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Hsu CC, Hsu I, Lee LH, Hsu R, Hsueh YS, Lin CY, Chang HH. Ovarian Follicular Growth through Intermittent Vaginal Gonadotropin Administration in Diminished Ovarian Reserve Women. Pharmaceutics 2022; 14:pharmaceutics14040869. [PMID: 35456706 PMCID: PMC9025251 DOI: 10.3390/pharmaceutics14040869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 02/05/2023] Open
Abstract
It is a challenge to obtain enough oocytes during in vitro fertilization (IVF) in women who have a poor ovarian response (POR) in achieving conception. We have adopted the characteristics of the first uterine pass effect, which we pioneered in employing the vaginal administration of gonadotropins in women receiving IVF treatments. In our previous study employing vaginal administration, faster absorption and slower elimination of gonadotropins were demonstrated, and, female subjects presented proper ovarian follicle growth and pregnancy rates. In this study, during 2016–2020, 300 to 675 IU of gonadotropins were administered vaginally every three days in 266 POR women for their controlled ovarian hyperstimulation (COH). The injections were performed with needles angled at 15–30° towards the middle-upper portions of the bilateral vaginal wall, with an injection depth of 1–2 mm. For the COH results, these women, on average, received 3.0 ± 0.9 vaginal injections and a total dose of 1318.4 ± 634.4 IU gonadotropins, resulting in 2.2 ± 1.9 mature oocytes and 1.0 ± 1.2 good embryos. Among these embryos, 0.9 ± 1.0 were transferred to reach a clinical pregnancy rate of 18.1% and a live birth rate of 16.7%. In conclusion, the intermittent vaginal administration of gonadotropins proved to be effective in POR women for their IVF treatments.
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Affiliation(s)
- Chao-Chin Hsu
- Taiwan United Birth-Promoting Experts Fertility Clinic, Tainan 710, Taiwan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei 104, Taiwan;
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, Tainan 701, Taiwan
- Correspondence: (C.-C.H.); (H.H.C.); Tel.: +886-6-2353535 (ext. 5683) (H.H.C.)
| | - Isabel Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei 104, Taiwan;
| | | | - Rosie Hsu
- Department of Pediatrics, National Taiwan University Hospital, Taipei 104, Taiwan;
| | - Yuan-Shuo Hsueh
- Department of Medical Science Industries, College of Health Sciences, Chang Jung Christian University, Tainan 711, Taiwan;
| | - Chih-Ying Lin
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Hui Hua Chang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
- School of Pharmacy, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin 640, Taiwan
- Correspondence: (C.-C.H.); (H.H.C.); Tel.: +886-6-2353535 (ext. 5683) (H.H.C.)
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Matsumoto L, Yamakami LYS, Turco EGL, Benetti-Pinto CL, Yela DA. Use of Triggers on in vitro Fertilization and Evaluation of Risk Factors for Sub-Optimal Maturation Rate. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:369-375. [PMID: 35108732 PMCID: PMC9948151 DOI: 10.1055/s-0041-1741455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the oocyte maturation rate in the treatment of in vitro fertilization (IVF) in terms of the use of human chorionic gonadotropin (hCG), agonist gonadotropin-releasing hormone (GnRH) and dual trigger and to evaluate the associated risk factors for sub-optimal maturation rates. METHODS A retrospective cohort study with 856 women who underwent IVF. They performed oocyte retrieval and were classified into 3 groups (1 - hCG, 2 - GnRH agonist, 3 - dual trigger). The primary outcome was maturation rate per trigger, and the secondary outcomes were the pregnancy rate per oocyte retrieval and the correlations between low maturation rate as well as the clinical and treatment characteristics of women. RESULTS The maturation rate was 77% in group 1; 76% in group 2, and 83% in group 3 (p = 0.003). Group 2 showed women with better ovarian reserve, greater number of oocytes collected, and more mature oocytes and embryos compared with the other groups (p < 0.001). The cumulative clinical pregnancy rate was no different between the groups (p = 0.755). Low ovarian reserve and low doses of follicle-stimulating hormone (FSH) administered during the stimulus were associated with a higher chance of null maturation rate. CONCLUSION The oocyte maturation rates and IVF results were similar in all groups. Low ovarian reserve is associated with the worst treatment results.
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Affiliation(s)
- Larissa Matsumoto
- Department of Human Reproduction, VidaBemVinda Human Reproduction Care Center, São Paulo, SP, Brazil
| | | | - Edson Guimarães Lo Turco
- Department of Human Reproduction, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Cristina Laguna Benetti-Pinto
- Department of Gynecology and Obstetrics, Faculty Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Daniela Angerame Yela
- Department of Gynecology and Obstetrics, Faculty Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Hershko Klement A, Oron G, Bentov Y. Editorial: The Expansion of Female Fertility. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 3:781019. [DOI: 10.3389/frph.2021.781019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
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Ovarian Folliculogenesis and Uterine Endometrial Receptivity after Intermittent Vaginal Injection of Recombinant Human Follicle-Stimulating Hormone in Infertile Women Receiving In Vitro Fertilization and in Immature Female Rats. Int J Mol Sci 2021; 22:ijms221910769. [PMID: 34639109 PMCID: PMC8509306 DOI: 10.3390/ijms221910769] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/26/2021] [Accepted: 09/30/2021] [Indexed: 12/26/2022] Open
Abstract
The uterine first-pass effect occurs when drugs are delivered vaginally. However, the effect of vaginally administered recombinant human follicle-stimulating hormone (rhFSH) on ovarian folliculogenesis and endometrial receptivity is not well established. We aimed to compare the efficacy of rhFSH administered vaginally and abdominally in clinical in vitro fertilization (IVF) treatment, pharmacokinetic study, and animal study. In IVF treatment, the number of oocytes retrieved, endometrial thickness and uterine artery blood perfusion were not different between women who received the rhFSH either vaginally or abdominally. For serum pharmacokinetic parameters, significantly lower Tmax, clearance, and higher AUC and T1/2_elimination of rhFSH were observed in women who received rhFSH vaginally, but urine parameters were not different. Immature female rats that received daily abdominal or vaginal injections (1 IU twice daily for 4 days) or intermittent vaginal injections (4 IU every other day for two doses) of rhFSH had more total follicles than the control group. In addition, the serum progesterone and progesterone receptors in the local endometrium were significantly higher in the groups treated with intermittent abdominal or vaginal injection of rhFSH, compared with those who recieved daily injection. In summary, vaginal administration of rhFSH may provide an alternative treatment regimen in women receiving IVF.
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Zhang X, Zheng A, Yang J, Feng T, Zhang Y, Hao Y, Li S, Qian Y. Application of Pulsed Rhythmic Drug Administration to Ovulation Induction Therapy in PCOS Patients with Clomiphene-Resistance: a Retrospective Research. Reprod Sci 2021; 28:3193-3199. [PMID: 34085207 PMCID: PMC8526461 DOI: 10.1007/s43032-021-00639-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Abstract
There is currently a dispute over the choice of ovulation induction treatment for infertile women with polycystic ovary syndrome (PCOS). The objective of this study is to compare the therapeutic effect of pulsed rhythmic administration protocol (PRAP) with conventional letrozole + human menopausal gonadotropin (HMG) in patients with clomiphene-resistance polycystic ovary syndrome (PCOS). A retrospective analysis of 821 intrauterine insemination (IUI) cycles between January 2015 and January 2020 was performed. Of these, 483 cycles were treated with a pulsed rhythmic administration protocol (PRAP), and 338 cycles were treated with conventional letrozole + HMG protocol (LHP). The therapeutic effect of the two protocols has been compared. The pregnancy rate was 18.07% in the LHP and 27.07% in the PRAP. The ongoing pregnancy rate in LHP was 14.46% and in PRAP was 22.73%. The research suggests that PRAP is more effective than LHP and could be an adequate ovulation induction strategy for the IUI cycle of patients with clomiphene-resistance PCOS.
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Affiliation(s)
- Xinyue Zhang
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
| | - Aiyan Zheng
- Center for Reproduction and Genetics, Suzhou Municipal Hospital, the Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, 215002, China
| | - Jihong Yang
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
| | - Ting Feng
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
| | - Yan Zhang
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
| | - Yingying Hao
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
| | - Suying Li
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China
| | - Yun Qian
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, China.
