Dual stimulation using corifollitropin alfa in 54 Bologna criteria poor ovarian responders – a case series

Accepted Manuscript

Dual stimulation using corifollitropin alfa in 54 Bologna criteria poor ovarian responders – a case series Birgit Alsbjerg , Thor Haahr , Helle O Elbaek , Rita Laursen , Betina B Povlsen , Peter Humaidan PII: DOI: Reference:

S1472-6483(19)30057-4 https://doi.org/10.1016/j.rbmo.2019.01.007 RBMO 2129

To appear in:

Reproductive BioMedicine Online

Received date: Revised date: Accepted date:

25 May 2018 1 January 2019 4 January 2019

Please cite this article as: Birgit Alsbjerg , Thor Haahr , Helle O Elbaek , Rita Laursen , Betina B Povlsen , Peter Humaidan , Dual stimulation using corifollitropin alfa in 54 Bologna criteria poor ovarian responders – a case series, Reproductive BioMedicine Online (2019), doi: https://doi.org/10.1016/j.rbmo.2019.01.007

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo editing, typesetting, and review of the resulting proof before it is published in its final form. Please note that during this process changes will be made and errors may be discovered which could affect the content. All legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Dual stimulation using corifollitropin alfa in 54 Bologna criteria poor ovarian responders – a case series

CR IP T

Birgit Alsbjerg a,b,*, Thor Haahr a,b, Helle O Elbaek a, Rita Laursen a, Betina B Povlsen a, Peter Humaidan a,b a The Fertility Clinic, Skive Regional Hospital, Denmark b Health, Aarhus University, Aarhus, Denmark *Corresponding author. E-mail address: [email protected] (B Alsbjerg).

Abstract

Research question: What are the reproductive outcomes of Bologna criteria poor responders undergoing dual stimulation (DuoStim) and subsequent cryopreserved embryo transfer?

M

AN US

Design: Case series of patients treated during the period August 2015 to March 2018 in a public fertility clinic. The study included 54 Bologna criteria poor responder IVF patients younger than 42 years receiving a follicular stimulation (DuoStim 1) followed by a luteal phase stimulation (DuoStim 2) within the same cycle, both stimulations being performed with corifollitropin alfa followed by a subsequent cryopreserved embryo transfer cycle. The primary endpoint was the number of oocytes retrieved in DuoStim 1 compared with DuoStim 2. The secondary endpoint was ongoing pregnancy rate (OPR) at 12 weeks of gestation.

ED

Results: The mean number of oocytes retrieved in DuoStim 1 and DuoStim 2 was 2.4  2.1 versus 3.7  2.6, respectively; thus, a total of 1.2 (95% CI, 0.46– 1.96) more oocytes was retrieved in DuoStim 2 compared with DuoStim 1 (P = 0.002). The OPR at 12 weeks was 20% (11/54) in this poor ovarian response population with a mean age of 36.7 years.

CE

PT

Conclusions: Luteal phase stimulation results in more oocytes in poor responders compared with follicular phase stimulation. DuoStim, using corifollitropin alfa followed by individualized FSH dosing, appears to be an alternative to conventional follicular phase stimulation, decreasing the risk of cycle cancellation.

AC

Key message

Luteal phase stimulation results in more oocytes than follicular phase stimulation in dual stimulation using corifollitropin alfa in a case series of Bologna criteria poor responders. The overall ongoing pregnancy rate was 20%. Dual stimulation followed by cryopreserved embryo transfer is an alternative to conventional follicular phase stimulation. Keywords: Bologna criteria, DuoStim, IVF, luteal phase stimulation, poor responders, POSEIDON criteria

ACCEPTED MANUSCRIPT

Introduction

AN US

CR IP T

The definition of poor ovarian response (POR) was established under the auspices of the European Society of Human Reproduction and Embryology (ESHRE), resulting in the Bologna criteria (Ferraretti et al., 2011). At least two of the following three criteria must be present to fulfil the Bologna criteria: (i) advanced maternal age (40 years) or any other risk factor for POR; (ii) a previous POR (3 oocytes with a conventional stimulation protocol; (iii) an abnormal ovarian reserve test (i.e. antral follicle count [AFC] <5–7 follicles or anti-Müllerian hormone [AMH] <0.5–1.1 ng/ml). Before this consensus, more than 35 different POR definitions had been used in previous studies (Surrey and Schoolcraft, 2000). Thus, a huge heterogeneity in the study populations was seen, resulting in a poor inter-study comparison and a poor predictive value of meta-analyses (Polyzos and Devroey, 2011). Although the Bologna criteria were an important step in reducing heterogeneity, recent publications have debated whether even within the Bologna population there is a still significant degree of heterogeneity (Humaidan et al., 2016, 2017; Papathanasiou, 2014; POSEIDON Group [Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number] et al., 2016).

