Effect of Fasting on ICSI Outcomes in Poor Responders
Condition: Infertility
MeSH terms: Infertility
Study type: Interventional

Summary: 
      This study is a prospective, randomized controlled trial conducted at the In Vitro
      Fertilization ( IVF) center of the Department of Obstetrics & Gynecology, Kasr El-Ainy
      Teaching Hospital, Faculty of Medicine, Cairo University, Egypt, from October 2018 to
      September 2019, to determine the clinical effect of fasting on ICSI outcomes in poor
      responders 360 participants will be randomized withdrawing closed envelopes for each patient
      into group A and group B .

      Group (A): patients will have periodic fasting for 4 weeks prior to the treatment cycle. The
      fasting method involves daily fasts of 14-16hours and restrict eating to an 8-10 hour "eating
      window" as 2-3 or more meals of balanced diet. Group (B): no fasting, patients will have
      usual balanced diet as 3 meals and 2 snacks all over the day. Both groups should take
      adequate water and non calorie beverages intake daily (2-3 liters).

      All patients will start the ICSI cycle using the same treatment protocol. Primary outcome is
      clinical pregnancy rate per cycle. Secondary outcomes include Body mass index (BMI) and
      waist/hip ratio (WHR), fasting insulin , fasting plasma glucose, Homeostatic model assessment
      (HOMA) index, lipid profile ( Triglycerides (TGs), total cholesterol, High density
      Lipoprotein (HDL), Low density Lipoprotein (LDL), AntiMullerian Hormone (AMH), Basal Follicle
      Stimulating Hormone (FSH), Luteinizing Hormone (LH), Estradiol (E2, Days of stimulation ,
      dose of gonadotrophins, number of M II oocytes retrieved, number of grade1and 2 embryos,
      number of frozen embryos, freeze all cycles, Ovarian Hyperstimulation syndrome (OHSS),
      Chemical pregnancy rate, clinical pregnancy, twins, abortion, ectopic pregnancy, preterm
      labour, live birth rate
    

Detailed description: 
      This study is a prospective, single-blinded (to the outcomes assessor), randomized controlled
      trial conducted at the In Vitro Fertilization ( IVF) center of the Department of Obstetrics &
      Gynecology, Kasr El-Ainy Teaching Hospital, Faculty of Medicine, Cairo University, Egypt,
      from October 2018 to September 2019, to determine the clinical effect of fasting on ICSI
      outcomes in poor responder patients. Ethical committee approval was obtained. The study will
      include 360 infertile patients with poor ovarian reserve (POR )diagnosed by low Antral
      follicle count (AFC)( less than 5 follicles), Elevated basal follicle-stimulating hormone
      (FSH) (more than 10 IU/mL) and low anti-Mullerian hormone (AMH)(less than 1.5 ng/ml),
      previous POR (≤three oocytes with a conventional stimulation protocol). Women with diabetes,
      thyroid disorder or other endocrine dysfunctions, uterine abnormalities were excluded.Also
      severe oligo-astheno-teratozoospermia or azospermia are excluded.

      All patients are informed about the study and consent is given by those who accept to
      participate.

      Careful history taking include infertility type, duration , cause, obstetric history, medical
      and surgical history and demographic distribution is taken. Full physical examination and 2
      dimensional (2D) transvaginal sonography (TVS) are done on day 2 to 5 of menses to assess
      antral follicle count, uterus and adnexa . Body mass index (BMI) and waist/hip ratio (WHR)
      are calculated, Blood samples are taken for fasting plasma glucose, lipid profile (
      Triglycerides (TGs), total cholesterol, High density Lipoprotein (HDL), Low density
      Lipoprotein (LDL),AntiMullerian Hormone (AMH), Basal Follicle Stimulating Hormone (FSH),
      Luteinizing Hormone (LH), Estradiol (E2) All 360 participants will be randomized withdrawing
      closed envelopes for each patient into group A and group B .

