The impact of Resveratrol on the outcome of the in vitro fertilization: a pilot randomized controlled trial

The impact of Resveratrol on the outcome of the in vitro fertilization: a pilot randomized controlled trial | 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 The impact of Resveratrol on the outcome of the in vitro fertilization: a pilot randomized controlled trial Alessandro Conforti, Giuseppe Gabriele Iorio, Raffaella Di Girolamo, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3894473/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Resveratrol is a natural polyphenolic compound present in plants and red wine with many potential health benefits. This compound has various anti-inflammatory and anti-tumor properties and can improve cellular mitochondrial activity. This pilot trial was designed to evaluate the effect on the outcome of IVF of Resveratrol supplementation in women > 35 years with good ovarian reserve (AMH > 1.2 ng/ml). Women were randomized to receive or placebo or Resveratrol (150 mg twice per day) for three months preceding the ovarian stimulation (OS). All patients were stimulated with a starting dose of recombinant FSH ranging between 150 and 300 IU according to age and ovarian reserve. GnRH antagonist flexible protocol was adopted for pituitary suppression. Triggering was performed with urinary hCG (10.000 IU). Results The study was conducted between January 2019 and December 2022 with aa total of 37 cases and 33 controls were recruited. A statistically significant increase in the follicle output rate (FORT) and follicle-to oocyte index (FOI) in women treated with resveratrol was observed compared with control group (0.92 versus 0.77 [ p = 0.02], and 0.77 versus 0.64 [ p = 0.006], respectively). No statistically significant differences in the number of oocytes retrieved, biochemical pregnancy, clinical pregnancy and live birth rates were observed between groups. Conclusions Preliminary results from this study indicate that pre-treatment with resveratrol may improve ovarian sensitivity to exogenous FSH, which in turn may decrease the risk of hypo-response to OS. ovarian sensitivity FORT FOI FSH POSEIDON hypo-response Figures Figure 1 Introduction Resveratrol is a natural polyphenolic compound present in plants and red wine with numerous health properties. Several in vivo and in vitro studies have demonstrated that this compound has various anti-inflammatory and anti-tumor properties ( 1 , 2 ). Moreover, resveratrol can improve cellular mitochondrial activity and trigger a series of molecular mediators capable of counteracting some of the most important metabolic mechanisms underlying aging ( 3 ). Mitochondria are major regulators of multiple vital cellular processes, including apoptosis, calcium homeostasis, and adenosine triphosphate (ATP) generation through the metabolic pathway known as oxidative phosphorylation. Several studies. reported a significant reduction in mitochondrial DNA levels in female oocytes in advanced maternal age hypothesizing a fundamental role in embryonic development and in vitro fertilization (IVF) success ( 4 ). Nonetheless, the effect of resveratrol on the ovarian sensitivity is still unknow. The ovarian sensitivity reflects the ability of the ovaries to response properly to exogenous gonadotropin. Women characterized by a reduced ovarian sensitivity (or “hypo-response”) are characterized by reduced the number of eggs retrieved despite the normal ovarian reserve. Evidence indicates that hypo-response is typically observed in women with reduced IVF prognosis ( 5 – 9 ). So far, several ovarian sensitivity indicators have been proposed ( 10 , 11 ). Genro et al. proposed the Follicle output rate (FORT) that is calculated as the ratio between the number of pre-ovulatory follicles obtained in response to OS with FSH administration and the pre-existing pool of small antral follicles ( 12 , 13 ). The ovarian sensitivity index (OSI) measures the ration between cumulative gonadotropin and the number of retrieved oocytes ( 14 ). More recently, Poseidon Group proposed follicle-to oocytes index (FOI) that consists in the ratio between the total number of oocytes collected at the end of OS, and the number of antral follicles available at the start of stimulation ( 10 ). Recently, FOI was proposed as clinical performance indicator by the Italian Society of Embryology, Reproduction and Research ( 15 ). Considering the relevance of ovarian response and aging on IVF success, the aim of the present pilot randomized controlled trial was to evaluate the effect of resveratrol supplementation on ovarian responsiveness in advanced reproductive age women with normal ovarian reserve candidates to IVF. METHODS Study design This randomized, single-blind, controlled, single-center, experimental study enrolled infertile women attending in vitro fertilization (IVF) at the IVF Unit of University Federico II, Naples, Italy, from January 2019 and December 2022. The study was approved by the local Ethics Committee of the University of Naples Federico II on January 2019 (n.328/18). The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guideline ( 16 ). This study was reported fulfilling POSORT and CONSORT recommendations ( 17 , 18 ). Patients fulfilling the inclusion and exclusion criteria (Table 1 ) were invited to participate in the study ( 19 – 22 ); the study was explained to all participants. Both oral informed consent and written informed consent were obtained by all patients included. Table 1 Study protocol selection criteria INCLUSION CRITERIA EXCLUSION CRITERIA Age ≥ 35 years Presence of ovarian neoformations at the time of OS Body Mass Index (BMI) ≤ 27 Kg/m2 Polycystic ovary syndrome (20) AMH > 1.2 ng/ml (19) Endometriosis III-IV Stage (21) Regular menstrual cycle (every 25–35 days) Endocrinopathies (disorders of the hypothalamic-pituitary axis, dysthyroidism or hyperprolactinaemia) Indication for ART Diabetes type I e II No previous ovarian surgery Severe male factor (22) Randomization We employed a stratified randomization scheme together with permuted block randomization. Randomization is then performed using PASS software with package blockrand for each stratum at a 1:1 allocation ratio and with block size determined as 2, 4, 6 and 8. The randomization list was prepared by an independent statistician not participating in the recruitment. Sequentially numbered, opaque sealed envelopes are used for allocation. Envelopes receive numbers in advance and are opened sequentially, only after the participant’s name has been written on the appropriate envelope. One member of the research team who labelled the containers was aware of the allocation. Researchers were unaware of treatment allocation until the envelope is opened. Treatment was not masked to care providers and investigators but masked to the participants and the outcome assessor. Clinical and Ultrasonographic Evaluation For each patient we collected: age, BMI Kg/m 2 , menstrual cycle characteristics, last menstrual period, basal FSH and LH, ovarian reserve markers (AMH and AFC) and number of years of infertility. The ultrasound examinations were executed using a Voluson E8 device (GE Healthcare, Zipf, Austria) with a transvaginal probe and they were all performed by two sonographers (G.G.I and SP) within the fifth day of OS. AFC was assessed using 2D-ultrasound and 3D-volume to reduce interobserver variability ( 23 ). AFC was assessed considering 2–10 mm antral follicles using trans-vaginal pelvic ultrasound (multi-frequency vaginal probe 