Can ovarian double-stimulation in the same menstrual cycle improve IVF outcomes?

GnRH agonist trigger in poor prognosis patients undergoing a multicycle approach through DuoStim or consecutive stimulations: a SWOT analysis

PURPOSE OF REVIEW

Identify the most recent and significant evidence regarding the ovulation trigger within the framework of a multicycle approach through DuoStim, providing valuable insights for improving treatment strategies in patients with a poor prognosis.

RECENT FINDINGS

The trigger method plays a pivotal role in optimizing in-vitro fertilization (IVF) stimulation, influencing oocyte retrieval and maturation rates, as well as follicle recruitment in consecutive ovarian stimulations such as double stimulation. Decision-making involves multiple factors and, while guidelines exist for conventional stimulation, specific recommendations for the multicycle approach are not well established.

SUMMARY

The different methods for inducing oocyte maturation underscore the need for personalization of IVF protocols. The GnRH agonist trigger induces rapid luteolysis and establishes favorable hormonal conditions that do not adversely affect the recruitment of consecutive follicular waves in the context of DuoStim. It serves as a valid alternative to hCG in freeze-all cycles. This strategy might enhance the safety and flexibility of ovarian stimulations with no impact on oocyte competence and IVF efficacy.

Investigating Ovulation Induction Outcomes in Patients with Decreased Ovarian Reserve Treated with Double Stimulation during The Follicular and Luteal Phases Compared to The Conventional Antagonist Cycle: A Randomized Clinical Trial

BACKGROUND

It is difficult to obtain healthy oocytes in poor ovarian responders with conventional treatment methods. Thus, the need to investigate new methods is essential. This study aims to investigate ovulation induction outcomes in patients with decreased ovarian reserve (DOR) in two groups treated with double stimulation (DuoStim) during the follicular and luteal phases in comparison with the antagonist cycle.

MATERIALS AND METHODS

This was a randomised clinical trial that enrolled the patients with reduced ovarian reserve. The patients referred for in vitro fertilization (IVF) at Molud Infertility Clinic, Ali Ebn Abitalib (AS) Hospital, Zahedan, Iran from 2020 to 2021. Participants were randomly divided into two groups, those who underwent treatment with DuoStim during the follicular and luteal phase (case group) and those who received the conventional antagonist cycle (control group).

RESULTS

The mean number of metaphase II (MII) eggs was 7.7 ± 3.1 in the case group and 6.1 ± 3.9 in the control group (P=0.063). The mean total number of retrieved eggs in the case group was 9.2 ± 3.7 and in the control group, it was 6.9 ± 4.4 (P=0.023). The mean number of embryos obtained in the case group was 6.5 ± 3.9; in the control group, it was 4.7 ± 2.8 (P=0.016).

CONCLUSION

The DuoStim method can effectively play a role in increasing the total number of retrieved eggs and embryos (registration number: IRCT20120817010617N8).

Luteal phase stimulation in double ovarian stimulation cycles is not affected by the follicle-stimulating hormone (FSH) receptor genotype: double ovarian stimulation is beneficial independently of the genotype at position 680 of the follicle-stimulating hormone receptor

OBJECTIVES

To determine whether follicle-stimulating hormone receptor (FSHR) genotype influences the outcome of ovarian stimulation treatment in luteal phase.

METHODS

A total of 299 patients were included in a retrospective study between July 2017 and December 2021. These patients carried out a double stimulation protocol and the variant Asn680Ser (rs6166; c.2039A>G) of FSH receptor was genotyped either as part of the pre-treatment fertility tests or for the current study. Patients undergoing a double stimulation treatment who could not be genotyped were excluded from this analysis.

RESULTS

The results obtained from ovarian stimulation in luteal phase were better than those obtained in conventional follicular phase. Statistically significant differences ( P  < 0.001) were found in the number of retrieved oocytes (5.47 vs. 4.18), retrieved MII (4.52 vs. 3.29) and fertilised oocytes (3.81 vs. 2.20). Furthermore, these differences remained regardless of the FSH receptor genotype for the 680 position in all groups ( P  < 0.05). In addition, stimulation in luteal phase lasts longer and requires more gonadotropins than in follicular phase. This is especially noteworthy in patients with Ser/Ser genotype, who required a slightly higher dose of gonadotropins compared to other genotypes in luteal phase, as previously observed in the follicular phase for this genotype. No significant differences in age, anti-Müllerian hormone levels, antral follicle count, BMI and type of trigger used in luteal phase were observed among groups of patients with different FSH receptor genotypes.

