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Zheng D, Wang Y, Chen L, Zeng L, Li R. Association between body mass index and in vitro fertilization/intra-cytoplasmic sperm injection outcomes: An analysis of 15,124 normal ovarian responders in China. Chin Med J (Engl) 2024; 137:837-845. [PMID: 38494342 PMCID: PMC10997229 DOI: 10.1097/cm9.0000000000002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND High body mass index (BMI) results in decreased fecundity, and women with high BMI have reduced rates of clinical pregnancy and live birth in in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI). Meanwhile, ovarian responses show great heterogeneity in patients with a high BMI. This study aimed to analyze the effects of a high BMI on IVF/ICSI outcomes in the Chinese female with normal ovarian response. METHODS We performed a retrospective cohort study comprising 15,124 patients from the medical record system of the Reproductive Center of Peking University Third Hospital, with 3530 (23.3%) in the overweight group and 1380 (9.1%) in the obese group, who had a normal ovarian response (5-15 oocytes retrieved) and underwent fresh embryo transfer (ET) cycles from January 2017 to December 2018, followed by linked frozen-thawed embryo transfer (FET) cycles from January 2017 to December 2020. Cumulative live birth rate (CLBR) was used as the primary outcome. Furthermore, a generalized additive model was applied to visually illustrate the curvilinear relationship between BMI and the outcomes. We used a decision tree to identify the specific population where high BMI had the greatest effect on IVF/ICSI outcomes. RESULTS High BMI was associated with poor IVF/ICSI outcomes, both in cumulative cycles and in separate fresh ET or FET cycles. In cumulative cycles, compared with the normal weight group, obesity was correlated with a lower positive pregnancy test rate (adjusted odds ratio [aOR]: 0.809, 95% confidence interval [CI]: 0.682-0.960), lower clinical pregnancy rate (aOR: 0.766, 95% CI: 0.646-0.907), lower live birth rate (aOR: 0.706, 95% CI: 0.595-0.838), higher cesarean section rate (aOR: 2.066, 95% CI: 1.533-2.785), and higher rate of large for gestational age (aOR: 2.273, 95% CI: 1.547-3.341). In the generalized additive model, we found that CLBR declined with increasing BMI, with 24 kg/m 2 as an inflection point. In the decision tree, BMI only made a difference in the population aged ≤34.5 years, with anti-Mullerian hormone >1.395 ng/mL, and the first time for IVF. CONCLUSIONS High BMI was related to poor IVF/ICSI outcomes in women with a normal ovarian response, and CLBR declined with increasing BMI, partly due to suppressed endometrial receptivity. A high BMI had the most negative effect on young women with anticipated positive prognoses.
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Affiliation(s)
- Danlei Zheng
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Yuanyuan Wang
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Lixue Chen
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China
| | - Rong Li
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing 100191, China
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Hu L, Bai L, Qin R, Wang X, Zhou J, Yu C, Chen Y, Wang S, Zhao S, Chen L, Lu R. Optimizing FSH Concentration Modulation in the Short-Acting GnRH-a Long Protocol for IVF/ICSI: A Retrospective Study. Adv Ther 2024; 41:215-230. [PMID: 37884809 DOI: 10.1007/s12325-023-02702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Exogenous gonadotropin (Gn) is given to regulate follicle-stimulating hormone (FSH) levels to achieve optimal ovarian response in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). The objective of this study was to analyze the optimal degree of change in FSH blood concentration with ovarian responsiveness in a short-acting gonadotropin-releasing hormone agonist (GnRH-a) long protocol for IVF/ICSI. METHODS This retrospective study was conducted at Changzhou Maternity and Child Health Hospital's Reproductive Center from May 2017 to May 2023. A total of 794 ovarian stimulation cycles for IVF/ICSI using the short-acting GnRH-a long protocol was included. Ovarian responsiveness was assessed based on the number of follicles > 14 mm on human chorionic gonadotropin (HCG) trigger day, refine-follicular output rate (Refine-FORT) and good quality embryos. Delta 1 referred to the change in FSH level between days 6-8 of gonadotropin usage and baseline FSH, while Delta 2 referred to the change in FSH level between HCG trigger day and days 6-8 of gonadotropin usage. Simple and multiple linear regression analysis were performed to adjust for confounding factors. RESULTS The number of follicles > 14 mm on HCG trigger day was found to be the most suitable indicator for evaluating ovarian responsiveness compared to the number of follicles > 16 mm and the number of retrieved oocytes. When Delta 1 ranged from 1.94 to 3.37, the number of follicles > 14 mm on HCG trigger day was the highest. When Delta 1 ranged from 3.37 to 5.90, the Refine-FORT was the highest. However, when Delta 1 exceeded 5.90, the number of follicles > 14 mm on HCG trigger day, Refine-FORT and good quality embryo all significantly decreased. On the other hand, when Delta 2 was ≤ - 1.58, the number of follicles > 14 mm on HCG trigger day and the Refine-FORT were both the highest. CONCLUSION This study identifies optimal Delta 1 and Delta 2 ranges for effective ovarian responsiveness in a short-acting GnRH-a long protocol for IVF/ICSI and introduces the novel measure of the number of follicles > 14 mm on HCG trigger day. The optimal range for Delta 1 was 1.94 to 3.37, and Delta 2 should be < - 1.58 for achieving a higher number and quality of oocytes.
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Affiliation(s)
- Lingmin Hu
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Lijing Bai
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Rui Qin
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
- Scientific Research and Education Department, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Xiaoyu Wang
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Jing Zhou
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Chunmei Yu
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Yang Chen
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Shuxian Wang
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Shenyu Zhao
- Department of Neurology, Changzhou Third People's Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China
| | - Li Chen
- Department of Reproduction, Changzhou Maternity and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China.
| | - Renjie Lu
- Changzhou Third People's Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, 213000, Jiangsu, China.