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Leijdekkers JA, Torrance HL, Schouten NE, van Tilborg TC, Oudshoorn SC, Mol BWJ, Eijkemans MJC, Broekmans FJM. Individualized ovarian stimulation in IVF/ICSI treatment: it is time to stop using high FSH doses in predicted low responders. Hum Reprod 2021; 35:1954-1963. [PMID: 31838515 PMCID: PMC7485616 DOI: 10.1093/humrep/dez184] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/06/2019] [Indexed: 11/25/2022] Open
Abstract
In IVF/ICSI treatment, the FSH starting dose is often increased in predicted low responders from the belief that it improves the chance of having a baby by maximizing the number of retrieved oocytes. This intervention has been evaluated in several randomized controlled trials, and despite a slight increase in the number of oocytes—on average one to two more oocytes in the high versus standard dose group—no beneficial impact on the probability of a live birth has been demonstrated (risk difference, −0.02; 95% CI, −0.11 to 0.06). Still, many clinicians and researchers maintain a highly ingrained belief in ‘the more oocytes, the better’. This is mainly based on cross-sectional studies, where the positive correlation between the number of retrieved oocytes and the probability of a live birth is interpreted as a direct causal relation. If the latter would be present, indeed, maximizing the oocyte number would benefit our patients. The current paper argues that the use of high FSH doses may not actually improve the probability of a live birth for predicted low responders undergoing IVF/ICSI treatment and exemplifies the flaws of directly using cross-sectional data to guide FSH dosing in clinical practice. Also, difficulties in the de-implementation of the increased FSH dosing strategy are discussed, which include the prioritization of intermediate outcomes (such as cycle cancellations) and the potential biases in the interpretation of study findings (such as confirmation or rescue bias).
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Affiliation(s)
- Jori A Leijdekkers
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nienke E Schouten
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Theodora C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Simone C Oudshoorn
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Marinus J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Cozzolino M, Cecchino GN, Bosch E, Garcia-Velasco JA, Garrido N. Minimal ovarian stimulation is an alternative to conventional protocols for older women according to Poseidon's stratification: a retrospective multicenter cohort study. J Assist Reprod Genet 2021; 38:1799-1807. [PMID: 33851314 DOI: 10.1007/s10815-021-02185-2] [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: 01/25/2021] [Accepted: 03/31/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To investigate whether minimal ovarian stimulation (mOS) is as effective as conventional ovarian stimulation (cOS) for older women belonging to different groups according to the Poseidon criteria. MATERIAL AND METHODS Observational retrospective multicentre cohort including women from Poseidon's groups 2 and 4 that underwent in vitro fertilization (IVF). We performed a mixed-effects logistic regression model, adding as a random effect the patients and the stimulation cycle considering the dependence of data. Survival curves were employed as a measure of the cumulative live birth rate (CLBR). The primary outcomes were live birth rate per embryo transfer and CLBR per consecutive embryo transfer and oocyte consumed until a live birth was achieved. RESULTS A total of 2002 patients underwent 3056 embryo transfers (mOS = 497 and cOS = 2559). The live birth rates per embryo transfer in mOS and cOS showed no significant difference in both Poseidon's groups. Likewise, the logistic regression showed similar live birth rates between the two protocols in Poseidon's groups 2 (OR 1.165, 95% CI 0.77-1.77; p = 0.710) and 4 (OR 1.264 95% CI 0.59-2.70; p = 0.387). However, the survival curves showed higher CLBR per oocyte in women that received mOS (Poseidon group 2: p < 0.001 and Poseidon group 4: p = 0.039). CONCLUSIONS Minimal ovarian stimulation is a good alternative to COS as a first-line treatment for patients belonging to Poseidon's groups 2 and 4. The number of oocytes needed to achieve a live birth seems inferior in mOS strategy than cOS.
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Affiliation(s)
- Mauro Cozzolino
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain. .,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar St, New Haven, CT, 06510, USA. .,Rey Juan Carlos University, Calle Tulipán, 28933, Móstoles, Madrid, Spain.
| | - Gustavo Nardini Cecchino
- Rey Juan Carlos University, Calle Tulipán, 28933, Móstoles, Madrid, Spain.,Department of Gynaecology, Federal University of São Paulo, São Paulo, Brazil.,Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | | | - Juan Antonio Garcia-Velasco
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain.,Rey Juan Carlos University, Calle Tulipán, 28933, Móstoles, Madrid, Spain.,IVI-RMA, Madrid, Spain
| | - Nicolás Garrido
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain
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Liang Y, Guo Q, Wu XH, Zhang LN, Ge J, Xu ML, Feng ZL, Wu XQ. Does the additional use of clomiphene citrate or letrozole for in vitro fertilization deserve more attention? BMC Pregnancy Childbirth 2021; 21:275. [PMID: 33794797 PMCID: PMC8017864 DOI: 10.1186/s12884-021-03668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adding clomiphene citrate (CC) and/or letrozole (LE) to in vitro fertilization (IVF) cycles for mild ovarian stimulation is a general approach. Although lots of researches have demonstrated partial benefits of the strategy, all-around effects of oral medications remained deficient. This paper aims to assess whether an addition of oral medication will result in considerable outcomes on T-Gn (total dose of gonadotropin), Gn days, total retrieved ova, high quality embryos, blastocyst number, ovarian hyperstimulation syndrome (OHSS) rate, clinical pregnancy rate and cumulative pregnancy rate, even if it was not conventional mild/minimal stimulations. RESULTS Participants were categorized to three diverse populations as high responders, normal responders and poor responders according to basal antral follicle count. T-Gn in patients treated with CC/LE distinctly decreased from 2496.96 IU/d to 1827.68 IU/d, from 2860.28 IU/d to 2119.99 IU/d, and from 3182.15 IU/d to 1802.84 IU/d, respectively. For high ovary responders and normal responders, the OHSS incidence rate also declined from 29.2 to 4.3% (P < 0.001) and from 1.1 to 0.0% (P = 0.090). Other, there was no statistical difference with respect to the T-retrieved ova (total retrieved ova), high quality embryos, cultured blastocyst and blastocyst number in high responders. For normal responders and poor ovary responders, T-Gn, Gn days, T-retrieved ova, high quality embryos, cultured blastocyst and blastocysts number in oral medications group all apparently decreased. Clinical pregnancy rate per fresh cycle of poor responders with prior oral medications was significantly decreased (25.7% vs. 50.8%, P = 0.005), and no significant differences in high responders and normal responders were expressed (52.5% vs. 44.2%, P = 0.310; 51.9% vs. 42.4%, P = 0.163) between two groups of participants. The numbers of cumulative pregnancy rates were lower in the conventional group compared to the add group for high (75.90% versus 81.03%, P = 0.279), normal (62.69% versus 71.36%, P = 0.016) and poor (39.74% versus 68.21%, P < 0.001) responders. CONCLUSIONS The addition of CC/LE to the ovulation induction during IVF has certain efficacy in terms of low cost, low OHSS incidence. CC/LE deserves more recommendations as a responsible strategy in high responders due to advantageous pregnancy outcomes. For normal responders, the strategy needs to be considered with more comprehensive factors.
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Affiliation(s)
- Ying Liang
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
| | - Qing Guo
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
| | - Xiao-Hua Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
| | - Li-Nan Zhang
- Department of Pathology and Pathophysiology, Hebei Medicine University, Shijiazhuang, Hebei, China
| | - Jun Ge
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
| | - Mei-Ling Xu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
| | - Zheng-Li Feng
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
| | - Xiao-Qian Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province China
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Datta AK, Maheshwari A, Felix N, Campbell S, Nargund G. Mild versus conventional ovarian stimulation for IVF in poor, normal and hyper-responders: a systematic review and meta-analysis. Hum Reprod Update 2021; 27:229-253. [PMID: 33146690 PMCID: PMC7902993 DOI: 10.1093/humupd/dmaa035] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mild ovarian stimulation has emerged as an alternative to conventional IVF with the advantages of being more patient-friendly and less expensive. Inadequate data on pregnancy outcomes and concerns about the cycle cancellation rate (CCR) have prevented mild, or low-dose, IVF from gaining wide acceptance. OBJECTIVE AND RATIONALE To evaluate parallel-group randomised controlled trials (RCTs) on IVF where comparisons were made between a mild (≤150 IU daily dose) and conventional stimulation in terms of clinical outcomes and cost-effectiveness in patients described as poor, normal and non-polycystic ovary syndrome (PCOS) hyper-responders to IVF. SEARCH METHODS Searches with no language restrictions were performed using Medline, Embase, Cochrane central, Pre-Medicine from January 1990 until April 2020, using pre-specified search terms. References of included studies were hand-searched as well as advance access articles to key journals. Only parallel-group RCTs that used ≤150 IU daily dose of gonadotrophin as mild-dose IVF (MD-IVF) and compared with a higher conventional dose (CD-IVF) were included. Studies were grouped under poor, normal or hyper-responders as described by the authors in their inclusion criteria. Women with PCOS were excluded in the hyper-responder group. The risk of bias was assessed as per Cochrane Handbook for the included studies. The quality of evidence (QoE) was assessed according to the GRADE system. PRISMA guidance was followed for review methodology. OUTCOMES A total of 31 RCTs were included in the analysis: 15 in the poor, 14 in the normal and 2 in the hyper-responder group. Live birth rates (LBRs) per randomisation were similar following use of MD-IVF in poor (relative risk (RR) 0.91 (CI 0.68, 1.22)), normal (RR 0.88 (CI 0.69, 1.12)) and hyper-responders (RR 0.98 (CI 0.79, 1.22)) when compared to CD-IVF. QoE was moderate. Cumulative LBRs (5 RCTs, n = 2037) also were similar in all three patient types (RR 0.96 (CI 0.86 1.07) (moderate QoE). Risk of ovarian hyperstimulation syndrome was significantly less with MD-IVF than CD-IVF in both normal (RR 0.22 (CI 0.10, 0.50)) and hyper-responders (RR 0.47 (CI 0.31, 0.72)), with moderate QoE. The CCRs were comparable in poor (RR 1.33 (CI 0.96, 1.85)) and hyper-responders (RR 1.31 (CI 0.98, 1.77)) but increased with MD-IVF among normal responders (RR 2.08 (CI 1.38, 3.14)); all low to very low QoE. Although fewer oocytes were retrieved and fewer embryos created with MD-IVF, the proportion of high-grade embryos was similar in all three population types (low QoE). Compared to CD-IVF, MD-IVF was associated with less gonadotrophin use and lower cost. WIDER IMPLICATIONS This updated review provides reassurance on using MD-IVF not only for the LBR per cycle but also for the cumulative LBR, with moderate QoE. With risks identified with 'freeze-all' strategies, it may be time to recommend mild-dose ovarian stimulation for IVF for all categories of women i.e. hyper, poor and normal responders to IVF.