5.0–7.5 MHz) according to the most recent guideline ( 24 ). Intervention Patients of study group received 3 months of treatment, before undergoing OS, with a nutraceutical formulation (2 daily capsules) containing trans -resveratrol and a form of resveratrol supported on Magnesium dihydroxide (total amount of resveratrol 150 mg) ( 25 , 26 ), folic acid (400 mcg), vitamin D (25 mcg), vitamin B12 (2.5 mcg), and vitamin B6 (1.4 mg) (GENANTE®, S&R Farmaceutici, Bastia Umbra PG, Italy), while control group received 3 months of treatment with placebo. After completing the treatment, patients undergo OS, oocyte retrieval and fresh embryo transfer. Patients of both groups performed OS as follows: - on day 2–3 of the menstrual cycle recombinant FSH (r-FSH) were administrated based on age and ovarian reserve (from 150 to 300 IU daily); - all patients were treated with flexible GnRH antagonist protocol at a dose of 0.25 mg/day in case of dominant follicle at the ultrasound (mean diameter > 13 mm or estradiol levels > 300 pg/ml); - in women with at least two follicles of mean diameter > 17 mm, 10.000 IU of hCG was administered as ovulation inducer; - oocyte retrieval (PU) was performed by ultrasound-guided transvaginal aspiration 34–36 hours after the trigger; - ultrasound-guided Embryo transfer (ET) was performed within 5 days of oocyte yield; - the luteal phase, except for cases deemed to be at risk of hyper-response, was supported with 400 mg of micronized vaginal progesterone per day. Outcomes This study aimed to investigate ovarian sensitivity indicators (FORT, FOI and OSI) and major efficacy and efficiency endpoints in IVF, including number of oocytes retrieved and number of mature oocytes (metaphase II oocytes), mature oocytes percentage, number of cleavage embryos and blastocysts, number of cryopreserved embryos, blastulation rate (for those patients underwent transfer on day five), defined as the percentage of inseminated oocytes reaching blastocyst stage, estradiol (E2) levels at peak, duration of stimulation, total dose of gonadotropins, biochemical pregnancy rate (BPR) per aspirated cycle (A pregnancy diagnosed only by the detection of beta hCG in serum or urine), clinical pregnancy rate (CPR) per aspirated cycle (a pregnancy diagnosed by ultrasonographic visualization of one or more gestational sacs or definitive clinical signs of pregnancy), live birth rate (LBR) per aspirated cycle (delivery after 22 completed weeks of gestational age) ( 27 ). Statistical methods Reproductive outcomes were compared between the resveratrol treated group (Study Group) and Control group. Continuous variables are expressed in terms of mean ± SD or median and interquartile range for parametric and non-parametric data, respectively. Categorical variables are expressed in terms of frequency and percentage. The distribution of continuous variables was evaluated with the Shapiro test. The two-sided t-test for independent samples was used to assess inter-group differences concerning parametric data. The two-sided Mann-Whitney U test was used to test inter-group differences for non-parametric data, whereas the Chi-square test was adopted to verify differences in terms of categorical data between groups. Results were analyzed using the statistical package SPSS 22 for Windows (Statistical Package for the Social Sciences, IBM, New York). A p-value < 0.05 was considered statistically significant. Sample size Since no data were available in the literature at the time of the enrollment, the present study is to beconsidered a pilot trial, considering a total sample size of 100 patients (50 per group). Interim-analysis In November 2022, an unplanned interim analysis was conducted on the basis of data from all randomly assigned patients. Results indicated a probability of more than 95% that we would find no significant differences in terms of CPR or LBR if we would include more patients in the trial. After considering all the evidence, the research group decided early closure of the trial. RESULTS A total of 73 women underwent randomization. Therefore, 40 patients were assigned to the test group and 33 to the reference group (Fig. 1 ). Three patients in the study group conceived naturally over the 3 months of therapy and were excluded from the final analysis. Demographic and infertility history data are summarized in Table 2 . Table 2 General characteristics of enrolled women. Study Group n = 37 Control Group n = 33 p-value Age 38.66 ± 2.18 38.04 ± 2.38 0.26 bmi 22.94 ± 2.95 22.86 ± 2.57 0.9 afc 9.74 ± 3.8 10.3 ± 4.07 0.55 AMH (ng/ml) 1.95 (1.52–3.2) 2.15 (1.4–3.67) 0.91 FSH 6.7 (6.15–7.55) 7.65 (6.15-9) 0.25 LH 5.8 (3.87–7.42) 5.3 (4.25–6.25) 0.95 Years of sterility 4 (3-6.5) 3 (2–4) 0.01 Parametric continuous data are presented as mean ± standard deviation Non parametric continuous data are presented as median and interquartile range The mean age and the BMI of the women enrolled in the study were comparable in the two groups. The two groups were also comparable regarding ovarian reserve (AMH and AFC), basal FSH and LH. Infertility duration was higher in study group ( p < 0.01). IVF outcomes are summarized in Table 3 . Table 3 Ovarian stimulations outcomes, embryos and pregnancies between the two study groups. Study Group n = 37 Control Group n = 33 p-value Total gonadotropin dose (IU) 1973.61 ± 395.14 1907.89 ± 475.08 0.53 E 2 at peak 1301 (996-2329.5) 1247 (901.5–1836) 0.53 Retrieved oocytes 7.89 ± 3.62 6.4 ± 3.84 0.1 M2 oocytes 6.26 ± 2.28 5.15 ± 2.7 0.1 % mature oocytes 0.89 (0.73-1) 0.88 (0.71-1) 0.76 FORT 0.92 (0.84-1) 0.77 (0.65–0.95) 0.02 FOI 0.77 (0.7–0.95) 0.64 (0.49–0.76) 0.006 OSI 4.44 (2.34–5.04) 2.86 (1.67–4.48) 0.25 Cleavage embryos/patient 2.16 ± 0.9 1.95 ± 1.14 0.39 Blastocysts/patient 1.47 ± 1.22 1 ± 1.21 0.11 Embryos transferred day 3 14/41 (34%) 15/39 (38.5%) 0.69 Embryos transferred day 5 23/41 (56%) 18/39 (46%) 0.37 Cryopreserved embryos/patient 0.79 ± 0.92 0.65 ± 0.93 0.53 Blastulation rate 0.3 (0.25–0.33) 0.25 (0.17–0.33) 0.45 BPR 9 (24.32%) 10 (30.3%) 0.57 CPR 9 (24.32%) 10 (30.3%) 0.57 LBR 6 (16.22%) 10 (30.3%) 0.16 FORT: Follicle output rate; FOI: follicle oocytes index; OSI: ovarian sensitivity index; BPR: biochemical pregnancy rate; CPR: clinical pregnancy rate; LBR: live-birth rate Parametric continuous data are presented as mean ± standard deviation Non parametric continuous data are presented as median and interquartile range Categorical variables are expressed in terms of frequency and percentage FOI and FORT were significantly higher in the study group than in the control group (p < 0.02 and p < 0.006, respectively). The two groups were not significantly different in terms of mean number of collected oocytes and mature oocytes, percentage of mature oocytes, OSI, total gonadotropin dose and peak estradiol levels. Furthermore, no significant difference was observed in terms of embryos and blastocyst collected and blastulation rate. The two groups were also similar regarding pregnancy outcomes (BPR, CPR and LBR). DISCUSSION Our study showed that resveratrol pretreatment for 3 months before IVF could increase ovarian sensitivity. Indeed, a significantly increased FORT and FOI was observed in study versus control group. Consistently an increased, despite not significant, OSI was observed in the study group compared with control group. To the best of our knowledge, this is the first study that have described an effect resveratrol on ovarian sensitivity. The mechanism by which the resveratrol could increase ovarian sensitivity should be still