Role of gonadotropin-releasing hormone antagonists in poor responders

Comparison of embryo quality and pregnancy outcomes for patients with low ovarian reserve in natural cycles and mildly stimulated cycles: a cohort study

BACKGROUND

As women with low ovarian reserve embark on the challenging journey of in-vitro fertilisation (IVF) treatment, the choice between natural and mildly stimulated cycles becomes a pivotal consideration. It is unclear which of these two regimens is superior for women with low ovarian reserve. Our study aims to assess the impact of natural cycles on embryo quality and pregnancy outcomes in women with low ovarian reserve undergoing IVF treatment compared to mildly stimulated cycles.

METHODS

This retrospective study enrolled consecutive patients with low ovarian reserve who underwent IVF/intracytoplasmic sperm injection (ICSI) at Guangdong Second Provincial General Hospital between January 2017 and April 2021. The primary outcome for pregnancy rate of 478 natural cycles and 448 mild stimulated cycles was compared. Secondary outcomes included embryo quality and oocyte retrieval time of natural cycles.

RESULTS

The pregnancy rate in the natural cycle group was significantly higher than that in the mildly stimulated cycle group (51.8% vs. 40.1%, p = 0.046). Moreover, natural cycles exhibited higher rates of available embryos (84.1% vs. 78.6%, p = 0.040), high-quality embryos (61.8% vs. 53.2%, p = 0.008), and utilisation of oocytes (73% vs. 65%, p = 0.001) compared to mildly stimulated cycles. Oocyte retrievals in natural cycles were predominantly performed between 7:00 and 19:00, with 94.9% occurring during this time frame. In natural cycles with high-quality embryos, 96.4% of oocyte retrievals were also conducted between 7:00 and 19:00.

CONCLUSION

Natural cycles with appropriately timed oocyte retrieval may present a valuable option for patients with low ovarian reserve.

Causal inference indicates that poor responders have similar outcomes with the antagonist protocol compared with flare

OBJECTIVE

To use causal inference to investigate whether the flare or antagonist protocol is better for poor responders going through controlled ovarian stimulation.

DESIGN

A retrospective study.

SETTING

Retrieval cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System.

PATIENTS

Patients in the United States underwent autologous in vitro fertilization cycles from 2014 to 2019 using either the flare or antagonist protocol.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Primary outcomes included oocytes retrieved, fertilized oocytes (2PNs), blastocysts, the cumulative live birth rate (CLBR), and cycle cancelation rate.

RESULTS

After propensity score matching, patients with a predicted poor response (antimüllerian hormone, <0.5) on their first in vitro fertilization cycle had similar outcomes on the antagonist protocol (CLBR of 14.2%, 95% confidence intervals [CIs]: 13.6%, 14.8%) compared with flare (CLBR of 13.6%, 95% CIs: 12.4%, 14.8%). We evaluated patients undergoing a second cycle after having a poor response (<4 oocytes retrieved) on their first cycle. Patients in the antagonist-to-antagonist group had a similar change in outcomes between the first and second cycles (average CLBR improvement of 13.9%, 95% CIs: 12.1%, 15.6%) compared with the antagonist-to-flare group (average CLBR improvement of 14.4%, 95% CIs: 10.9%, 18.3%). In addition, patients in the flare-to-antagonist group had a similar change in outcomes between the first and second cycles (average CLBR improvement of 10.4%, 95% CIs: 6.6%, 14.5%) compared with the flare-to-flare group (average CLBR improvement of 9.0%, 95% CIs: 5.1%, 13.4%).

CONCLUSION

Poor responders have similar outcomes on an antagonist protocol compared with a flare protocol for both the first and second cycles.

Effect of antagonist start day on cycle outcomes in poor responders

Background:

Despite the great advances in Assisted Reproductive Technologies (ART), management of poor responders has remained a great challenge. Gonadotropin releasing hormone antagonist (GnRH-ant) has been offered as a patient friendly protocol. In the literature, conflicting data exists about the effect of the GnRH-ant starting day on cycle outcomes.

Aim:

The aim of this study is to evaluate the effect of GnRH-ant starting day on cycle outcomes of patients with poor ovarian response defined by Bologna criteria.

Setting and Design:

This retrospective cohort study was conducted at an ART clinic of a tertiary hospital.

