ESHRE guideline: ovarian stimulation for IVF/ICSI†

STUDY QUESTION

What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?

SUMMARY ANSWER

The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.

WHAT IS KNOWN ALREADY

Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations-of which only 21 were formulated as strong recommendations-and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety.

LIMITATIONS REASON FOR CAUTION

Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker's fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker's fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker's fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker's fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker's fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker's fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker's fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker's fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker's fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker's fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker's fees from Ferring. T.T. reports speaker's fees from Merck, MSD and MLD. The other authors report no conflicts of interest.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

How to define, diagnose and treat poor responders? Responses from a worldwide survey of IVF clinics

Poor responders represent a significant percentage of couples treated in IVF units (10-24%), but the standard definition of poor responders remains uncertain and consequently optimal treatment options remain subjective and not evidence-based. In an attempt to provide uniformity on the definition, diagnosis and treatment of poor responders, a worldwide survey was conducted asking IVF professionals a set of questions on this complex topic. The survey was posted on www.IVF-worldwide.com, the largest and most comprehensive IVF-focused website for physicians and embryologists. A total of 196 centres replied, forming a panel of IVF units with a median of 400 cycles per year. The present study shows that the definition of poor responders is still subjective, and many practices do not use evidence-based treatment for this category of patients. Our hope is that by leveraging the great potential of the internet, future studies may provide immediate large-scale sampling to standardize both poor responder definition and treatment options.

Double Stimulation in the Same Ovarian Cycle (DuoStim) to Maximize the Number of Oocytes Retrieved From Poor Prognosis Patients: A Multicenter Experience and SWOT Analysis

A panel of experts known as the POSEIDON group has recently redefined the spectrum of poor responder patients and introduced the concept of suboptimal response. Since an ideal management for these patients is still missing, they highlighted the importance of tailoring the ovarian stimulation based on the chance of each woman to obtain an euploid blastocyst. Interestingly, a novel pattern of follicle recruitment has been defined: multiple waves may arise during a single ovarian cycle. This evidence opened important clinical implications for the treatment of poor responders. For instance, double stimulation in the follicular (FPS) and luteal phase (LPS) of the same ovarian cycle (DuoStim) is an intriguing option to perform two oocyte retrievals in the shortest possible time. Here, we reported our 2-year experience of DuoStim application in four private IVF centers. To date, 310 poor prognosis patients completed a DuoStim protocol and underwent IVF with blastocyst-stage preimplantation-genetic-testing. LPS resulted into a higher mean number of oocytes collected than FPS; however, their competence (i.e., fertilization, blastocyst, euploidy rates, and clinical outcomes after euploid single-embryo-transfer) was comparable. Importantly, the rate of patients obtaining at least one euploid blastocyst increased from 42.3% (n = 131/310) after FPS to 65.5% (n = 203/310) with the contribution of LPS. A summary of the putative advantages and disadvantages of DuoStim was reported here through a Strengths-Weaknesses-Opportunities-Threats analysis. The strengths of this approach make it very promising. However, more studies are needed in the future to limit its weaknesses, shed light on its putative threats, and realize its opportunities.

Implementing the ESHRE 'poor responder' criteria in research studies: methodological implications

The Bologna criteria for defining poor ovarian response (POR) during IVF provide a useful template for new research in this field of assisted conception. However, designing studies around the European Society for Human Reproduction and Embryology POR criteria can be methodologically challenging, as the new definition includes various POR subpopulations with diverse baseline characteristics and unknown clinical prognosis. When designing RCTs, potential result bias may be introduced if women from each subpopulation are not evenly allocated between intervention groups. In the case of small or moderate-size RCTs, a single-sequence randomization method may not ensure balanced allocation between groups. Stratified randomization methods provide an alternative methodological approach. Depending on the chosen methodology, patient characteristics and outcomes within each intervention group may be better reported according to relevant subpopulations.

Trends in 'poor responder' research: lessons learned from RCTs in assisted conception

BACKGROUND

A substantial minority of women undergoing IVF will under-respond to controlled ovarian hyperstimulation. These women-so-called 'poor responders'-suffer persistently reduced success rates after IVF. Currently, no single intervention is unanimously accepted as beneficial in overcoming poor ovarian response (POR). This has been supported by the available research on POR, which consists mainly of randomized controlled trials (RCTs ) with an inherent high-risk of bias. The aim of this review was to critically appraise the available experimental trials on POR and provide guidance towards more useful-less wasteful-future research.

METHODS

A comprehensive review was undertaken of RCTs on 'poor responders' published in the last 15 years. Data on various methodological traits as well as important clinical characteristics were extracted from the included studies and summarized, with a view to identifying deficiencies from which lessons can be learned. Based on this analysis, recommendations were provided for further research in this field of assisted conception.

