Milder is better? Advantages and disadvantages of "mild" ovarian stimulation for human in vitro fertilization

Relationship Between Number of Oocytes Retrieved and Embryo Euploidy Rate in Controlled Ovarian Stimulation Cycles

This cohort study is aimed to determine if higher number of oocytes retrieved affects the rate of euploidy in the embryos of women undergoing controlled ovarian stimulation (COS) for in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy (PGT-A). A negative trend between the number of oocytes retrieved and embryo euploidy rate was observed using Visual Analytics software, especially when a higher number of oocytes were retrieved. After regression analysis, patient age was the only variable found to have a statistically significant negative effect (p < 0.0001) on euploidy rate in all regression models. Number of oocytes retrieved was not found to have a statistically significant effect on euploidy rate when analyzed per number of biopsied blastocysts (p = 0.5356), per number of oocytes retrieved (p = 0.1025), and per number of fertilized oocytes (p = 0.7241). The parameter estimates in the linear regression models were negative for number of oocytes retrieved. This study shows a statistically significant effect between patient age and embryo euploidy rate, which is already known. There is some evidence to suggest that higher number of oocytes retrieved may negatively impact the number of euploid embryos per number of oocytes retrieved based on the visual analytic graphs, p value approaching significance, and the negative parameter estimates in the regression models.

Wenshenyang recipe treats infertility through hormonal regulation and inflammatory responses revealed by transcriptome analysis and network pharmacology

The Wenshenyang recipe (WSYR) has the effect of treating infertility, but the mechanisms underlying this activity have not been fully elucidated. In this study, network pharmacology and RNA sequencing were combined, with database-based “dry” experiments and transcriptome analysis-based “wet” experiments used conjointly to analyse the mechanism of WSYR in the treatment of infertility. In the dry analysis, 43 active compounds in WSYR and 44 therapeutic targets were obtained through a database search, 15 infertility pathways were significantly enriched, and key targets, such as ESR1, TP53, AKT1, IL-6, and IL-10 were identified. Then the wet experiments were performed to detect the expression changes of the 412 genes from 15 infertility pathways identified by dry analysis. HK-2 cells were treated with the three herbs of WSYR and subjected to targeted RNA sequencing. Based on the results, 92 of the 412 genes in 15 infertility pathways were identified as DEGs. Additionally, key targets, such as ESR2, STAT1, STAT3, and IL6, were also identified in the wet experiments. RT-qPCR experiments further verified that WSYR played an anti-inflammatory role by upregulating IL-4 and IL-10 and Epimedium brevicornu Maxim (Yinyanghuo) showed broader effect than Drynaria fortunei (Kunze) J. Sm (Gusuibu) and Cistanche deserticola Y.C.Ma (Roucongrong). By screening compounds of WSYR using molecular docking models of ESR1 and ESR2, it was further found that xanthogalenol in Gusuibu, arachidonate in Roucongrong, and anhydroicaritin in Yinyanghuo had good affinity for estrogen receptors. These findings provide evidence for an estrogen-regulating role of the three herbs in WSYR.

Ovarian Folliculogenesis and Uterine Endometrial Receptivity after Intermittent Vaginal Injection of Recombinant Human Follicle-Stimulating Hormone in Infertile Women Receiving In Vitro Fertilization and in Immature Female Rats

The uterine first-pass effect occurs when drugs are delivered vaginally. However, the effect of vaginally administered recombinant human follicle-stimulating hormone (rhFSH) on ovarian folliculogenesis and endometrial receptivity is not well established. We aimed to compare the efficacy of rhFSH administered vaginally and abdominally in clinical in vitro fertilization (IVF) treatment, pharmacokinetic study, and animal study. In IVF treatment, the number of oocytes retrieved, endometrial thickness and uterine artery blood perfusion were not different between women who received the rhFSH either vaginally or abdominally. For serum pharmacokinetic parameters, significantly lower Tmax, clearance, and higher AUC and T_1/2_elimination of rhFSH were observed in women who received rhFSH vaginally, but urine parameters were not different. Immature female rats that received daily abdominal or vaginal injections (1 IU twice daily for 4 days) or intermittent vaginal injections (4 IU every other day for two doses) of rhFSH had more total follicles than the control group. In addition, the serum progesterone and progesterone receptors in the local endometrium were significantly higher in the groups treated with intermittent abdominal or vaginal injection of rhFSH, compared with those who recieved daily injection. In summary, vaginal administration of rhFSH may provide an alternative treatment regimen in women receiving IVF.

