Outcomes of fertility preservation in women with endometriosis: comparison of progestin-primed ovarian stimulation versus antagonist protocols

Abstract

Background: PPOS protocols, initially described for FP in women with cancer, have many advantages compared to antagonist protocols. PPOS protocols were not evaluated for women with endometriosis. The objective of the study was to describe fertility preservation outcomes in women with endometriosis and to compare an antagonist protocol with a Progestin-Primed Ovarian Stimulation (PPOS) protocol. Method: We conducted a prospective cohort study associated with a cost-effectiveness analysis in a tertiary-care university hospital. The measured outcomes included the numbers of retrieved and vitrified oocytes, and direct medical costs. In the whole population, unique and multiple linear regressions analysis were performed to search for a correlation between individual characteristics and the number of retrieved oocyte. Results: We included 108 women with endometriosis who had a single stimulation cycle performed with either an antagonist or a PPOS protocol. Overall, 8.1 ± 6.6 oocytes were retrieved and 6.4 ± 5.6 oocytes vitrified per patient. In the multiple regression model, age (p = 0.001), prior ovarian surgery (p = 0.035), and anti-Mullerian hormone level (p = 0.001) were associated with the number of retrieved oocytes. Fifty-four women were stimulated with an antagonist protocol, and 54 with a PPOS protocol. A mean of 7.9 ± 7.4 oocytes were retrieved in the antagonist group and 8.2 ± 5.6 in the PPOS group (p = 0.78). A mean of 6.4 ± 6.4 oocytes were vitrified in the antagonist group and 6.4 ± 4.7 in the PPOS group (p = 1). In the cost-effectiveness analysis, the PPOS protocol was strongly dominant over the antagonist protocol. Conclusion: Fertility preservation procedures are feasible and effective for patients affected by endometriosis. Antagonist and PPOS protocols were associated with similar results but the medico-economic analysis was in favor of PPOS protocols.

Effectiveness of progesterone-primed ovarian stimulation in assisted reproductive technology: a systematic review and meta-analysis

“…Wen et al [ 12 ] and Begueria et al [ 8 ] included participants with a maximum age of 35 years. Iwami et al [ 3 ] and Mathieu d’Argent et al [ 11 ] included participants with maximum ages of 41 and 40 years. Peng et al [ 5 ] included participants aged ≥ 40 years.…”

“…PPOS can effectively prevent the activation and transmission phases of oestradiol (E2)-induced LH surges and thus serves as an alternative to conventional treatment with GnRH analogs. Prior studies have shown that the PPOS protocol with medroxyprogesterone acetate (MPA) produces competent oocytes/embryos and achieves comparable pregnancy outcomes to those of GnRH antagonist protocols [ 3 , 4 , 7 – 11 ], as well as short-term protocols [ 12 , 13 ] and mild stimulation protocols [ 5 ] (see Table 1 ). Coupled with the application of frozen-thawed embryo transfer (FET) and the dual trigger of GnRH agonist with low-dose hCG, the PPOS protocol also allows for nearly complete avoidance of OHSS occurrence [ 14 , 15 ], since all the embryo transfers after PPOS are frozen.…”

“…Coupled with the application of frozen-thawed embryo transfer (FET) and the dual trigger of GnRH agonist with low-dose hCG, the PPOS protocol also allows for nearly complete avoidance of OHSS occurrence [ 14 , 15 ], since all the embryo transfers after PPOS are frozen. There are many clinical studies on PPOS protocol use in infertile women, including women who have normal ovarian function, PCOS [ 4 , 15 ], poor ovarian response [ 7 , 9 ], who are of advanced maternal age [ 5 ], having endometriosis [ 11 ] and donated oocytes [ 10 ]. The reported findings are variable; some studies have shown better live birth outcomes, while others showed no difference.…”

“…The crucial clinical aspects of IVF protocols are efficacy and safety. Some studies have shown that the PPOS protocol may be cost-effective compared with the GnRH antagonist in planned freeze-only cycles, such as in preimplantation genetic testing or fertility preservation [ 11 , 16 ]. These results are very consistent with our clinical observations, but we still need more solid evidence.…”

Body Mass Index Showed No Impact on the Outcome of In Vitro Fertilization in Progestin-Primed Ovarian Stimulation Protocol

“…It has been widely used in patients receiving in vitro fertilization (IVF) since 2016 and showed good IVF outcomes [ 3 , 4 ]. Indeed, a PPOS protocol may be considered more “user friendly” for the patients in view of its advantage of fewer injections than a conventional protocol [ 5 ]. In this study, we showed the efficacy of PPOS protocol in various patients and validated its safety in embryonic morphology.…”