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.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Minimal Stimulation IVF versus Conventional IVF:
2
A Randomized Controlled Trial
3
Authors: John J. Zhang, M.D., Ph.D.1; Zaher Merhi, M.D.2, Mingxue Yang M.D.,
5
Ph.D.1; Daniel Bodri, M.D., Ph.D.1; Alejandro Chavez-Badiola, M.D.1; Sjoerd
6
Repping, Ph.D.3 ; Madelon van Wely, Ph.D.3
RI
PT
4
7
8
Institutions:
9
1. Reproductive Endocrinology and Infertility, New Hope Fertility Center, New York,
12
13
14
SC
11
NY, United States
2. Department of Obstetrics and Gynecology, Division of Reproductive Biology, New
York University School of Medicine, New York, NY, United States
3. Center for Reproductive Medicine, Academic Medical Center, University of
M
AN
U
10
Amsterdam, Amsterdam, the Netherlands
15
16
Corresponding author:
18
John J. Zhang, M.D., Ph.D.
19
Reproductive Endocrinology and Infertility
20
New Hope Fertility Center
21
4 Columbus Circle
22
New York, NY, 10019 United States
23
Phone: (212) 400-9636
24
Email: johnzhang98@yahoo.com
27
28
29
EP
AC
C
25
26
TE
D
17
Running title: Mini-IVF versus conventional IVF
Financial disclosure for all authors: None
30
31
Funding: Internal grant funding from New Hope Fertility Center
32
33
34
To be published in print: Table 4
35
1
ACCEPTED MANUSCRIPT
36
37
38
ABSTRACT
39
protocol that may reduce ovarian hyperstimulation syndrome (OHSS), multiple
40
pregnancy rates and cost while retaining high live birth rates.
BACKGROUND: Minimal stimulation IVF (mini-IVF) is an alternative IVF treatment
41
OBJECTIVE (S): We performed a randomized non-inferiority controlled trial with a
43
pre-specified border of -10% comparing one cycle of mini-IVF with single embryo
44
transfer to one cycle of conventional IVF with double embryo transfer.
RI
PT
42
45
STUDY DESIGN: Five hundred sixty four infertile women (age < 39) undergoing their
47
first IVF cycle were randomly allocated to either mini-IVF or conventional IVF. The
48
primary outcome was cumulative live birth rate per woman over a 6-month period.
49
Secondary outcomes included OHSS, multiple pregnancy rates, and gonadotropin
50
use. The primary outcome was cumulative live birth per randomized woman within a
51
time horizon of 6 months.
52
M
AN
U
SC
46
RESULTS: 564 couples were randomly assigned between February 2009 and
54
August 2013 with 285 allocated to mini-IVF and 279 to conventional IVF. The
55
cumulative live birth rate was 49% (140/285) for mini-IVF and 63% (176/279) for
56
conventional IVF (RR 0.76, 95% CI 0.64-0.89). There were no cases of OHSS after
57
mini-IVF compared to 16 (5.7%) moderate/severe OHSS cases after conventional
58
IVF. The multiple pregnancy rates were 6.4% in mini-IVF compared to 32% in
59
conventional IVF (RR 0.25, 95% CI 0.14-0.46). Gonadotropin consumption was
60
significantly lower with mini-IVF compared to conventional IVF (459 ± 131 versus
61
2079 ± 389 IU, p<0.0001).
EP
AC
C
62
TE
D
53
63
CONCLUSION (S): Compared to conventional IVF with double embryo transfer, mini-
64
IVF with single embryo transfer lowers live birth rate, completely eliminates OHSS,
65
reduces multiple pregnancy rates and reduces gonadotropin consumption.
66
67
Keywords: IVF; mini-IVF; clomiphene citrate; OHSS; multiple gestations
2
ACCEPTED MANUSCRIPT
68
Introduction
69
The current standard of in vitro fertilization (IVF) treatment involves ovarian
71
hyperstimulation with high-doses of gonadotropins in combination with transfer of one
72
or more embryos1. The major safety issues of conventional IVF are ovarian
73
hyperstimulation syndrome (OHSS) and multiple pregnancies. Women with OHSS
74
are at serious risk of potentially life-threatening conditions involving hospitalization in
75
1.8% of the cases5. Multiple pregnancies are associated with high risk of
76
preeclampsia, gestational diabetes, antepartum hemorrhage, anemia, preterm
77
delivery and cesarean section4,6,7-9. Preterm birth is associated with a high risk of
78
bronchopulmonary dysplasia, necrotizing enterocolitis, and cerebral palsy8,10,11,12.