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Affiliation(s)
| | | | | | - Stuart Campbell
- St George’s University of London, London, UK
- Create Fertility, London, UK
| | - Geeta Nargund
- Create Fertility, London, UK
- St Georges University Hospitals NHS Trust London, London, UK
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Montoya-Botero P, Drakopoulos P, González-Foruria I, Polyzos NP. Fresh and cumulative live birth rates in mild versus conventional stimulation for IVF cycles in poor ovarian responders: a systematic review and meta-analysis. Hum Reprod Open 2021; 2021:hoaa066. [PMID: 33614987 PMCID: PMC7882043 DOI: 10.1093/hropen/hoaa066] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/16/2020] [Indexed: 12/19/2022] Open
Abstract
STUDY QUESTION Are cumulative and live birth rates (LBRs) comparable in poor ovarian response women treated with different protocols of mild stimulation IVF (i.e. oral compounds, lower doses or shorter treatments) versus conventional IVF? SUMMARY ANSWER Mild ovarian stimulation (MOS) results in comparable outcomes to those of conventional stimulation in poor ovarian response patients with low ovarian reserve. WHAT IS KNOWN ALREADY Several randomized trials and meta-analyses have been published evaluating the role of mild (MOS) versus conventional ovarian stimulation in poor ovarian response patients. Most report a potentially higher safety profile, patient satisfaction and lower costs, suggesting that the higher cycle cancellation rate and fewer oocytes retrieved following MOS does not affect the final reproductive outcome. Additionally, over the last few years, new publications have added data regarding MOS, and shown the possible benefit of a higher oocyte yield which may also improve prognosis in patients with poor ovarian response. STUDY DESIGN SIZE DURATION We conducted a systematic search of relevant randomized controlled trials (RCTs). We searched electronic databases, including MEDLINE, EMBASE, LILACS-BIREME, CINAHL, The Cochrane Library, CENTRAL (Cochrane Register), Web of Science, Scopus, Trip Database and Open Grey, to identify all relevant studies published up to March 2020. We examined trial registries for ongoing trials. No publication-year or language restrictions were adopted. We explored the reference list of all included studies, reviews and abstracts of major scientific meetings. The primary outcomes were cumulative and fresh LBR (CLBR and FLBR) per woman randomized. PARTICIPANTS/MATERIALS SETTING METHODS We included subfertile women undergoing IVF/ICSI characterized as poor responders and compared primary and secondary outcomes between the different protocols of mild stimulation IVF (i.e. oral compounds, lower doses or shorter treatments) and conventional IVF. We used the PICO (Patients, Intervention, Comparison and Outcomes) model to select our study population. MAIN RESULTS AND THE ROLE OF CHANCE Overall, 15 RCTs were included in the meta-analysis. CLBR and FLBR were comparable between mild versus conventional stimulation (RR 1.15; 95% CI: 0.73 - 1.81; I2 = 0%, n = 424, moderate certainty and RR 1.01; 95% CI: 0.97 - 1.04; I 2 = 0%, n = 1001, low certainty, respectively). No difference was observed either when utilizing oral compounds (i.e. letrozole and clomiphene) or lower doses. Similarly, ongoing pregnancy rate (OPR) and clinical pregnancy rate (CPR) were equivalent when comparing the two groups (RR 1.01; 95% CI: 0.98 - 1.05; I 2 = 0%, n = 1480, low certainty, and RR 1.00; 95% CI: 0.97 - 1.03; I2 = 0%, n = 2355, low certainty, respectively). A significantly lower oocyte yield (mean differences (MD) -0.80; 95% CI: -1.28, -0.32; I2 = 83%, n = 2516, very low certainty) and higher rate of cycle cancellation (RR 1.48; 95% CI: 1.08 - 2.02; I2 = 62%, n = 2588, low certainty) was observed in the MOS group. LIMITATIONS REASONS FOR CAUTION The overall quality of the included studies was low to moderate. Even though strict inclusion criteria were used, the selected studies were heterogeneous in population characteristics and treatment protocols. We found no differences in CLBR between MOS and COS (95% CI: 0.73 - 1.81.). WIDER IMPLICATIONS OF THE FINDINGS MOS could be considered as a treatment option in low prognosis poor responder patients, given that it results in similar fresh and CLBRs compared with COS. A milder approach is associated with a lower number of oocytes retrieved and a higher cancellation rate, although treatment cost is significantly reduced. Future research should focus on which type of ovarian stimulation may be of benefit in better prognosis women. STUDY FUNDING/COMPETING INTERESTS There were no sources of financial support. N.P.P. received research grants, honoraria for lectures from: Merck Serono, MSD, Ferring Pharmaceuticals, Besins International, Roche Diagnostics, IBSA, Theramex and Gedeon Richter. P.D. received unrestricted grants and honoraria from Merck Serono, MSD and Ferring Pharmaceuticals. I.G.F. received unrestricted grants and honoraria from Merck Serono, MSD, Ferring Pharmaceuticals, Gedeon-Richter and IBSA. P.M.B. reported no conflict of interest. TRIAL REGISTRATION NUMBER CRD42020167260.
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Affiliation(s)
- Pedro Montoya-Botero
- Conceptum—Unidad de Fertilidad del Country, Bogotá 110221, Colombia
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona 08028, Spain
| | - Panagiotis Drakopoulos
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Iñaki González-Foruria
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona 08028, Spain
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona 08028, Spain
- Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
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Wang M, Jia L, Li XL, Guo JY, Fang C, Huang R, Liang XY. Cumulative live birth rates do not increase after 4 complete cycles in women with poor ovarian response: a retrospective study of 1,825 patients. F S Rep 2021; 2:201-208. [PMID: 34278355 PMCID: PMC8267389 DOI: 10.1016/j.xfre.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 11/05/2022] Open
Abstract
Objective To investigate whether the cumulative clinical pregnancy rates (CCPR) and cumulative live birth rates (CLBR) increase as the oocyte retrieval cycle increases in women with poor ovarian response. Design Retrospective cohort study. Setting Not applicable. Patient(s) Women diagnosed of poor ovarian response (POR) according to the Bologna criteria and who completed in vitro fertilization or intracytoplasmic sperm injection cycles between January 2014 and December 2018. Intervention(s) Not applicable. Main Outcome Measure(s) The conservative and optimistic estimations of CCPR and CLBR. Result(s) The conservative and optimistic estimates of CCPR peaked at the 6th complete cycle, reaching 36.44% and 71.61%, respectively. However, the conservative and optimistic estimates of CLBR peaked at the 4th complete cycle, reaching 20.22% and 38.31%, respectively. The live birth rate per complete cycle of mild stimulation protocol was comparable to other protocols after adjusting for the confounding factors. For patients ≤35 years, the live birth rate per complete cycle of progestin-primed ovarian stimulation (adjusted odds ratio = 0.51, 95% confidence interval: 0.30–0.87) and gonadotropin-releasing hormone antagonist protocol (adjusted odds ratio=0.45, 95% confidence interval: 0.24–0.81) were significantly lower than that of the mild stimulation. Conclusion(s) It is not advisable to initiate more than four complete cycles for POR patients since CLBR do not increase after that. For POR patients ≤35 years, the live birth rate per complete cycle increased in women with mild stimulation protocol.
