Clinical factors associated with unexpected poor or suboptimal response in Poseidon criteria patients

RESEARCH QUESTION

What clinical factors are associated with 'unexpected' poor or suboptimal responses to IVF ovarian stimulation per POSEIDON's criteria, and which AMH and AFC threshold values distinguish this population?

DESIGN

Tri-centre retrospective cohort study (2015-2017) involving first-time IVF and ICSI cycles with conventional ovarian stimulation (≥150 IU/day of FSH). Eligibility criteria included sufficient ovarian reserve markers according to POSEIDON's classification (AMH ≥1.2 ng/ml; AFC ≥5). Ovarian response categories were poor (<4 oocytes), suboptimal (4-9 oocytes) and normal (≥9 oocytes). Primary outcomes included clinical factors associated with an unexpected poor or suboptimal response to conventional ovarian stimulation using logistic regression analyses, and the threshold values of AMH and AFC predicting increased risk of such responses using ROC curves.

RESULTS

A total of 7625 patients met the inclusion criteria: 204 (9.3%) were poor and 1998 (90.7%) were suboptimal responders. Logistic regression identified significant clinical predictors for a poor or suboptimal response, including AFC, AMH, total gonadotrophin dose, gonadotrophin type and trigger type (P ≤ 0.02). The ROC curves indicated that AMH 2.87 ng/ml (AUC 0.740) and AFC 12 (AUC 0.826) were the threshold values predicting a poor or suboptimal response; AMH 2.17 ng/ml (AUC 0.741) and AFC 9 (AUC 0.835) predicted a poor response; and AMH 2.97 ng/ml (AUC 0.722) and AFC 12 (AUC 0.801) predicted a suboptimal response.

CONCLUSIONS

The threshold values of AMH and AFC predicting 'unexpected' poor or suboptimal response were higher than expected. These findings have critical implications for tailoring IVF stimulation regimens and dosages.

Ultra-low-dose and very-low-dose Lupron downregulation protocols for poor responders based on POSEIDON group 3 and 4 classifications

PURPOSE

The objective of this study was to assess if very-low-dose Lupron (VLDL) and ultra-low-dose Lupron (ULDL) protocols can have comparable cycle outcomes when compared to other "poor responder" stimulation protocols based on POSEIDON classification groups 3 (PG3) and 4 (PG4).

METHODS

A retrospective cohort study at a single, large academic center was performed. Women in PG3 (age < 35, AMH < 1.2 ng/mL) or PG4 (age ≥ 35, AMH < 1.2 ng/mL) undergoing in vitro fertilization using an ULDL (Lupron 0.1 to 0.05 mg daily), VLDL (Lupron 0.2 to 0.1 mg daily), microflare (Lupron 0.05 mg twice a day), estradiol priming/antagonist, antagonist, or minimal stimulation protocols from 2012 to 2021 were included. The primary outcome was the number of mature oocytes (MII) obtained. The secondary outcome was live birth rate (LBR).

RESULTS

The cohort included 3601 cycles. The mean age was 38.1 ± 3.8 years. In the PG3 group, ULDL and VLDL protocols produced a comparable number of MIIs (5.8 ± 4.3 and 5.9 ± 5.4, respectively) and live births (33.3% and 33.3%, respectively) when compared to other protocols. In the PG4 group, ULDL and VLDL protocols resulted in a higher percentage of MIIs when compared to microflare or minimal stimulation (Microflare/ULDL: adjusted relative risk (aRR) 0.78 (95% CI 0.65, 0.95); min stim/ULDL: aRR 0.47 (95% CI 0.38, 0.58); microflare/VLDL: aRR 0.77 (95% CI 0.63, 0.95); min stim/VLDL: aRR 0.47 (95% CI 0.38, 0.95)). There were no significant differences in LBR.

CONCLUSION

Dilute Lupron downregulation protocols have comparable outcomes to other poor responder protocols and are reasonable to use.

A randomized, non-inferiority trial on the DuoStim strategy in PGT-A cycles

RESEARCH QUESTION

Is the DuoStim strategy an effective alternative to two conventional ovarian stimulation cycles in poor-prognosis patients undergoing preimplantation genetic testing for aneuploidies (PGT-A) to improve euploidy rates and obtain the first euploid embryo in less time?

DESIGN

This randomized controlled trial was performed at IVI Madrid between June 2017 and December 2020 and included 80 patients with a suboptimal profile aged 38 or older undergoing PGT-A cycles. Patients were blindly randomized into two groups: 39 women underwent two ovarian stimulations in consecutive cycles (control group), whereas the double stimulation strategy was applied to 41 women (DuoStim group). The main outcome was the euploidy rate in each group. The secondary outcomes were the time it took to obtain a euploid embryo and the main cycle outcomes.

RESULTS

The baseline characteristics of the patients were similar. No differences were found between the control group and the DuoStim group in the mean days of stimulation (21.3 ± 1.6 versus 23.0 ± 1.4, P = 0.10), total gonadotrophins (4005 ± 450 versus 4245 ± 430, P = 0.43), metaphase II oocytes (8.7 ± 1.8 versus 6.8 ± 1.7, P = 0.15) or euploid embryos obtained (0.8 ± 0.4 versus 0.6 ± 0.4, P = 0.45). The euploid rate per randomized patient (ITT) was 16.1% in the control group versus 22.7% in the DuoStim group, with P-values of 0.371, and the euploidy rate per patient treated was 39.0% versus 45.7% in the control versus DuoStim groups. However, there was a significant difference in the average number of days it took to obtain a euploid blastocyst, favouring the DuoStim group (44.1 ± 2.0 versus 23.3 ± 2.8, P < 0.001).

CONCLUSIONS

The use of the DuoStim strategy in poor-prognosis patients undergoing PGT-A cycles maintains a similar euploidy rate while reducing the time required to obtain a euploid blastocyst.

Does the dose or type of gonadotropins affect the reproductive outcomes of poor responders undergoing modified natural cycle IVF (MNC-IVF)?

OBJECTIVE

Does the dose or type of gonadotropin affect the reproductive outcomes of poor responders undergoing IVF in a modified natural cycle (MNC-IVF)?

STUDY DESIGN

This is a retrospective cohort study including patients attending a tertiary referral University Hospital from 1st January 2017 until 1st March 2020. All predicted poor responders (Poseidon groups 3 and 4) who underwent MNC-IVF in our center were included. Mild ovarian stimulation (rFSH/uFSH/hp-hMG) was started when a follicle with a mean diameter of 12-14 mm was observed on ultrasound scan; GnRH antagonist was added from the next day onwards. Mature oocytes were inseminated using ICSI.

RESULTS

In total 484 patients undergoing 1398 cycles were included. Mean (SD) age and serum AMH were 38.2 (3.7) years and 0.28 (0.26) ng/ml, respectively. The daily dose of gonadotropins was either < 75 IU/d [11/1398 (0.8 %)] or 75 to < 100 IU/d [1303/1398 (93.2 %)] or ≥ 100 to 150 IU/d [84/1398 (6 %)]. Patients were stimulated with rFSH [251/1398 (18 %)], uFSH [45/1398 (3.2 %)] or hp-hMG [1102/1398 (78.8 %)]. Clinical pregnancy rate was 119/1398 (8.5 %). Live birth was achieved in 80/1398 (5.7 %) of cycles. There was no significant difference in rates of pregnancy and live birth across different types and doses of gonadotropins. The GEE multivariate regression analysis, adjusting for relevant confounders, showed that the type of treatment strategy (rFSH/uFSH/hp-hMG) and the daily dose of gonadotropins were not associated with live birth rates (LBR) (p value 0.08 and 0.8, respectively).

CONCLUSIONS

The type and daily dose of gonadotropins do not affect the reproductive outcome of poor responders undergoing MNC-IVF.

Four consecutive minimal ovarian stimulation (TetraStim) is a feasible alternative to increase the number of oocytes and improve live birth rates in poor responders who do not accept oocyte donation

OBJECTIVE

To present our experience using four consecutive minimal COS (TetraStim) followed by oocyte retrieval and vitrification to increase the number of oocytes in patients with POR for whom oocyte donation is not an option.

METHODS

We performed an observational study evaluating 128 poor responders submitted to TetraStim instead of oocyte donation cycles. Patients were submitted to four consecutive minimal COS started at luteal phase, oocyte retrieval, oocyte vitrification/warming, ICSI, endometrial priming and embryo transfer. We evaluated the number of vitrified oocytes, survival rate after warming, fertilization rate, cleavage rate, number of embryos transferred, clinical pregnancy rate, miscarriage rate and live birth rate.

RESULTS

The mean age was 38.1 ± 3.1 years. A total of 791 oocytes were recovered (6.1 ± 2.7/patient), 682 (86.2%) Metaphase II (5.3 ± 2.4/patient) were vitrified, 95.3% survived warming (5.1 ± 2.3/patient), 82% showed normal fertilization after ICSI (4.2 ± 2/patient), 79.2% reached cleavage stage (3.3 ± 1.6/patient), 313 cleavage stage embryos were transferred to 115 patients (2.7 ± 0.7/patient) and 14.7% of the patients had surplus embryos that were vitrified. Clinical pregnancy rate per patient was 31.3% and live birth rate per patient was 22.6%.

