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Saharkhiz N, Salehpoor S, Hosseini S, Nazari L, Sheibani S, Doohandeh T. Comparison In Vitro Fertilization Outcomes between DouStim and Minimal Stimulation Protocols in Poor Ovarian Responders: A Randomized Clinical Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2024; 18:135-139. [PMID: 38368516 PMCID: PMC10875315 DOI: 10.22074/ijfs.2023.552687.1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 03/13/2023] [Accepted: 04/09/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Various protocols have been approved to improve the response rate leading to successful fertilization in poor ovarian responders (PORs). The application of double ovarian stimulation (DuoStim) in the follicular and luteal phases of the same ovarian cycle has been shown as an intriguing option to achieve more oocyte retrievals in the shortest time. The aim of the current study is to compare the outcomes of different protocols, minimal stimulation (MS) and Duostim. MATERIALS AND METHODS This randomized clinical trial was performed on 42 in vitro fertilization (IVF) candidates with POR diagnosis. Patients were classified into two equal groups and treated with the DuoStim protocol and MS protocol. The IVF outcomes, including retrieved follicles, oocytes, metaphase II (MII) oocytes and embryos, were compared between these groups. RESULTS The patients' characteristics including age, anti-mullerian hormone (AMH), follicle stimulating hormone (FSH), luteinizing hormone (LH), and antral follicle count (AFC) were collected and compared. It showed there was no significant difference between the two groups baseline characteristics (P>0.05). We observed that the DuoStim protocol resulted in a significantly higher score in comparison with the MS protocols , including the number of follicles (6.23 ± 2.93 vs. 1.77 ± 1.66, P<0.001), retrieved oocytes (3.86 ± 2.57 vs. 1.68 ± 1.58, P=0.002), MII oocytes (3.36 ± 2.42 vs. 1.27 ± 1.27, P=0.001) and obtained embryos (2.04 ± 1.64 vs. 0.77 ± 0.86, P=0.003). CONCLUSION The DuoStim protocol is a favourable and time saving plan that is associated with more oocytes in a single stimulation cycle. The DuoStim protocol significantly can result in more frequent MII oocytes and embryos. We figured that the higher number of oocytes and embryos might have led to a higher rate of pregnancy (registration number: IRCT20200804048303N1).
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Affiliation(s)
- Nasrin Saharkhiz
- Preventive Gynecology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saghar Salehpoor
- Preventive Gynecology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sedigheh Hosseini
- Preventive Gynecology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Nazari
- Preventive Gynecology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samaneh Sheibani
- Preventive Gynecology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tahereh Doohandeh
- Preventive Gynecology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Ghahghayi F, Payandeh A, Najafian A, Ghasemi M, Jabari AJ. Investigating Ovulation Induction Outcomes in Patients with Decreased Ovarian Reserve Treated with Double Stimulation during The Follicular and Luteal Phases Compared to The Conventional Antagonist Cycle: A Randomized Clinical Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2024; 18:140-145. [PMID: 38368517 PMCID: PMC10875316 DOI: 10.22074/ijfs.2023.1978181.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 07/05/2023] [Accepted: 12/31/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND It is difficult to obtain healthy oocytes in poor ovarian responders with conventional treatment methods. Thus, the need to investigate new methods is essential. This study aims to investigate ovulation induction outcomes in patients with decreased ovarian reserve (DOR) in two groups treated with double stimulation (DuoStim) during the follicular and luteal phases in comparison with the antagonist cycle. MATERIALS AND METHODS This was a randomised clinical trial that enrolled the patients with reduced ovarian reserve. The patients referred for in vitro fertilization (IVF) at Molud Infertility Clinic, Ali Ebn Abitalib (AS) Hospital, Zahedan, Iran from 2020 to 2021. Participants were randomly divided into two groups, those who underwent treatment with DuoStim during the follicular and luteal phase (case group) and those who received the conventional antagonist cycle (control group). RESULTS The mean number of metaphase II (MII) eggs was 7.7 ± 3.1 in the case group and 6.1 ± 3.9 in the control group (P=0.063). The mean total number of retrieved eggs in the case group was 9.2 ± 3.7 and in the control group, it was 6.9 ± 4.4 (P=0.023). The mean number of embryos obtained in the case group was 6.5 ± 3.9; in the control group, it was 4.7 ± 2.8 (P=0.016). CONCLUSION The DuoStim method can effectively play a role in increasing the total number of retrieved eggs and embryos (registration number: IRCT20120817010617N8).
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Affiliation(s)
- Fatemeh Ghahghayi
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Abolfazl Payandeh
- Department of Biostatistics and Epidemiology, Infectious Diseases and Tropical Medicine Research Centre, Resistant Tuberculosis Institute, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Aida Najafian
- Department of Obstetrics, Gynaecology and Infertility, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Ghasemi
- Department of Obstetrics and Gynaecology, Molud Infertility Centre, Zahedan University of Medical Sciences, Zahedan, Iran
- Pregnancy Health Research Centre, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Ayob Jabari Jabari
- Department of Obstetrics and Gynaecology, Molud Infertility Centre, Zahedan University of Medical Sciences, Zahedan, Iran
- Cellular and Molecular Research Centre, Research Institute of Cellular and Molecular Science in Infectious Diseases, Zahedan University of Medical Sciences, Zahedan, Iran
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Wei H, Pan N, Wang Y, Ma C. Segmented in vitro fertilization and frozen embryo transfer in levonorgestrel-releasing intrauterine device treated patients with endometrial cancer. Arch Gynecol Obstet 2023; 308:1845-1852. [PMID: 37656272 PMCID: PMC10579151 DOI: 10.1007/s00404-023-07170-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/20/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE To evaluate the efficacy of levonorgestrel-releasing intrauterine device (LNG-IUD) during controlled ovarian stimulation (COS) in patients with early-stage endometrioid endometrial cancer (EEC). METHODS A retrospective study was conducted on patients with stage IA1 EEC who achieved complete response after fertility-sparing treatment from December 2018 to December 2021, with all the women who underwent COS having LNG-IUDs inserted in their uterine cavity. RESULTS 16 patients were enrolled who underwent 26 COS cycles and average age was 33.19 ± 4.04 years. 12 patients had 19 subsequent frozen-thawed embryo transfer (FET) cycles. Among the other four patients, no embryos were obtained in 1 patient, 1 patient got pregnancy spontaneously with term delivery after COS, 1 patient relapsed before FET, and 1 patient did not receive embryo transfer for personal reason. Among 19 FET cycles, the clinical pregnancy and live birth rates in each ET cycle were 36.84% (7/19) and 26.32% (5/19), respectively. 7 clinical pregnancies resulted in 2 miscarriages (28.6%), and 5 live births (71.4%). Totally 6 patients achieved 7 live births, and the cumulative live birth rate was 37.5% (6/16). Three (18.75%) out of 16 patients relapsed after COS during the follow-up period (31.31 ± 15.89 months) and two of them were initially diagnosed with moderately differentiated EEC. Time interval from COS to relapse was 6.63,11.67 and 16.23 months, respectively. CONCLUSION The combination of LNG-IUD treatment and segmented IVF may be a viable treatment strategy to improve oncological and reproductive outcomes for patients with early-stage EEC.
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Affiliation(s)
- Hongyi Wei
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, 102206, China
| | - Ningning Pan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China.
