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Poor ovarian reserve in the elderly test-tube and few eggs are hard injuries, and some studies have found that how many eggs can be retrieved determines the success rate to some extent.
Now with the delay of childbirth, more and more elderly sisters have joined the team of IVF, Sister L is one of them, 40 years old to start IVF, her story may help you avoid a lot of detours.
01 It is important to choose from 1 to 8
Sister L was busy with her career in her early years, and she didn't meet her MR.right until she was 40 years old, and she began to prepare for pregnancy as soon as she got married, but half a year passed, and there was no result
Age did not allow her to wait, walked into the hospital and the doctor checked the ovarian reserve, but she did not expect that the AMH was less than 1, and the doctor advised her to hurry up IVF.
Unexpectedly, after a stimulation, an egg was retrieved, and Mr.'s sperm problem was not optimistic, and he did not match the embryo in the end.
The unwilling Sister L promoted another round of rehearsals, but this time she didn't promote any of them, and she was discouraged and ready to change hospitals, let herself rest for a while, and start again.
During this time, she paid more attention to her diet, and also started her own exercise check-in program, and three months later, she went to another fertility center.
This time, the doctor carefully analyzed her information, and at the same time formulated a test-tube plan, and arranged for her to be injected with growth hormone and some oral drugs before entering the week.
Unexpectedly, this time she actually retrieved 8 eggs, which made her and her husband unbelievable.
In the end, she was matched with four embryos, and the pregnancy has been preliminarily confirmed, hoping that her luck can continue until the baby.
02 Please think twice about choosing a test-tube plan for the elderly
There are not many options for the elderly IVF, and in the face of ovarian function decline, which scheme can retrieve more eggs is the key to determining the success or failure of the elderly IVF, and it is also the most fundamental factor for Sister L's third success.
Among the commonly used ovulation induction programs for advanced age, which one is more effective? Sister Quanjie found a randomized controlled study.
Here, Sister Circle would like to remind that for example, many new drugs and new therapies need to be randomized and controlled before they are put into clinical trials to ensure medical safety.
The study included 384 women over the age of 40 with AMH <1, who were randomly divided into four groups and compared egg retrieval results from four common stimulation regimens.
Clomiphene group (127 people): stimulated with clomiphene alone, clomiphene 50mg, once a day for 5 days;
Modified microstimulation group (129 people): clomiphene + low-dose gonadotropin (Gn), clomiphene 50 mg/day × 5 days, Gn 150IU once every other day;
短方案组(64人):Gn+GnRH激动剂,Gn 300IU/天,GnRH激动剂0.1mg/天;
Antagonist group (64 people): Gn+GnRH antagonist, Gn 300 IU/day, GnRH antagonist 0.25 mg/day.
It was found that the final number of eggs in these patients differed significantly.
Clomiphene group: the average number of eggs retrieved was the lowest, only 2.1±0.9;
The average number of eggs retrieved in the modified microstimulation group was 3.7±1.8, which was significantly higher than that in the clomiphene group.
The average number of eggs retrieved in the short program group could reach 6.3±2.6, which was significantly higher than that of the first two groups.
The average number of eggs retrieved in the antagonist group was 6.5±2.8, which was similar to that in the short-regimen group.
From this trial, we can see that compared with the ordinary stimulation regimen of clomiphene, the number of eggs obtained by the microstimulation regimen has increased.
This shows that
From the perspective of advanced age test tubes, only with eggs can there be embryos and pregnancies behind, and only then can there be the last baby, and no eggs are like cooking without rice.
03Mainstream programs for the elderly in China
In China, there are many common mild stimulation programs in clinical practice for the elderly with low ovarian reserve.
For example, short regimen, ultra-short regimen, micro-stimulation, progesterone (MPA) micro-stimulation, antagonists, modified natural cycle, continuous ovulation induction of ovaries in follicular and luteal phases, ovulation induction in luteal phase, etc.
Compared with the traditional classical long schemes, these solutions have the advantages of short cycle, simple operation, economic efficiency, and high repeatability.
At present, the main antagonist programs, microstimulation programs and ovulation induction programs in the state of high progesterone are mainly used in various reproductive centers, so which of these programs has the largest number of eggs and the highest success rate?
Let's look at a study, this is a retrospective analysis, and the patients in the group were over 35 years old and had an AMH < 1.2, which was basically a little higher than the ovarian reserve in the previous study.
These patients were divided into three groups, antagonist regimen group (group A, 169 cycles), microstimulation regimen group (group B, 57 cycles), and ovulation induction in hyperprogesterone state (PPOS) group (group C, 59 cycles).
