The stimulation protocol in poor responder IVF; a minimal or high-dose stimulation? – A meta-analysis

Abstract

Background To determine whether a minimal stimulation (MS) or high-dose stimulation (HDS) protocol is a better option for patients classified as poor ovarian responders (POR) in terms of reproductive and pregnancy outcomes. Materials and methods A database search for evaluation of the study outcome by using meta-analysis method was carried out. The primary outcome was the clinical pregnancy (CP) rate for each of two groups, namely, the MS and HDS groups. The secondary outcomes were the gonadotropin dose used, duration of stimulation, cancellation rate, number of oocytes retrieved, number of fertilized oocytes, number of embryos transferred and live birth rates. Results Across five databases, 4670 potential studies for further screening were selected. But ultimately only six studies, three RCTs and three retrospective or case control studies were selected that meet the Bologna criteria for POR. In all there were 624 cycles. Our meta-analysis indicated that the CP rates, cycle cancellation rates, durations of stimulation, numbers of oocytes fertilized and numbers of embryos transferred were not statistically significant. Clearly, the number of oocytes retrieved in the MS group was significantly lower than in the HDS group, while the HDS group consumed significantly higher doses of gonadotropins than the MS group. The live birth rates were significantly higher in the MS group than in the HDS group. Conclusion MS should be the first-line protocol for managing POR because the live birth rate is significantly higher, even with fewer oocytes retrieved.

Cumulative live birth rate and cost-effectiveness analysis between GnRH-antagonist protocol and multiple minimal ovarian stimulation in poor responder

“…For the rst IVF cycle, GnRH-antagonist results in higher CLBR than MOS (12.92% versus 4.54%, Adjusted OR 2.606; 95%CI 1.386, 4.899, p = 0.003). However, GnRH-antagonist induces comparable CLBR with multiple MOS (12.92% versus 7.92%, Adjusted OR 1.702; 95%CI 0.971, 2.982, p = 0.063), but absolutely shorter time to live birth (9 (8, 10.75) months versus 11 (9,14) months, p = 0.014) and similar nancial expenditure compared to repeated MOS (20838 (17953, 23422) ¥ versus 21261.5 (15892.5, 35140.25) ¥, p = 0.13).…”

“…When it comes to the time to rst live birth, GnRH-antagonist showed obviously shorter time than repeated modi ed natural cycles (9 (8, 10.75) months versus 11 (9,14) months, p = 0.014).…”

“…Previous data on minimal ovarian stimulation (MOS) or modi ed nature cycles in POR is limited but suggested a relative realistic solution for parenthood for POR, compared to conventional high dose stimulation. Minimal ovarian stimulation showed relatively higher implantation rate, acceptable live birth rate and preferred cost-effectiveness, though with fewer oocytes retrieved [12][13][14][15][16][17][18]. Increased starting dose in predicted poor responders for IVF/ICSI has been proved not to raise live birth rate but is more highly priced [19,20].…”

The Conundrum of Poor Ovarian Response: From Diagnosis to Treatment

“…The incidence of poor ovarian response (POR) following ovarian stimulation varies worldwide between 5.6 and 35.1% [ 3 , 4 ]. Over the years, the efficient management of this strictly defined group of patients categorized as POR remains a conundrum [ 5 ].…”

Nova dosagem de testosterona transdérmica em gel previamente à estimulação ovariana controlada em pacientes potencialmente más respondedoras: resultados preliminares

“…A principal vantagem deste protocolo consiste no menor custo, pelas menores doses de gonadotrofinas utilizadas, além de ser um protocolo mais amigável para a paciente (MOHSEN;EL DIN, 2013;OZCAN CENKSOY et al, 2014). Uma meta-análise, comparando protocolos de alta dose de gonadotrofinas com os de mínima estimulação em más respondedoras, concluiu que o protocolo de alta dose não apresentou superioridade ao protocolo de mínima estimulação em relação às taxas de nascidos vivos e de gravidez clínica (JAMALUDIN et al, 2019). Desta forma, ambos os protocolos têm sido utilizados para a EOC em pacientes potencialmente más respondedoras, sendo a escolha por um ou outro individualizada, na dependência de vários fatores, como a experiência do médico, a CFA antes do início do tratamento, a resposta e o tipo de protocolo utilizado em ciclos prévios, entre outros fatores.…”