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Wei H, Pan N, Wang Y, Ma C. Analysis of risk factors for recurrence in infertile endometrial cancer patients after in vitro fertilization treatment. Front Endocrinol (Lausanne) 2023; 14:1224622. [PMID: 38075071 PMCID: PMC10702941 DOI: 10.3389/fendo.2023.1224622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/24/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose To investigate the oncologic outcomes of patients with early-stage endometrioid endometrial cancer (EEC) treated with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) following fertility-sparing treatment (FST). Methods A total of 62 patients who underwent IVF/ICSI treatment in a single fertility center between June 2010 and December 2021 after conservative treatment for early-stage EEC were assigned to a recurrence group and a non-recurrence group. Their clinical characteristics and disease outcomes were retrospectively evaluated. Results The 62 women with complete remission (CR) after FST for EEC underwent 103 IVF cycles, resulting in 41 fresh embryo transfers (ETs) and 70 frozen-thawed transfers; 27 (43.55%) achieved clinical pregnancies, and 20 (32.26%) gave birth to a total of 23 live neonates. Additionally, nine patients had live births from natural pregnancies after IVF failure, bringing the cumulative live birth rate to 46.77% (29/62). After a median follow-up period of 53.88 months (range 20.2-127.5 months), 17 patients (27.42%) experienced recurrence within 2.8 to 57.9 months after the first controlled ovarian stimulation (COS). The probability of relapse at 1, 2, and 3 years after the initiation of COS was 14.52% (9/62), 21% (13/62), and 25.81% (16/62), respectively. Factors such as the time to CR, the time to IVF, the frequency of COS, maintenance treatment before IVF, and histology type were not found to significantly affect recurrence (p = 0.079, 0.182, 0.093, 0.267, and 0.41, respectively). Live births (hazard ratio (HR): 0.28, 95% CI: 0.082-0.962, p = 0.043) and the protocol of letrozole plus gonadotropin-releasing hormone (GnRH) antagonist/agonist used during IVF (HR: 0.1, 95% CI: 0.011-0.882, p = 0.038) were identified as independent favorable factors for recurrence. Conclusions Live birth was associated with decreased recurrence of EEC. Reducing estrogen levels during COS may serve to mitigate the risk of endometrial cancer recurrence.
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Affiliation(s)
- Hongyi Wei
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Ningning Pan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Key Laboratory of Assisted Reproduction, Ministry of Education, Peking University, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
| | - Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Key Laboratory of Assisted Reproduction, Ministry of Education, Peking University, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Key Laboratory of Assisted Reproduction, Ministry of Education, Peking University, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
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Sparaco M, Carbone L, Landi D, Ingrasciotta Y, Di Girolamo R, Vitturi G, Marfia GA, Alviggi C, Bonavita S. Assisted Reproductive Technology and Disease Management in Infertile Women with Multiple Sclerosis. CNS Drugs 2023; 37:849-866. [PMID: 37679579 PMCID: PMC10570169 DOI: 10.1007/s40263-023-01036-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
Multiple sclerosis (MS) predominantly affects women of fertile age. Various aspects of MS could impact on fertility, such as sexual dysfunction, endocrine alterations, autoimmune imbalances, and disease-modifying therapies (DMTs). The proportion of women with MS (wMS) requesting infertility management and assisted reproductive technology (ART) is increasing over time. In this review, we report on data regarding ART in wMS and address safety issues. We also discuss the clinical aspects to consider when planning a course of treatment for infertility, and provide updated recommendations to guide neurologists in the management of wMS undergoing ART, with the goal of reducing the risk of disease activation after this procedure. According to most studies, there is an increase in relapse rate and magnetic resonance imaging activity after ART. Therefore, to reduce the risk of relapse, ART should be considered in wMS with stable disease. In wMS, especially those with high disease activity, fertility issues should be discussed early as the choice of DMT, and fertility preservation strategies might be proposed in selected cases to ensure both disease control and a safe pregnancy. For patients with stable disease taking DMTs compatible with pregnancy, treatment should not be interrupted before ART. If the ongoing therapy is contraindicated in pregnancy, then it should be switched to a compatible therapy. Prior to beginning fertility treatments in wMS, it would be reasonable to assess vitamin D serum levels, thyroid function and its antibody serum levels; start folic acid supplementation; and ensure smoking and alcohol cessation, adequate sleep, and food hygiene. Cervico-vaginal swabs for Ureaplasma urealyticum, Mycoplasma hominis, and Chlamydia trachomatis, as well as serology for viral hepatitis, HIV, syphilis, and cytomegalovirus, should be performed. Steroids could be administered under specific indications. Although the available data do not clearly show a definite raised relapse risk associated with a specific ART protocol, it seems reasonably safe to prefer the use of gonadotropin-releasing hormone (GnRH) antagonists for ovarian stimulation. Close clinical and radiological monitoring is reasonably recommended, particularly after hormonal stimulation and in case of pregnancy failure.
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Affiliation(s)
- Maddalena Sparaco
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Naples, Italy
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ylenia Ingrasciotta
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Raffaella Di Girolamo
- Department of Public Health, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Giacomo Vitturi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Alviggi
- Department of Public Health, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Miraglia, 2, 80138, Naples, Italy.
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Palomba S, Costanzi F, Nelson SM, Caserta D, Humaidan P. Interventions to prevent or reduce the incidence and severity of ovarian hyperstimulation syndrome: a systematic umbrella review of the best clinical evidence. Reprod Biol Endocrinol 2023; 21:67. [PMID: 37480081 PMCID: PMC10360244 DOI: 10.1186/s12958-023-01113-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threating iatrogenic complication of the early luteal phase and/or early pregnancy after in vitro fertilization (IVF) treatment. The aim of the current study was to identify the most effective methods for preventing of and reducing the incidence and severity of OHSS in IVF patients. A systematic review of systematic reviews of randomized controlled trials (RCTs) with meta-analysis was used to assess each potential intervention (PROSPERO website, CRD 268626) and only studies with the highest quality were included in the qualitative analysis. Primary outcomes included prevention and reduction of OHSS incidence and severity. Secondary outcomes were maternal death, incidence of hospital admission, days of hospitalization, and reproductive outcomes, such as incidence of live-births, clinical pregnancies, pregnancy rate, ongoing pregnancy, miscarriages, and oocytes retrieved. A total of specific interventions related to OHSS were analyzed in 28 systematic reviews of RCTs with meta-analyses. The quality assessment of the included studies was high, moderate, and low for 23, 2, and 3 studies, respectively. The certainty of evidence (CoE) for interventions was reported for 37 specific situations/populations and resulted high, moderate, and low-to-very low for one, 5, and 26 cases, respectively, while it was not reported in 5 cases. Considering the effective interventions without deleterious reproductive effects, GnRH-ant co-treatment (36 RCTs; OR 0.61, 95% C 0.51 to 0.72, n = 7,944; I2 = 31%) and GnRH agonist triggering (8 RCTs; OR 0.15, 95% CI 0.05 to 0.47, n = 989; I2 = 42%) emerged as the most effective interventions for preventing OHSS with a moderate CoE, even though elective embryo cryopreservation exhibited a low CoE. Furthermore, the use of mild ovarian stimulation (9 RCTs; RR 0.26, CI 0.14 to 0.49, n = 1,925; I2 = 0%), and dopaminergic agonists (10 RCTs; OR 0.32, 95% CI 0.23 to 0.44, n = 1,202; I2 = 13%) coadministration proved effective and safe with a moderate CoE. In conclusion, the current study demonstrates that only a few interventions currently can be considered effective to reduce the incidence of OHSS and its severity with high/moderate CoE despite the numerous published studies on the topic. Further well-designed RCTs are needed, particularly for GnRH-a down-regulated IVF cycles.
