Double stimulations during the follicular and luteal phases of poor responders in IVF/ICSI programmes (Shanghai protocol)

New stimulation regimens: endogenous and exogenous progesterone use to block the LH surge during ovarian stimulation for IVF

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.

Long-acting recombinant follicle-stimulating hormone in random-start ovarian stimulation protocols for fertility preservation in women with cancer

INTRODUCTION

The objective of this study was to assess the effectiveness and potential benefits of the use of long-acting recombinant follicle-stimulating hormone (FSH) in a random-start protocol for fertility preservation in women with cancer.

MATERIAL AND METHODS

This is a retrospective before-and-after study performed between February 2013 and December 2015 in women who underwent ovarian hyperstimulation for oocyte cryobanking using a random-start approach. In the first part of the study period, the women were treated with daily recombinant FSH whereas in the second part the stimulation was initiated with long-acting recombinant FSH. The primary aim of the study was to compare the number of oocytes stored in the two study periods. In all, 140 women were ultimately selected.

RESULTS

Compared with daily recombinant FSH, the use of the long-acting compound was associated with a reduced number of injections (12.5 ± 3.5 vs. 16.4 ± 0.3; p < 0.001) and a longer duration of stimulation (11.4 ± 1.9 vs. 10.6 ± 1.9, p = 0.01). Conversely, the number of oocytes collected (13.7 ± 9.5 vs. 11.3 ± 7.0, p = 0.10) as well as those cryopreserved (11.0 ± 8.0 vs. 9.5 ± 5.8, p = 0.21) did not differ.

CONCLUSIONS

The use of long-acting recombinant FSH in random-start protocols for fertility preservation appears to be a valuable option.

Double ovarian stimulation (DuoStim) protocol for fertility preservation in female oncology patients

This article describes a revised ovarian stimulation protocol (DuoStim) for fertility preservation in female oncology patients which aims to maximise the number of gametes obtained with subsequent improvement in cumulative birth rate, without delaying cancer treatment. Ten patients diagnosed with malignancy between September 2014 and October 2015 were included. The patients were treated with the DuoStim protocol, undergoing two consecutive ovarian stimulation cycles and two oocyte retrievals. The primary outcome was the number of oocytes collected and vitrified during each oocyte retrieval and in total. The protocol was evaluated regarding medical risk and patients' feedback. During the first oocyte collection 81 oocytes (61 metaphase II) were retrieved (mean = 8.1; range = 1-13) and during the second oocyte collection 82 oocytes (67 metaphase II) were retrieved (mean= 8.2; range = 1-19). A total of 163 oocytes (128 metaphase II) were collected (mean = 16.3; range = 6-32) and cancer treatment was not delayed for any of these patients. There were no cases of ovarian hyperstimulation syndrome recorded. More patients and long-term follow-up is needed to assess the efficacy and safety of the DuoStim protocol. However, these early results are encouraging, demonstrating an increase in number of mature oocytes retrieved during ovarian stimulation for oncology patients, without delaying cancer treatment.

[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.

Luteal-phase ovarian stimulation is a feasible method for poor ovarian responders undergoing in vitro fertilization/intracytoplasmic sperm injection-embryo transfer treatment compared to a GnRH antagonist protocol: A retrospective study

OBJECTIVE

Poor ovarian response to ovarian hyperstimulation is one of the biggest challenges in assisted reproduction technology. Although many stimulation protocols have been established to improve clinical outcomes in poor ovarian responders (PORs), which protocol is the most effective remains controversial. Luteal-phase ovarian stimulation (LPOS) has been used in normal ovarian responders with satisfactory outcomes. However, the efficacy of LPOS in PORs is unclear. This study aimed to compare the efficacy of LPOS and GnRH antagonist (GnRH-ant) in PORs.

MATERIALS AND METHODS

The clinical parameters in PORs who received LPOS (50 cycles in 39 patients) or GnRH-ant (158 cycles in 123 patients) were compared.

