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Xu X, Yang A, Han Y, Li S, Wang W, Hao G, Cui N. Nonlinear relationship between gonadotropin total dose applied and live birth rates in non-PCOS patients: a retrospective cohort study. Sci Rep 2024; 14:1462. [PMID: 38233530 PMCID: PMC10794227 DOI: 10.1038/s41598-024-51991-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
The purpose of this article is to explore the relationship between the total dose of follicle-stimulating hormone (FSH) applied during controlled ovulation stimulation and the live birth rates (LBRs) in non-PCOS population. Many studies have found no difference between the dose of FSH application and pregnancy outcomes such as clinical pregnancy rates after fresh embryo transfer. However, a recent large retrospective analysis found a negative correlation between live birth rates and increasing dose of FSH. It is still controversial about the association between FSH dose and LBRs. In addition, no studies have yet explored the nonlinear relationship between FSH and LBRs. This cohort study included a total of 11,645 patients who had accepted IVF/intracytoplasmic sperm injection (ICSI) at the second hospital of Hebei medical university between December 2014 to December 2019. PCOS was identified by Rotterdam PCOS criteria. We researched the association between FSH total dose and live birth rates (LBRs) using multivariate regression analysis. In addition, a model for nonlinear relationships based on a two-part linear regression was applied. The analysis of threshold effects indicated that LBR increased with every 1000 IU FSH when the concentration of FSH was lower than 1410 IU (OR 1.55, 95% CI [1.05, 2.28]); however, a negative association between FSH dose and LBR (OR 0.94, 95% CI [0.89, 0.99]) was found when the FSH total dose was higher than 1410 IU. It is worth noting that the relationship between LBR and FSH dose varied among patients of different ages (OR 0.92 vs 1.06, P for interaction < 0.05).
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Affiliation(s)
- Xiaoyuan Xu
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Aimin Yang
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Yan Han
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Siran Li
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Wei Wang
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Guimin Hao
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Na Cui
- Hebei Key Laboratory of Infertility and Genetics, Department of Reproductive Medicine, Hebei Clinical Research Center for Birth Defects, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China.
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Orvieto R, Aizer A, Saar-Ryss B, Marom-Haham L, Noach-Hirsh M, Haas J, Nahum R. Elective egg freezing patients may benefit from increasing the maximal daily gonadotropin dose above 300IU. Reprod Biol Endocrinol 2022; 20:171. [PMID: 36536380 PMCID: PMC9762009 DOI: 10.1186/s12958-022-01049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Nowadays, patients attempting social/elective egg freezing has spread globally. Ovarian stimulation (OS) with high daily gonatotropin doses, are commonly offered to this group of patients, aiming to achieve the maximal oocytes cohort with minimum IVF cycle attempts. We aim to assess the IVF-ET outcome, and specifically the oocyte yield, of patients undergoing two successive IVF cycle attempts for elective egg freezing (EEF), and whether changing the daily gonadotropin dose in the second IVF cycle attempt, affect the outcome. PATIENTS AND METHODS All women admitted to our IVF unit for social/EEF, who underwent 2 consecutive IVF cycle attempts, with only those who used in the first attempt a starting daily gonadotropin dose of 300 IU were included. Ovarian stimulation characteristics, duration of OS, number of retrieved oocytes, number of mature oocytes were assessed and compared between the 1st and the 2nd IVF cycle attempts, and between the different daily gonadotropin doses and the oocyte yields in the 2nd cycle attempt (increase, decrease or no change). MAIN OUTCOME MEASURES Oocytes and mature oocytes yield in the 2nd as compared to the 1st IVF cycle attempt. RESULTS A reduced oocyte yield in the 2nd cycle attempt was observed in those who highly responded in the 1st attempt, regardless the daily dose in the 2nd cycle attempt (whether it was increased, no change and decreased). Moreover, the proportion of patients with same or more oocytes in the 2nd IVF cycle attempt was significantly lower in patients with high peak E2 levels, compared to those with peak E2 levels < 9175 pmol/L. Among patients with high peak E2 (> 9175 pmol/L), those who achieved a lower oocytes yield in the 2nd IVF cycle attempt had lower basal Day-3 FSH/LH ratio (1.5 + 0.5 vs 1.8 + 0.8, p < 0.03) and higher oocyte (range: 7-28, median:10; vs range: 2-15, median:7) and mature oocytes yields. With a cut-off of 9 oocytes, 78.8% of those with > 9 oocytes and 61.8% of those with < 9 oocytes will achieve lower/higher oocytes yield in the 2nd IVF cycle attempt, respectively. CONCLUSIONS Ovarian stimulation with high daily gonatotropin doses (300 IU) should be offered to patients attempting social/EEF. Moreover, in their 2nd IVF cycle attempt, those with high peak E2 (> 9175 pmol/L) in the 1st attempt, and basal Day-3 FSH/LH ratio < 1.5 and/or more than 9 oocytes retrieved, should receive same OS protocol with no change in the daily gonadotropin dose.
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Affiliation(s)
- Raoul Orvieto
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- grid.12136.370000 0004 1937 0546The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Adva Aizer
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Bozhena Saar-Ryss
- grid.414259.f0000 0004 0458 6520Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon, and Ben Gurion University School of Medicine, Beer Sheva, Israel
| | - Lilach Marom-Haham
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Meirav Noach-Hirsh
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jigal Haas
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ravit Nahum
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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Comparison of the luteal phase estradiol priming stimulation and standard antagonist protocols in patients with diminished ovarian reserve undergoing ICSI. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1026448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Shrem G, Salmon-Divon M, Mahfoudh AM, Balayla J, Volodarsky-Perel A, Henderson S, Zeadna A, Son WY, Steiner N, Dahan MH. Influence of Maternal Age and Ovarian Reserve on the Decision to Continue or to Cancel IVF Cycles in Patients with One or Two Large Follicles: a Dual Effect. Reprod Sci 2022; 29:291-300. [PMID: 34115367 DOI: 10.1007/s43032-021-00649-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/30/2021] [Indexed: 10/21/2022]
Abstract
This study aimed to study whether IVF stimulation that results in one or two mature follicles should proceed to oocyte retrieval. This is a retrospective cohort study conducted at McGill University Health Center on 459 patients who underwent IVF treatment between 2011 and 2014, undergoing hormonal stimulation and monitoring of their ovarian response. The primary outcomes were pregnancy and live birth rates. Statistical modeling was used to determine individual roles of patient age and ovarian reserve on outcomes, while controlling for the other factors. Of the 459 cycles included in the study, 360 cycles (78.4%) ended in embryo transfer. Live birth rates per cycle were 15.6%, for the ≤ 34-year-olds; 6.5%, for the 35-39-year-olds; and 2.7%, for the ≥ 40-year-olds (p < 0.01). Twenty-five percent of the cycles in the ≥ 40-year-old group were canceled versus 17% and 15% in the 35-39-year-old and ≤ 34-year-old groups, respectively (p < 0.05). Testing likelihood of live birth as a function of age and antral follicular count (AFC) revealed that a 1-year increase in age reduces the likelihood of live birth by 11% (p < 0.05) and one-unit increase in AFC count leads to a 9% increase in the odds of a live birth (p < 0.05). For the youngest age group, the AFC had a most significant effect, and those with AFC > 11 had 56% live birth rate, while those with AFC ≤ 11 had only 6% of live birth rate. This study supports a shift in reasoning from age being the predictor of outcomes in women with a low response at IVF to both age and ovarian reserve needing to be taken into consideration.
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Affiliation(s)
- Guy Shrem
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, 845 Rue Sherbrooke O, Montréal, H3A 0G4, Canada.
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada.
- Department of Obstetrics and Gynecology, IVF Unit, Kaplan Medical Center, Rehovot, Israel.
| | - Mali Salmon-Divon
- Department of Molecular Biology, Ariel University, 40700, Ariel, Israel.
- Adelson School of Medicine, Ariel University, Ariel, Israel.
| | - Alina M Mahfoudh
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada
| | - Jacques Balayla
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, 845 Rue Sherbrooke O, Montréal, H3A 0G4, Canada
| | - Alexander Volodarsky-Perel
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, 845 Rue Sherbrooke O, Montréal, H3A 0G4, Canada
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Sara Henderson
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada
| | - Atif Zeadna
- Ben-Gurion University of the Negev, Medicine, Southern, Beer-Sheva, Israel
| | - Weon-Young Son
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada
| | - Naama Steiner
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, 845 Rue Sherbrooke O, Montréal, H3A 0G4, Canada
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada
- Ben-Gurion University of the Negev, Medicine, Southern, Beer-Sheva, Israel
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, 845 Rue Sherbrooke O, Montréal, H3A 0G4, Canada
- MUHC Reproductive Center, McGill University, Montréal, QC, H2L 4S8, Canada
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Clark ZL, Thakur M, Leach RE, Ireland JJ. FSH dose is negatively correlated with number of oocytes retrieved: analysis of a data set with ~650,000 ART cycles that previously identified an inverse relationship between FSH dose and live birth rate. J Assist Reprod Genet 2021; 38:1787-1797. [PMID: 33834326 PMCID: PMC8324604 DOI: 10.1007/s10815-021-02179-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/28/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate whether total FSH dose was negatively correlated with number of oocytes retrieved in a large data set where previously, a negative correlation between FSH dose and live birth rate was identified. METHODS Data from 650,637 fresh autologous in vitro fertilization (IVF) cycles reported to the Society for Assisted Reproductive Technology between 2004 and 2012 were included. Logistic regression analysis was performed to determine if the relationship between total FSH dose used during ART with number of oocytes retrieved was impacted by the patient's health prognosis, age, BMI, ovarian stimulation protocol, or infertility diagnosis. RESULTS The number of oocytes retrieved was negatively correlated with FSH dose (P < 0.0001). Regardless of patient prognosis, age, BMI, ovarian stimulation protocol, and infertility diagnosis, the highest number of oocytes retrieved was in the 1001-2000 IU FSH group, and was 36-51% lower in the > 5000 IU compared with the optimal, 1001-2000 IU, FSH groups. Overall, ~80% of patients received FSH doses outside of the optimal FSH dose. Moreover, 61% of good prognosis patients (excludes individuals likely prescribed higher FSH doses) received doses exceeding the optimal dose range. CONCLUSION The inverse relationship between FSH dose and the number of oocytes retrieved independent of patient age or health implies that excessive FSH doses during ART may be detrimental to oocyte retrieval.
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Affiliation(s)
- Zaramasina L Clark
- Molecular Reproductive Endocrinology Laboratory, Department of Animal Science, Michigan State University, East Lansing, MI, USA
- Present address: School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Mili Thakur
- Reproductive Genomics Program, The Fertility Center, Grand Rapids, MI, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Department of Obstetrics, Gynecology and Women's Health, Spectrum Health Medical Group, Michigan State University, Grand Rapids, MI, USA
| | - Richard E Leach
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Department of Obstetrics, Gynecology and Women's Health, Spectrum Health Medical Group, Michigan State University, Grand Rapids, MI, USA
| | - James J Ireland
- Molecular Reproductive Endocrinology Laboratory, Department of Animal Science, Michigan State University, East Lansing, MI, USA.