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Jiang Y, Cui C, Guo J, Wang T, Zhang C. A prediction model for high ovarian response in the GnRH antagonist protocol. Front Endocrinol (Lausanne) 2023; 14:1238092. [PMID: 38047110 PMCID: PMC10693331 DOI: 10.3389/fendo.2023.1238092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Backgrounds The present study was designed to establish and validate a prediction model for high ovarian response (HOR) in the GnRH antagonist protocol. Methods In this retrospective study, the data of 4160 cycles were analyzed following the in vitro fertilization (IVF) at our reproductive medical center from June 2018 to May 2022. The cycles were divided into a training cohort (n=3121) and a validation cohort (n=1039) using a random sampling method. Univariate and multivariate logistic regression analyses were used to screen out the risk factors for HOR, and the nomogram was established based on the regression coefficient of the relevant variables. The area under the receiver operating characteristic curve (AUC), the calibration curve, and the decision curve analysis were used to evaluate the performance of the prediction model. Results Multivariate logistic regression analysis revealed that age, body mass index (BMI), follicle-stimulating hormone (FSH), antral follicle count (AFC), and anti-mullerian hormone (AMH) were independent risk factors for HOR (all P< 0.05). The prediction model for HOR was constructed based on these factors. The AUC of the training cohort was 0.884 (95% CI: 0.869-0.899), and the AUC of the validation cohort was 0.884 (95% CI:0.863-0.905). Conclusion The prediction model can predict the probability of high ovarian response prior to IVF treatment, enabling clinicians to better predict the risk of HOR and guide treatment strategies.
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Affiliation(s)
- Yilin Jiang
- Reproductive Medical Center, Zhengzhou University People’s Hospital, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Chenchen Cui
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Jiayu Guo
- Reproductive Medical Center, Zhengzhou University People’s Hospital, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Ting Wang
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
- Reproductive Medical Center, Henan University People’s Hospital, Zhengzhou, China
| | - Cuilian Zhang
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
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Li Y, Wang Y, Liu H, Zhang S, Zhang C. Association between HOMA-IR and ovarian sensitivity index in women with PCOS undergoing ART: A retrospective cohort study. Front Endocrinol (Lausanne) 2023; 14:1117996. [PMID: 36967765 PMCID: PMC10034104 DOI: 10.3389/fendo.2023.1117996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION Insulin resistance (IR) may play a central role in the pathophysiology of polycystic ovary syndrome (PCOS). Controlled ovarian stimulation (COS) in PCOS women in the setting of assisted reproductive technology (ART) is always a challenge for clinicians. However, it remains unclear whether IR in women with PCOS correlates with reduced ovarian sensitivity to exogenous gonadotropin (Gn). This study aimed to explore the association between homeostasis model assessment of insulin resistance (HOMA-IR) and ovarian sensitivity index (OSI). METHODS In this retrospective cohort study, we explored the association between Ln HOMA-IR and Ln OSI based on smoothing splines generated by generalized additive model (GAM). Then the correlation between HOMA-IR and OSI was further tested with a multivariable linear regression model and subgroup analysis. RESULTS 1508 women with PCOS aged 20-39 years undergoing their first oocyte retrieval cycle were included consecutively between 2018 until 2022. We observed a negative association between Ln HOMA-IR and Ln OSI by using smoothing splines. In multivariable linear regression analysis, the inverse association between Ln HOMA-IR and Ln OSI was still found in PCOS women after adjustment for potential confounders (β = -0.18, 95% CI -0.25, -0.11). Compared with patients with the lowest tertile of HOMA-IR, those who had the highest tertile of HOMA-IR had lower OSI values (β = -0.25, 95% CI -0.36, -0.15). DISCUSSION Our study provided evidence for the inverse correlation between IR and the ovarian sensitivity during COS in PCOS women. Herein, we proposed new insights for individualized manipulation in PCOS patients with IR undergoing ART.
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Affiliation(s)
- Yan Li
- Reproductive Medicine Center, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou, Henan, China
| | - Yiwen Wang
- Reproductive Medicine Center, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou, Henan, China
| | - Hai Liu
- Department of Gynaecology and Obstetrics, Xinjiang Production and Construction Corps 13 Division Red Star Hospital, Hami, Xinjiang, China
| | - Shaodi Zhang
- Reproductive Medicine Center, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou, Henan, China
| | - Cuilian Zhang
- Reproductive Medicine Center, People’s Hospital of Zhengzhou University, Henan Provincial People’s Hospital, Zhengzhou, Henan, China
- *Correspondence: Cuilian Zhang,
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Wang M, Huang R, Liang X, Mao Y, Shi W, Li Q. Recombinant LH supplementation improves cumulative live birth rates in the GnRH antagonist protocol: a multicenter retrospective study using a propensity score-matching analysis. Reprod Biol Endocrinol 2022; 20:114. [PMID: 35941630 PMCID: PMC9358814 DOI: 10.1186/s12958-022-00985-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/24/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Luteinizing hormone (LH) is critical in follicle growth and oocyte maturation. However, the value of recombinant LH (r-LH) supplementation to recombinant follicle stimulating hormone (r-FSH) during controlled ovarian stimulation in the gonadotrophin releasing hormone (GnRH) antagonist regimen is controversial. METHODS This multicenter retrospective cohort study recruited 899 GnRH antagonist cycles stimulated with r-LH and r-FSH in 3 reproductive centers and matched them to 2652 r-FSH stimulating cycles using propensity score matching (PSM) for potential confounders in a 1:3 ratio. The primary outcome was the cumulative live birth rate (CLBR) per complete cycle. RESULTS The baseline characteristics were comparable in the r-FSH/r-LH and r-FSH groups after PSM. The r-FSH/r-LH group achieved a higher CLBR than the r-FSH group (66.95% vs. 61.16%, p = 0.006). R-LH supplementation also resulted in a higher 2-pronuclear embryo rate, usable embryo rate, and live birth rate in both fresh embryo transfer cycles and frozen-thawed embryo transfer (FET) cycles. No significant differences were found in the rate of moderate and severe ovarian hyperstimulation syndrome (OHSS), or cycle cancellation rate in the prevention of OHSS. CONCLUSIONS R-LH supplementation to r-FSH in the GnRH antagonist protocol was significantly associated with a higher CLBR and live birth rate in fresh and FET cycles, and improved embryo quality without increasing the OHSS rate and cycle cancellation rate.
