Clinical adjuncts in in vitro fertilization: a growing list

The effect of ovarian response parameters and the synergistic effect of assisted reproduction of poor ovarian response treated with platelet rich plasma: systematic review and meta-analysis

BACKGROUND

Poor ovarian response (POR) patients often encounter cycle cancellation and egg retrieval obstacles in assisted reproductive technology. Platelet rich plasma (PRP) ovarian injection is a potential treatment method, but the treatment methods are different, and the treatment results are controversial.

OBJECTIVE

This study adopts a systematic review and meta-analysis method based on clinical research to explore the efficacy and safety of PRP injection on POR.

METHOD

The following databases were searched for research published before March 2023; Medline (via PubMed), Web of Science, Scopus, Cochrane Library, Embase, Cochrane Library, and China National Knowledge Infrastructure Database (CNKI). The literature was then screened by two independent researchers, who extracted the data and evaluated its quality. Research was selected according to the inclusion criteria, and its quality was evaluated according to the NOS standard Cohort study. The bias risk of the included study was assessed with STATE 14.0. RevMan 5.3 software was used for meta-analysis.

MAIN RESULTS

Ten studies were included in the analysis, including 7 prospective cohort studies and 3 retrospective studies involving 836 patients. The results showed that after PRP treatment, follicle stimulating hormone (FSH) significantly decreased and anti-Mueller hormone (AMH) and luteinizing hormone (LH) significantly increased in POR patients, but estradiol did not change significantly; The number of antral follicles increased, and the number of obtaining eggs and mature oocytes significantly increased; The number of Metaphase type II oocytes, 2PN and high-quality embryos, and cleavage stage embryos significantly increased. In addition, the patient cycle cancellation rates significantly decreased. The rate of natural pregnancy assisted reproductive pregnancy and live birth increased significantly. Four reports made it clear that no adverse reactions were observed.

CONCLUSION

PRP may have the potential to improve pre-assisted reproductive indicators in POR patients, increase the success rate of in vitro fertilization-embryo transfer (IVF-ET) in POR patients, and improve embryo quality, and may be beneficial to the pregnancy outcome. There is no obvious potential risk in this study, but further clinical support is still needed.

Body mass index modified the effectiveness of low dose aspirin treatment on frozen-thawed embryo transfer outcome: a propensity score-matched study

Background

Low-dose aspirin is one of the widely used adjuvants in assisted reproductive technologies with the hope of improving the live birth rate. However, the studies regarding its effects are conflicting. The study aimed to investigate the association between aspirin administration and live birth following frozen-thawed embryo transfer (FET) in patients with different body mass index (BMI).

Methods

A retrospective cohort study was performed on 11,993 patients receiving FET treatments. 644 of which received a low-dose aspirin (100 mg/day) during endometrial preparation until 10 weeks after transfer. Propensity score matching was performed to avoid selection biases and potential confounders.

Results

The clinical pregnancy rate and live birth rate were similar before matching (54.4% versus 55.4%, RR: 1.02, 95%CI: 0.95-1.09, and 46.3 versus 47.8, RR: 1.03, 95%CI: 0.95-1.12 respectively). A weak association in favor of aspirin administration was found in the matched cohort (49.5% versus 55.4%, RR: 1.12, 95%CI: 1.01-1.24, and 41.9% versus 47.8%, RR: 1.14, 95%CI: 1.01-1.29 respectively). However, when stratified the patients with WHO BMI criteria, a significant increase in live birth rate associated with aspirin treatment was found only in patients with low BMI (<18.5 kg/m2) in either unmatched (46.4% versus 59.8%, RR:1.29, 95%CI:1.07-1.55) or matched cohort (44% versus 59.8%, RR: 1.36, 95%CI: 1.01-1.83) but not in patients with higher BMI categories. With the interaction analysis, less association between aspirin and live birth appeared in patients with normal BMI (Ratio of OR:0.49, 95%CI: 0.29-0.81) and high BMI (Ratio of OR:0.57, 95%CI: 0.27-1.2) compared with patients with low BMI.

Conclusion

BMI may be considered when evaluating aspirin's effect in FET cycles.

Applying a simplified economic evaluation approach to evaluate infertility treatments in clinical practice

IVF is the backbone of infertility treatment, but due to its costs, it is not affordable for everyone. The cost of IVF is further escalated by interventions added to the routine treatment, which are claimed to boost pregnancy rates, so-called add-ons. Consequently, it is critical to offset the increased costs of an intervention against a potentially higher benefit. Here, we propose using a simplified framework considering the cost of a standard IVF procedure to create one live-born baby as a benchmark for the cost-effectiveness of other fertility treatments, add-ons inclusive. This framework is a simplified approach to a formal economic evaluation, enabling a rapid assessment of cost effectiveness in clinical settings. For a 30-year-old woman, assuming a 44.6% cumulative live birth rate and a cost of $12 000 per complete cycle, the cost to create one live-born baby would be ∼$27 000 (i.e. willingness to pay). Under this concept, the decision whether to accept or reject a new treatment depends from an economic perspective on the incremental cost per additional live birth from the new treatment/add-on, with the $27 000 per live-born baby as a reference threshold. This threshold can vary with women's age, and other factors such as the economic perspective and risk of side effects can play a role. If a new add-on or treatment costs >$27 000 per live birth, it might be more rational to invest in a new IVF cycle rather than spending on the add-on. With the increasing number of novel technologies in IVF and the lack of a rapid approach to evaluate their cost-effectiveness, this simplified framework will help with a more objective assessment of the cost-effectiveness of infertility treatments, including add-ons.

