1
|
Vaiarelli A, Ruffa A, Cerrillo M, García-Velasco JA. GnRH agonist trigger in poor prognosis patients undergoing a multicycle approach through DuoStim or consecutive stimulations: a SWOT analysis. Curr Opin Obstet Gynecol 2024; 36:124-133. [PMID: 38597577 DOI: 10.1097/gco.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
PURPOSE OF REVIEW Identify the most recent and significant evidence regarding the ovulation trigger within the framework of a multicycle approach through DuoStim, providing valuable insights for improving treatment strategies in patients with a poor prognosis. RECENT FINDINGS The trigger method plays a pivotal role in optimizing in-vitro fertilization (IVF) stimulation, influencing oocyte retrieval and maturation rates, as well as follicle recruitment in consecutive ovarian stimulations such as double stimulation. Decision-making involves multiple factors and, while guidelines exist for conventional stimulation, specific recommendations for the multicycle approach are not well established. SUMMARY The different methods for inducing oocyte maturation underscore the need for personalization of IVF protocols. The GnRH agonist trigger induces rapid luteolysis and establishes favorable hormonal conditions that do not adversely affect the recruitment of consecutive follicular waves in the context of DuoStim. It serves as a valid alternative to hCG in freeze-all cycles. This strategy might enhance the safety and flexibility of ovarian stimulations with no impact on oocyte competence and IVF efficacy.
Collapse
Affiliation(s)
- Alberto Vaiarelli
- IVIRMA Global Research Alliance, GENERA, Clinica Valle Giulia, Rome, Italy
| | - Alessandro Ruffa
- IVIRMA Global Research Alliance, GENERA, Clinica Valle Giulia, Rome, Italy
| | - María Cerrillo
- IVIRMA Global Research Alliance, IVIRMA Madrid, Madrid, Spain
| | | |
Collapse
|
2
|
Chen Q, Huang X, Yang H, Lin Y. Benefit from luteal phase progestin-primed ovarian stimulation with clomiphene citrate supplementation in young women with diminished ovarian reserve: a retrospective study. Zhejiang Da Xue Xue Bao Yi Xue Ban 2024:1-9. [PMID: 38763766 DOI: 10.3724/zdxbyxb-2023-0533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
OBJECTIVES To compare the pregnant outcomes of luteal phase progestin-primed ovarian stimulation (PPOS) protocol with clomiphene citrate supplementation (LPPOS+CC) and follicular phase PPOS+CC protocol (FPPOS+CC) in young women with diminished ovarian reserve (DOR). METHODS A total of 483 women aged ≤35 years with DOR, who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI)/embryo transfer (ET) with controlled ovarian stimulation using LPPOS+CC (n=257) or FPPOS+CC (n=226) protocols during June 2018 and December 2021 at the First Affiliated Hospital of Wenzhou Medical University, were included in this retrospective study. The baseline characteristics, ovarian stimulation, endocrinological indicators, clinical outcomes between the two groups, and pregnancy outcomes of women achieved at least one high-quality cleavage-stage embryo or good-morphology blastocyst between the two groups were compared. RESULTS No statistically significant differences were identified between the groups with respect to number of oocytes retrieved, oocyte maturation rate, high-quality cleavage-stage embryo cycle rate, the percentage of women with profound pituitary suppression, preterm birth rate, and live birth rate (P>0.05). Compared to FPPOS+CC group, the duration of stimulation [11.0 (9.0,12.0) vs. 9.0 (8.0,11.0) d, P<0.01] was significantly longer in the LPPOS+CC group. The LH levels on the day of trigger [4.0 (2.7,5.3) vs. 5.1 (3.2,7.2) IU/L, P<0.01], the percentage of women with LH levels of >10 IU/L on the trigger day (3.13% vs. 10.67%, P<0.01), and the two pronucleate (2PN) rate of ICSI oocytes (72.16% vs. 79.56%, P<0.05) were significantly lower in the LPPOS+CC group than those in the FPPOS+CC group. The consumption of total gonadotropin [2213 (1650,2700) vs. 2000 (1575,2325) IU, P<0.01], the progesterone levels on the day of trigger [1.3 (0.8,2.9) vs. 0.9 (0.6,1.2) ng/mL, P<0.01], the clinical pregnancy rate [61.88% vs. 46.84%, P<0.01], and implantation rate [42.20% vs. 31.07%, P<0.01] in the LPPOS+CC group were significantly higher than those in the FPPOS+CC group. CONCLUSIONS Compared to FPPOS+CC, the LPPOS+CC protocol appears to have better pregnancy outcomes for young women with DOR undergoing IVF-ICSI-ET.
