Prospective evaluation of two stimulation protocols for low responders who were undergoing in vitro fertilization-embryo transfer

A randomized controlled trial of vaginal progesterone for luteal phase support in modified natural cycle - frozen embryo transfer

OBJECTIVE

Our aim was to study whether luteal phase support (LPS) increases the live-birth rate (LBR) in women undergoing modified natural cycle (mNC) frozen-thawed embryo transfer (FET).

METHODS

In a randomized controlled trial, conducted at a university-affiliated tertiary medical center, a total of 59 patients aged 18-45 years, underwent mNC-FET. FET was performed in mNC following ovulation triggering by hCG. Patients were randomized into two groups; The No-LPS Group included 28 women who did not receive LPS, and the LPS Group included 31 women who received vaginal progesterone for LPS. The main outcome measure was LBR.

RESULTS

Baseline demographic and clinical characteristics were comparable between the study groups. The no-LPS group and the LPS group did not differ with regard to clinical pregnancy rate (21.4% vs. 32.3%; respectively, p = .35), LBR (17.9% vs. 19.4%; respectively, p = .88), or spontaneous miscarriage rate (3.6% vs. 12.9%; respectively, p = .35). On multivariate logistic regression analysis, LPS was not associated with LBR after controlling for confounders.

CONCLUSION

The results of our study suggest that LPS after mNC-FET does not improve the reproductive outcome, and therefore, might not be necessary.C linicaltrials.gov identifier: NCT01483365.

Ovarian stimulation modalities in poor responders

In a group of IVF/ICSI cycles, despite the appropriate ovarian stimulation, the number of oocytes collected is below the expected value. This condition is defined as poor ovarian response (POR) to stimulation. POR brings the risk of cycle cancellation with an estimated rate of 20%. Infertility experts are trying to improve cycle outcomes of POR cases with multiple modifications. This review article will present the latest modifications on the management of POR. The studies performed for improving cycle outcome in POR cases were evaluated and their notable results were presented. The first intervention among infertility specialists is to make a standard definition for POR. The BOLOGNA criteria and the subsequent POSEIDON group definitions are the latest updates in POR management. GnRH antagonists, estradiol priming, double stimulation, letrozole administration, DHEA, and herbal therapy supplementations are the recent modifications done to improve oocyte retrieval and subsequent embryo transfer for POR cases. This review article presents the encouraging methods applied for POR cases to improve cycle outcome.

Do young women with unexplained infertility show manifestations of decreased ovarian reserve?

PURPOSE

To investigate whether unexplained infertility at a young age demonstrates manifestations of decreased ovarian reserve.

METHODS

A total of 100 women were divided into two equally sized groups. The study group comprised women aged ≤ 37 years diagnosed with unexplained infertility, and the control group included age-matched women with either mechanical factor or severe male factor infertility.

RESULTS

Both groups were comparable in their basic characteristics. Overall, women with unexplained infertility presented with inferior ovarian reserve results set against women of the control group. The number of ≥ 14-mm follicles on the day of hCG administration was significantly lower in the study compared with the control group (7.0 ± 4.5 vs. 10.4 ± 4.1 follicles, respectively, P < 0.001). Likewise, basal serum FSH was higher in the study compared with the control group (8.4 ± 5.5 vs. 6.4 ± 1.7 IU/L, respectively, P = 0.015), while antral follicle count was lower (10.9 ± 6.6 vs. 16.2 ± 6.6 follicles, respectively, P < 0.001). Furthermore, women with unexplained infertility required a higher total dose of FSH for ovarian stimulation (2,923 ± 1,701 vs. 2,196 ± 941 IU/L, respectively, P = 0.010), but exhibited a lower number of retrieved oocytes (9.3 ± 6.3 vs. 15.6 ± 7.9 oocytes, respectively, P < 0.001), alongside a lower number of achieved embryos (5.3 ± 4.0 vs. 8.0 ± 4.7 embryos, respectively, P = 0.002). Interestingly, the cumulative clinical pregnancy rate was not significantly different between the two groups (44% vs. 58%, respectively, P = 0.163).

CONCLUSIONS

Young women ≤ 37 years of age with unexplained infertility have clear manifestations of sub-optimal ovarian reserve set against controls. Our findings suggest that unexplained infertility at a young age may be a risk factor for developing poor ovarian response, specifically as a quantitative, rather than a qualitative, risk factor.

Modified natural-cycle cryopreserved embryo transfer: is a washout period needed after a failed fresh cycle?

RESEARCH QUESTION

Are the characteristics of the natural cycle or modified natural cycle (mNC), or live birth rates (LBR), affected by delaying frozen embryo transfer (FET) after a failed fresh IVF cycle?

DESIGN

In a retrospective study, conducted at a university-affiliated tertiary centre, 198 women aged 18-45 years undergoing their first FET cycle after a failed fresh embryo transfer attempt using an mNC were evaluated. Cycles were divided according to the time interval between oocyte retrieval and the start of the FET cycle into the immediate FET group (<22 days) and the delayed FET group (≥22 days). The main outcome measures were ovulation day and LBR.

RESULTS

The mean interval between oocyte retrieval and the start of the FET cycle was 15.6 ± 3.2 days in the immediate FET group and 84.8 ± 73.7 days in the delayed FET group (P < 0.001). Ovulation day was significantly delayed in the immediate FET group (day 17.1 ± 4.4 versus day 15.4 ± 3.7; P = 0.004). There was no difference between the immediate and delayed FET groups in terms of clinical pregnancy rate (CPR) (25.4% and 25.0%, respectively) or LBR (21.2% and 20.0%, respectively).

CONCLUSIONS

Natural-cycle characteristics are similar in immediate and delayed cycles, except for a slight delay in ovulation day. Deferring mNC-FET after a failed fresh IVF cycle does not improve the reproductive outcome. These results should encourage patients and clinicians who want to proceed with FET immediately after failure of fresh IVF.

Human chorionic gonadotropin serum levels following ovulation triggering and IVF cycle outcome

PURPOSE

The clinical significance of serum hCG levels after ovulation triggering was studied previously with conflicting results. Our aim was to study the correlation of hCG levels on the day after ovulation triggering using recombinant hCG (r-hCG) with treatment outcome.

METHODS

A prospective observational study of all fresh IVF/ICSI cycles in a single medical center, between January 2015 and June 2016, was performed. hCG serum levels were obtained 10-12 h following ovulation triggering with 250 mcg r-hCG. Clinical and laboratory outcome parameters were compared between cycles with serum hCG above and below median level. A multivariate regression analysis was performed in order to study the association between hCG levels and live birth rate, after controlling for confounders.

