EFFICACY OF SUPPLEMENTED ER-XIAN DECOCTION COMBINED WITH ACUPOINT APPLICATION FOR POOR OVARIAN RESPONSE

Poor ovarian response (POR) refers to the low response of ovaries to the stimulation of ovulation stimulating hormones, which leads to a low number of follicles and slow growth and development. With social developments in recent years, a series of social factors, such as increasing life and work pressure on females, increases the risk of suffering from POR (1), and this has a serious influence on female reproductive health. POR, a recently diagnosed disease caused by the development of IVF, means that appropriate ovarian stimulation is needed. Approximately 12% of patients who are undergoing IVF experience POR.

The key to improving the success rate of fertilization in vitro and embryo transfer is to control ovarian hyperstimulation. This is used to obtain an appropriate quantity of high-quality oocytes and embryos (2), which is mainly determined by ovarian response (3). However, ovarian hyperstimulation might have an influence on nidation, which causes a decrease in conception rates (4). Therefore, improving the efficacy of treating POR is critical (5-6). Traditional Chinese medicine recently obtained clinical efficacy for POR, such as supplemented Er-xian decoction and acupoint (7-9).

Er-xian decoction was a common decoction for female reproductive diseases in traditional Chinese medicine. However, the efficacy and safety of Er-xian decoctions combined with acupoint for POR were unknown. Therefore, we conducted this study to observe the efficacy of supplemented Er-xian decoction combined with acupoint application in treating POR. Er-xian decoction was a common decoction.

MATERIALS AND METHODS

Subjects

This study was conducted in accordance with the declaration of Helsinki and was conducted with approval from the Ethics Committee of Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine. All study participants provided written informed consent prior to therapy.

This study was an open-label randomized controlled trial. A total of 80 patients who were treated in the Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine from January 2016 to December 2017 were enrolled in the study. These patients were divided into two groups by tables of random numbers, and each group had the same number of patients. The youngest patient was 41 years old, and the oldest patient was 49. The longest course of the disease was ten years, the shortest course of the disease was three months, and the average age of menarche was at 14 years. No patients received Western medicine therapy in the three months before visiting our hospital. Furthermore, 15 patients had primary infertility, 23 patients had secondary infertility (10), 30 patients had failed embryo transfers, and 12 patients had issues with irregular menstruation, distress, anxiety, etc.

The criteria in the POR consensus proposed by ESHRE in 2011 were as follows:

1) patients were older than 40 years or had other risk factors for ovarian hyporesponsiveness;

2) the number of eggs obtained by conventional stimulation of in vitro fertilization was no more than three;

3) abnormal ovarian reserve function test (antral follicle count (AFC) < 5 ~ 7 or anti-Mullerian hormone (AMH) < 0.5 ~ 1.1 g/L).

At least two of the three above can be diagnosed as POR. POR can be directly diagnosed if POR is still present after two cycles of a maximum dose of ovarian stimulation.

Drugs

The formula for the supplemental Er-xian decoction (11): 30 g of herba Epimedii, 30 g of Curculigo orchioides, 10 g of radix Rehmanniae preparata, 10 g of human placentophagy, 20 g of Morindae officinalis, 6 g of cortex Phellodendri, 10 g of Anemarrhenae, 10 g of Angelica sinensis, 15 g of Ligustrum lucidum ait, 15 g of Ecliptae herba, 15 g of radix Boehmeriae, 10 g of fructus Lycii, 10 g of Chinese yam, 10 g of Cornus officinalis, and 6 g of radix Glycyrrhizae.

Drug composition of the acupoint application: 10 g of Curculigo orchioides, 15 g of herba Epimedii, 6 g of Anemarrhenae, 15 g of tuber fleeceflower stem, 10 g of cortex Phellodendri, and an appropriate ginger juice.

All these materials were purchased from the Pharmacy of Traditional Medicine in our hospital.

Kuntai capsules (12) (Batch no. Z20000083; approved by the state) was provided by Guiyang Xintian Pharmaceutical Co., Ltd. Primary functions: nourishing yin and clearing heat, soothing the nerves and eliminating anxiety. In addition, it can be used for perimenopausal disorders, distress and anxiety, insomnia and dreaminess, dizziness and tinnitus, soreness and weakness of the waist and knees, nocturnal emission, and night sweating (13). Color Doppler ultrasonography was completed with the help of the doctor assigned at the B-ultrasound room of the Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine. Sex hormones in blood samples, including follicle-stimulating hormones (FSH), luteinizing hormones (LH), estradiol (E2), inhibin B (INHB), and anti-Mullerian hormones (AMH), were examined by the clinical laboratory of the Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine.