79
Additionally, all these complications often lead to expensive hospital admissions13,
80
which impose a steep burden on societal expenses and health services14.
M
AN
U
SC
RI
PT
70
One of the most important factors influencing the rate of multiple births is the
82
number of embryos transferred15. Single embryo transfer (SET) effectively reduces
83
the incidence of multiple pregnancies, but also decreases pregnancy rates per
84
transfer16. Given this reduction in pregnancy chances, the majority of physicians and
85
patients in the United States are reluctant to practice an SET policy; the percentage
86
of SET in IVF cycles ranged between 8.9-14% among women less than 38 years of
87
age in 201217. This resulted in 25-29% multiple pregnancy rates among all
88
pregnancies achieved during the same period of time17.
EP
AC
C
89
TE
D
81
Minimal stimulation IVF (mini-IVF) combined with SET has the potential to
90
reduce OHSS and multiple pregnancy rates without significantly lowering live birth
91
rates. Mini-IVF entails the use of clomiphene citrate (CC), which allows an
92
endogenous rise in follicle-stimulating hormone (FSH) to be additive to the ovarian
93
stimulation using low doses of gonadotropins
19,20
. In triggering ovulation, mini-IVF
3
ACCEPTED MANUSCRIPT
frequently makes use of a gonadotropin-releasing hormone agonist (GnRHa), instead
95
of human chorionic gonadotropin (hCG), to prevent OHSS. A final contentious
96
feature of mini-IVF is a freeze-all-embryo policy to prevent any negative effect of
97
ovarian stimulation on endometrial receptivity24. In observational studies, mini-IVF
98
has been shown to lead to high pregnancy rates, low multiple pregnancy rates, low
99
OHSS rates, and low cost21,22.
RI
PT
94
The aim of this non-inferiority randomized trial was to compare the
101
effectiveness and safety of the mini-IVF strategy using freeze-all and SET with
102
conventional IVF using fresh double embryo transfer.
AC
C
EP
TE
D
M
AN
U
SC
100
4
ACCEPTED MANUSCRIPT
103
Materials and Methods
104
105
Study Oversight
This minimal ovarian stimulation trial was designed by investigators at the
107
Academic Medical Center (AMC), Amsterdam and the New Hope Fertility Center
108
(NHFC), New York. All the participants received IVF treatments in a single center
109
(NHFC, New York). The non-inferiority trial was approved by the Institutional Review
110
Board of New York Downtown Hospital (IRB approval reference number: JZ-09-08)
111
and was registered before its start at clinicaltrials.gov: NCT 00799929.
SC
RI
PT
106
The trial protocol was approved by a protocol review committee and a data
113
and safety monitoring board, both appointed by NHFC and by the institutional review
114
boards of the New York Downtown Hospital and the Biomedical Research Alliance of
115
New York (BRANY). Randomization, monitoring and data analysis were coordinated
116
at the Academic Medical Center in the Netherlands.
118
TE
D
117
M
AN
U
112
Study design and patients
Women were recruited between February 2009 and August 2013 via printed
120
and online media. Participants were responsible to pay for their own medications and
121
they were provided free services (i.e., oocyte retrieval and embryo transfer) as
122
compensation for participation. Inclusion criteria included women aged between 18
123
and 38, having normal menstrual cycles, requiring a first IVF treatment, and infertility
124
diagnoses of male, unexplained and tubal factors. Exclusion criteria included pre-
125
existing medical conditions (such as diabetes, hypertension, hypothyroidism, and
126
hyperprolactinemia), and BMI <18.5 or >32 kg/m2, and day 3 FSH > 12 mIU/mL.
