Minimal Stimulation IVF versus Conventional IVF

Accepted Manuscript
Minimal Stimulation IVF versus Conventional IVF: A Randomized Controlled Trial
John J. Zhang, M.D., Ph.D, Zaher Merhi, M.D, Mingxue Yang, M.D., Ph.D, Daniel
Bodri, M.D., Ph.D, Alejandro Chavez-Badiola, M.D, Sjoerd Repping, Ph.D, Madelon
van Wely, Ph.D
PII:
S0002-9378(15)00860-1
DOI:
10.1016/j.ajog.2015.08.009
Reference:
YMOB 10573
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 10 June 2015
Revised Date:
21 July 2015
Accepted Date: 4 August 2015
Please cite this article as: Zhang JJ, Merhi Z, Yang M, Bodri D, Chavez-Badiola A, Repping S, van Wely
M, Minimal Stimulation IVF versus Conventional IVF: A Randomized Controlled Trial, American Journal
of Obstetrics and Gynecology (2015), doi: 10.1016/j.ajog.2015.08.009.
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Minimal Stimulation IVF versus Conventional IVF:
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A Randomized Controlled Trial
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Authors: John J. Zhang, M.D., Ph.D.1; Zaher Merhi, M.D.2, Mingxue Yang M.D.,
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Ph.D.1; Daniel Bodri, M.D., Ph.D.1; Alejandro Chavez-Badiola, M.D.1; Sjoerd
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Repping, Ph.D.3 ; Madelon van Wely, Ph.D.3
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Institutions:
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1. Reproductive Endocrinology and Infertility, New Hope Fertility Center, New York,
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NY, United States
2. Department of Obstetrics and Gynecology, Division of Reproductive Biology, New
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3. Center for Reproductive Medicine, Academic Medical Center, University of
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Amsterdam, Amsterdam, the Netherlands
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Corresponding author:
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John J. Zhang, M.D., Ph.D.
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Reproductive Endocrinology and Infertility
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New Hope Fertility Center
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4 Columbus Circle
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New York, NY, 10019 United States
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Phone: (212) 400-9636
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Email: [email protected]
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Running title: Mini-IVF versus conventional IVF
Financial disclosure for all authors: None
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Funding: Internal grant funding from New Hope Fertility Center
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To be published in print: Table 4
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ABSTRACT
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protocol that may reduce ovarian hyperstimulation syndrome (OHSS), multiple
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pregnancy rates and cost while retaining high live birth rates.
BACKGROUND: Minimal stimulation IVF (mini-IVF) is an alternative IVF treatment
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OBJECTIVE (S): We performed a randomized non-inferiority controlled trial with a
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pre-specified border of -10% comparing one cycle of mini-IVF with single embryo
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transfer to one cycle of conventional IVF with double embryo transfer.
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STUDY DESIGN: Five hundred sixty four infertile women (age < 39) undergoing their
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first IVF cycle were randomly allocated to either mini-IVF or conventional IVF. The
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primary outcome was cumulative live birth rate per woman over a 6-month period.
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Secondary outcomes included OHSS, multiple pregnancy rates, and gonadotropin
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use. The primary outcome was cumulative live birth per randomized woman within a
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time horizon of 6 months.
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RESULTS: 564 couples were randomly assigned between February 2009 and
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August 2013 with 285 allocated to mini-IVF and 279 to conventional IVF. The
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cumulative live birth rate was 49% (140/285) for mini-IVF and 63% (176/279) for
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conventional IVF (RR 0.76, 95% CI 0.64-0.89). There were no cases of OHSS after
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mini-IVF compared to 16 (5.7%) moderate/severe OHSS cases after conventional
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IVF. The multiple pregnancy rates were 6.4% in mini-IVF compared to 32% in
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conventional IVF (RR 0.25, 95% CI 0.14-0.46). Gonadotropin consumption was
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significantly lower with mini-IVF compared to conventional IVF (459 ± 131 versus
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2079 ± 389 IU, p<0.0001).
