle (14.7% vs. 10.9%). CONCLUSION(S) Growth hormone as an adjuvant treatment in IVF/intracytoplasmic sperm injection cycles for poor responders should be cautiously used with the antagonist protocol, because there is still no identified impact on pregnancy outcomes. However, evaluation of the clinical pregnancy and live birth rates in our data was limited by low statistical power. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT02195947.
Collapse
Affiliation(s)
| | | | - Yomna Ali Bayoumi
- Department of Obstetrics and Gynaecology, Cairo University, Cairo, Egypt
| | | |
Collapse
|
45
|
Dakhly DMR, Bayoumi YA, Gad Allah SH. Which is the best IVF/ICSI protocol to be used in poor responders receiving growth hormone as an adjuvant treatment? A prospective randomized trial. Gynecol Endocrinol 2016; 32:116-9. [PMID: 26416521 DOI: 10.3109/09513590.2015.1092136] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This open label randomized study aims to define the best protocol to be used with growth hormone in poor responders, with comparison performed to delineate which protocol offers the best cycle outcomes. Two-hundred eighty-seven poor responders were included. The patients were randomly allocated into four groups receiving growth hormone (GH) as an adjuvant therapy added to either long or short agonist protocol, miniflare or antagonist protocols. The short/GH gave significantly lower mean number of oocytes when compared with the long/GH, antagonist/GH and miniflare/GH (4 ± 1.69 versus 5.06 ± 1.83, 4.95 + / = 1.90 and4.98 ± 2.51, respectively p = 0.005). Considering the number of fertilized oocytes, the long/GH showed significantly higher levels than short/GH and antagonist/GH (3.73 ± 1.47 versus 3.02 ± 1.52 and 2.89 ± 1.14, respectively). The main drawback is that it required significantly higher HMG dose and longer duration of stimulation. The long/GH was superior when compared with the three protocols regarding the number of oocytes retrieved and fertilized. But, when considering the clinical pregnancy rates, there was a difference in favor of the long/GH but not reaching a statistically significant value (ClinicalTrials.gov Identifier: NCT01897324).
Collapse
Affiliation(s)
- Dina M R Dakhly
- a Department of Obstetrics and Gynecology , Cairo University , Giza , Egypt
| | - Yomna A Bayoumi
- a Department of Obstetrics and Gynecology , Cairo University , Giza , Egypt
| | | |
Collapse
|
46
|
Lainas TG, Sfontouris IA, Venetis CA, Lainas GT, Zorzovilis IZ, Tarlatzis BC, Kolibianakis EM. Live birth rates after modified natural cycle compared with high-dose FSH stimulation using GnRH antagonists in poor responders. Hum Reprod 2015; 30:2321-30. [PMID: 26307091 DOI: 10.1093/humrep/dev198] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 07/16/2015] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Do live birth rates differ between modified natural cycles (MNCs) and cycles using high-dose follicle stimulating hormone (HDFSH) with gonadotrophin-releasing hormone (GnRH) antagonist in poor responder patients? SUMMARY ANSWER Live birth rates are significantly higher in MNC compared with HDFSH GnRH antagonist cycles in poor responder patients. WHAT IS KNOWN ALREADY Previous data on the efficiency of MNC in poor responders are very limited and suggest that MNC in vitro fertilization (IVF) does not offer a realistic solution for parenthood in these patients, since live birth rates are disappointingly low. To date, no studies exist comparing MNC with HDFSH stimulation protocols in poor