Collapse
Affiliation(s)
- Qianqian Chen
- Center of Reproductive Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
| | - Xuefeng Huang
- Center of Reproductive Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Haiyan Yang
- Center of Reproductive Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Yue Lin
- Center of Reproductive Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
| |
Collapse
|
3
|
Fuentes A, García-Ajofrín C, Romero R, Castillo JC, Ortíz JA, Hortal M, Guerrero J, Bernabeu A, Bernabeu R. Influence of the starting day of luteal phase stimulation on double stimulation cycles. Front Endocrinol (Lausanne) 2023; 14:1216671. [PMID: 37529596 PMCID: PMC10390300 DOI: 10.3389/fendo.2023.1216671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Background Double ovarian stimulation is one of the most used strategies in poor-prognosis patients. There is a high heterogeneity between the studies regarding the execution of this stimulation protocol. The aim of this study was to investigate whether the day on which luteal phase stimulation begins after the first oocyte retrieval affects ovarian response in DuoStim cycles. Methods This observational and retrospective study included 541 DuoStim cycles between January 2018 and December 2021 in a private fertility clinic. Patients were assigned to 4 groups according to the timing of the onset of luteal phase stimulation after oocyte retrieval (0-2nd day, 3rd day, 4th day and 5th-6th day). The primary outcome was the number of oocytes retrieved in the luteal phase in each group. Results No differences were found between groups in the number of oocytes collected (5.12 ± 3.56 vs. 5.39 ± 3.74 vs. 5.61 ± 3.94 vs. 5.89 ± 3.92; p=0,6), MII or number of follicles. An increase in the duration of stimulation was found when stimulation started on the 4th day (10.42 ± 2.31 vs. 10.68 ± 2.37 vs. 11.27 ± 2.40 vs. 10.65 ± 2.37 days, p=0,033). A lower number of fertilized oocytes was observed when stimulation began before the fourth day (3.36 ± 2.80 vs. 3.95 ± 2.53 vs. 4.03 ± 2.73 vs. 4.48 ± 3.11; p=0,036). The number of blastocysts was higher when the stimulation started 5-6 days after retrieval (1.82 ± 1.74 vs. 2.13 ± 1.61 vs. 2.33 ± 2.06 vs. 2.91 ± 2.39; p= 0,030). Discussion The number of oocytes retrieved does not differ depending on the day that stimulation begins. However, oocytes competence in terms of fertilized oocytes and blastulation, appears to be lower when the second stimulation starts before the fourth day after oocyte retrieval.
