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Lin G, Li X, Jin Yie SL, Xu L. Clinical evidence of coenzyme Q10 pretreatment for women with diminished ovarian reserve undergoing IVF/ICSI: a systematic review and meta-analysis. Ann Med 2024; 56:2389469. [PMID: 39129455 PMCID: PMC11321116 DOI: 10.1080/07853890.2024.2389469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/25/2024] [Accepted: 06/19/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND To quantitatively evaluate the effect of coenzyme Q10 (CoQ10) pretreatment on outcomes of IVF or ICSI in women with diminished ovarian reserve (DOR) based on the existing randomized controlled trials (RCTs). METHODS Nine databases were comprehensively searched from database inception to November 01, 2023, to identify eligible RCTs. Reproductive outcomes of interest consisted of three primary outcomes and six secondary outcomes. The sensitivity analysis was adopted to verify the robustness of pooled results. RESULTS There were six RCTs in total, which collectively involved 1529 participants with DOR receiving infertility treatment with IVF/ICSI. The review of available evidence suggested that CoQ10 pretreatment was significantly correlated with elevated clinical pregnancy rate (OR = 1.84, 95%CI [1.33, 2.53], p = 0.0002), number of optimal embryos (OR = 0.59, 95%CI [0.21, 0.96], p = 0.002), number of oocytes retrieved (MD = 1.30, 95%CI [1.21, 1.40], p < 0.00001), and E2 levels on the day of hCG (SMD = 0.37, 95%CI [0.07, 0.66], p = 0.01), along with a reduction in cycle cancellation rate (OR = 0.60, 95%CI [0.44, 0.83], p = 0.002), miscarriage rate (OR = 0.38, 95%CI [0.15, 0.98], p = 0.05), total days of Gn applied (MD = -0.89, 95%CI [-1.37, -0.41], p = 0.0003), and total dose of Gn used (MD = -330.44, 95%CI [-373.93, -286.96], p < 0.00001). The sensitivity analysis indicated that our pooled results were robust. CONCLUSIONS These findings suggested that CoQ10 pretreatment is an effective intervention in improving IVF/ICSI outcomes for women with DOR. Still, this meta-analysis included relatively limited sample sizes with poor descriptions of their methodologies. Rigorously conducted trials are needed in the future.
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Affiliation(s)
- Guangyao Lin
- Department of Gynecology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xuanling Li
- Department of Gynecology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Stella Lim Jin Yie
- Department of Gynecology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lianwei Xu
- Department of Gynecology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Effectiveness of GnRH Agonist Short Protocol Versus GnRH Antagonist Protocol in POSEIDON Groups 3 and 4: a Retrospective Cohort Study. Reprod Sci 2023:10.1007/s43032-023-01196-x. [PMID: 36808612 DOI: 10.1007/s43032-023-01196-x] [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: 10/04/2022] [Accepted: 02/05/2023] [Indexed: 02/19/2023]
Abstract
The aim of this study is to compare the ART (assisted reproductive technology) outcomes and cancellation rates between GnRH antagonist protocol and GnRH agonist short protocol in POSEIDON (Patient-Oriented Strategy Encompassing IndividualizeD Oocyte Number) groups 3 and 4. It is a retrospective cohort study conducted in the Department of Reproductive Medicine and Surgery of a tertiary-level hospital. Women who underwent ART treatment with either GnRH antagonist or GnRH agonist short protocol with fresh embryo transfer, between January 2012 and December 2019 belonging to POSEIDON 3 and 4 groups, were included. Among the 295 women who belonged to the POSEIDON groups 3 or 4, 138 women received GnRH antagonist and 157 women received GnRH agonist short protocol. The median total dose of gonadotropin in the GnRH antagonist protocol was not significantly different from GnRH agonist short protocol [3000, IQR (2481-3675) vs. 3175, IQR (2643-3993), p = 0.370]. There was a significant difference in the duration of stimulation between the GnRH antagonist and GnRH agonist short protocol [10, IQR (9-12) vs. 10, IQR (8-11), p = 0.002]. The median number of mature oocytes retrieved was significantly different in the cohort of women receiving GnRH antagonist protocol compared to GnRH agonist short protocol [3, IQR (2-5) vs. 3, IQR (2-4), p = 0.029]. There was no significant difference in the clinical pregnancy rate (24% vs. 20%, p = 0.503) and cycle cancellation rate (29.7% vs. 36.3%, p = 0.290) between the GnRH antagonist and agonist short protocols respectively. Live birth rate was not significantly different between the GnRH antagonist protocol (16.7%) and GnRH agonist short protocol (14.0%) [OR 1.23, 95% CI (0.56-2.68), p = 0.604]. After adjusting for the significant confounding factors, the live birth rate was not significantly associated with the antagonist protocol compared with the short protocol [aOR 1.08, 95% CI (0.44-2.63), p = 0.870]. Though GnRH antagonist protocol results in higher mature oocyte yield when compared with GnRH agonist short protocol, it does not translate into an increase in live birth in POSEIDON groups 3 and 4.
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Zhang X, Lu Y, Wu S, Zhao X, Li S, Zhang S, Tan J. Estimates of global research productivity in primary ovarian insufficiency from 2000 to 2021: Bibliometric analysis. Front Endocrinol (Lausanne) 2022; 13:959905. [PMID: 36387882 PMCID: PMC9645456 DOI: 10.3389/fendo.2022.959905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Primary ovarian insufficiency (POI) is a heterogeneous disease with diverse clinical phenotypes and etiologies, which is defined as ovarian dysfunction under the age of 40 years. The global prevalence of POI is approximately about 1.1%, and it severely affects female fertility. Nevertheless, bibliometric analysis in this field is extremely limited. We aimed to visualize the research hotspots and trends of POI using bibliometric analysis and tried to predict the future development of this field. METHODS The original articles regarding POI were culled from the Web of Science Core Collection. Countries, institutions, journals, authors, and keywords in this field were visually analyzed by employing CiteSpace software and Microsoft Excel 2021 software. RESULTS A total of 2,999 publications were included for further bibliometric analysis after screening the titles and abstracts stringently. The number of literature regarding POI significantly increased yearly. These publications come from 78 countries. The USA was dominant in the field of POI in terms of the number of publications (865), average citations per item (57.36), and h-index (112). The Institut National De La Sante Et De La Recherche Medicale Inserm is the most high-yield institution in this field with 351 publications. Fertility and Sterility ranked first with the highest number of publications (152), followed by Human Reproduction (138). According to the keyword cluster analysis from 2000 to 2021, the eight keyword clusters encountered frequently were apoptosis, osteoporosis, fertility preservation, mutation, fragile x syndrome, adrenal insufficiency, DNA repair, ovarian reserve. Keyword citation burst analysis revealed that whole-exome sequencing, ovarian tissue cryopreservation, and DNA repair had a citation burst until 2021. CONCLUSIONS Great progress has been made in POI research over the past 20 years, which is widely researched but unevenly developed in the world. In terms of influence, the United States may be in the lead. The research hotspots in POI are mainly pathogenesis and treatment, including genetic mutation, hormone therapy, fertility preservation, and stem cell transplantation.