RESULTS

Overall, 326 cycles were included. Median serum hCG level was 91.35 IU/L. hCG levels were lower as age and BMI were higher (p = 0.004, p < 0.001, respectively). The study groups did not differ with regard to clinical pregnancy rate (p = 0.14), live birth rate (p = 0.09), fertilization rate (p = 0.45), or metaphase II oocyte rate (p = 0.68). On multivariate regression analysis, hCG level was not associated with live birth (aOR 0.99, 95% CI 0.98-1.005), after controlling for patient's age and BMI.

CONCLUSIONS

hCG levels on the day after ovulation triggering with 250 mcg r-hCG are inversely correlated with patient age and BMI. However, they are not correlated with any clinical or laboratory outcome parameter. Therefore, testing for hCG levels after ovulation induction seems futile and cannot be recommended.

Defining Low Prognosis Patients Undergoing Assisted Reproductive Technology: POSEIDON Criteria-The Why

Women with impaired ovarian reserve or poor ovarian response (POR) to exogenous gonadotropin stimulation present a challenge for reproductive specialists. The primary reasons relate to the still limited knowledge about the POR pathophysiology and the lack of practical solutions for the management of these conditions. Indeed, clinical trials using the current standards to define POR failed to show evidence in favor of a particular treatment modality. Furthermore, critical factors for reproductive success, such as the age-dependent embryo aneuploidy rates and the intrinsic ovarian resistance to gonadotropin stimulation, are not taken into consideration by the current POR criteria. As a result, the accepted definitions for POR have been criticized for their inadequacy concerning the proper patient characterization and for not providing clinicians a guide for therapeutic management. A novel system to classify infertility patients with "expected" or "unexpected" inappropriate ovarian response to exogenous gonadotropins-the POSEIDON criteria-was developed to provide a more nuanced picture of POR and to guide physicians in the management of such patients. The new standards are provoking as they challenge the current terminology of POR in favor of the newly defined concept of "low prognosis." This article provides readers a critical appraisal of the existing criteria that standardize the definition of POR and explains the primary reasons for the development of the POSEIDON criteria.

Short versus long gonadotropin-releasing hormone analogue suppression protocols in advanced age women undergoing IVF/ICSI

OBJECTIVE

To compare the effective of two GnRH-a protocols for ovarian stimulation in advanced age women undergoing IVF/ICSI cycles.

STUDY DESIGN

A total of 1149 IVF-ET/ICSI cycles were retrospectively identified. The cycles were divided two groups, namely a long-protocol group and a short-protocol group.

RESULTS

The numbers of oocytes retrieved, and high-quality embryos in the long-protocol group were significantly greater than those in the short-protocol group. In the long-protocol group, the implantation and pregnancy rates were 17.22% and 33.67%, respectively, and these values were significantly higher than those in the short-protocol group (8.24% and 15.96%, p < 0.05).

CONCLUSIONS

Our study demonstrated that the long protocol was superior to the short protocol for advanced age women.

Trends in 'poor responder' research: lessons learned from RCTs in assisted conception

BACKGROUND

A substantial minority of women undergoing IVF will under-respond to controlled ovarian hyperstimulation. These women-so-called 'poor responders'-suffer persistently reduced success rates after IVF. Currently, no single intervention is unanimously accepted as beneficial in overcoming poor ovarian response (POR). This has been supported by the available research on POR, which consists mainly of randomized controlled trials (RCTs ) with an inherent high-risk of bias. The aim of this review was to critically appraise the available experimental trials on POR and provide guidance towards more useful-less wasteful-future research.

METHODS

A comprehensive review was undertaken of RCTs on 'poor responders' published in the last 15 years. Data on various methodological traits as well as important clinical characteristics were extracted from the included studies and summarized, with a view to identifying deficiencies from which lessons can be learned. Based on this analysis, recommendations were provided for further research in this field of assisted conception.

RESULTS

We selected and analysed 75 RCTs. A valid, 'low-risk' randomization method was reported in three out of four RCTs. An improving trend in reporting concealment of patient allocation was also evident over the 15-year period. In contrast, <1 in 10 RCTs 'blinded' patients and <1 in 5 RCTs 'blinded' staff to the proposed intervention. Only 1 in 10 RCTs 'blinded' ultrasound practitioners to patient allocation, when assessing the outcome of early pregnancy. The majority of trials reported an intention-to-treat analysis for at least one of their outcomes, with an improving trend in the recent years. Substantial variation was noted in the definitions used for 'poor responders', the most popular being 'low ovarian response at previous stimulation'. The preferred cut-off value for defining previous low response has been 'less or equal to three retrieved oocytes'. The most popular tests used for diagnosing diminished ovarian reserve have been antral follicle count and FSH. Although the Bologna criteria for POR were only recently introduced, they are expected to become a popular definition in future 'poor responder' trials. Numerous interventions have been studied on 'poor responders'. Most of these have been applied before/during controlled ovarian hyperstimulation. The antagonist protocol, the microdose flare protocol and the long down-regulation protocol have been among the most popular interventions. The analysis of outcomes revealed a clear improving trend in reporting live birth. In contrast, only 10% of RCTs reported significant improvement in reproductive outcomes among tested interventions. Twelve 'significant' interventions were reported, each supported by a single 'positive' RCT. Finally, trials of higher methodological quality were more likely to have been published in a high-impact journal.

CONCLUSIONS

Overall, the majority of published trials on POR suffer from methodological flaws and are, thus, regarded as being high-risk for bias. The same trials have used a variety of definitions for their poor responders and a variety of interventions for their head-to-head comparisons. Not surprisingly, discrepancies are also evident in the findings of trials comparing similar interventions. Based on the identified deficiencies, this novel type of 'methodology and clinical' review has introduced custom recommendations on how to improve future experimental research in the 'poor responder' population.

Regimen of ovarian stimulation affects oocyte and therefore embryo quality

Without any doubt the regimen used to mature multiple capable oocytes for IVF impacts IVF outcomes. Studies have indicated that the inclusion of LH activity, adjuvant agents such as growth hormone (GH), and regimens providing for simultaneous action of both LH and FSH during final oocyte maturation may have beneficial effects on IVF outcomes. Because of the difficulty in improving IVF outcomes in poor responders, the studies on GH are of particular interest. As pointed out in this review, the apparent beneficial effects of GH on oocyte competence may also apply to older women or to normal responders with reduced embryo quality. A much more difficult question is whether and how much ovarian stimulation impacts on oocyte competence. Paradoxically it seems that there are not demonstrated differences between the stimulated and the natural unstimulated cycle, whereas studies in laboratory animals and IVF patients have shown deleterious effects of higher compared with lower doses of gonadotropins. Recent studies suggest that the use of high doses of gonadotropins as an independent factor correlates negatively with the probability of live birth, whereas a high ovarian response per se is associated with better cumulative pregnancy rates, owing to the availability of more euploid and good-quality embryos. Although adjunctive use of androgens has not been discussed here, it is briefly covered in the first review of this series.

Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotrophin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth.

OBJECTIVES

To evaluate the effectiveness of the different GnRHa protocols as adjuncts to COH in women undergoing ART cycles.

SEARCH METHODS

We searched the following databases from inception to April 2015: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, CINAHL, PsycINFO, and registries of ongoing trials. Reference lists of relevant articles were also searched.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed trial eligibility and risk of bias, and extracted the data. The primary outcome measure was number of live births or ongoing pregnancies per woman/couple randomised. Secondary outcome measures were number of clinical pregnancies, number of oocytes retrieved, dose of gonadotrophins used, adverse effects (pregnancy losses, ovarian hyperstimulation, cycle cancellation, and premature luteinising hormone (LH) surges), and cost and acceptability of the regimens. We combined data to calculate odds ratios (OR) for dichotomous variables and mean differences (MD) for continuous variables, with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methods.

MAIN RESULTS

We included 37 RCTs (3872 women), one ongoing trial, and one trial awaiting classification. These trials made nine different comparisons between protocols. Twenty of the RCTs compared long protocols and short protocols. Only 19/37 RCTs reported live birth or ongoing pregnancy.There was no conclusive evidence of a difference between a long protocol and a short protocol in live birth and ongoing pregnancy rates (OR 1.30, 95% CI 0.94 to 1.81; 12 RCTs, n = 976 women, I² = 15%, low quality evidence). Our findings suggest that in a population in which 14% of women achieve live birth or ongoing pregnancy using a short protocol, between 13% and 23% will achieve live birth or ongoing pregnancy using a long protocol. There was evidence of an increase in clinical pregnancy rates (OR 1.50, 95% CI 1.18 to 1.92; 20 RCTs, n = 1643 women, I² = 27%, moderate quality evidence) associated with the use of a long protocol.There was no evidence of a difference between the groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort protocol (OR 1.78, 95% CI 0.72 to 4.36; one RCT, n = 150 women, low quality evidence), long luteal versus long follicular phase protocol (OR 1.89, 95% CI 0.87 to 4.10; one RCT, n = 223 women, low quality evidence), when GnRHa was stopped versus when it was continued (OR 0.75, 95% CI 0.42 to 1.33; three RCTs, n = 290 women, I² = 0%, low quality evidence), when the dose of GnRHa was reduced versus when the same dose was continued (OR 1.02, 95% CI 0.68 to 1.52; four RCTs, n = 407 women, I² = 0%, low quality evidence), when GnRHa was discontinued versus continued after human chorionic gonadotrophin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; one RCT, n = 181 women, low quality evidence), and when administration of GnRHa lasted for two versus three weeks before stimulation (OR 1.14, 95% CI 0.49 to 2.68; one RCT, n = 85 women, low quality evidence). Our primary outcomes were not reported for any other comparisons.Regarding adverse events, there were insufficient data to enable us to reach any conclusions except about the cycle cancellation rate. There was no conclusive evidence of a difference in cycle cancellation rate (OR 0.95, 95% CI 0.59 to 1.55; 11 RCTs, n = 1026 women, I² = 42%, low quality evidence) when a long protocol was compared with a short protocol. This suggests that in a population in which 9% of women would have their cycles cancelled using a short protocol, between 5.5% and 14% will have cancelled cycles when using a long protocol.The quality of the evidence ranged from moderate to low. The main limitations in the evidence were failure to report live birth or ongoing pregnancy, poor reporting of methods in the primary studies, and imprecise findings due to lack of data. Only 10 of the 37 included studies were conducted within the last 10 years.

AUTHORS' CONCLUSIONS

When long GnRHa protocols and short GnRHa protocols were compared, we found no conclusive evidence of a difference in live birth and ongoing pregnancy rates, but there was moderate quality evidence of higher clinical pregnancy rates in the long protocol group. None of the other analyses showed any evidence of a difference in birth or pregnancy outcomes between the protocols compared. There was insufficient evidence to make any conclusions regarding adverse effects.

Is the GnRH Antagonist Protocol Effective at Preventing OHSS for Potentially High Responders Undergoing IVF/ICSI?

Objective

To determine if the GnRH antagonist protocol is effective in preventing ovarian hyperstimulation syndrome (OHSS) in potentially high responders.

Methods

A total of 660 IVF-ET/ICSI cycles were retrospectively identified. The inclusion criterion was age ≤ 30 years. Cycles were divided into two groups: a GnRHa group and a GnRHant group. In the GnRHa group, the patients received one single injection of 1.0mg-1.3mg Triptorelin in previous mid-luteal phase. In the GnRHant group, a daily dose of 0.25 mg Cetrotide was initiated when a lead follicle obtained a mean diameter of 14 mm, continued up until the day of hCG administration. The duration of stimulation, total dose of Gn, implantation rate, pregnancy rate, and OHSS rate were compared.

Results

The duration of stimulation, E₂ level on hCG day, numbers of oocytes retrieved, MII oocytes, and high-quality embryos in the GnRHa group were all significantly more than those in the GnRHant group. In the GnRHa group, 83.53% of cancelled fresh-transferred cycles were cancelled because of high risk of OHSS, which was significantly higher than that in the GnRHant group (43.55%, P<0.05). The incidence of OHSS in the GnRHa group was slightly higher than that in the GnRHant group. The implantation and clinical pregnancy rates in the GnRHa group were significantly higher than those in the GnRHant group (37.36% VS 19.25%, 62.78% VS 31.06%; P<0.05).

Conclusions

Our study demonstrated that for potentially high responders, the GnRHant protocol can, to some extent, lower the cancellation and incidence rates of OHSS. The GnRHa protocol was superior to the GnRHant protocol in terms of implantation and clinical pregnancy rates.

Diminished ovarian reserve in the United States assisted reproductive technology population: diagnostic trends among 181,536 cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System

OBJECTIVE

To evaluate trends in diminished ovarian reserve (DOR) assignment in the Society for Assisted Reproductive Technology (SART) Clinic Outcomes Reporting System database and to evaluate its accuracy in predicting poor ovarian response (POR) as defined in European Society of Human Reproduction and Embryology's Bologna criteria (2011).

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 181,536 fresh, autologous ART cycles reported to SART by U.S. clinics in 2004 and 2011 (earliest and most recent available reporting years).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

DOR assignment was the primary exposure. POR, defined as cycle cancellation for poor response or less than 4 oocytes retrieved after conventional gonadotropin stimulation (>149 IU FSH daily), was the primary outcome. Secondary outcomes were live birth and number of oocytes retrieved. DOR prevalence, power of DOR and FSH (</≥12 mIU/mL) to predict POR, and live birth in POR cycles were also calculated.

