Ovarian response in three consecutive in vitro fertilization cycles

Assessment of Repetitive Controlled Ovarian Stimulation (COS) Cycles on Oocyte Donors: Impact on Oocyte Quality and Viable Embryo Yield

The utilization of donor eggs has broadened the options for Assisted Reproductive Technology (ART) among women facing challenges with egg quantity or quality. Given that donors are typically selected from young and fertile individuals, In Vitro Fertilization with egg donation (IVF-ED) tends to exhibit higher rates of implantation, pregnancy, and live births compared to IVF with the woman's own eggs, especially for females over 35 years old. This has led to a projected increase in the demand for IVF-ED, surpassing the number of available donors. Consequently, many centers opt to use oocyte donors for multiple cycles. However, the correlation between repeated Controlled Ovarian Stimulation (COS) cycles and the performance of donors in terms of viable blastocyst stage embryo (VEC) or blastocyst embryo rate is not definitively established and remains of interest. This study aims to explore the preimplantation characteristics of embryo development and oocyte maturation status based on the number of donor COS cycles, employing a Generalized Linear Mixed Model (GLMM) framework. The study encompasses 1965 embryo transfer (ET) cycles involving 399 donors who underwent a minimum of two and a maximum of nine controlled ovarian hyperstimulation (COS) cycles. The findings indicate that, with the patient undergoing six or more cycles of ovarian stimulation, despite a 3.9% increase in both maturation and fertilization rates, there is a corresponding decrease of 4.5% in VEC rate and 4.7% in blastulation rates. In essence, an escalating number of donor COS cycles appears to be associated with a disadvantageous reduction in embryo quality.

Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review

Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Consecutive ovarian stimulation is beneficial in patients with a poor response to high-dose follicle-stimulating hormone

OBJECTIVE

To investigate if an immediate additional IVF-ET cycle bear an advantage to patients with poor ovarian response in comparison to a cycle performed at some delay.

METHODS

A cohort study including 632 patients who underwent a fresh IVF-ET cycle with high-dose (≥300 IU/d) FSH stimulation that yielded ≤4 oocytes and did not achieve a clinical pregnancy. All underwent a second stimulation and oocyte pick-up (OPU), either consecutively or separately within 180 days (nonconsecutive OPU). The oocyte yield, number of embryos available for transfer, pregnancy live birth rates of the second OPU were compared between patients who had consecutive and nonconsecutive cycles.

RESULTS

Consecutive OPU was associated with more mature follicles in the second cycle compared to nonconsecutive OPU (p = .03) in addition to higher peak estradiol level (p < .0001), and more aspirated oocytes (p = .03) and available embryos (p = .023). There was no between-group difference in ongoing pregnancy and live birth rates. In a multivariate analysis of variance controlling for potential confounders, the difference in the number of aspirated oocytes and available embryos was associated significantly only with consecutive performance of the second cycle.

CONCLUSION

Immediate sequential stimulation (without an intervening menstrual cycle) in poor responders is advantageous over delayed stimulation in terms of number of aspirated oocytes and available embryos. The administration of high-dose FSH in the first cycle may benefit follicular recruitment also in the subsequent cycle. Although the effect is modest, given that each additional oocyte aspirated contributes to the outcome, it might be of significance especially in younger patients.

Effects of Bushen-Tiaojing-Fang on the pregnancy outcomes of infertile patients with repeated controlled ovarian stimulation

