A Comparison between progesterone-primed ovarian stimulation and GnRH antagonist protocol in the ART population undergoing freeze-all cycle bi-centric study.

A Comparison between progesterone-primed ovarian stimulation and GnRH antagonist protocol in the ART population undergoing freeze-all cycle bi-centric study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Comparison between progesterone-primed ovarian stimulation and GnRH antagonist protocol in the ART population undergoing freeze-all cycle bi-centric study. Dr.Seema Pandey, Dr.Shreya Gowni, Lokendra Bahadur Yadav This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7864283/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Objective The objective of this study was to evaluate the efficacy of the Progestin-Primed Ovarian Stimulation (PPOS) protocol in comparison to the GnRH antagonist protocol within our IVF / ICSI patient cohort. Materials and methods The present retrospective study was conducted from June 2023 to March 2025 in two centres in India among females undergo ART treatment. Out of 843 patients were included(n = 551) patients were kept in progesterone-primed ovarian stimulation (PPOS protocol) Group 1 while(n = 292) patient were assigned to GnRH antagonist protocol Group II respectively. Patients were further subdivided into 3 sub-groups based on there AMH values. Progesterone-primed ovarian stimulation (PPOS) is a promising treatment option for females with hyper response, like polycystic ovarian syndrome (PCOS). Results: Comparative analysis of outcomes between two Group I (PPOS regimen) and Group II (Antagonist regimen), respectively Group 1 Group II were compared as per the primary and secondary outcome parameters. Pregnancy in Group I & II- no significant difference between groups in terms of distribution of pregnancy [p = 0.0947; χ 2 = 0.004] No statistically significant difference in pregnancy outcomes was observed between the two groups across all AMH subgroups ( 5 ng/mL), with p-values of 0.675, 0.118, and 0.442, respectively. Conclusion The PPOS and GnRH antagonist protocols exhibited similar pregnancy outcomes with hyper-responder patients, clinicians should prefer the PPOS protocol for convenience, and reduction in the incidence of LH surge and OHSS. Progestin-primed ovarian stimulation GnRH antagonist High progesterone ovarian stimulation ART Infertility Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Infertility is one of the major problems in the world which affects about 8–12% (60–80 million couples) of the world’s population. Out of which several require ART treatments [ 1 ].Assisted reproductive technology (ART) is an important role in infertility treatment [ 2 , 3 ]. Controlled ovarian stimulation (COS) is an important component of ART that allows obtimum oocytes for in vitro fertilization (IVF) [ 2 , 3 , 4 ]. With the refinement of our stimulation protocal thinking, we were able to produce higher number of Oocytes and embryos, but at the same time, complications like premature LH serged, ovarian hyper stimulation syndrome, and multiple fetal gestation have been a concern even with our Antogonost Protocol[ 5 ]. Progestin-primed ovarian stimulation (PPOS)) are more flexible and have recently emerged in clinical practice [ 6 ]. Their advantages lie in better control of LH levels, lower costs, and easier administration making them patients friendly (i.e. oral, no injections) than conventional COS, while cos effects like total oocyte, mature oocyte and embryo formed and clinical pregnancy outcomes are similar to those of traditional COS [ 7 , 8 , 9 ]. However the biggest draback of PPOS is enablety to do a fresh embryo transer the index cycle, however, this may be best utilized in hyper-responders, donor oocyte program for the couples who require embryo biopsy for Preimplantation Genetic Testing for Aneuploidy (PGT-A). Although PPOS is effective, we need furthure research and clarity regarding progestin stimulation effect on oocyte competence, embryo availability, embryo implantation, and obstetric and neonatal outcome, especially in elderly women over 40, and women suffering from reccurent pregnancy losses [ 10 ]. Till certain years back, long agonist protocol & antagonist protocols were the most common downregulation regimens which were being used worldwide. In 2015 a novel protocol was found by Kuang where progesterone was used as an oral drug for downregulation and it was found to be very effective [ 11 ]. Principle was based on inhibition of ovulation by OCPs. This protocol is based on theories that high progesterone levels can affect the frequency of GnRH pulses, inhibit premature LH surges and suppress pituitary function. Therefore, PPOS has been successfully used in patients with PCOS, normo-responders, poor responders and endometriosis [ 5 ]. But, early exposure to high levels of progesterone can alter endometrial receptivity and lead to asynchrony between embryos and endometrium which allowed for preventing routine embryo transfer (ET). Thankfully, advancements in vitrification techniques have allowed us an effective Freeze all & FET Cycle with better pregnancy rates infact [ 5 ]. Wang and colleagues realized that this protocol could be very patient friendly in our hyper-responders, PCOS populations and for the donors in donor recipient cycles as these cycles don’t require fresh embryo transfer [ 12 ]. Although the advantages of PPOS are theoretically proved, few clinical research are available to show its superiority over the GnRH antagonist protocol. Specifically, this study aimed to identify any significant differences in key clinical parameters, including oocyte development, embryo formation, and clinical pregnancy rates (CPR). In this retrospective study we attempted to compare the two protocols in our ART population, where we were following freeze-all policie. Materials and methods This retrospective study was conducted from June 2023 to March 2025 in two centres in India in patients who were undergoing IVF/ICSI for various reasons. Participants were recruited into two groups, who met all of the following enrollment criteria: Inclusion criteria - Patients with a history of infertility for more than one year were included in the study. The age of participants ranged from 22 to 38 years. Eligible patients had a Body Mass Index (BMI) between 22–30 kg/m². Transvaginal ultrasonography of the pelvis confirmed a normal uterine anatomy with the presence of at least one ovary. Exclusion criteria - Patients with documented premature ovarian insufficiency or ovarian failure were excluded from the study. Other exclusion criteria included age more than 38 years, Serum AMH less than 1.3 ng/mL, the presence of a functional ovarian cyst with serum estradiol (E2) levels greater than 100 pg/mL, endometriosis of stage III and IV, and a history of recurrent pregnancy loss. Additionally, any contraindications to ovarian stimulation treatments led to exclusion from the study. The study was approved by the Medical Ethics Committee of the Hospital (VPIMS/IEC/090/2023). All patients gave informed consent to the use of their clinical data in this study. Monitoring of the cycle All the patients had baseline FSH, LH, prolactin, TSH, AMH and E2 along with antral follicular count (AFC) on day 2 or 3 of the cycle.TVS scan was repeated on day 6 of stimulation, along with serum estradiol (E2), scan was repeated every 2–3 days till 3 lead follicles reached beyond 18–20 mm of size. Trigger was decided based on no. of total follicles, serum E2 and serum LH levels. OPU was performed 34–36 hours after the trigger. 100% ICSI was done and all the embryos were frozen at blastocysts stage. Stimulation protocol Dose of the gonadotropin was decided as per each Patient’s Age, Weight, BMI, AMH and AFC was in the range of 150–450 IU/day from day 2–3 of menstruation after ruling out any residual follicle or cysts. Group I Patients had medroxyprogesterone acetate (MPA) at a daily dose of 10 mg twice a day from the same day of stimulation and was continued till the day of trigger. Group II Received injection cetrorelix (0.25mg) per day from day 5–7 as flexible protocol based on size of lead follicles ( more than 13mm or estrodiol level more than 300 pg/ml) and antagonist was continued till the trigger. Further dose adjustment of the gonadotropins was done as per ovarian follicular growth response and serum estradiol levels. The final stage of oocyte maturation was induced either by agonist trigger (1.0–2.0 mg of leuprolide) or dual trigger (injection leuprolide 1.0 mg plus injection hCG1000-5000 IU) when three or more leads follicles reached 18–20 mm in diameter. Oocyte retrieval, embryo culture, and frozen-thawed embryo transfer. Oocyte retrieval was performed under short general anesthesiaa andwith ultrasound guidance after 34–36 h of the trigger. Standard procedures were followed for icsi and and embryo culture. The blastocyst grading was done as per Gardener’s classification. All the good quality embryos were frozen by vitrification on the fifth day after oocyte retrieval, whereas the inferior quality embryos were placed for extended culture until the day 6. Embryos with > 50% intact blastomeres were considered to have survived the freezing procedure after thawing. Only surviving embryos were transferred. The endometrium for frozen-thawed embryo transfer (FET) cycles were prepared either by downregulation or by modified natural cycle. Progesterone supplementation was continued until 12 weeks of pregnancy. Primary outcome No. of total oocytes, MI, MII & GV retrieved, Blastocysts formation rates Secondary outcome: Clinical pregnancy rate, Ongoing pregnancy (cumulative live birth rate) & miscarriage rates. Statistical analysis The qualitative variables were expressed as absolute and relative frequencies, and the quantitative variables were expressed as the mean ± standard deviation. The association between categorical variables was evaluated using the chi-squared test and Fisher’s exact test of independence. To compare quantitative variables between the antagonist and progestin groups, we used the Student’s t-test for variables with normal distribution. The intra-group comparison was done using one-way Analysis of variance (ANOVA). We ran the analyses using the IBM SPSS Version 29, considered significant at p < 0.05. Results Patients baseline characteristic Total 1000 patients were included in the study with mean age of 28.80 (range 22–38) years undergoing IVF /ICSI for various reasons. Out of 1000 patients 95 patients were excluded due to a lack of follow-up and 62 patients excluded for missing data. Total 843 patients were included in the study. In the end, they were further divided into progesterone-primed ovarian stimulation ( PPOS protocol) Group 1 ( n = 551and GnRH antagonist protocol Group II ( n = 292) respectively .Patients were divided into three sub groups according to their AMH values; not every patient was included in AMH subgroup. In Group I patients (551) were divided in three sub-group less than 2ng/mL (185), between 2–5 ng/mL (238) and more than 5 ng/mL (128). Same with group II patients ( n = 292), 97 Patients had AMH less than 2ng/ml, 137 patinets had in the range of 2–5 ng/mL and 58 patients had the AMH more than 5 ng/mL.