Moral justification for the use of 'add-ons' in assisted reproductive technology: experts' views and experiences

RESEARCH QUESTION

What factors do assisted reproductive terchnology (ART) providers take into account when they make decisions about offering 'add-ons'?

DESIGN

A qualitative analysis of interviews with 31 ART professionals, focusing on their views and experiences in relation to add-ons, including the factors that are considered when doctors make decisions about their use.

RESULTS

The participants reported that a range of considerations are taken into account when it comes to justifying the use of a particular add-on in a given circumstance, including the likelihood of benefit and harm, patients' perceived psychological needs and preferences, and organizational expectations. Importantly, patient preferences, psychological factors and low risk of harm appear to be stronger motivations than increasing the likelihood of a live birth or the desire to innovate.

CONCLUSIONS

These findings suggest that it cannot be taken for granted that add-ons and innovation are closely linked. One possible response to this would be regulatory reform; for example, only allowing 'unproven' add-ons to be used in the context of formal scientific evaluation. Alternatively, it could be made clear that add-ons that are not undergoing formal evaluation have more in common with other therapies lacking a clear evidence base, such as complementary and alternative medicines, than with conventional medical practice. Practices in relation to add-ons may also require a focus on the responsibilities of corporations, and the standards applying to purveyors of consumer goods and services.

Is the use of IVF add-on treatments driven by patients or clinics? Findings from a UK patient survey

There are conflicting narratives over what drives demand for add-ons. We undertook an online survey of IVF patients to determine whether patients perceive that use of IVF add-ons is driven by patients or practitioners. People who underwent IVF in the UK in the previous five years were recruited via social media Survey questions focussed on the roles of clinician offer and patient request, including who first suggested use of add-ons in IVF consultations, where patients first heard about them, and which information sources they trusted. From a total of 261 responses, 224 met the inclusion criteria. Overall, 67% of respondents had used one or more IVF add-ons, most commonly: time-lapse imaging (27%), EmbryoGlue (27%), and endometrial scratching (26%). Overall, 81% of the add-ons used were offered to participants by clinicians (compared to 19% requested by themselves). Half (54%) reported being offered add-ons during consultations, compared to 24% who initiated discussion about add-ons. Higher proportions of private patients reported being offered (90%), requesting (47%) and using (74%) add-ons than those with NHS funding (74%, 29%, 52%, respectively). The main limitations of this study are the small sample size, recruitment via a convenience sample, and the self-reported data capture which is subject to recall bias.

In vitro fertilization with frozen embryo transfer increased histamine-mediated contractile sensitivity via PKCβ in human umbilical vein

OBJECTIVE

In vitro fertilization-embryo transfer (IVF-ET) technologies (especially frozen ET) have been widely used, which might affect maternal and fetal health. Information regarding influence of IVF-ET on the vasoconstriction of human umbilical vein (HUV) is limited. This study determined effects of frozen ET on histamine-mediated vascular responses in HUV and related mechanisms.

METHODS AND RESULTS

HUVs were collected from frozen ET conceived pregnancy and spontaneously conceived pregnancy (control). Histamine concentration in umbilical plasma was higher in frozen ET group than the control. Histamine-mediated contractile response curve was left-shifted in the frozen ET group when comparing with the control. In isolated HUV rings, H1R showed a critical role in regulating vascular constriction, while H2R played little roles in regulating vessel tone. Iberiotoxin and 4-aminopyridine didn't significantly change histamine-mediated constriction in HUVs. Histamine-induced vasoconstrictions were significantly decreased by nifedipine, KN93, or GF109203X, while the inhibitory effects were significantly greater in the frozen ET group in comparison to the control. The constrictions by Bay K8644, phenylephrine, or PDBu were stronger in frozen ET, respectively. There was a decrease in the protein expressions of H1R and H2R, an increase in protein expressions of BK_Caα and PKCβ.

CONCLUSIONS

Histamine-induced constriction in HUV was mainly via H1R. The increased sensitivity to histamine in HUV following frozen ET cycles were linked to the enhanced PKCβ protein expression and function. The new data and findings in this study provide important insight into influences of frozen ET on fetal vessel development and potential influence in long-term.

Impact of thyroid autoimmunity and vitamin D on in vitro fertilization/intracytoplasmic sperm injection outcomes among women with normal thyroid function

This prospective cohort study aimed to determine the impact of thyroid autoimmunity and total 25-hydroxyvitamin D concentration on early pregnancy outcomes in women undergoing in vitro fertilization/intracytoplasmic sperm injection who had intact thyroid function. The study included 1,297 women who underwent in vitro fertilization/intracytoplasmic sperm injection cycles, although only 588 patients received fresh embryo transfer. The study endpoints were clinical pregnancy, ongoing pregnancy, ectopic pregnancy, and early miscarriage rates. Our study found that the total 25-hydroxyvitamin D serum concentrations (P<0.001) and anti-Mullerian hormone levels (P=0.019) were lower among patients in the TAI group (n=518) than among those in the non-TAI group (n=779). Additionally, the study population in each group was divided into three subgroups according to the total vitamin D status based on clinical practice guidelines (deficient, <20 ng/mL; insufficient, 21-29 ng/mL; and sufficient, ≥30 ng/mL), TAI group: sufficient, n=144; insufficient, n=187; and deficient, n=187; non-TAI group: sufficient, n=329; insufficient, n=318, and deficient, n=133. In the TAI group, the number of good-quality embryos decreased in patients with vitamin D deficiency (P=0.007). Logistic regression analysis indicated that aging prevented women from achieving clinical (P=0.024) and ongoing pregnancy (P=0.026). The current findings suggest that patients with TAI had reduced serum vitamin D concentration. Furthermore, in the TAI group, the number of good-quality embryos decreased in patients with vitamin D deficiency. Finally, aging adversely impacted achieving clinical and ongoing pregnancy.