CONCLUSION

To our knowledge this is the first study that demonstrates that TetraStim can be an effective alternative for patients with POR with an indication to perform IVF with donated oocytes, but do not agree to use. TetraStim is a feasible alternative to increase the number of oocytes and embryos and improve pregnancy rates with no dropouts and very low cycle cancelation rate. However, randomized controlled studies must be performed to compare TetraStim with other treatments.

ART outcomes following ovarian stimulation in the luteal phase:a systematic review and meta-analysis

PURPOSE

This study aimed to evaluate the impact of luteal phase ovarian stimulation (LPS) on the outcomes of assisted reproductive technology (ART) for infertile couples and patients desiring non-urgent egg cryopreservation.

METHODS

We included all studies reported patients who received LPS and that used follicular phase ovarian stimulation (FPS) as a comparison group until January 2021. Prior meta-analysis regarding the outcomes of LPS in double stimulation and fertility preservation have already been published, so these studies were excluded. Risk of Bias in Non-randomized Studies of Interventions was used to assess the study quality. The study was registered in the International Prospective Register of Systematic Reviews database (CRD42020183946).

RESULTS

Twelve studies with a total of 4433 patients were included. The regimen employed can be categorized into two groups, but there is currently no evidence to support one over the other. After we excluded the largest study, the clinical pregnancy rate and live birth rate were similar after FPS and LPS. There were significantly more stimulation days and total gonadotropins used in the LPS group. After subgroup analysis, we found that poor responders received significantly more cumulus oocyte complexes (+0.64) in the LPS group.

CONCLUSION

Current evidence indicates that patients in the LPS group could achieve pregnancy outcomes non-inferior to those in the FPS group. Because of current debate over freeze-all policy and the limited data about live birth rate, the universal use of LPS is considered controversial. In the future, more well-designed studies are necessary to investigate the indications for LPS and its cost-effectiveness.

Influence of Maternal Age and Ovarian Reserve on the Decision to Continue or to Cancel IVF Cycles in Patients with One or Two Large Follicles: a Dual Effect

This study aimed to study whether IVF stimulation that results in one or two mature follicles should proceed to oocyte retrieval. This is a retrospective cohort study conducted at McGill University Health Center on 459 patients who underwent IVF treatment between 2011 and 2014, undergoing hormonal stimulation and monitoring of their ovarian response. The primary outcomes were pregnancy and live birth rates. Statistical modeling was used to determine individual roles of patient age and ovarian reserve on outcomes, while controlling for the other factors. Of the 459 cycles included in the study, 360 cycles (78.4%) ended in embryo transfer. Live birth rates per cycle were 15.6%, for the ≤ 34-year-olds; 6.5%, for the 35-39-year-olds; and 2.7%, for the ≥ 40-year-olds (p < 0.01). Twenty-five percent of the cycles in the ≥ 40-year-old group were canceled versus 17% and 15% in the 35-39-year-old and ≤ 34-year-old groups, respectively (p < 0.05). Testing likelihood of live birth as a function of age and antral follicular count (AFC) revealed that a 1-year increase in age reduces the likelihood of live birth by 11% (p < 0.05) and one-unit increase in AFC count leads to a 9% increase in the odds of a live birth (p < 0.05). For the youngest age group, the AFC had a most significant effect, and those with AFC > 11 had 56% live birth rate, while those with AFC ≤ 11 had only 6% of live birth rate. This study supports a shift in reasoning from age being the predictor of outcomes in women with a low response at IVF to both age and ovarian reserve needing to be taken into consideration.

Minimal ovarian stimulation is an alternative to conventional protocols for older women according to Poseidon's stratification: a retrospective multicenter cohort study

OBJECTIVE

To investigate whether minimal ovarian stimulation (mOS) is as effective as conventional ovarian stimulation (cOS) for older women belonging to different groups according to the Poseidon criteria.

MATERIAL AND METHODS

Observational retrospective multicentre cohort including women from Poseidon's groups 2 and 4 that underwent in vitro fertilization (IVF). We performed a mixed-effects logistic regression model, adding as a random effect the patients and the stimulation cycle considering the dependence of data. Survival curves were employed as a measure of the cumulative live birth rate (CLBR). The primary outcomes were live birth rate per embryo transfer and CLBR per consecutive embryo transfer and oocyte consumed until a live birth was achieved.

RESULTS

A total of 2002 patients underwent 3056 embryo transfers (mOS = 497 and cOS = 2559). The live birth rates per embryo transfer in mOS and cOS showed no significant difference in both Poseidon's groups. Likewise, the logistic regression showed similar live birth rates between the two protocols in Poseidon's groups 2 (OR 1.165, 95% CI 0.77-1.77; p = 0.710) and 4 (OR 1.264 95% CI 0.59-2.70; p = 0.387). However, the survival curves showed higher CLBR per oocyte in women that received mOS (Poseidon group 2: p < 0.001 and Poseidon group 4: p = 0.039).

CONCLUSIONS

Minimal ovarian stimulation is a good alternative to COS as a first-line treatment for patients belonging to Poseidon's groups 2 and 4. The number of oocytes needed to achieve a live birth seems inferior in mOS strategy than cOS.

A Novel Stimulation Protocol for Poor-Responder Patients: Combining the Stop GnRH-ag Protocol with Letrozole Priming and Multiple-Dose GnRH-ant: A Proof of Concept

OBJECTIVE

The objective of this study was to examine whether the combined Stop GnRH-agonist (GnRH-ag), letrozole priming, and multiple-dose GnRH-antagonist (GnRH-ant) protocol may improve in vitro fertilization/intracytoplasmic sperm injection cycle in poor ovarian responders (PORs).

DESIGN

This was a historical cohort, proof of concept study under tertiary setting at University affiliated Medical Center.

PATIENTS

Five PORs fulfilling the POSEIDON Group 4 criteria were included.

MAIN OUTCOME MEASURES

Number of oocytes retrieved, number of top-quality embryos (TQEs), and controlled ovarian hyperstimulation (COH) variables were the main outcome measures.

RESULTS

The combined Stop GnRH-ag, letrozole priming, and multiple-dose GnRH-ant COH protocol revealed significantly higher number of follicles >13 mm on the day of hCG administration and higher number of oocytes retrieved, with non-significantly more TQEs and a reasonable clinical pregnancy rate.

CONCLUSIONS

The combined Stop GnRH-ag, letrozole priming, and multiple-dose GnRH-ant COH protocol is a valuable tool in the armamentarium for treating POSEIDON Group 4 patients. Further large prospective studies are needed to elucidate its role in POR and to identify the specific characteristics of women (before initiating ovarian stimulation) that will aid both fertility specialists' counseling and their patients in adjusting the appropriate COH protocol.

Effects of Intraovarian Injection of Autologous Platelet-Rich Plasma on Ovarian Rejuvenation in Poor Responders and Women with Primary Ovarian Insufficiency

Injection of intraovarian platelet-rich plasma (PRP) was recently presented in terms of improvement ovarian function in women with a poor ovarian response (POR) or primary ovarian insufficiency (POI). In a before and after study, 17 poor responder women and 9 women with the diagnosis of POI were recruited. The multifocal intramedullary infusion of 1.5 ml activated PRP was performed into each ovary. The majority of women in both groups received the second PRP injection with the twofold increase in the dosage to 3ml, 3 months after the first injection. Evaluation of serum anti-mullerian hormone ( AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) was performed. In addition, all women were followed with regard to pregnancy outcome up to delivery. In the POI group, menstrual restoration was monitored. The significant difference was not detected regarding the hormonal profile between the three time points in both groups. With regard to pregnancy outcome, 8/17 (47%) of PORs had spontaneous pregnancy in response to PRP injection. Of those, three women (37.55%) had abortions, whereas 4 pregnancies (50%) led to healthy live births, and one woman (12.5%) was in the 24^th week of her pregnancy. Menstruation recovery occurred among 22.2% of women with POI after the second PRP injection, but no one became pregnant. Intraovarian injection of autologous PRP might be considered an alternative treatment in poor responders. As for women with POI, it is questionable whether PRP could induce menstrual recovery.

Meta-analysis of GnRH-antagonists versus GnRH-agonists in poor responder protocols

PURPOSE

Considering the insufficient evidence supporting an ideal protocol for poor responder management in IVF/ICSI cycles, the aim of the current meta-analysis was to compare GnRH-antagonist versus GnRH-agonist protocols in poor responders, evaluating effectiveness and safety.

METHODS

Meta-analysis was conducted using Medcalc 16.8 version software. Standardized mean differences (SMD), odds ratios (OR), and the respective 95% confidence intervals (CI) were determined appropriately. The Cochran Q statistic and the I² test were used to assess studies' heterogeneity.

