1. In women receiving in vitro fertilization (IVF) for decreased ovarian reserve, both intracytoplasmic sperm injection (ICSI) and assisted hatching (AH) were associated with lower rates of live birth than those who received no micromanipulation.
2. In women with an elevated FSH, neither ICSI nor AH were associated with improved live birth rates.
Evidence Rating Level: 2 (Good)
Study Rundown: Over the past decade, there have been tremendous advances in assisted reproductive technology (ART), allowing for an increase in IVF live birth rate. However, women with diminished ovarian reserve undergoing IVF have not experienced the benefit of these advances, with success rates 40-50% lower than those for women with other causes of infertility. To optimize outcomes and enhance live birth rates, clinics are increasingly employing micromanipulation techniques (methods of altering eggs and embryos prior to implantation) to maximize success. Two commonly used methods are intracytoplasmic sperm injection (ICSI), where a sperm is directly introduced into the egg, and assisted hatching (AH), where various techniques are used to help the embryo hatch through the zona pellucida and thus aid in implantation. While these techniques improve live birth rate for some, they are not without risk (e.g. AH is associated with an increased risk of twinning) and few studies have demonstrated efficacy in women with diminished ovarian reserve. In this study, researchers used the SART-CORS database to investigate whether ICSI and AH result in improved outcomes among women with diminished ovarian reserve undergoing ART treatments. The Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART-CORS) database is a national registry run by the CDC that collects information from all clinics in the United States on Assisted Reproductive Technology (ART) cycles.
Researchers found that ICSI and AH were not associated with an improved live birth rate and in some women were associated a lower rate. Strengths of this study include large sample size incorporating nationwide data. Authors assessed live birth rate among women meeting the SART definition of DOR as well as women with DOR by a more liberal criterion, elevated FSH, to account for heterogeneity in the diagnosis of DOR across clinics. Limitations include potential for bias introduced by variability in methods for performing assisted hatching. Additionally, data on anti-mullerian hormone (AMH) levels, a well-studied hormonal marker for decreased ovarian reserve, was unavailable. Reproduction of results in a prospectively designed investigation would confirm the findings represented herein.
Relevant Reading: Reproductive outcomes in patients with diminished ovarian reserve
In-Depth [retrospective cohort]: Using the SART database, researchers collected data on 422,949 fresh, nondonor, initial ART IVF cycles from women with decreased ovarian reserve (DOR), either defined by SART DOR category (n=38,926) or by elevated FSH in the 90-99th percentile (n=8,597). Researchers compared live birth rates and clinical pregnancy rates after two methods of micromanipulation, intracytoplasmic sperm injection (ICSI) and assisted hatching (AH).
For women in the SART DOR category, both ICSI and AH alone were associated with lower odds of live birth compared to cycles performed without micromanipulation (ICSI OR=0.87, p=0.002; AH OR=0.84, p<0.0001). When ICSI and AH were performed together, odds of live birth were lower (OR=0.73; <0.0001). In women with an elevated FSH, there was no significant difference in live birth rates between cycles that incorporated ICSI or AH and those that did not.
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