Poor ovarian response: the fertility ultramarathon and the decision to go one more.

Use of letrozole challenge test to adjust gonadotropin dose in non–down-regulated cycles

Background and Aims: For non-severe male factor infertility patients with poor and sub-optimal ovarian response, are there any differences in reproduction outcomes between IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection) methods? Methods: Retrospective cohort study. Patients with non-severe male infertility and poor ovarian response who underwent in vitro fertilization or intracytoplasmic sperm injection at the Center for Reproductive Medicine, Peking University Third Hospital between 2009 and 2019 were included in this study (n = 30,352). Results: In all groups, intracytoplasmic sperm injection cycles involved older patients and a longer duration of infertility, while body mass index, AMH, and bFSH levels were similar. Independent of the number of oocytes retrieved, intracytoplasmic sperm injection significantly increased the fertilization rate, while in vitro fertilization cycles showed a higher implantation rate, clinical pregnancy rate, and live birth rate. No differences were observed in most obstetric outcomes, including abortion, early abortion, multiple fetus, cesarean delivery, gestational age, and congenital malformations rates. However, in vitro fertilization cycles showed higher preterm delivery rates and lower birth weights in groups with 4-6, and 7-9 oocytes retrieved. A higher female/male infant ratio was observed in intracytoplasmic sperm injection cycles when 4-6 oocytes were retrieved. Conclusions: In patients with non-severe male infertility and poor or suboptimal ovarian response, even if intracytoplasmic sperm injection increased the fertilization rate, in vitro fertilization exhibited significant advantages in implantation, clinical pregnancy, and live birth rates. Our study indicates that poor ovarian response is not an indication for intracytoplasmic sperm injection in couples with non-severe male infertility.

Study question To investigate if the anti-ovarian antibody (AOA) is associated with poor ovarian response (POR) and pro-inflammatory immune responses in women undergoing assisted reproductive technology (ART) cycles. Summary answer The POR patients have a higher prevalence of AOAs. Women with autoimmune POR (POR(+)/AOA(+)) have dysregulated pro-inflammatory immune responses and metabolic factors. What is known already It has been proved that AOAs play important role in diseases that related to human reproduction such as premature ovarian failure (POF) which also termed as premature ovarian insufficiency (POI), infertility, polycystic ovary syndrome (PCOS), in vitro fertilization (IVF) implantation failure, and in poor ovarian response in IVF stimulation. The POR women had elevated inflammatory immune responses: increased NK cell count and cytotoxicity, B cell counts, Th1/Th2 ratio and elevated metabolic factors such as higher homocysteine and plasminogen activator inhibitor–1 (PAI–1) level. Study design, size, duration This study is a retrospective cohort study between December 2015 and February 2019. 248 women who underwent ART cycles were included. Study patients were divided into four groups based on AOA test and POR diagnose defined by the European Society of Human Reproduction and Embryology consensus: POR(-)/AOA (-) group (N = 148), POR(+)/AOA(-) group (N = 34), POR (-)/AOA (+) group (N = 44), POR(+)/AOA(+) group (N = 22). Peripheral blood was collected during the early follicular phase when they enter the program. Participants/materials, setting, methods The natural killer (NK) cell levels and cytotoxicity, T helper (Th) 1/Th2 cell ratios were measured by flowcytometry. Anti-phospholipid Antibodies (APA) was tested by enzyme linked immunosorbent assay (ELISA). AOA, 25 (OH) vitamin D level, homocysteine, PAI–1 level was tested by Immunofluorescence Assay.One way ANOVA was applied to compare the continuous variables among study groups. Chi-squared analysis or Fisher’s exact test were performed to compare the categorical variables. Main results and the role of chance The POR patients have a significantly higher prevalence of AOA than non-POR patients (39.3% vs. 22.9%, P = 0.017, OR 2.176 95% CI 1.156–4.099). Peripheral blood CD56+ NK cell level (%), NK cytotoxicity, CD19+CD5+ B–1 cell level (%) and IFN-g/IL–10 producing Th1/Th2 cell ratios were significantly higher in POR(+)/AOA(+) group than those of other groups (P < 0.05, P < 0.05, P < 0.05, P < 0.05, respectively). TNF-a/IL–10 producing Th1/Th2 cell ratio of POR(+)/AOA (+) group was significantly higher than those of POR(+)/AOA(-) and POR(-)/AOA(-) groups (P < 0.05, respectively). Peripheral blood homocysteine and vitamin D levels of the POR(+)/AOA (+) group were significantly lower than those of other groups (P < 0.005, respectively). Peripheral blood PAI–1 level of POR(+)/AOA(+) group was significantly higher than that of POR(-)/AOA(-) group (P < 0.05). In POR(+)/AOA(+) group, the prevalence of antiphospholipid antibody was significantly higher than that of POR(+)/AOA(-) group (54.5% vs 20.5%, P = 0.005, OR 4.667, 95% CI 1.532–14.216). Limitations, reasons for caution This was a single center study, results need to be validated across different center and study population. Wider implications of the findings: The diagnostic and therapeutic approaches for AOA (+) autoimmune POR patients should be differentiated from those for non-autoimmune POR. Trial registration number Not applicable