CONCLUSION

All patients undergoing IVF seem to benefit from luteal phase ovarian stimulation, regardless of their FSHR genotype.

Influence of the starting day of luteal phase stimulation on double stimulation cycles

Background

Double ovarian stimulation is one of the most used strategies in poor-prognosis patients. There is a high heterogeneity between the studies regarding the execution of this stimulation protocol. The aim of this study was to investigate whether the day on which luteal phase stimulation begins after the first oocyte retrieval affects ovarian response in DuoStim cycles.

Methods

This observational and retrospective study included 541 DuoStim cycles between January 2018 and December 2021 in a private fertility clinic. Patients were assigned to 4 groups according to the timing of the onset of luteal phase stimulation after oocyte retrieval (0-2^nd day, 3^rd day, 4^th day and 5^th-6^th day). The primary outcome was the number of oocytes retrieved in the luteal phase in each group.

Results

No differences were found between groups in the number of oocytes collected (5.12 ± 3.56 vs. 5.39 ± 3.74 vs. 5.61 ± 3.94 vs. 5.89 ± 3.92; p=0,6), MII or number of follicles. An increase in the duration of stimulation was found when stimulation started on the 4^th day (10.42 ± 2.31 vs. 10.68 ± 2.37 vs. 11.27 ± 2.40 vs. 10.65 ± 2.37 days, p=0,033). A lower number of fertilized oocytes was observed when stimulation began before the fourth day (3.36 ± 2.80 vs. 3.95 ± 2.53 vs. 4.03 ± 2.73 vs. 4.48 ± 3.11; p=0,036). The number of blastocysts was higher when the stimulation started 5-6 days after retrieval (1.82 ± 1.74 vs. 2.13 ± 1.61 vs. 2.33 ± 2.06 vs. 2.91 ± 2.39; p= 0,030).

Discussion

The number of oocytes retrieved does not differ depending on the day that stimulation begins. However, oocytes competence in terms of fertilized oocytes and blastulation, appears to be lower when the second stimulation starts before the fourth day after oocyte retrieval.

Twenty-first century oocyte cryopreservation—in vitro maturation of immature oocytes from ovarian tissue cryopreservation in cancer patients: A systematic review

Objectives:

Our review aimed to consolidate the latest update on the application of in vitro maturation among immature oocyte harvest in combination with ovarian tissue cryopreservation known as ovarian tissue oocyte–in vitro maturation.

Methods:

A thorough search for relevant studies was conducted via PubMed, Google Scholar, EMBASE, and clinical.gov databases up to December 2020. The primary outcome was the oocyte maturation rate, which measured the number of immature oocytes (geminal vesicle stage) that progressed to mature oocytes (meiosis II stage) following in vitro maturation. The secondary outcomes were the fertilization rate following intracytoplasmic sperm injection/in vitro fertilization of these oocytes for the embryo cryopreservation cohort. Our review included pre-pubertal girls and women with cancer who underwent ovarian tissue oocyte–in vitro maturation as fertility preservation.

Results:

The primary search identified 207 studies. Twelve manuscripts were selected for inclusion in our review following duplication assessment, title and abstract screening, and full-text evaluation tailored to our inclusion criteria. All the population belonged to a cancer group and underwent concurrent ovarian tissue oocyte–in vitro maturation. A total of 5724 immature oocytes were obtained following ovarian tissue cryopreservation. Approximately 33.84% of the immature oocytes successfully matured via in vitro maturation, which were cryopreserved as oocytes or fertilized as embryos and subsequently stored for future use.

Conclusion:

Our review proposed the potential application of ovarian tissue oocyte–in vitro maturation in increasing the number of mature oocytes. The acceptable improvement in oocyte maturation rate following in vitro maturation indicates that improving oocyte outcomes is an excellent cost-effective strategy for fertility preservation among women with cancer.

