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Dastjerdi MV, Ansaripour S, Ataei M, Gharedaghi R, Hoseini SMM, Mohazzab A, Zafardoust S. Comparison of luteal phase stimulation with follicular phase stimulation in poor ovarian response: a single-blinded randomized controlled trial. Contracept Reprod Med 2024; 9:6. [PMID: 38368372 PMCID: PMC10874545 DOI: 10.1186/s40834-024-00265-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/25/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND In the last decade, luteal-phase ovarian stimulation (LPOS) has been suggested as an alternative controlled ovarian stimulation (COS) protocol for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles mainly in women with a history of poor ovarian response (POR). The present randomized controlled trial study aimed to compare the outcomes of follicular phase ovarian stimulation (FPOS) and LPOS protocols in POR cases undergoing ICSI cycles. METHODS Seventy-eight POR patients who met the Bologna criteria and underwent an ICSI cycle were included. In this study, 39 POR cases were allocated to the FPOS group, and 39 POR cases were allocated to the LPOS group. The primary outcome was the number of metaphase II (MII) oocytes. In addition, the total number of oocytes, number of top-quality day 3 embryo, day 3 embryo development rate, chemical pregnancy and clinical pregnancy rates were defined as secondary outcomes. RESULTS The obtained results demonstrated that the number of MII oocytes significantly increased in the LPOS group compared to the FPOS group (P = 0.007). However, there was no significant difference between the two groups regarding the number of GV and MI oocytes, number of top-quality day 3 embryos and day 3 embryo development rate among both categories of patients. Also, the number of total and MII oocytes was significantly higher in the LPOS group (P = 0.016). CONCLUSION These results suggest that LPOS protocol effectively increases the number of mature oocytes in women with a history of POR. TRIAL REGISTRATION IRCT20210405050852N1 (Registered at Iranian registry of clinical trials; available at https://en.irct.ir/trial/55402 ).
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Affiliation(s)
| | - Soheila Ansaripour
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Mina Ataei
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
- Department of Obstetrics and Gynecology, Social Determinants of Health, Research Center, School of Medical Sciences, Alborz University of Medical Sciences, Karaj, Iran
| | - Roya Gharedaghi
- Department of Obstetrics and Gynecology, Social Determinants of Health, Research Center, School of Medical Sciences, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Arash Mohazzab
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
- Reproductive Immunology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Simin Zafardoust
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran.
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2
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Wang P, Gong Y, Li D, Zhao X, Zhang Y, Zhang J, Geng X, Zhang X, Tian Y, Li W, Sun G, Han R, Kang X, Li Z, Jiang R. Effect of induced molting on ovarian function remodeling in laying hens. Poult Sci 2023; 102:102820. [PMID: 37329628 PMCID: PMC10404790 DOI: 10.1016/j.psj.2023.102820] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/19/2023] Open
Abstract
Induced molting (IM) can restore the laying rate of aged laying hens to the peak level of laying and rejuvenate ovarian function for the second laying cycle. To explore the mechanism of ovarian function remodeling during IM in laying hens, in this study, ninety 71-wk-old laying lady hens with 60% laying rate and uniform weight were selected for molting induction by fasting. Samples (serum and fresh ovarian tissue) were collected on the day before fasting (F0), the 3rd and 16th days of fasting (F3, F16), and the 6th, 15th, 32nd days of refeeding (R6, R15, and R32), and the number of follicles in each period was counted. Then, the reproductive hormone levels in serum and antioxidant levels in ovarian tissues were detected at different stages, and the gene expression of the KIT-PI3K-PTEN-AKT pathway and GDF-9 in ovaries was measured by qRT-PCR. The results showed that the laying rate increased rapidly after refeeding and returned to the prefasting level by R32. At F16 and R6, the number of mature follicles significantly decreased; the number of primary and secondary follicles significantly increased; the contents of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and progesterone (P4) in serum decreased; the relative expression of KIT, PI3K, AKT, and GDF-9 significantly increased; and that of PTEN significantly decreased. At R15 and R32, except for GDF-9, which maintained a high expression state, other indicators showed opposing trends to those observed at F16 and R6. In conclusion, IM activated the KIT-PI3K-PTEN-AKT signaling pathway and promoted the activation of primordial follicles during the fasting period and early resumption of feeding; gonadotropin secretion increased gradually, which promoted the rapid development of primary and secondary follicles to mature follicles and ovulation. This study explained the mechanism of ovarian function remodeling in the process of IM and provided a theoretical basis for improving the ovarian function of laying hens and optimizing the IM program.
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Affiliation(s)
- Pengyu Wang
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Yujie Gong
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Donghua Li
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Xinlong Zhao
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Yihui Zhang
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Jun Zhang
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Xiaoqing Geng
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Xiaoran Zhang
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Yadong Tian
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Wenting Li
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Guirong Sun
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Ruili Han
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Xiangtao Kang
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Zhuanjian Li
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China
| | - Ruirui Jiang
- College of Animal Science and Technology, Henan Agricultural University, Zhengzhou 450046, China; Key Laboratory of Livestock and Poultry Resources (Poultry) Evaluation and Utilization, Ministry of Agriculture and Rural Affairs, Zhengzhou 450046, China.
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Tocci A, Barad D, Łukaszuk K, Orvieto R. Routine double-ovarian-stimulation (DuoStim) in poor responders lacks rationale, evidence, and follow-up. Hum Reprod 2023; 38:329-333. [PMID: 36692185 DOI: 10.1093/humrep/dead002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/22/2022] [Indexed: 01/25/2023] Open
Abstract
Double ovarian stimulation (DuoStim), initially only suggested for fertility preservation in cancer patients, is now increasingly also used in routine clinical IVF, especially in poor responders. The claimed rational for this is the alleged existence of multiple follicular waves in a single intermenstrual interval, allowing for retrieval of more oocytes in a single IVF cycle. This commentary argues that this expansion of purpose lacks rationale, evidence, and follow-up. Consequently, we suggest that, unless valid clinical indications have been established, DuoStim be only subject of controlled clinical trials with appropriate experimental consents.
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Affiliation(s)
- Angelo Tocci
- Reproductive Medicine Unit, Gruppo Donnamed, Rome, Italy
| | - David Barad
- Center for Human Reproduction, New York, NY, USA.,The Foundation for Reproductive Medicine, New York, NY, USA
| | - Krzysztof Łukaszuk
- INVICTA Fertility and Reproductive Centers, Gdańsk, Poland.,Department of Obstetrics and Gynaecological Nursing, Faculty of Health Sciences, Medical University of Gdańsk, Gdańsk, Poland.,iYoni App-For Fertility Treatment, LifeBite, Olsztyn, Poland
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jiang S, Chen L, Cai R, Kuang Y. A follow-up study on congenital anomalies of 2208 three-year old offspring born after luteal-phase stimulation. Reprod Biomed Online 2022; 45:589-598. [DOI: 10.1016/j.rbmo.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
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Kirillova A, Martazanova B, Mishieva N, Semenova M. Follicular waves in ontogenesis and female fertility. Biosystems 2021; 210:104558. [PMID: 34619293 DOI: 10.1016/j.biosystems.2021.104558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 10/20/2022]
Abstract
Antral follicle growth and recruitment are the basis of female reproduction. Follicular wave theory explains the recruitment, growth, and selection of antral follicles. This article is devoted to the follicular wave pattern in female reproduction throughout life. We highlight progress in understanding the rhythmic follicle changes based on clinical studies and studies on animal models. We review the follicular wave pattern before puberty, during pregnancy, and in perimenopause. Several mathematical models are known which quite accurately describe follicular wave dynamics. The follicular waves theory allows the implementation of the new approaches to ovarian stimulation. Stimulation in the luteal phase and double stimulation are used more widely nowadays for fertility preservation in cancer patients and for increasing the chances of IVF programs success in poor responder patients.
