Retrospective comparison of the effects of fresh and frozen embryo transfers on cumulative live birth rates in patients with poor ovarian response according to bologna criteria and poseidon subgroups.

This thesis study retrospectively compared the cumulative live birth rates of patients with poor ovarian response according to Bologna and POSEIDON criteria. Patients who initiated their first IVF cycle at Hacettepe University Faculty of Medicine Hospital between January 2017 and October 2023 were eligible for this study. Those who underwent oocyte retrieval and received treatment through IVF/Intracytoplasmic Sperm Injection (IVF/ICSI) following a standard ovarian stimulation protocol were included. The study encompassed patients who underwent either a fresh embryo transfer or a frozen-thawed embryo transfer (FET), with outcomes measured as either live births or the absence of live births despite the transfer of all embryos. Cycles where oocyte retrieval was not feasible due to inaccessible ovaries, patients with azoospermic partners, those undergoing fertility preservation, individuals with a BMI ≥ 35 kg/m2, patients younger than 18 or older than 45 years, those classified within WHO Group 1 (hypogonadotropic hypogonadal anovulatory), patients undergoing preimplantation genetic testing (PGT-M and PGT-SR) cycles, those receiving dual stimulation treatments, and patients diagnosed with premature ovarian insufficiency (POI) were excluded from the study. A total of 1250 patients experiencing their first aspiration cyle at the Hacettepe University IVF Center were included in the final analysis. The Bologna patients have at least two of the following three features; female-age ≥40 or prior ovarian surgery, AMH<1.1ng/ml or antral-follicle-count (AFC)<5-7, and obtaining ≤3 oocytes in prior conventional stimulation. POSEIDON patients were categorized into four groups; younger(<35) and older(≥35) women with AMH≥1.2/AFC≥5 experiencing an unexpected poor(<4 oocytes-retrieved) or suboptimal(4–9 oocytes-retrieved) response, along with respective younger and older counterparts with AMH<1.1/AFC<5. Non-POSEIDON patients were those with AMH≥1.2/AFC≥5 and >9 oocytes-retrieved. Each patient was classified according to both the Bologna and POSEIDON criteria, and Generalized Estimating Equations (GEE) analysis was used to compare the categories. The primary outcome measure was defined as the cumulative live birth rate. Out of 1250 patients, 79.6% (995 patients) were classified as POSEIDON, with sub-groups as follows: 5.28% (66 patients) Group 1a, 23.4% (293 patients) Group 1b, 3.6% (45 patients) Group 2a, 10.1% (126 patients) Group 2b, 14.64% (183 patients) Group 3, and 22.48% (281 patients) Group 4. The number of patients meeting v Bologna criteria was 17.4% (218 patients). For POSEIDON patients, median[IQR] values were: age 34 [30-38], AMH 1.33 [0.65-2.69], oocytes retrieved 4 [2-6], and embryo transfers 1 [1-2]. For non-POSEIDON patients: age 30 [27-33], AMH 4.63 [2.93-7.07], oocytes retrieved 13 [11-15], and embryo transfers 2 [1-3]. In Bologna patients: age 40 [36-42], AMH 0.46 [0.20-0.76], oocytes retrieved 2 [1-3], and embryo transfers 1 [0-1]. For non-Bologna patients: age 31 [28-36], AMH 2.30 [1.17-4.29], oocytes retrieved 6 [3-9], and embryo transfers 1 [1-2]. CDR for non-POSEIDON: 49.8%; Group 1a, 24.2%; Group 1b, 34.1%; Group 2a, 15.6%; Group 2b, 27.6%; Group 3, 20.8%; Group 4, 10.7%. In clustered-GEE analysis, using non-POSEIDON as reference, odds ratios (ORs) for live birth were: Group 1a OR 0.32 [0.18 - 0.60]; Group 1b OR 0.52 [0.37-0.74]; Group 2a OR 0.19 [0.08-0.43]; Group 2b OR 0.38 [0.24-0.61]; Group 3 OR 0.26 [0.17-0.41]; Group 4 OR 0.12 [0.08-0.19]. CDR for the Bologna group: 8.7% (OR: 0.10, 0.06-0.16); non-Bologna patients: 32.4% [OR: 0.48, 0.39-0.60]. The odds of achieving live-birth were ~3-fold higher in POSEIDON than in the Bologna group. Patients in the POSEIDON group have a cumulative live birth rate approximately two times lower than normal responders, while those in the Bologna group have a rate four times lower than patients in the Non-Bologna group. . Poseidon criteria cover a broader range of low-prognosis patients, while meeting Bologna criteria indicates a narrower, more specific group with poorer outcomes.