Double or dual stimulation in poor ovarian responders: where do we stand?

Recent advances in our recognition of two to three follicular waves of development in a single menstrual cycle has challenged the dogmatic approach of ovarian stimulation for in vitro fertilization starting in the early follicular phase. First shown in veterinary medicine and thereafter in women, luteal phase stimulation–derived oocytes are at least as competent as those retrieved following follicular phase stimulation. Poor ovarian responders still remain a challenge for many decades simply because they do not respond to ovarian stimulation. Performing follicular phase stimulation and luteal phase stimulation in the same menstrual cycle, named as double stimulation/dual stimulation, clearly increases the number of oocytes, which is a robust surrogate marker of live birth rate in in vitro fertilization across all female ages. Of interest, apart from one study, the bulk of evidence reports significantly higher number of oocytes following luteal phase stimulation when compared with follicular phase stimulation; hence, performing double stimulation/dual stimulation doubles the number of oocytes leading to a marked decrease in patient drop-out rate which is one of the major factors limiting cumulative live birth rates in such poor prognosis patients. The limited data with double stimulation/dual stimulation-derived embryos is reassuring for obstetric and neonatal outcome. The mandatory requirement of freeze-all and lack of cost-effectiveness data are limitations of this novel approach. Double stimulation/dual stimulation is an effective strategy when the need to obtain oocytes is urgent, including patients with malignant diseases undergoing oocyte cryopreservation and patients of advanced maternal age or with reduced ovarian reserve.

Live birth rate with double ovarian stimulation is superior to follicular phase ovarian stimulation per started cycle in poor ovarian responders

AIM

To compare the outcome of double ovarian stimulation (DOS) with follicular phase ovarian stimulation (FPS) per started cycle in poor ovarian responders (PORs).

METHODS

A total of 204 PORs who underwent ovulation induction for in vitro fertilization, cryopreservation of all embryos available, and frozen embryo transfer cycle were retrospectively analyzed. Of those, 146 received single FPS, and 58 received DOS. All viable embryos were cryopreserved and subsequently transferred within 1-6 months.

RESULTS

The number of oocytes collected and the number of mature oocytes per started cycle were higher in the DOS group compared to the FPS group (6.0 ± 1.9 vs. 2.8 ± 1.3 and 4.3 ± 1.3 vs. 2.2 ± 1.2, respectively, p = 0.001). Clinical pregnancy rate and live birth rate per started cycle were also significantly higher in the DOS group than the FPS group (41.4% vs. 16.4% and 36.2% vs. 15.1%, respectively, p < 0.001). The cancellation rate of embryo transfer due to no viable embryo was significantly lower in the DOS group (10.3%) than the FPS group (40.4%) (p = 0.001). In the DOS group, numbers of oocytes (3.2 ± 1.2 vs. 2.7 ± 1.1, p = 0.006), MII oocytes (2.6 ± 1.0 vs. 2.1 ± 0.8, p = 0.001), and cryopreserved blastocysts (1.5 ± 0.8 vs. 1.1 ± 0.7, p = 0.002) were significantly higher in the luteal ovarian stimulation compared to follicular ovarian stimulation.

CONCLUSIONS

Live birth per started cycle with DOS is superior to FPS in PORs. Luteal phase stimulation contributes to improving pregnancy rates in these patients.

Ovarian follicular waves during the menstrual cycle: physiologic insights into novel approaches for ovarian stimulation

Elucidation of multiple waves of antral ovarian follicular development during the menstrual cycle has challenged traditional concepts of female reproductive physiology and foundations of assisted reproductive therapies. Approximately two-thirds of women develop two follicle waves throughout an interovulatory interval and the remainder exhibit three waves of follicle development. Major and minor waves of follicle development have been observed. Major waves are those in which a dominant follicle develops; dominant follicles either regress or ovulate. In minor waves, physiologic selection of a dominant follicle is not manifest. Knowledge of waves of antral follicular development has led to the global adoption of novel ovarian stimulation strategies in which stimulation can be initiated at various times throughout the cycle. Random-start and luteal-phase ovarian stimulation regimens have had important clinical applications for women requiring urgent oocyte or embryo cryopreservation for fertility preservation prior to chemotherapy. Ovarian stimulation twice in the same cycle, referred to as double stimulation, may be used to optimize clinical outcomes in women with a poor ovarian response to stimulation as well as in those requiring fertility preservation before chemotherapy.