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Affiliation(s)
- Xudong Zhang
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Yimeng Lu
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Shanshan Wu
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Xinyang Zhao
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Shuyu Li
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Siwen Zhang
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Jichun Tan
- Center of Reproductive Medicine, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodeling of Liaoning Province, Shenyang, China
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Gonullu DC, McCulloh DH, Robinson LG, Oh C, Keefe DL. Response from the Authors Re: Letter to the Editor for Our Manuscript "Oocyte stimulation parameters influence the number and proportion of mature oocytes retrieved in assisted reproductive technology cycles". J Assist Reprod Genet 2021; 38:2805. [PMID: 34599459 DOI: 10.1007/s10815-021-02332-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Damla C Gonullu
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - David H McCulloh
- NYU Grossman School of Medicine, NYU Langone Fertility Center, New York, NY, 10016, USA.
| | - LeRoy G Robinson
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine , New York, NY, USA
| | - Cheongeun Oh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - David L Keefe
- NYU Grossman School of Medicine, NYU Langone Fertility Center, New York, NY, 10016, USA.,Department of Obstetrics and Gynecology, New York University Grossman School of Medicine , New York, NY, USA
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Qin Y. Effects of using letrozole in combination with the GnRH antagonist protocol for patients with poor ovarian response: A meta-analysis. J Gynecol Obstet Hum Reprod 2021; 50:102139. [PMID: 33838300 DOI: 10.1016/j.jogoh.2021.102139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 12/29/2020] [Accepted: 04/05/2021] [Indexed: 12/09/2022]
Abstract
This meta-analysis aimed to compare the outcomes of the gonadotrophin-releasing hormone (GnRH) antagonist/letrozole protocol with those of the conventional GnRH antagonist protocol for poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). We searched for relevant articles in PubMed, EMBASE, Google Scholar, and retrieved 452 records. Eventually, we selected five eligible trials with data for 564 patients characterized as poor ovarian responders. Our meta-analysis revealed that the clinical pregnancy rate (per cycle) with administration of letrozole might be a higher than that in the control groups (risk rate [RR]: 1.57, 95% confidence interval [CI]: 1.00-2.44, p = 0.05). .Moreover,it indicated that the total dose of gonadotrophin was significantly decreased with the administration of letrozole compared to control groups(mean difference [MD]: -529.37, 95% CI: -1207.45 to -111.25, p = 0.001),.However, there was no statistical difference in the number of retrieved oocytes(MD: 0.59, 95% CI: -0.36-1.54, p = 0.22), cycle cancelation rate (RR: 0.81, 95% CI: 0.58-1.12, p = 0.20), or estradiol concentration on the day of HCG administration(MD: -28.19, 95% CI: -77.71-21.33, p = 0.26) in the presence or absence of letrozole combination in the GnRH antagonist protocol. In conclusion, letrozole administration might improve clinical pregnancy rate in conventional GnRH antagonist protocol for poor responders. Moreover, letrozole co-treatment aslo can reduce the economic burden of poor responders during the GnRH antagonist cycle. Nevertheless, large-scale and multi-center randomized controlled trials are needed to further evaluate the efficacy of adjunctive letrozole administration in the GnRH antagonist protocol.
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Affiliation(s)
- Ying Qin
- Reproductive Medicine Center, Guangzhou Women and Children's Medical Center, No. 9 Jinsui Road, Guangzhou, Guangdong, 510120, China.
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Yang H, Zheng C, Zheng Q, Xu H, Li X, Hao M, Fang Y. Controlled ovarian hyperstimulation for poor ovarian responders undergoing in vitro fertilisation/intracytoplasmic sperm injection: a protocol for systematic review and Bayesian network meta-analysis. BMJ Open 2021; 11:e039122. [PMID: 33622939 PMCID: PMC7907865 DOI: 10.1136/bmjopen-2020-039122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Controlled ovarian hyperstimulation (COH) is the routine regimen used to generate a sufficient number of follicles during in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Poor ovarian response is a challenge encountered by many clinicians during COH and poor ovarian responders (PORs) usually have higher follicle stimulating hormone levels, lower levels of anti-Mullerian hormone and few oocytes retrieved, which have been attributed mainly to advanced maternal age and poor follicle reserve or other reasons that could impair ovarian response during ovarian stimulation. Over the last few decades, researchers have proposed a series of strategies and ovarian stimulation protocols to improve pregnancy outcomes in patients with POR during their IVF/ICSI treatment. However, clinical decisions regarding COH protocols in PORs during IVF/ICSI treatment remain controversial. Traditional pairwise meta-analysis only allows the direct comparison of two protocols in COH for patients with POR. However, many of these COH protocols have not been compared directly in randomised controlled trials (RCTs). Thus, we aim to use network meta-analysis (NMA) to assess the clinical effectiveness and safety of COH protocols and to generate treatment rankings of these COH protocols for the most clinically important and commonly reported outcomes events. METHODS AND ANALYSIS The PubMed, Embase, Cochrane Library, Web of Science, SinoMed, CNKI, WanFang database and Chongqing VIP information databases will be searched for all RCTs of COH for POR women during IVF/ICSI from inception to 31 March 2020. Primary outcomes will include live birth rate and number of oocytes retrieved. Secondary outcomes will include ongoing pregnancy rate, clinical pregnancy rate, miscarriage rate, ovarian hyperstimulation syndrome rate, multiple pregnancy rate and cycle cancellation rate. Pairwise meta-analysis and Bayesian NMA will be conducted for each outcome. Subgroup analysis, meta-regression, and sensitivity analysis will be performed to assess the robustness of the findings. The generation of NMA plots and subsequent results will be performed by using R V.4.0.1. The assessment of confidence in network estimates will use the Confidence in Network Meta-Analysis)web application (see https://cinema.ispm.unibe.ch/). ETHICS AND DISSEMINATION This review does not require ethics approval and the results of the NMA will be submitted to a peer-review journal.