(Fig. 1) This sub division comparison gives us an understanding of these two protocols in patients with variable AMH levels. There is no significant difference in no. of Oocytes (p = 0.777), no. of M II (p = 0.209) and Blastocysts (p = 0.79) in both groups. A significant difference can be seen in no. of M I (p = 0.022) & GV (< 0.001). The p values were calculated using student’s t–test at a significance level of 0.05 (Table 1 ). Table 1 Patients baseline characteristic of PPOS Group and Antagonist Group Group I(PPOS)(n = 551) Group II(Antagonist)(n = 292) t-values P value Demographic details Age (Mean ± S.D.) 28.80 ± 4.22 28.82 ± 4.16 -0.79 0.937 Outcomes (Primary) AMH 3.67 ± 2.87 3.78 ± 4.427 -3.19* 0.804 * Oocytes 12.42 ± 6.02 12.27 ± 7.71 0.306* 0.777 * M II 10.26 ± 4.58 9.77 ± 5.75 1.346* 0.209 * M I 1.64 ± 1.80 1.34 ± 1.88 2.291* 0.022 * GV 0.53 ± 1.77 1.16 ± 2.76 -4.029* < 0.001 * Blastocysts 6.07 ± 3.43 5.62 ± 3.68 1.761 * 0.79 * Outcomes(Secondary) Chi squared value Clinical pregnancy rate 422(76.6%) 225(77.1%) 0.004 # 0.0947 # *- values derived using t-test #- values derived using Chi squared test The p value was calculated with Chi squared Test and it was found that there is no significant difference (p > 0.05). (Fig. 2 ) Comparison between AMH sub-groups < 2.0 ng/mL (poor responders) There is no significant difference in no. of Oocytes (p = 0.074), &M I (p = 0.309). A significant difference was observed in no. of GV (p = 0.045), M II (p = 0.006) and Blastocysts (p = < 0.001) in both sub-groups. The p values were calculated using student’s t–test at a significance level of 0.05 (Table 2 ). Table 2 < 2.0 ng/mL (poor responders) Group I(PPOS) Group II(Antagonist) t-value p-value Demographic details Age (Mean ± S.D.) 30.18 ± 4.40 30.76 ± 3.73 AMH < 2.0 ng/mL 185 97 Outcomes (Primary) Oocytes 8.53 ± 3.99 7.03 ± 5.89 1.796 0.074 * M II 7.61 ± 3.45 5.68 ± 4.31 2.809 0.006 * M I 0.89 ± 1.33 0.66 ± 0.94 1.020 0.309 * GV 0.03 ± 0.16 0.68 ± 2.34 -3.088 0.045 * Blastocysts 5.29 ± 2.84 3.11 ± 3.26 3.958 < 0.001 * Outcomes (Secondary) χ 2 value Clinical pregnancy rate 73(59.34%) 24(63.15%) 0.176 0.675 # *- values derived using t-test #- values derived using Chi squared test Table 3 2-5ng/mL (normal responders) Group I(PPOS) Group II(Antagonist) t-value p-value Demographic details Age (Mean ± S.D.) 29.07 ± 4.26 29.40 ± 3.27 AMH 2–5 ng/mL 238 137 BMI Outcomes (Primary) Oocytes 11.35 ± 4.77 9.26 ± 4.13 2.638 0.009 * M II 9.32 ± 4.01 7.44 ± 4.05 2.741 0.007 * M I 1.59 ± 1.71 0.51 ± 0.70 6.382 < 0.001 * GV 0.48 ± 1.19 1.30 ± 3.14 -1.684 0.050 * Blastocysts 5.32 ± 2.99 4.74 ± 2.82 1.182 0.241 * Outcomes (Secondary) χ 2 value Clinical pregnancy rate 132(76.74%) 28(65.11%) 2.443 0.118 # *- values derived using t-test #- values derived using Chi squared test Comparison between CPR of two sub groups The p value was calculated with Chi squared Test and it was found that there is no significant difference (p = 0.176) (Fig. 3 ). 2-5ng/mL (normal responders) There is no significant difference in no. of GV (p = 0.050) and Blastocysts (p = 0.241) in both sub-groups. Significant difference was observed between no. of Oocytes (p = 0.009), MII (p = 0.007) & M I (p = < 0.001). The p values were calculated using student’s t–test at a significance level of 0.05 ( Table 3 ). Comparison between CPR of two sub groups The p value was calculated with Chi squared Test and it was found that there is no significant difference (p > 0.05) (Fig. 4 ). > 5.0ng/mL (hyper responders) There is no significant difference in no. of GV (p = 0.24), M I(p = 0.748) and Blastocysts (p = 0.442) in both sub-groups. A significant difference was seen in no. of Oocytes (p = 0.002) & M II(p = 0.013). The p values were calculated using student’s t–test at a significance level of 0.05 (Table 4 ). Table 4 > 5.0ng/mL (hyper responders) Group I(PPOS) Group II(Antagonist) t-value p-value Demographic details Age (Mean ± S.D.) 28.00 ± 3.79 29.65 ± 3.30 AMH > 5ng/mL 128 58 BMI Outcomes (Primary) Oocytes 17.13 ± 7.77 24.06 ± 9.40 -3.259 0.002 * M II 13.74 ± 5.05 17.29 ± 16.58 -2.536 0.013 * M I 2.00 ± 2.01 2.18 ± 2.40 -0.322 0.748 * GV 1.37 ± 3.42 4.59 ± 5.17 -2.464 0.24 * Blastocysts 7.96 ± 4.36 8.82 ± 5.46 -0.772 0.442 * Outcomes (Secondary) χ 2 value Clinical pregnancy rate 72(79.12%) 13(76.47%) 0.60 0.756 $ *- values derived using t-test $- values derived using Fisher’s Exact test Comparison between CPR of two sub groups The p value was calculated with Fisher’s Exact Test for independence and it was found that there is no significant difference (p > 0.05) (Fig. 5 ). Discussion In this study we investigated the utilization of Progestin-Primed Ovarian Stimulation (PPOS) compared to the conventional Antagonist protocol among patients exhibiting different ovarian reserve. Patient response types vary in characteristics and associated complications,characterized by an exaggerated ovarian reaction to stimulation, poses notable challenges and escalates the risk of complications such as Ovarian Hyper Stimulation Syndrome (OHSS) [ 5 ]. The primary objective of this study was to assess the efficacy of PPOS in comparison to the Antagonist protocol within our In Vitro Fertilization (IVF) patient cohort. Through a comparative analysis of outcomes between two principal cohorts, namely Group I (PPOS regimen) and Group II (Antagonist regimen), we aimed to discern any significant disparities in critical parameters including oocyte development, embryo formation & Clinical Pregnancy Rates (CPR). Upon comparing the Group I and Group II, no statistically significant differences were observed in the number of retrieved oocytes (p = 0.777), number of mature oocytes (p = 0.209), and blastocyst formation rates (p = 0.79) between the two groups, that strengthens our belief of PPOS being non inferior to our conventional antagonist protocol across all the groups of patients. However, a noteworthy discrepancy was noted in the number of immature oocytes (p = 0.022) and germinal vesicle (GV) stage oocytes (p 0.05) between Group I and Group II, indicative of comparable outcomes across both regimens. These findings underscore the equivalence in treatment efficacy between PPOS and the Antagonist protocol, as evidenced by our study outcomes, which associated with Handa and colleagues [ 13 ]. While the primary focus of this study revolves around the performance of the PPOS protocol in different responders we also tried to see the performance of PPOS across various AMH groups . For that the data was sub-divided into three categories according to their AMH levels which was used as marker of ovarian response. In the first sub-group (< 2.0ng/mL- poor responders) no significant difference in no. of Oocytes (p = 0.074), &M I (p = 0.309). A significant difference was observed in no. of GV (p = 0.045), M II (p = 0.006) and Blastocysts (p = 0.05) which clearly correlates with the results shown by a study conducted by Chen and colleagues on 340 patients in which it was shown that PPOS is a non-inferior alternative to novel GnRH antagonists in patients with poor-response [ 15 ]. In second sub-group (2-5ng/mL- normal responders) no significant difference in no. of GV (p = 0.050) and Blastocysts (p = 0.241) in both sub-groups. Significant difference was observed between no. of Oocytes (p = 0.009), MII (p = 0.007) & M I (p = 0.05). A study including 865 patients conducted by Zhou and colleagues showed that in numbers of oocytes retrieved, MII & blastocysts, no significant difference is observed between GnRH antagonist and PPOS groups but live birth rate was lower significantly in novel PPOS group where in our study no significant difference was seen in both of the groups [ 16 ]. The study also compared patients with poor response and PCOS which too displayed reduced live birth rates [ 16 ]. The third sub-group (> 5.0 ng/mL- hyper responders) no significant difference in no. of GV (p = 0.24), M I(p = 0.748) and Blastocysts (p = 0.442) in both sub-groups. A significant difference was seen in no. of Oocytes (p = 0.002) & M II(p = 0.013). The CPR was also found in-significant. It was observed that there are not many studies which exclusively state about effect of PPOS on the patients with hyper-response through many studies have conclusion about PCOS population such as Zhou and colleagues was observed that numbers of oocytes retrieved, MII & blastocysts, no significant difference is observed between GnRH antagonist and PPOS groups but live birth rate was lower significantly in novel PPOS group which is somehow similar to there results with normal ovarian reserve patients [ 16 ]. As the result suggests novel PPOS and conventional Antagonist regimen has no significant differences between theIr clinical pregnancy rates (CPR) and live birth rate. In all population patients PPOS and other protocols have effectively shown similar clinical pregnancy rates and cumulative live birth rates [ 17 ]. PPOS has shown similar outcomes in patients with different ovarian reserve according to the meta-analysis done by Guan and colleagues there are many studies which claim effectiveness of PPOS similar to that of GnRH Antagonist and suggests use of PPOS in oocyte donation cycles as to reduce incidence of OHSS [ 18 , 19 ]. As suggested by existing literature, progestins exert their action by suppressing the luteinizing hormone (LH) surge and gonadotropin-releasing hormone (GnRH) surge through their influence on progesterone receptors in the hypothalamus, although the precise mechanism remains under investigation [ 19 ]. The Progestin-Primed Ovarian Stimulation (PPOS) protocol has been identified as both effective and cost-efficient compared to conventional controlled ovarian stimulation approaches. Notably, it has demonstrated efficacy in suppressing premature LH surges and reducing the incidence of moderate to severe Ovarian Hyper Stimulation Syndrome (OHSS) [ 20 , 21 ]. Our findings, along with previous studies, provide compelling evidence supporting the utilization of the PPOS protocol, particularly in patients exhibiting hyper-responsiveness, potentially mitigating the occurrence of severe OHSS and premature LH surges and in oocyte-donation programs. However, it is imperative to acknowledge certain limitations inherent in the present study due to its retrospective design. The relatively modest sample size and the restriction of the study to two centers within a specific geographical area hinder the generalizability of the findings to the broader population. Additionally, the notable difference in sample sizes between the comparison groups constitutes a further limitation. Future multicenter studies encompassing a larger and more diverse patient cohort are warranted to reinforce and extend these findings, thereby enhancing the robustness and applicability of the conclusions drawn from this investigation. Conclusion In conclusion we can suggest that PPOS is an economical and non-inferior alternative to our conventional GnRH Antagonist protocol in patients with hyper response and other groups which can be used to prevent OHSS and LH surge with similar clinical pregnancy rate. However, its longterm implication on oocyte quality, epigenetic changes and neonatal outcome has to be studied and a wide net of safety to be dicided before it becomes a protocol of choice. Abbreviations PPOS Progesterone-primed ovarian stimulation GnRH Gonadotropin-releasing hormone CPR Cumulative Pregnancy Rate LH Luteinizing Hormone FSH Follicle-Stimulating Hormone TSH Thyroid Stimulating Hormone AFC Antral follicular count E2 Estradiol GV Germinal Vesicle OHSS Ovarian Hyper Stimulation Syndrome COS Controlled ovarian stimulation ART Assisted reproductive technology OS Ovarian stimulation MI Metaphase I MII Metaphase II ET Embryo transfer IVF In vitro fertilization ICSI Intracytoplasmic Sperm Injection FET Frozen Embryo Transfer MPA Medroxyprogesterone acetate AMH Anti-Müllerian Hormone USG Ultrasound Sonography OPU Ovum Pick-Up hCG Human chorionic gonadotropin PGT-A Preimplantation Genetic Testing for Aneuploidy PCOS Polycystic Ovary Syndrome ANOVA Analysis of variance Declarations Acknowledgements; Authors acknowledge the Vivekananda Polyclinic and Institute of Medical Sciences, for providing facilities and support during the study. Conflict of interest : The authors have no conflict of interest. Funding :Not associated Ethics statement; Ethical approval was obtained from the institutional Ethics committee of Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, India, with the reference number (VPIMS/IEC/090/2023). Informed consent : All patients provided informed consent for their clinical Data to be used in this study Availability of data and material; All Data available upon request from the Corresponding Authors References Katole A, Saoji AV. Prevalence of Primary Infertility and its Associated Risk Factors in Urban Population of Central India: A Community-Based Cross-Sectional Study. Indian J Community Med. 2019 Oct-Dec;44(4):337–341. Vander Borght M, Wyns C. Fertility and infertility: definition and epidemiology. Clin Biochem. 