Infertility
Conditions
Keywords
Poor ovarian response, Salvador/Warts/Hippo pathway, Follicular activation, Poor ovarian reserve
Brief summary
This study aims to assess whether activation of primordial follicles through ovarian cortex fragmentation may increase the number of antral follicles present in the ovary of patients with diminished ovarian reserve. Secondary outcomes include number of oocytes retrieved and pregnancy rates after IVF. Hypothesis; Evaluate whether the proposed intervention increases the pool of antral follicles (potentially stimulable ones).
Detailed description
Controlled, randomized, assessor-blind clinical trial. Thirty-six patients of La Fe University Hospital (Valencia), previously confirmed as poor responders according to the European Society of Human Reproduction and Embryology (ESHRE) criteria, will be randomized to two treatment arms: * Arm 1 (control): no intervention. * Arm 2 (intervention): ovarian cortex extraction by unilateral laparoscopic biopsy and ovarian tissue fragmentation in aliquots of 1 mm2. These fragments will be grafted under the ovarian cortex and meso-ovarium ipsilateraly. Subsequently the number of antral follicles in both intervention groups will be compared and also will be the number of antral follicles in the native ovary and the grafted one in each of the patients. Patients will receive a standard IVF treatment for poor responders according to the protocols of the assisted reproduction unit of La Fe University Hospital. The final aim is to assess the pregnancy rate in both groups, as well as parameters related to the reproduction technique when required.
Interventions
PROCEDUREIn vitro fragmentation of the ovarian tissue
Unilateral ovarian cortex extraction, in vitro fragmentation and reimplantation.
Sponsors
César Díaz García
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 40 Years
Healthy volunteers
No
Inclusion criteria
(must meet one): * At least two episodes of poor ovarian response (≤ 3 oocytes retrieved with a standard protocol). * A previous IVF cycle with ≤ 3 oocytes (following a standard stimulation protocol) and presence of an abnormal ovarian reserve test (antral follicle count of ≤ 5 or antimüllerian hormone ≤ 5pm).
Exclusion criteria
(must not meet any): * Patients under 18 or over 40 years. * Clinical signs of endometriosis. * Previous ovarian surgery. * Genital tract malformations. * Anovulatory patient (defined by the presence of irregular cycles and serum progesterone ≤ 10 ng / mL on cycle day 21). * Partner with severe male factor: severe oligoasthenozoospermia, oligoasthenoteratozoospermia and azoospermia. * All those patients who do not voluntarily give their express written consent.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Metaphase II (MII) | 36 hours after triggering | Number of mature MII oocytes retrieved in the IVF cycles after triggering. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Total Antral Follicle Count (AFC) - Final | Day 2-5 of the menstrual cycle 6 months after treatment | AFC assessment was done on day 2-5 of the menstrual cycle and was followed for 6-month. To determine AFC, ultrasound scan was performed using a GE iVoluson (General Electric, Spain) equipped with a 3D vaginal probe (6.5-9MHz). A bilateral two-dimensional scan was performed and the mean of the two largest diameters of each intra-ovarian avascular anechoic image was recorded. Antral follicles with a mean diameter from 2 to 10 mm were counted to establish AFC. Final measure refers to the AFC count after ovarian fragmentation treatment. |
| Initial Antimüllerian Hormone (AMH) Levels | Baseline, day 2-5 of the menstrual cycle prior to treatment | AMH levels were determined on day 2-5 of the menstrual cycle to establish the initial baseline levels for each patient. A microparticle immunoassay kit integrated in the ABBOTT AxSYM® Plus system and software 5.20 (Abbott Laboratories, Abbot Park, IL, USA) was used to determine AMH levels prior treatment. |
| Final AMH Levels | Day 2-5 of the menstrual cycle 6 months after the treatment | AMH levels were determined using a microparticle immunoassay kit integrated in the ABBOTT AxSYM® Plus system and software 5.20 (Abbott Laboratories, Abbot Park, IL, USA) 6 months after recruitment or basaline assessment. |
| Number of Cancelled IVF Cycles | End of stimulation cycle (less than or equal to 30 days) | Number of cancelled IVF cycles for low or no response to controlled ovarian stimulation. Cycles were cancelled because of a lack of an adequate follicular formation (one follicle of at least 17 mm) the day of triggering. |
| Total Antral Follicle Count (AFC) - Initial Measure | Baseline, day 2-5 of the menstrual cycle prior to treatment | AFC assessment was done on day 2-5 of the menstrual cycle. Ultrasound scan was performed using a GE iVoluson (General Electric, Spain) equipped with a 3D vaginal probe (6.5-9MHz). A bilateral two-dimensional scan was performed and the mean of the two largest diameters of each intra-ovarian avascular anechoic image was recorded. Antral follicles with a mean diameter from 2 to 10 mm were counted to establish AFC. Initial data refers to the measure taken before treatment. |
| Number of Cycles With Embryo Transfer (ET) | On day 3 after egg collection | One or 2 embryos were transferred on day 3 after egg collection. This outcome represents the number of cycles that culminate with embryo transfer. |
| Number and Percentage of Cycles With Clinical Pregnancy | 6 weeks after embryo transfer | Clinical pregnancy was defined as the presence of a gestational sac and heart beat under ultrasonography |
| Live Birth Rate | 9 months or birth of one or more live babies | Live birth rate was calculated by dividing the number of patients who achieved live birth in each cycle by the number of patients who initiated that cycle |
| Fertilization Rate | 18 hours after insemination | All the mature oocytes retrieved were inseminated by intracytoplasmic sperm injection (ICSI). Percentage of successfully fertilized oocytes were registered 18 hours after oocyte insemination. |
Countries
Spain
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Control Arm No intervention is performed. Assessment of antral follicle count. IVF treatment. | 18 |
| Experimental Arm Perform intervention described: Laparoscopy. In vitro fragmentation of the ovarian tissue.
