Mild ovarian stimulation

Effects of controlled ovarian stimulation regimens on top-quality blastocyst development and perinatal outcomes with the freeze-all strategy: A retrospective comparative study

OBJECTIVE

This study aimed to determine the effect of ovarian stimulation regimens on the top-quality blastocyst development rate and perinatal outcomes with the freeze-all strategy.

METHODS

A retrospective comparative cohort analysis of 149 in vitro fertilization (IVF) cycles using the freeze-all strategy was conducted. The IVF cycles were stimulated with either a gonadotropin-releasing hormone antagonist or clomiphene citrate along with gonadotropin based on the patient's serum anti-Müllerian hormone level. Oocyte retrieval, fertilization, and embryo culture were performed following standard procedures. All good-quality blastocysts were cryopreserved and used for frozen-thawed embryo transfer (FET) in subsequent cycles. The fertilization, blastulation, and top-quality blastocyst development rates were calculated. The perinatal outcomes of FET cycles, gestational period, and birth weight were assessed.

RESULTS

The main outcome of this study was the top-quality blastocyst development rate, and the secondary outcomes were perinatal parameters (e.g., gestational period and birth weight) between the stimulation regimens. Despite the higher number of usable-quality embryos in the antagonist group, the blastocyst development rate remained comparable (p=0.105). Similarly, perinatal outcomes were comparable in subsequent FET cycles (p=0.538).

CONCLUSION

These findings suggest that the choice between antagonist and clomiphene citrate with gonadotropin as stimulation in controlled ovarian stimulation regimens may not affect the top-quality blastocyst development rate. The IVF outcomes (e.g., clinical pregnancy, miscarriage, and live birth rates) remained unaffected in subsequent FET cycles. Unlike fresh embryo transfer, the birth weight and gestational length were not associated with prior controlled ovarian stimulation regimens when the freeze-all strategy was used.

Successful Live Birth Following Natural Cycle Oocyte Retrieval in a Woman with Primary Infertility and Atypical Primary Ovarian Insufficiency with a DNAH1 Gene Deletion Mutation

Background: Dynein, axonemal, heavy chain 1 (DNAH1) gene mutations have been found to be related to primary ciliary dyskinesia (PCD) and the DNAH1 gene is associated with abnormal flagellar morphology in spermatozoa. Infertility is a common condition in women presenting with primary ovarian insufficiency (POI) characterized by hypergonadotropic hypogonadism. The purpose of this study was to explore the clinical significance of genetic diagnostics in several Chinese primary infertile women with atypical POI. Methods: Four atypical POI patients and 100 healthy subjects were recruited, genetic pathogenicityc factors were investigated by whole exome sequencing (WES). Results: WES revealed a homozygous deletion mutation in the DNAH1 gene (NM_015512.5; c.11726_11727delCT, p.Pro3909Argfs*33) in one of the four POI patients. The 31-year-old affected woman presented with a normal menstrual cycle and elevated plasma levels of FSH, around the postmenopausal range, but had a normal antral follicle count and normal anti-Müllerian hormone levels. The patient, after two failed ovulation cycles, became pregnant in the third IVF cycle and delivered a healthy girl at term. Conclusions: The homozygous deletion mutation in the DNAH1 gene suggested that the patient might have a cilia movement disorder of the fallopian tubes, which is a known infertility factor. Moreover, the significantly elevated plasma level of FSH in this patient is likely one of the most important factors leading to her decreased fertility.

Oocyte stimulation parameters influence the number and proportion of mature oocytes retrieved in assisted reproductive technology cycles

PURPOSE

Whether differences in stimulation parameters alter the number and proportion of MII oocytes retrieved.

METHODS

Records of 2546 patients were examined, looking at age, day 2/3 follicle-stimulating hormone (FSH) and estradiol (E2) levels, total dose of gonadotropins administered (including FSH and human menopausal gonadotropin [hMG]), fraction of hMG administered, number of days of treatment with gonadotropins, and the dose of gonadotropins administered per day. We segregated the patients into 3 different classes depending on the trigger method used and 2 groups based on egg freeze vs. ICSI. Multiple regression methods were used to examine associations between stimulation parameters and the total number of eggs, number of immature oocytes (Poisson regression), and the fraction of retrieved oocytes that were immature (Logistic regression).

RESULTS

After adjustments for different triggers and egg freeze versus ICSI, both the #immature oocytes and the immature fraction of oocytes were associated with the total gonadotropin dose (inversely) and the gonadotropin dose/day (positively). Other parameters were associated with the number of immature oocytes but were also associated with the number of oocytes retrieved.

CONCLUSIONS

Stimulations using less total gonadotropin and more gonadotropin per day were associated with more immaturity. The type of trigger method used for final maturation was associated with immaturity but was believed to be predominantly due to trigger assignment to patients based on response. The association between use of ICSI and less immaturity was believed to be due to additional time for maturation in the ICSI group.

