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Wong KM, van Wely M, Verhoeve HR, Kaaijk EM, Mol F, van der Veen F, Repping S, Mastenbroek S. Transfer of fresh or frozen embryos: a randomised controlled trial. Hum Reprod 2021; 36:998-1006. [PMID: 33734369 PMCID: PMC7970725 DOI: 10.1093/humrep/deaa305] [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: 06/19/2017] [Revised: 08/24/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Is IVF with frozen-thawed blastocyst transfer (freeze-all strategy) more effective than IVF with fresh and frozen-thawed blastocyst transfer (conventional strategy)? SUMMARY ANSWER The freeze-all strategy was inferior to the conventional strategy in terms of cumulative ongoing pregnancy rate per woman. WHAT IS KNOWN ALREADY IVF without transfer of fresh embryos, thus with frozen-thawed embryo transfer only (freeze-all strategy), is increasingly being used in clinical practice because of a presumed benefit. It is still unknown whether this new IVF strategy increases IVF efficacy. STUDY DESIGN, SIZE, DURATION A single-centre, open label, two arm, parallel group, randomised controlled superiority trial was conducted. The trial was conducted between January 2013 and July 2015 in the Netherlands. The intervention was one IVF cycle with frozen-thawed blastocyst transfer(s) versus one IVF cycle with fresh and frozen-thawed blastocyst transfer(s). The primary outcome was cumulative ongoing pregnancy resulting from one IVF cycle within 12 months after randomisation. Couples were allocated in a 1:1 ratio to the freeze-all strategy or the conventional strategy with an online randomisation programme just before the start of down-regulation. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were subfertile couples with any indication for IVF undergoing their first IVF cycle, with a female age between 18 and 43 years. Differences in cumulative ongoing pregnancy rates were expressed as relative risks (RR) with 95% CI. All outcomes were analysed following the intention-to-treat principle. MAIN RESULTS AND THE ROLE OF CHANCE Two-hundred-and-five couples were randomly assigned to the freeze-all strategy (n = 102) or to the conventional strategy (n = 102). The cumulative ongoing pregnancy rate per woman was significantly lower in women allocated to the freeze-all strategy (19/102 (19%)) compared to women allocated to the conventional strategy (32/102 (31%); RR 0.59; 95% CI 0.36-0.98). LIMITATIONS, REASONS FOR CAUTION As this was a single-centre study, we were unable to study differences in study protocols and clinic performance. This, and the limited sample size, should make one cautious in using the results as the basis for definitive policy. All patients undergoing IVF, including those with a poor prognosis, were included; therefore, the outcome could differ in women with a good prognosis of IVF treatment success. WIDER IMPLICATIONS OF THE FINDINGS Our results indicate that there might be no benefit of a freeze-all strategy in terms of cumulative ongoing pregnancy rates. The efficacy of the freeze-all strategy in subgroups of patients, different stages of embryo development, and different freezing protocols needs to be further established and balanced against potential benefits and harms for mothers and children. STUDY FUNDING/COMPETING INTEREST(S) The Netherlands Organisation for Health Research and Development (ZonMW grant 171101007). S.M., F.M. and M.v.W. stated they are authors of the Cochrane review 'Fresh versus frozen embryo transfers in assisted reproduction'. TRIAL REGISTRATION NUMBER Dutch Trial Register, NTR3187. TRIAL REGISTRATION DATE 9 December 2011. DATE OF FIRST PATIENT’S ENROLMENT 8 January 2013.
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Affiliation(s)
- K M Wong
- Amsterdam UMC, University of Amsterdam, Centre for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - M van Wely
- Amsterdam UMC, University of Amsterdam, Centre for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - E M Kaaijk
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - F Mol
- Amsterdam UMC, University of Amsterdam, Centre for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - F van der Veen
- Amsterdam UMC, University of Amsterdam, Centre for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - S Repping
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,National Health Care Institute, Diemen, the Netherlands
| | - S Mastenbroek
- Amsterdam UMC, University of Amsterdam, Centre for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
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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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Vázquez AC, Rodríguez JMAG, Algara ALC, García JDM. Correlation between biochemical, ultrasonographic and demographic parameters with ovarian response to IVF/ICSI treatments in Mexican women. JBRA Assist Reprod 2021; 25:4-9. [PMID: 32489091 PMCID: PMC7863092 DOI: 10.5935/1518-0557.20200040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: Ovarian response from a conventional ovarian stimulation protocol is a crucial step in IVF/ICSI treatments. This ovarian response encompasses a wide range of outcomes at the extremes, leading to either excessive responses with the risk of life-threatening conditions like ovarian hyperstimulation syndrome (OHSS), or poor ovarian response (POR) with poor outcomes. This study aims to integrate biochemical, ultrasonographic and demographic parameters into a mathematical formula able to predict ovarian response to stimulation in IVF/ICSI in gonadotropin-releasing hormone (GnRH) antagonist protocols. Methods: This retrospective analysis included 147 patients submitted to an ovarian stimulation protocol combining recombinant FSH and gonadotropin-releasing hormone antagonist. All the parameters were correlated with the Spearman Rho and Pearson´s correlation coefficient. Once the data was normalized, we used the multiple linear regression models, checking the results with the progressive discriminating analysis. Results: We classified the database according to the correlation with the number of oocytes retrieved; the progressive discriminating analysis resulted in the following equation: oocytes retrieved = 2.312-0.130 (FSH) + 0.562 (AFC). Conclusions: The incorporation of 2 ovarian reserve parameters into a regression equation enables knowing the number of retrieved oocytes in each patient with 80.5% sensitivity and 55.4% specificity.