Effectiveness of GnRH Agonist Short Protocol Versus GnRH Antagonist Protocol in POSEIDON Groups 3 and 4: a Retrospective Cohort Study

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.

The cumulative live birth rate of recombinant follicle-stimulating hormone alfa verse urinary human follicle-stimulating hormone for ovarian stimulation in assisted reproductive technology cycles

Background

Infertility remains a significant public health concern. An issue with controlled ovarian stimulation (COS) is the selection of an exogenous gonadotropin (Gn) regimen, which is mainly based on urinary follicle-stimulating hormone (uFSH), recombinant follicle-stimulating hormone alfa (rFSH-alfa), and human menopausal gonadotropin (HMG). In addition, most previous studies focused on the clinical pregnancy rates or live birth rates (LBR) per transfer cycle, but not on the cumulative live birth rate (CLBR) per started cycle. The CLBR, appears to be a more comprehensive and accurate universal measure of IVF treatment success. Therefore, this study aimed to compare the cumulative live birth rate (CLBR) between rFSH-alfa and uFSH regimens for ovarian stimulation.

Methods

This retrospective cohort study included patients who underwent assisted reproductive technology (ART) with gonadotropin-releasing hormone (GnRH) agonist long protocol between March 2009 and December 2018. Patients were grouped according to the Gn regimen received (rFSH-alfa or uFSH). The main outcome was CLBR, which defined as the first live birth following the use of all fresh and frozen embryos derived from a single COS cycle.

Results

A total of 1078 cycles were analyzed (314 with rFSH-alfa and 764 with uFSH). The rFSH-alfa group was characterized by a higher number of retrieved oocytes (13.3 vs. 11.0) and transferable embryos (5.0 vs. 4.0), a higher fresh embryo transfer rate (35.0% vs. 26.3%), and a higher multiple birth rate among the fresh embryo transfer cycles (8.2% vs. 2.5%) (P < 0.05). There were no differences in pregnancy rate (32.7% vs. 33.8%) and LBR (25.5% vs. 26.9%) per transfer cycle (P > 0.05). No significant difference was found in clinical outcomes among the frozen embryo transfer cycles (P > 0.05). The CLBR per started cycle in the rFSH-alfa group was higher than in the uFSH group (53.5% vs. 43.1%, P < 0.05). After adjustment, rFSH-alfa was independently associated with a higher CLBR (OR = 1.56; 95%CI = 1.18–2.05; P = 0.0018).

Conclusions

rFSH-alfa and uFSH have similar pregnancy rates and LBR per transfer cycle, rFSH-alfa might achieve more transferrable blastocysts and higher CLBR per started cycle compared to uFSH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-01009-w.

Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective

Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.

Twinning in ART: Single embryo transfer policy

It is more than thirty years that perinatologists and healthcare personnel aim to reduce the morbidity associated with multiple pregnancy. In many cases, these complications stem from pregnancies achieved through artificial reproductive technologies (ART). Although dramatic measures have been taken to control those risks by increasing the proportion of single embryo transfers, the multiple pregnancy rate still remains relatively high among patient conceived through ART, carrying risks to both mothers and newborns, and is coupled with the related economic burden associated with prematurity. The aim of this review is to provide the current evidence regarding single embryo transfer to assist decision-makers and to promote patient knowledge toward an elective policy to reduce the risk of twinning. Single embryo transfer may aid in the further reduction of multiple pregnancy and, in most cases, will maintain patient autonomy and right of choice.

Effectiveness of music therapy as an adjuvant to conscious sedation in women undergoing transvaginal oocyte retrieval: A randomized controlled trial

AIM

Assisted reproductive technique (ART) has emerged as the highest form of treatment for infertile couples. Transvaginal oocyte retrieval is currently performed under conscious sedation in most centers. Since it is a relatively painful procedure, a number of adjuvant therapies have been tried to improve pain relief during the procedure. Music therapy is a nonpharmacological technique that has been successfully used for pain relief in perioperative and chronic pain of malignancy. However, studies evaluating its usefulness in ART-related procedures are limited. We evaluated the effectiveness of music therapy as an adjuvant for pain relief during oocyte retrieval.

METHODS

This was a randomized controlled trial conducted at a tertiary level teaching hospital in South India from September 2020 to March 2021. All women undergoing transvaginal oocyte retrieval were randomized to receive either music therapy along with conscious sedation (Group A) or conscious sedation alone (Group B). The primary outcome was postprocedure pain score assessed by the visual analog scale. Secondary outcomes included anxiety score.

RESULTS

A total of 109 women were randomized into Group A (54 women) and Group B (55 women). The postprocedure pain score was comparable between the two study groups (6.0, interquartile range [IQR] 4 to 6 vs. 6.0, IQR 4 to 6; p = 0.69). However, anxiety levels were found to be significantly lower in women who were offered music therapy (3.0, IQR 1 to 5 vs. 4.0, IQR 3 to 6; p = 0.004).

CONCLUSION

The use of music therapy as an adjuvant to conscious sedation was found to have no significant benefit in pain relief during oocyte retrieval.

Prevalence and performance of private equity-affiliated fertility practices in the United States

OBJECTIVE

To quantify the proportion of annual assisted reproductive technology (ART) cycles performed at private equity-affiliated fertility practices and to test for differences in services and success rates between private equity-affiliated and nonaffiliated practices.