Bushen-Tiaojing-Fang (BSTJF) is commonly used to treat infertility. This study investigated the effects of BSTJF on the pregnancy outcomes of patients with repeated controlled ovarian stimulation (COS), on mitochondrial function, and on oxidative stress in ovarian granulosa cells (GCs) and follicular fluid (FF). The samples and clinical data of 97 patients, including 35 in the control group, 29 in the placebo group and 33 in the BSTJF group, were collected for this study. The mitochondrial ultrastructure, ATP content, mitochondrial DNA (mtDNA) number, 8-hydroxy-2-deoxyguanosine (8-OHdG), Mn-superoxide dismutase (Mn-SOD), glutathione peroxidase (GSH-Px) activity levels, and mRNA expression levels of Mn-SOD, GSH-Px, and nuclear factor erythroid-derived factor 2-related factor 2 (Nrf2) were analyzed. The high-grade embryo (P < 0.001), implantation (P = 0.033), and clinical pregnancy (P = 0.031) rates, as well as the ATP content (P = 0.014), mtDNA number (P = 0.035), GSH-Px activity (P = 0.004 in GCs and P = 0.008 in FF) and mRNA expression levels (P = 0.019), were significantly lower in the placebo group than in the control group, whereas the 8-OHdG content was significantly (P = 0.006 in FF) higher in the placebo group than in the control group. Compared with those in the placebo group, the high-grade embryo rate (P = 0.007), antioxidant enzyme activity (P = 0.037 and 0.036 in Mn-SOD; P = 0.047 and 0.030 in GSH-Px) and mRNA level (P < 0.001 in Nrf2, P = 0.039 in Mn-SOD and P = 0.002 in GSH-Px) were significantly higher in the BSTJF group, as were changes in mitochondrial ultrastructure, ATP (P = 0.040) and mtDNA number (P = 0.013). In conclusion, BSTJF can improve oxidative stress in patients with repeated COS and pregnancy outcomes.

Could art cycles have a detrimental effect on ovarian reserve? A retrospective case control study

BACKGROUND

Even if it is supposed damage of repeated ART (assisted reproductive technology) cycles on oocyte pool, there is still no evidence in literature. Aim of the study is to investigate whether infertile women who undergo to several ART cycles can show a lower ovarian reserve measured by AMH (Anti-Mullerian hormone) levels.

METHODS

The study includes 282 infertile women, between 18 and 42 years, and allocated into two groups: 159 women previously submitted to two or more ART cycles (group A) and 123 women never submitted naïve to-ART cycles (group B). We tested whether AMH, FSH, LH and E2 levels were significantly different between the two groups, stratifying according to age.

RESULTS

Regardless to the age ranges bands, the AMH in group A was statistically significant lower than in group B with a statistical significance (P=0.047). In particular women aged over 35 previously submitted to one or more ART cycles showed lower AMH levels, than those paired with age, which had never been treated with ART.

CONCLUSIONS

Despite the limitations of the study, our data demonstrate a reduced AMH levels in women aged over 35 previously submitted to two or more repeated ART-cycles compared to patients never treated before. The strength of this study is the actuality of the topic that has not been discussed before in detail.

Comparison of clinical outcomes among dual ovarian stimulation, mild stimulation and luteal phase stimulation protocols in women with poor ovarian response

This study aimed to determine whether consecutive ovarian stimulation in follicular and luteal phases within a single menstrual cycle (dual stimulation) is achievable and superior to conventional stimulation for poor ovarian responders (PORs). Data of 260 PORs were retrospectively collected and divided into three groups. Group A comprised of cycles with dual ovarian stimulation (n = 76), which were divided into two subgroups (follicular [group A-F] and luteal phase stimulation [group A-L]); group B comprised of cycles with ovarian stimulation that was performed only in the luteal phase (n = 52). Group C comprised of mild ovarian stimulation cycles (n = 132). Baseline parameters were not different among the three groups. The numbers of oocytes and embryo obtained were less in group A-F than group B and C, while group A overall had significantly more oocytes and viable embryo retrieved than did group B and C. Group A-L consumed significantly less gonadotropin than group B, without compromising the number of retrieved oocytes and embryo. The pregnancy outcomes of transfer of embryo from different stimulation phases were similar. We conclude that dual ovarian stimulation protocol is effective and potentially optimal for PORs.

The effects of superovulation with gonadotropins on autoantibody levels in patients undergoing assisted reproductive cycles

PURPOSE

To evaluate the effect of controlled ovarian stimulation (COH) with gonadotropins on the serum levels of autoantibodies in the women who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles and to compare basal levels of these autoantibodies between groups according to history of COH.

METHODS

This prospective cohort study was performed from October 2014 to March 2016 in the Royan Institute. The volunteered infertile women with regard to the inclusion criteria, who underwent IVF/ICSI cycles, were recruited. The COH was performed according to standard long GnRH agonist protocol. The mean levels of the autoantibodies including anti-nuclear, anti-smooth muscle, anti-ovarian, anti-mitochondrial, anti β₂-glycoprotein I, anti-parietal cell and anti-follicle-stimulating hormone antibodies were measured at three time points: on the 3-5 days of the menstrual cycle, 1 week after starting of COH and the ovum pick-up (OPU) day.

