Management of poor responders in assisted reproduction still remained a big challenge for fertility specialists, despite of the high number of published papers on poor ovarian response in literature for the past two decades. Until now definition for poor responder patients is still not universally accepted in the field of the scientific community. However, these groups of patients usually have a lower controlled ovarian stimulation or IVF treatment outcomes when compared with normal responders. The limitation in identifying and solving the challenges of poor ovarian response in IVF treatment is due to the difficulty of no universally accepted definition in most of the literature. Poor responders are patients unable to develop sufficient number of mature oocytes for collection or the production of ≤ 3 follicles after a standard stimulation protocol. The number of developed follicles and number of eggs retrieved after a standard stimulation of ovary are the two major criteria used in predicting poor ovarian response. In this review, we have discussed the different concepts of controlling ovarian stimulation for the management of poor responders during in vitro fertilization (IVF) treatment.
The use of long protocol during controlled ovarian stimulation for assisted reproduction attracts high dosage of gonadotropins. High dose of gonadotropins can be detrimental to oocyte development, which affects its quality and compromises the treatment outcome. Mild stimulation protocols that attract low dose gonadotropins could be useful alternative regimen to address such problems. This study evaluated the efficacy of low dose clomiphene citrate based protocol plus low dose gonadotropins on predicted normal responder patients who had unsuspected poor in vitro fertilization (IVF) result, following an initial stimulation with long gonadotropin-releasing hormone (GnRH) agonist protocol. This a retrospective study of 65 infertile women who underwent 130 cycles in our center from January 2011 to December 2014. The initial IVF cycle (Group 1) was treated with long GnRH-a protocol plus a high dose of gonadotropins (≥150 IU/d), while second IVF cycle (Group 2) had low dose clomiphene citrate based protocol plus low dose gonadotropins (75–112.5 IU/d). The rate of cumulative pregnancy/started cycle (9.2% [6/65] vs. 51% [33/65]; P < 0001) was significantly better in CC protocol than the long GnRH agonist protocol. The number of oocytes retrieved was also higher in CC protocol compared to the long protocol (7.26 ± 1.95 vs. 5.98 ± 1.31; P = 0.03). There was a lower number of patients without embryos (12.31% vs. 33.85%; p < 0.0001) in CC protocol than long protocol. This study showed a better cumulative pregnancy rate in the low dose CC based protocol. There was a higher number of oocytes retrieved after using a lower total dose of recombinant FSH in CC protocol. Thus, clomiphene treatment plus low dose rFSH can be an alternative option for such patients in second cycle stimulation instead of repeating long protocol regimen. Randomized controlled studies with larger number of patients will be needed for more accurate evidence.
About 10 -15 % of all clinically recognized pregnancies result in spontaneous miscarriages, and chromosomal abnormalities are the most common reason. The conventional karyotyping on chorionic villus samples (CVSs) is limited by cell culture and its resolution. This study aimed at evaluating the efficiency of the application of high throughput genetic technology, including array comparative genomic hybridization (array CGH) and next generation sequencing (NGS) on the chromosomal copy number analysis of CVSs from early spontaneous miscarriages.Four hundred and thirty-six CVSs from early spontaneous abortion were collected. Genomic DNA was extracted using a routine method, and the chromosomal copy number variants (CNVs) were analyzed by array CGH and NGS. Two hundred and twenty-five samples (51.6 %) with abnormal chromosomes were identified among 436 samples, of which 188 samples (41.3 %) were aneuploidy, 23 samples (5.3 %) were segmental deletion and/or duplication cases, and 14 samples (3.2 %) were triploid. Two of the three cases with small segmental deletion and duplication were validated to be transferred from their fathers who were carriers of submicroscopic reciprocal translocation.A high chromosomal abnormality detection rate on CVSs from early spontaneous miscarriage was achieved by array CGH and NGS. Specifically, the detection of submicroscopic recombination, which is sometimes missed by conventional karyotyping, was important for genetic counseling for the couples that suffered from recurrent miscarriages.
Cesarean scar pregnancy (CSP) is on the rise worldwide due to the increasing rate of cesarean sections.It has been attributed to life threatening complications if not diagnosed early and managed aggressively.CSP is still a rare diagnosis, as available literature is mostly observational case series and few random controlled trials (RCT) to date.Treatment of CSP should be evidence based and focus on prevention of severe complications, conservation of fertility and maintaining women's health and quality life.Despite this prominent increase, no universal treatment guidelines have been established till now, and the management of CSP in clinical practice is based on few available published literatures.Treatment should be individualized by using parameters such as hemodynamic status of the patient, beta-hCG levels, imaging features, the desire for future pregnancy and the surgeon's skill.Current data does not support expectant management.In this article, we aim to find the pathophysiology, clinical presentation, most appropriate methods of diagnosis and treatment of CSP.
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