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Qin Y. Effects of using letrozole in combination with the GnRH antagonist protocol for patients with poor ovarian response: A meta-analysis. J Gynecol Obstet Hum Reprod 2021; 50:102139. [PMID: 33838300 DOI: 10.1016/j.jogoh.2021.102139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 12/29/2020] [Accepted: 04/05/2021] [Indexed: 12/09/2022]
Abstract
This meta-analysis aimed to compare the outcomes of the gonadotrophin-releasing hormone (GnRH) antagonist/letrozole protocol with those of the conventional GnRH antagonist protocol for poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). We searched for relevant articles in PubMed, EMBASE, Google Scholar, and retrieved 452 records. Eventually, we selected five eligible trials with data for 564 patients characterized as poor ovarian responders. Our meta-analysis revealed that the clinical pregnancy rate (per cycle) with administration of letrozole might be a higher than that in the control groups (risk rate [RR]: 1.57, 95% confidence interval [CI]: 1.00-2.44, p = 0.05). .Moreover,it indicated that the total dose of gonadotrophin was significantly decreased with the administration of letrozole compared to control groups(mean difference [MD]: -529.37, 95% CI: -1207.45 to -111.25, p = 0.001),.However, there was no statistical difference in the number of retrieved oocytes(MD: 0.59, 95% CI: -0.36-1.54, p = 0.22), cycle cancelation rate (RR: 0.81, 95% CI: 0.58-1.12, p = 0.20), or estradiol concentration on the day of HCG administration(MD: -28.19, 95% CI: -77.71-21.33, p = 0.26) in the presence or absence of letrozole combination in the GnRH antagonist protocol. In conclusion, letrozole administration might improve clinical pregnancy rate in conventional GnRH antagonist protocol for poor responders. Moreover, letrozole co-treatment aslo can reduce the economic burden of poor responders during the GnRH antagonist cycle. Nevertheless, large-scale and multi-center randomized controlled trials are needed to further evaluate the efficacy of adjunctive letrozole administration in the GnRH antagonist protocol.
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Affiliation(s)
- Ying Qin
- Reproductive Medicine Center, Guangzhou Women and Children's Medical Center, No. 9 Jinsui Road, Guangzhou, Guangdong, 510120, China.
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Papamentzelopoulou M, Stavros S, Mavrogianni D, Kalantzis C, Loutradis D, Drakakis P. Meta-analysis of GnRH-antagonists versus GnRH-agonists in poor responder protocols. Arch Gynecol Obstet 2021; 304:547-557. [PMID: 33423109 DOI: 10.1007/s00404-020-05954-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Considering the insufficient evidence supporting an ideal protocol for poor responder management in IVF/ICSI cycles, the aim of the current meta-analysis was to compare GnRH-antagonist versus GnRH-agonist protocols in poor responders, evaluating effectiveness and safety. METHODS Meta-analysis was conducted using Medcalc 16.8 version software. Standardized mean differences (SMD), odds ratios (OR), and the respective 95% confidence intervals (CI) were determined appropriately. The Cochran Q statistic and the I2 test were used to assess studies' heterogeneity. RESULTS GnRH-agonists were shown to correlate with fewer cancelled IVF/ICSI cycles (p = 0.044, OR = 1.268 > 1, 95% CI 1.007, 1.598), a larger number of embryos transferred (p = 0.008, SMD = - 0.230, 95% CI - 0.400, - 0.0599), and more clinical pregnancies (p = 0.018, OR = 0.748 < 1, 95% CI 0.588, 0.952). However, GnRH-antagonists resulted in a significantly shorter duration of ovarian stimulation (p = 0.007, SMD = - 0.426. 95% CI - 0.736, - 0.115). The number of oocytes and mature oocytes retrieved in both protocols did not differ statistically (p = 0.216, SMD = - 0.130, 95% CI - 0.337, 0.0763 and p = 0.807, SMD = - 0.0203, 95% CI - 0.183, 0.142, respectively). Moreover, a high heterogeneity among studies was observed regarding duration of ovarian stimulation (I2 = 90.6%), number of oocytes (I2 = 82.83%)/mature oocytes retrieved (I2 = 70.39%), and embryos transferred (I2 = 72.83%). CONCLUSIONS Based on the present meta-analysis, agonist protocols could be suggested as a first choice approach, in terms of effectiveness. Due to the high studies' heterogeneity, results should be considered with caution. Accordingly, larger cohort studies and meta-analyses like the present one will enhance the robustness of the emerging results to identify the ideal protocol for poor responders.
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Affiliation(s)
- Myrto Papamentzelopoulou
- Molecular Biology Unit, Division of Human Reproduction, 1st Department of Obstetrics and Gynecology, 'Alexandra' General Hospital, National and Kapodistrian University of Athens, 80, Vasilissis Sofias Ave, 11528, Athens, Greece.
| | - Sofoklis Stavros
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Despoina Mavrogianni
- Molecular Biology Unit, Division of Human Reproduction, 1st Department of Obstetrics and Gynecology, 'Alexandra' General Hospital, National and Kapodistrian University of Athens, 80, Vasilissis Sofias Ave, 11528, Athens, Greece
| | - Christos Kalantzis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros Drakakis
- Molecular Biology Unit, Division of Human Reproduction, 1st Department of Obstetrics and Gynecology, 'Alexandra' General Hospital, National and Kapodistrian University of Athens, 80, Vasilissis Sofias Ave, 11528, Athens, Greece.,1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Athens, Greece
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Le H, Nguyen DD, Cao AT, Nguyen HTL, Tham DC, Le TD, Hugues JN. Comparative Effectiveness of Mild or Conventional GnRH-Antagonist Protocols for Ovarian Stimulation in Poor Responders (Poseidon Group 4). FRONTIERS IN REPRODUCTIVE HEALTH 2020; 2:606036. [DOI: 10.3389/frph.2020.606036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: A panel of experts (the Poseidon Group) introduced a new and more detailed stratification for poor ovarian responders in order to predict the prognosis of IVF outcome according to the sensitivity to FSH. However, various arguments about the management strategy of these patients still remain, including the convenience and the cost. Therefore, this study was conducted to compare the efficacy of mild and conventional GnRH antagonist ovarian stimulation prescribed in patients classified in Poseidon Group 4.Methods: This retrospective cohort study included 359 poor responder patients (Poseidon Group 4) treated with mild or conventional GnRH antagonist stimulation regimens from 8/2017 to 7/2019 at Tam Anh Hospital ART Center. The main outcomes were the index of Follicular Output Rate (FORT) or Follicle to Oocyte Index (FOI), the number of day-2 embryos and top-quality embryos obtained. The t-test and Mann–Whitney U test in SPSS v25.0 was used to analyze the continuous data and Chi-squared/Exact test was used for binary variables. Multiple linear regression analysis was done by using Stata versions 15.0 to measure association between primary endpoints with stimulation regimen controlled for covariates and possible confounding factors.Results: In the overall group of poor responders, the conventional GnRH antagonist protocol performed better than the mild protocol. Subsequently, data were analyzed according to the AFC. In women with AFC < 3, no significant differences were observed between the 2 regimens regarding FORT (p = 0.71), FOI (p = 0.12), the number of day-2-embryos (p = 0.052) and the number of top-quality embryos (p = 0.26). In contrast, in women with AFC ≥ 3, mild stimulation regimen resulted in significantly poorer outcome compared to the conventional GnRH antagonist regimen, regarding FORT (p < 0.01), FOI (p < 0.01), the number of day-2-embryos (p < 0.01) and top-quality embryos (p = 0.01).Conclusions: Considering poor responders classified in Poseidon Group 4, both ovarian stimulation regimens resulted in similar outcome for patients with a very low ovarian reserve (AFC < 3). In contrast, the GnRH conventional antagonist protocol with maximum initial FSH dose (300–375 IU/day) and supplementary LH (75–150 IU/day) was more effective than the mild one for patients whose ovarian reserve was less reduced. The Clinical Trial was approved by the Ethnical Biomedical Research Committee Tam Anh General Hospital.
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Abrahami N, Izhaki I, Younis JS. Do young women with unexplained infertility show manifestations of decreased ovarian reserve? J Assist Reprod Genet 2019; 36:1143-1152. [PMID: 31115740 DOI: 10.1007/s10815-019-01467-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/28/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Noa Abrahami
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Reproductive Medicine Unit, Department of Obstetrics & Gynecology, Baruch-Padeh Medical Center, Poriya, Israel
| | - Ido Izhaki
- Department of Evolutionary and Environmental Biology, University of Haifa, Haifa, Israel
| | - Johnny S Younis
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel. .,Reproductive Medicine Unit, Department of Obstetrics & Gynecology, Baruch-Padeh Medical Center, Poriya, Israel.
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Abstract
PURPOSE OF REVIEW The management and treatment of patients with poor ovarian response is still a controversial issue in IVF. Increasing evidences demonstrate that the number of oocytes retrieved after a controlled ovarian stimulation (COS) greatly influences the clinical outcome in terms of cumulative live birth per started cycle. For this reason, any COS should aim to optimize the number of oocytes according to the ovarian reserve of the patient. The aim of this review is to provide an overview of new strategies proposed to manage poor responders according to the novel POSEIDON classification. RECENT FINDINGS Gonadotrophins cannot compensate for the absence of follicles in the ovary, therefore, COS in poor responders may benefit from the exploitation of multiple follicular waves within a single ovarian cycle, for instance, through luteal phase stimulation or double stimulation (follicular plus luteal) in the same ovarian cycle (DuoStim) protocols. SUMMARY Many strategies have been proposed to manage poor responder patients, however, a consensus upon which is the most beneficial has not been yet reached. DuoStim is the most promising approach to increase the number of oocytes collected in a single ovarian cycle; however, more embryological and clinical data is required, as well as an analysis of its cost-effectiveness.