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Affiliation(s)
- Huisheng Yang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chensi Zheng
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- Reproductive medicine center, Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
| | - Qiyan Zheng
- Department of Endocrinology Nephropathy, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Huanfang Xu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaotong Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mingzhao Hao
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yigong Fang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
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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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Xu H, Zheng C, He L, Su T, Wang H, Li Y, Zhao C, Zhang C, Bai Y, Tong G, Chen L, Zhao F, Yang H, Hao M, Yin Y, Yang L, Fang Y, Liu B. Effect of acupuncture on women with poor ovarian response: a study protocol for a multicenter randomized controlled trial. Trials 2020; 21:775. [PMID: 32912298 PMCID: PMC7488258 DOI: 10.1186/s13063-020-04690-8] [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: 09/29/2019] [Accepted: 08/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background Poor ovarian response (POR), a manifestation of low ovarian reserve and ovarian aging, leads to a significant reduction in the pregnancy rate after in vitro fertilization-embryo transfer. Acupuncture has increasingly been used to improve the ovarian reserve. The purpose of this study will be to evaluate the effect of acupuncture on increasing the number of retrieved oocytes after controlled ovarian hyperstimulation in women with POR. Methods This will be a multicenter randomized controlled trial. A total of 140 women with POR will be randomly assigned to receive acupuncture or nontreatment for 12 weeks before controlled ovarian hyperstimulation. The primary outcome will be the number of retrieved oocytes. The secondary outcomes will be antral follicle counts, serum levels of anti-Müllerian hormone, basal serum levels of follicle stimulating hormone, luteinizing hormone and estradiol levels, scores from the self-rating anxiety scale, fertilization rates, cleavage rates, available embryo rates, and high-quality embryo rates. The safety of acupuncture will also be assessed. Discussion The results of this trial will help to determine the effectiveness of acupuncture in the treatment of POR. This may provide a new treatment option for patients with POR and their physicians. Trial registration AMCTR-IPR-18000198. Registered on 10 August 2018.
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Affiliation(s)
- Huanfang Xu
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chensi Zheng
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liyun He
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Tongsheng Su
- Shanxi Provincial Hospital of Chinese Medicine, Taiyuan, Shanxi, China
| | - Huidan Wang
- Shandong University Reproductive Hospital, Jinan, Shandong, China
| | - Yu Li
- Sun Yat-sen Memorial Hospital of the Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Cui Zhao
- Lanzhou University First Hospital, Lanzhou, Gansu, China
| | - Cuilian Zhang
- Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yang Bai
- Huazhong University of Science and Technology Reproductive Medicine Center of Tongji Medical College, Wuhan, Hubei, China
| | | | - Li Chen
- East Region Military Command General Hospital, Nanjing, Jiangsu, China
| | - Fang Zhao
- Luoyang Women and Children Health Care Center, Luoyang, Henan, China
| | - Huisheng Yang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mingzhao Hao
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yaqian Yin
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Li Yang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yigong Fang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Baoyan Liu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China.
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Arvis P, Massin N, Lehert P. Effect of recombinant LH supplementation on cumulative live birth rate compared with FSH alone in poor ovarian responders: a large, real-world study. Reprod Biomed Online 2020; 42:546-554. [PMID: 33431337 DOI: 10.1016/j.rbmo.2020.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 12/21/2022]
Abstract
RESEARCH QUESTION The benefit of LH supplementation (LHS) over sole use of FSH during controlled ovarian stimulation (COS) remains controversial. Meta-analyses have provided some evidence that the benefit of LHS is limited to women with poor ovarian response (POR). This study aimed to assess the effectiveness of LHS on cumulative live birth rate (CLBR) in POR using a large controlled study in a real-world context. DESIGN This retrospective multicentre controlled study used data from registries at 12 French ART centres. All instances of POR undergoing ovarian stimulation and treated with follitrophin-alfa (FSH-α) with or without lutrophin-α were selected following an intention-to-treat principle. POR was defined according to the ESHRE Bologna criteria, and classified into three categories (Mild, Moderate and Severe) according to the Poor Responder Outcome Prediction (PROsPeR) score. The primary end-point was the CLBR associated with fresh and frozen embryos originating from the same ovarian stimulation. RESULTS A total of 9787 instances of ovarian stimulation (5218 LHS, 4569 FSH-α only) were analysed, 33.0%, 52.4% and 14.6% being allocated to the Mild, Moderate and Severe PROsPeR categories, respectively. Using a mixed logistic model and adjusting for matched subclasses and baseline POR severity, it was found that the benefit of LHS compared with use of FSH alone differed between baseline severity categories (interaction test, P = 0.007): a significant benefit of LHS for CLBR was found for patients in the Moderate (14.3% versus 11.3%, odds ratio [OR] = 1.37, 95% confidence interval [CI] 1.07-1.75, risk ratio [RR] = 1.29, P = 0.013) and Severe (9.8% versus 4.4%, OR = 2.40, 95% CI- 1.48-3.89, RR = 1.89, P < 0.001) categories, but not for the Mild category (18.8% versus 19.6%, OR = 0.95, 95% CI 0.78-1.15, RR = 0.95, P = 0.60). CONCLUSION LHS has a significant effect on increasing CLBR in moderately and severely poor ovarian responders.
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Affiliation(s)
| | | | - Philippe Lehert
- Faculty of Economics, UCL Mons, Louvain, Belgium, Faculty of Medicine, University of Melbourne, Melbourne Victoria, Australia
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Bosch E, Broer S, Griesinger G, Grynberg M, Humaidan P, Kolibianakis E, Kunicki M, La Marca A, Lainas G, Le Clef N, Massin N, Mastenbroek S, Polyzos N, Sunkara SK, Timeva T, Töyli M, Urbancsek J, Vermeulen N, Broekmans F. ESHRE guideline: ovarian stimulation for IVF/ICSI †. Hum Reprod Open 2020; 2020:hoaa009. [PMID: 32395637 PMCID: PMC7203749 DOI: 10.1093/hropen/hoaa009] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/05/2019] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION What is the recommended management of ovarian stimulation, based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation. WHAT IS KNOWN ALREADY Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS). PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations-of which only 21 were formulated as strong recommendations-and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety. LIMITATIONS REASON FOR CAUTION Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker's fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker's fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker's fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker's fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker's fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker's fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker's fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker's fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker's fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker's fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker's fees from Ferring. T.T. reports speaker's fees from Merck, MSD and MLD. The other authors report no conflicts of interest. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.