RESULTS

Compared with those in the GnRH-ant group, the PORs in the LPOS group showed significantly fewer basal antral follicles (3.1 ± 2.2 vs. 4.1 ± 1.6, p < 0.001) and a higher in vitro fertilization rate. There were no significant differences in the numbers of retrieved oocytes and D3 transferable embryos between the two groups. However, the pregnancy rate in the LPOS group (46.4%) was significantly higher than that in the GnRH-ant group (25.8% overall; 22.9% from fresh embryos and 29.6% from frozen embryos). Moreover, 23 PORs in the LPOS group underwent oocyte retrieval twice in one cycle, and the numbers of retrieved oocytes and transferable embryos from the luteal phase were significantly higher than those from the follicular phase in the same menstrual cycle.

CONCLUSIONS

Compared with the GnRH-ant protocol, the LPOS protocol may be a better regime for PORs that can increase the numbers of retrieved oocytes and transferable embryos as well as the pregnancy rate.

Optimal embryo transfer strategy in poor response may include freeze-all

PURPOSE

In this retrospective cohort study, we investigated the best embryo transfer strategy in ICSI cycles with ≤4 oocytes collected at oocyte retrieval.

METHODS

Women who underwent antagonist co-treatment COS for ICSI treatment between January 2010 and December 2015 at a private ART clinic (N = 2263). Eight hundred seventy-nine women (group 1) had ≤4 oocytes collected at oocyte retrieval, of whom 645 (group A) had cleavage stage embryo transfer (ET), and 234 (group B) had blastocyst ET. One thousand three hundred eighty-four women (group 2) had 10-15 oocytes collected at oocyte retrieval, of whom 676 (group C) had cleavage stage ET, and 708 women (group D) had blastocyst ET. Blastocyst vitrification was performed using the Cryotop method and FET using artificial cycles.

RESULTS

In group 1, the cancellation rate was significantly lower in group A (25.2 vs 38 %). The pregnancy rate (PR), clinical PR, implantation rate (IR), and live birth rate (LBR) per ET and per oocyte retrieval were all lower in group A. The clinical PR, IR, and LBR per ET of vitrified-warmed blastocyst ET were significantly the highest. In group 2, the cycle cancellation rate was significantly lower in group C (3.5 vs 13.4 %). The PR, clinical PR, and IR per ET and per oocyte retrieval were all lower in group C. The LBR per ET was significantly lower, but the LBR per oocyte retrieval was not significantly lower in group C. Again, the PR, clinical PR, and IR per ET of vitrified-warmed blastocyst ET were significantly the highest.

CONCLUSIONS

Day 5 ET strategy has been reserved for normal or high responders. The improved pregnancy outcomes from blastocyst culture and cryopreservation may challenge ART to extend this benefit to poor responders.

Ovarian stimulation in the luteal phase: systematic review and meta-analysis

PURPOSE

The purpose of this study was to evaluate whether outcomes are different if controlled ovarian stimulation (COS) is started in the luteal phase rather than the follicular phase.

METHODS

A systematic review and meta-analysis was performed. Sixteen studies were included in the qualitative analysis, and eight studies with a total of 338 women were included in the quantitative analysis.

RESULTS

Cycles initiated in the luteal phase were slightly longer (WMD 1.1 days, 95 % CI 0.39-1.9) and utilized more total gonadotropins (WMD 817 IU, 95 % CI 489-1144). However, no differences were noted in peak estradiol levels (WMD -411 pg/ml, 95 % CI -906-84.7) or in the total number of oocytes retrieved (WMD 0.52 oocytes, 95 % CI -0.74-1.7). There were slightly more mature oocytes retrieved in the luteal phase (WMD 0.77 oocytes, 95 % CI 0.21-1.3), and fertilization rates were significantly higher (WMD 10 %, 95 % CI 0.03-0.18). While only three studies reported pregnancy outcomes, no difference was noted in the FET pregnancy rates after COS in the luteal versus follicular phase (RR 0.95, 95 % CI 0.56-1.7). A post hoc power analysis revealed that a sample of this size was sufficient to detect a clinically meaningful difference of 2 oocytes retrieved with 93 % power.