elucidated, despite several hypothesis could be proposed. The main one might be related to the positive effect exerted by resveratrol on mitochondrial activity. Resveratrol can increase mitochondrial mass in human granulosa cells (GC) through a mechanism involving reduction of voltage-dependent potassium currents, intracellular calcium homeostasis, and regulation of mitomiRNAs ( 28 , 29 ). Women with reduced ovarian responsiveness exhibit reduced mitochondrial mass, cholesterol uptake capacity and expression of enzymes involved in steroidogenesis, such as StAR (Steroidogenic Acute Regulatory), 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) and aromatase, compared with normal responders ( 30 ). Low expression of these enzymes leads to a reduced estrogen and progesterone production even after OS. Since low responsiveness to FSH may correlate with reduced mitochondrial mass, we propose that the enhanced ovarian responsiveness observed in the present study is related to the ability of resveratrol to stimulate mitochondrial biogenesis in GC. Another mechanism of action could be related to the anti-inflammatory and antioxidant properties of resveratrol. Indeed, resveratrol might contrast the negative effect exerted by pro-inflammatory environmental factors related to the hypo-response physiopathology ( 31 , 32 ). The possibility of improving the sensitivity of the ovary to gonadotropins could be useful in reducing the number of patients with an unpredictable hypo-response to OS, as in the case of POSEIDON groups 1 and 2 patients ( 11 ). POSEIDON’s groups 1 and 2 encompass women who had poor (< 4) or suboptimal ( 4 – 9 ) number of oocytes retrieved after a conventional OS despite the presence of an adequate ovarian reserve, defined by an AFC of ≥ 5 and/or an AMH ≥ 1.2 ng/mL. Indeed, retrieval of fewer than 10 oocytes is associated with decreased cumulative live birth rates (CLBR) ( 33 ). Thus, given a patient who fits POSEIDON’s groups 1 or 2, the final goal would be to find ways to maximize oocyte yield aiming at obtaining more than 9 oocytes at the end of stimulation ( 33 , 34 ). Other studies have investigated the role of resveratrol in IVF. Consistently with a recently published randomized trial ( 35 ), we observed an increased, despite not significant, number of oocytes retrieved and MII oocytes and no effect in terms of BPR, CPR and LBR. This mild discrepancy could be related to the fact that we involved only women with advanced reproductive age that are associated per se with a reduced prognosis to IVF and poor ovarian response ( 36 ). In contrast with a retrospective analysis of Ochiai et al. we do not observe a detrimental effect of resveratrol on pregnancy outcome ( 37 ). This could be probably due to the retrospective design, heterogenous population and different IVF protocol adopted in Ochiai study comparing with our trial (mild versus conventional stimulation). Furthermore, the amount of resveratrol prescribed in Ochiai et al. study (200 mg daily) was higher comparing with our trial (150 mg daily). Finally, it should be considered that the age at the oocyte retrieval in Ochiai et al. study was significantly higher in women who were supplemented with resveratrol comparing with control group ( 37 ). The strengths of our study reside in the design, the prospective nature and the selective inclusion criteria involving specifically women with the worst IVF prognosis namely those with advanced reproductive age ( 38 , 39 ). The limitation of our study lies in the low sample size. This makes it impossible to speculate on the comparison between the groups in terms of oocytes parameters (es. retrieved and blastocytes) and pregnancy outcomes. Should we have reached a higher enrollment number the positive trend might have been significant in accordance to a previous study Gerli. et al ( 35 ). Difficulties in achieving the planned sample size were mainly related to the COVID-19 pandemic. At the time of enrollment, there was no published study on IVF outcomes in patients treated with resveratrol, so a sample size calculation could not be performed. Nonetheless, a post hoc analysis revealed that the number of women recruited were adequate to detect a difference in terms of FOI and FORT with a power over 90%. In conclusion, preliminary results from this study indicate that pre-treatment with resveratrol may improve ovarian sensitivity to exogenous FSH, which in turn may decrease the risk of unexpected hypo-response to OS in advanced reproductive age women. Declarations Ethics approval and consent to participate: This study was approved by the local Ethics Committee of the University of Naples Federico II on January 2019 (n.328/18). Consent for publication: Not applicable. Data Availability: Not applicable. Author Contribution: AC, BF, and CA designed study. SP, RDG, MYR performed data collection. AC and GGI analysed data. GGI prepared figures and tables. AC and CA supervised research. AC, GGI, BF and CA wrote manuscript. All authors reviewed the manuscript. Funding: This work was not funded. The company S&R Farmaceutici S.p.A (Bastia Umbra PG, Italy) provided the nutraceutical (GENANTE TM ) and placebo to carry out the study. Acknowledgements: Not applicable. Competing interests: AC and CA declare payment honoraria outside the submitted work, BF is co-inventors of the patent EPO n EP3810104A1; the other authors have nothing to declare. References Pervaiz S, Holme AL. Resveratrol: its biologic targets and functional activity. 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J Matern Fetal Neonatal Med. 2022;35(25):7640–8. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and Practice Committee. Female age-related fertility decline. Comm Opin No 589 Fertil Steril. 2014;101(3):633–4. Ochiai A, Kuroda K, Ikemoto Y, Ozaki R, Nakagawa K, Nojiri S, Takeda S, Sugiyama R. Influence of resveratrol supplementation on IVF-embryo transfer cycle outcomes. Reprod Biomed Online. 2019;39(2):205–10. Ubaldi FM, Cimadomo D, Vaiarelli A, Fabozzi G, Venturella R, Maggiulli R, Mazzilli R, Ferrero S, Palagiano A, Rienzi L. Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment. Front Endocrinol (Lausanne). 2019;10:94. Alviggi C, Humaidan P, Howles CM, Tredway D, Hillier SG. Biological versus chronological ovarian age: implications for assisted reproductive technology. Reprod Biol Endocrinol. 2009;7:101. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Feb, 2024 Reviews received at journal 28 Jan, 2024 Reviewers agreed at journal 27 Jan, 2024 Reviewers agreed at journal 27 Jan, 2024 Reviewers invited by journal 26 Jan, 2024 Editor assigned by journal 25 Jan, 2024 Submission checks completed at journal 25 Jan, 2024 First submitted to journal 24 Jan, 2024 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-3894473","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":269740106,"identity":"38c9206f-b5c4-41a3-999e-b27b462dc1ef","order_by":0,"name":"Alessandro Conforti","email":"","orcid":"","institution":"University of Naples “Federico II”","correspondingAuthor":false,"prefix":"","firstName":"Alessandro","middleName":"","lastName":"Conforti","suffix":""},{"id":269740107,"identity":"44879f38-41f3-4c6d-9526-33f1c2c63fc2","order_by":1,"name":"Giuseppe Gabriele Iorio","email":"data:image/png;base64,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","orcid":"","institution":"University of Naples “Federico II”","correspondingAuthor":true,"prefix":"","firstName":"Giuseppe","middleName":"Gabriele","lastName":"Iorio","suffix":""},{"id":269740108,"identity":"9851c5ab-68b5-4264-83db-7ac48c9ec9a6","order_by":2,"name":"Raffaella