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Lin MH, Wu FSY, Hwu YM, Lee RKK, Li RS, Li SH. Dual trigger with gonadotropin releasing hormone agonist and human chorionic gonadotropin significantly improves live birth rate for women with diminished ovarian reserve. Reprod Biol Endocrinol 2019; 17:7. [PMID: 30609935 PMCID: PMC6320621 DOI: 10.1186/s12958-018-0451-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/27/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diminished ovarian reserve (DOR) remains one of the greatest obstacles affecting the chance of a successful live birth after fertility treatment. The present study was set to investigate whether using a "dual trigger" consisted of human chorionic gonadotropin (hCG) plus gonadotropin releasing hormone agonist (GnRH-a) for final oocyte maturation could improve the IVF cycle outcomes for patients with diminished ovarian reserve. METHODS A total of 427 completed GnRH-antagonist downregulated IVF cycles with fresh embryo transfer (ET) were included in this retrospective analysis. DOR was defined as antral follicle count ≤5 and serum anti-Müllerian hormone level ≤ 1.1 ng/mL. The control group (n = 130) used a 6500 IU of recombinant hCG for trigger, and the study group (n = 297) used 0.2 mg of triptorelin plus 6500 IU of recombinant hCG for trigger. RESULTS The dual-trigger group had significantly higher oocyte fertilization rate (73.1% vs. 58.6%), clinical pregnancy rate (33.0% vs. 20.7%) and live birth rate (26.9% vs. 14.5%) when compared to the hCG trigger group. In addition, the abortion rate (17.4% vs. 37.0%) and embryo transfer cancellation rate (6.1% vs. 15.4%) were both significantly lower in the dual trigger group. The primary outcome measure was the live birth rate per oocyte retrieval cycle. Secondary outcome measures were embryo transfer cancellation rate, clinical pregnancy rate, implantation rate, chemical pregnancy rate and abortion rate per oocyte retrieval cycle. CONCLUSIONS Dual triggering the final oocyte maturation with GnRH-a and standard dose of hCG can significantly improve the live birth rate, clinical pregnancy rate, and fertilization rate in women with diminished ovarian reserve undergoing GnRH antagonist down-regulated IVF-ICSI cycles.
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Affiliation(s)
- Ming-Huei Lin
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
- 0000 0004 1762 5613grid.452449.aMackay Medical College, New Taipei City, Taiwan
| | - Frank Shao-Ying Wu
- IHMED Fertility Clinic, Taipei, Taiwan
- Taipei City Hospital, Heping-Fuyou Branch, Taipei, Taiwan
| | - Yuh-Ming Hwu
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
- 0000 0004 1762 5613grid.452449.aMackay Medical College, New Taipei City, Taiwan
| | - Robert Kuo-Kuang Lee
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0000 9337 0481grid.412896.0Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan
| | - Ryh-Sheng Li
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Sheng-Hsiang Li
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
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Ochin H, Ma X, Wang L, Li X, Song J, Meng Y, Shen J, Cui YG, Liu J. Low dose clomiphene citrate as a mild stimulation protocol in women with unsuspected poor in vitro fertilization result can generate more oocytes with optimal cumulative pregnancy rate. J Ovarian Res 2018; 11:37. [PMID: 29728130 PMCID: PMC5934891 DOI: 10.1186/s13048-018-0408-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of long protocol during controlled ovarian stimulation for assisted reproduction attracts high dosage of gonadotropins. High dose of gonadotropins can be detrimental to oocyte development, which affects its quality and compromises the treatment outcome. Mild stimulation protocols that attract low dose gonadotropins could be useful alternative regimen to address such problems. This study evaluated the efficacy of low dose clomiphene citrate based protocol plus low dose gonadotropins on predicted normal responder patients who had unsuspected poor in vitro fertilization (IVF) result, following an initial stimulation with long gonadotropin-releasing hormone (GnRH) agonist protocol. METHODS This a retrospective study of 65 infertile women who underwent 130 cycles in our center from January 2011 to December 2014. The initial IVF cycle (Group 1) was treated with long GnRH-a protocol plus a high dose of gonadotropins (≥150 IU/d), while second IVF cycle (Group 2) had low dose clomiphene citrate based protocol plus low dose gonadotropins (75-112.5 IU/d). RESULTS The rate of cumulative pregnancy/started cycle (9.2% [6/65] vs. 51% [33/65]; P < 0001) was significantly better in CC protocol than the long GnRH agonist protocol. The number of oocytes retrieved was also higher in CC protocol compared to the long protocol (7.26 ± 1.95 vs. 5.98 ± 1.31; P = 0.03). There was a lower number of patients without embryos (12.31% vs. 33.85%; p < 0.0001) in CC protocol than long protocol. CONCLUSIONS This study showed a better cumulative pregnancy rate in the low dose CC based protocol. There was a higher number of oocytes retrieved after using a lower total dose of recombinant FSH in CC protocol. Thus, clomiphene treatment plus low dose rFSH can be an alternative option for such patients in second cycle stimulation instead of repeating long protocol regimen. Randomized controlled studies with larger number of patients will be needed for more accurate evidence.
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Affiliation(s)
- Humphrey Ochin
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Xiang Ma
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Lin Wang
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Xuan Li
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Jie Song
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Yan Meng
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Jiandong Shen
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Yu-Gui Cui
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China
| | - Jiayin Liu
- Clinical Center for Reproductive Medicine, 300 Guangzhou Road. First Affiliated Hospital of Nanjing Medical University, 210029, The State Key Laboratory of Reproductive Medicine., Nanjing, People's Republic of China.
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13
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van Tilborg TC, Torrance HL, Oudshoorn SC, Eijkemans MJC, Koks CAM, Verhoeve HR, Nap AW, Scheffer GJ, Manger AP, Schoot BC, Sluijmer AV, Verhoeff A, Groen H, Laven JSE, Mol BWJ, Broekmans FJM, van Tilborg TC, Oudshoorn SC, Eijkemans MJC, Mochtar MH, Koks CAM, van Golde RJT, Verhoeve HR, Nap AW, Scheffer GJ, Manger AP, Hoek A, Schoot BC, Oosterhuis GJE, Kuchenbecker WKH, Fleischer K, de Bruin JP, Sluijmer AV, Friederich J, Verhoeff A, van Hooff MHA, van Santbrink EJP, Brinkhuis EA, Smeenk JMJ, Kwee J, de Koning CH, Groen H, van Wely M, Lambalk CB, Laven JSE, Mol BWJ, Broekmans FJM, Torrance HL. Individualized versus standard FSH dosing in women starting IVF/ICSI: an RCT. Part 1: The predicted poor responder. Hum Reprod 2017; 32:2496-2505. [DOI: 10.1093/humrep/dex318] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 10/13/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Theodora C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Simone C Oudshoorn
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marinus J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Carolien A M Koks
- Department of Obstetrics and Gynaecology, Maxima Medical Centre Veldhoven, PO Box 7777, 5500 MB Veldhoven, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis Oost, PO Box 95500, 1190 HM Amsterdam, The Netherlands
| | - Annemiek W Nap
- Department of Reproductive Medicine, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands
| | - Gabrielle J Scheffer
- Department of Obstetrics and Gynaecology, Gelre Hospital, PO Box 9014, 7300 DS Apeldoorn, The Netherlands
| | - A Petra Manger
- Department of Obstetrics and Gynaecology, Diakonessenhuis, PO Box 80250, 3508 TG Utrecht, The Netherlands
| | - Benedictus C Schoot
- Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, PO Box 1350, 5602 ZA Eindhoven, The Netherlands
- Department of Obstetrics and Gynaecology, University Hospital Gent, 9000 Gent, Belgium
| | - Alexander V Sluijmer
- Department of Gynaecology, Wilhelmina Hospital, PO Box 30001, 9400 RA Assen, The Netherlands
| | - Arie Verhoeff
- Department of Gynaecology, Maasstad Hospital, PO Box 9100, 3007 AC Rotterdam, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Joop S E Laven
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Ben Willem J Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, SA 5006 Adelaide, Australia
- The South Australian Health and Medical Research Unit, PO Box 11060, SA 5001 Adelaide, Australia
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Kutlu T, Özkaya E, Kumru P, Ayvacı H, Devranoğlu B, Sanverdi İ, Şahin Y, Sağlam B, Karateke A. Clinical analyses of successful and previously failed intracytoplasmic sperm injection cycle parameters in patients with poor ovarian reserve. Turk J Obstet Gynecol 2017; 14:58-63. [PMID: 28913136 PMCID: PMC5558319 DOI: 10.4274/tjod.04382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/15/2017] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine some major characteristic differences between two consecutive successful and unsuccessful intracytoplasmic sperm injection (ICSI) cycles in poor responders. Materials and Methods: Sixty women with poor ovarian response as determined using the Bologna criteria underwent ICSI cycles following an unsuccessful trial. Some parameters of both cycles including age, body mass index (BMI), serum follicle-stimulating hormone (FSH) and estradiol levels, antral follicle count, gonadotropin dosage, duration of stimulation, antagonist starting day, duration of antagonist administration, endometrial thickness at trigger day, number of total and fertilized oocytes, embryo transfer day, number of embryo cells, and fertilization rate were compared in the same patients to identify predictors of cycles with clinical pregnancy. Results: The mean age, BMI, serum FSH, estradiol concentrations, and antral follicle count were 35.9 years (range, 30-42 years), 25.9 kg/m2 (range, 18.4-33.5 kg/m2), 10.9 IU/mL (range, 7-13 IU/mL), 52.9 pg/mL (range, 11.6-75 pg/mL), and 4.7 (range, 2-10), respectively. A comparison of cycle characteristics showed a significantly higher total number of mature and fertilized oocytes in successful cycles. The fertilization rate was also significantly higher in cycles with clinical pregnancy. Early initiation of antagonist was shown to result in favorable outcomes. A comparison of embryo characteristics showed that transfer of higher-stage embryos and embryos with higher numbers of cells had a significant impact on cycle outcomes. Conclusion: Our comparison of parameters of failed and successful ICSI cycles in poor responders revealed significantly earlier antagonist initiation, higher total number of mature and fertilized oocytes, fertilization rate, and significantly higher stage of embryo development and cell numbers at transfer in cycles that resulted in clinical pregnancy.
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Affiliation(s)
- Tayfun Kutlu
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Enis Özkaya
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Pınar Kumru
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Habibe Ayvacı
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Belgin Devranoğlu
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - İlhan Sanverdi
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Yavuz Şahin
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Beyhan Sağlam
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ateş Karateke
- Zeynep Kamil Maternity and Children's Health Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
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Friedler S, Meltzer S, Saar-Ryss B, Rabinson J, Lazer T, Liberty G. An upper limit of gonadotropin dose in patients undergoing ART should be advocated. Gynecol Endocrinol 2016; 32:965-969. [PMID: 27345589 DOI: 10.1080/09513590.2016.1199018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AIM As no upper limit of the daily dose of gonadotropins (DD GN) used for controlled ovarian hyperstimulation (COH) in patients undergoing assisted reproductive technology (ART) has been established, we aimed to evaluate the efficacy of using different DD GN in terms of live-birth achievement. METHODS Data of patients treated at a single university medical center during the same period was analyzed retrospectively. Four groups were analyzed according to the DD GN administered: group I ("high dose"): >225- ≤ 375 IU; Group II ("Very high dose"): 376-450 IU; group III ("extremely high dose"): 451-600 IU. Normo-responders treated with DD GN ≤250 IU served as control (C). Variables included were DD GN, total GN dose/cycle, age, FSH, BMI, gravidity, parity, cycle number, IVF/ICSI, infertility diagnosis treatment protocol and outcome parameters. RESULTS The analysis of 1394 treatment cycles of 943 patients indicated that DD and total dose of GN correlated negatively with the number of oocytes, implantation, clinical pregnancy and live-birth rate (25.9%, 14.6%, 11.4% and 4.7% in groups C, I, II and III, respectively) The logistic regression analysis indicated that the adjusted odds ratios for LBR correlated inversely with the DD administered - independently from age, baseline FSH, BMI and previous failed cycles. CONCLUSIONS Increasing the daily dose of GN to doses higher than 450 IU or a total dose of 3000 IU/cycle is at least questionable if not harmful.