Collapse
Affiliation(s)
- Ana Fuentes
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
| | | | - Ruth Romero
- Department of Reproductive Medicine, Instituto Bernabeu Madrid, Madrid, Spain
| | - Juan Carlos Castillo
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
- Cátedra de Medicina Comunitaria y Salud Reproductiva, Universidad Miguel Hernández, Elche, Spain
| | - Jose A. Ortíz
- Department of Molecular Biology, Instituto Bernabeu BIOTECH, Alicante, Spain
| | - Mónica Hortal
- Department of Molecular Biology, Instituto Bernabeu BIOTECH, Alicante, Spain
| | - Jaime Guerrero
- Department of Embryology, Instituto Bernabeu, Alicante, Spain
| | - Andrea Bernabeu
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
- Cátedra de Medicina Comunitaria y Salud Reproductiva, Universidad Miguel Hernández, Elche, Spain
| | - Rafael Bernabeu
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
- Cátedra de Medicina Comunitaria y Salud Reproductiva, Universidad Miguel Hernández, Elche, Spain
| |
Collapse
|
4
|
Petrone P, Vaiarelli A, Blockeel C. Double stimulation for the management of poor-prognosis patients: where are we going? Curr Opin Obstet Gynecol 2023; 35:246-253. [PMID: 36912335 DOI: 10.1097/gco.0000000000000869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
PURPOSE OF REVIEW The technical improvements in IVF allowed the implementation of nonconventional ovarian stimulation protocols for some specific patients. Where time is crucial, such as with oncologic patients, poor-prognosis patients, patients with low ovarian reserve, and those with advanced maternal age, access to IVF treatment is even more critical. Some of these protocols might start in the late follicular phase, luteal phase, or involve both stimulations within the same ovarian cycle. RECENT FINDINGS Until now, published evidence showed that oocytes retrieved from unconventional protocol seem to be developmentally, genetically, and reproductively competent. Second stimulation in the same ovarian cycle after the conventional approach may represent a sound alternative to oocyte accumulation. This can be proposed in progress after careful counselling focused on the patients' chances of finding at least one euploid embryo on account of their age and of the number of blastocysts obtained after the conventional approach. SUMMARY The adoption of these new strategies, known as double stimulation protocol, can be conceived as a real full-personalization of ovarian stimulation. Multicentre prospective RCTs are urgently needed to evaluate the efficacy, efficiency, and costs of double stimulation versus two consecutive conventional approaches with standard or mild stimulation and in a different IVF setting.
Collapse
Affiliation(s)
- Pasquale Petrone
- Department of Surgical Sciences, Gynecologic Unit, University of Rome 'TorVergata'
- Brussels IVF, Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Christophe Blockeel
- Brussels IVF, Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
5
|
Clinical Application of Double Ovulation Stimulation in Patients with Diminished Ovarian Reserve and Asynchronous Follicular Development Undergoing Assisted Reproduction Technology. Curr Med Sci 2023; 43:304-312. [PMID: 36913110 DOI: 10.1007/s11596-022-2687-0] [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: 03/20/2022] [Accepted: 05/17/2022] [Indexed: 03/14/2023]
Abstract
OBJECTIVE This study aimed to compare the clinical effects of double ovulation stimulation (DouStim) applied during the follicular and luteal phases with the antagonist protocol in patients with diminished ovarian reserve (DOR) and asynchronous follicular development undergoing assisted reproductive technology (ART). METHODS The clinical data of patients with DOR and asynchronous follicular development receiving ART from January 2020 to December 2021 were retrospectively analyzed. The patients were divided into two groups according to their ovulation stimulation protocol: DouStim group (n=30) and antagonist group (n=62). Assisted reproduction and clinical pregnancy outcomes were compared between the two groups. RESULTS In the DouStim group, the number of oocytes retrieved, metaphase II (MII) oocytes, two-pronuclei (2PN), day 3 (D3) embryos, D3 high-quality embryos as well as blastocyst formation, implantation, and human chorionic gonadotropin-positive rates were significantly greater than those in the antagonist group (all P<0.05). No significant differences were found in MII, fertilization, or continued pregnancy rates at the first frozen embryo transfer (FET), in-vitro fertilization (IVF) cancellation, or early medical abortion rates between the groups (all P>0.05). Except for the early medical abortion rate, the DouStim group generally had favorable outcomes. In the DouStim group, the dosage and duration of gonadotropin and the fertilization rate were significantly greater in the first ovulation stimulation induction than in the second ovulation stimulation induction (P<0.05). CONCLUSION The DouStim protocol efficiently and economically obtained more mature oocytes and high-quality embryos for patients with DOR and asynchronous follicular development.
