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Zhang Y, Wang H, Zhang X, Hao Y, Yang J, Li Y, Feng T, Chen Y, Qian Y. The effects of flexible short protocol with gonadotropin-releasing hormone antagonist on preventing premature ovulation in poor responders. Arch Gynecol Obstet 2024; 309:689-697. [PMID: 38051371 PMCID: PMC10808440 DOI: 10.1007/s00404-023-07287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/31/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE The proportion of patients with poor ovarian response (POR) is increasing, but effective treatment remains a challenge. To control the hidden peaks of luteinizing hormone (LH) and premature ovulation for poor responders, this study investigated the efficacy of flexible short protocol (FSP) with gonadotropin-releasing hormone antagonist (GnRH-ant) on trigger day. METHODS The 662 cycles of POR patients were retrospectively analyzed. The cohort was divided into control and intervention groups. The intervention group (group A) with 169 cycles received a GnRH-ant given on trigger day. The control (group B) with 493 cycles received only FSP. The clinical outcomes of the two groups were compared. RESULTS Compared with group B, with gonadotropin-releasing hormone antagonist (GnRH-ant) on trigger day in group A the incidences of spontaneous premature ovulation decreased significantly (2.37% vs. 8.72%, P < 0.05). The number of fresh embryo-transfer cycles was 45 in group A and 117 in group B. There were no significant differences in clinical outcomes, including implantation rate, clinical pregnancy rate, live birth rate and the cumulative live birth rate (12.0% vs. 9.34%; 22.22% vs. 21.93%; 17.78% vs. 14.91%; 20.51% vs. 20%, respectively; P > 0.05) between the two group. CONCLUSION FSP with GnRH-ant addition on trigger day had no effect on clinical outcomes, but could effectively inhibit the hidden peaks of luteinizing hormone (LH) and spontaneous premature ovulation in POR. Therefore, it is an advantageous option for POR women.
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Affiliation(s)
- Yan Zhang
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Hongyou Wang
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224000, China
| | - Xinyue Zhang
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Yingying Hao
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Jihong Yang
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Yangbai Li
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Ting Feng
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Yandong Chen
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China
| | - Yun Qian
- Reproductive Center, Second Affiliated Hospital, Nanjing Medical University, Nanjing, 210011, China.
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Ip PNP, Mak JSM, Law TSM, Ng K, Chung JPW. A reappraisal of ovarian stimulation strategies used in assisted reproductive technology. HUM FERTIL 2023; 26:824-844. [PMID: 37980170 DOI: 10.1080/14647273.2023.2261627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 11/20/2023]
Abstract
Ovarian stimulation is a fundamental step in assisted reproductive technology (ART) with the intention of inducing ovarian follicle development prior to timed intercourse or intra-uterine insemination and facilitating the retrieval of multiple oocytes during a single in vitro fertilization (IVF) cycle. The basis of ovarian stimulation includes the administration of exogenous gonadotropins, with or without pre-treatment with oral hormonal therapy. Gonadotropin-releasing hormone agonist or antagonist is given in addition to the gonadotropins to prevent a premature rise of endogenous luteinizing hormone that would in turn lead to premature ovulation. With the advancement in technology, various stimulation protocols have been devised to cater for different patient needs. However, ovarian hyperstimulation syndrome and its serious complications may occur following ovarian stimulation. It is also evident that suboptimal ovarian stimulation strategies may have a negative impact on oogenesis, embryo quality, endometrial receptivity, and reproductive outcomes over recent years. This review describes the various forms of pre-treatment for ovarian stimulation and stimulation protocols, and aims to provide clinicians with the latest available evidence.