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Affiliation(s)
| | | | - Simone Broer
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Michael Grynberg
- Department of Reproductive Medicine & Fertility Preservation, Hopital Antoine Béclère, Clamart, France
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Skive, Denmark
| | - Estratios Kolibianakis
- Unit for Human Reproduction, 1 Dept of ObGyn, Medical School, Aristotle University, Thessaloniki, Greece
| | - Michal Kunicki
- INVICTA Fertility and Reproductive Centre, Department of Gynaecological Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Antonio La Marca
- Department of Obstetrics and Gynaecology, University of Modena Reggio Emilia and Clinica Eugin, Modena, Italy
| | | | - Nathalie Le Clef
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Nathalie Massin
- Department of Obstetrics, Gynaecology and Reproduction, University Paris-Est Créteil, Centre Hospitalier Intercommunal Créteil, Créteil, France
| | - Sebastiaan Mastenbroek
- Amsterdam Reproduction & Development, Center for Reproductive Medicine, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Nikolaos Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Sesh Kamal Sunkara
- Department of Women and Children’s Health, King’s College London, London, UK
| | | | - Mira Töyli
- Kanta-Häme Central Hospital, Hämeenlinna, Mehiläinen Clinics, Helsinki, Finland
| | - Janos Urbancsek
- Department of Obstetrics and Gynaecology, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Frank Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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11
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Zhang W, Xie D, Zhang H, Huang J, Xiao X, Wang B, Tong Y, Miao Y, Wang X. Cumulative Live Birth Rates After the First ART Cycle Using Flexible GnRH Antagonist Protocol vs. Standard Long GnRH Agonist Protocol: A Retrospective Cohort Study in Women of Different Ages and Various Ovarian Reserve. Front Endocrinol (Lausanne) 2020; 11:287. [PMID: 32457698 PMCID: PMC7225261 DOI: 10.3389/fendo.2020.00287] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/16/2020] [Indexed: 12/17/2022] Open
Abstract
Objective: To compare the cumulative live birth rates (cLBRs) after the first assisted reproductive technology (ART) cycle using flexible gonadotropin releasing hormone (GnRH)-antagonist protocol vs. standard long GnRH agonist protocol for controlled ovarian stimulation (COS) in infertile women with different ages and ovarian reserve. Methods: Women who underwent ART treatment at our center between June 1st, 2015 and December 31st, 2018 were screened. Among them, only women who underwent their first COS cycle with flexible GnRH antagonist protocol or standard long GnRH agonist protocol were included in this study. The main outcome measurement was cLBR. Results: A total of 4,402 patients were eligible for the analysis, of whom, 2,762 patients used the GnRH agonist protocol and 1,640 patients used the GnRH antagonist protocol. The cLBRs of women in the antagonist protocol group and long agonist protocol group were 45.3 and 50.0%, respectively. Subgroup multivariable regression analysis showed that, in patients with low ovarian reserve (AFC ≤ 7), the cLBR was significantly lower in the antagonist group than in the long agonist protocol group [OR (95% CI) 0.62 (0.41, 0.94)], which effect was more robust in younger patients (<30 y) [OR (95% CI) 0.29 (0.11, 0.74)]. The analysis also revealed remarkably lower cLBR in patients above 40 years regardless of their AFC, although the difference was not statistically significant. However, in patients with high ovarian reserve (AFC >24), the cLBR was higher in cycles with antagonist protocol than with the long agonist protocol [OR (95% CI) 1.43 (0.96, 2.12)], and the effect was of statistical significance in younger patients (< 30 y) [OR (95% CI) 1.78 (1.07, 2.96)]. Conclusion: The present study suggests that the flexible GnRH antagonist protocol might not be suitable for patients with low ovarian reserve (AFC ≤ 7) or patients aged over 40 years. However, flexible GnRH antagonist protocol might be strongly recommended for patients under 30 years old and with high ovarian reserve (AFC > 24). For the rest groups of patients in the present cohort, antagonist protocol was slightly favored because it had lower OHSS in general and in patients with poly-cystic ovarian syndrome (PCOS) according to previous publications.
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Affiliation(s)
- Wanlin Zhang
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Duo Xie
- Department of Obstetrics and Gynecology, 986 Hospital of Air Force, Xi'an, China
| | - Hengde Zhang
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Jianlei Huang
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Xifeng Xiao
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Binrong Wang
- Department of Anesthesiology, Xi'an International Medical Center Hospital, Xi'an, China
| | - Yafei Tong
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Ye Miao
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Xiaohong Wang
- Department of Obstetrics and Gynecology, Reproductive Medical Center, The Second Affiliated Hospital, Air Force Military Medical University, Xi'an, China
- *Correspondence: Xiaohong Wang
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12
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Lunenfeld B, Bilger W, Longobardi S, Kirsten J, D'Hooghe T, Sunkara SK. Decision points for individualized hormonal stimulation with recombinant gonadotropins for treatment of women with infertility. Gynecol Endocrinol 2019; 35:1027-1036. [PMID: 31392906 DOI: 10.1080/09513590.2019.1650345] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
It is essential that fertility treatment is individualized based on a thorough diagnostic work-up, with treatment tailored to the patients' requirements. This individualization should be kept in mind during the main decision points that occur before and during treatment. Treatment customization must include consideration of both the woman and her partner involved in the process together, including their collective treatment goals. Once treatment goals have been agreed and diagnostic evaluations performed, personalization based on patient characteristics, together with an understanding of treatment goals and patient preferences, enables the selection of appropriate treatments, protocols, products and their dosing. Following treatment initiation, monitoring and adaptation of product and dose can then ensure optimal outcomes. Currently, it is not possible to base treatment decisions on every characteristic of the patient and personalization is based on biomarkers that have been identified as the most relevant. However, in the future, the use of artificial intelligence coupled with continuous monitoring should enable greater individualization and improve outcomes. This review considers the current state-of-the-art related to decision points during individualized treatment of female infertility, before looking at future developments that might further assist in making individualized treatment decisions, including the use of computer-assisted decision making.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - Wilma Bilger
- Medical Affairs Fertility, Endocrinology & General Medicine, Merck Serono GmbH, Darmstadt, Germany
| | | | - Jan Kirsten
- Business Franchise Fertility, Merck KGaA, Darmstadt, Germany
| | - Thomas D'Hooghe
- Global Medical Affairs Fertility, Merck KGaA, Darmstadt, Germany
- Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Leuven, Belgium
- Department of Obstetrics and Gynecology, Yale University, New Haven, CT, USA
| | - Sesh K Sunkara
- Assisted Conception Unit, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, UK
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13
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Xu B, Chen Y, Geerts D, Yue J, Li Z, Zhu G, Jin L. Cumulative live birth rates in more than 3,000 patients with poor ovarian response: a 15-year survey of final in vitro fertilization outcome. Fertil Steril 2019; 109:1051-1059. [PMID: 29935642 DOI: 10.1016/j.fertnstert.2018.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To estimate the cumulative live birth rates (CLBRs) in women with poor ovarian response (POR) diagnosed according to the Bologna criteria. DESIGN A 15-year population-based observational cohort study. SETTING Teaching hospital. PATIENT(S) Between 2002 and 2016 a total of 3,391 women with POR were followed from their first fresh, nondonor IVF cycle until they had a live birth or discontinued treatment. All IVF and intracytoplasmic sperm injection (ICSI) cycles and cryocycles were included. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Live birth rates per initiated cycle, the conservative and optimistic CLBR for multiple IVF cycles. RESULT(S) The CLBRs after six IVF cycles were 14.9% for the conservative and 35.3% for the optimistic estimate. The CLBR decreased from 22% for women ≤30 years to 18.3% for women aged 31-34 years, 17.2% for 35-37 years, 13.5% for 38-40 years, 10.5% for 41-43 years, and 4.4% among women >43 years in the conservative analysis. There was a significant decreased CLBR starting at age 38 years compared with women <35 years. After adjusting for age, antral follicle count, basal FSH level, and IVF cycle number, natural cycles were associated with the lowest CLBR among all the protocols, and this difference was significant compared with the other protocols. CONCLUSION(S) For women with POR, the CLBR declined with increasing age. Women with advanced age (≥38 years) achieved a significantly lower CLBR than young poor responders (<35 years). Very low CLBR was associated with women aged >43 years old. Natural cycle IVF is of no benefit for these patients.