responders. STUDY DESIGN, SIZE, DURATION The present retrospective study included 161 MNCs (106 women in the MNC group) and 164 HDFSH antagonist cycles (136 women in the HDFSH group) performed between January 2008 and December 2013 at Eugonia Assisted Reproduction Unit. The patients included in the study had to fulfill the Bologna criteria for the definition of poor ovarian response. PARTICIPANTS/MATERIALS, SETTING, METHODS Irrespective of their age, poor responder patients should have a diminished ovarian reserve as shown by low antral follicle count (≤5) and increased basal FSH (>12 IU/l), and one or more previous failed IVF cycles in which ≤3 oocytes were retrieved using a high gonadotrophin dose. Analysis was performed by adjusting for the non-independence of the data. MAIN RESULTS AND THE ROLE OF CHANCE The probability of live birth was significantly higher in the MNC when compared with the HDFSH group (OR: 4.01, 95% CI: 1.14-14.09), after adjusting for basal FSH, female age and cause of infertility, variables which were shown to be associated with the probability of live birth in univariable analysis. MNCs were characterized by significantly lower total gonadotrophin dose (490.0 ± 35.2 IU versus 2826.1 ± 93.4 IU, P < 0.001), lower estradiol concentrations (237.5 ± 12.3 pg/ml versus 487.3 ± 29.8 pg/ml, P < 0.001), fewer follicles present on the day of hCG (1.9 ± 0.1 versus 3.2 ± 0.2, P < 0.001), fewer oocytes retrieved (1.1 ± 0.01 versus 2.4 ± 0.1, P < 0.001), fewer oocytes fertilized (0.7 ± 0.1 versus 1.4 ± 0.1, P < 0.001), fewer embryos transferred (0.7 ± 0.1 versus 1.4 ± 0.1, P < 0.001), fewer good-quality embryos available (0.5 ± 0.1 versus 0.8 ± 0.1, P < 0.001) and fewer good-quality embryos transferred (0.5 ± 0.05 versus 0.8 ± 0.1, P < 0.001) compared with the HDFSH group. However, the proportion of cycles with at least one good-quality embryo transferred per started cycle was similar between the two groups compared (62.5, 95% CI: 52.7-72.3 versus 62.7, 95% CI: 53.0-72.5, respectively). LIMITATIONS, REASONS FOR CAUTION This is a retrospective comparison between MNC and HDFSH GnRH antagonist protocols in a large group of poor responder patients according to the Bologna criteria. Although the two groups compared were not imbalanced for all basic characteristics and multivariate analysis were performed to adjust for all known confounders, it cannot be excluded that non-apparent sources of bias might still be present. Future randomized controlled trials are necessary to verify the present findings. WIDER IMPLICATIONS OF THE FINDINGS Both MNC and HDFSH antagonist protocols offer very low chances of live birth in poor responder patients who fulfill the Bologna criteria. However, MNC-IVF is a more patient-friendly approach, with a higher probability of live birth compared with the HDFSH antagonist protocol. In this respect, the current data might be of help in counseling such patients, who do not wish to undergo oocyte donation, prior to abandoning treatment altogether and/or proceeding to adoption. STUDY FUNDING/COMPETING INTERESTS No funding was obtained. C.A.V. reports personal fees and non-financial support from Merck, Sharp and Dome, personal fees and non-financial support from Merck Serono, personal fees and non-financial support from IPSEN Hellas S.A. outside the submitted work. B.C.T. reports grants from Merck Serono, grants from Merck Sharp & Dohme, personal fees from IBSA, personal fees from Merck Sharp & Dohme and personal fees from Ovascience outside the submitted work .