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CONCLUSION (S): Compared to conventional IVF with double embryo transfer, mini-
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IVF with single embryo transfer lowers live birth rate, completely eliminates OHSS,
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reduces multiple pregnancy rates and reduces gonadotropin consumption.
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Keywords: IVF; mini-IVF; clomiphene citrate; OHSS; multiple gestations
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Introduction
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The current standard of in vitro fertilization (IVF) treatment involves ovarian
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hyperstimulation with high-doses of gonadotropins in combination with transfer of one
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or more embryos1. The major safety issues of conventional IVF are ovarian
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hyperstimulation syndrome (OHSS) and multiple pregnancies. Women with OHSS
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are at serious risk of potentially life-threatening conditions involving hospitalization in
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1.8% of the cases5. Multiple pregnancies are associated with high risk of
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preeclampsia, gestational diabetes, antepartum hemorrhage, anemia, preterm
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delivery and cesarean section4,6,7-9. Preterm birth is associated with a high risk of
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bronchopulmonary dysplasia, necrotizing enterocolitis, and cerebral palsy8,10,11,12.
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Additionally, all these complications often lead to expensive hospital admissions13,
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which impose a steep burden on societal expenses and health services14.
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One of the most important factors influencing the rate of multiple births is the
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number of embryos transferred15. Single embryo transfer (SET) effectively reduces
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the incidence of multiple pregnancies, but also decreases pregnancy rates per
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transfer16. Given this reduction in pregnancy chances, the majority of physicians and
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patients in the United States are reluctant to practice an SET policy; the percentage
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of SET in IVF cycles ranged between 8.9-14% among women less than 38 years of
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age in 201217. This resulted in 25-29% multiple pregnancy rates among all
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pregnancies achieved during the same period of time17.
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Minimal stimulation IVF (mini-IVF) combined with SET has the potential to
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reduce OHSS and multiple pregnancy rates without significantly lowering live birth
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rates. Mini-IVF entails the use of clomiphene citrate (CC), which allows an
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endogenous rise in follicle-stimulating hormone (FSH) to be additive to the ovarian
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stimulation using low doses of gonadotropins
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frequently makes use of a gonadotropin-releasing hormone agonist (GnRHa), instead
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of human chorionic gonadotropin (hCG), to prevent OHSS. A final contentious
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feature of mini-IVF is a freeze-all-embryo policy to prevent any negative effect of
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ovarian stimulation on endometrial receptivity24. In observational studies, mini-IVF
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has been shown to lead to high pregnancy rates, low multiple pregnancy rates, low
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OHSS rates, and low cost21,22.
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The aim of this non-inferiority randomized trial was to compare the
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effectiveness and safety of the mini-IVF strategy using freeze-all and SET with
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conventional IVF using fresh double embryo transfer.
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Materials and Methods
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Study Oversight
This minimal ovarian stimulation trial was designed by investigators at the
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Academic Medical Center (AMC), Amsterdam and the New Hope Fertility Center
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(NHFC), New York. All the participants received IVF treatments in a single center
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(NHFC, New York). The non-inferiority trial was approved by the Institutional Review
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Board of New York Downtown Hospital (IRB approval reference number: JZ-09-08)
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and was registered before its start at clinicaltrials.gov: NCT 00799929.
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The trial protocol was approved by a protocol review committee and a data
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and safety monitoring board, both appointed by NHFC and by the institutional review
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boards of the New York Downtown Hospital and the Biomedical Research Alliance of
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New York (BRANY). Randomization, monitoring and data analysis were coordinated
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at the Academic Medical Center in the Netherlands.
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Study design and patients
Women were recruited between February 2009 and August 2013 via printed
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and online media. Participants were responsible to pay for their own medications and
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they were provided free services (i.e., oocyte retrieval and embryo transfer) as
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compensation for participation. Inclusion criteria included women aged between 18
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and 38, having normal menstrual cycles, requiring a first IVF treatment, and infertility
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diagnoses of male, unexplained and tubal factors. Exclusion criteria included pre-
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existing medical conditions (such as diabetes, hypertension, hypothyroidism, and
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hyperprolactinemia), and BMI <18.5 or >32 kg/m2, and day 3 FSH > 12 mIU/mL.
