An exploratory study of motivations for elective oocyte cryopreservation. / Estudio exploratorio de las motivaciones para la criopreservación de ovocitos en forma electiva.

Introduction: Oocyte vitrification is a scientific advance that has changed the reproductive perspective of human society. This procedure has been offered as an alternative to the voluntary postponement of pregnancy, giving women a new perspective on their reproductive autonomy. The number of women who consult and then choose to freeze oocytes has increased almost exponentially in Chile and throughout the world. There is little knowledge about the motivation, experience, and results of elective oocyte cryopreservation in Chile. The objective was to know the motivation, experience, and future reproductive desire of the women who underwent this technique. Methods: Cross-sectional descriptive study based on a questionnaire sent by e-mail in which females who had previously undergone elective oocyte cryopreservation between January 2011 and December 2019 at Clínica Alemana, Santiago, Chile, participated. Results: Of 342 women who had completed a cycle of elective oocyte cryopreservation, 193 agreed to participate, and of these, 98 (51%) answered the survey satisfactorily. Women who underwent this procedure for medical indication, including endometriosis, cancer, and low ovarian reserve, were excluded. The most frequent reason for the procedure was age (44%). Concerning the procedure: 94% do not regret having it done, and 74% of the women believe that they will use their oocytes at some point in their lives. Finally, from the time of oocyte cryopreservation to date, 11% of the surveyed women have used their vitrified oocytes, and 27% have become pregnant. Conclusions: Women who undergo elective oocyte cryopreservation for social reasons are mainly women without a partner whose main motivation is their reproductive age. The vast majority do not regret doing so.

Introducción: La vitrificación de óvulos es un avance científico que ha cambiado la perspectiva reproductiva de la sociedad humana. Este procedimiento se ha ofrecido como alternativa a la postergación voluntaria del embarazo, confiriéndole a la mujer una nueva perspectiva en su autonomía reproductiva. El número de mujeres que consultan y luego optan por congelar ovocitos ha aumentado en forma casi exponencial en Chile y en todo el mundo. En nuestro país, hay poco conocimiento acerca de la motivación, experiencia y resultados de la criopreservación electiva de ovocitos en Chile. El objetivo fue conocer la motivación, experiencia y el deseo reproductivo futuro de este grupo de mujeres sometidas a esta técnica. Métodos: Estudio descriptivo transversal, basado en un cuestionario enviado por correo electrónico en el que participaron mujeres que se habían sometido previamente a criopreservación electiva de ovocitos entre enero de 2011 y diciembre de 2019 en Clínica Alemana, Santiago de Chile. Resultados: De 342 mujeres que habían completado un ciclo de criopreservación electiva de ovocitos, 193 aceptaron participar y de estas, 98 (51%) de las mujeres contestaron la encuesta en forma satisfactoria. Se establecieron criterios de exclusión a aquellas mujeres que se habían sometido a este procedimiento por indicación médica como la endometriosis, el cáncer y la baja reserva ovárica. El motivo más frecuente para realizarse el procedimiento fue la edad (44%). En relación al procedimiento; el 94% no se arrepiente de haberlo realizado y 74% de las mujeres cree que utilizará sus ovocitos en algún momento de su vida. Por último, desde que se realizaron la criopreservación de ovocitos a la fecha, el 11% de las mujeres encuestadas ha usado sus ovocitos vitrificados y 27% ha logrado embarazarse con estos. Conclusión: Las mujeres que se someten a criopreservación electiva de ovocitos por razones sociales, son principalmente mujeres sin pareja que tiene como motivación principal su edad reproductiva y la gran mayoría de ellas no se arrepienten de haberlo realizado.

Estudio exploratorio de las motivaciones para la criopreservación de ovocitos en forma electiva / An exploratory study of motivations for elective oocyte cryopreservation

