title: Prognostic models for high and low ovarian responses in controlled ovarian stimulation using a GnRH antagonist protocol.
abstract: OBJECTIVE
  Can predictors of low and high ovarian responses be identified in patients undergoing controlled ovarian stimulation (COS) in a GnRH antagonist protocol?
  
  
  CONCLUSIONS
  Common prognostic factors for high and low ovarian responses were female age, antral follicle count (AFC) and basal serum FSH and LH.
  
  
  BACKGROUND
  Predictors of ovarian response have been identified in GnRH agonist protocols. With the introduction of GnRH antagonists to prevent premature LH rises during COS, and the gradual shift in use of long GnRH agonist to short GnRH antagonist protocols, there is a need for data on the predictability of ovarian response in GnRH antagonist cycles.
  
  
  METHODS
  A retrospective analysis of data from the Engage trial and validation with the Xpect trial. Prognostic models were constructed for high (>18 oocytes retrieved) and low (<6 oocytes retrieved) ovarian response. Model building was based on the recombinant FSH (rFSH) arm (n = 747) of the Engage trial. Multivariable logistic regression models were constructed in a stepwise fashion (P < 0.15 for entry). Validation based on calibration was performed in patients with equivalent treatment (n = 199) in the Xpect trial.
  
  
  METHODS
  Infertile women with an indication for COS prior to IVF. The Engage and Xpect trials included patients of similar ethnic origins from North America and Europe who had regular menstrual cycles. The main causes of infertility were male factor, tubal factor and endometriosis.
  
  
  RESULTS
  In the Engage trial, 18.3% of patients had a high and 12.7% had a low ovarian response. Age, AFC, serum FSH and serum LH at stimulation Day 1 were prognostic for both high and low ovarian responses. Higher AFC and LH were associated with an increased chance of high ovarian response. Older age and higher FSH correlated with an increased chance of low ovarian response. Region (North America/Europe) and BMI were prognostic for high ovarian response, and serum estradiol at stimulation Day 1 was associated with low ovarian response. The area under the receiver operating characteristic (ROC) curve (AUC) for the model for a high ovarian response was 0.82. Sensitivity and specificity were 0.82 and 0.73; positive and negative predictive values were 0.40 and 0.95, respectively. The AUC for the model for a low ovarian response was 0.80. Sensitivity and specificity were 0.77 and 0.73, respectively; positive and negative predictive values were 0.29 and 0.96, respectively. In Xpect, 19.1% of patients were high ovarian responders and 16.1% were low ovarian responders. The slope of the calibration line was 0.81 and 1.35 for high and low ovarian responses, respectively, both not statistically different from 1.0. In summary, common prognostic factors for high and low ovarian responses were female age, AFC and basal serum FSH and LH. Simple multivariable models are presented that are able to predict both a too low or too high ovarian response in patients treated with a GnRH antagonist protocol and daily rFSH.
  
  
  CONCLUSIONS
  Anti-Müllerian hormone was not included in the prediction modelling.
  
  
  CONCLUSIONS
  The findings will help with the identification of patients at risk of a too high or too low ovarian response and individualization of COS treatment.
  
  
  BACKGROUND
  Financial support for this study and the editorial work was provided by Merck, Sharp & Dohme Corp. (MSD), a subsidiary of Merck & Co. Inc., Whitehouse Station, NJ, USA. F.J.B. received a grant from CVZ to his institution; P.J.M.V. and H.W. are employees of MSD, and B.M.J.L.M. was an employee of MSD at the time of development of this manuscript.
  
  
  BACKGROUND
  NCT 00696800 and NCT00778999.
authors.affiliation: Division of Female and Baby, Department for Reproductive Medicine and Surgery, University Medical Center, Utrecht 3584 CX, The Netherlands f.broekmans@umcutrecht.nl.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Broekmans
authors.affiliation: MSD, Oss 5342CC, The Netherlands.
authors.forename: Pierre J M
authors.initials: PJ
authors.lastname: Verweij
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht 3508GA, The Netherlands.
authors.forename: Marinus J C
authors.initials: MJ
authors.lastname: Eijkemans
authors.affiliation: MSD, Oss 5342CC, The Netherlands.
authors.forename: Bernadette M J L
authors.initials: BM
authors.lastname: Mannaerts
authors.affiliation: MSD, Oss 5342CC, The Netherlands.
authors.forename: Han
authors.initials: H
authors.lastname: Witjes
mesh_terms: D000328:Adult; D003661:Decision Support Techniques; D005260:Female; D007987:Gonadotropin-Releasing Hormone / Q000037:antagonists & inhibitors*; D006801:Humans; D016015:Logistic Models; D010053:Ovary / Q000187:drug effects*; D010062:Ovulation Induction; D066230:Patient-Specific Modeling; D011379:Prognosis; D012189:Retrospective Studies
chemical_list: D007987:Gonadotropin-Releasing Hormone
keywords: GnRH antagonist; ovarian response; predictive modelling; recombinant FSH