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Leijdekkers JA, Eijkemans MJC, van Tilborg TC, Oudshoorn SC, van Golde RJT, Hoek A, Lambalk CB, de Bruin JP, Fleischer K, Mochtar MH, Kuchenbecker WKH, Laven JSE, Mol BWJ, Torrance HL, Broekmans FJM. Cumulative live birth rates in low-prognosis women. Hum Reprod 2020; 34:1030-1041. [PMID: 31125412 PMCID: PMC6555622 DOI: 10.1093/humrep/dez051] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/10/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Do cumulative live birth rates (CLBRs) over multiple IVF/ICSI cycles confirm the low prognosis in women stratified according to the POSEIDON criteria? SUMMARY ANSWER The CLBR of low-prognosis women is ~56% over 18 months of IVF/ICSI treatment and varies between the POSEIDON groups, which is primarily attributable to the impact of female age. WHAT IS KNOWN ALREADY The POSEIDON group recently proposed a new stratification for low-prognosis women in IVF/ICSI treatment, with the aim to define more homogenous populations for clinical trials and stimulate a patient-tailored therapeutic approach. These new criteria combine qualitative and quantitative parameters to create four groups of low-prognosis women with supposedly similar biologic characteristics. STUDY DESIGN, SIZE, DURATION This study analyzed the data of a Dutch multicenter observational cohort study including 551 low-prognosis women, aged <44 years, who initiated IVF/ICSI treatment between 2011 and 2014 and were treated with a fixed FSH dose of 150 IU/day in the first treatment cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS Low-prognosis women were categorized into one of the POSEIDON groups based on their age (younger or older than 35 years), anti-Müllerian hormone (AMH) level (above or below 0.96 ng/ml), and the ovarian response (poor or suboptimal) in their first cycle of standard stimulation. The primary outcome was the CLBR over multiple complete IVF/ICSI cycles, including all subsequent fresh and frozen-thawed embryo transfers, within 18 months of treatment. Cumulative incidence curves were obtained using an optimistic and a conservative analytic approach. MAIN RESULTS AND THE ROLE OF CHANCE The CLBR of the low-prognosis women was on average ~56% over 18 months of IVF/ICSI treatment. Younger unexpected poor (n = 38) and suboptimal (n = 179) responders had a CLBR of ~65% and ~68%, respectively, and younger expected poor responders (n = 65) had a CLBR of ~59%. The CLBR of older unexpected poor (n = 41) and suboptimal responders (n = 102) was ~42% and ~54%, respectively, and of older expected poor responders (n = 126) ~39%. For comparison, the CLBR of younger (n = 164) and older (n = 78) normal responders with an adequate ovarian reserve was ~72% and ~58% over 18 months of treatment, respectively. No large differences were observed in the number of fresh treatment cycles between the POSEIDON groups, with an average of two fresh cycles per woman within 18 months of follow-up. LIMITATIONS, REASONS FOR CAUTION Small numbers in some (sub)groups reduced the precision of the estimates. However, our findings provide the first relevant indication of the CLBR of low-prognosis women in the POSEIDON groups. Small FSH dose adjustments between cycles were allowed, inducing therapeutic disparity. Yet, this is in accordance with current daily practice and increases the generalizability of our findings. WIDER IMPLICATIONS OF THE FINDINGS The CLBRs vary between the POSEIDON groups. This heterogeneity is primarily determined by a woman's age, reflecting the importance of oocyte quality. In younger women, current IVF/ICSI treatment reaches relatively high CLBR over multiple complete cycles, despite reduced quantitative parameters. In older women, the CLBR remains relatively low over multiple complete cycles, due to the co-occurring decline in quantitative and qualitative parameters. As no effective interventions exist to counteract this decline, clinical management currently relies on proper counselling. STUDY FUNDING/COMPETING INTEREST(S) No external funds were obtained for this study. J.A.L. is supported by a Research Fellowship grant and received an unrestricted personal grant from Merck BV. S.C.O., T.C.v.T., and H.L.T. received an unrestricted personal grant from Merck BV. C.B.L. received research grants from Merck, Ferring, and Guerbet. K.F. received unrestricted research grants from Merck Serono, Ferring, and GoodLife. She also received fees for lectures and consultancy from Ferring and GoodLife. A.H. declares that the Department of Obstetrics and Gynaecology, University Medical Centre Groningen received an unrestricted research grant from Ferring Pharmaceuticals BV, the Netherlands. J.S.E.L. has received unrestricted research grants from Ferring, Zon-MW, and The Dutch Heart Association. He also received travel grants and consultancy fees from Danone, Euroscreen, Ferring, AnshLabs, and Titus Healthcare. B.W.J.M. is supported by an National Health and Medical Research Council Practitioner Fellowship (GNT1082548) and reports consultancy work for ObsEva, Merck, and Guerbet. He also received a research grant from Merck BV and travel support from Guerbet. F.J.M.B. received monetary compensation as a member of the external advisory board for Merck Serono (the Netherlands) and Ferring Pharmaceuticals BV (the Netherlands) for advisory work for Gedeon Richter (Belgium) and Roche Diagnostics on automated AMH assay development, and for a research cooperation with Ansh Labs (USA). All other authors have nothing to declare. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Jori A Leijdekkers
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Marinus J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Theodora C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Simone C Oudshoorn
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Ron J T van Golde
- Department of Reproductive Medicine, Maastricht University Medical Centre, P. Debyelaan 25, HX Maastricht, The Netherlands
| | - Annemieke Hoek
- Centre for Reproductive Medicine, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, GZ Groningen, The Netherlands
| | - Cornelis B Lambalk
- Centre for Reproductive Medicine, Amsterdam University Medical Centre, Free University of Amsterdam, De Boelelaan, HV Amsterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Henri Dunantstraat 1, GZ 's-Hertogenbosch, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, GA Nijmegen, T he Netherlands
| | - Monique H Mochtar
- Centre for Reproductive Medicine, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Walter K H Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Clinics, Dokter Spanjaardweg 27-29, 8025 BT Zwolle, The Netherlands
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Scenic Blvd & Wellington Road, Clayton, VIC, Australia
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan, CX Utrecht, The Netherlands
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Venetis C, d'Hooghe T, Barnhart KT, Bossuyt PMM, Mol BWJ. Methodologic considerations in randomized clinical trials in reproductive medicine. Fertil Steril 2020; 113:1107-1112. [PMID: 32482246 DOI: 10.1016/j.fertnstert.2020.04.038] [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: 02/17/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
Randomized controlled trials (RCTs) are the cornerstone of evidence-based medicine. In this series in Fertility and Sterility, several aspects of RCTs are discussed, with contributions on multicenter RCTs, different international settings, and integrity of RCTs. The present contribution deals with methodologic issues. We discuss different types of RCTs based on null hypothesis (superiority vs. noninferiority vs. equivalence) as well as frequentist versus Bayesian interpretation. We also discuss the use of RCTs in the era of personalized medicine and RCTs to address diagnostic and prognostic questions. Finally, we address the use of big data compared with the use of RCTs.
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Affiliation(s)
- Christos Venetis
- Centre for Big Data Research in Health, University of New South Wales Medicine, New South Wales, Australia; School of Women's and Children's Health, University of New South Wales Medicine, New South Wales, Australia; IVF Australia, Sydney, New South Wales, Australia
| | - Thomas d'Hooghe
- Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany; Reproductive Medicine Research Group, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Leuven, Belgium; Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.
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Orvieto R. HMG versus recombinant FSH plus recombinant LH in ovarian stimulation for IVF: does the source of LH preparation matter? Reprod Biomed Online 2019; 39:1001-1006. [PMID: 31672439 DOI: 10.1016/j.rbmo.2019.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/22/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022]
Abstract
Studies on the role of LH supplementation in patients undergoing assisted reproductive technique use different sources of LH bioactivity-containing preparations, daily doses and modes of administration. This review aims to critically present the available evidence comparing the effect of the two commercially available LH preparations (human menopausal gonadotrophin [HMG] and recombinant FSH + recombinant LH) with different sources of intrinsic LH bioactivity (HCG versus LH, respectively) on ovarian stimulation characteristics and IVF cycle outcomes. A literature review was conducted for all relevant articles reporting on IVF and intracytoplasmic sperm injection treatment outcome after ovarian stimulation using HMG or recombinant FSH plus recombinant LH. The available studies are mostly observational, using different daily doses and modes of administration. No statistically significant differences were observed in ovarian stimulation variables and clinical pregnancy and live birth rates when HMG was compared with recombinant FSH + recombinant LH. Moreover, combined analysis of all the available prospective and retrospective studies produced no firm conclusions in favour of either source of LH bioactivity. Further large randomized controlled studies are needed to investigate the effect of the LH source on IVF outcome and to identify patients who are most likely to benefit from the addition of LH bioactivity supplementation.