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Affiliation(s)
- Stefano Palomba
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa, n. 1035/1039, Rome, 00189, Italy.
| | - Flavia Costanzi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa, n. 1035/1039, Rome, 00189, Italy
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow, UK
- NIHR Bristol Biomedical Research Centre, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
- TFP, Oxford Fertility, Institute of Reproductive Sciences, Oxford, UK
| | - Donatella Caserta
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa, n. 1035/1039, Rome, 00189, Italy
| | - Peter Humaidan
- The Fertility Clinic, Faculty of Health, Skive Regional Hospital, Aarhus University, Aarhus C, Denmark
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Clinical Application of Double Ovulation Stimulation in Patients with Diminished Ovarian Reserve and Asynchronous Follicular Development Undergoing Assisted Reproduction Technology. Curr Med Sci 2023; 43:304-312. [PMID: 36913110 DOI: 10.1007/s11596-022-2687-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/17/2022] [Indexed: 03/14/2023]
Abstract
OBJECTIVE This study aimed to compare the clinical effects of double ovulation stimulation (DouStim) applied during the follicular and luteal phases with the antagonist protocol in patients with diminished ovarian reserve (DOR) and asynchronous follicular development undergoing assisted reproductive technology (ART). METHODS The clinical data of patients with DOR and asynchronous follicular development receiving ART from January 2020 to December 2021 were retrospectively analyzed. The patients were divided into two groups according to their ovulation stimulation protocol: DouStim group (n=30) and antagonist group (n=62). Assisted reproduction and clinical pregnancy outcomes were compared between the two groups. RESULTS In the DouStim group, the number of oocytes retrieved, metaphase II (MII) oocytes, two-pronuclei (2PN), day 3 (D3) embryos, D3 high-quality embryos as well as blastocyst formation, implantation, and human chorionic gonadotropin-positive rates were significantly greater than those in the antagonist group (all P<0.05). No significant differences were found in MII, fertilization, or continued pregnancy rates at the first frozen embryo transfer (FET), in-vitro fertilization (IVF) cancellation, or early medical abortion rates between the groups (all P>0.05). Except for the early medical abortion rate, the DouStim group generally had favorable outcomes. In the DouStim group, the dosage and duration of gonadotropin and the fertilization rate were significantly greater in the first ovulation stimulation induction than in the second ovulation stimulation induction (P<0.05). CONCLUSION The DouStim protocol efficiently and economically obtained more mature oocytes and high-quality embryos for patients with DOR and asynchronous follicular development.
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Galatis D, Kalopita K, Grypiotis I, Flessas I, Kiriakopoulos N, Micha G. Researching the Phenomenon of Poor Ovarian Responders and Management Strategies in IVF: A Narrative Review. Acta Med Acad 2022; 51:108-122. [PMID: 36318003 PMCID: PMC9982854 DOI: 10.5644/ama2006-124.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
This narrative review aims to summarize all the latest studies published between 2015-2021 concerning the management protocols adopted for poor ovarian response (POR) cases. Patients defined as "poor responders" show minimal response to controlled ovarian hyperstimulation, although there is no standard definition for POR. Although infertility specialists are endeavoring to improve cycle outcomes in poor responders by adopting multiple management strategies, still the estimated risk of cycle cancellation is about 20%. All the studies performed during this study period were evaluated and their results were recorded. The latest published protocols to improve oocyte retrieval in poor responders include: anti-Mϋllerian hormone, clomiphene citrate, co-enzyme Q10, corifollitropin, dehydroepiandrosterone, double stimulation, Follicle Stimulation Hormone, Growth Hormone, Gonadotropin-releasing hormone agonists, letrozole, human chorionic gonadotropin, Luteinizing Hormone, progesterone and testosterone. CONCLUSION: Although many strategies have been suggested to manage POR, none has been proven superior to the others. Further large-scale randomized studies are needed to validate experimental techniques leading towards successful individualized treatment regimens.
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Affiliation(s)
- Dionysios Galatis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece.
| | - Konstantina Kalopita
- Department of Anaesthesia, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Ioannis Grypiotis
- Department of Anaesthesia, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Ioannis Flessas
- Breast Center, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Nikolaos Kiriakopoulos
- V' Department of Ob/Gyn, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Georgia Micha
- Department of Anaesthesia, Helena Venizelou General and Maternity Hospital of Athens, Greece
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Jirge PR, Patil MM, Gutgutia R, Shah J, Govindarajan M, Roy VS, Kaul-Mahajan N, Sharara FI. Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective. J Hum Reprod Sci 2022; 15:112-125. [PMID: 35928474 PMCID: PMC9345274 DOI: 10.4103/jhrs.jhrs_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.
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Affiliation(s)
- Padma Rekha Jirge
- Shreyas Hospital and Sushrut Assisted Conception Clinic, Kohlhapur, India
| | | | | | - Jatin Shah
- Mumbai Fertility Clinic & IVF Centre, Mumbai, India
| | | | | | | | - Faddy I Sharara
- Virginia Center for Reproductive Medicine, Reston; Department of O&G, George Washington University, Washington, DC, USA
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Bülow NS, Holt MD, Skouby SO, Petersen KB, Englund ALM, Pinborg A, Macklon NS. Co-treatment with letrozole during ovarian stimulation for IVF/ICSI: a systematic review and meta-analysis. Reprod Biomed Online 2021; 44:717-736. [DOI: 10.1016/j.rbmo.2021.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 12/20/2022]
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Huang H, Takai Y, Samejima K, Gomi Y, Narita T, Ichinose S, Itaya Y, Ono Y, Matsunaga S, Saitoh M, Seki H. Severe hemoperitoneum resulting from restart of letrozole after oocyte retrieval procedure: a case report. J Med Case Rep 2021; 15:327. [PMID: 34174941 PMCID: PMC8236175 DOI: 10.1186/s13256-021-02938-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the field of oncofertility, patients with breast cancer are often administered letrozole as an adjuvant drug before and after oocyte retrieval to prevent an increase in circulating estradiol. CASE PRESENTATION We report a case of abdominal hemorrhage due to an ovarian rupture in a 29-year-old Japanese patient who restarted letrozole 2 days after an oocyte retrieval procedure in which 14 mature oocytes were retrieved. The patient had sought embryo cryopreservation as a fertility preservation option before undergoing treatment for recurrent breast cancer. A day after restarting letrozole treatment, the patient unexpectedly developed severe abdominal pain. Laparoscopic hemostasis was performed to manage the ovarian swelling and hemorrhage. CONCLUSIONS The ovaries can be restimulated by restart letrozole after an oocyte retrieval procedure. Therefore, reproductive-medicine practitioners should understand the potential complications of letrozole administration in such cases and take steps to ensure that they are minimized.