RESULTS

GnRH-agonists were shown to correlate with fewer cancelled IVF/ICSI cycles (p = 0.044, OR = 1.268 > 1, 95% CI 1.007, 1.598), a larger number of embryos transferred (p = 0.008, SMD = - 0.230, 95% CI - 0.400, - 0.0599), and more clinical pregnancies (p = 0.018, OR = 0.748 < 1, 95% CI 0.588, 0.952). However, GnRH-antagonists resulted in a significantly shorter duration of ovarian stimulation (p = 0.007, SMD = - 0.426. 95% CI - 0.736, - 0.115). The number of oocytes and mature oocytes retrieved in both protocols did not differ statistically (p = 0.216, SMD = - 0.130, 95% CI - 0.337, 0.0763 and p = 0.807, SMD = - 0.0203, 95% CI - 0.183, 0.142, respectively). Moreover, a high heterogeneity among studies was observed regarding duration of ovarian stimulation (I² = 90.6%), number of oocytes (I² = 82.83%)/mature oocytes retrieved (I² = 70.39%), and embryos transferred (I² = 72.83%).

CONCLUSIONS

Based on the present meta-analysis, agonist protocols could be suggested as a first choice approach, in terms of effectiveness. Due to the high studies' heterogeneity, results should be considered with caution. Accordingly, larger cohort studies and meta-analyses like the present one will enhance the robustness of the emerging results to identify the ideal protocol for poor responders.

Comparative study between single versus dual trigger for poor responders in GnRH-antagonist ICSI cycles: A randomized controlled study

OBJECTIVE

To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the number of retrieved oocytes and clinical pregnancy rate in poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles using a GnRH-antagonist protocol.

METHODS

A randomized controlled trial included poor ovarian responders indicated for ICSI using a GnRH-antagonist protocol. They were divided equally into two groups: group I received 10 000 units of hCG plus 0.2 mg of triptorelin while group II received 10 000 units of hCG only for triggering of ovulation. The primary outcome parameter was the number of oocytes retrieved. Secondary outcomes included metaphase II oocytes number, cancellation rate, number of obtained embryos, chemical and clinical pregnancy rates.

RESULTS

One hundred and sixty women were included in the study, with 80 women in each treatment group. Dual triggering was associated with higher number of retrieved oocytes (5.3 ± 1.9 vs 4.5 ± 2.4, P=0.014), metaphase II oocytes (3.8 ± 1.4 vs 3.1 ± 1.7, P=0.004), total and grade 1 embryos (2.7 ± 1.1 and 2.3 ± 1.0 vs 1.9 ± 1.2 and 1.1 ± 0.2, P=0.001 and 0.021 respectively), and transferred embryos (2.2 ± 0.9 vs 1.6 ± 0.9, P=0.043, and lower cancellation rate (7.5% vs 20%, P=0.037) compared with single triggering. There were significantly higher chemical (25% vs 11.3%, P=0.039) and clinical (22.5% vs 8.8%, P=0.028) pregnancy rates in women with dual triggering compared with those with single triggering.

CONCLUSION

Dual triggering is associated with better IVF outcome in poor responders compared with single trigger. Clinical trial registration NCT04008966.

Corifollitropin alfa for poor responders patients, a prospective randomized study

BACKGROUND

Poor ovarian response remains one of the biggest challenges for reproductive endocrinologists. The introduction of corifollitropin alpha (CFA) offered an alternative option to other gonadotropins for its longer half-life, its more rapid achievement of the threshold and higher FSH levels. We compared two different protocols with CFA, a long agonist and a short antagonist, and a no-CFA protocol.

METHODS

Patients enrolled fulfilled at least two of the followings: AFC < 5, AMH < 1,1 ng/ml, less than three oocytes in a previous cycle, age > 40 years. Ovarian stimulation with an antagonist protocol was performed either with 300 UI rFSH and 150 UI rLH or 300UI HMG. In the long agonist group, after pituitary suppression with triptorelin, CFA was given the 1-2th day of cycle and 300 UI rFSH and 150 UI rLH the 5th day. In the short antagonist group CFA was given the 1-2th day of cycle and 300 UI rFSH and 150 UI rLH the 5th day. The primary objective was the effect on the number of oocytes and MII oocytes. Secondary objective were pregnancy rates, ongoing pregnancies and ongoing pregnancies per intention to treat.

RESULTS

The use of CFA resulted in a shorter lenght of stimulation and a lower number of suspended treatments. Both the CFA protocols were significantly different from the no-CFA group in the number of retrieved oocytes (p < 0,05), with a non-significant difference in favour of the long agonist protocol. Both CFA groups yielded higher pregnancy rates, especially the long protocol, due to the higher number of oocytes retrieved (p < 0,05), as implantation rates did not differ. The cumulative pregnancy rate was also different, due to the higher number of cryopreserved blastocysts (p < 0,02).

CONCLUSIONS

The long agonist protocol with the addition of rFSH and rLH showed the best results in all the parameters. A short antagonist protocol with CFA was less effective, but not significantly, although provided better results compared to the no-CFA group. We suggest that a long agonist protocol with CFA and recombinant gonadotropins might be a valuable option for poor responders.

TRIAL REGISTRATION

The study was approved by the local Ethics Committee (EudraCT2015-002817-31).

Does daily co administration of gonadotropins and letrozole during the ovarian stimulation improve IVF outcome for poor and sub optimal responders?

Background

Co-administration of letrozole during the first 5 days of ovarian stimulation was suggested to improve IVF outcomes in poor responders. We aimed to determine whether poor/sub-optimal responders might benefit from Letrozole co-treatment throughout the entire stimulation course.

Methods

We retrospectively reviewed the medical files of women who demonstrated poor (oocyte yield ≤3) and sub-optimal (4 ≤ oocyte yield ≤9) ovarian response during conventional multiple-dose antagonist stimulation protocols and were co-treated in a subsequent cycle with 5 mg Letrozole from the first day of stimulation until trigger day. A self-paired comparison between gonadotropins-only and gonadotropins-letrozole cycles was performed.

Results

Twenty-four patients were included. Mean patients’ age was 39.83 ± 4.60 and mean day-3-FSH was 12.77 ± 4.49 IU/m. Duration of stimulation and total gonadotropins dose were comparable between the two cycle groups. Peak estradiol levels were significantly lower in gonadotropins-letrozole cycles (2786.74 ± 2118.53 vs 1200.13 ± 535.98, p < 0.05). Number of retrieved oocytes (3.29 ± 2.15 vs 6.46 ± 3.20, p < 0.05), MII-oocytes (2.47 ± 1.65 vs 5.59 ± 3.20, p < 0.05), 2PN-embryos (1.78 ± 1.50, 4.04 ± 2.74, p < 0.05) and top-quality embryos (0.91 ± 0.97 vs. 2.35 ± 1.66, p < 0.05) were significantly higher in the gonadotropins-letrozole cycles. Clinical pregnancy rate in gonadotropins-letrozole cycles was 31.5%.

Conclusion

Letrozole co-treatment during the entire stimulation course improves ovarian response and IVF outcomes in poor/sub-optimal responders.

Expression of genes that regulate follicle development and maturation during ovarian stimulation in poor responders

RESEARCH QUESTION

Sex hormone-binding globulin (SHBG), androgen receptor (AR), LH beta polypeptide (LHB), progesterone receptor membrane component 1 (PGRMC1) and progesterone receptor membrane component 2 (PGRMC2) regulate follicle development and maturation. Their mRNA expression was assessed in peripheral blood mononuclear cells (PBMC) of normal and poor responders, during ovarian stimulation.

DESIGN

Fifty-two normal responders and 15 poor responders according to the Bologna criteria were enrolled for IVF and intracytoplasmic sperm injection and stimulated with 200 IU of follitrophin alpha and gonadotrophin-releasing hormone antagonist. HCG was administered for final oocyte maturation. On days 1, 6 and 10 of stimulation, blood samples were obtained, serum hormone levels were measured, RNA was extracted from PBMC and real-time polymerase chain reaction was carried out to identify the mRNA levels. Relative mRNA expression of each gene was calculated by the comparative 2^-DDCt method.

RESULTS

Differences between mRNA levels of each gene on the same time point between the two groups were not significant. PGRMC1 and PGRMC2 mRNA levels were downregulated, adjusted for ovarian response and age. Positive correlations between PGRMC1 and AR (standardized beta = 0.890, P < 0.001) from day 1 to 6 and PGRMC1 and LHB (standardized beta = 0.806, P < 0.001) from day 1 to 10 were found in poor responders. PGRMC1 and PGRMC2 were positively correlated on days 6 and 10 in normal responders.

CONCLUSIONS

PGRMC1 and PGRMC2 mRNA are significantly decreased during ovarian stimulation, with some potential differences between normal and poor responders.

Assessing the practice of LuPOR for poor responders: a prospective study evaluating follicular fluid cfDNA levels during natural IVF cycles

PURPOSE

The aim of this study is to provide data on the practice of Luteal Phase Oocyte Retrieval (LuPOR). The authors assess cell-free DNA levels in follicular fluid (ff cfDNA) from poor responders undergoing natural cycles, and comparing it to respective data originating from follicular phase oocyte retrievals.

