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Hochberg A, Dahan MH, Yarali H, Vuong LN, Esteves SC. Clinical factors associated with unexpected poor or suboptimal response in Poseidon criteria patients. Reprod Biomed Online 2024; 49:103852. [PMID: 38657290 DOI: 10.1016/j.rbmo.2024.103852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 04/26/2024]
Abstract
RESEARCH QUESTION What clinical factors are associated with 'unexpected' poor or suboptimal responses to IVF ovarian stimulation per POSEIDON's criteria, and which AMH and AFC threshold values distinguish this population? DESIGN Tri-centre retrospective cohort study (2015-2017) involving first-time IVF and ICSI cycles with conventional ovarian stimulation (≥150 IU/day of FSH). Eligibility criteria included sufficient ovarian reserve markers according to POSEIDON's classification (AMH ≥1.2 ng/ml; AFC ≥5). Ovarian response categories were poor (<4 oocytes), suboptimal (4-9 oocytes) and normal (≥9 oocytes). Primary outcomes included clinical factors associated with an unexpected poor or suboptimal response to conventional ovarian stimulation using logistic regression analyses, and the threshold values of AMH and AFC predicting increased risk of such responses using ROC curves. RESULTS A total of 7625 patients met the inclusion criteria: 204 (9.3%) were poor and 1998 (90.7%) were suboptimal responders. Logistic regression identified significant clinical predictors for a poor or suboptimal response, including AFC, AMH, total gonadotrophin dose, gonadotrophin type and trigger type (P ≤ 0.02). The ROC curves indicated that AMH 2.87 ng/ml (AUC 0.740) and AFC 12 (AUC 0.826) were the threshold values predicting a poor or suboptimal response; AMH 2.17 ng/ml (AUC 0.741) and AFC 9 (AUC 0.835) predicted a poor response; and AMH 2.97 ng/ml (AUC 0.722) and AFC 12 (AUC 0.801) predicted a suboptimal response. CONCLUSIONS The threshold values of AMH and AFC predicting 'unexpected' poor or suboptimal response were higher than expected. These findings have critical implications for tailoring IVF stimulation regimens and dosages.
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Affiliation(s)
- Alyssa Hochberg
- Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada.; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel..
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
| | - Hakan Yarali
- Anatolia IVF, Ankara, Turkey.; Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Lan N Vuong
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.; IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam.; HOPE Research Center, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
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Orvieto R, Kadmon AS, Morag N, Segev-Zahav A, Nahum R. Determining the optimal daily gonadotropin dose to maximize the oocyte yield in elective egg freezing cycles. Reprod Biol Endocrinol 2024; 22:64. [PMID: 38844947 PMCID: PMC11155010 DOI: 10.1186/s12958-024-01236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/10/2024] Open
Abstract
OBJECTIVE Ovarian stimulation (OS) with high daily gonadotropin doses are commonly offered to patients attempting social/elective egg freezing. However, the optimal daily gonadotropin dose that would allow a higher oocyte yield in the successive IVF cycle attempt was not settled and should be determined. PATIENTS AND METHODS Data from all women admitted to our IVF unit for social/EEF, who underwent two consecutive IVF cycle attempts, with only those who used in the first attempt a starting daily gonadotropin dose of 300IU were analyzed. Patients characteristics and OS variables were used in an attempt to build a logistic model, helping in determining the daily gonadotropin dose that should be offered to patient during their second EEF attempt, aiming to further increase their oocyte yield. RESULTS Three hundred and thirteen consecutive women undergoing two successive IVF cycle attempts were evaluated. Using logistic regression model, two equations were developed using individual patient-level data that determine the daily gonadotropin dose needed aiming to increase the oocyte yield in the successive cycle. (a): X=-0.514 + 2.87*A1 + 1.733*A2-0.194* (E2/1000) and (b): P = EXP(X) / [1 + EXP(X)]. CONCLUSIONS Using the aforementioned equations succeeded in determining the daily gonadotropin dose that might result in increasing oocyte yield, with an AUC of 0.85. Any additional oocyte retrieved to these EEF patients might get them closer to fulfil their desire to parenthood.
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel.
- Faculty of Medical and Health Science, Tel-Aviv University, Tel Aviv, Israel.
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Faculty of Medical and Health Science, Tel-Aviv University, Tel Aviv, Israel.
| | - Anouk Savir Kadmon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Arrow Program for Medical Education, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Nira Morag
- Faculty of Medical and Health Science, Tel-Aviv University, Tel Aviv, Israel
| | - Aliza Segev-Zahav
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Ravit Nahum
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medical and Health Science, Tel-Aviv University, Tel Aviv, Israel
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3
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Xu X, Wang X, Jiang Y, Sun H, Chen Y, Zhang C. Development and validation of a prediction model for unexpected poor ovarian response during IVF/ICSI. Front Endocrinol (Lausanne) 2024; 15:1340329. [PMID: 38505752 PMCID: PMC10949528 DOI: 10.3389/fendo.2024.1340329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/31/2024] [Indexed: 03/21/2024] Open
Abstract
Background Identifying poor ovarian response (POR) among patients with good ovarian reserve poses a significant challenge within reproductive medicine. Currently, there is a lack of published data on the potential risk factors that could predict the occurrence of unexpected POR. The objective of this study was to develop a predictive model to assess the individual probability of unexpected POR during in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatments. Methods The development of the nomogram involved a cohort of 10,404 patients with normal ovarian reserve [age, ≤40 years; antral follicle count (AFC), ≥5; and anti-Müllerian hormone (AMH), ≥1.2 ng/ml] from January 2019 to December 2022. Univariate regression analyses and least absolute shrinkage and selection operator regression analysis were employed to ascertain the characteristics associated with POR. Subsequently, the selected variables were utilized to construct the nomogram. Results The predictors included in our model were body mass index, basal follicle-stimulating hormone, AMH, AFC, homeostasis model assessment of insulin resistance (HOMA-IR), protocol, and initial dose of gonadotropin. The area under the receiver operating characteristic curve (AUC) was 0.753 [95% confidence interval (CI) = 0.7257-0.7735]. The AUC, along with the Hosmer-Lemeshow test (p = 0.167), demonstrated a satisfactory level of congruence and discrimination ability of the developed model. Conclusion The nomogram can anticipate the probability of unexpected POR in IVF/ICSI treatment, thereby assisting professionals in making appropriate clinical judgments and in helping patients to effectively manage expectations.
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Affiliation(s)
- Xiaohang Xu
- Reproductive Medical Center, People’s Hospital of Zhengzhou University, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xue Wang
- Reproductive Medical Center, People’s Hospital of Zhengzhou University, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yilin Jiang
- Reproductive Medical Center, People’s Hospital of Zhengzhou University, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Haoyue Sun
- Reproductive Medical Center, People’s Hospital of Zhengzhou University, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yuanhui Chen
- Reproductive Medical Center, People’s Hospital of Zhengzhou University, Zhengzhou, China
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Cuilian Zhang
- Reproductive Medical Center, Henan Provincial People’s Hospital, Zhengzhou, China
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Uncu G, Aslan K, Cakir C, Avci B, Kasapoglu I, Alviggi C. Do we overlook predictive factors in Poseidon 1 patients? A retrospective analysis co-evaluating antral follicle counts & diameters. J Ovarian Res 2024; 17:1. [PMID: 38169411 PMCID: PMC10759700 DOI: 10.1186/s13048-023-01323-x] [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: 10/11/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND An unexpected impaired ovarian response pertains to an insufficient reaction to controlled ovarian hyperstimulation. This deficient reaction is identified by a reduced count of mature follicles and retrieved oocytes during an IVF cycle, potentially diminishing the likelihood of a successful pregnancy. This research seeks to examine whether the characteristics of antral follicles can serve as predictive indicators for the unexpected impaired ovarian response to controlled ovarian stimulation (COS). METHODS This retrospective cohort study was conducted at a tertiary university hospital. The electronic database of the ART (assisted reproductive technologies) center was screened between the years 2012-2022. Infertile women under 35 years, with normal ovarian reserve [anti-Müllerian hormone (AMH) > 1.2 ng/ml, antral follicle count (AFC) > 5] who underwent their first controlled ovarian stimulation (COS) cycle were selected. Women with < 9 oocytes retrieved (group 1 of the Poseidon classification) constituted the group A, whereas those with ≥ 9 oocytes severed as control (normo-responders) one (group B). Demographic, anthropometric and hormonal variables together with COS parameters of the two groups were compared. RESULTS The number of patients with < 9 oocytes (group A) was 404, and those with ≥ 9 oocytes were 602 (group B). The mean age of the group A was significantly higher (30.1 + 2.9 vs. 29.4 + 2.9, p = 0.01). Group A displayed lower AMH and AFC [with interquartile ranges (IQR); AMH 1.6 ng/ml (1-2.6) vs. 3.5 ng/ml (2.2-5.4) p < 0.01, AFC 8 (6-12) vs. 12 (9-17), p < 0.01]. The number of small antral follicles (2-5 mm) of the group A was significantly lower [6 (4-8) vs. 8 (6-12) p < 0.01), while the larger follicles (5-10 mm) remained similar [3 (1-5) vs. 3(1-6) p = 0.3] between the groups. CONCLUSION The propensity of low ovarian reserve and higher age are the main risk factors for the impaired ovarian response. The proportion of the small antral follicles may be a predictive factor for ovarian response to prevent unexpected poor results.
