Antagonist Stimulation Protocol Research Articles

Evaluation of the Impact of Letrozole in Combination with the GnRH Antagonist Ovarian Stimulation Protocol in Patients Expected to Have a Poor Ovarian Response (POSEIDON Groups 3 and 4).

Background and Objectives: The objective of this study was to evaluate the impact of adjuvant letrozole administration during ovarian stimulation using the gonadotropin-releasing hormone (GnRH) antagonist protocol on treatment outcomes in women categorized into POSEIDON groups 3 and 4. Materials and Methods: This retrospective cohort study analyzed data from patients classified into POSEIDON groups 3 and 4 who underwent fresh embryo transfer subsequent to intracytoplasmic sperm injection following a GnRH antagonist stimulation protocol between January 2017 and December 2021. Patients were divided into two groups: the GnRH-LZ group, who received letrozole at a dosage of 5 mg/day for five consecutive days, and the GnRH-ant group, who did not receive adjuvant letrozole. The primary outcome measure of the study was a comparative analysis of live birth rates between the two groups. Results: A total of 449 patients were deemed suitable for final analysis and were allocated into two groups: 281 patients in the GnRH-ant group and 168 patients in the GnRH-LZ group. Live birth rates were found to be comparable in both groups (11% vs. 9%, p = 0.497). Letrozole administration significantly reduced the total amount of gonadotropins required (2606.2 ± 1284.5 vs. 3097.8 ± 1073.3, p < 0.001), the duration of ovarian stimulation (11.2 ± 3.9 vs. 10.2 ± 3, p = 0.005), and the serum peak estradiol concentration (901.4 ± 599.6 vs. 463.8 ± 312.3, p < 0.001). Conclusions: Adjuvant letrozole administration did not demonstrate a significant impact on live birth rates among women categorized into POSEIDON groups 3 and 4. However, this approach may offer potential cost reductions by diminishing the necessity for exogenous gonadotropins and shortening the duration of ovarian stimulation.

Oocytes on ice: Exploring the advancements in elective egg freezing for women.

Female fecundity decreases significantly after the age of 32, and rapidly so after age 37. There is no treatment to prevent this decline. Furthermore, globally, women are getting married later and the age at which they have their first child is increasing. As of July 2023, elective egg freezing (EEF) or oocyte cryopreservation (OC) for age-related fertility decline, commenced in Singapore. With medical advancements in OC, EEF is no longer considered experimental. The aim of this review is to examine the existing literature around EEF with regard to reproductive outcomes and its safety, to better guide clinicians in counselling young single women. Published studies were examined to increase understanding on optimal age for EEF, ideal number of oocytes for a live birth, recommended OC protocols, cryopreservation techniques affecting thaw survival or fertilisation, oocyte storage and pregnancy risks. Models predict that EEF should be performed at age <37 years and to achieve a 70% chance of live birth, women would need 14, 15 and 26 mature oocytes at ages 30-34, 35-37 and >38 years, respec-tively. An antagonist stimulation protocol with an agonist trigger would minimise ovarian hyper-stimulation syndrome and duration of stimulation without affecting outcomes. Oocyte vitrification in comparison to slow freezing increases thaw survival, fertilisation and clinical pregnancy rates. No increased risks exist for the woman, future pregnancy or child when compared with conventional IVF. EEF is a viable option for single women desiring fertility preservation. Financial costs are significant, but returns are worthwhile if oocytes are utilised.

STUDY ON DETERMINANTS OF SUCCESSFUL OUTCOME IN ICSI PREGNANCIES IN A TERTIARY CARE CENTRE

Objectives: A descriptive study was done at the government medical college in Thiruvananthapuram to find out the determinants of the successful outcome of intracytoplasmic sperm injection (ICSI) pregnancies. Methods: The study was done on 60 ART-conceived patients who underwent ICSI and became positive for pregnancy during 1 year. Their pregnancy was followed up, and data was collected in a structured proforma about determinants of successful outcomes. Results: Out of 60 in vitro fertilization (IVF)-conceived subjects (n=60), the maximum age group (40%) that underwent IVF treatment was between 31 and 35 years old, and they belonged to an upper-lower socio-economic status. 45% of patients had a normal body mass index, 46.7% were overweight, and 8.3% were obese. 73.3% were nulliparas.78.3% had primary infertility, and 21.1% had secondary infertility. The prevalence of male infertility was 6.7%, and female infertility was 81.7%. 81.1% had regular menstrual cycles. 8.3% of patients had medical disorders, and 48% of patients had previous surgeries like polypectomy, polycystic ovarian drilling, and laparoscopy for endometriosis. 71.7% were given the GnRH antagonist stimulation protocol for 8–12 days, and 11–15 eggs were obtained in 66.7% of the patients. 91.7% of frozen embryos were transferred. Conclusion: The success of an ICSI pregnancy is determined by the younger age of the female partner, female factor infertility, antagonist stimulation protocol, and the transfer of a frozen embryo.

