Title: Effect of diminished ovarian reserve on the outcome of fresh embryo transfer in IVF/ICSI
cycles among young women: A retrospective cohort study
Version: 1 Date: 26 Feb 2024
Reviewer:  Maw-Sheng Lee
Reviewer's report:
General comments:
This is a single center retrospective cohort study with large sample size#up to 1027 cases in
both study and control groups after PSM). It showed that the DOR group had a significantly
lower LBR ( CPR and IR ) and BC formation rate as compared to the non-DOR group. But the
perinatal outcomes (including preterm birth and LBW risk) were not different between these
two groups. The valuable point is its inclusion of both ART and Birth outcomes.
Some questions were raised during reviewing the manuscript such as
1. Why the definition to choose DOR patient differ from the Poseidon criteria (as discussed in
the discussion) from AFC < 5 to AFC < 7? Will the outcome and conclusion become different
if the definition changed to the international consensual criteria?
2. The patient group actually is an inhomogeneous group since it contained patients treated
with different ovulation induction protocols, such as FP long protocol and antagonist protocol.
What is the ratio of each protocol in these two subgroups? Reviewer also cannot be sure about
whether the triggering criteria were the same for patients stimulated by these two protocols in
that center. In addition, poor response might more easily occur in the really poor DOR group
by long protocol than antagonist protocol. It is possible that the results might also changed if
we focused on patients treated by different protocols. But the authors did not make any analysis
about the results from different protocols. Suggest them to make analysis again by different
protocols.
3. The analysis in Table 1 showed that BC cases comprised only 5% (42-51 cases) (but could not
understand why the numbers of blastocysts could reach thousands (986-2568)). This may make
conclusion about differences in BC formation rates in question. After D3 ET, how many go to
freezing directly and how many go to BC culture? All these were not mentioned in the method.
4. In Discussion
… DOR group needed higher Gn? Because
this is a retrospective review, the increased dose used for patients in DOR group might be due to
subjective bias before starting the treatment. Unless applying PSM to equalize the dosage and
check the pregnancy outcome to prove it
Specific comments:
Abstract :
Conclusion : last sentence … forn ? through live birth cycles
Background#
…advancing age ? advanced age
…natural ovulation? natural pregnancy? Or spontaneous pregnancy?
Methods#
Controlled superovulation procedures
… 0.2mg trigger of recombinant hCG? Should be clarified
… GnRH-a dose? 0.1 or 0.2 mg? not mentioned!
IVF and embryo culture#
…IVF#38 h of the trigger? When to OPU? 36 h?
Fresh ET and luteal support #
Delete “both the patient and”
…the couple -> the couples.
…gel (Serono,…) -> Crinone?
Determination of pregnancy outcome#
… uterine horn? Already excluded uterine malformation
… miscarriage… before 28 weeks?
According to the International Glossary in Infertility and Fertility Care
Preterm birth should be defined in 22-37 GWs
22-28 GWs belonged to preterm birth not miscarriage
Fresh ET and luteal support :
D3 embryos, “scoring 1-2” … no defined
hCG was detected 14 days after the ET (or OPU??) The same for D3 and D5 ET?
Observation indicators? Variables? #
2. Ovulation induction and response
3. Embryology parameters
Table 1 :
Legend: Others: including…
According to method
There should be no cases of mild stimulation and LP stimulation protocol
Figure 2: after match
no (missing?) control curve was shown
Table 2 title remove “test”
Or add the “test” to the paragraph title
To keep uniformity between paragraph and table title
Had better changed to the title as : Ovulation induction, response and embryo laboratory
outcomes …
Discussion :
… thus current investigation. Repetitive, pls remove either “this” or “current”
… birth “quality”? Hard to define, pls just mention birth “weight” as discussed
…[24]. Our current finding concurs with that research. (Because their study reported earlier)
In summary :
…significantly lowers clinical pregnancy …
LBR …“not” comparable to those in the non-DOR
Cannot say comparable even is a satisfactory LBR, it is still significantly lower.
…viable embryos —> high quality viable embryos