RESULT(S)

DOR prevalence increased from 19% to 26% from 2004 to 2011. Among cycles clinically assigned as DOR, incidence of POR decreased from 32% to 30%, and live birth improved from 15% to 17%. Comparing basal FSH ≥12 versus clinical assignment of DOR, basal FSH had a higher specificity (92.2% vs. 81.6%) and positive predictive value (38.3% vs. 30.9%) for predicting POR. Live birth among POR cycles was 4%.

CONCLUSION(S)

DOR diagnosis is increasing, and accuracy remains poor, despite the availability of additional diagnostic parameters such as antral follicle count and antimüllerian hormone. POR entailed poor outcomes, but the majority of patients clinically assigned as DOR did not experience POR. Development and use of more accurate predictors of POR are needed to minimize patient distress resulting from overdiagnosis.

Comparative prospective study of 2 ovarian stimulation protocols in poor responders: effect on implantation rate and ongoing pregnancy

Background

In patients treated with IVF, the incidence of poor ovarian response (POR) after ovarian stimulation varies from 9 to 25 %. However, at present, there are no clear guidelines for treating these poor responders. This study was designed to compare two different ovarian stimulation protocols and addresses future perspectives in the management of these unfortunate patients.

Method

Four hundred and forty poor responders were studied during their second IVF cycle. They had all failed to become pregnant during their first IVF cycle where the long GnRH-agonist stimulation protocol (P1) was used. Patients were prospectively randomly assigned to 2 protocol groups (P2 or P3, 220 patients in each arm) at the start of ovarian stimulation according to the order of entry into the study including one patient per each stimulation protocols: The P2 group was treated with a contraceptive pill + flare-up GnRH-agonist protocol and the P3 group with the GnRH-antagonist protocol. The ovarian stimulation characteristics as well as the clinical and ongoing pregnancy rates were compared.

Result(s)

Although the numbers of embryos obtained and transferred were significantly higher with the P2 protocol, the implantation and ongoing pregnancy rates per transfer were the same in the two studied groups (8.9 % versus 14.6 % and 8.4 % versus 14.2 % for the P2 and P3 protocols, respectively). Good prognostic factors for ongoing pregnancy with both protocols were: a maternal age <36, no tobacco consumption, a total dose of gonadotropins injection <5000 IU and an endometrial thickness >10 mm.

Conclusion(s)

In poorly responding patients treated with IVF, the implantation and ongoing pregnancy rates per transfer were not significantly different between the two protocols studied: contraceptive pill + flare-up GnRH-agonist protocol and the GnRH-antagonist protocol. It is suggested that current strategies for the management of poor responders be reconsidered in the light of the potential contribution of age and the effect of life style changes on fertility potential. A customised policy of ovarian stimulation in these patients including mild stimulation protocols, sequential IVF cycles, oocytes-embryos freeze all protocols and blastocyst transfers after screening may improve the clinical outcome.

Poor responders in IVF: an update in therapy

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.

Endometrial nerve fibre density in patients undergoing IVF: a pilot study

The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. Presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. This prospective pilot study assessed the presence of nerve fibres in endometrium of women undergoing IVF due to various causes and examined the correlation between the presence of nerve fibres and IVF success. A total of 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Correlations between the presence and density of nerve fibres and aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. Presence of nerve fibres was not correlated with cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without correlation to presence of nerve fibres in the endometrium. Nerve fibres were identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. The presence of nerve fibres does not appear to interfere with implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research. The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. The presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. Our aim was to assess the presence of nerve fibres in endometrium of women with various causes of infertility undergoing IVF and to examine the association between the presence of nerve fibres in the endometrium and IVF success. In a prospective study, 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Associations between the presence and density of nerve fibres and the aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. No association was found between the presence of nerve fibres and the cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without association with the presence of nerve fibres in the endometrium. Nerve fibres can be identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. Their presence does not interfere with embryo implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research.

Controlled ovarian stimulation using a long gonadotropin-releasing hormone antagonist protocol: a proof of concept and feasibility study

BACKGROUND/AIMS

To evaluate the feasibility of a long protocol of controlled ovarian stimulation prior to in vitro fertilization (IVF) and embryo transfer with a gonadotropin-releasing hormone (GnRH) antagonist used for pituitary and ovarian suppression.

METHODS

Thirty patients undergoing IVF/intracytoplasmic sperm injection were randomized into two groups. The control group (n = 16) received a standard flexible GnRH antagonist protocol. Ovarian stimulation consisted of 225 IU/day of recombinant follicle-stimulating hormone for 5 days, followed by 225 IU/day of human menopausal gonadotropin until human chorionic gonadotropin (hCG) administration. The study group (n = 14) received 0.25 mg of GnRH antagonist daily for 7 days, thereafter, upon confirmation of pituitary and ovarian suppression, ovarian stimulation was commenced with the same protocol as used in the control group. Hormone and follicle dynamics, as well as laboratory characteristics and cycle outcome, were compared for both groups.

RESULTS

Both groups were comparable in baseline characteristics. Pituitary and ovarian suppression were effectively achieved in 12/14 patients in the study group. The duration of ovarian stimulation and gonadotropin consumption were similar in both groups, as was also the number and size of follicles on hCG day.

CONCLUSION

The results of our study confirm the feasibility of a long GnRH antagonist protocol. This regimen could become another option to optimize GnRH antagonist protocols, and should thus be further explored.

[Prospective randomised study of long versus short agonist protocol with poor responder patients during in vitro fertilization]

OBJECTIVES

Different ovarian stimulation protocols are used for in vitro fertilization (IVF) in "poor responder" patients. Our work aims at comparing two ovarian stimulation protocols (long agonist half-dose protocol versus short agonist protocol without pretreatment) in this population of women.

PATIENTS AND METHODS

This prospective, randomized study was realized at the University Hospital of Saint-Étienne and concerns "poor responder" patients (age between 38 and 42 years and FSH at day 3 more than 9.5 IU/L; and/or antral follicles count less or equal to 6; and/or failure of previous stimulation). The primary endpoint is based on the number of oocytes retrieved at the end of an IVF cycle.

RESULTS

Out of the 44 patients randomized, 39 cycles were taken into account (20 in the long protocol, 19 in the short one). At the end of the stimulation (FSH-r 300 to 450 UI/d), the number of follicles recruited appears higher in the long protocol but the difference is not significant (diameter between 14 and 18 mm: 3.0±2.31 vs. 1.88±1.89 and diameter greater than 18 mm: 3.9±2 85 vs. 3.06±2.77). The same tendency is observed for all the following criteria: the number of retrieved oocytes (6.74±2.73 vs. 6.38±4.26), the total number of embryos (3.16±2.03 vs. 2.25±2.11), the pregnancy rate per retrieval (21% vs. 19%) and per cycle (20% vs. 16%), and the number of children born alive.