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Affiliation(s)
- Patricia N P Ip
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jennifer S M Mak
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tracy S M Law
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Karen Ng
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jacqueline P W Chung
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
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3
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Effectiveness of GnRH Agonist Short Protocol Versus GnRH Antagonist Protocol in POSEIDON Groups 3 and 4: a Retrospective Cohort Study. Reprod Sci 2023:10.1007/s43032-023-01196-x. [PMID: 36808612 DOI: 10.1007/s43032-023-01196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/05/2023] [Indexed: 02/19/2023]
Abstract
The aim of this study is to compare the ART (assisted reproductive technology) outcomes and cancellation rates between GnRH antagonist protocol and GnRH agonist short protocol in POSEIDON (Patient-Oriented Strategy Encompassing IndividualizeD Oocyte Number) groups 3 and 4. It is a retrospective cohort study conducted in the Department of Reproductive Medicine and Surgery of a tertiary-level hospital. Women who underwent ART treatment with either GnRH antagonist or GnRH agonist short protocol with fresh embryo transfer, between January 2012 and December 2019 belonging to POSEIDON 3 and 4 groups, were included. Among the 295 women who belonged to the POSEIDON groups 3 or 4, 138 women received GnRH antagonist and 157 women received GnRH agonist short protocol. The median total dose of gonadotropin in the GnRH antagonist protocol was not significantly different from GnRH agonist short protocol [3000, IQR (2481-3675) vs. 3175, IQR (2643-3993), p = 0.370]. There was a significant difference in the duration of stimulation between the GnRH antagonist and GnRH agonist short protocol [10, IQR (9-12) vs. 10, IQR (8-11), p = 0.002]. The median number of mature oocytes retrieved was significantly different in the cohort of women receiving GnRH antagonist protocol compared to GnRH agonist short protocol [3, IQR (2-5) vs. 3, IQR (2-4), p = 0.029]. There was no significant difference in the clinical pregnancy rate (24% vs. 20%, p = 0.503) and cycle cancellation rate (29.7% vs. 36.3%, p = 0.290) between the GnRH antagonist and agonist short protocols respectively. Live birth rate was not significantly different between the GnRH antagonist protocol (16.7%) and GnRH agonist short protocol (14.0%) [OR 1.23, 95% CI (0.56-2.68), p = 0.604]. After adjusting for the significant confounding factors, the live birth rate was not significantly associated with the antagonist protocol compared with the short protocol [aOR 1.08, 95% CI (0.44-2.63), p = 0.870]. Though GnRH antagonist protocol results in higher mature oocyte yield when compared with GnRH agonist short protocol, it does not translate into an increase in live birth in POSEIDON groups 3 and 4.
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4
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Sfakianoudis K, Simopoulou M, Grigoriadis S, Pantou A, Tsioulou P, Maziotis E, Rapani A, Giannelou P, Nitsos N, Kokkali G, Koutsilieris M, Pantos K. Reactivating Ovarian Function through Autologous Platelet-Rich Plasma Intraovarian Infusion: Pilot Data on Premature Ovarian Insufficiency, Perimenopausal, Menopausal, and Poor Responder Women. J Clin Med 2020; 9:jcm9061809. [PMID: 32532000 PMCID: PMC7355907 DOI: 10.3390/jcm9061809] [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: 05/13/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022] Open
Abstract
Intraovarian platelet-rich plasma (PRP) infusion was recently introduced in the context of addressing ovarian insufficiency. Reporting on its effectiveness prior to adopting in clinical routine practice is imperative. This study aims to provide pilot data regarding PRP application for ovarian rejuvenation. Four pilot studies were conducted on poor ovarian response (POR), premature ovarian insufficiency (POI), perimenopause, and menopause, respectively. Each pilot study reports on thirty patients, 120 participants were recruited in total. All participants provided written informed consent prior to treatment. Primary outcome measures for the POR pilot study were levels of anti-müllerian hormone (AMH), antral follicle count (AFC) and oocyte yield. For the POI, perimenopausal and menopausal pilot studies primary outcome measures were restoration of menstrual cycle, and Follicle Stimulating Hormone (FSH) levels. A significant improvement on the hormonal profile and the ovarian reserve status was noted, along with improved intracytoplasmic sperm injection (ICSI) cycle performance concerning POR participants. Menstruation recovery was observed in 18 out of 30 POI patients, along with a statistically significant improvement on levels of AMH, FSH, and AFC. Similarly, 13 out of 30 menopausal women positively responded to PRP treatment. Finally, menstruation regularity, improved hormonal levels and AFC were reported for 24 out of 30 perimenopausal women. To conclude, PRP infusion appears to convey promising results in addressing ovarian insufficiency.