Guideline No. 315: Prevention of Ovarian Hyperstimulation Syndrome

Summary Statements1.The particular follicle-stimulating hormone formulation used for ovarian stimulation does not affect the incidence of ovarian hyperstimulation syndrome. (I)2.Coasting may reduce the incidence of severe ovarian hyperstimulation syndrome. (III)3.Coasting for longer than 3 days reduces in vitro fertilization pregnancy rates. (II-2)4.The use of either luteinizing hormone or human chorionic gonadotropin for final oocyte maturation does not influence the incidence of ovarian hyperstimulation syndrome. (I)5.There is no clear published evidence that lowering the human chorionic gonadotropin dose will result in a decrease in the rate of ovarian hyperstimulation syndrome. (III)6.Cabergoline starting from the day of human chorionic gonadotropin reduces the incidence of ovarian hyperstimulation syndrome in patients at higher risk and does not appear to lower in vitro fertilization pregnancy rates. (II-2)7.Avoiding pregnancy by freezing all embryos will prevent severe prolonged ovarian hyperstimulation syndrome in patients at high risk. (II-2)8.Pregnancy rates are not affected when using gonadotropin-releasing hormone (GnRH) agonists in GnRH antagonist protocols for final egg maturation when embryos are frozen by vitrification for later transfer. (II-2) Recommendations1.The addition of metformin should be considered in patients with polycystic ovarian syndrome who are undergoing in vitro fertilization because it may reduce the incidence of ovarian hyperstimulation syndrome. (I-A)2.Gonadotropin dosing should be carefully individualized, taking into account the patient’s age, body mass, antral follicle count, and previous response to gonadotropins. (II-3B)3.Cycle cancellation before administration of human chorionic gonadatropin is an effective strategy for the prevention of ovarian hyperstimulation syndrome, but the emotional and financial burden it imposes on patients should be considered before the cycle is cancelled. (III-C)4.Gonadotropin-releasing hormone (GnRH) antagonist stimulation protocols are recommended in patients at high risk for ovarian hyperstimulation syndrome (OHSS). The risk of severe OHSS in patients on GnRH antagonist protocols who have a very robust ovarian stimulation response can be reduced by using a GnRH agonist as a substitute for human chorionic gonadotropin to trigger final oocyte maturation. (I-B)5.A gonadotropin-releasing hormone (GnRH) antagonist protocol with a GnRH agonist trigger for final oocyte maturation is recommended for donor oocyte and fertility preservation cycles. (III-C)6.Albumin or other plasma expanders at the time of egg retrieval are not recommended for the prevention of ovarian hyperstimulation syndrome. (I-E)7.Elective single embryo transfer is recommended in patients at high risk for ovarian hyperstimulation syndrome. (III-C)8.Progesterone, rather than human chorionic gonadotropin, should be used for luteal phase support. (I-A)9.Outpatient culdocentesis should be considered for the prevention of disease progression in severe ovarian hyperstimulation syndrome. (II-2B)

P-452 Economic impact of antagonist stimulation protocol vs progestin primed stimulation protocol in oocyte donor program A retrospective study

Abstract Study question Is the cost per oocyte lower in antagonist ovarian stimulation protocol vs progestin primed ovarian stimulation protocol in oocyte donation program? Summary answer The cost per oocyte is lower in progestin primed stimulation protocol in oocyte donation program What is known already 1. The use of progesterone during ovarian stimulation is effective in blocking the LH surge, and it does not affect the number of oocytes collected or the quality of the embryos obtained. Progestins can be used orally and are less expensive than GnRH analogues. These new regimens enable more flexibility and are interesting but their medical and economic significance remains to be demonstrated. Study design, size, duration Calculation of cost-effectiveness ratios (cost per mature oocyte achieved) using data derived from retrospective clinical practice in a large egg donor program of a single University Hospital between 2011 and 2021 5677 egg donor cycles identified from the electronic medical records database were eligible. Participants/materials, setting, methods Donors fulfilled national legal and medical-guide requirements, 18- 35 y.o, regular menstrual cycles, BMI 18-30 Kg/m2, no relevant medical history and normal karyotype. They were divided into 2 groups(4subgroups): Antagonist FSH stimulation group(subcategory recombinant and biosimilar FSH) and Progestin primed FSHstimulation group(subcategory recombinant and biosimilar FSH). Demographic data were collected and compared between groups. The cost per unit of gonadotrophin, progestin and antagonist was calculated according to the manufacturer’s sale price. Main results and the role of chance The mean age of women recruited into the study was 26,5 years. The distribution into the different study groups was as follows: 1.1. 3155 (55,6%) in recombinant FSH antagonists group (FSHrA), Mean days stimulation 9,17-antagonists 4,91; mature eggs:13,62 2.2. 1489 (26,2%) in biosimilar recombinant FSH antagonist group (FSHrbA), Mean days: stimulation 9,17-antagonists 5,28; mean mature eggs: 13,37 3.3. 187 (3%) in recombinant FSH progestin primed group (FSHrPP), Mean days stimulation 9,26-desogestrel 23; mean mature eggs: 12,54 4.4. 846 (14,9%) in biosimilar recombinant FSH progestin primed group(FSHrbPP). Mean days stimulation 9,07-desogestrel 24; Mean mature eggs: 13,78 According to clinical outcomes in oocyte donor, we did not find statistical differences neither in the mean of days of stimulation nor in mature eggs collected in each treatment group but there is a higher rate in the range of 0-4 mature eggs collected in Progestin primed group. The costs for each drug were as follows: 0,33-0,382€ per unit of recombinant FSH; 0,299-0,33€ per unit of recombinant biosimilar FSH; 25,85€ per unit of Ganirelix; 0,14 per unit of Desogestrel. In conclusion, cost savings can be achieved using FSH progestin primed treatment. The cost per mature oocyte is 52,59€ compared with 58,25€ per oocyte in FSH antagonist group. Limitations, reasons for caution Cancellations before reaching pickup are not contemplated,they may increase the total cost of the cycle. Although the days of stimulation are equivalent in the different groups, the cost of visits including the costs of nursing, infrastructure, patient care time and consumables might be different between the groups. Wider implications of the findings Progestins can present an effective option for egg donation programs in terms of cost Trial registration number not applicable

Egg donor self-reports of ovarian hyperstimulation syndrome: severity by trigger type, oocytes retrieved, and prior history

PurposeTo evaluate self-reported survey data provided by US oocyte donors on their experiences with ovarian hyperstimulation syndrome and possible correlations between OHSS severity and number of oocytes retrieved, trigger type, and prior OHSS history.MethodsAn 85-question retrospective survey was administered online. Survey questions included demographic information, reasons for donating, immediate per-cycle experiences and outcomes, perceptions of informed consent, and perceived impact of donation on long-term health. Quantitative Data for this study was collected between February 2019 and September 2020 via QualtricsXM (January 2019), an online survey platform. Follow-up interviews were also conducted. Participants were recruited via fertility clinics, egg donation agencies, and online forum. The research was approved by the University of California, San Francisco Institutional Review Board (#14-14765).ResultsOf 420 initiated US oocyte donor online surveys, 289 (68%) respondents provided detailed information on per cycle experiences with ovarian hyperstimulation syndrome, number of oocytes retrieved, and trigger type over a total of 801 cycles. On cycles where donors reported receiving GnRH agonist triggers (n = 337), they reported milder OHSS compared to cycles with hCG or dual triggers. Among donors undergoing multiple retrieval cycles, the severity of OHSS in second cycles was strongly associated with OHSS severity in first cycles.ConclusionSelf-reported OHSS in oocyte donors is lower in GnRH antagonist stimulation protocols combined with GnRHa trigger and in cycles where donors reported fewer than 30 oocytes retrieved. Donors who reported severe OHSS on a prior cycle were significantly more likely to experience severe OHSS on a subsequent cycle.