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Affiliation(s)
- Haipeng Huang
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan.
| | - Yasushi Takai
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Kouki Samejima
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Yosuke Gomi
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Tatsuya Narita
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Shunichiro Ichinose
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Yukiko Itaya
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Yosihisa Ono
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Sigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Masahiro Saitoh
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
| | - Hiroyuki Seki
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-3550, Japan
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12
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Cozzolino M, Cecchino GN, Bosch E, Garcia-Velasco JA, Garrido N. Minimal ovarian stimulation is an alternative to conventional protocols for older women according to Poseidon's stratification: a retrospective multicenter cohort study. J Assist Reprod Genet 2021; 38:1799-1807. [PMID: 33851314 DOI: 10.1007/s10815-021-02185-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/31/2021] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Mauro Cozzolino
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain. .,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar St, New Haven, CT, 06510, USA. .,Rey Juan Carlos University, Calle Tulipán, 28933, Móstoles, Madrid, Spain.
| | - Gustavo Nardini Cecchino
- Rey Juan Carlos University, Calle Tulipán, 28933, Móstoles, Madrid, Spain.,Department of Gynaecology, Federal University of São Paulo, São Paulo, Brazil.,Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | | | - Juan Antonio Garcia-Velasco
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain.,Rey Juan Carlos University, Calle Tulipán, 28933, Móstoles, Madrid, Spain.,IVI-RMA, Madrid, Spain
| | - Nicolás Garrido
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain
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13
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Liang Y, Guo Q, Wu XH, Zhang LN, Ge J, Xu ML, Feng ZL, Wu XQ. Does the additional use of clomiphene citrate or letrozole for in vitro fertilization deserve more attention? BMC Pregnancy Childbirth 2021; 21:275. [PMID: 33794797 PMCID: PMC8017864 DOI: 10.1186/s12884-021-03668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adding clomiphene citrate (CC) and/or letrozole (LE) to in vitro fertilization (IVF) cycles for mild ovarian stimulation is a general approach. Although lots of researches have demonstrated partial benefits of the strategy, all-around effects of oral medications remained deficient. This paper aims to assess whether an addition of oral medication will result in considerable outcomes on T-Gn (total dose of gonadotropin), Gn days, total retrieved ova, high quality embryos, blastocyst number, ovarian hyperstimulation syndrome (OHSS) rate, clinical pregnancy rate and cumulative pregnancy rate, even if it was not conventional mild/minimal stimulations. RESULTS Participants were categorized to three diverse populations as high responders, normal responders and poor responders according to basal antral follicle count. T-Gn in patients treated with CC/LE distinctly decreased from 2496.96 IU/d to 1827.68 IU/d, from 2860.28 IU/d to 2119.99 IU/d, and from 3182.15 IU/d to 1802.84 IU/d, respectively. For high ovary responders and normal responders, the OHSS incidence rate also declined from 29.2 to 4.3% (P < 0.001) and from 1.1 to 0.0% (P = 0.090). Other, there was no statistical difference with respect to the T-retrieved ova (total retrieved ova), high quality embryos, cultured blastocyst and blastocyst number in high responders. For normal responders and poor ovary responders, T-Gn, Gn days, T-retrieved ova, high quality embryos, cultured blastocyst and blastocysts number in oral medications group all apparently decreased. Clinical pregnancy rate per fresh cycle of poor responders with prior oral medications was significantly decreased (25.7% vs. 50.8%, P = 0.005), and no significant differences in high responders and normal responders were expressed (52.5% vs. 44.2%, P = 0.310; 51.9% vs. 42.4%, P = 0.163) between two groups of participants. The numbers of cumulative pregnancy rates were lower in the conventional group compared to the add group for high (75.90% versus 81.03%, P = 0.279), normal (62.69% versus 71.36%, P = 0.016) and poor (39.74% versus 68.21%, P < 0.001) responders. CONCLUSIONS The addition of CC/LE to the ovulation induction during IVF has certain efficacy in terms of low cost, low OHSS incidence. CC/LE deserves more recommendations as a responsible strategy in high responders due to advantageous pregnancy outcomes. For normal responders, the strategy needs to be considered with more comprehensive factors.
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Affiliation(s)
- Ying Liang
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China.
| | - Qing Guo
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Xiao-Hua Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Li-Nan Zhang
- Department of Pathology and Pathophysiology, Hebei Medicine University, Shijiazhuang, Hebei, China
| | - Jun Ge
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Mei-Ling Xu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Zheng-Li Feng
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Xiao-Qian Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
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14
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Montoya-Botero P, Drakopoulos P, González-Foruria I, Polyzos NP. Fresh and cumulative live birth rates in mild versus conventional stimulation for IVF cycles in poor ovarian responders: a systematic review and meta-analysis. Hum Reprod Open 2021; 2021:hoaa066. [PMID: 33614987 PMCID: PMC7882043 DOI: 10.1093/hropen/hoaa066] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/16/2020] [Indexed: 12/19/2022] Open
Abstract
STUDY QUESTION Are cumulative and live birth rates (LBRs) comparable in poor ovarian response women treated with different protocols of mild stimulation IVF (i.e. oral compounds, lower doses or shorter treatments) versus conventional IVF? SUMMARY ANSWER Mild ovarian stimulation (MOS) results in comparable outcomes to those of conventional stimulation in poor ovarian response patients with low ovarian reserve. WHAT IS KNOWN ALREADY Several randomized trials and meta-analyses have been published evaluating the role of mild (MOS) versus conventional ovarian stimulation in poor ovarian response patients. Most report a potentially higher safety profile, patient satisfaction and lower costs, suggesting that the higher cycle cancellation rate and fewer oocytes retrieved following MOS does not affect the final reproductive outcome. Additionally, over the last few years, new publications have added data regarding MOS, and shown the possible benefit of a higher oocyte yield which may also improve prognosis in patients with poor ovarian response. STUDY DESIGN SIZE DURATION We conducted a systematic search of relevant randomized controlled trials (RCTs). We searched electronic databases, including MEDLINE, EMBASE, LILACS-BIREME, CINAHL, The Cochrane Library, CENTRAL (Cochrane Register), Web of Science, Scopus, Trip Database and Open Grey, to identify all relevant studies published up to March 2020. We examined trial registries for ongoing trials. No publication-year or language restrictions were adopted. We explored the reference list of all included studies, reviews and abstracts of major scientific meetings. The primary outcomes were cumulative and fresh LBR (CLBR and FLBR) per woman randomized. PARTICIPANTS/MATERIALS SETTING METHODS We included subfertile women undergoing IVF/ICSI characterized as poor responders and compared primary and secondary outcomes between the different protocols of mild stimulation IVF (i.e. oral compounds, lower doses or shorter treatments) and conventional IVF. We used the PICO (Patients, Intervention, Comparison and Outcomes) model to select our study population. MAIN RESULTS AND THE ROLE OF CHANCE Overall, 15 RCTs were included in the meta-analysis. CLBR and FLBR were comparable between mild versus conventional stimulation (RR 1.15; 95% CI: 0.73 - 1.81; I2 = 0%, n = 424, moderate certainty and RR 1.01; 95% CI: 0.97 - 1.04; I 2 = 0%, n = 1001, low certainty, respectively). No difference was observed either when utilizing oral compounds (i.e. letrozole and clomiphene) or lower doses. Similarly, ongoing pregnancy rate (OPR) and clinical pregnancy rate (CPR) were equivalent when comparing the two groups (RR 1.01; 95% CI: 0.98 - 1.05; I 2 = 0%, n = 1480, low certainty, and RR 1.00; 95% CI: 0.97 - 1.03; I2 = 0%, n = 2355, low certainty, respectively). A significantly lower oocyte yield (mean differences (MD) -0.80; 95% CI: -1.28, -0.32; I2 = 83%, n = 2516, very low certainty) and higher rate of cycle cancellation (RR 1.48; 95% CI: 1.08 - 2.02; I2 = 62%, n = 2588, low certainty) was observed in the MOS group. LIMITATIONS REASONS FOR CAUTION The overall quality of the included studies was low to moderate. Even though strict inclusion criteria were used, the selected studies were heterogeneous in population characteristics and treatment protocols. We found no differences in CLBR between MOS and COS (95% CI: 0.73 - 1.81.). WIDER IMPLICATIONS OF THE FINDINGS MOS could be considered as a treatment option in low prognosis poor responder patients, given that it results in similar fresh and CLBRs compared with COS. A milder approach is associated with a lower number of oocytes retrieved and a higher cancellation rate, although treatment cost is significantly reduced. Future research should focus on which type of ovarian stimulation may be of benefit in better prognosis women. STUDY FUNDING/COMPETING INTERESTS There were no sources of financial support. N.P.P. received research grants, honoraria for lectures from: Merck Serono, MSD, Ferring Pharmaceuticals, Besins International, Roche Diagnostics, IBSA, Theramex and Gedeon Richter. P.D. received unrestricted grants and honoraria from Merck Serono, MSD and Ferring Pharmaceuticals. I.G.F. received unrestricted grants and honoraria from Merck Serono, MSD, Ferring Pharmaceuticals, Gedeon-Richter and IBSA. P.M.B. reported no conflict of interest. TRIAL REGISTRATION NUMBER CRD42020167260.