127
Screening tests before initiation of treatment included complete blood count, varicella
128
and rubella titer, pap smear, syphilis, HIV 1 and 2, hepatitis B, hepatitis C, chlamydia,
AC
C
EP
119
5
ACCEPTED MANUSCRIPT
129
gonorrhea, prolactin, thyroid-stimulating hormone, cycle day 3 FSH and estradiol
130
(E2). Ultrasound testing was performed at baseline and women with any submucosal
131
or large intramural fibroids requiring surgery were excluded from the study.
133
Informed consent and randomization
RI
PT
132
After obtaining written informed consent, women were randomly allocated to
135
mini-IVF or conventional IVF at a 1:1 ratio. The randomization was done at the start
136
of the cycle using sequentially numbered opaque envelopes that had been prepared
137
on basis of a computer-generated list at the Academic Medical Center in the
138
Netherlands and sent to NHFC in New York. Women and medical staff were not
139
blinded for treatment allocation. Outcome data were not disclosed to participants or
140
investigators until completion of the trial.
M
AN
U
SC
134
141
Mini-IVF
TE
D
142
After oral contraceptive pill pre-treatment during 10-14 days, adequate
144
suppression was confirmed with an E2 level of <75 pg/mL. Minimal ovarian
145
stimulation was started with an extended regimen (from day 3 until the day before
146
triggering) of CC (50 mg/day orally) in conjunction with gonadotropin injections
147
(Bravelle and/or Menopur, Ferring, Parsippany, NJ; Follistim, Merck, White House
148
Station, NJ; or Gonal F, EMD Serono, Rockland, MA) starting on cycle day 4-7 with
149
75-150 IU’s daily. No hypothalamic-pituitary suppression was performed and the final
150
maturation of oocytes was induced by a GnRHa nasally (Synarel nasal spray, Pfizer,
151
New York, NY) when the lead follicle reached a diameter of 18 mm or greater (Figure
152
1). Oocyte retrieval was performed mostly with local anesthesia and follicular flushing
153
was performed as needed. Retrieved oocytes were fertilized by conventional IVF or
AC
C
EP
143
6
ACCEPTED MANUSCRIPT
154
ICSI as indicated and subsequently cultured until the blastocyst stage. All blastocysts
155
were vitrified using the CryoTop method (Kitazato Biopharma)25. A single thawed
156
blastocyst was transferred in a subsequent natural or artificially prepared cycle with
157
oral Estrace (Actavis Pharma, Inc, Parsippany, NJ) 22.
159
RI
PT
158
Conventional IVF
Conventional ovarian stimulation consisted of a long GnRHa protocol using
161
mid-luteal down-regulation (Leuprolide Acetate, Teva, Sellersville, PA) followed by
162
stimulation with daily gonadotropins injections (Bravelle and/or Menopur, Ferring,
163
Parsippany, NJ; Follistim, Merck, White House Station, NJ; or Gonal F, EMD Serono,
164
Rockland, MA) at a dose of 150-300 IU’s daily starting in the early follicular phase
165
(cycle day 3). The final maturation of oocytes was induced with the standard hCG
166
(Novarel, Ferring, Parsippany, NJ; Pregnyl, Merck, White House Station, NJ; or
167
Ovidrel, EMD Serono, Rockland, MA), rather than GnRHa, when at least two follicles
168
reached 18 mm or greater. Oocyte retrieval was performed using mostly general
169
anesthesia because of the presence of a large number of mature follicles. Retrieved
170
oocytes were fertilized by conventional IVF or ICSI according to the same indications
171
as in the mini-IVF protocol and subsequently cultured until the blastocyst stage. Two
172
or one blastocysts– the latter if two embryos were not available or if there was a
173
medical contraindication for DET– were transferred in the fresh cycle. Remaining
174
supernumerary blastocysts were vitrified and two thawed blastocysts or one
175
blastocyst if two were not available were transferred in subsequent naturally or
176
artificially prepared cycles with oral Estrace (Actavis Pharma, Inc, Parsippany, NJ).