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Leijdekkers JA, Eijkemans MJC, van Tilborg TC, Oudshoorn SC, McLernon DJ, Bhattacharya S, Mol BWJ, Broekmans FJM, Torrance HL. Predicting the cumulative chance of live birth over multiple complete cycles of in vitro fertilization: an external validation study. Hum Reprod 2019; 33:1684-1695. [PMID: 30085143 DOI: 10.1093/humrep/dey263] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Are the published pre-treatment and post-treatment McLernon models, predicting cumulative live birth rates (LBR) over multiple complete IVF cycles, valid in a different context? SUMMARY ANSWER With minor recalibration of the pre-treatment model, both McLernon models accurately predict cumulative LBR in a different geographical context and a more recent time period. WHAT IS KNOWN ALREADY Previous IVF prediction models have estimated the chance of a live birth after a single fresh embryo transfer, thereby excluding the important contribution of embryo cryopreservation and subsequent IVF cycles to cumulative LBR. In contrast, the recently developed McLernon models predict the cumulative chance of a live birth over multiple complete IVF cycles at two certain time points: (i) before initiating treatment using baseline characteristics (pre-treatment model) and (ii) after the first IVF cycle adding treatment related information to update predictions (post-treatment model). Before implementation of these models in clinical practice, their predictive performance needs to be validated in an independent cohort. STUDY DESIGN, SIZE, DURATION External validation study in an independent prospective cohort of 1515 Dutch women who participated in the OPTIMIST study (NTR2657) and underwent their first IVF treatment between 2011 and 2014. Participants underwent a total of 2881 complete treatment cycles, with a complete cycle defined as all fresh and frozen thawed embryo transfers resulting from one episode of ovarian stimulation. The follow up duration was 18 months after inclusion, and the primary outcome was ongoing pregnancy leading to live birth. PARTICIPANTS/MATERIALS, SETTING, METHODS Model performance was externally validated up to three complete treatment cycles, using the linear predictor as described by McLernon et al. to calculate the probability of a live birth. Discrimination was expressed by the c-statistic and calibration was depicted graphically in a calibration plot. In contrast to the original model development cohort, anti-Müllerian hormone (AMH), antral follicle count (AFC) and body weight were available in the OPTIMIST cohort, and evaluated as potential additional predictors for model improvement. MAIN RESULTS AND THE ROLE OF CHANCE Applying the McLernon models to the OPTIMIST cohort, the c-statistic of the pre-treatment model was 0.62 (95% CI: 0.59-0.64) and of the post-treatment model 0.71 (95% CI: 0.69-0.74). The calibration plot of the pre-treatment model indicated a slight overestimation of the cumulative LBR. To improve calibration, the pre-treatment model was recalibrated by subtracting 0.35 from the intercept. The post-treatment model calibration plot revealed accurate cumulative LBR predictions. After addition of AMH, AFC and body weight to the McLernon models, the c-statistic of the updated pre-treatment model improved slightly to 0.66 (95% CI: 0.64-0.68), and of the updated post-treatment model remained at the previous level of 0.71 (95% CI: 0.69-0.73). Using the recalibrated pre-treatment model, a woman aged 30 years with 2 years of primary infertility who starts ICSI treatment for male factor infertility has a chance of 40% of a live birth from the first complete cycle, increasing to 72% over three complete cycles. If this woman weighs 70 kg, has an AMH of 1.5 ng/mL and an AFC of 10 measured at the beginning of her treatment, the updated pre-treatment model revises the estimated chance of a live birth to 30% in the first complete cycle and 59% over three complete cycles. If this woman then has five retrieved oocytes, no embryos cryopreserved and a single fresh cleavage stage embryo transfer in her first ICSI cycle, the post-treatment model estimates the chances of a live birth at 28 and 58%, respectively. LIMITATIONS, REASONS FOR CAUTION Two randomized controlled trials (RCT) evaluating the effectiveness of gonadotropin dose individualization on basis of the AFC were nested within the OPTIMIST study. The strict dosing regimens, the RCT in- and exclusion criteria and the limited follow up time of 18 months might have influenced model performance in this independent cohort. Also, consistent with the original model development study, external validation was performed using the optimistic assumption that the cumulative LBR in couples who discontinue treatment without a live birth would have been equal to that of those who continue treatment. WIDER IMPLICATIONS OF THE FINDINGS After national recalibration to account for geographical differences in IVF treatment, the McLernon prediction models can be introduced as new counselling tools in clinical practice to inform patients and to complement clinical reasoning. These models are the first to offer an objective and personalized estimate of the cumulative probability of a live birth over multiple complete IVF cycles. STUDY FUNDING/COMPETING INTEREST(S) No external funds were obtained for this study. M.J.C.E., D.J.M. and S.B. have nothing to disclose. J.A.L, S.C.O, T.C.v.T. and H.LT. received an unrestricted personal grant from Merck BV. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for ObsEva, Merck and Guerbet. F.J.M.B. receives monetary compensation as a member of the external advisory board for Merck BV (the Netherlands) and Ferring pharmaceutics BV (the Netherlands), for consultancy work for Gedeon Richter (Belgium) and Roche Diagnostics on automated AMH assay development, and for a research cooperation with Ansh Labs (USA). TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- J A Leijdekkers
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - M J C Eijkemans
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - T C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - S C Oudshoorn
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - D J McLernon
- Institute of Applied Health Sciences, Medical Statistics Team, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - S Bhattacharya
- School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, UK
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Scenic Blvd & Wellington Road, Clayton VIC, Australia
| | - F J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - H L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, CX Utrecht, The Netherlands
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An AMH-based FSH dosing algorithm for OHSS risk reduction in first cycle antagonist protocol for IVF/ICSI. Eur J Obstet Gynecol Reprod Biol 2019; 237:42-47. [PMID: 31009858 DOI: 10.1016/j.ejogrb.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/13/2018] [Accepted: 02/01/2019] [Indexed: 11/24/2022]
Abstract
The study assessed the impact of an AMH algorithm for FSH dosing in 589 patients to maintain pregnancy rates while minimizing OHSS rates in 1st antagonist cycles for IVF. Patients with low AMH < 12 pmol/L (n = 203) had maximal stimulation with corifollitropin, patients with AMH 12-32 pmol/L (n = 256) had standard stimulation with 150 IU/day of rFSH and patients with AMH > 32 pmol/L (n = 130) had minimal stimulation with 112 IU/day of HP-hMG. The proportion of patients with targeted (5-14) number of oocytes at retrieval was: Low AMH 42%, intermediate AMH 76% and high AMH 67% (p < 0.001). Low responses (≤ 4 oocytes) was found in 55%, 16% and 26% (p < 0.001) in the low, intermediate and high AMH group, respectively. Excessive responses (≥15 oocytes) was found in 2.5%, 6.2% and 6.1% in the low, intermediate and high AMH groups, respectively. Despite the high proportion of low responses, the ongoing pregnancy rates in the high AMH group was 41% per started cycle. A total of 14 patients had OHSS preventive actions like agonist triggering (n = 12) and/or cryopreservation of all embryos (n = 4) and all avoided OHSS. Three (0.5%) patients were admitted to hospital with severe OHSS, and all occurred after hCG triggering and all cases were late OHSS in relation to pregnancy. All were in the high AMH group after aspiration of 10-15 follicles. The conclusion is that among high AMH patients, low dose HP-hMG will limit the mean number of oocytes, without compromising pregnancy rates. The OHSS risk will be low, but as long as transfer after hCG triggering is used OHSS will occur unless a cut-off for OHSS preventive actions as low as 10-15 follicles is used.
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Anckaert E, Denk B, He Y, Torrance HL, Broekmans F, Hund M. Evaluation of the Elecsys ® anti-Müllerian hormone assay for the prediction of hyper-response to controlled ovarian stimulation with a gonadotrophin-releasing hormone antagonist protocol. Eur J Obstet Gynecol Reprod Biol 2019; 236:133-138. [PMID: 30909009 DOI: 10.1016/j.ejogrb.2019.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/23/2018] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This non-interventional study aimed to validate a pre-specified anti-Müllerian hormone (AMH) cut-off of 15 pmol/L (2.10 ng/mL) for the prediction of hyper-response to controlled ovarian stimulation (COS) using the fully automated Elecsys® AMH immunoassay. STUDY DESIGN One hundred and forty-nine women aged <44 years with regular menstrual cycles underwent COS with 150 IU/day follicle-stimulating hormone in a gonadotrophin-releasing hormone (GnRH) antagonist protocol. Response to COS (poor vs normal vs hyper-response) was defined by number of oocytes retrieved and occurrence of ovarian hyper-stimulation syndrome (OHSS). RESULTS Significant differences were seen between response classes for the number of follicles prior to follicle puncture (p < 0.001), the number of retrieved oocytes (p < 0.001) and the occurrence of OHSS (p < 0.001), which were all highest in hyper-responders. The area under the receiver operating characteristic curve for AMH to predict hyper-response was 82.1% (95% confidence interval [CI]: 72.5-91.7). When applying the AMH cut-off of 15.0 pmol/L, a sensitivity of 81.3% (95%CI: 54.4-96.0) to predict hyper-response and a specificity of 64.7% (95%CI: 55.9-72.8) to identify poor/normal responders was reached. CONCLUSION The Elecsys® AMH assay can reliably predict hyper-response to COS in women undergoing a GnRH antagonist treatment protocol.
