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

Effects of Intraovarian Injection of Autologous Platelet-Rich Plasma on Ovarian Rejuvenation in Poor Responders and Women with Primary Ovarian Insufficiency

Injection of intraovarian platelet-rich plasma (PRP) was recently presented in terms of improvement ovarian function in women with a poor ovarian response (POR) or primary ovarian insufficiency (POI). In a before and after study, 17 poor responder women and 9 women with the diagnosis of POI were recruited. The multifocal intramedullary infusion of 1.5 ml activated PRP was performed into each ovary. The majority of women in both groups received the second PRP injection with the twofold increase in the dosage to 3ml, 3 months after the first injection. Evaluation of serum anti-mullerian hormone ( AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) was performed. In addition, all women were followed with regard to pregnancy outcome up to delivery. In the POI group, menstrual restoration was monitored. The significant difference was not detected regarding the hormonal profile between the three time points in both groups. With regard to pregnancy outcome, 8/17 (47%) of PORs had spontaneous pregnancy in response to PRP injection. Of those, three women (37.55%) had abortions, whereas 4 pregnancies (50%) led to healthy live births, and one woman (12.5%) was in the 24^th week of her pregnancy. Menstruation recovery occurred among 22.2% of women with POI after the second PRP injection, but no one became pregnant. Intraovarian injection of autologous PRP might be considered an alternative treatment in poor responders. As for women with POI, it is questionable whether PRP could induce menstrual recovery.

Management Strategies for POSEIDON Group 2

Although individualization of ovarian stimulation aims at maximal efficacy and safety in assisted reproductive treatments, in its current form it is far from ideal in achieving the desired success in women with a low prognosis. This could be due a failure to identify such women who are likely to have a low prognosis with currently used prognostic characteristics. Introduction of the patient-oriented strategies encompassing individualized oocyte number (POSEIDON) concept reinforces recognizing such low prognosis groups and stratifying in accordance with important prognostic factors. The POSEIDON concept provides a practical approach to the management of these women and is a useful tool for both counseling and clinical management. In this commentary, we focus on likely management strategies for POSEIDON group 2 criteria.

The influence of different growth hormone addition protocols to poor ovarian responders on clinical outcomes in controlled ovary stimulation cycles: A systematic review and meta-analysis

BACKGROUND

Growth hormone (GH) is used as an adjuvant therapy in in vitro fertilization and embryo transfer (IVF-ET) for poor ovarian responders, but findings for its effects on outcomes of IVF have been conflicting. The aim of the study was to compare IVF-ET outcomes among women with poor ovarian responders, and find which subgroup can benefit from the GH addition.

METHODS

We searched the databases, using the terms "growth hormone," "GH," "IVF," "in vitro fertilization." Randomized controlled trials (RCT) were included if they assessed pregnancy rate, live birth rate, collected oocytes, fertilization rate, and implantation rate. Extracted the data from the corresponding articles, Mantel-Haenszel random-effects model, or fixed-effects model was used. Eleven studies were included.

RESULTS

Clinical pregnancy rate (RR 1.65, 95% CI 1.23-2.22), live birth rate (RR1.73, 1.25-2.40), collected oocytes number (SMD 1.09, 95% CI 0.54-1.64), MII oocytes number (SMD 1.48, 0.84-2.13), and E2 on human chorionic gonadotropin (HCG) day (SMD 1.03, 0.18-1.89) were significantly increased in the GH group. The cancelled cycles rate (RR 0.65, 0.45-0.94) and the dose of gonadotropin (Gn) (SMD -0.83, -1.47, -0.19) were significantly lower in patients who received GH. Subgroup analysis indicated that the GH addition with Gn significantly increased the clinical pregnancy rate (RR 1.76, 1.25-2.48) and the live birth rate (RR 1.91, 1.29-2.83).

CONCLUSION

The GH addition can significantly improve the clinical pregnancy rate and live birth rate. Furthermore, the GH addition time and collocation of medications may affect the pregnancy outcome.