Effects of using letrozole in combination with the GnRH antagonist protocol for patients with poor ovarian response: A meta-analysis

This meta-analysis aimed to compare the outcomes of the gonadotrophin-releasing hormone (GnRH) antagonist/letrozole protocol with those of the conventional GnRH antagonist protocol for poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). We searched for relevant articles in PubMed, EMBASE, Google Scholar, and retrieved 452 records. Eventually, we selected five eligible trials with data for 564 patients characterized as poor ovarian responders. Our meta-analysis revealed that the clinical pregnancy rate (per cycle) with administration of letrozole might be a higher than that in the control groups (risk rate [RR]: 1.57, 95% confidence interval [CI]: 1.00-2.44, p = 0.05). .Moreover,it indicated that the total dose of gonadotrophin was significantly decreased with the administration of letrozole compared to control groups(mean difference [MD]: -529.37, 95% CI: -1207.45 to -111.25, p = 0.001),.However, there was no statistical difference in the number of retrieved oocytes(MD: 0.59, 95% CI: -0.36-1.54, p = 0.22), cycle cancelation rate (RR: 0.81, 95% CI: 0.58-1.12, p = 0.20), or estradiol concentration on the day of HCG administration(MD: -28.19, 95% CI: -77.71-21.33, p = 0.26) in the presence or absence of letrozole combination in the GnRH antagonist protocol. In conclusion, letrozole administration might improve clinical pregnancy rate in conventional GnRH antagonist protocol for poor responders. Moreover, letrozole co-treatment aslo can reduce the economic burden of poor responders during the GnRH antagonist cycle. Nevertheless, large-scale and multi-center randomized controlled trials are needed to further evaluate the efficacy of adjunctive letrozole administration in the GnRH antagonist protocol.

Cumulative live birth rate of low prognosis patients with POSEIDON stratification: a single-centre data analysis

RESEARCH QUESTION

Does patient-oriented strategies encompassing individualized oocyte number (POSEIDON) classification help stratify the reproductive potential of patients with low prognosis more effectively from the perspective of prognosis; and as cumulative live birth rate (CLBR) is an effect indication, how is CLBR in patients stratified using POSEIDON?

DESIGN

A retrospective cohort study of 10,615 women who underwent IVF treatment at the Peking University Third Hospital between January 2017 and December 2017. Patients were stratified according to POSEIDON criteria. Clinical characteristics, fresh embryo transfer outcomes and CLBR during the first two ovarian stimulation cycles were recorded.

RESULTS

Gonadotrophin-releasing hormone antagonist protocol was the most used treatment in both ovarian stimulation cycles. After the failure of the first IVF treatment, 2063 (29.2%) women continued the second treatment, and 10.9% of them switched to the micro-stimulation protocol. Compared with the non-POSEIDON group, the CLBR of the first cycle in each POSEIDON group was lower (P < 0.001). The CLBRs of the second cycle in older patients (POSEIDON groups 2b and 4) and in younger patients with poor ovarian reserve (POSEIDON group 3) were lower than that in non-POSEIDON group (group 2b, P = 0.001; group 3, P = 0.019; group 4, P < 0.001). Subgroup analysis showed that younger patients had higher CLBR than older patients in both cycles (P < 0.001).

CONCLUSION

The CLBRs vary among different POSEIDON groups. The results may help reproductive specialists to understand the characteristics of low prognosis patients better and to develop individualized treatment plans.

Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment

Advanced maternal age (AMA; >35 year) is associated with a decline in both ovarian reserve and oocyte competence. At present, no remedies are available to counteract the aging-related fertility decay, however different therapeutic approaches can be offered to women older than 35 year undergoing IVF. This review summarizes the main current strategies proposed for the treatment of AMA: (i) oocyte cryopreservation to conduct fertility preservation for medical reasons or "social freezing" for non-medical reasons, (ii) personalized controlled ovarian stimulation to maximize the exploitation of the ovarian reserve in each patient, (iii) enhancement of embryo selection via blastocyst-stage preimplantation genetic testing for aneuploidies and frozen single embryo transfer, or (iv) oocyte donation in case of minimal/null residual chance of pregnancy. Future strategies and tools are in the pipeline that might minimize the risks of AMA through non-invasive approaches for embryo selection (e.g., molecular analyses of leftover products of IVF, such as spent culture media). These are yet challenging but potentially ground-breaking perspectives promising a lower clinical workload with a higher cost-effectiveness. We also reviewed emerging experimental therapeutic approaches to attempt at restoring maternal reproductive potential, e.g., spindle-chromosomal complex, pronuclear or mitochondrial transfer, and chromosome therapy. In vitro generation of gametes is also an intriguing challenge for the future. Lastly, since infertility is a social issue, social campaigns, and education among future generations are desirable to promote the awareness of the impact of age and lifestyle habits upon fertility. This should be a duty of the clinical operators in this field.

Double Stimulation in the Same Ovarian Cycle (DuoStim) to Maximize the Number of Oocytes Retrieved From Poor Prognosis Patients: A Multicenter Experience and SWOT Analysis

A panel of experts known as the POSEIDON group has recently redefined the spectrum of poor responder patients and introduced the concept of suboptimal response. Since an ideal management for these patients is still missing, they highlighted the importance of tailoring the ovarian stimulation based on the chance of each woman to obtain an euploid blastocyst. Interestingly, a novel pattern of follicle recruitment has been defined: multiple waves may arise during a single ovarian cycle. This evidence opened important clinical implications for the treatment of poor responders. For instance, double stimulation in the follicular (FPS) and luteal phase (LPS) of the same ovarian cycle (DuoStim) is an intriguing option to perform two oocyte retrievals in the shortest possible time. Here, we reported our 2-year experience of DuoStim application in four private IVF centers. To date, 310 poor prognosis patients completed a DuoStim protocol and underwent IVF with blastocyst-stage preimplantation-genetic-testing. LPS resulted into a higher mean number of oocytes collected than FPS; however, their competence (i.e., fertilization, blastocyst, euploidy rates, and clinical outcomes after euploid single-embryo-transfer) was comparable. Importantly, the rate of patients obtaining at least one euploid blastocyst increased from 42.3% (n = 131/310) after FPS to 65.5% (n = 203/310) with the contribution of LPS. A summary of the putative advantages and disadvantages of DuoStim was reported here through a Strengths-Weaknesses-Opportunities-Threats analysis. The strengths of this approach make it very promising. However, more studies are needed in the future to limit its weaknesses, shed light on its putative threats, and realize its opportunities.

Increased rounds of gonadotropin stimulation have side effects on mouse fallopian tubes and oocytes

In this study, it was evaluated if increased rounds of gonadotropin stimulation could affect in mice: (i) expression levels of proteins regulating cell cycle and DNA repair in fallopian tubes and (ii) meiotic spindle morphology of ovulated oocytes. To this end, adult female mice were subjected or not (Control) to 6 or 8 rounds of gonadotropin stimulation. Ovulated oocytes were incubated with anti A/B tubulin to evaluate spindle morphology. Fallopian tubes were analyzed to detect Cyclin D1, phospho-p53/p53, phospho-AKT/AKT, phospho-GSK3B/GSK3B, SOX2, OCT3/4, phospho-B-catenin/B-catenin, phospho-CHK1 and phospho-H2A.X protein levels. After 6 rounds, Cyclin D1, p53 and phospho-p53 contents were higher than Control. After 8 rounds, the contents of phosphorylated AKT, GSK3B and p53 as well as of total p53, Cyclin D1 and OCT3/4 significantly increased in comparison with Control. Conversely, SOX2 and B-catenin were similarly expressed among all experimental groups. The finding that phospho-CHK1 and phospho-H2A.X protein levels were undetectable supported the absence of extensive DNA damage. Oocytes number and percentage of normal meiotic spindles drastically decreased from 6 rounds onward. Altogether, our results demonstrated that 6 and 8 cycles of gonadotropin stimulation reduce mouse reproductive performances by inducing over-expression and over-activation of proteins controlling cell cycle progression in fallopian tubes and by impairing oocyte spindle.