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Affiliation(s)
- Ellen Anckaert
- Laboratory of Hormonology and Tumour Markers, Universitair Ziekenhuis Brussel, Free University of Brussels, Brussels, Belgium.
| | | | - Ying He
- Roche Diagnostics GmbH, Penzberg, Germany
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Frank Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Martin Hund
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
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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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12
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van Tilborg TC, Torrance HL, Oudshoorn SC, Eijkemans MJC, Koks CAM, Verhoeve HR, Nap AW, Scheffer GJ, Manger AP, Schoot BC, Sluijmer AV, Verhoeff A, Groen H, Laven JSE, Mol BWJ, Broekmans FJM, van Tilborg TC, Oudshoorn SC, Eijkemans MJC, Mochtar MH, Koks CAM, van Golde RJT, Verhoeve HR, Nap AW, Scheffer GJ, Manger AP, Hoek A, Schoot BC, Oosterhuis GJE, Kuchenbecker WKH, Fleischer K, de Bruin JP, Sluijmer AV, Friederich J, Verhoeff A, van Hooff MHA, van Santbrink EJP, Brinkhuis EA, Smeenk JMJ, Kwee J, de Koning CH, Groen H, van Wely M, Lambalk CB, Laven JSE, Mol BWJ, Broekmans FJM, Torrance HL. Individualized versus standard FSH dosing in women starting IVF/ICSI: an RCT. Part 1: The predicted poor responder. Hum Reprod 2017; 32:2496-2505. [DOI: 10.1093/humrep/dex318] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 10/13/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Theodora C van Tilborg
- 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
| | - Simone C Oudshoorn
- 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
| | - Carolien A M Koks
- Department of Obstetrics and Gynaecology, Maxima Medical Centre Veldhoven, PO Box 7777, 5500 MB Veldhoven, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis Oost, PO Box 95500, 1190 HM Amsterdam, The Netherlands
| | - Annemiek W Nap
- Department of Reproductive Medicine, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands
| | - Gabrielle J Scheffer
- Department of Obstetrics and Gynaecology, Gelre Hospital, PO Box 9014, 7300 DS Apeldoorn, The Netherlands
| | - A Petra Manger
- Department of Obstetrics and Gynaecology, Diakonessenhuis, PO Box 80250, 3508 TG Utrecht, The Netherlands
| | - Benedictus C Schoot
- Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, PO Box 1350, 5602 ZA Eindhoven, The Netherlands
- Department of Obstetrics and Gynaecology, University Hospital Gent, 9000 Gent, Belgium
| | - Alexander V Sluijmer
- Department of Gynaecology, Wilhelmina Hospital, PO Box 30001, 9400 RA Assen, The Netherlands
| | - Arie Verhoeff
- Department of Gynaecology, Maasstad Hospital, PO Box 9100, 3007 AC Rotterdam, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Joop S E Laven
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Postbus 2040, 3000 CA Rotterdam, 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
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van Tilborg TC, Oudshoorn SC, Eijkemans MJC, Mochtar MH, van Golde RJT, Hoek A, Kuchenbecker WKH, Fleischer K, de Bruin JP, Groen H, van Wely M, Lambalk CB, Laven JSE, Mol BWJ, Broekmans FJM, Torrance HL, van Tilborg TC, Oudshoorn SC, Eijkemans MJC, Mochtar MH, Koks CAM, van Golde RJT, Verhoeve HR, Nap AW, Scheffer GJ, Manger AP, Hoek A, Schoot BC, Oosterhuis GJE, Kuchenbecker WKH, Fleischer K, de Bruin JP, Sluijmer AV, Friederich J, Verhoeff A, van Hooff MHA, van Santbrink EJP, Brinkhuis EA, Smeenk JMJ, Kwee J, de Koning CH, Groen H, van Wely M, Lambalk CB, Laven JSE, Mol BWJ, Broekmans FJM, Torrance HL. Individualized FSH dosing based on ovarian reserve testing in women starting IVF/ICSI: a multicentre trial and cost-effectiveness analysis. Hum Reprod 2017; 32:2485-2495. [DOI: 10.1093/humrep/dex321] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/13/2017] [Indexed: 01/21/2023] Open
Affiliation(s)
- Theodora C van Tilborg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Simone C Oudshoorn
- 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
| | - Monique H Mochtar
- Centre for Reproductive Medicine, Academic Medical Centre Amsterdam, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Ron J T van Golde
- Department of Reproductive Medicine, Maastricht University Medical Centre+, PO Box 5800, 6202 AZ Maastricht, The Netherlands
- GROW—School for Oncology and Developmental Biology, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Annemieke Hoek
- Centre for Reproductive Medicine, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Walter K H Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Clinics, PO box 10400, 8000GK Zwolle, The Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, PO box 90153, 5200 ME ‘s-Hertogenbosch, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Madelon van Wely
- Centre for Reproductive Medicine, Academic Medical Centre Amsterdam, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Cornelis B Lambalk
- Centre for Reproductive Medicine, VU University Medical Centre, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Joop S E Laven
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Postbus 2040, 3000 CA Rotterdam, 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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Magnusson Å, Nilsson L, Oleröd G, Thurin-Kjellberg A, Bergh C. The addition of anti-Müllerian hormone in an algorithm for individualized hormone dosage did not improve the prediction of ovarian response-a randomized, controlled trial. Hum Reprod 2017; 32:811-819. [PMID: 28175316 DOI: 10.1093/humrep/dex012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/11/2017] [Indexed: 11/13/2022] Open
Abstract
Study question Does the addition of anti-Müllerian hormone (AMH) to a conventional dosage regimen, including age, antral follicle count (AFC) and BMI, improve the rate of targeted ovarian response, defined as 5-12 oocytes after IVF? Summary answer The addition of AMH did not alter the rate of targeted ovarian response, 5-12 oocytes, or decreased the rate of ovarian hyperstimulation syndrome (OHSS) or cancelled cycles due to poor ovarian response. What is known already Controlled ovarian hyperstimulation (COH) in connection with IVF is sometimes associated with poor ovarian response resulting in low pregnancy and live birth rates or leading to cycle cancellations, but also associated with excessive ovarian response, causing an increased risk of OHSS. Even though it is well-established that both AMH and AFC are strong predictors of ovarian response in IVF, few randomized trials have investigated their impact on achieving an optimal number of oocytes. Study design, size and duration Between January 2013 and May 2016, 308 patients starting their first IVF treatment were randomly assigned, using a computerized randomization program with concealed allocation of patients and in the proportions of 1:1, to one of two dosage algorithms for decisions on hormone starting dose, an algorithm, including AMH, AFC, age and BMI (intervention group), or an algorithm, including only AFC, age and BMI (control group). The study was blinded to patients and treating physicians. Participants/materials, setting, methods Women aged >18 and <40 years, with a BMI above 18.0 and below 35.0 kg/m2 starting their first IVF cycle where standard IVF was planned, were eligible. All patients were treated with a GnRH agonist protocol and recombinant FSH was used for stimulation. The study was performed as a single-centre study at a large IVF unit at a university hospital. Main results and the role of chance The rate of patients having the targeted number of oocytes retrieved was 81/152 (53.3%) in the intervention group versus 96/155 (61.9%) in the control group (P = 0.16, difference: -8.6, 95% CI: -20.3; 3.0). Cycles with poor response (<5 oocytes) were more frequent in the AMH group, 39/152 (25.7%) versus the non-AMH group, 17/155 (11.0%) (P < 0.01), while the number of cancelled cycles due to poor ovarian response did not differ 7/152 (4.6%) and 4/155 (2.6%) (P = 0.52). An excessive response (>12 oocytes) was seen in 32/152 (21.1%) and 42/155 (27.1%) patients, respectively (P = 0.27). Moderate or severe OHSS was observed among 5/152 (3.3%) and 6/155 (3.9%) patients, respectively (P = 1.0). Live birth rates were 48/152 (31.6%) and 42/155 (27.1%) per started cycle. Limitations, reasons for caution The categorization of AMH values in predicted low, normal and high responders was originally established using the Diagnostic Systems Laboratories assay and was translated to more recently released assays, lacking international standards and well-established reference intervals. The interpretation of AMH values between different assays should therefore be made with some caution. Wider implications of the findings An individualised dosage regimen including AMH compared with a non-AMH dosage regimen in an unselected patient population did not alter the number of women achieving the targeted number of oocytes, or the cancellation rate due to poor response or the occurrence of moderate/severe OHSS. However, this study cannot answer the question if using an algorithm for dose decision of FSH is superior to a standard dose and neither which ovarian reserve test is the most effective. Study funding/competing interest Financial support was received through Sahlgrenska University Hospital (ALFGBG-70 940) and unrestricted grants from Ferring Pharmaceuticals and the Hjalmar Svensson Research Foundation. None of the authors declares any conflict of interest. Trial registration The study was registered at www.clinicaltrials.gov NCT02013973. Trial registration date 6 December 2013. DATE OF FIRST PATIENT RANDOMIZED 14 January 2013.