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Affiliation(s)
- Meng Wang
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lei Jia
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-Lan Li
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia-Yi Guo
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Cong Fang
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rui Huang
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yan Liang
- Reproductive Medicine Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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12
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Aslih N, Michaeli M, Mashenko D, Ellenbogen A, Lebovitz O, Atzmon Y, Shalom-Paz E. More is not always better-lower estradiol to mature oocyte ratio improved IVF outcomes. Endocr Connect 2021; 10:146-153. [PMID: 33416511 PMCID: PMC7983485 DOI: 10.1530/ec-20-0435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/05/2021] [Indexed: 11/08/2022]
Abstract
AIM To find a cut-off ratio of estradiol/metaphase II oocyte (E2/M2) ratio and to evaluate the correlation with patients' characteristics, embryo morphokinetics using EmbryoScope™ and IVF cycle outcomes. MATERIAL AND METHODS For this retrospective cohort study, records of all fresh cycles that were cultured and scored by EmbryoScope™ were evaluated. The peak E2/M2 ratio was calculated on the day of human chorionic gonadotropin (hCG) administration and correlated to embryo morphokinetic quality and cycle outcomes. A receiver operating characteristics analysis was calculated for the E2/M2 ratio and clinical pregnancy rates. RESULTS A total of 2461 oocytes were collected from 319 patients. Receiver operating characteristics analysis revealed a cutoff of 204 as a discriminative point to predict clinical pregnancy with a sensitivity of 69.5% and specificity of 62.1% (P < 0.001). E2/M2 > 204 group were older, had higher E2 concentration, fewer M2 oocytes despite elevated gonadotrophin doses. E2/M2 ratio ≤ 204 was correlated with higher fertilization rate, better embryo quality, higher pregnancy and live birth rates, and more frozen embryos. CONCLUSION E2/M2 ratio < 204 yielded the best probability to achieve good quality embryos with good morphokinetic scores and better pregnancy outcomes and may be used to predict IVF cycle outcomes. Advanced maternal age and low ovarian response received higher concentrations of gonadotrophins, which resulted in higher E2/M2 ratio. Milder stimulation to those patients may improve their cycle outcomes.
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Affiliation(s)
- Nardin Aslih
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
| | - Mediea Michaeli
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
| | - Diana Mashenko
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
| | - Adrian Ellenbogen
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
| | - Oshrit Lebovitz
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
| | - Yuval Atzmon
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
| | - Einat Shalom-Paz
- Department of Obstetrics and Gynecology, MDIVF Unit, Hillel Yaffe Medical Center, IsraelTechnion – Israel Institute of Technology, Hadera, Haifa, Israel
- Correspondence should be addressed to E Shalom-Paz:
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Zhang X, Feng T, Yang J, Hao Y, Li S, Zhang Y, Qian Y. A flexible short protocol in women with poor ovarian response over 40 years old. J Ovarian Res 2021; 14:3. [PMID: 33402208 PMCID: PMC7786950 DOI: 10.1186/s13048-020-00761-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 12/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ovarian responsiveness to controlled ovarian stimulation is essential for a successful clinical outcome in assisted reproductive technology (ART) cycles. We aimed to find a suitable new ovulation stimulation protocol for poor ovarian response (POR) patients over 40 years old. METHODS A retrospective analysis of 488 ART cycles was evaluated from January 2015 to June 2019. Comparisons were made between the flexible short protocol (FSP), routine short protocol and mild stimulation protocol. RESULTS Compared with the routine short protocol, the FSP delayed the gonadotropin start time and reduced the total gonadotropin dose per stimulation cycle. At the same time, compared with the mild stimulation protocol, the FSP improved oocyte quality and embryo quality and improved embryo implantation potential after transfer. Furthermore, the use of the FSP reduced the probability of premature ovulation, as it inhibited the premature luteinizing hormone (LH) surge to a certain extent. CONCLUSIONS The FSP yielded better outcomes than other protocols for patients with POR over 40 years old in our study. However, further prospective studies are needed to provide more substantial evidence and to determine whether the FSP can be successful for both patients over 40 years group and younger POR patients.
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Affiliation(s)
- Xinyue Zhang
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China
| | - Ting Feng
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China
| | - Jihong Yang
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China
| | - Yingying Hao
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China
| | - Suying Li
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China
| | - Yan Zhang
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China
| | - Yun Qian
- Reproductive Medical Center of the Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan, 210011, Nanjing, China.
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Le H, Nguyen DD, Cao AT, Nguyen HTL, Tham DC, Le TD, Hugues JN. Comparative Effectiveness of Mild or Conventional GnRH-Antagonist Protocols for Ovarian Stimulation in Poor Responders (Poseidon Group 4). FRONTIERS IN REPRODUCTIVE HEALTH 2020; 2:606036. [DOI: 10.3389/frph.2020.606036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: A panel of experts (the Poseidon Group) introduced a new and more detailed stratification for poor ovarian responders in order to predict the prognosis of IVF outcome according to the sensitivity to FSH. However, various arguments about the management strategy of these patients still remain, including the convenience and the cost. Therefore, this study was conducted to compare the efficacy of mild and conventional GnRH antagonist ovarian stimulation prescribed in patients classified in Poseidon Group 4.Methods: This retrospective cohort study included 359 poor responder patients (Poseidon Group 4) treated with mild or conventional GnRH antagonist stimulation regimens from 8/2017 to 7/2019 at Tam Anh Hospital ART Center. The main outcomes were the index of Follicular Output Rate (FORT) or Follicle to Oocyte Index (FOI), the number of day-2 embryos and top-quality embryos obtained. The t-test and Mann–Whitney U test in SPSS v25.0 was used to analyze the continuous data and Chi-squared/Exact test was used for binary variables. Multiple linear regression analysis was done by using Stata versions 15.0 to measure association between primary endpoints with stimulation regimen controlled for covariates and possible confounding factors.Results: In the overall group of poor responders, the conventional GnRH antagonist protocol performed better than the mild protocol. Subsequently, data were analyzed according to the AFC. In women with AFC < 3, no significant differences were observed between the 2 regimens regarding FORT (p = 0.71), FOI (p = 0.12), the number of day-2-embryos (p = 0.052) and the number of top-quality embryos (p = 0.26). In contrast, in women with AFC ≥ 3, mild stimulation regimen resulted in significantly poorer outcome compared to the conventional GnRH antagonist regimen, regarding FORT (p < 0.01), FOI (p < 0.01), the number of day-2-embryos (p < 0.01) and top-quality embryos (p = 0.01).Conclusions: Considering poor responders classified in Poseidon Group 4, both ovarian stimulation regimens resulted in similar outcome for patients with a very low ovarian reserve (AFC < 3). In contrast, the GnRH conventional antagonist protocol with maximum initial FSH dose (300–375 IU/day) and supplementary LH (75–150 IU/day) was more effective than the mild one for patients whose ovarian reserve was less reduced. The Clinical Trial was approved by the Ethnical Biomedical Research Committee Tam Anh General Hospital.
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Dai X, Wang Y, Yang H, Gao T, Yu C, Cao F, Xia X, Wu J, Zhou X, Chen L. AMH has no role in predicting oocyte quality in women with advanced age undergoing IVF/ICSI cycles. Sci Rep 2020; 10:19750. [PMID: 33184364 PMCID: PMC7661530 DOI: 10.1038/s41598-020-76543-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
It has been widely acknowledged that anti-Müllerian hormone (AMH) is a golden marker of ovarian reserve. Declined ovarian reserve (DOR), based on experience from reproductive-aged women, refers to both the quantitative and qualitative reduction in oocytes. This view is challenged by a recent study clearly showing that the quality of oocytes is similar in young women undergoing IVF cycles irrespective of the level of AMH. However, it remains elusive whether AMH indicates oocyte quality in women with advanced age (WAA). The aim of this study was to investigate this issue. In the present study, we retrospectively analysed the data generated from a total of 492 IVF/ICSI cycles (from January 2017 to July 2020), and these IVF/ICSI cycles contributed 292 embryo transfer (ET) cycles (from June 2017 to September 2019, data of day 3 ET were included for analysis) in our reproductive centre. Based on the level of AMH, all patients (= > 37 years old) were divided into 2 groups: the AMH high (H) group and the AMH low (L) group. The parameters of in vitro embryo development and clinical outcomes were compared between the two groups. The results showed that women in the L group experienced severe DOR, as demonstrated by a higher rate of primary diagnosis of DOR, lower antral follicle count (AFC), higher level of basal follicle stimulating hormone (FSH) and cancelation cycles, lower level of E2 production on the day of surge, and fewer oocytes and MII oocytes retrieved. Compared with women in the H group, women in the L group showed slightly reduced top embryo formation rate but a similar normal fertilization rate and blastocyst formation rate. More importantly, we found that the rates of implantation, spontaneous miscarriage and livebirth were similar between the two groups, while the pregnancy rate was significantly reduced in the L group compared with the H group. Further analysis indicated that the higher pregnancy rate of women in the H group may be due to more top embryos transferred per cycle. Due to an extremely low implantation potential for transfer of non-top embryos from WAA (= > 37 years old) in our reproductive centre, we assumed that all the embryos that implanted may result from the transfer of top embryos. Based on this observation, we found that the ratio of embryos that successfully implanted or eventually led to a livebirth to top embryos transferred was similar between the H and the L groups. Furthermore, women with clinical pregnancy or livebirth in the H or L group did not show a higher level of serum AMH but were younger than women with non-pregnancy or non-livebirth. Taken together, this study showed that AMH had a limited role in predicting in vitro embryo developmental potential and had no role in predicting the in vivo embryo developmental potential, suggesting that in WAA, AMH should not be used as a marker of oocyte quality. This study supports the view that the accumulation of top embryos via multiple oocyte retrieval times is a good strategy for the treatment of WAA.