Effect of vaginal/oral tadalafil on endometrial thickness in IVF patients: a double-blind, placebo controlled RCT: a pilot study.

To investigate the effect of tadalafil (a long working phosphodiesterase type 5 inhibitor) on the endometrial thickness, biochemical pregnancy rates and clinical pregnancy rates in women in an in vitro fertilization treatment. This study investigates the use of vaginal and oral administration of tadalafil. This is a prospective double-blind placebo-controlled randomized controlled trial with 58 patients in an in vitro fertilization treatment with a short antagonist stimulation protocol. The study population is divided into three equal groups comparing oral and vaginal administration of tadalafil to a control group. No significant difference in endometrial thickness and number of biochemical and clinical pregnancies was found between the three groups. This study could not show a significant benefit of administration of tadalafil. However, a trend towards more pregnancies in the group treated with oral tadalafil is seen, more research in specific subgroups is needed.

P-695 Anti-muellerian Hormone (AMH) and Plasminogen Activator Inhibitor (PAI-1) are robust follicular-fluid (FF) biomarkers predictive of follicle maturity and oocyte quality in women undergoing IVF cycles

Abstract Study question Is AMH the in-vivo trigger that correlates with PAI-1 in the follicular-fluid micro-milieu to influence maturity and quality of oocytes derived in vitro during IVF? Summary answer Lower FF-AMH levels correlate with top quality oocytes whereas Lower FF-PAI-1 levels correlate with follicle-maturity as reflected in mature MII oocytes retrieved in IVF cycles What is known already Ovulation is a time-coordinated tightly regulated proteolytic event. PAI-1, primarily produced by granulosa cells, is a major form of PAI in FF of human preovulatory follicles, allowing localized degradation and regulating ovulation.While ovulation process is rendered redundant in IVF cycles; nevertheless FF PAI-1 concentration may influence maturity of oocyte within the follicle. AMH is exclusively produced by granulosa cells of pre-antral &amp; early-antral ovarian follicles in the adult female and secreted into FF. Although AMH is widely accepted as an ovarian-reserve marker, very few studies have explored direct putative correlation of FF-AMH with oocyte quality in stimulated IVF cycles. Study design, size, duration Prospective study of n = 1150 (Power of study &amp;gt;85%) women (mean age 30.22±4.25 years, BMI 23.97±4.53, W/H ratio 0.88±0.06) undergoing antagonist stimulation protocol with r-FSH (September 2015-December 2018). On day of ovum pick-up, original aspirate per follicle was pooled per patient. AMH and PAI-1 were evaluated in pooled FF by ELISA method using diagnostic kits. These protein-biomolecules were expressed as ratio of total protein content. SerumE2, LH, P on d/hCG trigger were also estimated by RadioImmunoAssay. Participants/materials, setting, methods Elderly women (age&amp;gt;35 years), women with polycystic-ovaries, endometriosis were excluded. Embryo-transfer (ET) was done either on Day3 or day5. Luteal-phase was supported with micronized progesterone. All cycles were divided into Low FF-AMH (≤1.72 ng/mg protein), High FF-AMH (&amp;gt;1.72ng/mg protein) and Low FFPAI-1 (≤592.1 ng/mg protein), High FFAI-1 (&amp;gt;592.1 ng/mg protein) groups. Oocyte quality was graded as poor, average and top based on morphological assessment of COC-complex, zona-pellucida (thickness, regularity) and cytoplasm (granularity, vacuolation, refractile bodies). Main results and the role of chance Mean Age, Baseline D3-Serum AMH, E2 d/hCG and number of eggs retrieved did not differ significantly between low vs. High FF AMH groups as well as Low vs. High FF-PAI-1 groups. Low FF AMH group displayed significantly higher percent of top-quality oocytes (70.38±11.5 vs. 52.16±8.3;p&amp;lt;0.0001) and higher fertilization rates (88.68±10.7 vs. 72.5±9.2%; p = 0.004) compared to High FF AMH group. Incidences of total fertilization failure were significantly higher in high FF AMH (3.25% vs. 1.1%, p = 0.0002) compared to Low-FFAMH group. FF-AMH correlated with oocyte-quality (Pearsonr=0.48); lower-levels increased the odds of top-quality oocytes. Thresholds of FF-AMH for top quality oocytes was &amp;lt;1.8 ng/mg protein;ROCAUC:85%) Low FF PAI-1 group had significantly higher Percentage of MII oocytes (93.55 vs. 74.8%; p &amp;lt; 0.0001), Rates of Fertilization (86.35 vs. 71.04, p = 0.008) and cleavage (79.19 vs. 69.85;p=0.03) compared to High FF-PAI-1 group. FF-PAI-1 correlated with oocyte-maturity (Pearsonr=0.51), lower-levels increased the odds of obtaining MII-oocytes. Cutoff of FF PAI-1 for mature MII oocytes was &amp;lt;504.4 ng/mg protein;ROCAUC:76%). FF-AMH showed strong positive correlation with FF-PAI-1 (Pearsonr=0.66) Limitations, reasons for caution Several other molecules in the follicular-fluid milieu may be responsible for maturity status and quality of oocytes. Although these are apparently the most plausible of markers; role of other factors cannot be ruled out. Also, it may be better to study mono-follicular aspirates rather than pooled FF for each patient. Wider implications of the findings FF-levels of AMH and PAI-1 as non-invasive endogenous biomarkers of oocyte maturity and quality in-vitro may facilitate better understanding of the physiological pathway governing in-vivo ovulation process. This study reiterates ‘Follicle-maturation’ is the rate-determining step that sets off a cascade mechanism triggering oocyte-maturation and quality further influencing fertilization, embryo development. Trial registration number In patients with polycystic ovarian syndrome (PCOS), are serum androgen levels (total and free testosterone) associated with the risk of endometrial hyperplasia or cancer?