Mathematical Modeling and Simulation Provides Evidence for New Strategies of Ovarian Stimulation

New approaches to ovarian stimulation protocols, such as luteal start, random start or double stimulation, allow for flexibility in ovarian stimulation at different phases of the menstrual cycle. It has been proposed that the success of these methods is based on the continuous growth of multiple cohorts ("waves") of follicles throughout the menstrual cycle which leads to the availability of ovarian follicles for ovarian controlled stimulation at several time points. Though several preliminary studies have been published, their scientific evidence has not been considered as being strong enough to integrate these results into routine clinical practice. This work aims at adding further scientific evidence about the efficiency of variable-start protocols and underpinning the theory of follicular waves by using mathematical modeling and numerical simulations. For this purpose, we have modified and coupled two previously published models, one describing the time course of hormones and one describing competitive follicular growth in a normal menstrual cycle. The coupled model is used to test ovarian stimulation protocols in silico. Simulation results show the occurrence of follicles in a wave-like manner during a normal menstrual cycle and qualitatively predict the outcome of ovarian stimulation initiated at different time points of the menstrual cycle.

How effective are the non-conventional ovarian stimulation protocols in ART? A systematic review and meta-analysis

PURPOSE

To compare the effectiveness of starting the ovarian stimulation on the early follicular phase ("Conventional") with the newer range of non-conventional approaches starting in the luteal phase ("Luteal"), random-start, and studies implementing them in DuoStim ("Conventional"+"Luteal").

METHODS

Systematic review. We searched CENTRAL, PubMed, and Embase, on March 2020. We included randomized and non-randomized controlled trials that compared "Luteal," random-start ovarian stimulation or DuoStim with "Conventional"; we analyzed them by subgroups: oocyte freezing and patients undergoing ART treatments, both, in the general infertile population and among poor responders.

RESULTS

The following results come from a sensitivity analysis that included only the low/moderate risk of bias studies. When comparing "Luteal" to "Conventional," clinically relevant differences in MII oocytes were ruled out in all subgroups. We found that "Luteal" probably increases the COH length both, in the general infertile population (OR 2.00 days, 95% CI 0.81 to 3.19, moderate-quality evidence) and in oocyte freezing cycles (MD 0.85 days, 95% CI 0.53 to 1.18, moderate-quality evidence). When analyzing DuoStim among poor responders, we found that it appears to generate a higher number of MII oocytes in comparison with a single "Conventional" (MD 3.35, 95%CI 2.54-4.15, moderate-quality evidence).

CONCLUSION

Overall, this systematic review of the available data demonstrates that in poor responders, general infertile population and oocyte freezing for cancer stimulation in the late follicular and luteal phases can be utilized in non-conventional approaches such as random-start and DuoStim cycles, offering similar outcomes to the conventional cycles but potentially with increased flexibility, within a reduced time frame. However, more well-designed trials are required to establish certainty.

Controlled ovarian hyperstimulation for fertility preservation in women with breast cancer: Practical issues

In Korean women, a westernized lifestyle is associated with an increased risk of breast cancer. Fertility preservation has become an increasingly important issue for women with breast cancer, in accordance with substantial improvements in survival rate after cancer treatment. The methods of controlled ovarian hyperstimulation (COH) for fertility preservation in breast cancer patients have been modified to include aromatase inhibitors to reduce the potential harm associated with increased estradiol levels. Random-start COH and dual ovarian stimulation are feasible options to reduce the total duration of fertility preservation treatment and to efficiently collect oocytes or embryos. Using a gonadotropin-releasing hormone agonist as a trigger may improve cycle outcomes in breast cancer patients undergoing COH for fertility preservation. In young breast cancer patients with BRCA mutations, especially BRCA1 mutations, the possibility of diminished ovarian reserve may be considered, although further studies are necessary. Herein, we review the current literature on the practical issues surrounding COH for fertility preservation in women with breast cancer.

