Poor Ovarian Stimulation Response in In Vitro Fertilization (IVF) Program
Condition: Infertility
MeSH terms: Infertility
Study type: Interventional
Phase: Early Phase 1

Summary: 
      The aim of this study is to assess the role of AMH in prediction of poor ovarian response as
      well as the relation between ESR2 (+1730G>A) (rs4986938), FSHR p.Thr307Ala (c.919A>G, rs6165)
      and FSHR p.Asn680Ser (c.2039A>G, rs6166) SNPs and the poor response in Egyptian women
      undergoing IVF procedure. Discovering the genetic variants associated with ovarian response
      is an important step towards individualized pharmacogenetic protocols of ovarian stimulation.
    

Detailed description: 
      In-vitro fertilization treatment safety is highly challenged by the erratic individual
      variability to controlled ovarian hyperstimulation (COH). One of the diverse predictive
      factors is the AMH, which is considered to be the most sensitive marker. Nowadays, practices
      of pharmacogenetics could predict the stimulation success and thus tailoring the treatment
      reaching advancement in patient care. Since the efficiency of the Follicle stimulating
      hormone (FSH) dose is greatly related to the success of COH, the FSHR gene is treated as the
      primary candidate in explaining the difference in COH results.Furthermore, the estrogen
      receptors are important genes for improvements in the diagnosis and treatment of infertility.

      Materials and Methods: Starting June 2013, couples with unexplained infertility, seeking the
      first attempt IVF/ICSI treatment cycle will be recruited in "AL shark Al-Awsat fertility
      center".In this prospective study, 216 Couples fulfilling our inclusion criteria will enroll
      in this study after informed consent. Ovarian stimulation will be performed according to the
      GnRH antagonist protocol with a fixed daily morning dose of Human menopausal gonadotrophin
      (HMG) [Merional® 75 IU ampoules, IBSA institut] intra-muscular injection starting on cycle
      day 2. Based on the patient's body mass index and hormonal profile, the daily dose of HMG
      will be adjusted to (225 IU) for participants with AMH levels > 1.5 ng/ml and/or FSH levels ≤
      8 mIU/ml and to (300 IU) for participants with AMH levels < 1.5 ng/ml and/or FSH levels > 8
      mIU/ml, doses will be increased by 75 IU in cases with BMI > 30 Kg/m2. On day 2 of the
      menstrual cycle, the dose of HMG will be commenced for all patients and will be maintained
      for 9-11 days according to each participant individual ovarian response assessed by
      trans-vaginal ultrasound folliculometry starting on cycle day 7 and continued every other day
      until the day of Human chorionic gonadotrophin (hCG) injection. On cycle day 7, the GnRH
      antagonist Cetrorelix 0.25 mg [Cetrotide® 0.25 mg syringes, Merck Serono] will be introduced
      as daily subcutaneous injections and continued till the day of ovulation triggering. Finally,
      when at least 3 follicles will reach 17 mm in diameter, ovulation will be triggered by a
      single intra-muscular injection of 10,000 IU of hCG [Choriomon® 5000 IU ampoules, IBSA
      institut]. 36 hours later, oocyte retrieval will be performed and will be guided by
      transvaginal ultrasound. According to our primary outcome, the number of oocytes collected,
      patients will be classified as poor responders (4 oocytes or less) and will be considered as
      good responders if they produced 5 or more oocytes. The good responders group will serve as
      the control group.

      Genotyping:Peripheral blood will be collected from each patient in an EDTA-containing tube.
      Genomic DNA will be extracted from lymphocytes of peripheral blood by fully automated system
      of QIAcube using QIAamp DNA Blood Mini Kit (250) plus QIAamp DNA Blood Mini Accessory Set B,
      cat. no. 1043369. Detection of the polymorphisms ESR2 (+1730G>A) (rs4986938), FSHR
      p.Thr307Ala (c.919A>G, rs6165) and FSHR p.Asn680Ser (c.2039A>G, rs6166) SNPs will be
      performed using the TaqMan system by real-time polymerase chain reaction (PCR). Primers and
      probes will be provided by applied biosystem, Life Technologies. Assays will be performed
      with TaqMan Universal Master Mix.

      Statistical analysis: Data will be statistically described in terms of mean and standard
      deviation, for quantitative data and frequencies (number of cases) and relative frequencies
      (percentages) for qualitative data. Hardy-Weinberg (H-W) Equilibrium for each polymorphism
      will be tested using the Chi-square test. Comparison of quantitative variables will be done
      using unpaired t test when comparing 2 categories and one way analysis of variance (ANOVA)
      with post hoc test when comparing more than 2 categories.

      For comparing categorical data, Chi square test will be performed. Exact test will be used
      instead when the expected frequency is less than 5.

      Genotype and allele frequencies will be compared between the disease and the control groups
      using chi-square tests. Odds ratio (OR) with 95% confidence intervals will be calculated. A
      probability value (P value) less than 0.05 will be considered statistically significant. All
      statistical calculations will be done using SPSS (Statistical Package for the Social Science;
      SPSS Inc., Chicago, IL, USA) version 22.
    

Intervention name(s): Human menopausal gonadotrophin (HMG); GnRH antagonist Cetrorelix; Human chorionic gonadotrophin (hCG)
Intervention type(s): Drug; Drug; Drug
Intervention description(s): [Merional® 75 IU ampoules, IBSA institut]; [Cetrotide® 0.25 mg syringes, Merck Serono]; [Choriomon® 5000 IU ampoules, IBSA institut]
Other intervention name(s): Merional®; Cetrotide®; Choriomon®
Intervention MeSH terms: Chorionic Gonadotropin; Cetrorelix; Menotropins
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Screening
Keywords: in vitro fertilization; controlled ovarian hyperstimulation; poor ovarian response; estrogen receptor 2 gene polymorphism; follicle stimulating hormone receptor gene polymorphism; anti-mullerian hormone