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Affiliation(s)
- Anastasia Kirillova
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After V.I.Kulakov, of the Ministry of Healthcare of Russian Federation, Moscow, Russia.
| | - Bella Martazanova
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After V.I.Kulakov, of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Nona Mishieva
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After V.I.Kulakov, of the Ministry of Healthcare of Russian Federation, Moscow, Russia
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6
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Hanson BM, Tao X, Zhan Y, Jenkins TG, Morin SJ, Scott RT, Seli EU. Young women with poor ovarian response exhibit epigenetic age acceleration based on evaluation of white blood cells using a DNA methylation-derived age prediction model. Hum Reprod 2021; 35:2579-2588. [PMID: 33049778 DOI: 10.1093/humrep/deaa206] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/22/2020] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Is poor ovarian response associated with a change in predicted age based on a DNA methylation-derived age prediction model (the Horvath algorithm) in white blood cells (WBCs) or cumulus cells (CCs)? SUMMARY ANSWER In young women, poor ovarian response is associated with epigenetic age acceleration within WBC samples but is not associated with age-related changes in CC. WHAT IS KNOWN ALREADY The majority of human tissues follow predictable patterns of methylation which can be assessed throughout a person's lifetime. DNA methylation patterns may serve as informative biomarkers of aging within various tissues. Horvath's 'epigenetic clock', which is a DNA methylation-derived age prediction model, accurately predicts a subject's true chronologic age when applied to WBC but not to CC. STUDY DESIGN, SIZE, DURATION A prospective cohort study was carried out involving 175 women undergoing ovarian stimulation between February 2017 and December 2018. Women were grouped according to a poor (≤5 oocytes retrieved) or good (>5 oocytes) response to ovarian stimulation. Those with polycystic ovary syndrome (PCOS) (n = 35) were placed in the good responder group. PARTICIPANTS/MATERIALS, SETTING, METHODS DNA methylation patterns from WBC and CC were assessed for infertile patients undergoing ovarian stimulation at a university-affiliated private practice. DNA was isolated from peripheral blood samples and CC. Bisulfite conversion was then performed and a DNA methylation array was utilized to measure DNA methylation levels throughout the genome. Likelihood ratio tests were utilized to assess the relationship between predicted age, chronologic age and ovarian response. MAIN RESULTS AND THE ROLE OF CHANCE The Horvath-predicted age for WBC samples was consistent with patients' chronologic age. However, predicted age from analysis of CC was younger than chronologic age. In subgroup analysis of women less than 38 years of age, poor ovarian response was associated with an accelerated predicted age in WBC (P = 0.017). Poor ovarian response did not affect the Horvath-predicted age based on CC samples (P = 0.502). No alternative methylation-based calculation was identified to be predictive of age for CC. LIMITATIONS, REASONS FOR CAUTION To date, analyses of CC have failed to identify epigenetic changes that are predictive of the aging process within the ovary. Despite the poor predictive nature of both the Horvath model and the novel methylation-based age prediction model described here, it is possible that our efforts failed to identify appropriate sites which would result in a successful age-prediction model derived from the CC epigenome. Additionally, lower DNA input for CC samples compared to WBC samples was a methodological limitation. We acknowledge that a universally accepted definition of poor ovarian response is lacking. Furthermore, women with PCOS were included and therefore the group of good responders in the current study may not represent a population with entirely normal methylation profiles. WIDER IMPLICATIONS OF THE FINDINGS The process of ovarian and CC aging continues to be poorly understood. Women who demonstrate poor ovarian response to stimulation represent a common clinical challenge, so clarifying the exact biological changes that occur within the ovary over time is a worthwhile endeavor. The data from CC support a view that hormonally responsive tissues may possess distinct epigenetic aging patterns when compared with other tissue types. Future studies may be able to determine whether alternative DNA methylation sites can accurately predict chronologic age or ovarian response to stimulation from CC samples. Going forward, associations between epigenetic age acceleration and reproductive and general health consequences must also be clearly defined. STUDY FUNDING/COMPETING INTEREST(S) No external funding was obtained for the study and there are no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Brent M Hanson
- IVI-Reproductive Medicine Associates of New Jersey, Basking Ridge, NJ, USA
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology and Infertility Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Xin Tao
- Foundation for Embryonic Competence, Basking Ridge, NJ, USA
| | - Yiping Zhan
- Foundation for Embryonic Competence, Basking Ridge, NJ, USA
| | - Timothy G Jenkins
- Department of Surgery, Division of Urology University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Physiology & Developmental Biology, Brigham Young University, Provo, UT, USA
| | - Scott J Morin
- IVI-Reproductive Medicine Associations of Northern California, San Francisco, CA, USA
| | - Richard T Scott
- IVI-Reproductive Medicine Associates of New Jersey, Basking Ridge, NJ, USA
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology and Infertility Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Emre U Seli
- IVI-Reproductive Medicine Associates of New Jersey, Basking Ridge, NJ, USA
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility Yale University School of Medicine, New Haven, CT, USA
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Llácer J, Moliner B, Luque L, Bernabéu A, Lledó B, Castillo JC, Guerrero J, Ten J, Bernabéu R. Luteal phase stimulation versus follicular phase stimulation in poor ovarian responders: results of a randomized controlled trial. Reprod Biol Endocrinol 2020; 18:9. [PMID: 32033610 PMCID: PMC7007665 DOI: 10.1186/s12958-020-00570-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/04/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In young women with poor ovarian response, luteal-phase ovarian stimulation (LPOS) is a potential method for collecting competent oocytes. The aim of this study was to assess the efficacy of LPOS compared with follicular phase ovarian stimulation (FPOS) in young women with poor ovarian response (POR). METHODS This single-center, prospective, randomized pilot study compared LPOS and FPOS in women with POR fulfilling Bologna criteria who underwent in vitro fertilization at the Instituto Bernabeu. The primary outcome was the number of metaphase II (MII) oocytes obtained by follicular puncture. RESULTS Sixty women were included in the study, with 27 women completing LPOS and 30 undergoing FPOS. There was no statistically significant difference in the number of MII oocytes obtained between the LPOS group and the FPOS group (2.1 ± 2.0 vs. 2.6 ± 2.2, p = 0.31). Length of stimulation was also similar in both groups (8.35 ± 2.8 vs. 8.15 ± 4.1 days, p = 0.69). Similarly, there was no significant difference in the follicle-stimulating hormone total dose, number of cumulus-oocyte complexes, survival rate, fertilization rate, or cancellation rate between groups. A significantly higher Ovarian Sensitivity Index was observed in the LPOS group versus the FPOS group (0.96 vs. 0.57, p = 0.037). CONCLUSION LPOS was comparable with FPOS in terms of efficacy and may improve ovarian responsiveness in young women with POR. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02625532; EudraCT identifier: 2015-003856-31.
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Affiliation(s)
- Joaquín Llácer
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Belén Moliner
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Lydia Luque
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Andrea Bernabéu
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Belén Lledó
- grid.476436.40000 0001 0259 6889Department of Clinical Laboratory, Instituto Bernabeu, 03016 Alicante, Spain
| | - Juan Carlos Castillo
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Jaime Guerrero
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Jorge Ten
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
| | - Rafael Bernabéu
- grid.476436.40000 0001 0259 6889Department of Reproductive Medicine, Instituto Bernabeu, Av. Albufereta 31-37, 03016 Alicante, Spain
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Rodriguez-Purata J, Devesa M, Parriego M, Pardos C, Rodriguez I, Polyzos NP, Martínez F, Coroleu B. Linking back-to-back stimulation cycles with oral contraceptives or progestins in women undergoing embryo accumulation for preimplantation genetic testing, a retrospective study. Gynecol Endocrinol 2018; 34:955-960. [PMID: 29768947 DOI: 10.1080/09513590.2018.1473363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
This retrospective study was carried out to determine which strategy is associated with improved outcomes in two back-to-back cycles when undergoing embryo accumulation. Eighty patients with two stimulation cycles performed with <45 days between retrievals between Jan'16-Mar'17 were included. Patients were segregated according to the strategy used to link stimulations: spontaneous menses (SM), vaginal micronized progesterone (VMP) or oral contraceptive pills (OCP). Main outcome measure was oocytes retrieved. The oocytes retrieved difference between cycles was -0.9 in SM, -1.5 in VMP and +0.4 in OCPs. Although not statistically significant, more oocytes retrieved were observed in the 2ndcycle when OCPs were used (9.0 ± 3.7 vs. 9.4 ± 4.1)? whereas fewer oocytes retrieved were observed when SM (9.4 ± 3.9 vs. 8.5 ± .0) or VMP (9.8 ± 5.7 vs. 8.2 ± 4.4) were used. After adjusting for age, gonadotropins and stimulation days (2nd cycle) and treatment group in an ANCOVA model, no treatment was associated with a higher average number of oocytes retrieved (power: 14.9%) or a higher difference of oocytes retrieved (power: 22.3%). Although no statistical significance was reached, OCPs were observed to achieve higher average and positive difference of oocytes retrieved in the 2nd cycle.