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Affiliation(s)
- Xiuliang Dai
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Yufeng Wang
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Haiyan Yang
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Tingting Gao
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Chunmei Yu
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Fang Cao
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Xiyang Xia
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Jun Wu
- Research Center for Bone and Stem Cells, Department of Anatomy, Histology and Embryology, Nanjing Medical University, Nanjing, 210029, China.
| | - Xianju Zhou
- Department of Neurology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, 510315, Guangdong, China. .,Department of Neurology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China.
| | - Li Chen
- Department of Reproductive Medicine Center, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu, China.
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Mild stimulation protocol vs conventional controlled ovarian stimulation protocol in poor ovarian response patients: a prospective randomized controlled trial. Arch Gynecol Obstet 2020; 301:1331-1339. [PMID: 32211953 DOI: 10.1007/s00404-020-05513-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/12/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the efficacy of mild ovarian stimulation protocol and conventional controlled ovarian stimulation (COS) protocol for poor ovarian response (POR) patients undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). METHODS This single-center prospective randomized controlled trial conducted from September 2013 to September 2015, including 191 patients who met the Bologna criteria of POR. Ninety-seven patients allocated to the mild ovarian stimulation group (MS group) were stimulated according to the letrozole/antagonist protocol, while 94 patients in the controlled ovarian stimulation group (COS group) were stimulated according to a high dose of gonadotropin (Gn) combined with gonadotropin-releasing hormone agonist (GnRH-a) stop protocol. The cumulative live birth rate was the primary outcome. Chinese clinical trial number ChiCTR-TRC-13003454. RESULTS Comparing with the COS group, both the stimulation duration and the total gonadotropin dose were significantly shorter and lower in the MS group (P < 0.001). A higher number of retrieved oocytes (P = 0.003) and transferrable embryos (P = 0.029) were obtained in the COS group. The cumulative live birth rates (OR 1.103; 95% CI 0.53 to 2.28; P = 0.791) were comparable between the two groups. CONCLUSIONS The increase of Gn dose during ovulation stimulation was associated with a higher number of transferrable embryos for POR patients, but this increase did not lead to a concomitant improvement of reproductive outcome, especially in terms of the cumulative live birth rate. Using a mild stimulation protocol was economically preferential while it was as effective as higher doses of Gn stimulation protocol in reproductive outcome for POR patients.
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Blumenfeld Z. What Is the Best Regimen for Ovarian Stimulation of Poor Responders in ART/IVF? Front Endocrinol (Lausanne) 2020; 11:192. [PMID: 32362870 PMCID: PMC7180183 DOI: 10.3389/fendo.2020.00192] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/18/2020] [Indexed: 12/12/2022] Open
Abstract
The infertile patients with aging ovaries-also sometimes referred to as impending premature ovarian insufficiency (POI), impending premature ovarian failure (POF), or poor ovarian responders (POR), constitute a significant and increasing bulk of the patients appealing to IVF/ART. Different causes have been cited in the literature, among the identified etiologies, including chromosomal and genetic etiology, metabolic, enzymatic, iatrogenic, toxic, autoimmune, and infectious causes. Although the most successful and ultimate treatment of POI/POF/POR patients is egg donation (ED), many, if not most, of these infertile women are reluctant to consent to ED upon the initial diagnostic interview, requesting alternative solutions despite the low odds for success. Despite anecdotal case reports, no unequivocal treatment proved to be successful for these patients in prospective randomized controlled trials. Nevertheless, the addition of growth hormone (GH) to ovarian stimulation in POR with GH deficiency may improve the results of controlled ovarian hyperstimulation (COH) and the IVF success. In patients with autoimmune etiology for POR/POI, the combination of glucocorticosteroids, pituitary-ovarian suppression, and COH may be successful in achieving the desired conception.
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Liu Y, Su R, Wu Y. Cumulative Live Birth Rate and Cost-Effectiveness Analysis of Gonadotropin Releasing Hormone-Antagonist Protocol and Multiple Minimal Ovarian Stimulation in Poor Responders. Front Endocrinol (Lausanne) 2020; 11:605939. [PMID: 33519714 PMCID: PMC7841408 DOI: 10.3389/fendo.2020.605939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/30/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The overall cumulative live birth rate (CLBR) of poor ovarian responders (POR) is extremely low. Minimal ovarian stimulation (MOS) provides a relatively realistic solution for ovarian stimulation in POR. Our study aimed to investigate whether multiple MOS strategies resulted in higher CLBR compared to conventional gonadotropin releasing hormone (GnRH) antagonists in POR. METHODS This retrospective study included 699 patients (1,058 cycles) from one center, who fulfilled the Bologna criteria between 2010 and 2018. Overall, 325 women (325 cycles) were treated with one-time conventional GnRH antagonist ovarian stimulation (GnRH-antagonist). Another 374 patients (733 cycles) were treated with multiple MOS including natural cycles. CLBR and time-and-cost-benefit analyses were compared between these two groups of women. RESULTS GnRH antagonists provided more retrieved oocytes, meiosis II oocytes, fertilized oocytes, and more viable embryos compared to both the first MOS (p < 0.001) and the cumulative corresponding numbers in multiple MOSs (p < 0.001). For the first in vitro fertilization (IVF) cycle, GnRH antagonists resulted in higher CLBR than MOS [12.92 versus 4.54%, adjusted OR (odds ratio) 2.606; 95% CI (confidence interval) 1.386, 4.899, p = 0.003]. The one-time GnRH-antagonist induced comparable CLBR (12.92 versus 7.92%, adjusted OR 1.702; 95% CI 0.971, 2.982, p = 0.063), but a shorter time to live birth [9 (8, 10.75) months versus 11 (9, 14) months, p = 0.014] and similar financial expenditure compared to repeated MOS [20,838 (17,953, 23,422) ¥ versus 21,261.5 (15,892.5, 35,140.25) ¥, p = 0.13]. CONCLUSION Both minimal ovarian stimulation (MOS) and GnRH-antagonists provide low chances of live birth in poor responders. The GnRH antagonist protocol is considered a suitable choice for PORs with comparable CLBR, shorter times to live birth, and similar financial expenditure compared to repeated MOS.
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Affiliation(s)
- Yuan Liu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rongjia Su
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Wu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- *Correspondence: Yu Wu,
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Peng Q, Cao X, Wang J, Wang L, Xu J, Ji X, Liu S, Zhu J, Dong X. Progestin-primed ovarian stimulation vs mild stimulation in women with advanced age above 40: a retrospective cohort study. Reprod Biol Endocrinol 2019; 17:91. [PMID: 31706340 PMCID: PMC6842539 DOI: 10.1186/s12958-019-0518-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/27/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated that progestin-primed ovarian stimulation (PPOS) protocol was a feasible and efficient method in in vitro fertilization (IVF) cycle. However, its application in women with advanced age has not been determined yet. The purpose of this study was to investigate its efficacy in women aged ≥40 years old. METHODS This retrospective cohort study included patients with ages of ≥40 years old at the time of ovarian stimulation. The embryonic and clinical outcome of mild stimulation and PPOS were compared. Primary outcome was top-quality embryo rate on day 3, and secondary outcome was clinical pregnancy rate. RESULTS Baseline characteristics of patients was similar in mild stimulation (122 cycles) and PPOS (47 cycles). No significant difference was found in the number of retrieved and mature oocytes and the fertilization and cleavage rates. Of interest, the rate of top-quality embryos was significantly higher in PPOS group (50.08% vs 33.29%, p = 0.015), with an increasing trend of viable embryo rate (73.55% vs 61.16%). A greater amount of gonadotropin was observed in PPOS group (2061.17 ± 1254.63 IU vs 1518.14 ± 547.25 IU, p < 0.05) in spite of comparable duration of stimulation. After FET cycle, no significant difference was found in the clinical pregnancy rates between mild stimulation (12.5%) and PPOS group (16.7%). CONCLUSIONS Higher percentage of top-quality embryos on Day 3 and comparable clinical pregnancy rate was obtained in PPOS protocol, which could be considered as a feasible ovarian stimulation protocol in women aged above 40 years old.