ED

M

Overall the pregnancy rates of POR patients are low. In POR patients fulfilling the Bologna criteria, La Marca et al. (2015) reported a live birth rate per started cycle of approximately 6%. This finding is very similar to the results of Polyzos et al. (2014) who, based on a cohort of 485 POR, reported a live birth rate per cycle of 7.1% in patients <40 years and 5.2% 40 years old. Furthermore, this study found that the only independent variable related to the live birth rate was the number of oocytes retrieved. The estimated effect of collecting three oocytes compared with two oocytes was a relative increase in the predicted live birth rate by 25% (Sunkara et al., 2011). Obviously, age plays an important role for the reproductive outcome of the POR patient as reported by Bozdag et al. (2017) who found better prognoses for POR patients <40 compared with POR patients 40 years.

AC

CE

PT

A new approach to increasing the number of oocytes available over a short period is the double stimulation (DuoStim), which was developed through modifications of the so-called Shanghai protocol, introducing a combination of follicular phase as well as luteal phase stimulation (Kuang et al., 2014; Liu et al., 2017; Moffat et al., 2014; Ubaldi et al., 2016). The reported advantage of DuoStim is more oocytes retrieved within a shorter time span, thus the chance of having transferable embryos increases, theoretically reducing time to live birth as well as cycle cancellation. In line with this, Ubaldi et al. (2016) reported the same euploidy rate of blastocysts when comparing follicular phase to luteal phase, and the accumulation of embryos resulted in a lower cycle cancellation rate. This study is thought to be the first to analyse the reproductive outcomes of Bologna criteria POR patients undergoing DuoStim, using corifollitropin alfa.

ACCEPTED MANUSCRIPT

Materials and methods Patients This retrospective case series study included patients treated in a public fertility clinic from August 2015 to March 2018. Eighty-one patients who underwent DuoStim were traced in the clinical database. Only patients completing both DuoStim 1 and 2 and who fulfilled the aforementioned Bologna criteria (Ferraretti et al., 2011) were included in the study. If patients had more than one DuoStim cycle, only the first DuoStim cycle was included.

CR IP T

Ethical approval

The Central Denmark Region Ethical Committee on Health Research Ethics indicated that the study did not need ethical approval (request no: 61/2017, dated 8 May 2017) according to the Act on Research Ethics Review of Health Projects, Act Number 593 of 14 July 2011 section 14 (1).

AN US

Stimulation protocol

PT

ED

M

Follicular phase stimulation (DuoStim 1 protocol) started on the second or third menstrual cycle day using a single subcutaneous dose of 150 mg corifollitropin alfa (Elonva; MSD, Denmark). A daily dose of gonadotrophin-releasing hormone (GnRH) antagonist (0.25 mg) was introduced on the fifth stimulation day and continued until ovulation trigger. Moreover, from the sixth stimulation day a daily bolus of 300 IU recombinant FSH (rFSH) was added to the stimulation protocol. Patients 35 years old were treated with gonadotrophins containing LH activity (Pergoveris; Merck, Denmark or Menopur; Ferring, Denmark) and younger patients were treated with rFSH (Gonal-F; Merck, Denmark or Bemfola; Gedeon Richter, Scandinavia). The maximal dose of additional gonadotrophins prescribed was 375 IU. Monitoring was performed via ultrasound every third to fourth day as required. When one to three follicles reached 17 mm, ovulation was triggered with a bolus of GnRH agonist (GnRHa), buserelin 0.5 mg (Suprefact; Sanofi, Denmark). Oocyte retrieval was performed 36 h later.