P-681 Balance of Estrogen:Androgen ratio (Estradiol E2: Dehydroepiandrosterone-sulphate DHEAS) and its symbiotic correlationship with Vascular-Endothelial Growth-Factor (VEGF) critically foments implantation and pregnancy outcomes in IVF cycles

Abstract Study question Is the estrogen/androgen balance vital for implantation and does this E2:DHEAS ratio coordinate with neoangiogenesis/neovascularisation (VEGF) to facilitate establishment of viable pregnancy in IVF cycles? Summary answer The Estradiol E2:DHEAS ratio independently as well as in symbiotic correlationship with VEGF is strongly predictive of invasive implantation and pregnancy outcomes in IVF cycles What is known already Decidualization of endometrial stroma and vascularization at feto-maternal interface is necessary for implantation. Estrogen Estradiol E2 is among the factors widely known to regulate these processes. Androgen Dehydroepiandrosterone (DHEA) is the designated primary precursor for natural estrogens. DHEA-induced PCOS mice have demonstrated adverse impacts on Embryo implantation and decidualization. However, role of DHEA/S in human implantation has not yet been explored. Vascular-Endothelial growth-factor (VEGF) is known to influence vascularization, angiogenesis, endometrial receptivity. Higher VEGF expression in endometrium is associated with pregnancy. However endometrial-biopsy for VEGF estimation is an invasive method for implantation studies and cannot be applied to ongoing cycles. Study design, size, duration Prospective study of n = 235 (Power of study&amp;gt;85%) non-PCOS, normal-responder infertile females (mean age 31.77±2.42 years, BMI 24.4±4.1, W/H ratio 0.82±0.07) undergoing fresh IVF treatment cycles using standard antagonist stimulation protocol at our fertility clinic during January 2019-December 2020. Elderly women (age&amp;gt;35 years), women with polycystic-ovaries, endometriosis and frozen-thawed cycles were excluded.7 cycles were cancelled owing to no embryo transfer (ET). Day3-cleavage stage or day5-blastocyst stage embryos were transferred (n = 228). Luteal-phase was supported with Micronized progesterone. Participants/materials, setting, methods Serum levels of Estradiol E2 and DHEAS were measured by Radio-Immunoassay and VEGF estimation by ELISA on day ET, day7, day14 post ET. Cycles were divided into Pregnant (P:n=73) and Non-Pregnant (NP=n=155) groups. Main outcome measures: Clinical Pregnancy (CPR:n=70=30.70%), Live-Birth (LBR:28.94%) rates. Secondary outcome measures: Biochemical-pregnancy (BCP:n=3=1.31%), Early-Miscarriage (EM:n=4=1.75%) rates. Pregnant=Serum βhCG&amp;gt;50 on d14ET. BCP=No exponential rise/tapering βhCG levels post d14ET, CP=positive cardiac activity at 6-8 weeks gestation, EM=non-viable intra-uterine pregnancy upto 12 weeks gestation. Main results and the role of chance dET: E2 did not differ significantly (780±50 vs. 750±30 pg/ml;p=0.61) whereas DHEAS = (212±11 vs. 170±6 ng/dL;p=0.0005), E2:DHEAS = (3.72±0.13 vs. 4.65±0.17;p=0.0011), VEGF = (658±20 vs. 495±16;p&amp;lt;0.0001) differed significantly between P vs. NP groups; indicating importance of E2/DHEAS ratio. D7ET: E2 = (790±57 vs. 222±19;p&amp;lt;0.0001), DHEAS = (381±28 vs. 1262±70;p&amp;lt;0.0001), E2:DHEAS = (2.37±0.25 vs. 0.30±0.029;p&amp;lt;0.0001), VEGF = (636±23.61 vs. 480±10.13;p&amp;lt;0.0001) displayed statistically robust differences between P vs. NP groups. d14ET: E2 = (855±73.45 vs. 193.2±13.31;p&amp;lt;0.0001), VEGF = (544.2±15.80 vs. 452.3±16.77;p=0.0011) displayed statistically robust differences between P vs. NP groups. Interestingly, although DHEAS = (685±41.05 vs. 806±55.37;p=0.18) did not differ significantly, E2:DHEAS = (1.643±0.26 vs. 0.45±0.048;p&amp;lt;0.0001) showed highly significant difference; again highlighting importance of E2/DHEAS balance. Ratio E2:DHEAS on d7ET correlated strongly with d7VEGF (Pearson r = 0.31,p&amp;lt;0.0001). ROC curve for d7 E2:DHEAS had AUC 78%, p &amp;lt; 0.0001 Hormone values and their rising trends (d/ET to d7/ET to d14/ET) varied with pregnancy outcome status E2= LB:(d/ET:780±50 to d7/ET:790±57 to d14/ET:855±73.45) vs. BCP:(d/ET:723.3±157.6 to d7/ET:743.3±159 to d14/ET:770±153) vs. EM:(d/ET:906.3±104 to d7/ET:1150±113 to d14/ET:1758±127) DHEAS= LB:(d/ET:212±11 to d7/ET:381±28 to d14/ET:685±41.05) vs. BCP:(d/ET:248.3±55 to d7/ET:266.7±71.2 to d14/ET:400±120.3) vs. EM:(d/ET:243.8±27 to d7/ET:303.8±11.43 to d14/ET:391.3±49) E2:DHEAS= LB:(d/ET:3.72±0.13 to d7/ET:2.37±0.25 to d14/ET:1.643±0.26) vs. BCP:(d/ET:2.93±0.15 to d7/ET:2.97±0.4 to d14/ET:2.12±0.32) vs. EM:(d/ET:3.78±0.40 to d7/ET:3.77±0.26 to d14/ET:4.68±0.59) Decreasing E2:DHEAS ratio (d/ET-d7/ET-d14/ET) is vital for successful implantation/Live-birth VEGF= LB:(d/ET:658±20 to d7/ET:636±23.61 to d14/ET:544.2±15.80) vs. BCP:(d/ET:513.3±37.56 to d7/ET:628.3±40.45 to d14/ET:468.3±35.63) vs. EM:(d/ET:647.5±78.8 to d7/ET:887.5±60 to d14/ET:1138±94.4) Limitations, reasons for caution This study is limited by small sample size and is not a randomized controlled trial. We have taken only representative molecules into consideration. There is a plethora of factors involved during the implantation process. Multi-centric systematic studies are needed to corroborate these findings and account for the probable confounding factors. Wider implications of the findings This novel study explores and highlights significance of maintenance of a critical estrogen/androgen ratio (E2:DHEAS), rather than individual estrogen or androgen markers, in the implantation process. We have also underscored how this ratio coordinates symbiotically with VEGF as a critical non-invasive determinant of implantation and pregnancy-outcomes in ongoing IVF cycles. Trial registration number Not Applicable

