Luteal phase after conventional stimulation in the same ovarian cycle might improve the management of poor responder patients fulfilling the Bologna criteria: a case series
Luteal phase after conventional stimulation in 100 patients with the Bologna criteria increased the chance of a live birth in a single ovarian cycle with no risk for treatment discontinuation.
Volume 113, Issue 1, Pages 121–130
Authors:
Alberto Vaiarelli, M.D., Ph.D., Danilo Cimadomo, Ph.D., Alessandro Conforti, M.D., Ph.D., Mauro Schimberni, M.D., Maddalena Giuliani, M.D., Pietro D’Alessandro, M.D., Silvia Colamaria, M.D., Carlo Alviggi, M.D., Ph.D., Laura Rienzi, M.Sc., Filippo Maria Ubaldi, M.D., Ph.D.
Abstract:
Objective
To assess the clinical contribution of luteal-phase stimulation (LPS) to follicular-phase stimulation (FPS) in a single ovarian cycle (DuoStim) for poor responder patients fulfilling the Bologna criteria.
Design
Observational study (years 2015-2017) including women satisfying ≥2 of the following characteristics: maternal age ≥40 years and/or ≤3 oocytes retrieved after previous conventional stimulation and/or reduced ovarian reserve (i.e., antral follicle count <7 follicles or antimüllerian hormone <1.1 ng/mL). The LPS was started regardless of the outcome of the FPS.
Setting
Private in vitro fertilization center.
Patient(s)
A total of 100 of 297 patients fulfilling the Bologna criteria chose to undergo DuoStim.
Intervention(s)
The FPS and LPS with the same antagonist protocol and agonist trigger, intracytoplasmic sperm injection with ejaculated sperm, preimplantation genetic testing for aneuploidies, and vitrified-warmed euploid single blastocyst transfer.
Main Outcome Measure(s)
The contribution of LPS to the cumulative live birth rate (CLBR) per intention-to-treat (ITT).
Result(s)
Patients (100) underwent FPS (maternal age, 42.1 ± 1.4 y; previous in vitro fertilization cycles with ≤3 collected oocytes, 0.7 ± 0.9; antral follicle count, 3.8 ± 1.2 follicles; and antimüllerian hormone, 0.56 ± 0.3 ng/mL). Ninety-one patients completed DuoStim. All patients were included in the analysis. More oocytes were obtained after LPS with similar developmental and chromosomal competence as paired FPS-derived ones. The CLBR per ITT increased from 7% after FPS to 15% after DuoStim. Conversely, the CLBR per ITT among the 197 patients that chose a conventional controlled ovarian stimulation strategy was 8%, as only 17 patients who were not pregnant returned for a second stimulation after the first attempt (drop-out rate, 81%).
Conclusion(s)
The LPS-derived oocytes increased the CLBR per ITT in a single ovarian cycle in patients fulfilling the Bologna criteria. The DuoStim strategy is promising to manage this thorny population of patients, especially to avoid discontinuation after a first failed attempt.
Comments
Although an approximately doubling in LBR, the p value = 0.07. I'm curious if this potential benefit is cost effective to have so many days away from work in a short duration vs spread out a few months? I suppose the patient’s employer could be a big factor there, and you could also make the argument that if ovarian reserve is already not ideal, time is of the essence even if the LBR is not significantly increased.
Congratulations to the authors for bringing this topic to our attention. I do think there may be a benefit from this approach which may not be biological but more from a psychological point of view as suggested in the article. There is such thing as treatment exhaustion which seems to be driving many of the differences among both groups. By having two retrievals close to each other, the number of gametes available increases in a short period of time which would increase the chances of success among poor responders. The question about whether this approach is superior to two retrievals farther apart is still unresolved, but if patients are dropping out and not having that other retrieval done, without taking into account potential decreases in ovarian reserve, that may be reason enough to offer DuoStim.