Introducción La vitrificación de óvulos es un avance científico que ha cambiado la perspectiva reproductiva de la sociedad humana. Este procedimiento se ha ofrecido como alternativa a la postergación voluntaria del embarazo, confiriéndole a la mujer una nueva perspectiva en su autonomía reproductiva. El número de mujeres que consultan y luego optan por congelar ovocitos ha aumentado en forma casi exponencial en Chile y en todo el mundo. En nuestro país, hay poco conocimiento acerca de la motivación, experiencia y resultados de la criopreservación electiva de ovocitos en Chile. El objetivo fue conocer la motivación, experiencia y el deseo reproductivo futuro de este grupo de mujeres sometidas a esta técnica. Métodos Estudio descriptivo transversal, basado en un cuestionario enviado por correo electrónico en el que participaron mujeres que se habían sometido previamente a criopreservación electiva de ovocitos entre enero de 2011 y diciembre de 2019 en Clínica Alemana, Santiago de Chile. Resultados De 342 mujeres que habían completado un ciclo de criopreservación electiva de ovocitos, 193 aceptaron participar y de estas, 98 (51%) de las mujeres contestaron la encuesta en forma satisfactoria. Se establecieron criterios de exclusión a aquellas mujeres que se habían sometido a este procedimiento por indicación médica como la endometriosis, el cáncer y la baja reserva ovárica. El motivo más frecuente para realizarse el procedimiento fue la edad (44%). En relación al procedimiento; el 94% no se arrepiente de haberlo realizado y 74% de las mujeres cree que utilizará sus ovocitos en algún momento de su vida. Por último, desde que se realizaron la criopreservación de ovocitos a la fecha, el 11% de las mujeres encuestadas ha usado sus ovocitos vitrificados y 27% ha logrado embarazarse con estos. Conclusión Las mujeres que se someten a criopreservación electiva de ovocitos por razones sociales, son principalmente mujeres sin pareja que tiene como motivación principal su edad reproductiva y la gran mayoría de ellas no se arrepienten de haberlo realizado.

Introduction Oocyte vitrification is a scientific advance that has changed the reproductive perspective of human society. This procedure has been offered as an alternative to the voluntary postponement of pregnancy, giving women a new perspective on their reproductive autonomy. The number of women who consult and then choose to freeze oocytes has increased almost exponentially in Chile and throughout the world. There is little knowledge about the motivation, experience, and results of elective oocyte cryopreservation in Chile. The objective was to know the motivation, experience, and future reproductive desire of the women who underwent this technique. Methods Cross-sectional descriptive study based on a questionnaire sent by e-mail in which females who had previously undergone elective oocyte cryopreservation between January 2011 and December 2019 at Clínica Alemana, Santiago, Chile, participated. Results Of 342 women who had completed a cycle of elective oocyte cryopreservation, 193 agreed to participate, and of these, 98 (51%) answered the survey satisfactorily. Women who underwent this procedure for medical indication, including endometriosis, cancer, and low ovarian reserve, were excluded. The most frequent reason for the procedure was age (44%). Concerning the procedure: 94% do not regret having it done, and 74% of the women believe that they will use their oocytes at some point in their lives. Finally, from the time of oocyte cryopreservation to date, 11% of the surveyed women have used their vitrified oocytes, and 27% have become pregnant. Conclusions Women who undergo elective oocyte cryopreservation for social reasons are mainly women without a partner whose main motivation is their reproductive age. The vast majority do not regret doing so.

Recomendaciones en el manejo de pacientes de medicina reproductiva en tiempos de SARS-CoV-2: Un resumen de la literatura / Management recommendation of reproductive medicine patients in SARS-CoV-2 time: A literature summarize

La pandemia de SARS-CoV-2 es una emergencia sanitaria sin precedentes, que ha implicado un reordenamiento en la priorización de procedimientos médicos electivos, frente a un potencial colapso del sistema de salud a nivel mundial y riesgo de contagio del personal y pacientes. Al igual que en el resto del mundo, en Chile la mayoría de los centros de medicina reproductiva han debido suspender sus diferentes terapias de reproducción asistida (TRA). Sin embargo, a raiz de la disminución del número de contagios y mayor evidencia científica disponible, la Sociedad Europea de Reproducción Humana y Embriología (ESHRE) ha recomendado reiniciar los ciclos de medicina reproductiva de forma gradual, a través de sistemas de triage, priorizando pacientes por medio de la generación de distintos escenarios. Considerando esta recomendación, se realizó una revisión sobre la evidencia existente respecto a SARS-CoV-2 / COVID-19 en medicina reproductiva recopilando diferentes directrices de las principales sociedades internacionales, con el objetivo de generar una recomendación ajustada a la realidad nacional.