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Affiliation(s)
- Å Magnusson
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Reproductive Medicine, Sahlgrenska University Hospital, SE Gothenburg, Sweden
| | - L Nilsson
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Reproductive Medicine, Sahlgrenska University Hospital, SE Gothenburg, Sweden
| | - G Oleröd
- Department of Clinical Chemistry, Sahlgrenska University Hospital, SE Gothenburg, Sweden
| | - A Thurin-Kjellberg
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Reproductive Medicine, Sahlgrenska University Hospital, SE Gothenburg, Sweden
| | - C Bergh
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Reproductive Medicine, Sahlgrenska University Hospital, SE Gothenburg, Sweden
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15
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Establishment and validation of a score to predict ovarian response to stimulation in IVF. Reprod Biomed Online 2017; 36:26-31. [PMID: 29111311 DOI: 10.1016/j.rbmo.2017.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/06/2017] [Accepted: 09/14/2017] [Indexed: 11/22/2022]
Abstract
This study aimed to integrate clinical and biological parameters in a score able to predict ovarian response to stimulation for IVF in gonadotrophin-releasing hormone (GnRH) antagonist protocols. A progressive discriminant analysis to establish a score including the main clinical and biological parameters predicting ovarian response was performed by retrospectively analysing data from the first ovarian stimulation cycle of 494 patients. The score was validated in a prospectively enrolled, independent set of 257 patients undergoing their first ovarian stimulation cycle. All ovarian stimulations were performed using a combination of GnRH antagonist and recombinant FSH. Ovarian response was assessed through ovarian sensitivity index (OSI). Parameters from the patients' database were classified according to correlation with OSI: the progressive discriminant analysis resulted in the following calculation: score = 0.192 - (0.004 × FSH (IU/l)) + (0.012 × LH:FSH ratio) + (0.002 × AMH (ng/ml)) - (0.002 × BMI (kg/m2)) + (0.001 × AFC) - (0.002 × age (years)). This score was significantly correlated with OSI in the retrospective (r = 0.599; P < 0.0001) and prospective (r = 0.584; P < 0.0001) studies. In conclusion, the score including clinical and biological parameters could explain 60% of the variance in ovarian response to stimulation.
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Fauser BC. Patient-tailored ovarian stimulation for in vitro fertilization. Fertil Steril 2017; 108:585-591. [DOI: 10.1016/j.fertnstert.2017.08.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/10/2017] [Indexed: 11/29/2022]
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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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Management of ovarian stimulation for IVF: narrative review of evidence provided for World Health Organization guidance. Reprod Biomed Online 2017; 35:3-16. [PMID: 28501428 DOI: 10.1016/j.rbmo.2017.03.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 03/24/2017] [Accepted: 03/30/2017] [Indexed: 01/08/2023]
Abstract
In this paper, a review of evidence provided to the World Health Organization (WHO) guideline development, who prepare global guidance on the management of ovarian stimulation for women undergoing IVF, is presented. The purpose of ovarian stimulation is to facilitate retrieval of multiple oocytes during a single IVF cycle. Availability of multiple oocytes compensates for inefficiencies in subsequent stages of the cycle, which include oocyte maturation, IVF, embryo culture, embryo transfer, and implantation. Multiple embryos can be transferred in most women, and spare embryos can be frozen to allow for future chances of pregnancy without the need for repeated ovarian stimulation and oocyte retrieval. Our evidence synthesis team addressed 10 clinical questions on management of ovarian stimulation for IVF, prepared a narrative review of the evidence and drafted recommendations to be considered through WHO guideline development processes. Our main outcome measures were live birth, clinical pregnancy, and ovarian hyperstimulation syndrome.
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Zheng H, Chen S, Du H, Ling J, Wu Y, Liu H, Liu J. Ovarian response prediction in controlled ovarian stimulation for IVF using anti-Müllerian hormone in Chinese women: A retrospective cohort study. Medicine (Baltimore) 2017; 96:e6495. [PMID: 28353597 PMCID: PMC5380281 DOI: 10.1097/md.0000000000006495] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The predictive value of anti-Müllerian hormone (AMH) in Chinese women undergoing in vitro fertilization (IVF) treatment is data deficient. To determine the attributes of AMH in IVF, oocyte yield, cycle cancellation, and pregnancy outcomes were analyzed. All patients initiating their first IVF cycle with gonadotropin-releasing hormone agonist treatment in our center from October 2013 through December 2014 were included, except patients diagnosed with polycystic ovarian syndrome. Serum samples collected prior to IVF treatment were used to determine serum AMH levels. A total of 4017 continuous cycles were analyzed. The AMH level was positively correlated with the number of oocytes retrieved. Overall, AMH was significantly correlated with risk of cycle cancellation, poor ovarian response (POR, 3, or fewer oocytes retrieved) and high response (>15 oocytes), with an area under the curve (AUC) of 0.83, 0.89, and 0.82 respectively. An AMH cutoff of 0.6 ng/mL had a sensitivity of 54.0% and a specificity of 90.0% for the prediction of cycle cancellation, and cutoff of 0.8 ng/mL with a sensitivity of 55.0% and a specificity of 94.0% for the prediction of POR. Compared with AMH >2.0 ng/mL, patients with AMH < 0.6 ng/mL had a 53.6-fold increased risk of cancellation (P < 0.001), and AMH <0.80 ng/mL were 17.5 times more likely to experience POR (P < 0.001). However, AMH was less predictive of pregnancy and live birth, with AUCs of 0.55 and 0.53, respectively. Clinical pregnancy rate, ongoing pregnancy rate, and live birth rate per retrieval according to the AMH level (≤0.40, 0.41-0.60, 0.61-0.80, 0.81-1.00, 1.01-1.50, 1.51-2.00, and >2.00 ng/mL) showed no significant differences. Even with AMH≤0.4 ng/mL, 50.0% of all the patients achieved pregnancy and 34.8% of patients achieved live birth after transfer. Our results suggested that AMH is a fairly robust metric for the prediction of cycle cancellation and oocyte yield for Chinese women, but it is a relatively poor test for prediction of pregnancy outcomes. Patients with low levels of AMH still can achieve reasonable treatment outcomes and low AMH levels in isolation do not represent an appropriate marker for withholding fertility treatment.