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Affiliation(s)
- Meng Wang
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510000, China
| | - Rui Huang
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510000, China
| | - Xiaoyan Liang
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510000, China
| | - Yundong Mao
- Reproductive Medicine Center, State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Wenhao Shi
- Reproductive Medicine Center, Northwest Women's and Children's Hospital, Xi'an 710000, China
| | - Qian Li
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510000, China.
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Wu S, Hao G, Zhang Y, Chen X, Ren H, Fan Y, Zhang Y, Bi X, Du C, Bai L, Wu X, Tan J. Poor ovarian response is associated with air pollutants: A multicentre study in China. EBioMedicine 2022; 81:104084. [PMID: 35660784 PMCID: PMC9163489 DOI: 10.1016/j.ebiom.2022.104084] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Human evidence on the association between air pollution and ovarian response is scarce. Poor ovarian response (POR) with an incidence of 5–35% is a tricky problem in IVF treatment. Methods In this large-scale multicentre study, we included 2186 women with POR (< 4 oocytes retrieved) and 7033 women with a normal ovarian response (10–15 oocytes retrieved), who underwent their first in vitro fertilization treatment in five cities in northern China during 2015–2020. Average concentrations of six air pollutants (PM2.5, PM10, O3, NO2, CO, and SO2) during different exposure windows (5 days, 1, 3, 6, and 12 months) before oocyte pick up (OPU) were calculated using data from the air monitoring station nearest to the residential site as approximate individual exposure. Logistic regression models were employed to assess the association between exposure to air pollutants and the risk of POR. Stratification analyses were conducted based on female age. Sensitivity analyses were performed in poor responders identified by Bologna criteria and women with unexpected POR. Findings We detected that increased SO2 exposure during all exposure windows before OPU was associated with a higher risk of POR, especially for women ≤ 30 years old. In the stratified analysis, the effect sizes were larger for the unexpected poor ovarian response. Interpretation The findings provide human evidence for adverse effects of exposure to ambient air pollutants on ovarian response and underscore the need to reduce ambient air pollution exposure in women of reproductive age to protect human fertility. Funding This study was granted from the National Key Research and Development Program (2018YFC1004203), the Major Special Construction Plan for Discipline Construction Project of China Medical University (3110118033), the Shengjing Freelance Researcher Plan of Shengjing Hospital of China Medical University, and the National Natural Science Foundation of China (82071601), the Central Government Special Fund for Local Science and Technology Development (2020JH6/10500006).
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Affiliation(s)
- Shanshan Wu
- Centre of Reproductive Medicine, Department of Obstetrics and Gynaecology, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang, Liaoning 110022, PR China; Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodelling of Liaoning Province, Shenyang, Liaoning 110022, PR China
| | - Guimin Hao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, PR China
| | - Yunshan Zhang
- Tianjin Central Hospital of Obstetrics and Gynaecology, Tianjin 300100, PR China
| | - Xiujuan Chen
- Reproductive Medicine Centre, Affiliated Hospital, Inner Mongolia Medical University, Hohhot, Inner Mongolia, 010050, PR China
| | - Haiqin Ren
- Jinghua Hospital, Shenyang, Liaoning 110022, PR China
| | - Yanli Fan
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, PR China
| | - Yinfeng Zhang
- Tianjin Central Hospital of Obstetrics and Gynaecology, Tianjin 300100, PR China
| | - Xingyu Bi
- Centre of Reproductive Medicine, Children's Hospital of Shanxi and Women Health Centre of Shanxi, Taiyuan, Shanxi 030013, PR China
| | - Chen Du
- Reproductive Medicine Centre, Affiliated Hospital, Inner Mongolia Medical University, Hohhot, Inner Mongolia, 010050, PR China
| | - Lina Bai
- Jinghua Hospital, Shenyang, Liaoning 110022, PR China
| | - Xueqing Wu
- Centre of Reproductive Medicine, Children's Hospital of Shanxi and Women Health Centre of Shanxi, Taiyuan, Shanxi 030013, PR China.
| | - Jichun Tan
- Centre of Reproductive Medicine, Department of Obstetrics and Gynaecology, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang, Liaoning 110022, PR China; Key Laboratory of Reproductive Dysfunction Disease and Fertility Remodelling of Liaoning Province, Shenyang, Liaoning 110022, PR China.