RESULTS

Of all participants (n = 189), 73 women had history of COH (group B) and 116 women did not have such history (group A). The analysis indicated that the autoantibodies changes during COH were similar in both groups. COH has no significant impact on the level of autoantibodies during the stimulation cycle. Multiple logistic regression analysis showed that the serum levels of anti-smooth muscle antibody on OPU day was the positive predictive factors for live birth following ART cycles in the studied population.

CONCLUSION

No significant effect of COH on the studied autoantibodies by the time of OPU was found but further studies are required to interpret these results.

The Effect of Dose Adjustments in a Subsequent Cycle of Women With Suboptimal Response Following Conventional Ovarian Stimulation

Several infertile patients, who may even represent around 40% of the infertile cohort, may respond "suboptimally" (4-9 oocytes retrieved) following IVF, despite being predicted as normal responders. The aim of our longitudinal study was to evaluate the ovarian response of suboptimal responders in terms of the number of oocytes retrieved, following their second IVF cycle, evaluating exclusively patients who had the same stimulation protocol and used the same or higher initial dose of the same type of gonadotropin compared to their previous failed IVF attempt. Overall, our analysis included 160 patients treated with a fixed antagonist protocol in their second cycle with the same [53 (33.1%)] or higher [107 (66.9%)] starting dose of rFSH. The number of oocytes retrieved was significantly higher in the second IVF cycle [6 (5-8) vs. 9 (6-12), p < 0.001]. According to our results, a dose increment of rFSH remained the only significant predictor of the number of oocytes retrieved in the subsequent IVF cycle (coefficient 0.02, p-value = 0.007) after conducting GEE multivariate regression, while adjusting for relevant confounders. A regression coefficient of 0.02 for the starting dose implies that an increase of 50 IU of the initial rFSH dose would lead to 1 more oocyte.

Molecular Mechanisms Responsible for Increased Vulnerability of the Ageing Oocyte to Oxidative Damage

In their midthirties, women experience a decline in fertility, coupled to a pronounced increase in the risk of aneuploidy, miscarriage, and birth defects. Although the aetiology of such pathologies are complex, a causative relationship between the age-related decline in oocyte quality and oxidative stress (OS) is now well established. What remains less certain are the molecular mechanisms governing the increased vulnerability of the aged oocyte to oxidative damage. In this review, we explore the reduced capacity of the ageing oocyte to mitigate macromolecular damage arising from oxidative insults and highlight the dramatic consequences for oocyte quality and female fertility. Indeed, while oocytes are typically endowed with a comprehensive suite of molecular mechanisms to moderate oxidative damage and thus ensure the fidelity of the germline, there is increasing recognition that the efficacy of such protective mechanisms undergoes an age-related decline. For instance, impaired reactive oxygen species metabolism, decreased DNA repair, reduced sensitivity of the spindle assembly checkpoint, and decreased capacity for protein repair and degradation collectively render the aged oocyte acutely vulnerable to OS and limits their capacity to recover from exposure to such insults. We also highlight the inadequacies of our current armoury of assisted reproductive technologies to combat age-related female infertility, emphasising the need for further research into mechanisms underpinning the functional deterioration of the ageing oocyte.

Intercycle variability of the ovarian response in patients undergoing repeated stimulation with corifollitropin alfa in a gonadotropin-releasing hormone antagonist protocol

OBJECTIVE

To determine whether individual subject variation in ovarian response between repeated cycles with the same ovarian stimulation protocol can be predicted.

DESIGN

Retrospective data analysis.

SETTING

Multicenter, open-label, uncontrolled clinical trial.

PATIENT(S)

Women aged 18-39 from a phase 3, open-label, uncontrolled trial with complete data across all cycles (n = 176).

INTERVENTION(S)

Up to three cycles of a single injection of 150 μg corifollitropin alfa for 7 days, then daily recombinant FSH/hMG until three follicles reached ≥17 mm. Gonadotropin-releasing hormone antagonist from stimulation day 5 until day of hCG administration.

MAIN OUTCOME MEASURE(S)

Numbers of follicles ≥11 mm on day of hCG in cycles 1-3, transition in ovarian response type between cycles from low (0-<6), normal (6-<18), and high (≥18), and serum FSH concentrations and antral follicle count (AFC) at each cycle start.