BackgroundPrediction of ovarian response prior to the ovarian stimulation cycle is useful in determining the optimal starting dose of recombinant follicle-stimulating hormone (r-FSH). This study was designed to (I) evaluate which of the following parameters (age, AMH, and FSH) can be used as a predictor of ovarian response to GnRH antagonist stimulation protocol, (II) determine the cutoff value of AMH and age for predicting poor and high ovarian response, and (III) investigate the relationship between age, AMH level, and other clinical parameters. It is a retrospective study. A total of 318 women with a mean age of 28.2 ± 5.9 years old were included in this study. Hormone levels (FSH, LH, PRL, E2, and AMH) and the number of collected oocytes were determined. Based on the number of retrieved oocytes, the participants were divided into three groups: poor response (oocytes < 4, n= 51), normal response (oocytes 4–14, n= 192), and high response (oocytes > 14, n= 75).ResultsA significant increase has been found in AMH level and number of retrieved oocytes and mature oocytes from low to normal and high ovarian response group (P < 0.001). Also, the age in the poor ovarian response group was significantly greater than normal and high ovarian response groups (P < 0.001). A significant positive correlation has been found between the number of retrieved oocytes and mature oocytes and level of AMH (P < 0.001). The receiver operating characteristic (ROC) curves showed that both AMH and age had the highest accuracy in the prediction of poor ovarian response with a cutoff value < 1.45 and > 31.5 years, respectively. Additionally, the ROC analysis has shown that the AMH had the highest accuracy, followed by age in the prediction of high ovarian response with a cutoff value > 3.55 and < 27.5 years, respectively.ConclusionsThis study demonstrates that AMH level and women’s age may be used as potential predictors of ovarian response to GnRH antagonist stimulation protocol.

The definition presented here represents the first realistic attempt by the scientific community to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. POR to ovarian stimulation usually indicates a reduction in follicular response, resulting in a reduced number of retrieved oocytes. It has been recognized that, in order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. By definition, the term POR refers to the ovarian response, and therefore, one stimulated cycle is considered essential for the diagnosis of POR. However, patients of advanced age with an abnormal ORT may be classified as poor responders since both advanced age and an abnormal ORT may indicate reduced ovarian reserve and act as a surrogate of ovarian stimulation cycle outcome. In this case, the patients should be more properly defined as 'expected poor responder'. If this definition of POR is uniformly adapted as the 'minimal' criteria needed to select patients for future clinical trials, more homogeneous populations will be tested for any new protocols. Finally, by reducing bias caused by spurious POR definitions, it will be possible to compare results and to draw reliable conclusions.