RESULTS

We selected and analysed 75 RCTs. A valid, 'low-risk' randomization method was reported in three out of four RCTs. An improving trend in reporting concealment of patient allocation was also evident over the 15-year period. In contrast, <1 in 10 RCTs 'blinded' patients and <1 in 5 RCTs 'blinded' staff to the proposed intervention. Only 1 in 10 RCTs 'blinded' ultrasound practitioners to patient allocation, when assessing the outcome of early pregnancy. The majority of trials reported an intention-to-treat analysis for at least one of their outcomes, with an improving trend in the recent years. Substantial variation was noted in the definitions used for 'poor responders', the most popular being 'low ovarian response at previous stimulation'. The preferred cut-off value for defining previous low response has been 'less or equal to three retrieved oocytes'. The most popular tests used for diagnosing diminished ovarian reserve have been antral follicle count and FSH. Although the Bologna criteria for POR were only recently introduced, they are expected to become a popular definition in future 'poor responder' trials. Numerous interventions have been studied on 'poor responders'. Most of these have been applied before/during controlled ovarian hyperstimulation. The antagonist protocol, the microdose flare protocol and the long down-regulation protocol have been among the most popular interventions. The analysis of outcomes revealed a clear improving trend in reporting live birth. In contrast, only 10% of RCTs reported significant improvement in reproductive outcomes among tested interventions. Twelve 'significant' interventions were reported, each supported by a single 'positive' RCT. Finally, trials of higher methodological quality were more likely to have been published in a high-impact journal.

CONCLUSIONS

Overall, the majority of published trials on POR suffer from methodological flaws and are, thus, regarded as being high-risk for bias. The same trials have used a variety of definitions for their poor responders and a variety of interventions for their head-to-head comparisons. Not surprisingly, discrepancies are also evident in the findings of trials comparing similar interventions. Based on the identified deficiencies, this novel type of 'methodology and clinical' review has introduced custom recommendations on how to improve future experimental research in the 'poor responder' population.

CpG-Adjuvanted Hepatitis B Vaccine (HEPLISAV-B®) Update

Introduction: HEPLISAV-B is a hepatitis B vaccine composed of rHBsAg mixed with a synthetic oligonucleotide containing CpG motifs that stimulate innate immunity through TLR9. This vaccine was recently approved by FDA in view of its superior efficacy.Areas covered: Published literature on HEPLISAV-B was critically reviewed. Four randomized controlled trials among 7,056 subjects receiving 2 doses of HEPLISAV-B and 3,214 subjects receiving 3 doses of Engerix-B showed superior seroprotection rate (SPR) (anti-HBs ≥10 mIU/mL) of 90-100%, compared with 71-90% in those receiving Engerix-B. Furthermore, the seroprotection rate was also significantly higher in HEPLISAV-B compared with Engerix-B recipients in persons with traditionally poor vaccine responses such as older adults, diabetics, and those with chronic kidney disease. The safety profiles among 9,871 subjects were similar between HEPLISAV-B and Engerix-B .Expert opinion: HEPLISAV-B, a CpG adjuvant mixed with HBsAg, is more efficacious and produced earlier seroprotection compared to existing vaccines, with a favorable safety profile. The shorter, two-dose regimen, earlier seroprotection, higher adherence, and a higher seroprotection rate, especially in populations with traditionally poor vaccine response, makes this an important therapeutic option in hepatitis B vaccination.

Luteal phase after conventional stimulation in the same ovarian cycle might improve the management of poor responder patients fulfilling the Bologna criteria: a case series

OBJECTIVE

To assess the clinical contribution of luteal-phase stimulation (LPS) to follicular-phase stimulation (FPS) in a single ovarian cycle (DuoStim) for poor responder patients fulfilling the Bologna criteria.

DESIGN

Observational study (years 2015-2017) including women satisfying ≥2 of the following characteristics: maternal age ≥40 years and/or ≤3 oocytes retrieved after previous conventional stimulation and/or reduced ovarian reserve (i.e., antral follicle count <7 follicles or antimüllerian hormone <1.1 ng/mL). The LPS was started regardless of the outcome of the FPS.

SETTING

Private in vitro fertilization center.

PATIENT(S)

A total of 100 of 297 patients fulfilling the Bologna criteria chose to undergo DuoStim.

INTERVENTION(S)

The FPS and LPS with the same antagonist protocol and agonist trigger, intracytoplasmic sperm injection with ejaculated sperm, preimplantation genetic testing for aneuploidies, and vitrified-warmed euploid single blastocyst transfer.