P-591 Cellular heterogeneity in the preovulatory follicle correlates with response to stimulation with recombinant FSH and affects somatic cell gene expression levels

Abstract Study question What is the difference in the composition and gene expression of pre-ovulatory follicular somatic cells between normo- and hyporesponder patients to rFSH stimulation? Summary answer Gene expression changes in the somatic cells of the preovulatory follicles of hyporesponder patients is partly attributable to distinct cell populations. What is known already Some women undergoing IVF respond suboptimally to the preceding ovarian stimulation without an indication of poor ovarian insufficiency nor advanced age. The gene expression levels in the somatic cells of their pre-ovulatory follicles have not been determined. However, the somatic cells play key roles in the transfer of gonadotrophin signals and in steroidogenesis. In the preovulatory follicle, being &amp;gt;20 mm in size, the somatic cells are exposed to various molecular gradients that drive their differentiation. Due to advancements in sequencing technologies the importance of somatic cell sub-populations in the etiologies of ovarian infertility can now be investigated by bioinformatic methods. Study design, size, duration Consecutive IVF patients &amp;lt;41 years of age were recruited at Nova Vita Clinic, Estonia, undergoing the antagonist stimulation protocol with rFSH administration. Ovarian puncture was performed for all patients after 36 hours of hCG stimulaton. rFSH dose &amp;gt;200 IU per one retrieved oocyte was considered as an indication for hyporesponse. Ten normo- and 9 hyporesponder patients were enrolled. Participants/materials, setting, methods Cells from the follicular fluid devoid of the cumulus oocyte complex were collected by centrifugation. RNA-seq was performed on the pooled cells of all participants. The study groups were compared by differential gene expression analysis by DESeq2. Single-cell RNA-seq was performed for &amp;gt;6000 individual cells of 3 normoresponder patients and cellular sub-populations were determined with Seurat package. CIBERTSORTx software was used to deconvolute the proportion of cell types from bulk RNA-seq data of all participants. Main results and the role of chance Alterations in the gene expression of ovarian somatic cells have been previously attributed to female age. We demonstrate that 407 genes are differentially expressed (FDR&amp;lt;0.05) between normo- and hyporesponder IVF patients after age adjustment. These genes were enriched into pathways of extracellular matrix reorganization (31 genes, FDR&amp;lt;0.005), post-translational protein phosphorylation (16 genes, FDR&amp;lt;0.006) and regulation of insulin-like growth factor transport and uptake by insulin-like growth factor binding proteins (16 genes, FDR&amp;lt;0.019). In addition, the sequencing of &amp;gt; 24 000 individual cells from 3 normoresponder patients revealed the somatic cell types of the preovulatory follicle in high resolution indicating the presence of immune cell populations (N = 4), epithelial cells, theca, cumulus cells and mural granulosa cell sub-populations (N = 7). Bioinformatic cell type deconvolution demonstrated significant differences between proportions of distinct cell sub-populations between normo- and hyporesponder patients and that several differentially expressed genes between the study groups can be attributed to a specific mural granulosa sub-population. Limitations, reasons for caution The number of study participants is small due to the high cost of the study methods. Wider implications of the findings The study demonstrates that hyporesponse to stimulation is associated with age-unrelated disturbances in gene expression of preovulatory somatic cells and that different somatic cell populations may have important underlying functions in the ovarian etiologies of infertility. Trial registration number not applicable

COMPARISON OF A 'FREEZE-ALL' STRATEGY VERSUS A 'FRESH TRANSFER' STRATEGY AMONG POOR RESPONDERS IN ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

Background: The standard procedure in ART is the use of fresh embryo transfer (FET) which has stood the test of time. But in recent years, frozen embryo transfer has also been used by many quite successfully and it may be a viable alternative to FET. Aim and Objective: The main aim of the study is to nd out if the clinical pregnancy rate per randomized patient after the rst good quality blastocyst transfer is superior in a freeze-all as compared with same cycle transfer strategy in poor responders. The main objective of present study is to compare the 'freeze-all' strategy with same cycle transfer strategy among poor responders in articial conception technology. Methods: An observational, prospective, cohort study was conducted between August 2018 and January 2019. In total, 102 poor responder patients (as per Poseidon criteria) were taken for COS with GnRH antagonist stimulation protocol and blastocyst stage embryo transfer was performed. Clinical pregnancy rate and ongoing pregnancy rate were signicantly higher in frozen em Results: bryo transfer group than fresh embryo transfer group. Conclusion: In poor responder group of patients, IVF outcomes can be improved by implementing freeze all policy. Major concern in poor responder patients is reduced oocyte competence due to availability of lesser oocyte. Therefore, better outcomes could be achieved with the help of Pre implantation genetic screening synchronized with latest endometrium receptivity markers which is only possible with freeze all policy.