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Affiliation(s)
- Konstantinos Sfakianoudis
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Mara Simopoulou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
- Correspondence: ; Tel.: +30-2107462592; Fax: +30-2107462571
| | - Sokratis Grigoriadis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Agni Pantou
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Petroula Tsioulou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Evangelos Maziotis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Anna Rapani
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Polina Giannelou
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Nikolaos Nitsos
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Georgia Kokkali
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
| | - Michael Koutsilieris
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75, Mikras Asias, 11527 Athens, Greece; (S.G.); (P.T.); (E.M.); (A.R.); (M.K.)
| | - Konstantinos Pantos
- Centre for Human Reproduction, Genesis Athens Clinic, 14–16, Papanikoli, 15232 Athens, Greece; (K.S.); (A.P.); (P.G.); (N.N.); (G.K.); (K.P.)
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Fàbregues F, Solernou R, Ferreri J, Guimerá M, Peralta S, Casals G, Peñarrubia J, Creus M, Manau D. Comparison of GnRH agonist versus luteal estradiol GnRH antagonist protocol using transdermal testosterone in poor responders. JBRA Assist Reprod 2019; 23:130-136. [PMID: 30614665 PMCID: PMC6501741 DOI: 10.5935/1518-0557.20180090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: Transdermal testosterone has been used in different doses and in different
stimulation protocols in poor responders. The aim of the present study is to
compare the luteal estradiol/GnRH antagonists protocol
versus long GnRH agonists in poor responder patients
according to the Bologna criteria, in which transdermal testosterone has
been used prior to the stimulation with gonadotropins. Methods: In this retrospective analysis, a total of 141 poor responder patients
according to the Bologna criteria were recruited. All patients were treated
with transdermal testosterone preceding ovarian stimulation with
gonadotropins during 5 days. In 53 patients we used the conventional
antagonist protocol (Group 1). In 88 patients (GrH pituitary suppression was
achieved by leuprolide acetate according to the conventional long protocol
(Group 2). We analyzed the ovarian stimulation parameters and IVF
outcomes. Results: Comparing groups 1 and 2, there were no significant differences between
cancellation rates and number of oocytes retrieved. However the total
gonadotropin dose used and the mean length of stimulation were significantly
lower in group 1 when compared to group 2. There were no significant
differences in pregnancy outcomes; however, there was a slight increase in
the implantation rate in group 1 vis-a-vis group 2, although statistical
significance was not achieved. Conclusion: TT in poor responder patients can be effective both with the conventional
agonist's long protocol and with the conventional antagonist's protocol.
However, short regimes with previous estradiol antagonists in the luteal
phase facilitate ovarian stimulation by shortening the days of treatment and
the consumption of gonadotropins
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Affiliation(s)
- Francesc Fàbregues
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Roser Solernou
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Janisse Ferreri
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Marta Guimerá
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Sara Peralta
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Gemma Casals
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Joana Peñarrubia
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Montserrat Creus
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Dolors Manau
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
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Tulić L, Vidaković S, Tulić I, Ćurčić M, Stojnić J, Jeremić K. Oxidative Stress Markers in GnRH Agonist and Antagonist Protocols in IVF. J Med Biochem 2017; 36:163-170. [PMID: 28680360 PMCID: PMC5471649 DOI: 10.1515/jomb-2017-0001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/07/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Our aim was to study the effect of GnRH agonist and antagonist protocols of ovarian stimulation on oxidative stress parameters in serum and the influence of oxidative stress parameters change on the outcome of IVF cycles. METHODS This prospective study included 82 patients who underwent IVF procedures. We determined SOD, MDA and SH groups in serum. Serum samples were obtained between the second and fourth day of the cycle and on the day of HCG administration during ovarian stimulation. RESULTS Patients were divided into two groups depending on the protocol of stimulation. The mean total and mature oocytes number and number of fertilized oocytes were higher in GnRH agonist group. There was no significant difference in biochemical pregnancy, miscarriage and live-birth rate in both groups. Mean serum SOD was significantly lower, while mean serum MDA and SH groups were significantly higher after ovarian stimulation. Delivery rate was higher in patients without OS while miscarriage rate was higher in patients with OS. CONCLUSIONS Our study confirmed that there is a difference in the concentration of oxidative stress parameters before and after ovarian stimulation. IVF outcome is better in patients without OS after ovarian stimulation. However, the protocol of ovarian stimulation is neither associated with a change in oxidative stress parameters nor with the outcome of ART procedures.