Materials and Methods:

A total of 361 cycles using flexible GnRH-ant, 195 in Group A (GnRH-ant administered before day 6 of stimulation) and 166 cycles in Group B (GnRH-ant started on or after day 6), were selected retrospectively for the study.

Statistical analysis:

Statistical analysis of data was carried out using using IBM SPSS Statistics Software (20.0, SPSS Inc., Chicago, IL, USA). Independent samples t-test and Mann–Whitney U test were used to analyze the variables.

Results:

Total antral follicle count was significantly higher in Group A compared to Group B (P = 0.009). Duration of stimulation was significantly shorter (P < 0.01) and total dose of gonadotropin used was lower in Group A when compared to Group B (P < 0.01). While higher number of oocytes was retrieved from Group A (P = 0.037), no between-group differences were observed in number of mature oocytes, fertilized oocytes, clinical pregnancy rate or ongoing pregnancy rate (OPR) per embryo transfer (P > 0.05).

Conclusion:

Early GnRH-ant start may point out a favourable response to ovarian stimulation in poor responders. However, clinical or OPRs were not different from the late GnRH-ant start group.

GnRH agonist long protocol versus GnRH antagonist protocol for various aged patients with diminished ovarian reserve: A retrospective study

This retrospective analysis compared the efficiency of the gonadotropin- releasing hormone (GnRH) antagonist (GnRH-ant) protocol and the GnRH agonist long (GnRH-a) protocol for patients with diminished ovarian reserve (DOR). A total of 1,233 patients with DOR (anti-Mullerian hormone <1.1 ng/mL) were recruited for this retrospective case-control study. They were divided into two groups according to female age. Younger patients were assigned to POSEIDON group3 (PG3: age ≤35 years); older patients were assigned to POSEIDON group 4 (PG4: age >35 years). All patients with DOR underwent controlled ovarian stimulation and fresh embryo transfer (ET) on day 3. We recruited 283 GnRH-a and 54 GnRH-ant cycles for PG3, and 663 GnRH-a and 233 GnRH-ant cycles for PG4. In PG3, the GnRH-a protocol was associated with a lower ET cancellation rate (30/283 = 10.2% vs. 12/54 = 22.2%, p = 0.018) and a higher live birth rate (7/54 = 13.0% vs. 78/283 = 27.6%, p = 0.024) than the GnRH-ant protocol for the initiated cycles. Furthermore, the GnRH-a protocol was correlated with a higher implantation rate than the GnRH-ant protocol for ET cycles (146/577 = 25.3% vs. 11/103 = 10.7%, P = 0.027). No differences in the ET cancellation rate, live birth rate and implantation rate between GnRH-a and GnRH-ant groups were observed among PG4 patients. In conclusion, the GnRH-a protocol was more effective than the GnRH-ant protocol for young patients with DOR. The low ET cancellation rate and high implantation rate may be related to embryo quality or endometrial receptivity, which warrant further investigation.

Comparison of the standard GnRH antagonist protocol and the luteal phase estradiol/GnRH antagonist priming protocol in poor ovarian responders

BACKGROUND/AIM

The aim of the study was to compare the luteal estradiol patch/GnRH antagonists priming protocol (LPP) with the standard GnRH antagonist protocol in poor ovarian responders (PORs) in terms of the outcomes of in vitro fertilization (IVF) treatment.

MATERIALS AND METHODS

IVF outcomes of 265 cycles in 265 patients (106 in the LPP group, 159 in the standard GnRH antagonist group) were evaluated retrospectively.

RESULTS

Mean length of stimulation (11.4 ± 2.7 vs. 10.0 ± 2.7 days; P < 0.05) and the total gonadotropin dose (3403 ± 1060 vs. 2984 ± 1112) used were significantly greater in the LPP group than in the standard GnRH antagonist protocol group. The mean number of oocytes retrieved (3.5 ± 2.6 vs. 3.7 ± 2.8), the number of mature oocytes (2.8 ± 2.2 vs. 2.6 ± 2.2), fertilization rates (65% vs. 62%), the number of embryos transferred (1.6 ± 0.6 vs. 1.7 ± 0.6), and implantation rates (16% vs. 13%) were similar. The cancellation rate did not significantly differ between the groups (9.4% vs. 13.2%). There were no significant differences in the clinical pregnancy (11.3% vs. 13.2%) or live birth rates per patient (3.8% vs. 9.4%) and clinical pregnancy (18.8% vs. 22.6%) or live birth rates per embryo transfer (6.3% vs. 12.9%) between the groups.