2018; 62:2–10. Zhou Z, Zheng D, Wu H, Li R, Xu S, Kang Y, et al. Epidemiology of infertility in China: a population-based study. BJOG: An International Journal of Obstetrics & Gynecology. 2018;125(4):432–41.. Dosouto C, Haahr T, Humaidan P. Advances in ovulation trigger strat egies. Panminerva Med. 2019;61(1):42–51. Ata B, Capuzzo M, Turkgeldi E, Yildiz S, La Marca A. Progestins for pituitary suppression during ovarian stimulation for ART: a comprehensive and systematic review including meta-analyses. Human Reproduction Update. 2021;27(1):48–66.. Huang J, Lu W, Wang L, Zhang T, Liu C, Liu S, et al.A preliminary effect analysis of family doctor and medical insurance payment coordination reform in Changning District of Shanghai, China. BMC family practice. 2019;20:1–0. Massin N. New stimulation regimens: endogenous and exogenous pro gesterone use to block the LH surge during ovarian stimulation for IVF. Hum Reprod Update. 2017;23(2):211–220. La Marca A, Capuzzo M. Use of progestins to inhibit spontaneous ovu lation during ovarian stimulation: the beginning of a new era? Reprod Biomed Online. 2019;39(2):321–331. Welp AM, Williams CD, Smith LP, Purcell S, Goodman LR. Oral medroxyprogesterone acetate for the use of ovulation suppression in in vitro fertilization: a cohort trial. Fertility and Sterility. 2024;121(5):806–13. Pai AH, Sung YJ, Li CJ, Lin CY, Chang CL. Progestin primed ovarian stimulation (PPOS) protocol yields lower euploidy rate in older patients undergoing IVF. Reproductive Biology and Endocrinology. 2023;21(1):72. Caetano JP, Calazans LC, Amorim LV, Pereira LM, Xavier EB, Campos AL, et al. Progestin-Primed Ovarian Stimulation is a non-inferior alternative to the GnRH Antagonist Protocol in patients undergoing assisted reproductive techniques: a retrospective study. JBRA Assisted Reproduction. 2022;26(1):38. Wang Y, Chen Q, Wang N, Chen H, Lyu Q, Kuang Y. Controlled ovarian stimulation using medroxyprogesterone acetate and hMG in patients with polycystic ovary syndrome treated for IVF: a double-blind randomized crossover clinical trial. Medicine. 2016;95(9):e2939. Handa M, Takiuchi T, Kawaguchi S, Hon CC, Moody J, Okazaki Y, et al Adverse effects of progestin-primed ovarian stimulation: combination of clinical study and single cell analysis. Reproductive Biomedicine Online. 2025 Jan 20:104833. Qin X, Fan L, Luo Y, Deng Z, Zeng Z, Jiang X, et al. Progestin-primed ovarian stimulation (PPOS) in preimplantation genetic testing for aneuploidy: a retrospective study and meta-analysis. Archives of Gynecology and Obstetrics. 2025 Feb 13:1–3. Chen Q, Chai W, Wang Y, Cai R, Zhang S, Lu X, et al. Progestin vs. gonadotropin-releasing hormone antagonist for the prevention of premature luteinizing hormone surges in poor responders undergoing in vitro fertilization treatment: a randomized controlled trial. Frontiers in endocrinology. 2019; 10:796. Zhou R, Dong M, Huang L, Wang S, Fan L, Liang X, et al. Comparison of cumulative live birth rates between progestin-primed ovarian stimulation protocol and gonadotropin-releasing hormone antagonist protocol in different populations. Frontiers in Endocrinology. 2023 Apr 18 Baid R, Pai HD, Palshetkar NP, Pai RD. Progestin primed ovarian stimulation protocol: current status in assisted reproductive technology. Fertility Science and Research. 2022;9(1):16–22. Guan S, Feng Y, Huang Y, Huang J. Progestin-primed ovarian stimulation protocol for patients in assisted reproductive technology: a meta-analysis of randomized controlled trials. Frontiers in endocrinology. 2021 Aug 31. Yildiz S, Turkgeldi E, Angun B, Eraslan A, Urman B, Ata B. Comparison of a novel flexible progestin primed ovarian stimulation protocol and the flexible gonadotropin releasing hormone antagonist protocol for assisted reproductive technology. Fertil Steril 2019 Kao TC, Hsieh YC, Yang IJ, Wu MY, Chen MJ, Yang JH, et al. Progestin-primed ovarian stimulation versus GnRH antagonist protocol in poor responders: Risk of premature LH surge and outcome of oocyte retrieval. Journal of the Formosan Medical Association. 2023;122(1):29–35. Choudhary RA, Vora PH, Darade KK, Pandey S, Ganla KN. A prospective randomised comparative clinical trial study of luteal phase letrozole versus ganirelix acetate administration to prevent severity of early onset OHSS in ARTs. International Journal of Fertility & Sterility. 2021;15(4):263. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 16 Nov, 2025 Reviews received at journal 13 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviews received at journal 27 Oct, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 27 Oct, 2025 Submission checks completed at journal 16 Oct, 2025 First submitted to journal 15 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7864283","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":537317910,"identity":"e283f828-2c23-44ed-becb-a8d4d066da00","order_by":0,"name":"Dr.Seema Pandey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBCDBH4IfQCIGRsYGAoYeAhqkWxAaGlsYDAgQovBAbgWkDUGuJWat7c/fPBzj12e8fnDBx/dqLkjJz+7uf3BDwMGGXMcWmTOnDE27HmWXGx2Iy3ZOOfYM2ODOwcbG3uADrNswK5FQiKHTYLnwIHEbTd4zKRz2A4nbpBIbGzgAWqBOhVTi/zz5z//ALVs7j///XfOv8OJ82ckNjb+wadFgsGMGWTLBoYcNubctsOJDTcSG5vx2sKTYywtcyA5ccaNNGPp3L7DYL/MljGQwK2F/fjDj28O2CX29x9++Dnn22FgiLU/+PimwsYelxZspiCRJGkZBaNgFIyCUQAHAGfxZGV9ZHGNAAAAAElFTkSuQmCC","orcid":"","institution":"Vivekananda Institute of Medical Sciences","correspondingAuthor":true,"prefix":"Dr.","firstName":"Seema","middleName":"","lastName":"Pandey","suffix":""},{"id":537317911,"identity":"7737af8b-e186-4d1b-9848-5821fce3162a","order_by":1,"name":"Dr.Shreya Gowni","email":"","orcid":"","institution":"Matrika Infertility Centre D.No. 1-8-143,","correspondingAuthor":false,"prefix":"Dr.","firstName":"Shreya","middleName":"","lastName":"Gowni","suffix":""},{"id":537317912,"identity":"9c129ebe-a629-489f-b780-84a48388cf1e","order_by":2,"name":"Lokendra Bahadur Yadav","email":"","orcid":"","institution":"Vivekananda Institute of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Lokendra","middleName":"Bahadur","lastName":"Yadav","suffix":""}],"badges":[],"createdAt":"2025-10-15 06:08:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7864283/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7864283/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95524552,"identity":"083f6f11-7d2e-440d-a21c-44e16071afe5","added_by":"auto","created_at":"2025-11-10 10:02:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":159646,"visible":true,"origin":"","legend":"","description":"","filename":"middleeastmsppos.docx","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/1182b89d178d19e9a1f993c1.docx"},{"id":95524453,"identity":"f299aab5-172f-4c47-9d22-254b4548122e","added_by":"auto","created_at":"2025-11-10 10:02:47","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5312,"visible":true,"origin":"","legend":"","description":"","filename":"0e98dc1d27bb4f7c9b48f82f57aa1883.json","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/1b58aaf5f102aa63cf7c3964.json"},{"id":95525795,"identity":"7857bce2-8fbd-4efb-a904-58a5e1924520","added_by":"auto","created_at":"2025-11-10 10:05:42","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":103805,"visible":true,"origin":"","legend":"","description":"","filename":"0e98dc1d27bb4f7c9b48f82f57aa18831enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/439714ce4b46652e97c90f6b.xml"},{"id":95525885,"identity":"6ced2bff-6b32-4afa-ac72-6abd3fd48108","added_by":"auto","created_at":"2025-11-10 10:05:48","extension":"eps","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":168826,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage1.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/d91e03d0b77a4049a8232064.eps"},{"id":95358004,"identity":"344e3a63-9b16-4149-9777-52b64c085714","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":590,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage10.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/dd5ad426b95f8225238f6f30.eps"},{"id":95358009,"identity":"65c545cb-ec8f-4578-a9ee-932dd6fb9d3b","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/855164ce7004a46cde257bd0.eps"},{"id":95358016,"identity":"62d69404-e461-4178-9f01-ad04d54f74f9","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/b19dddfb1102c1516b474456.eps"},{"id":95525887,"identity":"94386d79-6c4c-447a-b80f-88386a5f5cdb","added_by":"auto","created_at":"2025-11-10 10:05:48","extension":"eps","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69934,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage13.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/09fad50205d20397980b8b99.eps"},{"id":95358011,"identity":"6c6c0740-878c-4326-891a-5799c67fe586","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69343,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage14.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/89e5ed9947d32797faf457d2.eps"},{"id":95358014,"identity":"8bdbaca6-04fe-4c7d-917a-018b4d34d90b","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":597,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage15.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/a3c4d67c221ebbaabc209cd5.eps"},{"id":95358024,"identity":"ed2c88fe-0e27-41ea-ad97-96c409788acf","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":594,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage16.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/863af8109e98c1ee4ddfc1a6.eps"},{"id":95525128,"identity":"f12bbd8d-216f-4183-922c-1ee098b63b5a","added_by":"auto","created_at":"2025-11-10 10:04:18","extension":"eps","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":583,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage17.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/d693a82a679a8ee9d43cf1df.eps"},{"id":95525328,"identity":"eab5a66c-c2be-49c6-801e-1eb691fd3e30","added_by":"auto","created_at":"2025-11-10 10:04:50","extension":"eps","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82896,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage18.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/7d0d7ea36e1f11e60918d71e.eps"},{"id":95358039,"identity":"8caaaf76-54f0-4e3f-8ca5-179109a19baf","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"eps","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74762,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage19.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/ea2a420432b43d3424abb1dc.eps"},{"id":95358037,"identity":"4d9c7e2a-3f72-4494-a2ea-187e24e3185b","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"eps","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165996,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage2.