DISCUSSION AND CONCLUSION

The study did not reveal any difference between the two protocols but the long half-dose seems to be better.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A systematic review of randomized trials for the treatment of poor ovarian responders: is there any light at the end of the tunnel?

OBJECTIVE

To assess the definitions for "poor ovarian responders" used among randomized trials for the treatment of women with impaired response to stimulation.

DESIGN

Systematic review.

SETTING

None.

PATIENT(S)

Poor ovarian responders.

INTERVENTION(S)

Treatment modalities for the management of poor ovarian responders.

MAIN OUTCOME MEASURE(S)

Number and nature of the criteria used to define poor ovarian response to stimulation and threshold values used.

RESULT(S)

Among 47 randomized trials, 41 different definitions for the patients with poor ovarian response have been used. No more than 3 trials used the same definition, whereas even trials from the same research groups used different definitions across different trials. None of the criteria used was adopted in more than 50% of the trials. Age and antral follicle count were adopted only in 9% of the definitions, whereas the criteria of number of follicles on the final stimulation day and number of oocytes retrieved were used in more than 40% of the trials; nonetheless, even for these criteria, the threshold values were consistently different.

CONCLUSION(S)

The variability regarding the definition of poor ovarian responders appears to be striking. Although the Bologna criteria developed by European Society for Human Reproduction and Embryology consensus in 2011 aim to define a consistent group of patients, their applicability needs to be tested through clinical trials. Meanwhile, meta-analyses of the currently available trials should be strongly discouraged because they may lead to the adoption of interventions of ambiguous value.

Dehydroepiandrosterone supplementation increases baseline follicular phase progesterone levels

The use of dehydroepiandrosterone (DHEA) supplementation in infertile patients with diminished ovarian reserve (DOR) has become increasingly popular. It has been our observation that serum progesterone levels during the follicular phase are often increased during controlled ovarian stimulation when DHEA is coadministered. Our aim was to compare progesterone levels during the follicular phase before and during DHEA supplementation in women with DOR undergoing in vitro fertilization (IVF). In a case-control study, we compared progesterone levels during the follicular phase in IVF cycles before and during DHEA supplementation in 15 women with DOR who received 75 mg of DHEA daily. Progesterone levels on stimulation day 5 (0.5 ± 0.29 ng/ml vs. 1.54 ± 0.49 ng/ml; p < 0.0001) and on the day of human chorionic gonadotropin administration (0.75 ± 0.31 ng/ml vs. 1.87 ± 0.49 ng/ml; p < 0.0001) were significantly higher during DHEA treatment. The number of retrieved and fertilized oocytes was similar in both the groups. DHEA administration during IVF cycles in women with DOR causes a significant elevation of progesterone levels without an apparent deleterious effect on cycle outcome.

Does 75 IU difference improve the cycle performance in poor responders? Comparison of daily 375 versus 450 IU gonadotrophin doses

OBJECTIVE

To compare the efficacy on the cycle performance of 375 versus 450 IU/day gonadotrophin on the microdose flare-up protocol in poor responders.

STUDY DESIGN

A total of 91 poor responder patients who were treated with the microdose flare-up protocol were enrolled in this study. Group 1 (n = 40) was stimulated with 375 IU/day gonadotrophin. Group 2 (n = 51) was stimulated with 450 IU/day gonadotrophin. Main outcome measurements were accepted as the results of controlled ovarian hyperstimulation, implantation, clinical pregnancy, and live birth rates.

RESULTS

Baseline characteristics are similar between the two groups. Higher number of oocyte cumulus complexes and lower total gonadotrophin requirement were noted in Group 1 compared with Group 2. Number of metaphase II oocytes and implantation rates were similar between the groups. A trend toward higher clinical pregnancy and live birth rate was observed in Group 1 but these results did not reach statistical significance.

CONCLUSIONS

Total gonadotrophin costs are lower using the 375 IU/day gonadotrophin compared to the 450 IU/day in poor responders. Additional 75 IU/day does not give any improvement neither embryology nor pregnancy outcomes.

Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotrophin-releasing hormone agonists (GnRHa) are used in assisted reproduction technology (ART) cycles to prevent a luteinizing hormone surge. Various protocols have been described in the literature, such as long protocols (continuous and stop or reduce dose, long luteal, or long follicular protocol); short protocols and ultrashort protocols.

OBJECTIVES

To determine the most effective GnRHa protocol as an adjuvant to gonadotrophins in ART cycles.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINHAHL and PsycINFO. Reference lists of relevant articles were also searched. All the searches were updated to August 2010.

SELECTION CRITERIA

Only randomised controlled trials comparing any two protocols of GnRHa in in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) cycles were included.

DATA COLLECTION AND ANALYSIS

The primary outcome measure was live births per women. Secondary outcome measures were pregnancy rate, ongoing pregnancy rate, number of oocytes retrieved and amount of gonadotrophins used. Data were independently extracted in 2 x 2 tables by two authors. Odds ratios (OR) with 95% confidence intervals (CI) were calculated after verifying the presence of homogeneity of treatment effect across all trials. For continuous variables mean differences (MD) were calculated.

MAIN RESULTS

Of 29 included studies, 17 compared long with short protocols; two compared long with ultrashort protocols; four compared a follicular versus luteal start of GnRHa; three compared continuation versus stopping the GnRHa at the start of stimulation; three compared continuation of the same dose versus reduced dose of GnRHa and one compared a short versus short stop protocol.There was no evidence of a difference in the live birth rate but this outcome was only reported by three studies.There was evidence of a significant increase in clinical pregnancy rate (OR 1.50, 95% CI 1.16 to 1.93) in a long protocol when compared to a short protocol. That is there is a 50% increase in chance of achieving pregnancy if a long protocol is used as compared to a short protocol, although this difference could range from 16% to 93% increased chance of pregnancy. This difference did not persist when the meta-analysis was done only on the studies with adequate randomisation (OR 1.38, 95% CI 0.93 to 2.05).There was evidence of an increased number of oocytes (MD 1.61, 95% CI 0.18 to 3.04) obtained when a long protocol was used as compared to a short protocol. That is there is a 60% increase in the number of oocytes retrieved when a long protocol is used as compared to a short protocol, although this difference could range from 18% to 304% more oocytes.There was evidence of an increase (MD 12.90, 95% CI 3.29 to 22.51) in the requirement for gonadotrophins in long as compared to short protocols. That is approximately 12.9 more ampoules of gonadotrophins were consumed when a long protocol was used as compared to a short protocol. This difference could range from 3.29 to 22.51 more gonadotrophin ampoules.There was no evidence of a difference in any of the outcome measures for luteal versus follicular start of GnRHa and stopping versus continuation of GnRHa at the start of stimulation.