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Affiliation(s)
- Pedro Montoya-Botero
- Conceptum—Unidad de Fertilidad del Country, Bogotá 110221, Colombia
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona 08028, Spain
| | - Panagiotis Drakopoulos
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Iñaki González-Foruria
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona 08028, Spain
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona 08028, Spain
- Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
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15
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Abstract
Letrozole, an aromatase inhibitor that blocks estrogen synthesis by inhibiting the final step of the estrogen biosynthetic pathway, has been used in the applications of a wide range of infertility settings. It has been more than 20 years since the initial clinical trial of letrozole for ovulation induction. In light of the accumulating clinical and basic evidence, the efficacy and safety of letrozole have been identified. This mini review focuses on our current knowledge of the applications and mechanisms of letrozole for female infertility and various questions are put forward about how letrozole could be more effectively used.
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16
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Datta AK, Maheshwari A, Felix N, Campbell S, Nargund G. Mild versus conventional ovarian stimulation for IVF in poor, normal and hyper-responders: a systematic review and meta-analysis. Hum Reprod Update 2020; 27:229-253. [PMID: 33146690 PMCID: PMC7902993 DOI: 10.1093/humupd/dmaa035] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mild ovarian stimulation has emerged as an alternative to conventional IVF with the advantages of being more patient-friendly and less expensive. Inadequate data on pregnancy outcomes and concerns about the cycle cancellation rate (CCR) have prevented mild, or low-dose, IVF from gaining wide acceptance. OBJECTIVE AND RATIONALE To evaluate parallel-group randomised controlled trials (RCTs) on IVF where comparisons were made between a mild (≤150 IU daily dose) and conventional stimulation in terms of clinical outcomes and cost-effectiveness in patients described as poor, normal and non-polycystic ovary syndrome (PCOS) hyper-responders to IVF. SEARCH METHODS Searches with no language restrictions were performed using Medline, Embase, Cochrane central, Pre-Medicine from January 1990 until April 2020, using pre-specified search terms. References of included studies were hand-searched as well as advance access articles to key journals. Only parallel-group RCTs that used ≤150 IU daily dose of gonadotrophin as mild-dose IVF (MD-IVF) and compared with a higher conventional dose (CD-IVF) were included. Studies were grouped under poor, normal or hyper-responders as described by the authors in their inclusion criteria. Women with PCOS were excluded in the hyper-responder group. The risk of bias was assessed as per Cochrane Handbook for the included studies. The quality of evidence (QoE) was assessed according to the GRADE system. PRISMA guidance was followed for review methodology. OUTCOMES A total of 31 RCTs were included in the analysis: 15 in the poor, 14 in the normal and 2 in the hyper-responder group. Live birth rates (LBRs) per randomisation were similar following use of MD-IVF in poor (relative risk (RR) 0.91 (CI 0.68, 1.22)), normal (RR 0.88 (CI 0.69, 1.12)) and hyper-responders (RR 0.98 (CI 0.79, 1.22)) when compared to CD-IVF. QoE was moderate. Cumulative LBRs (5 RCTs, n = 2037) also were similar in all three patient types (RR 0.96 (CI 0.86 1.07) (moderate QoE). Risk of ovarian hyperstimulation syndrome was significantly less with MD-IVF than CD-IVF in both normal (RR 0.22 (CI 0.10, 0.50)) and hyper-responders (RR 0.47 (CI 0.31, 0.72)), with moderate QoE. The CCRs were comparable in poor (RR 1.33 (CI 0.96, 1.85)) and hyper-responders (RR 1.31 (CI 0.98, 1.77)) but increased with MD-IVF among normal responders (RR 2.08 (CI 1.38, 3.14)); all low to very low QoE. Although fewer oocytes were retrieved and fewer embryos created with MD-IVF, the proportion of high-grade embryos was similar in all three population types (low QoE). Compared to CD-IVF, MD-IVF was associated with less gonadotrophin use and lower cost. WIDER IMPLICATIONS This updated review provides reassurance on using MD-IVF not only for the LBR per cycle but also for the cumulative LBR, with moderate QoE. With risks identified with ‘freeze-all’ strategies, it may be time to recommend mild-dose ovarian stimulation for IVF for all categories of women i.e. hyper, poor and normal responders to IVF.