Effectiveness of mild ovarian stimulation versus GnRH agonist protocol in women undergoing assisted reproductive technology: a meta-analysis

OBJECTIVE

our meta-analysis was conducted to evaluate the effectiveness of the mild ovulation induction protocol using CC/gonadotropin/GnRH antagonist compared to the conventional GnRH agonist protocol in women undergoing ART.

METHOD

Six electronic databases were searched from their date of establishment until August 2016. Outcomes in our analysis were calculated in terms of relative risk (RR) and weighted mean differences (WMD) and standard mean differences (SMD) with 95% confidence intervals (CI) using random effect models or fixed effect models.

RESULTS

Six prospective controlled clinical trials with 1543 women comparing the clinical impacts of the two protocols were included. The synthesized results suggested a significant reduction in the quantity of gonadotropins (SMD: -1.96, 95% CI: -2.28 to 1.64, I² = 78.5%), the incidence of OHSS (RR: 0.16, 95% CI 0.03-0.86, I² = 0%) and an increase in the cycle cancelation rate (RR: 1.46, 95% CI 1.05-2.03, I² = 89.4%). While no evidence of statistically significant differences between the groups existed in the other clinical outcomes.

CONCLUSION

This study suggested that the probable benefits of the mild protocol, including its less costs and safer process without reducing the overall IVF treatment success rates, seemed to make it a better treatment option. Larger sample prospective trials evaluating live birth, clinical pregnancy, OHSS, multiple pregnancy incidence and so on were desired to establish.

Mild versus conventional antagonist ovarian stimulation protocols in expected normal responders undergoing IVF/ICSI: a case-control study

Mild controlled ovarian hyperstimulation (COH) protocols combining clomiphene citrate (CC) or letrozole with gonadotropins were introduced as an effective alternative of conventional COH in normal responders undergoing IVF/ICSI. In this case-control study, we compared 41 participants treated with a mild stimulation protocol receiving gonadotropins combined with either CC (n = 24) or letrozole (n = 17) with 71 subfertile participants with matching baseline characteristics, conforming with the same inclusion criteria and treated with a conventional antagonist protocol. Live birth was determined in reduced rates in the study group compared to the control group, reaching marginal statistical significance [4/41 versus 19/71, p = 0.050], as also in the respective number of clinical pregnancies [6/41 versus 22/71, p = 0.054], although the incidence of miscarriage was similar for both groups [2/41 versus 5/71, p = 0.714]. Most of the secondary parameters examined, favored the conventional antagonist protocol. There was no difference in any of the outcomes reported between the three different stimulation groups in post-hoc analysis. Mild stimulation regimens with the aid of either CC or letrozole employing GnRH antagonists do not seem to constitute an equally effective method as compared to the conventional antagonist protocol to be offered in good prognosis subfertile women seeking an induced cycle toward IVF/ICSI.

A Higher Ovarian Response after Stimulation for IVF Is Related to a Higher Number of Euploid Embryos

This study has analysed the relationship between ovarian response and the number of euploid embryos. This is a post hoc analysis of a subset of data generated during a prospective cohort study previously published. Forty-six oocyte donors were subjected to ovarian stimulation with 150 IU of rFSH and 75 IU of hp-hMG in a GnRH agonist long protocol. Preimplantation genetic screening was performed in all viable embryos. We observed a positive relationship between ovarian response and the number of euploid embryos. When ovarian response was above the median (≥17 oocytes), the mean number of euploid embryos per donor was 5.0 ± 2.4, while when <17 oocytes were obtained the mean number of euploid embryos was 2.7 ± 1.4 (p = 0.000). Aneuploidy rate did not increase with ovarian response or gonadotropin doses. Also, the number of euploid embryos was inversely related to the amount of gonadotropins needed per oocyte obtained (ovarian sensitivity index). These results suggest that the number of euploid embryos available for embryo transfer increases as the number of oocytes obtained does. Considering the total number of euploid embryos seems more relevant than the aneuploidy rate.