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Affiliation(s)
| | - Marta Devesa
- a Hospital Universitari Dexeus , Barcelona , Spain
| | | | - Clara Pardos
- a Hospital Universitari Dexeus , Barcelona , Spain
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Ortega I, García-Velasco JA, Pellicer A. Ovarian manipulation in ART: going beyond physiological standards to provide best clinical outcomes. J Assist Reprod Genet 2018; 35:1751-1762. [PMID: 30056596 DOI: 10.1007/s10815-018-1258-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/03/2018] [Indexed: 12/11/2022] Open
Abstract
Current knowledge on ovarian physiology has challenged the traditional concept of folliculogenesis, creating the basis for novel ovarian stimulation protocols in assisted reproduction technology. The purpose of this review was to evaluate the efficacy of novel clinical interventions that could aid clinicians in individualizing their protocols to patients' characteristics and personal situations. We conducted a literature review of the available evidence on new approaches for ovarian stimulation from both retrospective and prospective studies in the PubMed database. Here, we present some of the most important interventions, including follicle growth in the gonadotropin-independent and dependent stage, manipulation of estradiol production throughout ovarian stimulation, control of mid-cycle gonadotropin surges, and luteal phase support after different stimulation protocols and trigger agents. The latest research on IVF has moved physicians away from the classical physiology, allowing the development of new strategies to decouple organ functions from the female reproductive system and challenging the traditional concept of IVF.
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Affiliation(s)
- Israel Ortega
- IVI-Madrid, Madrid, Spain. .,Instituto de Investigación Sanitaria La Fé, Valencia, Spain.
| | - Juan A García-Velasco
- IVI-Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria La Fé, Valencia, Spain.,Rey Juan Carlos University, Madrid, Spain.,IdiPAZ, Madrid, Spain
| | - Antonio Pellicer
- Instituto de Investigación Sanitaria La Fé, Valencia, Spain.,Rey Juan Carlos University, Madrid, Spain.,IdiPAZ, Madrid, Spain.,IVI-Roma, Rome, Italy
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10
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Luteal Phase Ovarian Stimulation May Improve Oocyte Retrieval and Oocyte Quality in Poor Ovarian Responders Undergoing In Vitro Fertilization: Preliminary Results from a Single-Center Prospective Pilot Study. Adv Ther 2018; 35:847-856. [PMID: 29869107 DOI: 10.1007/s12325-018-0713-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Luteal phase ovarian stimulation (LPOS) has been proven a feasible protocol for infertile patients. High progesterone level in the luteal phase could physiologically inhibit premature luteinizing hormone surge, from which poor ovarian responders (PORs) could obtain benefits. Therefore, we aimed to compare clinical outcomes between LPOS and follicular phase ovarian stimulation (FPOS) protocol in PORs undergoing in vitro fertilization (IVF). METHODS This prospective pilot study was performed at one tertiary center from January 2016 to October 2017. A total of 60 PORs who met Bologna criteria and undergoing IVF were enrolled. Thirty PORs were allocated to the LPOS group and 30 PORs were allocated to the FPOS group. Basic characteristics, cycle characteristics, and pregnancy outcomes were compared between the two groups. RESULTS The length of stimulation was significantly longer in the LPOS group than in the FPOS group. The numbers of retrieved oocytes, metaphase II oocytes, fertilized oocytes, and day-3 embryos were significantly higher in the LPOS group than in the FPOS group. Conversely, we could not find any significant difference for clinical pregnancy rate, ongoing pregnancy rate, abortion rate, and cancellation rate. The multivariate analysis showed that only LPOS (p = 0.007) was significantly associated the possibility to retrieve three or more oocytes, whereas basal follicle-stimulating hormone (FSH) < 8 IU/l (p = 0.103) and antral follicle count (AFC) ≥ 3 (p = 0.143) did not significantly affect this event. CONCLUSION LPOS allows improved oocyte retrieval and oocyte quality in PORs with respect to FPOS, despite comparable pregnancy outcomes. LPOS may be considered a feasible option for oocytes accumulation in PORs. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03238833.
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11
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Mutlu MF, Mutlu İ, Erdem M, Güler İ, Erdem A. Comparison of the standard GnRH antagonist protocol and the luteal phase estradiol/GnRH antagonist priming protocol in poor ovarian responders. Turk J Med Sci 2017; 47:470-475. [PMID: 28425233 DOI: 10.3906/sag-1602-111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 07/17/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM The aim of the study was to compare the luteal estradiol patch/GnRH antagonists priming protocol (LPP) with the standard GnRH antagonist protocol in poor ovarian responders (PORs) in terms of the outcomes of in vitro fertilization (IVF) treatment. MATERIALS AND METHODS IVF outcomes of 265 cycles in 265 patients (106 in the LPP group, 159 in the standard GnRH antagonist group) were evaluated retrospectively. RESULTS Mean length of stimulation (11.4 ± 2.7 vs. 10.0 ± 2.7 days; P < 0.05) and the total gonadotropin dose (3403 ± 1060 vs. 2984 ± 1112) used were significantly greater in the LPP group than in the standard GnRH antagonist protocol group. The mean number of oocytes retrieved (3.5 ± 2.6 vs. 3.7 ± 2.8), the number of mature oocytes (2.8 ± 2.2 vs. 2.6 ± 2.2), fertilization rates (65% vs. 62%), the number of embryos transferred (1.6 ± 0.6 vs. 1.7 ± 0.6), and implantation rates (16% vs. 13%) were similar. The cancellation rate did not significantly differ between the groups (9.4% vs. 13.2%). There were no significant differences in the clinical pregnancy (11.3% vs. 13.2%) or live birth rates per patient (3.8% vs. 9.4%) and clinical pregnancy (18.8% vs. 22.6%) or live birth rates per embryo transfer (6.3% vs. 12.9%) between the groups. CONCLUSION LPP does not improve IVF outcomes when compared with the standard GnRH antagonist protocol in PORs.
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Affiliation(s)
- Mehmet Fırat Mutlu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yüksek İhtisas University Ankara, Turkey
| | - İlknur Mutlu
- IVF Unit, Novaart IVF and Women Health Center, Ankara, Turkey
| | - Mehmet Erdem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - İsmail Güler
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ahmet Erdem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gazi University, Ankara, Turkey
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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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Huang L, Wang S, Ma Y. Combined evaluation of risk factors predicting poor ovarian responders in Chinese patients undergoing in vitro fertilization. Gynecol Endocrinol 2016; 32:124-7. [PMID: 26489886 DOI: 10.3109/09513590.2015.1101442] [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] [Indexed: 11/13/2022] Open
Abstract
This study aimed to explore the parameters associated with poor ovarian response (POR) to develop an early warning score model (EWSM) for detecting POR in Chinese women undergoing in vitro fertilization, in order to improve the outcomes. Between 2005 and 2011, we recruited 736 patients with POR after IVF and 736 individuals with normal ovarian response after IVF as controls. Clinical parameters were determined to evaluate the ovarian reserve. We then compared the clinical parameters between the POR and control groups, and performed a multivariate analysis to determine the independent factors associated with ovarian response. Receiver-operator characteristic (ROC) was used to analyze the predicted values of individual and combined risk factors. The predicted values were further tested in another cohort of 957 patients. Age, basal follicle-stimulating hormone (bFSH), antral follicle count (AFC), and FSH/luteinizing hormone (LH) ratio were identified as independent factors associated with ovarian response. The EWSM was established using a combination of these parameters. The sensitivity and specificity of the EWSM were 74.6% and 93.6%, respectively. In conclusion, combination of individual risk factors could predict POR with high specificity. The EWSM may help in the evaluation of IVF treatment at an early stage.
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Affiliation(s)
- Lu Huang
- a Reproductive Medicine Department , Beijing Obstetrics and Gynecology Hospital, Capital Medical University , Beijing , China
| | - Shuyu Wang
- a Reproductive Medicine Department , Beijing Obstetrics and Gynecology Hospital, Capital Medical University , Beijing , China
| | - Yanmin Ma
- a Reproductive Medicine Department , Beijing Obstetrics and Gynecology Hospital, Capital Medical University , Beijing , China
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Abstract
BACKGROUND Poor ovarian response and retrieval of no oocytes following ovarian stimulation for in vitro fertilization (IVF) is a challenging problem for both the patient and the clinician. FINDINGS Recent evidence indicates that folliculogenesis occurs in a wave-like fashion indicating that there are multiple follicular recruitment waves in the same menstrual cycle. This relatively new scientific concept provides new opportunities for the utilization of ovarian stimulation in women with poor ovarian response. This communication reports on the social and scientific rationale for the use of luteal phase ovarian stimulation following oocyte retrieval in the same cycle (also called double stimulation). CONCLUSIONS Data to date showed that double ovarian stimulation in poor responders provides shorter time for retrieving mature oocytes with the potential formation of good quality embryos, and thus healthy pregnancies.