Di Girolamo","email":"","orcid":"","institution":"University of Naples “Federico II”","correspondingAuthor":false,"prefix":"","firstName":"Raffaella","middleName":"Di","lastName":"Girolamo","suffix":""},{"id":269740109,"identity":"b146f237-58b7-42fc-b9dc-6ee32f1f28a6","order_by":3,"name":"Marika Ylenia Rovetto","email":"","orcid":"","institution":"University of Naples “Federico II”","correspondingAuthor":false,"prefix":"","firstName":"Marika","middleName":"Ylenia","lastName":"Rovetto","suffix":""},{"id":269740110,"identity":"7891953b-f9d0-45dc-8886-ab46171daac8","order_by":4,"name":"Silvia Picarelli","email":"","orcid":"","institution":"University of Naples “Federico II”","correspondingAuthor":false,"prefix":"","firstName":"Silvia","middleName":"","lastName":"Picarelli","suffix":""},{"id":269740111,"identity":"8dbc63b3-0adf-4a8c-ba6a-abb8c18533b1","order_by":5,"name":"Federica Cariati","email":"","orcid":"","institution":"University of Naples “Federico II”","correspondingAuthor":false,"prefix":"","firstName":"Federica","middleName":"","lastName":"Cariati","suffix":""},{"id":269740112,"identity":"50ec3266-b338-498b-be4f-42c112caee68","order_by":6,"name":"Rosaria Gentile","email":"","orcid":"","institution":"University of Perugia","correspondingAuthor":false,"prefix":"","firstName":"Rosaria","middleName":"","lastName":"Gentile","suffix":""},{"id":269740113,"identity":"896e5117-57aa-4688-82d5-3a10d8ee8ce2","order_by":7,"name":"Antonio D'Amato","email":"","orcid":"","institution":"University of Bari. 1st Unit of Obstetrics and Gynecology","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"D'Amato","suffix":""},{"id":269740114,"identity":"e9221aaf-7315-4e76-95fe-384595a75131","order_by":8,"name":"Orion Gliozheni","email":"","orcid":"","institution":"University of Medicine of Tirana, University Hospital for Obstetrics \u0026 Gynecology “Koco Gliozheni”. Tirana","correspondingAuthor":false,"prefix":"","firstName":"Orion","middleName":"","lastName":"Gliozheni","suffix":""},{"id":269740115,"identity":"a717fba7-adca-40e6-952c-7f4a4b05b844","order_by":9,"name":"Bernard Fioretti","email":"","orcid":"","institution":"University of Perugia","correspondingAuthor":false,"prefix":"","firstName":"Bernard","middleName":"","lastName":"Fioretti","suffix":""},{"id":269740116,"identity":"54ecfc99-15ee-431b-bf21-7f31ccea4bdf","order_by":10,"name":"Carlo Alviggi","email":"","orcid":"","institution":"University of Naples ‘Federico II”","correspondingAuthor":false,"prefix":"","firstName":"Carlo","middleName":"","lastName":"Alviggi","suffix":""}],"badges":[],"createdAt":"2024-01-24 15:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3894473/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3894473/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50331602,"identity":"a4bd4e86-92d7-4dc8-a20b-6de23cdecfae","added_by":"auto","created_at":"2024-01-29 21:49:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20097,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT flow diagram.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1JOR.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3894473/v1/04f82506a73b085c056200e7.jpg"},{"id":50332174,"identity":"52da309c-8b3b-4fcc-95af-0d8a1926a036","added_by":"auto","created_at":"2024-01-29 21:57:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":408810,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3894473/v1/4ccc763a-6270-49b6-8db7-752a27e818e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of Resveratrol on the outcome of the in vitro fertilization: a pilot randomized controlled trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eResveratrol is a natural polyphenolic compound present in plants and red wine with numerous health properties. Several \u003cem\u003ein vivo\u003c/em\u003e and \u003cem\u003ein vitro\u003c/em\u003e studies have demonstrated that this compound has various anti-inflammatory and anti-tumor properties (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Moreover, resveratrol can improve cellular mitochondrial activity and trigger a series of molecular mediators capable of counteracting some of the most important metabolic mechanisms underlying aging (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Mitochondria are major regulators of multiple vital cellular processes, including apoptosis, calcium homeostasis, and adenosine triphosphate (ATP) generation through the metabolic pathway known as oxidative phosphorylation. Several studies. reported a significant reduction in mitochondrial DNA levels in female oocytes in advanced maternal age hypothesizing a fundamental role in embryonic development and \u003cem\u003ein vitro\u003c/em\u003e fertilization (IVF) success (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Nonetheless, the effect of resveratrol on the ovarian sensitivity is still unknow. The ovarian sensitivity reflects the ability of the ovaries to response properly to exogenous gonadotropin. Women characterized by a reduced ovarian sensitivity (or \u0026ldquo;hypo-response\u0026rdquo;) are characterized by reduced the number of eggs retrieved despite the normal ovarian reserve. Evidence indicates that hypo-response is typically observed in women with reduced IVF prognosis (\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). So far, several ovarian sensitivity indicators have been proposed (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Genro \u003cem\u003eet al.\u003c/em\u003e proposed the Follicle output rate (FORT) that is calculated as the ratio between the number of pre-ovulatory follicles obtained in response to OS with FSH administration and the pre-existing pool of small antral follicles (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The ovarian sensitivity index (OSI) measures the ration between cumulative gonadotropin and the number of retrieved oocytes (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). More recently, Poseidon Group proposed follicle-to oocytes index (FOI) that consists in the ratio between the total number of oocytes collected at the end of OS, and the number of antral follicles available at the start of stimulation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Recently, FOI was proposed as clinical performance indicator by the Italian Society of Embryology, Reproduction and Research (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Considering the relevance of ovarian response and aging on IVF success, the aim of the present pilot randomized controlled trial was to evaluate the effect of resveratrol supplementation on ovarian responsiveness in advanced reproductive age women with normal ovarian reserve candidates to IVF.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis randomized, single-blind, controlled, single-center, experimental study enrolled infertile women attending \u003cem\u003ein vitro\u003c/em\u003e fertilization (IVF) at the IVF Unit of University Federico II, Naples, Italy, from January 2019 and December 2022. The study was approved by the local Ethics Committee of the University of Naples Federico II on January 2019 (n.328/18).\u003c/p\u003e \u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guideline (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This study was reported fulfilling POSORT and CONSORT recommendations (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Patients fulfilling the inclusion and exclusion criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were invited to participate in the study (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e); the study was explained to all participants. Both oral informed consent and written informed consent were obtained by all patients included.