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Screening tests before initiation of treatment included complete blood count, varicella
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and rubella titer, pap smear, syphilis, HIV 1 and 2, hepatitis B, hepatitis C, chlamydia,
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gonorrhea, prolactin, thyroid-stimulating hormone, cycle day 3 FSH and estradiol
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(E2). Ultrasound testing was performed at baseline and women with any submucosal
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or large intramural fibroids requiring surgery were excluded from the study.
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Informed consent and randomization
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After obtaining written informed consent, women were randomly allocated to
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mini-IVF or conventional IVF at a 1:1 ratio. The randomization was done at the start
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of the cycle using sequentially numbered opaque envelopes that had been prepared
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on basis of a computer-generated list at the Academic Medical Center in the
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Netherlands and sent to NHFC in New York. Women and medical staff were not
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blinded for treatment allocation. Outcome data were not disclosed to participants or
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investigators until completion of the trial.
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Mini-IVF
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After oral contraceptive pill pre-treatment during 10-14 days, adequate
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suppression was confirmed with an E2 level of <75 pg/mL. Minimal ovarian
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stimulation was started with an extended regimen (from day 3 until the day before
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triggering) of CC (50 mg/day orally) in conjunction with gonadotropin injections
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(Bravelle and/or Menopur, Ferring, Parsippany, NJ; Follistim, Merck, White House
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Station, NJ; or Gonal F, EMD Serono, Rockland, MA) starting on cycle day 4-7 with
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75-150 IU’s daily. No hypothalamic-pituitary suppression was performed and the final
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maturation of oocytes was induced by a GnRHa nasally (Synarel nasal spray, Pfizer,
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New York, NY) when the lead follicle reached a diameter of 18 mm or greater (Figure
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1). Oocyte retrieval was performed mostly with local anesthesia and follicular flushing
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was performed as needed. Retrieved oocytes were fertilized by conventional IVF or
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ICSI as indicated and subsequently cultured until the blastocyst stage. All blastocysts
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were vitrified using the CryoTop method (Kitazato Biopharma)25. A single thawed
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blastocyst was transferred in a subsequent natural or artificially prepared cycle with
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oral Estrace (Actavis Pharma, Inc, Parsippany, NJ) 22.
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Conventional IVF
Conventional ovarian stimulation consisted of a long GnRHa protocol using
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mid-luteal down-regulation (Leuprolide Acetate, Teva, Sellersville, PA) followed by
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stimulation with daily gonadotropins injections (Bravelle and/or Menopur, Ferring,
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Parsippany, NJ; Follistim, Merck, White House Station, NJ; or Gonal F, EMD Serono,
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Rockland, MA) at a dose of 150-300 IU’s daily starting in the early follicular phase
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(cycle day 3). The final maturation of oocytes was induced with the standard hCG
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(Novarel, Ferring, Parsippany, NJ; Pregnyl, Merck, White House Station, NJ; or
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Ovidrel, EMD Serono, Rockland, MA), rather than GnRHa, when at least two follicles
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reached 18 mm or greater. Oocyte retrieval was performed using mostly general
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anesthesia because of the presence of a large number of mature follicles. Retrieved
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oocytes were fertilized by conventional IVF or ICSI according to the same indications
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as in the mini-IVF protocol and subsequently cultured until the blastocyst stage. Two
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or one blastocysts– the latter if two embryos were not available or if there was a
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medical contraindication for DET– were transferred in the fresh cycle. Remaining
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supernumerary blastocysts were vitrified and two thawed blastocysts or one
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blastocyst if two were not available were transferred in subsequent naturally or
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artificially prepared cycles with oral Estrace (Actavis Pharma, Inc, Parsippany, NJ).
