The live birth in a woman with resistant ovary syndrome after in vitro oocyte maturation and preimplantation genetic testing for aneuploidy

Resistant ovary syndrome: Two case reports and a literature review of effective controlled ovarian stimulation in IVF

INTRODUCTION

Resistant ovary syndrome (ROS) represents a rare reproductive endocrine disorder that is predominantly associated with infertility, characterized by heightened endogenous gonadotropin levels in the presence of a normal ovarian reserve. Patients with ROS typically exhibit a poor response to exogenous gonadotropins during controlled ovarian stimulation (COS). Due to the absence of a universally accepted effective COS protocol, this study aims to contribute to the existing body of literature by detailing 2 successful pregnancies achieved through conventional in vitro fertilization (c-IVF) in patients with ROS, and through retrospective analysis, seeks to elucidate the factors contributing to the successful ovarian stimulation in these cases, with the ultimate goal of establishing clinical guidelines for ROS management.

PATIENT CONCERNS

The central challenge addressed in this study pertains to the effective induction of oocyte maturation during c-IVF COS in ROS patients.

DIAGNOSIS

The study focuses on 2 infertile women diagnosed with ROS who sought to conceive via c-IVF.

INTERVENTIONS

The patients were subjected to a COS protocol involving pituitary downregulation followed by ovarian stimulation using recombinant follicle-stimulating hormone (r-FSH) and human menopausal gonadotropin (HMG), preceded by 3 cycles of hormone replacement therapy (HRT) pretreatment.

OUTCOMES

The proposed protocol elicited a favorable ovarian response, culminating in the retrieval of numerous mature oocytes and the development of multiple viable embryos via c-IVF, ultimately leading to successful live births post-embryo transfer.

CONCLUSIONS

Our study suggests that the outlined COS protocol may serve as a viable treatment option for ROS patients aspiring to conceive through c-IVF, thereby potentially expanding the therapeutic repertoire for this challenging condition.

Usable blastocysts developed from in-vitro-matured metaphase I oocytes in preimplantation genetic testing cycles

RESEARCH QUESTION

Are blastocysts derived from in-vitro-matured metaphase I (MI) oocytes less likely to produce usable embryos for transfer compared with those derived from in-vivo-matured oocytes in cycles undergoing preimplantation genetic testing (PGT)?

DESIGN

The primary outcome was usable blastocyst rate, which was compared between blastocysts derived from in-vitro-matured MI oocytes after ovarian stimulation and from in-vivo-matured oocytes. Logistic regression analysis using generalized estimating equations was used to control for confounders in the analysis of factors that may influence the chance of a blastocyst being usable and in the comparison of embryological outcomes. Student's t-test, Mann-Whitney U test, chi-squared tests or Fisher's exact tests were used to compare clinical and pregnancy outcomes.

RESULTS

A total of 1810 injected metaphase II (MII) oocytes from 154 PGT cycles involving 154 couples were included in this study. A total of 1577 MII oocytes were in-vivo-matured and 233 were in-vitro-matured MI oocytes. The usable blastocyst rate was similar between the in-vitro-matured MI oocyte group and the in-vivo-matured oocyte group (adjusted RR 0.97, 95% CI 0.40 to 2.34). Three live births were achieved using usable blastocysts derived from in-vitro-matured MI oocytes.

CONCLUSIONS

If in-vitro-matured MI oocytes can be fertilized and develop into blastocysts, their ability to provide usable embryos for transfer is similar compared with those developed from in-vivo-matured oocytes. These blastocysts could be considered valuable for women with few viable embryos in assisted reproductive technology cycles.

Application value of Early-Follicular Phase Long-Acting Gonadotropin-Releasing Hormone Agonist Long Protocol in patients with resistant ovary syndrome

BACKGROUND

Resistant ovarian syndrome(ROS) is a rare disease. It is difficult to diagnose and treat. Most of the literature reports on assisted pregnancy treatment for ROS patients are individual case reports. In this paper, the ovulation stimulation protocol and assisted pregnancy process of ROS infertile patients in our reproductive center were summarized and analyzed to provide information and support for the clinical treatment of ROS patients.

METHODS

From January 2017 to March 2022, assisted reproductive technology treatments and clinical characteristics parameters of six patients with ROS were retrospectively reviewed. Based on controlled ovarian stimulation protocols, these stimulation cycles were separated into four groups: Early-Follicular Phase Long-Acting Gonadotropin-Releasing Hormone Agonist Long Protocol (EFLL) group (n = 6), Progestin Primed Ovarian Stimulation(PPOS) protocol group (n = 5), mild-stimulation protocol group (n = 2), and Natural cycle protocol group (n = 3).