Collapse
|
6
|
Kale A, Kale A. Oocyte Quality and Blastocyst Formation Rate with Dual Stimulation in Patients Belonging to POSEIDON Groups 3 and 4: A Retrospective Comparative Study. J Obstet Gynaecol India 2023; 73:57-61. [PMID: 36879944 PMCID: PMC9984652 DOI: 10.1007/s13224-022-01703-1] [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: 03/17/2022] [Accepted: 08/22/2022] [Indexed: 03/06/2023] Open
Abstract
Aim To evaluate the oocyte retrieval rate and blastocyst formation rate with DuoStim protocol in patients belonging to POSEIDON groups 3 and 4. Methods This observational, retrospective, single-center study including 90 patients belonging to POSEIDON groups 3 and 4 was conducted at a tertiary care hospital from October 2017 to March 2020. Patients were allocated into two groups based on POSEIDON classification criteria: group A (POSEIDON group 3) and group B (POSEIDON group 4). DuoStim protocol was performed with human menopausal gonadotropin (hMG) at 225 IU and 300 IU in groups A and B, respectively. Study groups were again subdivided by considering the phase in which stimulation had been done [follicular phase stimulation (FPS) and luteal phase stimulation (LPS)], and then, inference was made accordingly in terms of oocytes retrieval rate and blastocysts formation rate. Data were compiled and analyzed using statistical software SPSS version 20. Results The baseline characteristics of two groups were compatible with POSEIDON groups 3 and 4. A significant difference was found between study groups with respect to age and anti-mullerian hormone levels (p < 0.05). Significantly, a greater number of oocytes and blastocysts were obtained in LPS stage, substantially more in group A (3.69 ± 3.4 vs. 4.52 ± 4.3 and 1.36 ± 0.65 vs. 3.17 ± 1.84) than group B (2.2 ± 1.36 vs. 3.6 ± 4.5 and 0.41 ± 0.8 vs. 1.29 ± 2.04). A greater blastulation rate (50 vs. 66.7% and 33.3 vs. 50%) and 100% oocyte maturity rate were observed in LPS stage of both the study groups. Conclusion In patients belonging to POSEIDON groups 3 and 4, the number of oocytes retrieved and blastocyst formation rate were greater in LPS stage when compared to FPS with DuoStim protocol.
Collapse
Affiliation(s)
- Ashish Kale
- Department of Obstetrics and Gynaecology, Ashakiran Hospitals and ASHA IVF Centre, #555, Narayan Chambers, Opposite Narayan Peth Police Station, Pune, Maharashtra 411030 India
| | - Ashwini Kale
- Department of Obstetrics and Gynaecology, Ashakiran Hospitals and ASHA IVF Centre, #555, Narayan Chambers, Opposite Narayan Peth Police Station, Pune, Maharashtra 411030 India
| |
Collapse
|
7
|
Polat M, Mumusoglu S, Yarali Ozbek I, Bozdag G, Yarali H. Double or dual stimulation in poor ovarian responders: where do we stand? Ther Adv Reprod Health 2021; 15:26334941211024172. [PMID: 34263172 PMCID: PMC8252377 DOI: 10.1177/26334941211024172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022] Open
Abstract
Recent advances in our recognition of two to three follicular waves of development in a single menstrual cycle has challenged the dogmatic approach of ovarian stimulation for in vitro fertilization starting in the early follicular phase. First shown in veterinary medicine and thereafter in women, luteal phase stimulation–derived oocytes are at least as competent as those retrieved following follicular phase stimulation. Poor ovarian responders still remain a challenge for many decades simply because they do not respond to ovarian stimulation. Performing follicular phase stimulation and luteal phase stimulation in the same menstrual cycle, named as double stimulation/dual stimulation, clearly increases the number of oocytes, which is a robust surrogate marker of live birth rate in in vitro fertilization across all female ages. Of interest, apart from one study, the bulk of evidence reports significantly higher number of oocytes following luteal phase stimulation when compared with follicular phase stimulation; hence, performing double stimulation/dual stimulation doubles the number of oocytes leading to a marked decrease in patient drop-out rate which is one of the major factors limiting cumulative live birth rates in such poor prognosis patients. The limited data with double stimulation/dual stimulation-derived embryos is reassuring for obstetric and neonatal outcome. The mandatory requirement of freeze-all and lack of cost-effectiveness data are limitations of this novel approach. Double stimulation/dual stimulation is an effective strategy when the need to obtain oocytes is urgent, including patients with malignant diseases undergoing oocyte cryopreservation and patients of advanced maternal age or with reduced ovarian reserve.
