Sudy On Ovulation Promotion Protocols For Patients With Poor Ovarian Response

Objective(s): The aim of this study is to compare the clinical value of the progestin primed ovarian stimulation(PPOS)protocols,the gonadotrophin releasing hormone-antagonist(Gn RH-A)protocols(hereafter referred to as the antagonist protocols)and the mild stimulation protocols in patients with poor ovarian response(POR)according to the Poseidon classification criteria.This study will provide the abasis and reference for the development of cost-effective and individualized ovarian stimulation protocols.Methods: Retrospective analysis of POR cases undergoing in vitro fertilization(IVF)/intracytoplasmic sperm injection(ICSI)-embryo transfer(ET)assisted conception at the Centre for Reproductive Genetics,Calmette Hospital,Kunming Medical University,from 01/01/2018 to 31/12/2022 A total of 677 cycles(158 cycles for the PPOS programme;373 cycles for the antagonist programme;146cycles for the microstimulation programme)were recorded in POR cases.Groups were grouped according to the Poseidon classification criteria: unintended POR group,i.e.group A(included in Poseidon groups 1 and 2);intended POR group,i.e.group B(included in Poseidon groups 3 and 4).The above two groups A and B were then divided into three subgroups according to the ovulation promotion protocol(1=PPOS protocol group,2=antagonist protocol group,3=microstimulation protocol group).Patients in each group were statistically analysed separately for baseline conditions,ovulation promotion,laboratory parameters and pregnancy outcomes.Results:(1)Unexpected POR group(Group A):(1)Basal situation: the differences in age,basal estradiol(E2),body mass index(BMI)and anti-Müllerian hormone(AMH)between the three groups were not statistically significant(P > 0.05).The differences were statistically significant(P < 0.05)in the A1 group,with higher values of follicle stimulation hormone(FSH)and luteinizing hormone(LH)than in the A2 group,and lower values of antral follicle count(AFC)than in the A2 group.The difference was statistically significant(P < 0.05);(2)Ovulation promotion:compared with group A1 and group A3,group A2 had the highest total gonadotrophin(Gn)dose,total number of Gn days,E2 on trigger day and endometrial thickness on trigger day,and the lowest LH level on trigger day,all differences were statistically significant(P < 0.05);group A1 P levels on trigger day were significantly higher than those in group A3,with statistically significant differences(P < 0.05);(3)Laboratory indicators: the differences were not statistically significant(P > 0.05)among the three groups in terms of 2PN fertilization rate,normal egg cleavage rate and high quality embryo rate;however,group A2 had the highest number of eggs obtained,MII eggs,normal egg cleavage,available embryos and the lowest cycle cancellation rate compared to groups A1 and A3.The difference was statistically significant(P < 0.05);the number of good quality embryos was higher in group A2 than in group A3,and the difference was statistically significant(P < 0.05);(4)Pregnancy outcome: in the first frozen embryo transfer(FET)cycle,there was no statistically significant difference between the three groups in terms of pregnancy outcome(P > 0.05)and cumulative pregnancy rate(P > 0.05).(2)Expected POR group(Group B):(1)Basal situation: in the three groups,there was no statistically significant difference in age,basal LH value and AFC(P >0.05);BMI in group B1 was higher than that in group B2,and the difference was statistically significant(P < 0.05);basal E2 value and AMH in group B2 were higher than those in group B3,while basal FSH value was lower than those in group B3,and the difference was statistically significant(P < 0.05);(2)Ovulation promotion:trigger day P levels were significantly higher in group B1 than in groups B2 and B3,with a statistically significant difference(P < 0.05);(3)Laboratory indicators: among the three groups,group B1 had the highest rate of normal egg cleavage,with statistically significant differences(P < 0.05),and had a similar rate of high quality embryos as group B2,with no statistically significant differences(P > 0.05);compared with groups B1 and B3,group B2 had the highest number of eggs obtained,MII eggs,normal egg cleavage,available embryos and high quality embryos,and the lowest cycle The differences were statistically significant(P < 0.05);the rate of highquality embryos in group B3 was higher than that in group B2,and the differences were statistically significant(P < 0.05);(4)Pregnancy outcome: in the FET cycle,there was no statistically significant difference between the three groups in terms of pregnancy outcome(P > 0.05)and cumulative pregnancy rate(P > 0.05).Conclusion(s): In controlled ovarian hyperstimulation(COH)in POR patients,the antagonist regimen has the highest dosage and duration of use of Gn compared to the PPOS and microstimulation regimens,but the early onset LH peak and cycle cancellation rates are significantly lower,and the number of eggs obtained in a single cycle,the number of MII eggs,the number of normal oocytes cleaved,the number of available The highest number of eggs obtained in a single cycle,the highest number of MII eggs,the highest number of normal oocytes,the highest number of available embryos and the highest number of good quality embryos make it the preferred option for POR patients.The microstimulation option is more economical,simpler and has a higher rate of quality embryos and can be used as a means of accumulating quality embryos.Although all three regimens have similar pregnancy outcomes,the antagonist regimen has a higher cumulative pregnancy rate per retrieval cycle;the PPOS regimen has a higher β-subunit human chorionic gonadotropin(h CG)(+)rate,a higher clinical pregnancy rate,a higher live birth rate and a lower miscarriage rate in FET cycles in patients with unanticipated POR.In the POR population,age has a significant negative effect on live birth rates,with older age associated with lower live birth rates.In summary,clinicians should develop individualised strategies for helping patients to conceive and choose a more appropriate ovulation programme for their individual circumstances.