Conditions: Infertility, Female
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 90
Healthy volunteers: yes

Brief summary:
The worldwide prevalence of primary and secondary infertility is estimated at \~2% and 10.5%, respectively, among women aged 20-44 years and attempting to conceive. Poor ovarian responders (PORs) involve 9-24% of patients undergoing in-vitro fertilization (IVF). proper tailoring of the ovarian stimulation protocol in order to maximize the number of oocytes collected represents a crucial step for them to eventually conceive.

Recent evidence indicates that in the same menstrual cycle, there are multiple follicular recruitment waves. This coincides with the theory that folliculogenesis occurs in a wave-like fashion. Thus, within a single menstrual cycle, there can theoretically be multiple opportunities for a clinician to collect oocytes, as opposed to the conventional single cohort of antral follicles during the follicular phase.

Utilizing this concept, clinicians have been attempting to retrieve oocytes from poor responders using both the follicular-phase stimulation (FPS) and the luteal-phase stimulation (LPS) protocols to increase the number of oocytes collected shorter within shorter period of time. By increasing the number of the retrieved oocytes collected, a better clinical can be assured since there is a clear relationship between the number of oocytes collected and live birth rates across all female age groups.

which protocol is the most effective remains controversial and the efficacy of PPOS in POR compared with that of conventional protocols is unclear.

Detailed description:
The study will be conducted on 90 infertile women indicated for ICSI with criteria of poor ovarian response defined by Bologna criteria All participants will be informed about the nature of the study and informed consent will be taken from all of them.

Group 1:45 patients will be given the progestin primed double stimulation protocol.

Group 2: 45 patients will be given the flexible GnRh antagonist follicular controlled ovarian stimulations will be done in 2 cycles.

Written informed consents will be obtained from all participants who accept to participate in the research protocol.

Work up:

1. Complete history taking and full assessment of different infertility factors.
2. Hormonal investigations

   * FSH, LH, E2, Prolactin
   * AMH, TSH
3. Basal transvaginal ultrasound

Clinical and embryological procedures:

Group 1:

I. The follicular phase of the double stimulation protocol

1. luteal phase priming using combined contraceptive pills from day 21 of the previous cycle for one week (0.03 mg ethinyl estradiol, gestodene 0.075 mg, Gynera tab, Bayer Pharma AG., Berlin, Germany).
2. Controlled ovarian hyper-stimulation with 225-375 IU of gonadotropins will be started day 2-3 of menses after vaginal ultrasound confirming the absence of ovarian cysts.
3. Dydrogesterone (Duphaston, Abbott company, Illinois, United states) at 20 mg/day will be started from the first day of the ovulation induction.
4. Patient response will be monitored by:

   1. Transvaginal follicular scanning and the dose of the gonadotropins will be modified according to the response.
   2. Serum estradiol.
   3. Serum progesterone and LH on the day of triggering.
5. GnRh agonist triggering (Decapeptyl, Ferring, SAINT-PREX Switzerland) in a dose of 2 ampules of 0.2 mg will be administered when leading follicle \>18 mm in diameter.
6. Oocyte pickup will be done 36 hours after GnRh administration with precaution of leaving the follicles measuring 11 mm or less.
7. After the pick-up, oocytes will be denuded. The denuded oocytes are then assessed for nuclear status. Mature oocytes will be used for ICSI.

II. The luteal phase of the double stimulation protocol

Controlled ovarian hyper-stimulation with 225-375 IU of gonadotropins will be started the next day after the previous oocyte pickup simultaneously with Dydrogesterone (Duphaston, Abbott company, Illinois, United states) at 20 mg/day.

The rest will be as the follicular phase.

III. Fertilization and embryo quality:

The fertilization check, which will be performed 16 to 20 hours after ICSI. The resultant embryos will be scored, and they will be vitrified for subsequent transfer.