CONCLUSION

LPP does not improve IVF outcomes when compared with the standard GnRH antagonist protocol in PORs.

A comparative study of luteal estradiol pre-treatment in GnRH antagonist protocols and in micro dose flare protocols for poor-responding patients

PURPOSE

This study aims to verify if luteal estradiol pre-treatment improves IVF/ICSI outcomes in a GnRH antagonist protocol as compared with a micro dose GnRH agonist protocol in poor-responding patients.

METHODS

A total of 116 IVF/ICSI cycles were included in this prospective randomized single blind clinical trial. The selected women were randomly assigned to receive an estradiol pre-treatment in a GnRH antagonist protocol (daily oral Estradiol Valerate 4 mg preceding the IVF cycle from the 21st day until the first day of the next cycle) or in oral contraceptive pill micro dose GnRH agonist protocol.

RESULTS

The patients in the luteal estradiol protocol required more days of stimulation (10.9 ± 1.6 vs. 10.2 ± 1.8) and a greater gonadotropin requirement (3,247.8 ± 634.6 vs. 2,994.8 ± 611 IU), yet similar numbers of oocytes were retrieved and fertilized. There was no significant difference between the two groups in terms of the implantation rates (9.8 vs. 7.9 %) and the clinical pregnancy rates per transfer (16.3 vs. 15.6 %).

CONCLUSION

This study demonstrates that the use of estradiol during a preceding luteal phase in a GnRH antagonist protocol can provide similar IVF outcomes when compared to a micro dose GnRH agonist protocol.

GnRH antagonist versus long GnRH agonist protocol in poor IVF responders: a randomized clinical trial

OBJECTIVE

To compare the efficacy of the long GnRH agonist and the fixed GnRH antagonist protocols in IVF poor responders.

STUDY DESIGN

This was a randomized controlled trial performed in the Iakentro IVF centre, Thessaloniki, from January 2007 to December 2011, concerning women characterised as poor responders after having 0-4 oocytes retrieved at a previous IVF cycle. They were assigned at random, using sealed envelopes, to either a long GnRH agonist protocol (group I) or a GnRH antagonist protocol (group II).

RESULTS

Overall 364 women fulfilled the inclusion criteria and were allocated to the two groups: finally 330 participated in our trial. Of these, 162 were treated with the long GnRH agonist protocol (group I), and 168 with the fixed GnRH antagonist protocol (group II). Numbers of embryos transferred and implantation rates were similar between the two groups (P=NS). The overall cancellation rate was higher in the antagonist group compared to the agonist group, but the difference was not significant (22.15% vs. 15.2%, P=NS). Although clinical pregnancy rates per transfer cycle were not different between the two groups (42.3% vs. 33.1%, P=NS), the clinical pregnancy rate per cycle initiated was significantly higher in the agonist compared to the antagonist group (35.8% vs. 25.6%, P=0.03).

CONCLUSIONS

Although long GnRH agonist and fixed GnRH antagonist protocols seem to have comparable pregnancy rates per transfer in poor responders undergoing IVF, the higher cancellation rate observed in the antagonist group suggests the long GnRH agonist protocol as the first choice for ovarian stimulation in these patients.

Does the degree of hypothalamic-pituitary-ovarian recovery after oral contraceptive pills affect outcomes of IVF/ICSI cycles receiving GnRH-antagonist adjuvant therapy in women over 35 years of age?

PURPOSE

To evaluate if the degree of recovery of serum gonadotropins after oral contraceptive pills (OCP) pretreatment has an impact on ovarian response in GnRH-antagonist IVF cycles in women of advanced maternal age.

METHODS

In this retrospective cohort study, we included 98 women 35-42 years undergoing their first IVF cycle receiving gonadotropins and a fixed GnRH-antagonist adjuvant protocol. Data analysis was carried out according to changes in serum FSH, LH and estradiol (E(2)) levels (basal and post-OCP) divided in quartiles, and also according to absolute levels. The main outcomes were peak serum E(2), number of mature oocytes retrieved, length of stimulation, and amount of gonadotropins used.