MAIN OUTCOME MEASURE(S)

The contribution of LPS to the cumulative live birth rate (CLBR) per intention-to-treat (ITT).

RESULT(S)

Patients (100) underwent FPS (maternal age, 42.1 ± 1.4 y; previous in vitro fertilization cycles with ≤3 collected oocytes, 0.7 ± 0.9; antral follicle count, 3.8 ± 1.2 follicles; and antimüllerian hormone, 0.56 ± 0.3 ng/mL). Ninety-one patients completed DuoStim. All patients were included in the analysis. More oocytes were obtained after LPS with similar developmental and chromosomal competence as paired FPS-derived ones. The CLBR per ITT increased from 7% after FPS to 15% after DuoStim. Conversely, the CLBR per ITT among the 197 patients that chose a conventional controlled ovarian stimulation strategy was 8%, as only 17 patients who were not pregnant returned for a second stimulation after the first attempt (drop-out rate, 81%).

CONCLUSION(S)

The LPS-derived oocytes increased the CLBR per ITT in a single ovarian cycle in patients fulfilling the Bologna criteria. The DuoStim strategy is promising to manage this thorny population of patients, especially to avoid discontinuation after a first failed attempt.

Cycle cancellation and pregnancy after luteal estradiol priming in women defined as poor responders: a systematic review and meta-analysis

STUDY QUESTION

Does a luteal estradiol (LE) stimulation protocol improve outcomes in poor responders to IVF?

SUMMARY ANSWER

LE priming is associated with decreased cycle cancellation and increased chance of clinical pregnancy in poor responders

WHAT IS KNOWN ALREADY

Poor responders to IVF are one of the most challenging patient populations to treat. Many standard protocols currently exist for stimulating these patients but all have failed to improve outcomes.

STUDY DESIGN, SIZE, DURATION

Systematic review and meta-analysis including eight published studies comparing assisted reproduction technology (ART) outcomes in poor responders exposed to controlled ovarian hyperstimulation with and without LE priming. A search of the databases MEDLINE, EMBASE and PUBMED was carried out for studies in the English language published up to January 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Studies evaluating women defined as poor responders to ART were evaluated. These studies were identified following a systematic review of the literature and data were analyzed using the DerSimonian-Laird random effects model. The main outcomes of interest were cycle cancellation rate and clinical pregnancy. Although the definition of clinical pregnancy varied between studies, the principal definition included fetal cardiac activity as assessed by transvaginal ultrasonography after 5 weeks of gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 2249 publications were identified from the initial search, and the bibliographies, abstracts and other sources yielded 11 more. After excluding duplications, 1227 studies remained and 8 ultimately met the inclusion criteria. Compared with women undergoing non-LE primed protocols (n = 621), women exposed to LE priming (n = 468) had a lower risk of cycle cancellation [relative risk (RR): 0.60, 95% confidence interval (CI): 0.45-0.78] and an improved chance of clinical pregnancy (RR: 1.33, 95% CI: 1.02-1.72). There was no significant improvement in the number of mature oocytes obtained or number of zygotes obtained per cycle.

LIMITATIONS, REASONS FOR CAUTION

These findings are limited by the body of literature currently available. As the poor responder lacks a concrete definition, there is some heterogeneity to these results, which merits caution when applying our findings to individual patients. Furthermore, the increased clinical pregnancy rate demonstrated when using the LE protocol may be principally related to the decreased cycle cancellation rate.

WIDER IMPLICATIONS OF THE FINDINGS

The LE protocol may be of some utility in the poor responder to IVF and may increase clinical pregnancy rates in this population by improving stimulation and thereby decreasing cycle cancellation.

STUDY FUNDING/COMPETING INTERESTS

NIH K12 HD063086 (ESJ, MGT), NIH T32 HD0040135-11 (KAR), F32 HD040135-10 NIH (KRO), 5K12HD000849-25 (PTJ). No competing interests.

A novel "delayed start" protocol with gonadotropin-releasing hormone antagonist improves outcomes in poor responders

OBJECTIVE

To investigate whether delaying the start of ovarian stimulation with GnRH antagonist improves ovarian response in poor responders.

DESIGN

Retrospective study.

SETTING

Academic medical center.

PATIENT(S)

Thirty patients, who responded poorly and did not get pregnant with conventional estrogen priming antagonist IVF protocol.

INTERVENTION(S)

Delayed-start antagonist protocol (estrogen priming followed by early follicular-phase GnRH antagonist treatment for 7 days before ovarian stimulation).

MAIN OUTCOME MEASURE(S)

Number of dominant follicles and mature oocytes retrieved, mature oocyte yield, and fertilization rate.