To determine the predictive value of serum anti-müllerian hormone (AMH) concentrations and antral follicle counts (AFC), on ovarian response and live birth rates after IVF and compare with age and basal FSH. Basal levels of AMH, FSH and antral follicle count were measured in 192 patients prior to IVF treatment. The predictive value of these parameters were evaluated in terms of retrieved oocyte number and live birth rates. Poor responders in IVF were older, had lower AFC and AMH but higher basal FSH levels. In multivariate analysis AFC was the best and only independent parameter among other parameters and AMH was better than age and basal FSH to predict poor response to ovarian stimulation. Addition of AMH, basal FSH, age and total gonadotropin dose to AFC did not improve its prognostic reliability. Area under curve (AUC) for each parameter according to ROC analysis also revealed that AFC performed better in poor response prediction compared with AMH, basal FSH and age. The cut-off point for mean AMH and AFC in discriminating the best between poor and normal ovarian response cycles was 0.94 ng/mL (with a sensitivity of 70% and a specificity of 86%) and 5.5 (with a sensitivity of 91% and a specificity of 91%), respectively. However, age was the only independent predictor of live birth in IVF as compared to hormonal and ultrasound indices of ovarian reserve. AFC is better than AMH to predict poor ovarian response. Although AMH and AFC could be used to predict ovarian response they had limited value in live birth prediction. The only significant predictor of the probability of achieving a live birth was age.

This study aims to investigate alterations in immune cell counts within preovulatory follicles of patients with poor ovarian response (POR) during assisted reproductive technology (ART), classified according to the POSEIDON criteria. This single-centre cross-sectional study included 543 women undergoing IVF/ICSI treatment, selected based on specific inclusion and exclusion criteria: 292 with normal ovarian response and 251 with poor response. Follicular fluid (FF) was collected on the day of oocyte retrieval and analysed by flow cytometry to determine the proportions of macrophages (Mφs), M1 and M2 Mφs, T cells (CD4 and CD8 T cells), dendritic cells (DCs), including type 1 conventional dendritic cells (cDC1) and type 2 conventional dendritic cells (cDC2), and neutrophils. Multivariable logistic regression assessed the relationship between immune cell counts and POR, Pearson correlation determined associations with the number of retrieved oocytes, and receiver operating characteristic (ROC) curves evaluated the predictive power of immune cell counts for POR. Immune cells accounted for 52.57% (±23.90%) of the total cell population in the follicular microenvironment, which was approximately equal to that of granulosa cells, with Mφs being the most abundant, followed sequentially by T cells, DCs, and neutrophils. In patients with POR, overall Mφs infiltration in the follicular microenvironment decreased, whereas M1 and M2 polarization increased. T cell infiltration increased, with a decrease in the CD4/CD8 ratio. Both cDC1 and cDC2 were significantly elevated. Moreover, multivariable logistic regression revealed that the total macrophage count, CD4 T cell count, and cDC2 count were independent predictors of POR. Notably, cDC2 showed the largest area under the ROC curve, suggesting its strong potential as a biomarker for predicting POR. The proportion of immune cells in preovulatory follicles were significantly altered in patients with POR. These findings suggest that immune cell dynamics in the follicular microenvironment may play a crucial role in determining ovarian response and prognosis, indicating that targeted immunomodulatory strategies could be considered in future therapeutic approaches.