METHODS

Forty-seven women were eligible for this prospective study. Participants were classified as poor responders based on Bologna criteria while being detected with a second follicular wave. Follicular fluid was collected and prepared for cfDNA extraction. Levels of cfDNA were quantified via Q-PCR employing the ALU115 and ALU247 primers. These primers are associated with apoptotic and necrotic events. Levels of ff cfDNA resulting from follicular phase oocyte retrieval (FoPOR) and LuPOR-performed in a single menstrual cycle were associated with the number and maturation status of yielded oocytes and the number and fertilization status of resulting zygotes. Survival rate following thawing of cryopreserved zygotes, along with the resulting number of cleavage stage and blastocyst stage embryos are provided.

RESULTS

Mean levels of ALU115 were significantly lower during FoPOR when compared to LuPOR (0.79 ± 0.72 vs 1.46 ± 1.59 ng/μl, p = 0.02). Regarding the FoPOR group, a significant positive correlation of serum estradiol and ALU115 concentration (p = 0.04) was revealed. A significant negative correlation between serum estradiol and cfDNA integrity was observed both during FoPOR (p = 0.03) and LuPOR (p = 0.03). A significant lower number of retrieved (1.09 ± 0.28 vs 1.29 ± 0.58, p = 0.02) and MII oocytes (0.77 ± 0.55 vs 1.08 ± 0.61, p = 0.02) was observed when comparing the FoPOR to LuPOR groups respectively. The integrity of cfDNA was observed to be higher in FoPOR originating embryos that arrested either prior to cleavage (0.28 ± 0.13 vs 0.17 ± 0.10, p = 0.006) or prior to blastocyst formation (0.28 ± 0.12 vs 0.13 ± 0.06, p = 0.04). In the case of LuPOR originating embryos, cfDNA integrity was observed to be higher in embryos that arrested only prior to the blastocyst stage (0.27 ± 0.20 vs 0.11 ± 0.07, p = 0.008). Similarly, cfDNA integrity was observed to be lower in top quality blastocysts originating from FoPOR (0.07 ± 0.04 vs 0.17 ± 0.05, p = 0.03) and in top quality cleavage stage embryos (0.09 ± 0.06 vs 0.31 ± 0.22, p = 0.01) and blastocysts (0.06 ± 0.02 vs 0.14 ± 0.06, p = 0.02) originating from LuPOR.

CONCLUSIONS

Our results indicate that ff originating from LuPOR presents with higher levels of cfDNA. The higher cfDNA levels are attributed to mainly apoptotic events, as the ALU247 levels and DNA integrity did not differ statistically significantly between FoPOR and LuPOR. The absolute mean level of ALU247 corresponding to necrotic events was higher in LuPOR. Regarding embryological data, cfDNA integrity was correlated with both number and quality of cleavage stage embryos in both FoPOR and LuPOR, along with blastocyst stage embryos in LuPOR. Necrotic events were associated with poorer blastocyst formation rate and blastocyst quality in LuPOR. As the comparison between FoPOR and LuPOR results to similar IVF laboratory data, the practice of LuPOR may stand as a promising approach for poor responders, while it merits further investigation.

Mild versus conventional ovarian stimulation for IVF in poor responders: a systematic review and meta-analysis

Mild ovarian stimulation is a treatment option for poor responders in IVF treatment. Our updated review evaluated mild IVF solely from randomized controlled trials (RCTs) that used genuine low-dose gonadotrophin (≤150 IU daily) alone or in combination with oral medications, comparing it with conventional-dose (>150 IU/ daily) IVF for poor responders. Electronic searches on MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and PreMEDLINE, and hand searches from 2002 up to 31 January 2019, identified 14 RCTs, which were compiled with the above inclusion criteria. The risk of bias (ROB) and quality of evidence (QOE) were assessed as per Cochrane Collaboration. Meta-analyses found no difference in live birth rate (four RCTs, n = 1057, RR 0.91, CI 0.66 to 1.25) (moderate QOE), ongoing pregnancy rate (six RCTs, n = 1782, RR 1.01, CI 0.86 to 1.20) (moderate-high QOE) and cycle cancellation rates (14 RCTs, n = 2746, RR 1.38, CI 0.99 to 1.92) (low QOE). Fewer oocytes and embryos were obtained from mild IVF; however, the number and proportion of high-grade embryos were similar. Mild IVF resulted in reduced gonadotrophin use and cost. The inference remained unchanged when smaller studies with ROB were excluded, or whether gonadotrophin alone or combination with oral medication was used. The evidence of equal efficacy from a pooled population, which was adequately powered for live birth, supported a mild IVF strategy for poor responders in preference to more expensive conventional IVF. Although clinical heterogeneity remained a limiting factor, it increased the generalizability of the findings.

Growth hormone therapy in children: predictive factors and short-term and long-term response criteria

PURPOSE

The definition of growth response in growth hormone (GH)-treated children is controversial. This study aims at: (1) evaluating short-term and long-term efficacy of GH treatment in a cohort of short children with GH deficiency (GHD); (2) assessing and compare various poor response criteria; (3) identifying predictive factors of growth response.

METHODS

Our study included 94 children, affected by isolated GHD and treated with GH until they reached final height. Criteria used for calculating the proportion of poor responders to GH for the first year were gain in height (ΔHt) SDS < 0.5 ("Bang criterion"), <0.3 or <0.4 SDS for less-severe and severe GHD, respectively ("Ranke criterion"), height velocity (HV) < mean -1 SDS ("Bakker criterion"); for adult height "Cianfarani criterion" was total ΔHt < 1 SDS.

RESULTS

After 1 year of treatment we defined "poor responders" 55.3% of patients according to Bang criterion, 40.9% according to Bakker criterion and 23.4% according to Ranke criterion. At the end of the treatment, poor responders according to Cianfarani criterion were 22.34%; almost everyone in our population (97.9%) achieved mMid-parental height (MPH). Median final Ht was -1.11 SDS. Our analysis revealed a significant negative association between ΔHt and age at diagnosis.

CONCLUSIONS

Bang criterion generated the highest number of poor responders, but had a low negative predictive value (67.5%); Ranke and Cianfarani criteria displayed similar rate of poor response. There is no reliable predictive factor of growth hormone response. However, almost all children treated reached MPH, suggesting good treatment efficacy.

Modified natural cycle IVF versus conventional stimulation in advanced-age Bologna poor responders

RESEARCH QUESTION

Do ongoing pregnancy rates (OPR) differ between modified natural cycle IVF (MNC-IVF) and conventional high-dose ovarian stimulation (HDOS) in advanced-age Bologna poor responders?

DESIGN

This was a retrospective cohort study including patients with poor ovarian response (POR) attending a tertiary referral university hospital from 1 January 2011 to 1 March 2017. All women who fulfilled the Bologna criteria for POR and aged ≥40 years who underwent their first intracytoplasmic sperm injection (ICSI) cycle in the study centre were included.

RESULTS

In total, 476 advanced-age Bologna poor responder patients were included in the study: 189 in the MNC-IVF group and 287 in the HDOS group. OPR per patient were significantly lower in the MNC-IVF group (5/189, 2.6%) compared with the HDOS group (29/287, 10.1%) (P = 0.002). However, after adjustment for relevant confounders (number of oocytes and presence of at least one top-quality embryo), the multivariate logistic regression analysis showed that the type of treatment strategy (HDOS versus MNC-IVF) was not significantly associated with OPR (odds ratio 2.56, 95% confidence interval 0.9-7.6).

CONCLUSIONS

In advanced-age Bologna poor responders, MNC-IVF, which is a more patient-friendly approach, could be a reasonable alternative in this difficult-to-treat group of women.

Human growth hormone for poor responders: a randomized placebo-controlled trial provides no evidence for improved live birth rate

RESEARCH QUESTION

Does the addition of human growth hormone (HGH) to an IVF cycle improve the live birth rate in previously documented poor responders to FSH?

DESIGN

Double-blind, placebo-controlled, randomized clinical trial comparing HGH to placebo in maximal stimulation in an IVF cycle. The study was stopped after 4 years. Women receiving ovarian stimulation in one IVF cycle, having failed to produce more than 5 eggs in a previous cycle with more than 250 IU/day of FSH were included. Basal FSH was ≤15 IU/l, body mass index <33 kg/m², age <41 years. HGH or placebo were added from the start of the cycle in a double-blinded manner. The primary outcome was live birth rate.

MAIN RESULTS

The live birth rates following an IVF cycle were 9/62 (14.5%) for growth hormone and 7/51 (13.7%) for the placebo group (risk difference 0.8%, 95% confidence interval [CI] -12.1 to 13.7%; odds ratio [OR] 1.07, 95% CI 0.37-3.10). There was a greater odds of oocyte retrieval with growth hormone (OR 5.67, 95% CI 1.54-20.80) but no better chance of embryo transfer (OR 1.42, 95% CI 0.50-4.00). Birth weights were comparable.

CONCLUSIONS

Planned participant numbers were not reached. It was not possible to demonstrate an increase in live birth rate from the addition of growth hormone in women with a previous poor ovarian response to IVF.

Indocyanine green angiography findings in patients with neovascular age-related macular degeneration refractory to ranibizumab switched to aflibercept

PURPOSE

To describe indocyanine green angiography (ICGA) and visual acuity (VA) results in patients with neovascular age-related macular degeneration (nAMD) refractory to ranibizumab switched to aflibercept.