DESIGN

Cross-sectional analysis of national data set.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

The primary outcome measures were the volume of ART cycles performed, the percentage of retrievals resulting in live births, and the percentage of transfers resulting in live births. The secondary outcomes included the median income of the practice location, the use of preimplantation genetic testing, the clinical service availability, and the patient reasons for seeking treatment.

RESULT(S)

Of the practices listed on the Centers for Disease Control's 2018 Fertility Clinic Success Rates Report, 14.7% had a private equity affiliation. Of the 305,883 ART cycles performed in 2018, 29.3% (89,535) occurred at private equity-affiliated practices. Patients at private equity-affiliated practices were 6.75% (95% confidence interval [CI], -10.15%, -3.36%) less likely to initiate a cycle due to male factor infertility, and 10.60% (95% CI, 3.49, 17.76) more likely to use preimplantation genetic testing before embryo transfer. No statistically significant differences were found in success rates among women aged <35 years. The average median household income (standard error) in zip codes with private equity-affiliated practices compared with nonaffiliated practices was $83,610 ($35,990) and $72,161 ($32,314), respectively.

CONCLUSION(S)

A major portion of fertility practices in the United States are private equity-affiliated, and these practices perform an even greater portion of ART cycles in the United States each year. Fertility appears to be the medical specialty with the greatest market share owned by private equity. Our findings corroborate preliminary research, which forecasts the increasing involvement and consolidation by private equity in fertility. Future research should continue monitoring for differences in outcomes, financing, case mix, service use, and accessibility.

Effect of Vitamin D Supplementation on In Vitro Fertilization Outcomes: A Trial Sequential Meta-Analysis of 5 Randomized Controlled Trials

Despite numerous studies indicating an imperative role of vitamin D for reproduction, the importance of vitamin D supplementation on in vitro fertilization (IVF) outcomes remains controversial. We therefore performed this meta-analysis to investigate the IVF outcomes of vitamin D supplementation in infertile women with vitamin D deficiency. We systematically searched PubMed, Embase and the Cochrane library for identifying all relevant studies published before August 2021. Pregnancy rate was defined as the primary outcome while good quality embryo, fertilization rate, ongoing pregnancy, and miscarriage were secondary outcomes. We used Review Manager 5.3 (RevMan) to conduct meta-analysis and examined the robustness of the primary outcome by trial sequential analysis. Five studies were included in the final analysis and it suggested that vitamin D supplementation was associated with improved chemical pregnancy rate (risk ratio [RR] = 1.53, 95% confidence interval [CI] = 1.06 to 2.20, p = 0.02) but not benefited in improving clinical pregnancy rate (RR = 1.34, 95% CI = 0.81 to 2.24, p = 0.25) and all secondary outcomes. Trial sequential analysis suggested further studies are needed to confirm this conclusion. We concluded that vitamin D supplementation should be prescribed to improve chemical pregnancy in infertile women with vitamin D deficiency and more studies are required to further confirm this finding.

The role of growth hormone in assisted reproduction

In contemporary ART, the use of "add-ons" during ovarian stimulation has increased, especially in poor responders. Growth Hormone (GH) is an adjunctive therapy that has been studied extensively in the translational and clinical setting, with an ongoing scientific debate over its effectiveness and optimal use. In this review, we aim to provide an overview of the physiologic basis for the use of GH in ART, and to summarize the latest evidence regarding its clinical use, primarily as an adjunct to ovarian stimulation, but also in the IVF lab and with regards to its effects on the endometrium.

Common practices among consistently high-performing in vitro fertilization programs in the United States: 10-year update

OBJECTIVE

To evaluate similarities and differences in clinical and laboratory practices among high-performing fertility clinics.

DESIGN

Cross-sectional questionnaire study of selected programs.

SETTING

Academic and private fertility practices performing in vitro fertilization (IVF).

PATIENT(S)

Not applicable.

INTERVENTION(S)

A comprehensive survey was conducted of 13 IVF programs performing at least 100 cycles a year and having high cumulative singleton delivery rates for 2 years.

MAIN OUTCOME MEASURE(S)

Clinical and laboratory IVF practices.

RESULT(S)

Although many areas of clinical practice varied among top programs, some commonalities were observed. All programs used a combination of follicle-stimulating hormone and luteinizing hormone for IVF stimulation, intramuscular progesterone in frozen embryo transfer cycles, ultrasound-guided embryo transfers, and a required semen analysis before starting the IVF cycle. Common laboratory practices included vitrification of embryos at the blastocyst stage, air quality control with positive air pressure and high-efficiency particulate air filtration, use of incubator gas filters, working on heated microscope stages, and incubating embryos in a low-oxygen environment, most often in benchtop incubators.

CONCLUSION(S)

Some areas of consistency in clinical and laboratory practices were noted among high-performing IVF programs that are likely contributing to their success. High-performing programs focused on singleton deliveries. As the field of IVF is rapidly evolving, it is imperative that we share best practices in an effort to improve outcomes from all clinics for the good of our patients.

