Materials and Methods
Study population
This is a retrospective cohort study. Patients were treated with routine practice of IVF from July 2016 to December 2018 at Mei-Tsun Reproductive Medical Center. The data was collected from medical records and the computerized database. The definition of a poor responder fits into at least two of the following criteria: (1) A previous episode of poor ovarian response (≤3 oocytes) under a standard dose of medication; (2) An abnormal ovarian reserve with AFC (Antral Follicle Counts) <5–7 follicles or AMH (Anti-Mullerian Hormone) <0.5–1.1 ng/mL; (3) Women above 40 years of age or those with other risk factors for poor response such as previous ovarian surgery, genetic defects, chemotherapy, radiotherapy, and autoimmune disorders.
Patient characteristics including age, body mass index (BMI), basal AFC, and basal hormone levels were recorded. Clinical parameters including gonadotropin dosage, E2 levels at human chorionic gonadotropin (hCG) day, number of oocytes retrieved, fertilization rate, clinical pregnancy rate, and live birth rates were analyzed.
Supplementation
Each patient received dehydroepiandrosterone (DHEA 30mg, Wild Yam Root extract, VIVA Pharmaceutical Inc., Canada) 90 mg daily from 3 months prior to starting IVF cycle until the day of human chorionic gonadotropin (hCG) trigger. Metformin (Metformin Hydrochloride 500 mg , Swiss Pharmaceutical Co.,Ltd , Taiwan ) was given to the patients 1500mg daily from 3 months prior to starting IVF cycle until a positive pregnancy test or menstrual bleeding appeared.
IVF process
Controlled ovarian hyperstimulation was performed using the short GnRH agonist protocol. Buserelin nasal spray (Buserelin acetate 10.5mg, Sanofi-Aventis Deutschland GmbH , Germany), 300μg three times daily, was administered from day 2 of treatment cycle until the day human chorionic gonadotropin (hCG) trigger. Ovarian stimulation was achieved the next day with 300 IU dose recombinant FSH (rFSH: Gonal-f® , Merck-Serono, Geneva, Switzerland, or Puregone® , Organon, Espanola S.A., Barcelona, Spain) and 150 IU dose hMG (Pergovaris , 150 rFSH+75 rLH, Merck Serono, Aubonne, Switzerland, or Merional , 75 FSH+75 LH, IBSA Institut Biochimique S.A.,Switzerland ). The selection of the type of gonadotropin was individualized according to each patient’s characteristics. Serial folliculometry and assessment of serum E2, P4 and LH levels were monitored every 1-2 days, starting from 3-5 days after stimulation and continued until two or more follicles reached 17 mm in diameter or when per-follicle E2 level reached 200 pg/ml. Dual trigger, combined recombinant hCG (Ovidrel® 250μg, Merck-Serono, Geneva, Switzerland) and GnRH agonist (Lupro 2 mg, Nang Kuang Pharmaceutical Co, Ltd., Tainan, Taiwan), were administered. Oocytes were retrieved 34–36 hours after oocyte trigger under the guidance of transvaginal ultrasound. Intracytoplasmic sperm injection (ICSI) was performed in all patients to diminish potential fertilization failure. The best morphologically graded embryos from the stimulated cycle was selected for embryo transfer at 3 days after oocyte retrieval. Luteal support commenced from the second day after oocyte retrieval with Crinone 8% Progesterone Vaginal Gel (Progesterone 90mg, Merck Serono, Hertfordshire, UK) andUtrogestan (Micronised Progesterone 100mg, Arich Enterprise Co., Ltd., Taiwan). A pregnancy test was carried out 15 days after embryo transfer. Once a positive pregnancy test was observed, progesterone was continued until 10-12 weeks of gestation. A clinical pregnancy was confirmed with the presence of a fetal heart beat at 7 weeks of gestation by ultrasonography. A live birth was defined as delivery after 24 weeks of gestation.
Statistical analysis
All data were analyzed using the commercially available software package SPSS (SPSS Inc., Chicago, IL, USA) and presented as mean±standard deviation or number (%). Statistical analysis was carried out using Mann-Whitney U test for continuous data and χ2 test for categorical data. Differences were considered to be significant when p value< 0.05.