IV. Embryo transfer

\- Starting from the next menstrual cycle Day 3, patients will receive oral estradiol valerate (Cyclo-Progynova (white tablets); Bayer, Germany) daily. From Day 10 onwards, endometrium growth will be monitored by transvaginal ultrasound. When endometrial thickness ≥ 7 mm. Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 mg ampule IM every other day) will be initiated and Embryo transfer will be scheduled on Day 3, 4 or 5 with maximum number of 3 class A embryos whether of cleavage or blastocyst stage.

V. Luteal support - Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 mg ampule IM every other day) will be continued until pregnancy testing 18 days after embryo transfer. The pregnant cases will continue the luteal support till the 12 weeks of gestation.

Group 2:

VI. The flexible GnRH antagonist protocol controlled ovarian stimulation This controlled ovarian stimulation will be done twice in two different cycles

In each cycle:

1. luteal phase priming using combined contraceptive pills from day 21 of the previous cycle for one week (0.03 mg ethinyl estradiol, gestodene 0.075 mg , Gynera tab, Bayer Pharma AG., Berlin, Germany).
2. Controlled ovarian hyper-stimulation using antagonist protocol will be used. Stimulation with 225-375 IU of gonadotropins will be started day 2-3 of menses after vaginal ultrasound confirming the absence of ovarian cysts.
3. GnRH antagonist ( Cetrotide , Merck Serono, Darmstadt, Germany) will be given daily as the biggest oocyte reaches size 14 mm.
4. Patient response will be monitored by:

   1. Transvaginal follicular scanning and the dose of the gonadotropins will be modified according to the response.
   2. Serum estradiol.
   3. Serum progesterone on the day of triggering.
5. GnRh agonist triggering (Decapeptyl, Ferring, Saint-Prex Switzerland) in a dose of 2 ampules 0.2 mg will be administered when leading follicle \>18 mm in diameter. While in the second cycle HCG triggering (Choriomon, IBSA, Lugano, Switzerland) in a dose of 10,000 IU will be administered when the leading follicle \>18 mm in diameter.
6. Oocyte pickup will be done 36 hours after GnRh administration.
7. After the pick-up, oocytes will be denuded. The denuded oocytes are then assessed for nuclear status. Mature oocytes will be used for ICSI.

VII. Fertilization and embryo quality:

The fertilization check, which will be performed 16 to 20 hours after ICSI. The resultant embryos will be scored.

Embryos of the first cycle will be vitrified while embryos of the second cycle will be freshly transferred unless there is excess for vitrification for subsequent trials of transfer.

VIII. Embryo transfer

\- Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 mg ampule IM every other day) will be initiated on the day of the oocyte pick up of the second cycle. Embryo transfer will be scheduled on Day 3, 4 or 5 with maximum number of 3 class A embryos whether of cleavage or blastocyst stage that will be a mixture of the thawed embryos of the first cycle and fresh embryos of the second cycle.

IX. Luteal support Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 mg ampule IM every other day) will be continued until pregnancy testing 18 days after embryo transfer. The pregnant cases will continue the luteal support till the 12 weeks of gestation.

Arms:
arm 1: luteal phase priming using combined contraceptive pills from day 21 of the previous cycle for one week by Gynera tab. Controlled ovarian hyper-stimulation with 225-375 IU of gonadotropins will be started day 2-3 of menses after vaginal ultrasound confirming the absence of ovarian cysts. Duphaston at 20 mg/day will be started from the first day of the ovulation induction.Decapeptyl in a dose of 2 ampules of 0.2 mg will be administered when leading follicle \>18 mm in diameter for triggering.Then, Controlled ovarian hyper-stimulation the next day after the previous oocyte pickup simultaneously with Duphaston. Starting from the next menstrual cycle Day 3, patients will receive oral estradiol valerate (Cyclo-Progynova (white tablets) daily.When endometrial thickness ≥ 7 mm.Embryo transfer will be scheduled on Day 3, 4 or 5 with maximum number of 3 class A embryos whether of cleavage or blastocyst stage. arm 2: This step will be done twice in two different cycles In each cycle: luteal phase priming using combined contraceptive pills from day 21 of the previous cycle for one week by Gynera tab. Controlled ovarian hyper-stimulation using antagonist protocol will be used. Stimulation with 225-375 IU of gonadotropins will be started day 2-3 of menses after vaginal ultrasound confirming the absence of ovarian cysts. Cetrotide ampule will be given daily as the biggest oocyte reaches size 14 mm. Decapeptyl ampules 0.2 mg will be administered when leading follicle \>18 mm in diameter. While in the second cycle HCG triggering (Choriomon)in a dose of 10,000 IU will be administered when the leading follicle \>18 mm in diameter. Embryo transfer will be scheduled on Day 3, 4 or 5 with maximum number of 3 class A embryos whether of cleavage or blastocyst stage that will be a mixture of the thawed embryos of the first cycle and fresh embryos of the second cycle.