      Group (A): patients will have periodic fasting for 4 weeks prior to the treatment cycle. The
      fasting method involves daily fasts of 14-16hours and restrict eating to an 8-10 hour "eating
      window" as 2-3 or more meals of balanced diet. Group (B): no fasting, patients will have
      usual balanced diet as 3 meals and 2 snacks all over the day. Both groups should take
      adequate water and non calorie beverages intake daily (2-3 liters) Subjects are instructed to
      wait for spontaneous menses. The next visit is scheduled on day 2 of next cycle when
      transvaginal ultrasound is done to confirm that endometrial thickness <5mm, no ovarian cyst
      by ultrasound. Body mass index (BMI) and waist/hip ratio (WHR) are calculated. Blood samples
      are taken for fasting plasma glucose, lipid profile ( Triglycerides (TGs), total cholesterol,
      High density Lipoprotein (HDL), Low density Lipoprotein (LDL), AntiMullerian Hormone (AMH),
      Basal Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Estradiol (E2),and then
      antagonist protocol is followed. Gonadotropins as Intramuscular (I.M.) injections of 150-300
      (International units) I.U. of highly purified Human Menopausal Gonadotropins daily (Merional,
      75 I.U. /vial, IBSA). and Urofollitropin or highly purified human follicle stimulating
      hormone(Fostimon®, 75 I.U. /vial, IBSA) are give in a ratio of 1:1.The dose is adjusted
      according to the age, BMI, Antral follicle count (AFC), serum levels of AMH, FSH and ovarian
      response.

      On the sixth day of stimulation , a visit is scheduled to assess the ovarian response (
      folliculometry) by TVS. Gonadotrophin releasing hormone antagonist (GnRH antagonist) which is
      Cetrorelix 0.25mg ( Cetrotide®, 0.25 mg/ vial, Merck Serono, is filled and mixed with diluent
      from a prefilled syringe with a 20 gauge needle) is given subcutaneously (S.C.) by 27-gauge
      needle starting from the 6th day of stimulation (fixed antagonist protocol).

      Next visits are every other day for follow up using the TVS. The trigger by Human Chorionic
      Gonadotrophin (HCG)10000 I.U., I.M. ( Pregnyl, Organon) is given when at least 3 follicles
      reach 18mm in mean diameter or more and E2 level is less than 2500 pg/ml. Ovum retrieval is
      done 34 hours after HCG injection and embryo transfer using Wallace catheter on day 2 to 3.
      Luteal support includes natural Progesterone 400 mg 1x2 as rectal suppository, Folic acid 0.5
      mg orally once daily, Amoxicillin-Clavulanic Acid 1gm 1x2x7 orally, Progesterone 100 I.M.
      injections daily for 10 days, Acetylsalicylic Acid (75 mg) orally once daily Quantitative ß-
      HCG in serum after is done after 14 days of embryo transfer.TVS is performed to detect
      clinical pregnancy at 6-7 weeks of gestation.

      Primary outcome is clinical pregnancy rate per cycle. Secondary outcomes include Body mass
      index (BMI) and waist/hip ratio (WHR), fasting plasma glucose, lipid profile ( Triglycerides
      (TGs), total cholesterol, High density Lipoprotein (HDL), Low density Lipoprotein (LDL),
      AntiMullerian Hormone (AMH), Basal Follicle Stimulating Hormone (FSH), Luteinizing Hormone
      (LH), Estradiol (E2, Days of stimulation , dose of gonadotrophins, number of M II oocytes
      retrieved, number of grade1and 2 embryos, number of frozen embryos, freeze all cycles,
      Ovarian Hyperstimulation syndrome (OHSS), Chemical pregnancy rate, clinical pregnancy, twins,
      abortion, ectopic pregnancy, preterm labour, live birth rate
    

Intervention name(s): Fasting; No fasting
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Periodic fasting last for 4weeks prior to the treatment cycle. The fasting method involves daily fasts of 14-16hours and restrict eating to an 8-10 hour "eating window" as 2-3 or more meals of balanced diet. Patients should take adequate water and non calorie beverages intake daily (2-3 liters).; Patients will not fast . But they will take balanced food and drink 2 to 3 liters of water and non caloric drinks all the day for 4 weeks
Other intervention name(s): Periodic fasting
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Other
Keywords: Infertility; Poor ovarian reserve; Intracytoplasmic sperm injection; fasting