RESULTS

By quartile analysis, patients with the highest levels of serum gonadotropins suppression and also patients with gonadotropin rebound needed larger amounts of LH during the treatment. On the other hand, women with absolute suppression of FSH/LH had increased length of stimulation.

CONCLUSIONS

The results of this study provide data that assist in clinical management. Gonadotropin serum levels after OCP treatment provide information for optimization of supplementation with LH in GnRH-antagonist cycles in women over age 35.

Comparison of different stimulation protocols efficacy in poor responders undergoing IVF: a retrospective study

PURPOSE

To compare the efficacy of different stimulation protocols on pregnancy outcomes in poor responders undergoing in vitro fertilization (IVF).

MATERIALS AND METHODS

This was a retrospective study to compare the efficacy of four different protocols including gonadotropin-releasing hormone (GnRH) agonist (long, short and miniflare) and GnRH antagonist on pregnancy outcomes in poor responders. This investigation was performed on 566 poor respond patients who were candidates for IVF. Main outcome measures included the total number of oocytes and mature oocytes retrieved, pregnancy rates, implantation and overall cancellation rates which were compared between four mentioned groups.

RESULTS

Number of follicles >18 mm on hCG day were significantly higher in GnRH-a long versus GnRH antagonist, GnRH-a short and GnRH-a miniflare protocols. The mean number of oocytes and mature oocytes retrieved were significantly higher in GnRH-a long versus miniflare (4.7 ± 3.05 versus 3.26 ± 2.9 and 3.69 ± 3.1 versus 2.65 ± 2.2, respectively). There were no significant differences in implantation, pregnancy and overall cancellation rates between four groups.

CONCLUSION

The present study suggests that the application of four different protocols in poor respond patients seem to have similar efficacy in improving clinical outcomes such as implantation, pregnancy rates and cancellation rate even though GnRH-a long protocol yielded more retrieved oocytes and mature oocytes compared to GnRH-a miniflare protocol.

GnRH antagonist multiple dose protocol with oral contraceptive pill pretreatment in poor responders undergoing IVF/ICSI

Objective

To investigate the effectiveness of GnRH antagonist multiple-dose protocol (MDP) with oral contraceptive pill (OCP) pretreatment in poor responders undergoing IVF/ICSI, compared with GnRH antagonist MDP without OCP pretreatment and GnRH agonist low-dose long protocol (LP).

Methods

A total of 120 poor responders were randomized into three groups according to controlled ovarian stimulation (COS) options; GnRH antagonist MDP after OCP pretreatment (group 1), GnRH antagonist MDP without OCP pretreatment (group 2) or GnRH agonist luteal low-dose LP without OCP pretreatment (group 3). Patients allocated in group 1 were pretreated with OCP for 21days in the cycle preceding COS, and ovarian stimulation using recombinant human FSH (rhFSH) was started 5 days after discontinuation of OCP.

Results

There were no differences in patients' characteristics among three groups. Total dose and days of rhFSH used for COS were significantly higher in group 3 than in group 1 or 2. The numbers of mature oocytes, fertilized oocytes and grade I, II embryos were significantly lower in group 2 than in group 1 or 3. There were no significant differences in the clinical pregnancy rate and implantation rate among three groups.

Conclusion

GnRH antagonist MDP with OCP pretreatment is at least as effective as GnRH agonist low-dose LP in poor responders and can benefit the poor responders by reducing the amount and duration of FSH required for follicular maturation.

Extended high dose letrozole regimen versus short low dose letrozole regimen as an adjuvant to gonadotropin releasing hormone antagonist protocol in poor responders undergoing IVF-ET

OBJECTIVE

To compare the efficacy and cost-effectiveness of extended high dose letrozole regimen/HPuFSH-gonadotropin releasing hormone antagonist (GnRHant) protocol with short low dose letrozole regimen/HPuFSH-GnRHant protocol in poor responders undergoing IVF-ET.

METHODS

In this randomized controlled trial, 136 women who responded poorly to GnRH agonist long protocol in their first IVF cycle were randomized into two equal groups using computer generated list and were treated in the second IVF cycle by either extended letrozole regimen (5 mg/day during the first 5 days of cycle and 2.5 mg/day during the subsequent 3 days) combined with HPuFSH-GnRHant protocol or short letrozole regimen (2.5 mg/day from cycle day 3-7) combined with HPuFSH-GnRHant protocol.

