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Blazquez A, Falcó N, Caño E, Rodriguez F, Vassena R, Miguel-Escalada I, Popovic M, Rodriguez A. No association between LH levels and ovarian response in oocyte donors triggered with gonadotropin-releasing hormone agonist: A prospective study. Eur J Obstet Gynecol Reprod Biol 2024; 294:163-169. [PMID: 38266482 DOI: 10.1016/j.ejogrb.2024.01.022] [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: 08/28/2023] [Revised: 12/14/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Are circulating luteinizing hormone (LH) levels predictive of ovarian response in oocyte donors triggered with gonadotropin-releasing hormone (GnRH) agonists? STUDY DESIGN A prospective cohort study with 224 oocyte donation cycles between 2021 and 2022 at a single center, examined the relationship between circulating luteinizing hormone (LH) levels and ovarian response. Oocyte donors underwent GnRH antagonist downregulation followed by GnRH agonist trigger. LH, estradiol, and progesterone levels were measured on day one of stimulation, trigger-day and 12 h post-trigger. Oocyte retrieval and maturity rates were analyzed using univariate and multivariate analyses, and the correlation between post-trigger LH levels and outcomes was assessed by Pearson's correlation test. A significance level of p < 0.05 was used. RESULTS Mean age was 26 ± 4.3 years, mean body mass index (BMI, kg/m2) was 22.6 ± 3.2 and mean antral follicle count (AFC) was 21.7 ± 8.2. Post-trigger LH levels averaged 51.3 IU/L (SD 34.8), and oocyte retrieval rate and maturity rates were 112,7% (+/-48,1%) and 77,8% (+/- 17,2%), respectively. No significant differences were found in these outcomes for donors with post-trigger LH values below and above 15 IU/L (Mann Whitney's p > 0.05). However, exploratory analyses revealed that post-trigger LH values < 22 IU/L and basal LH levels < 4 IU/L were associated with significantly lower oocyte retrieval rate (90 % vs 110 %, p = 0.019 and 100 % vs 110 %, p = 0.019, respectively). CONCLUSIONS This study, a first in exclusively focusing on oocyte donors, did not support the previously reported LH value of 15 IU/L as predictive of suboptimal ovarian response. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT05109403.
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Affiliation(s)
| | - Noelia Falcó
- Clínica EUGIN - Eugin Group, Barcelona 08006, Spain
| | - Elena Caño
- Clínica EUGIN - Eugin Group, Barcelona 08006, Spain
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Ip PNP, Mak JSM, Law TSM, Ng K, Chung JPW. A reappraisal of ovarian stimulation strategies used in assisted reproductive technology. HUM FERTIL 2023; 26:824-844. [PMID: 37980170 DOI: 10.1080/14647273.2023.2261627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 11/20/2023]
Abstract
Ovarian stimulation is a fundamental step in assisted reproductive technology (ART) with the intention of inducing ovarian follicle development prior to timed intercourse or intra-uterine insemination and facilitating the retrieval of multiple oocytes during a single in vitro fertilization (IVF) cycle. The basis of ovarian stimulation includes the administration of exogenous gonadotropins, with or without pre-treatment with oral hormonal therapy. Gonadotropin-releasing hormone agonist or antagonist is given in addition to the gonadotropins to prevent a premature rise of endogenous luteinizing hormone that would in turn lead to premature ovulation. With the advancement in technology, various stimulation protocols have been devised to cater for different patient needs. However, ovarian hyperstimulation syndrome and its serious complications may occur following ovarian stimulation. It is also evident that suboptimal ovarian stimulation strategies may have a negative impact on oogenesis, embryo quality, endometrial receptivity, and reproductive outcomes over recent years. This review describes the various forms of pre-treatment for ovarian stimulation and stimulation protocols, and aims to provide clinicians with the latest available evidence.
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Affiliation(s)
- Patricia N P Ip
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jennifer S M Mak
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tracy S M Law
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Karen Ng
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jacqueline P W Chung
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
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Nichols JH, Ali M, Anetor JI, Chen LS, Chen Y, Collins S, Das S, Devaraj S, Fu L, Karon BS, Kary H, Nerenz RD, Rai AJ, Shajani-Yi Z, Thakur V, Wang S, Yu HYE, Zamora LE. AACC Guidance Document on the Use of Point-of-Care Testing in Fertility and Reproduction. J Appl Lab Med 2022; 7:1202-1236. [DOI: 10.1093/jalm/jfac042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 05/11/2022] [Indexed: 11/14/2022]
Abstract
Abstract
Background
The AACC Academy revised the reproductive testing section of the Laboratory Medicine Practice Guidelines: Evidence-Based Practice for Point-of-Care Testing (POCT) published in 2007.