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Affiliation(s)
- Lidija Tulić
- Department of In Vitro Fertilization, Gynecology and Obstetrics Institute, Faculty of Medicine, University of Belgrade, Clinical Center of Serbia, Serbia
| | - Snežana Vidaković
- Department of In Vitro Fertilization, Gynecology and Obstetrics Institute, Faculty of Medicine, University of Belgrade, Clinical Center of Serbia, Serbia
| | - Ivan Tulić
- Department of In Vitro Fertilization, Gynecology and Obstetrics Institute, Faculty of Medicine, University of Belgrade, Clinical Center of Serbia, Serbia
| | - Marijana Ćurčić
- Department of Toxicology »Academic Danilo Soldatović«, Faculty of Pharmacy, University of Belgrade, Serbia
| | - Jelena Stojnić
- Department of In Vitro Fertilization, Gynecology and Obstetrics Institute, Faculty of Medicine, University of Belgrade, Clinical Center of Serbia, Serbia
| | - Katarina Jeremić
- Department of In Vitro Fertilization, Gynecology and Obstetrics Institute, Faculty of Medicine, University of Belgrade, Clinical Center of Serbia, Serbia
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Jeve YB, Bhandari HM. Effective treatment protocol for poor ovarian response: A systematic review and meta-analysis. J Hum Reprod Sci 2016; 9:70-81. [PMID: 27382230 PMCID: PMC4915289 DOI: 10.4103/0974-1208.183515] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Poor ovarian response represents an increasingly common problem. This systematic review was aimed to identify the most effective treatment protocol for poor response. We searched MEDLINE, EMBASE, and The Cochrane Library from 1980 to October 2015. Study quality assessment and meta-analyses were performed according to the Cochrane recommendations. We found 61 trials including 4997 cycles employing 10 management strategies. Most common strategy was the use of gonadotropin-releasing hormone antagonist (GnRHant), and was compared with GnRH agonist protocol (17 trials; n = 1696) for pituitary down-regulation which showed no significant difference in the outcome. Luteinizing hormone supplementation (eight trials, n = 847) showed no difference in the outcome. Growth hormone supplementation (seven trials; n = 251) showed significant improvement in clinical pregnancy rate (CPR) and live birth rate (LBR) with an odds ratio (OR) of 2.13 (95% CI 1.06-4.28) and 2.96 (95% CI 1.17-7.52). Testosterone supplementation (three trials; n = 225) significantly improved CPR (OR 2.4; 95% CI 1.16-5.04) and LBR (OR 2.18; 95% CI 1.01-4.68). Aromatase inhibitors (four trials; n = 223) and dehydroepiandrosterone supplementation (two trials; n = 57) had no effect on outcome.