SARS-CoV-2 pandemic is an unprecedented health emergency, which involves a reorganization of elective procedures, facing a potential global health system collapse. In Chile, as in the rest of the world. most reproductive medicine centers have suspended their different assisted reproduction therapies (ART). However, due to the decrease in the number of infections and due to a greater collection of scientific evidence, the European Society for Human Reproduction and Embryology (ESHRE) have recommended restarting cycles gradually through triage systems, prioritizing patients through the generation of different scenarios. With this in mind, we carried out a review of the existing evidence so far regarding SARS-CoV-2 and reproductive medicine, and we tried to compile the different guidelines of the main international societies, to generate a recommendation adjusted to our local scenario.

Heterogeneity Among Poor Ovarian Responders According to Bologna Criteria Results in Diverging Cumulative Live Birth Rates.

Research Question: Does reproductive outcome differ among the various subgroups of poor ovarian responders according to the Bologna criteria? Design: This was a retrospective, cohort study including poor ovarian responders according to Bologna criteria, undergoing an ICSI cycle from January 2011 until December 2017. Patients were divided into four groups: (1) age ≥ 40 years and abnormal ovarian response test, (2) age ≥ 40 years, abnormal ovarian reserve test and one previous poor response to stimulation, (3) age ≥ 40 years and one previous poor response, (4) abnormal ovarian reserve test and one previous poor response. Result(s): Overall, 846 cycles in 706 Bologna poor ovarian responders were included: 310 cycles in group 1, 169 in group 2, 52 in group 3, and 315 in group 4. There were significant differences in age, antral follicle count, antimüllerian hormone, cycle cancellation rates, and number of retrieved oocytes between the four groups. Live birth and cumulative live birth rate differed significantly between groups and were highest in Group 4 [Live birth rate: 7.4% (1) vs. 4.1% (2) vs. 5.8% (3) vs. 13.4% (4), p = 0.001 and Cumulative live birth rate: 8.3% (1) vs. 4.1 % (2) vs. 9.6% (3) vs. 16.8% (4) p < 0.001]. The multivariate GEE analysis revealed that the number of MIIs and the Bologna criteria pattern were the variables which were significantly associated with cumulative live birth rate. Conclusion(s): Poor ovarian responders represent a heterogeneous population. The young subpopulation has a better clinical prognosis in terms of fresh and cumulative live birth rate.

Modified natural cycle IVF versus conventional stimulation in advanced-age Bologna poor responders.

RESEARCH QUESTION: Do ongoing pregnancy rates (OPR) differ between modified natural cycle IVF (MNC-IVF) and conventional high-dose ovarian stimulation (HDOS) in advanced-age Bologna poor responders? DESIGN: This was a retrospective cohort study including patients with poor ovarian response (POR) attending a tertiary referral university hospital from 1 January 2011 to 1 March 2017. All women who fulfilled the Bologna criteria for POR and aged ≥40 years who underwent their first intracytoplasmic sperm injection (ICSI) cycle in the study centre were included. RESULTS: In total, 476 advanced-age Bologna poor responder patients were included in the study: 189 in the MNC-IVF group and 287 in the HDOS group. OPR per patient were significantly lower in the MNC-IVF group (5/189, 2.6%) compared with the HDOS group (29/287, 10.1%) (P = 0.002). However, after adjustment for relevant confounders (number of oocytes and presence of at least one top-quality embryo), the multivariate logistic regression analysis showed that the type of treatment strategy (HDOS versus MNC-IVF) was not significantly associated with OPR (odds ratio 2.56, 95% confidence interval 0.9-7.6). CONCLUSIONS: In advanced-age Bologna poor responders, MNC-IVF, which is a more patient-friendly approach, could be a reasonable alternative in this difficult-to-treat group of women.

Cumulative Live Birth Rates Following Stimulation With Corifollitropin Alfa Compared With hp-hMG in a GnRH Antagonist Protocol in Poor Ovarian Responders.