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C.E DK, C. VTT, J.C. EM, G.W.M. LE, Irene H, Mariette G, J.T. VGR, Willem V, D. LK, J.M. BF, M.E. BA. The Impact of BRCA1- and BRCA2 Mutations on Ovarian Reserve Status. Reprod Sci 2022; 30:270-282. [PMID: 35705781 PMCID: PMC9810575 DOI: 10.1007/s43032-022-00997-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/02/2022] [Indexed: 01/07/2023]
Abstract
This study aimed to investigate whether female BRCA1- and BRCA2 mutation carriers have a reduced ovarian reserve status, based on serum anti-Mullerian hormone (AMH) levels, antral follicle count (AFC) and ovarian response to ovarian hyperstimulation. A prospective, multinational cohort study was performed between October 2014 and December 2019. Normo-ovulatory women, aged 18-41 years old, applying for their first PGT-cycle for reason of a BRCA mutation (cases) or other genetic diseases unrelated to ovarian reserve (controls), were asked to participate. All participants underwent a ICSI-PGT cycle with a long-agonist protocol for controlled ovarian hyperstimulation. Linear and logistic regression models were used to compare AMH, AFC and ovarian response in cases and controls. Sensitivity analyses were conducted on BRCA1- and BRCA2 mutation carrier subgroups. Thirty-six BRCA mutation carriers (18 BRCA1- and 18 BRCA2 mutation carriers) and 126 controls, with mean female age 30.4 years, were included in the primary analysis. Unadjusted median AMH serum levels (IQR) were 2.40 (1.80-3.00) ng/ml in BRCA mutation carriers and 2.15 (1.30-3.40) ng/ml in controls (p = 0.45), median AFC (IQR) was 15.0 (10.8-20.3) and 14.5 (9.0-20.0), p = 0.54, respectively. Low response rate was 22.6% among BRCA mutation carriers and 9.3% among controls, p = 0.06. Median number of retrieved oocytes was 9 (6-14) in carriers and 10 (7-13) in controls, p = 0.36. No substantial differences were observed between BRCA1- and BRCA2 mutation carriers. Based on several biomarkers, no meaningful differences in ovarian reserve status were observed in female BRCA mutation carriers compared to controls in the context of ICSI-PGT treatment.
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Affiliation(s)
- Drechsel Katja C.E
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - van Tilborg Theodora C.
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Eijkemans Marinus J.C.
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Lentjes Eef G.W.M.
- Central Diagnostic Laboratory (CDL), University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Homminga Irene
- Department of Obstetrics and Gynaecology, Section Reproductive Medicine, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Goddijn Mariette
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine Amsterdam UMC, University of Amsterdam, Meibergdreef 9, AZ 1105 Amsterdam, The Netherlands
| | - van Golde Ron J.T.
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands ,GROW - School for Oncology and Developmental Biology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Verpoest Willem
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Lichtenbelt Klaske D.
- Department of Genetics, University Medical Centre Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Broekmans Frank J.M.
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Bos Anna M.E.
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Lawrenz B, Fatemi H. Editorial: Ovarian Stimulation, Endocrine Responses and Impact Factors Affecting the Outcome of IVF Treatment. Front Endocrinol (Lausanne) 2022; 13:857089. [PMID: 35498408 PMCID: PMC9047918 DOI: 10.3389/fendo.2022.857089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Barbara Lawrenz
- IVF Department, ART Fertility Clinic, Abu Dhabi, United Arab Emirates
- Obstetrical Department, Women’s University Hospital Tübingen, Tübingen, Germany
- *Correspondence: Barbara Lawrenz,
| | - Human Fatemi
- IVF Department, ART Fertility Clinic, Abu Dhabi, United Arab Emirates
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Moffat R, Hansali C, Schoetzau A, Ahler A, Gobrecht U, Beutler S, Raggi A, Sartorius G, De Geyter C. Randomised controlled trial on the effect of clomiphene citrate and gonadotropin dose on ovarian response markers and IVF outcomes in poor responders. Hum Reprod 2021; 36:987-997. [PMID: 33367742 DOI: 10.1093/humrep/deaa336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 10/21/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Does the gonadotropin (GN) starting dose and the addition of clomiphene citrate (CC) during the early follicular phase influence oocyte yield in poor responders undergoing ovarian stimulation for IVF treatment? SUMMARY ANSWER The number of retrieved oocytes was similar regardless of the starting dose of GN (150 versus 450 IU) with or without the addition of CC (100 mg from Day 3 to 7 versus placebo). WHAT IS KNOWN ALREADY ART in poor responders is a challenge for patients and clinicians. So far, randomised controlled studies addressing interventions have shown that neither the GN dose nor the addition of oral medication has any significant effect on the clinical outcome of ART in poor responders. There is limited knowledge about the effect of GN starting dose in combination with CC during the early follicular phase of ovarian stimulation on ovarian response markers and ART outcome. STUDY DESIGN, SIZE, DURATION This single-centre randomised double-blinded clinical trial was conducted from August 2013 until November 2017. Using the Bologna criteria, 220 of 2288 patients (9.6%) were identified as poor responders and 114 eligible participants underwent ovarian stimulation in a GnRH-antagonist protocol for ART. PARTICIPANTS/MATERIALS, SETTING, METHODS The participants were equally randomised to one of four treatment arms: Group A (n = 28) received 100 mg CC (Day 3-7) and a starting dose of 450 IU HMG, Group B (n = 29) received 100 mg CC and a starting dose of 150 IU HMG, Group C (n = 30) received placebo and a starting dose of 450 IU HMG and Group D (n = 27) received placebo and a starting dose of 150 IU HMG. Serum levels of FSH, LH, estradiol and progesterone were