RESULT(S)

The mean (SD) numbers of follicles ≥11 mm on day of hCG were 13.4 (6.2), 13.3 (5.4), and 13.8 (6.4) in cycles 1, 2 and 3, respectively. Between cycles 1 and 2, 11.9% switched from normal to low or high response, and 12.5% switched from low or high to normal response; 75.6% remained in the same category. Between cycles 2 and 3, 15.9% switched from normal to low or high response, and 10.2% switched from low or high to normal response; 73.9% remained in the same category. These shifts are symmetrical in nature, in that the percentage of subjects who shift from normal to low or high response is comparable to the percentage of subjects who shift from low or high to normal response. Baseline FSH and AFC did not significantly predict transition in ovarian response.

CONCLUSION(S)

The variability in ovarian responses between repeated cycles using the same protocol was not explained by baseline FSH and AFC.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00696878 Protocol P05714.

A novel "delayed start" protocol with gonadotropin-releasing hormone antagonist improves outcomes in poor responders

OBJECTIVE

To investigate whether delaying the start of ovarian stimulation with GnRH antagonist improves ovarian response in poor responders.

DESIGN

Retrospective study.

SETTING

Academic medical center.

PATIENT(S)

Thirty patients, who responded poorly and did not get pregnant with conventional estrogen priming antagonist IVF protocol.

INTERVENTION(S)

Delayed-start antagonist protocol (estrogen priming followed by early follicular-phase GnRH antagonist treatment for 7 days before ovarian stimulation).

MAIN OUTCOME MEASURE(S)

Number of dominant follicles and mature oocytes retrieved, mature oocyte yield, and fertilization rate.

RESULT(S)

The number of patients who met the criteria to proceed to oocyte retrieval was significantly higher in the delayed-start protocol [21/30 (70%)] compared with the previous conventional estrogen priming antagonist cycle [11/30 (36.7%)]. The number of dominant follicles was significantly higher in the delayed-start (4.2 ± 2.7) compared with conventional (2.4 ± 1.3) protocol. In patients who had oocyte retrieval after both protocols (n = 9), the delayed start resulted in shorter ovarian stimulation (9.4 ± 1.4 days vs. 11.1 ± 2.0 days), higher number of mature oocytes retrieved (4.9 ± 2.0 vs. 2.2 ± 1.1), and a trend toward increased fertilization rates with intracytoplasmic sperm injection (ICSI; 86 ± 17% vs. 69 ± 21%) compared with conventional protocol. After delayed start, the average number of embryos transferred was 2.8 ± 1.4 with implantation rate of 9.8% and clinical pregnancy rate of 23.8%.

CONCLUSION(S)

The delayed-start protocol improves ovarian response in poor responders by promoting and synchronizing follicle development without impairing oocyte developmental competence.

The effect of GnRH analogues for pituitary suppression on ovarian response in repeated ovarian stimulation cycles

INTRODUCTION

Ovarian stimulation is employed in assisted reproduction techniques in order to obtain as many oocytes as possible. The early rise in oestradiol levels may lead to the premature end of the respective cycle. In order to avoid such an effect, pituitary suppression has been employed. The aim of this study was to evaluate whether maintenance or replacement of the type of GnRH analogue (i.e., agonist or antagonist) employed for pituitary suppression in the consecutive intracytoplasmic sperm injection (ICSI) cycle would negatively influence oocyte quality and ICSI outcome.

MATERIAL AND METHODS

A retrospective observational study was conducted including 181 women with primary infertility. Patients were divided into four different groups according to the GnRH analogue used for pituitary suppression in the first and consecutive cycle.

RESULTS

When a GnRH agonist was employed for pituitary suppression in the first cycle, the consecutive cycle showed comparable outcomes when performed with either a GnRH agonist or a GnRH antagonist. When the first cycle was performed with a GnRH antagonist, the use of the GnRH agonist in the successive cycle led to an increased number of oocytes retrieved (7.5% vs. 10.3%, p = 0.032) and the production of a higher number of embryos (4.5% vs. 6.3%, p = 0.036).

CONCLUSIONS

When the first cycle is carried out with a GnRH antagonist, the use of a GnRH agonist in the successive cycle would lead to increased numbers of oocytes collected and embryos produced.