Collapse
Affiliation(s)
- Trifon G Lainas
- Eugonia Assisted Reproduction Unit, 7 Ventiri Street, Athens 11528, Greece
| | | | - Christos A Venetis
- Department of Women's and Children's Health, St George Hospital, School of Women's and Children's Health, University of New South Wales, Kogarah, NSW 2217, Australia
| | - George T Lainas
- Eugonia Assisted Reproduction Unit, 7 Ventiri Street, Athens 11528, Greece
| | | | - Basil C Tarlatzis
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Ring Road, Nea Efkarpia, Thessaloniki 56429, Greece
| | - Efstratios M Kolibianakis
- Unit for Human Reproduction, 1st Department of Obstetrics & Gynaecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Ring Road, Nea Efkarpia, Thessaloniki 56429, Greece
| |
Collapse
|
47
|
Abstract
The effect of dehydroepiandrosterone (DHEA) therapy on improvement of reproduction outcome is uncertain. Many earlier studies have shown conflicting results. Therefore, a review of the literature is needed to explore the role of DHEA in reproduction. We conducted a literature search of MEDLINE (Ovid) and Pub-Med (2000-June 2014) for all relevant articles that included the terms "dehydroepiandrosterone," "DHEA," and "in vitro fertilization." Among the search-identified articles, seven prospective self-controlled studies and four retrospective case-control studies showed DHEA as an adjuvant therapy able to improve in vitro fertilization outcomes in poor responders (women with diminished ovarian reserve and/or poor ovarian response). However, four randomized controlled trials did not support the benefit of DHEA therapy for poor responders. By contrast, one prospective randomized study showed that DHEA might be beneficial to reproduction in women without diminished ovarian reserve (normal responders). In summary, a review of the previously published studies does not provide clear evidence that DHEA can be a useful treatment to improve ovarian function in poor responders.
Collapse
Affiliation(s)
- Li-Te Lin
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Su-Ao and Yuanshan Branch, Yilan, Taiwan, ROC; Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan, ROC
| | - Kuan-Hao Tsui
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan, ROC; Department of Pharmacy and Graduate Institute of Pharmaceutical Technology, Tajen University, Pingtung County, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Division of Gynecology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC.
| |
Collapse
|
48
|
Maged AM, Nada AM, Abohamila F, Hashem AT, Mostafa WA, Elzayat AR. Delayed Start Versus Conventional GnRH Antagonist Protocol in Poor Responders Pretreated With Estradiol in Luteal Phase: A Randomized Controlled Trial. Reprod Sci 2015; 22:1627-31. [PMID: 26045549 DOI: 10.1177/1933719115590666] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the new delayed start protocol against the conventional gonadotropin (Gn)-releasing hormone antagonist protocol in poor responders (PORs). STUDY DESIGN A total of 160 women with poor response to previous in vitro fertilization (IVF) cycle were randomized either to start Gn then Cetrotide 0.25 subcutaneously (sc) added when leading follicle (DF) reach >12 mm or Cetrotide 0.25 mg sc started first from day 2 to day 8 then Gn therapy was added and Cetrotide restarted when DF reach >12 mm. RESULTS There was a statistically significant difference between conventional and delayed start protocols regarding the needed dose of Gn for stimulation (4368 ± 643 and 3798 ± 515), level of estradiol (E2; 778 ± 371 and 1076 ± 453), and endometrial thickness at human chorionic gonadotropin triggering (8.6 ± 1.8 and 9.8 ± 1.9), the number of DF (3.4 ± 1.5 and 4.9 ± 2.1), the number of retrieved follicles (2.4 ± 2.1 and 4.3 ± 2.5), and successful embryo transfer (13 vs 16), respectively (P < .05). There was a highly statistically significant difference between the 2 study groups regarding the number of oocytes fertilized (1.2 ± 2.0 vs 3.3 ± 1.4), metaphase II oocytes (0.9 ± 1.0 vs 2.7 + 1.6), and grade I embryos (0.7 ± 0.9 vs 2.1 + 1.1; P < .001). The chemical pregnancy, clinical pregnancy, and abortion rate showed a statistically significant difference between the 2 study groups (P value .003 and .006, respectively). CONCLUSION Delayed start protocol significantly improved clinical pregnancy rate and IVF cycle parameters in PORs.