AC
C
EP
TE
D
M
AN
U
SC
160
177
178
7
ACCEPTED MANUSCRIPT
179
Outcomes
The primary outcome was cumulative live birth per randomized woman
181
(including fresh and subsequent frozen embryo transfers) within a time horizon of 6
182
months. Secondary outcomes were clinical pregnancy rate, OHSS, multiple
183
pregnancy rate, gonadotropin usage, number of retrieved, mature and fertilized
184
oocytes, implantation rate, cancellation rate, and failed fertilization. A clinical
185
pregnancy was defined as at least one intrauterine sac at 6 weeks gestation and live
186
birth was defined as a child born after 22 weeks of gestation or weighing at least 500
187
grams.
SC
RI
PT
180
189
M
AN
U
188
Sample size calculation and statistical analysis
Sample size calculation was based on an expected cumulative live birth rate of
191
65% in ≤ 38 years old women following conventional IVF based on U.S. SART
192
registry data from 2007 because recruitment started in 200917. A non-inferiority
193
margin of -10% was considered a clinically significant difference. Thus, 564 women
194
were needed to assure that with a power of 80% the lower limit of a one-sided 95%
195
confidence interval (CI) was within a pre-specified border of -10%.
EP
TE
D
190
The effectiveness of mini-IVF versus conventional IVF was expressed as a
197
risk ratio for cumulative live birth, with corresponding 95% CI. The risk difference and
198
95% CI for live birth as well as the relative risks (RR) and 95% CI for all binary
199
secondary outcomes were calculated. For continuous outcomes, data were
200
expressed as means ± standard deviation (SD) and the difference between both
201
arms was compared using t-test. Chi-square and Fisher exact tests were used for
202
categorical data as appropriate. The analysis of all outcomes was on an intention to
AC
C
196
8
ACCEPTED MANUSCRIPT
treat basis. P<0.05 was considered statistically significant. SPSS 22.0 was used to
204
perform all statistical analyses.
AC
C
EP
TE
D
M
AN
U
SC
RI
PT
203
9
ACCEPTED MANUSCRIPT
205
Results
206
A total of 771 women were assessed for eligibility (Figure 2). Of these, 180
208
women did not fulfill the inclusion criteria (41 had no indication for IVF, 20 had pre-
209
existing medical conditions interfering with IVF treatment, 75 had abnormal screening
210
results, 2 were pregnant at the time of screening, 9 had personal problems, and 33
211
had multiple reasons) and 27 women did not give informed consent. A total of 564
212
women were randomly allocated to the mini-IVF strategy or to conventional IVF. Four
213
women in the mini-IVF arm and six women in the conventional IVF arm did not
214
receive the allocated intervention due to withdrawal before starting treatment.
215
Additionally, three women in the mini-IVF arm and six women in the conventional IVF
216
arm dropped-out after starting treatment due to reasons detailed in Figure 2.
217
Cancelled cycles, failed fertilization, and blastocyst developmental failure in each arm
218
are shown in Figure 2. In the mini-IVF arm, of the 281 participants who received the
219
allocated intervention, 6 did not make it to the oocyte retrieval stage (3 had ovarian
220
cyst at the baseline ultrasound, 1 had no follicular development, and 2 prematurely
221
ovulated) and 44 had no embryo transfer for reasons such as failed fertilization, failed
222
blastocyst formation, and spontaneous pregnancy prior to embryo transfer. In the
223
conventional IVF arm, of the 273 participants who received the allocated intervention,
224
20 did not make it to the oocyte retrieval stage (3 failed to have ovarian suppression
225
and 17 did not have appropriate follicular development) and 22 did not have embryo
226
transfer for similar reasons as those in the mini-IVF arm.
AC
C
EP
TE
D
M
AN
U
SC
RI
PT
207
227
Baseline characteristics did not differ between both arms (Table 1). Most
228
women (68%) were younger than 35 years of age. Primary and secondary outcomes
229
are listed in Table 2. The cumulative live birth rate per randomized woman (including
230
live births from frozen-thawed embryo transfers in both arms of the study) was 49%
10
ACCEPTED MANUSCRIPT
in the mini-IVF arm and 63% in the conventional IVF arm, resulting in a RR of 0.78
232
(95% CI: 0.67 to 0.90). The average absolute difference of mini-IVF versus
233
conventional IVF was -14% (95% CI: -6 to -22%). None of the women in the mini-IVF
234
arm developed OHSS because of the use of GnRHa, while moderate/severe OHSS
235
occurred in 16 (5.7%) women in the conventional IVF arm. Seven of these women
236
were hospitalized and underwent transvaginal paracentesis for symptomatic relief.