Diagnostic criteria of Western medicine

To date, there are no specific and unified international diagnostic criteria. In the present study, the Bologna criteria were regarded as the diagnostic reference (14). Patients were diagnosed with POR when they met two of the following three criteria:

1) age ≥ 40 years, or other risk factors that can cause POR;

2) POR occurred during the previous embryo transfer cycle (15), and the number of eggs retrieved was ≤ 3 by regular ovarian stimulation;

3) ovarian reserve decreases (16), including basic antral follicle count (AFC) < 5 – 7, or AMH < 0.5 – 1.1 g/ mL. If patients are over 40 years old or have a decline in the ovarian reserve, POR will continue to exist after the maximum dosage is applied during two continuous ovarian stimulation cycles (170, thereby confirming the diagnosis.

Diagnostic criteria of traditional Chinese medicine by syndrome differentiation

The following are clinical characteristics of POR based on clinical guidelines for treatment by Chinese herbs edited by the Ministry of Health and the ‘deficiency of qi and blood in females, scanty menstruation, and amenorrhoea’ in the traditional Chinese medicine (TCM) Textbook of TCM Gynaecology used by regular colleges.

Primary symptoms: 1) delayed menorrhea, hypomenorrhea, light-colored or dark red menorrhea, clear and thin menorrhea, impeded menorrhea, or even amenorrhea; 2) soreness and weakness of the waist and knee, dizziness and tinnitus.

Secondary symptoms: 1) dim complexion, or with dark spots; 2) lassitude, chills in the whole or part of the body, and cold limbs; 3) hectic fever and sweating; 4) vaginal dryness; 5) hypaphrodisia; 6) insomnia and forgetfulness; 7) tongue and pulse bleak tongue and a thin coating on the tongue; thin string pulse, or feeble and weak thin pulse. If a patient has all the primary symptoms, and at least two secondary symptoms, the patient can be diagnosed with POR.

The criteria of the enrolled patients

Inclusion criteria:

1) > 40 years old;

2) bFSH level > 10 IU/L, or (and) an increasing bFSH/LH levels ( ≥ 3.0);

3) baseline E2 level < 20 pg/ml;

4) baseline INHB level < 45 ng/L;

5) baseline AMH level < 1.1 ng/ml;

6) baseline AFC < 5.

Exclusion criteria:

1) Patients with unsound reproductive organs caused by congenital aplasia, secondary amenorrhea caused by organ damage during growth, premature ovarian failure and function decline caused by ovariectomy and chemotherapy, gonadal dysgenesis, or tumors occurring in the reproductive system.

2) Patients with cardiovascular, kidney and liver disease, and mental disorders.

3) Patients who orally took hormones within the past three months.

4) Patients who are unable to take the supplemental Er-xian decoction or those who have adverse reactions to acupoint application, patients who did not comply with the treatment, and patients without complete data to evaluate the efficacy.

5) Diagnosis of endometrial adhesions, uterine malformations, endometrial tuberculosis, or untreated endometrial diseases by ultrasound, hysterosalpingography, hysteroscopy, or laparoscopy.

The standard for clinical efficacy

Based on contents related to POR in the following books: “Reference Standards of Clinical Research on New Drugs”, and “Obstetrics and Gynecology”:

Cure: the menstrual cycle and menstrual blood volume returned to normal. The symptoms of POR disappeared, sex hormone levels INHB and AFC (18) remained normal, and reproductive organ functions remained normal three months after stopping the drugs.

Markedly effective: the menstrual cycle was close to normal (within 40 days), menstrual blood volume clearly increased, menstruation spontaneously occurred once within three months after stopping the drugs, the symptoms of low estrogen and others were alleviated, and FSH, FSH/LH, E2, INHB, and AFC were close to normal.