Study question Whether women pregnant after a poor response in IVF have obstetric and perinatal complications more frequently than women with pregnancies after a normal response in IVF? Summary answer There were no statistically significant differences in obstetric and perinatal complications rate between poor responders and normal responders in Chinese women. What is known already Poor ovarian response usually indicates a reduction in follicular response, resulting in a reduced number of retrieved oocytes. Patients are less likely to conceive and have a higher risk of cycle cancellation and low clinical pregnancy rate. Whether poor ovarian response is associated with obstetric and perinatal complications is however debated. Study design, size, duration Design: Prospective, monocentric, observational study. Size: 1664 women with poor ovarian response and 1061 women with normal ovarian response duration : July 1, 2017 to Aug 15, 2019.Participants/materials, setting, methods: 1664 women with poor ovarian response and 1061 women with normal ovarian response undergoing IVF or ICSI were enrolled in this study. The primary outcome was obstetric and perinatal complications rate. Main results and the role of chance 1664 women with POR and 1061 women with NOR were enrolled in this study.Poor and normal responders did not have significantly different incidences in obstetric and perinatal complications(25.42% vs 25.45%), nor were there a significant difference in preeclampsia, gestational diabetes mellitus, postpartum hemorrhage or abruptio placentae. But POR group have a lower frequency of twin pregnancies(8.47% vs 28.66%,P&amp;lt;0.01),low birth weight(5.08% vs 14.23%,P&amp;lt;0.01)and prematurity (9.32% vs 17.03%,P&amp;lt;0.01). Limitations, reasons for caution Despite its size, an observational study such as this has a number of inherent limitations, and the best way to confirm its findings will be to compare obstetric and perinatal outcomes in different subgroup of pregnancies following ART in an adequately powered randomized, controlled trial. Wider implications of the findings: This prospective, monocentric, observational study suggests that women with poor ovarian response did not have higher perinatal complication rate than women with normal ovarian response. Oocyte quality and quantity may not affect the rate of perinatal complications. Trial registration number Not applicable

Poor ovarian response is a significant problem encountered during in vitro fertilization and embryo transfer procedures. Many infertile women may suffer from poor ovarian response and its incidence tends to be increasing in young patients nowadays. It is a major cause of maternal infertility because it is associated with low pregnancy and live birth rates. However, the cause of poor ovarian response is not clear. In this study, we extracted microRNAs from human follicular fluid and performed miRNA sequencing to investigate a potential posttranscriptional mechanism underlying poor ovarian response. The results showed that many miRNAs were obviously different between the poor ovarian response and non-poor ovarian response groups. We then performed quantitative polymerase chain reaction, Western blot analysis and used an in vitro culture system to verify the sequencing results and to study the mechanism. Notably, we found that miRNA-15a-5p was significantly elevated in the young poor ovarian response group. Furthermore, we demonstrated that high levels of miR-15a-5p in the young poor ovarian response group repressed granulosa cell proliferation by regulating the PI3K-AKT-mTOR signaling pathway and promoted apoptosis through BCL2 and BAD. This could explain the reduced oocyte retrieval number seen in poor ovarian response patients.