Assessment of antral follicle count. IVF treatment.
In vitro fragmentation of the ovarian tissue: Unilateral ovarian cortex extraction, in vitro fragmentation and reimplantation. | 16 |
| Total | 34 |
Baseline characteristics
| Characteristic | Control Arm | Experimental Arm | Total |
|---|---|---|---|
| Age, Continuous | 37 years | 37.5 years | 37.3 years |
| Baseline AMH | 0.36 ng/mL | 0.44 ng/mL | 0.4 ng/mL |
| Baseline Antral Follicle Count (AFC) | 5 number of follicles | 4 number of follicles | 4.5 number of follicles |
| Body Mass Index (BMI) | 21 kg/m^2 | 22.4 kg/m^2 | 21.7 kg/m^2 |
| Infertile duration | 36 months | 48 months | 42 months |
| Infertility etiology Male factor | 1 Participants | 0 Participants | 1 Participants |
| Infertility etiology Only POR | 16 Participants | 15 Participants | 31 Participants |
| Infertility etiology Tubal factor | 1 Participants | 1 Participants | 2 Participants |
| Number of previous IVF cycles | 1 Participants | 1 Participants | 2 Participants |
| Previous deliveries | 1 Participants | 1 Participants | 2 Participants |
| Previous gestations | 7 Participants | 6 Participants | 13 Participants |
| Previous miscarriages | 6 Participants | 5 Participants | 11 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 18 Participants | 16 Participants | 34 Participants |
| Sex: Female, Male Female | 18 Participants | 16 Participants | 34 Participants |
| Sex: Female, Male Male | 0 Participants | 0 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 16 | 0 / 15 |
| other Total, other adverse events | 0 / 16 | 1 / 15 |
| serious Total, serious adverse events | 0 / 16 | 0 / 15 |
Outcome results
Primary
Number of Metaphase II (MII)
Number of mature MII oocytes retrieved in the IVF cycles after triggering.
Time frame: 36 hours after triggering
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Control Arm | Number of Metaphase II (MII) | 4 Oocytes |
| Experimental Arm | Number of Metaphase II (MII) | 2 Oocytes |
p-value: 0.302Wilcoxon (Mann-Whitney)
Secondary
Fertilization Rate
All the mature oocytes retrieved were inseminated by intracytoplasmic sperm injection (ICSI). Percentage of successfully fertilized oocytes were registered 18 hours after oocyte insemination.
Time frame: 18 hours after insemination
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Control Arm | Fertilization Rate | 100 Percentage of fertilized oocytes |
| Experimental Arm | Fertilization Rate | 33.3 Percentage of fertilized oocytes |
p-value: 0.48Chi-squared
Secondary
Final AMH Levels
AMH levels were determined using a microparticle immunoassay kit integrated in the ABBOTT AxSYM® Plus system and software 5.20 (Abbott Laboratories, Abbot Park, IL, USA) 6 months after recruitment or basaline assessment.
Time frame: Day 2-5 of the menstrual cycle 6 months after the treatment
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Control Arm | Final AMH Levels | 0.35 ng/mL |
| Experimental Arm | Final AMH Levels | 0.29 ng/mL |
p-value: 0.496Wilcoxon (Mann-Whitney)
Secondary
Initial Antimüllerian Hormone (AMH) Levels
AMH levels were determined on day 2-5 of the menstrual cycle to establish the initial baseline levels for each patient. A microparticle immunoassay kit integrated in the ABBOTT AxSYM® Plus system and software 5.20 (Abbott Laboratories, Abbot Park, IL, USA) was used to determine AMH levels prior treatment.