AC

CE

After a 4-day stimulation-free period, patients started luteal phase stimulation (DuoStim 2 protocol) using corifollitropin alfa and on the sixth stimulation day additional gonadotrophins and GnRH antagonist co-treatment were administered as described in DuoStim 1. All patients did have menstrual bleeding during this period. GnRHa (0.5 mg buserelin, Suprefact; Sanofi) was used as standard to induce ovulation. If no oocytes were retrieved in the follicular phase stimulation despite the presence of follicles, a bolus of human chorionic gonadotrophin (HCG) 10,000 IU (Pregnyl; MSD, Denmark) was used to induce ovulation in the luteal phase stimulation (Figure 1).

Embryo culture and cryopreservation Intracytoplasmic sperm injection or IVF fertilization was performed depending on sperm quality. Embryos were cultured in 5% O2, 6% CO2 and 89% N2 atmosphere and vitrified on days 3, 5 or 6 using ‘the Cryotec method’ (Gandhi et al., 2017). Only good-quality embryos were vitrified and the criteria were: a minimum of seven blastomeres on day 3 according to the ALPHA/ESHRE

ACCEPTED MANUSCRIPT consensus scoring system for cleavage-stage embryos (ALPHA Scientists in Reproductive Medicine; ESHRE Special Interest Group Embryology, 2011) or at blastocyst stage day 5 or 6, if blastocysts had at least an expansion score grade 3 and score A or B for inner cell mass and trophectoderm according to the Gardner and Schoolcraft grading system (Gardner and Schoolcraft, 1999). Due to a change in clinical practice only blastocysts were vitrified after June 2016.

Embryo transfer

CR IP T

The majority of embryo transfer cycles were hormonal replacement treatment cycles; only three cycles were semi-natural cycles using HCG for ovulation induction at the request of the patient. Details of frozen embryo transfer are described elsewhere (Tomas et al., 2012).

Outcomes

M

AN US

An HCG test was performed 9 or 11 days after blastocyst embryo transfer. The pregnancy test was considered positive if HCG was >10 IU/l. Measurements <45 IU/l were repeated after 48 h. A biochemical pregnancy was a pregnancy that stops growing before it becomes ultrasound visible. The implantation rate was defined as number of ultrasound-visible gestation sacs divided by number of embryos transferred. A clinical pregnancy was an ultrasound-confirmed gestational sac and an ongoing pregnancy was defined as a viable pregnancy detected by ultrasound examination at 12 weeks of gestation. Early pregnancy loss (including biochemical and clinical loss) was defined as loss of pregnancy before gestational week 7.

Statistics

CE

PT

ED

Statistical comparison of DuoStim 1 versus DuoStim 2 was analysed as a paired sample based on the Student’s t-test analysis. The assumptions of normal distribution and equal variances were checked by a Q–Q plot and the Bland– Altman plot, respectively. If these assumptions were not met, the nonparametric Wilcoxon signed-rank test was used. For dichotomous outcomes either the Fisher’s exact test or the chi-squared test was used. Statistical analyses were carried out using Stata Statistical Software: Release 12.1 (StataCorp, College Station, TX, USA).

Results

AC

The present study included a total of 54 patients all younger than 42 years and with an average age of 36.7 years (SD 3.6). The mean total antral follicle count was 4.4 (SD 1.9) measured on the first day of stimulation in the DuoStim 1. A total of 52 (96%) patients had previously had at least one stimulation with fewer than four oocytes retrieved. For the distribution in different Bologna criteria categories, see Supplementary Figure 1. Using the POSEIDON classification 13 patients were group 3 patients and 41 were group 4. Prior to DuoStim 1, patients had a mean number of 2.8 (SD 1.6) failed cycles. Besides the diagnosis of POR, a total of 45 patients (83%) also had a secondary infertility diagnosis (see Table 1 for baseline characteristics).

ACCEPTED MANUSCRIPT The mean number of oocytes retrieved in DuoStim 1 and DuoStim 2 was 2.4 (SD 2.1) and 3.7 (SD 2.6), respectively, thus a total of 1.3 (95% CI, 0.46–1.96) more oocytes were retrieved in DuoStim 2 compared with DuoStim 1, P = 0.002. In contrast, significantly more FSH was consumed in DuoStim 2 as the FSH consumption was 1.37 (95% CI, 1.14–1.63) times higher compared with DuoStim 1. Neither the number of embryos cryopreserved nor the number of patients with no embryos cryopreserved differed significantly when comparing DuoStim 1 to DuoStim 2 (Table 2).