Effective: menstruation occurred more than once within three months following treatment, menstrual blood volume increased, and the symptoms of low estrogen and others were alleviated. Treatment was also considered effective if menstruation did not occur, but ovarian function clearly improved, as detected by serum examination and B-ultrasound, hormone levels fluctuated, AMH increased, and INHB and AFC improved.

Ineffective: after continuous treatment for 3 – 6 months, there was no clear improvement in the quantity, color, and quality of menstruation or menstruation did not occur. The relevant symptoms were not obviously alleviated, and no improvement was detected through laboratory tests. Low sex hormones in serum and genital atrophy did not improve.

The standard of efficacy evaluation of traditional Chinese medicine

Based on the reference standard of clinical practice of new drugs of TCM, issued by the Ministry of Health, and scoring methods of emmeniopathy and perimenopausal disorders in TCM textbooks, “TCM Gynaecology”, and “Chinese Obstetrics and Gynaecology” (second volume), used at regular colleges:

Efficacy indicator (n) = (total scores before treatment - total scores after treatment) / total scores before treatment × 100%.

Clinical cure: n ≥ 90%;

Markedly effective: n ≥ 70% and n < 90%;

Effective: n ≥ 30% and n < 70%;

Ineffective: n < 30%.

The standard of efficacy evaluation in menstruation conditions

Cure: the score returns to 0, the menstrual cycle returns to normal, and menstrual quantity returns to normal.

Markedly effective: the score goes down under half the score before treatment. The menstrual cycle is close to normal (within 40 days), menstrual quantity clearly increases, and menstruation occurs spontaneously once within three months after stopping the drugs.

Effective: the score becomes ½ – ¾ of the score before treatment, menstrual quantity increases, and menstruation occurs more than once within three months through treatment.

Ineffective: after continuous treatment for 3 – 6 months, there were no obvious improvements in the quantity, color, and quality of menstruation or menstruation did not occur.

Treatment method

In the experimental group: drug composition of the supplemented Er-xian decoction: 30 g of herba Epimedii, 30 g of Curculigo orchioides, 10 g of radix Rehmanniae preparata, 10 g of human placentophagy, 20 g of Morindae officinalis, 6 g of cortex Phellodendri, 10 g of Anemarrhenae, 10 g of angelica sinensis, 15 g of Ligustrum lucidum Ait, 15 g of herba Ecliptae, 15 g of radix Boehmeriae, 10 g of Fructus Lycii, 10 g of Chinese yam, 10 g of Cornus officinalis, and 6 g of radix Glycyrrhizae.

A dose was decocted twice. Then, 300 ml of the decoction was obtained and administered twice (150 ml each time). The decoction was administered for three months and stopped during menstruation. The following drugs were ground into powder and mixed well with the appropriate ginger juice, such as 10 g of Curculigo orchioides, 15 g of herba Epimedii, 6 g of Anemarrhenae, 15 g of tuber fleeceflower stem, and 10 g of cortex Phellodendri.

These were then applied to the acupoints, such as Zhongji, Guan Yuan, Shen Shu, and Zusanli, and fixed by special tape for 4 – 6 hours, three times a week. The acupoint application was stopped during menstruation. Changes on the skin were monitored during treatment, and changes in meridian conduction were carefully checked. If symptoms, such as blisters, redness, and swollen areas appeared, the acupoint application was stopped and the residual drugs removed. At the same time, researchers needed to be aware of patients’ mental needs, observe any changes in emotion, and answer patients’ questions to adjust and relieve their moods. This would be helpful for the effects of the drugs.

In the control group, Kuntai capsules were taken orally, four capsules each time, three times a day, for three months, and stopped during menstruation.

Observation of safety

1) Conventional check-up; 2) routine blood and urine tests; 3) liver and kidney function tests; 4) electrocardiogram and gynecologic ultrasonography. The test results were recorded, and the side effects were observed after taking medicine.

Observation of efficacy

Main indicators:

1) Symptoms, physical signs, tongue, and pulse in TCM before and after treatment;

2) Changes in menstruation before and after treatment;

3) Experimental indicators: changes in sex hormones, such as INHB, AMH, and AFC, were detected. Blood was drawn during the 2 – 5 days, and B-ultrasound was used (AMH was not relevant to the menstrual cycle).