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Affiliation(s)
- S Friedler
- a Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Faculty of Health Sciences, Ben Gurion University of the Negev , Beersheba , Israel
| | - S Meltzer
- a Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Faculty of Health Sciences, Ben Gurion University of the Negev , Beersheba , Israel
| | - B Saar-Ryss
- a Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Faculty of Health Sciences, Ben Gurion University of the Negev , Beersheba , Israel
| | - J Rabinson
- a Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Faculty of Health Sciences, Ben Gurion University of the Negev , Beersheba , Israel
| | - T Lazer
- a Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Faculty of Health Sciences, Ben Gurion University of the Negev , Beersheba , Israel
| | - G Liberty
- a Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Faculty of Health Sciences, Ben Gurion University of the Negev , Beersheba , Israel
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16
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Youssef MA, van Wely M, Al-Inany H, Madani T, Jahangiri N, Khodabakhshi S, Alhalabi M, Akhondi M, Ansaripour S, Tokhmechy R, Zarandi L, Rizk A, El-Mohamedy M, Shaeer E, Khattab M, Mochtar MH, van der Veen F. A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF: a multicenter randomized non-inferiority trial. Hum Reprod 2016; 32:112-118. [PMID: 27836979 DOI: 10.1093/humrep/dew282] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/23/2016] [Accepted: 10/10/2016] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION In subfertile women with poor ovarian reserve undergoing IVF does a mild ovarian stimulation strategy lead to comparable ongoing pregnancy rates in comparison to a conventional ovarian stimulation strategy? SUMMARY ANSWER A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF leads to similar ongoing pregnancy rates as a conventional ovarian stimulation strategy. WHAT IS KNOWN ALREADY Women diagnosed with poor ovarian reserve are treated with a conventional ovarian stimulation strategy consisting of high-dose gonadotropins and pituitary downregulation with a long mid-luteal start GnRH-agonist protocol. Previous studies comparing a conventional strategy with a mild ovarian stimulation strategy consisting of low-dose gonadotropins and pituitary downregulation with a GnRH-antagonist have been under powered and their effectiveness is inconclusive. STUDY DESIGN, SIZE, DURATION This open label multicenter randomized trial was designed to compare one cycle of a mild ovarian stimulation strategy consisting of low-dose gonadotropins (150 IU FSH) and pituitary downregulation with a GnRH-antagonist to one cycle of a conventional ovarian stimulation strategy consisting of high-dose gonadotropins (450 IU HMG) and pituitary downregulation with a long mid-luteal GnRH-agonist in women of advanced maternal age and/or women with poor ovarian reserve undergoing IVF between May 2011 and April 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples seeking infertility treatment were eligible if they fulfilled the following inclusion criteria: female age ≥35 years, a raised basal FSH level >10 IU/ml irrespective of age, a low antral follicular count of ≤5 follicles or poor ovarian response or cycle cancellation during a previous IVF cycle irrespective of age. The primary outcome was ongoing pregnancy rate per woman randomized. Analyses were on an intention-to-treat basis. We randomly assigned 195 women to the mild ovarian stimulation strategy and 199 women to the conventional ovarian stimulation strategy. MAIN RESULTS AND THE ROLE OF CHANCE Ongoing pregnancy rate was 12.8% (25/195) for mild ovarian stimulation versus 13.6% (27/199) for conventional ovarian stimulation leading to a risk ratio of 0.95 (95% CI: 0.57-1.57), representing an absolute difference of -0.7% (95% CI: -7.4 to 5.9). This 95% CI does not extend below the predefined threshold of 10% for inferiority. The duration of ovarian stimulation was significantly lower in the mild ovarian stimulation strategy than in the conventional ovarian stimulation strategy (mean difference -1.2 days, 95% CI: -1.88 to -0.62). Also, a significantly lower amount of gonadotropins was used in the mild simulation strategy, with a mean difference of 3135 IU (95% CI: -3331 to -2940). LIMITATIONS, REASONS FOR CAUTION A limitation of our study was the lack of data concerning the cryopreservation of surplus embryos, so we are not informed on cumulative pregnancy rates. Another limitation is that we were not able to follow up on the ongoing pregnancies in all centers, so we are not informed on live birth rates. WIDER IMPLICATIONS OF THE FINDINGS The results are directly applicable in daily clinical practice and may lead to considerable cost savings as high dosages of gonadotropins are not necessary in women with poor ovarian reserve undergoing IVF. A health economic analysis of our data planned to test the hypothesis that mild ovarian stimulation strategy is more cost-effective than the conventional ovarian stimulation strategy is underway. STUDY FUNDING/COMPETING INTERESTS This study was supported by NUFFIC scholarship (the Netherlands) and STDF short-term fellowship (Egypt). TRIAL REGISTRATION NUMBER NTR2788 (Trialregister.nl). TRIAL REGISTER DATE 01 March 2011. DATE OF FIRST PATIENT'S ENROLMENT May 2011.
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Affiliation(s)
- M A Youssef
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands .,Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - M van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - H Al-Inany
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - T Madani
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, 2, Hafez St., Banihashem St., Resalat Ave., 16635-148 Tehran, Iran
| | - N Jahangiri
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, 2, Hafez St., Banihashem St., Resalat Ave., 16635-148 Tehran, Iran
| | - S Khodabakhshi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, 2, Hafez St., Banihashem St., Resalat Ave., 16635-148 Tehran, Iran
| | - M Alhalabi
- Division of Embryology and Reproductive Medicine, Faculty of Medicine, and Assisted Reproduction Unit, Orient Hospital, Damascus University, Damascus, Syria
| | - M Akhondi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - S Ansaripour
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - R Tokhmechy
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - L Zarandi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Shahid Beheshti University, Evin, PO Box 19615-1177 Tehran, Iran
| | - A Rizk
- Department of Obstetrics & Gynecology, Faculty of Medicine, Banha University, El-Shaheed Farid Nada, Qism Banha, Banha, Al Qalyubia Governorate 13511 Banha, Egypt
| | - M El-Mohamedy
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - E Shaeer
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - M Khattab
- Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University, Kasr-Alaini St. El-manial district, Giza, Egypt
| | - M H Mochtar
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
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Selman H, Rinaldi L. Effectiveness of corifollitropin alfa used for ovarian stimulation of poor responder patients. Int J Womens Health 2016; 8:609-615. [PMID: 27799826 PMCID: PMC5074728 DOI: 10.2147/ijwh.s117577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the efficiency and efficacy of corifollitropin alfa (follicle-stimulating hormone–carboxy terminal peptide) in the treatment of poor responder patients. Methods A total of 85 poor responder patients with a mean age 40.2±3.9 years entered our assisted fertilization program. The patients were prospectively randomized into two groups based on the ovarian stimulation regimen used: group A (study group) (n=42) received clomiphene citrate and corifollitropin alfa for the first 7 days of stimulation followed by recombinant follicle stimulating hormone (rFSH) in a gonadotropin-releasing hormone antagonist protocol, and group B (control group) (n=43) received clomiphene citrate and a daily injection of rFSH in a gonadotropin-releasing hormone antagonist protocol. We analyzed the stimulation outcome, the number of retrieved oocytes, cleaving embryos, and pregnancy and implantation rates as well. Results Comparable results were observed between the two groups in terms of demographic data, stimulation outcome, and the number of canceled cycles. There were no differences evident between groups A and B with respect to the number of retrieved oocytes (3.0±0.8 and 2.7±0.7, respectively) and the number of cleaving embryos (1.8±0.6 and 1.7±0.7, respectively). Higher, though not statistically significant, differences were observed in favor of group A compared to group B in terms of pregnancy rate per cycle (19% and 16.3%, respectively), pregnancy rate per transfer (21.6% and 17.9%, respectively), and implantation rate (14.7% and 13.4%, respectively). Also, miscarriage rate was similar between patients treated with corifollitropin alfa and those treated with daily rFSH injection (12.5% and 14.2%, respectively). Conclusion The results show that ovarian stimulation with corifollitropin alfa appears to be as efficacious and efficient as daily injection rFSH regimen to treat patients with poor ovarian response.
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Ataalla WM, Elhamid TA, Elhalwagy AE. Adjuvant sildenafil therapy in poor responders undergoing in vitro fertilization: A prospective, randomized, double-blind, placebo-controlled trial. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2016. [DOI: 10.1016/j.mefs.2015.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bastu E, Buyru F, Ozsurmeli M, Demiral I, Dogan M, Yeh J. A randomized, single-blind, prospective trial comparing three different gonadotropin doses with or without addition of letrozole during ovulation stimulation in patients with poor ovarian response. Eur J Obstet Gynecol Reprod Biol 2016; 203:30-4. [PMID: 27236602 DOI: 10.1016/j.ejogrb.2016.05.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/24/2016] [Accepted: 05/13/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this randomized controlled trial (RCT) was to investigate whether IVF outcomes would differ between patients with POR who received three different gonadotropin doses with or without the addition of letrozole during ovulation stimulation. STUDY DESIGN Only those who fulfilled two of the three Bologna criteria were included to the study. 95 patients met the inclusion criteria and agreed to participate in the study. In the first group, 31 patients were treated with 450IU gonadotropins. In the second group, 31 patients were treated with 300IU gonadotropins. The third group comprised 33 patients and was treated with 150IU gonadotropins in combination with letrozole. RESULTS The results indicate that differences in doses of hMG and rFSH in patients with POR result in a similar number of retrieved MII and fertilized oocytes, similar fertilization rates, number of transferred embryos, implantation, cancelation, chemical, clinical, and ongoing pregnancy rates. CONCLUSIONS Increasing the dose of gonadotropins during ovulation stimulation is an intuitively appealing approach when the patient is a poor responder. However, increasing the dose does not necessarily improve the reproductive outcome. Using a mild stimulation with addition of letrozole was as effective as stimulation with higher doses of gonadotropins alone in this patient population.