Collapse
Affiliation(s)
- Ahmed M Maged
- Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Giza, Egypt
| | - Adel M Nada
- Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Giza, Egypt
| | - Fouad Abohamila
- Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Giza, Egypt
| | - Ahmed T Hashem
- Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Giza, Egypt
| | - Walaa Ai Mostafa
- Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Giza, Egypt
| | - Ahmed R Elzayat
- Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Giza, Egypt
| |
Collapse
|
49
|
Haas J, Zilberberg E, Machtinger R, Kedem A, Hourvitz A, Orvieto R. Do poor-responder patients benefit from increasing the daily gonadotropin dose during controlled ovarian hyperstimulation for IVF? Gynecol Endocrinol 2015; 31:79-82. [PMID: 25223892 DOI: 10.3109/09513590.2014.959919] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We aim to assess the in vitro fertilization-embryo transfer (IVF-ET) outcome in patients receiving an extremely high 450 daily dose (IU) of gonadotropins during controlled ovarian hyperstimulation (COH) for IVF. Moreover, in those who failed to conceive while using 450 daily dose (IU) of gonadotropins, we aim to evaluate whether increasing the daily dose gonadotropins to 600 IU will improve IVF outcome. All consecutive women, admitted to our IVF unit and underwent COH consisting of daily gonadotropin dose of 450 IU were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate were assessed. Nine-hundred one consecutive IVF cycles were evaluated. While there was no between-group difference in the duration of COH, patients who conceived were significantly younger, yielded higher number of oocytes retrieved and embryos transferred and had significantly lower cancellations. In a sub-analysis, including only those patients who failed to conceive while using 450 daily dose (IU) of gonadotropins, and who underwent a subsequent IVF cycle attempt with the used of 600 IU daily dose of gonadotropins, no improvements in COH characteristics or cancellation rates were observed with increasing the daily gonadotropin dose to 600 IU. To conclude, in poor responders undergoing COH with an extremely high daily gonadotropin dose (450 IU), the most important factors that predict IVF success are female age and the number of oocytes retrieved. Moreover, patients who failed to conceive on a daily gonadotropin dose of 450 IU will not benefit from increasing the dose to 600 IU and should therefore consider the options of egg donation or adoption.
Collapse
Affiliation(s)
- Jigal Haas
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer) , Ramat Gan , Israel and
| | | | | | | | | | | |
Collapse
|
50
|
Jeve YB. The combined use of antimullerian hormone and age to predict the ovarian response to controlled ovarian hyperstimulation in poor responders: A novel approach. J Hum Reprod Sci 2014; 6:259-62. [PMID: 24672166 PMCID: PMC3963310 DOI: 10.4103/0974-1208.126298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/27/2013] [Accepted: 12/31/2013] [Indexed: 11/29/2022] Open
Abstract
CONTEXT: Reduced ovarian response to stimulation represents one of the most intractable problems in infertility treatment. As failed cycle can cause considerable amount of emotional and economical loss, there are various attempts made to predict ovarian response. AIMS: To evaluate different factors influencing outcome of assisted reproduction in women with predicted reduced response (antimullerian hormone between 1 and 5 pmol/L) and to develop a model using of AMH and age to predict the number of oocytes in poor responders. SETTINGS AND DESIGN: Retrospective study in a teaching hospital. MATERIALS AND METHODS: We analyzed 85 cycles (57 women) with predicted reduced response with serum AMH value between 1 and 5 pmol/L. Standard ovarian stimulation protocol was used. Primary outcome measures were clinical pregnancy rates and oocytes retrieved. STATISTICAL ANALYSIS USED: Data were analyzed using Microsoft excel and MetlabR software. RESULTS: Clinical pregnancy rate/ET was 20.33%, in this group. AMH and age was analyzed using linear regression model which produced an equation to give predicted oocyte count if AMH and age are known. (Oocytes = age × (-ß) + Serum AMH × α) (Constant ß=0.0102 and α = 1.0407). CONCLUSIONS: Combined use of serum AMH and age to predict ovarian response within reduced responder group should be further evaluated. For first time, we suggested combining both factors to predict ovarian response using a simple equation which allow developing tailored strategy.
Collapse
Affiliation(s)
- Yadava Bapurao Jeve
- Department Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, UK
| |
Collapse
|