METHODS

This study is a prospective interventional case series. Thirty-two eyes of 32 patients with nAMD showing a poor response after at least 24 months of ranibizumab were switched to aflibercept. Twenty eyes had type I choroidal neovascularization (CNV group), and 12 eyes had polypoidal choroidal vasculopathy (PCV group). After an initial loading dose of three monthly aflibercept injections, treatment was continued on a treat-and-extend basis. ICGA was performed just before the first aflibercept injection (baseline) and 12 and 24 months later. The variables recorded were: closure of polyps and lesion area, VA, number of aflibercept injections, dry macula, and pigment epithelium detachment.

RESULTS

The following means were recorded in the CNV and PCV groups, respectively: number of ranibizumab injections 20.4 ± 11.2 and 22.4 ± 12.9 (p = 0.740); baseline VA (before aflibercept) 73.2 ± 9.1 and 70.3 ± 13.7 letters (p = 0.654); and final VA 73.0 ± 7.6 and 69.3 ± 15.6 letters (p = 0.509). VA remained stable (p = 0.761 and 0.964) after 15.5 ± 3 and 15.1 ± 3.5 aflibercept injections (p = 0.244). At 24 months, dry macula was noted in 40 to 50% of the eyes (p = 0.620). Complete resolution of polyps was observed in 58% at 12 months and 92% at 24 months.

CONCLUSIONS

In patients with nAMD refractory to ranibizumab, aflibercept was effective at maintaining VA and closing numerous polyps. In half of the patients, dry macula was observed at 24 months.

Dual stimulation using corifollitropin alfa in 54 Bologna criteria poor ovarian responders - a case series

RESEARCH QUESTION

What are the reproductive outcomes of Bologna criteria poor responders undergoing dual stimulation (DuoStim) and subsequent cryopreserved embryo transfer?

DESIGN

Case series of patients treated during the period August 2015 to March 2018 in a public fertility clinic. The study included 54 Bologna criteria poor responder IVF patients younger than 42 years receiving a follicular stimulation (DuoStim 1) followed by a luteal phase stimulation (DuoStim 2) within the same cycle, both stimulations being performed with corifollitropin alfa followed by a subsequent cryopreserved embryo transfer cycle. The primary endpoint was the number of oocytes retrieved in DuoStim 1 compared with DuoStim 2. The secondary endpoint was ongoing pregnancy rate (OPR) at 12 weeks of gestation.

RESULTS

The mean number of oocytes retrieved in DuoStim 1 and DuoStim 2 was 2.4 ± 2.1 versus 3.7 ± 2.6, respectively; thus, a total of 1.2 (95% CI, 0.46-1.96) more oocytes was retrieved in DuoStim 2 compared with DuoStim 1 (P = 0.002). The OPR at 12 weeks was 20% (11/54) in this poor ovarian response population with a mean age of 36.7 years.

CONCLUSIONS

Luteal phase stimulation results in more oocytes in poor responders compared with follicular phase stimulation. DuoStim, using corifollitropin alfa followed by individualized FSH dosing, appears to be an alternative to conventional follicular phase stimulation, decreasing the risk of cycle cancellation.

Does the "delayed start" protocol with gonadotropin-releasing hormone antagonist improve the pregnancy outcome in Bologna poor responders? a randomized clinical trial

BACKGROUND

Recently, a novel approach with delaying the start of controlled ovarian stimulation along with gonadotropin-releasing hormone (GnRH) antagonist pretreatment for 7 days after estrogen priming for further suppression of endogenous follicle stimulating hormone (FSH) during the early follicular phase, resulting in more FSH-responsive follicles and thus improving synchronous follicular development was introduced. Two clinical trials have examined this strategy and reported controversial results. This study aimed to compare the effect of delayed-start GnRH antagonist protocol and standard GnRH antagonist in patients with poor ovarian response (POR) undergoing in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI).

METHODS

This randomized clinical trial was conducted at infertility department of Royan Institute from January 2017 to June 2018. Poor ovarian response was defined according to the Bologna criteria. The eligible women were randomly allocated into an experimental and control groups. In experimental group, patients received delayed-start GnRH antagonist protocol with estrogen priming followed by early follicular-phase GnRH antagonist treatment for 7 days before ovarian stimulation with gonadotropin and in control group, patients treated with estrogen priming antagonist protocol. IVF/ICSI outcomes were compared between groups.

RESULTS

Among all the 250 patients examined 156 women were eligible for study and finally 120 patients were allocated to intervention (n = 60) and control (n = 60) groups. Demographic characteristics and hormonal profiles of the patients did not differ between groups. The statistical analysis showed that there were significant differences between groups regarding the total dose of used gonadotropins (P < 0.001), stimulation duration (P < 0.001), number of retrieved oocytes (P = 0.01) and top quality embryo (P < 0.001) and also cancellation (P = 0.002) and fertilization rates (P = 0.002).

CONCLUSION

On the basis of present results the delayed-start protocol in poor responders can improve the fertilization rate and quality of embryos and reduce the cycle cancellation but have no significant effect on clinical pregnancy rate; however, larger randomized clinical trials are required to compare it with other protocols.

TRIAL REGISTRATION

NCT, NCT03134690. Registered 1 May 2017 - Retrospectively registered, http://www.clinicaltrial.gov / NCT03134690.

Pituitary suppression protocol among Bologna poor responders undergoing ovarian stimulation using corifollitropin alfa: does it play any role?

RESEARCH QUESTION

Does the type of pituitary suppression protocol influence cumulative live birth rate (LBR) in Bologna poor responders treated with corifollitropin alfa (CFA)?

DESIGN

Retrospective cohort analysis including poor responder patients fulfilling the Bologna criteria who underwent their first intracytoplasmic sperm injection cycle using a CFA-based ovarian stimulation protocol between 2011 and 2017. The starting dose of CFA was 150 µg. The primary outcome was cumulative LBR, defined as the first delivery of a live born resulting from the fresh and all the subsequent frozen embryo transfers.

RESULTS

A total of 717 cycles were divided into three groups: A (gonadotrophin-releasing hormone [GnRH] antagonist protocol, n = 407), B (long GnRH agonist protocol, n = 224) and C (short GnRH agonist protocol, n = 86). Cumulative LBR did not significantly differ between groups (20.1% versus 17.4% versus 14.0%; P = 0.35). Significantly more patients in Group A had supernumerary embryos cryopreserved (28.3% versus 18.4% versus 11.6%; P < 0.001). Days of additional highly purified human menopausal gonadotrophin 300 IU injections following CFA were significantly different between Groups A, B and C (3 versus 5 versus 3 days; P < 0.001). Multivariate logistic regression analysis showed that the number of oocytes retrieved remained an independent predictive factor (odds ratio 1.23, 95% confidence interval 1.16-1.31) for cumulative LBR.

CONCLUSIONS

Poor responders according to the Bologna criteria in whom CFA is used for ovarian stimulation had comparable cumulative LBR, irrespective of the type of pituitary suppression. An increase in number of oocytes retrieved is an independent variable related to cumulative LBR.

The addition of growth hormone adjuvant therapy to the long down regulation protocol in poor responders undergoing in vitro fertilization: Randomized control trial

OBJECTIVE

to detect the impact of growth hormone (GH) co-treatment to the long down regulation protocol, on the outcomes of IVF/ICSI cycles in poor responders.

STUDY DESIGN

this parallel open label randomized control trial was conducted in a university hospital. It included 240 females satisfying the bologna criteria for poor responders. The enrolled females were randomized into 2 groups: A (long/GH) receiving GH adjuvant therapy to the long protocol and group B (control) receiving the long protocol alone. The main outcome measure was the live birth rate (fresh, frozen and cumulative).

RESULTS

GH supplementation improved the number of collected oocytes (5.4 ± 1.7 vs. 4.3 ± 2.1), MII oocytes (4.1 ± 2.1 vs. 2.1 ± 1.4), fertilized oocytes (4.0 ± 2.2 vs. 2.0 ± 1.2), transferred embryos (2.4 ± 0.9 vs. 1.6 ± 1.1) and cryopreserved (0.5 ± 0.7 vs. 0.2 ± 0.5). There was no significant difference in the live birth rate whether fresh (17.5% vs. 14.1%) or cumulative (18.3% vs. 14.7%).

CONCLUSIONS

Further studies are needed to know the true impact of adding GH to the induction protocols in poor responders, as there was no difference in the live birth rates between the study groups, indicating a lack of trend toward benefit from GH supplementation in poor responders.

CLINICAL TRIAL REGISTRATION

NCT02338206.

A Case Series on Platelet-Rich Plasma Revolutionary Management of Poor Responder Patients

Poor responders are described as those In Vitro Fertilization (IVF) patients who are failing to respond to controlled ovarian stimulation protocols. Extensive research has focused on crafting the optimal treatment. However, it appears that each approach fails to be established as effective or guaranteed towards successful management. Platelet-Rich Plasma (PRP) is a novel, highly promising approach that has been successfully applied for an array of medical issues. In this case series, we present 3 poor responder patients with the common denominator of: failed IVF attempts, poor oocyte yield, and poor embryo quality. The option of oocyte donation was rejected. All patients were treated with autologous PRP ovarian infusion following written consent. Within a 3-month interval, follicle-stimulating hormone decreased by 67.33%, while Anti-Müllerian hormone increased by 75.18%. These impressive results on the biochemical infertility markers alone are classified as a complete biological paradox, coupled by improved embryo quality. Results report a natural conception at 24 weeks, an uncomplicated healthy pregnancy at 17 weeks and a successful live birth. To our knowledge, this is the first time such an approach and results are reported, where PRP treatment on poor responders lead to overcoming their challenging reproductive barrier.