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/41ea1022399c8f075fdbc651.eps"},{"id":95358028,"identity":"a61e763f-fc7d-458d-b071-a1f35efd8dc5","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60353,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage20.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/bf01a42574479d955f4248b1.eps"},{"id":95358022,"identity":"4fb87bd5-75d8-4a4b-8620-cd2d0f9f47c7","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":590,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage10.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/142bf38cf7d4b8669063563d.eps"},{"id":95524669,"identity":"0ab897d9-b538-4b6a-b893-1be2c54db747","added_by":"auto","created_at":"2025-11-10 10:03:12","extension":"eps","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/53a5526c832fe3d4d63f4874.eps"},{"id":95525545,"identity":"0bd070e4-dc9d-4a26-9d83-610673e4b998","added_by":"auto","created_at":"2025-11-10 10:05:16","extension":"eps","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":590,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage10.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/d1fdba24812f0ed5c8ba3ec4.eps"},{"id":95526027,"identity":"0ec0f217-c714-42c6-b771-1892e4155351","added_by":"auto","created_at":"2025-11-10 10:06:05","extension":"eps","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/cfd07d13ffc0db6abf3a4e15.eps"},{"id":95525464,"identity":"f6f37428-d7ac-418f-88d5-4150cea794db","added_by":"auto","created_at":"2025-11-10 10:05:06","extension":"eps","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/c9cf54d98341dd85018bb58e.eps"},{"id":95524569,"identity":"6b1b94cc-39e4-49b2-933f-27516b03529c","added_by":"auto","created_at":"2025-11-10 10:02:56","extension":"eps","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/1db48df7ea5f78b89d72d124.eps"},{"id":95525842,"identity":"8b2ccfed-0611-4641-b2d1-a2fb143f51d3","added_by":"auto","created_at":"2025-11-10 10:05:43","extension":"eps","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":381,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage27.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/e52cfd274cb9331a4444def8.eps"},{"id":95358018,"identity":"7a5e4547-50c1-4986-835f-08bf6639374c","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/6c6ce3ad2c59614a6dcf3d6f.eps"},{"id":95358025,"identity":"e0f467c7-414b-43ff-8b96-ed7df4986950","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/2a9e1a0776a580bbf08d3811.eps"},{"id":95524686,"identity":"f0608466-dc52-4d4c-bb9c-88239bf80cb0","added_by":"auto","created_at":"2025-11-10 10:03:13","extension":"eps","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78186,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage3.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/e416f3855d62b5daecc5075f.eps"},{"id":95358029,"identity":"9caa8881-a602-4891-94e2-2815c0e37f31","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":26,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":381,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage27.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/28e4d683b73204350b9ef7ae.eps"},{"id":95525903,"identity":"2e6f6477-36ca-4e58-883e-093cc7db541a","added_by":"auto","created_at":"2025-11-10 10:05:49","extension":"eps","order_by":27,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77530,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage31.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/144570bf048fc4ed26a29e3f.eps"},{"id":95524575,"identity":"029793a7-39ae-4e7c-b4fd-da5731a7129f","added_by":"auto","created_at":"2025-11-10 10:02:56","extension":"eps","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79042,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage32.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/13bb04b0aed5cb8f36fe3e5a.eps"},{"id":95525561,"identity":"c76770f9-0314-4593-9cb1-977610e7bf15","added_by":"auto","created_at":"2025-11-10 10:05:17","extension":"eps","order_by":29,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78822,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage33.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/1818faf009ec605be635092c.eps"},{"id":95358045,"identity":"e4d69f3b-9b04-4c94-bc9c-f0d1c241ef40","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"eps","order_by":30,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80299,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage34.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/3d5a7e073e58b7f4bcac4c38.eps"},{"id":95525896,"identity":"39a7d90e-1b7e-4a01-9846-67f3710dd119","added_by":"auto","created_at":"2025-11-10 10:05:49","extension":"eps","order_by":31,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77607,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage35.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/3820ba5b89c9a502dbc6fc25.eps"},{"id":95358038,"identity":"448d7cdf-842d-4eff-a7aa-bfd0ad77942a","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"eps","order_by":32,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80312,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage36.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/0dc3d6b1d76038532a83b7eb.eps"},{"id":95524396,"identity":"0921934e-44d0-4d3f-aaa2-93bd7f47b8b4","added_by":"auto","created_at":"2025-11-10 10:02:43","extension":"eps","order_by":33,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73321,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage4.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/ebf6c763c495941f312980f5.eps"},{"id":95358047,"identity":"be3fb6b9-9a11-4574-bac8-916a91e1bc1e","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"eps","order_by":34,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":597,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage5.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/a6a9b39d4ba4cc7ab3fb235a.eps"},{"id":95525534,"identity":"800e5632-1397-46bb-a860-57924d9d4de5","added_by":"auto","created_at":"2025-11-10 10:05:14","extension":"eps","order_by":35,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73839,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage6.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/66d859c717db008382bd29c4.eps"},{"id":95524826,"identity":"935e949e-20c9-4e1b-bce3-f16ab2c59401","added_by":"auto","created_at":"2025-11-10 10:03:37","extension":"eps","order_by":36,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/d414e4c557ffce860f3c561d.eps"},{"id":95358026,"identity":"824369f7-58f1-47df-bdd1-91b031332fa5","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"eps","order_by":37,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":598,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage11.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/bb560bae53693ed76036cbe0.eps"},{"id":95524424,"identity":"a804922b-3530-4232-a593-261dd75afc89","added_by":"auto","created_at":"2025-11-10 10:02:46","extension":"eps","order_by":38,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":381,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage27.eps","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/e397eba544bb79d1fc8ae0cb.eps"},{"id":95358031,"identity":"0e55ad17-58ce-438a-a6e0-505033853950","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":39,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13430,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/521d4642252a3615678c4fff.png"},{"id":95358035,"identity":"1ccf277e-a608-4e52-923b-fc5c3fa38c41","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":40,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13939,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/bf527fc7af700a7a2d97cadf.png"},{"id":95358042,"identity":"36f0e41c-2e68-4df6-b7fc-b0a07a494552","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":41,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13498,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/d81711ad15615fc8c211564a.png"},{"id":95358049,"identity":"2d6254d1-4ff2-4efe-a8fa-e81da56f5fdd","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":42,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12834,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/074d2eff9da0cf57fe60b06e.png"},{"id":95525728,"identity":"e2494f45-5f73-4315-9004-2b2b8e6ce743","added_by":"auto","created_at":"2025-11-10 10:05:37","extension":"png","order_by":43,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4493,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/1013ef729ceb74e071c92438.png"},{"id":95358051,"identity":"33dcfbf5-e895-49ec-b002-787173b6eff0","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":44,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4776,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/6676241ad848dac9dec36f5a.png"},{"id":95358032,"identity":"924222e6-dbaa-4d26-87db-5f2ebe9c0ff7","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":45,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4679,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/068c5484d4e6bcdb01d757ec.png"},{"id":95358053,"identity":"e81e24a3-b337-4c5e-a5b3-ab27539d9840","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"png","order_by":46,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4445,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/6dcd2b07074f8f3fd3853e86.png"},{"id":95358043,"identity":"2a3da86a-abc1-425f-8dce-75b791125e24","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"xml","order_by":47,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101224,"visible":true,"origin":"","legend":"","description":"","filename":"0e98dc1d27bb4f7c9b48f82f57aa18831structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/6ba73ce2f3b943d3531c5ef0.xml"},{"id":95358056,"identity":"f30ee2cf-f6d7-4792-90aa-947744c44c20","added_by":"auto","created_at":"2025-11-07 07:03:46","extension":"html","order_by":48,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121248,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/f34e744a1e1fa22c8a7d8655.html"},{"id":95525570,"identity":"40389af2-3999-4243-b704-6d465d9fcda2","added_by":"auto","created_at":"2025-11-10 10:05:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157536,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart showing the Patient enrolment to PPOS protocol Group and GnRH antagonist protocol group respectively\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/72ad9500db0c651995cdfa92.jpg"},{"id":95525343,"identity":"8780306f-c7f8-4562-a9cc-bd23522588bc","added_by":"auto","created_at":"2025-11-10 10:04:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39822,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of pregnancy rates between two group\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/8e5e41e41bd5c61fe14c9fcc.jpg"},{"id":95358002,"identity":"197c8e33-7968-48c7-95a5-8d4098b7affb","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41763,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of pregnancy rates between \u0026nbsp;sub-group I\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/460afcfe991ff039a3818e7e.jpg"},{"id":95525772,"identity":"5bde86e0-20a3-49fa-a339-6b2aa75ffd81","added_by":"auto","created_at":"2025-11-10 10:05:41","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":41938,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of pregnancy rates between sub-group II\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/7eec3071afe7a737a116ed1b.jpg"},{"id":95358007,"identity":"4ebc5d47-1bd7-4ff2-82c7-f304bbf4f1bf","added_by":"auto","created_at":"2025-11-07 07:03:45","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":36253,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of pregnancy rates between sub-group III\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/3ce876d15cff33c68a25e2ca.jpg"},{"id":95530807,"identity":"1899a094-25dc-4691-9169-f1dba6e847d6","added_by":"auto","created_at":"2025-11-10 10:22:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1319890,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7864283/v1/feca1dbf-6768-4b7b-97e4-a6d28e342558.