Correlation of LH level and steroid concentrations in GnRH antagonist protocol: A sub-analysis of Ganirelix phase III study of China

BackgroundBased on the data obtained from a phase III, multicenter, open-label, randomized clinical trial that compared the use of GnRH agonist vs. antagonist for LH-suppression in IVF cycles, the present study attempted to determine the effect of LH level on steroid concentrations and IVF outcomes in the GnRH antagonist protocol. MethodsA total of 109 patients with the GnRH antagonist protocol were stratified into three subgroups according to the stimulation day six LH levels (LH <25%, 25–75%, and >75%), and the effect of LH on steroid biosynthesis and the related IVF outcomes between subgroups was observed. ResultsIn comparing the three subgroups of GnRH antagonist, no difference in number of oocytes, top quality embryos and ongoing pregnancy was observed. The high LH group on day six was exposed to significantly lower concentrations of rFSH from day six onwards, and had significantly higher estradiol levels on the day of hCG. The progesterone levels did not differ between groups at the start of the stimulation, but patients with the highest LH on day six also had significantly (P < 0.0001) higher progesterone levels on day six (higher estradiol on day six and hCG, lower total rFSH dosage). Due to the significantly lower increase in progesterone in the high LH group between day six and the day of hCG, no difference in progesterone level was observed on the day of hCG. ConclusionsFor steroid biosynthesis, early follicular phase LH levels help pregnenolone metabolize primarily via the ∆5 pathway in the GnRH antagonist stimulation protocol, but not via the ∆4 pathway.

Higher blastocyst implantation in frozen versus fresh embryo transfers in good prognosis patients.

There is emerging evidence that frozen embryo transfers provide a more favorable environment for implantation as compared to fresh embryo transfers. Our objective was to determine if there is a clinical benefit to frozen versus fresh blastocyst transfers in good prognosis patients. Subjects undergoing their first or second IVF/ICSI cycle <38 years of age in an OCP pretreated GnRH antagonist stimulation protocol with supernumerary embryos available for blastocyst cryopreservation were eligible for analysis. Primary transfer was exclusively blastocyst transfer. Exclusion criteria consisted of rescue ICSI, preimplantation genetic testing, donor oocytes, and surrogacy. The cohort was divided into two groups based on whether they underwent a fresh vs. frozen primary transfer. The implantation rates were compared using mixed-effects logistic regression. The clinical pregnancy and live birth rates were compared using logistic regression adjusted for number of oocytes retrieved and number of embryos transferred. All models included age, reason for treatment, and number of prior births as covariates. A total of 615 subjects were included in the study. There were no differences in the two groups with respect to age, BMI, baseline ovarian reserve testing, total gonadotropin dosage, and duration of stimulation. The implantation rate was higher in the frozen-embryo group as compared to the fresh-embryo group (59% and 48% respectively; OR 1.58; 95% CI 1.02-2.44). There was a trend towards higher clinical pregnancy and live birth rates in the frozen-embryo group. These differences persisted in the adjusted analysis. Among good prognosis patients undergoing IVF, frozen embryo transfer was associated with improved implantation rates. Consideration should be given to primary frozen blastocyst transfer in this population.

Comparison of Reproductive Outcomes on addition of GnRH agonist for Luteal phase Support in Antagonist IVF cycle

Background: The luteal phase supplementation was reported to be necessary in Controlled Ovarian Hyperstimulation cycles for IVF or ICSI, independently when agonistsor antagonist were used for pituitary desensitization. Theeffectiveness of GnRH agonist in luteal phase supplementation remains controversial.Aims and Objectives: This study aimed at comparing theclinical outcomes of addition of GnRH agonist for lutealphase support in antagonist IVF cycle.Materials and Methods: A cross-sectional study of 150eligible clients who underwent assisted reproduction program in two autonomous IVF centers between 1st January,2017 and 31st December, 2020. Clients were divided intotwo groups; (I) Antagonist stimulation protocol with progesterone and oestradiol valerate and (II) Antagonist Protocol with a single bolus of buserelin in addition to progesterone and oestradiol valerate for luteal phase support. Theprimary outcome was live birth rates while the secondaryoutcomes were clinical pregnancy, miscarriage rates andthe safety for OHSS.Results: There were no statistically significant differencesbetween the number of oocyte received, fertilized, embryosavailability for transfer, duration of infertility, duration ofFSH usage, endometrial thickness and OHSS risk betweenthe groups (p>0.05). The clinical pregnancy and live birthrates were more in group II while the miscarriage rate waslower compared to group I. The differences were statistically significant (p < 0.005).Conclusion: From this study, buserelin addition to the luteal phase of antagonist cycles appears to improve pregnancy outcomes with no associated increase in OHSS risk.Further multi- centered studies with larger sample sizes arerequired to validate these findings.

P-622 Prothrombotic biomarkers during controlled ovarian stimulation for assisted reproductive techniques

Abstract Study question Does the evolution of prothrombotic biomarkers over time differ between antagonist and long agonist stimulation protocols for assisted reproductive techniques (ART) ? Summary answer The hypercoagulable state was higher and persistent in the agonist and antagonist with hCG triggering groups compared to the antagonist with GnRH agonist triggering group. What is known already Controlled ovarian stimulation (COS) for ART is associated with supra-physiological serum estradiol levels, a hypercoagulable state and an increased risk of venous thrombosis. Most thromboembolic events associated with COS occur in the context of ovarian hyperstimulation syndrome (OHSS). The use of hCG for final follicular maturation increases the risk of OHSS. In antagonist protocols, GnRH agonist triggering is known to prevent or reduce OHSS and is therefore widely used in women at risk. The impact of the different IVF protocols on pro-thrombotic biomarkers is unknown. Study design, size, duration In this prospective observational cohort study, infertile women undergoing COS for ART in 2017-2019 at the University Hospitals of Geneva and Lausanne (Switzerland) were included. We evaluated changes in key coagulation parameters (D-dimers, factor VIII, fibrinogen activity, protein S and protein C) and thrombin generation, our primary outcome, (using 5 pM of tissue factor) by calibrated automated thrombinography before stimulation (T1), on the day of ovulation triggering (T2) and seven days after triggering (T3). Participants/materials, setting, methods COS was started without hormonal pre-treatment. Protocols were prescribed according to the standards used in each centre taking into account the risk of OHSS (agonist protocol with hCG trigger in women without OHSS risk (Group 1); antagonist protocol in women at risk of OHSS with hCG trigger (Group 2;) or GnRH agonist trigger (Group 3;); variation of endogenous thrombin potential (ETP) was measured and compared among groups using mixed effects linear regression model. Main results and the role of chance A total of 64 women were included: 24 were in group 1, 16 in group 2, and 24 in group 3. The mean age (SD) was 37.8 (2.8), 35.9(5.2) and 34(4.6) years in groups 1, 2 and 3 respectively. As expected, women in group 1 had a statistically lower level of anti-müllerian hormone (p = &amp;lt; 0.001), a lower antral follicular count (p = &amp;lt; 0.001) and lower number of MII oocytes and embryos obtained (p = &amp;lt; 0.001). Mean serum estradiol levels were 1836 (1160), 1628 (815) and 3754 (2165) ng/L at T2, and 945 (471), 1061 (495) and 413 (729) ng/L at T3, in group 1 to 3, respectively. In multivariable regression analysis, the levels in group 3 were statistically higher at T2 and lower at T3 (overall time*group interaction: p &amp;lt; 0.001). The mean ETP was similar between all groups at T1, and increased in all groups at T2 (1442, 1426 and 1486 nM/min in groups 1, 2 and 3, respectively) (p = 0.013). Overall, ETP evolution over time was statistically different between groups, with the lowest increase of ETP between T1 and T3 in group 3. Protein C and protein S levels were stable, while D-dimers, fibrinogen and factor VIII increased at T2 and T3 in all groups. Limitations, reasons for caution Stimulation protocols were prescribed according to the clinical profile and OHSS risks; groups therefore differ substantially in regards to age and ovarian reserve. Thromboembolic events are rare events after COS, we therefore evaluated biological markers of hypercoagulability and not clinical events. Wider implications of the findings Women with GnRH agonist triggering protocol did not increase mean ETP in the week after ovulation, while women with hCG triggering did. This different prothrombotic profile was independent of the variation of the other coagulation parameters investigated. This effect of ovulation triggering should be confirmed by further studies. Trial registration number NCT04188444