Appraisal of Experimental Methods to Manage Menopause and Infertility: Intraovarian Platelet-Rich Plasma vs. Condensed Platelet-Derived Cytokines

The first published description of intraovarian platelet-rich plasma (PRP) appeared in mid-2016, when a new experimental technique was successfully used in adult human ovaries to correct the reduced fertility potential accompanying advanced maternal age. Considering the potential therapeutic scope of intraovarian PRP would likely cover both menopause and infertility, the mainstream response has ranged from skeptical disbelief to welcome astonishment. Indeed, reports of intraovarian PRP leading to restored menses in menopause (as an alternative to conventional hormone replacement therapy) and healthy term livebirths for infertility patients (from IVF or as unassisted conceptions) continue to draw notice. Yet, any proper criticism of ovarian PRP applications will be difficult to rebut given the heterogenous patient screening, varied sample preparations, wide differences in platelet incubation and activation protocols, surgical/anesthesia techniques, and delivery methods. Notwithstanding these aspects, no adverse events have thus far been reported and ovarian PRP appears well tolerated by patients. Here, early studies guiding the transition of ‘ovarian rejuvenation’ from experimental to clinical are outlined, with mechanisms to explain results observed in both veterinary and human ovarian PRP research. Current and future challenges for intraovarian cytokine treatment are also discussed.

Seasonal Influence on Assisted Reproductive Technology Outcomes: A Retrospective Analysis of 1409 Cycles

Background:

It is well known that seasonal variations influence natural conception and birth rates variably in different populations. It has been hypothesised that similar seasonal influences may affect treatment outcomes following assisted reproductive technology (ART). However, most studies report conflicting results.

Aim:

The aim of the study is to elucidate whether seasonality had any impact on the treatment success of the ART program.

Study Setting and Design:

We conducted a retrospective cohort study at a university-level tertiary care hospital in South India.

Materials and Methods:

All couples who underwent ART between January 2012 and December 2016 were included in the study. We divided the study population into three groups based on the seasonal differences experienced in our region. The primary outcome was live birth rate (LBR).

Statistical Analysis:

Univariate and multiple logistic regression models were used to compare outcomes and results reported as odds ratio (OR) and 95% confidence interval (CI).

Results:

Univariate analysis revealed no significant difference in LBR in monsoon season (174/651, 26.7% vs. 83/319, 26.0%; OR 1.04, 95% CI 0.77,1.41; P = 0.81) as compared to summer. However, LBR was significantly higher in winter season (114/341, 33.4% vs. 83/319, 26.0%; OR 1.43; 95% CI: 1.02, 2.00; P = 0.04). Further, multivariate analysis following adjustment for various confounding factors revealed no significant statistical difference in LBR in monsoon (adjusted odds ratio [aOR], 0.92; 95% CI: 0.66, 1.26; P = 0.59) or winter (aOR 1.32; 95% CI: 0.92, 1.88; P = 0.13) as compared to summer season.

Conclusion:

The current study found no significant effect of seasonal variation on LBR following ART.

Single oral dose of vitamin D3 supplementation prior to in vitro fertilization and embryo transfer in normal weight women: the SUNDRO randomized controlled trial

BACKGROUND

Improving in vitro fertilization success is an unmet need. Observational studies have suggested that women with deficient or insufficient vitamin D have lower chances of in vitro fertilization success, but whether supplementation improves clinical pregnancy rate remains unclear.

OBJECTIVE

This study aimed to determine whether oral vitamin D₃ supplementation improves clinical pregnancy in women undergoing an in vitro fertilization cycle.

STUDY DESIGN

The "supplementation of vitamin D and reproductive outcome" trial is a 2-center randomized superiority double-blind placebo-controlled trial. Subjects were recruited between October 2016 and January 2019. Participants were women aged 18 to 39 years with low vitamin D (peripheral 25-hydroxyvitamin D of <30 ng/mL), serum calcium of ≥10.6 mg/dL, body mass index of 18 to 25 kg/m², and antimüllerian hormone levels of >0.5 ng/mL and starting their first, second, or third treatment cycle of conventional in vitro fertilization or intracytoplasmic sperm injection. The primary outcome was the cumulative clinical pregnancy rate per cycle. Pregnancies obtained with both fresh or frozen embryo transfers were included. Clinical pregnancy was defined as an intrauterine gestational sac with a viable fetus. The primary analysis was performed according to the intention-to-treat principle and could also include natural conceptions. Secondary outcomes included total dose of gonadotropins used, embryologic variables (number of oocytes retrieved, number of suitable oocytes retrieved, fertilization rate, and rate of top-quality embryos), and clinical outcomes (miscarriage rate and live birth rate).

RESULTS

Overall, 630 women were randomized 2 to 12 weeks before the initiation of the in vitro fertilization cycle to receive either a single dose of 600,000 IU of vitamin D₃ (n=308) or placebo (n=322). Interestingly, 113 (37%) and 130 (40%) women achieved a clinical pregnancy in the treatment and placebo groups, respectively (P=.37). The risk ratio of clinical pregnancy in women receiving vitamin D₃ was 0.91 (95% confidence interval, 0.75-1.11). Compared with the placebo, vitamin D₃ supplementation did not improve the rate of clinical pregnancy. Exploratory subgroup analyses for body mass index, age, indication to in vitro fertilization, ovarian reserve, interval between drug administration and initiation of the cycle, and basal levels of 25-hydroxyvitamin D failed to highlight any clinical situation that could benefit from the supplementation.

CONCLUSION

In women with normal weight with preserved ovarian reserve and low vitamin D levels undergoing in vitro fertilization cycles, a single oral dose of 600,000 IU of vitamin D₃ did not improve the rate of clinical pregnancy. Although the findings do not support the use of vitamin D₃ supplementation to improve in vitro fertilization success rates, further studies are required to rule out milder but potentially interesting benefits and explore the effectiveness of alternative modalities of supplementation.

How common is add-on use and how do patients decide whether to use them? A national survey of IVF patients

STUDY QUESTION

What is the prevalence and pattern of IVF add-on use in Australia?