Methods
A panel of Academy members with expertise in POCT and laboratory medicine was formed to develop guidance for the use of POCT in reproductive health, specifically ovulation, pregnancy, premature rupture of membranes (PROM), and high-risk deliveries. The committee was supplemented with clinicians having Emergency Medicine and Obstetrics/Gynecology training.
Results
Key recommendations include the following. First, urine luteinizing hormone (LH) tests are accurate and reliable predictors of ovulation. Studies have shown that the use of ovulation predicting kits may improve the likelihood of conception among healthy fertile women seeking pregnancy. Urinary LH point-of-care testing demonstrates a comparable performance among other ovulation monitoring methods for timing intrauterine insemination and confirming sufficient ovulation induction before oocyte retrieval during in vitro fertilization. Second, pregnancy POCT should be considered in clinical situations where rapid diagnosis of pregnancy is needed for treatment decisions, and laboratory analysis cannot meet the required turnaround time. Third, PROM testing using commercial kits alone is not recommended without clinical signs of rupture of membranes, such as leakage of amniotic fluid from the cervical opening. Finally, fetal scalp lactate is used more than fetal scalp pH for fetal acidosis due to higher success rate and low volume of sample required.
Conclusions
This revision of the AACC Academy POCT guidelines provides recommendations for best practice use of POCT in fertility and reproduction.
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Affiliation(s)
| | | | | | | | - Yu Chen
- Dr. Everett Chalmers Regional Hospital, Horizon Health Network, Dalhousie University, and Memorial University , Fredericton, NB , Canada
| | - Sean Collins
- Vanderbilt University Medical Center , Nashville, TN , USA
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System , Nashville, TN , USA
| | - Saswati Das
- Dr. Ram Manohar Lohia Hospital, Atal Bihari Vajpayee Institute of Medical Sciences , New Delhi , India
| | - Sridevi Devaraj
- Texas Children’s Hospital and Baylor College of Medicine , Houston, TX , USA
| | - Lei Fu
- Sunnybrook Health Sciences Center , Toronto, ON , Canada
| | | | - Heba Kary
- King Fahd Armed Forces Hospital , Jeddah , Saudi Arabia
| | | | - Alex J Rai
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital , New York, NY , USA
| | - Zahra Shajani-Yi
- Laboratory Corporation of America (LabCorp) , San Diego, CA, USA
| | - Vinita Thakur
- Eastern Health Authority, Health Science Center and Memorial University , St. John’s, NL , Canada
| | - Sihe Wang
- Akron Children’s Hospital , Akron, OH , USA
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Yanagimachi R. Mysteries and unsolved problems of mammalian fertilization and related topics. Biol Reprod 2022; 106:644-675. [PMID: 35292804 PMCID: PMC9040664 DOI: 10.1093/biolre/ioac037] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Mammalian fertilization is a fascinating process that leads to the formation of a new individual. Eggs and sperm are complex cells that must meet at the appropriate time and position within the female reproductive tract for successful fertilization. I have been studying various aspects of mammalian fertilization over 60 years. In this review, I discuss many different aspects of mammalian fertilization, some of my laboratory's contribution to the field, and discuss enigmas and mysteries that remain to be solved.
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Affiliation(s)
- Ryuzo Yanagimachi
- Institute for Biogenesis Research, University of Hawaii Medical School, Honolulu, Hawaii, USA
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Ganer Herman H, Horowitz E, Mizrachi Y, Farhi J, Raziel A, Weissman A. Prediction, assessment, and management of suboptimal GnRH agonist trigger: a systematic review. J Assist Reprod Genet 2022; 39:291-303. [PMID: 35306603 PMCID: PMC8956771 DOI: 10.1007/s10815-021-02359-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This systematic review aimed to identify baseline patient demographic and controlled ovarian stimulation characteristics associated with a suboptimal response to GnRHa triggering, and available options for prevention and management of suboptimal response. METHODS PubMed, Google Scholar, Medline, and the Cochrane Library were searched for keywords related to GnRHa triggering, and peer-reviewed articles from January 2000 to September 2021 included. RESULTS Thirty-seven studies were included in the review. A suboptimal response to GnRHa triggering was more likely following long-term or recent oral contraceptive use and with a low or high body mass index. Low basal serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol serum levels were correlated with suboptimal oocyte yield, as was a low serum LH level on the day of triggering. A prolonged stimulation period and increased gonadotropin requirements were correlated with suboptimal response to triggering. Post-trigger LH < 15 IU/L best correlated with an increased risk for empty follicle syndrome and a lower oocyte retrieval rate. Retriggering with hCG may be considered in patients with suboptimal response according to post-trigger LH, as in cases of failed aspiration. CONCLUSION Pre-treatment assessment of patient characteristics, with pre- and post-triggering assessment of clinical and endocrine cycle characteristics, may identify cases at risk for suboptimal response to GnRHa triggering and optimize its utilization.