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Affiliation(s)
- Yadava Bapurao Jeve
- Leicester Fertility Centre, University Hospitals of Leicester, LE1 5WW, United Kingdom
| | - Harish Malappa Bhandari
- Department of Reproductive Medicine, Sub-specialty Trainee in Reproductive Medicine and Surgery, Newcastle Fertility Centre at Life, Newcastle upon Tyne, NE1 4EP, United Kingdom
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8
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Şahin S, Selçuk S, Devranoğlu B, Kutlu T, Kuyucu M, Eroğlu M. Comparison of long GnRH agonist versus GnRH antagonist protocol in poor responders. Turk J Obstet Gynecol 2014; 11:203-206. [PMID: 28913020 PMCID: PMC5558361 DOI: 10.4274/tjod.80090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/05/2014] [Indexed: 12/01/2022] Open
Abstract
Objective: To compare long GnRH agonist with GnRH antagonist protocol in poor responders. Materials and Methods: Medical charts of 531 poor responder women undergoing in-vitro fertilization (IVF) cycle at Zeynep Kamil Maternity and Children’s Hospital, IVF Center were retrospectively analysed. Those who received at least 300 IU/daily gonadotropin and had ≤3 oocytes retrieved were enrolled in the study. Poor responders were categorized into two groups as those who received long GnRH agonist or GnRH antagonist regimen. Results: Treatment duration and total gonadotropin dosage were significantly higher in women undergoing the long GnRH agonist regimen compared with the GnRH antagonist regimen (p<0.001 for both). Although the number of total and mature oocytes retrieved was similar between the groups, good quality embryos were found to be higher in the GnRH antagonist regimen. The day of embryo transfer and number of transferred embryos were similar in the groups. No statistically significant differences were detected in pregnancy (10.5% vs 14.1%), clinical pregnancy (7.7% vs 10.6%) and early pregnancy loss rates (27.2% vs 35%) between the groups. Conclusion: GnRH antagonist regimen may be preferable to long GnRH regimen as it could decrease the cost and treatment duration in poor responders.
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Affiliation(s)
- Sadık Şahin
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Selçuk Selçuk
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Belgin Devranoğlu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Tayfun Kutlu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Melda Kuyucu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
| | - Mustafa Eroğlu
- Zeynep Kamil Women and Children's Diseases Education and Research Hospital, Clinics of Obstetrics and Gynecology, İstanbul, Turkey
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9
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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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10
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Xiao J, Chang S, Chen S. The effectiveness of gonadotropin-releasing hormone antagonist in poor ovarian responders undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril 2013; 100:1594-601.e1-9. [PMID: 24055048 DOI: 10.1016/j.fertnstert.2013.08.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 08/14/2013] [Accepted: 08/15/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of gonadotropin-releasing hormone (GnRH) antagonist in poor ovarian responders undergoing in vitro fertilization (IVF). DESIGN Systematic review and meta-analysis. SETTING Affiliated hospital with a medical university. PATIENT(S) None. INTERVENTION(S) Electronic search. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate, number of oocytes retrieved, cycle cancellation rate. RESULT(S) A total of 12 published studies (1,332 cases) were included. Both the stimulation period (mean difference [MD], -0.43; 95% confidence interval [CI], -0.68 to -0.17) and the gonadotropin dosage (MD, -5.41; 95% CI, -7.51 to -3.31) were statistically significantly lower in the GnRH antagonist protocol than in the long GnRH agonist protocol. Both the endometrial thickness (MD -0.45; 95% CI, -0.76 to -0.13) and estrogen (E2) level on the day of hCG administration (MD, -1,299.15; 95% CI, -1,716.34 to -881.95) were statistically significantly lower in the GnRH antagonist protocol than the GnRH agonist protocol. Fewer oocytes were retrieved for the GnRH antagonist protocol than the long GnRH agonist protocol (MD, -0.34; 95% CI, -0.54 to -0.13) or the short GnRH agonist protocol (MD, -0.54; 95% CI, -0.9, 8 to -0.10). The cycle cancellation and clinical pregnancy rates were not statistically significantly different between the two groups. CONCLUSION(S) Compared with GnRH agonist protocols, the GnRH antagonist protocol is associated with fewer oocytes retrieved, lower E2 levels, and thinner endometrium whereas the clinical pregnancy and cycle cancellation rates are similar.