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Affiliation(s)
- John Zhang
- Reproductive Endocrinology and Infertility, New Hope Fertility Center, 4 Columbus Circle, New York, NY, 10019, USA.
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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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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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Synchronization of ovarian stimulation with follicle wave emergence in patients undergoing in vitro fertilization with a prior suboptimal response: a randomized, controlled trial. Fertil Steril 2012; 98:881-7.e1-2. [DOI: 10.1016/j.fertnstert.2012.06.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 06/25/2012] [Accepted: 06/26/2012] [Indexed: 11/16/2022]
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Day 3 embryo transfer may have better pregnancy outcomes in younger than 35-year-old patients with poor ovarian response. J Assist Reprod Genet 2012; 29:1077-81. [PMID: 23011285 DOI: 10.1007/s10815-012-9830-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To explore the pregnancy outcomes of embryo transfer with D2 or D3 embryos in patients with poor ovarian response. METHODS The pregnancy outcomes of 620 patients who had poor ovarian response and underwent the first in vitro fertilization-embryo transfer (IVF-ET) were retrospectively analyzed. Of the 620 cycles, all available fresh D2 embryos were used in 365 cycles (day 2 embryo transfer) and all available fresh D3 embryos were used in 255 cycles (day 3 embryo transfer) without superfluous embryos for freezing. RESULTS There was a significant difference in clinical pregnancy rate between day 2 (32.73 %) and day 3 (50.83 %) embryo transfer in younger than 35-year-old patients, but no significant differences in implantation rate, live birth rate and spontaneous abortion rate (P > 0.05). There were similar pregnancy outcomes between day 2 and 3 embryo transfer in 35-year and older patients. CONCLUSION D3 embryo transfer may have better pregnancy outcomes in younger than 35-year-old patients with poor ovarian response.
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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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21
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Dilbaz S, Demir B, Cinar O, Dede S, Aydin S, Beydilli G, Goktolga U. Does 75 IU difference improve the cycle performance in poor responders? Comparison of daily 375 versus 450 IU gonadotrophin doses. Gynecol Endocrinol 2011; 27:1001-6. [PMID: 21500998 DOI: 10.3109/09513590.2011.569784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the efficacy on the cycle performance of 375 versus 450 IU/day gonadotrophin on the microdose flare-up protocol in poor responders. STUDY DESIGN A total of 91 poor responder patients who were treated with the microdose flare-up protocol were enrolled in this study. Group 1 (n = 40) was stimulated with 375 IU/day gonadotrophin. Group 2 (n = 51) was stimulated with 450 IU/day gonadotrophin. Main outcome measurements were accepted as the results of controlled ovarian hyperstimulation, implantation, clinical pregnancy, and live birth rates. RESULTS Baseline characteristics are similar between the two groups. Higher number of oocyte cumulus complexes and lower total gonadotrophin requirement were noted in Group 1 compared with Group 2. Number of metaphase II oocytes and implantation rates were similar between the groups. A trend toward higher clinical pregnancy and live birth rate was observed in Group 1 but these results did not reach statistical significance. CONCLUSIONS Total gonadotrophin costs are lower using the 375 IU/day gonadotrophin compared to the 450 IU/day in poor responders. Additional 75 IU/day does not give any improvement neither embryology nor pregnancy outcomes.
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Affiliation(s)
- Serdar Dilbaz
- Department of IVF, Etlik Zubeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
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22
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Ata B, Zeng X, Son WY, Holzer H, Tan SL. Follicular synchronization using transdermal estradiol patch and GnRH antagonists in the luteal phase; does it increase oocyte yield in poor responders to gonadotropin stimulation for in vitro fertilization (IVF)? A comparative study with microdose flare-up protocol. Gynecol Endocrinol 2011; 27:876-9. [PMID: 21495800 DOI: 10.3109/09513590.2011.569596] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this retrospective study was to compare the oocyte yield with the luteal estradiol patch (LPA) - GnRH antagonist and microdose (MD) flare-up protocols in anticipated poor responders. Fifty-seven women who underwent IVF treatment following stimulation with LPA or MD protocols at McGill Reproductive Centre were matched for age and markers of ovarian reserve. Numbers of oocytes collected (6 vs 7), mature oocytes collected (5 vs 5), and oocyte maturation rates (72% vs 74%) were similar. The numbers of good quality embryos available (2 vs 1) and embryos transferred (3 vs 3) were likewise similar. Embryo implantation rate of 16.7% and clinical pregnancy rate of 38.9% achieved in the LPA group were almost 50% higher than the corresponding figures at 10.3% and 22.2% in the MD group; however, the differences were not statistically significant (p > 0.05 for all comparisons). Although the results do not suggest an increased oocyte yield or follicular synchronization with the LPA protocol, the observed trend toward higher embryo implantation and clinical pregnancy rates requires further research.
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Affiliation(s)
- Baris Ata
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill Reproductive Centre, McGill University, Montreal, Quebec, Canada.
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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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24
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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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Nichi M, de Cassia Sávio Figueira R, Paes de Almeida Ferreira Braga D, Souza Setti A, Iaconelli A, Borges E. Decreased fertility in poor responder women is not related to oocyte morphological status. Arch Med Sci 2011; 7:315-20. [PMID: 22291773 PMCID: PMC3258723 DOI: 10.5114/aoms.2011.22084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 06/20/2011] [Accepted: 06/24/2010] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In women showing impaired fertility, a decreased response to ovarian stimulation is a major problem, limiting the number of oocytes to be used for assisted reproduction techniques (ART). Despite the several definitions of poor response, it is still a matter of debate whether young poor responder patients also show a decrease in oocyte quality. The objective in this study was to investigate whether poor ovarian response to the superstimulation protocol is accompanied by impaired oocyte quality. MATERIAL AND METHODS This study included 313 patients younger than 35 years old, undergoing intracytoplasmic sperm injection. Patients with four or fewer MII oocytes (poor-responder group, PR, n = 57) were age-matched with normoresponder patients (NR, n = 256). RESULTS A higher rate of oocyte retrieval and a trend towards an increase in MII oocyte rate were observed in the NR group when compared to the PR group (71.6 ±1.1% and 74.1 ±1.0% vs. 56.3 ±2.9% and 66.5 ±3.7%; p< 0.0001 and p = 0.056, respectively). A trend toward increased implantation rates was observed in the NR group when compared to the PR group (44 and 24.5 ±2.0% vs. 28.8 and 16.4 ±3.9%; p= 0.0305 and p= 0.0651, respectively). CONCLUSIONS Low response to ovarian stimulation is apparently not related to impaired oocyte quality. However, embryos produced from poor responder oocytes show impaired capacity to implant and to carry a pregnancy to term.
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Affiliation(s)
- Marcílio Nichi
- Department of Animal Reproduction, Faculty of Veterinary Medicine, University of São Paulo, Brazil
| | | | - Daniela Paes de Almeida Ferreira Braga
- Fertility – Assisted Fertilization Center, São Paulo, Brazil
- Sapientiae Institute – Educational and Research Center in Assisted Reproduction, São Paulo, Brazil
| | - Amanda Souza Setti
- Sapientiae Institute – Educational and Research Center in Assisted Reproduction, São Paulo, Brazil
| | | | - Edson Borges
- Fertility – Assisted Fertilization Center, São Paulo, Brazil
- Department of Gynecology and Obstetrics - Botucatu Medical School/UNESP, São Paulo, Brazil
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Figueira RDCS, Braga DPAF, Nichi M, Madaschi C, Semião-Francisco L, Iaconelli A, Borges E. Poor ovarian response in patients younger than 35 years: is it also a qualitative decline in ovarian function? HUM FERTIL 2010; 12:160-5. [PMID: 19544121 DOI: 10.1080/14647270902942928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate whether poor response to controlled ovarian stimulation (COS) is due to a qualitative decline in ovarian function. METHODS This retrospective cohort study included 436 patients younger than 35-years old, undergoing COS for intracytoplasmic sperm injection (ICSI). Patients with four or fewer MII oocytes after COS (poor-responder group, PR, n = 52) were age-matched with normoresponder patients (NR, n = 364). RESULTS Although similar duration of stimulation (10.5 +/- 0.4 and 9.3 +/- 0.8 days; p = 0.1358), increased doses of gonadotrophins (2510 +/- 865 and 2253 +/- 572 IU; p = 0.0061) were used in the PR. The results show a increased chance of cycle ending of PR (PR: 26.9% and NR: 3.1%; p < 0.0001). Although the lower total number of oocytes retrieved (2.4 +/- 1.4 and 16.2 +/- 9.3; p < 0.0001), equal rate of fertilization (70.2% and 72.0%, p = 0.1190) and high quality embryos were obtained (50.0% and 45.2%; p = 0.4895), resulting in similar implantation (14.5% and 19.7%; p = 0.2246) and abortion (10.0% and 15.4%; p = 1.00) rates, respectively. A trend towards increased pregnancy rate per embryo transfer in NR group was noted (PR: 26.3% and NR: 42.2%; p = 0.0818). CONCLUSIONS Low ovarian response could be associated mainly with a quantitative rather than a qualitative decline in ovarian function. Therefore, even if the ovarian response to stimulation is low, patients aged < or =35 years should process to oocyte retrieval.