RESULTS

A total of 16 cycles of ovulation stimulation were carried out in 6 patients with ROS. A total of 19 oocytes were retrieved, as well as 13 MII oocytes, 11 two pronuclear(2PN) fertilized embryos, and 8 excellent embryos. The oocytes acquisition rate was 50% and the fertilization rate of 2PN was 57.9%, and the excellent embryo rate was 72.7%. The EFLL protocol obtained 17 oocytes, 12 MII oocytes, 11 2PN fertilized embryos, and 8 excellent embryos; the mild-stimulation protocol obtained 1 oocyte; the Natural cycle protocol obtained 1 oocyte, and oocytes were not matured after in vitro maturation (IVM); the PPOS protocol obtained no oocytes. Compared with three other protocols, The fertilization rate of 2PN (64.7%) and excellent embryo rate (72.7%) in the EFLL protocol were higher than those of other protocols(0%). Two fresh cycle embryo transfers resulted in live births, while two frozen-thawed embryo transfer cycles resulted in one live birth and one clinical pregnancy using the EFLL protocol.

CONCLUSION

Although the current study is based on a small sample of participants, the findings suggest that the EFLL protocol can be employed for ovarian stimulation and may result in a live birth in ROS patients.

Resistant ovary syndrome: Pathogenesis and management strategies

Resistant ovary syndrome (ROS) is a rare and difficult gynecological endocrine disorder that poses a serious risk to women’s reproductive health. The clinical features are normal sex characteristics, regular female karyotype, and usual ovarian reserve, but elevated endogenous gonadotropin levels and low estrogen levels with primary or secondary amenorrhea. Although there have been many case reports of the disease over the past 50 years, the pathogenesis of the disease is still poorly understood, and there are still no effective clinical management strategies. In this review, we have collected all the current reports on ROS and summarized the pathogenesis and treatment strategies for this disease, intending to provide some clinical references for the management and treatment of this group of patients and provide the foothold for future studies.

Oocyte maturation abnormalities - A systematic review of the evidence and mechanisms in a rare but difficult to manage fertility pheneomina

A small proportion of infertile women experience repeated oocyte maturation abnormalities (OMAS). OMAS include degenerated and dysmorphic oocytes, empty follicle syndrome, oocyte maturation arrest (OMA), resistant ovary syndrome and maturation defects due to primary ovarian insufficiency. Genetic factors play an important role in OMAS but still need specifications. This review documents the spectrum of OMAS and to evaluate the multiple subtypes classified as OMAS. In this review, readers will be able to understand the oocyte maturation mechanism, gene expression and their regulation that lead to different subtypes of OMAs, and it will discuss the animal and human studies related to OMAS and lastly the treatment options for OMAs. Literature searches using PubMed, MEDLINE, Embase, National Institute for Health and Care Excellence were performed to identify articles written in English focusing on Oocyte Maturation Abnormalities by looking for the following relevant keywords. A search was made with the specified keywords and included books and documents, clinical trials, animal studies, human studies, meta-analysis, randomized controlled trials, reviews, systematic reviews and options written in english. The search detected 3,953 sources published from 1961 to 2021. After title and abstract screening for study type, duplicates and relevancy, 2,914 studies were excluded. The remaining 1,039 records were assessed for eligibility by full-text reading and 886 records were then excluded. Two hundred and twenty seven full-text articles and 0 book chapters from the database were selected for inclusion. Overall, 227 articles, one unpublished and one abstract paper were included in this final review. In this review study, OMAS were classified and extensively evaluatedand possible treatment options under the light of current information, present literature and ongoing studies. Either genetic studies or in vitro maturation studies that will be handled in the future will lead more informations to be reached and may make it possible to obtain pregnancies.

Rescue in vitro maturation may increase the pregnancy outcomes among women undergoing intracytoplasmic sperm injection

INTRODUCTION

To investigate whether rescue in vitro maturation (R-IVM) improves the reproductive outcomes among women undergoing intracytoplasmic sperm injection (ICSI) after one oocyte retrieved cycle.