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Affiliation(s)
- Jinsong Xiao
- Reproductive Medicine Center, Taihe Hospital, Hubei University of Medicine, Shiyan City, People's Republic of China.
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A comparative study on oxidative and antioxidative markers of serum and follicular fluid in GnRH agonist and antagonist cycles. J Assist Reprod Genet 2012; 29:1175-83. [PMID: 22886458 DOI: 10.1007/s10815-012-9843-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 07/30/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To determine whether concentrations of oxidative stress markers of follicular fluid and serum are different in GnRH agonist protocol from GnRH antagonist protocol. MATERIAL AND METHOD This was a cross-sectional study. Eighty-four women undergoing controlled ovarian stimulation with either GnRH agonist (n = 39) or GnRH antagonist protocols (n = 45) for IVF/ICSI treatment were assigned by a physician. Blood was obtained at the time of oocyte retrieval, and follicular fluid (FF) from the mature follicles of each ovary was centrifuged and frozen until analysis. Malondialdehyde (MDA), nitric oxide (NO), protein carbonyl (PC), hydroxyl proline (OH-P), sodium oxide dismutase (SOD), reduced glutathione (GSH), glutathione peroxidase (GSH-Px), adenosine deaminase (ADA) and xanthine oxidase (XO) were assessed in the serum and follicular fluid of each participants. RESULTS The mean serum concentrations of GSH-Px, GSH and MDA were lower in the GnRH antagonist group compared to GnRH agonist group, but mean serum SOD was higher in the GnRH antagonist group. The mean follicular SOD, ADA and NO were higher in GnRH antagonist group than GnRH agonist group. The IVF/ICSI outcomes were similar in both groups. CONCLUSION(S) GnRH antagonist protocol is associated with increased oxidative stress. The relation of GnRH analogues with oxidative stress and its implication in follicular growth needs to be addressed in further studies.
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Polyzos NP, Devroey P. A systematic review of randomized trials for the treatment of poor ovarian responders: is there any light at the end of the tunnel? Fertil Steril 2011; 96:1058-61.e7. [PMID: 22036048 DOI: 10.1016/j.fertnstert.2011.09.048] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the definitions for "poor ovarian responders" used among randomized trials for the treatment of women with impaired response to stimulation. DESIGN Systematic review. SETTING None. PATIENT(S) Poor ovarian responders. INTERVENTION(S) Treatment modalities for the management of poor ovarian responders. MAIN OUTCOME MEASURE(S) Number and nature of the criteria used to define poor ovarian response to stimulation and threshold values used. RESULT(S) Among 47 randomized trials, 41 different definitions for the patients with poor ovarian response have been used. No more than 3 trials used the same definition, whereas even trials from the same research groups used different definitions across different trials. None of the criteria used was adopted in more than 50% of the trials. Age and antral follicle count were adopted only in 9% of the definitions, whereas the criteria of number of follicles on the final stimulation day and number of oocytes retrieved were used in more than 40% of the trials; nonetheless, even for these criteria, the threshold values were consistently different. CONCLUSION(S) The variability regarding the definition of poor ovarian responders appears to be striking. Although the Bologna criteria developed by European Society for Human Reproduction and Embryology consensus in 2011 aim to define a consistent group of patients, their applicability needs to be tested through clinical trials. Meanwhile, meta-analyses of the currently available trials should be strongly discouraged because they may lead to the adoption of interventions of ambiguous value.