Collapse
Affiliation(s)
- Mehtap Polat
- Anatolia IVF and Women's Health Center, Ankara, Turkey
| | - Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University Medical School, Ankara, Turkey
| | | | - Gurkan Bozdag
- Department of Obstetrics and Gynecology, Hacettepe University Medical School, Ankara, Turkey
| | - Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University Medical School, Ankara 06100, Turkey
| |
Collapse
|
8
|
Ovarian Stimulation TEGGO, Bosch E, Broer S, Griesinger G, Grynberg M, Humaidan P, Kolibianakis E, Kunicki M, La Marca A, Lainas G, Le Clef N, Massin N, Mastenbroek S, Polyzos N, Sunkara SK, Timeva T, Töyli M, Urbancsek J, Vermeulen N, Broekmans F. ESHRE guideline: ovarian stimulation for IVF/ICSI †. Hum Reprod Open 2020; 2020:hoaa009. [PMID: 32395637 PMCID: PMC7203749 DOI: 10.1093/hropen/hoaa009] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/05/2019] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION What is the recommended management of ovarian stimulation, based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation. WHAT IS KNOWN ALREADY Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS). PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations—of which only 21 were formulated as strong recommendations—and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety. LIMITATIONS, REASON FOR CAUTION Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker’s fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker’s fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker’s fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker’s fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker’s fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker’s fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker’s fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker’s fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker’s fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker’s fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker’s fees from Ferring. T.T. reports speaker’s fees from Merck, MSD and MLD. The other authors report no conflicts of interest. Disclaimer This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available atwww.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.
Collapse
Affiliation(s)
- The Eshre Guideline Group On Ovarian Stimulation
- IVI-RMS Valencia, Valencia, Spain.,Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany.,Department of Reproductive Medicine & Fertility Preservation, Hopital Antoine Béclère, Clamart, France.,The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Skive, Denmark.,Unit for Human Reproduction, 1 Dept of ObGyn, Medical School, Aristotle University, Thessaloniki, Greece.,INVICTA Fertility and Reproductive Centre, Department of Gynaecological Endocrinology, Medical University of Warsaw, Warsaw, Poland.,Department of Obstetrics and Gynaecology, University of Modena Reggio Emilia and Clinica Eugin, Modena, Italy.,Eugonia Assisted Reproduction Unit, Athens, Greece.,European Society of Human Reproduction and Embryology, Grimbergen, Belgium.,Department of Obstetrics, Gynaecology and Reproduction, University Paris-Est Créteil, Centre Hospitalier Intercommunal Créteil, Créteil, France.,Amsterdam Reproduction & Development, Center for Reproductive Medicine, University Medical Center Amsterdam, Amsterdam, The Netherlands.,Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.,Department of Women and Children's Health, King's College London, London, UK.,Hospital "Dr. Shterev", Sofia, Bulgaria.,Kanta-Häme Central Hospital, Hämeenlinna, Mehiläinen Clinics, Helsinki, Finland.,Department of Obstetrics and Gynaecology, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | | | - Simone Broer
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Michael Grynberg
- Department of Reproductive Medicine & Fertility Preservation, Hopital Antoine Béclère, Clamart, France
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Skive, Denmark
| | - Estratios Kolibianakis
- Unit for Human Reproduction, 1 Dept of ObGyn, Medical School, Aristotle University, Thessaloniki, Greece
| | - Michal Kunicki
- INVICTA Fertility and Reproductive Centre, Department of Gynaecological Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Antonio La Marca
- Department of Obstetrics and Gynaecology, University of Modena Reggio Emilia and Clinica Eugin, Modena, Italy
| | | | - Nathalie Le Clef
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Nathalie Massin
- Department of Obstetrics, Gynaecology and Reproduction, University Paris-Est Créteil, Centre Hospitalier Intercommunal Créteil, Créteil, France
| | - Sebastiaan Mastenbroek
- Amsterdam Reproduction & Development, Center for Reproductive Medicine, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Nikolaos Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Sesh Kamal Sunkara