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Outcomes
The primary outcome was cumulative live birth per randomized woman
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(including fresh and subsequent frozen embryo transfers) within a time horizon of 6
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months. Secondary outcomes were clinical pregnancy rate, OHSS, multiple
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pregnancy rate, gonadotropin usage, number of retrieved, mature and fertilized
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oocytes, implantation rate, cancellation rate, and failed fertilization. A clinical
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pregnancy was defined as at least one intrauterine sac at 6 weeks gestation and live
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birth was defined as a child born after 22 weeks of gestation or weighing at least 500
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grams.
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Sample size calculation and statistical analysis
Sample size calculation was based on an expected cumulative live birth rate of
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65% in ≤ 38 years old women following conventional IVF based on U.S. SART
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registry data from 2007 because recruitment started in 200917. A non-inferiority
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margin of -10% was considered a clinically significant difference. Thus, 564 women
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were needed to assure that with a power of 80% the lower limit of a one-sided 95%
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confidence interval (CI) was within a pre-specified border of -10%.
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The effectiveness of mini-IVF versus conventional IVF was expressed as a
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risk ratio for cumulative live birth, with corresponding 95% CI. The risk difference and
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95% CI for live birth as well as the relative risks (RR) and 95% CI for all binary
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secondary outcomes were calculated. For continuous outcomes, data were
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expressed as means ± standard deviation (SD) and the difference between both
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arms was compared using t-test. Chi-square and Fisher exact tests were used for
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categorical data as appropriate. The analysis of all outcomes was on an intention to
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treat basis. P<0.05 was considered statistically significant. SPSS 22.0 was used to
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perform all statistical analyses.
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Results
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A total of 771 women were assessed for eligibility (Figure 2). Of these, 180
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women did not fulfill the inclusion criteria (41 had no indication for IVF, 20 had pre-
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existing medical conditions interfering with IVF treatment, 75 had abnormal screening
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results, 2 were pregnant at the time of screening, 9 had personal problems, and 33
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had multiple reasons) and 27 women did not give informed consent. A total of 564
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women were randomly allocated to the mini-IVF strategy or to conventional IVF. Four
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women in the mini-IVF arm and six women in the conventional IVF arm did not
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receive the allocated intervention due to withdrawal before starting treatment.
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Additionally, three women in the mini-IVF arm and six women in the conventional IVF
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arm dropped-out after starting treatment due to reasons detailed in Figure 2.
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Cancelled cycles, failed fertilization, and blastocyst developmental failure in each arm
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are shown in Figure 2. In the mini-IVF arm, of the 281 participants who received the
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allocated intervention, 6 did not make it to the oocyte retrieval stage (3 had ovarian
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cyst at the baseline ultrasound, 1 had no follicular development, and 2 prematurely
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ovulated) and 44 had no embryo transfer for reasons such as failed fertilization, failed
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blastocyst formation, and spontaneous pregnancy prior to embryo transfer. In the
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conventional IVF arm, of the 273 participants who received the allocated intervention,
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20 did not make it to the oocyte retrieval stage (3 failed to have ovarian suppression
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and 17 did not have appropriate follicular development) and 22 did not have embryo
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transfer for similar reasons as those in the mini-IVF arm.
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Baseline characteristics did not differ between both arms (Table 1). Most
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women (68%) were younger than 35 years of age. Primary and secondary outcomes
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are listed in Table 2. The cumulative live birth rate per randomized woman (including
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live births from frozen-thawed embryo transfers in both arms of the study) was 49%
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in the mini-IVF arm and 63% in the conventional IVF arm, resulting in a RR of 0.78
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(95% CI: 0.67 to 0.90). The average absolute difference of mini-IVF versus
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conventional IVF was -14% (95% CI: -6 to -22%). None of the women in the mini-IVF
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arm developed OHSS because of the use of GnRHa, while moderate/severe OHSS
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occurred in 16 (5.7%) women in the conventional IVF arm. Seven of these women
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were hospitalized and underwent transvaginal paracentesis for symptomatic relief.
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Multiple pregnancy rate was significantly lower in the mini-IVF arm (6.4% versus
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32%, RR= 0.25, 95% CI: 0.14 to 0.46) and they were all monozygotic twins due to
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the fact that only one embryo was transferred in this arm. Women in the mini-IVF arm
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required significantly lower total doses of gonadotropins per cycle (459 ± 131 versus
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2079 ± 389 IU, p<0.0001).
