An Observational Retrospective Cohort Trial on 4,828 IVF Cycles Evaluating Different Low Prognosis Patients Following the POSEIDON Criteria

Objective: To study the actual controlled ovarian stimulation (COS) management in women with suboptimal response, comparing clinical outcomes to the gonadotropins consume, considering potential role of luteinizing hormone (LH) addition to follicle-stimulating hormone (FSH).Design: Monocentric, observational, retrospective, real-world, clinical trial on fresh intra-cytoplasmic sperm injection (ICSI) cycles retrieving from 1 to 9 oocytes, performed at Humanitas Fertility Center from January 1st, 2012 to December 31st, 2015.Methods: COS protocols provided gonadotropin releasing-hormone (GnRH) agonist long, flare-up, short and antagonist. Both recombinant and urinary FSH were used for COS and LH was added according to the clinical practice. ICSI outcomes considered were: gonadotropins dosages; total, mature, injected and frozen oocytes; cumulative, transferred and frozen embryos; implantation rate; pregnancy, delivery and miscarriage rates. Outcomes were compared according to the gonadotropin regimen used during COS.Results: Our cohort showed 20.8% of low responders, defined as 1-3 oocytes retrieved and 79.2% of "suboptimal" responders, defined as 4-9 oocytes retrieved. According to recent POSEIDON stratification, cycles were divided in group 1 (6.9%), 2 (19.8%), 3 (11.7%), and 4 (61.5%). The cohort was divided in 3 groups, according to the gonadotropin's regimen. Women treated with FSH plus LH showed worst prognostic factors, in terms of age, basal FSH, AMH, and AFC. This difference was evident in suboptimal responders, whereas only AMH and AFC were different among treatment groups in low responders. Although a different result, in terms of oocytes and embryos detected, major ICSI outcomes (i.e., pregnancy and delivery rates) were similar among groups of COS treatment. Outcomes were significantly different among Poseidon groups. Implantation, pregnancy and delivery rates were significantly higher in Poseidon group 1 and progressively declined in other POSEIDON groups, reaching the worst percentage in group 4.Conclusions: In clinical practice, women with worst prognosis factors are generally treated with a combination of LH and FSH. Despite low prognosis women showed a reduced number of oocytes retrieved, the final ICSI outcome, in terms of pregnancy, is similarly among treatment group. This result suggests that the LH addition to FSH during COS could improve the quality of oocytes retrieved, balancing those differences that are evident at baseline

In vitro fertilization (IVF) and hormone-dependent brain tumors: could the new era of IVF and social freezing change our incidentally discovered brain tumor management?

The new era of IVF and social freezing could change our ethical indication of the monitoring and treatment of brain lesions, especially those related to hormones such as meningiomas. The data regarding IVF in Italy (IARTR Italian Assisted Reproductive Technology Register) reveal a progressive increase of cycles from 52676 cycles in 2010 to 95110 in 2013. The same results have been reported in Europe (European Register EHSRE 2013) (1) and the results of the data from the last 4 years confirm this trend. This indicates that the “incidental hormone related lesions” will strongly increase over the coming years. Meningiomas represent the most common primary brain tumor (34% of CNS). Incidence in females is nearly twice of that in men (2). Recent data reported incidental meningioma findings in 2.5% of the population. Ten percent of meningiomas contain estrogen receptors. A large number of meningiomas show very slow growth (3). The literature reports several cases regarding meningiomas fast growing in hyperestrogenic and hyperprogestinic states. In recent studies, progesterone also seems to be strongly correlated to increased risks of recurrence compared to estrogen and estrogen/progesterone . Estrogen expression in meningiomas is present in a much higher proportion of cases than expression based on immunohistochemical results due to the different sensitivity of the applied technique. While the functional role of the estrogen expression is still debated the majority of meningiomas express progesterone (PR) receptors (4