CR IP T

Only 6% (3/54) of patients did not have any oocytes retrieved at all. Two patients did not undergo the second retrieval, one patient due to premature ovulation and the other patient due to lack of follicular development. A third patient had ‘empty follicle syndrome’ in both retrievals despite changing the trigger drug. Overall, 41% (22/54) of patients did not have any embryo cryopreserved after both DuoStim.

M

AN US

A total of 32 patients went through at least one embryo transfer and the ongoing pregnancy rate (OPR) per transfer (week 12) was 24% (11/45). The overall OPR per patient was 20% (11/54) and successfully implanting embryos originated from both DuoStim 1 and DuoStim 2 (Table 3). However, it was not possible to track implanting embryos in all cases as some patients had pooled embryos from DuoStim 1 and 2 for double embryo transfer resulting in a single pregnancy. Thirty-six single embryo transfers (21 from DuoStim 1 and 15 from DuoStim 2) resulted in five ongoing pregnancies; two of these pregnancies arose from ‘DuoStim 1 oocytes’ and three pregnancies arose from ‘DuoStim 2 oocytes’. Four pregnant patients still have cryopreserved embryos.

Discussion

AC

CE

PT

ED

The present study investigated the use of a DuoStim protocol in Bologna criteria POR patients. Results show that DuoStim in combination with corifollitropin alfa can be used effectively for this population, resulting in low cycle cancellation rates, an acceptable OPR as well as a good number of embryos available for transfer. Although it was observed that more oocytes were retrieved during the luteal phase stimulation, this finding might be biased by a significantly higher FSH consumption. Nevertheless, the good number of embryos for transfer suggests that time to live birth might be optimized using the DuoStim protocol in the Bologna POR population compared with conventional stimulation protocols. However, corroborative studies comparing the DuoStim protocol with conventional stimulation protocols are needed to draw firm conclusions. Corifollitropin alfa is used in the DuoStim protocol due to its long-lasting profile, with a half-life of 68 h and a maximal serum concentration after 44 h (Fauser et al., 2011). This pharmacokinetic profile showed its advantage compared with daily-administered rFSH in a study including Bologna POR only. In another study, although no significant difference in live birth rate during fresh embryo transfer was seen, significantly more embryos were cryopreserved in the group treated with corifollitropin alfa compared with rFSH (Drakopoulos et al., 2017). Moreover, corifollitropin alfa is more patient-friendly due to fewer injections needed during stimulation. Compared with the Shanghai protocol reported by Kuang et al. (2014), this new concept using corifollitropin alfa is very simple due to identical follicular and luteal phase stimulations and a minimum of injections

ACCEPTED MANUSCRIPT without additional oral administration. Furthermore, the reproductive outcome of the present protocol was comparable to the Shanghai protocol study reporting 11/38 (29%) ongoing pregnancies in Bologna criteria patients.

CR IP T

The mean age of the present study population was 36.7 years. Whether the result from this population can be compared with other Bologna subpopulations, especially in patients older than 40 years, is not known. However, previous studies reported live birth rates per started cycle for different Bologna criteria subgroups ranging from 5 to 10% (Bozdag et al., 2017; Busnelli et al., 2015; Humaidan et al., 2016; La Marca et al., 2015; Polyzos et al., 2014), indicating the poor value of inter-study comparison.

AN US

In the present study, a total of 41% of patients (22/54) did not have any embryos cryopreserved in either DuoStim 1 or DuoStim 2. Some of these patients were subsequently offered oocyte donation, and others underwent an additional DuoStim protocol, whereas some couples decided to stop fertility treatment. Zhang et al. (2015) concluded that a reduced cancellation rate per menstrual cycle alleviates some of the stress that poor responders have following unsuccessful oocyte retrieval (Zhang, 2015). Unfortunately, no study up to now has investigated patient satisfaction and burden of the DuoStim concept; however, it is our daily clinical experience that patients tolerate this protocol very well, especially due to the reduced monitoring during stimulation.