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Mira Töyli
- Kanta-Häme Central Hospital, Hämeenlinna, Mehiläinen Clinics, Helsinki, Finland
| | - Janos Urbancsek
- Department of Obstetrics and Gynaecology, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Frank Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
9
|
Vaiarelli A, Cimadomo D, Petriglia C, Conforti A, Alviggi C, Ubaldi N, Ledda S, Ferrero S, Rienzi L, Ubaldi FM. DuoStim - a reproducible strategy to obtain more oocytes and competent embryos in a short time-frame aimed at fertility preservation and IVF purposes. A systematic review. Ups J Med Sci 2020; 125:121-130. [PMID: 32338123 PMCID: PMC7721001 DOI: 10.1080/03009734.2020.1734694] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/21/2020] [Indexed: 12/15/2022] Open
Abstract
Recent evidence suggests that follicular development occurs in a wave-like model during the ovarian cycle, where up to three cohorts of follicles are recruited to complete folliculogenesis. This understanding overtakes the previous dogma stating that follicles grow only during the follicular phase of the menstrual cycle. Therefore, in in vitro fertilization (IVF), novel protocols regarding ovarian stimulation have been theorized based on the use of gonadotrophins to prompt the growth of antral follicles at any stage of the menstrual cycle. These unconventional protocols for ovarian stimulation aim at a more efficient management of poor-prognosis patients, otherwise exposed to conflicting outcomes after conventional approaches. DuoStim appears among these unconventional stimulation protocols as one of the most promising. It combines two consecutive stimulations in the follicular and luteal phases of the same ovarian cycle, aimed at increasing the number of oocytes retrieved and embryos produced in the short time-frame. This protocol has been suggested for the treatment of all conditions requiring a maximal and urgent exploitation of the ovarian reserve, such as oncological patients and poor responders at an advanced maternal age. At present, data from independent studies have outlined the consistency and reproducibility of this approach, which might also reduce the drop-out between consecutive failed IVF cycles in poor-prognosis patients. However, the protocol must be standardized, and more robust studies and cost-benefit analyses are needed to highlight the true clinical pros and cons deriving from DuoStim implementation in IVF.
Collapse
Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Cecilia Petriglia
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Nicolò Ubaldi
- Catholic University of the Sacred Heart, Rome, Italy
| | - Sergio Ledda
- Department of Veterinary Medicine, University of Sassari, Sassari, Italy
| | - Susanna Ferrero
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| |
Collapse
|
10
|
Konstantinos S, Petroula T, Evangelos M, Polina G, Argyro G, Sokratis G, Anna R, Andrianos N, Agni P, Michael K, Konstantinos P, George M, Mara S. Assessing the practice of LuPOR for poor responders: a prospective study evaluating follicular fluid cfDNA levels during natural IVF cycles. J Assist Reprod Genet 2020; 37:1183-1194. [PMID: 32221790 DOI: 10.1007/s10815-020-01743-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/12/2020] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The aim of this study is to provide data on the practice of Luteal Phase Oocyte Retrieval (LuPOR). The authors assess cell-free DNA levels in follicular fluid (ff cfDNA) from poor responders undergoing natural cycles, and comparing it to respective data originating from follicular phase oocyte retrievals. METHODS Forty-seven women were eligible for this prospective study. Participants were classified as poor responders based on Bologna criteria while being detected with a second follicular wave. Follicular fluid was collected and prepared for cfDNA extraction. Levels of cfDNA were quantified via Q-PCR employing the ALU115 and ALU247 primers. These primers are associated with apoptotic and necrotic events. Levels of ff cfDNA resulting from follicular phase oocyte retrieval (FoPOR) and LuPOR-performed in a single menstrual cycle were associated with the number and maturation status of yielded oocytes and the number and fertilization status of resulting zygotes. Survival rate following thawing of cryopreserved zygotes, along with the resulting number of cleavage stage and blastocyst stage embryos are provided. RESULTS Mean levels of ALU115 were significantly lower during FoPOR when compared to LuPOR (0.79 ± 0.72 vs 1.46 ± 1.59 ng/μl, p = 0.02). Regarding the FoPOR group, a significant positive correlation of serum estradiol and ALU115 