RESULT(S)

The number of patients who met the criteria to proceed to oocyte retrieval was significantly higher in the delayed-start protocol [21/30 (70%)] compared with the previous conventional estrogen priming antagonist cycle [11/30 (36.7%)]. The number of dominant follicles was significantly higher in the delayed-start (4.2 ± 2.7) compared with conventional (2.4 ± 1.3) protocol. In patients who had oocyte retrieval after both protocols (n = 9), the delayed start resulted in shorter ovarian stimulation (9.4 ± 1.4 days vs. 11.1 ± 2.0 days), higher number of mature oocytes retrieved (4.9 ± 2.0 vs. 2.2 ± 1.1), and a trend toward increased fertilization rates with intracytoplasmic sperm injection (ICSI; 86 ± 17% vs. 69 ± 21%) compared with conventional protocol. After delayed start, the average number of embryos transferred was 2.8 ± 1.4 with implantation rate of 9.8% and clinical pregnancy rate of 23.8%.

CONCLUSION(S)

The delayed-start protocol improves ovarian response in poor responders by promoting and synchronizing follicle development without impairing oocyte developmental competence.

Is there an ideal stimulation regimen for IVF for poor responders and does it change with age?

PURPOSE

To determine whether there is a superior treatment modality for 'poor' responders.

METHOD

Retrospective analysis of three stimulation regimens, with patients stratified based on age, stimulation regime and response in previous cycles ("poor' responder or "non poor" responder). Fertilisation, embryo utilisation and clinical pregnancy rates were assessed. There were a total of 1,608 cycles in the 'poor' responder and 8,489 cycles in the 'non poor' responder groups.

RESULTS

In 'poor' responders there was no significant difference in fertilisation rate, nor utilisation rate between the three stimulation regimes and no differences in the pregnancy rate/initiated cycle irrespective of age and stimulation regimen in any of the groups. 'Non poor' responders had a significantly greater pregnancy rate/initiated cycle for all stimulation regimens in both age groups compared with 'poor' responders.

CONCLUSION

This large retrospective study of 'poor' responders has not shown a difference in pregnancy rates/initiated cycle between stimulation regimens.

Use of Growth Hormone in the IVF Treatment of Women With Poor Ovarian Reserve

Growth hormone (GH) has been used as an adjunct in the field of female infertility treatment for more than 25 years, although, apart from treating women with GH deficiency its role has not yet been clarified. Contributing to this lack of clarity is that several underpowered studies have been performed on women undergoing IVF treatment, with a previous "poor response" to ovarian stimulation, which have suggested a favorable outcome. Meta-analysis of randomized controlled trials has demonstrated a benefit for the use of the adjunct growth hormone, in comparison to placebo; with reductions in the duration of ovarian stimulation required prior to oocyte retrieval, with a greater number of oocytes collected, and improvements in many of the early clinical parameters with the use of GH. However, no benefit of an increased chance of a live birth with the use of growth hormone for the "poor responding" patient has been determined. Consequently the role of GH to treat a woman with a poor response to ovarian stimulation cannot be supported on the basis of the available evidence. However, the place for GH in the treatment of women undergoing IVF may yet still be determined, as it is also used, without firm evidence of benefit; for women with poor embryonic development, poor endometrial development and for women who do not conceive despite multiple embryo transfers (recurrent implantation failure).

Clomiphene citrate versus high doses of gonadotropins for in vitro fertilisation in women with compromised ovarian reserve: a randomised controlled non-inferiority trial

BACKGROUND

The aim of the present randomised controlled non-inferiority trial is to test whether in women with compromised ovarian reserve requiring in vitro fertilisation, a protocol of ovarian stimulation using exclusively clomiphene citrate performs similarly to a regimen with high doses of gonadotropins.

METHODS

Women with day 3 serum FSH > 12 IU/ml on at least two occasions or previous poor response to hyper-stimulation were recruited at four Italian infertility units. Selected women were allocated to clomiphene citrate 150 mg/day from day 3 to day 7 of the cycle (n=145) or to a short protocol with GnRH agonist 0.1 mg and recombinant FSH 450 IU daily (n=146). They were randomised by means of a computer-generated list into two groups. The study was not blinded. The main outcome of the study was the delivery rate per started cycle.

RESULTS

The study was interrupted after the scheduled two years of recruitment before reaching the sample size. 148 women were allocated to clomiphene citrate and 156 to the short protocol with high doses of gonadotropins; 124 and 125 participants were analysed in the groups, respectively. Women allocated to high doses of gonadotropins retrieved more oocytes and had a higher probability to perform embryo-transfer. However, the chances of success were similar. The delivery rate per started cycle in women receiving clomiphene citrate and high-dose gonadotropins was 3% (n=5) and 5% (n=7), respectively (p=0.77). The mean estimated cost per delivery in the two groups was 81,294 and 113,107 Euros, respectively. No side-effects or adverse events were observed.