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Pandian Z, McTavish AR, Aucott L, Hamilton MP, Bhattacharya S. Interventions for 'poor responders' to controlled ovarian hyper stimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev 2010:CD004379. [PMID: 20091563 DOI: 10.1002/14651858.cd004379.pub3] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The success of in-vitro fertilisation (IVF) depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response. OBJECTIVES To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of IVF. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG) (5/1/2009), the Cochrane Central Register of Controlled trials (CENTRAL) (4th Quarter 2008), MEDLINE (1950 to November week 3 2008), EMBASE (1980 to 2008 week 52) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to clarify data that were unclear from the trial reports. SELECTION CRITERIA Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included. DATA COLLECTION AND ANALYSIS Two reviewers independently scanned the abstracts, identified relevant papers, assessed trial quality and extracted relevant data for inclusion. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis. MAIN RESULTS The new search identified fifteen trials. Three trials were eligible for inclusion. Ten trials involving eight different comparison groups have been included. Only one trial reported live birth rates.The number of oocytes retrieved were significantly less in the conventional GnRHa long protocol compared to stop protocol and GnRH antagonist protocol.Total dose of gonadotrophins used was significantly higher in the GnRHa long protocol group compared to the Stop protocol and GnRH antagonist groups.Cancellation rates were significantly higher in the GnRHa flare up group compared to the GnRHa long protocol group.None of the studies reported a difference in the miscarriage and ectopic pregnancy rates. AUTHORS' CONCLUSIONS There is insufficient evidence to support the routine use of any particular intervention either for pituitary down regulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.
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Affiliation(s)
- Zabeena Pandian
- Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, UK, AB25 2ZD
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Qublan HS, Malkawi HY, Tahat YA, Areidah S, Nusair B, Khreisat BM, Al-Quraan G, Abu-Assaf A, Hadaddein MF, Abu-Jassar H. In-vitrofertilisation treatment: Factors affecting its results and outcome. J OBSTET GYNAECOL 2009; 25:689-93. [PMID: 16263545 DOI: 10.1080/01443610500292353] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of this study was to determine factors affecting results and outcome of in-vitro fertilisation (IVF). In this retrospective study, a total of 891 infertile women underwent IVF/ICSI cycles at the King Hussein Medical Center (KHMC) between January 2001 and December 2002. Conventional IVF treatment was performed in 64.6% of women and intracytoplasmic sperm injection (ICSI) in 35.4%, using a standardised long luteal protocol. Pregnancy rate was analysed according to age, type of infertility, cause of infertility, duration of infertility, number of eggs collected and follicle stimulating hormone (FSH) levels. A total of 126 cycles (14.1%) were cancelled. Among 765 cycles continued, fertilisation rate was 73.9%, implantation rate was 15.1% and pregnancy rate was 29.8%. Pregnant women had a multiple pregnancy rate of 28.9%, abortion rate of 13.6% and ectopic pregnancy rate of 1.3%. Duration and type of infertility had no significant effect on the pregnancy rate. Factors which appear to affect significantly the outcome of treatment include the woman's age, cause of infertility, basal concentrations of FSH, adequate ovarian responsiveness and the number of eggs collected. In some cases with poor outcome, the understanding of these factors may predict the results and lead to the development of new strategies to improve the outcome of IVF treatment.
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Affiliation(s)
- H S Qublan
- IVF-Center, King Hussein Medical Center, Royal Medical Services, Amman, Jordan.
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Siristatidis CS, Hamilton MP. What should be the maximum FSH dose in IVF/ICSI in poor responders? J OBSTET GYNAECOL 2009; 27:401-5. [PMID: 17654194 DOI: 10.1080/01443610701327420] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Various protocols of ovarian stimulation have been proposed for optimising IVF/ICSI results in women presenting with a poor response to controlled ovarian stimulation; however, achieving a good response to stimulation for this category of patients still remains a challenge. The most extensively employed strategy to improve follicular response in these so-called 'poor responders' involves the use of high doses of gonadotrophins. A small number of randomised controlled trials and retrospective studies have evaluated the effectiveness of the high-dose FSH regimes over a 300 IU threshold. The results of these studies have shown these approaches to be of little or no clinical benefit, although both the costs of treatment and side-effects were higher. There are other studies that have examined 450 IU FSH regimens or even more. This paper presents an overview in all these clinical trials, trying to evaluate the safest and most effective upper limit of FSH that may be used for controlled ovarian hyperstimulation.
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Affiliation(s)
- C S Siristatidis
- Assisted Reproduction Unit, Aberdeen University, Aberdeen Maternity Hospital, Aberdeen, UK.
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Ferreira RC, Braga DPDAF, Bonetti TCDS, Pasqualotto FF, Iaconelli A, Borges E. Negative influence of paternal age on clinical intracytoplasmic sperm injection cycle outcomes in oligozoospermic patients. Fertil Steril 2009; 93:1870-4. [PMID: 19409557 DOI: 10.1016/j.fertnstert.2008.12.043] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 11/11/2008] [Accepted: 12/10/2008] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the effect of male age on clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles, according to sperm concentration. DESIGN Retrospective, observational study. SETTING Assisted reproduction center. PATIENT(S) The study included 1,024 couples undergoing ICSI cycles with fresh spermatozoa. INTERVENTION(S) The influence of paternal age on ICSI outcomes of oligozoospermic and normozoospermic patients was evaluated. MAIN OUTCOME MEASURE(S) Rates of high-quality embryos, pregnancy, implantation, and miscarriage were evaluated through linear logistic regression analyses. RESULT(S) When the sperm concentration was abnormal, paternal age influenced implantation (regression coefficient value = -0.7009) and pregnancy rates (odds ratio = 0.95, 95% confidence interval 0.91-0.99). However, in normozoospermic patients, no influence of paternal age was observed on implantation (regression coefficient value = 0.0566) or pregnancy rates (odds ratio = 1.00, 95% confidence interval 0.97-1.03). CONCLUSION(S) For couples in which the men are oligozoospermic, the implantation rate could be impaired by increased paternal age. In these couples, the chance of pregnancy decreased 5% for each year of paternal age. When men are normozoospermic, this effect is not observed.
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Affiliation(s)
- Renata Cristina Ferreira
- Sapientiae Institute, Educational and Research Center in Assisted Reproduction, São Paulo, Brazil
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Merviel P, Lourdel E, Boulard V, Cabry R, Claeys C, Oliéric MF, Sanguinet P, Brasseur F, Henri I, Copin H. [Premature ovarian failure: which protocols?]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2008; 36:872-881. [PMID: 18703373 DOI: 10.1016/j.gyobfe.2008.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 06/15/2008] [Indexed: 05/26/2023]
Abstract
This review shows the results of the various studies concerning the protocols applied to the women presenting a premature ovarian failure. Will be thus analyzed the natural cycles (or semi-natural), the increase in the dose of gonadotrophins, the clomiphene citrate and the anti-aromatases, the protocols with GnRH agonists long, short, stop or microdoses, the protocols with GnRH antagonists and the adjuvant treatments: aspirin, nitric oxyde, recombinant LH recombining, growth hormone and androgens. The interest of several protocols is to collect a sufficient number of oocytes (and thus of embryos to be transferred), making it possible to obtain reasonable rates of pregnancy. However, it arises that the rates of pregnancy observed among these women depend not only on their ovarian reserve and their age, but are also function of the type of infertility, of the cycle number and the uterus.