Concomitant use of FSH and low-dose recombinant hCG during the late follicular phase versus conventional controlled ovarian stimulation for intracytoplasmic sperm injection cycles

The objective of this study was to investigate the effects of low-dose hCG supplementation on ICSI outcomes and controlled ovarian stimulation (COS) cost. Three hundred and thirty patients undergoing ICSI were split into groups according to the COS protocol: (i) control group (n = 178), including patients undergoing conventional COS treatment; and (ii) low-dose hCG group (n = 152), including patients undergoing COS with low-dose hCG supplementation. Lower mean total doses of FSH administered and higher mean oestradiol level and mature oocyte rates were observed in the low-dose hCG group. A significantly higher fertilization rate, high-quality embryo rate and blastocyst formation rate were observed in the low-dose hCG group as compared to the control group. The miscarriage rate was significantly higher in the control group compared to the low-dose hCG group. A significantly lower incidence of OHSS was observed in the low-dose hCG group. There was also a significantly lower gonadotropin cost in the low-dose hCG group as compared to the control group ($1235.0 ± 239.0×$1763.0 ± 405.3, p < 0.001). The concomitant use of low-dose hCG and FSH results in a lower abortion rate and increased number of mature oocytes retrieved, as well as improved oocyte quality, embryo quality and blastocyst formation and reduced FSH requirements.

Ovarian stimulation protocols for IVF: is more better than less?

Conventional ovarian stimulation protocols for IVF are designed to achieve maximum oocyte yields. Conventional protocols, however, are associated with patient discomfort, increased risk of ovarian hyperstimulation syndrome and higher costs. In recent years, mild stimulation protocols have risen in popularity. These protocols typically use lower doses (≤150 IU/day), shorter duration of exogenous gonadotrophins, or both, compared with conventional protocols, with the goal of limiting the number of retrieved oocytes to less than eight. The pregnancy rate per cycle (fresh embryo transfer only) is lower with mild stimulation compared with conventional stimulation; however, the cumulative pregnancy rate seems to be comparable between the approaches. Reports are conflicting on the effects of mild versus conventional stimulation on embryo quality. This article expands on a live debate held at the American Society for Reproductive Medicine 2015 Annual Meeting to compare the advantages and disadvantages of the 'more is better' (conventional protocol) versus 'less is best' (mild protocol) approaches to ovarian stimulation. Both protocols are associated with benefits and challenges, and physicians must consider the needs of the individual patient when determining the best treatment options. Further prospective studies comparing a variety of outcomes with conventional and mild stimulation are needed.

Advancement in the treatment of diminished ovarian reserve by traditional Chinese and Western medicine

Diminished ovarian reserve (DOR) refers to the decreased production of mature ova in ovarium and decreased quality of oocyte, leading to deficiency of the female sex hormone and decreased fertility. DOR can also develop into premature ovarian failure, which affects female life quality and constitutes an important cause of female infertility. A fast lifestyle, environmental deterioration and accumulated understanding of this disease, have led to an increase in the incidence of DOR. Therefore, reasonable and effective treatment for DOR is particularly important to improve ovarian function and female life quality as well as reduce infertility. This mini review provides recent updates regarding DOR and a summary of advancements in the treatment of DOR using Chinese and Western Medicine.

Comparison between follicular stimulation and luteal stimulation protocols with clomiphene and HMG in women with poor ovarian response

This retrospective study is to compare the follicular mild stimulation and luteal simulation protocols for poor responders undergoing in vitro fertilization (IVF). A total of 131 women were diagnosed as poor responders. Thirty-three women started ovarian stimulation in early-luteal phase and 98 women started in early follicular phase with 100 mg/d clomiphene citrate and 75-150 IU/d HMG. There were more oocytes retrieved (2.8 ± 2.0 versus 2.0 ± 1.2, p < 0.05), more available embryos (1.8 ± 1.4 versus 1.3 ± 1.1, p < 0.05) and top-quality embryos (0.9 ± 0.9 versus 0.4 ± 0.6, p < 0.05), and reduced cycle cancellation rate (12.1% versus 30.6%, p < 0.05) in luteal group than in follicular group. The clinical pregnancy (17.7%, 20.0% and 41.2%) and live-birth rates (10.78%, 20.0% and 29.4%) after transferring embryos obtained from luteal, follicular and mixed stages were comparable (p > 0.05). For poor responders, luteal phase stimulation could be an option because of increasing the chance to obtain competent embryos and reducing the cycle cancellation rate.