Gonadotropin-releasing hormone antagonist versus progestin for the prevention of premature luteinising hormone surges in poor responders undergoing in vitro fertilisation treatment: study protocol for a randomised controlled trial

BACKGROUND

Progress in vitrification techniques has allowed reproductive physicians to consider new strategies for using progestin as an alternative to a GnRH analogue to improve in vitro fertilisation (IVF). However, the role of progestin in blocking luteinising hormone (LH) surges and its potential in clinical practice are unclear, especially for poor responders. We designed a prospective randomised controlled trial (RCT) to compare the efficacy of a gonadotropin-releasing hormone (GnRH) antagonist and progestin in blocking LH surges and premature ovulation in poor responders.

METHODS/DESIGN

Poor responders who meet the Bologna criteria will be randomised to one of two stimulation regimens-gonadotropin-releasing hormone (GnRH) antagonist or progestin-primed ovarian stimulation (PPOS)-using a computer-generated random number. Fresh embryos were transferred in the GnRH antagonist group and frozen embryos were transferred in the PPOS group. The primary outcome is the incidence of premature LH surges. Secondary outcomes include the number of oocytes retrieved, the number of embryos available for transfer, implantation rates and clinical pregnancy. The sample size for this trial is estimated as 340 participants, with 170 participants in each group. The data analysis will be by intention to treat.

DISCUSSION

To our knowledge, this is the first RCT to examine the efficacy of administering progestin orally to block LH surges and premature ovulation compared with the GnRH antagonist protocols in poor responders undergoing IVF treatment.

TRIAL REGISTRATION

www.chictr.org.cn . ChiCTR-IPR-17010906 . Registered on 18 March 2017.

Ovarian manipulation in ART: going beyond physiological standards to provide best clinical outcomes

Current knowledge on ovarian physiology has challenged the traditional concept of folliculogenesis, creating the basis for novel ovarian stimulation protocols in assisted reproduction technology. The purpose of this review was to evaluate the efficacy of novel clinical interventions that could aid clinicians in individualizing their protocols to patients' characteristics and personal situations. We conducted a literature review of the available evidence on new approaches for ovarian stimulation from both retrospective and prospective studies in the PubMed database. Here, we present some of the most important interventions, including follicle growth in the gonadotropin-independent and dependent stage, manipulation of estradiol production throughout ovarian stimulation, control of mid-cycle gonadotropin surges, and luteal phase support after different stimulation protocols and trigger agents. The latest research on IVF has moved physicians away from the classical physiology, allowing the development of new strategies to decouple organ functions from the female reproductive system and challenging the traditional concept of IVF.

Same Cycle Shift from IVF with Own Oocytes to Oocyte Donation in No or Poor Response Cycles

Our In-Vitro Fertilisation Centre is situated in a large developing country, Madagascar, with very bad roads and low income patients. Therefore we try to find ways to reduce as much as possible the number of attempts to obtain a pregnancy. Poor or no response to ovarian stimulation in In Vitro Fertilization (IVF) cycles is a great challenge. Here we describe a method whereby we shift from IVF to Oocyte Donation (OD) during the same cycle for patients whose ovaries do not respond properly to ovulation stimulation. Patients were superovulated with a long protocol agonist treatment and ultrasonically monitored for IVF/ICSI. When, at half way of the stimulation, it was clear that there was a no or poor response, gonadotropin administration was stopped and immediately replaced by estrogens; when the endometrium was considered to be sufficiently receptive, some donated oocytes from our concomitant oocyte donation (OD) program were fertilized with the patient's husband sperm and progesterone was added to the patients' treatment. After 48 hours the resulting embryos were transferred. Five poor responders patients underwent the described procedure. Three conceived, one of which aborted at 9 weeks, while the other two are ongoing. These patients signed the consent form accepting the possibility to shift from IVF to OD during the same cycle and three clinical pregnancies were obtained. OD through this technique seems more acceptable by poor responders than planned OD. This is a preliminary report and to our knowledge it is the first report of such a method.

[In vitro fertilization versus conversion to intrauterine insemination in patients with poor response to controlled ovarian hyperstimulation]

In women undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF), a poor ovarian response, defined as three of fewer mature follicles, can lead to cancellation of the cycle. However, in women with at least one patent tube and normal semen parameters, conversion to intrauterine insemination (IUI) is considered an option, offering reasonable pregnancy rates at a lower cost and without the complications associated with oocyte retrieval. Studies have shown that in cycles with only one mature follicle, IVF should be canceled. However, in cycles with 2 or 3 mature follicles, patients have the choice between IVF and conversion to IUI. Some studies have shown that IVF is superior to IUI in such cases, whereas other reports failed to find any difference. Most of these studies are retrospective and limited by the presence of several biases and low numbers of cycles, and to this date, there is no consensus on the best approach. We have thus designed a multicenter, randomized non-inferiority study, comparing live birth rates following conversion to IUI or IVF in patients with 2 or 3 mature follicles in COH cycles. Nine hundred and forty patients will be randomized on trigger day to either IVF or conversion to IUI. Our study will also include a medico-economic analysis.

Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back

Diminished fertility and poor ovarian response pose a conundrum to the experts in the field of reproductive medicine. There is limited knowledge about the risk factors of diminished ovarian reserve other than the iatrogenic ones. One of the leading causes of infertility in women today is diminished ovarian reserve (DOR). DOR is characterized by a low number of eggs in a woman's ovaries and/or with poor quality of the remaining eggs, which boils down to impaired development of the existing eggs, even with assisted reproductive techniques. A good number of such women with low ovarian reserve may conceive with their own eggs, if they are given individualized treatment that is tailored for their profile. Such patients should be counseled appropriately for an aggressive approach towards achieving fertility. The sooner the treatment is started, the better the chances of pregnancy.

Clinical analyses of successful and previously failed intracytoplasmic sperm injection cycle parameters in patients with poor ovarian reserve

Objective:

To determine some major characteristic differences between two consecutive successful and unsuccessful intracytoplasmic sperm injection (ICSI) cycles in poor responders.

Materials and Methods:

Sixty women with poor ovarian response as determined using the Bologna criteria underwent ICSI cycles following an unsuccessful trial. Some parameters of both cycles including age, body mass index (BMI), serum follicle-stimulating hormone (FSH) and estradiol levels, antral follicle count, gonadotropin dosage, duration of stimulation, antagonist starting day, duration of antagonist administration, endometrial thickness at trigger day, number of total and fertilized oocytes, embryo transfer day, number of embryo cells, and fertilization rate were compared in the same patients to identify predictors of cycles with clinical pregnancy.

Results:

The mean age, BMI, serum FSH, estradiol concentrations, and antral follicle count were 35.9 years (range, 30-42 years), 25.9 kg/m² (range, 18.4-33.5 kg/m²), 10.9 IU/mL (range, 7-13 IU/mL), 52.9 pg/mL (range, 11.6-75 pg/mL), and 4.7 (range, 2-10), respectively. A comparison of cycle characteristics showed a significantly higher total number of mature and fertilized oocytes in successful cycles. The fertilization rate was also significantly higher in cycles with clinical pregnancy. Early initiation of antagonist was shown to result in favorable outcomes. A comparison of embryo characteristics showed that transfer of higher-stage embryos and embryos with higher numbers of cells had a significant impact on cycle outcomes.

Conclusion:

Our comparison of parameters of failed and successful ICSI cycles in poor responders revealed significantly earlier antagonist initiation, higher total number of mature and fertilized oocytes, fertilization rate, and significantly higher stage of embryo development and cell numbers at transfer in cycles that resulted in clinical pregnancy.

Efficacy of Dehydroepiandrosterone (DHEA) to overcome the effect of ovarian ageing (DITTO): A proof of principle double blinded randomized placebo controlled trial

OBJECTIVE

To evaluate the effect of DHEA supplementation on In-Vitro Fertilisation (IVF) outcome as assessed by ovarian response, oocyte developmental competence and live birth rates in women predicted to have poor ovarian reserve (OR). The feasibility of conducting a large trial is also assessed by evaluating the recruitment rates and compliance of the recruited participants with DHEA/placebo intake and follow-up rates.

STUDY DESIGN

A single centre, double blinded, placebo controlled, randomized trial was performed over two years with 60 women undergoing in-vitro fertilisation (IVF). Subjects were randomized, based on a computer-generated pseudo-random code to receive either DHEA or placebo with both capsules having similar colour, size and appearance. 60 women with poor OR based on antral follicle count or anti-Mullerian hormone thresholds undergoing IVF were recruited. They were randomised to receive DHEA 75mg/day or placebo for at-least 12 weeks before starting ovarian stimulation. They had long protocol using hMG 300 IU/day. Data analysed by "intention to treat". Ovarian response, live birth rates and molecular markers of oocyte quality were compared between the study and control groups.