CONCLUSIONS

In women with compromised ovarian reserve selected for in vitro fertilisation, ovarian stimulation with clomiphene citrate or high-dose gonadotropins led to similar chances of pregnancy but the former is less expensive.

TRIAL REGISTRATION

Trial registered on http://www.clinicaltrials.gov (NCT01389713).

Neovascular age-related macular degeneration: intraocular inflammatory cytokines in the poor responder to ranibizumab treatment

Purpose

To determine the levels of interleukin (IL)-6, vascular endothelial growth factor-A, platelet-derived growth factor, placental growth factor (PLGF), and other cytokines in the aqueous fluid of patients with neovascular age-related macular degeneration who respond poorly to ranibizumab.

Patients and methods

This is an observational, prospective study. Thirty-two eyes from 30 patients were included in the study: 11 patients who responded poorly to ranibizumab and were switched to aflibercept (AF group), 8 patients who received ranibizumab and photodynamic therapy (PDT group), and 13 patients who responded to ranibizumab (control group). Aqueous fluid samples were collected for analysis of cytokine levels at baseline and after 1, 2, and 3 months of treatment. The effect of treatment on cytokine levels was compared between the study groups and between different time points using a linear mixed-effect regression model.

Results

In the AF group, there was an increase in vascular endothelial growth factor-C, IL-7, and angiopoeitin-2 levels (P=0.01) and a decrease in intercellular adhesion molecule and IL-17 levels (P=0.01) between baseline and 3 months. After adjustment for age, sex, race, and type of lesion at baseline, the PLGF level was higher (P=0.02) and the IL-7 level was lower (P=0.04) in the ranibizumab non-responder group than in the ranibizumab responder group.

Conclusion

Switching from ranibizumab to aflibercept did not reduce intraocular levels of angiogenesis cytokines, but resulted in improvement of central subfield thickness. PLGF levels were higher in poor responders to ranibizumab. The response of lesions to medication might be related to the stage of choroidal neovascularization.

Trial registration

www.ClinicalTrial.gov (NCT02218177c).

Hypothalamic-pituitary suppression with oral contraceptive pills does not improve outcome in poor responder patients undergoing in vitro fertilization-embryo transfer cycles

PURPOSE

To evaluate and compare the use of OCP with GnRHa for hypothalamic-pituitary suppression in poor responder IVF patients.

METHODS

Retrospective analysis of IVF-ET cycles of poor responders. Hypothalamic-pituitary suppression with OCP (Group I, n = 29) or GnRHa (Group II, n = 52), followed by stimulation with gonadotropin, oocyte retrieval, and embryo transfer. Baseline characteristics and cycle outcomes were compared.

RESULTS

73 women underwent 81 cycles from 1/1/1999 to 1/1/2000. Baseline characteristics were similar. 31/81 (38%) cycles were cancelled (Group I, 14/29 (48%) vs. Group II, 17/52 (33%), NS). Cycle outcomes including amount of gonadotropin, number of eggs retrieved, number of embryos transferred, and embryo quality were similar. Patients in Group I required fewer days of stimulation to reach oocyte retrieval. Pregnancy outcomes were similar in the two groups.

CONCLUSION

Our retrospective analysis revealed no improvement in IVF cycle outcomes in poor responders who received OCPs to achieve hypothalamic-pituitary suppression instead of GnRHa.

Does the time interval between antimüllerian hormone serum sampling and initiation of ovarian stimulation affect its predictive ability in in vitro fertilization-intracytoplasmic sperm injection cycles with a gonadotropin-releasing hormone antagonist? A retrospective single-center study

OBJECTIVE

To investigate whether the time interval between serum antimüllerian hormone (AMH) sampling and initiation of ovarian stimulation for in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) may affect the predictive ability of the marker for low and excessive ovarian response.

DESIGN

Retrospective cohort study.

SETTING

University-based tertiary center.

PATIENT(S)

Five hundred and forty women with AMH values measured before their first IVF-ICSI cycle.

INTERVENTION(S)

Eligible patients treated with 150-225 IU recombinant follicle-stimulating hormone (FSH) in a gonadotropin-releasing hormone (GnRH) antagonist protocol.

MAIN OUTCOME MEASURE(S)

Predictive ability of AMH for low and excessive ovarian response in relation to the time interval between serum AMH sampling and initiation of ovarian stimulation for IVF-ICSI.