measured on Day 1 and 5 and on the day of ovulation induction. Available embryos were cultured up to the blastocyst stage and were always transferred in the same cycle. The primary outcome was the number of oocytes collected after ovarian stimulation. Other outcome measures were response to ovarian stimulation, embryo development and obstetrical outcome. MAIN RESULTS AND THE ROLE OF CHANCE All study participants (n = 114) fulfilled at least two of the Bologna criteria for poor responders. Median age of the study population was 38.5 years. There were 109 patients who underwent oocyte retrieval. The number of oocytes retrieved was similar among the groups (±SD; 95% confidence intervals); A: 2.85 (±0.48; 2.04-3.98), B: 4.32 (±0.59; 3.31-5.64); C: 3.33 (±0.52; 2.45-4.54); D: 3.22 (±0.51; 2.36-4.41); P overall = 0.246. However, ovarian stimulation with 150 IU plus CC resulted in a higher number of blastocysts compared to ovarian stimulation with 450 IU plus CC (±SD; 95% confidence intervals); A: 0.83 (±0.15; 0.58-1.2), B: 1.77 (±0.21; 1.42-2.22); P overall = 0.006. Mean FSH serum levels were lower in the groups with a starting dose of 150 IU. Adding CC did not affect mean serum FSH levels. There were no differences in estradiol concentrations among the groups. Endometrial thickness was lower in the groups receiving CC. The overall live birth rate (LBR) was 12.3%, and the cumulative LBR was 14.7%. LIMITATIONS, REASONS FOR CAUTION The trial was powered to detect differences in neither the number of blastocysts nor the LBR, which would be the preferable primary outcome of interventional trials in ART. WIDER IMPLICATIONS OF THE FINDINGS We found that ovarian stimulation with 150 IU gonadotrophin in combination with 100 mg CC produced more blastocysts. The effect of adding CC to GN on LBR in poor responders remains to be proven in randomised trials. High GN doses (450 IU) resulted in high FSH serum levels but increased neither the estradiol levels nor the number of retrieved oocytes, implying that granulosa cell function is not improved by high FSH serum levels. Lower starting doses of GN lead to a reduction of costs of medication. The small but significant difference in blastocyst formation and the lower FSH levels in the treatment groups receiving less GN may be an indication of better oocyte quality with higher developmental competence. STUDY FUNDING/COMPETING INTEREST(S) The costs for the HMG used for ovarian stimulation were provided by IBSA Switzerland. The study was also supported by the Repronatal Foundation, Basel, Switzerland. The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER NCT01577472. TRIAL REGISTRATION DATE 13 April 2012. DATE OF FIRST PATIENT’S ENROLMENT August 2013.
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Affiliation(s)
- R Moffat
- Reproductive Medicine and Gynecologic Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland.,Fertisuisse, Private Fertility Center, Olten and Basel, Switzerland
| | - C Hansali
- Reproductive Medicine and Gynecologic Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
| | - A Schoetzau
- Reproductive Medicine and Gynecologic Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
| | - A Ahler
- Reproductive Medicine and Gynecologic Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
| | - U Gobrecht
- Reproductive Medicine and Gynecologic Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
| | - S Beutler
- Fertisuisse, Private Fertility Center, Olten and Basel, Switzerland
| | - A Raggi
- Fertisuisse, Private Fertility Center, Olten and Basel, Switzerland
| | - G Sartorius
- Fertisuisse, Private Fertility Center, Olten and Basel, Switzerland
| | - C De Geyter
- Reproductive Medicine and Gynecologic Endocrinology (RME), University Hospital, University of Basel, Basel, Switzerland
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Hu L, Sun B, Ma Y, Li L, Wang F, Shi H, Sun Y. The Relationship Between Serum Delta FSH Level and Ovarian Response in IVF/ICSI Cycles. Front Endocrinol (Lausanne) 2020; 11:536100. [PMID: 33224104 PMCID: PMC7674484 DOI: 10.3389/fendo.2020.536100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background When ovarian response to FSH stimulation for IVF/ICSI is unsatisfactory, the FSH dose is often adjusted in the treatment cycles, thereby assuming that hormone status and follicular development were insufficient for optimal stimulation. Objectives To evaluate whether serum delta FSH levels between D6 of gonadotrophin use and basal serum FSH or between D6 of gonadotrophin use and D1 of gonadotrophin use predict ovarian response in IVF/ICSI cycles. Method The participants of this retrospective study were chosen from the Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University between August 2015 and December 2017 (n = 3,109), and during the COS, each participant was given a fixed dose of rFSH in the first 6 days. Delta FSH1: The difference of serum FSH between D6 of gonadotrophin use and basal serum FSH. Delta FSH2: The difference of serum FSH between D6 of gonadotrophin use and D1 of gonadotrophin use. Logistic regression was used to analyze the association between delta FSH1 level and delta FSH2 level and ovarian response. Besides, we also use the tertile statistics to divide the groups. Results Part I: Delta FSH1 levels (mean: 1.41 ± 3.46) in normal responders were higher than delta FSH1 levels (mean: 1.07 ± 23.89) in hyper responders (P = 0.0248). The tertile of delta FSH1 is dif ≤ 0, 0 < dif ≤ 2.25 and dif > 2.25. Compared with the hyper responder, the delta FSH1 (0 < dif ≤ 2.25 and dif > 2.25) in the normal responder has a higher ratio and is statistically significant. Part II: Delta FSH2 levels (mean: 4.90 ± 2.84) in normal responders were similar with delta FSH2 levels (mean: 4.74 ± 2.09) in hyper responders (P = 0.103). The tertile of delta FSH1 is dif ≤ 3.91, 3.91 < dif ≤ 5.69 and dif > 5.69. Compared with the hyper responders, the delta FSH2 (3.91 < dif ≤ 5.69 and dif > 5.69) in the normal responders has a higher ratio and is statistically significant. Conclusions There is a weak relationship between ovarian response and serum delta FSH levels.