RESULTS

There were no significant differences between both groups with regard to number of oocytes retrieved and clinical pregnancy rate (5.39 ± 2.08 vs. 5.20 ± 1.88 and 22.06% vs. 16.18%, respectively).The total gonadotropins dose and medications cost per cycle were significantly lower in extended letrozole group (44.87 ± 9.16 vs. 59.97 ± 14.91 ampoules and 616.52 ± 94.97 vs. 746.84 ± 149.21 US Dollars ($), respectively).The cost-effectiveness ratio was 2794 $ in extended letrozole group and 4616 $ in short letrozole group.

CONCLUSION

Extended letrozole regimen/HPuFSH-GnRHant protocol was more cost-effective than short letrozole regimen/HPuFSH-GnRHant protocol in poor responders undergoing IVF-ET.

[Cancellation of IVF-ET cycles: poor prognosis, poor responder, or variability of the response to controlled ovarian hyperstimulation? An analysis of 142 cancellations]

INTRODUCTION

This retrospective study aimed at analyzing IVF-ET management and outcome after cancellation of a first cycle for poor response.

PATIENTS AND METHOD

One hundred and forty-two infertile patients were included in this observational study. After an overall analysis on the outcome of the second IVF-ET attempt, a sub-analysis was performed according to the presence or the absence of poor prognostic criteria defined as mentioned: patient age superior to 38 years old, antral follicle count (3-9 mm in diameter) inferior to 10 on cycle day 3 and day 3 serum AMH and FSH levels less than 1 ng/mL and more than 10 IU/mL, respectively. Main outcome measures were the cancellation rates, pregnancy and live birth rates.

RESULTS

When a controlled ovarian stimulation was performed, patients with poor prognosis had higher cancellation rates (37.8% vs. 13.3%, P<0.004) and lower pregnancy and live birth rates (22.2% vs. 35.0%, P<0.05 and 11.1% vs. 26.1%, P<0.05, respectively) as compared to good prognosis women.

CONCLUSION

The relatively high cancellation rate in patients with poor prognosis raises the question of the use of IVF modified natural cycle in this group.

Natural cycle IVF/IVM may be more desirable for poor responder patients after failure of stimulated cycles

OBJECTIVE

To describe pregnancies and live births resulted from natural cycle IVF combined with in-vitro maturation (natural-cycle IVF/IVM) for three poor responder women after failure of stimulated cycles.

METHODS

For case 1 and 2, the mature oocytes from aspirated follicles were inseminated by intracytoplasmic sperm injection (ICSI) immediately; immature oocytes were matured in vitro, and the embryos from mature and immature oocytes transferred on day 3 after oocyte retrieval. For case 3, 3 consecutive natural cycles were performed, in which the matured oocytes from in vivo or in vitro were vitrified in the first and second cycle, and warmed on the retrieval day of the third fresh cycle. Then the embryos resulted from vitrified-warmed and fresh oocytes were transferred.

RESULTS

A total of 15 oocytes were obtained from the 7 retrieval cycles for the three cases. The case 1 was successfully pregnant at her first natural cycle, and case 2 was pregnant after two consecutive cycles. The two cases had successfully delivered and case 3 was in her ongoing pregnancy at the time of submission.

CONCLUSION

These results demonstrate that natural-cycle IVF/IVM might be a reasonable and efficient treatment alternative for poor responder patients when stimulated cycle has failed.

Poor prognosis for ovarian response to stimulation: results of a randomised trial comparing the flare-up GnRH agonist protocol vs. the antagonist protocol

OBJECTIVE

To determine the efficacy of the flare-up agonist and the antagonist protocols in patients with poor prognosis for ovarian response.

METHODS

A randomised trial was conducted on two hundred and twenty-one women considered as having poor prognosis for ovarian response to stimulation, based on previous cycles or clinical criteria. All women were prospectively randomised into two groups of treatment (flare-up group and antagonist group) by computer-assisted randomisation in a 1:1 ratio. The main outcome measure was clinical pregnancy rate.

RESULTS

Groups were homogeneous in age and baseline characteristics. Duration of stimulation, gonadotropin consumption, number of oocytes retrieved and number and quality of embryos transferred did not differ significantly between the groups. E(2) level the day of hCG administration was significantly higher in the flare-up group. Pregnancy rates per started cycle were 15% in the flare-up group and 14.1% in the antagonist group. Cancellation rates were 12.5% in the flare-up group and 16.3% in the antagonist group. None of these differences reached statistical significance.