AUTHORS' CONCLUSIONS

The pregnancy rate was found to be higher when GnRHa was used in a long protocol as compared to a short or ultrashort protocol. There was no evidence of a difference in live birth rate, but this outcome was only reported by three studies. There was no evidence of a difference in the outcomes amongst various long protocols; nor that stopping or reducing GnRHa at the start of stimulation was associated with a reduced pregnancy rate. For all comparison, except a long versus short protocol, there was a lack of power.

Spontaneous ovulation versus HCG triggering for timing natural-cycle frozen-thawed embryo transfer: a randomized study

In ovulatory patients, frozen-thawed embryo transfer (FET) is commonly performed during a natural cycle (NC). The objective was to compare serial monitoring until documentation of ovulation with human chorionic gonadotrophin (HCG) triggering, for timing NC-FET. Sixty women with regular menstrual cycles undergoing NC-FET were randomized into two groups: group A (n=30) had FET in a natural cycle after ovulation triggering with HCG; group B (n=30) had FET in a natural cycle after detection of spontaneous ovulation. The main outcome measure was the number of monitoring visits at the clinic per cycle. Secondary outcome measures included implantation rate, clinical pregnancy and live-birth rates. Both groups were similar in terms of demographic characteristics and reproductive history. Clinical and laboratory characteristics of fresh and frozen cycles and pregnancy and delivery rates were comparable for both groups. The number of monitoring visits in group A (3.2 ± 1.4) was significantly lower than in group B (4.7 ± 1.6) (P=0.002). In patients undergoing NC-FET, triggering ovulation by HCG can significantly reduce the number of visits necessary for cycle monitoring without an adverse effect on cycle outcome. Ovulation triggering can increase both patient convenience and cycle cost effectiveness.

ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria

The definition presented here represents the first realistic attempt by the scientific community to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. POR to ovarian stimulation usually indicates a reduction in follicular response, resulting in a reduced number of retrieved oocytes. It has been recognized that, in order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. By definition, the term POR refers to the ovarian response, and therefore, one stimulated cycle is considered essential for the diagnosis of POR. However, patients of advanced age with an abnormal ORT may be classified as poor responders since both advanced age and an abnormal ORT may indicate reduced ovarian reserve and act as a surrogate of ovarian stimulation cycle outcome. In this case, the patients should be more properly defined as 'expected poor responder'. If this definition of POR is uniformly adapted as the 'minimal' criteria needed to select patients for future clinical trials, more homogeneous populations will be tested for any new protocols. Finally, by reducing bias caused by spurious POR definitions, it will be possible to compare results and to draw reliable conclusions.

Evidence-based management of poor ovarian response

Poor ovarian response is not infrequent and represents one of the major therapeutic challenges in in vitro fertilization. Although several tests have been proposed, which aim at predicting poor response to ovarian stimulation, available data are conflicting regarding their accuracy and clinical usefulness. Even though several therapeutic approaches have been explored, a single effective strategy has not yet been established. One of the major limitations of interpreting the relevant literature is the wide variability in the definitions used for poor ovarian response. Regarding the interventions that have been proposed to improve the probability of pregnancy in poor responders, limited evidence from relevant randomized controlled trials suggests that addition of growth hormone during ovarian stimulation, as well as performing embryo transfer on day 2 instead of day 3, might be beneficial. Further randomized control trials are warranted to reliably determine which would be the best approach for treating poor ovarian response.

Interventions for 'poor responders' to controlled ovarian hyper stimulation (COH) in in-vitro fertilisation (IVF)

BACKGROUND

The success of in-vitro fertilisation (IVF) depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response.

OBJECTIVES

To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of IVF.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG) (5/1/2009), the Cochrane Central Register of Controlled trials (CENTRAL) (4th Quarter 2008), MEDLINE (1950 to November week 3 2008), EMBASE (1980 to 2008 week 52) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to clarify data that were unclear from the trial reports.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently scanned the abstracts, identified relevant papers, assessed trial quality and extracted relevant data for inclusion. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis.

MAIN RESULTS

The new search identified fifteen trials. Three trials were eligible for inclusion. Ten trials involving eight different comparison groups have been included. Only one trial reported live birth rates.The number of oocytes retrieved were significantly less in the conventional GnRHa long protocol compared to stop protocol and GnRH antagonist protocol.Total dose of gonadotrophins used was significantly higher in the GnRHa long protocol group compared to the Stop protocol and GnRH antagonist groups.Cancellation rates were significantly higher in the GnRHa flare up group compared to the GnRHa long protocol group.None of the studies reported a difference in the miscarriage and ectopic pregnancy rates.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the routine use of any particular intervention either for pituitary down regulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.

Pregnancies and live births following ICSI with testicular spermatozoa after repeated implantation failure using ejaculated spermatozoa

The use of testicular spermatozoa for IVF/intracytoplasmic sperm injection (ICSI) is currently indicated exclusively for patients with azoospermia, since a favourable outcome is expected even when very few spermatozoa are present in the ejaculate. Here, a series of four couples with long-standing male factor infertility and multiple failed IVF/ICSI cycles are described. In all couples, the use of ejaculated spermatozoa for ICSI resulted in poor embryo quality and repeated implantation failure. Testicular sperm aspiration was performed in subsequent cycles, and testicular spermatozoa were used for ICSI. Embryo implantation and ongoing pregnancies/deliveries were achieved in all four couples. It is postulated that spermatozoa are subjected to post-testicular damage during sperm transport between the seminiferous tubules and epididymis, with the injection of damaged spermatozoa being the cause for repetitive IVF/ICSI failures. In selected patients, the use of testicular spermatozoa for IVF/ICSI should be considered, even when motile spermatozoa can be identified in the ejaculate.

Embryo implantation rates in natural and stimulated assisted reproduction treatment cycles in poor responders

Controlled ovarian stimulation with exogenous gonadotrophins and gonadotrophin-releasing hormone (GnRH) analogues enables the collection of multiple oocytes and subsequent development of multiple embryos. However, interfering with the natural hormonal milieu may decrease the probability of successful embryo implantation due to effects on oocytes and/or endometrium. In order to provide a fair comparison of embryo implantation rates between natural cycles and stimulated cycles, bias caused by the presence of multiple embryos available for transfer in stimulated cycles should be avoided. This retrospective study analysed embryo implantation rates in cycles in which only a single embryo was available for transfer in 304 women who had poorly responded to ovarian stimulation in the previous cycle. Embryo implantation rates with different stimulation protocols were as follows: natural cycle, 20% (6/30); gonadotrophin only, 5.6% (3/54); long GnRH protocol, 3.8% (2/52); co-flare protocol, 1.9% (1/52); microdose flare-up, 15.4% (4/26); GnRH antagonists, 14.4% (13/90). Although the difference was not statistically significant there was a trend towards higher implantation rates with natural cycles in this group of women. Natural cycle IVF may be a reasonable and patient-friendly treatment choice yielding an acceptable outcome for women who are known or anticipated poor responders to ovarian stimulation.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

[Premature ovarian failure: which protocols?]