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Laboratory outcome data are summarized in Table 3 and details on the
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transfer procedures and their outcomes are summarized in Table 4. In total, 340 and
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334 fresh and/or frozen embryo transfers procedures were performed in the mini-IVF
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and conventional IVF arms, respectively. In the mini-IVF arm, strict SET was
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performed, while in the conventional IVF arm 1.7 embryos on average were
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transferred in either fresh or subsequent frozen cycles (Table 4). Following the first
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FET cycle, the implantation rate was significantly higher in the conventional IVF arm
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(58%) compared to the mini-IVF arm (47%; p=0.02) (Table 4). However, implantation
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rate declined in subsequent FET cycles in the conventional IVF arm but increased in
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subsequent FET cycles in the mini-IVF arm to have tendency towards statistical
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significance in the 3rd FET cycle (30% in the conventional IVF versus 54% in the
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mini-IVF; p=0.1; Table 4). Additionally, clinical pregnancy rate dropped in subsequent
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FET cycles in the conventional IVF arm (68% in the first FET cycle then 49%, 40%
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and 33% in subsequent cycles) while it remained constant in subsequent FET cycles
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in the mini-IVF arm (47% in the first FET cycle then 48%, 54% and 50% in
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subsequent cycles) (Table 4).
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Discussion
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This randomized trial compared the mini-IVF strategy including freeze-all and
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SET to conventional IVF with fresh double embryo transfer in women aged less than
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39. The results indicated that the cumulative live birth rate in mini-IVF was 14% lower
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than that observed in conventional IVF but at the same time mini-IVF completely
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eliminated OHSS, significantly reduced the risk of multiple pregnancy, and resulted in
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a 78% reduction in total gonadotropin dose used per cycle.
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Our study has several strengths. The design was rigorous and meticulous
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where only a small number of women withdrew after giving an informed consent and
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only a small number of women were lost to follow up. The patient population included
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women of various ethnicities making the results more generalizable. Furthermore, the
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conventional IVF arm resulted in pregnancy rates, OHSS and multiple pregnancies
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rates that were comparable to the rates observed in U.S. registries, strengthening our
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predefined power calculation17.
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There are several limitations to our study. First and foremost, we compared
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two completely different strategies thus preventing us to disentangle the effects of
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various components of mini-IVF such as SET and the disengagement of stimulation
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and transfer. In other words, it is impossible to attribute the observed effects of mini-
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IVF on live birth rates, OHSS, multiple pregnancy rates and gonadotropin use to the
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method of ovarian stimulation, to the freeze-all concept or to the single embryo
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transfer policy as these are all integral parts of mini-IVF. Future randomized
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controlled trials should focus on strictly evaluating these various components.
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Second, our study was a single center study, thus hampering generalisability.
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Though mini-IVF resulted in significantly lower live birth rates, it is too early to
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state that it is inferior to conventional IVF. In our power calculation, we used a
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reduction of 10% as a clinically relevant reduction in live birth rates following mini-
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IVF. The absolute difference observed in our study was -14% with a 95% boundary
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of -22% to -6%. Thus, the pre-specified acceptable 10% difference is still within the
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95% CI of the observed difference. Furthermore, mini-IVF significantly reduced
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OHSS, multiple pregnancy rate and gonadotropin use, thereby increasing safety of
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IVF and controlling the cost of unwanted side effects. It is unknown if patients are
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willing to trade off these marginally lower live birth rates for increased safety and
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reduced costs. It is also unknown whether a lower cost of mini-IVF would motivate
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women to undergo more than one mini-IVF cycle for the same price as a single
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conventional IVF cycle. In this respect, it would be worthwhile comparing the
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cumulative pregnancy and live birth rates of two consecutive mini-IVF cycles with one
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conventional IVF cycle. As mini-IVF is also likely to result in less treatment burden
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and stress, future trials should consider these additional relevant dimensions into
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account. The data provided in this study are the ingredients for shared decision-
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making in order to choose between mini-IVF and conventional IVF on a case by case
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basis39.