RESULT(S)

All patients had their AMH concentration measured up to 12 months before initiation of stimulation. The level of AMH demonstrated a statistically significant positive correlation with number of oocytes retrieved. The time interval between AMH measurement and initiation of stimulation had no influence on this correlation. The area under the receiver operator characteristic curve (ROC AUC) of AMH was high for both poor (0.72) and excessive response (0.80). The ROC regression analysis demonstrated that the time interval from sampling did not affect the performance of either poor response or excessive response prediction.

CONCLUSION(S)

A time interval up to 12 months between AMH serum sampling and initiation of ovarian stimulation does not appear to affect the correlation between AMH level and the number of oocytes retrieved and the predictive ability of AMH to identify women at risk of low or excessive ovarian response.

The effects of intra-ovarian autologous platelet rich plasma injection on IVF outcomes of poor responder women and women with premature ovarian insufficiency

Objective:

There are controversial results regarding the administrations of platelet rich plasma (PRP) to increase in-vitro fertilization (IVF) success rates in the current literature. The aim of this study was to evaluate the effects of intra-ovarian PRP injections on IVF outcomes of poor responder women and women with premature ovarian insufficiency (POI).

Material and Methods:

The medical history and outcome of women receiving intra-ovarian PRP injections performed in a single tertiary center between 2018 and 2021 was retrospectively reviewed.

Results:

In total 71 women were included, of whom 21 were diagnosed with POI according to European Society of Human Reproduction and Embryology criteria and 50 were poor responders according to Bologna criteria. Number of retrieved oocytes, number of 2 pronuclear embryos and number of cleavage stage embryos were significantly higher in poor responder women after PRP injections. However clinical pregnancy rates and live birth delivery rates were similar before and after PRP injections in poor responders. In women with POI, 8 embryos were obtained in cycles commenced after PRP injections but no clinical pregnancies were achieved in this group of patients.

Conclusion:

Intra-ovarian PRP injections do not appear to increase live birth rates or clinical pregnancy rates in poor responder women or in those with POI, in this cohort.

Demographic characteristics and clinical profile of poor responders in IVF / ICSI: A comparative study

BACKGROUND

Ovarian response varies considerably among individuals and depends on various factors. Poor response in IVF yields lesser oocytes and is associated with poorer pregnancy perspective. Cycle cancellation due to poor response is frustrating for both clinician and the patient. Studies have shown that women conceiving after poor ovarian response have more pregnancy complications like PIH and preeclampsia than women with normal ovarian response. In addition, poor ovarian response could be a predictor of early menopause. This paper studies various demographic and clinical profiles of poor responders and tries to look at the known and unknown factors which could contribute to poor ovarian response in IVF.

MATERIALS AND METHODS

Data were collected retrospectively from 104 poor responders who had less than four oocytes at retrieval and compared with 324 good responders for factors like age, BMI, type of sub fertility, duration of sub fertility, environmental factors like stress at work, smoking, pelvic surgery, chronic medical disorder, indication of IVF, basal FSH, mean age of menopause in their mothers etc.

RESULTS

Among the poor responders, 60.57% were above 35 years of age compared to 36.41% in control group, which is statistically significant. Mean age of menopause in mother was found to be four years earlier in poor responder group. Male factor and unexplained infertility were significantly (P<0.05) higher in good responders (P<0.05). Significant proportion (31.73%) of women in study group had undergone some pelvic surgery (P<0.05).

CONCLUSION

Apart from age, prior pelvic surgery also could be used as predictors for poor ovarian response. Heredity also plays a major role in determining ovarian response.

The effectiveness of transdermal testosterone gel 1% (androgel) for poor responders undergoing in vitro fertilization

The study was conducted on 110 poor responders undergoing in vitro fertilization (IVF) from October 2015 to July 2016 at the IVF Center of Millitary Medical University, Vietnam. Its aim is to investigate the effectiveness of transdermal androgel before using controlled ovarian stimulation on patients undergoing IVF. A prospective, descriptive study was conducted to compare between the group of patients who used testosterone gel and the group of those who did not in terms of the following indicators: the number of oocytes retrieved, MII oocytes, fertilization rate, number of embryos, pregnancy rate, and embryo implantation rate. The number of oocytes retrieved, number of embryos, pregnancy rate, and embryo implantation rate of the group of patients using transdermal androgel before Controlled Ovarian Stimulation (COS) were found higher than those of the control group, with statistical significance. The use of androgel before stimulating ovarian can improve the responsiveness of poor responders when undergoing IVF.

Microdose flare protocol with interrupted follicle stimulating hormone and added androgen for poor responders--an observational pilot study

OBJECTIVE

To investigate whether temporarily withholding FSH and adding androgen could improve follicular response during a microdose flare protocol in women with slow follicular growth or asynchronous follicular development.

DESIGN

Observational pilot study.

SETTING

University-affiliated private fertility center.