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA Comparison between progesterone-primed ovarian stimulation and GnRH antagonist protocol in the ART population undergoing freeze-all cycle bi-centric study.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInfertility is one of the major problems in the world which affects about 8\u0026ndash;12% (60\u0026ndash;80\u0026nbsp;million couples) of the world\u0026rsquo;s population. Out of which several require ART treatments [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].Assisted reproductive technology (ART) is an important role in infertility treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Controlled ovarian stimulation (COS) is an important component of ART that allows obtimum oocytes for in vitro fertilization (IVF) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith the refinement of our stimulation protocal thinking, we were able to produce higher number of Oocytes and embryos, but at the same time, complications like premature LH serged, ovarian hyper stimulation syndrome, and multiple fetal gestation have been a concern even with our Antogonost Protocol[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eProgestin-primed ovarian stimulation (PPOS)) are more flexible and have recently emerged in clinical practice [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Their advantages lie in better control of LH levels, lower costs, and easier administration making them patients friendly (i.e. oral, no injections) than conventional COS, while cos effects like total oocyte, mature oocyte and embryo formed and clinical pregnancy outcomes are similar to those of traditional COS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever the biggest draback of PPOS is enablety to do a fresh embryo transer the index cycle, however, this may be best utilized in hyper-responders, donor oocyte program for the couples who require embryo biopsy for Preimplantation Genetic Testing for Aneuploidy (PGT-A). Although PPOS is effective, we need furthure research and clarity regarding progestin stimulation effect on oocyte competence, embryo availability, embryo implantation, and obstetric and neonatal outcome, especially in elderly women over 40, and women suffering from reccurent pregnancy losses [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTill certain years back, long agonist protocol \u0026amp; antagonist protocols were the most common downregulation regimens which were being used worldwide. In 2015 a novel protocol was found by Kuang where progesterone was used as an oral drug for downregulation and it was found to be very effective [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Principle was based on inhibition of ovulation by OCPs.\u003c/p\u003e\u003cp\u003eThis protocol is based on theories that high progesterone levels can affect the frequency of GnRH pulses, inhibit premature LH surges and suppress pituitary function. Therefore, PPOS has been successfully used in patients with PCOS, normo-responders, poor responders and endometriosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBut, early exposure to high levels of progesterone can alter endometrial receptivity and lead to asynchrony between embryos and endometrium which allowed for preventing routine embryo transfer (ET).\u003c/p\u003e\u003cp\u003eThankfully, advancements in vitrification techniques have allowed us an effective Freeze all \u0026amp; FET Cycle with better pregnancy rates infact [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Wang and colleagues realized that this protocol could be very patient friendly in our hyper-responders, PCOS populations and for the donors in donor recipient cycles as these cycles don\u0026rsquo;t require fresh embryo transfer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough the advantages of PPOS are theoretically proved, few clinical research are available to show its superiority over the GnRH antagonist protocol.\u003c/p\u003e\u003cp\u003eSpecifically, this study aimed to identify any significant differences in key clinical parameters, including oocyte development, embryo formation, and clinical pregnancy rates (CPR).\u003c/p\u003e\u003cp\u003eIn this retrospective study we attempted to compare the two protocols in our ART population, where we were following freeze-all policie.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis retrospective study was conducted from June 2023 to March 2025 in two centres in India in patients who were undergoing IVF/ICSI for various reasons. Participants were recruited into two groups, who met all of the following enrollment criteria:\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion criteria\u003c/b\u003e-\u003c/p\u003e\u003cp\u003ePatients with a history of infertility for more than one year were included in the study. The age of participants ranged from 22 to 38 years. Eligible patients had a Body Mass Index (BMI) between 22\u0026ndash;30 kg/m\u0026sup2;. Transvaginal ultrasonography of the pelvis confirmed a normal uterine anatomy with the presence of at least one ovary.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExclusion criteria\u003c/b\u003e-\u003c/p\u003e\u003cp\u003ePatients with documented premature ovarian insufficiency or ovarian failure were excluded from the study. Other exclusion criteria included age more than 38 years, Serum AMH less than 1.3 ng/mL, the presence of a functional ovarian cyst with serum estradiol (E2) levels greater than 100 pg/mL, endometriosis of stage III and IV, and a history of recurrent pregnancy loss. Additionally, any contraindications to ovarian stimulation treatments led to exclusion from the study. The study was approved by the Medical Ethics Committee of the Hospital (VPIMS/IEC/090/2023). All patients gave informed consent to the use of their clinical data in this study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eMonitoring of the cycle\u003c/h2\u003e\u003cp\u003eAll the patients had baseline FSH, LH, prolactin, TSH, AMH and E2 along with antral follicular\u003c/p\u003e\u003cp\u003ecount (AFC) on day 2 or 3 of the cycle.TVS scan was repeated on day 6 of stimulation, along with serum estradiol (E2), scan was repeated every 2\u0026ndash;3 days till 3 lead follicles reached beyond 18\u0026ndash;20 mm of size. Trigger was decided based on no. of total follicles, serum E2 and serum LH levels. OPU was performed 34\u0026ndash;36 hours after the trigger. 100% ICSI was done and all the embryos were frozen at blastocysts stage.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStimulation protocol\u003c/h3\u003e\n\u003cp\u003eDose of the gonadotropin was decided as per each Patient\u0026rsquo;s Age, Weight, BMI, AMH and AFC was in the range of 150\u0026ndash;450 IU/day from day 2\u0026ndash;3 of menstruation after ruling out any residual follicle or cysts. Group I Patients had medroxyprogesterone acetate (MPA) at a daily dose of 10 mg twice a day from the same day of stimulation and was continued till the day of trigger.\u003c/p\u003e\u003cp\u003eGroup II Received injection cetrorelix (0.25mg) per day from day 5\u0026ndash;7 as flexible protocol based on size of lead follicles ( more than 13mm or estrodiol level more than 300 pg/ml) and antagonist was continued till the trigger. Further dose adjustment of the gonadotropins was done as per ovarian follicular growth response and serum estradiol levels. The final stage of oocyte maturation was induced either by agonist trigger (1.0\u0026ndash;2.0 mg of leuprolide) or dual trigger (injection leuprolide 1.0 mg plus injection hCG1000-5000 IU) when three or more leads follicles reached 18\u0026ndash;20 mm in diameter.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOocyte retrieval, embryo culture, and frozen-thawed embryo transfer.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOocyte retrieval was performed under short general anesthesiaa andwith ultrasound guidance after 34\u0026ndash;36 h of the trigger. Standard procedures were followed for icsi and and embryo culture. The blastocyst grading was done as per Gardener\u0026rsquo;s classification. All the good quality embryos were frozen by vitrification on the fifth day after oocyte retrieval, whereas the inferior quality embryos were placed for extended culture until the day 6. Embryos with \u0026gt;\u0026thinsp;50% intact blastomeres were considered to have survived the freezing procedure after thawing. Only surviving embryos were transferred.\u003c/p\u003e\u003cp\u003eThe endometrium for frozen-thawed embryo transfer (FET) cycles were prepared either by downregulation or by modified natural cycle. Progesterone supplementation was continued until 12 weeks of pregnancy.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePrimary outcome\u003c/strong\u003e\u003cp\u003eNo. of total oocytes, MI, MII \u0026amp; GV retrieved, Blastocysts formation rates\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eSecondary outcome:\u003c/h3\u003e\n\u003cp\u003eClinical pregnancy rate, Ongoing pregnancy (cumulative live birth rate) \u0026amp; miscarriage rates.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe qualitative variables were expressed as absolute and relative frequencies, and the quantitative variables were expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. The association between categorical variables was evaluated using the chi-squared test and Fisher\u0026rsquo;s exact test of independence. To compare quantitative variables between the antagonist and progestin groups, we used the Student\u0026rsquo;s t-test for variables with normal distribution. The intra-group comparison was done using one-way Analysis of variance (ANOVA). We ran the analyses using the IBM SPSS Version 29, considered significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatients baseline characteristic\u003c/h2\u003e\u003cp\u003eTotal 1000 patients were included in the study with mean age of 28.80 (range 22\u0026ndash;38) years undergoing IVF /ICSI for various reasons. Out of 1000 patients 95 patients were excluded due to a lack of follow-up and 62 patients excluded for missing data. Total 843 patients were included in the study. In the end, they were further divided into progesterone-primed ovarian stimulation \u003cb\u003e(\u003c/b\u003ePPOS protocol) Group 1 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;551and GnRH antagonist protocol Group II (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;292) respectively .Patients were divided into three sub groups according to their AMH values; not every patient was included in AMH subgroup. In Group I patients (551) were divided in three sub-group less than 2ng/mL (185), between 2\u0026ndash;5 ng/mL (238) and more than 5 ng/mL (128). Same with group II patients ( n\u0026thinsp;=\u0026thinsp;292), 97 Patients had AMH less than 2ng/ml, 137 patinets had in the range of 2\u0026ndash;5 ng/mL and 58 patients had the AMH more than 5 ng/mL.(Fig.\u0026nbsp;1)\u003c/p\u003e\u003cp\u003eThis sub division comparison gives us an understanding of these two protocols in patients with variable AMH levels.