This review shows the results of the various studies concerning the protocols applied to the women presenting a premature ovarian failure. Will be thus analyzed the natural cycles (or semi-natural), the increase in the dose of gonadotrophins, the clomiphene citrate and the anti-aromatases, the protocols with GnRH agonists long, short, stop or microdoses, the protocols with GnRH antagonists and the adjuvant treatments: aspirin, nitric oxyde, recombinant LH recombining, growth hormone and androgens. The interest of several protocols is to collect a sufficient number of oocytes (and thus of embryos to be transferred), making it possible to obtain reasonable rates of pregnancy. However, it arises that the rates of pregnancy observed among these women depend not only on their ovarian reserve and their age, but are also function of the type of infertility, of the cycle number and the uterus.

How to improve the probability of pregnancy in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature to identify randomized controlled trials, which evaluate interventions aiming to improve the probability of pregnancy in poor responders undergoing in vitro fertilization (IVF).

DESIGN

Systematic review and meta-analysis.

SETTING

University-based hospital.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy rate.

RESULT(S)

Twenty-two eligible randomized controlled trials were identified that evaluated in total 15 interventions to increase pregnancy rates in poor responders. Based on limited evidence, the only interventions that appear to increase the probability of pregnancy were the addition of GH to ovarian stimulation (odds ratio for live birth: 5.22, confidence interval: 95% 1.09-24.99) and the performance of embryo transfer on day 2 compared with day 3 (ongoing pregnancy rate: 27.7% vs. 16.3%, respectively; difference: +11.4, 95% confidence interval: +1.6 to +21.0).

CONCLUSION(S)

Insufficient evidence exists to recommend most of the treatments proposed to improve pregnancy rates in poor responders. Currently, there is some evidence to suggest that addition of GH, as well as performing embryo transfer on day 2 versus day 3, appear to improve the probability of pregnancy.

Pituitary suppression regimens in poor responders undergoing IVF treatment: a systematic review and meta-analysis

Many randomized trials have evaluated the use of various pituitary suppression regimens to improve outcome of poor responders undergoing IVF treatment. A systematic review was conducted of the trials of gonadotrophin-releasing hormone (GnRH) agonist long regimen, GnRH agonist short regimen, GnRH antagonist regimen, as well as other pituitary suppression regimens in poor responders undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment. The search included MEDLINE, EMBASE, Cochrane Library, National Research Register and ISI proceedings, and all randomized controlled trials comparing the various pituitary suppression regimens in poor responders were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. The main outcome measures were number of oocytes retrieved, cycles cancelled before oocyte retrieval and pregnancy rates. A total of 680 women considered as poor responders undergoing IVF/ICSI treatment were included in nine randomized controlled trials. The quality of these studies was variable: for example, only three of the studies had clear evidence of allocation concealment. Meta-analyses of the results of the studies did not show a consistent benefit for any one pituitary suppression regimen over the other regimens in improving outcome measures. Currently available evidence does not favour any one pituitary suppression regimen for women with poor ovarian response undergoing IVF/ICSI treatment.

A three-arm randomised controlled trial comparing Gonadotrophin Releasing Hormone (GnRH) agonist long regimen versus GnRH agonist short regimen versus GnRH antagonist regimen in women with a history of poor ovarian response undergoing in vitro fertilisation (IVF) treatment: Poor responders intervention trial (PRINT)

BACKGROUND

Poor response to ovarian stimulation with exogenous gonadotrophins occurs in 9-24% of women undergoing in vitro fertilisation (IVF) treatment, which represents an estimated 4000-10,000 women per year in the UK. Poor responders often have their treatment cycle cancelled because of expected poor outcome.One treatment strategy that may influence outcome is the choice of pituitary suppression regimen prior to the initiation of ovarian stimulation. The three commonly used pituitary suppression regimens in IVF treatment are:(1) the GnRH agonist long regimen,(2) the GnRH agonist short regimen and(3) the GnRH antagonist regimen.A systematic review of randomised controlled trials of these pituitary suppression regimens has shown the evidence to be either inconclusive or inconsistent. We therefore designed a three arm randomised trial to evaluate the effectiveness of these regimens in women who had poor ovarian response in a previous IVF treatment cycle.

METHODS/DESIGN

Consenting, eligible women will be randomised to one of the three regimens using an internet-based trial management programme that ensures allocation concealment and employs block randomisation and minimisation for prognostic variables. The primary outcome is the number of oocytes retrieved. Other outcomes include total dose of follicle stimulating hormone (FSH) used for ovarian stimulation, mature oocytes retrieved, embryos available for transfer, implantation rate and clinical pregnancy rate.The sample size for this trial has been estimated as 102 participants with 34 participants in each of the three arms. Appropriate interim analysis will be conducted by a Data Monitoring and Ethics Committee (DMEC), and the final analysis will be by intention to treat.

TRIAL REGISTRATION

ISRCTN27044628.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Different ovarian stimulation protocols for women with diminished ovarian reserve

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A luteal estradiol protocol for expected poor-responders improves embryo number and quality

OBJECTIVE

To compare embryo and oocyte data between a standard protocol and a luteal phase estradiol protocol.

DESIGN

Retrospective paired cohort analysis.

SETTING

Private in vitro fertilization (IVF) center.

PATIENT(S)

60 poor-responder patients undergoing 120 IVF cycles.

INTERVENTION(S)

Addition of luteal estradiol to the standard IVF protocol.

MAIN OUTCOME MEASURE(S)

Number of embryos with > or = 7 cells on day 3 of development.

RESULT(S)

The luteal phase estradiol protocol showed a statistically significantly greater number of embryos with > or = 7 cells, oocytes retrieved, mature oocytes, and embryos than did the standard protocol. There was no difference between the two protocols with respect to basal antral follicle count, days of stimulation, number of follicles > or = 14 mm on day of surge, or endometrial thickness on day of surge. A trend toward improved pregnancy outcomes was found with the luteal estradiol protocol.

CONCLUSION(S)

Giving estradiol in the luteal phase preceding IVF hyperstimulation increases the number and the quality of embryos achieved in patients deemed to have a poor response to IVF. Ultimately, this may translate into improved pregnancy outcomes in these patients.

Interventions for 'poor responders' to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF)

BACKGROUND

The success of in-vitro fertilisation (IVF) treatment depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response.

OBJECTIVES

To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of in vitro fertilisation.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG), the Cochrane Central Register of Controlled trials (CENTRAL) (The Cochrane Library 2003, Issue 1), MEDLINE (1966 to August 2006), EMBASE (1980 to August 2006) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to identify or clarify data that were unclear from the trial reports.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned the abstracts, identified relevant papers, assessed inclusion and trial quality and extracted relevant data. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis.