CONCLUSION

Although initiating COS in the luteal phase requires a longer stimulation and a higher dose of total gonadotropin, these differences are not clinically significant. Furthermore, COS initiated in the luteal phase does not compromise the quantity or quality of oocytes retrieved compared to outcomes of traditional stimulation in the follicular phase.

Freezing oocytes or embryos after controlled ovarian hyperstimulation in cancer patients: the state of the art

Quality of life of young cancer survivors has become a major issue. However, anticancer therapies can have a detrimental impact on fertility. It is now well-established that all patients should receive information about the fertility risks associated with their cancer treatment and the fertility preservation options available. Currently, oocyte or embryo banking after controlled ovarian hyperstimulation represents the most effective method for preserving female fertility. Over the past years innovative protocols of ovarian stimulation have been developed to enable cancer patients to undergo oocyte or embryo cryopreservation irrespective of the phase of the cycle or without exogenous follicle-stimulating hormone-related increase in serum estradiol levels. The present article reviews the different protocols of ovarian hyperstimulation for cancer patients, candidates for fertility preservation.

Luteal-phase ovarian stimulation vs conventional ovarian stimulation in patients with normal ovarian reserve treated for IVF: a large retrospective cohort study

OBJECTIVE

We have previously reported a new luteal-phase ovarian stimulation (LPS) strategy for infertility treatment. The purpose of this study was to systematically assess the efficiency and safety of this strategy by comparing it with conventional ovarian stimulation protocols.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients with normal ovarian reserve undergoing ovum pick-up (OPU) cycles between April 2012 and September 2013 were enrolled: 708 patients underwent the LPS protocol compared with 745 patients who underwent the mild treatment protocol and 1287 patients who underwent the short-term protocol.

MEASUREMENTS

Number of mature oocytes retrieved and top-quality embryos obtained, implantation rate, pregnancy rate, live birth and ongoing pregnancy rate and neonatal outcomes.

RESULTS

The numbers of mature oocytes retrieved and top-quality embryos obtained per OPU cycle were significantly increased in the LPS group (10·9 ± 7·6 and 4·6 ± 4·3, respectively) compared with the mild treatment group (3·7 ± 3·0 and 1·8 ± 1·8, respectively, both P < 0·001) or the short-term group (9·1 ± 5·5 and 3·7 ± 3·1, respectively, both P < 0·001). Moreover, the total gonadotrophin used was also the highest in the LPS group. No significant differences were identified in the implantation rate (35·5% vs 34·8%, P > 0·05), pregnancy rate (46·2% vs 43·7%, P > 0·05) or live birth and ongoing pregnancy rate (44·4% vs 41·7%, P > 0·05) per frozen-thawed embryo transfer (FET) cycle in the LPS and mild treatment groups, respectively. However, the LPS protocol achieved a higher implantation rate (35·5% vs 31·8%, P = 0·012), pregnancy rate (46·2% vs 41·9%, P = 0·041), and live birth and ongoing pregnancy rate (44·4% vs 39·2%, P = 0·012) compared with the short-term protocol. Neonatal outcomes in the LPS group were similar to the other two groups.

CONCLUSIONS

The available data suggest that LPS is a feasible strategy for infertility treatment and complements the available follicular-phase ovarian stimulation strategies.

Flexibility in starting ovarian stimulation at different phases of the menstrual cycle for treatment of infertile women with the use of in vitro fertilization or intracytoplasmic sperm injection

OBJECTIVE

To investigate flexibility in starting controlled ovarian stimulation at any phase of the menstrual cycle in infertile women undergoing treatment with assisted reproduction.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary-care medical center.

PATIENT(S)

At total of 150 infertile patients undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Ninety of the women also underwent frozen embryo transfer (FET) procedures.

INTERVENTION(S)

Depending on the phase of the menstrual cycle when ovarian stimulation was started, three groups of patients were identified, namely: conventional group (ovarian stimulation started in the early follicular phase), late follicular phase group, and luteal phase group. When dominant follicles were observed, final oocyte maturation was triggered with the use of GnRH agonist and hCG. In all three groups, viable embryos were cryopreserved for subsequent transfer.