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Affiliation(s)
- Ercan Bastu
- Department of Obstetrics and Gynecology, Istanbul University School of Medicine, Istanbul, Turkey.
| | - Faruk Buyru
- Department of Obstetrics and Gynecology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Mehmet Ozsurmeli
- Department of Obstetrics and Gynecology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Irem Demiral
- Department of Obstetrics and Gynecology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Murat Dogan
- Department of Obstetrics and Gynecology, Istanbul University School of Medicine, Istanbul, Turkey
| | - John Yeh
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Habumuremyi S, Stephens C, Fawcett KA, Deschner T, Robbins MM. Endocrine assessment of ovarian cycle activity in wild female mountain gorillas (Gorilla beringei beringei). Physiol Behav 2016; 157:185-95. [PMID: 26875514 DOI: 10.1016/j.physbeh.2016.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 12/22/2022]
Abstract
Variability of fertility (i.e. number of births per female per year) has been reported in females of many primate species but only a few studies have explored the associated physiological and behavioral patterns. To investigate the proximate mechanisms of variability in fertility of wild female mountain gorillas (Gorilla beringei beringei), we quantified the occurrence of ovulation, matings, and successful pregnancies among females. We examined the profiles of immunoreactive pregnanediol-3-glucuronide (iPdG) for sixteen females (seven nulliparous and nine parous females, including one geriatric female; average sampling period for fecal sample collection and behavioral observations per female=175 days; SD=94 days, range=66-358 days) monitored by the staff of the Dian Fossey Gorilla Fund's Karisoke Research Center in Parc National des Volcans, Rwanda. We quantified ovarian cycles from iPdG profiles using an algorithm that we developed by adjusting the method of Kassam et al. (1996) to the characteristics of ovarian cycle profiles based on fecal hormone measurements. The mean length of ovarian cycles was 29±4 days (median: 28 days, N=13 cycles), similar to ovarian cycle lengths of other great apes and humans. As expected, we found that female mountain gorillas exhibit longer follicular phases (mean±SD: 21±3 days, N=13 cycles) than luteal phases (mean±SD: 8±3 days, N=13 cycles). We also found that the frequency of ovarian cycles was greater in parous females (i.e. 20 ovarian cycles across 44 periods of 28 days; 45.5%) than in nulliparous females (i.e. two ovarian cycles across 34 periods of 28 days; 6%). However, the frequency of days on which matings were observed did not differ significantly between parous and nulliparous females, nor between pregnant and non-pregnant females. Five pregnancies were detected with iPdG levels, but only three resulted in live births, indicating miscarriages of the other two. In sum, this study provides information on the underlying endocrine patterns of variation in fertility depending on parity, mating behavior, and pregnancy success in a critically endangered great ape.
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Affiliation(s)
- Sosthene Habumuremyi
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany; Dian Fossey Gorilla Fund International, 800 Cherokee Ave SE, Atlanta, GA 30315-1440, USA; Institut d'Enseignement Supérieur de Ruhengeri (INES-Ruhengeri), Musanze, North Province, Rwanda.
| | - Colleen Stephens
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
| | - Katie A Fawcett
- Dian Fossey Gorilla Fund International, 800 Cherokee Ave SE, Atlanta, GA 30315-1440, USA
| | - Tobias Deschner
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
| | - Martha M Robbins
- Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
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Fleming R, Seifer DB, Frattarelli JL, Ruman J. Assessing ovarian response: antral follicle count versus anti-Müllerian hormone. Reprod Biomed Online 2015; 31:486-96. [PMID: 26283017 DOI: 10.1016/j.rbmo.2015.06.015] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/27/2015] [Accepted: 06/23/2015] [Indexed: 11/29/2022]
Abstract
Oocyte number and quality decline with age; however, fertility varies significantly even among women of the same age. Various measures have been developed to predict response to ovarian stimulation and reproductive potential. Evaluation of ovarian reserve can identify patients who may experience poor response or hyper-response to exogenous gonadotrophins and can aid in the personalization of treatment to achieve good response and minimize risks. In recent years, two key methods, antral follicle count (AFC), an ultrasound biomarker of follicle number, and the concentration of serum anti-Müllerian hormone (AMH), a hormone biomarker of follicle number, have emerged as preferred methods for assessing ovarian reserve. In this review, a live debate held at the American Society for Reproductive Medicine 2013 Annual Meeting is expanded upon to compare the predictive values, merits, and disadvantages of AFC and AMH level. An ovarian reserve measure without limitations has not yet been discovered, although both AFC and AMH have good predictive value. Published evidence, however, as well as the objectivity and potential standardization of AMH level and the convenience of testing any time throughout the menstrual cycle, leans towards AMH level becoming the gold-standard biomarker to evaluate ovarian reserve and predict ovarian response to stimulation.
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Affiliation(s)
- Richard Fleming
- Glasgow Centre for Reproductive Medicine, 21 Fifty Pitches Way, Gardonald Business Park, Glasgow G51-4FD, UK.
| | - David B Seifer
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - John L Frattarelli
- Fertility Institute of Hawaii, 1401 South Beretania St, Suite 250, Honolulu, HI 96814, USA
| | - Jane Ruman
- Ferring Pharmaceuticals, Inc, 100 Interpace Pkwy, Parsippany, NJ 07054, USA
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Merviel P, Cabry-Goubet R, Lourdel E, Devaux A, Belhadri-Mansouri N, Copin H, Benkhalifa M. Comparative prospective study of 2 ovarian stimulation protocols in poor responders: effect on implantation rate and ongoing pregnancy. Reprod Health 2015; 12:52. [PMID: 26025412 PMCID: PMC4460718 DOI: 10.1186/s12978-015-0039-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 05/08/2015] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Philippe Merviel
- Department of Gynecology, Obstetrics and Reproductive Medicine, Amiens University Medical Center, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France. .,School of Medicine, University of Picardie Jules Verne, Chemin du Thil, 80025, Amiens cedex 1, France.
| | - Rosalie Cabry-Goubet
- Reproductive Biology and Medical Cytogenetics Department, University Hospital, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France. .,School of Medicine, University of Picardie Jules Verne, Chemin du Thil, 80025, Amiens cedex 1, France.
| | - Emmanuelle Lourdel
- Department of Gynecology, Obstetrics and Reproductive Medicine, Amiens University Medical Center, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France.
| | - Aviva Devaux
- Reproductive Biology and Medical Cytogenetics Department, University Hospital, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France. .,School of Medicine, University of Picardie Jules Verne, Chemin du Thil, 80025, Amiens cedex 1, France.
| | - Naima Belhadri-Mansouri
- Reproductive Biology and Medical Cytogenetics Department, University Hospital, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France. .,School of Medicine, University of Picardie Jules Verne, Chemin du Thil, 80025, Amiens cedex 1, France.
| | - Henri Copin
- Reproductive Biology and Medical Cytogenetics Department, University Hospital, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France. .,School of Medicine, University of Picardie Jules Verne, Chemin du Thil, 80025, Amiens cedex 1, France.
| | - Moncef Benkhalifa
- Reproductive Biology and Medical Cytogenetics Department, University Hospital, 124 rue Camille Desmoulins, F-80054, Amiens cedex 1, France. .,School of Medicine, University of Picardie Jules Verne, Chemin du Thil, 80025, Amiens cedex 1, France.
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La Marca A, Grisendi V, Giulini S, Sighinolfi G, Tirelli A, Argento C, Re C, Tagliasacchi D, Marsella T, Sunkara SK. Live birth rates in the different combinations of the Bologna criteria poor ovarian responders: a validation study. J Assist Reprod Genet 2015; 32:931-7. [PMID: 25925345 DOI: 10.1007/s10815-015-0476-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 04/06/2015] [Indexed: 01/22/2023] Open
Abstract
PURPOSE to compare the baseline characteristics and chance of live birth in the different categories of poor responders identified by the combinations of the Bologna criteria and establish whether these groups comprise a homogenous population. METHODS database containing clinical and laboratory information on IVF treatment cycles carried out at the Mother-Infant Department of the University Hospital of Modena between year 2007 and 2011 was analysed. This data was collected prospectively and recorded in the registered database of the fertility centre. Eight hundred and thirty women fulfilled the inclusion/ exclusion criteria of the study and 210 women fulfilled the Bologna criteria definition for poor ovarian response (POR). Five categories of poor responders were identified by different combinations of the Bologna criteria. RESULTS There were no significant differences in female age, AFC, AMH, cycle cancellation rate and number of retrieved oocytes between the five groups. The live birth rate ranged between 5.5 and 7.4 % and was not statistically different in the five different categories of women defined as poor responders according to the Bologna criteria. CONCLUSION The study demonstrates that the different groups of poor responders based on the Bologna criteria have similar IVF outcomes. This information validates the Bologna criteria definition as women having a uniform poor prognosis and also demonstrates that the Bologna criteria poor responders in the various subgroups represent a homogenous population with similar pre-clinical and clinical outcomes.
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Affiliation(s)
- Antonio La Marca
- Mother-Infant Department, Institute of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Policlinico di Modena Largo del Pozzo, 41100, Modena, Italy,
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Patrizio P, Vaiarelli A, Levi Setti PE, Tobler KJ, Shoham G, Leong M, Shoham Z. How to define, diagnose and treat poor responders? Responses from a worldwide survey of IVF clinics. Reprod Biomed Online 2015; 30:581-92. [PMID: 25892496 DOI: 10.1016/j.rbmo.2015.03.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 02/26/2015] [Accepted: 03/03/2015] [Indexed: 01/14/2023]
Abstract
Poor responders represent a significant percentage of couples treated in IVF units (10-24%), but the standard definition of poor responders remains uncertain and consequently optimal treatment options remain subjective and not evidence-based. In an attempt to provide uniformity on the definition, diagnosis and treatment of poor responders, a worldwide survey was conducted asking IVF professionals a set of questions on this complex topic. The survey was posted on www.IVF-worldwide.com, the largest and most comprehensive IVF-focused website for physicians and embryologists. A total of 196 centres replied, forming a panel of IVF units with a median of 400 cycles per year. The present study shows that the definition of poor responders is still subjective, and many practices do not use evidence-based treatment for this category of patients. Our hope is that by leveraging the great potential of the internet, future studies may provide immediate large-scale sampling to standardize both poor responder definition and treatment options.
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Affiliation(s)
| | - Alberto Vaiarelli
- Centre for Reproductive Medicine, Vrije University Brussels, Belgium
| | - Paolo E Levi Setti
- Department of Gynecology, Division of Gynecology and Reproductive Medicine, Humanitas Research Hospital Fertility Center, Rozzano, Milan 20084, Italy
| | - Kyle J Tobler
- Department of Gynecology and Obstetrics, Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gon Shoham
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Zeev Shoham
- Department of Obstetrics and Gynaecology, Kaplan Medical Center, Rehovot, Israel; Hadassah Medical School, Jerusalem, Israel
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Haas J, Zilberberg E, Machtinger R, Kedem A, Hourvitz A, Orvieto R. Do poor-responder patients benefit from increasing the daily gonadotropin dose during controlled ovarian hyperstimulation for IVF? Gynecol Endocrinol 2015; 31:79-82. [PMID: 25223892 DOI: 10.3109/09513590.2014.959919] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We aim to assess the in vitro fertilization-embryo transfer (IVF-ET) outcome in patients receiving an extremely high 450 daily dose (IU) of gonadotropins during controlled ovarian hyperstimulation (COH) for IVF. Moreover, in those who failed to conceive while using 450 daily dose (IU) of gonadotropins, we aim to evaluate whether increasing the daily dose gonadotropins to 600 IU will improve IVF outcome. All consecutive women, admitted to our IVF unit and underwent COH consisting of daily gonadotropin dose of 450 IU were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate were assessed. Nine-hundred one consecutive IVF cycles were evaluated. While there was no between-group difference in the duration of COH, patients who conceived were significantly younger, yielded higher number of oocytes retrieved and embryos transferred and had significantly lower cancellations. In a sub-analysis, including only those patients who failed to conceive while using 450 daily dose (IU) of gonadotropins, and who underwent a subsequent IVF cycle attempt with the used of 600 IU daily dose of gonadotropins, no improvements in COH characteristics or cancellation rates were observed with increasing the daily gonadotropin dose to 600 IU. To conclude, in poor responders undergoing COH with an extremely high daily gonadotropin dose (450 IU), the most important factors that predict IVF success are female age and the number of oocytes retrieved. Moreover, patients who failed to conceive on a daily gonadotropin dose of 450 IU will not benefit from increasing the dose to 600 IU and should therefore consider the options of egg donation or adoption.