Prevention of Ovarian Hyperstimulation Syndrome: A Review

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.

Efficacy and safety of late-start Corifollitropin-alfa administration for controlled ovarian hyperstimulation in IVF: a cohort, case-control study

OBJECTIVE

To investigate efficacy and safety of a controlled ovarian stimulation (COS) protocol in which a single dose of Corifollitropin-alfa (CFα) was administered on day 4 of a GnRH-antagonist cycle.

DESIGN

Cohort case-control study.

SETTING

University Hospital.

PATIENTS

One hundred twenty-two normally cycling women expected to be normal responders to COS.

INTERVENTIONS

In 61 patients, CFα (100-150 μg) was injected subcutaneously on day 4 of a spontaneous menstrual cycle; a GnRH-antagonist was added from day 8 (fixed protocol; 0.25 mg/day). If needed to complete follicular maturation, recombinant FSH (rFSH) daily injections (150/200 IU/day) were given from day 11. A control group of 61 matched women was stimulated with daily subcutaneous injections of rFSH (100-150 U/day) from day 4 of the cycle, and received GnRH-antagonist (0.25 mg/day) from day 8. IVF or ICSI was performed according to the sperm characteristics, and 1-2 embryos were transferred in utero under US guidance on day 2.

MAIN OUTCOME MEASURES

Number of retrieved cumulus-oocyte complexes (COCs), clinical pregnancy rate (PR), implantation rate (IR), ongoing PR at 10 weeks, number of injections/cycle, ovarian hyperstimulation syndrome (OHSS) rate.

RESULTS

No cycle was cancelled and the mean number of retrieved COCs was comparable in patients and controls. About 60% of CF-alfa treated women had no need of daily rFSH addition, and the mean number of injections/cycle was significantly lower in the CF-alfa group than in controls (p < 0.05). The ongoing PR/transfer was 36.8% in CF-alfa group and 37.5% in controls. No patient developed severe OHSS, and the incidence of moderate OHSS was similar in cases and controls.

CONCLUSIONS

CFα may be started on day 4 of the cycle obtaining results comparable to those of a COS using day 4-start daily rFSH, with significantly less injections and a similar risk of OHSS.

Comparison of pregnancy outcome after letrozole versus clomiphene treatment for mild ovarian stimulation protocol in poor responders

BACKGROUND

Poor ovarian response to controlled ovarian stimulation is one of the most important interest points in assisted reproduction. Mild ovarian stimulation seems to be preferable to high dose of FSH regimens in women with a history of poor ovarian response in previous protocol. Clomiphene citrate and letrozole alone or in combination with FSH have been used in mild ovarian stimulation protocol.

OBJECTIVE

To compare the efficacy of letrozole and clomiphene citrate for mild ovarian stimulation on assisted reproductive technology outcomes in poor responders.

MATERIALS AND METHODS

In a randomized control study, 184 women aged between 20 and 45 years with the history of poor response to ovarian stimulation who were candidate for ART were randomly subdivided into two groups: group I (n= 80), women who underwent the clomiphene/gonadotropin/antagonist protocol; and group II (n= 87), patients who underwent the letrozole/gonadotropin/antagonist protocol. Groups were compared regarding implantation, chemical and clinical pregnancy rates.

RESULTS

There was a significant difference in the mean endometrial thickness between two groups (9.16±1.2 mm vs. 8.3±0.3 mm). The implantation rate was significantly higher in letrozole group compare to clomiphene group (7.2 vs. 6.6%, p=0.024 respectively). No significant differences were found in chemical and clinical pregnancy rate between two groups.

CONCLUSION

In mild ovarian stimulation protocol, letrozole and clomiphene have similar value for the poor responder. The optimal treatment strategy for these patients remains debated.

The "graying" of infertility services: an impending revolution nobody is ready for

BACKGROUND

As demand for infertility services by older women continues to grow, because achievable in vitro fertilization (IVF) outcomes are widely underestimated, most fertility centers do not offer maximal treatment options with use of autologous oocytes. Limited data suggest that clinical IVF outcomes in excess of what the American Society for Reproductive Medicine (ASRM) considers "futile" can, likely, be achieved up to at least age 45 years.