The impact of ovarian stimulation for IVF on the developing embryo

The use of assisted reproductive technologies (ART) has been increasing over the past three decades, and, in developed countries, ART account for 1-3% of annual births. In an attempt to compensate for inefficiencies in IVF procedures, patients undergo ovarian stimulation using high doses of exogenous gonadotrophins to allow retrieval of multiple oocytes in a single cycle. Although ovarian stimulation has an important role in ART, it may also have detrimental effects on oogenesis, embryo quality, endometrial receptivity and perinatal outcomes. In this review, we consider the evidence for these effects and address possible underlying mechanisms. We conclude that such mechanisms are still poorly understood, and further knowledge is needed in order to increase the safety of ovarian stimulation and to reduce potential effects on embryo development and implantation, which will ultimately be translated into increased pregnancy rates and healthy offspring.

Predictors of ovarian response: progress towards individualized treatment in ovulation induction and ovarian stimulation

Ovarian stimulation is applied in the clinic to restore mono-ovulatory cycles in anovulatory women (ovulation induction) or to induce the development of multiple dominant follicles for assisted reproduction. Ovarian response is the endocrine and follicular reaction of the ovaries to stimulation. Achieving an appropriate ovarian response to anti-estrogens or exogenous gonadotrophins is central to ovulation induction and ovarian stimulation protocols. However, achieving an adequate response, without cycle cancellation or adverse events related to under- or over-stimulation, is complicated by high intra- and inter-individual variability. To predict each patient's ovarian response to medication for ovarian stimulation and to individualize the starting dose of exogenous gonadotrophin or the need for exogenous luteinizing hormone, various clinical, endocrine, ovarian ultrasonographic and genetic characteristics have been explored. Some of these features have been incorporated into prediction models. In this review, the methodology behind predictive factors and prediction models and their potential clinical applicability across ovulation induction and ovarian stimulation are explored.

Cryopreservation of supernumerary high quality embryos predicts favorable outcomes for patients undergoing repeated cycles of in vitro fertilization

OBJECTIVE

To determine whether the decline in pregnancy and implantation rates in repeated fresh IVF cycles is associated with the availability of embryo cryopreservation.

DESIGN

Retrospective study.

SETTING

Assisted reproductive unit at an academic institution.

PATIENT(S)

Women <38 years old (1,037), undergoing nondonor fresh or frozen embryo transfer (FET) cycles between January 1, 2000 and December 31, 2005.

INTERVENTION(S)

In fresh cycles, women used either pituitary desensitization or GnRH antagonists in combination with gonadotropin stimulation protocols before oocyte retrieval. In FET cycles, endometrial development was achieved by oral E(2) and vaginal P after pituitary desensitization. Embryo transfer occurred either on day 3 or on day 5.

MAIN OUTCOME MEASURE(S)

Implantation and pregnancy rates (PR).

RESULT(S)

Excluding FET cycles, implantation rates and PRs declined significantly in repeated cycles compared to the initial one. However, women with supernumerary embryos for cryopreservation appeared to produce embryos with higher implantation potential but were excluded from the analysis. When FET cycles were included, there were no significant declines in PRs for at least three repeated cycles.

CONCLUSION(S)

Embryo cryopreservation stratifies women with high quality embryos from those with low quality embryos who require repeat fresh attempts, resulting in an accelerated decline in observed PRs and implantation rates.

Effect of repeated assisted reproduction techniques on the ovarian response

PURPOSE OF REVIEW

Despite the increasing success of assisted reproduction techniques, most couples need more than one cycle of controlled ovarian hyperstimulation to achieve a pregnancy. The effect of several cycles on the ovarian response in subsequent cycles is a concern for gynaecologists and patients. In addition, egg donors have the possible risk of an ovarian reserve decrease. In this review, we present published evidence on the effects of repeated assisted reproduction techniques on the ovarian response.

RECENT FINDINGS

Recent available data indicate that ovarian response persists with subsequent cycles of controlled ovarian hyperstimulation in terms of oocytes being retrieved, although it is not clear whether an increased level of gonadotropins is required to achieve this response. There is a decrease in the number of oocytes retrieved in subsequent cycles due to increased female age as more cycles are needed. The oocytes retrieved in one cycle seem to come from the antral pool that otherwise would be atretic due to dominant follicle selection.