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Affiliation(s)
- Gürkan Uncu
- Faculty of Medicine, Dept. of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey.
| | - Kiper Aslan
- Faculty of Medicine, Dept. of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey
| | - Cihan Cakir
- Faculty of Medicine, Dept of Histology and Embryology, Bursa Uludag University, Bursa, Turkey
| | - Berrin Avci
- Faculty of Medicine, Dept of Histology and Embryology, Bursa Uludag University, Bursa, Turkey
| | - Isil Kasapoglu
- Faculty of Medicine, Dept. of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
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Suñol J, Castillo JC, Ortiz JA, Ten J, Fuentes A, Moliner B, Martínez M, Llácer J, Guerrero J, Pitas A, Bernabeu A, Bernabeu R. Conventional follicular-phase ovarian stimulation vs. luteal-phase stimulation in suboptimal responders: a randomized controlled trial. F S Rep 2023; 4:344-352. [PMID: 38204945 PMCID: PMC10774905 DOI: 10.1016/j.xfre.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 01/12/2024] Open
Abstract
Objective To compare the oocyte yield between follicular-phase stimulation (FPS) and luteal-phase stimulation (LPS) in suboptimal responders. Design Prospective, randomized, crossover clinical trial. Patients Forty-one patients with infertility according to the POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) criteria (1b/2b). Interventions Crossover study on 2 assigned ovarian stimulations that started randomly in the follicular or luteal phase. The in vitro fertilization cycles were not consecutive but separated in time (45 days to 6 months). The random crossover design ensured that all subjects received the first treatment by chance. Main Outcome Measures The primary objective was the number of cumulus-oocyte complexes retrieved in each cycle. Secondary objectives were number of metaphase II and fertilized oocytes, additional doses of recombinant follicle-stimulating hormone, and the duration of ovarian stimulation (days). Results The mean number of cumulus-oocyte complexes retrieved was similar between the FPS and LPS groups (7.5 ± 4.6 vs. 7.0 ± 4.1; 95% confidence interval [CI] for the mean, 5.8-8.7 vs. 5.6-8.3, respectively; the difference between means, -0.5; 95% CI, -1.8 to +1.5). Similarly, the mean number of metaphase II oocytes retrieved was not different between the FPS and LPS groups (5.4 ± 3.6 vs. 5.2 ± 2.8; 95% CI for the mean, 4.2-6.5 vs. 4.3-6.1, respectively; the difference between means, -0.2; 95% CI, -1.2 to +1.1). Moreover, the secondary objectives were similar between FPS and LPS groups. Conclusions In this study, the oocyte yield in LPS did not increase in suboptimal responders compared with that in FPS when the onset of LPS was separated in time from FPS. Clinical Trial Registration Number NCT039393990 https://beta.clinicaltrials.gov/study/NCT03939390.
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Affiliation(s)
- Jorge Suñol
- Bernabeu Institute, Reproductive Medicine, Palma de Mallorca, Spain
| | | | | | - Jorge Ten
- Bernabeu Institute, Reproductive Medicine, Alicante, Spain
| | - Ana Fuentes
- Bernabeu Institute, Reproductive Medicine, Elche, Spain
| | - Belén Moliner
- Bernabeu Institute, Reproductive Medicine, Alicante, Spain
| | - María Martínez
- Bernabeu Institute, Reproductive Medicine, Cartagena, Spain
| | - Joaquín Llácer
- Bernabeu Institute, Reproductive Medicine, Alicante, Spain
| | - Jaime Guerrero
- Bernabeu Institute, Reproductive Medicine, Alicante, Spain
| | - Ana Pitas
- Bernabeu Institute, Reproductive Medicine, Alicante, Spain
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Orvieto R, Aizer A, Saar-Ryss B, Marom-Haham L, Noach-Hirsh M, Haas J, Nahum R. Elective egg freezing patients may benefit from increasing the maximal daily gonadotropin dose above 300IU. Reprod Biol Endocrinol 2022; 20:171. [PMID: 36536380 PMCID: PMC9762009 DOI: 10.1186/s12958-022-01049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Nowadays, patients attempting social/elective egg freezing has spread globally. Ovarian stimulation (OS) with high daily gonatotropin doses, are commonly offered to this group of patients, aiming to achieve the maximal oocytes cohort with minimum IVF cycle attempts. We aim to assess the IVF-ET outcome, and specifically the oocyte yield, of patients undergoing two successive IVF cycle attempts for elective egg freezing (EEF), and whether changing the daily gonadotropin dose in the second IVF cycle attempt, affect the outcome. PATIENTS AND METHODS All women admitted to our IVF unit for social/EEF, who underwent 2 consecutive IVF cycle attempts, with only those who used in the first attempt a starting daily gonadotropin dose of 300 IU were included. Ovarian stimulation characteristics, duration of OS, number of retrieved oocytes, number of mature oocytes were assessed and compared between the 1st and the 2nd IVF cycle attempts, and between the different daily gonadotropin doses and the oocyte yields in the 2nd cycle attempt (increase, decrease or no change). MAIN OUTCOME MEASURES Oocytes and mature oocytes yield in the 2nd as compared to the 1st IVF cycle attempt. RESULTS A reduced oocyte yield in the 2nd cycle attempt was observed in those who highly responded in the 1st attempt, regardless the daily dose in the 2nd cycle attempt (whether it was increased, no change and decreased). Moreover, the proportion of patients with same or more oocytes in the 2nd IVF cycle attempt was significantly lower in patients with high peak E2 levels, compared to those with peak E2 levels < 9175 pmol/L. Among patients with high peak E2 (> 9175 pmol/L), those who achieved a lower oocytes yield in the 2nd IVF cycle attempt had lower basal Day-3 FSH/LH ratio (1.5 + 0.5 vs 1.8 + 0.8, p < 0.03) and higher oocyte (range: 7-28, median:10; vs range: 2-15, median:7) and mature oocytes yields. With a cut-off of 9 oocytes, 78.8% of those with > 9 oocytes and 61.8% of those with < 9 oocytes will achieve lower/higher oocytes yield in the 2nd IVF cycle attempt, respectively. CONCLUSIONS Ovarian stimulation with high daily gonatotropin doses (300 IU) should be offered to patients attempting social/EEF. Moreover, in their 2nd IVF cycle attempt, those with high peak E2 (> 9175 pmol/L) in the 1st attempt, and basal Day-3 FSH/LH ratio < 1.5 and/or more than 9 oocytes retrieved, should receive same OS protocol with no change in the daily gonadotropin dose.