METHODS

In an attempt to point out an evolving demographic trend in IVF, we here report our center's IVF data for 2010-2012 and national U.S. data for 1997-2010. Though our center's data are representative of only one IVF center's patients, they, likely, are unique since they probably represent the most adversely selected IVF patient population ever reported and, thus, are predictive of future demographic trends. In addition we performed a systematic review of the literature on the subject based on PubMed, Medline and Google Scholar searches till year-end 2013. The literature search was performed using key words and phrases relevant to fertility treatments in older women.

RESULTS

As demonstrated by our center's patient demographics and national U.S. data, IVF centers are destined to treat increasingly adversely selected patients. Despite our center's already extremely adversely selected patient population, age-specific IVF cycle outcomes in women above age 40 years, nevertheless, exceeded criteria for "futility" by the ASRM and widely quoted outcome expectations in the literature for patient ages. Age 43 discriminates between better and poorer clinical pregnancy and live birth rates.

CONCLUSIONS

"Graying" of the infertility populations in the developed world, a problem with potentially far-reaching medical and societal consequences, has so far been only insufficiently addressed in the literature. As women's postmenopausal life spans already exceed postmenarcheal life spans at the start of the 20th century, the "graying" of infertility services can be expected to further accelerate, no longer as in recent decades bringing only women in their 40s into maternity wards but also women in their 50s and 60s. Medicine and society better get ready for this revolution.

Should mild stimulation be the order of the day?

Mild stimulation protocols aim to reduce the physical, financial and emotional burden associated with the conventional IVF protocol without compromising the pregnancy rate. Such protocols help to decrease the complications and the discomfort related to the prolonged administration of agonist and large doses of gonadotrophins, by limiting the number of oocytes recruited to no more than eight. The per cycle pregnancy rates are lower though the cumulative pregnancy rate in a year is equivalent. This CPR comes by going through earlier repeat cycles. Whether this reduces the physical, emotional or financial burden remains a matter of debate. There is need to standardize these protocol and do more trials to compare the two effectively. Till such time there is a clear benefit above the conventional protocol it will not be the protocol of choice with most physicians.

"Mild" vs. "long" protocol for controlled ovarian hyperstimulation in patients with expected poor ovarian responsiveness undergoing in vitro fertilization (IVF): a large prospective randomized trial

BACKGROUND

This large prospective, randomized study was designed to compare the "mild" protocol with clomiphene citrate, low-dose gonadotropins and a GnRH-antagonist (CC/Gn/GnRH-ant protocol) with the "long" protocol with a GnRH-agonist and high-dose Gn for the controlled ovarian hyperstimulation (COH) of patients with expected poor ovarian responsiveness undergoing IVF.

MATERIALS AND METHODS

A total of 695 women with clinical, endocrine and ultrasound characteristics suggesting a low ovarian reserve and a poor responsiveness to COH were recruited and randomly assigned to receive the CC/Gn/GnRH-ant "mild" protocol (mild group, n = 355) or the "long" protocol with high-dose Gn (long group, n = 340).

RESULTS

The "mild" stimulation led to significantly shorter follicular phase, lower consumption of exogenous Gn and lower peak estradiol level than the "long" regimen. With the "long" protocol, significantly less cycles were cancelled due to the lack of ovarian response; further, it obtained significantly more oocytes, more mature oocytes, more embryos, and a thicker endometrium. As for the final IVF outcome, however, the two stimulation regimens obtained comparable implantation rate, clinical pregnancy rate, and ongoing pregnancy rate at 12 weeks.

CONCLUSIONS

In conclusion, the "mild" CC/Gn/GnRH-ant stimulation protocol is a valid alternative to the long protocol with high Gn dose as it obtains a comparable success rate and requires significantly less medications, with an obvious economical advantage.