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Our mini-IVF protocol was originally developed at Kato Ladies Clinic in Japan
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and was successfully adapted and modified by our center22. In contrast to other
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treatment protocols where CC was only used for a few days in the early follicular
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phase27, CC was administered in our protocol during the whole stimulation phase in
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conjunction with a low-dose of gonadotropins. This extended regimen favors the
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development of a mild ovarian response but also takes advantage of the ability of CC
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to prevent premature LH surge thus reducing the risk of premature ovulation in
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addition to decreasing the amount of gonadotropins needed19. We also disengaged
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the embryo transfer from the stimulation phase, since it has been demonstrated that
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the CC based minimal ovarian stimulation protocol was more efficient when embryos
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were electively vitrified (preferably at a blastocyst stage) and transferred at a later
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naturally or artificially prepared frozen embryo transfer cycle21.
Our trial is in line with recent evidence which suggests that segmentation of
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IVF treatment could overcome the impaired endometrial receptivity frequently
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occurring in stimulated cycles with gonadotropins28. In this respect, it is of note that
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the live birth rates per embryo transfer were stable in the mini-IVF arm (39% in the
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first frozen embryo transfer cycle then 41%, 54% and 50% in subsequent cycles)
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while the live birth rates in the conventional IVF arm dropped from 62% after fresh
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transfer to 30% in the fourth frozen embryo transfer cycle. Besides a potential effect
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on endometrial receptivity, this might indicate an increased embryo quality in the
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mini-IVF arm as compared to the conventional IVF arm. This hypothesis is yet to be
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determined.
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In conclusion, mini-IVF with SET has a lower live birth rate, eliminates OHSS,
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reduces gonadotropin consumption, and reduces multiple pregnancy rates compared
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to conventional IVF with double embryo transfer. How these different dimensions are
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weighed by couples deciding between mini-IVF or conventional IVF, and whether the
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lower live birth rate could be offset by a series of “lower cost” mini-IVF cycles, should
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be the subject of future studies.
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Gerris J, De Sutter P, De Neubourg D, et al. A real-life prospective health
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randomized clinical trial. Human reproduction 1999;14:2581-7.
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Table 1. Demographics and baseline characteristics of the participants
Mini-IVF
279
Age (years)
32.4±3.6
31.9±4
BMI (kg/m2)