Time frame: Baseline, day 2-5 of the menstrual cycle prior to treatment
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Control Arm | Initial Antimüllerian Hormone (AMH) Levels | 0.36 ng/mL |
| Experimental Arm | Initial Antimüllerian Hormone (AMH) Levels | 0.44 ng/mL |
p-value: 0.427Wilcoxon (Mann-Whitney)
Secondary
Live Birth Rate
Live birth rate was calculated by dividing the number of patients who achieved live birth in each cycle by the number of patients who initiated that cycle
Time frame: 9 months or birth of one or more live babies
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Control Arm | Live Birth Rate | 3 Participants |
| Experimental Arm | Live Birth Rate | 1 Participants |
p-value: 0.51295% CI: [0.04, 3.05]Chi-squared
Secondary
Number and Percentage of Cycles With Clinical Pregnancy
Clinical pregnancy was defined as the presence of a gestational sac and heart beat under ultrasonography
Time frame: 6 weeks after embryo transfer
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (COUNT_OF_UNITS) |
|---|---|---|
| Control Arm | Number and Percentage of Cycles With Clinical Pregnancy | 3 Number of IVF cycles |
| Experimental Arm | Number and Percentage of Cycles With Clinical Pregnancy | 2 Number of IVF cycles |
p-value: 0.68495% CI: [0.13, 3.68]Chi-squared
Secondary
Number of Cancelled IVF Cycles
Number of cancelled IVF cycles for low or no response to controlled ovarian stimulation. Cycles were cancelled because of a lack of an adequate follicular formation (one follicle of at least 17 mm) the day of triggering.
Time frame: End of stimulation cycle (less than or equal to 30 days)
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Control Arm | Number of Cancelled IVF Cycles | 3 Number of cycles |
| Experimental Arm | Number of Cancelled IVF Cycles | 2 Number of cycles |
p-value: 0.68495% CI: [0.13, 3.68]Chi-squared
Secondary
Number of Cycles With Embryo Transfer (ET)
One or 2 embryos were transferred on day 3 after egg collection. This outcome represents the number of cycles that culminate with embryo transfer.
Time frame: On day 3 after egg collection
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (COUNT_OF_UNITS) |
|---|---|---|
| Control Arm | Number of Cycles With Embryo Transfer (ET) | 8 Number of IVF cycles |
| Experimental Arm | Number of Cycles With Embryo Transfer (ET) | 4 Number of IVF cycles |
p-value: 0.236Chi-squared
Secondary
Total Antral Follicle Count (AFC) - Final
AFC assessment was done on day 2-5 of the menstrual cycle and was followed for 6-month. To determine AFC, ultrasound scan was performed using a GE iVoluson (General Electric, Spain) equipped with a 3D vaginal probe (6.5-9MHz). A bilateral two-dimensional scan was performed and the mean of the two largest diameters of each intra-ovarian avascular anechoic image was recorded. Antral follicles with a mean diameter from 2 to 10 mm were counted to establish AFC. Final measure refers to the AFC count after ovarian fragmentation treatment.
Time frame: Day 2-5 of the menstrual cycle 6 months after treatment
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Control Arm | Total Antral Follicle Count (AFC) - Final | 5 Follicles |
| Experimental Arm | Total Antral Follicle Count (AFC) - Final | 5 Follicles |
p-value: 0.021Wilcoxon (Mann-Whitney)
Secondary
Total Antral Follicle Count (AFC) - Initial Measure
AFC assessment was done on day 2-5 of the menstrual cycle. Ultrasound scan was performed using a GE iVoluson (General Electric, Spain) equipped with a 3D vaginal probe (6.5-9MHz). A bilateral two-dimensional scan was performed and the mean of the two largest diameters of each intra-ovarian avascular anechoic image was recorded. Antral follicles with a mean diameter from 2 to 10 mm were counted to establish AFC. Initial data refers to the measure taken before treatment.
Time frame: Baseline, day 2-5 of the menstrual cycle prior to treatment
Population: Of the 18 patients in the initial control group, 2 dropped out of the study (one because she did not want to follow up and the other because she divorced her husband). Of the 16 patients in the experimental group, one patient left the study before treatment because she moved to another city.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Control Arm | Total Antral Follicle Count (AFC) - Initial Measure | 5 Follicles |
| Experimental Arm | Total Antral Follicle Count (AFC) - Initial Measure | 4 Follicles |
p-value: 0.449Wilcoxon (Mann-Whitney)