Effect of mid-follicular phase recombinant LH versus urinary HCG supplementation in poor ovarian responders undergoing IVF - a prospective double-blinded randomized study

Luteinizing hormone (LH) is crucial for the development of follicular growth and oocyte maturation, especially in the management of poor ovarian responders (PORs). This study presents the results of a prospective double-blinded randomized study to compare the effect of mid-follicular phase recombinant LH (rLH) supplementation with urinary human chorionic gonadotrophin (uHCG) supplementation when using a fixed gonadotrophin-releasing hormone (GnRH) antagonist protocol in IVF cycles. A total of 49 women with poor ovarian response (POR) according to the Bologna criteria were recruited. This study showed no statistically significant difference in cycle cancellation rates, numbers of oocytes retrieved per cycle initiated, fertilization rates, the numbers of embryos obtained per cycle initiated, implantation, clinical pregnancy and live birth rates, although the live birth rate per cycle initiated in the uHCG group (29.2%) was 3.6 times that of the rLH group (8.0%). Further studies are required to verify if uHCG supplementation produces better clinical outcomes compared with rLH in women with POR.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of poor responders in IVF: is there anything new?

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.

Live birth from a 46-year-old using fresh autologous oocytes through in vitro fertilization

OBJECTIVE

To report a live birth with IVF from a 46-year-old woman using autologous oocytes.

DESIGN

Case report.

SETTING

Reproductive endocrinology and infertility private practice and ambulatory IVF center.

PATIENT(S)

One 46-year-old nulligravid woman.

INTERVENTION(S)

IVF with fresh ET.

MAIN OUTCOME MEASURE(S)

Live birth after IVF.

RESULT(S)

A 46-year-old with antimullerian hormone (AMH) level less than 0.16 conceived through IVF using autologous oocytes. A total of seven oocytes were retrieved, from which four embryos were transferred at the cleavage stage, resulting in a pregnancy and delivery of a healthy male infant weighing 1,580 g at 31 and 3/7 weeks' estimated gestational age.

CONCLUSION(S)

The prognosis for a live birth from IVF in a patient with very advanced reproductive age, particularly with an undetectable AMH level using autologous oocytes, remains extremely poor. This case should be interpreted with caution so as to not provide false hope to women aged 45 and above.

Corifollitropin α followed by menotropin for poor ovarian responders' trial (COMPORT): a protocol of a multicentre randomised trial

BACKGROUND

Poor response to ovarian stimulation affects a significant proportion of infertile couples undergoing in vitro fertilisation (IVF) treatment. Recently, the European Society of Human Reproduction and Embryology developed new criteria to define poor ovarian response, the so-called Bologna criteria. Although preliminary studies in these patients demonstrated very low pregnancy rates, a recent pilot study has shown promising results in women <40 years old fulfilling the criteria, after treatment with corifollitropin α followed by highly purified menotropin (hpHMG) in a gonadotropin-releasing hormone (GnRH) antagonist setting. Corifollitropin α followed by menotropin for poor ovarian responders' trial (COMPORT) is a randomised trial aiming to investigate whether this novel protocol is superior to treatment with recombinant follicle-stimulating hormone (FSH) in an antagonist setting for young poor responders.

METHODS/DESIGN

COMPORT is a multicentre, open label, phase III randomised trial using a parallel two-arm design. 150 patients <40 years old fulfilling the 'Bologna criteria' will be randomised to corifollitropin α followed by hpHMG (group A) or recombinant FSH (group B) in a GnRH antagonist protocol for IVF/intracytoplasmic sperm injection (ICSI). The primary outcome is the ongoing pregnancy rate (defined as the presence of intrauterine gestational sac with an embryonic pole demonstrating cardiac activity at 9-10 weeks of gestation). Secondary outcomes are clinical and biochemical pregnancy rates and number of oocytes retrieved. Central randomisation will be performed using a computer-generated list and allocation concealment will be secured with the use of sealed-opaque envelopes. A sample size of 150 women is essential to detect a difference of 19.5% in ongoing pregnancy rates between group A (28%) and group B (8.5%) with a power of 85% and a level of significance at 0.05 using a two-sided Fisher's exact test.

Optimal usage of the GnRH antagonists: a review of the literature

Gonadotropin-releasing hormone (GnRH) antagonists, which became commercially available from 1999, have been used for the prevention of premature luteinizing hormone (LH) surges in controlled ovarian stimulation for in vitro fertilization or intracytoplasmic sperm injection. This review focuses on the recent literature on the use of GnRH antagonists and provides guidelines for optimal use in light of increasing evidence showing that GnRH antagonists are safe and effective, allowing flexibility of treatment in a wide range of patient populations. This includes patients undergoing first-line controlled ovarian stimulation, poor responders, and women diagnosed with polycystic ovary syndrome. The GnRH antagonist offers a viable alternative to the long agonists, providing a shorter duration of treatment with fewer injections and with no adverse effects on assisted reproductive technology outcome. This results in a significantly lower amount of gonadotropins required, which is likely to lead to improved patient compliance.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Should androgen supplementation be used for poor ovarian response in IVF?