Interventions: intervention 1: Duphaston intervention 2: Gonadotropin intervention 3: Cetrotide Injectable Product intervention 4: Decapeptyl intervention 5: Chorionic Gonadotropin intervention 6: Combined Oral Contraceptive intervention 7: Cyclo-Progynova intervention 8: progesterone
Intervention descriptions: intervention 1: will be used for pituitary suppression in the first arm:20 mg/day will be started from the first day of the ovulation induction in the follicular phase and in the luteal phase will be started the next day after oocyte pickup at 20 mg/day. intervention 2: will be used for controlled ovarian hyperstimulation in both arms intervention 3: will used in the second arm for pituitary suppression in the second group daily when the biggest oocyte reaches size 14 mm till ovulation triggering intervention 4: will be used for ovulation triggering.in the first arm:in a dose of 2 ampules of 0.2 mg will be administered when leading follicle \>18 mm in diameter. in the second arm:in a dose of 2 ampules 0.2 mg will be administered when leading follicle \>18 mm in diameter in the first cycle only. intervention 5: will be used in the second cycle of the second arm for ovulation triggering in a dose of 10,000 IU when the leading follicle \>18 mm in diameter. intervention 6: luteal phase priming from day 21 of the cycle before controlled ovarian stimulation for one week . intervention 7: Starting from cycle Day 3 of the intented cycle for thawed embryo transfer, patients will receive the white tablets of Cyclo-Progynova daily. From Day 10 onwards, endometrium growth will be monitored by transvaginal ultrasound. intervention 8: in the intended cycle of embryo transfer when endometrial thickness ≥ 7 mm. Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 mg ampule IM every other day) will be continued until pregnancy testing 18 days after embryo transfer and in pregnant cases will continued till the 12 weeks of gestation.

Protocol document:
Prot_SAP_001.pdf: 
 
Progestin Primed Double Stimulation 
Protocol Versus Flexible GnRH Antagonist 
Protocol in Poor Responders 
 
 
 
ClinicalTrials.gov ID: NCT04537078 
Date:01/26/2022 


AIM OF THE WORK  
The primary aim of this work is to assess the difference between the progestin 
primed double stimulation protocol and the conventional GnRH antagonist protocol 
in poor responders regarding the number of M2 oocytes retrieved, the fertilization 
rate, the resultant embryos number, the implantation rate and the clinical pregnancy 
rate.  
While the secondary aims are:  
1. Assessing the difference in the ongoing pregnancy rate in both protocols.  
2. Assessing the difference between the follicular phase and the luteal phase of the 
progestin primed double stimulation protocol regarding the total days of controlled 
ovarian hyperstimulation, the total gonadotropin dosage, the number of M2 oocytes 
retrieved ,the fertilization rate and the resultant embryos number.  
3. Assessing the difference between the follicular phase of the progestin primed 
double stimulation protocol and the first round of the conventional GnRH antagonist 
protocol regarding the number of M2 oocytes retrieved the fertilization rate and the 
resultant embryos number.  
 