SUMMARY ANSWER

Among women having IVF in the last 3 years, 82% had used one or more IVF add-on, most commonly acupuncture, preimplantation genetic testing for aneuploidy and Chinese herbal medicine.

WHAT IS KNOWN ALREADY

IVF add-ons are procedures, techniques or medicines which may be considered nonessential to IVF, but usually used in attempts to improve the probability of conception and live birth. The use of IVF add-ons is believed to be widespread; however, there is little information about the prevalence and patterns of use in different settings.

STUDY DESIGN, SIZE, DURATION

An online survey was distributed via social media to women in Australia who had undergone IVF since 2017. Women were excluded if they were gestational surrogates, used a surrogate, or underwent ovarian stimulation for oocyte donation or elective oocyte cryopreservation only. The survey was open from 21 June to 14 July 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Survey questions included demographics, IVF and medical history, and use of IVF add-ons including details of the type of add-on, costs and information sources used. Participants were also asked about the relative importance of evidence regarding safety and effectiveness, factors considered in decision-making and decision regret.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1590 eligible responses were analysed. Overall, 82% of women had used one or more add-ons and these usually incurred an additional cost (72%). Around half (54%) had learned about add-ons from their fertility specialist, and most reported that the decision to use add-ons was equally shared with the specialist. Women placed a high level of importance on scientific evidence for safety and efficacy, and half (49%) assumed that add-ons were known to be safe. Most women experienced some regret at the decision to use IVF add-ons (66%), and this was more severe among women whose IVF was unsuccessful (83%) and who believed that the specialist had a larger contribution to the decision to use add-ons (75%).

LIMITATIONS, REASONS FOR CAUTION

This retrospective survey relied on patient recall. Some aspects were particularly prone to bias such as contributions to decision-making. This approach to capturing IVF add-on use may yield different results to data collected directly from IVF clinics or from fertility specialists.

WIDER IMPLICATIONS OF THE FINDINGS

There is a very high prevalence of IVF add-on use in Australia which may be generalisable to other settings with similar models of IVF provision. Although women placed high importance on scientific evidence to support add-ons, most add-ons do not have robust evidence of safety and effectiveness. This suggests that IVF patients are not adequately informed about the risks and benefits of IVF add-ons, or are not aware of the paucity of evidence to support their use.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by a McKenzie Postdoctoral Fellowship Grant (University of Melbourne), a Department of Obstetrics and Gynaecology Innovation Grant (University of Melbourne) and an NHMRC Investigator Grant (APP1195189). A.P. declares that he provides fertility services at Melbourne IVF (part of Virtus Health). J.W. reports grants from Wellcome Trust, during the conduct of the study, and that publishing benefits his career. The remaining authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Preimplantation genetic testing for aneuploidy: are we examining the correct outcomes?

Questions continue to be raised regarding the benefit of genetic assessment of embryos prior to transfer in IVF, specifically with regards to preimplantation genetic testing for aneuploidy (PGT-A). To evaluate and quantify these concerns, we appraised the most recent (2012-2019) randomized controlled trials on the topic. Only two of these six studies listed cumulative live birth rates per started cycle, with both eliciting a statistically non-significant result. This article describes the concern that a focus on results from the first embryo transfer compared to cumulative outcomes falsely construes PGT-A as having superior outcomes, whilst its true benefit is not confirmed, and it cannot actually improve the true pregnancy outcome of an embryo pool.

The Follicular Output Rate (FORT) as a method to evaluate transdermal testosterone efficacy in poor responders

Objective:

Follicular Output Rate (FORT) is an efficient quantitative and qualitative marker of ovarian responsiveness to gonadotropins. Transdermal testosterone (TT) has been used as adjuvant therapy to gonadotrophins in order to improve ovarian response in poor responders (PR). The aim of this study was to analyze whether TT can improve follicular sensitivity to gonadotropins using FORT.

Methods:

This retrospective study, held in a tertiary-care university hospital included 90 PR patients, according to the Bologna criteria. Patients in Group 1 (n = 46) received transdermal application of testosterone preceding gonadotrophin ovarian stimulation under pituitary suppression. In Group 2 (n = 44) ovarian stimulation was carried out with high-dose gonadotrophin in association with minidose GnRH agonist protocol. We analyzed ovarian stimulation parameters and IVF outcomes. We determined antral follicle count (AFC) (3-8 mm) before ovarian stimulation, pre-ovulatory follicle count (PFC) (16-22 mm) and the day of hCG administration. We calculated the FORT using the PFCx100/AFC ratio.

Results:

Baseline characteristics and ovarian reserve parameters were similar in both groups. FORT and oocytes retrieved were significantly higher in group 1 vs group 2. There were no significant differences in pregnancy rates. In group 1 there was a significant correlation between FORT and AFC.

Conclusions:

This study suggests that the potential beneficial mechanism of TT in poor responder patients may be based on increasing the antral follicle sensitivity to gonadotrophin. FORT is an excellent tool to demonstrate this.

Resumed ovarian function and pregnancy in early menopausal women by whole dimension subcortical ovarian administration of platelet-rich plasma and gonadotropins

OBJECTIVE

This study was designed to investigate if whole dimension subcortical ovarian administration of platelet-rich plasma with gonadotropin, in proximity to most ovarian follicles, is effective in restoring ovarian functions in women during early menopause.