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Affiliation(s)
- Raoul Orvieto
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- grid.12136.370000 0004 1937 0546The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Adva Aizer
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Bozhena Saar-Ryss
- grid.414259.f0000 0004 0458 6520Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon, and Ben Gurion University School of Medicine, Beer Sheva, Israel
| | - Lilach Marom-Haham
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Meirav Noach-Hirsh
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jigal Haas
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ravit Nahum
- grid.413795.d0000 0001 2107 2845Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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Esteves SC, Yarali H, Vuong LN, Conforti A, Humaidan P, Alviggi C. POSEIDON groups and their distinct reproductive outcomes: Effectiveness and cost-effectiveness insights from real-world data research. Best Pract Res Clin Obstet Gynaecol 2022; 85:159-187. [PMID: 35725717 DOI: 10.1016/j.bpobgyn.2022.05.003] [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: 01/31/2022] [Revised: 05/04/2022] [Accepted: 05/09/2022] [Indexed: 12/14/2022]
Abstract
The Patient-Oriented Strategies Encompassing IndividualizeDOocyte Number (POSEIDON) criteria identify and classify the so-called 'low-prognosis' patients undergoing assisted reproductive technology (ART). Recent large-scale studies using real-world data (RWD) have shown that patients classified under this system have distinct reproductive outcomes. Moreover, these studies also confirm that POSEIDON patients are commonly found in fertility centers. RWD has substantiated the validity of the POSEIDON biomarkers' thresholds (antral follicle count [AFC] and/or anti-Müllerian hormone [AMH]) for patient classification. Lastly, a predictive model has been developed and validated to estimate the POSEIDON metric of success (i.e., number of oocytes needed to achieve at least one euploid blastocyst). Although more evidence is needed in this area, current insights from RWD research indicate that infertility patients can be counseled and managed more effectively under the POSEIDON scope, with potential gains for all parties involved.
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Affiliation(s)
- Sandro C Esteves
- Andrology and Human Reproduction Clinic, Av. Dr. Heitor Penteado, 1464, Campinas, Brazil; Faculty of Health, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Hakan Yarali
- Anatolia IVF and Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Lan N Vuong
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam; IVFMD, My Duc Hospital, Ho Chi Minh City, Viet Nam; HOPE Research Center, My Duc Hospital, Ho Chi Minh City, Viet Nam
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | - Peter Humaidan
- Faculty of Health, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Fertility Clinic Skive, Skive Regional Hospital, Skive & Aarhus University, Aarhus, Denmark
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
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Boudry L, Racca A, Tournaye H, Blockeel C. Type and dose of gonadotropins in poor ovarian responders: does it matter? Ther Adv Reprod Health 2021; 15:26334941211024203. [PMID: 34263173 PMCID: PMC8243085 DOI: 10.1177/26334941211024203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/07/2021] [Indexed: 12/15/2022] Open
Abstract
Infertile patients with a diminished ovarian reserve, also referred to as
poor ovarian responders, constitute a substantial and increasing
population of patients undergoing in vitro
fertilization. The management of patients with poor ovarian response
is still a controversial issue. Almost a century has passed since the
introduction of the first gonadotropin. A broad collection of urinary
and recombinant gonadotropins, including biosimilars, is commercially
available now. Despite great advances in assisted reproductive
technology, there remains uncertainty about the optimal treatment
regimen for ovarian stimulation in poor ovarian responders. Although
oocyte donation is the most successful and ultimate remedy for poor
ovarian responders, most patients persist on using their own oocytes
in several attempts, to achieve the desired pregnancy. The aim of this
review is twofold: first, to provide an overview of the commercially
available gonadotropins and summarize the available evidence
supporting the use of one or another for ovarian stimulation in poor
ovarian responders, and second, to address the controversies on the
dosage of gonadotropins for this specific in vitro
fertilization population.
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Affiliation(s)
- Liese Boudry
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, 1090, Brussels, Belgium
| | - Annalisa Racca
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Herman Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium; Department of Obstetrics, Gynecology, Perinatology and Reproduction, Institute of Professional Education, Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium; Department of Obstetrics and Gynaecology, University of Zagreb, Zagreb, Croatia
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Kasapoglu I, Orhan A, Aslan K, Sen E, Kaya A, Avcı B, Uncu G. Are all antral follicles the same? Size of antral follicles as a key predictor for response to controlled ovarian stimulation. J OBSTET GYNAECOL 2021; 42:461-466. [PMID: 34155958 DOI: 10.1080/01443615.2021.1910640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The aim of this study was to evaluate whether antral follicle size has any value with respect to antral follicle count (AFC) in predicting ovarian response to controlled ovarian stimulation. Patients who were considered to be normal responders based on their ovarian reserve markers were consecutively recruited. Total AFC was the number of 2-10 mm follicles in both ovaries. Antral follicles were separated into two subgroups according to the size: 2-5 mm and 6-10 mm follicles. Patients were divided into two main groups according to ovarian response to COS. Group 1 (suboptimal response, 4-9 oocytes retrieved, n = 61) and Group 2 (normal responders, ≥10 oocytes retrieved, n = 65). Demographic parameters were comparable between the groups. The number of 2-5 mm follicles was significantly lower in the suboptimal response group (5 [4:7] and 8 [6:10], respectively, p < .001). The ratio of 2-5 mm follicles to total antral follicles was also significantly lower in Group 1 (44.4% and 75%, respectively, p < .001). The ratio of small antral follicles was positively correlated with ovarian response (r = 0.587, p < .001). In conclusion, the ratio of small (2-5 mm) antral follicles could be a more specific predictive marker than AFC for ovarian response.IMPACT STATEMENTWhat is already known on this subject? Prediction of the ovarian response during ovarian stimulation is commonly based on antral follicle count and anti-mullerian hormone. The ovarian response may be inadequate even in patients with normal antral follicle count and anti-mullerian hormone.What do the results of this study add? A high ratio of small-size (2-5 mm) basal antral follicles is a predictive factor for higher ovarian response to ovarian hyperstimulation.What are the implications of these findings for clinical practice and/or further research? To obtain optimal ovarian response, the antral follicles should be evaluated initially in a more detailed and systematic way by taking their sizes into consideration in addition to their counts. Small antral follicle count rather than whole antral follicle count may be beneficial for optimising the ovarian response. Future studies may determine the cut off values of small antral follicle count for high/poor ovarian response.
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Affiliation(s)
- Isil Kasapoglu
- Department of Obstetrics and Gynecology, Bursa Uludag University School of Medicine, Bursa, Turkey
| | - Adnan Orhan
- Department of Obstetrics and Gynecology, Bursa Uludag University School of Medicine, Bursa, Turkey
| | - Kiper Aslan
- Department of Obstetrics and Gynecology, Bursa Uludag University School of Medicine, Bursa, Turkey
| | - Esra Sen
- Department of Histology and Embryology, Istanbul Aydin University, Istanbul, Turkey
| | - Aysenur Kaya
- Department of Obstetrics and Gynecology, Bursa Uludag University School of Medicine, Bursa, Turkey
| | - Berrin Avcı
- Department of Histology and Embryology, Bursa Uludag University School of Medicine, Bursa, Turkey
| | - Gurkan Uncu
- Department of Obstetrics and Gynecology, Bursa Uludag University School of Medicine, Bursa, Turkey
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10
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Esteves SC, Yarali H, Vuong LN, Carvalho JF, Özbek İY, Polat M, Le HL, Pham TD, Ho TM. Antral follicle count and anti-Müllerian hormone to classify low-prognosis women under the POSEIDON criteria: a classification agreement study of over 9000 patients. Hum Reprod 2021; 36:1530-1541. [PMID: 33822057 DOI: 10.1093/humrep/deab056] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the agreement between antral follicle count (AFC) and anti-Müllerian hormone (AMH) levels when used to patient classification according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria? SUMMARY ANSWER Our study indicates a strong agreement between the AFC and the AMH levels in classifying POSEIDON patients; thus, either can be used for this purpose, although one in four women will have discordant values when both biomarkers are used. WHAT IS KNOWN ALREADY According to the POSEIDON criteria, both AFC and AMH may be used to classify low-prognosis patients. Proposed AFC and AMH thresholds of 5 and 1.2 ng/ml, respectively, have their basis in published literature; however, no study has yet determined the reproducibility of patient classification in comparing one biomarker with the other, nor have their thresholds ever been validated within this patient population. STUDY DESIGN, SIZE, DURATION A population-based cohort study involving 9484 consecutive patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were infertile women between 22 and 46 years old in their first in vitro fertilization/intracytoplasmic sperm injection cycle of standard ovarian stimulation with exogenous gonadotropins whose baseline ovarian reserves had been assessed by both AFC and AMH. Details of pre- and post-treatment findings were input into a coded research file. Two indicators of interest were created to classify patients according to the POSEIDON criteria based upon AFC and AMH values. Patients who did not fit any of the four POSEIDON groups were classified as non-POSEIDON. AFC was determined in the early follicular phase using two-dimensional (2D) transvaginal ultrasonography, whereas AMH values were based on the modified Beckman Coulter generation II enzyme-linked immunosorbent assay. Agreement rates were computed between AFC and AMH to classify patients using Cohen's kappa statistics. Logistic regression analyzes were carried out to examine the association between ovarian markers and low (<4) and suboptimal (4-9) oocyte yield. MAIN RESULTS AND THE ROLE OF CHANCE The degree of agreement in classifying patients according to POSEIDON groups was strong overall (kappa = 0.802; 95% CI: 0.792-0.811). A total of 73.8% of individuals were classified under the same group using both biomarkers. The disagreement rates were ∼26% and did not diverge when AFC or AMH was used as the primary biomarker criterion. Significant regression equations were found between ovarian markers and oocyte yield (P < 0.0001). For low oocyte yield, the optimal AFC and AMH cutoff values were 5 and 1.27 ng/ml with sensitivities of 0.61 and 0.66, specificities of 0.81 and 0.72, and AUC receiver operating characteristics of 0.791 and 0.751, respectively. For suboptimal oocyte yield respective AFC and AMH cutoffs were 12 and 2.97 ng/ml with sensitivities of 0.74 and 0.69, specificities of 0.76 and 0.66 and AUCs of 0.81 and 0.80. LIMITATIONS, REASONS FOR CAUTION Our study relied on 2D transvaginal sonography to quantify the AFC and manual Gen II assay for AMH determination and classification of patients. AMH data must be interpreted in an assay-specific manner. Treatment protocols varied across centers potentially affecting patient classification. WIDER IMPLICATIONS OF THE FINDINGS Three of four patients will be classified the same using either AFC or AMH values. Both biomarkers provide acceptable and equivalent accuracy in predicting oocyte yield further supporting their use and proposed thresholds in daily clinical practice for patient classification according to the POSEIDON criteria. However, the sensitivity of POSEIDON thresholds in predicting low oocyte yield is low. Clinicians should adopt the biomarker that may best reflect their clinical setting. STUDY FUNDING/COMPETING INTEREST(S) Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. The remaining authors have nothing to disclose. TRIAL REGISTRATION NUMBER not applicable.