\u003c/p\u003e\u003cp\u003eThere is no significant difference in no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.777), no. of M II (p\u0026thinsp;=\u0026thinsp;0.209) and Blastocysts (p\u0026thinsp;=\u0026thinsp;0.79) in both groups. A significant difference can be seen in no. of M I (p\u0026thinsp;=\u0026thinsp;0.022) \u0026amp; GV (\u0026lt;\u0026thinsp;0.001). The p values were calculated using student\u0026rsquo;s t\u0026ndash;test at a significance level of 0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients baseline characteristic of PPOS Group and Antagonist Group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup I(PPOS)(n\u0026thinsp;=\u0026thinsp;551)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup II(Antagonist)(n\u0026thinsp;=\u0026thinsp;292)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et-values\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eDemographic details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.82\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.937\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eOutcomes (Primary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAMH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.427\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-3.19*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.804\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOocytes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.42\u0026thinsp;\u0026plusmn;\u0026thinsp;6.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.27\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.306*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.777\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.346*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.209 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.291*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.022\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-4.029*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlastocysts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.761\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.79\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes(Secondary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChi squared value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical pregnancy rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e422(76.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e225(77.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0947\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*- values derived using t-test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e#- values derived using Chi squared test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cp\u003eThe p value was calculated with Chi squared Test and it was found that there is no significant difference (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eComparison between AMH sub-groups\u003c/h3\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e2.0 ng/mL (poor responders)\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThere is no significant difference in no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.074), \u0026amp;M I (p\u0026thinsp;=\u0026thinsp;0.309). A significant difference was observed in no. of GV (p\u0026thinsp;=\u0026thinsp;0.045), M II (p\u0026thinsp;=\u0026thinsp;0.006) and Blastocysts (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in both sub-groups. The p values were calculated using student\u0026rsquo;s t\u0026ndash;test at a significance level of 0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u0026thinsp;\u0026lt;\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e2.0 ng/mL (poor responders)\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eGroup I(PPOS)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eGroup II(Antagonist)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003et-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDemographic details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e30.18\u0026thinsp;\u0026plusmn;\u0026thinsp;4.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e30.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAMH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2.0 ng/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eOutcomes (Primary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOocytes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e8.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e7.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e1.796\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.074\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e7.61\u0026thinsp;\u0026plusmn;\u0026thinsp;3.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e5.68\u0026thinsp;\u0026plusmn;\u0026thinsp;4.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e2.809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.006\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e0.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e1.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.309\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e0.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e-3.088\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.045\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlastocysts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e5.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e3.958\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes (Secondary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical pregnancy rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e73(59.34%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e24(63.15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.675\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"10\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e*- values derived using t-test\u003c/p\u003e\u003cp\u003e#- values derived using Chi squared test\u003c/p\u003e\u003c/tbody\u003e\u003c/table\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e2-5ng/mL (normal responders)\u003c/span\u003e\u003c/p\u003e\u003ctable\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eGroup I(PPOS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eGroup II(Antagonist)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003et-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eDemographic details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e29.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e29.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAMH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e2\u0026ndash;5 ng/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eOutcomes (Primary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOocytes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e11.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e9.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e2.638\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0.009\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eM II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e9.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e2.741\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0.007\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eM I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e6.382\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eGV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e-1.684\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0.050\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBlastocysts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e5.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e4.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e1.182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0.241\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOutcomes (Secondary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eClinical pregnancy rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e132(76.74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e28(65.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e2.443\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0.118\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003e*- values derived using t-test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003e#- values derived using Chi squared test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eComparison between CPR of two sub groups\u003c/h2\u003e\u003cp\u003eThe p value was calculated with Chi squared Test and it was found that there is no significant difference (p\u0026thinsp;=\u0026thinsp;0.176) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e2-5ng/mL (normal responders)\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThere is no significant difference in no. of GV (p\u0026thinsp;=\u0026thinsp;0.050) and Blastocysts (p\u0026thinsp;=\u0026thinsp;0.241) in both sub-groups. Significant difference was observed between no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.009), MII (p\u0026thinsp;=\u0026thinsp;0.007) \u0026amp; M I (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The p values were calculated using student\u0026rsquo;s t\u0026ndash;test at a significance level of 0.05 (\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eComparison between CPR of two sub groups\u003c/h2\u003e\u003cp\u003eThe p value was calculated with Chi squared Test and it was found that there is no significant difference (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e\u0026gt;\u0026thinsp;5.0ng/mL (hyper responders)\u003c/h2\u003e\u003cp\u003eThere is no significant difference in no. of GV (p\u0026thinsp;=\u0026thinsp;0.24), M I(p\u0026thinsp;=\u0026thinsp;0.748) and Blastocysts (p\u0026thinsp;=\u0026thinsp;0.442) in both sub-groups. A significant difference was seen in no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.002) \u0026amp; M II(p\u0026thinsp;=\u0026thinsp;0.013). The p values were calculated using student\u0026rsquo;s t\u0026ndash;test at a significance level of 0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u0026thinsp;\u0026gt;\u0026thinsp;5.0ng/mL (hyper responders)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup I(PPOS)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup II(Antagonist)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eDemographic details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAMH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5ng/mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eOutcomes (Primary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOocytes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-3.259\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.74\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.29\u0026thinsp;\u0026plusmn;\u0026thinsp;16.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.013\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.748\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.464\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.24\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlastocysts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.96\u0026thinsp;\u0026plusmn;\u0026thinsp;4.