Study question Is there an impact of recombinant luteinizing-hormone (rLH) administration timing during controlled ovarian stimulation (COS) on ovarian response and intracytoplasmic sperm injection (ICSI) cycles outcomes? Summary answer rLH supplementation in patients with poor ovarian response (POR) improves laboratorial and clinical outcomes when started in the mid-follicular phase, in GnRH antagonist ICSI cycles. What is known already Meta-analyses demonstrated that the use of rLH combined with rFSH for COS may lead to more ongoing pregnancies than rFSH alone. However, there is limited evidence that the timing of rLH addition to rFSH may impact the ovarian response or the outcomes of ICSI, based on a limited casuistic, which demonstrated improved ovarian response, embryo quality and pregnancy rate with LH supplementation from GnRH antagonist administration day, in estimated POR patients. The objective of the present study was to further investigate this hypothesis in a larger population, and in subpopulations of patients stratified by age and response to COS. Study design, size, duration This historical cohort study included data obtained via chart review of 1278 ICSI cycles performed in 1278 patients between 2015 and 2018, in a private university-affiliated in vitro fertilization center. Post hoc power analysis was calculated, given α of 5%, sample size of 1278, and effect size for implantation rate. The achieved power was superior to 99%. Participants/materials, setting, methods Two groups were formed according to timing of LH administration: Group LH-start (n = 323), in which LH was started on day–1; and Group LH-mid (n = 955), in which LH was started with GnRH antagonist. Then, data were stratified according to female age (&amp;lt;35 years-old, n = 283, and ≥35 years-old, n = 995) and response to COS (poor response (POR): ≤4 retrieved oocytes, n = 423, and normal response: &amp;gt;5 retrieved oocytes, n = 855). Ovarian response and ICSI outcomes were compared among the groups. Main results and the role of chance In POR patients, significantly higher fertilization rate (68.3% ± 2.5 vs. 78.6% ± 3.7, p = 0.023), blastocyst development rate (22.5% ± 7.2 vs. 44.7% ± 6.2, p = 0.022) and implantation rate (17.6% ± 59.1 vs. 20.2% ± 43.2, p &amp;lt; 0.001) were observed in Group LH-mid, even though the amount of LH used in these patients was not significant different from that used in Group LH-mid from patients with normal response to COS (1062.35 IU ± 54.33 vs. 925.81 IU ± 414.41, p: 0.431, respectively). For the general group and in patients aged ≥ 35 years, higher blastocyst development rates were observed in Group LH-mid compared to Group LH-start (33.0% ± 31.9 vs. 40.8% ± 32.6, p = 0.012, and 28.8% ± 30.4 vs 38.5% ± 32.3, p = 0.006, respectively). In patients aged &amp;lt; 35 years and in those with normal response to COS, similar outcomes were obtained irrespective of timing of LH administration. Limitations, reasons for caution The limitations included the retrospective design and limited sample size in subpopulations. In addition, the reduced clinical outcomes related to POR patients may hamper the true estimation of the differences between the stimulation groups in terms of pregnancy and miscarriage rates. Wider implications of the findings: In POR patients, mid-follicular phase LH supplementation starting with 150 IU daily doses, may rescue the ongoing cycle by compensating an initial slow response, and balancing the deprivation of endogenous LH in GnRH antagonist cycles, with no need of expending more gonadotropin compared to patients with normal response to COS. Trial registration number Not applicable

Day 2 embryo transfer (ET) and day 3 ET afford similar reproductive outcomes in the poor responder

Is poor ovarian response associated with a change in predicted age based on a DNA methylation-derived age prediction model (the Horvath algorithm) in white blood cells (WBCs) or cumulus cells (CCs)? In young women, poor ovarian response is associated with epigenetic age acceleration within WBC samples but is not associated with age-related changes in CC. The majority of human tissues follow predictable patterns of methylation which can be assessed throughout a person's lifetime. DNA methylation patterns may serve as informative biomarkers of aging within various tissues. Horvath's 'epigenetic clock', which is a DNA methylation-derived age prediction model, accurately predicts a subject's true chronologic age when applied to WBC but not to CC. A prospective cohort study was carried out involving 175 women undergoing ovarian stimulation between February 2017 and December 2018. Women were grouped according to a poor (≤5 oocytes retrieved) or good (>5 oocytes) response to ovarian stimulation. Those with polycystic ovary syndrome (PCOS) (n = 35) were placed in the good responder group. DNA methylation patterns from WBC and CC were assessed for infertile patients undergoing ovarian stimulation at a university-affiliated private practice. DNA was isolated from peripheral blood samples and CC. Bisulfite conversion was then performed and a DNA methylation array was utilized to measure DNA methylation levels throughout the genome. Likelihood ratio tests were utilized to assess the relationship between predicted age, chronologic age and ovarian response. The Horvath-predicted age for WBC samples was consistent with patients' chronologic age. However, predicted age from analysis of CC was younger than chronologic age. In subgroup analysis of women less than 38 years of age, poor ovarian response was associated with an accelerated predicted age in WBC (P = 0.017). Poor ovarian response did not affect the Horvath-predicted age based on CC samples (P = 0.502). No alternative methylation-based calculation was identified to be predictive of age for CC. To date, analyses of CC have failed to identify epigenetic changes that are predictive of the aging process within the ovary. Despite the poor predictive nature of both the Horvath model and the novel methylation-based age prediction model described here, it is possible that our efforts failed to identify appropriate sites which would result in a successful age-prediction model derived from the CC epigenome. Additionally, lower DNA input for CC samples compared to WBC samples was a methodological limitation. We acknowledge that a universally accepted definition of poor ovarian response is lacking. Furthermore, women with PCOS were included and therefore the group of good responders in the current study may not represent a population with entirely normal methylation profiles. The process of ovarian and CC aging continues to be poorly understood. Women who demonstrate poor ovarian response to stimulation represent a common clinical challenge, so clarifying the exact biological changes that occur within the ovary over time is a worthwhile endeavor. The data from CC support a view that hormonally responsive tissues may possess distinct epigenetic aging patterns when compared with other tissue types. Future studies may be able to determine whether alternative DNA methylation sites can accurately predict chronologic age or ovarian response to stimulation from CC samples. Going forward, associations between epigenetic age acceleration and reproductive and general health consequences must also be clearly defined. No external funding was obtained for the study and there are no conflicts of interest. N/A.