237
Multiple pregnancy rate was significantly lower in the mini-IVF arm (6.4% versus
238
32%, RR= 0.25, 95% CI: 0.14 to 0.46) and they were all monozygotic twins due to
239
the fact that only one embryo was transferred in this arm. Women in the mini-IVF arm
240
required significantly lower total doses of gonadotropins per cycle (459 ± 131 versus
241
2079 ± 389 IU, p<0.0001).
M
AN
U
SC
RI
PT
231
Laboratory outcome data are summarized in Table 3 and details on the
243
transfer procedures and their outcomes are summarized in Table 4. In total, 340 and
244
334 fresh and/or frozen embryo transfers procedures were performed in the mini-IVF
245
and conventional IVF arms, respectively. In the mini-IVF arm, strict SET was
246
performed, while in the conventional IVF arm 1.7 embryos on average were
247
transferred in either fresh or subsequent frozen cycles (Table 4). Following the first
248
FET cycle, the implantation rate was significantly higher in the conventional IVF arm
249
(58%) compared to the mini-IVF arm (47%; p=0.02) (Table 4). However, implantation
250
rate declined in subsequent FET cycles in the conventional IVF arm but increased in
251
subsequent FET cycles in the mini-IVF arm to have tendency towards statistical
252
significance in the 3rd FET cycle (30% in the conventional IVF versus 54% in the
253
mini-IVF; p=0.1; Table 4). Additionally, clinical pregnancy rate dropped in subsequent
254
FET cycles in the conventional IVF arm (68% in the first FET cycle then 49%, 40%
255
and 33% in subsequent cycles) while it remained constant in subsequent FET cycles
AC
C
EP
TE
D
242
11
ACCEPTED MANUSCRIPT
in the mini-IVF arm (47% in the first FET cycle then 48%, 54% and 50% in
257
subsequent cycles) (Table 4).
AC
C
EP
TE
D
M
AN
U
SC
RI
PT
256
12
ACCEPTED MANUSCRIPT
258
Discussion
259
This randomized trial compared the mini-IVF strategy including freeze-all and
261
SET to conventional IVF with fresh double embryo transfer in women aged less than
262
39. The results indicated that the cumulative live birth rate in mini-IVF was 14% lower
263
than that observed in conventional IVF but at the same time mini-IVF completely
264
eliminated OHSS, significantly reduced the risk of multiple pregnancy, and resulted in
265
a 78% reduction in total gonadotropin dose used per cycle.
SC
RI
PT
260
Our study has several strengths. The design was rigorous and meticulous
267
where only a small number of women withdrew after giving an informed consent and
268
only a small number of women were lost to follow up. The patient population included
269
women of various ethnicities making the results more generalizable. Furthermore, the
270
conventional IVF arm resulted in pregnancy rates, OHSS and multiple pregnancies
271
rates that were comparable to the rates observed in U.S. registries, strengthening our
272
predefined power calculation17.
TE
D
M
AN
U
266
There are several limitations to our study. First and foremost, we compared
274
two completely different strategies thus preventing us to disentangle the effects of
275
various components of mini-IVF such as SET and the disengagement of stimulation
276
and transfer. In other words, it is impossible to attribute the observed effects of mini-
277
IVF on live birth rates, OHSS, multiple pregnancy rates and gonadotropin use to the
278
method of ovarian stimulation, to the freeze-all concept or to the single embryo
279
transfer policy as these are all integral parts of mini-IVF. Future randomized
280
controlled trials should focus on strictly evaluating these various components.
281
Second, our study was a single center study, thus hampering generalisability.