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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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13
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Pu D, Wu J, Liu J. Comparisons of GnRH antagonist versus GnRH agonist protocol in poor ovarian responders undergoing IVF. Hum Reprod 2011; 26:2742-9. [PMID: 21778283 DOI: 10.1093/humrep/der240] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In view of the discrepancies about the GnRH antagonist (GnRH-ant) ovarian stimulation protocols having some potential advantages compared with the GnRH agonist (GnRH-a) protocols in poor ovarian responders IVF/ICSI, a meta-analysis of the published data was performed to compare the efficacy of GnRH-ant versus GnRH-a protocols for ovarian stimulation in IVF poor response patients. METHODS We searched for all published articles indexed in MEDLINE (1950-2010), EMBASE (1974-2010) and China National Knowledge Infrastructure (CNKI, 1994-2010). Any randomized controlled study that compared the GnRH-ant with GnRH-a in ovarian stimulation protocols for poor responders undergoing IVF/ICSI was included, and data were extracted independently by two reviewers. The searches yielded 64 articles, from which 14 studies met the inclusion criteria. We performed this meta-analysis involving 566 IVF patients in a GnRH-ant protocol group and 561 patients in a GnRH-a protocol group with Review Manager 4.2 software. Odds ratio (OR) and weighted mean difference (WMD) with 95% confidence intervals (CIs) were used to evaluate dichotomous and continuous data, respectively. RESULTS Fourteen eligible studies were included in this meta-analysis. GnRH-ant protocols resulted in a statistically significantly lower duration of stimulation compared with GnRH-a protocols (P = 0.04; WMD: -1.88, 95% CI: -3.64, -0.12), but there was no significant difference in the number of oocytes retrieved (P = 0.51; WMD: -0.17, 95% CI -0.69, 0.34) or the number of mature oocytes retrieved (P = 0.99; WMD: -0.01, 95% CI: -1.14, 1.12). Moreover, no significant difference was found in the cycle cancellation rate (CCR, P = 0.67; OR: 1.01, 95% CI: 0.71-1.42) or clinical pregnancy rate (CPR, P = 0.16; OR: 1.23, 95% CI: 0.92, 1.66). CONCLUSIONS Clear advantage was gained in duration of stimulation with GnRH-ant in poor ovarian responders undergoing IVF, although there was no statistical difference in the number of oocytes retrieved, the number of mature oocytes retrieved, the CCR and CPR between GnRH-ant and GnRH-a protocols. These results may be helpful to our clinical practice. However, further controlled randomized prospective studies with larger sample sizes are needed.
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Affiliation(s)
- Danhua Pu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University, 210029 Nanjing, People's Republic of China
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Gleicher N, Weghofer A, Barad DH. Defining ovarian reserve to better understand ovarian aging. Reprod Biol Endocrinol 2011; 9:23. [PMID: 21299886 PMCID: PMC3042920 DOI: 10.1186/1477-7827-9-23] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 02/07/2011] [Indexed: 11/10/2022] Open
Abstract
Though a widely utilized term and clinical concept, ovarian reserve (OR) has been only inadequately defined. Based on Medline and PubMed searches we here define OR in its various components, review genetic control of OR, with special emphasis on the FMR1 gene, and discuss whether diminished OR (DOR) is treatable. What is generally referred to as OR reflects only a small portion of total OR (TOR), a pool of growing (recruited) follicles (GFs) at different stages of maturation. Functional OR (FOR) depends on size of the follicle pool at menarche and the follicle recruitment rate. Both vary between individuals and, at least partially, are under genetic control. The FMR1 gene plays a role in defining FOR at all ages. Infertility treatments have in the past almost exclusively only centered on the last two weeks of folliculogenesis, the gonadotropin-sensitive phase. Expansions of treatments into earlier stages of maturation will offer opportunity to significantly improve ovarian stimulation protocols, especially in women with DOR. Dehydroepiandrosterone (DHEA) may represent a first such intervention. Data generated in DHEA-supplemented women, indeed, suggest a new ovarian aging concept, based on aging of ovarian environments and not, as currently is believed, aging oocytes.
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Affiliation(s)
- Norbert Gleicher
- Center for Human Reproduction - New York, New York, NY, USA
- Foundation for Reproductive Medicine, New York, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Andrea Weghofer
- Center for Human Reproduction - New York, New York, NY, USA
- Department of Obstetrics and Gynecology, University of Vienna School of Medicine, Vienna, Austria
| | - David H Barad
- Center for Human Reproduction - New York, New York, NY, USA
- Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Obstetrics Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
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