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Affiliation(s)
- P Merviel
- Service de gynécologie obstétrique et médecine de la reproduction, centre d'Assistance médicale à la procréation (AMP), CHU d'Amiens, 124, rue Camille-Desmoulins, 80054 Amiens cedex 1, France.
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Kucuk T, Göktolga Ü, Sozen E. Efficiency of follicle-stimulating hormone, commenced in the luteal phase, for overcoming a poor response in assisted reproduction. J Obstet Gynaecol Res 2008; 34:574-7. [DOI: 10.1111/j.1447-0756.2008.00750.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Randomized controlled pilot trial of luteal phase recombinant FSH stimulation in poor responders. Reprod Biomed Online 2008; 17:745-50. [DOI: 10.1016/s1472-6483(10)60400-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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34
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Different ovarian stimulation protocols for women with diminished ovarian reserve. J Assist Reprod Genet 2007; 24:597-611. [PMID: 18034299 DOI: 10.1007/s10815-007-9181-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols. METHODS Literature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews. RESULTS A lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients. CONCLUSIONS The ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.
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Kucuk T, Sozen E. Luteal start of exogenous FSH in poor responder women. J Assist Reprod Genet 2007; 24:635-8. [PMID: 18008156 DOI: 10.1007/s10815-007-9176-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 10/29/2007] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To compare the effectiveness of using recFSH commenced in the luteal phase with a long GnRH agonist protocol or in the early follicular phase with a short GnRH agonist protocol, in infertile women designated as poor responders undergoing treatment with assisted reproduction in a prospective, randomized, controlled study. MATERIALS AND METHODS Forty-two couples undergoing an ICSI cycle of whom female partner diagnosed as poor responder were included in the study. Recombinant FSH was given daily from day 21 of the previous cycle upon initiation of GnRH agonist in the study group. Control group was given FSH on day 2 in a short protocol GnRH agonist regimen. The number of metaphase 2 oocytes was analysed as the main outcome measure; pregnancy rate and clinical pregnancy rate were secondary outcome measures. RESULTS Patients in the study group had significantly higher number of metaphase 2 oocytes. Although not statistically significantly patients in the study group had higher pregnancy/clinical pregnancy rates, as well. CONCLUSION This preliminary study shows that luteal start of recFSH simultaneously with long protocol GnRH agonist in poor responder women produced better results comparing to short protocol GnRH agonist plus high dose FSH regimen.
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Affiliation(s)
- Tansu Kucuk
- Department of Obstetrics and Gynecology, GATA School of Medicine, 06018, Etlik, Ankara, Turkey.
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36
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Kumbak B, Oral E. Quality of residual follicles may depend on the etiology of “declining” ovarian function? Fertil Steril 2007; 88:1480-1; author reply 1481. [DOI: 10.1016/j.fertnstert.2007.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Shanbhag S, Aucott L, Bhattacharya S, Hamilton MA, McTavish AR. Interventions for 'poor responders' to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev 2007:CD004379. [PMID: 17253503 DOI: 10.1002/14651858.cd004379.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The success of in-vitro fertilisation (IVF) treatment depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response. OBJECTIVES To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of in vitro fertilisation. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG), the Cochrane Central Register of Controlled trials (CENTRAL) (The Cochrane Library 2003, Issue 1), MEDLINE (1966 to August 2006), EMBASE (1980 to August 2006) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to identify or clarify data that were unclear from the trial reports. SELECTION CRITERIA Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included. DATA COLLECTION AND ANALYSIS Two review authors independently scanned the abstracts, identified relevant papers, assessed inclusion and trial quality and extracted relevant data. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis. MAIN RESULTS Nine trials involving six different comparison groups have been included in this review. Only one trial reported live birth rates. Four groups compared the long protocol with another intervention. Only one comparison group (bromocryptine versus long protocol) reported a higher clinical pregnancy rate per cycle, in the bromocryptine arm (OR 5.60, 95% CI 1.40 to 22.47). Two comparison groups showed a lower number of oocytes in the long protocol group (versus stop and gonadotrophin releasing hormone (GnRH) antagonist protocols). However, two comparison groups also showed lower cancellation rates in the long protocol treatment group (versus stop and GnRHa flare-up protocols). None reported any evident difference in the adverse effects. AUTHORS' CONCLUSIONS There is insufficient evidence to support the routine use of any particular intervention either for pituitary downregulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.
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Affiliation(s)
- S Shanbhag
- University of Aberdeen, Assisted Reproduction Unit, Aberdeen Maternity Hospital, Aberdeen, Scotland, UK, AB25 2ZD.
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Ng EHY, Yeung WSB, Ho PC. Patients with three or less dominant follicles may not be associated with reduced pregnancy rate of in vitro fertilization treatment. Eur J Obstet Gynecol Reprod Biol 2006; 129:54-9. [PMID: 16584831 DOI: 10.1016/j.ejogrb.2006.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Revised: 03/06/2006] [Accepted: 03/08/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The management of poor ovarian responders remains a great challenge in in vitro fertilization (IVF) treatment. This study compared implantation and pregnancy rates among women who developed <or=3 dominant follicles of >or=16 mm in diameter and those who had >3 dominant follicles after ovarian stimulation. STUDY DESIGN Retrospective study. RESULTS Out of 911 consecutive patients receiving ovarian stimulation between January 2000 and December 2002, 894 (98.1%) patients underwent oocyte retrieval. Women with <or=3 dominant follicles were significantly older, required a longer duration and a higher dosage of gonadotrophin but produced lesser number of developing follicles, number of oocytes aspirated and number of embryos frozen when compared with those with >3 dominant follicles. Despite a significantly higher percentage of non-elective single embryo transfer in women with <or=3 dominant follicles, implantation rate, pregnancy rate and pregnancy outcomes were comparable for women with <or=3 and >3 dominant follicles. CONCLUSION Implantation and pregnancy rates appeared to be comparable for women who developed <or=3 and >3 dominant follicles during IVF treatment.
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Affiliation(s)
- Ernest H Y Ng
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong Special Administrative Region, PR China.
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Papaleo E, De Santis L, Fusi F, Doldi N, Brigante C, Marelli G, Persico P, Cino I, Ferrari A. Natural cycle as first approach in aged patients with elevated follicle-stimulating hormone undergoing intracytoplasmic sperm injection: a pilot study. Gynecol Endocrinol 2006; 22:351-4. [PMID: 16864143 DOI: 10.1080/09513590600818992] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Poor ovarian response to standard in vitro fertilization-embryo transfer (IVF-ET) protocols or different regimens of treatment, as consequence of a diminished ovarian reserve, correlates strictly with patient age, elevated follicle-stimulating hormone (FSH) and reduced antral follicle count. The aim of the present pilot study was to evaluate the outcome of patients with poor prognostic features undergoing IVF-ET with natural cycles as a first approach and not as a consequence of a previous failure treatment. MATERIALS AND METHODS Eighteen aged patients (mean +/- standard deviation 40.2 +/- 0.7 years, range 37-43 years) with elevated serum FSH and reduced antral follicle count underwent intracytoplasmic sperm injection (ICSI) after spontaneous ovulation. RESULTS A total of 26 natural cycles with ICSI were analyzed. Pregnancy was observed in three patients, of which two were ongoing as assessed by fetal heart beat at ultrasound scan performed 4-5 weeks after ET. CONCLUSION The overall pregnancy rates achieved (11.5% per cycle, 20.0% per ET) are comparable with those of conventional IVF-ET in aged patients, and not impaired by a single embryo transferred. Better embryo quality, as a consequence of natural selection of oocytes, better endometrium receptivity and monthly repeatability of the procedure, can balance the relatively low chance to perform ET.
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Affiliation(s)
- Enrico Papaleo
- IVF Unit, Gynaecological-Obstetric Department, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy.
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Macklon NS, Stouffer RL, Giudice LC, Fauser BCJM. The science behind 25 years of ovarian stimulation for in vitro fertilization. Endocr Rev 2006; 27:170-207. [PMID: 16434510 DOI: 10.1210/er.2005-0015] [Citation(s) in RCA: 338] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.