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Affiliation(s)
- Jigal Haas
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer) , Ramat Gan , Israel and
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Pabalan N, Trevisan CM, Peluso C, Jarjanazi H, Christofolini DM, Barbosa CP, Bianco B. Evaluating influence of the genotypes in the follicle-stimulating hormone receptor (FSHR) Ser680Asn (rs6166) polymorphism on poor and hyper-responders to ovarian stimulation: a meta-analysis. J Ovarian Res 2014; 7:285. [PMID: 25526787 PMCID: PMC4279698 DOI: 10.1186/s13048-014-0122-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/11/2014] [Indexed: 01/09/2023] Open
Abstract
Background/aims Reported associations of controlled ovarian hyperstimulation response (COH) with genotypes of the Ser680Asn (N680S) polymorphism in the follicle stimulating hormone receptor (FSHR) gene have conflicting results. Methods PubMed and Embase databases were searched for studies that investigated the N680S polymorphism in the FSHR gene in COH. Parameters used to examine ovarian response were poor and hyper-responses to COH. Using the meta-analytic approach, we estimated ovarian response risk (odds ratio [OR] with 95% confidence intervals) according to genotype. Results Our findings showed that SS genotype carriers were most likely to be poor responders (OR 1.61, p = 0.08) compared to the NN and NS genotypes which showed no associations (OR 0.93-0.95, p = 0.75-0.78). Heterogeneity of these pooled ORs warranted examining its sources. We detected outlying studies in each of the three N680S genotypes. Omitting these outliers erased the heterogeneity of the recalculated pooled outcomes. It also materially altered the SS effects where carriers became slightly unlikely to be poor responders (OR 0.90, p = 0.52). The S allele carrier effect was modulated for poor responders (OR 1.24, p = 0.39) in the Non-Hispanic Caucasian (NHC) subgroup. The likelihood of the S allele carriers (OR 1.47, p = 0.02) and the unlikelihood of the N allele carriers (OR 0.64, p = 0.007) were significant in our hyper-response findings. Confined to NHC retained significance of the S allele effects (OR 1.57, p = 0.01) but not among the N allele carriers (OR 0.68, p = 0.18). Conclusions In summary, this is a meta-analytical confirmation of the FSHR SS genotype role in COH response. Hyper-responder analysis strengths lie on the non-heterogeneity and robustness of its results. Non-robustness and heterogeneity of the poor-responder results compose its limitations. Thus, poor response findings probably require caution as to the interpretation as a susceptibility marker for ovarian response. Electronic supplementary material The online version of this article (doi:10.1186/s13048-014-0122-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Noel Pabalan
- Center for Research and Development, Angeles University Foundation, Angeles City, 2009, Philippines. .,Graduate School, Cebu Doctors' University, Mandaue City, 6014, Philippines. .,Research and Extensions Office, Saint Louis University, BaguioCity, 2006, Philippines.
| | - Camila Martins Trevisan
- Human Reproduction and Genetics Center, Department of Collective Health - Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André/SP, São Paulo, Zip Code 09060-650, Brazil.
| | - Carla Peluso
- Human Reproduction and Genetics Center, Department of Collective Health - Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André/SP, São Paulo, Zip Code 09060-650, Brazil.
| | - Hamdi Jarjanazi
- Environmental Monitoring and Reporting Branch, Ontario Ministry of the Environment, 125 Resources Road, Etobicoke, ON, M9P 3V6, Canada.
| | - Denise Maria Christofolini
- Human Reproduction and Genetics Center, Department of Collective Health - Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André/SP, São Paulo, Zip Code 09060-650, Brazil.
| | - Caio Parente Barbosa
- Human Reproduction and Genetics Center, Department of Collective Health - Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André/SP, São Paulo, Zip Code 09060-650, Brazil.
| | - Bianca Bianco
- Human Reproduction and Genetics Center, Department of Collective Health - Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, Santo André/SP, São Paulo, Zip Code 09060-650, Brazil.
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Shaban MM. Mini-dose long gonadotropin-releasing hormone (GnRH) agonist versus agonist flare stimulation protocol for in vitro fertilization poor responders. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2013.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Management of poor responders in IVF: is there anything new? BIOMED RESEARCH INTERNATIONAL 2014; 2014:352098. [PMID: 25136579 PMCID: PMC4127291 DOI: 10.1155/2014/352098] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/26/2014] [Indexed: 12/22/2022]
Abstract
Despite the fact that in the last two decades an enormous number of papers on the topic of poor ovarian response have been published in the literature, so far it has been impossible to identify any efficient treatment to improve the ovarian response and the clinical outcome of this group of patients. The incidence of poor ovarian responders among infertile women has been estimated at 9–24% but according to recent reviews, it seems to have slightly increased. The limitation in quantifying the incidence of these patients among the infertile population is due to the difficulty of a clear definition in literature. A recent paper by the Bologna ESHRE working group on poor ovarian response has been the first real attempt to find a common definition. Current literature proposes new risk factors which could be the cause of a reduction in ovarian reserve, which also includes genetic factors. This represents the first necessary step towards finding applicable solutions for these patients. To date, there is a substantial lack of literature that identifies an ideal protocol for these patients. The use of the “Bologna criteria” and the introduction of long acting gonadotropin in clinical practice have given rise to new promising stimulation protocols for this group of patients.
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Mahajan N. Should mild stimulation be the order of the day? J Hum Reprod Sci 2014; 6:220-6. [PMID: 24672159 PMCID: PMC3963303 DOI: 10.4103/0974-1208.126282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 09/14/2013] [Accepted: 09/22/2013] [Indexed: 11/04/2022] Open
Abstract
Mild stimulation protocols aim to reduce the physical, financial and emotional burden associated with the conventional IVF protocol without compromising the pregnancy rate. Such protocols help to decrease the complications and the discomfort related to the prolonged administration of agonist and large doses of gonadotrophins, by limiting the number of oocytes recruited to no more than eight. The per cycle pregnancy rates are lower though the cumulative pregnancy rate in a year is equivalent. This CPR comes by going through earlier repeat cycles. Whether this reduces the physical, emotional or financial burden remains a matter of debate. There is need to standardize these protocol and do more trials to compare the two effectively. Till such time there is a clear benefit above the conventional protocol it will not be the protocol of choice with most physicians.
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Affiliation(s)
- Nalini Mahajan
- Department of Reproductive Medicine, NOVA IVI Fertility, New Delhi, India
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Revelli A, Chiadò A, Dalmasso P, Stabile V, Evangelista F, Basso G, Benedetto C. "Mild" vs. "long" protocol for controlled ovarian hyperstimulation in patients with expected poor ovarian responsiveness undergoing in vitro fertilization (IVF): a large prospective randomized trial. J Assist Reprod Genet 2014; 31:809-15. [PMID: 24700398 DOI: 10.1007/s10815-014-0227-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/20/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND This large prospective, randomized study was designed to compare the "mild" protocol with clomiphene citrate, low-dose gonadotropins and a GnRH-antagonist (CC/Gn/GnRH-ant protocol) with the "long" protocol with a GnRH-agonist and high-dose Gn for the controlled ovarian hyperstimulation (COH) of patients with expected poor ovarian responsiveness undergoing IVF. MATERIALS AND METHODS A total of 695 women with clinical, endocrine and ultrasound characteristics suggesting a low ovarian reserve and a poor responsiveness to COH were recruited and randomly assigned to receive the CC/Gn/GnRH-ant "mild" protocol (mild group, n = 355) or the "long" protocol with high-dose Gn (long group, n = 340). RESULTS The "mild" stimulation led to significantly shorter follicular phase, lower consumption of exogenous Gn and lower peak estradiol level than the "long" regimen. With the "long" protocol, significantly less cycles were cancelled due to the lack of ovarian response; further, it obtained significantly more oocytes, more mature oocytes, more embryos, and a thicker endometrium. As for the final IVF outcome, however, the two stimulation regimens obtained comparable implantation rate, clinical pregnancy rate, and ongoing pregnancy rate at 12 weeks. CONCLUSIONS In conclusion, the "mild" CC/Gn/GnRH-ant stimulation protocol is a valid alternative to the long protocol with high Gn dose as it obtains a comparable success rate and requires significantly less medications, with an obvious economical advantage.
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Affiliation(s)
- Alberto Revelli
- Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, St. Anna Hospital, via Ventimiglia 3, 10126, Torino, Italy,
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Kara M, Aydin T, Aran T, Turktekin N, Ozdemir B. Comparison of GnRH agonist and antagonist protocols in normoresponder patients who had IVF-ICSI. Arch Gynecol Obstet 2013; 288:1413-6. [PMID: 23708392 DOI: 10.1007/s00404-013-2903-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To measure the estradiol (E2) and progesterone levels on day of human chorionic gonadotropin (hCG) and to assess follicular development, pregnancy rates and IVF-ICSI outcomes comparing gonadotropin releasing hormone (GnRH) agonist and antagonist protocols. METHODS A total 195 women were included in the study. The patients were treated with agonist or antagonist protocol according to the clinician's and patient's preference. GnRH agonist and antagonists were administered to 77 and 118 patients, respectively. RESULTS Retrieved oocyte number (RON), metaphase two oocyte number (MON), E2 and progesteron levels on day of hCG, and fertilization rate were significantly higher in agonist group than antagonist group (p < 0.05). Implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) were significantly higher in antagonist group than agonist group (p < 0.05). However, there was no significant difference between both groups in relation with total follicle stimulating hormone (FSH). CONCLUSION GnRH agonist treatment seems to be associated with higher serum E2 and progesterone levels and resulted in lower pregnancy rates than antagonist treatment.