\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\u003eStudy protocol selection criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINCLUSION CRITERIA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEXCLUSION CRITERIA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresence of ovarian neoformations at the time of OS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Mass Index (BMI)\u0026thinsp;\u0026le;\u0026thinsp;27 Kg/m2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolycystic ovary syndrome (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAMH\u0026thinsp;\u0026gt;\u0026thinsp;1.2 ng/ml (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndometriosis III-IV Stage (21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular menstrual cycle (every 25\u0026ndash;35 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndocrinopathies (disorders of the hypothalamic-pituitary axis, dysthyroidism or hyperprolactinaemia)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication for ART\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes type I e II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo previous ovarian surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere male factor (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRandomization\u003c/h2\u003e \u003cp\u003eWe employed a stratified randomization scheme together with permuted block randomization. Randomization is then performed using PASS software with package blockrand for each stratum at a 1:1 allocation ratio and with block size determined as 2, 4, 6 and 8. The randomization list was prepared by an independent statistician not participating in the recruitment. Sequentially numbered, opaque sealed envelopes are used for allocation. Envelopes receive numbers in advance and are opened sequentially, only after the participant\u0026rsquo;s name has been written on the appropriate envelope. One member of the research team who labelled the containers was aware of the allocation. Researchers were unaware of treatment allocation until the envelope is opened. Treatment was not masked to care providers and investigators but masked to the participants and the outcome assessor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eClinical and Ultrasonographic Evaluation\u003c/h2\u003e \u003cp\u003eFor each patient we collected: age, BMI Kg/m\u003csup\u003e2\u003c/sup\u003e, menstrual cycle characteristics, last menstrual period, basal FSH and LH, ovarian reserve markers (AMH and AFC) and number of years of infertility. The ultrasound examinations were executed using a Voluson E8 device (GE Healthcare, Zipf, Austria) with a transvaginal probe and they were all performed by two sonographers (G.G.I and SP) within the fifth day of OS. AFC was assessed using 2D-ultrasound and 3D-volume to reduce interobserver variability (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). AFC was assessed considering 2\u0026ndash;10 mm antral follicles using trans-vaginal pelvic ultrasound (multi-frequency vaginal probe 5.0\u0026ndash;7.5 MHz) according to the most recent guideline (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003ePatients of study group received 3 months of treatment, before undergoing OS, with a nutraceutical formulation (2 daily capsules) containing \u003cem\u003etrans\u003c/em\u003e-resveratrol and a form of resveratrol supported on Magnesium dihydroxide (total amount of resveratrol 150 mg) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), folic acid (400 mcg), vitamin D (25 mcg), vitamin B12 (2.5 mcg), and vitamin B6 (1.4 mg) (GENANTE\u0026reg;, S\u0026amp;R Farmaceutici, Bastia Umbra PG, Italy), while control group received 3 months of treatment with placebo. After completing the treatment, patients undergo OS, oocyte retrieval and fresh embryo transfer.\u003c/p\u003e \u003cp\u003ePatients of both groups performed OS as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e- on day 2\u0026ndash;3 of the menstrual cycle recombinant FSH (r-FSH) were administrated based on age and ovarian reserve (from 150 to 300 IU daily);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- all patients were treated with flexible GnRH antagonist protocol at a dose of 0.25 mg/day in case of dominant follicle at the ultrasound (mean diameter\u0026thinsp;\u0026gt;\u0026thinsp;13 mm or estradiol levels\u0026thinsp;\u0026gt;\u0026thinsp;300 pg/ml);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- in women with at least two follicles of mean diameter\u0026thinsp;\u0026gt;\u0026thinsp;17 mm, 10.000 IU of hCG was administered as ovulation inducer;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- oocyte retrieval (PU) was performed by ultrasound-guided transvaginal aspiration 34\u0026ndash;36 hours after the trigger;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- ultrasound-guided Embryo transfer (ET) was performed within 5 days of oocyte yield;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- the luteal phase, except for cases deemed to be at risk of hyper-response, was supported with 400 mg of micronized vaginal progesterone per day.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate ovarian sensitivity indicators (FORT, FOI and OSI) and major efficacy and efficiency endpoints in IVF, including number of oocytes retrieved and number of mature oocytes (metaphase II oocytes), mature oocytes percentage, number of cleavage embryos and blastocysts, number of cryopreserved embryos, blastulation rate (for those patients underwent transfer on day five), defined as the percentage of inseminated oocytes reaching blastocyst stage, estradiol (E2) levels at peak, duration of stimulation, total dose of gonadotropins, biochemical pregnancy rate (BPR) per aspirated cycle (A pregnancy diagnosed only by the detection of beta hCG in serum or urine), clinical pregnancy rate (CPR) per aspirated cycle (a pregnancy diagnosed by ultrasonographic visualization of one or more gestational sacs or definitive clinical signs of pregnancy), live birth rate (LBR) per aspirated cycle (delivery after 22 completed\u003c/p\u003e \u003cp\u003eweeks of gestational age) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eReproductive outcomes were compared between the resveratrol treated group (Study Group) and Control group. Continuous variables are expressed in terms of mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median and interquartile range for parametric and non-parametric data, respectively. Categorical variables are expressed in terms of frequency and percentage. The distribution of continuous variables was evaluated with the Shapiro test. The two-sided t-test for independent samples was used to assess inter-group differences concerning parametric data. The two-sided Mann-Whitney U test was used to test inter-group differences for non-parametric data, whereas the Chi-square test was adopted to verify differences in terms of categorical data between groups. Results were analyzed using the statistical package SPSS 22 for Windows (Statistical Package for the Social Sciences, IBM, New York). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eSince no data were available in the literature at the time of the enrollment, the present study is to beconsidered a pilot trial, considering a total sample size of 100 patients (50 per group).