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Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
| | - Hakan Yarali
- Anatolia IVF, Ankara, Turkey.,Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Lan N Vuong
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam.,HOPE Research Center, My Duc Hospital, Ho Chi Minh City, Vietnam
| | | | | | | | - Ho L Le
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Toan D Pham
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Tuong M Ho
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
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11
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Ebid AHIM, Motaleb SMA, Mostafa MI, Soliman MMA. Novel nomogram-based integrated gonadotropin therapy individualization in in vitro fertilization/intracytoplasmic sperm injection: A modeling approach. Clin Exp Reprod Med 2021; 48:163-173. [PMID: 34024083 PMCID: PMC8176155 DOI: 10.5653/cerm.2020.03909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/10/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE This study aimed to characterize a validated model for predicting oocyte retrieval in controlled ovarian stimulation (COS) and to construct model-based nomograms for assistance in clinical decision-making regarding the gonadotropin protocol and dose. METHODS This observational, retrospective, cohort study included 636 women with primary unexplained infertility and a normal menstrual cycle who were attempting assisted reproductive therapy for the first time. The enrolled women were split into an index group (n=497) for model building and a validation group (n=139). The primary outcome was absolute oocyte count. The dose-response relationship was tested using modified Poisson, negative binomial, hybrid Poisson-Emax, and linear models. The validation group was similarly analyzed, and its results were compared to that of the index group. RESULTS The Poisson model with the log-link function demonstrated superior predictive performance and precision (Akaike information criterion, 2,704; λ=8.27; relative standard error (λ)=2.02%). The covariate analysis included women's age (p<0.001), antral follicle count (p<0.001), basal follicle-stimulating hormone level (p<0.001), gonadotropin dose (p=0.042), and protocol type (p=0.002 and p<0.001 for short and antagonist protocols, respectively). The estimates from 500 bootstrap samples were close to those of the original model. The validation group showed model assessment metrics comparable to the index model. Based on the fitted model, a static nomogram was built to improve visualization. In addition, a dynamic electronic tool was created for convenience of use. CONCLUSION Based on our validated model, nomograms were constructed to help clinicians individualize the stimulation protocol and gonadotropin doses in COS cycles.
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12
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Polyzos NP, Popovic-Todorovic B. SAY NO to mild ovarian stimulation for all poor responders: it is time to realize that not all poor responders are the same. Hum Reprod 2021; 35:1964-1971. [PMID: 32830232 DOI: 10.1093/humrep/deaa183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Over the last 25 years, a vast body of literature has been published evaluating different treatment modalities for the management of poor ovarian responders. Despite the evidence that maximizing ovarian response can improve the chances of live born babies in poor responders, there are still voices suggesting that all poor responders are the same, irrespective of their age and their actual ovarian reserve. This has resulted in the suggestion of adopting a mild ovarian stimulation approach for all poor responders, based on the results of several trials which failed to identity differences when comparing mild and more intense stimulation in predicted poor responders. The current article analyzes in detail these studies and discusses the shortcomings in terms of type of population included, outcomes and settings performed, which may actually be responsible for the belief that only mild stimulation should be used. In the era of individualization in medicine, it must be realized that there are subgroups of predicted poor responders who will benefit from an individual rather than 'one fits all' mild stimulation approach and thus we should provide the same standard of treatment for all our poor responder patients.
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Affiliation(s)
- N P Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
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13
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Esteves SC, Conforti A, Sunkara SK, Carbone L, Picarelli S, Vaiarelli A, Cimadomo D, Rienzi L, Ubaldi FM, Zullo F, Andersen CY, Orvieto R, Humaidan P, Alviggi C. Improving Reporting of Clinical Studies Using the POSEIDON Criteria: POSORT Guidelines. Front Endocrinol (Lausanne) 2021; 12:587051. [PMID: 33815269 PMCID: PMC8017440 DOI: 10.3389/fendo.2021.587051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 02/19/2021] [Indexed: 12/19/2022] Open
Abstract
The POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) criteria were developed to help clinicians identify and classify low-prognosis patients undergoing assisted reproductive technology (ART) and provide guidance for possible therapeutic strategies to overcome infertility. Since its introduction, the number of published studies using the POSEIDON criteria has increased steadily. However, a critical analysis of existing evidence indicates inconsistent and incomplete reporting of critical outcomes. Therefore, we developed guidelines to help researchers improve the quality of reporting in studies applying the POSEIDON criteria. We also discuss the advantages of using the POSEIDON criteria in ART clinical studies and elaborate on possible study designs and critical endpoints. Our ultimate goal is to advance the knowledge concerning the clinical use of the POSEIDON criteria to patients, clinicians, and the infertility community.
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Affiliation(s)
- Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, Brazil
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | - Sesh K. Sunkara
- Department of Women’s Health, Faculty of Life Sciences, King’s College London, London, United Kingdom
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | - Silvia Picarelli
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | | | | | - Laura Rienzi
- Center for Reproductive Medicine, GENERA, Rome, Italy
| | | | - Fulvio Zullo
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, Faculty of Health and Medical Sciences, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Peter Humaidan
- Faculty of Health, Aarhus University, Aarhus, Denmark
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
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14
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Christodoulaki A, Boel A, Tang M, De Roo C, Stoop D, Heindryckx B. Prospects of Germline Nuclear Transfer in Women With Diminished Ovarian Reserve. Front Endocrinol (Lausanne) 2021; 12:635370. [PMID: 33692760 PMCID: PMC7937897 DOI: 10.3389/fendo.2021.635370] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
Diminished ovarian reserve (DOR) is associated with a reduced quantity and quality of the retrieved oocytes, usually leading to poor reproductive outcomes which remain a great challenge for assisted reproduction technology (ART). Women with DOR often have to seek for oocyte donation, precluding genetically related offspring. Germline nuclear transfer (NT) is a novel technology in ART that involves the transfer of the nuclear genome from an affected oocyte/zygote of the patient to the cytoplast of an enucleated donor oocyte/zygote. Therefore, it offers opportunities for the generation of genetically related embryos. Currently, although NT is clinically applied only in women with serious mitochondrial DNA disorders, this technology has also been proposed to overcome certain forms of female infertility, such as advanced maternal age and embryo developmental arrest. In this review, we are proposing the NT technology as a future treatment option for DOR patients. Strikingly, the application of different NT strategies will result in an increase of the total number of available reconstituted embryos for DOR patients.