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Affiliation(s)
- Mustafa Kara
- Department of Obstetrics and Gynecology, Bozok University Medical Faculty, Adnan Menderes Boulevard No 44, 66200, Yozgat, Turkey,
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Hur YS, Park JH, Ryu EK, Park SJ, Lee JH, Lee SH, Yoon J, Yoon SH, Hur CY, Lee WD, Lim JH. Effect of micro-vibration culture system on embryo development. J Assist Reprod Genet 2013; 30:835-41. [PMID: 23657828 DOI: 10.1007/s10815-013-0007-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 04/26/2013] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Micro-vibration culture system was examined to determine the effects on mouse and human embryo development and possible improvement of clinical outcomes in poor responders. MATERIALS AND METHODS The embryonic development rates and cell numbers of blastocysts were compared between a static culture group (n = 178) and a micro-vibration culture group (n = 181) in mice. The embryonic development rates and clinical results were compared between a static culture group (n = 159 cycles) and a micro-vibration culture group (n = 166 cycles) in poor responders. A micro-vibrator was set at a frequency of 42 Hz, 5 s/60 min duration for mouse and human embryo development. RESULTS The embryonic development rate was significantly improved in the micro-vibration culture group in mice (p < 0.05). The cell numbers of mouse blastocysts were significantly higher in the micro-vibration group than in the static culture group (p < 0.05). In the poor responders, the rate of high grade embryos was not significantly improved in the micro-vibration culture group on day 3. However, the optimal embryonic development rate on day 5 was improved in the micro-vibration group, and the total pregnancy rate and implantation rate were significantly higher in the micro-vibration group than in the static culture group (p < 0.05). CONCLUSIONS Micro-vibration culture methods have a beneficial effect on embryonic development in mouse embryos. In poor responders, the embryo development rate was improved to a limited extent under the micro-vibration culture conditions, but the clinical results were significantly improved.
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Affiliation(s)
- Yong Soo Hur
- Department of Anatomy, School of Medicine, Kangwon National University, Chuncheon, 200-701, Korea.
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Reichman DE, Gunnala V, Meyer L, Spandorfer S, Schattman G, Davis OK, Rosenwaks Z. In vitro fertilization versus conversion to intrauterine insemination in the setting of three or fewer follicles: how should patients proceed when follicular response falls short of expectation? Fertil Steril 2013; 100:94-9. [PMID: 23615126 DOI: 10.1016/j.fertnstert.2013.02.049] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/28/2013] [Accepted: 02/28/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether in vitro fertilization (IVF) cycles with suboptimal response should be converted to intrauterine insemination (IUI) or proceed to oocyte retrieval (OR). DESIGN Retrospective cohort. SETTING Academic medical center. PATIENT(S) All patients initiating IVF from January 2004 through December 2011. INTERVENTION(S) OR versus conversion to IUI. MAIN OUTCOME MEASURE(S) A total of 1,098 patients were identified whose IVF cycles were characterized by recruitment of three or fewer follicles, excluding patients with bilateral tubal disease or severe male factor. Cycles with three follicles were defined as those with three follicles ≥ 14 mm with no fourth follicle ≥ 10 mm. Cycles with two or fewer follicles were similarly defined. Outcomes were compared for patients proceeding with OR (n = 624) versus converting to IUI (n = 474). Age-adjusted relative risks for pregnancy were calculated, stratifying for number of follicles. RESULT(S) The likelihood of retrieving at least one mature oocyte (82.9% vs. 94.8% vs. 96.2%), having at least one zygote (61.9% vs. 76.8% vs. 84.2%), and undergoing transfer (57.1% vs. 73.0% vs. 83.3%) increased significantly with increasing follicle number. Patients with three or fewer follicles were 2.6 times more likely to achieve a live birth with IVF versus IUI (9.3% vs. 3.4%). This benefit was only apparent when at least two follicles were present. No benefit was gained by performing OR in the setting of one follicle. CONCLUSION(S) IVF compared with IUI presents superior pregnancy rates in the setting of two or more follicles. Assisted reproduction programs may benefit their patients by pursuing IVF in this scenario.
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Affiliation(s)
- David E Reichman
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York 10021, USA
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Abstract
BACKGROUND In view of the discrepancies about the luteal estradiol treatment before stimulation protocols having some potential advantages compared with the standard protocols in poor ovarian responders undergoing IVF, a meta-analysis of the published data was performed to compare the efficacy of the luteal estradiol pre-treatment protocols in IVF poor response patients. METHODS We searched for all published articles. The searches yielded 32 articles, from which seven studies met the inclusion criteria. We performed this meta-analysis involving 450 IVF patients in luteal estradiol pre-treatment protocol group and 606 patients in standard protocol group. RESULTS The luteal estradiol protocol resulted in a significantly higher duration of stimulation compared with the standard protocol. In addition, the number of oocytes retrieved and mature oocytes retrieved were significantly higher in the luteal estradiol protocols than those in the standard protocols. The cycle cancellation rate (CCR) in the luteal estradiol protocols was lower than the standard protocols. Moreover, no significant difference was found in the clinical pregnancy rate (CPR). CONCLUSIONS The addition of the estradiol in the luteal phase preceding IVF in poor responders improved IVF cycle outcomes, including increasing the number of oocytes retrieved and mature oocytes retrieved and decreasing the CCR.
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Affiliation(s)
- Xiaoxia Chang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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La Marca A, Papaleo E, Grisendi V, Argento C, Giulini S, Volpe A. Development of a nomogram based on markers of ovarian reserve for the individualisation of the follicle-stimulating hormone starting dose in in vitro fertilisation cycles. BJOG 2012; 119:1171-9. [DOI: 10.1111/j.1471-0528.2012.03412.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Random anti-Müllerian hormone predicts ovarian response in women with high baseline follicle-stimulating hormone levels : anti-Müllerian hormone in poor responders in assisted reproductive treatment. J Assist Reprod Genet 2012; 29:797-802. [PMID: 22573035 DOI: 10.1007/s10815-012-9794-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 04/30/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To evaluate the predictive value of random serum anti-Müllerian hormone (AMH) in the assessment of ovarian response in patients with diminished ovarian reserve (DOR; diagnosed after the observation of elevated baseline levels of early follicular follicle-stimulating hormone [FSH]) who were undergoing intracytoplasmic sperm injection-embryo transfer (ICSI-ET) and to compare the random serum AMH and baseline FSH levels in these patients for the prediction of poor ovarian response. DESIGN Retrospective study. SETTING University hospital. PATIENTS One hundred and thirty-nine patients who were undergoing ICSI-ET cycles with early follicular FSH level >9 IU/mL. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Poor ovarian response in ICSI-ET cycles. RESULTS For the identification of women at risk of cycle cancellation, an AMH cut-off level ≤1.2 ng/mL had 97.3 % sensitivity, 31.3 % specificity, 33.9 % positive predictive value, and 96.9 % negative predictive value in the women with high baseline FSH levels. An AMH cut-off level ≥1 ng/mL had a sensitivity of 58.7 % and specificity of 95.1 % for prediction of retrieval of 4 or more oocytes. By using a serum AMH cutoff level of 1.5 ng/mL, the ongoing pregnancies were predicted with 83.3 % sensitivity and 82.5 % specificity and yielded a positive predictive value of 31.2 % and a negative predictive value 98.1 %. CONCLUSION Measurement of random serum AMH level is a useful tool in the prediction of ovarian response in patients with high serum early follicular FSH levels.
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Yoldemir T, Fraser IS. Pregnancy Rates in Older Poor Responders Who Achieve Embryo Transfer in Long Down-Regulated ART Cycles Are Comparable to Those in Younger Poor Responders. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:459-64. [DOI: 10.1016/s1701-2163(16)35252-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jadaon JE, Ben-Ami M, Haddad S, Radin O, Bar-Ami S, Younis JS. Prospective evaluation of early follicular ovarian stromal blood flow in infertile women undergoing IVF-ET treatment. Gynecol Endocrinol 2012; 28:356-9. [PMID: 22456029 DOI: 10.3109/09513590.2011.633659] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To evaluate the role of early follicular stromal flow studies in predicting ovarian response during IVF-ET treatment and to assess their correlation with ovarian reserve parameters and clinical pregnancy achievement. MATERIALS & METHODS One hundred and sixty-eight consecutive and unselected infertile women undergoing their first IVF-ET treatment were included in the study. Basal ovarian reserve and stromal Doppler flow studies were performed in a natural cycle before starting treatment. Four Doppler indices were measured; peak systolic velocity (PSV), pulsatility index (PI), resistance index (RI) and systole/diastole ratio (S/D). Following completion of IVF-ET treatment Pearson's correlation analysis was performed to examine the correlation between Doppler indices, ovarian response, basal ovarian reserve parameters and clinical pregnancy achievement. RESULTS A positive correlation was found between the number of ≥14 mm follicles on hCG day and PSV. The number of ≥14 mm follicles and retrieved oocytes had a significant negative correlation with RI and S/D ratio. As well, the number of fertilized oocytes had a significant negative correlation with S/D ratio. Absence of a Doppler signal in one or both ovaries was significantly higher in the women with poor response (31%) as compared to women with normal response (16%). In addition, RI correlated positively with basal FSH as well as FSH/LH ratio and negatively with AFC. The S/D ratio had a negative correlation with AFC (p = 0.027). A significant positive correlation between PSV, total ovarian volume (p = 0.011) and mean ovarian volume (p = 0.019) was detected. However, no correlation between all four Doppler indices and age was detected. Moreover, Doppler indices did not differ significantly between conception and non-conception cycles following IVF-ET treatment. CONCLUSIONS Early follicular stromal Doppler signals is correlated with ovarian response as well as basal ovarian reserve parameters, but have no correlation with age neither with clinical pregnancy achievement in infertile women undergoing IVF-ET treatment.
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Affiliation(s)
- Jimmy E Jadaon
- Reproductive Medicine Unit, Department of Obstetrics and Gynecology, Poriya Medical Center, Tiberias, Israel.
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Tutuncu L, Dundar O. Increasing the Stimulation Dose of rFSH in Unexpected Poor Responders Is Not Associated with Better IVF Outcome. ScientificWorldJournal 2012. [DOI: 10.1100/2012/202804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this retrospective study is to determine whether increasing the stimulation dose of rFSH in unexpected poor responders is associated with better in vitro fertilization (IVF) outcome or not. A total of forty eligible women who fulfilled our definition of poor responders and who did not achieve an ongoing pregnancy in the first cycle and returned for a second higher rFSH dose IVF cycle with a long-agonist protocol were included to the study. The first low-dose cycles and the second high-dose cycles were compared to each other. Main outcome measures of the study were duration of stimulation, number of follicles, number of oocytes retrieved, number of embryos, and E2 level on day of hCG injection. There were no significant differences in duration of stimulation, number of follicles, number of oocytes retrieved, number of embryos, and E2 level on day of hCG injection between the first low- and second high-dose cycles. Daily dose and total dose of rFSH were significantly higher in the second high-dose cycles. Increasing the dose of rFSH in a second stimulation cycle after first unsuccessful treatment cycle will add only to the cost and discomfort of the treatment and might adversely affect pregnancy rates.