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eInterim-analysis\u003c/h2\u003e \u003cp\u003eIn November 2022, an unplanned interim analysis was conducted on the basis of data from all randomly assigned patients. Results indicated a probability of more than 95% that we would find no significant differences in terms of CPR or LBR if we would include more patients in the trial. After considering all the evidence, the research group decided early closure of the trial.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 73 women underwent randomization. Therefore, 40 patients were assigned to the test group and 33 to the reference group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThree patients in the study group conceived naturally over the 3 months of therapy and were excluded from the final analysis. Demographic and infertility history data are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eGeneral characteristics of enrolled women.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy Group\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;33\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.66 \u0026plusmn; 2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.04 \u0026plusmn; 2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ebmi\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.94 \u0026plusmn; 2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.86 \u0026plusmn; 2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eafc\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.74 \u0026plusmn; 3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.3 \u0026plusmn; 4.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAMH (ng/ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.95 (1.52\u0026ndash;3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.15 (1.4\u0026ndash;3.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.7 (6.15\u0026ndash;7.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.65 (6.15-9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.8 (3.87\u0026ndash;7.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3 (4.25\u0026ndash;6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of sterility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3-6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eParametric continuous data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/p\u003e \u003cp\u003eNon parametric continuous data are presented as median and interquartile range\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean age and the BMI of the women enrolled in the study were comparable in the two groups. The two groups were also comparable regarding ovarian reserve (AMH and AFC), basal FSH and LH. Infertility duration was higher in study group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). IVF outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\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 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOvarian stimulations outcomes, embryos and pregnancies between the two study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy Group\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;33\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal gonadotropin dose (IU)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1973.61 \u0026plusmn; 395.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1907.89 \u0026plusmn; 475.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eE\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e \u003cb\u003eat peak\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1301 (996-2329.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1247 (901.5\u0026ndash;1836)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRetrieved oocytes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.89 \u0026plusmn; 3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4 \u0026plusmn; 3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM2 oocytes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.26 \u0026plusmn; 2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.15 \u0026plusmn; 2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e% mature oocytes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89 (0.73-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88 (0.71-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFORT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92 (0.84-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77 (0.65\u0026ndash;0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFOI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.77 (0.7\u0026ndash;0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.64 (0.49\u0026ndash;0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOSI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.44 (2.34\u0026ndash;5.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.86 (1.67\u0026ndash;4.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCleavage embryos/patient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.16 \u0026plusmn; 0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.95 \u0026plusmn; 1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlastocysts/patient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.47 \u0026plusmn; 1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 \u0026plusmn; 1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmbryos transferred\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eday 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/41 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/39 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmbryos transferred\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eday 5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23/41 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18/39 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCryopreserved embryos/patient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79 \u0026plusmn; 0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65 \u0026plusmn; 0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlastulation rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3 (0.25\u0026ndash;0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25 (0.17\u0026ndash;0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBPR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (24.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCPR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (24.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLBR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (16.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFORT: Follicle output rate; FOI: follicle oocytes index; OSI: ovarian sensitivity index; BPR: biochemical pregnancy rate; CPR: clinical pregnancy rate; LBR: live-birth rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eParametric continuous data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/p\u003e \u003cp\u003eNon parametric continuous data are presented as median and interquartile range\u003c/p\u003e \u003cp\u003eCategorical variables are expressed in terms of frequency and percentage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFOI and FORT were significantly higher in the study group than in the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.006, respectively). The two groups were not significantly different in terms of mean number of collected oocytes and mature oocytes, percentage of mature oocytes, OSI, total gonadotropin dose and peak estradiol levels. Furthermore, no significant difference was observed in terms of embryos and blastocyst collected and blastulation rate. The two groups were also similar regarding pregnancy outcomes (BPR, CPR and LBR).