Impact Of TVCD On The Prediction Of Poor Ovarian Response In Women Undergoing In Vitro Fertilization

Cancellation rates due to poor ovarian response remain high in IVF-embryo transfer (IVF-ET) treatment. The result is a cancellation or a decreased success rate due to a poor ovarian response. Therefore, one crucial aspect to the success of any IVF attempt is an optimal ovarian stimulation and ovarian response to stimulation is the ultimate test. Earlier cancellations may help to decrease the psychological, financial, and medical burden of ovarian stimulation. Various tests have been developed to assess ovarian reserve and to predict the response to ovarian stimulation. However, parameters such as age or basal FSH alone are of limited value for the prediction of individual ovarian response. Several investigations have been carried out to assess the usefulness of transvaginal and pulsed Doppler ultrasound imaging for the prediction of follicular response.Objective: 1. To analyze the predictive value of dynamic antral follicle count (cycle day 2 and day 6) for poor ovarian response during IVF in women down-regulated with a luteal start of GnRH analogue (short protocol). 2. To evaluate whether intraovarian blood flow (cycle day 2 and day 6) are predictive of ovarian response in patients undergoing in vitro fertilization.Methods: 72 cycles of 51 patients with an indication for IVF/ICSI are studied. Women older than 35 years old and with a high (>8 IU/L) basal serum FSH level are not offered IVF/ICSI treatment. All women underwent a cycle with a short protocol.Transvaginal ultrasound was performed on CD2 and CD6 of the stimulation cycle by the same doctor. Using a Sequoia512 Color Doppler with a 5.0-7.0MHz vaginal transducer. All ovarian follicles measuring 2-10 mm on both ovaries were counted on CD2, and those measuring 4-15 mm were counted on CD6. The average number of follicles per patient was used for calculations. Intraovarian stromal blood flow was measured including peak systolic velecity and resistence index on the same day.Basal serum FSH level was determined in this spontaneous cycle CD2 before the treatment cycle. For all patients, ovarian stimulation was commenced at CD3 with a daily dose of 150-300 IU recombinant FSH (rFSH) IM (Gonal-F; Serono)(or) in combination with 300-600 IU of hMG. Both hMG contain 75 IU FSH and 75 IU LH). The starting dose was adjusted according to the patient's age and basal serum FSH values and basal antral follicle count (AFC) et al. The subjects returned on CD6 ofstimulation for an assessment of follicular recruitment and growth by transvaginal ultrasound. The gonadotropin dose and timing of subsequent scans were determined by the subject's response to controlled ovarian stimulation. When there were at least three follicles that were >18 mm in diameter, hCG was administered and transvaginal oocyte retrieval was performed 36 hours later. All subjects received 10,000 IU of hCG. Subjects who did not have at least one follicle of >10 mm after 9 days of gonadotropin stimulation and those who had one follicle of >16 mm but no follicles between 10 and 16 mm at any day had their cycles canceled before oocyte retrieval.To date, there is no uniform definition of poor response. At a mean fertilization rate of 50%-60% in IVF, retrieval of four oocytes would be needed to reach an average of two embryos available for transfer. Thus, in this study we defined poor response as: collection of fewer than four oocytes at retrieval or cycle cancellation due to impaired follicular reaction in response to exogenous gonadotropins.Then we divided our subjects to two groups.Results: In the comparable group of poor responders, CD2-AFC, CD6-AFC were significantly lower than that of normal responders (P<0.01). CD2-AFC and CD6-AFC had the highest combination of specificity. Intraovarian blood flow was also found to be effective (P<0.05). Serum FSH and age were comparable between groups. This may be due to the selection bias in the present study.Conclusions: Dynamic AFC and intraovarian blood flow during a short IVF protocol is helpful in predicting ovarian response. The superiority of ultrasound parameters over hormonal parameters may help clinicians and women to cancel invalid cycles earlier and decrease the psychological, financial, and medical burden of a later cancellation. We found that CD6-AFC was a better predictor of poor ovarian response than CD2-AFC. The indexes of ultrasound are important when considering the ease and availability of ultrasound.