MAIN RESULTS

Nine trials involving six different comparison groups have been included in this review. Only one trial reported live birth rates. Four groups compared the long protocol with another intervention. Only one comparison group (bromocryptine versus long protocol) reported a higher clinical pregnancy rate per cycle, in the bromocryptine arm (OR 5.60, 95% CI 1.40 to 22.47). Two comparison groups showed a lower number of oocytes in the long protocol group (versus stop and gonadotrophin releasing hormone (GnRH) antagonist protocols). However, two comparison groups also showed lower cancellation rates in the long protocol treatment group (versus stop and GnRHa flare-up protocols). None reported any evident difference in the adverse effects.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the routine use of any particular intervention either for pituitary downregulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.

Evaluation of the utility of multiple endocrine and ultrasound measures of ovarian reserve in the prediction of cycle cancellation in a high-risk IVF population

BACKGROUND

Unexpectedly poor response leading to IVF cycle cancellation is a distressing treatment outcome. We have prospectively assessed several markers of ovarian reserve in a high risk IVF population to determine their utility in predicting IVF cycle cancellation.

METHODS

Eighty-four women at high risk of cycle cancellation due to raised FSH, previous poor response and/or age > or =40 years attending for high-dose short protocol IVF treatment had baseline measures of FSH, inhibin B, anti-Müllerian hormone (AMH), antral follicle count (AFC) and ovarian volume. A GnRH agonist was then administered and, 24 h later, estradiol (E(2)) and inhibin B measures were repeated.

RESULTS

Fifty-seven per cent of patients in this study had a poor response to stimulation, and 15% were cancelled. Using multivariate logistic regression, we found that day 3 inhibin B levels were the best predictor of cycle cancellation with an area under the receiver operating curve (ROC AUC) = 0.78 (P = 0.017). When only considering baseline variables, mean ovarian volume was the best predictor of cycle cancellation (ROC AUC = 0.78; P = 0.016). AMH concentrations were the best predictor of a poor response (P = 0.003), and AMH was also predictive of cycle cancellation (P = 0.007) with very little inter-cycle variability. None of the parameters studied were predictive of ongoing pregnancy.

CONCLUSIONS

This group of at-risk patients had a high rate of poor response to simulation and cancellation. Although several measures of ovarian reserve were able to predict cycle cancellation, none were able to predict pregnancy. AMH was predictive of both cycle cancellation and poor response with little inter-cycle variability.

Clinical and biological parameters influencing implantation: score to determine number of embryos to transfer

Choosing the number of embryos to be transferred is a major problem in assisted reproductive technologies. This study aimed to establish and validate a score predicting implantation rates in order to help in the choice of the number of embryos to be transferred, allowing the best compromise between high pregnancy rate and low multiple pregnancy risk. Clinical and biological parameters influencing implantation rates were retrospectively analysed in 739 embryo transfers and an implantation score was established. This score was then prospectively validated in 521 embryo transfers. Three parameters (age, ovarian response to FSH stimulation and embryo morphology) appeared to be predictive of the implantation rates and were included in an implantation score (3-9). The prospective study confirmed the validity of the score since implantation rates were higher when the score increased (5.9% for score 3 versus 22.4% for score 9; P < 0.05). Therefore, success rates can be predicted by the implantation score, which is of clinical value in choosing the number of embryos to be transferred in order to decrease multiple pregnancies while keeping high pregnancy rates. However, choosing the right number of embryos to be transferred needs further studies, since the percentage of multiple pregnancies remained relatively high in this prospective study (27%).

A comparison of three downregulation approaches for poor responders undergoing in vitro fertilization

OBJECTIVE

To assess the efficacy of three different GnRH agonist (GnRH-a) stimulation regimens to improve ovarian response in poor responders undergoing IVF.

DESIGN

Retrospective cohort study.

SETTING

Center for Reproductive Health at the University of Cincinnati Medical Center.

PATIENT(S)

Women diagnosed as poor responders who presented consecutively from January 1999 to January 2004.

INTERVENTION(S)

Patients underwent three different stimulation regimens during IVF cycles: [1] stop protocol: GnRH-a 500 microg/d administered from the midluteal phase to the start of menses, then gonadotropins from day 2 of cycle, [2] microdose flare: GnRH-a 20 microg administered twice daily with gonadotropins from day 2 to the day of hCG administration, or [3] regular dose flare: gonadotropins beginning with GnRH-a on day 2 at 1 mg/d for 3 days, followed by 250 microg/d until the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Ovarian response, implantation rates, clinical pregnancy and delivery rates.

RESULT(S)

Sixty-one IVF cycles were included in the study. None of the comparisons reached statistical significance; however, the microdose group demonstrated a trend toward a higher completed pregnancy rate.

CONCLUSION(S)

The microdose flare protocol for poor responders demonstrated a trend toward higher delivery rates. A larger prospective study would need to be performed to determine whether this trend leads to a significant finding in this patient population.

Abdominal ultrasound-guided embryo transfer improves clinical pregnancy rates after in vitro fertilization: experiences from 330 clinical investigations

PURPOSE

To investigate the effect of ultrasound-guided embryo transfer on the rate of implantation and clinical pregnancy.

METHODS

A prospective randomized trial was performed to compare ultrasound-guided embryo transfer with the traditional method. A total of 330 patients were randomly divided into two groups on the day of embryo transfer. For the cases (n = 178), ultrasound-guided was used; controls (n = 152) was performed using routine methods.

RESULTS

The rate of implantation and clinical pregnancy for the cases (19.6 and 37.1%, respectively) was significantly higher than for the controls (12.6 and 25%, respectively; p < 0.05).

CONCLUSION

Ultrasound-guided embryo transfer can significantly increase the rate of implantation and clinical pregnancy, and should be recommended as a routine procedure in the process of in vitro fertilization and embryo transfer (IVF-ET).

Role of the nonhuman primate for research related to women's health

This overview of the current status of medical problems that affect women is related to current studies on pathophysiology and therapeutic interventions using nonhuman primates to demonstrate the utility of the primate model for the study of disease processes in women. The current medical literature on women's health is compared with the literature on nonhuman primate research. The findings reviewed in the articles of ILAR Journal Volume 45 Issue 2 of 2004 are evaluated in the context of the scope and problems associated with disease entities in women. Nonhuman primate research with known information regarding women's disease is discussed, and the utility of the animal model for the study of human disease is highlighted, based on its significant relevance due to similarities of nonhuman primate and human subjects' physiology, metabolism, and responses to therapeutic interventions. Additional advantages of the animal model include the ability to control the experimental environment and the capacity to perform chronic study procedures. These findings allow us to utilize the nonhuman primate as the most relevant model in the animal world for the study of human disease processes.