AC
C
EP
273
282
Though mini-IVF resulted in significantly lower live birth rates, it is too early to
283
state that it is inferior to conventional IVF. In our power calculation, we used a
13
ACCEPTED MANUSCRIPT
reduction of 10% as a clinically relevant reduction in live birth rates following mini-
285
IVF. The absolute difference observed in our study was -14% with a 95% boundary
286
of -22% to -6%. Thus, the pre-specified acceptable 10% difference is still within the
287
95% CI of the observed difference. Furthermore, mini-IVF significantly reduced
288
OHSS, multiple pregnancy rate and gonadotropin use, thereby increasing safety of
289
IVF and controlling the cost of unwanted side effects. It is unknown if patients are
290
willing to trade off these marginally lower live birth rates for increased safety and
291
reduced costs. It is also unknown whether a lower cost of mini-IVF would motivate
292
women to undergo more than one mini-IVF cycle for the same price as a single
293
conventional IVF cycle. In this respect, it would be worthwhile comparing the
294
cumulative pregnancy and live birth rates of two consecutive mini-IVF cycles with one
295
conventional IVF cycle. As mini-IVF is also likely to result in less treatment burden
296
and stress, future trials should consider these additional relevant dimensions into
297
account. The data provided in this study are the ingredients for shared decision-
298
making in order to choose between mini-IVF and conventional IVF on a case by case
299
basis39.
TE
D
M
AN
U
SC
RI
PT
284
Our mini-IVF protocol was originally developed at Kato Ladies Clinic in Japan
301
and was successfully adapted and modified by our center22. In contrast to other
302
treatment protocols where CC was only used for a few days in the early follicular
303
phase27, CC was administered in our protocol during the whole stimulation phase in
304
conjunction with a low-dose of gonadotropins. This extended regimen favors the
305
development of a mild ovarian response but also takes advantage of the ability of CC
306
to prevent premature LH surge thus reducing the risk of premature ovulation in
307
addition to decreasing the amount of gonadotropins needed19. We also disengaged
308
the embryo transfer from the stimulation phase, since it has been demonstrated that
AC
C
EP
300
14
ACCEPTED MANUSCRIPT
309
the CC based minimal ovarian stimulation protocol was more efficient when embryos
310
were electively vitrified (preferably at a blastocyst stage) and transferred at a later
311
naturally or artificially prepared frozen embryo transfer cycle21.
Our trial is in line with recent evidence which suggests that segmentation of
313
IVF treatment could overcome the impaired endometrial receptivity frequently
314
occurring in stimulated cycles with gonadotropins28. In this respect, it is of note that
315
the live birth rates per embryo transfer were stable in the mini-IVF arm (39% in the
316
first frozen embryo transfer cycle then 41%, 54% and 50% in subsequent cycles)
317
while the live birth rates in the conventional IVF arm dropped from 62% after fresh
318
transfer to 30% in the fourth frozen embryo transfer cycle. Besides a potential effect
319
on endometrial receptivity, this might indicate an increased embryo quality in the
320
mini-IVF arm as compared to the conventional IVF arm. This hypothesis is yet to be
321
determined.
M
AN
U
SC
RI
PT
312
In conclusion, mini-IVF with SET has a lower live birth rate, eliminates OHSS,
323
reduces gonadotropin consumption, and reduces multiple pregnancy rates compared
324
to conventional IVF with double embryo transfer. How these different dimensions are
325
weighed by couples deciding between mini-IVF or conventional IVF, and whether the
326
lower live birth rate could be offset by a series of “lower cost” mini-IVF cycles, should
327
be the subject of future studies.
329
EP
AC
C
328
TE
D
322
330
15
ACCEPTED MANUSCRIPT
331
References
332
1.
Macklon NS, Stouffer RL, Giudice LC, Fauser BC. The science behind 25
334
years of ovarian stimulation for in vitro fertilization. Endocrine reviews 2006;27:170-
335
207.
336
2.
337
appraisal of potential benefits and drawbacks. Human reproduction 1999;14:2681-6.
338
3.
339
Human reproduction update 2009;15:13-29.
340
4.
341
stimulation for subfertility treatment. Lancet 2005;365:1807-16.
342
5.
343
hyperstimulation syndrome (OHSS) - time for reassessment. Human fertility
344
2007;10:175-81.
345
6.
346
outcomes in multifetal pregnancies. BJOG : an international journal of obstetrics and
347
gynaecology 2004;111:1294-6.
348
7.
349
singletons and twins after assisted conception: a systematic review of controlled
350
studies. Bmj 2004;328:261.
351
8.
352
mortality risks of multiple births. Obstetrics and gynecology clinics of North America
353
2005;32:1-16, vii.