Dual stimulation in unexpected poor responder POSEIDON classification group 1, sub-group 2a: A cross-sectional study

BACKGROUND

Poor ovarian response management is a complex and controversial issue in the field of reproductive medicine.

OBJECTIVE

The aim of this study was to apply double stimulation in the same cycle in unexpected poor responders in POSEIDON classification group 1, sub group 2a and compare assisted reproductive technology outcomes between luteal phase and follicular phase ovarian stimulation.

MATERIALS AND METHODS

In this cross-sectional study, 10 women with age < 35 yr, antral follicle count > 5, and anti-müllerian hormone > 1.2 ng/mL were enrolled. All participants received conventional antagonist protocol in the follicular phase and only the cycles with retrieved oocytes < 4 in this phase included. The luteal phase ovarian stimulation was initiated from the day of first oocytes retrieval by 300 IU of human menopausal gonadotropin / day. When dominant follicles amounted to 14 mm in mean diameter, 0.25 mg/day of gonadotropin-releasing hormone antagonist was initiated and 10,000 IU human chorionic gonadotropin was injected when at least two follicles with a mean diameter of 17 mm were observed. Oocyte retrieval was carried out 34-36 hr following human chorionic gonadotropin injection. Finally, a comparison was made between the two phase in terms of the number of retrieved oocytes as well as the number of obtained embryos and fertilization rates.

RESULTS

Numbers of retrieved oocytes (p = 0.004), mature oocytes (p = 0.016), and embryos (p = 0.013) was significantly higher in luteal phase in compared with follicular phase. Quality of embryos was similar in two phases.

CONCLUSION

Double stimulation protocol can increase number of retrieved oocytes in unexpected PORs.

Freeze-all, for whom, when, and how

Background: The 'freeze-all' practice refers to the cryopreservation of all mature oocytes or viable embryos after ovarian stimulation. The development of the vitrification technique has been crucial to make this approach a reality, since it increases the post-thaw survival rates and permits comparable implantation rates with fresh embryos. Nonetheless, as implantation probabilities are comparable to fresh embryo transfer in normo-responder patients, the freeze- all strategy has demonstrated no benefits overall.Method: Narrative review in which we give an overview of this approach, discuss recent advances in the field, as well as for whom, when and how it is recommended to emply the freeze-all technique.Results: However, there is some clinical evidence that shows its feasibility. Thus, it has been demonstrated that elevation of progesterone at the end of ovarian stimulation decreases the implantation rates after the transfer of day 6 blastocysts in fresh and some uterine pathologies; freeze-all is also the preferred option for patients undergoing pre-implantation genetic testing, since there is an improvement of the results and it allows for inclusion of all blastocysts of the cohort. In high responders, the freeze-all strategy optimizes the response whilst also minimizing the risk of ovarian hyperstimulation syndrome.Conclusion: Due to the different cases that a reproductive expert might encounter, it is essential to highlight benefits and drawbacks of this practice.

DuoStim - a reproducible strategy to obtain more oocytes and competent embryos in a short time-frame aimed at fertility preservation and IVF purposes. A systematic review

Recent evidence suggests that follicular development occurs in a wave-like model during the ovarian cycle, where up to three cohorts of follicles are recruited to complete folliculogenesis. This understanding overtakes the previous dogma stating that follicles grow only during the follicular phase of the menstrual cycle. Therefore, in in vitro fertilization (IVF), novel protocols regarding ovarian stimulation have been theorized based on the use of gonadotrophins to prompt the growth of antral follicles at any stage of the menstrual cycle. These unconventional protocols for ovarian stimulation aim at a more efficient management of poor-prognosis patients, otherwise exposed to conflicting outcomes after conventional approaches. DuoStim appears among these unconventional stimulation protocols as one of the most promising. It combines two consecutive stimulations in the follicular and luteal phases of the same ovarian cycle, aimed at increasing the number of oocytes retrieved and embryos produced in the short time-frame. This protocol has been suggested for the treatment of all conditions requiring a maximal and urgent exploitation of the ovarian reserve, such as oncological patients and poor responders at an advanced maternal age. At present, data from independent studies have outlined the consistency and reproducibility of this approach, which might also reduce the drop-out between consecutive failed IVF cycles in poor-prognosis patients. However, the protocol must be standardized, and more robust studies and cost-benefit analyses are needed to highlight the true clinical pros and cons deriving from DuoStim implementation in IVF.