The standard of symptom scores

The Kupperman (19) scoring method was referred to. The range of scores in the degree of the symptom: 0 – 3 points. Four levels were divided according to the scores, in which the highest and most serious symptom was allocated three points, continuous symptoms were allocated two points, occasional symptoms were allocated one point, and having no symptoms were allocated zero points. Accumulative points = the indicator of each symptom × the sum of the severity factors of each symptom.

The scores of menstruation conditions

Based on the revised Kupperman symptom indicator scores: the score for normal is zero, the score for amenorrhea for 3 – 6 months is one, the score for amenorrhea for 6 – 12 months is two, and the score for amenorrhea for more than 12 months is three.

Statistical analysis

SPSS 11.5 was used to perform the analysis. The sample size formula: N = Z2 × (P × (1 – P)) / E2. N: sample size; Z: statistics, Z = 1.64 when the confidence is 90%; E: error value; P: probability value. All measurement data was expressed as ± standard deviation (SD), and a t-test was performed. Enumeration data were expressed as a percentage, and an χ2–test was performed. For all data, P < 0.05 was considered statistically significant. P < 0.01 indicates that there were significant statistical differences, while P > 0.05 indicates there were no significant differences. T he Minimum Standards of Reporting Checklist contains details of the experimental design, statistics, and resources used in this study.

RESULTS

A total of 80 patients were divided into two groups: the experimental group (n = 40), and the control group (n = 40). For the 40 patients in the experimental group, the clinical total effective rate was 90%, the cure rate was 15% (six patients), the marked effective rate was 35% (14 patients), the effective rate was 40% (16 patients), and the ineffective rate was 10% (four patients). For the 40 patients in the control group, the total effective rate was 50%, the cure rate 5% (two patients), the markedly effective rate was 15% (six patients), the effective rate was 30% (12 patients), and the ineffective rate was 50% (20 patients).

Table 1. Two groups of patients before treatment TCM syndrome score comparison (± s).

Note: through analyzing this table, there were no significant differences in the symptom scores in the two groups before treatment (P > 0.05) therefore, the two groups could be compared.

Table 2. Two groups of patients before treatment serum FSH, FSH/LH, E2 comparison.

There were no statistical differences, but there was a statistical significance in the expression level of sex hormones before treatment in the two groups (P > 0.05).

Table 3. Two groups of patients before treatment serum INHB, AMH, AFC comparison.

There were no significant differences, but there was a statistical significance in the INHB, AMH, and AFC before treatment in the two groups, P > 0.05.

The results showing the comparison of TCM symptom scores between the two groups before treatment are in Table 1. The results showing the comparison of sex hormones between the two groups before treatment are in Table 2. The results showing the comparison of AMH between the two groups before treatment are in Table 3. The results showing the comparison of comprehensive efficacy between the two groups are in Table 4. The results showing the comparison of menstrual changes between the two groups are in Table 5. The results showing the comparison of perimenopausal symptom scores before and after treatment in the two groups are in Table 6. The results showing the comparison of sex hormones before and after treatment in the two groups are in Table 7. The results showing the comparison of INHB, AMH, and AFC before and after treatment in the two groups are in Table 8.

Table 4. Two groups of comprehensive curative effect comparison.

Note: according to the above table, through the χ2 test, the experimental group scored better than the control group, and there were statistical differences (P < 0.05).

Table 5. Two groups of menstrual conditions change comparison.

Note: according to the above table, through the χ2 test, menstruation improved, there were significant differences (P < 0.05), and the experimental group scored better than the control group.

Table 6. Two groups patients before and after treatment of Kupperman Score comparison.

Note: according to the above table, through t-tests, there were no statistical differences before treatment (P > 0.05); therefore, they could be compared. Symptoms scores decreased clearly after treatment during the perimenopause, and there were significant differences between the two groups (P < 0.01). The experimental group scored better than the control group in improving symptoms, and there were significant differences (P < 0.05).

All patients in both groups were examined after treatment, and it was revealed that there were no adverse effects. In the experimental group, there were no abnormalities in blood, urine, liver, and kidneys. Furthermore, none of the patients dropped out during the study.

Table 7. Two groups of patients before and after treatment of sex hormone comparison.

Note: there were no statistical differences before treatment in FSH, FSH/LH, E2, etc. (P > 0.05); therefore, they can be compared. Compared with before treatment, FSH decreased after treatment, and there were statistical differences (P < 0.01). Compared with before treatment, E2 increased after treatment, and there were statistical differences (P < 0.01). At the same time, comparing the FSF/LH between the two groups showed that these decreased, but there were no significant differences (P > 0.05).