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Affiliation(s)
- Qian Peng
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Xiang Cao
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Jing Wang
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Lin Wang
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Jun Xu
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Xiaowei Ji
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Suying Liu
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China
| | - Jin Zhu
- Department of Obstetrics and Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.
| | - Xi Dong
- Reproductive medicine centre, Zhongshan hospital, Fudan University, Shanghai, China.
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Zolton JR, Collins GG, Greenwood EA, Hobeika E, Jeelani R, Beltsos A, Kearns WG. A 2019 reproductive update from the Midwest Reproductive Symposium International. J Assist Reprod Genet 2019; 36:2233-2236. [PMID: 31677038 DOI: 10.1007/s10815-019-01594-8] [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: 08/28/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022] Open
Abstract
"Mystery, Medicine, and the Magnificent Mile," the theme for the annual Midwest Reproductive Symposium International (MRSi) in Chicago, IL, captured the attention of reproductive professionals all over the world. Each year, the conference agenda encompasses emerging technologies in assisted reproduction, updates in the management of reproductive diseases, and common challenges encountered in clinical practice. The structure of the meeting, offering a mixture of lectures, panel discussions, and interactive workshops, creates a collaborative environment for physicians, geneticists, embryologists, nurses, mental health professionals, basic scientists, business administrative professionals, reproductive endocrinology and infertility fellows, and obstetrics and gynecology residents. The goal of the MRSi meeting is to provide all reproductive professionals the opportunity to exchange ideas, foster relationships, and deliver quality patient care. As the field continues to evolve, MRSi provides an exciting venue to uncover the mysteries of reproductive medicine with enthusiasm and collaboration.
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Affiliation(s)
- Jessica R Zolton
- Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Bldg 10; Room 8N248B, MSC 1840, Bethesda, MD, 20892, USA.
| | | | - Eleni A Greenwood
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Elie Hobeika
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Illinois College of Medicine, Chicago, IL, USA
| | | | | | - William G Kearns
- Advagenix, Rockville, MD, Department of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Ishii R, Tachibana N, Okawa R, Enomoto M, Asami M, Toriumi R, Hamada M, Horikawa M, Akiba Y, Taketani Y. Different anti-Műllerian hormone (AMH) levels respond to distinct ovarian stimulation methods in assisted reproductive technology (ART): Clues to better ART outcomes. Reprod Med Biol 2019; 18:263-272. [PMID: 31312105 PMCID: PMC6613008 DOI: 10.1002/rmb2.12270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/11/2019] [Accepted: 03/18/2019] [Indexed: 01/12/2023] Open
Abstract
PURPOSE We asked whether the relationship between anti-Műllerian hormone (AMH) value and the response to ovarian stimulation (OS) might be AMH value-related and differ for each regimen, aiming at getting clues as to how to choose OS protocols according to AMH levels. We further addressed how AMH value connects with ART outcome. METHODS A total of 1112 women undergoing egg retrieval in ART were included. We adopted four OS protocols, that is, clomiphene, clomiphene + low-dose gonadotropins (Gns), GnRH (Gn-releasing hormone) + Gns (short), and GnRH antagonist. RESULTS Anti-Műllerian hormone showed a stronger correlation with egg number compared with age over a wide age range. When patients were stratified into four groups by AMH value (<1, 1-2, 2-3, and 3≦ ng/mL), the relationship between AMH and egg number differed among differential OS regimes. The number of eggs rose as AMH and total doses of Gn increased. When analyzed for each AMH group, egg number, but not AMH, was associated with pregnancy rate. CONCLUSION Different AMH levels exhibit characteristic responses to distinct OS regimens. To improve ART outcomes, personalized OS should be selected so as to maximize egg number, which seems to be a more precise variable than AMH for predicting pregnancy.
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Affiliation(s)
- Rena Ishii
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
| | | | - Riho Okawa
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
| | - Megumi Enomoto
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
| | - Mai Asami
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
| | - Rena Toriumi
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
- Department of Obstetrics and GynecologyKyorin University School of MedicineTokyoJapan
| | - Michiko Hamada
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
| | - Michiharu Horikawa
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
- Artemis Women's HospitalLenia Medical CorporationTokyoJapan
| | - Yoko Akiba
- Women’s Clinic Oizumi GakuenLenia Medical CorporationTokyoJapan
| | - Yuji Taketani
- Artemis Women's HospitalLenia Medical CorporationTokyoJapan
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22
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Pan W, Tu H, Jin L, Hu C, Xiong J, Pan W, Yu D, Wang R, Li Y, Huang W, Liao S. Comparison of recombinant and urinary follicle-stimulating hormones over 2000 gonadotropin-releasing hormone antagonist cycles: a retrospective study. Sci Rep 2019; 9:5329. [PMID: 30926887 PMCID: PMC6441040 DOI: 10.1038/s41598-019-41846-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 03/08/2019] [Indexed: 01/12/2023] Open
Abstract
The objective of this paper was to compare the effect of recombinant follicle-stimulating hormone (rFSH) and urinary follicle-stimulating hormone (uFSH) on pregnancy rates and live birth rates with the gonadotropin-releasing hormone (GnRH) antagonist protocol in China. This retrospective study was conducted from January 2014 through August 2017. Patients treated with uFSH had significantly higher levels of luteinizing hormone (3.79 mIU/ml vs. 3.09 mIU/ml) and progesterone (0.93 ng/ml vs. 1.16 ng/ml) on the day of human chorionic gonadotropin (HCG) administration, and they also had higher pregnancy rates (24.19% vs. 22.86%). There was no significant difference in the rate of live births. In the logistic regression results of the rFSH group, the pregnancy rate was positively correlated with the level of luteinizing hormone, with an odds ratio (OR) of 1.09 (95% confidence interval [CI]: 1.00-1.18; P = 0.048). In the uFSH group, the pregnancy rate was negatively correlated with the progesterone level on the day of HCG administration, with an OR of 0.47 (95% CI: 0.27-0.77; P = 0.004). Our research concluded that uFSH performed better than rFSH in terms of pregnancy rates when it was associated with the GnRH antagonist protocol. Meanwhile, no significant differences in the rate of live births were observed between the two groups.
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Affiliation(s)
- Wei Pan
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, PR China
- Economics and Management School, Wuhan University, Wuhan, 430072, China
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, 430072, China
| | - Haiting Tu
- Economics and Management School, Wuhan University, Wuhan, 430072, China
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, 430072, China
| | - Lei Jin
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, PR China
| | - Cheng Hu
- Economics and Management School, Wuhan University, Wuhan, 430072, China
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, 430072, China
| | - Jianwu Xiong
- Economics and Management School, Wuhan University, Wuhan, 430072, China
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, 430072, China
| | - Wulin Pan
- Economics and Management School, Wuhan University, Wuhan, 430072, China
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, 430072, China
| | - Dongyang Yu
- Economics and Management School, Wuhan University, Wuhan, 430072, China
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, 430072, China
| | - Renjie Wang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, PR China
| | - Yuehan Li
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, PR China
| | - Weiming Huang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, PR China
| | - ShuJie Liao
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, PR China.