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Affiliation(s)
- Antonia Christodoulaki
- Ghent-Fertility and Stem cell Team (G-FaST), Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Annekatrien Boel
- Ghent-Fertility and Stem cell Team (G-FaST), Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Maoxing Tang
- Ghent-Fertility and Stem cell Team (G-FaST), Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
- Reproductive Medicine Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Chloë De Roo
- Ghent-Fertility and Stem cell Team (G-FaST), Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominic Stoop
- Ghent-Fertility and Stem cell Team (G-FaST), Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Björn Heindryckx
- Ghent-Fertility and Stem cell Team (G-FaST), Department for Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
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15
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Chinta P, Antonisamy B, Mangalaraj AM, Kunjummen AT, Kamath MS. POSEIDON classification and the proposed treatment options for groups 1 and 2: time to revisit? A retrospective analysis of 1425 ART cycles. Hum Reprod Open 2021; 2021:hoaa070. [PMID: 33614989 PMCID: PMC7882041 DOI: 10.1093/hropen/hoaa070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/20/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Do live birth outcomes differ when Patient-Oriented Strategy Encompassing IndividualizeD Oocyte Number (POSEIDON) stratified groups are compared with women with good prognosis (non-POSEIDON group) undergoing ART? SUMMARY ANSWER The current study showed no significant difference in the live birth rates (LBRs) per embryo transfer between POSEIDON groups 1 and 2 when compared with women in the non-POSEIDON group undergoing ART. WHAT IS KNOWN ALREADY Recently, there has been a lot of focus on the POSEIDON classification for low prognosis women undergoing ART and various management options have been advocated. For POSEIDON groups 1 and 2, low starting dose and gonadotrophin receptor polymorphism have been suggested as possible reasons for a hyporesponse, and increasing the starting gonadotrophin dose, the addition of recombinant LH and dual stimulation have been suggested as treatment options. Most of these treatment options are hypothetical in nature and need validation. STUDY DESIGN SIZE DURATION In the current cohort study, a total of 1425 cycles were analyzed retrospectively following a single cycle fresh embryo transfer. The study period was from January 2013 to June 2018. PARTICIPANTS/MATERIALS SETTING METHODS Women undergoing ART at a tertiary level infertility clinic were included. Clinical and treatment-related details were obtained from the hospital's electronic medical records. The ART outcomes in a non-POSEIDON group (women with an adequate ovarian reserve and/or optimal ovarian response i.e. >9 oocytes retrieved in the previous ART cycle) and a low prognosis group stratified by POSEIDON criteria were compared. We also examined the effectiveness of the modifications made in the current ART treatment protocols among women with an adequate ovarian reserve who had a history of poor/suboptimal response (POSEIDON 1 and 2). MAIN RESULTS AND THE ROLE OF CHANCE There was no statistically significant difference in the LBR per embryo transfer in POSEIDON group 1 (32/109, 29%) and group 2 (17/58, 29%) when compared with the non-POSEIDON group (340/1041, 33%) (adjusted odds ratio (aOR) 0.69; 95% CI 0.37-1.27 and aOR 0.93, 95% CI 0.43-1.97, respectively), while significantly lower LBR were observed in POSEIDON groups 3 (17/97, 17.5%) and 4 (12/120, 10%) (aOR 0.49; 95% CI 0.28-0.89 and aOR 0.38, 95% CI 0.19-0.74, respectively). The gonadotrophin dose alone was increased in one-quarter of the cycles and in another 27% the dose was increased along with the protocol change among POSEIDON group 1. In POSEIDON group 2, a change in the dose alone and in combination with protocol change was performed in 5 and 41% of cycles, respectively. LIMITATIONS REASONS FOR CAUTION A limitation of our study is the retrospective nature of the study with an inherent risk of unknown confounders influencing the outcomes. Other limitations are the lack of cumulative live birth data and the relatively small sample within POSEIDON group 2, which could lead to a type II error. WIDER IMPLICATIONS OF THE FINDINGS The current study showed no significant difference in the LBR between the POSEIDON groups 1 and 2 when compared with the non-POSEIDON group of women, while groups 3 and 4 had significantly lower LBR. The simple gonadotrophin/protocol changes in groups 1 and 2 resulted in LBRs comparable to women with good prognosis. These findings call for revisiting the proposed treatment strategies for POSEIDON groups 1 and 2. STUDY FUNDING/COMPETING INTERESTS No funding was obtained. There are no competing interests to declare.
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Affiliation(s)
- Parimala Chinta
- Department of Reproductive Medicine, Christian Medical College, Vellore, India
| | | | - Ann M Mangalaraj
- Department of Reproductive Medicine, Christian Medical College, Vellore, India
| | | | - Mohan S Kamath
- Department of Reproductive Medicine, Christian Medical College, Vellore, India
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16
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Drakopoulos P, Blockeel C, Makrigiannakis A, De Vos M, Tournaye H, Pluchino N. Personalized ovarian stimulation based on expected number of euploid embryos. Hum Reprod 2021; 36:261-262. [PMID: 33156909 DOI: 10.1093/humrep/deaa274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Obstetrics and Gynecology, University of Crete, Heraklion, Crete, Greece
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Obstetrics and Gynaecology, University of Zagreb, Zagreb, Croatia
| | | | - Michel De Vos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herman Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nicola Pluchino
- Department of Obstetrics and Gynecology, University Hospital of Geneva, Geneva, Switzerland
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17
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Esteves SC, Yarali H, Vuong LN, Carvalho JF, Özbek İY, Polat M, Le HL, Pham TD, Ho TM. Low Prognosis by the POSEIDON Criteria in Women Undergoing Assisted Reproductive Technology: A Multicenter and Multinational Prevalence Study of Over 13,000 Patients. Front Endocrinol (Lausanne) 2021; 12:630550. [PMID: 33790862 PMCID: PMC8006427 DOI: 10.3389/fendo.2021.630550] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To estimate the prevalence of low-prognosis patients according to the POSEIDON criteria using real-world data. DESIGN Multicenter population-based cohort study. SETTINGS Fertility clinics in Brazil, Turkey, and Vietnam. PATIENTS Infertile women undergoing assisted reproductive technology using standard ovarian stimulation with exogenous gonadotropins. INTERVENTIONS None. MAIN OUTCOME MEASURES Per-period prevalence rates of POSEIDON patients (overall, stratified by POSEIDON groups and by study center) and the effect of covariates on the probability that a patient be classified as "POSEIDON". RESULTS A total of 13,146 patients were included. POSEIDON patients represented 43.0% (95% confidence interval [CI] 42.0-43.7) of the studied population, and the prevalence rates varied across study centers (range: 38.6-55.7%). The overall prevalence rates by POSEIDON groups were 44.2% (group 1; 95% CI 42.6-45.9), 36.1% (group 2; 95% CI 34.6-37.7), 5.2% (group 3; 95% CI 4.5-6.0), and 14.4% (group 4; 95% CI: 13.3-15.6). In general, POSEIDON patients were older, had a higher body mass index (BMI), lower ovarian reserve markers, and a higher frequency of female factor as the primary treatment indication than non-POSEIDON patients. The former required larger doses of gonadotropin for ovarian stimulation, despite achieving a 2.5 times lower number of retrieved oocytes than non-POSEIDON patients. Logistic regression analyses revealed that female age, BMI, ovarian reserve, and a female infertility factor were relevant predictors of the POSEIDON condition. CONCLUSIONS The estimated prevalence of POSEIDON patients in the general population undergoing ART is significant. These patients differ in clinical characteristics compared with non-POSEIDON patients. The POSEIDON condition is associated with female age, ovarian reserve, BMI, and female infertility. Efforts in terms of diagnosis, counseling, and treatment are needed to reduce the prevalence of low-prognosis patients.