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study showed that resveratrol pretreatment for 3 months before IVF could increase ovarian sensitivity. Indeed, a significantly increased FORT and FOI was observed in study versus control group. Consistently an increased, despite not significant, OSI was observed in the study group compared with control group.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study that have described an effect resveratrol on ovarian sensitivity. The mechanism by which the resveratrol could increase ovarian sensitivity should be still elucidated, despite several hypothesis could be proposed. The main one might be related to the positive effect exerted by resveratrol on mitochondrial activity. Resveratrol can increase mitochondrial mass in human granulosa cells (GC) through a mechanism involving reduction of voltage-dependent potassium currents, intracellular calcium homeostasis, and regulation of mitomiRNAs (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Women with reduced ovarian responsiveness exhibit reduced mitochondrial mass, cholesterol uptake capacity and expression of enzymes involved in steroidogenesis, such as StAR (Steroidogenic Acute Regulatory), 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) and aromatase, compared with normal responders (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Low expression of these enzymes leads to a reduced estrogen and progesterone production even after OS. Since low responsiveness to FSH may correlate with reduced mitochondrial mass, we propose that the enhanced ovarian responsiveness observed in the present study is related to the ability of resveratrol to stimulate mitochondrial biogenesis in GC.\u003c/p\u003e \u003cp\u003eAnother mechanism of action could be related to the anti-inflammatory and antioxidant properties of resveratrol. Indeed, resveratrol might contrast the negative effect exerted by pro-inflammatory environmental factors related to the hypo-response physiopathology (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The possibility of improving the sensitivity of the ovary to gonadotropins could be useful in reducing the number of patients with an unpredictable hypo-response to OS, as in the case of POSEIDON groups 1 and 2 patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). POSEIDON\u0026rsquo;s groups 1 and 2 encompass women who had poor (\u0026lt;\u0026thinsp;4) or suboptimal (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) number of oocytes retrieved after a conventional OS despite the presence of an adequate ovarian reserve, defined by an AFC of \u0026ge;\u0026thinsp;5 and/or an AMH\u0026thinsp;\u0026ge;\u0026thinsp;1.2 ng/mL. Indeed, retrieval of fewer than 10 oocytes is associated with decreased cumulative live birth rates (CLBR) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Thus, given a patient who fits POSEIDON\u0026rsquo;s groups 1 or 2, the final goal would be to find ways to maximize oocyte yield aiming at obtaining more than 9 oocytes at the end of stimulation (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOther studies have investigated the role of resveratrol in IVF. Consistently with a recently published randomized trial (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), we observed an increased, despite not significant, number of oocytes retrieved and MII oocytes and no effect in terms of BPR, CPR and LBR. This mild discrepancy could be related to the fact that we involved only women with advanced reproductive age that are associated per se with a reduced prognosis to IVF and poor ovarian response (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In contrast with a retrospective analysis of Ochiai et al. we do not observe a detrimental effect of resveratrol on pregnancy outcome (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). This could be probably due to the retrospective design, heterogenous population and different IVF protocol adopted in Ochiai study comparing with our trial (mild versus conventional stimulation). Furthermore, the amount of resveratrol prescribed in Ochiai et al. study (200 mg daily) was higher comparing with our trial (150 mg daily). Finally, it should be considered that the age at the oocyte retrieval in Ochiai et al. study was significantly higher in women who were supplemented with resveratrol comparing with control group (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe strengths of our study reside in the design, the prospective nature and the selective inclusion criteria involving specifically women with the worst IVF prognosis namely those with advanced reproductive age (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe limitation of our study lies in the low sample size. This makes it impossible to speculate on the comparison between the groups in terms of oocytes parameters (es. retrieved and blastocytes) and pregnancy outcomes. Should we have reached a higher enrollment number the positive trend might have been significant in accordance to a previous study Gerli. et al (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Difficulties in achieving the planned sample size were mainly related to the COVID-19 pandemic. At the time of enrollment, there was no published study on IVF outcomes in patients treated with resveratrol, so a sample size calculation could not be performed. Nonetheless, a post hoc analysis revealed that the number of women recruited were adequate to detect a difference in terms of FOI and FORT with a power over 90%.\u003c/p\u003e \u003cp\u003eIn conclusion, preliminary results from this study indicate that pre-treatment with resveratrol may improve ovarian sensitivity to exogenous FSH, which in turn may decrease the risk of unexpected hypo-response to OS in advanced reproductive age women.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved by the local Ethics Committee of the University of Naples Federico II on January 2019 (n.328/18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u0026nbsp;\u003c/strong\u003eAC, BF, and CA designed study. SP, RDG, MYR performed\u0026nbsp;data collection. AC and GGI analysed data. GGI prepared figures and tables. AC and CA supervised research. AC, GGI, BF and CA wrote manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis work was not funded. The company S\u0026amp;R Farmaceutici S.p.A (Bastia Umbra PG, Italy) provided the nutraceutical\u0026nbsp;(GENANTE\u003csup\u003eTM\u003c/sup\u003e) and placebo to carry out the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eAC and CA declare payment honoraria outside the submitted work, BF is co-inventors of the patent EPO n EP3810104A1; the other authors have nothing to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePervaiz S, Holme AL. Resveratrol: its biologic targets and functional activity. Antioxid Redox Signal. 2009;11:2851\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGusman J, Malonne H, Atassi G. A reappraisal of the potential chemopreventive and chemotherapeutic properties of resveratrol. Carcinogenesis. 2001;22:1111\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark SJ, Ahmad F, Philp A, Baar K, Williams T, Luo H, et al. Resveratrol ameliorates aging-related metabolic phenotypes by inhibiting cAMP phosphodiesterases. Cell. 2012;148:421\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay-Panloup P, Boucret L, Chao de la Barca JM, Desquiret-Dumas V, Ferr\u0026eacute;-L'Hotellier V, Morini\u0026egrave;re C, Descamps P, Procaccio V, Reynier P. Ovarian ageing: the role of mitochondria in oocytes and follicles. 