CE

PT

ED

M

Empty follicle syndrome is reported at similar rates in GnRHa-triggered cycles compared with HCG-triggered cycles (Blazquez et al., 2014). However, in the present study, the response to ovulation trigger or the so-called mature follicle:oocyte ratio was considered; thus, if no oocytes were retrieved from large sized follicles in DuoStim 1, this would automatically elicit an HCG trigger in the subsequent DuoStim 2. A total of 10 patients had no oocytes retrieved after DuoStim 1 despite adequate follicular size. However, only three of these patients did not have oocytes retrieved in DuoStim 2 after using HCG trigger. Other dualstimulation protocols have been used with HCG as ovulation trigger without compromising the follicular development during the luteal phase stimulation (Liu et al., 2017; Zhang, 2015). This was seen despite the fact that the elevated progesterone concentration caused by the continuous corpus luteum stimulation by HCG, which has a significantly longer half-life compared with the GnRHamediated LH surge, was used in the present study. Whether a higher follicular phase oocyte number could be achieved after HCG triggering in both stimulations needs to be further investigated.

AC

The overall aim of the DuoStim concept is to achieve more oocytes within a shorter time span in a patient-friendly manner. However, whether this new protocol will reduce time to pregnancy still needs to be investigated in a randomized controlled trial. The time spent on two stimulations and subsequent cryopreserved embryo transfer must be taken into account. Furthermore, there is a minor risk that cryopreserved embryos might not survive. Other patient groups may also benefit from the DuoStim concept, especially patients who need oocyte or embryo cryopreservation before cancer treatment. Another group of patients who could benefit from the therapeutic advantage of DuoStim are those with a low oocyte retrieval rate. Even after an oocyte retrieval from normo-responding ovaries with more than 10 follicles, a luteal

ACCEPTED MANUSCRIPT phase stimulation can still be conducted without compromising the number of oocytes retrieved from the luteal phase stimulation. Another small sub-group is patients with auto-transplanted ovarian tissue. This group of patients has a very low number of antral follicles and a low live birth rate using conventional stimulation protocols (Jensen et al., 2015). A limitation of this study was that not all vitrified embryos were blastocysts. This was caused by a change in clinical practice within the study period and the implantation rate of the cleavage embryos was lower compared with the implantation rate of the blastocysts; 4/16 (25%) versus 16/38 (42%).

AN US

CR IP T

Despite retrieving significantly more oocytes in DuoStim 2, this did not result in significantly more embryos cryopreserved. Hypothetically this could be caused by compromised oocyte quality during the luteal phase stimulation. However, Ubaldi et al. (2016) reported similar numbers of euploid embryos from DuoStim 1 and DuoStim 2, implying that the oocyte quality is similar despite differences in, for example, progesterone levels during stimulations. Whether a higher number of study patients would result in a higher rate of embryos cryopreserved is speculative. However, the POSEIDON database estimates that for a 40-yearold patient, on average, a total of 12 oocytes is needed to have one euploid blastocyst, which must be considered in a future RCT.

ED

M

The preliminary results of this case series of Bologna criteria poor responders was nine ongoing singleton pregnancies and two twin pregnancies. Moreover, four pregnant patients still have spare embryos cryopreserved, increasing the chance of a second child. The total OPR per DuoStim cycle was 20%, which is considered to be high and of clinical importance in this Bologna criteria population. However, randomized controlled studies are needed to compare the DuoStim protocol with conventional IVF protocols.

PT

Luteal phase stimulation results in more oocytes in poor responders compared with follicular phase stimulation. Hence, it is concluded that DuoStim using corifollitropin alfa and a subsequent individualized FSH dose appears to be a valid alternative to conventional follicular stimulation, decreasing the risk of cycle cancellation.

CE

Acknowledgements

AC

We wish to thank all clinical staff for their careful contributions to data collection for the clinical database.

Declaration: The authors report no financial or commercial conflicts of interest. References

ALPHA Scientists in Reproductive Medicine; ESHRE Special Interest Group Embryology. The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting. Hum Reprod 2011;26:1270–1283. Blazquez A, Guillen JJ, Colome C, Coll O, Vassena R, Vernaeve V. Empty follicle syndrome prevalence and management in oocyte donors. Hum Reprod 2014;29:2221–2227. Bozdag G, Polat M, Yarali I, Yarali H. Live birth rates in various subgroups of poor ovarian responders fulfilling the Bologna criteria. Reprod Biomed Online 2017;34:639–644.