MAIN OUTCOME MEASURE(S)

PRIMARY OUTCOME

number of mature oocytes retrieved.

SECONDARY OUTCOMES

fertilization rate, viable embryo rate per oocyte retrieved, cancellation rate, and clinical pregnancy outcomes from FET cycles.

RESULTS(S)

There were no differences in the mean number of mature oocytes retrieved in the conventional group, late follicular phase group, and luteal phase group (5.7 ± 3.6, 5.2 ± 3.7, and 5.2 ± 3.9, respectively). Similarly, no significant differences were observed in the viable embryo rate per oocyte retrieved (37.9%, 38.5%, and 43.6%), clinical pregnancy rates (41.5%, 45.5%, and 38.9%), and implantation rates (30.7%, 30.2%, and 27.1%) in the three groups.

CONCLUSION(S)

All three ovarian stimulation protocols were observed to be equally effective. These results demonstrate that ovarian stimulation can be commenced on any day of the menstrual cycle.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-OPN-15007332.

GnRH agonist trigger for the induction of oocyte maturation in GnRH antagonist IVF cycles: a SWOT analysis

Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of ovarian hyperstimulation syndrome during IVF treatment. This trigger concept, however, results in early corpora lutea demise and consequently luteal phase dysfunction and impaired endometrial receptivity. The aim of this strenghths, weaknesses, opportunities and threats analysis was to summarize the progress made over the past 15 years to optimize ongoing pregnancy rates after GnRHa trigger. The advantages and potential drawbacks of this type of triggering are reviewed. The current approach to the management of GnRHa trigger in autologous cycles is based on the peak serum oestradiol level or follicle number and aims at a fresh embryo transfer or a segmentation approach with elective cryopreservation policy. We recommend intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/ml after GnRHa trigger or dual trigger with GnRHa and HCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL. On the contrary, we recommend HCG 1500 IU 35 h after GnRHa trigger if there are less than 25 follicles, or freeze all oocytes or embryos if there are over 25 follicles.

Comparison between follicular stimulation and luteal stimulation protocols with clomiphene and HMG in women with poor ovarian response

This retrospective study is to compare the follicular mild stimulation and luteal simulation protocols for poor responders undergoing in vitro fertilization (IVF). A total of 131 women were diagnosed as poor responders. Thirty-three women started ovarian stimulation in early-luteal phase and 98 women started in early follicular phase with 100 mg/d clomiphene citrate and 75-150 IU/d HMG. There were more oocytes retrieved (2.8 ± 2.0 versus 2.0 ± 1.2, p < 0.05), more available embryos (1.8 ± 1.4 versus 1.3 ± 1.1, p < 0.05) and top-quality embryos (0.9 ± 0.9 versus 0.4 ± 0.6, p < 0.05), and reduced cycle cancellation rate (12.1% versus 30.6%, p < 0.05) in luteal group than in follicular group. The clinical pregnancy (17.7%, 20.0% and 41.2%) and live-birth rates (10.78%, 20.0% and 29.4%) after transferring embryos obtained from luteal, follicular and mixed stages were comparable (p > 0.05). For poor responders, luteal phase stimulation could be an option because of increasing the chance to obtain competent embryos and reducing the cycle cancellation rate.

Luteal phase ovarian stimulation following oocyte retrieval: is it helpful for poor responders?

BACKGROUND

Poor ovarian response and retrieval of no oocytes following ovarian stimulation for in vitro fertilization (IVF) is a challenging problem for both the patient and the clinician.

FINDINGS

Recent evidence indicates that folliculogenesis occurs in a wave-like fashion indicating that there are multiple follicular recruitment waves in the same menstrual cycle. This relatively new scientific concept provides new opportunities for the utilization of ovarian stimulation in women with poor ovarian response. This communication reports on the social and scientific rationale for the use of luteal phase ovarian stimulation following oocyte retrieval in the same cycle (also called double stimulation).

CONCLUSIONS

Data to date showed that double ovarian stimulation in poor responders provides shorter time for retrieving mature oocytes with the potential formation of good quality embryos, and thus healthy pregnancies.