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Best Pract Res Clin Obstet Gynaecol. 2022;85(Pt B):159\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRotterdam ESHRE, ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRevised American Society for Reproductive Medicine classification of endometriosis. : 1996. Fertil Steril. 1997;67(5):817\u0026thinsp;\u0026ndash;\u0026thinsp;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorshedi M. 2010 New 2010 WHO Standards (5th Edition) for the Evaluation of Human Semen. WHO Press Geneva.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroekmans FJ, de Ziegler D, Howles CM, Gougeon A, Trew G, Olivennes F. The antral follicle count: practical recommendations for better standardization. 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Front Nutr. 2020;7:570047.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, Rienzi L, Sunde A, Schmidt L, Cooke ID, Simpson JL, van der Poel S. The International Glossary on Infertility and Fertility Care, 2017. Hum Reprod. 2017;32(9):1786\u0026ndash;801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRagonese F, Monarca L, De Luca A, Mancinelli L, Mariani M, Corbucci C, Gerli S, Iannitti RG, Leonardi L, Fioretti B. Resveratrol depolarizes the membrane potential in human granulosa cells and promotes mitochondrial biogenesis. Fertil Steril. 2021;115(4):1063\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBattaglia R, Caponnetto A, Caringella AM, Cortone A, Ferrara C, Smirni S, Iannitti R, Purrello M, D'Amato G, Fioretti B, Di Pietro C. Resveratrol Treatment Induces Mito-miRNome Modification in Follicular Fluid from Aged Women with a Poor Prognosis for In Vitro Fertilization Cycles. Antioxid (Basel). 2022;11(5):1019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBildik G, Esmaeilian Y, Hela F, Akin N, İltumur E, Yusufoglu S, Yildiz CS, Yakin K, Oktem O. Cholesterol uptake or trafficking, steroid biosynthesis, and gonadotropin responsiveness are defective in young poor responders. Fertil Steril. 2022;117(5):1069\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachtinger R, Gaskins AJ, Racowsky C, Mansur A, Adir M, Baccarelli AA, Calafat AM, Hauser R. Urinary concentrations of biomarkers of phthalates and phthalate alternatives and IVF outcomes. 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Comm Opin No 589 Fertil Steril. 2014;101(3):633\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchiai A, Kuroda K, Ikemoto Y, Ozaki R, Nakagawa K, Nojiri S, Takeda S, Sugiyama R. Influence of resveratrol supplementation on IVF-embryo transfer cycle outcomes. Reprod Biomed Online. 2019;39(2):205\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUbaldi FM, Cimadomo D, Vaiarelli A, Fabozzi G, Venturella R, Maggiulli R, Mazzilli R, Ferrero S, Palagiano A, Rienzi L. Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment. Front Endocrinol (Lausanne). 2019;10:94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlviggi C, Humaidan P, Howles CM, Tredway D, Hillier SG. Biological versus chronological ovarian age: implications for assisted reproductive technology. Reprod Biol Endocrinol. 2009;7:101.\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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-ovarian-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jovr","sideBox":"Learn more about [Journal of Ovarian Research](http://ovarianresearch.biomedcentral.com)","snPcode":"13048","submissionUrl":"https://submission.nature.com/new-submission/13048/3","title":"Journal of Ovarian Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ovarian sensitivity, FORT, FOI, FSH, POSEIDON, hypo-response","lastPublishedDoi":"10.21203/rs.3.rs-3894473/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3894473/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eResveratrol is a natural polyphenolic compound present in plants and red wine with many potential health benefits. This compound has various anti-inflammatory and anti-tumor properties and can improve cellular mitochondrial activity. This pilot trial was designed to evaluate the effect on the outcome of IVF of Resveratrol supplementation in women\u0026thinsp;\u0026gt;\u0026thinsp;35 years with good ovarian reserve (AMH\u0026thinsp;\u0026gt;\u0026thinsp;1.2 ng/ml). Women were randomized to receive or placebo or Resveratrol (150 mg twice per day) for three months preceding the ovarian stimulation (OS). All patients were stimulated with a starting dose of recombinant FSH ranging between 150 and 300 IU according to age and ovarian reserve. GnRH antagonist flexible protocol was adopted for pituitary suppression. Triggering was performed with urinary hCG (10.000 IU).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study was conducted between January 2019 and December 2022 with aa total of 37 cases and 33 controls were recruited. A statistically significant increase in the follicle output rate (FORT) and follicle-to oocyte index (FOI) in women treated with resveratrol was observed compared with control group (0.92 \u003cem\u003eversus\u003c/em\u003e 0.77 [\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02], and 0.77 \u003cem\u003eversus\u003c/em\u003e 0.64 [\u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.006], respectively). No statistically significant differences in the number of oocytes retrieved, biochemical pregnancy, clinical pregnancy and live birth rates were observed between groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePreliminary results from this study indicate that pre-treatment with resveratrol may improve ovarian sensitivity to exogenous FSH, which in turn may decrease the risk of hypo-response to OS.\u003c/p\u003e","manuscriptTitle":"The impact of Resveratrol on the outcome of the in vitro fertilization: a pilot randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-29 21:49:16","doi":"10.21203/rs.3.rs-3894473/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-02-01T09:36:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-28T18:44:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b33fbe8e-3272-4bfd-b7a3-721aafd15afd","date":"2024-01-27T22:23:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74883235-67ae-43ed-b2c4-0c927aeb207a","date":"2024-01-27T07:21:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-26T13:44:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-26T02:29:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-25T05:50:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Ovarian Research","date":"2024-01-24T15:10:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-ovarian-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jovr","sideBox":"Learn more about [Journal of Ovarian Research](http://ovarianresearch.biomedcentral.com)","snPcode":"13048","submissionUrl":"https://submission.nature.com/new-submission/13048/3","title":"Journal of Ovarian Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1190b0d7-334c-4807-aa3b-3acb1459bf2e","owner":[],"postedDate":"January 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-03-13T01:47:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-29 21:49:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3894473","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3894473","identity":"rs-3894473","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}