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Affiliation(s)
| | | | | | - Stuart Campbell
- St George's University of London, London, UK.,Create Fertility, London, UK
| | - Geeta Nargund
- Create Fertility, London, UK.,St Georges University Hospitals NHS Trust London, London, UK
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17
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Bonardi B, Massarotti C, Bruzzone M, Goldrat O, Mangili G, Anserini P, Spinaci S, Arecco L, Del Mastro L, Ceppi M, Demeestere I, Lambertini M. Efficacy and Safety of Controlled Ovarian Stimulation With or Without Letrozole Co-administration for Fertility Preservation: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:574669. [PMID: 33117711 PMCID: PMC7575927 DOI: 10.3389/fonc.2020.574669] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/01/2020] [Indexed: 01/01/2023] Open
Abstract
Background: The co-administration of letrozole during controlled ovarian stimulation (COS) with gonadotropins is used to limit the potentially harmful effects of a supra-physiological rise in estrogen levels on hormone-sensitive cancers. However, the efficacy and safety of adding letrozole to COS remain debated. Methods: This is a systematic review and meta-analysis of published studies that compared the efficacy and safety of COS with co-administration of letrozole vs. COS without letrozole in all patient populations. A secondary analysis was done including only the studies in breast cancer patients. The primary efficacy endpoint was the number of retrieved mature Metaphase II (MII) oocytes. Secondary efficacy and safety endpoints were total number of oocytes, maturation rate, fertilization rate, number of cryopreserved embryos, peak estradiol levels, progesterone levels, and total gonadotropin dose. Data for each endpoint were reported and analyzed thorough mean ratio (MR) with 95% confidence interval (CI). Results: A total of 11 records were selected including 2,121 patients (990 patients underwent COS with letrozole and 1,131 COS without letrozole). The addition of letrozole to COS did not have any negative effect on the number of mature oocytes collected (MR = 1.00, 95% CI = 0.87–1.16; P = 0.967) and the other efficacy endpoints. COS with letrozole was associated with significantly decreased peak estradiol levels (MR = 0.28, 95% CI = 0.24–0.32; P < 0.001). Similar results were observed in the secondary analysis including only breast cancer patients. Conclusions: These findings are reassuring on the efficacy and safety of COS with gonadotropins and letrozole and are particularly important for fertility preservation in women with hormone-sensitive cancers.
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Affiliation(s)
- Benedetta Bonardi
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudia Massarotti
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Anserini
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Spinaci
- Division of Breast Surgery, Ospedale Villa Scassi, Genova, Italy
| | - Luca Arecco
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Breast Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marcello Ceppi
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Isabelle Demeestere
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Fertility Clinic, CUB-Hôpital Erasme, Brussels, Belgium
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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18
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The Conundrum of Poor Ovarian Response: From Diagnosis to Treatment. Diagnostics (Basel) 2020; 10:diagnostics10090687. [PMID: 32932955 PMCID: PMC7555981 DOI: 10.3390/diagnostics10090687] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/27/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
Despite recent striking advances in assisted reproductive technology (ART), poor ovarian response (POR) diagnosis and treatment is still considered challenging. Poor responders constitute a heterogeneous cohort with the common denominator of under-responding to controlled ovarian stimulation. Inevitably, respective success rates are significantly compromised. As POR pathophysiology entails the elusive factor of compromised ovarian function, both diagnosis and management fuel an ongoing heated debate depicted in the literature. From the criteria employed for diagnosis to the plethora of strategies and adjuvant therapies proposed, the conundrum of POR still puzzles the practitioner. What is more, novel treatment approaches from stem cell therapy and platelet-rich plasma intra-ovarian infusion to mitochondrial replacement therapy have emerged, albeit not claiming clinical routine status yet. The complex and time sensitive nature of this subgroup of infertile patients indicates the demand for a consensus on a horizontally accepted definition, diagnosis and subsequent effective treating strategy. This critical review analyzes the standing criteria employed in order to diagnose and aptly categorize POR patients, while it proceeds to critically evaluate current and novel strategies regarding their management. Discrepancies in diagnosis and respective implications are discussed, while the existing diversity in management options highlights the need for individualized management.
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19
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Vaiarelli A, Cimadomo D, Petriglia C, Conforti A, Alviggi C, Ubaldi N, Ledda S, Ferrero S, Rienzi L, Ubaldi FM. DuoStim - a reproducible strategy to obtain more oocytes and competent embryos in a short time-frame aimed at fertility preservation and IVF purposes. A systematic review. Ups J Med Sci 2020; 125:121-130. [PMID: 32338123 PMCID: PMC7721001 DOI: 10.1080/03009734.2020.1734694] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/21/2020] [Indexed: 12/15/2022] Open
Abstract
Recent evidence suggests that follicular development occurs in a wave-like model during the ovarian cycle, where up to three cohorts of follicles are recruited to complete folliculogenesis. This understanding overtakes the previous dogma stating that follicles grow only during the follicular phase of the menstrual cycle. Therefore, in in vitro fertilization (IVF), novel protocols regarding ovarian stimulation have been theorized based on the use of gonadotrophins to prompt the growth of antral follicles at any stage of the menstrual cycle. These unconventional protocols for ovarian stimulation aim at a more efficient management of poor-prognosis patients, otherwise exposed to conflicting outcomes after conventional approaches. DuoStim appears among these unconventional stimulation protocols as one of the most promising. It combines two consecutive stimulations in the follicular and luteal phases of the same ovarian cycle, aimed at increasing the number of oocytes retrieved and embryos produced in the short time-frame. This protocol has been suggested for the treatment of all conditions requiring a maximal and urgent exploitation of the ovarian reserve, such as oncological patients and poor responders at an advanced maternal age. At present, data from independent studies have outlined the consistency and reproducibility of this approach, which might also reduce the drop-out between consecutive failed IVF cycles in poor-prognosis patients. However, the protocol must be standardized, and more robust studies and cost-benefit analyses are needed to highlight the true clinical pros and cons deriving from DuoStim implementation in IVF.
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Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Cecilia Petriglia
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Nicolò Ubaldi
- Catholic University of the Sacred Heart, Rome, Italy
| | - Sergio Ledda
- Department of Veterinary Medicine, University of Sassari, Sassari, Italy
| | - Susanna Ferrero
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
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Wu JL, Keller P, Kanchwala M, Xing C, Babayev SN, Carr BR, Bukulmez O, Word RA. Controlled Ovarian Stimulation Protocols Alter Endometrial Histomorphology and Gene Expression Profiles. Reprod Sci 2020; 27:895-904. [PMID: 32046444 PMCID: PMC7539809 DOI: 10.1007/s43032-019-00093-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023]
Abstract
Although it is well appreciated that ovarian stimulation protocols for in vitro fertilization (IVF) alter endometrial receptivity, the precise cellular mechanisms are not known. To gain insights into potential mechanisms by which different ovarian stimulation protocols alter the endometrium, we compared histologic and gene expression profiles of endometrium from women undergoing conventional ovarian stimulation for IVF (C-IVF) with those undergoing minimal stimulation with clomiphene citrate (MS-IVF). Sixteen women undergoing MS-IVF (n = 8) or C-IVF (n = 8) were recruited for endometrial biopsy at the time of oocyte retrieval. Endometrial glands were large, tortuous, and secretory with C-IVF but small and undifferentiated with MS-IVF. Whereas RNA sequencing did not reveal changes in estrogen receptor or its co-regulators or classic proliferation associated genes in MS-IVF, together with immunohistochemistry, Wnt signaling was disrupted in endometrium from MS-IVF cycles with significant upregulation of Wnt inhibitors. Secreted frizzled-related protein 1 (sFRP1) was increased fourfold (p < 0.01), and sFRP4 was upregulated sixfold (p < 0.01) relative to C-IVF. Further these proteins were localized to subepithelial endometrial stroma. These data indicate that MS-IVF protocols with CC do not seem to impact endometrial estrogen signaling as much as would be expected from the reported antiestrogenic properties of CC. Rather, the findings of this study highlight Wnt signaling as a major factor for endometrial development during IVF cycles.