24.7±3.8
24.9±3.8
Baseline FSH (mIU/mL)
8.6±2.2
8.5±2.3
Infertility duration (years)
2.4±1.5
Primary infertility
127 (45)
Nulliparous
207 (73)
Ethnicity
Caucasian
Black
Asian
Mixed/other
Male
AC
C
Unknown
EP
Infertility diagnoses
TE
D
Hispanic
Tubal
RI
PT
285
2.5±1.5
132 (47)
207 (74)
M
AN
U
Randomized patients
Conventional IVF
SC
460
461
Mixed male/female
143 (50)
126 (45)
55 (19)
70 (25)
42 (15)
46 (16)
35 (12)
29 (10)
10 (4)
8 (3)
78 (27)
101 (36)
69 (24)
66 (24)
70 (25)
48 (17)
21 (7)
29 (10)
47 (16)
35 (12)
Other (PCO, DOR, endometriosis,
multiple)
462
463
464
Values are expressed as n, mean ± SD or n (%)
P > 0.1 for all comparisons between the mini-IVF and the conventional IVF arms
21
ACCEPTED MANUSCRIPT
465
Table 2. Primary and secondary outcomes in the treatment groups
Pregnancy outcome
Randomized patients
Clinical pregnancy
Live births
Mini-IVF
Conventional
IVF
285
279
161 (57)
211 (76)
0.67 (0.57-0.78)
140 (49)
176 (63)
0.78 (0.67-0.90)
9 (6.4)
56 (32)
Total clomiphene dosec
Total gonadotropin
Days of stimulationc
Peak E2 (pg/mL)c
p-value
---
459±131
2079±389
<0.0001a
10.7±5.7
10.4±5.7
0.48a
1657±1067
3255±2344
<0.0001a
0 (0)
16 (5.7)
<0.0001b
Values are expressed as n, n (%) or mean ± SD
t-test
b
Chi-square test
c
Among those who started ovarian stimulation (n=548)
a
AC
C
467
468
469
470
471
472
473
474
475
476
477
478
479
480
EP
Moderate/severe OHSSc
0.25 (0.14-0.46)
513±101
TE
D
dose/cyclec
M
AN
U
Stimulation outcome
SC
Multiple pregnancy per live
births
RR (95% CI)
RI
PT
466
22
ACCEPTED MANUSCRIPT
Table 3. Laboratory outcome data
p-value
285
Conventional
IVF
279
Oocyte retrievals
275 (97)
253 (91)
0.61b
# of retrieved oocytesc
4.3±3.2
Inseminated oocytes (IVF or ICSI)c
3.7±2.8
Fertilized (2PN) oocytesc
3.1±2.4
Blastocysts (total)d
2.6±1.9
5.9±4.3
<0.0001a
Cycles with blastocysts transferred/frozen
234 (82)
235 (84)
0.84 a
12.8±8
<0.0001a
10±6.7
<0.0001a
8.3±5.8
<0.0001a
EP
TE
D
Values are expressed as n, mean ± SD or n (%)
a
t-test
b
Chi-square test
c
Among those who had oocyte retrieval (n=528)
d
Among those who reached blastocyst stage (n=469)
AC
C
483
484
485
486
487
488
489
490
491
492
493
494
495
496
---
M
AN
U
Randomized patients
SC
Mini-IVF
RI
PT
481
482
23
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Table 4. Outcome of fresh and frozen-thawed embryo transfers in both arms
2nd FET
3rd FET
4th FET
5th FET
6
---
228
80
26
---
1±0
1±0
1±0
1±0
---
---
106 (47)*
38 (48)
14 (54)
3 (50)
---
---
106/228
(47)*
90 (39)a
9 (9.3)
38/80
(48)
33 (41)d
0
14/26
(54)
14 (54)f
0
3/6
(50)
3 (50)i
0
-------
25
9
2
1.5±0.5
1.5±0.5
1.6±0.5
8/25
(32)
4/9 (44)
1/2
10 (40)
3 (33)
0
10/33
(30)
8 (32)g
0
5/13
(38)
3 (33)j
2 (66)
0
-----
TE
D
EP
AC
C
RI
PT
---
Total # of
embryo
120
111
67
transfers
Transferred
1.7±0.5
1.7±0.5
1.6±0.5
embryo (s) per
cycle
DET/total #
87/120
84/111
37/67
embryo
(72)
(75)
(55)
transfers
Clinical
89 (74) 76 (68)** 33 (49)
pregnancy
Implantation
117/207 113/195
42/104
rate
(56)
(58)**
(40)
b
c
Live birth
74 (62)
67 (60)
24 (36)e
Multiple
27 (34)
31 (45)
6 (22)
pregnancy
Values are expressed as n, mean ± SD, or n (%)
ET, embryo transfer
FET, frozen embryo transfer
DET, double embryo transfer
Chi-square test:
a vs b, p=0.0001, RR= 0.73 (0.62-0.86)
a vs c, p=0.0003, RR= 0.76 (0.65-0.88)
d vs e, p=0.61, RR= 1.11 (0.82-1.49)
f vs g, p=0.16, RR= 1.54 (0.89-2.63)
h vs i, p=0.62, RR= 1.50 (0.44-5.09)
* vs **, p<0.05
Conventional IVF
499
500
501
502
503
504
505
506
507
508
509
510
511
Total # of
embryo
transfers
Transferred
embryo (s) per
cycle
Clinical
pregnancy
Implantation
rate
Live birth
Multiple
pregnancy
1st FET
SC
Mini IVF
Fresh
ET
M
AN
U
497
498
0
0
24
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Figure legends
517
Figure 1: Schematic diagrams of mini-IVF and conventional IVF protocols. In the
518
artificially prepared frozen embryo transfer (part 2) of the mini-IVF protocol, oral
519
estradiol treatment was started on day 3 and given daily then progesterone treatment
520
was added on day 13 onward to the estradiol pills.