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Affiliation(s)
- Nick S Macklon
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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41
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Kan A, Ng EHY, Yeung WSB, Ho PC. Perifollicular vascularity in poor ovarian responders during IVF. Hum Reprod 2006; 21:1539-44. [PMID: 16488903 DOI: 10.1093/humrep/del021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Normal ovarian responders who have follicles with good vascularity shown by power Doppler scanning are associated with a better pregnancy rate following IVF treatment. This study evaluated the significance of perifollicular vascularity and follicular fluid hormonal profile in poor responders who developed < or = 3 dominant follicles. METHODS Before oocyte retrieval, they underwent power Doppler examination for perifollicular vascularity. Patients who had all follicles with low-grade vascularity were classified as Group A, whereas those with at least one follicle with high-grade vascularity were Group B. Their follicular fluid concentrations of estradiol (E2), progesterone, HCG, vascular endothelial growth factor (VEGF) and inhibin B were measured. RESULTS A total of 58 consecutive patients were recruited: 38 in Group A and 20 in Group B. Implantation rate, clinical pregnancy rate and follicular fluid hormonal concentrations were comparable for Groups A and B. Multiple pregnancy and live birth rates appeared higher, whereas miscarriage rate were lower in Group B than Group A, but these differences did not reach statistical significance. CONCLUSION There were no significant differences in the implantation, clinical pregnancy and live birth rates among poor responders with and without high-grade perifollicular vascularity.
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Affiliation(s)
- Anita Kan
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, People's Republic of China
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Ubaldi FM, Rienzi L, Ferrero S, Baroni E, Sapienza F, Cobellis L, Greco E. Management of poor responders in IVF. Reprod Biomed Online 2005; 10:235-46. [PMID: 15823231 DOI: 10.1016/s1472-6483(10)60946-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Correct controlled ovarian stimulation is of paramount importance in assisted reproductive technologies. Therefore, analysis of the ovarian reserve of the patient is mandatory to tailor the best ovarian stimulation regimen. When the ovarian reserve is reduced, the induction of a multifollicular growth remains a challenge. Several factors could be associated with reduced ovarian response. However, reduced ovarian reserve either in older patients or in young patients represents the most frequent aetiological factor. Whatever is the aetiology, one of the main problems is how to predict a reduced ovarian response, and although several tests have been suggested, no very accurate predictive test is available. A variety of different stimulation protocols have been suggested but the lack of any large-scale, prospective, randomized, controlled trials of the different management strategies and the lack of a uniform definition of the population may result in comparisons of heterogeneous groups of patients, making it difficult to draw any definitive conclusions. Natural cycle IVF may represent an easy and cheap approach in the management of this group of patients. Although no controlled large prospective randomized studies are available to compare the natural IVF procedure with ovarian stimulation IVF in poor responder patients, the efficacy of natural cycle IVF is hampered by high cancellation rates mainly due to untimely LH surge. The use of gonadotrophin-releasing hormone antagonists in the late follicular phase, which reduces the premature LH rise rate, and the improvements in laboratory conditions and fertilization techniques, increase the embryo transfer rates, making this procedure more cost-effective.
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Affiliation(s)
- F M Ubaldi
- Centre for Reproductive Medicine, European Hospital, Via Portuense 700-00148, Rome, Italy.
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Galey-Fontaine J, Cédrin-Durnerin I, Chaïbi R, Massin N, Hugues JN. Age and ovarian reserve are distinct predictive factors of cycle outcome in low responders. Reprod Biomed Online 2005; 10:94-9. [PMID: 15705301 DOI: 10.1016/s1472-6483(10)60808-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The respective roles of age and ovarian reserve in predicting IVF outcome do not seem to be equivalent, as a high pregnancy rate seems to be preserved in the youngest women, despite low ovarian recruitment. The purpose of this study was to analyse the outcome of IVF/intracytoplasmic sperm injection (ICSI) procedures according to both age and ovarian reserve of patients with a low ovarian response to stimulation. A total of 163 IVF/ICSI cycles selected by a low response were analysed. The IVF outcome differed according to the women's age, with a cut-off value at 36 years. While the number of transferred embryos was similar, the pregnancy rate (PR) was 14.6% in younger patients but 4.9% (P < 0.04) in older ones. An elevated FSH was constantly associated with a poor cycle outcome. In contrast, when the FSH was normal, PR was significantly higher (P < 0.05) in women aged <36 (23.8%) than in women aged > or =36 (6.5%). This study shows that assisted reproduction outcome in women with a low ovarian response is primarily dependent on the ovarian status. The negative influence of age is relevant in patients with normal FSH. Therefore, even if the ovarian response to stimulation is low, patients aged <36 years with a normal FSH should proceed to oocyte retrieval.
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Affiliation(s)
- Julie Galey-Fontaine
- Centre for Reproductive Medicine, Jean Verdier Hospital (AP-HP), Bondy 93143, University Paris XIII, France
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Humaidan P, Bungum L, Bungum M, Hald F, Agerholm I, Blaabjerg J, Yding Andersen C, Lindenberg S. Reproductive outcome using a GnRH antagonist (cetrorelix) for luteolysis and follicular synchronization in poor responder IVF/ICSI patients treated with a flexible GnRH antagonist protocol. Reprod Biomed Online 2005; 11:679-84. [PMID: 16417730 DOI: 10.1016/s1472-6483(10)61685-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To investigate the possible beneficial effect of a new stimulation protocol (termed 'CRASH') on the outcome of poor responder patients, a multicentre, prospective longitudinal study including a total of 36 women undergoing 72 IVF/intracytoplasmic sperm injection (ICSI) cycles with patients serving as their own controls, was conducted. A poor responder patient was defined as a patient with four or fewer oocytes extracted from five or fewer follicles and with a total FSH consumption exceeding 2000 IU in a preceding long agonist down-regulation protocol. The CRASH protocol included 3 mg of the gonadotrophin-releasing hormone (GnRH) antagonist cetrorelix given in the late luteal phase on cycle day 23. Stimulation with recombinant human FSH (rhFSH) started on cycle day 2, followed by a flexible GnRH antagonist protocol. The results showed significantly more follicles (5.4 versus 3.5), oocytes (4.3 versus 2.4) and transferable embryos (1.8 versus 0.8) with the CRASH protocol as compared with the preceding long protocol (P < 0.005 in all cases). The implantation rate and pregnancy rate per transfer was 18.4 and 38.5% respectively, approaching the clinical outcome of normal responder patients. The CRASH protocol thus may constitute an attractive alternative to conventional protocols for low responder patients, improving their clinical outcome.
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Affiliation(s)
- P Humaidan
- The Fertility Clinic, Viborg Hospital Skive, Skive, Denmark.
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Loutradis D, Drakakis P, Milingos S, Stefanidis K, Michalas S. Alternative Approaches in the Management of Poor Response in Controlled Ovarian Hyperstimulation (COH). Ann N Y Acad Sci 2003; 997:112-9. [PMID: 14644816 DOI: 10.1196/annals.1290.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Improving pregnancy rates in patients with many failed attempts remains a challenge during IVF-ET or ICSI-ET programs. The availability of good-quality oocytes is a prerequisite for good results in such programs. The use of a personalized protocol for controlled ovarian hyperstimulation (COH) that gives the best possible results for the specific patient is a main factor for the success in IVF or ICSI. The response of many patients to the ovarian stimulation used is very poor, giving fewer oocytes than expected, resulting in much lower, if any, pregnancy rates. The definition of a poor responder is not clear and differs among researchers. A variety of strategies have been used to improve response in these patients, regardless of the definition used. These include various ovulation induction protocols that we believe might assist these patients achieve a pregnancy. The difficulty is greater due to the fact that poor responders are not a homogeneous group and each patient may have a different cause. More studies with large numbers of patients are needed in order to find those protocols that could provide these couples with an acceptable pregnancy rate.