354
9.
355
final data for 2001. National vital statistics reports : from the Centers for Disease
RI
PT
333
Fauser BC, Devroey P, Yen SS, et al. Minimal ovarian stimulation for IVF:
SC
Verberg MF, Macklon NS, Nargund G, et al. Mild ovarian stimulation for IVF.
M
AN
U
Fauser BC, Devroey P, Macklon NS. Multiple birth resulting from ovarian
Mocanu E, Redmond ML, Hennelly B, Collins C, Harrison R. Odds of ovarian
EP
TE
D
Walker MC, Murphy KE, Pan S, Yang Q, Wen SW. Adverse maternal
AC
C
Helmerhorst FM, Perquin DA, Donker D, Keirse MJ. Perinatal outcome of
Alexander GR, Slay Wingate M, Salihu H, Kirby RS. Fetal and neonatal
Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM, Sutton PD. Births:
16
ACCEPTED MANUSCRIPT
356
Control and Prevention, National Center for Health Statistics, National Vital Statistics
357
System 2002;51:1-102.
358
10.
359
perinatology 2006;33:301-13.
360
11.
361
developmental disability at six years of age after extremely preterm birth. The New
362
England journal of medicine 2005;352:9-19.
363
12.
364
population-based study. Human reproduction 2001;16:504-9.
365
13.
366
outcomes in singletons and multiples born after IVF or ICSI, stratified for neonatal
367
risk criteria. Acta obstetricia et gynecologica Scandinavica 2014.
368
14.
369
economic study of elective single embryo transfer versus two-embryo transfer in first
370
IVF/ICSI cycles. Human reproduction 2004;19:917-23.
371
15.
372
embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection.
373
The Cochrane database of systematic reviews 2013;7:CD003416.
374
16.
375
who's afraid of single embryo transfer? Human reproduction 1998;13:2663-4.
376
17.
377
Technology,
378
https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0.)
Pharoah PO. Risk of cerebral palsy in multiple pregnancies. Clinics in
RI
PT
Marlow N, Wolke D, Bracewell MA, Samara M, Group EPS. Neurologic and
SC
Ericson A, Kallen B. Congenital malformations in infants born after IVF: a
M
AN
U
van Heesch MM, Evers JL, Dumoulin JC, et al. A comparison of perinatal
TE
D
Gerris J, De Sutter P, De Neubourg D, et al. A real-life prospective health
EP
Pandian Z, Marjoribanks J, Ozturk O, Serour G, Bhattacharya S. Number of
AC
C
Coetsier T, Dhont M. Avoiding multiple pregnancies in in-vitro fertilization:
Clinic Summary Report, SART CORS. Society for Assisted Reproductive
2014.
(Accessed
Aug
4,
2014,
at
17
ACCEPTED MANUSCRIPT
379
18.
Simon C, Cano F, Valbuena D, Remohi J, Pellicer A. Clinical evidence for a
380
detrimental effect on uterine receptivity of high serum oestradiol concentrations in
381
high and normal responder patients. Human reproduction 1995;10:2432-7.
382
19.
383
large-scale retrospective study. Reproductive biomedicine online 2007;15:134-48.
384
20.
385
physiological concepts and clinical consequences. Endocrine reviews 1997;18:71-
386
106.
387
21.
388
with elective single embryo transfer policy: age-specific results of a large, single-
389
centre, Japanese cohort. Reproductive biology and endocrinology : RB&E
390
2012;10:35.
391
22.
392
IVF
393
biomedicine online 2010;21:485-95.
394
23.
395
hyperstimulation syndrome. Fertility and sterility 2008;90:S188-93.
396
24.
397
releasing hormone agonist trigger in assisted reproductive technology-"The king is
398
dead, long live the king!". Fertility and sterility 2014;102:339-41.
399
25.
400
oocytes and embryos: the Cryotop method. Theriogenology 2007;67:73-80.
401
26.
402
vitro fertilisation: a randomised non-inferiority trial. Lancet 2007;369:743-9.
