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

High sperm DNA fragmentation: do we have robust evidence to support antioxidants and testicular sperm extraction to improve fertility outcomes? a narrative review

To date, infertility affects 10% to 15% of couples worldwide. A male factor is estimated to account for up to 50% of cases. Oral supplementation with antioxidants could be helpful to improve sperm quality by reducing oxidative damage. At the same time, there is a growing interest in the literature on the use of testicular sperm in patients with high DNA fragmentation index (DFI). This narrative review aims to evaluate the effectiveness of supplementation of oral antioxidants in infertile men with high DFI compared to testicular sperm retrieval. The current evidence is non-conclusive because of serious risk of bias due to small sample sizes and statistical methods. Further large well-designed randomised placebo-controlled trials are still required to clarify the exact role of these to different therapeutic approaches

appraisal of clinical complications after 23 827 oocyte retrievals in a large assisted reproductive technology program

Objective To assess complications encountered after transvaginal oocyte retrieval procedures. Design Retrospective analysis. Setting University hospital, fertility center. Patient(s) A total of 23,827 consecutive transvaginal oocyte retrieval procedures in 12,615 patients. Intervention(s) Oocyte retrieval procedures performed between June 1996 and October 2016. Main Outcome Measure(s) All oocyte retrieval complications. Those requiring hospital admission for at least 24 hours were considered severe. Result(s) A total of 96 patients (0.76 %) suffered complications, with hospital admission necessary for 71 patients (0.56 %). When calculated per retrieval, the overall complication rate was 0.4%, whereas 0.29% was the admission rate, with an average duration of hospital stay of 2.77 ± 2.5 days. A surgical procedure was necessary for 24 patients (0.1% per retrieval and 0.19% per patient). Multivariate analysis showed a significant correlation between complications and women age, body mass index (BMI), the number oocyte retrieved, and the mean time to complete oocyte retrieval. The incidence of complications was significantly higher for physicians who had performed 250 retrievals (odds ratio 0.63, 95% confidence interval 0.40–0.99). Conclusion(s) Oocyte retrieval can be considered a safe procedure but is not without risks. The most important, identifiable, risk factors for the occurrence of complications are: [1] high number of oocytes retrieved, [2] a long duration of the procedure and mean time per oocyte retrieved, [3] inexperience of the surgeon, [4] younger patients with a lesser BMI, and [5] history of prior abdominal or pelvic surgery or pelvic inflammatory disease. Clinical Trial Registration Number NCT03282279

low molecular weight heparin in women with repeated implantation failure

Implantation failure is common in assisted reproduction techniques (ART). The role of low-molecular-weight heparin (LMWH) is a matter of debate as a potential factor to improve implantation. Aim: To evaluate the pregnancy rate in patients with or without heparin administration. Materials & methods: We performed a retrospective observational analysis of patients with at least two IVF/intracytoplasmic sperm injection cycles with implantation failure, screened for inherited thrombophilia and submitted to further ART cycles with or without administration of LMWH. A total of 265 patients fulfilled the enrollment criteria. Of these 149 (56%) were primary infertile and 116 (44%) were secondary infertile. Their mean age was 36.3 ± 3.6 years. We analyzed basal FSH, smoking habit, gene variants for inherited thrombophilia (i.e., MTHFR C677T, prothrombin G202A10G and Factor V Leiden). The patients underwent 569 new ART cycles: 512 (90%) without and 57 (10%) with LMWH. Results: In total 105 clinical pregnancies were ..

Evolution of human oocyte cryopreservation: slow freezing versus vitrification

The purpose is to determine the efficiency and efficacy of oocyte cryopreservation by slow freezing versus vitrification, recent data collected from the Italian National Assisted Reproductive Technology Register during the period 2009-2014 will be presented and reviewed. The data on oocyte cryopreservation were also compared with the results obtained with embryo cryopreservation and relative IVF with fresh oocytes. During the period 2009-2014 preservation of oocytes by vitrification had a significantly higher survival rate, implantation, and pregnancy rate than slow freezing; however, there are still large variations in success rates among centers in relation to the number of procedures performed. Vitrification has now become the method of choice for oocyte cryopreservation because of better results than slow freezing, but still requires a more standardized utilization. The transfer of fresh or cryopreserved embryo still shows a statistically significant better performance than transfers with embryos obtained with cryopreserved oocytes. Only in a few centers with much experience in cryopreservation are the results between transfers of frozen embryos or embryos obtained from oocyte cryopreservation comparable

ART in Male Cancer Patients Including Sperm Donation

Infertile male cancer survivors may benefit from the use of sperm cryopreserved before starting antineoplastic treatments or by attempting testicular sperm retrieval, if they did not bank sperm, or by using donor sperm. Intrauterine insemination (IUI) with cryopreserved sperm provides a clinical pregnancy rate of 13.1% per cycle with a live birth rate of 9.3%. IUI is simple and affordable but requires sperm of good quality. Intrauterine insemination with donor sperm (IUI-D) provides higher success rates, although there are no specific reports in cancer survivors. In unselected population, live birth rates per IUI-D range from 8.4% in the natural cycle to 21.3% using hormonal stimulation. Conventional in vitro fertilization (IVF) is more complex and expensive but can be used with sub-optimal sperm and provides higher success rates than IUI (clinical pregnancy rate of 27.8% per cycle with a live birth rate of 24.6%). Intracytoplasmic sperm injection (ICSI) is the most efficient option when sperm parameters (number, motility, and morphology) are very poor. ICSI clinical pregnancy rate and live birth rate per cycle are 38.2% and 32.9%, respectively. The ICSI combined with surgically retrieved testicular sperm (TESE or micro-TESE) is the most expensive option with clinical pregnancy rate per cycle of 32.3% and the live birth rate of 23.9%