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van Tilborg TC, Broekmans FJ, Dólleman M, Eijkemans MJ, Mol BW, Laven JS, Torrance HL. Individualized follicle-stimulating hormone dosing and in vitro fertilization outcome in agonist downregulated cycles: a systematic review. Acta Obstet Gynecol Scand 2016; 95:1333-1344. [DOI: 10.1111/aogs.13032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/24/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Theodora C. van Tilborg
- Department of Reproductive Medicine and Gynecology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Frank J.M. Broekmans
- Department of Reproductive Medicine and Gynecology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Madeleine Dólleman
- Department of Reproductive Medicine and Gynecology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Marinus J.C. Eijkemans
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Ben Willem Mol
- The Robinson Institute; School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide SA Australia
| | - Joop S.E. Laven
- Division of Reproductive Medicine; Department of Obstetrics and Gynecology; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Helen L. Torrance
- Department of Reproductive Medicine and Gynecology; University Medical Center Utrecht; Utrecht The Netherlands
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Polyzos NP, Sunkara SK. Reply: Is it necessary to recognize the sub-optimal responder. Hum Reprod 2015; 30:2959. [PMID: 26489440 DOI: 10.1093/humrep/dev255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nikolaos P Polyzos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium Department of Clinical Medicine, Faculty of Health, University of Aarhus, Aarhus, Denmark
| | - Sesh K Sunkara
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
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22
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Broekmans FJ. The sub-optimal response to controlled ovarian stimulation: manageable or inevitable? Hum Reprod 2015. [PMID: 26202583 DOI: 10.1093/humrep/dev150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- F J Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, PO Box 85500, Utrecht, GA 3508, The Netherlands
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23
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Affiliation(s)
- Gautam N Allahbadia
- Rotunda-The Center For Human Reproduction, Mumbai, India ; New Hope IVF, Sharjah, UAE
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van Helden J, Weiskirchen R. Performance of the two new fully automated anti-Müllerian hormone immunoassays compared with the clinical standard assay. Hum Reprod 2015; 30:1918-26. [DOI: 10.1093/humrep/dev127] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/14/2015] [Indexed: 11/12/2022] Open
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Lindsay JO, Bergman A, Patel AS, Alesso SM, Peyrin-Biroulet L. Systematic review: the financial burden of surgical complications in patients with ulcerative colitis. Aliment Pharmacol Ther 2015; 41:1066-78. [PMID: 25855078 DOI: 10.1111/apt.13197] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/03/2014] [Accepted: 03/24/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients undergoing colectomy for ulcerative colitis (UC) may experience complications associated with reduced quality of life (QoL), and maybe a considerable economic burden to healthcare systems. Appreciation of these burdens is important to evaluate the cost effectiveness of newer interventions for UC vs. colectomy. AIM To identify data representing resource utilisation or costs of complications arising from colorectal procedures in patients with UC, and data representing patient QoL, as reported by health state utility values (HSUVs). METHODS Embase, MEDLINE and The Cochrane Library were searched for studies (1995-2014) reporting resource use/costs of surgical complications, and HSUVs data in adult patients with UC, undergoing colorectal procedures. Conference proceedings (January 2011-January 2014) were hand-searched. RESULTS Twelve studies reported resource use/costs, and three reported HSUVs data in patients with UC experiencing surgical complications. Additional mean costs of postoperative complications ranged from $18 650/patient with complications at a 6-month follow-up (46% incidence) to $34 714/patient with complications over a 5-year period (49% incidence). Pouchitis, pouch failure and small bowel obstruction carried the greatest burden. Marked reductions in HSUVs were observed for patients with UC experiencing surgical complications, vs. patients with UC in a remission state. CONCLUSIONS There is a paucity of well reported studies on resource use/cost, and QoL burden of surgical complications in patients with UC. However, surgical complications represent a substantial burden both in terms of cost and of quality of life, with reoperations, physician fees, additional in-patient hospital stays and infertility treatment being the main cost drivers.
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Affiliation(s)
- J O Lindsay
- Endoscopy Unit, Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, Whitechapel, London
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Smith V, Osianlis T, Vollenhoven B. Prevention of Ovarian Hyperstimulation Syndrome: A Review. Obstet Gynecol Int 2015; 2015:514159. [PMID: 26074966 PMCID: PMC4446511 DOI: 10.1155/2015/514159] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 04/29/2015] [Indexed: 01/01/2023] Open
Abstract
The following review aims to examine the available evidence to guide best practice in preventing ovarian hyperstimulation syndrome (OHSS). As it stands, there is no single method to completely prevent OHSS. There seems to be a benefit, however, in categorizing women based on their risk of OHSS and individualizing treatments to curtail their chances of developing the syndrome. At present, both Anti-Müllerian Hormone and the antral follicle count seem to be promising in this regard. Both available and upcoming therapies are also reviewed to give a broad perspective to clinicians with regard to management options. At present, we recommend the use of a "step-up" regimen for ovulation induction, adjunct metformin utilization, utilizing a GnRH agonist as an ovulation trigger, and cabergoline usage. A summary of recommendations is also made available for ease of clinical application. In addition, areas for potential research are also identified where relevant.
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Affiliation(s)
- Vinayak Smith
- Alice Springs Hospital, Department of Obstetrics and Gynaecology, Alice Springs, NT 0870, Australia
| | - Tiki Osianlis
- Monash IVF, 252 Clayton Road, Clayton, VIC 3168, Australia
| | - Beverley Vollenhoven
- Monash IVF, 252 Clayton Road, Clayton, VIC 3168, Australia
- Monash Health, Women's and Children's Program, Monash Medical Centre, Clayton Road, Clayton, VIC 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
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Jungheim ES, Meyer MF, Broughton DE. Best practices for controlled ovarian stimulation in in vitro fertilization. Semin Reprod Med 2015; 33:77-82. [PMID: 25734345 DOI: 10.1055/s-0035-1546424] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
As applications for IVF have expanded over the years, so too have approaches to controlled ovarian stimulation (COS) for IVF. With this expansion and improved knowledge of basic reproductive biology, there is increasing interest in how COS practice influences IVF outcomes, and whether or not specific treatment scenarios call for personalized approaches to COS. For the majority of women undergoing COS and their treating physicians, the goal is to achieve a healthy live birth through IVF in a fresh cycle. Opinions on how COS strategy best leads to this common goal varies among centers as many clinicians base COS strategy not on evidence obtained through prospective randomized trials, but rather through observational studies and experience. Overall, when it comes to COS most clinicians recognize the approach should not be "one size fits all," but rather a patient-centered approach that takes the existing evidence into consideration. We outline the existing evidence for best practices in COS for IVF, highlighting how these practices may be incorporated into a patient-centered approach.