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Affiliation(s)
- Hadas Ganer Herman
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Horowitz
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Mizrachi
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Farhi
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arieh Raziel
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Weissman
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Liest S, Riishede Christiansen I, Prætorius L, Bogstad J, Freiesleben NLC, Pinborg A, Løssl K. HCG Trigger After Failed GnRH Agonist Trigger Resulted in Two Consecutive Live Births: A Case Report. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:764299. [PMID: 36303957 PMCID: PMC9580704 DOI: 10.3389/frph.2021.764299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Failed gonadotropin-releasing hormone (GnRH) agonist trigger with no oocyte retrieved during aspiration of several follicles is a rare but recurrent situation that can be rescued by the termination of the aspiration procedure, retriggering by human chorion gonadotropin (hCG), and repeated oocyte pickup 36 h later. Failed GnRH agonist trigger is frustrating and unsatisfactory, and fertility doctors must be aware of possible hCG retriggering and retained opportunity for successful cycle outcome.Objective: In this case report, we present a woman who experienced failed GnRH agonist trigger and rescue hCG retrigger followed by two consecutive live births after frozen-thawed single blastocyst transfers.Methods: A case report.Results: Two healthy children were born in 2018 and 2020, respectively as a result of controlled ovarian stimulation for IVF, failed GnRH agonist trigger followed by hCG re-trigger, and successful retrieval of 25 oocytes.Conclusion: Retriggering with hCG after failed GnRH agonist trigger can result in consecutive live births, and such knowledge can prevent cycle cancellation and patient discouragement. Knowledge on retriggering with hCG and consecutive live births after failed GnRH agonist trigger can prevent cycle cancellation and patient discouragement.
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Affiliation(s)
- Sara Liest
- Department of Obstetrics and Gynecology, North Zealand Hospital, Hillerød, Denmark
- *Correspondence: Sara Liest
| | - Iben Riishede Christiansen
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lisbeth Prætorius
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jeanette Bogstad
- The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nina la Cour Freiesleben
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anja Pinborg
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kristine Løssl
- The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Kristine Løssl
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Orvieto R, Nahum R, Frei J, Zandman O, Frenkel Y, Haas J. GnRH-Agonist Ovulation Trigger in Patients Undergoing Controlled Ovarian Hyperstimulation for IVF with Stop GnRH-Agonist Combined with Multidose GnRH-Antagonist Protocol. Gynecol Obstet Invest 2021; 86:427-431. [PMID: 34537779 DOI: 10.1159/000517177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to characterize those patients undergoing the stop gonadotropin-releasing hormone (GnRH)-agonist combined with multidose GnRH-antagonist protocol, with suboptimal response to GnRH-agonist trigger in in vitro fertilization (IVF) cycles. DESIGN This is a cohort study. SETTING The study was conducted in a university hospital. PATIENTS All consecutive women admitted to our IVF unit from February 2020 through November 2020 who reached the ovum pick-up stage were reviewed. INTERVENTIONS Triggering final oocyte maturation by GnRH-ag alone (GnRH-ag trigger group), or combined with hCG (dual trigger group), in patients undergoing the stop GnRH-agonist combined with multidose GnRH-antagonist protocol was performed. MAIN OUTCOME MEASURE The main outcome measure was LH level 12 h after the trigger. RESULTS Five out of the 32 patients (15.6%) demonstrated suboptimal response as reflected by LH levels <15 IU/L 12 h after GnRH-agonist trigger. Moreover, while no differences were observed in oocyte recovery rate, maturity, or embryo quality between the different study groups (GnRH-ag trigger and dual trigger groups), those achieving a suboptimal response to the GnRH-agonist trigger (post-trigger LH <15 mIU/mL) demonstrated significantly higher number of follicles and peak estradiol levels at the day of trigger, compared to those with optimal response (post-trigger LH >15 mIU/mL). CONCLUSIONS The stop GnRH-agonist combined with GnRH-antagonist protocol enables the substitution of hCG with GnRH-ag for final oocyte maturation. However, caution should be taken in high responders, where the dual trigger with small doses of hCG (1,000-1,500 IU) should be considered, aiming to avoid suboptimal response (post-trigger LH levels <15 IU/L).