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.772\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.442\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcomes (Secondary)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical pregnancy rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72(79.12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13(76.47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.756\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*- values derived using t-test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e$- values derived using Fisher\u0026rsquo;s Exact test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eComparison between CPR of two sub groups\u003c/h2\u003e\u003cp\u003eThe p value was calculated with Fisher\u0026rsquo;s Exact Test for independence and it was found that there is no significant difference (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study we investigated the utilization of Progestin-Primed Ovarian Stimulation (PPOS) compared to the conventional Antagonist protocol among patients exhibiting different ovarian reserve. Patient response types vary in characteristics and associated complications,characterized by an exaggerated ovarian reaction to stimulation, poses notable challenges and escalates the risk of complications such as Ovarian Hyper Stimulation Syndrome (OHSS) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary objective of this study was to assess the efficacy of PPOS in comparison to the Antagonist protocol within our In Vitro Fertilization (IVF) patient cohort. Through a comparative analysis of outcomes between two principal cohorts, namely Group I (PPOS regimen) and Group II (Antagonist regimen), we aimed to discern any significant disparities in critical parameters including oocyte development, embryo formation \u0026amp; Clinical Pregnancy Rates (CPR).\u003c/p\u003e\u003cp\u003eUpon comparing the Group I and Group II, no statistically significant differences were observed in the number of retrieved oocytes (p\u0026thinsp;=\u0026thinsp;0.777), number of mature oocytes (p\u0026thinsp;=\u0026thinsp;0.209), and blastocyst formation rates (p\u0026thinsp;=\u0026thinsp;0.79) between the two groups, that strengthens our belief of PPOS being non inferior to our conventional antagonist protocol across all the groups of patients. However, a noteworthy discrepancy was noted in the number of immature oocytes (p\u0026thinsp;=\u0026thinsp;0.022) and germinal vesicle (GV) stage oocytes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) among the patients reciieving antagonist protocol. Notably, secondary outcomes such as clinical pregnancy rates demonstrated no significant variance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) between Group I and Group II, indicative of comparable outcomes across both regimens. These findings underscore the equivalence in treatment efficacy between PPOS and the Antagonist protocol, as evidenced by our study outcomes, which associated with Handa and colleagues [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the primary focus of this study revolves around the performance of the PPOS protocol in different responders we also tried to see the performance of PPOS across various AMH groups .\u003c/p\u003e\u003cp\u003eFor that the data was sub-divided into three categories according to their AMH levels which was used as marker of ovarian response. In the first sub-group (\u0026lt;\u0026thinsp;2.0ng/mL- poor responders) no significant difference in no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.074), \u0026amp;M I (p\u0026thinsp;=\u0026thinsp;0.309). A significant difference was observed in no. of GV (p\u0026thinsp;=\u0026thinsp;0.045), M II (p\u0026thinsp;=\u0026thinsp;0.006) and Blastocysts (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in both sub-groups. The difference between CPR was found insignificant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) which clearly correlates with the results shown by a study conducted by Chen and colleagues on 340 patients in which it was shown that PPOS is a non-inferior alternative to novel GnRH antagonists in patients with poor-response [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn second sub-group (2-5ng/mL- normal responders) no significant difference in no. of GV (p\u0026thinsp;=\u0026thinsp;0.050) and Blastocysts (p\u0026thinsp;=\u0026thinsp;0.241) in both sub-groups. Significant difference was observed between no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.009), MII (p\u0026thinsp;=\u0026thinsp;0.007) \u0026amp; M I (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001), CPR was observed non-significant(p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). A study including 865 patients conducted by Zhou and colleagues showed that in numbers of oocytes retrieved, MII \u0026amp; blastocysts, no significant difference is observed between GnRH antagonist and PPOS groups but live birth rate was lower significantly in novel PPOS group where in our study no significant difference was seen in both of the groups [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The study also compared patients with poor response and PCOS which too displayed reduced live birth rates [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe third sub-group (\u0026gt;\u0026thinsp;5.0 ng/mL- hyper responders) no significant difference in no. of GV (p\u0026thinsp;=\u0026thinsp;0.24), M I(p\u0026thinsp;=\u0026thinsp;0.748) and Blastocysts (p\u0026thinsp;=\u0026thinsp;0.442) in both sub-groups. A significant difference was seen in no. of Oocytes (p\u0026thinsp;=\u0026thinsp;0.002) \u0026amp; M II(p\u0026thinsp;=\u0026thinsp;0.013). The CPR was also found in-significant. It was observed that there are not many studies which exclusively state about effect of PPOS on the patients with hyper-response through many studies have conclusion about PCOS population such as Zhou and colleagues was observed that numbers of oocytes retrieved, MII \u0026amp; blastocysts, no significant difference is observed between GnRH antagonist and PPOS groups but live birth rate was lower significantly in novel PPOS group which is somehow similar to there results with normal ovarian reserve patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs the result suggests novel PPOS and conventional Antagonist regimen has no significant differences between theIr clinical pregnancy rates (CPR) and live birth rate. In all population patients PPOS and other protocols have effectively shown similar clinical pregnancy rates and cumulative live birth rates [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePPOS has shown similar outcomes in patients with different ovarian reserve according to the meta-analysis done by Guan and colleagues there are many studies which claim effectiveness of PPOS similar to that of GnRH Antagonist and suggests use of PPOS in oocyte donation cycles as to reduce incidence of OHSS [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs suggested by existing literature, progestins exert their action by suppressing the luteinizing hormone (LH) surge and gonadotropin-releasing hormone (GnRH) surge through their influence on progesterone receptors in the hypothalamus, although the precise mechanism remains under investigation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Progestin-Primed Ovarian Stimulation (PPOS) protocol has been identified as both effective and cost-efficient compared to conventional controlled ovarian stimulation approaches. Notably, it has demonstrated efficacy in suppressing premature LH surges and reducing the incidence of moderate to severe Ovarian Hyper Stimulation Syndrome (OHSS) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur findings, along with previous studies, provide compelling evidence supporting the utilization of the PPOS protocol, particularly in patients exhibiting hyper-responsiveness, potentially mitigating the occurrence of severe OHSS and premature LH surges and in oocyte-donation programs.\u003c/p\u003e\u003cp\u003eHowever, it is imperative to acknowledge certain limitations inherent in the present study due to its retrospective design. The relatively modest sample size and the restriction of the study to two centers within a specific geographical area hinder the generalizability of the findings to the broader population. Additionally, the notable difference in sample sizes between the comparison groups constitutes a further limitation. Future multicenter studies encompassing a larger and more diverse patient cohort are warranted to reinforce and extend these findings, thereby enhancing the robustness and applicability of the conclusions drawn from this investigation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion we can suggest that PPOS is an economical and non-inferior alternative to our conventional GnRH Antagonist protocol in patients with hyper response and other groups which can be used to prevent OHSS and LH surge with similar clinical pregnancy rate. However, its longterm implication on oocyte quality, epigenetic changes and neonatal outcome has to be studied and a wide net of safety to be dicided before it becomes a protocol of choice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePPOS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProgesterone-primed ovarian stimulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGnRH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGonadotropin-releasing hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCPR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCumulative Pregnancy Rate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLuteinizing Hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eFSH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFollicle-Stimulating Hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTSH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThyroid Stimulating Hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAFC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntral follicular count\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eE2\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEstradiol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGV\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGerminal Vesicle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOHSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOvarian Hyper Stimulation Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCOS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eControlled ovarian stimulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eART\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAssisted reproductive technology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOvarian stimulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMetaphase I\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMII\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMetaphase II\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eET\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmbryo transfer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIVF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIn vitro fertilization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eICSI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntracytoplasmic Sperm Injection\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eFET\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFrozen Embryo Transfer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMPA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedroxyprogesterone acetate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAMH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnti-M\u0026uuml;llerian Hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUSG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUltrasound Sonography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOPU\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOvum Pick-Up\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ehCG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman chorionic gonadotropin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePGT-A\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePreimplantation Genetic Testing for Aneuploidy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePCOS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolycystic Ovary Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eANOVA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnalysis of variance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors acknowledge the Vivekananda Polyclinic and Institute of Medical Sciences, for providing facilities and support during the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e: The authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e :Not associated\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eEthics statement;\u003c/strong\u003e Ethical approval was obtained from the institutional Ethics committee of Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, India, with the reference number (VPIMS/IEC/090/2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Informed consent\u003c/strong\u003e: All patients provided informed consent for their clinical Data to be used in this study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material;\u003c/strong\u003e All Data available upon request from the Corresponding Authors\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKatole A, Saoji AV. Prevalence of Primary Infertility and its Associated Risk Factors in Urban Population of Central India: A Community-Based Cross-Sectional Study. Indian J Community Med. 2019 Oct-Dec;44(4):337\u0026ndash;341.