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Affiliation(s)
- Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- *Correspondence: Sandro C. Esteves, ; orcid.org/0000-0002-1313-9680
| | - Hakan Yarali
- Anatolia IVF, Ankara, Turkey
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Lan N. Vuong
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
- HOPE Research Center, My Duc Hospital, Ho Chi Minh City, Vietnam
| | | | | | | | - Ho L. Le
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Toan D. Pham
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Tuong M. Ho
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
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18
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Wang B, Liu W, Liu Y, Zhang W, Ren C, Guan Y. What Does Unexpected Suboptimal Response During Ovarian Stimulation Suggest, an Overlooked Group? Front Endocrinol (Lausanne) 2021; 12:795254. [PMID: 35002973 PMCID: PMC8727549 DOI: 10.3389/fendo.2021.795254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Unlike poor ovarian response, despite being predicted to be normal responders based on their ovarian reserve markers, many patients respond suboptimally to ovarian stimulation. Although we can improve the number of retrieved oocytes by increasing the recombinant FSH dose and adding LH, the effect of suboptimal ovarian response on cumulative live birth rate (CLBR) and offspring safety is unclear. This study focuses on the unexpected suboptimal response during ovulation induction, and its causes and outcomes are analysed for the first time with a large amount of data used to compare the cumulative pregnancy rate (CPR), CLBR and offspring safety of patients with one complete ART cycle with all embryos used. Our analysis included 5218 patients treated with the GnRH agonist long protocol for their first IVF-embryo transfer (ET) cycles. Patients were divided into two groups according to whether the ovarian response was suboptimal. Propensity score matching (PSM) was utilized for sampling at up to 1:1 nearest-neighbour matching with caliper 0.05 to balance the baseline and improve comparability between the groups. Results showed that age, BMI and basal FSH were independent risk factors for slow response; the initial dosage of Gn, FSH on the first day of Gn, and LH on the first day of Gn were independent protective factors for suboptimal response. Suboptimal responders were also more likely to have irregular menses. Regarding the clinical pregnancy rate of the fresh IVF/ICSI-ET cycles, the adjusted results of the two groups were not significantly different. There was no difference in the CPR, CLBR, or offspring safety-related data, such as gestational age, preterm delivery rate, birthweight, birth-height and Apgar Scores between the two groups after PSM. Age-related changes in the number of oocytes retrieved from women aged 20-40 years old between the two groups were different, indicating that suboptimal response in elderly patients suggests a decline in ovarian reserve. Although we can now improve the outcomes of suboptimal responders, it increases the cost to the patients and the time to live birth, which requires further attention.
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Affiliation(s)
- Bijun Wang
- Reproductive Medicine Center, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Road, Zhengzhou, China
| | - Wenxia Liu
- Reproductive Medicine Center, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Road, Zhengzhou, China
| | - Yi Liu
- Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Wen Zhang
- Reproductive Medicine Center, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Road, Zhengzhou, China
| | - Chenchen Ren
- Gynecology and Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Chenchen Ren, ; Yichun Guan,
| | - Yichun Guan
- Reproductive Medicine Center, The Third Affiliated Hospital of Zhengzhou University, Kangfuqian Road, Zhengzhou, China
- *Correspondence: Chenchen Ren, ; Yichun Guan,
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19
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Papathanasiou A, Mawal N. The risk of poor ovarian response during repeat IVF. Reprod Biomed Online 2020; 42:742-747. [PMID: 33487556 DOI: 10.1016/j.rbmo.2020.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/27/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
RESEARCH QUESTION What are the incidence and risk factors for poor ovarian response (POR) during repeat IVF? DESIGN A retrospective analysis of 1224 consecutive patients who underwent at least two IVF stimulations in a single centre over a 6-year period. Risk factors from the initial treatment were assessed for association with POR during repeat IVF using logistic regression analysis. A simple, practical predictive model was constructed and evaluated for accuracy and calibration, based on the factors that demonstrated significant association with subsequent POR. POR during repeat IVF was defined as ≤3 retrieved oocytes or cancellation before retrieval following recruitment of ≤3 mature follicles. RESULTS The risk of POR during repeat IVF was approximately 11.5%. A higher POR risk during repeat IVF is associated with a reduced oocyte yield during the initial treatment (≤3 oocytes: odds ratio [OR] 14, 95% confidence interval [CI] 6.42-30.24; 4-9 oocytes: OR 4.13, 95% CI 2.00-8.54; 10-15 oocytes: OR 1) and low ovarian reserve (anti-Müllerian hormone [AMH] <5.4 pmol/l: OR 3.54, 95% CI 2.24-5.59; AMH 5.4-25 pmol/l: OR 1). Women with low ovarian reserve who experience POR during the initial IVF have the highest risk of suffering POR again during repeat IVF (57% within 1 year). Other groups, such as women with unexpected POR or expected poor responders with suboptimal ovarian response during the initial IVF, are also at risk of exhibiting POR during a subsequent treatment (28% within 1 year). CONCLUSIONS As there is a clear association between POR and lower live birth rates, this practical model may help manage patients' expectations during repeat IVF treatment.
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Affiliation(s)
| | - Nausheen Mawal
- Bourn Hall Clinic, High Street, Bourn Cambridge CB23 2TN, UK
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20
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Drakopoulos P, Bardhi E, Boudry L, Vaiarelli A, Makrigiannakis A, Esteves SC, Tournaye H, Blockeel C. Update on the management of poor ovarian response in IVF: the shift from Bologna criteria to the Poseidon concept. Ther Adv Reprod Health 2020; 14:2633494120941480. [PMID: 32844159 PMCID: PMC7416136 DOI: 10.1177/2633494120941480] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/18/2020] [Indexed: 12/18/2022] Open
Abstract
Despite the considerate progress to which assisted reproduction technology (ART)
has been subject since 1978, some issues remain unresolved. Notably, the
clinical management of patients with a poor ovarian response is still a
challenge in everyday practice, frustrating to both the patient and the
fertility expert. Poor ovarian responders (PORs) embody 9–24% of patients
undergoing ovarian stimulation, meaning that up to one in four patients conceals
a poor reproductive prognosis. The last decade has witnessed the attempts of the
medical community to standardize diagnosis of POR with the developing of the
Bologna Criteria and the subsequent evolution of the low prognosis patient
elaborated in the POSEIDON classification. The aim of this article is to
summarize all evidence concerning etiology and management of poor ovarian
response, including the most recent advances and future prospects in this
regard.
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Affiliation(s)
- Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium. Department of Obstetrics and Gynecology, Medical School, University of Crete, Heraklion, Greece
| | - Erlisa Bardhi
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Liese Boudry
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Alberto Vaiarelli
- G.EN.E.R.A., Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | - Antonis Makrigiannakis
- Department of Obstetrics and Gynecology, Medical School, University of Crete, Heraklion, Greece
| | - Sandro C Esteves
- ANDROFERT-Andrology and Human Reproduction Clinic, Brazil, São Paulo
| | - Herman Tournaye
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Christophe Blockeel
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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21
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Leijdekkers JA, Torrance HL, Broekmans FJM. Reply: The low responder according to the POSEIDON criteria: is the prognosis really poor? Hum Reprod 2020; 34:2557-2558. [PMID: 31756245 PMCID: PMC6936720 DOI: 10.1093/humrep/dez195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jori A Leijdekkers
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Helen L Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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22
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Esteves SC, Roque M, Sunkara SK, Conforti A, Ubaldi FM, Humaidan P, Alviggi C. Oocyte quantity, as well as oocyte quality, plays a significant role for the cumulative live birth rate of a POSEIDON criteria patient. Hum Reprod 2020; 34:2555-2557. [PMID: 31756248 DOI: 10.1093/humrep/dez181] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, São Paulo, Brazil.,Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | - Sesh K Sunkara
- Department of Women's Health, Faculty of Life Sciences, King's College London, UK
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | | | - Peter Humaidan
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - Carlo Alviggi
- Department of Women's Health, Faculty of Life Sciences, King's College London, UK
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23
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Abu-Musa A, Haahr T, Humaidan P. Novel Physiology and Definition of Poor Ovarian Response; Clinical Recommendations. Int J Mol Sci 2020; 21:ijms21062110. [PMID: 32204404 PMCID: PMC7139860 DOI: 10.3390/ijms21062110] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/24/2020] [Accepted: 03/06/2020] [Indexed: 12/11/2022] Open
Abstract
Poor ovarian response (POR) to controlled ovarian stimulation (OS) presents a major challenge in assisted reproduction. The Bologna criteria represented the first serious attempt to set clear criteria for the definition of POR. However, the Bologna criteria were questioned because of the persistent heterogeneity among POR patients and the inability to provide management strategies. Based on these facts, a more recent classification, the POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) classification, was developed to provide a homogeneous and refined definition of POR that significantly reduces the heterogeneity of the Bologna criteria definition of POR and helps in the clinical handling and counseling of patients. In this review, we discuss the impact of the POSEIDON classification on the clinical management of patients with POR.
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Affiliation(s)
- Antoine Abu-Musa
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
- Correspondence:
| | - Thor Haahr
- The Fertility Clinic Skive Regional Hospital, 7800 Skive, Denmark; (T.H.); (P.H.)
- Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark
| | - Peter Humaidan
- The Fertility Clinic Skive Regional Hospital, 7800 Skive, Denmark; (T.H.); (P.H.)
- Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark
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24
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Fischer R, Baukloh V. Commentary: Management Strategies for POSEIDON Groups 3 and 4. Front Endocrinol (Lausanne) 2020; 11:34. [PMID: 32117060 PMCID: PMC7011089 DOI: 10.3389/fendo.2020.00034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022] Open
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25
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Fischer R, Baukloh V. Commentary: A Novel Predictive Model to Estimate the Number of Mature Oocytes Required for Obtaining at Least One Euploid Blastocyst for Transfer in Couples Undergoing in vitro Fertilization/Intracytoplasmic Sperm Injection: The ART Calculator. Front Endocrinol (Lausanne) 2020; 11:618. [PMID: 32982992 PMCID: PMC7492587 DOI: 10.3389/fendo.2020.00618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
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26
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Esteves SC, Carvalho JF, Bento FC, Santos J. A Novel Predictive Model to Estimate the Number of Mature Oocytes Required for Obtaining at Least One Euploid Blastocyst for Transfer in Couples Undergoing in vitro Fertilization/Intracytoplasmic Sperm Injection: The ART Calculator. Front Endocrinol (Lausanne) 2019; 10:99. [PMID: 30873117 PMCID: PMC6403136 DOI: 10.3389/fendo.2019.00099] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
The POSEIDON group (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) has introduced "the ability to retrieve the number of oocytes needed to achieve at least one euploid embryo for transfer" as an intermediate marker of successful outcome in IVF/ICSI cycles. This study aimed to develop a novel calculator to predict the POSEIDON marker. We analyzed clinical and embryonic data of infertile couples who underwent IVF/ICSI with the intention to have trophectoderm biopsy for preimplantation genetic testing for aneuploidy. We used the negative binomial distribution to model the number of euploid blastocysts and the adaptive LASSO (Least Absolute Shrinkage and Selection Operator) method for variable selection. The fitted model selected female age, sperm source used for ICSI, and the number of mature (metaphase II) oocytes as predictors (p < 0.0001). Female age was the most important factor for predicting the probability of a blastocyst being euploid given each mature oocyte (loglikelihood of age [adjusted for sperm source]: 30.9; df = 2; p < 0.0001). The final predictive model was developed using logistic regression analysis, and internally validated by the holdout method. The predictive ability of the model was assessed by the ROC curve, which resulted in an area under the curve of 0.716. Using the final model and mathematical equations, we calculated the individualized probability of blastocyst euploidy per mature retrieved oocyte and the minimum number of mature oocytes required to obtain ≥1 euploid blastocyst-with their 95% confidence interval [CI]-for different probabilities of success. The estimated predicted probabilities of a mature oocyte turn into a euploid blastocyst decreased progressively with female age and was negatively modulated overall by use of testicular sperm across age (p < 0.001). A calculator was developed to make two types of predictions automatically, one using pretreatment information to estimate the minimum number of mature oocytes to achieve ≥1 euploid blastocyst, and another based on the actual number of mature oocytes collected/accumulated to estimate the chances of having a euploid blastocyst using that oocyte cohort for IVF/ICSI. The new ART calculator may assist in clinical counseling and individualized treatment planning regarding the number of oocytes required for at least one euploid blastocyst in IVF/ICSI procedures.
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Affiliation(s)
- Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
| | | | - Fabiola C. Bento
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
| | - Jonathan Santos
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- CliniSYS, Tecnologia e Sistemas de Saúde, Campinas, Brazil
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27
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Esteves SC, Yarali H, Ubaldi FM, Carvalho JF, Bento FC, Vaiarelli A, Cimadomo D, Özbek İY, Polat M, Bozdag G, Rienzi L, Alviggi C. Validation of ART Calculator for Predicting the Number of Metaphase II Oocytes Required for Obtaining at Least One Euploid Blastocyst for Transfer in Couples Undergoing in vitro Fertilization/Intracytoplasmic Sperm Injection. Front Endocrinol (Lausanne) 2019; 10:917. [PMID: 32038484 PMCID: PMC6992582 DOI: 10.3389/fendo.2019.00917] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
This multicenter study evaluated the reliability of the recently published ART calculator for predicting the minimum number of metaphase II (MII) oocytes (MIImin) to obtain at least one euploid blastocyst in patients undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). We used clinical and embryonic retrospective data of 1,464 consecutive infertile couples who underwent IVF/ICSI with the intention to have preimplantation genetic testing for aneuploidy. The validation procedure followed a stepwise approach. Firstly, we assessed the distribution of euploid blastocysts per patient and found that it followed a negative binomial distribution. Secondly, we used generalized linear models and applied the Lasso procedure-including MII oocytes to adjust the data-to select the factors predicting the response variable "euploid blastocyst." Third, a logistic regression model-fit to the binomial response euploid (yes/no) for each MII oocyte-was built using the relevant factors. The observational unit was the "woman" whereas the response was the pair (m, n), where n is the number of retrieved MII oocytes and m the corresponding number of euploid blastocysts. The model was internally validated by randomly splitting the data into training and validation sets. The R-squares (~0.25) and the area under the ROC curve (~0.70) did not differ between the training and validation datasets. Fourth, mathematical equations and the calculated probabilities generated by the validation model were used to determine the MIImin required for obtaining at least one euploid blastocyst according to different success probabilities. Lastly, we compared the fittings generated by the validation model and the ART calculator and assessed the predictive value of the latter using the validation dataset. The fittings were sufficiently close for both the estimated probabilities of blastocyst euploid per MII oocyte (r = 0.91) and MIImin (r = 0.88). The ART calculator positive predictive values, i.e., the frequency of patients with at least one euploid blastocyst among those who achieved the estimated MIImin, were 84.8%, 87.5%, and 90.0% for 70%, 80%, and 90% predicted probabilities of success, respectively. The ART calculator effectively predicts the MIImin needed to achieve at least one euploid blastocyst in individual patients undergoing IVF/ICSI. The prediction tool might be used for counseling and planning IVF/ICSI treatments.
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Affiliation(s)
- Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Faculty of Health, Aarhus University, Aarhus, Denmark
- *Correspondence: Sandro C. Esteves
| | | | | | | | - Fabiola C. Bento
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
| | | | | | | | | | | | - Laura Rienzi
- G.E.N.E.R.A., Center for Reproductive Medicine, Rome, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
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28
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Humaidan P, La Marca A, Alviggi C, Esteves SC, Haahr T. Future Perspectives of POSEIDON Stratification for Clinical Practice and Research. Front Endocrinol (Lausanne) 2019; 10:439. [PMID: 31354620 PMCID: PMC6637950 DOI: 10.3389/fendo.2019.00439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/18/2019] [Indexed: 12/19/2022] Open
Abstract
A total of 50% of patients undergoing IVF treatment has previously been estimated to fulfill the POSEIDON classification criteria; importantly, although the reproductive prognosis differs between patients, POSEIDON patients share the same characteristic of a low ovarian response to exogenous gonadotropin stimulation-independent of age. POSEIDON patients require focused attention as regards ovarian stimulation in order to increase the chances of having at least one euploid blastocyst for transfer-the success criterion for stimulation set forth by the POSEIDON Group. The key to success seems to be individualization in all steps of treatment. In this perspective article we discuss the future impact of the POSEIDON stratification for daily clinical practice as well as for research.