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ravit Nahum
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Judith Frei
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Orit Zandman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Yulia Frenkel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Suboptimal response to GnRH agonist trigger: causes and practical management. Curr Opin Obstet Gynecol 2021; 33:213-217. [PMID: 33896918 DOI: 10.1097/gco.0000000000000701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW GnRH agonist products are used extensively worldwide to trigger ovulation and final oocyte maturation in in vitro fertilization cycles. The purpose of this article is to outline possible causes for a suboptimal response to the GnRH agonist trigger. RECENT FINDINGS Risk factors for such a suboptimal response include prolonged hormonal contraceptive use, previous GnRHa-induced pituitary downregulation, a hypogonadotropic/hypogonadal condition, patient error, environmental conditions that may damage the GnRHa product used, GnRH and luteinizing hormone (LH) receptors polymorphisms, low baseline LH and low endogenous serum LH levels on trigger day as well as low BMI. The induction of an adequate LH surge can be ascertained by an LH urine test 12 h post trigger. SUMMARY In most cases, GnRHa trigger elicits effective LH+follicle stimulating hormone surges, resulting in mature, fertilizable oocytes. Clinical awareness to conditions that may predispose to a suboptimal response to the GnRHa trigger may prevent failed oocyte retrial.
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Cumulative live-birth, perinatal and obstetric outcomes for POSEIDON groups after IVF/ICSI cycles: a single-center retrospective study. Sci Rep 2020; 10:11822. [PMID: 32678263 PMCID: PMC7366673 DOI: 10.1038/s41598-020-68896-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/30/2020] [Indexed: 11/08/2022] Open
Abstract
Recently, perinatal outcomes and cumulative live birth rate (CLBR) have widely been utilized to assess the fertility outcomes and safety of assisted reproductive technology (ART), but more robust research is needed to address the success rates of live-healthy births resulting from this procedure, particularly for patients with low prognosis. This study aims to assess and comparative perinatal outcomes and CLBR per cycle of in vitro fertilization/Intracytoplasmic sperm injection (IVF/ICSI) between four groups of low prognosis characterized by POSEIDON criteria. A retrospective assessment was done among infertile women with a low prognosis undergoing IVF/ICSI at a reproductive center in China. Data were collected between January 2011 and December 2015 with a follow-up of at least two years, and censoring was defined by three-cycle completion, discontinuation, or having a live birth. Participants were grouped into 4 groups according to the POSEIDON classification (POSEIDON1, POSEIDON2, POSEIDON3, and POSEIDON4). The main outcomes were perinatal and obstetric outcomes with CLBR per cycle after IVF/ICSI procedure. And IVF/ICSI-technique outcomes as a secondary outcome. Statistical analyses were performed by SPSS, and a p value of < 0.05 was considered significant. A total of 461 eligible participants underwent a total of 825 IVF/ICSI cycles. POSEIDON1 had the best perinatal outcomes in terms of live births (≥ 28w) (54.8%). POSEIDON4 had a higher risk for perinatal and obstetric complications with abortion rate (9.8%); LBW (11.7%), PTD (23.5%), PROM (11.7%), and gestational diabetes (17.6%). POSEIDON2 had a high rate for malpresentation (14.2%), and cesarean delivery(57.2%), while POSEIDON3 was much associated with the occurrences of placenta previa (9.3%) compared to other groups (p value = 0.001). After adjusting odds ratio by age and BMI, POSEIDON4 had the least odds for biochemical pregnancy (p value = 0.019); and the least odds for clinical pregnancy (p value = 0.001) of the four groups. CLBR per cycle was better in POSEIDON1 and increased with an increasing number of cycles in all groups during the three cycles. Conservative CLBR after three complete cycles were 77.27%, 42.52%, 51.4% and 22.34%, while optimistic CLBR were 79.01%, 51.19%, 58.59% and 34.46% in POSEIDON1 to POSEIDON4, respectively. Younger women with low prognosis and normal ovarian reserve have a higher probability for live births and better perinatal outcomes compared with older women with poor or normal ovarian reserve. Besides, young women with low prognosis, despite ovarian reserve status, can increase their probability of conception and get relatively higher CLBR by undergoing multiple cycles of IVF/ICSI. Age is therefore considered as a critical parameter in predicting the perinatal outcome and CLBR.
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