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Affiliation(s)
- Levent Tutuncu
- IVF Unit, Department of Obstetrics and Gynecology, Haydarpasa Training Hospital, Gulhane Military Medical Academy, Haydarpasa, 34668 Istanbul, Turkey
| | - Ozgur Dundar
- IVF Unit, Department of Obstetrics and Gynecology, Haydarpasa Training Hospital, Gulhane Military Medical Academy, Haydarpasa, 34668 Istanbul, Turkey
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Chang EM, Han JE, Won HJ, Kim YS, Yoon TK, Lee WS. Effect of estrogen priming through luteal phase and stimulation phase in poor responders in in-vitro fertilization. J Assist Reprod Genet 2011; 29:225-30. [PMID: 22160464 DOI: 10.1007/s10815-011-9685-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 11/20/2011] [Indexed: 10/14/2022] Open
Abstract
PURPOSE To verify whether a novel protocol administering E(2) during the luteal phase of the preceding cycle and during ovarian stimulation in GnRH antagonist cycle could enhance follicular response and hence improve outcomes in poor responders. METHODS In this retrospective analysis, a total of 155 poor responder patients subjected to IVF/ICSI were analyzed. All the patients had history of more than one prior IVF cycle failure with poor response (less than 5 oocytes retrieved and/or maximal E₂ level less than 500 pg/mL) by using conventional long agonist or antagonist protocol. In luteal E2 treatment protocol (n = 86), oral estradiol valerate 4 mg/day was initiated on luteal day 21 and either stopped at menstrual cycle day 3 (Protocol A, n = 28) or continued during the period of ovarian stimulation until the day of hCG injection (Protocol B, n = 58). IVF parameters and pregnancy outcome of luteal E2 treatments group were compared with a standard GnRH antagonist protocol (n = 69) which the patients received no hormonal pretreatment. RESULTS Compared to standard GnRH antagonist protocol, cancellation rate was lower with luteal E2 group (15.1% vs 37.7%, p < 0.01). Moreover, patients treated with luteal estrogen resulted in an increased number of oocytes retrieved (4.5 ± 2.9 vs 3.2 ± 1.9; p < 0.01). A trend toward increase in number of normally fertilized embryos (2.9 ± 2.1vs 2.3 ± 1.9; p = 0.043), and increased prevalence of good quality embryos (51.2% vs 25%; p = 0.047) were noted. Comparing protocol A and B, there were no significant difference between embryologic data, however there were slight increase in ongoing pregnancy rate in protocol B compared to A (27.1% vs 20%, p = 0.357), although statistical significance was not achieved. CONCLUSION Estrogen priming through luteal phase and stimulation phase improved ovarian responsiveness and this may lead to an increase in pregnancy rate in poor responders with failed cycle.
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Affiliation(s)
- Eun Mi Chang
- Fertility Center of CHA Gangnam Medical Center, Department of Obstetrics and Gynecology, College of Medicine, CHA University, 650-9 Yeoksam, Kangnamgu, Seoul 135-081, Korea
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Weissman A, Horowitz E, Ravhon A, Golan A, Levran D. Dehydroepiandrosterone supplementation increases baseline follicular phase progesterone levels. Gynecol Endocrinol 2011; 27:1014-7. [PMID: 21500990 DOI: 10.3109/09513590.2011.569611] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ariel Weissman
- Department of Obstetrics and Gynecology, IVF Unit, Edith Wolfson Medical Center, Holon, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Kamble L, Gudi A, Shah A, Homburg R. Poor responders to controlled ovarian hyperstimulation forin vitrofertilisation (IVF). HUM FERTIL 2011; 14:230-45. [DOI: 10.3109/14647273.2011.608241] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yoo JH, Cha SH, Park CW, Kim JY, Yang KM, Song IO, Koong MK, Kang IS, Kim HO. Comparison of mild ovarian stimulation with conventional ovarian stimulation in poor responders. Clin Exp Reprod Med 2011; 38:159-63. [PMID: 22384436 PMCID: PMC3283064 DOI: 10.5653/cerm.2011.38.3.159] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 08/16/2011] [Accepted: 08/30/2011] [Indexed: 11/10/2022] Open
Abstract
Objective To compare the IVF outcomes of mild ovarian stimulation with conventional ovarian stimulation in poor responders. Methods From 2004 to 2009, 389 IVF cycles in 285 women showed poor responses (defined as either a basal FSH level ≥12 mIU/mL, or the number of retrieved oocytes ≤3, or serum E2 level on hCG day <500 pg/mL) were analyzed, retrospectively. In total, 119 cycles with mild ovarian stimulation (m-IVF) and 270 cycles with conventional ovarian stimulation (c-IVF) were included. Both groups were divided based on their age, into groups over and under 37 years old. Results The m-IVF group was lower than the c-IVF group in the duration of stimulation, total doses of gonadotropins used, serum E2 level on hCG day, the number of retrieved oocytes, and the number of mature oocytes. However, there was no significant difference in the number of good embryos, the number of transferred embryos, the cancellation rate, or the clinical pregnancy rate. In the m-IVF group over 37 years old, the clinical pregnancy rate and live birth rate were higher when compared with the c-IVF group, but this result was not statistically significant. Conclusion In poor responder groups, mild ovarian stimulation is more cost effective and patient friendly than conventional IVF. Therefore, we suggest that mild ovarian stimulation could be considered for poor responders over 37 years old.
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Affiliation(s)
- Ji Hee Yoo
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
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Lee VCY, Chan CCW, Ng EHY, Yeung WSB, Ho PC. Sequential use of letrozole and gonadotrophin in women with poor ovarian reserve: a randomized controlled trial. Reprod Biomed Online 2011; 23:380-8. [DOI: 10.1016/j.rbmo.2011.05.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 05/16/2011] [Accepted: 05/18/2011] [Indexed: 11/26/2022]
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Pu D, Wu J, Liu J. Comparisons of GnRH antagonist versus GnRH agonist protocol in poor ovarian responders undergoing IVF. Hum Reprod 2011; 26:2742-9. [PMID: 21778283 DOI: 10.1093/humrep/der240] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In view of the discrepancies about the GnRH antagonist (GnRH-ant) ovarian stimulation protocols having some potential advantages compared with the GnRH agonist (GnRH-a) protocols in poor ovarian responders IVF/ICSI, a meta-analysis of the published data was performed to compare the efficacy of GnRH-ant versus GnRH-a protocols for ovarian stimulation in IVF poor response patients. METHODS We searched for all published articles indexed in MEDLINE (1950-2010), EMBASE (1974-2010) and China National Knowledge Infrastructure (CNKI, 1994-2010). Any randomized controlled study that compared the GnRH-ant with GnRH-a in ovarian stimulation protocols for poor responders undergoing IVF/ICSI was included, and data were extracted independently by two reviewers. The searches yielded 64 articles, from which 14 studies met the inclusion criteria. We performed this meta-analysis involving 566 IVF patients in a GnRH-ant protocol group and 561 patients in a GnRH-a protocol group with Review Manager 4.2 software. Odds ratio (OR) and weighted mean difference (WMD) with 95% confidence intervals (CIs) were used to evaluate dichotomous and continuous data, respectively. RESULTS Fourteen eligible studies were included in this meta-analysis. GnRH-ant protocols resulted in a statistically significantly lower duration of stimulation compared with GnRH-a protocols (P = 0.04; WMD: -1.88, 95% CI: -3.64, -0.12), but there was no significant difference in the number of oocytes retrieved (P = 0.51; WMD: -0.17, 95% CI -0.69, 0.34) or the number of mature oocytes retrieved (P = 0.99; WMD: -0.01, 95% CI: -1.14, 1.12). Moreover, no significant difference was found in the cycle cancellation rate (CCR, P = 0.67; OR: 1.01, 95% CI: 0.71-1.42) or clinical pregnancy rate (CPR, P = 0.16; OR: 1.23, 95% CI: 0.92, 1.66). CONCLUSIONS Clear advantage was gained in duration of stimulation with GnRH-ant in poor ovarian responders undergoing IVF, although there was no statistical difference in the number of oocytes retrieved, the number of mature oocytes retrieved, the CCR and CPR between GnRH-ant and GnRH-a protocols. These results may be helpful to our clinical practice. However, further controlled randomized prospective studies with larger sample sizes are needed.
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Affiliation(s)
- Danhua Pu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University, 210029 Nanjing, People's Republic of China
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Zarek SM, Muasher SJ. Mild/minimal stimulation for in vitro fertilization: an old idea that needs to be revisited. Fertil Steril 2011; 95:2449-55. [DOI: 10.1016/j.fertnstert.2011.04.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 04/13/2011] [Accepted: 04/13/2011] [Indexed: 11/29/2022]
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Ferraretti AP, La Marca A, Fauser BCJM, Tarlatzis B, Nargund G, Gianaroli L. ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod 2011; 26:1616-24. [PMID: 21505041 DOI: 10.1093/humrep/der092] [Citation(s) in RCA: 1135] [Impact Index Per Article: 87.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- A P Ferraretti
- S.I.S.Me.R Reproductive Medicine Unit, Via Mazzini 12, 40138 Bologna, Italy.
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Revelli A, Casano S, Salvagno F, Delle Piane L. Milder is better? Advantages and disadvantages of "mild" ovarian stimulation for human in vitro fertilization. Reprod Biol Endocrinol 2011; 9:25. [PMID: 21324155 PMCID: PMC3048523 DOI: 10.1186/1477-7827-9-25] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 02/16/2011] [Indexed: 11/24/2022] Open
Abstract
In the last decades, several steps have been made aiming at rendering human IVF more successful on one side, more tolerable on the other side. The "mild" ovarian stimulation approach, in which a lower-than-average dose of exogenous gonadotropins is given and gonadotropin treatment is started from day 2 to 7 of the cycle, represents a significant step toward a more patient's friendly IVF. However, a clear view of its virtues and defects is still lacking, because only a few prospective randomized trials comparing "mild" vs. conventional stimulation exist, and they do not consider some important aspects, such as, e.g., thawing cycles. This review gives a complete panorama of the "mild" stimulation philosophy, showing its advantages vs. conventional ovarian stimulation, but also discussing its disadvantages. Both patients with a normal ovarian responsiveness to exogenous gonadotropins and women with a poor ovarian reserve are considered. Overall, we conclude that the level of evidence supporting the use of "mild" stimulation protocols is still rather poor, and further, properly powered prospective studies about "mild" treatment regimens are required.
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Affiliation(s)
- Alberto Revelli
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, via Ventimiglia 3, 10126 Torino, Italy
| | - Simona Casano
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, via Ventimiglia 3, 10126 Torino, Italy
| | - Francesca Salvagno
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, via Ventimiglia 3, 10126 Torino, Italy
| | - Luisa Delle Piane
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, via Ventimiglia 3, 10126 Torino, Italy
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Shastri SM, Barbieri E, Kligman I, Schoyer KD, Davis OK, Rosenwaks Z. Stimulation of the young poor responder: comparison of the luteal estradiol/gonadotropin-releasing hormone antagonist priming protocol versus oral contraceptive microdose leuprolide. Fertil Steril 2011; 95:592-5. [DOI: 10.1016/j.fertnstert.2010.10.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 09/11/2010] [Accepted: 10/04/2010] [Indexed: 11/24/2022]
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Chou LL, Hwu YM, Lin MH, Lin SY, Lee RKK. Outcomes of High Initial Daily Doses of Gonadotropin in Patients With Poor Ovarian Reserve. Taiwan J Obstet Gynecol 2010; 49:442-8. [DOI: 10.1016/s1028-4559(10)60096-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2010] [Indexed: 11/27/2022] Open
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