PATIENTS  
This study is a randomized controlled study performed at infertility and assisted 
reproduction unit of El-Shatby Maternity Hospital and Madinah Fertility center.  
Sample size:  
Sample size calculation is done by the staff members of Medical Research Institute, 
Alexandria University using NCSS PASS statistical software version 20.  
Participants:  
The study will be conducted on 80 infertile women indicated for ICSI with criteria 
of poor ovarian response defined by Bologna criteria (15)  
All participants will be informed about the nature of the study and informed consent 
will be taken from all of them.  
Inclusion criteria:  
1. Indicated infertile women for ICSI of poor responders defined by Bologna criteria 
either two or more of the following:(15)  
 
(i) advanced maternal age or any other risk factor for POR.  
(ii) a previous POR ; less than 3-5 oocytes retrieved per cycle.  
(iii) an abnormal ovarian reserve test (ORT): AFC less than 5-7 or AMH is less than 
1.1 ng/ml. 
Or two episodes of POR after maximal stimulation are sufficient to define a patient 
as poor responder in the absence of advanced maternal age or abnormal ORT.  
Exclusion criteria:  
1. Male factor infertility due to azoospermia.  
2. Patients with uncorrected uterine pathology.  
3. Patients with the diagnosis of severe endometriosis.  
4. Patients with BMI over 35.  
 


METHODS  
Study design:  
• Randomized controlled study in which 90 patients will be divided into two groups:  
 
Group 1:45 patients will be given the progestin primed double stimulation protocol.  
Group 2: 45 patients will be given the flexible GnRh antagonist follicular controlled 
ovarian stimulations will be done in 2 cycles.  
• Written informed consents will be obtained from all participants who accept to 
participate in the research protocol.  
 
Work up:  
1. Complete history taking and full assessment of different infertility factors.  
2. Hormonal investigations  
- FSH, LH, E2, Prolactin  
- AMH, TSH  
3. Basal transvaginal ultrasound  
 


Clinical and embryological procedures:  
Group 1:  
I. The follicular phase of the double stimulation protocol  
a. luteal phase priming using combined contraceptive pills from day 21 of the 
previous cycle for one week (0.03 mg ethinyl estradiol, gestodene 0.075 mg, Gynera 
tab, Bayer Pharma AG., Berlin, Germany).  
b. Controlled ovarian hyper-stimulation with 225-375 IU of gonadotropins will be 
started day 2-3 of menses after vaginal ultrasound confirming the absence of ovarian 
cysts.  
c. Dydrogesterone (Duphaston, Abbott company, Illinois, United states) at 20 
mg/day will be started from the first day of the ovulation induction.  
d. Patient response will be monitored by:  
1. Transvaginal follicular scanning and the dose of the gonadotropins will be 
modified according to the response.  
2. Serum estradiol.  
3. Serum progesterone and LH on the day of triggering.  
 
e. GnRh agonist triggering (Decapeptyl, Ferring, SAINT-PREX Switzerland) in a 
dose of 2 ampules of 0.2 mg will be administered when leading follicle >18 mm in 
diameter.  
 
f. Oocyte pickup will be done 36 hours after GnRh administration with precaution 
of leaving the follicles measuring 11 mm or less.  
 
g. After the pick-up, oocytes will be denuded. The denuded oocytes are then assessed 
for nuclear status. Mature oocytes will be used for ICSI.  
 


 
II. The luteal phase of the double stimulation protocol  
 
Controlled ovarian hyper-stimulation with 225-375 IU of gonadotropins will be 
started the next day after the previous oocyte pickup simultaneously with 
Dydrogesterone (Duphaston, Abbott company, Illinois, United states) at 20 mg/day.  
The rest will be as the follicular phase.  
III. Fertilization and embryo quality:  
 
The fertilization check, which will be performed 16 to 20 hours after ICSI. The 
resultant embryos will be scored, and they will be vitrified for subsequent transfer.  
IV. Embryo transfer  
 
- Starting from the next menstrual cycle Day 3, patients will receive oral estradiol 
valerate (Cyclo-Progynova (white tablets); Bayer, Germany) daily. From Day 10 
onwards, endometrium growth will be monitored by transvaginal ultrasound. When 
endometrial thickness ≥ 7 mm. Progesterone administration (as 800 mg/day vaginal 
suppositories per day and 100 mg ampule IM every other day) will be initiated and 
Embryo transfer will be scheduled on Day 3, 4 or 5 with maximum number of 3 class 
A embryos whether of cleavage or blastocyst stage.  
 