concentration (p = 0.04) was revealed. A significant negative correlation between serum estradiol and cfDNA integrity was observed both during FoPOR (p = 0.03) and LuPOR (p = 0.03). A significant lower number of retrieved (1.09 ± 0.28 vs 1.29 ± 0.58, p = 0.02) and MII oocytes (0.77 ± 0.55 vs 1.08 ± 0.61, p = 0.02) was observed when comparing the FoPOR to LuPOR groups respectively. The integrity of cfDNA was observed to be higher in FoPOR originating embryos that arrested either prior to cleavage (0.28 ± 0.13 vs 0.17 ± 0.10, p = 0.006) or prior to blastocyst formation (0.28 ± 0.12 vs 0.13 ± 0.06, p = 0.04). In the case of LuPOR originating embryos, cfDNA integrity was observed to be higher in embryos that arrested only prior to the blastocyst stage (0.27 ± 0.20 vs 0.11 ± 0.07, p = 0.008). Similarly, cfDNA integrity was observed to be lower in top quality blastocysts originating from FoPOR (0.07 ± 0.04 vs 0.17 ± 0.05, p = 0.03) and in top quality cleavage stage embryos (0.09 ± 0.06 vs 0.31 ± 0.22, p = 0.01) and blastocysts (0.06 ± 0.02 vs 0.14 ± 0.06, p = 0.02) originating from LuPOR. CONCLUSIONS Our results indicate that ff originating from LuPOR presents with higher levels of cfDNA. The higher cfDNA levels are attributed to mainly apoptotic events, as the ALU247 levels and DNA integrity did not differ statistically significantly between FoPOR and LuPOR. The absolute mean level of ALU247 corresponding to necrotic events was higher in LuPOR. Regarding embryological data, cfDNA integrity was correlated with both number and quality of cleavage stage embryos in both FoPOR and LuPOR, along with blastocyst stage embryos in LuPOR. Necrotic events were associated with poorer blastocyst formation rate and blastocyst quality in LuPOR. As the comparison between FoPOR and LuPOR results to similar IVF laboratory data, the practice of LuPOR may stand as a promising approach for poor responders, while it merits further investigation.
Collapse
Affiliation(s)
| | - Tsioulou Petroula
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maziotis Evangelos
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Giannelou Polina
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Glava Argyro
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Grigoriadis Sokratis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Rapani Anna
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nezos Andrianos
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Pantou Agni
- Genesis Athens Clinic, Centre for Human Reproduction, Athens, Greece
| | - Koutsilieris Michael
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Mastorakos George
- Assisted Conception Unit, 2nd Department of Obstetrics & Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Simopoulou Mara
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
- Assisted Conception Unit, 2nd Department of Obstetrics & Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| |
Collapse
|
11
|
What is the true place of a double stimulation and double oocyte retrieval in the same cycle for patients diagnosed with poor ovarian reserve? A systematic review including a meta-analytical approach. J Assist Reprod Genet 2019; 37:181-204. [PMID: 31797242 DOI: 10.1007/s10815-019-01638-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/12/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE This systematic review including a meta-analytical approach aims to investigate the safety and efficacy of employing a double ovarian stimulation (DuoStim) and a subsequent double oocyte retrieval in the same menstrual cycle, in poor ovarian reserve (POR) patients. METHODS A systematic search of literature was performed in the databases of PubMed/MEDLINE, Embase, and Cochrane Central Library up until March 2019. Both prospective and retrospective cohort studies considered suitable for inclusion reported on women with POR undergoing a DuoStim in the follicular (FPS) and luteal phase (LPS) of the same menstrual cycle. Following the systematic review of the literature, a meta-analytical approach was attempted. RESULTS This study indicates that DuoStim is correlated with a higher number of retrieved oocytes, mature MII oocytes, and good-quality embryos in comparison to conventional stimulation. Additionally, LPS seems to be correlated with an equal or an even higher overall performance in comparison to FPS. CONCLUSION DuoStim favors an enhanced clinical outcome in regard to the total number of yielded oocytes, mature oocytes, and available embryos, along with the quality of obtained embryos. Sourced data indicate that LPS is not correlated with a higher aneuploidy rate. This option may present as promising for the time-sensitive nature of POR patients' management, by enabling a higher oocyte yield during a single menstrual cycle.