RI
PT
Teramoto S, Kato O. Minimal ovarian stimulation with clomiphene citrate: a
SC
Fauser BC, Van Heusden AM. Manipulation of human ovarian function:
M
AN
U
Kato K, Takehara Y, Segawa T, et al. Minimal ovarian stimulation combined
Zhang J, Chang L, Sone Y, Silber S. Minimal ovarian stimulation (mini-IVF) for
vitrification
and
cryopreserved
embryo
transfer.
Reproductive
TE
D
utilizing
EP
Practice Committee of American Society for Reproductive M. Ovarian
AC
C
Humaidan P, Polyzos NP. Human chorionic gonadotropin vs. gonadotropin-
Kuwayama M. Highly efficient vitrification for cryopreservation of human
Heijnen EM, Eijkemans MJ, De Klerk C, et al. A mild treatment strategy for in-
18
ACCEPTED MANUSCRIPT
403
27.
Zarek SM, Muasher SJ. Mild/minimal stimulation for in vitro fertilization: an old
404
idea that needs to be revisited. Fertility and sterility 2011;95:2449-55.
405
28.
406
Evidence of impaired endometrial receptivity after ovarian stimulation for in vitro
407
fertilization: a prospective randomized trial comparing fresh and frozen-thawed
408
embryo transfer in normal responders. Fertility and sterility 2011;96:344-8.
409
29.
410
culture is associated with an elevated incidence of monozygotic twinning after single
411
embryo transfer. Fertility and sterility 2011;95:2140-2.
412
30.
413
reproduction 2000;15:1856-64.
414
31.
415
M, Valkenburg M. Prevention of twin pregnancy after in-vitro fertilization or
416
intracytoplasmic sperm injection based on strict embryo criteria: a prospective
417
randomized clinical trial. Human reproduction 1999;14:2581-7.
418
32.
419
after IVF and ICSI: a randomized study. Human reproduction 2001;16:1900-3.
420
33.
421
blastocyst transfer: a prospective randomized trial. Fertility and sterility 2004;81:551-
422
5.
423
34.
424
double-embryo transfer in in vitro fertilization. The New England journal of medicine
425
2004;351:2392-402.
RI
PT
Shapiro BS, Daneshmand ST, Garner FC, Aguirre M, Hudson C, Thomas S.
SC
Kawachiya S, Bodri D, Shimada N, Kato K, Takehara Y, Kato O. Blastocyst
M
AN
U
Multiple gestation pregnancy. The ESHRE Capri Workshop Group. Human
TE
D
Gerris J, De Neubourg D, Mangelschots K, Van Royen E, Van de Meerssche
EP
Martikainen H, Tiitinen A, Tomas C, et al. One versus two embryo transfer
AC
C
Gardner DK, Surrey E, Minjarez D, Leitz A, Stevens J, Schoolcraft WB. Single
Thurin A, Hausken J, Hillensjo T, et al. Elective single-embryo transfer versus
19
ACCEPTED MANUSCRIPT
426
35.
427
transfer with day 3 embryo transfer in similar patient populations. Fertility and sterility
428
2000;73:126-9.
429
36.
430
transfer versus one cycle with double embryo transfer: a randomized controlled trial.
431
Human reproduction 2005;20:702-8.
432
37.
433
hyperstimulation syndrome (OHSS): a review. Human reproduction update
434
2002;8:559-77.
435
38.
436
agonist for triggering of final oocyte maturation: time for a change of practice?
437
Human reproduction update 2011;17:510-24.
438
39.
439
dimensions of infertility care quality: consensus between professionals and patients.
440
Human reproduction 2013;28:1584-97.
RI
PT
SC
Delvigne A, Rozenberg S. Epidemiology and prevention of ovarian
M
AN
U
Humaidan P, Kol S, Papanikolaou EG, Copenhagen Gn RHATWG. GnRH
TE
D
Dancet EA, D'Hooghe TM, Spiessens C, et al. Quality indicators for all
EP
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
Lukassen HG, Braat DD, Wetzels AM, et al. Two cycles with single embryo
AC
C
441
Milki AA, Hinckley MD, Fisch JD, Dasig D, Behr B. Comparison of blastocyst
20
ACCEPTED MANUSCRIPT
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
ACCEPTED MANUSCRIPT
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
ACCEPTED MANUSCRIPT
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