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Affiliation(s)
- Emily S Jungheim
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa F Meyer
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
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Anderson RA, Anckaert E, Bosch E, Dewailly D, Dunlop CE, Fehr D, Nardo L, Smitz J, Tremellen K, Denk B, Geistanger A, Hund M. Prospective study into the value of the automated Elecsys antimüllerian hormone assay for the assessment of the ovarian growing follicle pool. Fertil Steril 2015; 103:1074-1080.e4. [PMID: 25681853 DOI: 10.1016/j.fertnstert.2015.01.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/16/2014] [Accepted: 01/01/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate a new fully automated assay measuring antimüllerian hormone (AMH; Roche Elecsys) against antral follicle count in women of reproductive age. DESIGN Prospective cohort study. SETTING Hospital infertility clinics and academic centers. PATIENT(S) Four hundred fifty-one women aged 18 to 44 years, with regular menstrual cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) AMH and antral follicle count (AFC) determined at a single visit on day 2-4 of the menstrual cycle. RESULT(S) There was a statistically significant variance in AFC but not in AMH between centers. Both AFC and AMH varied by age (overall Spearman rho -0.50 for AFC and -0.47 for AMH), but there was also significant between-center variation in the relationship between AFC and age but not for AMH. There was a strong positive correlation between AMH and AFC (overall spearman rho 0.68), which varied from 0.49 to 0.87 between centers. An agreement table using AFC cutoffs of 7 and 15 showed classification agreement in 63.2%, 56.9% and 74.5% of women for low, medium, and high groups, respectively. CONCLUSION(S) The novel fully automated Elecsys AMH assay shows good correlations with age and AFC in women of reproductive age, providing a reproducible measure of the growing follicle pool.
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Affiliation(s)
- Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, United Kingdom.
| | - Ellen Anckaert
- Laboratory of Hormonology and Tumour Markers, Universitair Ziekenhuis Brussel, Free University of Brussels (VUB), Brussels, Belgium
| | | | - Didier Dewailly
- Department of Endocrine Gynaecology and Reproductive Medicine, Hôpital Jeanne de Flandre, Centre Hospitalier de Lille, Université Lille 2, Lille, France
| | - Cheryl E Dunlop
- MRC Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Daniel Fehr
- UniKiD, Univ.-Frauenklinik Düsseldorf, Düsseldorf, Germany
| | - Luciano Nardo
- GyneHealth Reproductive Health Group, Manchester, United Kingdom
| | - Johan Smitz
- Laboratory of Hormonology and Tumour Markers, Universitair Ziekenhuis Brussel, Free University of Brussels (VUB), Brussels, Belgium
| | | | | | | | - Martin Hund
- Roche Diagnostics International Ltd., Rotkreuz, Switzerland
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Hamdine O, Eijkemans M, Lentjes E, Torrance H, Macklon N, Fauser B, Broekmans F. Ovarian response prediction in GnRH antagonist treatment for IVF using anti-Müllerian hormone. Hum Reprod 2014; 30:170-8. [DOI: 10.1093/humrep/deu266] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Abstract
Despite the development of in vitro fertilization (IVF) more than 30 years ago, the cost of treatment remains high. Furthermore, over the years, more sophisticated technologies and expensive medications have been introduced, making IVF increasingly inaccessible despite the increasing need. Globally, the option to undergo IVF is only available to a privileged few. In recent years, there has been growing interest in exploring strategies to reduce the cost of IVF treatment, which would allow the service to be provided in low-resource settings. In this review, we explore the various ways in which the cost of this treatment can be reduced.
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Affiliation(s)
- Pek Joo Teoh
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
| | - Abha Maheshwari
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
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Broekmans FJ, Verweij PJM, Eijkemans MJC, Mannaerts BMJL, Witjes H. Prognostic models for high and low ovarian responses in controlled ovarian stimulation using a GnRH antagonist protocol. Hum Reprod 2014; 29:1688-97. [PMID: 24903202 PMCID: PMC4093990 DOI: 10.1093/humrep/deu090] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Can predictors of low and high ovarian responses be identified in patients undergoing controlled ovarian stimulation (COS) in a GnRH antagonist protocol? SUMMARY ANSWER Common prognostic factors for high and low ovarian responses were female age, antral follicle count (AFC) and basal serum FSH and LH. WHAT IS KNOWN ALREADY Predictors of ovarian response have been identified in GnRH agonist protocols. With the introduction of GnRH antagonists to prevent premature LH rises during COS, and the gradual shift in use of long GnRH agonist to short GnRH antagonist protocols, there is a need for data on the predictability of ovarian response in GnRH antagonist cycles. STUDY DESIGN, SIZE, DURATION A retrospective analysis of data from the Engage trial and validation with the Xpect trial. Prognostic models were constructed for high (>18 oocytes retrieved) and low (<6 oocytes retrieved) ovarian response. Model building was based on the recombinant FSH (rFSH) arm (n = 747) of the Engage trial. Multivariable logistic regression models were constructed in a stepwise fashion (P < 0.15 for entry). Validation based on calibration was performed in patients with equivalent treatment (n = 199) in the Xpect trial. PARTICIPANTS/MATERIALS, SETTING, METHODS Infertile women with an indication for COS prior to IVF. The Engage and Xpect trials included patients of similar ethnic origins from North America and Europe who had regular menstrual cycles. The main causes of infertility were male factor, tubal factor and endometriosis. MAIN RESULTS AND THE ROLE OF CHANCE In the Engage trial, 18.3% of patients had a high and 12.7% had a low ovarian response. Age, AFC, serum FSH and serum LH at stimulation Day 1 were prognostic for both high and low ovarian responses. Higher AFC and LH were associated with an increased chance of high ovarian response. Older age and higher FSH correlated with an increased chance of low ovarian response. Region (North America/Europe) and BMI were prognostic for high ovarian response, and serum estradiol at stimulation Day 1 was associated with low ovarian response. The area under the receiver operating characteristic (ROC) curve (AUC) for the model for a high ovarian response was 0.82. Sensitivity and specificity were 0.82 and 0.73; positive and negative predictive values were 0.40 and 0.95, respectively. The AUC for the model for a low ovarian response was 0.80. Sensitivity and specificity were 0.77 and 0.73, respectively; positive and negative predictive values were 0.29 and 0.96, respectively. In Xpect, 19.1% of patients were high ovarian responders and 16.1% were low ovarian responders. The slope of the calibration line was 0.81 and 1.35 for high and low ovarian responses, respectively, both not statistically different from 1.0. In summary, common prognostic factors for high and low ovarian responses were female age, AFC and basal serum FSH and LH. Simple multivariable models are presented that are able to predict both a too low or too high ovarian response in patients treated with a GnRH antagonist protocol and daily rFSH. LIMITATIONS, REASONS FOR CAUTION Anti-Müllerian hormone was not included in the prediction modelling. WIDER IMPLICATIONS OF THE FINDINGS The findings will help with the identification of patients at risk of a too high or too low ovarian response and individualization of COS treatment. STUDY FUNDING/COMPETING INTERESTS Financial support for this study and the editorial work was provided by Merck, Sharp & Dohme Corp. (MSD), a subsidiary of Merck & Co. Inc., Whitehouse Station, NJ, USA. F.J.B. received a grant from CVZ to his institution; P.J.M.V. and H.W. are employees of MSD, and B.M.J.L.M. was an employee of MSD at the time of development of this manuscript. TRIAL REGISTRATION NUMBERS NCT 00696800 and NCT00778999.