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Affiliation(s)
- Bei Xu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yingjia Chen
- Department of Neurology, University of California, San Francisco, California
| | - Dirk Geerts
- Department of Medical Biology, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands
| | - Jing Yue
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Zhou Li
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Guijin Zhu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lei Jin
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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14
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Zarei A, Parsanezhad ME, Kutenaei MA, Jahromi BN, Esfahani PS, Bakhshaei P. Delayed Start Protocol with Gonadotropin-releasing Hormone Antagonist in Poor Responders Undergoing In Vitro Fertilization: A Randomized, Double-blinded, Clinical Trial. Oman Med J 2018; 33:506-511. [PMID: 30410693 DOI: 10.5001/omj.2018.92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objectives We sought to determine the effects of the delayed start protocol with gonadotropin-releasing hormone (GnRH) antagonists in poor responders undergoing in vitro fertilization (IVF). Methods This randomized clinical trial was conducted during a 15-month period from April 2014 to July 2015 in clinics in Shiraz, Iran. A total of 42 poor responders with primary infertility were randomly assigned to the controlled ovarian stimulation group utilizing the delayed start protocol (n = 21) or the traditional group (n = 21) using GnRH antagonist, Cetrotide. The primary endpoint was the number of patients undergoing oocyte pick-up, implantation, and the rate of pregnancy. Results The baseline characteristics of the two study groups were comparable including age, infertility duration, and body mass index. The number of follicles measuring > 13 mm in diameter (p = 0.057), retrieved oocytes (p = 0.564), mature metaphase II oocytes (p = 0.366), embryos (p = 0.709), and transferred embryos (p = 0.060) were comparable between the two groups. The number of patients undergoing oocyte pick-up (p = 0.311), the rates of implantation (p = 0.407), and pregnancy (p = 0.596) were also comparable between the two groups. Conclusions The delayed start protocol was not associated with better conception results or cycle outcomes in poor responders with primary infertility undergoing IVF cycles.
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Affiliation(s)
- Afsoon Zarei
- Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Maryam Azizi Kutenaei
- Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bahia Namavar Jahromi
- Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Pardis Bakhshaei
- Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, Iran
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15
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Sanverdi I, Kutlu HT, Bilgic BE, Incebiyik A. A comparison of treatment results of the different treatment protocols in patients with poor ovarian response. Gynecol Endocrinol 2018; 34:524-527. [PMID: 29258385 DOI: 10.1080/09513590.2017.1416464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
To compare the effect of the different protocols in patients receiving in vitro fertilization treatment due to poor ovarian response. Seventy-seven of the patients included in the study were treated with gonadotropin (450 IU) + GnRH antagonist (group 1), 84 of the patients were treated with gonadotropin (450 IU) + microdose GnRH analog (group 2), and 53 of the patients were treated with clomiphene citrate (100 mg/day) + gonadotropin (300 IU) + GnRH antagonist (Group 3). In assessing total gonadotropin dosage, patients in Group 3 detected significantly less gonadotropin as compared to the other two groups (p < .001). Group 1 were superior to the other two groups with respect to retrieved oocytes, meiosis II oocytes and number of embryos obtained at the end of the treatment. As for the evaluation of clinical pregnancy, although the highest pregnancy rate was in Group 3, this finding was not of statistical significance. Although increasing the dosage of gonadotropins for ovarian hyper stimulation treatment in patients with poor ovarian response is beneficial with respect to retrieved oocytes, meiosis II oocytes and number of embryos, the increased dosage does not provide a statistically significant increase in clinical pregnancy rates.
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Affiliation(s)
- Ilhan Sanverdi
- a Department of Obstetrics and Gynaecology , Zeynep Kamil Women Health Training and Research Hospital , Istanbul , Turkey
| | - Huseyin Tayfun Kutlu
- a Department of Obstetrics and Gynaecology , Zeynep Kamil Women Health Training and Research Hospital , Istanbul , Turkey
| | - Bulent Emre Bilgic
- b Zeynep Kamil Women Health Training and Research Hospital, IVF Center , Istanbul , Turkey
| | - Adnan Incebiyik
- c Department of Gynecology and Obstetrics , Harran University, Faculty of Medicine , Sanliurfa , Turkey
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16
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Ma S, Ma R, Xia T, Afnan M, Song X, Xu F, Hao G, Zhu F, Han J, Zhao Z. Efficacy and safety of Ding-Kun-Dan for female infertility patients with predicted poor ovarian response undergoing in vitro fertilization/intracytoplasmic sperm injection: study protocol for a randomized controlled trial. Trials 2018; 19:124. [PMID: 29458401 PMCID: PMC5819272 DOI: 10.1186/s13063-018-2511-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/29/2018] [Indexed: 12/05/2022] Open
Abstract
Background Women undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) who have a predicted poor ovarian response (POR) present a challenge for reproductive medicine specialists. Traditional Chinese medicine (TCM) is commonly used in China for such patients, in the belief that it will improve the ovarian response and ultimately increase pregnancy rates. However, there is a lack of high-quality evidence about the effect of TCM on improving ovarian response in such patients. The purpose of this study is to evaluate ongoing viable pregnancy rate at 12 weeks’ gestation and related indicators of ovarian response in fertile women who have a predicted poor ovarian response having immediate versus delayed IVF/ICSI after 3 months of Ding-Kun-Dan (DKD) pre-treatment. Methods/design This study is a multicenter, randomized controlled, parallel-group, phase III, superiority clinical trial. Two hundred and seventy-eight eligible female infertility patients with POR will be included in the study and randomly allocated into an immediate treatment group and a DKD group in a 1:1 ratio. Both groups will receive IVF or ICSI as a standard treatment while in the DKD group, a commercially available Chinese medicine, DKD, will be administrated for 3 months before the IVF/ICSI cycle starts. The primary outcome of the study is the ongoing pregnancy rate at 12 weeks’ gestation. The secondary outcomes include total gonadotropin dosage, duration of stimulation, estradiol (E2) and progesterone (P) levels on human chorionic gonadotropin (hCG) trigger day, cycle cancellation rate, number of oocytes retrieved, high-quality embryo rate, biochemical pregnancy rate, the change of serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), and E2 levels and all side effects, safety outcomes, and any adverse events. The protocol was approved by the Ethics Committee of the First Teaching Hospital of Tianjin university of TCM (approval no. TYLL2017[K] 004). Discussion IVF/ICSI is increasingly used to treat couples desiring a baby. Many of these women will have poor ovarian function. In China, DKD is commonly used for these patients prior to undergoing IVF/ICSI. There is no effective treatment for poor ovarian response in Western medicine currently. It is important, therefore, to undertake this randomized control trial to determine whether DKD is effective or not. Trial registration Chinese Clinical Trial Registry, ID: ChiCTR-IOR-17011697. Registered on 19 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2511-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Saihua Ma
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China
| | - Ruihong Ma
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China
| | - Tian Xia
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China.