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Affiliation(s)
- Linli Hu
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo Sun
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yujia Ma
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lu Li
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hao Shi
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yingpu Sun
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Obstetrical and Gynecological Diseases (Reproductive Medicine) Clinical Research Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Engineering Laboratory of Preimplantation Genetic Diagnosis and Screening, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Camargo-Mattos D, García U, Camargo-Diaz F, Ortiz G, Madrazo I, Lopez-Bayghen E. Initial ovarian sensitivity index predicts embryo quality and pregnancy potential in the first days of controlled ovarian stimulation. J Ovarian Res 2020; 13:94. [PMID: 32807228 PMCID: PMC7433193 DOI: 10.1186/s13048-020-00688-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND To determine if a modified ovarian sensitivity index (MOSI), based on initial follicular measurements and the initial follicle-stimulating hormone (FSH) dose, can predict the production of high-quality embryos for successful implantation during in vitro fertilization (IVF). METHODS This study consisted of two phases: 1) a retrospective study and 2) a prospective observational study. For the first phase, 363 patients charts were reviewed, of which 283 had embryos transferred. All women underwent a standardized antagonist-based IVF protocol. At the first follow-up (Day 3/4), the number and size of the follicles were determined. MOSI was calculated as ln (number follicles (≥6 mm) × 1000 / FSH initial dose). Afterward, the number and quality of the ova, embryo development, and the number and quality of the blastocysts were determined. Embryo implantation was confirmed by β-hCG. For the second phase, 337 IVF cycles were followed to determine MOSI's accuracy. RESULTS MOSI could predict the production of ≥4 high-quality embryos by Day 2 (AUC = 0.69, 95%CI:0.63-0.75), ≥2 blastocysts (AUC = 0.74, 95%CI:0.68-0.79), and ≥ 35% rate of blastocyst formation (AUC = 0.65, 95%CI:0.58-0.72). Using linear regression, MOSI was highly associated with the number of ova captured (β = 5.15), MII oocytes (β = 4.31), embryos produced (β = 2.90), high-quality embryos (β = 0.98), and the blastocyst formation rate (β = 0.06, p < 0.01). Using logistic regression, MOSI was highly associated with achieving ≥4 high-quality embryos (odds ratio = 2.80, 95%CI:1.90-4.13), ≥2 blastocysts (odds ratio = 3.40, 95%CI:2.33-4.95), and ≥ 35% blastocysts formation rate (odds ratio = 1.96, 95%CI:1.31-2.92). This effect was independent of age, BMI, and antral follicle count. For implantation, MOSI was significantly associated with successful implantation (odds ratio = 1.79, 95%CI:1.25-2.57). For the prospective study, MOSI was highly accurate at predicting ≥6 high-quality embryos on Day 2 (accuracy = 68.5%), ≥6 blastocysts (accuracy = 68.0%), and a blastocyst formation rate of ≥35% (accuracy = 61.4%). CONCLUSION MOSI was highly correlated with key IVF parameters that are associated with achieved pregnancy. Using this index with antagonist cycles, clinicians may opt to stop an IVF cycle, under the assumption that the cycle will fail to produce good blastocysts, preventing wasting the patient's resources and time.
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Affiliation(s)
- David Camargo-Mattos
- Clinical Research, Instituto de Infertilidad y Genética México SC, Ingenes, México City, Mexico
| | - Uziel García
- Clinical Research, Instituto de Infertilidad y Genética México SC, Ingenes, México City, Mexico
| | - Felipe Camargo-Diaz
- Clinical Research, Instituto de Infertilidad y Genética México SC, Ingenes, México City, Mexico
| | - Ginna Ortiz
- Clinical Research, Instituto de Infertilidad y Genética México SC, Ingenes, México City, Mexico
| | - Ivan Madrazo
- Clinical Research, Instituto de Infertilidad y Genética México SC, Ingenes, México City, Mexico
| | - Esther Lopez-Bayghen
- Departamento de Toxicología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN), Avenida Instituto Politécnico Nacional 2508, San Pedro Zacatenco, 07360, México City, Mexico.
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Leijdekkers JA, van Tilborg TC, Torrance HL, Oudshoorn SC, Brinkhuis EA, Koks CAM, Lambalk CB, de Bruin JP, Fleischer K, Mochtar MH, Kuchenbecker WKH, Laven JSE, Mol BWJ, Broekmans FJM, Eijkemans MJC. Do female age and body weight modify the effect of individualized FSH dosing in IVF/ICSI treatment? A secondary analysis of the OPTIMIST trial. Acta Obstet Gynecol Scand 2019; 98:1332-1340. [PMID: 31127607 DOI: 10.1111/aogs.13664] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/05/2019] [Accepted: 05/21/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The OPTIMIST trial revealed that for women starting in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment, no substantial differences exist in first cycle and cumulative live birth rates between an antral follicle count (AFC)-based individualized follicle-stimulating hormone (FSH) dose and a standard dose. Female age and body weight have been suggested to cause heterogeneity in the effect of FSH dose individualization. The objective of the current study is to evaluate whether these patient characteristics modify the effect of AFC-based individualized FSH dosing in IVF/ICSI treatment. MATERIAL AND METHODS A secondary data-analysis of the OPTIMIST trial. Women initiating IVF/ICSI treatment were classified as predicted poor (AFC 0-7), suboptimal (AFC 8-10) or hyper responders (AFC >15), and randomly allocated to a standard FSH dose (150 IU/d) or an individualized FSH dose (450, 225 or 100 IU/d for predicted poor, suboptimal and hyper responders, respectively). In each predicted response category, logistic regression models with interaction terms were used to evaluate the presence of effect modification. The first cycle was analyzed, and the primary outcomes were first complete cycle live birth rate (including fresh plus frozen-thawed embryo transfers) and ovarian hyperstimulation syndrome (OHSS) risks. RESULTS No effect modification was revealed in the predicted poor (n = 234) and suboptimal (n = 277) responders. In the predicted hyper responders (n = 521), the effect of the individualized FSH dose on the first cycle live birth rate was modified by female age (P = 0.02) and the effect on OHSS risks was modified by body weight (P = 0.02). A dose reduction from 150 to 100 IU/d generally decreased the OHSS risks in predicted hyper responders, but also reduced the chance of a live birth in young women, and had no beneficial impact on OHSS risks in women with a relatively low body weight. CONCLUSIONS In women with a predicted hyper response undergoing IVF/ICSI treatment, female age and body weight seem to modify the effect of FSH dose individualization. Although a reduced FSH starting dose generally decreases the OHSS risks, it may also reduce the chance of a live birth, specifically for young women. Future studies could consider these findings when investigating the optimal approach to reduce OHSS risks while maintaining the probability of a live birth for predicted hyper responders in IVF/ICSI treatment.