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Affiliation(s)
- John L Wu
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patrick Keller
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- The Cecil H. and Ida Green Center for Reproductive Biology Sciences, Department of Obstetrics and Gynecology, The Green Center for Reproductive Biological Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mohammed Kanchwala
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chao Xing
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Bioinformatics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Samir N Babayev
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bruce R Carr
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Orhan Bukulmez
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - R Ann Word
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- The Cecil H. and Ida Green Center for Reproductive Biology Sciences, Department of Obstetrics and Gynecology, The Green Center for Reproductive Biological Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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21
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Ferreiro E, de Uralde BL, Abreu R, García-Velasco JA, Muñoz E. Aromatase Inhibitors for Ovarian Stimulation in Patients with Breast Cancer. Curr Drug Targets 2020; 21:910-921. [PMID: 32077823 DOI: 10.2174/1389450121666200220124607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Breast cancer is the most common malignancy diagnosed in women, and its treatment has a high probability of loss of fertility. Oocyte vitrification is the most commonly used technique to preserve fertility before starting oncological treatment. Aromatase inhibitors induce hypoestrogenemia while promoting the release of gonadotropins and constitute an alternative drug for ovarian stimulation in patients with breast cancer. OBJECTIVE In this mini-review, we update and describe the current status of aromatase inhibitor use in controlled ovarian stimulation for oocyte vitrification in patients with breast cancer. RESULTS Aromatase inhibitors are commonly used in combination with gonadotropins for ovarian stimulation in patients with breast cancer who preserve their fertility through oocyte vitrification. They achieve similar ovarian responses as conventional ovarian stimulation protocols in regards to the number of oocytes, and no additional complications after their use have been reported. Furthermore, aromatase inhibitors seem to be safe not only for offspring, as no more congenital defects occur in newborns from pregnancies achieved after their use, but also for the patients, as no more malignancy recurrence or increased mortality was found in cohort studies. CONCLUSION Aromatase inhibitors are elective drugs for ovarian stimulation in patients with breast cancer who decide to preserve their fertility through oocyte vitrification.
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Affiliation(s)
- Esteban Ferreiro
- IVIRMA Vigo, Plaza Francisco Fernandez del Riego, 7 36203, Vigo Pontevedra, Spain
| | | | - Rita Abreu
- IVIRMA Vigo, Plaza Francisco Fernandez del Riego, 7 36203, Vigo Pontevedra, Spain
| | | | - Elkin Muñoz
- IVIRMA Vigo, Plaza Francisco Fernandez del Riego, 7 36203, Vigo Pontevedra, Spain
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22
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Løssl K, Freiesleben NLC, Wissing ML, Birch Petersen K, Holt MD, Mamsen LS, Anderson RA, Andersen CY. Biological and Clinical Rationale for Androgen Priming in Ovarian Stimulation. Front Endocrinol (Lausanne) 2020; 11:627. [PMID: 33013703 PMCID: PMC7498541 DOI: 10.3389/fendo.2020.00627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/31/2020] [Indexed: 12/24/2022] Open
Abstract
Androgen receptors are expressed by all stages of growing follicles, and follicular fluid androgen levels are positively correlated to granulosa cell androgen receptor and follicle-stimulating hormone (FSH) receptor expression. Thus, androgens may promote follicular growth, accumulation and/or responsiveness to gonadotropins. This is explored therapeutically in the concept of androgen priming, to improve the ovarian response to stimulation in assisted reproduction. Androgen effects may be achieved in two different ways, either directly by providing exogenous androgen or by providing luteinizing hormone (LH) activity [i.e., LH or human chorionic gonadotropin (hCG)] to stimulate local ovarian production of androgen. The androgen concentrations in follicular fluid by far exceed the levels in female circulation and it has recently been shown that there was no correlation between serum testosterone levels and follicular fluid androgen levels. There is some evidence that administration of exogenous dehydroepiandrosterone or testosterone increases live birth rates, but an optimal protocol has not been established and such adjuvant treatment should be considered experimental. Furthermore, studies exploring long-term administration of LH activity, achieving LH levels comparable to those seen in women with polycystic ovary syndrome, are awaited. The aim of the present review is to discuss critically the most suitable approach for androgen priming from a biological and clinical standpoint, and to evaluate current approaches and results obtained in clinical trials.
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Affiliation(s)
- Kristine Løssl
- The Fertility Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | | | | | - Linn Salto Mamsen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Richard A. Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, University Hospital of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Claus Yding Andersen
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23
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Monteiro CDS, Scheffer BB, Carvalho RFD, Scheffer JB. The impact of dehydroepiandrosterone in poor ovarian responders on assisted reproduction technology treatment. JBRA Assist Reprod 2019; 23:414-417. [PMID: 31251010 PMCID: PMC6798587 DOI: 10.5935/1518-0557.20190045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
One in six couples worldwide will experience at least one infertility problem
during their reproductive years. Between 5.6% and 35.1% of women will exhibit
poor ovarian response. A variety of methods have been applied to improve ovarian
response, including dehydroepiandrosterone. In the ovaries,
dehydroepiandrosterone promotes follicular development and granulosa cell
proliferation by increasing intraovarian androgen concentrations while
simultaneously enhancing the level of follicular insulin-like growth factor-1,
which promotes folliculogenesis. Dehydroepiandrosterone supplementation may
improve in vitro fertilization outcomes and ovarian response in
patients with poor ovarian response. However, a few questions still loom over
the effectiveness of dehydroepiandrosterone.
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Affiliation(s)
| | - Bruno Brum Scheffer
- Brazilian Institute of Assisted Reproduction (IBRRA), Belo Horizonte, MG, Brazil
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24
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Zhang J, Merhi Z. Safety data for the use of nasal human menopausal gonadotropins: a potential novel approach for fertility treatment. JBRA Assist Reprod 2019; 23:169-171. [PMID: 30500132 PMCID: PMC6501747 DOI: 10.5935/1518-0557.20180078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Some of the common side effects of the injectable gonadotropins, used during fertility treatments, are pain at the injection site, skin erythema, muscle pain, and rarely vasovagal reflex. These side effects cause inconvenience and lower patient's tolerance for fertility treatments.The purpose of this study was to evaluate the safety and efficacy of an FDA-approved dose of nasal human menopausal gonadotropins (Menopur) in women undergoing fertility treatment. Healthy regularly cycling reproductive-aged women (n=4) with infertility were enrolled. A total of 75 IU of each Menopur bottle was dissolved and placed in a nasal pump spray device (concentration of 3.75 IU/spray). Each participant was allowed to inhale a total of 2 sprays daily after which ovarian response during the follicular phase was monitored by transvaginal ultrasound and serum hormone measurement. None of the participants reported any side effects at the nasal site of drug administration. No known common side effects of the Menopur drug were reported by any of the participants. Despite adequate absorption of the nasal Menopur, as confirmed by elevated serum FSH levels while taking the nasal medication, 3 out of 4 participants did not show any follicular growth until cycle day 13 while only one participant who agreed to continue taking the medication until cycle day 20 developed one dominant follicle and had elevated serum estradiol levels. This FDA approved case series suggest that nasal route of Menopur administration seems to be safe at a very low doses and it constitutes a potential novel approach for ovarian stimulation.