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

M

AN US

CR IP T

Busnelli A, Papaleo E, Del Prato D, La Vecchia I, Iachini E, Paffoni A, Candiani M, Somigliana E. A retrospective evaluation of prognosis and cost-effectiveness of IVF in poor responders according to the Bologna criteria. Hum Reprod 2015;30:315–322. Drakopoulos P, Vuong TNL, Ho NAV, Vaiarelli A, Ho MT, Blockeel C, Camus M, Lam AT, van de Vijver A, Humaidan P, Tournaye H, Polyzos NP. Corifollitropin alfa followed by highly purified HMG versus recombinant FSH in young poor ovarian responders: a multicentre randomized controlled clinical trial. Hum Reprod 2017;32:2225–2233. Fauser BC, Alper MM, Ledger W, Schoolcraft WB, Zandvliet A, Mannaerts BM, Engage Investigators. Pharmacokinetics and follicular dynamics of corifollitropin alfa versus recombinant FSH during ovarian stimulation for IVF. Reprod Biomed Online 2011;22 Suppl 1:S23–31. Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L, ESHRE working group on Poor Ovarian Response Definition. ESHRE consensus on the definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod 2011;26:1616–1624. Gandhi G., Kuwayama M., Kagalwala S., Pangerkar P. (2017) Appendix A: Cryotech® Vitrification Thawing. In: Nagy Z., Varghese A., Agarwal A. (eds) Cryopreservation of Mammalian Gametes and Embryos. Methods in Molecular Biology, vol 1568. Humana Press, New York, NY Gardner DK, Schoolcraft WB. Culture and transfer of human blastocysts. Curr Opin Obstet Gynecol 1999;11:307–311. Humaidan P, Alviggi C, Fischer R, Esteves SC. The novel POSEIDON stratification of ‘Low prognosis patients in Assisted Reproductive Technology’ and its proposed marker of successful outcome. F1000Res 2016;5:2911. Humaidan P, Chin W, Rogoff D, D’Hooghe T, Longobardi S, Hubbard J, Schertz J; ESPART Study Investigators‡. Efficacy and safety of follitropin alfa/lutropin alfa in ART: a randomized controlled trial in poor ovarian responders. Hum Reprod 2017;32:544–555. Jensen AK, Kristensen SG, Macklon KT, Jeppesen JV, Fedder J, Ernst E, Andersen CY. Outcomes of transplantations of cryopreserved ovarian tissue to 41 women in Denmark. Hum Reprod 2015;30:2838–2845. Kuang Y., Chen Q., Hong Q., Lyu Q., Ai A., Fu Y., Shoham Z. Double stimulations during the follicular and luteal phases of poor responders in IVF/ICSI programmes (Shanghai protocol). Reprod BioMed Online 2014;29:684–691. La Marca A, Grisendi V, Giulini S, Sighinolfi G, Tirelli A, Argento C, Re C, Tagliasacchi D, Marsella T, Sunkara SK. Live birth rates in the different combinations of the Bologna criteria poor ovarian responders: a validation study. J Assist Reprod Genet 2015;32:931–937. Liu C, Jiang H, Zhang W, Yin H. Double ovarian stimulation during the follicular and luteal phase in women >/ = 38 years: a retrospective case-control study. Reprod Biomed Online 2017;35:678–684. Moffat R, Pirtea P, Gayet V, Wolf JP, Chapron C, de Ziegler D. Dual ovarian stimulation is a new viable option for enhancing the oocyte yield when the time for assisted reproductive technology is limited. Reprod Biomed Online 2014;29:659–661. Papathanasiou A. Implementing the ESHRE ‘poor responder’ criteria in research studies: methodological implications. Hum Reprod 2014;29:1835–1838. Polyzos NP, Devroey P. A systematic review of randomized trials for the treatment of poor ovarian responders: is there any light at the end of the tunnel? Fertil Steril 2011;96:1058–61.e7. Polyzos NP, Nwoye M, Corona R, Blockeel C, Stoop D, Haentjens P, Camus M, Tournaye H. Live birth rates in Bologna poor responders treated with ovarian stimulation for IVF/ICSI. Reprod Biomed Online 2014;28:469–474. Poseidon Group (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number), Alviggi C, Andersen CY, Buehler K, Conforti A, De Placido G, Esteves SC, Fischer R, Galliano D, Polyzos NP, Sunkara SK, Ubaldi FM, Humaidan P. A new more detailed stratification of low responders to ovarian stimulation: from a poor ovarian response to a low prognosis concept. Fertil Steril 2016;105:1452–1453. Sunkara SK, Rittenberg V, Raine-Fenning N, Bhattacharya S, Zamora J, Coomarasamy A. Association between the number of eggs and live birth in IVF treatment: an analysis of 400 135 treatment cycles. Hum Reprod 2011;26:1768–1774. Surrey ES, Schoolcraft WB. Evaluating strategies for improving ovarian response of the poor responder undergoing assisted reproductive techniques. Fertil Steril 2000;73:667–676. Tomas C, Alsbjerg B, Martikainen H, Humaidan P. Pregnancy loss after frozen-embryo transfer--a comparison of three protocols. Fertil Steril 2012;98:1165–1169. Ubaldi FM, Capalbo A, Vaiarelli A, Cimadomo D, Colamaria S, Alviggi C, Trabucco E, Venturella R, Vajta G, Rienzi L. Follicular versus luteal phase ovarian stimulation during the same