V. Luteal support  
- Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 
mg ampule IM every other day) will be continued until pregnancy testing 18 days 
after embryo transfer. The pregnant cases will continue the luteal support till the 12 
weeks of gestation.  
 


Group 2:  
VI. The flexible GnRH antagonist protocol controlled ovarian stimulation  
 
This controlled ovarian stimulation will be done twice in two different cycles  
In each cycle:  
a) luteal phase priming using combined contraceptive pills from day 21 of the 
previous cycle for one week (0.03 mg ethinyl estradiol, gestodene 0.075 mg , Gynera 
tab, Bayer Pharma AG., Berlin, Germany).  
b) Controlled ovarian hyper-stimulation using antagonist protocol will be used. 
Stimulation with 225-375 IU of gonadotropins will be started day 2-3 of menses 
after vaginal ultrasound confirming the absence of ovarian cysts.  
c) GnRH antagonist ( Cetrotide , Merck Serono, Darmstadt, Germany) will be given 
daily as the biggest oocyte reaches size 14 mm.  
d) Patient response will be monitored by:  
1. Transvaginal follicular scanning and the dose of the gonadotropins will be 
modified according to the response.  
2. Serum estradiol.  
3. Serum progesterone on the day of triggering.  
 
e) GnRh agonist triggering (Decapeptyl, Ferring, Saint-Prex Switzerland) in a dose 
of 2 ampules 0.2 mg will be administered when leading follicle >18 mm in diameter. 
While in the second cycle HCG triggering (Choriomon, IBSA, Lugano, Switzerland) 
in a dose of 10,000 IU will be administered when the leading follicle >18 mm in 
diameter.  
 
f) Oocyte pickup will be done 36 hours after GnRh administration.  
 
g) After the pick-up, oocytes will be denuded. The denuded oocytes are then assessed 
for nuclear status. Mature oocytes will be used for ICSI.  
 
VII. Fertilization and embryo quality:  
 
The fertilization check, which will be performed 16 to 20 hours after ICSI. The 
resultant embryos will be scored.  
Embryos of the first cycle will be vitrified while embryos of the second cycle will 
be freshly transferred unless there is excess for vitrification for subsequent trials of 
transfer.  
 


VIII. Embryo transfer  
 
- Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 
mg ampule IM every other day) will be initiated on the day of the oocyte pick up of 
the second cycle. Embryo transfer will be scheduled on Day 3, 4 or 5 with maximum 
number of 3 class A embryos whether of cleavage or blastocyst stage that will be a 
mixture of the thawed embryos of the first cycle and fresh embryos of the second 
cycle.  
 
IX. Luteal support  
 
Progesterone administration (as 800 mg/day vaginal suppositories per day and 100 
mg ampule IM every other day) will be continued until pregnancy testing 18 days 
after embryo transfer. The pregnant cases will continue the luteal support till the 12 
weeks of gestation.  


Statistical analysis  
Statistical analysis of the data  
Data were fed to the computer and analyzed using IBM SPSS software package 
version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using 
number and percent. The Kolmogorov-Smirnov test was used to verify the normality 
of distribution Quantitative data were described using range (minimum and 
maximum), mean, standard deviation, median and interquartile range (IQR). 
Significance of the obtained results was judged at the 5% level.  
The used tests were  
1 - Chi-square test  
For categorical variables, to compare between different groups  
2 - Fisher’s Exact or Monte Carlo correction  
Correction for chi-square when more than 20% of the cells have expected count less 
than 5  
3 - Student t-test  
For normally distributed quantitative variables, to compare between two studied 
groups  
4 - Mann Whitney test  
For abnormally distributed quantitative variables, to compare between two studied 
groups  
5 –Wilcoxon signed ranks test  
For abnormally distributed quantitative variables, to compare between two 
periods