Poor ovarian response is reported in 9-24% of IVF cycles. Several interventions have been proposed to improve the outcome, although evidence to support these has been scant. There has been interest in the use of adjuvant androgens in this context and a recent worldwide survey showed that nearly a quarter of IVF clinicians used dehydroepiandrosterone (DHEA) in poor responders. We examine the rationale for the use of adjuvant androgens and suggest that the current clinical uncertainty should be addressed by a randomized controlled trial of DHEA in poor responders.

Effect of androgen supplementation or modulation on ovarian stimulation outcome in poor responders: a meta-analysis

Many trials have evaluated the use of androgen supplements and androgen-modulating agents to improve outcome of poor responders undergoing IVF treatment. This study conducted a systematic review and meta-analysis of controlled trials of androgen adjuvants (testosterone, dehydroepiandrostereone) and the androgen-modulating agent (letrozole) in poor responders undergoing IVF treatment. Searches were conducted on MEDLINE, EMBASE, Cochrane Library, ISRCTN Register and ISI proceedings. All randomized and non-randomized controlled trials were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. The main outcome measure was clinical pregnancy rate. The secondary outcome measures were dose and duration of gonadotrophin use, cycles cancelled before oocyte retrieval, oocytes retrieved and ongoing pregnancy rates. A total of 2481 cycles in women considered as poor responders undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment were included in nine controlled trials. Meta-analyses of these studies did not show any significant difference in the number of oocytes retrieved and ongoing pregnancy/live-birth rates with androgen supplementation or modulation compared with the control groups. There is currently insufficient evidence from the few randomized controlled trials to support the use of androgen supplementation or modulation to improve live birth outcome in poor responders undergoing IVF/ICSI treatment.

Controlled ovarian hyperstimulation for low responders in in vitro fertilization/intracytoplasmic sperm injection: a low-dose flare protocol

In this retrospective study of 652 anticipated low response women, the overall clinical outcomes (live birth rate and clinical pregnancy rate [PR]) of low-dose flare (LDF) protocol appeared lower than those of conventional down-regulation (DR) (LDF: 15.1% vs. DR: 20.6% and LDF: 10.3% vs. DR: 17.4%, respectively). The findings that LDF protocol improved the clinical outcome in older women, or when LDF followed an unsuccessful IVF/intracytoplasmic sperm injection (ICSI) cycle with DR (LDF: 19.4% vs. DR: 9.76% and LDF: 13.9% vs. DR: 4.2% respectively), need further evaluation through randomized trials.

Gonadotropin-releasing hormone antagonist use is associated with increased pregnancy rates in ovulation induction-intrauterine insemination to in vitro fertilization conversions, independent of age and estradiol level on the day of human chorionic gonadotropin administration

OBJECTIVE

To determine whether the use of GnRH antagonist in cycles converted from ovulation induction-IUI to IVF affects cycle outcome and pregnancy rates.

DESIGN

Retrospective cohort study.

SETTING

Academic research institution.

PATIENT(S)

One hundred eighty-two consecutive patients with ovulation induction-IUI to IVF conversions undergoing oocyte retrieval conducted at our institution from 2004 to 2006.

INTERVENTION(S)

The relation between observation of fetal heartbeat and GnRH antagonist exposure was evaluated with use of multivariable logistic regression. The difference in intermediate cycle outcomes by antagonist exposure was estimated with use of linear regression.

MAIN OUTCOME MEASURE(S)

Fetal cardiac activity on early ultrasound, intermediate cycle parameters.

RESULT(S)

For patients given treatment with a GnRH antagonist, the odds ratio for achieving pregnancy was 2.13 (95% confidence interval = 1.03-4.39) compared with untreated patients, independent of age and E(2) levels on day of hCG. Patients given antagonist had 1.6 more follicles and 2.1 more oocytes retrieved, 1.9 more mature oocytes, and 2.3 more fertilized oocytes, and the fertilization rate was 9.7% higher.

CONCLUSION(S)

Gonadotropin-releasing hormone antagonist use in ovulation induction-IUI to IVF conversions was associated with increased pregnancy rates and improved intermediate cycle parameters, controlled for age and E(2) levels on day of hCG. Addition of a GnRH antagonist should be considered in ovulation induction-IUI to IVF conversions.

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

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