The cumulative dose of gonadotropins used for controlled ovarian stimulation does not influence the odds of embryonic aneuploidy in patients with normal ovarian response

OBJECTIVE

Controlled ovarian hyperstimulation (COH) promotes multifollicular growth, increasing the chance of obtaining euploid embryos that will successfully implant. Whether aneuploidy is increased from COH with exogenous gonadotropins interfering with natural selection of dominant follicles is a concern. This study evaluates the association between gonadotropin exposure and aneuploidy.

METHODS

This is a retrospective cohort study of 828 patients that underwent 1122 IVF cycles involving controlled ovarian stimulation and trophectoderm biopsy for preimplantation genetic screening (PGS), from 2010 to 2015. Polymerase chain reaction (PCR) was used to assess aneuploidy. Kruskal-Wallis tests and logistic regression with generalized estimating equations (GEEs) were used for data analysis.

RESULTS

Overall, after controlling for patient age, ovarian reserve, stimulation protocol, days of stimulation, and diagnoses, there was no significant association between cumulative gonadotropin (GND) dose and the odds of aneuploidy (adjusted OR = 1.049, p = 0.232). Similarly, in cycles where patients did not require COH beyond cycle day 12, there was no significant association between cumulative gonadotropin dose and the odds of aneuploidy (adjusted OR = 0.909, p = 0.148). However, in cases where patients were stimulated past cycle day 12, there was a significant increase in the odds of aneuploidy (adjusted OR = 1.20, 95% CI 1.125-1.282, p < 0.0001) with increasing cumulative gonadotropin dose, with a small effect size (Cohen's d = 0.10, 95% CI 0.08-0.12). In this cohort, there was a 16.4% increase in the odds of aneuploidy for each 1000-u increase in cumulative GND exposure (adjusted OR = 1.164, p = 0.002). When the analysis was restricted to low responders (peak estradiol <500 pg/mL or <4 mature follicles achieved; there was no significant association between gonadotropin dose and aneuploidy (adjusted OR = 1.12, 95% CI 0.982-1.28, p = 0.09), regardless of the duration of COH required to reach vaginal oocyte retrieval.

CONCLUSION

The degree of exposure to exogenous gonadotropins did not significantly modify the likelihood of aneuploidy in patients with a normal ovarian response to stimulation (not requiring COH beyond cycle day 12). Patients requiring prolonged COH were demonstrated to have elevated odds of aneuploidy with increasing cumulative gonadotropin dose. This finding may reflect an increased tendency towards oocyte and embryonic aneuploidy in patients with a diminished response to gonadotropin stimulation.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Should mild stimulation be the order of the day?

Mild stimulation protocols aim to reduce the physical, financial and emotional burden associated with the conventional IVF protocol without compromising the pregnancy rate. Such protocols help to decrease the complications and the discomfort related to the prolonged administration of agonist and large doses of gonadotrophins, by limiting the number of oocytes recruited to no more than eight. The per cycle pregnancy rates are lower though the cumulative pregnancy rate in a year is equivalent. This CPR comes by going through earlier repeat cycles. Whether this reduces the physical, emotional or financial burden remains a matter of debate. There is need to standardize these protocol and do more trials to compare the two effectively. Till such time there is a clear benefit above the conventional protocol it will not be the protocol of choice with most physicians.

MILD ovarian stimulation with GnRH-antagonist vs. long protocol with low dose FSH for non-PCO high responders undergoing IVF: a prospective, randomized study including thawing cycles

OBJECTIVE

To compare the effectiveness of two stimulation protocols in non-polycystic ovary (PCO) high responders undergoing in vitro fertilization (IVF).

DESIGN

Prospective randomized trial.

SETTING

A Reproductive Medicine and IVF Unit of a University Hospital and a private IVF Clinic.

METHODS

Four hundred-and-twelve normoovulatory women with good ovarian responsiveness were randomized to receive either the "mild" (FSH 150 IU/day from day 4 of a spontaneous cycle followed by GnRH-antagonist from day 8; n = 205) or the "long" (FSH 150 IU/day; n = 207) stimulation protocol. The outcome of these two regimens was compared including "fresh" and thawing cycles.

RESULTS

The total FSH dose and the peak estradiol level were significantly lower in the "mild" protocol, whereas the retrieved oocytes, fertilization rate, number and quality of embryos, pregnancy and implantation rates, cumulative "fresh plus thaw" success rate, and incidence of severe ovarian hyperstimulation syndrome were comparable with the two regimens.

CONCLUSIONS

In young, normoovulatory patients with good ovarian responsiveness undergoing IVF the "mild" stimulation protocol has effectiveness and risks comparable to the "long" protocol with low FSH starting dose, even when thawing cycles are included in the comparison.