METHODS

Platelet-rich plasma, prepared from 40 mL of autologous peripheral blood using the buffy coat method, was injected into extended subcortical area of bilateral ovaries along with recombinant follicle-stimulating hormone (rFSH) (Gonal-F 300IU) under laparoscopic guidance. The posttreatment ovarian folliculogenesis and serum levels of FSH, luteinizing hormone (LH), and estradiol were followed up for 6 months at weekly to monthly intervals. IVF was carried out in women resuming ovulatory functions.

RESULTS

Twelve early menopausal women with mean age of 44.42 ± 2.84 were enrolled. After treatment, 11 women resumed their menstrual period in 37.1 ± 23.5 days. Their average serum FSH was 70.47 ± 20.92 and 26.22 ± 17.55 IU/L, luteinizing hormone was 34.81 ± 11.86 and 14.3 ± 12.8 IU/L, before and after treatment, respectively. The mid-cycle E2 was 251.1 ± 143.8 pg/mL. Ten oocyte retrievals were carried out among six participants, four of them received controlled ovarian stimulation and another two using natural ovulation cycles. Thirteen mature eggs were retrieved which were then ICSI fertilized to obtain 10 normally fertilized 2PN oocytes. Two participants had cleavage stage embryos transferred of which one achieved clinical pregnancy.

CONCLUSIONS

Whole dimension subcortical ovarian administration of platelet-rich plasma with gonadotropin was shown to restore ovarian functions, at least temporarily, and could increase the probability of pregnancy using autologous oocytes in women with early menopause.

Human growth hormone use in poor ovarian response - caution and opportunities

Human growth hormone has found favour as a co-gonadotrophin in assisted reproduction particularly in the circumstances of a poor response to stimulation. Its use has been based on animal studies suggesting insulin-like growth factor-1 enhances granulosa and cumulus cell function and possibly oocyte quality. While there is limited ovarian cellular information in women, the use of human growth hormone is alleged to improve egg numbers, embryo quality, clinical pregnancies and live birth in women with a poor ovarian response. A number of cohort studies have claimed these benefits compared with prior nil treatment, but there are a limited number of quality randomised controlled studies. The few good randomised trials indicate an enhanced ovarian response in terms of oestradiol secretion and oocyte maturity with controversial improvement in ongoing pregnancy and live birth. Given the cost of the medication, the lack of convincing data on enhanced clinical outcomes and the theoretical possibility of side effects, we propose it is still too early to determine human growth hormone’s true cost-benefit for widespread use. However, a number of emerging randomised trials may tilt the equation to a positive outlook in the future. Meanwhile, the hormone should only be used after full informed consent from the patient as to its effectiveness and efficacy.

A narrative review of platelet-rich plasma (PRP) in reproductive medicine

PURPOSE

Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research.

METHODS

A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure.

RESULTS

In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure.

CONCLUSIONS

Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.

Antioxidant pretreatment for male partner before ART for male factor subfertility: a randomized controlled trial

STUDY QUESTION

Does oral antioxidant pretreatment for the male partner improve clinical pregnancy rate in couples undergoing ART for male factor subfertility?

SUMMARY ANSWER

There was no significant difference in clinical pregnancy rate following oral antioxidant pretreatment for male partner in couples undergoing ART for male factor subfertility compared to no pretreatment.

WHAT IS KNOWN ALREADY

Damage to sperm mediated by reactive oxygen species (ROS) contributes significantly to male factor infertility. The ROS-related injury reduces fertilization potential and adversely affects the sperm DNA integrity. Antioxidants act as free radical scavengers to protect spermatozoa against ROS induced damage. During ART, use of sperms which have been exposed to ROS-mediated damage may affect the treatment outcome. Pretreatment with antioxidants may reduce the ROS-mediated sperm DNA damage. Currently, antioxidants are commonly prescribed to men who require ART for male factor subfertility but there is ambiguity regarding their role.

STUDY DESIGN SIZE DURATION

This was an open label, randomized controlled trial conducted at a tertiary level infertility clinic between February 2013 and October 2019. The trial included 200 subfertile couples who were undergoing ART treatment for male factor subfertility.

PARTICIPANTS/MATERIALS SETTING METHODS

Couples were randomized into treatment arm (n = 100) and control arm (n = 100). In the treatment arm, the male partner received oral antioxidants (Vitamin C, Vitamin E and Zinc) for 3 months just prior to the ART cycle. In the control arm, no antioxidant was given to the male partner. The primary outcome was clinical pregnancy rate, while live birth rate (LBR), miscarriage rate and changes in semen parameters were the secondary outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

Out of 200 women randomized, 135 underwent embryo transfer as per protocol. Following intention to treat analysis, no significant difference was noted in clinical pregnancy (36/100, 36% vs 26/100, 26%; odds ratio (OR) 1.60, 95% CI 0.87 to 2.93) and LBR (25/100, 25% vs 22/100, 22%; OR 1.18, 95% CI 0.61 to 2.27) between antioxidant and no pretreatment arms. The clinical pregnancy rate per embryo transfer was significantly higher following antioxidant pretreatment (35/64, 54.7% vs 26/71, 36.6%; OR 2.09, 95% CI 1.05 to 4.16) compared to no pretreatment. There was no significant difference in LBR per embryo transfer (25/64, 39.1%, vs 22/71, 31.0%; OR 1.43, 95% CI 0.70 to 2.91) after antioxidant pretreatment versus no pretreatment. The semen parameters of sperm concentration (median, interquartile range, IQR) (18.2, 8.6 to 37.5 vs 20.5, 8.0 to 52.5, million/ml; P = 0.97), motility (median, IQR) (34, 20 to 45 vs 31, 18 to 45%; P = 0.38) and morphology (mean ± SD) (2.0 ± 1.4 vs 2.2 ± 1.5%; P = 0.69) did not show any significant improvement after intake of antioxidant compared to no treatment, respectively.

