Poor responders to controlled ovarian hyperstimulation forin vitrofertilisation (IVF)

Early or late response in poor responders: does it make a difference in cycle outcome?

Ovarian response to stimulation mainly determines the length of stimulation. However, there is no clarity in the literature regarding the optimal duration required to achieve oocyte maturity in patients with the poor ovarian response (POR) defined by Bologna criteria. Therefore, a total of 267 cycles that fulfilled the inclusion criteria were selected retrospectively. Group A constitute of patients with a stimulation period < 9 d (n = 70); and group B included patients with a stimulation period ≥ 9 d (n = 133). The results showed that antral follicle count (5.72 ± 1.82 vs. 5.10 ± 1.78, p = 0.023), serum oestradiol level on hCG day (1286.88 ± 778.18 pg/mL vs. 820.14 ± 479.04 pg/mL, p = 0.001), and total gonadotropin dose used (2949.53 ± 727.92 IU vs 2020.94 ± 415.17 IU, p = 0.0001) were higher in group B when compared to group A. Although the number of total (5.47 ± 3.32 vs 3.86 ± 2.15, p = 0.0001) and mature oocytes retrieved (4.34 ± 2.88 vs 2.84 ± 1.67, p = 0.0001) were higher in group B, no significant difference was observed in the pregnancy rates between groups (25.6 vs 15.7%, p > 0.05). In conclusion, no deleterious effect of a shorter duration of stimulation on cycle outcome was seen in patients with POR.

The Exploration of Poor Ovarian Response-Related Risk Factors: A Potential Role of Growth Differentiation Factor 8 in Predicting Ovarian Response in IVF-ET Patient

Controlled ovarian hyperstimulation (COH) is the most common therapeutic protocol to obtain a considerable number of oocytes in IVF-ET cycles. To date, the risk factors affecting COH outcomes remain elusive. Growth differentiation factor 8 (GDF-8), a member of transforming growth factor β (TGF-β) superfamily, has been long discerned as a crucial growth factor in folliculogenesis, and the aberrant expression of GDF-8 is closely correlated with the reproductive diseases. However, less is known about the level of GDF-8 in IVF-ET patients with different ovarian response. In the present study, the potential risk factors correlated with ovarian response were explored using logistic regression analysis methods. Meanwhile, the expression changes of GDF-8 and its responsible cellular receptors in various ovarian response patients were determined. Our results showed that several factors were intensely related to poor ovarian response (POR), including aging, obesity, endometriosis, surgery history, and IVF treatment, while irregular menstrual cycles and PCOS contribute to hyperovarian response (HOR). Furthermore, POR patients exhibited a decrease in numbers of MII oocytes and available embryos, thereby manifesting a lower clinical pregnancy rate. The levels of GDF-8, ALK5, and ACVR2B in POR patients were higher compared with those in control groups, whereas the expression level of ACVR2A decreased in poor ovarian response patients. In addition, clinical correlation analysis results showed that the concentration of GDF-8 was negatively correlated with LH and estradiol concentration and antral follicle count. Collectively, our observations provide a novel insight of ovarian response-associated risk factors, highlighting the potential role of GDF-8 levels in ovarian response during COH process.

The stimulation protocol in poor responder IVF; a minimal or high-dose stimulation? - A meta-analysis

Background To determine whether a minimal stimulation (MS) or high-dose stimulation (HDS) protocol is a better option for patients classified as poor ovarian responders (POR) in terms of reproductive and pregnancy outcomes. Materials and methods A database search for evaluation of the study outcome by using meta-analysis method was carried out. The primary outcome was the clinical pregnancy (CP) rate for each of two groups, namely, the MS and HDS groups. The secondary outcomes were the gonadotropin dose used, duration of stimulation, cancellation rate, number of oocytes retrieved, number of fertilized oocytes, number of embryos transferred and live birth rates. Results Across five databases, 4670 potential studies for further screening were selected. But ultimately only six studies, three RCTs and three retrospective or case control studies were selected that meet the Bologna criteria for POR. In all there were 624 cycles. Our meta-analysis indicated that the CP rates, cycle cancellation rates, durations of stimulation, numbers of oocytes fertilized and numbers of embryos transferred were not statistically significant. Clearly, the number of oocytes retrieved in the MS group was significantly lower than in the HDS group, while the HDS group consumed significantly higher doses of gonadotropins than the MS group. The live birth rates were significantly higher in the MS group than in the HDS group. Conclusion MS should be the first-line protocol for managing POR because the live birth rate is significantly higher, even with fewer oocytes retrieved.