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Affiliation(s)
- Jori A Leijdekkers
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Theodora C van Tilborg
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Simone C Oudshoorn
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Egbert A Brinkhuis
- Department of Obstetrics and Gynecology, Meander Medical Center, Amersfoort, The Netherlands
| | - Carolien A M Koks
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Cornelis B Lambalk
- Center for Reproductive Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique H Mochtar
- Center for Reproductive Medicine, Amsterdam University Medical Center, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Broekmans FJ. Individualization of FSH Doses in Assisted Reproduction: Facts and Fiction. Front Endocrinol (Lausanne) 2019; 10:181. [PMID: 31080437 PMCID: PMC6497745 DOI: 10.3389/fendo.2019.00181] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/04/2019] [Indexed: 11/30/2022] Open
Abstract
The art of ovarian stimulation for IVF/ICSI treatment using exogenous FSH should be balanced against the relative contribution of other steps of the ART process such as the IVF-lab-phase and the Embryo-Transfer. The aim of ovarian stimulation is to obtain a certain number of oocytes, that will enable the best probability of achieving a live birth. It has been suggested that more oocytes will create a better prospect for pregnancy, but studies on the question whether the retrieval of a few oocytes less or more will make the difference are not clearly supportive for this mantra. Personalization strategies have been the subject of many studies over the past 20 years. Creating the optimal response in a patient in terms of live birth prognosis as well as OHSS risks may be based on information from the Ovarian Reserve testing using the Antral Follicle Count or Anti-Mullerian Hormone, the patient's bodyweight, the ovarian response in a previous cycle, and the dosage level of FSH. Taken together, steering the ovarian response into a supposed optimal range may appear difficult as the interrelation for each of these factors with the egg number is weak. Using OR testing for choosing FSH dosage, compared to a standard normal dosage of 150 IU, has been studied in several trials. Dosage individualization, in general, does not appear to improve the prospects for live birth, but the reduction in OHSS risk may be substantial. This implies that the use of high dosages of FSH in predicted LOW responders lacks any cost-benefit for the patient and may be abandoned, while in predicted HIGH responders, reduction of the usual dosage level of 150 IU may create better safety, provided that in case of an unexpected LOW response cancelation of the cycle is refrained from. In view of recent developments in using GnRH agonist triggering of final oocyte maturation, the trend could be that with the Antagonist co-medication system and a standard dosage of 150 IU of FSH, prior ovarian reserve testing may become futile, as safety can be managed well in actual HIGH responders by replacing the high dose hCG trigger.
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Oudshoorn SC, van Tilborg TC, Eijkemans MJC, Oosterhuis GJE, Friederich J, van Hooff MHA, van Santbrink EJP, Brinkhuis EA, Smeenk JMJ, Kwee J, de Koning CH, Groen H, Lambalk CB, Mol BWJ, Broekmans FJM, Torrance HL. Individualized versus standard FSH dosing in women starting IVF/ICSI: an RCT. Part 2: The predicted hyper responder. Hum Reprod 2018; 32:2506-2514. [PMID: 29121269 DOI: 10.1093/humrep/dex319] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 10/12/2017] [Indexed: 01/06/2023] Open
Abstract
STUDY QUESTION Does a reduced FSH dose in women with a predicted hyper response, apparent from a high antral follicle count (AFC), who are scheduled for IVF/ICSI lead to a different outcome with respect to cumulative live birth rate and safety? SUMMARY ANSWER Although in women with a predicted hyper response (AFC > 15) undergoing IVF/ICSI a reduced FSH dose (100 IU per day) results in similar cumulative live birth rates and a lower occurrence of any grade of ovarian hyperstimulation syndrome (OHSS) as compared to a standard dose (150 IU/day), a higher first cycle cancellation rate and similar severe OHSS rate were observed. WHAT IS KNOWN ALREADY Excessive ovarian response to controlled ovarian stimulation (COS) for IVF/ICSI may result in increased rates of cycle cancellation, the occurrence of OHSS and suboptimal live birth rates. In women scheduled for IVF/ICSI, an ovarian reserve test (ORT) can be used to predict response to COS. No consensus has been reached on whether ORT-based FSH dosing improves effectiveness and safety in women with a predicted hyper response. STUDY DESIGN SIZE, DURATION Between May 2011 and May 2014, we performed an open-label, multicentre RCT in women with regular menstrual cycles and an AFC > 15. Women with polycystic ovary syndrome (Rotterdam criteria) were excluded. The primary outcome was ongoing pregnancy achieved within 18 months after randomization and resulting in a live birth. Secondary outcomes included the occurrence of OHSS and cost-effectiveness. Since this RCT was embedded in a cohort study assessing over 1500 women, we expected to randomize 300 predicted hyper responders. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with an AFC > 15 were randomized to an FSH dose of 100 IU or 150 IU/day. In both groups, dose adjustment was allowed in subsequent cycles (maximum 25 IU in the reduced and 50 IU in the standard group) based on pre-specified criteria. Both effectiveness and cost-effectiveness were evaluated from an intention-to-treat perspective. MAIN RESULTS AND THE ROLE OF CHANCE We randomized 255 women to a daily FSH dose of 100 IU and 266 women to a daily FSH dose of 150 IU. The cumulative live birth rate was 66.3% (169/255) in the reduced versus 69.5% (185/266) in the standard group (relative risk (RR) 0.95 [95%CI, 0.85-1.07], P = 0.423). The occurrence of any grade of OHSS was lower after a lower FSH dose (5.2% versus 11.8%, RR 0.44 [95%CI, 0.28-0.71], P = 0.001), but the occurrence of severe OHSS did not differ (1.3% versus 1.1%, RR 1.25 [95%CI, 0.38-4.07], P = 0.728). As dose reduction was not less expensive (€4.622 versus €4.714, delta costs/woman €92 [95%CI, -479-325]), there was no dominant strategy in the economic analysis. LIMITATIONS, REASONS FOR CAUTION Despite our training programme, the AFC might have suffered from inter-observer variation. Although strict cancellation criteria were provided, selective cancelling in the reduced dose group (for poor response in particular) cannot be excluded as observers were not blinded for the FSH dose and small dose adjustments were allowed in subsequent cycles. However, as first cycle live birth rates did not differ from the cumulative results, the open design probably did not mask a potential benefit for the reduced dosing group. As this RCT was embedded in a larger cohort study, the power in this study was unavoidably lower than it should be. Participants had a relatively low BMI from an international perspective, which may limit generalization of the findings. WIDER IMPLICATIONS OF THE FINDINGS In women with a predicted hyper response scheduled for IVF/ICSI, a reduced FSH dose does not affect live birth rates. A lower FSH dose did reduce the incidence of mild and moderate OHSS, but had no impact on severe OHSS. Future research into ORT-based dosing in women with a predicted hyper response should compare various safety management strategies and should be powered on a clinically relevant safety outcome while assessing non-inferiority towards live birth rates. STUDY FUNDING/COMPETING INTEREST(S) This trial was funded by The Netherlands Organization for Health Research and Development (ZonMW, Project Number 171102020). SCO, TCvT and HLT received an unrestricted research grant from Merck Serono (the Netherlands). CBL receives grants from Merck, Ferring and Guerbet. BWJM is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for OvsEva, Merck and Guerbet. FJMB receives monetary compensation as a member of the external advisory board for Ferring pharmaceutics BV and Merck Serono for consultancy work for Gedeon Richter (Belgium) and Roche Diagnostics (Switzerland) and for a research cooperation with Ansh Labs (USA). All other authors have nothing to declare. TRIAL REGISTRATION NUMBER Registered at the ICMJE-recognized Dutch Trial Registry (www.trialregister.nl). Registration number: NTR2657. TRIAL REGISTRATION DATE 20 December 2010. DATE OF FIRST PATIENT’S ENROLMENT 12 May 2011.
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Affiliation(s)
- Simone C Oudshoorn
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Theodora C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marinus J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - G Jur E Oosterhuis
- Department of Obstetrics and Gynaecology, St. Antonius Hospital, PO box 2500, 3430 EM Nieuwegein, The Netherlands
| | - Jaap Friederich
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Noordwest Ziekenhuisgroep, PO Box 750, 1780 AT Den Helder, The Netherlands
| | - Marcel H A van Hooff
- Department of Gynaecology, St. Franciscus Gasthuis, PO Box 10900, 3004 BA Rotterdam, The Netherlands
| | - Evert J P van Santbrink
- Fertility Clinic Reinier de Graaf group, Diaconessenhuis Voorburg, PO Box 998, 2275 CX, Voorburg, The Netherlands
| | - Egbert A Brinkhuis
- Department of Obstetrics and Gynaecology, Meander Medical Centre, PO Box 1502, 3800 BM Amersfoort, The Netherlands
| | - Jesper M J Smeenk
- Centre for Reproductive Medicine, Elisabeth-TweeSteden Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - Janet Kwee
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis West, PO Box 9243, 1006 AE Amsterdam, The Netherlands
| | - Corry H de Koning
- Department of Gynaecology, Tergooi Hospital, PO Box 1201 DA Blaricum, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Cornelis B Lambalk
- Centre for Reproductive Medicine, VU University Medical Centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Ben Willem J Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, SA 5006 Adelaide, Australia.,The South Australian Health and Medical Research Unit, PO Box 11060, SA 5001 Adelaide, Australia
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
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van Tilborg TC, Torrance HL, Oudshoorn SC, Eijkemans MJC, Mol BW, Broekmans FJM. The end for individualized dosing in IVF ovarian stimulation? Reply to letters-to-the-editor regarding the OPTIMIST papers. Hum Reprod 2018; 33:984-988. [DOI: 10.1093/humrep/dey064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Indexed: 01/22/2023] Open
Affiliation(s)
- T C van Tilborg
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - H L Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - S C Oudshoorn
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - M J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - B W Mol
- The Robinson Research Institute, School of Pediatrics and Reproductive Health, University of Adelaide, SA 5006 Adelaide, Australia
- The South Australian Health and Medical Research Unit, PO Box 11060, SA 5001 Adelaide, Australia
| | - F J M Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
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