PATIENT(S)

Twenty-six women aged 34-47 years with poor response to stimulation or a previous cancelled IVF cycle and with slow or asynchronous follicular growth during a microdose flare cycle.

INTERVENTION(S)

For 13 women, after initiation of ovarian stimulation using the microdose flare protocol, gonadotropin administration was interrupted and transdermal testosterone gel was added for several days (4.4 ± 1.2 d) starting after cycle day 7 (mean cycle day 10 ± 2.6).

MAIN OUTCOME MEASURE(S)

FSH, E2, follicular growth, and total number of mature oocytes retrieved were determined for all of the patients. Cycle cancellation rate as well as pregnancy rate following embryo transfer were also documented when applicable.

RESULT(S)

FSH levels declined (25.2 ± 6.5 to 6.8 ± 3.2 IU/L), E2 levels increased (896 ± 687 to 2,163 ± 1,667 pmol/L), and follicular growth improved significantly during gonadotropin interruption and were tracked for 2 days during this time frame. The average number of oocytes retrieved was 5.3 ± 2.6, and the ratio of mature to total oocytes was 4:5. Four of the 13 women in the interruption group conceived following frozen embryo transfer, whereas none in the control group did.

CONCLUSION(S)

The androgen-interrupted FSH protocol may improve follicular response to gonadotropins in cycles that might otherwise be cancelled.

Luteal-phase protocol in poor ovarian response: a comparative study with an antagonist protocol

Objective

This retrospective study compared the effect of the luteal phase ovarian stimulation protocol (LP group) with the gonadotrophin-releasing hormone (GnRH) antagonist protocol (AN group) in women with poor ovarian responses.

Methods

Ovarian stimulation was initiated with 225 IU of human gonadotrophin (hMG) daily. When the dominant follicle diameter exceeded 13 mm, 0.25 mg of a GnRH antagonist was used daily until human chorionic gonadotrophin (HCG) administration in the AN group. A GnRH antagonist was not used in the LP group. Ovulation was induced with HCG for all patients when at least one follicle reached a diameter of 16 mm or one dominant follicle reached 18 mm. The highest quality embryos were transferred or cryopreserved for later transfer.

Results

From January 2013 to December 2015, 274 women with poor ovarian response were included. A total of 108 patients underwent the luteal phase ovarian stimulation protocol while 166 patients underwent the GnRH antagonist protocol. hMG was used for more total days in the LP group was than in the AN group. Oestradiol levels on the day of HCG administration in the LP group were significantly lower than those in the AN group. The mean number of oocytes retrieved in the LP and AN groups was 3.5 ± 2.5 and 3.5 ± 2.9, respectively. The mean number of embryos of the highest quality was 1.7 ± 1.2 and 1.7 ± 1.5, respectively. The clinical pregnancy and implantation rates in the LP and AN groups were 26.2% (22/84) and 25% (29/116), and 15.5% (24/155) and 16.3% (35/215), respectively.

Conclusions

The luteal phase ovarian stimulation protocol can be applied in women with poor ovarian response and attain comparable clinical pregnancy and implantation rates to those of the GnRH antagonist protocol.

Can serum estradiol levels on the fourth day of IVF/ICSI cycle predict outcome in poor responder women?

We aimed to investigate the value of fourth day serum estradiol levels in predicting cycle outcome in poor responders. The medical records of 426 patients with low oocyte yield following controlled ovarian hyperstimulation (COH) treatment for a procedure in our institution's center for ART between 2008 and 2013 were evaluated. Eighty-eight patients exhibiting poor ovarian response (POR) were included in the study. The clinical outcomes of IVF/ICSI were compared based on the basal hormone profile, clinical, and laboratory parameters. Cycle day 4 E2 levels below 110 pg/ml had an odds ratio of 6.05 (95% CI 2.33-15.7; p < 0.001) for embryo transfer. The early follicular response to ovarian stimulation can be anticipated with the cycle day 4 estradiol levels during COH. When a low day 4 serum estradiol level is encountered, abandoning the current COH and proceeding with agents that increase ovarian response to ovarian stimulation before the next treatment cycle can be a realistic approach.

Combined Use of Autologous Bone Marrow-derived Stem Cells and Platelet-rich Plasma for Ovarian Rejuvenation in Poor Responders

Background:

The management of poor responders is still a challenge in modern-assisted reproductive technology. Several researches are showing encouraging results with autologous bone marrow-derived stem cells (ABMDSCs) and platelet-rich plasma (PRP) individually. Hence, we decided to study the synergistic effect of ABMDSCs with PRP.

Aims and Objective:

The aim of the study was to assess the safety and efficacy of intraovarian instillation of ABMDSCs combined with PRP in poor responders.