CONCLUSIONS

No statistically significant differences were observed between the two protocols regarding clinical pregnancy rates. In patients with poor prognosis for ovarian response, the flare-up agonist and the antagonist protocols were comparable regarding clinical pregnancy rates.

Effects of prolonging administration gonadotropin on unexpectedly poor ovarian responders undergoing in vitro fertilization

BACKGROUND

There are still some patients who show poor response to ovarian stimulation prior to evidence of normal ovarian reserve in vitro fertilization. However, there are few studies about how to treat the unexpectedly ovarian poor responder in vitro fertilization. The main aim of this study evaluate the effect of prolonging administration follicle-stimulating hormone in woman with the unexpectedly ovarian poor responder in vitro fertilization on implantation rate, clinical pregnancy rate and live birth rate.

METHODS

922 patients subjected to IVF were divided into two groups according to the predicted criterion of ovarian poor response. 116 patients predicted poor response received the short protocol (group C). The others received the long protocol, among the latter, there were 149 patients undergoing unexpectedly ovarian poor response (group B) and 657 patients exhibited normal ovarian response (group A). The doses of gonadotropin, duration of administration, implantation rate, clinical pregnancy rate and live birth rate were recorded among three groups.

RESULTS

The implantation rate of embryo, clinic pregnancy rate and delivery rate are similar between the group A and group B, while there are significant differences between the doses of gonadotropins (35.1 +/- 8.9 ampules vs.53.0 +/- 15.9 ampules) and the duration of administration (15.3 +/- 3.6D vs. 9.8 +/- 2.6D) of these two groups. There are no significant differences about clinical pregnancy rate and live birth rate between group B and group C.

CONCLUSION

Prolonging administration gonadotropin on the unexpectedly poor ovarian responders does not lower live birth rate in vitro fertilization.

The use of lead follicle diameter to initiate gonadotropin-releasing hormone antagonist does not affect in vitro fertilization clinical pregnancy, implantation, or live birth rates: a prospective, randomized study

In this prospective, randomized study, waiting for the lead follicle to reach 14 mm before initiating GnRH antagonist administration effectively prevents an LH surge and ovulation during an IVF cycle. Furthermore, delaying GnRH start until the dominant follicle reaches 14 mm neither impacts the clinical pregnancy, implantation, or live birth rates nor increases the incidence of severe ovarian hyperstimulation syndrome.

Is there an ideal stimulation regimen for IVF for poor responders and does it change with age?

PURPOSE

To determine whether there is a superior treatment modality for 'poor' responders.

METHOD

Retrospective analysis of three stimulation regimens, with patients stratified based on age, stimulation regime and response in previous cycles ("poor' responder or "non poor" responder). Fertilisation, embryo utilisation and clinical pregnancy rates were assessed. There were a total of 1,608 cycles in the 'poor' responder and 8,489 cycles in the 'non poor' responder groups.

RESULTS

In 'poor' responders there was no significant difference in fertilisation rate, nor utilisation rate between the three stimulation regimes and no differences in the pregnancy rate/initiated cycle irrespective of age and stimulation regimen in any of the groups. 'Non poor' responders had a significantly greater pregnancy rate/initiated cycle for all stimulation regimens in both age groups compared with 'poor' responders.

CONCLUSION

This large retrospective study of 'poor' responders has not shown a difference in pregnancy rates/initiated cycle between stimulation regimens.

Natural-cycle in vitro fertilization in poor responder patients: a survey of 500 consecutive cycles

OBJECTIVE

To determine the role of the natural cycle for in vitro fertilization (IVF) in poor responder patients.

DESIGN

Retrospective survey.

SETTING

Private center for assisted reproduction.

PATIENT(S)

294 women who were poor responders in a previous IVF cycle.

INTERVENTION(S)

Analysis of 500 consecutive natural cycles IVF.

MAIN OUTCOME MEASURE(S)

Number of cycles with oocytes, pregnancy rate per cycle, per transfer, and implantation rate.