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Grisendi V, Mastellari E, La Marca A. Ovarian Reserve Markers to Identify Poor Responders in the Context of Poseidon Classification. Front Endocrinol (Lausanne) 2019; 10:281. [PMID: 31139145 PMCID: PMC6517840 DOI: 10.3389/fendo.2019.00281] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 04/16/2019] [Indexed: 12/05/2022] Open
Abstract
It is well-known that poor ovarian reserve is a cause of infertility, poor response to gonadotrophin stimulation and poor success rate after in vitro fertilization (IVF) cycles. Some years ago a consensus was elaborated on precise criteria which can lead to a correct identification of poor responders (the Bologna criteria). More recently, the POSEIDON group has proposed a new stratified classification of patients with low prognosis, also with the aim of providing clinical indications for the management of these patients. A literature search was carried out for studies that investigated the ability of ovarian reserve markers, in particular AMH and AFC, to predict poor ovarian response in IVF cycles; secondly, studies regarding the Bologna criteria and their prognostic value were analyzed and available literature on POSEIDON classification was reported. The most recent markers of ovarian reserve (serum AMH and ultrasound AFC) have shown to provide a direct and accurate measurement of ovarian follicle pool. These markers have generally shown comparable predictive power for ovarian response and a number of retrieved oocytes in IVF cycles. "Abnormal ovarian reserve test" is a very important parameter both in the Bologna criteria and in the POSEIDON classification. Several studies have already been published about the reproductive outcome of patients defined as poor responders according to the ESHRE Bologna criteria: all of them agree on the poor IVF outcome and low pregnancy rate of these patients. Instead, being the POSEIDON classification of very recent publication, the efficacy of the POSEIDON approach in improving management and outcomes of POR patients has yet to be tested and validated with future prospective clinical trials. Prediction of poor response may help clinicians choose the stimulation protocol with the aim of gaining patient compliance and cost reduction, and many efforts have been made by researchers in this sense, including the formulation of the Bologna criteria and of the POSEIDON classification, in which the ovarian reserve markers (AMH and AFC) play a fundamental role.
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Ubaldi FM, Cimadomo D, Vaiarelli A, Fabozzi G, Venturella R, Maggiulli R, Mazzilli R, Ferrero S, Palagiano A, Rienzi L. Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment. Front Endocrinol (Lausanne) 2019; 10:94. [PMID: 30842755 PMCID: PMC6391863 DOI: 10.3389/fendo.2019.00094] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 02/01/2019] [Indexed: 12/13/2022] Open
Abstract
Advanced maternal age (AMA; >35 year) is associated with a decline in both ovarian reserve and oocyte competence. At present, no remedies are available to counteract the aging-related fertility decay, however different therapeutic approaches can be offered to women older than 35 year undergoing IVF. This review summarizes the main current strategies proposed for the treatment of AMA: (i) oocyte cryopreservation to conduct fertility preservation for medical reasons or "social freezing" for non-medical reasons, (ii) personalized controlled ovarian stimulation to maximize the exploitation of the ovarian reserve in each patient, (iii) enhancement of embryo selection via blastocyst-stage preimplantation genetic testing for aneuploidies and frozen single embryo transfer, or (iv) oocyte donation in case of minimal/null residual chance of pregnancy. Future strategies and tools are in the pipeline that might minimize the risks of AMA through non-invasive approaches for embryo selection (e.g., molecular analyses of leftover products of IVF, such as spent culture media). These are yet challenging but potentially ground-breaking perspectives promising a lower clinical workload with a higher cost-effectiveness. We also reviewed emerging experimental therapeutic approaches to attempt at restoring maternal reproductive potential, e.g., spindle-chromosomal complex, pronuclear or mitochondrial transfer, and chromosome therapy. In vitro generation of gametes is also an intriguing challenge for the future. Lastly, since infertility is a social issue, social campaigns, and education among future generations are desirable to promote the awareness of the impact of age and lifestyle habits upon fertility. This should be a duty of the clinical operators in this field.
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Affiliation(s)
- Filippo Maria Ubaldi
- 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
- *Correspondence: Danilo Cimadomo
| | - Alberto Vaiarelli
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Gemma Fabozzi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Roberta Venturella
- Department of Experimental and Clinical Medicine, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Roberta Maggiulli
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Rossella Mazzilli
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Andrology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Susanna Ferrero
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Antonio Palagiano
- Department of Gynecological, Obstetrical and Reproductive Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
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Dehydroepiandrosterone Ameliorates Abnormal Mitochondrial Dynamics and Mitophagy of Cumulus Cells in Poor Ovarian Responders. J Clin Med 2018; 7:jcm7100293. [PMID: 30241351 PMCID: PMC6210273 DOI: 10.3390/jcm7100293] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 12/30/2022] Open
Abstract
Mitochondrial dysfunction is related to reproductive decline in humans, with consequences for in vitro fertilization (IVF). We assessed whether dehydroepiandrosterone (DHEA) could regulate mitochondrial homeostasis and mitophagy of cumulus cells (CCs) in poor ovarian responders (PORs). A total of 66 women who underwent IVF treatment at the Reproductive Medicine Center of Kaohsiung Veterans General Hospital were included in this study. Twenty-eight normal ovarian responders (NOR) and 38 PORs were enrolled. PORs were assigned to receive DHEA supplementation (n = 19) or not (n = 19) before IVF cycles. DHEA prevents mitochondrial dysfunction by decreasing the activation of DNM1L and MFF, and increasing MFN1 expression. Downregulation of PINK1 and PRKN occurred after DHEA treatment, along with increased lysosome formation. DHEA not only promoted mitochondrial mass but also improved mitochondrial homeostasis and dynamics in the CCs of POR. We also observed effects of alterations in mRNAs known to regulate mitochondrial dynamics and mitophagy in the CCs of POR. DHEA may prevent mitochondrial dysfunction through regulating mitochondrial homeostasis and mitophagy.
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Ma S, Ma R, Xia T, Afnan M, Song X, Xu F, Hao G, Zhu F, Han J, Zhao Z. Efficacy and safety of Ding-Kun-Dan for female infertility patients with predicted poor ovarian response undergoing in vitro fertilization/intracytoplasmic sperm injection: study protocol for a randomized controlled trial. Trials 2018; 19:124. [PMID: 29458401 PMCID: PMC5819272 DOI: 10.1186/s13063-018-2511-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/29/2018] [Indexed: 12/05/2022] Open
Abstract
Background Women undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) who have a predicted poor ovarian response (POR) present a challenge for reproductive medicine specialists. Traditional Chinese medicine (TCM) is commonly used in China for such patients, in the belief that it will improve the ovarian response and ultimately increase pregnancy rates. However, there is a lack of high-quality evidence about the effect of TCM on improving ovarian response in such patients. The purpose of this study is to evaluate ongoing viable pregnancy rate at 12 weeks’ gestation and related indicators of ovarian response in fertile women who have a predicted poor ovarian response having immediate versus delayed IVF/ICSI after 3 months of Ding-Kun-Dan (DKD) pre-treatment. Methods/design This study is a multicenter, randomized controlled, parallel-group, phase III, superiority clinical trial. Two hundred and seventy-eight eligible female infertility patients with POR will be included in the study and randomly allocated into an immediate treatment group and a DKD group in a 1:1 ratio. Both groups will receive IVF or ICSI as a standard treatment while in the DKD group, a commercially available Chinese medicine, DKD, will be administrated for 3 months before the IVF/ICSI cycle starts. The primary outcome of the study is the ongoing pregnancy rate at 12 weeks’ gestation. The secondary outcomes include total gonadotropin dosage, duration of stimulation, estradiol (E2) and progesterone (P) levels on human chorionic gonadotropin (hCG) trigger day, cycle cancellation rate, number of oocytes retrieved, high-quality embryo rate, biochemical pregnancy rate, the change of serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), and E2 levels and all side effects, safety outcomes, and any adverse events. The protocol was approved by the Ethics Committee of the First Teaching Hospital of Tianjin university of TCM (approval no. TYLL2017[K] 004). Discussion IVF/ICSI is increasingly used to treat couples desiring a baby. Many of these women will have poor ovarian function. In China, DKD is commonly used for these patients prior to undergoing IVF/ICSI. There is no effective treatment for poor ovarian response in Western medicine currently. It is important, therefore, to undertake this randomized control trial to determine whether DKD is effective or not. Trial registration Chinese Clinical Trial Registry, ID: ChiCTR-IOR-17011697. Registered on 19 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2511-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Saihua Ma
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China
| | - Ruihong Ma
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China
| | - Tian Xia
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China.
| | - Masoud Afnan
- Center of Reproductive Medicine, Tianjin United Family Hospital and Clinics, No. 22 Tanjiang Street, Hexi district, Tianjin, 300221, China
| | - Xueru Song
- Center of Reproductive Medicine, General Hospital of Tianjin Medical University, No. 154 Anshan Street, Nankai district, Tianjin, 300052, China
| | - Fengqin Xu
- Center of Reproductive Medicine, Tianjin First Center Hospital, No. 24 Fukang Road, Nankai district, Tianjin, 300190, China
| | - Guimin Hao
- Center of Reproductive Medicine, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Xinhua district, Shijiazhuang, 050000, China
| | - Fangfang Zhu
- The Graduate School, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Nankai district, Tianjin, 300073, China
| | - Jingpei Han
- The Graduate School, Tianjin University of Traditional Chinese Medicine, No. 312 Anshan West Road, Nankai district, Tianjin, 300073, China
| | - Zhimei Zhao
- Reproductive Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Chang Ling Street, Xi Qing district, Tianjin, 300112, China
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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.