Optimization of The Cell Aggregates Method for Isolation and Purification of Human Granulosa Cells from Follicular Fluid

BACKGROUND

Aspirated ovarian follicular fluids (FF) contain luteal granulosa cells (LGCs) and other contaminating cell types. Several strategies, such as the antibody binding methods, the flask method, the cell strainer and positive selection of granulosa aggregates after density gradient (DG) centrifugation, were tested as LGC purification methods. Each of these strategies has its own advantages and disadvantages. Positive selection of granulosa aggregates after DG centrifugation is simple, rapid and efficient in terms of LGC recovery. However, it results in a low purity. Here, we aimed to test whether modifying the traditional protocol by collecting the aggregates from the FF, before the DG centrifugation could decrease the percentage of contaminating cells.

MATERIALS AND METHODS

In the present prospective study, 32 FF, from 32 women,were randomly assigned into one of the two purification techniques: positive selection of granulosa aggregates from the FF, after DG centrifugation (DG/ Agg, n=16) or positive selection of granulosa aggregates from the FF, before DG centrifugation (Agg/DG, n=16). At the end of each procedure cell count, vitality, morphology and purity of the cell suspension were evaluated.

RESULTS

No significant difference was detected in the total number of GCs between DG/Agg and Agg/DG (P>0.05). However, higher percentage of GCs with normal morphology was detected in Agg/DG compared to DG/Agg (P<0.001). Moreover, lower percentages of white blood cells (P<0.01), red blood cells (P<0.001) and epithelial cells (P<0.01) were identified in Agg/DG compared to DG/Agg.

CONCLUSION

Here we showed that positive selection of granulosa aggregates from the FF prior to DG technique had a higher purity compared to the traditional protocol. Thus, it could be a method of choice to prepare GCs for research purposes in clinical in vitro fertilization settings.

What is the true place of a double stimulation and double oocyte retrieval in the same cycle for patients diagnosed with poor ovarian reserve? A systematic review including a meta-analytical approach

PURPOSE

This systematic review including a meta-analytical approach aims to investigate the safety and efficacy of employing a double ovarian stimulation (DuoStim) and a subsequent double oocyte retrieval in the same menstrual cycle, in poor ovarian reserve (POR) patients.

METHODS

A systematic search of literature was performed in the databases of PubMed/MEDLINE, Embase, and Cochrane Central Library up until March 2019. Both prospective and retrospective cohort studies considered suitable for inclusion reported on women with POR undergoing a DuoStim in the follicular (FPS) and luteal phase (LPS) of the same menstrual cycle. Following the systematic review of the literature, a meta-analytical approach was attempted.

RESULTS

This study indicates that DuoStim is correlated with a higher number of retrieved oocytes, mature MII oocytes, and good-quality embryos in comparison to conventional stimulation. Additionally, LPS seems to be correlated with an equal or an even higher overall performance in comparison to FPS.

CONCLUSION

DuoStim favors an enhanced clinical outcome in regard to the total number of yielded oocytes, mature oocytes, and available embryos, along with the quality of obtained embryos. Sourced data indicate that LPS is not correlated with a higher aneuploidy rate. This option may present as promising for the time-sensitive nature of POR patients' management, by enabling a higher oocyte yield during a single menstrual cycle.

Evaluation of the Second Follicular Wave Phenomenon in Natural Cycle Assisted Reproduction: A Key Option for Poor Responders through Luteal Phase Oocyte Retrieval