Background: Bologna criteria poor ovarian responders have a very low prognosis. Although, it has been proposed that LH supplementation could be beneficial in women with previous hypo-response to FSH. There are no studies comparing the cumulative live birth rates (LBRs) between corifollitropin alfa (CFA) and highly purified human menopausal gonadotrophin (hp-hMG). Objective: To compare cumulative LBRs in Bologna poor ovarian responders undergoing ovarian stimulation with CFA followed by hp-hMG vs. hp-hMG alone in a GnRH antagonist protocol. Design: This is a retrospective cohort study. We included in total 917 poor responders fulfilling the Bologna criteria for poor ovarian response (POR) at a university-affiliated tertiary center from January 2011 until March 2017. Patients were administered either fixed daily doses of 300-450 IU of hp-hMG (group A) or a single dose of 150 µg of CFA followed by daily injections of ≥300 IU of hp-hMG from Day 8 of stimulation until the day of ovulation trigger (group B), in a fixed GnRH antagonist protocol. Results: LBRs after fresh embryo transfer (ET) were similar in group A 71/510 (14%) and B 42/407 (10%). Cumulative LBR per cycle was significantly higher in group A (16.9%) compared to group B (11.8%); (P = 0.03). However, logistic regression analysis showed no association between the type of gonadotropin administered and cumulative LBR. Only age was significantly associated with cumulative LBR (OR = 0.93, P = 0.007). Conclusion: Cumulative LBRs are similar in Bologna poor responders stimulated with CFA followed by hp-hMG compared to hp-hMG monotreatment in an antagonist protocol.

Pituitary suppression protocol among Bologna poor responders undergoing ovarian stimulation using corifollitropin alfa: does it play any role?

RESEARCH QUESTION: Does the type of pituitary suppression protocol influence cumulative live birth rate (LBR) in Bologna poor responders treated with corifollitropin alfa (CFA)? DESIGN: Retrospective cohort analysis including poor responder patients fulfilling the Bologna criteria who underwent their first intracytoplasmic sperm injection cycle using a CFA-based ovarian stimulation protocol between 2011 and 2017. The starting dose of CFA was 150 µg. The primary outcome was cumulative LBR, defined as the first delivery of a live born resulting from the fresh and all the subsequent frozen embryo transfers. RESULTS: A total of 717 cycles were divided into three groups: A (gonadotrophin-releasing hormone [GnRH] antagonist protocol, n = 407), B (long GnRH agonist protocol, n = 224) and C (short GnRH agonist protocol, n = 86). Cumulative LBR did not significantly differ between groups (20.1% versus 17.4% versus 14.0%; P = 0.35). Significantly more patients in Group A had supernumerary embryos cryopreserved (28.3% versus 18.4% versus 11.6%; P < 0.001). Days of additional highly purified human menopausal gonadotrophin 300 IU injections following CFA were significantly different between Groups A, B and C (3 versus 5 versus 3 days; P < 0.001). Multivariate logistic regression analysis showed that the number of oocytes retrieved remained an independent predictive factor (odds ratio 1.23, 95% confidence interval 1.16-1.31) for cumulative LBR. CONCLUSIONS: Poor responders according to the Bologna criteria in whom CFA is used for ovarian stimulation had comparable cumulative LBR, irrespective of the type of pituitary suppression. An increase in number of oocytes retrieved is an independent variable related to cumulative LBR.

The role of progesterone elevation in IVF.

Elevation of progesterone during the late follicular phase of stimulated in-vitro fertilization cycles is a frequent event, which negatively impacts the outcome. Over the years evidence has demonstrated a direct relationship between late-follicular elevated progesterone and endometrial receptivity. In this regard, elective cryopreservation of all good quality embryos and transfer in a subsequent frozen/thawed cycle is the most common strategy adopted by clinicians in case of elevated progesterone. Nonetheless, recent evidence suggests that elective cryopreservation might not entirely resolve the reduced pregnancy outcomes associated with the elevation of progesterone, considering that the increase may affect not only implantation, but also embryo quality.

Cumulative live birth rates in in-vitro fertilization.

Traditionally, in-vitro fertilization (IVF) success rates have been reported in terms of live birth per fresh cycle or embryo transfer. However, reporting IVF outcomes using cumulative live birth rates (LBR), defined as the first live birth following the use of all fresh and frozen embryos derived from a single ovarian stimulation cycle appears to be a better measure of IVF treatment success. Although there is an initial increase in fresh LBR with the number of oocytes retrieved, LBR either reach a plateau or may even decline when more than 15-20 oocytes are harvested. On the other hand, when all fresh and frozen embryos are taken into account, cumulative LBR have a significant positive association with ovarian response. Cumulative LBR are a more suitable are more comprehensive when reporting success in an IVF program. Cumulative LBR increase with the number of oocytes retrieved, suggesting that ovarian stimulation may have a minimal or no detrimental effect on oocyte/embryo quality.