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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
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Sighinolfi G, Grisendi V, La Marca A. How to personalize ovarian stimulation in clinical practice. J Turk Ger Gynecol Assoc 2017; 18:148-153. [PMID: 28890430 PMCID: PMC5590212 DOI: 10.4274/jtgga.2017.0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Controlled ovarian stimulation (COS) in in vitro fertilization (IVF) cycles is the starting point from which couple’s prognosis depends. Individualization in follicle-stimulating hormone (FSH) starting dose and protocol used is based on ovarian response prediction, which depends on ovarian reserve. Anti-Müllerian hormone levels and the antral follicle count are considered the most accurate and reliable markers of ovarian reserve. A literature search was performed for studies that addressed the ability of ovarian reserve markers to predict poor and high ovarian response in assisted reproductive technology cycles. According to the predicted response to ovarian stimulation (poor- normal- or high- response), it is possible to counsel couples before treatment about the prognosis, and also to individualize ovarian stimulation protocols, choosing among GnRH-agonists or antagonists for endogenous FSH suppression, and the FSH starting dose in order to decrease the risk of cycle cancellation and ovarian hyperstimulation syndrome. In this review we discuss how to choose the best COS therapy, based on ovarian reserve markers, in order to enhance chances in IVF.
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Affiliation(s)
- Giovanna Sighinolfi
- Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia and Clinica Eugin, Modena, Italy
| | - Valentina Grisendi
- Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia and Clinica Eugin, Modena, Italy
| | - Antonio La Marca
- Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia and Clinica Eugin, Modena, Italy
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Farquhar C, Rombauts L, Kremer JAM, Lethaby A, Ayeleke RO. Oral contraceptive pill, progestogen or oestrogen pretreatment for ovarian stimulation protocols for women undergoing assisted reproductive techniques. Cochrane Database Syst Rev 2017; 5:CD006109. [PMID: 28540977 PMCID: PMC6481489 DOI: 10.1002/14651858.cd006109.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Among subfertile women undergoing assisted reproductive technology (ART), hormone pills given before ovarian stimulation may improve outcomes. OBJECTIVES To determine whether pretreatment with the combined oral contraceptive pill (COCP) or with a progestogen or oestrogen alone in ovarian stimulation protocols affects outcomes in subfertile couples undergoing ART. SEARCH METHODS We searched the following databases from inception to January 2017: Cochrane Gynaecology and Fertility Group Specialised Register, The Cochrane Central Register Studies Online, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the reference lists of relevant articles and registers of ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of hormonal pretreatment in women undergoing ART. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary review outcomes were live birth or ongoing pregnancy and pregnancy loss. MAIN RESULTS We included 29 RCTs (4701 women) of pretreatment with COCPs, progestogens or oestrogens versus no pretreatment or alternative pretreatments, in gonadotrophin-releasing hormone (GnRH) agonist or antagonist cycles. Overall, evidence quality ranged from very low to moderate. The main limitations were risk of bias and imprecision. Most studies did not describe their methods in adequate detail. Combined oral contraceptive pill versus no pretreatmentWith antagonist cycles in both groups the rate of live birth or ongoing pregnancy was lower in the pretreatment group (OR 0.74, 95% CI 0.58 to 0.95; 6 RCTs; 1335 women; I2 = 0%; moderate quality evidence). There was insufficient evidence to determine whether the groups differed in rates of pregnancy loss (OR 1.36, 95% CI 0.82 to 2.26; 5 RCTs; 868 women; I2 = 0%; moderate quality evidence), multiple pregnancy (OR 2.21, 95% CI 0.53 to 9.26; 2 RCTs; 125 women; I2 = 0%; low quality evidence), ovarian hyperstimulation syndrome (OHSS; OR 0.98, 95% CI 0.28 to 3.40; 2 RCTs; 642 women; I2 = 0%, low quality evidence), or ovarian cyst formation (OR 0.47, 95% CI 0.08 to 2.75; 1 RCT; 64 women; very low quality evidence).In COCP plus antagonist cycles versus no pretreatment in agonist cycles, there was insufficient evidence to determine whether the groups differed in rates of live birth or ongoing pregnancy (OR 0.89, 95% CI 0.64 to 1.25; 4 RCTs; 724 women; I2 = 0%; moderate quality evidence), multiple pregnancy (OR 1.36, 95% CI 0.85 to 2.19; 4 RCTs; 546 women; I2 = 0%; moderate quality evidence), or OHSS (OR 0.63, 95% CI 0.20 to 1.96; 2 RCTs; 290 women, I2 = 0%), but there were fewer pregnancy losses in the pretreatment group (OR 0.40, 95% CI 0.22 to 0.72; 5 RCTs; 780 women; I2 = 0%; moderate quality evidence). There were no data suitable for analysis on ovarian cyst formation.One small study comparing COCP versus no pretreatment in agonist cycles showed no clear difference between the groups for any of the reported outcomes. Progestogen versus no pretreatmentAll studies used the same protocol (antagonist, agonist or gonadotrophins) in both groups. There was insufficient evidence to determine any differences in rates of live birth or ongoing pregnancy (agonist: OR 1.35, 95% CI 0.69 to 2.65; 2 RCTs; 222 women; I2 = 24%; low quality evidence; antagonist: OR 0.67, 95% CI 0.18 to 2.54; 1 RCT; 47 women; low quality evidence; gonadotrophins: OR 0.63, 95% CI 0.09 to 4.23; 1 RCT; 42 women; very low quality evidence), pregnancy loss (agonist: OR 2.26, 95% CI 0.67 to 7.55; 2 RCTs; 222 women; I2 = 0%; low quality evidence; antagonist: OR 0.36, 95% CI 0.06 to 2.09; 1 RCT; 47 women; low quality evidence; gonadotrophins: OR 1.00, 95% CI 0.06 to 17.12; 1 RCT; 42 women; very low quality evidence) or multiple pregnancy (agonist: no data available; antagonist: OR 1.05, 95% CI 0.06 to 17.76; 1 RCT; 47 women; low quality evidence; gonadotrophins: no data available). Three studies, all using agonist cycles, reported ovarian cyst formation: rates were lower in the pretreatment group (OR 0.16, 95% CI 0.08 to 0.32; 374 women; I2 = 1%; moderate quality evidence). There were no data on OHSS. Oestrogen versus no pretreatmentIn antagonist or agonist cycles, there was insufficient evidence to determine whether the groups differed in rates of live birth or ongoing pregnancy (antagonist versus antagonist: OR 0.79, 95% CI 0.53 to 1.17; 2 RCTs; 502 women; I2 = 0%; low quality evidence; antagonist versus agonist: OR 0.88, 95% CI 0.51 to 1.50; 2 RCTs; 242 women; I2 = 0%; very low quality evidence), pregnancy loss (antagonist versus antagonist: OR 0.16, 95% CI 0.02 to 1.47; 1 RCT; 49 women; very low quality evidence; antagonist versus agonist: OR 1.59, 95% CI 0.62 to 4.06; 1 RCT; 220 women; very low quality evidence), multiple pregnancy (antagonist versus antagonist: no data available; antagonist versus agonist: OR 2.24, 95% CI 0.09 to 53.59; 1 RCT; 22 women; very low quality evidence) or OHSS (antagonist versus antagonist: no data available; antagonist versus agonist: OR 1.54, 95% CI 0.25 to 9.42; 1 RCT; 220 women). Ovarian cyst formation was not reported. Head-to-head comparisonsCOCP was compared with progestogen (1 RCT, 44 women), and with oestrogen (2 RCTs, 146 women), and progestogen was compared with oestrogen (1 RCT, 48 women), with an antagonist cycle in both groups. COCP in an agonist cycle was compared with oestrogen in an antagonist cycle (1 RCT, 25 women). Data were scant but there was no clear evidence that any of the groups differed in rates of live birth or ongoing pregnancy, pregnancy loss or other adverse events. AUTHORS' CONCLUSIONS Among women undergoing ovarian stimulation in antagonist protocols, COCP pretreatment was associated with a lower rate of live birth or ongoing pregnancy than no pretreatment. There was insufficient evidence to determine whether rates of live birth or ongoing pregnancy were influenced by pretreatment with progestogens or oestrogens, or by COCP pretreatment using other stimulation protocols. Findings on adverse events were inconclusive, except that progesterone pretreatment may reduce the risk of ovarian cysts in agonist cycles, and COCP in antagonist cycles may reduce the risk of pregnancy loss compared with no pretreatment in agonist cycles.
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Affiliation(s)
- Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Luk Rombauts
- Monash UniversityMonash IVF and Department of O&G246 Clayton RdMelbourneAustralia
| | - Jan AM Kremer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9101NijmegenNetherlands6500 HB
| | - Anne Lethaby
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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