METHODS

Between January 2019 and December 2020, 2602 women who underwent ICSI in the Reproductive Medicine Center of Tongji Hospital, Wuhan, China, were included in our retrospective cohort study. There were 2112 women undergoing only ICSI and 490 women with R-IVM followed by ICSI. The intermediate reproductive outcomes and pregnancy outcomes were assessed, including the number of normally fertilized embryos, number of cleaved embryos, number of good-quality embryos, number of day-3 available embryos, number of embryos cultured past day-3, number of blastocysts, number of available blastocysts, biochemical pregnancy, miscarriage, clinical pregnancy and live birth. The perinatal outcomes were also assessed, including preterm birth and birth weight. The abovementioned outcomes were also calculated for in vivo matured and R-IVM oocytes separately in women undergoing ICSI with R-IVM group.

RESULTS

Compared with the women who underwent only ICSI, those who underwent ICSI with R-IVM had higher numbers of MII oocytes, normally fertilized embryos, cleaved embryos, day-3 available embryos, embryos cultured past day-3, and higher oocyte maturation rate, available embryo rate than women undergoing only ICSI. Additionally, we found that women undergoing ICSI with R-IVM had an increased chance of clinical pregnancy (adjusted OR=1.50, 95% CI: 1.17-1.93) and cumulative live birth (adjusted OR=1.35, 95% CI: 1.07-1.71). After propensity score matching (PSM), the cumulative live birth rate was 60.1% for women undergoing ICSI with R-IVM versus 54.9% for women undergoing only ICSI (OR=1.24, 95% CI: 0.94-1.63). The reproductive outcomes were also significantly different when calculated for in vivo matured and R-IVM oocytes separately in women undergoing ICSI with R-IVM group. All live births from R-IVM embryos were healthy and without malformations or complications.

CONCLUSION

R-IVM may improve the reproductive outcomes of women undergoing ICSI. It may also provide a reference for the safety of R-IVM. This study maybe support a routine application of R-IVM among patients who intend to undergo ICSI.

Live birth after in vitro maturation in women with gonadotropin resistance ovary syndrome: report of two cases

PURPOSE

Gonadotropin-resistant ovary syndrome (GROS) is a rare endocrine disorder that causes hypergonadotropic hypogonadism, amenorrhea, and infertility. This study reports live birth in two women with GROS who underwent fertility treatment with in vitro maturation (IVM).

METHODS

Both patients had primary infertility, amenorrhea (primary and secondary), typical secondary sexual characters, elevated gonadotropin levels, normal ovarian reserve, normal chromosomal characteristics, and previous nonresponsiveness gonadotropin stimulations. One patient had polymorphism of the follicle-stimulating hormone receptor, which is a predictor of poor ovarian response. Given unresponsiveness to exogenous gonadotropin stimulations, IVM with human chorionic gonadotropin priming (hCG-IVM) was performed in both patients. All transferrable embryos were vitrified.

RESULTS

Both patients achieved pregnancy after their first frozen embryos transfer, and each delivered a healthy baby boy.

CONCLUSIONS

These results suggest that IVM should be a first-line therapeutic option for patients with GROS.

Utilization of in vitro maturation in cases with a FSH receptor mutation

PURPOSE

To identify the FSH receptor (FSHR) variant and efficacy of in vitro maturation (IVM) in a 28-year-old woman with secondary amenorrhea, primary infertility, and ovarian resistance to FSH, and to analyze the genotype-to-phenotype relationship in cases of FSHR mutation for the development of an IVM algorithm for use in patients with gonadotropin resistance syndrome (GRS).

METHODS

Oocytes retrieved after menstruation induction with norethisterone, followed by daily estrogen and an ovulatory trigger, underwent IVM, ICSI, and culture in a time-lapse (TL) incubator. Embryo transfers were performed on day 2, and after thawing on day 5. Genes associated with disorders of sex development were sequenced for both the patient and her parents. All reported cases of FSHR mutation were analyzed to investigate genotype/phenotypic relationships.

RESULTS

After ovum pickup, seven of 16 oocytes matured and all fertilized. After unsuccessful day 2 transfer, our patient delivered with a thawed day 5 blastocyst, the sole embryo without abnormal TL phenotypes. Genetic analysis revealed a new composite heterozygous FSHR variant. Analysis of our patient case with published cases of GRS revealed associations among FSHR variant genotype, location on the FSHR, functionality of tested variants, and type of amenorrhea. An algorithm for application of IVM for GRS patients was developed.

CONCLUSIONS

We report two novel variants of the FSHR. Although IVM successfully matured some oocytes, only one resulted in an embryo with normal TL phenotypes. We recommend FSHR genetic testing in GRS patients, which will help guide their suitability for IVM.