Metabolite Profiling in the Pursuit of Biomarkers for IVF Outcome: The Case for Metabolomics Studies

Background. This paper presents the literature on biomarkers of in vitro fertilisation (IVF) outcome, demonstrating the progression of these studies towards metabolite profiling, specifically metabolomics. The need for more, and improved, metabolomics studies in the field of assisted conception is discussed. Methods. Searches were performed on ISI Web of Knowledge SM for literature associated with biomarkers of oocyte and embryo quality, and biomarkers of IVF outcome in embryo culture medium, follicular fluid (FF), and blood plasma in female mammals. Results. Metabolomics in the field of female reproduction is still in its infancy. Metabolomics investigations of embryo culture medium for embryo selection have been the most common, but only within the last five years. Only in 2012 has the first metabolomics investigation of FF for biomarkers of oocyte quality been reported. The only metabolomics studies of human blood plasma in this context have been aimed at identifying women with polycystic ovary syndrome (PCOS). Conclusions. Metabolomics is becoming more established in the field of assisted conception, but the studies performed so far have been preliminary and not all potential applications have yet been explored. With further improved metabolomics studies, the possibility of identifying a method for predicting IVF outcome may become a reality.

MILD ovarian stimulation with GnRH-antagonist vs. long protocol with low dose FSH for non-PCO high responders undergoing IVF: a prospective, randomized study including thawing cycles

OBJECTIVE

To compare the effectiveness of two stimulation protocols in non-polycystic ovary (PCO) high responders undergoing in vitro fertilization (IVF).

DESIGN

Prospective randomized trial.

SETTING

A Reproductive Medicine and IVF Unit of a University Hospital and a private IVF Clinic.

METHODS

Four hundred-and-twelve normoovulatory women with good ovarian responsiveness were randomized to receive either the "mild" (FSH 150 IU/day from day 4 of a spontaneous cycle followed by GnRH-antagonist from day 8; n = 205) or the "long" (FSH 150 IU/day; n = 207) stimulation protocol. The outcome of these two regimens was compared including "fresh" and thawing cycles.

RESULTS

The total FSH dose and the peak estradiol level were significantly lower in the "mild" protocol, whereas the retrieved oocytes, fertilization rate, number and quality of embryos, pregnancy and implantation rates, cumulative "fresh plus thaw" success rate, and incidence of severe ovarian hyperstimulation syndrome were comparable with the two regimens.

CONCLUSIONS

In young, normoovulatory patients with good ovarian responsiveness undergoing IVF the "mild" stimulation protocol has effectiveness and risks comparable to the "long" protocol with low FSH starting dose, even when thawing cycles are included in the comparison.

Detrimental effects of high-dose gonadotropin on outcome of IVF: making a case for gentle ovarian stimulation strategies

OBJECTIVE

Limited data identify detrimental influences of aggressive use of gonadotropins (G) for controlled ovarian hyperstimulation (COH); the underlying mechanisms however remain unclear. We report on the relationship between G dose and in vitro fertilization (IVF) cycle parameters (ovarian response, endometrial thickness [EMT]) and cycle outcome (implantation rate [IR] and clinical pregnancy [CP] rate) in a cohort of women undergoing IVF.

METHODS

Retrospective analysis of fresh embryo transfer (ET) cycles. Univariate and multivariable regression analyses assessed relationship between G dose and outcomes of interest.

RESULTS

Higher G dose related positively with advancing age (P < .001) and inversely with EMT (P < .001). The overall CP rate was 30%. Significantly lower IR (.003) and CP rate (.002) were observed across increasing tertiles of G dose. Increasing G dose was identified as an independent negative predictor of EMT after adjusting for age, COH protocol and duration, infertility diagnosis, and ovarian response (P = .016). Adjusting for age, suppression protocol (gonadotropin-releasing hormone agonist vs antagonist), infertility diagnoses, EMT, quality, and cleavage of ET, lower G dose was an independent positive predictor of CP rate (odds ratio for CP rate was 1.57 for G dose in middle compared to the highest G dose quartile (95% confidence interval 1.09-2.24). Stratified analyses identified detrimental associations of higher G dose with CP rate to be relevant in women aged 35 years and younger.

CONCLUSIONS

Our analyses suggest detrimental influences of higher G dose on the endometrium and confirm the previously reported adverse association between higher G dose and IVF outcome. Gentler COH regimens may be of particular benefit in women aged ≤35 years.