521
IVF,
522
gonadotropin-releasing hormone agonist. US, ultrasound. HCG, human chorionic
523
gonadotropin.
524
525
526
527
528
529
530
Figure 2: Trial profile: screening, eligibility, randomization, and follow-up.
ICSI,
Intracytoplasmic
sperm
injection.
GnRHa,
SC
fertilization.
M
AN
U
vitro
AC
C
EP
TE
D
in
RI
PT
512
513
514
515
516
25
Figure 1
ACCEPTED MANUSCRIPT
PART 1
Mini IVF
Initial Office
Visit
Stimulation
Birth Control
Pills (14 d)
Clomid 1 Tab Daily &
Low Dose Gonadotropins
GnRH a
Nasal Spray
(Ovulation
Induction)
[Randomization]
Day of Menstrual Cycle #1
3-5
--
--
21
3
Day of Menstrual Cycle #2
8
10
Blood & US
Blood & US
12
Blood & US
PART 2
Mini IVF
SC
3
8, 10, 12, 14
Blood & US
PART 1
Conventional IVF
Day of Menstrual Cycle #3
Pregnancy Test
Frozen
Embryo Transfer
--
19
26
TE
D
Blood & US
M
AN
U
--
Stimulation
Daily Gonadotropins
EP
Daily Lupron
Subcutaneous Injection (28 d)
HCG Injection
(Ovulation
Induction)
AC
C
[Randomization]
--
Day of Menstrual Cycle #1
3-5
--
21
--
3
Blood & US
Day of Menstrual Cycle #2
8
10
Blood & US
Blood & US
PART 2
Conventional IVF
Egg
Retrieval &
Fertilization
IVF/ ICSI
14
Day of Menstrual Cycle #2
Egg
Retrieval &
Fertilization
IVF/ ICSI
--
12
14
Blood & US
Embryo Transfer
Daily Progesterone
in Oil Injections
--
14
Blood & US
Embryo Transfer
Daily Estradiol & Progesterone
Initial Office
Visit
--
RI
PT
--
Egg
Retrieval &
Fertilization
IVF/ ICSI
Fresh
Embryo Transfer
Pregnancy Test
19
26
--
ACCEPTED MANUSCRIPT
Figure 2
771 assessed for eligibility
285 Allocated to receive Mini IVF
3 withdrew consent after randomization
1 spontaneous pregnancy
M
AN
U
564 Randomized
EP
TE
D
281 Received allocated intervention
6 no egg retrieval
3 did not start stimulation due to persistent
cyst
1 canceled due to absent follicular
development
2 prematurely ovulated
44 had no embryo transfer
2 had no egg retrieved
9 fertilization failure
31 had no blastocysts available
1 spontaneous pregnancy prior to first
embryo transfer
1 withdrawn from treatment
1 spontaneous pregnancy after failed
embryo transfer
AC
C
SC
RI
PT
180 Did not meet inclusion criteria
41 no indication for IVF
20 pre-existing medical condition
preventing/interfering with IVF
treatment
75 abnormal screening results
(including BMI, elevated FSH
levels, irregular cycles)
2 pregnant at the time of screening
9 partnership problems
33 multiple/other reasons
27 Declined to participate
279 Allocated to receive conventional IVF
6 withdrew consent after randomization
273 Received allocated intervention
20 no egg retrieval
3 did not start stimulation due to
suppression failure
17 canceled due to insufficient follicular
development
22 had no embryo transfer
2 fertilization failure
16 had no blastocysts available
1 spontaneous pregnancy prior to first
embryo transfer
3 withdrawn from treatment
2 spontaneous pregnancies after failed
embryo transfer
2 spontaneous abortions (18 and 21 weeks)
3 lost to follow-up
4 lost to follow-up
285 Analyzed
279 Analyzed