P–622 Prothrombotic biomarkers during controlled ovarian stimulation for assisted reproductive techniques

Abstract Study question Does the evolution of prothrombotic biomarkers over time differ between antagonist and long agonist stimulation protocols for assisted reproductive techniques (ART) ? Summary answer The hypercoagulable state was higher and persistent in the agonist and antagonist with hCG triggering groups compared to the antagonist with GnRH agonist triggering group. What is known already Controlled ovarian stimulation (COS) for ART is associated with supra-physiological serum estradiol levels, a hypercoagulable state and an increased risk of venous thrombosis. Most thromboembolic events associated with COS occur in the context of ovarian hyperstimulation syndrome (OHSS). The use of hCG for final follicular maturation increases the risk of OHSS. In antagonist protocols, GnRH agonist triggering is known to prevent or reduce OHSS and is therefore widely used in women at risk. The impact of the different IVF protocols on pro-thrombotic biomarkers is unknown. Study design, size, duration In this prospective observational cohort study, infertile women undergoing COS for ART in 2017–2019 at the University Hospitals of Geneva and Lausanne (Switzerland) were included. We evaluated changes in key coagulation parameters (D-dimers, factor VIII, fibrinogen activity, protein S and protein C) and thrombin generation, our primary outcome, (using 5 pM of tissue factor) by calibrated automated thrombinography before stimulation (T1), on the day of ovulation triggering (T2) and seven days after triggering (T3). Participants/materials, setting, methods COS was started without hormonal pre-treatment. Protocols were prescribed according to the standards used in each centre taking into account the risk of OHSS (agonist protocol with hCG trigger in women without OHSS risk (Group 1); antagonist protocol in women at risk of OHSS with hCG trigger (Group 2;) or GnRH agonist trigger (Group 3;); variation of endogenous thrombin potential (ETP) was measured and compared among groups using mixed effects linear regression model. Main results and the role of chance A total of 64 women were included: 24 were in group 1, 16 in group 2, and 24 in group 3. The mean age (SD) was 37.8 (2.8), 35.9(5.2) and 34(4.6) years in groups 1, 2 and 3 respectively. As expected, women in group 1 had a statistically lower level of anti-müllerian hormone (p = &amp;lt;0.001), a lower antral follicular count (p = &amp;lt;0.001) and lower number of MII oocytes and embryos obtained (p = &amp;lt;0.001). Mean serum estradiol levels were 1836 (1160), 1628 (815) and 3754 (2165) ng/L at T2, and 945 (471), 1061 (495) and 413 (729) ng/L at T3, in group 1 to 3, respectively. In multivariable regression analysis, the levels in group 3 were statistically higher at T2 and lower at T3 (overall time*group interaction: p &amp;lt; 0.001). The mean ETP was similar between all groups at T1, and increased in all groups at T2 (1442, 1426 and 1486 nM/min in groups 1, 2 and 3, respectively) (p = 0.013). Overall, ETP evolution over time was statistically different between groups, with the lowest increase of ETP between T1 and T3 in group 3. Protein C and protein S levels were stable, while D-dimers, fibrinogen and factor VIII increased at T2 and T3 in all groups. Limitations, reasons for caution Stimulation protocols were prescribed according to the clinical profile and OHSS risks; groups therefore differ substantially in regards to age and ovarian reserve. Thromboembolic events are rare events after COS, we therefore evaluated biological markers of hypercoagulability and not clinical events. Wider implications of the findings: Women with GnRH agonist triggering protocol did not increase mean ETP in the week after ovulation, while women with hCG triggering did. This different prothrombotic profile was independent of the variation of the other coagulation parameters investigated. This effect of ovulation triggering should be confirmed by further studies. Trial registration number NCT04188444

P–684 Impact of GnRH antagonist pretreatment on oocyte yield after ovarian stimulation: a retrospective analysis