RESULTS

The recruitment rate was 39% (60/154). A total of 52 participants (27 versus 25 in the study and placebo groups) were included in the final analysis after excluding eight. While the mean (standard deviation) DHEA levels were similar at recruitment (9.4 (5) versus 7.5 (2.4) ng/ml; P=0.1), the DHEA levels at pre-stimulation were higher in the study group than in the controls (16.3 (5.8) versus 11.1 (4.5) ng/ml; P<0.01). The number (median, range) of oocytes retrieved (4, 0-18 versus 4, 0-15 respectively; P=0.54) and live birth rates (7/27, 26% versus 8/25, 32% respectively; RR (95% CI): 0.74 (0.22-2.48) and mRNA expression of developmental biomarkers in granulosa and cumulus cells were similar between the groups.

CONCLUSION

Pre-treatment DHEA supplementation, albeit statistical power in this study is low, did not improve the response to controlled ovarian hyperstimulation or oocyte quality or live birth rates during IVF treatment with long protocol in women predicted to have poor OR.

Retrospective analysis of treatments with recombinant FSH and recombinant LH versus human menopausal gonadotropin in women with reduced ovarian reserve

PURPOSES

The aim of this study is to determine whether a clinical advantage is gained with use of LH in combination with FSH or as a component of human menopausal gonadotropin (hMG) to achieve optimal ovarian stimulation.

METHODS

In this study, we compared retrospectively two regimens, r-FSH/r-LH and hMG, for the treatment of women with reduced ovarian reserve, identified as subjects with antral follicle count (AFC) < 11 and AMH ≤ 1.1 ng/ml.

RESULTS

Overall, the clinical pregnancy per started cycle was higher in the r-FSH/r-LH group (12.5 vs. 8.1%, P < 0.02), while implantation (11.1 vs. 9.5%) and miscarriage rates (29.9 vs. 35.9%) were comparable. Data were further analysed performing separate comparisons in subpopulations with different ranges of AFC, i.e. < 4, 4-6 and 7-10. Major differences between the two regimens were observed in women with AFC < 4. In this subpopulation, not only was the clinical pregnancies per started cycle higher in the r-FSH/r-LH group (10.2 vs. 1.5%, P < 0.01), but also implantation was significantly higher (13.0 vs. 2.8%, P < 0.02).

CONCLUSIONS

A r-FSH/r-LH regimen appears to be beneficial for the treatment of women with extremely poor ovarian reserve. It should be considered however that, being retrospective, this study is affected by obvious limitations, such as post-treatment patient selection criteria and absence of randomisation.

Adolescents with cannabis use disorders: Adaptive treatment for poor responders

OBJECTIVE

Treatment response as measured by both retention and abstinence attainment rates for adolescents with cannabis use disorders (CUD) has been unsatisfactory. This study tested the hypothesis that adaptive treatment (AT) will improve outcomes for poor responders (PR) to evidence-based practice interventions.

METHOD

A total of 161 adolescents, 13-18years of age, diagnosed with DSM-IV CUD, enrolled in this outpatient, randomized, AT study. Following a 7-session weekly motivational enhancement and cognitive behavioral therapy intervention (MET/CBT-7) only poor responders (defined as failing to achieve abstinence at week seven for any reason) were randomized into a 10-week AT phase of either an individualized enhanced CBT or an Adolescent Community Reinforcement Approach (ACRA) intervention. Good responders (GR) enrolled only in follow-up assessments starting at the completion of the AT phase (week 17).

RESULTS

Eighty adolescents (50%) met the criterion for poor response to treatment. Thirty seven percent of poor responders completed the AT phase and 27% of them achieved abstinence. There was no significant difference in retention and abstinence rates between the AT conditions. Although the majority of GR relapsed by week 17, they significantly differed from PR both for drug use (71% vs. 91%, respectively; p<0.05) and reporting to scheduled assessment on that week (78% vs. 54%, respectively; p<0.01).

CONCLUSION

Continuity of care to achieve abstinence among poor responders remains a therapeutic necessity and a research challenge. Examining innovative AT designed interventions including potential integrative approaches should be further studied in order to improve treatment outcomes.

Mid-luteal estradiol levels of poor/good responders and intracytoplasmic sperm injection

Objective:

To assess mid-luteal estradiol (E2) levels in poor and good responders and determine its effect on the outcome after intracytoplasmic sperm injection (ICSI).

Methods:

The current study was carried out in females who underwent ICSI from June 2011 to September 2013 in “Islamabad Clinic Serving Infertile Couples”. They were categorized into good and poor responders on the basis of female age ≤40 years, basal follicle stimulating hormone ≤12 mIU/ml, and antral follicle count >5, respectively. Their mid-luteal E2 measured on the day of embryo transfer was stratified into groups (A-E) on the basis of 20th, 40th, 60th and 80th percentile values. The outcome was categorized into non-pregnant with beta human chorionic Gonadotrophin (hCG) 5-25 m IU/ml, and clinical pregnancy with beta hCG>25 m IU/ml.

Results:

The conception rate was 12% (63/513) in poor responders and 72% (237/329) in good responders respectively. The mid-luteal E2 levels were higher in conception as compared to non-conception cycles (p<0.001) in good and poor responders.

Conclusion:

Maximum pregnancies in poor and good responders (53% and 98% respectively) with mid-luteal E2 levels above 80^th percentiles confirm the role of the increase in mid-luteal E2 for augmentation in conception rate of females after ICSI.

[Poor responders: How could we improve our results?]

OBJECTIVES

Finding an efficient treatment for poor responders still poses a tremendous challenge for assisted reproductive technology. In 2011, an international consensus has been reached in Bologna on how to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. This article provides an objective assessment of the different treatment options currently available.

METHODS

A search of the database PUBMED was carried out for studies published in English between October 2000 and April 2016.

RESULTS

There is no ideal protocol to manage poor responders even though the antagonist protocol seems to have an advantage of clinicians. This is thanks to better patient tolerance and reduced total dose of gonadotrophin as well as shorter time of stimulation. It seems that there is no benefit in increasing the gonadotrophin daily doses over 300IU nor using any specific type of gonadotrophin. Today, there is insufficient evidence to recommend any additional treatment for poor responders. Only dehydroepiandrosterone (DHEA) seems to increase embryonic quality and pregnancy rate, however further exploration and complementary prospective studies are necessary.

CONCLUSION

New treatment strategies such as "oocyte banking" or double stimulation during the same cycle, could provide new prospects in poor responders management.

Evaluation of results obtained with corifollitropin alfa after poor ovarian response in previous cycle using recombinant follicular stimulating hormone in the long-term protocol

Objective

This study evaluated the use of Corifollitropin alfa in patients with previous poor response to recombinant follicle stimulating hormone in long-term protocols using gonadotropin-releasing hormone.

Methods

Twenty-seven poor responders to previous treatment with the long term protocol using the recombinant follicle stimulating hormone (Group 1) were selected and then submitted to a second attempt using the same long term protocol with Corifollitropin alfa instead of the recombinant follicle stimulating hormone (Group 2).

Ovarian down-regulation was achieved using subcutaneous administration of Leuprolide Acetate. Ovarian stimulation was performed with recombinant follicle stimulating hormone until the administration of human chorionic gonadotropin, followed by follicular aspiration (Group 1). Group 2 was submitted to this same protocol using Corifollitropin alfa instead of recombinant follicle stimulating hormone.

Results

There were significant differences in the number of aspirated oocytes, percentage of mature oocytes, amount of injected oocytes and transferred embryos - with all of these parameters being increased in the Corifollitropin alfa group. In addition, the rates of pregnancy and ongoing pregnancy were also significantly higher in the Corifollitropin alfa group.

Conclusion

The present study demonstrated that the use of Corifollitropin alfa in the long-term protocol could be a highly effective alternative for patients with poor ovarian response, who were unsuccessful in a previous treatment with In Vitro Fertilization - Intracytoplasmic Sperm Injection.

Prediction of Poor Ovarian response by Biochemical and Biophysical Markers: A Logistic Regression Model

OBJECTIVES

To study correlation between ovarian reserve with biophysical markers (antral follicle count and ovarian volume) and biochemical markers (S. FSH, S. Inhibin B, and S. AMH) and use these markers to predict poor ovarian response to ovarian induction.

METHODS

This is a prospective observational study. One hundred infertile women attending the Obst & Gynae Dept, KGMU were recruited. Blood samples were collected on day 2/day 3 for assessment of S. FSH, S. Inhibin B, and S. AMH and TVS were done for antral follicle count and ovarian volume. Clomephene citrate 100 mg 1OD was given from day 2 to 6, and patients were followed up with serial USG measurements. The numbers of dominant follicles (> or = 14 mm) at the time of hCG administration were counted. Patients with <3 follicles in the 1st cycle were subjected to the 2nd cycle of clomephene 100 mg 1OD from day 2 to day 6 with Inj HMG 150 IU given i.m. starting from day 8 and every alternate day until at least one leading follicle attained ≥18 mm. Development of <3 follicles at end of the 2nd cycle was considered as poor response.