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVander Borght M, Wyns C. Fertility and infertility: definition and epidemiology. Clin Biochem. 2018; 62:2\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou Z, Zheng D, Wu H, Li R, Xu S, Kang Y, et al. Epidemiology of infertility in China: a population-based study. BJOG: An International Journal of Obstetrics \u0026amp; Gynecology. 2018;125(4):432\u0026ndash;41..\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDosouto C, Haahr T, Humaidan P. Advances in ovulation trigger strat egies. Panminerva Med. 2019;61(1):42\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAta B, Capuzzo M, Turkgeldi E, Yildiz S, La Marca A. Progestins for pituitary suppression during ovarian stimulation for ART: a comprehensive and systematic review including meta-analyses. Human Reproduction Update. 2021;27(1):48\u0026ndash;66..\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang J, Lu W, Wang L, Zhang T, Liu C, Liu S, et al.A preliminary effect analysis of family doctor and medical insurance payment coordination reform in Changning District of Shanghai, China. BMC family practice. 2019;20:1\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMassin N. New stimulation regimens: endogenous and exogenous pro gesterone use to block the LH surge during ovarian stimulation for IVF. Hum Reprod Update. 2017;23(2):211\u0026ndash;220.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLa Marca A, Capuzzo M. Use of progestins to inhibit spontaneous ovu lation during ovarian stimulation: the beginning of a new era? Reprod Biomed Online. 2019;39(2):321\u0026ndash;331.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWelp AM, Williams CD, Smith LP, Purcell S, Goodman LR. Oral medroxyprogesterone acetate for the use of ovulation suppression in in vitro fertilization: a cohort trial. Fertility and Sterility. 2024;121(5):806\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePai AH, Sung YJ, Li CJ, Lin CY, Chang CL. Progestin primed ovarian stimulation (PPOS) protocol yields lower euploidy rate in older patients undergoing IVF. Reproductive Biology and Endocrinology. 2023;21(1):72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCaetano JP, Calazans LC, Amorim LV, Pereira LM, Xavier EB, Campos AL, et al. Progestin-Primed Ovarian Stimulation is a non-inferior alternative to the GnRH Antagonist Protocol in patients undergoing assisted reproductive techniques: a retrospective study. JBRA Assisted Reproduction. 2022;26(1):38.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Y, Chen Q, Wang N, Chen H, Lyu Q, Kuang Y. Controlled ovarian stimulation using medroxyprogesterone acetate and hMG in patients with polycystic ovary syndrome treated for IVF: a double-blind randomized crossover clinical trial. Medicine. 2016;95(9):e2939.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHanda M, Takiuchi T, Kawaguchi S, Hon CC, Moody J, Okazaki Y, et al Adverse effects of progestin-primed ovarian stimulation: combination of clinical study and single cell analysis. Reproductive Biomedicine Online. 2025 Jan 20:104833.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQin X, Fan L, Luo Y, Deng Z, Zeng Z, Jiang X, et al. Progestin-primed ovarian stimulation (PPOS) in preimplantation genetic testing for aneuploidy: a retrospective study and meta-analysis. Archives of Gynecology and Obstetrics. 2025 Feb 13:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Q, Chai W, Wang Y, Cai R, Zhang S, Lu X, et al. Progestin vs. gonadotropin-releasing hormone antagonist for the prevention of premature luteinizing hormone surges in poor responders undergoing in vitro fertilization treatment: a randomized controlled trial. Frontiers in endocrinology. 2019; 10:796.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou R, Dong M, Huang L, Wang S, Fan L, Liang X, et al. Comparison of cumulative live birth rates between progestin-primed ovarian stimulation protocol and gonadotropin-releasing hormone antagonist protocol in different populations. Frontiers in Endocrinology. 2023 Apr 18\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaid R, Pai HD, Palshetkar NP, Pai RD. Progestin primed ovarian stimulation protocol: current status in assisted reproductive technology. Fertility Science and Research. 2022;9(1):16\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuan S, Feng Y, Huang Y, Huang J. Progestin-primed ovarian stimulation protocol for patients in assisted reproductive technology: a meta-analysis of randomized controlled trials. Frontiers in endocrinology. 2021 Aug 31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYildiz S, Turkgeldi E, Angun B, Eraslan A, Urman B, Ata B. Comparison of a novel flexible progestin primed ovarian stimulation protocol and the flexible gonadotropin releasing hormone antagonist protocol for assisted reproductive technology. Fertil Steril 2019\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKao TC, Hsieh YC, Yang IJ, Wu MY, Chen MJ, Yang JH, et al. Progestin-primed ovarian stimulation versus GnRH antagonist protocol in poor responders: Risk of premature LH surge and outcome of oocyte retrieval. Journal of the Formosan Medical Association. 2023;122(1):29\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoudhary RA, Vora PH, Darade KK, Pandey S, Ganla KN. A prospective randomised comparative clinical trial study of luteal phase letrozole versus ganirelix acetate administration to prevent severity of early onset OHSS in ARTs. International Journal of Fertility \u0026amp; Sterility. 2021;15(4):263.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-fertility-society-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mefj","sideBox":"Learn more about [High Temperature Corrosion of Materials](https://www.springer.com/journal/43043)","snPcode":"43043","submissionUrl":"https://submission.nature.com/new-submission/43043/3","title":"Middle East Fertility Society Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Progestin-primed ovarian stimulation, GnRH antagonist, High progesterone ovarian stimulation, ART, Infertility","lastPublishedDoi":"10.21203/rs.3.rs-7864283/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7864283/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThe objective of this study was to evaluate the efficacy of the Progestin-Primed Ovarian Stimulation (PPOS) protocol in comparison to the GnRH antagonist protocol within our IVF / ICSI patient cohort.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e\u003cp\u003eThe present retrospective study was conducted from June 2023 to March 2025 in two centres in India among females undergo ART treatment. Out of 843 patients were included(n\u0026thinsp;=\u0026thinsp;551) patients were kept in progesterone-primed ovarian stimulation (PPOS protocol) Group 1 while(n\u0026thinsp;=\u0026thinsp;292) patient were assigned to GnRH antagonist protocol Group II respectively. Patients were further subdivided into 3 sub-groups based on there AMH values. Progesterone-primed ovarian stimulation (PPOS) is a promising treatment option for females with hyper response, like polycystic ovarian syndrome (PCOS).\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eComparative analysis of outcomes between two Group I (PPOS regimen) and Group II (Antagonist regimen), respectively Group 1 Group II were compared as per the primary and secondary outcome parameters. Pregnancy in Group I \u0026amp; II- no significant difference between groups in terms of distribution of pregnancy [p\u0026thinsp;=\u0026thinsp;0.0947; χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.004] No statistically significant difference in pregnancy outcomes was observed between the two groups across all AMH subgroups (\u0026lt;\u0026thinsp;2 ng/mL, 2\u0026ndash;5 ng/mL, and \u0026gt;\u0026thinsp;5 ng/mL), with p-values of 0.675, 0.118, and 0.442, respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe PPOS and GnRH antagonist protocols exhibited similar pregnancy outcomes with hyper-responder patients, clinicians should prefer the PPOS protocol for convenience, and reduction in the incidence of LH surge and OHSS.\u003c/p\u003e","manuscriptTitle":"A Comparison between progesterone-primed ovarian stimulation and GnRH antagonist protocol in the ART population undergoing freeze-all cycle bi-centric study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-07 07:03:40","doi":"10.21203/rs.3.rs-7864283/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-16T10:26:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-14T01:09:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T08:45:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T07:29:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52916325395204930863837448765234875462","date":"2025-10-29T18:42:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80061703797813818333275031472022643457","date":"2025-10-28T06:48:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204448536854165965592413842780323664254","date":"2025-10-27T20:34:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-27T20:31:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4669319825694866585478163277592000511","date":"2025-10-27T18:29:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T17:43:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T17:39:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-16T07:59:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Fertility Society Journal","date":"2025-10-15T05:57:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-fertility-society-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mefj","sideBox":"Learn more about [High Temperature Corrosion of Materials](https://www.springer.com/journal/43043)","snPcode":"43043","submissionUrl":"https://submission.nature.com/new-submission/43043/3","title":"Middle East Fertility Society Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"126b4114-b61b-4076-92f5-5a9f06610416","owner":[],"postedDate":"November 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T11:26:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-07 07:03:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7864283","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7864283","identity":"rs-7864283","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}