Abstract Study question Does a 3-day pretreatment course with a GnRH antagonist in the early follicular phase increase the number of oocytes in a GnRH antagonist stimulation protocol? Summary answer The administration of 3 days of GnRH antagonist before starting ovarian stimulation in a GnRH antagonist protocol increases the number of COCs (Cumulus-Oocyte-Complexes). What is known already The GnRH antagonist protocol is characterized by higher gonadotropin and E2 serum levels at the start of ovarian stimulation (OS), compared with a long pituitary down regulation protocol. The unsuppressed FSH level at the start of a GnRH antagonist cycle allows the initial growth of follicles before addition of exogenous FSH, which may result in asynchrony of the follicular cohort. Menstrual administration of a GnRH antagonist can inhibit follicle growth and improve homogeneity of recruitable follicles. Previous studies showed a trend toward higher numbers of COCs and improved maturation and fertilization rates of retrieved oocytes. Study design, size, duration Retrospective single center crossover study, including consecutive women enrolled in an IVF program in a university hospital from January 2011 to December 2020. All women underwent one standard GnRH antagonist stimulation cycle (“standard cycle”) and one GnRH antagonist stimulation cycle preceded by early administration of GnRH antagonist for 3 days (“pretreatment cycle”). Women with basal progesterone levels &amp;gt;1.5ng/ml, and women undergoing oocyte freezing, oocyte donation or PGT were excluded. In total, 427 patients were included. Participants/materials, setting, methods Women were included when the pretreatment cycle occurred within a time interval of &amp;lt; 12 months following the start of stimulation in the standard cycle. The primary outcome was the total number of COCs. Main results and the role of chance The average female age was 35.1 ± 4.7 years. Indications for fertility treatment included unexplained infertility (34.3%), male-factor infertility (33.3%), age (16.9%), PCOS (8.2%) and endometriosis (2.6%). All cycles were divided into two groups: group 1 (standard, 427 cycles) and group 2 (pretreatment, 427 cycles). The mean duration of stimulation was similar in both groups (10.3 vs 10.3 days, p = 0.2). The starting dose of gonadotropin (196.8 vs 234.9IU, p &amp;lt; 0.001) and total amount of gonadotropin used (2000.7 vs 2415.2IU, p &amp;lt; 0.001) were higher in group 2. The total number of obtained COCs (6.2 vs 8.8 p &amp;lt; 0.001) and the number of mature oocytes (4.2 vs 6.4 p &amp;lt; 0.001) were significantly higher in group 2. The Generalized estimating equation (GEE) multivariate regression analysis showed that the pretreatment strategy had a significant positive effect on the number of COCs (coefficient 2.8, p value &amp;lt;0.001 after adjusting for the confounders age, indication of infertility, stimulation dose, type and total amount of gonatropins used). Limitations, reasons for caution Despite the large dataset, the presence of biases related to the retrospective study design cannot be excluded. Besides, the impact of GnRH pretreatment on pregnancy rate cannot be assessed because of the crossover design. Wider implications of the findings: A 3-day course of GnRH antagonist pretreatment increases the number of COCs obtained after OS. Furthermore, since the initiation of OS in a GnRH antagonist protocol relies on the occurrence of spontaneous menses, addition of three days of GnRH antagonist pretreatment may enhance scheduling flexibility without reducing efficacy. Trial registration number Not applicable

Predictive factors of ovarian response to GnRH antagonist stimulation protocol: AMH and age are potential candidates

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.

Is there any correlation between Estradiol supplementation, as luteal phase support, and clinical pregnancy in ART cycles? A cross-sectional study.

Background Endometrial receptivity is one of the important factors in assisted reproductive technology (ART) success. In the luteal phase of an ART cycle, serum estradiol (E2) and progesterone are often placed in low levels. Supporting the luteal phase with progesterone is a usual method.ObjectiveTo evaluate the effects of E2 supplementation plus progesterone on the luteal phase support in the antagonist protocol who have undergone intracytoplasmic sperm injection-embryo transfer cycles.Materials and Methods In this cross-sectional study, 200 patients with antagonist stimulation protocol, who had undergone intracytoplasmic sperm injection treatment, were divided into two groups based on the use of E2 supplementation. In both groups, 400 mg progesterone suppositories (CyclogestⓇ), twice a day/vaginally, was administered starting from the day of oocyte collection until the fetal heart activity. However, in the E2 group, in addition to progesterone, 4 mg tablet of E2 was received daily. Beta hCG was checked 14 days after the embryo transfer, and the clinical pregnancy rate was the main endpoint.ResultsThe patients' characteristics were matched, and insignificant differences were observed, except for endometrial thickness. The clinical outcomes showed the rate of pregnancy was higher in the E2 group compared to the control group; nonetheless, statistically, there was no noticeable difference.ConclusionE2 supplementation had no beneficial effect in the luteal phase support of IVF cycles. Nevertheless, more studies are required to confirm the supportive role of E2 supplementation for embryo implantation and to improve the outcomes in ART cycles.

Does daily co administration of gonadotropins and letrozole during the ovarian stimulation improve IVF outcome for poor and sub optimal responders?

BackgroundCo-administration of letrozole during the first 5 days of ovarian stimulation was suggested to improve IVF outcomes in poor responders. We aimed to determine whether poor/sub-optimal responders might benefit from Letrozole co-treatment throughout the entire stimulation course.MethodsWe retrospectively reviewed the medical files of women who demonstrated poor (oocyte yield ≤3) and sub-optimal (4 ≤ oocyte yield ≤9) ovarian response during conventional multiple-dose antagonist stimulation protocols and were co-treated in a subsequent cycle with 5 mg Letrozole from the first day of stimulation until trigger day. A self-paired comparison between gonadotropins-only and gonadotropins-letrozole cycles was performed.ResultsTwenty-four patients were included. Mean patients’ age was 39.83 ± 4.60 and mean day-3-FSH was 12.77 ± 4.49 IU/m. Duration of stimulation and total gonadotropins dose were comparable between the two cycle groups. Peak estradiol levels were significantly lower in gonadotropins-letrozole cycles (2786.74 ± 2118.53 vs 1200.13 ± 535.98, p < 0.05). Number of retrieved oocytes (3.29 ± 2.15 vs 6.46 ± 3.20, p < 0.05), MII-oocytes (2.47 ± 1.65 vs 5.59 ± 3.20, p < 0.05), 2PN-embryos (1.78 ± 1.50, 4.04 ± 2.74, p < 0.05) and top-quality embryos (0.91 ± 0.97 vs. 2.35 ± 1.66, p < 0.05) were significantly higher in the gonadotropins-letrozole cycles. Clinical pregnancy rate in gonadotropins-letrozole cycles was 31.5%.ConclusionLetrozole co-treatment during the entire stimulation course improves ovarian response and IVF outcomes in poor/sub-optimal responders.