Collapse
|
12
|
Rashtian J, Zhang J. Luteal-phase ovarian stimulation increases the number of mature oocytes in older women with severe diminished ovarian reserve. Syst Biol Reprod Med 2018; 64:216-219. [PMID: 29564925 DOI: 10.1080/19396368.2018.1448902] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
In older women with severe diminished ovarian response (DOR), in vitro fertilization (IVF) treatment is much less successful due to the low number of mature oocytes collected. The objective of this study was to assess whether follicular-phase stimulation (FPS) and luteal-phase stimulation (LPS) in the same menstrual cycle (double ovarian stimulation) in older women with severe DOR will produce a higher number of oocytes compared to FPS alone. Women with DOR (n = 69; mean age = 42.4) who underwent double ovarian stimulation for IVF were included. Women underwent ovarian stimulation in FPS using clomiphene citrate, letrozole, and gonadotropins followed by oocyte retrieval. The next day following oocyte retrieval, women underwent a second ovarian stimulation (LPS) using the same medications followed by a second oocyte retrieval. T-test was performed in order to compare the clinical characteristics and outcome in the same participant between FPS and LPS. Although antral follicle count at the start of FPS tended to be higher than at the start of the LPS cycle, there was no statistically significant difference between the duration of ovarian stimulation, peak estradiol levels, number of small (<14 mm) or large (≥ 14 mm) follicles, the total number of oocytes retrieved, or the total number of mature oocytes. Each woman had double the number of mature oocytes collected following a double ovarian stimulation compared to FPS alone. The addition of LPS to the conventional FPS increases the number of mature oocytes retrieved in the same IVF cycle, thus potentially increasing the chances of pregnancy in older women with severe DOR. ABBREVIATIONS AFC: antral follicle count; BMI: body mass index; DOR: diminished ovarian reserve; E2: estradiol; FPS: follicular-phase stimulation; FSH: follicle stimulating hormone; GnRH: gonadotropin-releasing hormone; HCG: human chorionic gonadotropin; IRB: institutional review board; IVF: in vitro fertilization; LH: luteinizing hormone; LPS: luteal-phase stimulation; MII: metaphase II.
Collapse
Affiliation(s)
- Justin Rashtian
- a Drexel University College of Medicine , Philadelphia , PA , USA
| | - John Zhang
- b Reproductive Endocrinology and Infertility , New Hope Fertility Center , New York , NY , USA
| |
Collapse
|
13
|
Rasool S, Shah D. The futile case of the aging ovary: is it mission impossible? A focused review. Climacteric 2017; 21:22-28. [DOI: 10.1080/13697137.2017.1410784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S. Rasool
- Department of Reproductive Medicine, Gynaecworld, Mumbai, India
| | - D. Shah
- Department of Reproductive Medicine, Gynaecworld, Mumbai, India
| |
Collapse
|
14
|
Rasool S, Shah D. Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back. FERTILITY RESEARCH AND PRACTICE 2017; 3:15. [PMID: 29046817 PMCID: PMC5637249 DOI: 10.1186/s40738-017-0041-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/25/2017] [Indexed: 01/29/2023]
Abstract
Diminished fertility and poor ovarian response pose a conundrum to the experts in the field of reproductive medicine. There is limited knowledge about the risk factors of diminished ovarian reserve other than the iatrogenic ones. One of the leading causes of infertility in women today is diminished ovarian reserve (DOR). DOR is characterized by a low number of eggs in a woman's ovaries and/or with poor quality of the remaining eggs, which boils down to impaired development of the existing eggs, even with assisted reproductive techniques. A good number of such women with low ovarian reserve may conceive with their own eggs, if they are given individualized treatment that is tailored for their profile. Such patients should be counseled appropriately for an aggressive approach towards achieving fertility. The sooner the treatment is started, the better the chances of pregnancy.
Collapse
Affiliation(s)
- Sabahat Rasool
- Gynaecworld, Kwality House, 1st Floor, Kemps Corner, Mumbai, India
| | - Duru Shah
- Scientific Director & Fertility Expert, Gynaecworld, Kwality House, 1st Floor, Kemps Corner, Mumbai, India
| |
Collapse
|