| | - Masoud Afnan
- Center of Reproductive Medicine, Tianjin United Family Hospital and Clinics, No. 22 Tanjiang Street, Hexi district, Tianjin, 300221, China
| | - Xueru Song
- Center of Reproductive Medicine, General Hospital of Tianjin Medical University, No. 154 Anshan Street, Nankai district, Tianjin, 300052, China
| | - Fengqin Xu
- Center of Reproductive Medicine, Tianjin First Center Hospital, No. 24 Fukang Road, Nankai district, Tianjin, 300190, China
| | - Guimin Hao
- Center of Reproductive Medicine, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Xinhua district, Shijiazhuang, 050000, China
| | - Fangfang Zhu
- The Graduate School, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Nankai district, Tianjin, 300073, China
| | - Jingpei Han
- The Graduate School, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Nankai district, Tianjin, 300073, China
| | - Zhimei Zhao
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China
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17
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Rasool S, Shah D. The futile case of the aging ovary: is it mission impossible? A focused review. Climacteric 2017; 21:22-28. [DOI: 10.1080/13697137.2017.1410784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S. Rasool
- Department of Reproductive Medicine, Gynaecworld, Mumbai, India
| | - D. Shah
- Department of Reproductive Medicine, Gynaecworld, Mumbai, India
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18
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Rasool S, Shah D. Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back. FERTILITY RESEARCH AND PRACTICE 2017; 3:15. [PMID: 29046817 PMCID: PMC5637249 DOI: 10.1186/s40738-017-0041-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/25/2017] [Indexed: 01/29/2023]
Abstract
Diminished fertility and poor ovarian response pose a conundrum to the experts in the field of reproductive medicine. There is limited knowledge about the risk factors of diminished ovarian reserve other than the iatrogenic ones. One of the leading causes of infertility in women today is diminished ovarian reserve (DOR). DOR is characterized by a low number of eggs in a woman's ovaries and/or with poor quality of the remaining eggs, which boils down to impaired development of the existing eggs, even with assisted reproductive techniques. A good number of such women with low ovarian reserve may conceive with their own eggs, if they are given individualized treatment that is tailored for their profile. Such patients should be counseled appropriately for an aggressive approach towards achieving fertility. The sooner the treatment is started, the better the chances of pregnancy.
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Affiliation(s)
- Sabahat Rasool
- Gynaecworld, Kwality House, 1st Floor, Kemps Corner, Mumbai, India
| | - Duru Shah
- Scientific Director & Fertility Expert, Gynaecworld, Kwality House, 1st Floor, Kemps Corner, Mumbai, India
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19
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Siristatidis C, Salamalekis G, Dafopoulos K, Basios G, Vogiatzi P, Papantoniou N. Mild Versus Conventional Ovarian Stimulation for Poor Responders Undergoing IVF/ICSI. ACTA ACUST UNITED AC 2017; 31:231-237. [PMID: 28358705 DOI: 10.21873/invivo.11050] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/21/2017] [Accepted: 01/24/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND/AIM Mild stimulation protocols have been implemented to be offered to subfertile patients who respond poorly to ovarian stimulation. We aimed to compare the efficacy of mild versus conventional gonadotropin-releasing hormone (GnRH)-agonist and antagonist protocols in poor responders undergoing in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) cycles. PATIENTS AND METHODS A total of 58 poorly-responding patients were divided into two groups: mild group (n=33), receiving clomiphene citrate 100 mg and 0.25 mg of cetrorelix with 150 IU of gonadotrophins daily; conventional group (n=25), undergoing the long GnRH-agonist or -antagonist protocols. The primary outcome was the number of cumulus oocyte complexes (COCs) retrieved. RESULTS A lower number of COCs [median (range)=1 (0-4) vs. 3 (0-8.4), p<0.001] was retrieved in the mild stimulation compared to the conventional group. Secondary outcomes favored the conventional group, whereas live birth (9.1% vs. 12%), clinical pregnancy (12.1% vs. 20%) and miscarriage rate (40% vs. 40%) were similar in the two groups. CONCLUSION Mild ovarian stimulation is inferior to conventional regimes when applied to poor responders undergoing IVF/ICSI, in terms of the numbers of retrieved COCs.
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Affiliation(s)
- Charalampos Siristatidis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Salamalekis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Dafopoulos
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larissa, Greece
| | - George Basios
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Vogiatzi
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Papantoniou
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Ebrahimi M, Akbari-Asbagh F, Ghalandar-Attar M. Letrozole+ GnRH antagonist stimulation protocol in poor ovarian responders undergoing intracytoplasmic sperm injection cycles: An RCT. Int J Reprod Biomed 2017. [DOI: 10.29252/ijrm.15.2.101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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21
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Benbassat B, Mitov K, Savova A, Tachkov K, Petrova G. Cost-effectiveness of different types of COH protocols for in vitro fertilization at national level. BIOTECHNOL BIOTEC EQ 2016. [DOI: 10.1080/13102818.2016.1261636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Boriana Benbassat
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Konstantin Mitov
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Alexandra Savova
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Konstantin Tachkov
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Guenka Petrova
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
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22
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Youssef MA, van Wely M, Al-Inany H, Madani T, Jahangiri N, Khodabakhshi S, Alhalabi M, Akhondi M, Ansaripour S, Tokhmechy R, Zarandi L, Rizk A, El-Mohamedy M, Shaeer E, Khattab M, Mochtar MH, van der Veen F. A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF: a multicenter randomized non-inferiority trial. Hum Reprod 2016; 32:112-118. [PMID: 27836979 DOI: 10.1093/humrep/dew282] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/23/2016] [Accepted: 10/10/2016] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION In subfertile women with poor ovarian reserve undergoing IVF does a mild ovarian stimulation strategy lead to comparable ongoing pregnancy rates in comparison to a conventional ovarian stimulation strategy? SUMMARY ANSWER A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF leads to similar ongoing pregnancy rates as a conventional ovarian stimulation strategy. WHAT IS KNOWN ALREADY Women diagnosed with poor ovarian reserve are treated with a conventional ovarian stimulation strategy consisting of high-dose gonadotropins and pituitary downregulation with a long mid-luteal start GnRH-agonist protocol. Previous studies comparing a conventional strategy with a mild ovarian stimulation strategy consisting of low-dose gonadotropins and pituitary downregulation with a GnRH-antagonist have been under powered and their effectiveness is inconclusive. STUDY DESIGN, SIZE, DURATION This open label multicenter randomized trial was designed to compare one cycle of a mild ovarian stimulation strategy consisting of low-dose gonadotropins (150 IU FSH) and pituitary downregulation with a GnRH-antagonist to one cycle of a conventional ovarian stimulation strategy consisting of high-dose gonadotropins (450 IU HMG) and pituitary downregulation with a long mid-luteal GnRH-agonist in women of advanced maternal age and/or women with poor ovarian reserve undergoing IVF between May 2011 and April 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples seeking infertility treatment were eligible if they fulfilled the following inclusion criteria: female age ≥35 years, a raised basal FSH level >10 IU/ml irrespective of age, a low antral follicular count of ≤5 follicles or poor ovarian response or cycle cancellation during a previous IVF cycle irrespective of age. The primary outcome was ongoing pregnancy rate per woman randomized. Analyses were on an intention-to-treat basis. We randomly assigned 195 women to the mild ovarian stimulation strategy and 199 women to the conventional ovarian stimulation strategy. MAIN RESULTS AND THE ROLE OF CHANCE Ongoing pregnancy rate was 12.8% (25/195) for mild ovarian stimulation versus 13.6% (27/199) for conventional ovarian stimulation leading to a risk ratio of 0.95 (95% CI: 0.57-1.57), representing an absolute difference of -0.7% (95% CI: -7.4 to 5.9). This 95% CI does not extend below the predefined threshold of 10% for inferiority. The duration of ovarian stimulation was significantly lower in the mild ovarian stimulation strategy than in the conventional ovarian stimulation strategy (mean difference -1.2 days, 95% CI: -1.88 to -0.62). Also, a significantly lower amount of gonadotropins was used in the mild simulation strategy, with a mean difference of 3135 IU (95% CI: -3331 to -2940). LIMITATIONS, REASONS FOR CAUTION A limitation of our study was the lack of data concerning the cryopreservation of surplus embryos, so we are not informed on cumulative pregnancy rates. Another limitation is that we were not able to follow up on the ongoing pregnancies in all centers, so we are not informed on live birth rates. WIDER IMPLICATIONS OF THE FINDINGS The results are directly applicable in daily clinical practice and may lead to considerable cost savings as high dosages of gonadotropins are not necessary in women with poor ovarian reserve undergoing IVF. A health economic analysis of our data planned to test the hypothesis that mild ovarian stimulation strategy is more cost-effective than the conventional ovarian stimulation strategy is underway. STUDY FUNDING/COMPETING INTERESTS This study was supported by NUFFIC scholarship (the Netherlands) and STDF short-term fellowship (Egypt). TRIAL REGISTRATION NUMBER NTR2788 (Trialregister.nl). TRIAL REGISTER DATE 01 March 2011. DATE OF FIRST PATIENT'S ENROLMENT May 2011.