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Affiliation(s)
- John Zhang
- Reproductive Endocrinology and Infertility, New Hope Fertility Center, New York, NY
| | - Zaher Merhi
- Reproductive Endocrinology and Infertility, New Hope Fertility Center, New York, NY.,Department of Obstetrics and Gynecology, Division of Reproductive Biology, New York University School of Medicine, New York, NY
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Abstract
BACKGROUND As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of these steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. OBJECTIVES To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART) procedures. METHODS Published Cochrane systematic reviews of couples undergoing ART procedures (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The primary outcome of the overview was live birth or the composite outcome live birth or ongoing pregnancy, as reported by the included reviews. Our secondary outcomes were clinical pregnancy, multiple pregnancy, miscarriage, and ovarian hyperstimulation syndrome. We excluded studies of intrauterine insemination and ovulation induction.We undertook selection of systematic reviews, data extraction, and quality assessment in duplicate. We assessed review quality by using the AMSTAR tool. We organised reviews by their relevance to specific stages in the ART cycle. We summarised their findings in the text and reported data for each outcome in 'Additional tables'. MAIN RESULTS We included 68 systematic reviews published in the Cochrane Library up to May 2018. All were of high quality. These reviews identified 38 interventions that were effective (n = 23) or promising (n = 15), and they identified 19 interventions that were ineffective (n = 2) or possibly ineffective (n = 17). For 15 interventions, review authors were unable to draw conclusions owing to lack of evidence.We identified an additional 11 protocols and four titles for future inclusion in this overview. AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly, and the stakes are high. Using the best available evidence to optimise outcomes is best practice. Evidence from this overview could be used to develop clinical practice guidelines and protocols that can be applied in daily clinical practice to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.
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Affiliation(s)
- Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Jane Marjoribanks
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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26
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Vaiarelli A, Cimadomo D, Trabucco E, Vallefuoco R, Buffo L, Dusi L, Fiorini F, Barnocchi N, Bulletti FM, Rienzi L, Ubaldi FM. Double Stimulation in the Same Ovarian Cycle (DuoStim) to Maximize the Number of Oocytes Retrieved From Poor Prognosis Patients: A Multicenter Experience and SWOT Analysis. Front Endocrinol (Lausanne) 2018; 9:317. [PMID: 29963011 PMCID: PMC6010525 DOI: 10.3389/fendo.2018.00317] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/28/2018] [Indexed: 01/15/2023] Open
Abstract
A panel of experts known as the POSEIDON group has recently redefined the spectrum of poor responder patients and introduced the concept of suboptimal response. Since an ideal management for these patients is still missing, they highlighted the importance of tailoring the ovarian stimulation based on the chance of each woman to obtain an euploid blastocyst. Interestingly, a novel pattern of follicle recruitment has been defined: multiple waves may arise during a single ovarian cycle. This evidence opened important clinical implications for the treatment of poor responders. For instance, double stimulation in the follicular (FPS) and luteal phase (LPS) of the same ovarian cycle (DuoStim) is an intriguing option to perform two oocyte retrievals in the shortest possible time. Here, we reported our 2-year experience of DuoStim application in four private IVF centers. To date, 310 poor prognosis patients completed a DuoStim protocol and underwent IVF with blastocyst-stage preimplantation-genetic-testing. LPS resulted into a higher mean number of oocytes collected than FPS; however, their competence (i.e., fertilization, blastocyst, euploidy rates, and clinical outcomes after euploid single-embryo-transfer) was comparable. Importantly, the rate of patients obtaining at least one euploid blastocyst increased from 42.3% (n = 131/310) after FPS to 65.5% (n = 203/310) with the contribution of LPS. A summary of the putative advantages and disadvantages of DuoStim was reported here through a Strengths-Weaknesses-Opportunities-Threats analysis. The strengths of this approach make it very promising. However, more studies are needed in the future to limit its weaknesses, shed light on its putative threats, and realize its opportunities.
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Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Elisabetta Trabucco
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
| | - Roberta Vallefuoco
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
| | - Laura Buffo
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
| | - Ludovica Dusi
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
| | - Fabrizio Fiorini
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | - Nicoletta Barnocchi
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | | | - Laura Rienzi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
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27
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Almind G, Faerch E, Lindenberg F, Lindenberg S. Mild stimulation approach for In Vitro Fertilization treatment: Retrospective data from one Danish Centre. Facts Views Vis Obgyn 2018; 10:81-84. [PMID: 31110646 PMCID: PMC6516186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
AIM OF STUDY Over the last decade, the laboratory procedures in artificial reproduction have improved. Hyperstimulation causes an overload of eggs which will never be used. The present study was designed to evaluate the efficiency of a mild stimulation. To obtain oocytes for In Vitro Fertilization (IVF) a short antagonist protocol using Tamoxiphene and FSH was compared to conventional IVF. METHODS A retrospective and observatory study including all patients with unexplained infertility. In total 720 cycles with mild stimulation protocol and 8,446 cycles with regular short antagonist IVF protocol were analysed. The observation period was from January 2011 until September 2017. All patients were recruited in the same time period and allocated to different treatments upon their request. Low stimulation using orally administrated anti-estrogenic drugs combined with FSH in the form of injections was used in order to obtain up to four mature follicles. RESULTS The clinical pregnancy rate (CPR) per embryo transfer (ET) was 25% for the mild stimulation group. The CPR for the control group with conventional IVF was 23%. CONCLUSION Mild stimulation may be an important step towards an easier IVF approach, more tolerable for women, easier and cheaper for the women and the society, while maintaining an acceptable success rate in terms of CPR. Large prospective studies need to be performed.
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Affiliation(s)
- G Almind
- Copenhagen Fertility Center, Lygten 3c, 2400 Copenhagen, Denmark
| | - E Faerch
- Copenhagen Fertility Center, Lygten 3c, 2400 Copenhagen, Denmark
| | - F Lindenberg
- Copenhagen Fertility Center, Lygten 3c, 2400 Copenhagen, Denmark
| | - S Lindenberg
- Copenhagen Fertility Center, Lygten 3c, 2400 Copenhagen, Denmark
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28
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Lindheim SR, Glenn TL, Smith MC, Gagneux P. Ovulation Induction for the General Gynecologist. J Obstet Gynaecol India 2018; 68:242-252. [PMID: 30065537 DOI: 10.1007/s13224-018-1130-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/27/2018] [Indexed: 12/15/2022] Open
Abstract
The practice of ovulation induction often falls to the reproductive endocrinology and infertility specialist. However, attitudes toward the evaluation and treatment of infertility has shifted among general obstetrician-gynecologists (OB-GYN). This review discusses the underlying scientific basis of anovulation and clinical guidelines regarding the use of different medications for the purpose of promoting follicular recruitment and ovulation for the general OB-GYN.
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Affiliation(s)
- Steven R Lindheim
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St, Suite 3800 Weber CHE, Dayton, OH 45409 USA
| | - Tanya L Glenn
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St, Suite 3800 Weber CHE, Dayton, OH 45409 USA
- 2Department of Obstetrics and Gynecology, Wright-Patterson Medical Center, Wright-Patterson Air Force Base, 4881 Sugar Maple Dr, Dayton, OH 45433 USA
| | - Megan C Smith
- 1Division of Reproductive Endocrine Infertility, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, 128 Apple St, Suite 3800 Weber CHE, Dayton, OH 45409 USA
| | - Pascal Gagneux
- 3Department of Cellular and Molecular Medicine, University of California San Diego, San Diego, CA USA
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