Long-term followup of adolescent and young adult females with hypergonadotropic hypogonadism

The condition characterized by elevated gonadotrophins (gonadotropins elevated into the menopausal range), low sex steroids, and menstrual disorders was previously termed Premature Ovarian Failure (POF). However, over the last two years an effort has been made by many authors to have the term Primary Ovarian Insufficiency (POI) exclusively applied. Irrespective of the term, the condition concerns adolescent and young adult women under 40 years who experience cessation of menstruation for more than 3 cycles (whereas these women in the past had a rhythmic menstrual cycle) or amenorrhea for 4-6 months against the background of a previously disturbed menstrual cycle. Determining the cause of POI is difficult, and it is even harder to deal with problems arising from the paucity of estrogen as well as to draw up the plan for long-term monitoring of these patients. This paper presents long-term therapeutic management strategies concerning emotional health, hormone replacement therapy, maintenance of bone health, family planning, other associated disorders as well as possible research options for the future.

Anti-Mullerian hormone is a better marker than inhibin B, follicle stimulating hormone, estradiol or antral follicle count in predicting the outcome of in vitro fertilization

OBJECTIVE

The present study aims to compare anti-Mullerian hormone (AMH) with other ovarian reserve markers and to find a cut-off value of AMH for predicting ovarian response towards controlled ovarian hyperstimulation in an in vitro fertilization (IVF) program.

MATERIALS AND METHODS

A prospective analysis was performed in 180 patients undergoing their first IVF trial, which is being conducted at a department of assisted reproduction in a tertiary medical center. The main outcome measures were determined as age and antral follicle count as well as the serum concentrations of follicle stimulating hormone, luteinizing hormone (LH), estradiol (E2), inhibin B and AMH. The predictive power of the aforementioned measures in specifying ovarian response was determined by means of discriminate analyses.

RESULTS

As expected, day 3 LH levels were significantly high in the poor responder group. The poor responders had significantly lower antral follicle counts, retrieved oocyte number, and mature oocyte counts as well as day 3 AMH levels (5.8 ± 2.32 vs. 1.8 ± 0.80 ng/ml). There was a positive correlation with antral follicle count, basal AMH, E2 and follicle count on the day of HCG administration and negative correlation with age. The AMH level was addressed as the only significant factor in determination of mature oocyte number. A cut-off point for serum AMH concentration indicating the value of 2.97 ng/ml was found to predict the poor ovarian response with a sensitivity of 100.0% and a specificity of 89.6%. However, the same cut-off point was not as predictive for the non-conception circumstance.

CONCLUSION

The present study concludes that AMH is a promising biochemical marker for the prediction of ovarian response and that a cut-off point indicating the value of 2.97 ng/ml can be adopted for this prediction.

Milder is better? Advantages and disadvantages of "mild" ovarian stimulation for human in vitro fertilization

In the last decades, several steps have been made aiming at rendering human IVF more successful on one side, more tolerable on the other side. The "mild" ovarian stimulation approach, in which a lower-than-average dose of exogenous gonadotropins is given and gonadotropin treatment is started from day 2 to 7 of the cycle, represents a significant step toward a more patient's friendly IVF. However, a clear view of its virtues and defects is still lacking, because only a few prospective randomized trials comparing "mild" vs. conventional stimulation exist, and they do not consider some important aspects, such as, e.g., thawing cycles. This review gives a complete panorama of the "mild" stimulation philosophy, showing its advantages vs. conventional ovarian stimulation, but also discussing its disadvantages. Both patients with a normal ovarian responsiveness to exogenous gonadotropins and women with a poor ovarian reserve are considered. Overall, we conclude that the level of evidence supporting the use of "mild" stimulation protocols is still rather poor, and further, properly powered prospective studies about "mild" treatment regimens are required.

Primary ovarian insufficiency

Primary ovarian insufficiency is a subclass of ovarian dysfunction in which the cause is within the ovary. In most cases, an unknown mechanism leads to premature exhaustion of the resting pool of primordial follicles. Primary ovarian insufficiency might also result from genetic defects, chemotherapy, radiotherapy, or surgery. The main symptom is absence of regular menstrual cycles, and the diagnosis is confirmed by detection of raised follicle-stimulating hormone and declined oestradiol concentrations in the serum, suggesting a primary ovarian defect. The disorder usually leads to sterility, and has a large effect on reproductive health when it arises at a young age. Fertility-preservation options can be offered to some patients with cancer and those at risk of early menopause, such as those with familial cases of primary ovarian insufficiency. Long-term deprivation of oestrogen has serious implications for female health in general; and for bone density, cardiovascular and neurological systems, wellbeing, and sexual health in particular.

Evidence that oocyte quality in younger women with diminished oocyte reserve is superior to those of women of advanced reproductive age

Evidence is provided supporting the hypothesis that the much improved prognosis for younger women with diminished oocyte reserve compared to women of advanced reproductive age is related to a difference in mechanism for oocyte depletion. For younger women the majority have had destruction of certain portions of their ovarian tissue but the remaining spared ovarian tissue has proportionately the same percentage of normal follicles as their age peers. The hypothesis continues that some factor that is responsible for earlier development of primary to antral follicles persists with the early conceptus and protects it from early programmed cell death. Thus by natural selection most women of advanced reproductive age have oocytes that fertilize normally and produce normal morphologic embryos, but lacking this apoptosis inhibiting factor dies very early between days 6 and 12 from fertilization.