SUMMARY

The mechanisms involved in the recruitment from atresia of more than one follicle are discussed and it is shown that repetitive ovarian stimulation does not appear to affect the ovarian reserve. Published evidence shows that gonadotropins alter the physiologic selection of one single dominant follicle but do not accelerate the recruitment of follicles from further cycles, confirming that there is no detrimental effect on ovarian function after repetitive controlled ovarian hyperstimulation.

FSH: what is the highest dose for ovarian stimulation that makes sense on an evidence-based level?

The widely applied practice of a gonadotrophin dose increase in case of low response is not on an evidence-based level and not efficacious. All known comparative studies failed to show a difference in favour of the high-dose group regarding their pregnancy rate per embryo transfer. However if more oocytes and more embryos are available for cryopreservation, the real benefit in terms of cumulative pregnancy outcome might be with the high-dose regimen. This publication will show - as a review of the literature - that the frequent clinical practice of increasing the FSH dose does not lead to a higher pregnancy rate, which is in line with recommendation for milder stimulation regimes in IVF. Thus, the collective evidence to date would suggest that 150 IU/day to 250 IU/day of FSH or human menopausal gonadotrophin (HMG) is an appropriate starting dose for most women undergoing ovarian hyperstimulation for IVF as part of a gonadotrophin-releasing hormone (GnRH) antagonist or a long GnRH agonist protocol.

Impact of recombinant FSH dose adjustments on ovarian response in the second treatment cycle with IVF or ICSI in “standard” patients treated with 150 IU/day during the first cycle

BACKGROUND

A dose of 150 IU/day of recombinant follicle stimulating hormone (rFSH) is commonly used as a "standard" dose for "standard" patients in the first in vitro fertilization (IVF) treatment cycle. In the second cycle, the starting dose is adjusted in those patients who had an inappropriate response during the first cycle. The purpose of the study was to assess the impact of dose adjustments on ovarian response.

MATERIALS AND METHODS

Retrospective study including 567 first IVF/intracytoplasmic sperm injection (ICSI) cycles using the long agonist protocol in "standard" patients. In the second cycle 385 patients who had failed to achieve an ongoing pregnancy were included. The starting dose in the second cycle was adjusted according to the response in the first cycle.

RESULTS

A total of 215 patients (55.8%) had altered starting dose in the second cycle: 193 (50.1%) received >150 IU/day, whereas 22 (5.7%) had <150 IU/day. In the group given >150 IU/day, significantly more follicles (9.8 vs. 8.3, p = 0.002) and oocytes (8.4 vs. 6.7, p <0.0001) were obtained in the second cycle. In the group given <150 IU/day, there were significantly fewer follicles (20.4 vs. 13.5, p <0.0001) and oocytes (16.4 vs. 11.4, p = 0.005) in the second cycle. In the group given <150 IU/day in the second cycle, six (27.3%) had an appropriate ovarian response (5-14 oocytes) in the first cycle compared to 14 (63.6%) women in the second cycle (p = 0.01). The ongoing pregnancy rates in all of the first (32.1%) and second cycles (27%) were similar (p = NS).

CONCLUSION

In a "standard" patient population, 55.8% needed an altered starting dose in the second cycle and rFSH dose adjustments had a significant impact on the ovarian response.

Effect of repeated assisted reproductive technology on ovarian response

PURPOSE OF REVIEW

Based on current rates of success, many infertile couples who desire pregnancy have to undergo repeated cycles of assisted reproductive technology. Concern has been raised that repeated cycles of assisted reproductive technology may have a detrimental effect on future ovarian response and function, as well as pregnancy. This review summarizes current knowledge of the effects of repeated assisted reproductive technology, highlighting recent publications.

RECENT FINDINGS

The available published evidence so far indicates that the follicular response and the number of oocytes retrieved appears to be maintained with repeated treatment and the only significant decline in ovarian response is because of an increase in female age. Similarly pregnancy and live birth rates decline to a small degree only up to cycle 3 or 4, with increasing female age again being the prime determinant. Encouraging patients to undertake repeated treatment without undue delay leads to improved cumulative rates of pregnancy and live birth. Current evidence does not indicate that ovarian stimulation leads to an increased risk of ovarian malignancy.

SUMMARY

Couples should be counselled from the outset that assisted reproductive technology treatment is a continuum and a number of treatment cycles may be necessary. At present, there is little indication that repeated cycles have a detrimental effect on ovarian function, although the outcome of further research is awaited.