Table 8. Two groups of patients before and after treatment of INHB, AMH, AFC comparison.

Note: after treatment, compared with before treatment, INHB decreased in the two groups, and there were statistical differences (P < 0.01). AMH in both groups increased, and there were significant differences (P < 0.01). The experimental group scored better than the control group for the increase of AMH, and there were significant differences between the two groups. Compared with the before treatment, AFC increased substantially, and there were statistical significances (P < 0.01). According to the above statement, there were significant differences in INHB, AMH, and AFC between the two groups (P < 0.01).

DISCUSSION

With social development in recent years, life and work pressure on women has increased, which adds more risk factors of POR and brings greater influence on reproductive health. At present, the two-child policy is in effect, and an increasing number of older women are deciding to give birth to a second child. However, age is an important pathological factor that causes POR. POR, a disease caused by the development of IVF, requires appropriate ovarian stimulation. However, the ovary may produce only a few eggs, and insufficient endometrial receptivity causes IVF to fail. The main pathological basis is that ovarian reserves decrease. POR, which is a common problem in the female reproductive system, has an influence on reproductive capacity and sexual function, which may induce oligomenorrhea and menopause, and even cause premature ovarian failure (POF).

To date, there are many methods to treat POR that are effective in increasing egg retrieval rates. Still, there is no confirmed method to cure this disease. Although excessive ovarian stimulation can influence nidation and decrease the conception rate, it has been reported that the excessive ovarian stimulation could be predicted by the level of serum progesterone (20). The proper ovarian function could also involve various reasons, SIRT6, gonadotropins, and steroid hormones are reported the essential factor to improve the condition of ovarian function (21, 22). The incidence of POR can be found in approximately 12% (1) of patients undergoing IVF. It is essential to determine how to improve ovarian function, repair ovulation function, or prevent the decline in ovarian function during the period of POR to increase the success rate of IVF-ET.

In the present study, the outcomes showed that in the experimental group, the total effective rate was 90%, the cure rate was 15% (six patients), the markedly effective rate was 35% (14 patients), the effective rate was 40% (16 patients), and the ineffective rate was 10% (four patients). In the control group, the total effective rate was 50%, the cure rate was 5% (two patients), the markedly effective rate was 15% (six patients), the effective rate was 30% (12 patients), and the ineffective rate was 50% (20 patients). The differences were statistically significant.

This study aims to observe the efficacy of supplemented Er-xian decoction combined with acupoint application in treating POR. The results showed that when a poor ovarian response was treated with supplemented Er-xian decoctions combined with acupoint applications, there were definite benefits. Improvements in perimenopausal symptoms, menstruation conditions, hormone levels, INHB, and AFC were significantly higher in the experimental group than in the control group. In addition, there was a high level of safety and few side effects. However, there were several limitations in this study. First, this trial was an open-label trial, so no blinding was designed. Second, this study was a single-center trial, and the sample size was limited. The effect of Er- xian on cancers that predominantly affect women (endometrial or breast cancer) remains unknown and requires further research.

In conclusion, the experimental group had better results than the control group in improving clinical efficacy, perimenopausal symptoms, menstrual conditions, hormone levels, INHB, and AFC. The efficacy of the supplemented Er-xian decoction was confirmed, and in terms of safety, there were no side effects or allergies found in the present study. This indicates that the supplemented Er-xian decoction is safe and reliable in clinical practice. It also avoids the side effects of Western medicine, such as damage to liver function and increased carcinogenic risks.

Abbreviations: AFC, antral follicle count; AMH, anti-Mullerian hormone; E2, estradiol; FSH, follicle-stimulating hormone; INHB, inhibin B; LH, luteinizing hormone; POF, premature ovarian failure; POR, poor ovarian response; SD, standard deviation; TCM, traditional Chinese medicine;

Source of funding: Clinical study of Dugeng decoctum in The Treatment of Various Syndromes before and after Menopause with Kidney Yin Deficiency, scientific research project of Traditional Chinese Medicine of Jiangxi Provincial Health and Family Planning Commission (No: 2017A085).

Conflict of interests: None declared.

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