The study mainly analyzed the clinical outcomes and cost-effectiveness ratios of the three ovulation induction regimens.
结果发现，A组获卵数：4.46±1.45；B组获卵数：2.42±1.12；C组获卵数：3.28±1.62。
In terms of the number of eggs obtained, the number of eggs obtained by the antagonist regimen was significantly higher than that of the ovulation induction regimen under microstimulation and hyperprogesterone status, which is also consistent with the conclusion of the previous study.
From the perspective of cumulative pregnancy rate, the pregnancy rate of group A: 35.5%; Pregnancy rate in group B: 21.43%; The pregnancy rate in group C was 23.73%.
In terms of cumulative pregnancy rate, the cumulative pregnancy rate of antagonist regimens was significantly higher than that of ovulation induction regimens in microstimulation and hyperprogesterone regimens.
From the perspective of cycle cancellation rate, there were 16 cases of cycle cancellation in group A, accounting for 0.95%; There were 12 cases in group B, accounting for 19.64%; There were 9 cases in group C, accounting for 21.05%.
For elderly patients with low ovarian reserve, cycle cancellation is a very frustrating thing and difficult to avoid, so the low cycle cancellation rate is very important, and from the data point of view, the antagonist regimen has the lowest cycle cancellation rate.
From the perspective of the cost of single eggs, group A is 3817±1450 yuan; Group B: 5,868±1,820 yuan; Group C 4484±1678 yuan.
It can be seen that the antagonist group has the lowest cost for single eggs.
From the perspective of the cost of a single usable embryo: 7276±2329 yuan for group A; Group B: 7978±2560 yuan; Group C 7466±2175 yuan.
In terms of the cost of a single available embryo, the antagonistic regimen group had the lowest cost.
From the perspective of the cost of obtaining a clinical pregnancy, group A is 47,957±22,388 yuan; Group B: 67,450±35,210 yuan; Group C 61,984±33,463 yuan.
In terms of the cost of obtaining a clinical pregnancy, Group A also has the lowest cost.
Based on the above results,
04Why does the antagonist regimen work so well?
Let's first take a look at the stimulation process of the antagonist regimen, on the 2nd to 3rd day of menstruation, after the blood is drawn for sex hormone and B-ultrasound examination, the ovulation induction drugs (Guonafen, Pulizen, Lishenbao, etc.) are started.
Stimulation drugs need to be injected daily, and after continuous injection for 4-5 days, blood is drawn to check estrogen, B ultrasound is done, and antagonists (such as Ganirek, Sizekai, etc.) are added in a timely manner according to the growth of follicles.
Antagonists and ovulation induction drugs are injected together for 4-5 days until the follicle grows to about 18mm, and night injections (such as Dabijia, Aize, chorionic gonadotropin, etc.) are given to promote the final maturity of the follicle, and the whole ovulation induction time is generally 8-10 days.
In terms of the dosage of stimulation drugs in the previous study, the antagonist group was 2048±203, the microstimulation group was 1299±253, and the hyperprogesterone ovulation induction group was 1471±241
The antagonist regimen increased the number of eggs retrieved while increasing the number of available embryos compared to other shorter regimens.
But we should also see the facts.
In short, I still hope that the sisters can take advantage of the youth, if there are plans to have children, the baby should be held as soon as possible, but the advanced age is not without the baby, and it is equally important to find the right direction.
Antagonist regimens are one direction for older sisters with low ovarian reserve, but like I said earlier, this is not for everyone, as high doses of the drug can also cause damage to the eggs.
Therefore, what plan to use still requires the sisters to understand some knowledge and communicate in-depth with their reproductive doctors, and finally find a personalized path that suits them.
Solemnly declared
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On the way to hold the baby, I am willing to accompany you through the most helpless years
——THE END——
bibliography
[1] Flexible Antagonist versus Agonist Flare Protocol in Women above 40 Undergoing IVF, A retrospective Cohort Study. JBRA Assist Reprod. 2023 Sep 12; 27(3):381-385. doi: 10.5935/1518-0557.20220064.
[2] A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF: a multicenter randomized non-inferiority trial. Hum Reprod. 2017 Jan; 32(1):112-118. doi: 10.1093/humrep/dew282. Epub 2016 Nov 11.
[3] Zheng Juan, Zhou Liming, Sun Yiting, et al. Comparison of clinical outcomes of three ovulation induction regimens in elderly patients with low ovarian reserve[J]. Chinese Journal of Reproduction and Contraception,2020,40(3):194-200. DOI:10.3760/cma.j.cn101441-20190325-00121.