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Affiliation(s)
- Frank J Broekmans
- Division of Female and Baby, Department for Reproductive Medicine and Surgery, University Medical Center, Utrecht 3584 CX, The Netherlands
| | | | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht 3508GA, The Netherlands
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Broer SL, Broekmans FJ, Laven JS, Fauser BC. Anti-Müllerian hormone: ovarian reserve testing and its potential clinical implications. Hum Reprod Update 2014; 20:688-701. [DOI: 10.1093/humupd/dmu020] [Citation(s) in RCA: 395] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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La Marca A, Sunkara SK. Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: from theory to practice. Hum Reprod Update 2013; 20:124-40. [PMID: 24077980 DOI: 10.1093/humupd/dmt037] [Citation(s) in RCA: 338] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The main objective of individualization of treatment in IVF is to offer every single woman the best treatment tailored to her own unique characteristics, thus maximizing the chances of pregnancy and eliminating the iatrogenic and avoidable risks resulting from ovarian stimulation. Personalization of treatment in IVF should be based on the prediction of ovarian response for every individual. The starting point is to identify if a woman is likely to have a normal, poor or a hyper response and choose the ideal treatment protocol tailored to this prediction. The objective of this review is to summarize the predictive ability of ovarian reserve markers, such as antral follicle count (AFC) and anti-Mullerian hormone (AMH), and the therapeutic strategies that have been proposed in IVF after this prediction. METHODS A systematic review of the existing literature was performed by searching Medline, EMBASE, Cochrane library and Web of Science for publications in the English language related to AFC, AMH and their incorporation into controlled ovarian stimulation (COS) protocols in IVF. Literature available to May 2013 was included. RESULTS The search generated 305 citations of which 41 and 25 studies, respectively, reporting the ability of AMH and AFC to predict response to COS were included in this review. The literature review demonstrated that AFC and AMH, the most sensitive markers of ovarian reserve identified to date, are ideal in planning personalized COS protocols. These sensitive markers permit prediction of the whole spectrum of ovarian response with reliable accuracy and clinicians may use either of the two markers as they can be considered interchangeable. Following the categorization of expected ovarian response to stimulation clinicians can adopt tailored therapeutic strategies for each patient. Current scientific trend suggests the elective use of the GnRH antagonist based regimen for hyper-responders, and probably also poor responders, as likely to be beneficial. The selection of the appropriate and individualized gonadotrophin dose is also of paramount importance for effective COS and subsequent IVF outcomes. CONCLUSION Personalized IVF offers several benefits; it enables clinicians to give women more accurate information on their prognosis thus facilitating counselling especially in cases of extremes of ovarian response. The deployment of therapeutic strategies based on selective use of GnRH analogues and the fine tuning of the gonadotrophin dose on the basis of potential ovarian response in every single woman can allow for a safer and more effective IVF practice.
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Affiliation(s)
- Antonio La Marca
- Mother-Infant Department, Institute of Obstetrics and Gynaecology, University of Modena and Reggio Emilia, 41100 Modena, Italy
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Broer SL, Dólleman M, van Disseldorp J, Broeze KA, Opmeer BC, Bossuyt PMM, Eijkemans MJC, Mol BW, Broekmans FJM. Prediction of an excessive response in in vitro fertilization from patient characteristics and ovarian reserve tests and comparison in subgroups: an individual patient data meta-analysis. Fertil Steril 2013; 100:420-9.e7. [PMID: 23721718 DOI: 10.1016/j.fertnstert.2013.04.024] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/12/2013] [Accepted: 04/12/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate whether ovarian reserve tests (ORTs) add prognostic value to patient characteristics, such as female age, in the prediction of excessive response to ovarian hyperstimulation in patients undergoing IVF, and whether their performance differs across clinical subgroups. DESIGN Authors of studies reporting on basal FSH, antimüllerian hormone (AMH), or antral follicle count (AFC) in relation to ovarian response to ovarian hyperstimulation were invited to share original data. Random intercept logistic regression models were used to estimate added value of ORTs on patient characteristics, while accounting for between-study heterogeneity. Receiver operating characteristic regression analyses were performed to study the effect of patient characteristics on ORT accuracy. SETTING In vitro fertilization clinics. PATIENT(S) A total of 4,786 women for the main analysis, with a subgroup of 1,023 women with information on all three ORTs. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Excessive response prediction. RESULT(S) We included 57 studies reporting on 32 databases. Female age had an area under the receiver operating characteristic curve of 0.61 for excessive response prediction. Antral follicle count and AMH significantly added prognostic value to this. A model with female age, AFC, and AMH had an area under the receiver operating characteristic curve of 0.85. The combination of AMH and AFC, without age, had similar accuracy. Subgroup analysis indicated that FSH performed significantly worse in predicting excessive response in higher age groups, AFC did significantly better, and AMH performed the same. CONCLUSION(S) We demonstrate that AFC and AMH add value to female age in the prediction of excessive response and that, for AFC and FSH, the discriminatory performance is affected by female age.
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Affiliation(s)
- Simone L Broer
- Department of Reproductive Medicine and Gynaecology, University Medical Center Utrecht, Utrecht, the Netherlands
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Polyzos NP, Nelson SM, Stoop D, Nwoye M, Humaidan P, Anckaert E, Devroey P, Tournaye H. Does the time interval between antimüllerian hormone serum sampling and initiation of ovarian stimulation affect its predictive ability in in vitro fertilization-intracytoplasmic sperm injection cycles with a gonadotropin-releasing hormone antagonist? A retrospective single-center study. Fertil Steril 2013; 100:438-44. [PMID: 23602319 DOI: 10.1016/j.fertnstert.2013.03.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 02/27/2013] [Accepted: 03/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate whether the time interval between serum antimüllerian hormone (AMH) sampling and initiation of ovarian stimulation for in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) may affect the predictive ability of the marker for low and excessive ovarian response. DESIGN Retrospective cohort study. SETTING University-based tertiary center. PATIENT(S) Five hundred and forty women with AMH values measured before their first IVF-ICSI cycle. INTERVENTION(S) Eligible patients treated with 150-225 IU recombinant follicle-stimulating hormone (FSH) in a gonadotropin-releasing hormone (GnRH) antagonist protocol. MAIN OUTCOME MEASURE(S) Predictive ability of AMH for low and excessive ovarian response in relation to the time interval between serum AMH sampling and initiation of ovarian stimulation for IVF-ICSI. RESULT(S) All patients had their AMH concentration measured up to 12 months before initiation of stimulation. The level of AMH demonstrated a statistically significant positive correlation with number of oocytes retrieved. The time interval between AMH measurement and initiation of stimulation had no influence on this correlation. The area under the receiver operator characteristic curve (ROC AUC) of AMH was high for both poor (0.72) and excessive response (0.80). The ROC regression analysis demonstrated that the time interval from sampling did not affect the performance of either poor response or excessive response prediction. CONCLUSION(S) A time interval up to 12 months between AMH serum sampling and initiation of ovarian stimulation does not appear to affect the correlation between AMH level and the number of oocytes retrieved and the predictive ability of AMH to identify women at risk of low or excessive ovarian response.
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Affiliation(s)
- Nikolaos P Polyzos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
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Nelson SM. Biomarkers of ovarian response: current and future applications. Fertil Steril 2013; 99:963-9. [PMID: 23312225 DOI: 10.1016/j.fertnstert.2012.11.051] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 11/13/2012] [Accepted: 11/26/2012] [Indexed: 01/31/2023]
Abstract
With our increasing appreciation that simply maximizing oocyte yield for all patients is no longer an appropriate stimulation strategy and that age alone cannot accurately predict ovarian response, there has been an explosion in the literature regarding the utility of biomarkers to predict and individualize treatment strategies. Antral follicle count (AFC) and antimüllerian hormone (AMH) have begun to dominate the clinical scene, and although frequently pitted against each other as alternatives, both may contribute and indeed be synergistic. Their underlying technologies are continuing to develop rapidly and overcome the standardization issues that have limited their development to date. In the context of in vitro fertilization (IVF), their linear relationship with oocyte yield and thereby extremes of ovarian response has led to improved pretreatment patient counseling, individualization of stimulation strategies, increased cost effectiveness, and enhanced safety. This review highlights that although biomarkers of ovarian response started in the IVF clinic, their future extends well beyond the boundaries of assisted reproduction. The automation of AMH and its introduction into the routine repertoire of clinical biochemistry has tremendous potential. A future where primary care physicians, endocrinologists, and oncologists can rapidly assess ovarian dysfunction and the ovarian reserve more accurately than with the current standard of follicle-stimulating hormone (FSH) is an exciting possibility. For women, the ability to know the duration of their own reproductive life span will be empowering and allow them to redefine the meaning of family planning.
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Affiliation(s)
- Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow, United Kingdom.
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