RESULTS

Univariate analyses showed that s. inhibin B presented the highest (ROCAUC = 0.862) discriminating potential for predicting poor ovarian response, In multivariate logistic regression model, the variables age, FSH, AMH, INHIBIN B, and AFC remained significant, and the resulting model showed a predicted accuracy of 84.4 %.

CONCLUSION

A derived multimarker computation by a logistic regression model for predicting poor ovarian response was obtained through this study. Thus, potential poor responders could be identified easily, and appropriate ovarian stimulation protocol could be devised for such pts.

Addition of growth hormone to the microflare stimulation protocol among women with poor ovarian response

OBJECTIVE

To assess the efficacy of adding growth hormone (GH) to the microflare stimulation protocol among women with poor ovarian response.

METHODS

A parallel, open-label, randomized controlled trial was conducted among patients with poor ovarian response who attended a center in Cairo, Egypt, between July 10 and December 31, 2014. Participants were randomly assigned using a computer program (random block size of 4-8) to undergo the microflare protocol with or without GH. Primary outcomes were the mean numbers of mature oocytes retrieved and fertilized. Analyses were done per protocol: women with cycle cancellations were excluded.

RESULTS

The analysis included 72 women in the GH group and 73 in the microflare only group. The mean number of oocytes collected was 7.2±1.5 in the GH group versus 4.7±1.2 in the microflare only group (P<0.001). The mean number of metaphase II oocytes was 5.2±1.2 in the GH group and 2.8±1.0 in the microflare only group (P<0.001). The mean number of fertilized oocytes was higher in the GH group (4.2±1.1) than in the microflare only group (2.5±0.7; P<0.001).

CONCLUSION

Addition of GH to the microflare stimulation protocol provided some potential benefits to women with poor ovarian response. However, further studies are required before it could be recommended for routine clinical use. ClinicalTrials.gov:NCT02185326.

Ovarian Features after 2 Weeks, 3 Weeks and 4 Weeks Transdermal Testosterone Gel Treatment and Their Associated Effect on IVF Outcomes in Poor Responders

This study was performed to investigate the effect of of transdermal testosterone gel (TTG) on controlled ovarian stimulation (COS) and IVF outcomes and ovarian morphology according to pretreatment duration in poor responders. A total of 120 women were recruited for this pilot study. They were randomized into control, 2 weeks, 3 weeks or 4 weeks TTG treatment groups. For three TTG treatment groups, 12.5 mg TTG was applied daily for 2 weeks, 3 weeks or 4 weeks in preceding period of study stimulation cycle. After 3 weeks of TTG pretreatment, significant increase of antral follicle count (AFC) and significant decreases of mean follicular diameter (MFD) and resistance index (RI) value of ovarian stromal artery were observed (p=0.026, p<0.001, p<0.01, respectively). The total dose of rhFSH administered for COS significantly decreased after 3 and 4 weeks TTG treatment both compared with control group (p<0.001, p<0.001). The numbers of oocytes retrieved and mature oocytes were significanty higher in 3 and 4 weeks TTG treatment groups than control group (p<0.001, p<0.001 in the number of oocytes retrieved; p<0.001, p<0.001 in the number of mature oocytes). The clinical pregnancy rate and live birth rate were increased only in 4 weeks TTG treatment group compared with control group (p=0.030 and p=0.042, respectively). These data demonstrated that TTG pretreatment for 3 to 4 weeks increases AFC and ovarian stromal blood flow, thereby potentially improving the ovarian response to COS and IVF outcome in poor responders undergoing IVF/ICSI.

Comparison of pregnancy outcome after letrozole versus clomiphene treatment for mild ovarian stimulation protocol in poor responders

BACKGROUND

Poor ovarian response to controlled ovarian stimulation is one of the most important interest points in assisted reproduction. Mild ovarian stimulation seems to be preferable to high dose of FSH regimens in women with a history of poor ovarian response in previous protocol. Clomiphene citrate and letrozole alone or in combination with FSH have been used in mild ovarian stimulation protocol.

OBJECTIVE

To compare the efficacy of letrozole and clomiphene citrate for mild ovarian stimulation on assisted reproductive technology outcomes in poor responders.

MATERIALS AND METHODS

In a randomized control study, 184 women aged between 20 and 45 years with the history of poor response to ovarian stimulation who were candidate for ART were randomly subdivided into two groups: group I (n= 80), women who underwent the clomiphene/gonadotropin/antagonist protocol; and group II (n= 87), patients who underwent the letrozole/gonadotropin/antagonist protocol. Groups were compared regarding implantation, chemical and clinical pregnancy rates.

RESULTS

There was a significant difference in the mean endometrial thickness between two groups (9.16±1.2 mm vs. 8.3±0.3 mm). The implantation rate was significantly higher in letrozole group compare to clomiphene group (7.2 vs. 6.6%, p=0.024 respectively). No significant differences were found in chemical and clinical pregnancy rate between two groups.

CONCLUSION

In mild ovarian stimulation protocol, letrozole and clomiphene have similar value for the poor responder. The optimal treatment strategy for these patients remains debated.

Cost-effectiveness analysis comparing continuation of assisted reproductive technology with conversion to intrauterine insemination in patients with low follicle numbers

OBJECTIVE

To compare the cost effectiveness of proceeding with oocyte retrieval vs. converting to intrauterine insemination (IUI) in patients with ≤4 mature follicles during assisted reproductive technology (ART) cycles.

DESIGN

Probabilistic decision analysis. The cost effectiveness of completing ART cycles in poor responders was compared to that for converting the cycles to IUI.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Cost-effectiveness analysis.

MAIN OUTCOME MEASURE(S)

Cost effectiveness, which was defined as the average direct medical costs per ongoing pregnancy.

RESULT(S)

In patients with 1-3 mature follicles, completing ART was more cost effective if the cost of a single ART cycle was between $10,000 and $25,000. For patients with 4 mature follicles, if an ART cycle cost<$18,025, it was more cost effective to continue with oocyte retrieval than to convert to IUI.

CONCLUSION(S)

In patients with ≤4 mature follicles following ovarian stimulation in ART cycles, it was on average more cost effective to proceed with oocyte retrieval rather than convert to IUI. However, important factors, such as age, prior ART failures, other fertility factors, and medications used in each individual case need to be considered before this analysis model can be adapted by individual practices.

Association between intrafollicular concentration of benzene and outcome of controlled ovarian stimulation in IVF/ICSI cycles: a pilot study

BACKGROUND

Several studies have shown that exposure to benzene is associated to menstrual disorders, miscarriages and other disorders of the reproductive system. We performed an observational prospective pilot study to evaluate if levels of benzene in follicular fluid were correlated with response to controlled ovarian stimulation.

METHOD

Thirty-four normogonadotrophic women undergoing IVF were enrolled. Intra-follicular benzene levels were evaluated by chromatography/mass spectrometry. Based on median benzene level, we divided the study population in two groups: Group A with a "low" intra-follicular benzene concentration (n=19, benzene <0.54 ng/mL) and Group B with a "high" intra-follicular benzene concentration (n=15, benzene ≥ 0.54 ng/mL). The ovarian response to gonadotrophins and the outcome of IVF were analyzed in the two groups.

RESULTS

The two groups did not differ in terms of demographic or anthropometric characteristics. Group B had significantly higher basal FSH levels, lower estradiol peak concentration, and fewer oocytes retrieved and embryos transferred (p<0.05). Number of gonadotrophin vials, length of controlled ovarian stimulation and ongoing pregnancy rate were similar in the two groups.

CONCLUSION

In conclusion, ovarian response to endogenous and exogenous gonadotrophins appeared to be influenced by intra-follicular benzene levels.

Serum anti-Müllerian hormone level as a predictor of poor ovarian response in in vitro fertilization patients

Purpose

To evaluate the clinical value of day 3 serum anti-Müllerian hormone (AMH) compared with day 3 serum follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG) day estradiol (E2) levels and antral follicle count (AFC) in the prediction of poor ovarian response in controlled ovarian hyperstimulation (COH).

Methods

AMH, FSH and AFC on day 3 as well as hCG day E2 levels were determined in 164 subjects. Receiver operating curve analyses and area under curves (AUC) of the study parameters were performed. Predictive values of the levels of day 3 AMH, FSH, AFC, and hCG day E2 as clinical parameters of ovarian response to COH were studied.

Results

Thirty-eight women were defined as poor responders. The day 3 AMH and hCG day E2 levels and AFC of normal responders were significantly higher than those of the poor responders. In predicting poor response, the AUC of day 3 AMH level was significantly higher than that of day 3 FSH level but was similar to the hCG day E2 level. Day 3 AMH, FSH and hCG day E2 levels and AFC were found to predict a poor response. Day 3 AMH and hCG day E2 levels were more predictive compared with day 3 FSH level and AFC. The cut-off level of AMH was ≤2 with a sensitivity of 78.9% and a specificity of 73.8%.

Conclusion

Day 3 AMH has the ability to predict a poor response to COH and it is more predictive than day 3 FSH and AFC.