Design:

This was an interventional pilot study. Study Period: January 2017 to January 2019.

Materials and Methods:

We designed a pilot study using Patient-oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) Group 3 and 4 poor responder patients (n = 20). The study group underwent laparoscopic/transvaginal intraovarian instillation of ABMDSCs combined with PRP and the outcome was analyzed – primary outcome – antral follicular count (AFC) and mature MII oocytes and secondary outcome – Anti-Mullerian hormone (AMH) levels and number of Grade A and B embryos frozen on day 3. The Wilcoxon signed-rank test and Pearson correlation were used for the statistical analysis and P < 0.05 was considered statistically significant.

Results:

After 6 weeks of intraovarian instillation ABMDSCs mixed with PRP, patients were reassessed for AFC and AMH and their response to subsequent controlled ovarian stimulation (COS) cycle was observed. Statistically significant improvement was seen in AFC, MII oocytes, and Grade A and Grade B embryos. AMH was also increased in some patients, but the result was not statistically significant.

Conclusion:

Our results suggest that intraovarian instillation of ABMDSCs combined with PRP is safe and it optimized the recruitment of existing dormant primordial follicles to improve oocyte yield and hence the number and quality of embryos after COS in POSEIDON Group 3 and 4 poor responders.

Management Strategies for POSEIDON Group 2

Although individualization of ovarian stimulation aims at maximal efficacy and safety in assisted reproductive treatments, in its current form it is far from ideal in achieving the desired success in women with a low prognosis. This could be due a failure to identify such women who are likely to have a low prognosis with currently used prognostic characteristics. Introduction of the patient-oriented strategies encompassing individualized oocyte number (POSEIDON) concept reinforces recognizing such low prognosis groups and stratifying in accordance with important prognostic factors. The POSEIDON concept provides a practical approach to the management of these women and is a useful tool for both counseling and clinical management. In this commentary, we focus on likely management strategies for POSEIDON group 2 criteria.

Comparison of GnRH agonist versus luteal estradiol GnRH antagonist protocol using transdermal testosterone in poor responders

Objective:

Transdermal testosterone has been used in different doses and in different stimulation protocols in poor responders. The aim of the present study is to compare the luteal estradiol/GnRH antagonists protocol versus long GnRH agonists in poor responder patients according to the Bologna criteria, in which transdermal testosterone has been used prior to the stimulation with gonadotropins.

Methods:

In this retrospective analysis, a total of 141 poor responder patients according to the Bologna criteria were recruited. All patients were treated with transdermal testosterone preceding ovarian stimulation with gonadotropins during 5 days. In 53 patients we used the conventional antagonist protocol (Group 1). In 88 patients (GrH pituitary suppression was achieved by leuprolide acetate according to the conventional long protocol (Group 2). We analyzed the ovarian stimulation parameters and IVF outcomes.

Results:

Comparing groups 1 and 2, there were no significant differences between cancellation rates and number of oocytes retrieved. However the total gonadotropin dose used and the mean length of stimulation were significantly lower in group 1 when compared to group 2. There were no significant differences in pregnancy outcomes; however, there was a slight increase in the implantation rate in group 1 vis-a-vis group 2, although statistical significance was not achieved.

Conclusion:

TT in poor responder patients can be effective both with the conventional agonist's long protocol and with the conventional antagonist's protocol. However, short regimes with previous estradiol antagonists in the luteal phase facilitate ovarian stimulation by shortening the days of treatment and the consumption of gonadotropins

Day 6 estradiol level predicts cycle cancellation among poor responder patients undergoing in vitro fertilization-embryo transfer cycles using a gonadotropin-releasing hormone agonist flare regimen

PURPOSE

To compare two GnRHa flare protocols among poor responders undergoing IVF-ET and to evaluate if a Day 6 estradiol level can predict outcome.

METHODS

Retrospective analyses of GnRHa flare IVF cycles among poor responders. Group A ("miniflare," N = 36) 40 microg GnRHa s.c. b.i.d. from Day 3; Group B ("standard flare," N = 24) 1 mg GnRHa on Days 2-3; 0.5 mg GnRHa from Day 4. ROC analysis was performed to find a Day 6 estradiol value that is predictive of cycle outcome.

RESULTS

With the standard flare, patients required less gonadotropins and tended to have fewer cancellations and higher pregnancy rates. A Day 6 estradiol level < or = 75 pg/mL was predictive of cycle cancellation, but not of pregnancy outcome.

CONCLUSIONS

Standard GnRHa flare offers some advantages over the miniflare. Day 6 estradiol < or = 75 pg/mL is predictive of cycle cancellation. When the estradiol level is low on Day 6 (no flare), early cancellation should be considered.