Background: Emergence of Luteal Phase Oocyte Retrieval (LuPOR) may revolutionize the practice regarding the time-sensitive nature of poor responders ascertaining a higher number of oocytes, in a shorter amount of time. This may be especially important in view of employing the approach of natural cycles for Poor Responders. We suggest the acronym LuPOR describing the clinical practice of luteal phase oocyte retrieval. The aim of the study is to offer insight regarding the identity of LuPOR, and highlight how this practice may improve management of the special subgroup of poor responders. Materials and Methods: The present retrospective observational clinical study includes the collection and statistical analysis of data from 136 poor responders who underwent follicular oocyte retrieval (FoPOR) and subsequent LuPOR in natural cycles, during their In Vitro Fertilization (IVF) treatment, from the time period of 2015 to 2018. All 136 participants were diagnosed with poor ovarian reserve (POR) according to Bologna criteria. The 272 cycles were categorized as follows: 136 natural cycles with only FoPORs (Control Group) and 136 natural cycles including both FoPORs and LuPORs. Results: Our primary results indicate no statistically significant differences with regards to the mean number of oocytes, the maturation status, and fertilization rate between FoPOR and LuPOR in natural cycles. Secondarily, we demonstrate a statistically significant higher yield of oocytes (2.50 ± 0.78 vs. 1.25 ± 0.53), better oocyte maturity status (1.93 ± 0.69 vs. 0.95 ± 0.59) and higher fertilization rate (1.31 ± 0.87 vs. 0.61 ± 0.60) in natural cycles including both FoPOR and LuPOR, when compared to cycles including only FoPOR. Conclusion: Our study may contribute towards the establishment of an efficient poor responders’ management through the natural cycle approach, paving a novel clinical practice and ascertaining the opportunity to employ oocytes and embryos originating from a luteal phase follicular wave.

Double stimulation in the same ovarian cycle (DuoStim) is an intriguing strategy to improve oocyte yield and the number of competent embryos in a short timeframe

Proper ovarian stimulation regimens are crucial for any patient undergoing in-vitro fertilization (IVF). However, maximizing the oocyte yield in advanced maternal age patients with poor or suboptimal response is still a challenge. In fact, no standard treatment has been outlined yet to manage these women. Across the last years, an improved efficiency of the IVF units via blastocyst culture, vitrification and reliable embryo selection approaches paved the way to the investigation of novel unconventional stimulation protocols, like double stimulation in a single ovarian cycle (DuoStim). DuoStim, by conjugating follicular phase stimulation (FPS) and luteal phase stimulation (LPS) in the same ovarian cycle, allows to maximize the number of oocytes obtained in a short timeframe, a precious outcome when we aim at shortening time to pregnancy. In this regard, LPS seems to contribute to conventional stimulation with more oocytes with a comparable competence as FPS, retrieved per ovarian cycle. Although any stimulation protocol which exploits anovulatory waves of follicular growth needs a thorough investigation, no evidence has been produced to question the safety of DuoStim, which to date represents the most intriguing strategy to treat poor prognosis in IVF.

Luteal phase ovarian stimulation for poor ovarian responders

Objective

To compare the clinical outcomes of follicular versus luteal phase ovarian stimulation in women with poor ovarian response (Bologna criteria) undergoing IVF.

Methods

This retrospective study investigated 446 patients submitted to 507 cycles in three groups. First, the two larger cohorts were examined: 154 patients treated with luteal phase ovarian stimulation (Group Lu); and 231 patients administered follicular phase ovarian stimulation (Group Fo). Then the clinical outcomes of 61 patients submitted to double ovarian stimulation were analyzed. Clinical outcomes included number of retrieved oocytes, fertilization rate, cleavage rate, top-quality embryo rate, clinical pregnancy rate (CPR), and live birth rate (LBR).

Results

Longer stimulation, higher dosages of HMG, and higher MII oocyte rates were achieved in Group Lu (p<0.001). There were no significant differences in CPR and LBR between the two groups offered frozen-thawed embryo transfer (28.4% vs. 33.0%, p=0.484; 22.9% vs. 25.5%, p=0.666). In the double ovarian stimulation group, the number of oocytes retrieved in the luteal phase stimulation protocol was higher (p=0.035), although luteal phase stimulation yielded a lower rate of MII oocytes (p=0.031). CPR and LBR were not statistically different (13.8% vs. 21.4%, p=0.525; 10.3% vs. 14.3%, p=0.706).

Conclusion

Luteal phase ovarian stimulation may be a promising protocol to treat women with POR, particularly for patients unable to yield enough viable embryos through follicular phase ovarian stimulation or other protocols.