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

M

AN US

CR IP T

menstrual cycle (DuoStim) in a reduced ovarian reserve population results in a similar euploid blastocyst formation rate: new insight in ovarian reserve exploitation. Fertil Steril 2016;105:1488–1495.e1. Zhang J. Luteal phase ovarian stimulation following oocyte retrieval: is it helpful for poor responders? Reprod Biol Endocrinol 2015;13:76–015–0076–2.

AN US

CR IP T

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

M

Figure 1 Dual stimulation (DuoStim) protocol. GnRH = gonadotrophin-releasing hormone; GnRHa = GnRH agonist; HCG = human chorionic gonadotrophin.

AC

CE

PT

ED

M

AN US

CR IP T

ACCEPTED MANUSCRIPT

Dr Birgit Alsbjerg obtained her MD degree at the University of Aarhus, Denmark in 2001 and her speciality degree in obstetrics and gynaecology at Aarhus University Hospital in 2011. Currently working at the Fertility Clinic, Skive Regional Hospital, her research interests include reproductive endocrinology and frozen–thawed embryo transfer protocols.

ACCEPTED MANUSCRIPT Table 1 Baseline characteristics

a

1 (2%) 10 (19%) 9 (17%) 19 (35%) 5 (9%) 1 (2%) 2.8  1.6

Nine patients did not have a secondary diagnosis.

CR IP T

Age (mean years  SD) Body mass index (mean kg/m2  SD) Antral follicle counts (mean, n  SD) Secondary diagnosisa, n (%) Anovulation Tubal factor Male factor Single Endometriosis Other Previous failed cycles; before DuoStim 1 (mean, n  SD)

n = 54 36.7  3.6 24.9  4.0 4.4  1.9

DuoStim 1 (n = 54) 1679 (SD 814)

DuoStim 2 (n = 54) 2299 (SD 1267)

P-value

5.8 (SD 2.3)

6.3 (SD 3.2)

0.005

2.4 (SD 2.1)

M

3.7 (SD 2.6)

0.002

10

6

NS

1.5 (SD 0.9)

1.8 (SD 1.8)

NS

33/54 (61%)

32/54 (59%)

NS

PT

ED

Mean of total FSH/FSH + LH dosea Mean days of additional FSH/FSH + LH Mean number of oocytes retrieved Number of oocytes retrieved Mean number of embryos vitrified Cancellation rate, n (%)b

AN US

Table 2 Cycle characteristics in 54 patients undergoing the DuoStim protocol

AC

CE

Values presented as mean ( SD), number or number (%). NS = non-significant. a All patients were given 150 IU corifollitropin alfa. b Cancellation rate: percentages of patients who did not have embryos for cryopreservation.

0.001

ACCEPTED MANUSCRIPT

Table 3 Clinical outcome of cryopreserved embryo transfers after DuoStim

One embryo vitrified after warming.

M ED PT CE AC

(96%)

(47%) (37%) (29%) (24%)

10/21 (48%) 2

AN US

a

36 9 57 55/57 16 38 21/45 20/54 13/45 11/45

CR IP T

Number of single embryo transfers Number of double embryo transfers Number of embryos warmed Embryo survival ratea Cleavage embryos transferred Blastocysts transferred Positive pregnancy test rate per embryo transfer Implantation rate Clinical pregnancy rate Ongoing pregnancy rate week 12 per embryo transfer Total miscarriage rate Number of twin pregnancies