Study design
pregnancy loss, hepatic, renal, or heart disease, azoospermia, infertility, uterine infertility, heart movements, allergic disease, tubal occlusion
MAY, SECONDARY, AZOOSPERMIA, PREGNANCY LOSS
Our prospective open-label randomized clinical trial investigated whether G-CSF priming preceding ART enhanced preantral follicle growth, thus increasing the ART pregnancy rate in patients with poor ovarian reserve. Between May 19, 2014 and November 26, 2018, a total of 465 patients sought ART treatment at Women’s Clinic Jinno; 111 met study inclusion criteria. Eleven declined participation, leaving 100 to be enrolled and randomly assigned to groups undergoing or not undergoing G-CSF priming prior to standard ART. Randomization involved patients drawing from a box containing group assignments in sealed envelopes mixed 1:1 (Fig. Participant flow diagram. The rate of live delivery among patients was 32% (16/50) in the G-CSF group, significantly higher than 14% (7/49) in controls (chi-squared test). G-CSF, granulocyte colony-stimulating factor; OPU, oocyte pick-up; IVF, in vitro fertilization; ICSI, intracytoplasmic sperm injection; ET, embryo transfer. To more clearly detect G-CSF-related improvement of ovarian reserve, we limited our study to patients with mildly to moderately decreased ovarian reserve, excluding patients with severe diminution. We chose a serum AMH concentration lower than 2 ng/mL as an inclusion criterion for our study, given that 93% of infertile women in their forties have been found to have values below 2 ng/mL [Based on such considerations, our inclusion criteria were age between 20 and 42 years; no more than 1 prior oocyte retrieval attempt; serum AMH concentration below 2 ng/mL; day-3 serum FSH concentration below 30 IU/L; a medical history free of serious allergic disease, severe hepatic, renal, or heart disease, or uterine infertility; and a male partner without azoospermia.All enrolled patients initially received conventional infertility treatments in 2 consecutive cycles. (Since no patient in either group had bilateral tubal occlusion, we believed that a chance of pregnancy using conventional treatment existed.) During these 2 cycles the G-CSF group, but not the control group, underwent subcutaneous administration of G-CSF (100 μg of lenograstim; Neutrogin, Chyugai Pharmaceuticals, Tokyo, Japan) during the early luteal phase, based upon basal body temperature records, vaginal ultrasonographic findings, and, if necessary, serum progesterone determinations (Fig. Both groups consisted of patients who had failed to conceive with conventional infertility treatments and then underwent ART using controlled ovarian stimulation. Embryos were transferred 2, 3, or 5 days after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Remaining embryos were cryopreserved at the blastocyst stage. When IVF/ICSI and fresh embryo transfer (ET) failed to result in delivery, cryopreserved embryos were thawed and transferred (cryopreserved ET) in subsequent spontaneous cycles. During actual ART treatment using fresh or cryopreserved ET, neither group received G-CSF.Clinical pregnancy and ongoing pregnancy were diagnosed by ultrasonographic detection of a gestational sac and fetal heart movements, respectively. Abortion and delivery were defined as pregnancy loss before 22 weeks and birth after 22 weeks, respectively. Clinical pregnancy rates by IVF/ICSI-fresh ET (per ovarian stimulation) were compared between groups as the primary outcome measure. Cumulative live delivery rates, follicular growth, fertilization, and embryonic development were compared between groups as secondary outcome measures.To elucidate stimulatory effects of G-CSF priming on preantral follicle growth, pre- To achieve a power of 0.8 and an α error of 0.05, the minimum number of participants required to identify a difference between hypothetical pregnancy rates of 10% and 25% in control and G-CSF groups was 113 patients per group, so we planned to recruit those numbers. However, interim assessment halfway through the expected trial duration already showed statistically significant benefit from G-CSF priming that was greater than expected. We therefore ended our trial with 50 enrollees per group, considering the ethical importance of offering potential benefits of G-CSF priming to control patients in a timely manner.Informed consent was obtained from all patients. The study was approved by the Ethics Committees of both the Inagi Municipal Hospital and Women’s Clinic Jinno, and registered with the UMIN in Japan (UMIN000013956).