LIMITATIONS REASONS FOR CAUTION

The objective assessment of sperm DNA damage was not carried out before and after the antioxidant pretreatment. Since the clinicians were aware of the group allotment, performance bias cannot be ruled out.

WIDER IMPLICATIONS OF THE FINDINGS

The current study did not show any significant difference in clinical pregnancy and LBR following antioxidant pretreatment for the male partner in couples undergoing ART for male subfertility. The findings need further validation in a larger placebo-controlled randomized trial.

STUDY FUNDING/COMPETING INTERESTS

This trial has been funded by Fluid Research grant of Christian Medical College, Vellore (internal funding). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

CTRI/2013/02/003431.

TRIAL REGISTRATION DATE

26 February 2013.

DATE OF FIRST PATIENT’S ENROLMENT

11 February 2013.

Sildenafil might impair maternal-fetal immunotolerance by suppressing myeloid-derived suppressor cells in mice

Myeloid-derived suppressor cells (MDSCs) as an important population of immune cells were found to restrain T cell function, polarize T-helper cells (Th) 1/Th2 toward Th2 response and induce regulatory T cells (Tregs), therefore enhancing the immunotolerance during pregnancy. Sildenafil has been applied for poor endometrial quality in implantation failure patients. Nevertheless, investigations have shown that sildenafil could reduce MDSCs-dependent immunosuppression. Whether sildenafil affects embryo implantation by suppressing MDSCs? To address this question, using the mice model, we investigated the amounts of immune cells in peripheral blood and endometrial cells from control group (CG), sildenafil low-dose group (LDG) and high-dose group (HDG). We found that both treatment groups displayed a marked deficiency in polymorphonuclear (PMN)-MDSCs and Th2 from mice blood and endometrium as compared to these from CG. The frequency of Tregs in endometrium from HDG was lower than those from CG. Th1/Th2 ratio in both periphery and uterus from study groups showed a significant increase as compared to those from CG. By relevance analysis, we found that the level of Tregs positively correlated with the level of PMN-MDSCs, whereas the Th1/Th2 ratio negatively correlated with the frequency of PMN-MDSCs in uterus. Moreover, there was a positive relationship between the amount of blood PMN-MDSCs and endometrial PMN-MDSCs. These results suggest that we should carefully weigh the pros and cons of using sildenafil when applied to patients with poor endometrial receptivity.

Relationship between nutrition and reproduction

BACKGROUND

Recently, the relationship between nutrition and reproduction is being studied. In particular, when older women receive reproductive treatment, egg aging causes greater problems than organic factors.

METHODS

This study investigated the relationship between nutrition and reproduction with a focus on factors that cause aging, including oxidation, glycation, and chronic inflammation. A large volume of data concerning each nutrient's relationship with reproductive medicine was collected from a number of observational studies.

MAIN FINDINGS

The results showed that refined carbohydrates should be avoided and care should be taken to achieve proper intake of omega-3 fatty acids. Folic acid and vitamin D were also effective. For men, antioxidant measures are especially effective. The effects of antioxidants are related to insulin resistance, which causes chronic inflammation.

CONCLUSION

Recent research has shown that rather than meal content, meal intervals are more important for improving insulin resistance. Future research should examine lifestyle-related nutrition factors and their relationships to reproductive treatment.

Which key performance indicators are optimal to assess clinical management of assisted reproduction cycles?

Like all industries, fertility clinics should identify and follow reference markers of its activity-key performance indicators (KPI)-to allow assisted reproductive technology outcomes to be monitored and compared. Clinical KPIs revolve around following set parameters of the patient population, procedures, and outcome data. Moreover, KPIs should also include identified protocols and standard operating procedures followed in daily practice and should keep track of multiple pregnancy rates, a ruthless confounder of assisted reproductive technology outcomes.

Anogenital distance in newborn infants conceived by assisted reproduction and natural conception

RESEARCH QUESTION

Does anogenital distance (AGD) differ in newborn infants conceived through assisted reproduction technology (ART) compared with those conceived naturally?

DESIGN

This case-control study looked at anthropometric and anogenital measurements in 247 male and 200 female newborns born after ART (n = 121) or natural conception (n = 326), within 24 h of birth. Anogenital measurements included distance from the centre of the anus to the anterior clitoris (AGDAC) and to the posterior fourchette (AGDAF) in female infants, and from the centre of the anus to the posterior base of the scrotum (AGDAS) and to the anterior base of the penis (AGDAP) in male infants.

RESULTS

ART mothers were older, more likely to be nulliparous and delivered by Caesarean section at an earlier gestational week. AGDAS of male infants was approximately twice the AGDAF of female infants (17.6 ± 5.0 versus 9.1 ± 3.6 mm). AGDAF in female infants conceived by ART compared with those conceived naturally was not significantly different (8.8 ± 3.6 versus 9.3 ± 3.6 mm; P = 0.404). AGDAC were also comparable for both groups (27.4 ± 6.3 versus 27.7 ± 7.1 mm; P = 0.770). In male infants, no significant difference was seen between ART and natural conception groups in terms of AGDAS (17.4 ± 4.6 versus 17.7 ± 5.2 mm, P = 0.742) and AGDAP (37.5 ± 6.6 versus 38.0 ± 6.7 mm, P = 0.589). When adjusted for gestational age, weight, length and head circumference, mode of conception was not associated with differences in any of the anogenital measurements.

CONCLUSIONS

AGD measurements in infants conceived by ART are no different from those of infants conceived naturally.