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Affiliation(s)
- M A Youssef
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands .,Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - M van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - H Al-Inany
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - T Madani
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, 2, Hafez St., Banihashem St., Resalat Ave., 16635-148 Tehran, Iran
| | - N Jahangiri
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, 2, Hafez St., Banihashem St., Resalat Ave., 16635-148 Tehran, Iran
| | - S Khodabakhshi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, 2, Hafez St., Banihashem St., Resalat Ave., 16635-148 Tehran, Iran
| | - M Alhalabi
- Division of Embryology and Reproductive Medicine, Faculty of Medicine, and Assisted Reproduction Unit, Orient Hospital, Damascus University, Damascus, Syria
| | - M Akhondi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - S Ansaripour
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - R Tokhmechy
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - L Zarandi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - A Rizk
- Department of Obstetrics & Gynecology, Faculty of Medicine, Banha University, El-Shaheed Farid Nada, Qism Banha, Banha, Al Qalyubia Governorate 13511 Banha, Egypt
| | - M El-Mohamedy
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - E Shaeer
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - M Khattab
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - M H Mochtar
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
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Gingold JA, Lee JA, Whitehouse MC, Rodriguez-Purata J, Sandler B, Grunfeld L, Mukherjee T, Copperman AB. Maximum basal FSH predicts reproductive outcome better than cycle-specific basal FSH levels: waiting for a "better" month conveys limited retrieval benefits. Reprod Biol Endocrinol 2015; 13:91. [PMID: 26272081 PMCID: PMC4536597 DOI: 10.1186/s12958-015-0078-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/14/2015] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Elevated follicle stimulating hormone (FSH) is associated with poor vaginal oocyte retrieval (VOR) outcomes and cycle cancellations but intercycle variability in basal FSH reportedly does not predict ovarian response. METHODS We conducted a retrospective cohort study of basal FSH (n = 15573 cycles) in couples (n = 9132) who initiated IVF cycle(s) with basal estradiol (E2) <100 pg/mL between 2002 and 2014 to reevaluate this hypothesis. The most recent (current) FSH, maximum FSH (Max FSH) and prior cycle maximum basal FSH (PMax FSH) were computed for each cycle. Metaphase II (MII) oocyte counts were modeled by age, stimulation type, prior peak E2 level, prior MII count, Max FSH, PMax FSH and current FSH. Antral follicle counts, pregnancy, clinical pregnancy and live birth rates were modeled as secondary outcomes. RESULTS Max FSH level distinguished completed cycles from cancelled cycles better than PMax FSH or current FSH (AUC of 0.72, 0.71 and 0.61, respectively, p < 0.001). Fewer MIIs were retrieved (5.7 ± 3.8) in cycles with Max FSH >13 mIU/mL (n = 1475) than those with ≤13 mIU/mL (n = 11978) (11.6 ± 7.1) (p < 0.001). Max FSH was a better predictor of MII count than PMax FSH or current FSH after controlling for age, stimulation type, prior peak E2 level and prior MII count. Additional MIIs were retrieved on average in cycles with PMax FSH >13 mIU/mL (n = 1930) whose current FSH was ≤13 mIU/ml rather than >13 mIU/ml (p < 0.01) after controlling for age, cycle number and stimulation type. However, no improvement in pregnancy or live birth rate was detected. CONCLUSIONS Max FSH is the best FSH-based predictor of ovarian reserve. Retrieval benefits from waiting for a "better" month appear to exist but are limited.
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Affiliation(s)
- Julian A Gingold
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA.
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Klingenstein Pavilion 1176 Fifth Avenue 9th Floor, New York, New York, 10029, USA.
- OB/GYN & Women's Health Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA.
| | - Joseph A Lee
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA.
| | - Michael C Whitehouse
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA
| | - Jorge Rodriguez-Purata
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA
| | - Benjamin Sandler
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Klingenstein Pavilion 1176 Fifth Avenue 9th Floor, New York, New York, 10029, USA
| | - Lawrence Grunfeld
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Klingenstein Pavilion 1176 Fifth Avenue 9th Floor, New York, New York, 10029, USA
| | - Tanmoy Mukherjee
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Klingenstein Pavilion 1176 Fifth Avenue 9th Floor, New York, New York, 10029, USA
| | - Alan B Copperman
- Reproductive Medicine Associates of New York, 635 Madison Ave 10th Floor, New York, New York, 10022, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Klingenstein Pavilion 1176 Fifth Avenue 9th Floor, New York, New York, 10029, USA
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Shrestha D, La X, Feng HL. Comparison of different stimulation protocols used in in vitro fertilization: a review. ANNALS OF TRANSLATIONAL MEDICINE 2015. [PMID: 26207230 DOI: 10.3978/j.issn.2305-5839.2015.04.09] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Infertility is one of the major medical problems in the western world caused by genetic or epigenetic factors, or both, which has led to continuous research and advancements in the field of assisted reproductive technology (ART). Many stimulation protocols are available for controlled ovarian hyperstimulation (COH) in in vitro fertilization (IVF). This review compares the agonist long protocol, antagonist protocol and minimal stimulation protocol. Gonadotropin-releasing hormone (GnRH) antagonist and minimal stimulation protocol has shorter duration of treatment and less gonadotropin use. GnRH agonist long protocol is better in folliculogenesis and pregnancy rate, which is the imperative goal of COH. Despite its costly and lengthy approach, GnRH agonist long protocol has delivered satisfactory results in most women. On the other hand, patients with poor ovarian reserve may have greater advantage when considering minimal stimulation protocol. Evidently, it is crucial to have a larger scale studies with more focused comparisons, which take into account the differences in patients' response criteria and additional confounding variables (age, BMI, previous IVF outcomes etc.), in order to reach to a more definite conclusions.