Low dosing of gonadotropins in in vitro fertilization cycles for women with poor ovarian reserve: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of low doses of gonadotropins and gonadotropins combined with oral compounds compared with high doses of gonadotropins in ovarian stimulation regimens in terms of ongoing pregnancy per fresh IVF attempt in women with poor ovarian reserve undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment.

DESIGN

A systematic review and meta-analysis of randomized controlled studies that evaluate the effectiveness of low dosing of gonadotropins alone or combined with oral compounds compared with high doses of gonadotropins in women with poor ovarian reserve undergoing IVF/ICSI treatment.

SETTING

Not applicable.

PATIENT(S)

Subfertile women with poor ovarian reserve undergoing IVF/ICSI treatment.

INTERVENTION(S)

We searched the PubMed, EMBASE, Web of Science, the Cochrane Library, and the Clinical Trials Registry using medical subject headings and free text terms up to June 2016, without language or year restrictions. We included randomized controlled studies (RCTs) enrolling subfertile women with poor ovarian reserve undergoing IVF/ICSI treatment and comparing low doses of gonadotropins and gonadotropins combined with oral compounds versus high doses of gonadotropins. We assessed the risk of bias using the criteria recommended by the Cochrane Collaboration. We pooled the results by meta-analysis using the fixed and random effects model.

MAIN OUTCOMES MEASURE(S)

The primary outcome was ongoing pregnancy rate (PR) per woman randomized.

RESULT(S)

We retrieved 787 records. Fourteen RCTs (N = 2,104 women) were included in the analysis. Five studies (N = 717 women) compared low doses of gonadotropins versus high doses of gonadotropins. There was no evidence of a difference in ongoing PR (2 RCTs: risk rate 0.98, 95% confidence interval 0.62-1.57, I² = 0). Nine studies (N = 1,387 women) compared ovarian stimulation using gonadotropins combined with the oral compounds letrozole (n = 6) or clomiphene citrate (CC) (n = 3) versus high doses of gonadotropins. There was no evidence of a difference in ongoing PR (3 RCTs: risk rate 0.90, 95% confidence interval 0.63-1.27, I² = 0).

CONCLUSION(S)

We found no evidence of a difference in pregnancy outcomes between low doses of gonadotropins and gonadotropins combined with oral compounds compared with high doses of gonadotropins in ovarian stimulation regimens. Whether low doses of gonadotropins or gonadotropins combined with oral compounds is to be preferred is unknown, as they have never been compared head to head. A health economic analysis to test the hypothesis that an ovarian stimulation with low dosing is more cost-effective than high doses of gonadotropins is needed.

PROSPERO REGISTRATION NUMBER

CRD42016041301.

Pregnancy prognosis in women with anti-Müllerian hormone below the tenth percentile

Although serum anti-Müllerian hormone (AMH) is considered a good predictor of ovarian response during in vitro fertilisation (IVF), pregnancies have been reported with low values, questioning its usefulness as a predictor of treatment outcome. A retrospective study was therefore carried out to assess the IVF treatment outcomes in women with AMH below the tenth percentile of the study population. In all, 134 women with AMH ≤ 3 pmol/L underwent 180 IVF cycles. The mean age at the time of treatment was 37 ± 5 years. Fifty-three (29.4%) cycles were abandoned because of poor response to gonadotrophins, 12 (6.7%) due to absence of eggs at oocyte retrieval and 18 (10%) due to fertilisation failure. Seven (3.8%) had a biochemical pregnancy, 4 (2.2%) had a missed miscarriage and 8 (4.4%) had a live birth. When stratified by age, women older than 42 years had less number of follicles (p < 0.05) and those older than 39 years had less oocytes (p < 0.01) compared to those 35 years and younger. Live births declined with increasing age, when age was assessed as a continuous variable (p = 0.023). Women with low AMH levels have a high probability of treatment cancellation, failure to proceed to embryo transfer and a low chance of achieving a viable pregnancy.