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Affiliation(s)
- Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- *Correspondence: Peter Humaidan
| | - Antonio La Marca
- Department of Obstetrics, Gynecology and Pediatric Sciences, Institute of Obstetrics and Gynecology, University of Modena, Modena, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science, and Odontostomatology, University of Naples, Federico II, Naples, Italy
- Istituto per l'Endocrinologia e l'Oncologia Sperimentale, Consiglio Nazionale Delle Ricerche, Naples, Italy
| | - Sandro C. Esteves
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery, University of Campinas, Campinas, Brazil
| | - Thor Haahr
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
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29
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Polyzos NP, Drakopoulos P. Management Strategies for POSEIDON's Group 1. Front Endocrinol (Lausanne) 2019; 10:679. [PMID: 31632353 PMCID: PMC6779707 DOI: 10.3389/fendo.2019.00679] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 09/18/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Nikolaos P. Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- *Correspondence: Nikolaos P. Polyzos ;
| | - Panagiotis Drakopoulos
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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30
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Conforti A, Esteves SC, Cimadomo D, Vaiarelli A, Di Rella F, Ubaldi FM, Zullo F, De Placido G, Alviggi C. Management of Women With an Unexpected Low Ovarian Response to Gonadotropin. Front Endocrinol (Lausanne) 2019; 10:387. [PMID: 31316461 PMCID: PMC6610322 DOI: 10.3389/fendo.2019.00387] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/29/2019] [Indexed: 12/04/2022] Open
Abstract
POSEIDON groups 1 and 2 patients respond poorly (<4 oocytes retrieved) or sub-optimally (4-9 oocytes retrieved) to gonadotropin stimulation despite the presence of adequate ovarian parameters, which negatively affect their cumulative chances of delivering a baby using Assisted Reproductive Technology. A polygenic trait involving gonadotropins and/or their receptors seems to be the primary pathophysiology mechanism explaining this phenomenon. The clinical management is mainly focused on maximizing oocyte yield as to increase the likelihood of having at least one euploid embryo for transfer. Indices such as FORT (follicle output rate) and FOI (follicle-to-oocyte index) may be used to determine if the ovarian reserve was properly explored during a previous ovarian stimulation. Testing for the presence of common polymorphisms affecting gonadotropins and/or their receptors can also be considered to identify patients at risk of hypo-response. An individualized estimation of the minimum number of oocytes needed to obtain at least one euploid embryo can assist counseling and treatment planning. Among currently existing pharmacological interventions, use of recombinant FSH in preference over urinary gonadotropin preparations, FSH dosage increase, and use of rLH supplementation may be considered -alone or combined- for optimally managing POSEIDON's groups 1 and 2 patients. However, given the recent introduction of the POSEIDON criteria, there is still a lack of studies examining the role of interventions specifically to patients classified as groups 1 and 2, thus making it an area for open research.
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Affiliation(s)
- Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
- *Correspondence: Alessandro Conforti
| | - Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery, University of Campinas, Campinas, Brazil
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Danilo Cimadomo
- GENERA, Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | - Alberto Vaiarelli
- GENERA, Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | - Francesca Di Rella
- Medical Oncology, Department of Senology, National Cancer Institute, IRCCS Fondazione G. Pascale, Naples, Italy
| | | | - Fulvio Zullo
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
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31
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Li Y, Li X, Yang X, Cai S, Lu G, Lin G, Humaidan P, Gong F. Cumulative Live Birth Rates in Low Prognosis Patients According to the POSEIDON Criteria: An Analysis of 26,697 Cycles of in vitro Fertilization/Intracytoplasmic Sperm Injection. Front Endocrinol (Lausanne) 2019; 10:642. [PMID: 31608011 PMCID: PMC6761219 DOI: 10.3389/fendo.2019.00642] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/04/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: The POSEIDON criteria are used to stratify patients with low prognosis after assisted reproductive technology (ART) treatment. Since its introduction, there has been no large study about the prognosis of the POSEIDON population. We used the POSEIDON criteria in Chinese women who underwent repeated ART treatment and analyzed the association between POSEIDON criteria and the cumulative live-birth rate (CLBR). Methods: This was a retrospective cohort study of 62,749 women (97,388 cycles) who underwent ART treatment at the Reproductive and Genetic Hospital of CITIC-XIANGYA between January 2014 and June 2017. Among them, 19,781 (31.52%) women fulfilled the POSEIDON criteria, including 26,697 cycles. The optimal and conservative CLBRs within a complete IVF/ICSI treatment cycle were calculated, as well as the CLBRs following repeated ovarian stimulation cycles. Results: In POSEIDON groups 1, 2, 3, and 4, the optimal and conservative CLBRs of three complete consecutive in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles were 83.87 and 66.06%, 53.67 and 37.72%, 44.24 and 27.98%, and 14.20 and 9.68%, respectively. The POSEIDON stratification [group 2: odds ratio (OR) = 2.319, 95% confidence interval (CI): 2.131-2.525, P < 0.001; group 3: OR = 1.356, 95% CI: 1.005-1.828, P = 0.046; group 4: OR = 3.525, 95% CI: 2.774-4.479, P < 0.001; all vs. group 1] and ovarian stimulation protocol [gonadotropin-releasing hormone (GnRH) antagonist protocol: OR = 1.856, 95% CI: 1.640-2.100, P < 0.001; other protocols: OR = 1.651, 95% CI: 1.155-2.361, P = 0.006; both vs. long GnRH agonist protocol] were associated with live birth in the first stimulation cycle. For the second stimulation cycle, the POSEIDON stratification (except POSEIDON group 3) and ovarian stimulation protocol were associated with live birth. A change in ovarian stimulation protocol was not associated with an improvement in the live birth rate. Conclusions: More than 30% of women who undergo IVF/ICSI treatment may be classified as low prognosis. Different reproductive outcomes were observed among the four POSEIDON groups. The most optimal outcomes after three successive cycles of IVF/ICSI treatment were observed in groups 1, 2, and 3.
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Affiliation(s)
- Yuan Li
- Institute of Reproduction and Stem Cell Engineering, Basic Medicine College, Central South University, Changsha, China
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
| | - Xiaofeng Li
- Institute of Reproduction and Stem Cell Engineering, Basic Medicine College, Central South University, Changsha, China
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
| | - Xiaoyi Yang
- Institute of Reproduction and Stem Cell Engineering, Basic Medicine College, Central South University, Changsha, China
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
| | - Sufen Cai
- Institute of Reproduction and Stem Cell Engineering, Basic Medicine College, Central South University, Changsha, China
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
| | - Guangxiu Lu
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
| | - Ge Lin
- Institute of Reproduction and Stem Cell Engineering, Basic Medicine College, Central South University, Changsha, China
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
| | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Skive, Denmark
| | - Fei Gong
- Institute of Reproduction and Stem Cell Engineering, Basic Medicine College, Central South University, Changsha, China
- Reproductive and Genetic Hospital of Citic-Xiangya, Changsha, China
- Key Laboratory of Stem Cells and Reproductive Engineering, National Health and Family Planning Commission, Changsha, China
- *Correspondence: Fei Gong
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Drakopoulos P, Errázuriz J, Santos-Ribeiro S, Tournaye H, Vaiarelli A, Pluchino N, Blockeel C, Polyzos NP. Cumulative live birth rates in in-vitro fertilization. ACTA ACUST UNITED AC 2018; 71:207-210. [PMID: 30486636 DOI: 10.23736/s0026-4784.18.04347-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Traditionally, in-vitro fertilization (IVF) success rates have been reported in terms of live birth per fresh cycle or embryo transfer. However, reporting IVF outcomes using cumulative live birth rates (LBR), defined as the first live birth following the use of all fresh and frozen embryos derived from a single ovarian stimulation cycle appears to be a better measure of IVF treatment success. Although there is an initial increase in fresh LBR with the number of oocytes retrieved, LBR either reach a plateau or may even decline when more than 15-20 oocytes are harvested. On the other hand, when all fresh and frozen embryos are taken into account, cumulative LBR have a significant positive association with ovarian response. Cumulative LBR are a more suitable are more comprehensive when reporting success in an IVF program. Cumulative LBR increase with the number of oocytes retrieved, suggesting that ovarian stimulation may have a minimal or no detrimental effect on oocyte/embryo quality.
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Affiliation(s)
- Panagiotis Drakopoulos
- Center for Reproductive Medicine, Brussels University Hospital, Brussels, Belgium - .,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium -
| | - Joaquín Errázuriz
- Center for Reproductive Medicine, Brussels University Hospital, Brussels, Belgium.,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium.,Center for Reproductive Medicine, German Clinic, Santiago, Chile
| | - Samuel Santos-Ribeiro
- Center for Reproductive Medicine, Brussels University Hospital, Brussels, Belgium.,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium.,Department of Obstetrics, Gynecology and Reproductive Medicine, Santa Maria University Hospital, Lisbon, Portugal
| | - Herman Tournaye
- Center for Reproductive Medicine, Brussels University Hospital, Brussels, Belgium
| | - Alberto Vaiarelli
- Valle Giulia Clinic, Genera Centers for Reproductive Medicine, Rome, Italy
| | - Nicola Pluchino
- Division of Obstetrics and Gynecology, University Hospital of Geneva, Geneva, Switzerland
| | - Christophe Blockeel
- Center for Reproductive Medicine, Brussels University Hospital, Brussels, Belgium.,Department of Obstetrics and Gynecology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nikolaos P Polyzos
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Free University of Brussels, Brussels, Belgium.,Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
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