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Affiliation(s)
- Dimitris Loutradis
- 1st Dept OB/GYN, Athens University Medical School, Alexandria Maternity Hospital, Athens, Greece
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Fasouliotis SJ, Simon A, Laufer N. Evaluation and treatment of low responders in assisted reproductive technology: a challenge to meet. J Assist Reprod Genet 2000; 17:357-73. [PMID: 11077616 PMCID: PMC3489420 DOI: 10.1023/a:1009465324197] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To investigate the various methods of evaluation and treatment of patients with a low response to controlled ovarian hyperstimulation in assisted reproductive technologies (ART). METHODS Review and analysis of relevant studies published in the last decade, identified through the literature and Medline searches. RESULTS While a universally accepted definition for low responders is still lacking, these patients are reported to represent about 10% of the ART population. Several ovarian reserve screening techniques have been proposed; however, currently the best-characterized and most sensitive screening tools available are the basal day 3 serum follicle-stimulating hormone level and the clomiphene citrate challenge test. When abnormal, these tests allow physicians to counsel patients that their prognosis for conception is poor. Although the presence of a normal result does indicate better long-term chances for conception, on age-related decline in fecundity remains and patient age should still be considered when counseling patients with normal screening results. Several stimulation protocols have been applied in the low-response group with varying success. Recent studies show that the use of a minidose gonadotropin-releasing hormone-agonist protocol may result in significantly decreased cycle cancellations as well as increased clinical and ongoing pregnancies, and thus is proposed as a first-line therapy. Studies evaluating supplementary forms of treatment to the ovulation induction regimen show improved outcome when pretreating with oral contraceptives, whereas there seems to be no benefit from cotreatment with growth hormone or glucocorticoids. Blastocyst culture and transfer and assisted hatching in low responders are still under evaluation, whereas natural cycle in vitro fertilization may be used in cases of repeated failures as a last option before resorting to oocyte donation or adoption. Future possible forms of treatment like in vitro maturation of immature human oocytes, cytoplasm, and nuclear transfer currently are experimental in nature and their efficacy has still to be proven. CONCLUSIONS The evaluation and treatment of low responders in ART remains a challenge. Understanding of the underlying etiology and pathophysiology of this disorder may help the clinician to approach it successfully.
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Affiliation(s)
- S J Fasouliotis
- Department of Obstetrics and Gynecology, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
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Salha O, Balen AH. New concepts in superovulation strategies for assisted conception treatments. Curr Opin Obstet Gynecol 2000; 12:201-6. [PMID: 10873121 DOI: 10.1097/00001703-200006000-00007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Controlled ovarian stimulation for in-vitro fertilization treatment using preparations that contain follicle-stimulating hormone has been routinely performed since the 1980s. The early preparations were urinary human menopausal gonadotrophins, containing follicle-stimulating hormone and luteinizing hormone. In the early 1990s, highly purified follicle-stimulating hormone preparations were introduced because of a desire to provide drugs for subcutaneous administration with a lower risk of allergic reactions. Intensive research resulted in the discovery of recombinant follicle-stimulating hormone, which is more potent that the highly purified follicle-stimulating hormone, resulting in significantly higher clinical pregnancy rates. The two recombinant follicle-stimulating hormone preparations available appear to be equally effective and provide comparable results. Gonadotrophin-releasing hormone antagonists, which have recently been introduced, appear to be effective in preventing a premature rise in luteinizing hormone during ovarian stimulation for in-vitro fertilization, as well as improved response to lower doses of gonadotrophins. It is envisaged that the availability of recombinant gonadotrophins and gonadotrophin-releasing hormone antagonists will ultimately lead to shorter, cheaper and safer treatments, using reduced dosages.
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Affiliation(s)
- O Salha
- Department of Reproductive Medicine, Leeds General Infirmary, UK
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Abstract
Mammalian ovaries consist of follicles as basic functional units. The total number of ovarian follicles is determined early in life, and the depletion of this pool leads to reproductive senescence. Each follicle develops to either ovulate or, more likely, to undergo degeneration. The dynamics of ovarian follicle development have interested endocrinologists and developmental biologists for many years. With the advent of assisted reproductive techniques in humans, the possibility of regulating follicle development in vivo and in vitro has gained clinical relevance. In this review, we focus upon key branching points during the development of ovarian follicles as well as factors involved in determining the eventual destiny of individual follicles. We discuss inconsistencies in the literature regarding the definitions of follicle recruitment and selection and propose to name the two major steps of follicle development as initial and cyclic recruitment, respectively. Because some of these disparities have arisen due to differences in the animal systems studied, we also compare the development of the ovarian follicles of both humans and rats. We also review the status of knowledge of several puzzling clinical issues that may provide important clues toward unlocking the mechanisms of follicle development.
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Affiliation(s)
- E A McGee
- Department of Gynecology and Obstetrics, Stanford University School of Medicine, California 94305-5317, USA
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Surrey ES, Schoolcraft WB. Evaluating strategies for improving ovarian response of the poor responder undergoing assisted reproductive techniques. Fertil Steril 2000; 73:667-76. [PMID: 10731523 DOI: 10.1016/s0015-0282(99)00630-5] [Citation(s) in RCA: 216] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess the efficacy of various controlled ovarian hyperstimulation (COH) regimens in the prior poor-responder patient preparing for assisted reproductive techniques. DESIGN English-language literature review. PATIENT(S) Candidates for assisted reproductive techniques who had been defined as having a prior suboptimal response to standard COH regimens. INTERVENTION(S) A variety of regimes are reviewed, including increased gonadotropin doses, change of gonadotropins, adjunctive growth hormone (GH), luteal phase (long) GnRH agonist (GnRH-a) initiation, early follicular phase (flare) GnRH-a initiation, low-dose luteal phase (ultrashort) GnRH-a initiation, progestin pretreatment, and microdose flare GnRH-a initiation. MAIN OUTCOME MEASURE(S) Maximal serum E(2) levels, follicular development, dose, and duration of gonadotropin therapy, cycle cancellation rates, oocytes retrieved, embryos transferred, and clinical and ongoing pregnancy rates. RESULT(S) A lack of uniformity in definition of the poor responder and of prospective randomized trials make data interpretation somewhat difficult. Of the varied strategies proposed, those that seem to be more uniformly beneficial are microdose GnRH-a flare and late luteal phase initiation of a short course of low-dose GnRH-a discontinued before COH. CONCLUSION(S) No single regimen will benefit all poor responders. General acceptance of uniform definitions and performance of large-scale prospective randomized trials are critical. Development of a reliable precycle screen will allow effective differentiation among normal responders, poor responders, and those who will not conceive with their own oocytes.
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Affiliation(s)
- E S Surrey
- Colorado Center for Reproductive Medicine, Englewood, Colorado, USA
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al-Mizyen E, Sabatini L, Lower AM, Wilson CM, al-Shawaf T, Grudzinskas JG. Does pretreatment with progestogen or oral contraceptive pills in low responders followed by the GnRHa flare protocol improve the outcome of IVF-ET? J Assist Reprod Genet 2000; 17:140-6. [PMID: 10911573 PMCID: PMC3455662 DOI: 10.1023/a:1009462004650] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Women undergoing in vitro fertilization with low ovarian reserve and poor response to controlled ovarian hyperstimulation (COH) present a management dilemma. In a retrospective observational study, we compared the pretreatment use of the gestogen medroxyprogesterone acetate (10 mg twice daily from day 15 of the cycle for a minimum of 2 weeks) with an oral contraceptive pill (one tablet daily from day 4 of the cycle for a minimum of 3 weeks). METHODS The criteria for inclusion in the study included one or more of the following: abandoned cycles due to poor response, fewer than four oocytes retrieved following a standard COH protocol, age > 39 years, and elevated basal serum follicle-stimulating hormone (FSH). Thirty-eight women received pretreatment with gestogen, and a similar number of women received pretreatment with the pill. The flare protocol was used in all treatment cycles combined with an individualized dose of human menopausal gonadotropin (hMG) (4-8 ampoules/day of 75 units FSH/ampoule) depending on previous response, age, and early follicular serum FSH level. Both groups were similar in mean age, duration of infertility, early follicular FSH levels, and the distribution of various aetiologies. RESULTS Twenty-nine cycles were abandoned before oocyte retrieval, 15 (39.5%) in the pill group and 14 (36.8%) in the gestogen group, because of an inadequate ovarian response. The mean (+/- SD) number of ampoules (75 IU FSH/ampoule) of hMG used per cycle was similar in the pill and gestogen groups (59.7 +/- 19.3 vs. 70.2 +/- 29.4, respectively). There also was no difference seen in the numbers of oocytes retrieved (4.4 +/- 2.3 vs. 4.2 +/- 2.5), total number of embryos (2.5 +/- 2.4 vs. 2.2 +/- 1.1), or the number of embryos transferred (1.8 +/- 1.2 vs. 2.1 +/- 1.0) in the pill and gestogen groups, respectively. One pregnancy in each group resulted following embryo transfer in 22 women in the pill group and in 24 women in the gestogen group. CONCLUSIONS We conclude that pre-IVF treatment with oral contraceptive pill or gestogen combined with the flare protocol in women at high risk of or with a history of poor ovarian response, as defined in this study, did not appear to result in an improvement in outcome of IVF-embryo transfer.
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Affiliation(s)
- E al-Mizyen
- Fertility Centre, Royal Hospitals Trust, St. Bartholomew's Hospital, London, England
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