Adjunctive Treatments in ART

Abstract

A variety of approaches have been proposed to enhance ovarian response or implantation in the assistive reproductive technologies of which many have offered routinely in the absence of adequate evidence supporting their use. In this chapter, we investigate four commonly employed adjunctive treatments and critically assess both the logic behind and evidence supporting their use. (1) Growth hormone has been evaluated in a variety of randomized clinical trials as adjunctive therapy for controlled ovarian hyperstimulation regimes. Its use does not appear to be beneficial for the average patient, but there is suggestive evidence that ovarian response and live birth rates may be improved in a subset of prior poor responders. However, the ideal dose or duration has not been determined. (2) DHEA has only been evaluated in a small prospective published randomized trial which demonstrated enhanced pregnancy rates and embryo quality in poor responders who had failed IVF. Case control studies do not consistently confirm enhanced IVF pregnancy rates, although ovarian response may be improved. The appropriate dose and duration of therapy has not been defined. (3) The addition of low dose aspirin had been shown in earlier meta-analyses to slightly increase IVF pregnancy rates. However, recent randomized clinical trials demonstrate no benefit when administered routinely prior to IVF. Nevertheless, it is possible that administration to a subset of patients with antiphospholipid antibody syndrome, recurrent pregnancy loss, or history of prior failed cycles, may be of some benefit, although confirmatory data is lacking. (4) Analysis of results from trials on the effect of acupuncture and IVF cycle outcome is confounded by variables including variations in technique, patient populations, timing, and control groups. An overview of randomized control trials shows no clearly defined benefit of acupuncture on IVF pregnancy and delivery rates, although the ideal study has not been performed. If there is a benefit of this approach, it may be when performed the day of embryo transfer. In conclusion, it is critical that adjunctive therapies be critically evaluated in appropriately designed randomized trials before they are generally accepted and introduced into widespread use.