RESULT(S)

Oocytes were found in 391 cases (78.1%), and cleaving embryos suitable for transfer were obtained in 285 cycles (57.0%). Pregnancy was observed in 49 cases, with a pregnancy rate of 9.8% per cycle, 17.1% per transfer, and 16.7% per patient. The patients were subdivided arbitrarily by the women's age into three groups. Patients 35 years old or younger showed a pregnancy rate of 18.1% per cycle, 29.2% per transfer, and 31.7% per patient. Women aged between 36 and 39 years showed a pregnancy rate of 11.7% per cycle, 20.6% per transfer, and 20.3% per patient. Women 40 years old or older showed a pregnancy rate of 5.8% per cycle, 10.5% per transfer, and 9.7% per patient. No differences were found for any of the evaluated parameters, independent of which cycle was the first, the second, third, fourth, or fifth, or further consecutive cycle.

CONCLUSION(S)

In poor responder patients, natural-cycle IVF is an effective treatment, especially in younger women.

Gonadotrophin releasing hormone antagonist in IVF/ICSI

OBJECTIVE

To study the efficacy of gonadotrophin releasing hormone (GnRH) antagonist in In-vitro-fertilization/Intracytoplasmic sperm injection (IVF/ICSI) cycles.

TYPE OF STUDY

Observational study.

SETTING

Reproductive Medicine Unit, Christian Medical College Hospital, Vellore, Tamil Nadu.

MATERIALS AND METHODS

GnRH antagonists were introduced into our practice in November 2005. Fifty-two women undergoing the antagonist protocol were studied and information gathered regarding patient profile, treatment parameters (total gonadotrophin dosage, duration of treatment, and oocyte yield), and outcomes in terms of embryological parameters (cleavage rates, implantation rates) and clinical pregnancy. These parameters were compared with 121 women undergoing the standard long protocol. The costs between the two groups were also compared.

MAIN OUTCOME

Clinical pregnancy rate.

RESULTS

The clinical pregnancy rate per embryo transfer in the antagonist group was 31.7% which was comparable to the clinical pregnancy rate in women undergoing the standard long protocol (30.63%). The costs between the two groups were comparable.

CONCLUSIONS

GnRH antagonist protocol was found to be effective and comparable to the standard long protocol regimen. In addition it was simple, convenient, and patient friendly.

Management of the poor responder: the role of GnRH agonists and antagonists

PURPOSE

Evaluate the relative benefit of various doses and regimens of GnRH agonists (GnRHa) and antagonists (GnRHant) in the management of the poor responder.

METHODS

Review of English language publications with an emphasis on prospective randomized trials where available.

RESULTS

The lack of a uniformly applied definition of the poor responder and dearth of prospective randomized trials make data analysis difficult. Traditional GnRHa flare and long luteal phase protocols do not appear to be beneficial. Reduction of GnRHa doses, "stop" protocols, and microdose GnRHa flare regimes all appear to enhance outcomes, although the relative benefit of one approach over another has not been conclusively demonstrated. GnRHant does improve outcomes in this patient population, although, in general, pregnancy rates appear to be lower in comparison to microdose GnRHa flare regimes.

CONCLUSIONS

There is no one controlled ovarian hyperstimulation (COH) protocol which is best suited for all poor responders. Low dose GnRHa regimes appear to be most advantageous. Prediction of compromised response prior to cycle initiation by a thorough assessment of ovarian reserve as well as a careful review of past response should allow for selection of an appropriate COH protocol for each individual patient.

Different ovarian stimulation protocols for women with diminished ovarian reserve

PURPOSE

To review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols.

METHODS

Literature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews.

RESULTS

A lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients.

CONCLUSIONS

The ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.

Ultrashort gonadotropin-releasing hormone agonist combined with flexible multidose gonadotropin-releasing hormone antagonist for poor responders in in vitro fertilization/embryo transfer programs

To evaluate the appropriate controlled ovarian hyperstimulation (COH) protocol in poor responders, we compared the stimulation characteristics of 21 cycles, which included the ultrashort gonadotropin-releasing hormone (GnRH) agonist combined with the flexible multidose GnRH antagonist, to the patients' previous failed in vitro fertilization attempts. The use of an ultrashort GnRH-agonist/GnRH-antagonist COH protocol resulted in a statistically significantly greater number of follicles larger than 14 mm on the day of hCG administration, a higher number of oocytes retrieved and embryos transferred, and a reasonable clinical pregnancy rate (14.3%).