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Affiliation(s)
- Deekshya Shrestha
- 1 Department of Reproduction, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China ; 2 The New Fertility Center, New York Hospital Queens Affiliated Weill Medical College of Cornell University, New York, NY, USA
| | - Xiaolin La
- 1 Department of Reproduction, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China ; 2 The New Fertility Center, New York Hospital Queens Affiliated Weill Medical College of Cornell University, New York, NY, USA
| | - Huai L Feng
- 1 Department of Reproduction, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China ; 2 The New Fertility Center, New York Hospital Queens Affiliated Weill Medical College of Cornell University, New York, NY, USA
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Abstract
INTRODUCTION Assisted reproduction techniques are the frequent treatment of infertility. Despite the advances in science and technology, the management of poor responder patients is still considered as one of the most urgent problems. The lack of unified definition makes the management of the poor responder patients very difficult. The aim of this review is to examine and compare the different studies done about the problem of poor responder patients. METHODS On an online research of MEDLINE/PUBMED, we found several studies on pharmacological treatment for poor responders' patients. RESULTS Our review shows that in the years numerous therapies for the management of these patients who do not respond to ovarian stimulation have been evaluated and studied, but the main problem is the large and still not well-defined meaning of poor responder women. CONCLUSION The management of the poor responder patients is very difficult. Currently, there is no any standard treatment for poor responder patients. Considering the importance of the problem, it is important to identify a diagnostic and therapeutic target. Our review shows that there are many studies with different therapeutic approaches which deserve further in-depth study to standardize diagnostic and therapeutic target.
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Affiliation(s)
- V Giovanale
- Department of Gynecologic-Obstetrical Sciences and Urological Sciences, University of Rome Sapienza, Sant'Andrea Hospital , Rome , Italy
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Şahin S, Selçuk S, Devranoğlu B, Kutlu T, Kuyucu M, Eroğlu M. Comparison of long GnRH agonist versus GnRH antagonist protocol in poor responders. Turk J Obstet Gynecol 2014; 11:203-206. [PMID: 28913020 PMCID: PMC5558361 DOI: 10.4274/tjod.80090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/05/2014] [Indexed: 12/01/2022] Open
Abstract
Objective: To compare long GnRH agonist with GnRH antagonist protocol in poor responders. Materials and Methods: Medical charts of 531 poor responder women undergoing in-vitro fertilization (IVF) cycle at Zeynep Kamil Maternity and Children’s Hospital, IVF Center were retrospectively analysed. Those who received at least 300 IU/daily gonadotropin and had ≤3 oocytes retrieved were enrolled in the study. Poor responders were categorized into two groups as those who received long GnRH agonist or GnRH antagonist regimen. Results: Treatment duration and total gonadotropin dosage were significantly higher in women undergoing the long GnRH agonist regimen compared with the GnRH antagonist regimen (p<0.001 for both). Although the number of total and mature oocytes retrieved was similar between the groups, good quality embryos were found to be higher in the GnRH antagonist regimen. The day of embryo transfer and number of transferred embryos were similar in the groups. No statistically significant differences were detected in pregnancy (10.5% vs 14.1%), clinical pregnancy (7.7% vs 10.6%) and early pregnancy loss rates (27.2% vs 35%) between the groups. Conclusion: GnRH antagonist regimen may be preferable to long GnRH regimen as it could decrease the cost and treatment duration in poor responders.
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Affiliation(s)
- Sadık Şahin
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Selçuk Selçuk
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Belgin Devranoğlu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Tayfun Kutlu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Melda Kuyucu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Mustafa Eroğlu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
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Xiao JS, Su CM, Zeng XT. Comparisons of GnRH antagonist versus GnRH agonist protocol in supposed normal ovarian responders undergoing IVF: a systematic review and meta-analysis. PLoS One 2014; 9:e106854. [PMID: 25216031 PMCID: PMC4162565 DOI: 10.1371/journal.pone.0106854] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/08/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of GnRH antagonist and GnRH agonist in supposed normal ovarian responders undergoing IVF. METHODS Data from 6 databases were retrieved for this study. The RCTs of GnRH agonist and GnRH antagonist use during IVF-EF therapy for patients with supposed normal ovarian response were included. A meta-analysis was performed with Revman 5.1software. RESULTS Twenty-three RCTs met the inclusion criteria. The number of stimulation days (mean difference (MD): -0.66, 95% confidence interval (CI): -1.04∼-0.27), Gn amount (MD: -2.92, 95% CI: -5.0∼-0.85), E2 values on the day of HCG (MD: -330.39, 95% CI: -510.51∼-150.26), Number of oocytes retrieved (MD: -1.33, 95% CI: -2.02∼-0.64), clinical pregnancy rate (odds ratio (OR): 0.87, 95% CI: 0.75-1.0), and ovarian hyperstimulation syndrome (OHSS) incidence (OR: 0.59, 95% CI: 0.42∼0.82) were significantly lower in GnRH antagonist protocol than GnRH agonist protocol. However, the endometrial thickness on the day of HCG (MD: -0.04, 95% CI: -0.23∼0.14), the ongoing pregnancy rate (OR: 0.87, 95% CI: 0.74∼1.03), live birth rate (OR: 0.89, 95% CI: 0.64∼1.24), miscarriage rate (OR: 1.17, 95% CI: 0.85∼1.61), and cycle cancellation rate (OR: 1.11, 95% CI: 0.90∼1.37) did not significantly differ between the 2 groups. CONCLUSIONS During IVF treatment for patients with supposed normal responses, the incidence of OHSS were significantly lower, whereas the ongoing pregnancy and live birth rates were similar in the GnRH antagonist compared with the standard long GnRH agonist protocols.
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Affiliation(s)
- Jin-song Xiao
- Reproductive Medicine Center, Taihe Hospital, Hubei University of medicine, Shiyan City, Hubei Province, China
| | - Cun-mei Su
- Reproduction Medicine and Treatment Center of Yunnan Province Population and Family Planning Science and Technology Institute, No. 150, Wuhua District, Kunming, Yunnan, China
| | - Xian-tao Zeng
- Evidence-Based Medicine Center of Hubei Medical College Affiliated Taihe Hospital, Shiyan City, HuBei, China
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