This research aimed to retrospectively investigate the possible association between poor ovarian stimulation and selected thrombophilia markers in Iranian women with infertility. For this study 100 Iranian infertile women, with a history of at least three Assisted Reproduction Technology (ART) failures (50 with a poor ovarian response and 50 with a normal response), referred to Royan Institute were selected. Targeted genetic variation evaluation for Factor V G1691A, F II Prothrombin G20210A, MTHFR C677T, MTHFR A1298C was performed by PCR-RFLP followed by Sanger Sequencing. The association between these variants and the ovarian response was examined. The results showed an association between Factor V G1691A mutation and poor ovarian response. The heterozygosity rate of the FVL was significantly different between poor responders compared with the normal response group (p-value ≤ 0.05). In conclusion screening of this polymorphism can be used as a genetic determinant of ovarian response functioning through a vascular mechanism. A larger study with bigger sample size is recommended. Impact statement What is already known on this subject? Thrombophilia is a multi-genetic disease that is associated with changes in homeostatic mechanisms. Some studies have suggested that thrombophilia has no relationship with poor ovarian response and reduced ovarian reserve in general infertile population undergoing ART. What do the results of this study add? Our results showed a significant association between the FVL heterozygote mutation and poor ovarian response. What are the implications of these findings for clinical practice and/or further research? Screening of FVL polymorphism may be suggested as a predictive test for ovarian stimulation response in infertile women undergoing ART. Further prospective studies with bigger sample size evaluating other thrombophilia markers and ovarian response, as well as further in-vitro studies may help clarify the biological mechanisms behind the effect of the FVL polymorphism on ovarian response, oocyte quality and embryo quality.

Due to the influence of economic, social and many other factors, there are more and more reproductive problems. Originally introduced for managing male factor infertility, intracytoplasmic sperm injection had become the most commonly used fertilization treatment in the world, with broadened indications including low oocyte yield, prior fertilization failure with conventional in vitro fertilization etc. However, academic evidence for better live-birth outcomes of intracytoplasmic sperm injection over conventional in vitro fertilization is limited. Thus, we aimed to compare the reproductive outcomes of conventional in vitro fertilization and intracytoplasmic sperm injection in patients with non-severe male factor infertility across poor and different sub-optimal ovarian response categories. The fertility rate, implantation rate, clinical pregnancy rate, live birth rate and other obstetric outcomes were mainly compared. Our results showed that independent of the number of oocytes retrieved, intracytoplasmic sperm injection significantly increased the fertilization rate, while conventional in vitro fertilization cycles showed a higher implantation rate, clinical pregnancy rate, and live birth rate. No differences were observed in most obstetric outcomes. Our study indicates that poor ovarian response is not an indication for intracytoplasmic sperm injection in couples with non-severe male infertility.

Predictive value of poor ovarian response to initial gonadotropin stimulation