Abstract
Since 2010, numerous studies reported from PIVET, a pioneer IVF facility established over 40 years ago, have explored the use of three adjuvants designed to improve laboratory and clinical outcomes in cases where a poor prognosis has been demonstrated. The adjuvants reported commenced with recombinant growth hormone (rGH), followed by dehydroepiandrosterone (DHEA) after developing a unique troche to avoid the first-pass effect and, subsequently, melatonin. The studies show that rGH is beneficial in the situation where women have poor-quality embryos in the setting of additional poor prognosis factors, such as advanced female age, a very low ovarian reserve, an insulin growth factor profile in the lowest quartile or recurrent implantation failure. The studies also imply that the adjuvants may actually reduce live birth productivity rates if used on women without poor prognosis factors; hence, further studies, which can now be better designed, should be undertaken to explore the notion of underlying adult growth hormone deficiency in some cases as well as the suggestion that DHEA can provide equivalent benefits in some poor prognosis settings. Melatonin showed no suggestive benefits in any of the studies and can be excluded from consideration in this context. Future studies should compare rGH and DHEA with a focus on those women who have poor embryo quality with additional poor prognosis factors. Such trials should be extended to 12 weeks to cover the entire period of oocyte activation.
Highlights
Assisted reproductive technology (ART) has earnt a well-respected position in modern medicine with its current widespread application generating more than 10 million offspring since the first child born in 1978, in truth, the technology still has a poor prognosis for approximately one-third of women currently seeking assistance for infertility
The protocol of Subhas Mukherjee, Sunit Mukherjee and SK Bhattacharya [3,4] relied on ovarian stimulation with gonadotropins, trans-vaginal ovum pick-up (OPU) and embryo cryopreservation prior to embryo thawing for a single embryo transfer (SET) as a frozen embryo transfer (FET) procedure in a natural cycle
Apart from the main limiting factor, that of advanced female age ≥40 years, recent studies have shown several other specific variables that can limit the prognosis, namely, the woman’s ovarian reserve [7], which itself is attendant upon the antral follicle count (AFC) and the serum anti-Mullerian hormone (AMH) level, as well as the woman’s IGF serum profile represented by insulin growth factor-1 (IGF-1), insulin growth factor binding protein-3 (IGFBP-3) and the IGF ratio, being IGFBP-3/IGF-1 [8]
Summary
Assisted reproductive technology (ART) has earnt a well-respected position in modern medicine with its current widespread application generating more than 10 million offspring since the first child born in 1978, in truth, the technology still has a poor prognosis for approximately one-third of women currently seeking assistance for infertility. Understanding the reasons underlying this poor prognosis group of women requires a reflection of the historical evolution of in vitro fertilisation (IVF) from the earliest attempts of the pioneers Robert Edwards and Patrick Steptoe who came together in 1969 [1,2]. Their frustrations with controlled ovarian stimulation led to natural cycle IVF and ignoring the poor prognosis group
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